Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning
Shoulder dystocia is an obstetric emergency that occurs when the baby's anterior shoulder becomes trapped behind the pubic bone during childbirth after delivery of the head. Risk factors include previous shoulder dystocia, large baby size (macrosomia), diabetes, and certain complications during labor like prolonged pushing. Diagnosis involves difficulty delivering the baby's head or shoulders with normal traction. Management begins by calling for help and stopping pushing, and uses maneuvers like McRoberts position and suprapubic pressure to widen the pelvis and disimpact the shoulder. If these fail, internal maneuvers are attempted to rotate the baby before considering more extreme options. Complications can include maternal and fetal injuries.
1) Abnormal uterine action refers to any deviation from normal uterine contractions that can affect the progress of labor. It is one of the leading causes of dystocia or difficult labor.
2) Some types of abnormal uterine action include excessive contractions, abnormal polarity, uterine inertia, spastic lower segment, constriction rings, and generalized tonic contractions.
3) Management depends on the specific type but may include oxytocin stimulation of contractions, artificial rupture of membranes, operative vaginal delivery, or caesarean section if needed to deliver the baby safely. Close monitoring of maternal and fetal wellbeing is important.
This document discusses minor disorders that may occur in newborns during the postpartum period. It defines minor disorders as non-life threatening conditions that can be effectively managed. The document then describes several common minor disorders such as stuffy nose, sticky eyes, jaundice, skin rashes, vomiting, engorge breast, diarrhea, neonatal constipation, urine retention, vaginal discharge, umbilical granuloma, and regurgitation. For each disorder, the document discusses symptoms, causes, and recommended treatment or management. The conclusion emphasizes that while these minor disorders should not be neglected, they can generally be effectively managed with proper nursing care and education.
This document discusses the theories of labor onset and the signs and stages of labor. It covers the factors that influence labor, including uterine stretching, prostaglandin release, and changes in hormone levels. The document also describes the fetal passenger and maternal birth canal, presenting fetal positions, and the cardinal movements that occur during delivery.
LABOUR MONITORING BY PARTOGRAPH BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses the use of a partograph to monitor labor. It begins by explaining the importance of monitoring during labor to detect problems early. It then describes the components of the partograph including patient identification, fetal condition, labor progress, and maternal condition. The document outlines how to use the partograph to assess cervical dilation, descent of the fetal head, contractions and other metrics against alert and action lines to monitor labor progress and make decisions about interventions or transfers.
Dystocia refers to difficult or slow labor progress that may be caused by abnormalities of the passageway (mother's pelvis), passenger (baby), or powers (uterine contractions). There are two main types of uterine dysfunction that can cause dystocia: hypotonic dysfunction where contractions are insufficient and hypertonic dysfunction where contractions are incoordinated. Labor patterns are considered abnormal if the active phase of dilation progresses less than 1 cm/hr for nulliparous women or 1.5 cm/hr for multiparous women. Arrest disorders occur when dilation or descent stops progressing for over 2 hours. Precipitous labor is extremely rapid labor and delivery caused by abnormally low resistance in the birth canal
Kangaroo Mother Care (KMC) involves securing low birth weight or preterm infants skin-to-skin to the mother's chest. It promotes the health and development of these infants through improved temperature regulation, breastfeeding, and bonding with the mother. The key components of KMC are maintaining the infant in the kangaroo position, keeping them skin-to-skin on the mother's chest, securing them with a wrap, exclusive breastfeeding when possible, continuing KMC after hospital discharge with support, and benefits both the infant and mother.
Shoulder dystocia is an obstetric emergency that occurs when the baby's anterior shoulder becomes trapped behind the pubic bone during childbirth after delivery of the head. Risk factors include previous shoulder dystocia, large baby size (macrosomia), diabetes, and certain complications during labor like prolonged pushing. Diagnosis involves difficulty delivering the baby's head or shoulders with normal traction. Management begins by calling for help and stopping pushing, and uses maneuvers like McRoberts position and suprapubic pressure to widen the pelvis and disimpact the shoulder. If these fail, internal maneuvers are attempted to rotate the baby before considering more extreme options. Complications can include maternal and fetal injuries.
1) Abnormal uterine action refers to any deviation from normal uterine contractions that can affect the progress of labor. It is one of the leading causes of dystocia or difficult labor.
2) Some types of abnormal uterine action include excessive contractions, abnormal polarity, uterine inertia, spastic lower segment, constriction rings, and generalized tonic contractions.
3) Management depends on the specific type but may include oxytocin stimulation of contractions, artificial rupture of membranes, operative vaginal delivery, or caesarean section if needed to deliver the baby safely. Close monitoring of maternal and fetal wellbeing is important.
This document discusses minor disorders that may occur in newborns during the postpartum period. It defines minor disorders as non-life threatening conditions that can be effectively managed. The document then describes several common minor disorders such as stuffy nose, sticky eyes, jaundice, skin rashes, vomiting, engorge breast, diarrhea, neonatal constipation, urine retention, vaginal discharge, umbilical granuloma, and regurgitation. For each disorder, the document discusses symptoms, causes, and recommended treatment or management. The conclusion emphasizes that while these minor disorders should not be neglected, they can generally be effectively managed with proper nursing care and education.
This document discusses the theories of labor onset and the signs and stages of labor. It covers the factors that influence labor, including uterine stretching, prostaglandin release, and changes in hormone levels. The document also describes the fetal passenger and maternal birth canal, presenting fetal positions, and the cardinal movements that occur during delivery.
LABOUR MONITORING BY PARTOGRAPH BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses the use of a partograph to monitor labor. It begins by explaining the importance of monitoring during labor to detect problems early. It then describes the components of the partograph including patient identification, fetal condition, labor progress, and maternal condition. The document outlines how to use the partograph to assess cervical dilation, descent of the fetal head, contractions and other metrics against alert and action lines to monitor labor progress and make decisions about interventions or transfers.
Dystocia refers to difficult or slow labor progress that may be caused by abnormalities of the passageway (mother's pelvis), passenger (baby), or powers (uterine contractions). There are two main types of uterine dysfunction that can cause dystocia: hypotonic dysfunction where contractions are insufficient and hypertonic dysfunction where contractions are incoordinated. Labor patterns are considered abnormal if the active phase of dilation progresses less than 1 cm/hr for nulliparous women or 1.5 cm/hr for multiparous women. Arrest disorders occur when dilation or descent stops progressing for over 2 hours. Precipitous labor is extremely rapid labor and delivery caused by abnormally low resistance in the birth canal
Kangaroo Mother Care (KMC) involves securing low birth weight or preterm infants skin-to-skin to the mother's chest. It promotes the health and development of these infants through improved temperature regulation, breastfeeding, and bonding with the mother. The key components of KMC are maintaining the infant in the kangaroo position, keeping them skin-to-skin on the mother's chest, securing them with a wrap, exclusive breastfeeding when possible, continuing KMC after hospital discharge with support, and benefits both the infant and mother.
The document defines and classifies uterine inertia, which is an abnormal relaxation of the uterus during labor causing lack of progress. It describes primary and secondary uterine inertia, their causes and clinical presentations. It discusses various management schemes for hypotonic inertia including medications, oxytocin, prostaglandins and operative deliveries if needed. Hypertonic inertia is also defined as uncoordinated uterine action with irregular painful contractions.
This document outlines the management of the second stage of labor. It begins with the definition of the second stage and principles of assisting the natural expulsion of the fetus slowly. It then details general measures like positioning, monitoring, and analgesia. Specific steps are provided for preparing for delivery, maintaining asepsis, perineal cleansing, positioning the mother, conducting the delivery in three phases, and preventing perineal lacerations including episiotomy. Immediate newborn care procedures are also summarized.
The document provides information on the immediate and essential care of newborn babies. It discusses the characteristics, reflexes, and measurements of newborns. It also outlines the steps for immediate basic care including maintaining temperature, establishing breathing, vitamin K injection, and initiating breastfeeding. The document summarizes assessment methods for gestational age and provides details on the Ballard scoring system.
Pathophysiology of Normal Labour by Sunil Kumar Dahasunil kumar daha
Please find the power point on Management and pathophysiology of Normal Labour . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
The document outlines guidelines for postpartum care in India, including:
- Scheduling at least 3 postpartum visits for the mother and baby on the 3rd day, 7th day, and 6th week after delivery.
- Conducting examinations and monitoring vital signs during the visits, counseling on diet, rest, hygiene, breastfeeding, family planning, and identifying any danger signs that require emergency referral.
- Providing immediate postpartum care for the first hour after delivery and ensuring the mother and baby are not left unattended for the first 48 hours to monitor for complications.
Labour and Delivery... Stages of labour.pptxSandesh Sharma
This document provides an overview of gynecology and labor and delivery presented by Sandesh Sharma. It discusses the types of labor as normal or abnormal, the stages of labor including the first, second, third and fourth stages. Each stage is described in detail outlining what occurs and what the mother may experience. Additionally, it covers the mechanism of labor including engagement, descent, flexion, internal rotation, crowning, extension, and external rotation of the fetus through the birth canal. Complications that may occur are also summarized.
This document describes the four phases of parturition: quiescence, activation, stimulation, and involution. It discusses the factors that influence each phase such as hormones and uterine activity. There are three stages of labor: first stage involves cervical dilation, second stage is delivery of the baby, and third stage involves placental separation and expulsion. The document provides details on the characteristics of uterine contractions during labor, cervical dilation, formation of the lower uterine segment, and mechanisms of placental separation and hemostasis after delivery.
This document provides information on the second stage of labour, including its definition, duration, phases, physiology, management, and the cardinal movements involved in normal delivery. Key points include:
- The second stage begins with full cervical dilation and ends with birth of the baby. It typically lasts 2 hours for primiparous women and 30 minutes for multiparous women.
- It involves three phases: latent, active, and transition. Important physiological changes include uterine contraction, soft tissue displacement, and fetal rotation and extension.
- Management includes monitoring the woman's pushing efforts, positioning, preparing for delivery, and potentially applying controlled traction during crowning. Spontaneous delivery of the head is preferred over techniques like
The document discusses physiology of lactation and breastfeeding recommendations. It recommends exclusive breastfeeding for six months, and continued breastfeeding for at least one year. The benefits of breastfeeding for both mother and baby are described. Proper positioning and attachment for breastfeeding are explained. Common issues like sore nipples, engorgement and mastitis are addressed. Research suggests skin-to-skin contact immediately after birth stimulates breastfeeding behavior in newborns.
The document discusses the physiology of labor, including theories of labor initiation and premonitory signs that labor is imminent. It describes the stages of uterine contractions that characterize true labor, cervical changes like effacement and dilation, and other signs like bloody show. Nursing considerations are outlined for events like rupture of membranes, including actions to take for problems like cord prolapse.
Postpartum care involves monitoring for common medical complications like headaches, hemorrhoids, varicose veins, and vulvar edema. It also addresses mental health issues such as postpartum blues, depression, and psychosis. Counseling is provided on breastfeeding, sexuality, and contraception. The routine postpartum visit at 4-6 weeks involves patient education, maternal monitoring, laboratory tests, breastfeeding support, perineal care, and prevention of complications like venous thrombosis.
Shoulder dystocia occurs when the baby's shoulders become stuck after delivery of the head. It has a low incidence rate of 0.2-1% and risk factors include fetal macrosomia, obesity, diabetes and others. Diagnosis is made when normal maneuvers by the midwife fail to deliver the baby. Management involves calling for help, clearing the baby's airways, and performing maneuvers like McRoberts and Rubin's to rotate the shoulders and decrease their diameter in order to allow delivery. More invasive maneuvers like cleidotomy may be needed if these fail to deliver the anterior shoulder.
This document discusses the first stage of labor and its management. The main events of the first stage are dilatation of the cervix and effacement of the cervix. It describes the processes involved like softening and thinning of the cervix. Management of the first stage focuses on monitoring the mother and fetus, providing comfort, and assessing progress. Complications that may arise include maternal distress, fetal distress, cephalopelvic disproportion, and prolonged labor.
NURSING MANAGEMENT DURINGTHE POSTPARTUM PERIOD 2021.pdfssuser873e5a1
The document discusses nursing management of the postpartum period, including assessing the physical and emotional changes a woman experiences, monitoring for complications, and providing education on self-care and infant care. It outlines the assessments nurses should perform, including vital signs, a head-to-toe examination checking systems like breasts, uterus, bladder, and lochia, and ensuring the woman's needs are addressed during recovery. The goal of postpartum care is to help the woman and family adapt to the newborn while assisting recovery and identifying any deviations from normal postpartum progression.
Ten percent of all pregnancies are complicated by hypertension (HTN).Eclampsia and preeclampsia account for about half of these cases worldwide.
In 1619, Varandaeus coined the term eclampsia in a treatise on gynecology.
DEFINITION: Eclampsia is defined as the clinical presentation of an unexplained seizure, convulsion, or altered mental status in the setting of the signs and symptoms of preeclampsia. It is considered a complication of severe preeclampsia.
A woman with preeclampsia develops:
--- high blood pressure (>140 mmHg systolic or >90 mmHg diastolic)
--- protein in the urine
--- swelling (edema) of the legs, hands, face or entire body.
Retained placenta can be defined as lack of placental expulsion within 30 minutes of delivery of an infant. it is more common in preterm. Retained Placenta can lead to massive PPH and increase maternal morbidity and mortality.
The document discusses lactation, its physiology and causes of lactation failure. It describes the prolactin and oxytocin reflexes which are involved in milk production and ejection. Psychological and social factors are common causes of insufficient milk production according to the document. Engorged breasts, sore nipples and mastitis are mentioned as biological local causes. The management of lactation failure involves prevention, early detection and treatment. Relactation techniques including frequent breastfeeding and the use of supplements are described to reestablish milk production.
Series of events that takes place in the genital organ in an effort to expel the viable products of conception out of the womb through the vagina into the outer world is called labour.
there are four stages of labour.
The document discusses the transitional period between the first and second stages of labor. It describes the physiological changes that occur as contractions become stronger and the cervix fully dilates. These include restlessness in the mother, rupture of membranes, and urges to push. As the fetal head descends, it displaces soft tissues in the pelvis. Several signs like expulsive contractions and appearance of the presenting part indicate transition to the active second stage of labor, but can only be confirmed by vaginal examination.
The document defines and classifies uterine inertia, which is an abnormal relaxation of the uterus during labor causing lack of progress. It describes primary and secondary uterine inertia, their causes and clinical presentations. It discusses various management schemes for hypotonic inertia including medications, oxytocin, prostaglandins and operative deliveries if needed. Hypertonic inertia is also defined as uncoordinated uterine action with irregular painful contractions.
This document outlines the management of the second stage of labor. It begins with the definition of the second stage and principles of assisting the natural expulsion of the fetus slowly. It then details general measures like positioning, monitoring, and analgesia. Specific steps are provided for preparing for delivery, maintaining asepsis, perineal cleansing, positioning the mother, conducting the delivery in three phases, and preventing perineal lacerations including episiotomy. Immediate newborn care procedures are also summarized.
The document provides information on the immediate and essential care of newborn babies. It discusses the characteristics, reflexes, and measurements of newborns. It also outlines the steps for immediate basic care including maintaining temperature, establishing breathing, vitamin K injection, and initiating breastfeeding. The document summarizes assessment methods for gestational age and provides details on the Ballard scoring system.
Pathophysiology of Normal Labour by Sunil Kumar Dahasunil kumar daha
Please find the power point on Management and pathophysiology of Normal Labour . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
The document outlines guidelines for postpartum care in India, including:
- Scheduling at least 3 postpartum visits for the mother and baby on the 3rd day, 7th day, and 6th week after delivery.
- Conducting examinations and monitoring vital signs during the visits, counseling on diet, rest, hygiene, breastfeeding, family planning, and identifying any danger signs that require emergency referral.
- Providing immediate postpartum care for the first hour after delivery and ensuring the mother and baby are not left unattended for the first 48 hours to monitor for complications.
Labour and Delivery... Stages of labour.pptxSandesh Sharma
This document provides an overview of gynecology and labor and delivery presented by Sandesh Sharma. It discusses the types of labor as normal or abnormal, the stages of labor including the first, second, third and fourth stages. Each stage is described in detail outlining what occurs and what the mother may experience. Additionally, it covers the mechanism of labor including engagement, descent, flexion, internal rotation, crowning, extension, and external rotation of the fetus through the birth canal. Complications that may occur are also summarized.
This document describes the four phases of parturition: quiescence, activation, stimulation, and involution. It discusses the factors that influence each phase such as hormones and uterine activity. There are three stages of labor: first stage involves cervical dilation, second stage is delivery of the baby, and third stage involves placental separation and expulsion. The document provides details on the characteristics of uterine contractions during labor, cervical dilation, formation of the lower uterine segment, and mechanisms of placental separation and hemostasis after delivery.
This document provides information on the second stage of labour, including its definition, duration, phases, physiology, management, and the cardinal movements involved in normal delivery. Key points include:
- The second stage begins with full cervical dilation and ends with birth of the baby. It typically lasts 2 hours for primiparous women and 30 minutes for multiparous women.
- It involves three phases: latent, active, and transition. Important physiological changes include uterine contraction, soft tissue displacement, and fetal rotation and extension.
- Management includes monitoring the woman's pushing efforts, positioning, preparing for delivery, and potentially applying controlled traction during crowning. Spontaneous delivery of the head is preferred over techniques like
The document discusses physiology of lactation and breastfeeding recommendations. It recommends exclusive breastfeeding for six months, and continued breastfeeding for at least one year. The benefits of breastfeeding for both mother and baby are described. Proper positioning and attachment for breastfeeding are explained. Common issues like sore nipples, engorgement and mastitis are addressed. Research suggests skin-to-skin contact immediately after birth stimulates breastfeeding behavior in newborns.
The document discusses the physiology of labor, including theories of labor initiation and premonitory signs that labor is imminent. It describes the stages of uterine contractions that characterize true labor, cervical changes like effacement and dilation, and other signs like bloody show. Nursing considerations are outlined for events like rupture of membranes, including actions to take for problems like cord prolapse.
Postpartum care involves monitoring for common medical complications like headaches, hemorrhoids, varicose veins, and vulvar edema. It also addresses mental health issues such as postpartum blues, depression, and psychosis. Counseling is provided on breastfeeding, sexuality, and contraception. The routine postpartum visit at 4-6 weeks involves patient education, maternal monitoring, laboratory tests, breastfeeding support, perineal care, and prevention of complications like venous thrombosis.
Shoulder dystocia occurs when the baby's shoulders become stuck after delivery of the head. It has a low incidence rate of 0.2-1% and risk factors include fetal macrosomia, obesity, diabetes and others. Diagnosis is made when normal maneuvers by the midwife fail to deliver the baby. Management involves calling for help, clearing the baby's airways, and performing maneuvers like McRoberts and Rubin's to rotate the shoulders and decrease their diameter in order to allow delivery. More invasive maneuvers like cleidotomy may be needed if these fail to deliver the anterior shoulder.
This document discusses the first stage of labor and its management. The main events of the first stage are dilatation of the cervix and effacement of the cervix. It describes the processes involved like softening and thinning of the cervix. Management of the first stage focuses on monitoring the mother and fetus, providing comfort, and assessing progress. Complications that may arise include maternal distress, fetal distress, cephalopelvic disproportion, and prolonged labor.
NURSING MANAGEMENT DURINGTHE POSTPARTUM PERIOD 2021.pdfssuser873e5a1
The document discusses nursing management of the postpartum period, including assessing the physical and emotional changes a woman experiences, monitoring for complications, and providing education on self-care and infant care. It outlines the assessments nurses should perform, including vital signs, a head-to-toe examination checking systems like breasts, uterus, bladder, and lochia, and ensuring the woman's needs are addressed during recovery. The goal of postpartum care is to help the woman and family adapt to the newborn while assisting recovery and identifying any deviations from normal postpartum progression.
Ten percent of all pregnancies are complicated by hypertension (HTN).Eclampsia and preeclampsia account for about half of these cases worldwide.
In 1619, Varandaeus coined the term eclampsia in a treatise on gynecology.
DEFINITION: Eclampsia is defined as the clinical presentation of an unexplained seizure, convulsion, or altered mental status in the setting of the signs and symptoms of preeclampsia. It is considered a complication of severe preeclampsia.
A woman with preeclampsia develops:
--- high blood pressure (>140 mmHg systolic or >90 mmHg diastolic)
--- protein in the urine
--- swelling (edema) of the legs, hands, face or entire body.
Retained placenta can be defined as lack of placental expulsion within 30 minutes of delivery of an infant. it is more common in preterm. Retained Placenta can lead to massive PPH and increase maternal morbidity and mortality.
The document discusses lactation, its physiology and causes of lactation failure. It describes the prolactin and oxytocin reflexes which are involved in milk production and ejection. Psychological and social factors are common causes of insufficient milk production according to the document. Engorged breasts, sore nipples and mastitis are mentioned as biological local causes. The management of lactation failure involves prevention, early detection and treatment. Relactation techniques including frequent breastfeeding and the use of supplements are described to reestablish milk production.
Series of events that takes place in the genital organ in an effort to expel the viable products of conception out of the womb through the vagina into the outer world is called labour.
there are four stages of labour.
The document discusses the transitional period between the first and second stages of labor. It describes the physiological changes that occur as contractions become stronger and the cervix fully dilates. These include restlessness in the mother, rupture of membranes, and urges to push. As the fetal head descends, it displaces soft tissues in the pelvis. Several signs like expulsive contractions and appearance of the presenting part indicate transition to the active second stage of labor, but can only be confirmed by vaginal examination.
Management of normal labour involves careful history taking, examination of the patient and fetus, and monitoring progress through each stage of labour. The first stage focuses on preparing the mother, allowing light foods and mobility. Fetal wellbeing is assessed through monitoring the heart rate, fluid color and scalp sampling if needed. The second stage has the mother push on contractions while in position for delivery. Episiotomy may be done and perineal support given. The third stage uses active management including oxytocin to deliver the placenta to prevent hemorrhage.
The third stage of labor involves the separation and expulsion of the placenta after childbirth. The placenta separates from the uterine wall due to uterine contraction. The uterus then contracts further to aid the descent and expulsion of the placenta through the birth canal. Midwives monitor for signs of separation and use techniques like controlled cord traction or fundal pressure to deliver the placenta if needed. Oxytocic drugs may also be used to aid delivery or prevent hemorrhage. Care of both mother and newborn continues for at least an hour after completion of the third stage to ensure uterine contraction and monitor for complications.
The document discusses the mechanism of normal labor, including:
1. Labor involves an increase in myometrial contractions leading to cervical effacement and dilation, expelling the fetus from the uterus.
2. Labor has three stages - cervical dilation during stage one, descent and birth of the baby in stage two, and delivery of the placenta in stage three.
3. Fetal positioning, size, and engagement in the pelvis combined with uterine contractions and pelvic anatomy facilitate the cardinal movements that enable the fetus to navigate the birth canal.
Normal labor involves several stages of fetal positioning and movement through the female pelvis. The fetal skull flexes to reduce its diameter for descent through the birth canal. As labor progresses, the baby engages and the posterior parietal bone glides past the sacral promontory. During crowning, the biparietal diameter stretches the vulval outlet without recession. The shoulders then rotate and the occiput faces the pubic symphysis. Birth of the shoulders and trunk follows, with the posterior shoulder sweeping the perineum and the trunk expelled in lateral flexion. External rotation and restitution position the head for extension and release of the chin through the perineum.
The normal mechanism of labour involves the fetus descending through the birth canal in stages. First, there is descent, flexion, and internal rotation of the fetal head as it engages in the pelvis. Next, further descent causes crowning and extension to deliver the head. The head then undergoes restitution and external rotation to align with the shoulders. Finally, the shoulders and body are delivered to complete the birth.
The document discusses several topics related to labour and delivery:
- The physiological mechanisms that initiate labour, including hormonal and anatomical changes in the mother and fetus.
- How uterine contractions progress cervical dilation and effacement in the first stage of labour.
- The second stage where contractions expel the fetus through the birth canal.
- The third stage where the placenta is delivered.
- Methods for assessing and monitoring labour including physical exams, cardiotocography to monitor the fetal heart rate, and use of the partogram to track labour progress.
The document provides information on managing the normal postpartum period, or puerperium. It defines the puerperium as lasting 6 weeks after delivery of the placenta. During this time, the mother's body returns to its non-pregnant state through physical changes in organs like the uterus, breasts, cardiovascular and gastrointestinal systems. Proper management of the first hour after delivery and routine observations are important to prevent postpartum hemorrhage. With no complications, patients can typically be discharged 6 hours after a normal vaginal delivery or after 3 days for a Cesarean section. Follow-up postnatal care is also required during the 6-week period.
Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care
Intrapartum Care: Skills workshop Examination in labourSaide OER Africa
Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning
The first stage of labor involves the dilation of the cervix from 0-10cm as contractions become stronger and more frequent. It is divided into three phases: latent, active, and transitional. Several factors influence the progress of labor including uterine contractions, cervical effacement and dilation, fetal descent, and pressure from amniotic fluid. Monitoring includes regular assessment of maternal and fetal vital signs, uterine contractions, cervical dilation, and fetal heart rate. Natural pain management methods include breathing exercises, hydrotherapy, and doula support.
This document discusses problems that can occur with fetal position, presentation, or size during labor and delivery. It describes issues like occipitoposterior position where the baby's head is facing the wrong way, breech presentation where the baby is feet or butt first, face or brow presentations which are types of abnormal head position, and transverse lie where the baby is laying horizontally across the womb. It provides information on assessment of these problems, contributing risk factors, potential complications, and therapeutic management approaches including manual maneuvers, positions, and when cesarean delivery may be recommended.
Primary Maternal Care: The puerperium and family planningSaide OER Africa
Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book complements the national protocol of antenatal care in South Africa. It covers: booking for antenatal care, assesing fetal growth and wellbeing, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical conditions
The document summarizes the normal process of labor and delivery in 3 stages:
1) The first stage begins with regular contractions and ends with full cervical dilation. It involves engagement and descent of the fetus through the birth canal.
2) The second stage begins with full dilation and ends with delivery of the baby. It involves rotation and extension of the fetus.
3) The third stage involves delivery of the placenta, usually within 5-10 minutes of birth. The process ensures the fetus can safely pass through the birth canal during contractions.
This document discusses various complications that can arise regarding the mother and passenger (baby) during pregnancy and childbirth. It covers complications such as prolapse of the umbilical cord, multiple gestation, fetal positioning issues like face presentation and brow presentation, fetal size issues like macrosomia and shoulder dystocia, and breech presentation. It also discusses managing the mother's psyche and emotional state during birth as that can impact the birthing process if she is feeling afraid, tense or unsupported. Effective management strategies are provided for each complication depending on whether a normal spontaneous delivery is possible or if cesarean section is required.
This document discusses several conditions that can cause difficulties during childbirth due to the size relationship between the baby's head and the mother's pelvis, including inlet contraction, outlet contraction, and cephalopelvic disproportion. It describes the normal measurements of the pelvic inlet and outlet, potential causes of each condition, assessment findings, management strategies, and complications. It also covers shoulder dystocia, defining it as when the baby's anterior shoulder gets stuck under the pubic bone after the head is delivered. Risk factors, pathophysiology, assessment findings, and management techniques like McRoberts position and suprapubic pressure are outlined.
Childbirth involves three stages: cervical dilation, descent and birth of the infant, and delivery of the placenta. It is a complex physiological process influenced by hormones like oxytocin. A normal vertex birth involves six phases: engagement and descent of the fetal head, internal rotation, delivery by extension, restitution, and external rotation of the shoulders. Monitoring of the fetus and mother during labor can be done externally via Doppler or cardiotocography, or more invasively using scalp electrodes or intrauterine pressure catheters. The postpartum period following childbirth lasts around six weeks as the mother recovers.
The document summarizes the birth process, which consists of three stages: early labor, active labor, pushing and delivery, and delivery of the placenta. Contractions become stronger and more frequent during early and active labor as the cervix dilates. Transition occurs when the cervix is fully dilated and pushing begins. The baby's head emerges during crowning and delivery. Shortly after, the placenta detaches and is delivered.
The document summarizes the process of a normal spontaneous vaginal delivery in three stages:
1) Labor - Beginning with early signs and progressing through three stages of cervical dilation.
2) Delivery - Beginning with full dilation and ending with the birth of the baby through contractions and pushing.
3) Placental delivery - Beginning with separation from the uterine wall and ending with expulsion from the vagina.
The document discusses various topics related to fetal lie, presentation, position, and labor including:
- The fetal lie can be longitudinal, transverse, or oblique relative to the mother's long axis.
- Cephalic presentation is most common, with other possibilities including breech, face, brow, and transverse lie.
- Fetal position describes the relationship of parts of the presenting fetal head to the mother's right or left side.
- Leopold's maneuvers are used to determine fetal position and presentation during vaginal exams.
- The cardinal movements of labor are engagement, descent, flexion, internal rotation, extension, and external rotation.
The document provides information on the management of the second stage of labor by nurses. It discusses the normal physiology of the second stage, including cervical dilation, fetal descent and rotation, and maternal efforts. It describes the mechanism of labor, including engagement, descent, flexion, internal rotation, crowning, extension, and birth of the shoulders and trunk. Monitoring labor progress and managing the second stage with techniques like the partogram are also summarized.
Identify the onset of the second stage of labour.
Decide when the patient should start to bear down.
Communicate effectively with the patient during labour.
Use the maternal effort to the best advantage when the patient bears down.
Make careful observations during the second stage of labour.
Assess the fetal condition during the time the patient bears down.
Accurately evaluate progress in the second stage of labour.
Manage a patient with a prolonged second stage of labour.
Diagnose and manage impacted shoulders.
BREECH DELIVERY By Odokoyero Abdalah Fadhil and Nanfuka MariamOdokonyerofadhil
This document provides an overview of breech delivery, including:
1. Definitions of breech presentation and breech birth, as well as the epidemiology and types/classifications of breech presentations.
2. Risk factors for breech presentation, the diagnosis process, and management options including external cephalic version and vaginal breech delivery.
3. Details on the procedure for a vaginal breech delivery, including positioning, maneuvers to assist delivery of the legs, shoulders, and head, as well as potential complications.
Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book complements the national protocol of antenatal care in South Africa. It covers: booking for antenatal care, assesing fetal growth and wellbeing, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical conditions
There are three main types of version procedures described in the document:
1. External cephalic version involves externally manipulating the fetus from the outside of the uterus to change its position from breech or transverse to head-down before labor begins.
2. Internal cephalic version is rarely used today but involves inserting one hand inside the uterus to change the fetus' position, usually from transverse to head-down, during labor when the cervix is fully dilated.
3. Bipolar version involves using one hand externally on the abdomen and two fingers of the other hand inserted in the uterus to change the fetus' position, primarily in cases of placenta previa when the fetus is not viable.
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Intrapartum Care: The second stage of labour
1. 4
The second
stage of labour
Before you begin this unit, please take the THE NORMAL SECOND
corresponding test at the end of the book to
assess your knowledge of the subject matter. You STAGE OF LABOUR
should redo the test after you’ve worked through
the unit, to evaluate what you have learned
4-1 What is the second stage of labour?
The second stage of labour starts when the
Objectives patient’s cervix is fully dilated and ends when
the infant is completely delivered.
When you have completed this unit you
should be able to: The second stage of labour starts when the cervix
• Identify the onset of the second stage of is fully dilated.
labour.
• Decide when the patient should start to 4-2 What symptoms and signs suggest that
bear down. the second stage of labour has begun?
• Communicate effectively with a patient One or more of the following may occur:
during labour. 1. Uterine contractions increase in both
• Use the maternal effort to the best frequency and duration, i.e. they are more
advantage when the patient bears down. frequent and last longer.
• Make careful observations during the 2. The patient becomes restless.
second stage of labour. 3. Nausea and vomiting often occur.
4. The patient has an uncontrollable urge to
• Accurately evaluate progress in the
bear down (push).
second stage of labour. 5. The perineum bulges during a contraction
• Manage a patient with a prolonged as it is stretched by the fetal head.
second stage of labour.
If the symptoms and signs suggest that
• Diagnose and manage impacted the second stage of labour has begun, an
shoulders. abdominal examination must be done to
assess the amount of head palpable above the
2. 74 INTRAPAR TUM CARE
pelvic brim, followed by a vaginal examination 4-6 If the cervix is fully dilated but
to assess whether the cervix is fully dilated. the head not yet engaged, when is it
safe to wait for engagement before
4-3 Is there a difference between allowing the patient to bear down?
primigravidas and multigravidas at the 1. If there are no signs of fetal distress.
start of the second stage of labour? 2. If there are no signs of cephalopelvic
Yes. In primigravidas the head is usually disproportion.
engaged when the cervix reaches full
dilatation. In contrast, multigravidas often Waiting for engagement of the head in a
reach full cervical dilatation when the fetal
patient with a fully dilated cervix should only be
head is still not engaged.
allowed if there are no signs of fetal distress or
cephalopelvic disproportion.
4-4 What is the definition of
engagement of the fetal head?
Usually primigravidas only reach full cervical
The fetal head is engaged when the largest dilatation after the fetal head has engaged.
transverse diameter of the head (the biparietal However the fetal head may only engage after
diameter) has passed through the pelvic inlet. the cervix is fully dilated in a multigravida.
When the fetal head is engaged, 2/5 or less of Therefore, there is a greater chance of
the head is palpable above the pelvic brim. cephalopelvic disproportion in a primigravida
who reaches full cervical dilatation with an
The fetal head is engaged when only 2/5 or less of unengaged fetal head.
the head is palpable above the brim of the pelvis
4-7 How long should you wait before asking
the patient to bear down if the cervix is fully
Engagement usually starts before the onset
dilated but the head is not yet engaged?
of labour. Initially 5/5 of the head is palpable
above the pelvic brim. Engagement of the head 1. The patient should be assessed after an
cannot be determined on vaginal examination. hour if there are no signs of fetal distress
and the maternal observations are normal.
2. Usually engagement of the head will occur
MANAGING THE SECOND during this time and the patient will feel a
strong urge to bear down within an hour.
STAGE OF LABOUR 3. If the head has still not engaged after an
hour, you can wait a further hour provided
that all other observations are normal
4-5 Should the patient start bearing down
and there are no signs of cephalopelvic
as soon as the cervix is fully dilated?
disproportion.
No. The patient should wait until the fetal head 4. If the head has not engaged after waiting
starts to distend the perineum, when she will two hours, delivery by Caesarean
experience a strong urge to bear down. Only section is most likely indicated A careful
one fifth or less of the fetal head or no fetal examination of the patient must be done
head will be palpable above the brim of the for cephalopelvic disproportion which may
pelvis at this time be present as a result of a big fetus or an
abnormal presentation of the fetal head.
A patient should only start bearing down when
the fetal head distends the perineum and she has
a strong urge to bear down.
3. THE SECOND STAGE OF LABOUR 75
4-8 In what position should 4-9 How would you get the best
the patient be delivered? maternal co-operation during
the second stage of labour?
1. The patient is usually delivered on her
back (i.e. the dorsal position) because it is 1. Good communication between the
easier for the person managing the delivery. patient and the midwife or doctor is
However, this position has the disadvantage very important. A relationship of trust
that it may cause postural hypotension developed during the first stage of labour
which may result in fetal distress. This will encourage good communication and
problem can be avoided if a firm pillow is co-operation during the second stage.
placed under one of the patient’s hips so 2. The patient must know what is expected
that she is turned 15 degrees onto her side of her during the second stage. The person
and does not lie flat on her back. conducting the delivery should encourage
2. The lateral position (i.e. on her side) and support the patient and inform her
prevents the problem of postural about the progress. Good co-operation and
hypotension. In addition, the person attempts at bearing down should be praised.
conducting the delivery has a good view
of the vulva and perineum, the pelvic 4-10 How should you ensure that a patient
muscles are relaxed, and the delivery can bears down as effectively as possible?
be better controlled. The lateral position
is particularly useful when the patient will 1. While the patient is passive in the first
not give her full co-operation. stage, she must actively use her strength
3. The upright position (i.e. vertical or during the second stage of labour to
squatting position) is becoming more assist the uterine contractions. The more
frequently used. The patient sits on her heels effectively she uses her strength, the
and supports herself on outstretched arms. shorter the second stage will be.
This position has the following advantages: 2. The midwife or doctor must make sure
• The maternal effort becomes more that the patient knows when and how to
effective. bear down.
• The duration of the second stage is 3. It is important that she rests between
shortened. contractions and bears down during
• Fewer patients need an assisted contractions.
delivery. 4. At the height of the contraction, the
4. The semi-Fowler’s position, where the patient is asked to take a deep breath, to
patient’s back is lifted to 45 degrees from put her chin on her chest, and to bear
the horizontal, may be used instead of down as if she were going to empty her
the upright position. This partial sitting rectum. This action is most effective and
position is comfortable both for the patient easiest if the patient holds onto her legs or
and the person conducting the delivery. some other firm object.
5. Each bearing down effort should last
The position used during the second stage of as long as possible. This is better than a
labour depends on the patient’s choice and number of short efforts.
the circumstances under which the delivery is 6. When the patient needs to breathe while
conducted. The position chosen should allow pushing, she must quickly breathe out, take
for the best maternal effort at bearing down. a deep breath and bear down again.
7. With multigravidas, it is sometimes
necessary for the patient to breathe rather
than push during a contraction to prevent
the fetal head from delivering too quickly.
4. 76 INTRAPAR TUM CARE
bearing down, a doctor must assess the
Good communication between the patient
patient for a possible assisted delivery.
and the person conducting the delivery is very 2. If a primigravida has inadequate
important during labour. uterine contractions and there are no
signs of cephalopelvic disproportion
4-11 What observations must be made (i.e. 2+ moulding or less), an oxytocin
during the second stage of labour? infusion should be started. When strong
contractions are obtained the patient must
If the head is still not engaged and it is decided start bearing down.
to wait for engagement, the same observations 3. If there is no progress in the descent
usually made during the first stage of labour of the head and signs of cephalopelvic
should be continued. disproportion are present (i.e. 3+
If the head is engaged and the patient is asked moulding), the patient should not bear
to bear down, the following observations down. Instead she should concentrate
must be done: on her breathing during contractions. A
Caesarean section is indicated.
1. Listen to the fetal heart between
contractions to determine the baseline fetal
heart rate. With strong contractions and good bearing down
2. Listen to the fetal heart immediately after there should be progress in the descent of the
each contraction. If the fetal heart rate presenting part onto the perineum.
remains the same as that of the baseline
rate, you are reassured that the fetus is in
good condition. However, if the fetal heart 4-14 How should you manage fetal
is slower at the end of the contraction, distress in the second stage of labour?
and the slow heart rate takes more than 1. An episiotomy should be done, if the fetal
30 seconds to return to the baseline rate head distends the perineum when the
(i.e. a late deceleration), the fetus must be patient bears down, so that the fetus can be
delivered as rapidly as possible because delivered with the next contraction.
fetal distress has developed. 2. If the perineum does not bulge with
3. Observe the frequency and duration of the contractions and it appears as if the fetus
uterine contractions. will not be delivered after the next two
4. Look for any vaginal bleeding. efforts at bearing down, then:
5. Record the progress of labour. • Assess and proceed with an
assisted delivery if there are no
4-12 How is progress monitored contraindications.
in the second stage of labour? • Otherwise an emergency Caesarean
section must be performed. While
With every uterine contraction and bearing
preparing the patient, intra-uterine
down effort there should be some progress in
resuscitation must be done.
the descent of the fetal head onto the perineum.
4-15 How should a normal vaginal
4-13 What should be done if there
delivery be managed?
is no progress in the descent of
the head onto the perineum? The midwife or doctor managing the
delivery must always be prepared for possible
1. If the patient has at least two contractions
complications. Equipment which may be
in 10 minutes, each lasting 40 seconds
required must be at hand and in good working
or more and there is no progress in the
order. Drugs which may be needed must be
descent of the head after four attempts at
easily available.
5. THE SECOND STAGE OF LABOUR 77
1. Emptying the bladder: Any factor, such EPISIOTOMY
as a full bladder, that prevents descent of
the fetal head or decreases the strength of
uterine contractions should be corrected. 4-16 What is the place of an
Therefore, it is very important for the episiotomy in modern midwifery?
patient to empty her bladder before
starting to bear down. An episiotomy is not done routinely but only if
2. Supporting the perineum: A swab should be there is a good indication, such as:
placed over the patient’s anus to prevent the 1. When the infant needs to be delivered
vulva, and later the fetal head, being soiled without delay:
with stool (i.e. faeces). It is important to • Fetal distress during the second stage
support the perineum in order to: of labour.
• Increase flexion of the fetal head so that • Maternal exhaustion.
the smallest possible diameter passes • A prolonged second stage of labour
through the vagina. This can be done by when the fetal head bulges the
pressing immediately above the anus. perineum and it is obvious that an
• Relieve the pressure on the perineum. episiotomy will hasten the delivery.
Remember that the perineum must be • When a quick and easy second stage
in view all the time. is needed, e.g. in a patient with heart
3. Crowning of the head: When the head is valve disease.
crowning the vaginal outlet is stretched 2. When there is a high risk of a third degree
and an episiotomy may be indicated. The tear:
midwife or doctor should place one hand • A thick, tight perineum.
on the vertex to prevent sudden delivery of • A previous third degree tear.
the head. The other hand, supporting the • A repaired rectocoele.
perineum, is now moved upwards to help 3. When a breech or forceps delivery is done.
extend the head. It is important that the fetal
head is only controlled and not held back. 4-17 Does a second degree
4. Feeling for a cord: Check that the umbilical tear heal faster and with fewer
cord is not wrapped tightly around the complications than an episiotomy?
infant’s neck. A loose cord can be slipped
over the head but a tight cord should be Yes. A second degree tear is easier to
clamped and cut. repair and heals quicker with less pain and
5. Delivering of the shoulders and body: With discomfort than an episiotomy. Therefore,
gentle continuous posterior traction on a second degree tear is preferable to an
the head and lateral flexion, the anterior episiotomy. A episiotomy should not be done
shoulder is delivered from under the routinely in primigravidas.
symphysis pubis. The posterior shoulder is
then lifted over the perineum. The rest of An episiotomy should only be done if there is a
the infant’s body is now delivered, following
definite indication.
the curve of the birth canal and not by
simply pulling it straight out of the vagina.
4-18 Which type of episiotomy
should be done?
Usually a mediolateral episiotomy is done.
However, if the midwife or doctor has
experience with the technique, a median
episiotomy can be done.
6. 78 INTRAPAR TUM CARE
PROLONGED SECOND 4-21 How should a patient with
prolonged second stage of labour
STAGE OF LABOUR be managed during transfer to a
hospital for Caesarean section?
4-19 What is the definition of a 1. The patient should lie on her side and not
prolonged second stage of labour? bear down with contractions. Instead, she
should concentrate on her breathing.
1. When diagnosing a prolonged second stage 2. An intravenous infusion should be
the time is usually measured from the start started and two ampoules (5 μg each)
of bearing down. of hexoprenaline (Ipradol) given slowly
2. If a primigravida bears down for more than intravenously or three nifedipine
45 minutes, or a multigravida for more (Adalat) 10 mg capsules (30 mg in total)
than 30 minutes, without the infant being given by mouth, provided there are no
delivered, a prolonged second stage of contraindications.
labour is diagnosed. 3. If there are any signs of fetal distress the
3. The most senior clinician available should patient should be given oxygen by face
be notified and called to help. mask.
The second stage of labour is prolonged if it lasts 4-22 What factors indicate that a
longer than 45 minutes in a primigravida or 30 patient is at an increased risk of a
minutes in a multigravida. prolonged second stage of labour?
1. Factors during the antenatal period which
4-20 How should you manage a patient suggest that the patient will deliver a large
with a prolonged second stage of labour? infant:
• A patient with a symphysis-fundus
1. Usually an assisted delivery is done height measurement above the 90th
once cephalopelvic disproportion has centile, when multiple pregnancy and
been excluded and 1/5 or no fetal head polyhydramnios have been excluded,
remains palpable above the pelvic brim. i.e. there appears to be a large fetus.
A Caesarean section should be done if • Any patient with a symphysis-fundus
cephalopelvic disproportion is present. height of 40 cm or more may have a
2. If a doctor is not available, the patient fetus of 4 kg or more. Very few with a
should be referred to a level 1 or 2 symphysis fundus measurement of less
hospital with facilities to perform a than 40 cm will have a term infant of
Caesarean section. 4 kg or more.
• A patient with diabetes mellitus.
Prolonged second stage of labour is a dangerous • A patient who weighs more than 85 kg.
complication which requires immediate and • A patient with a previous infant
weighing 4 kg or more at birth.
appropriate management.
2. Factors during the first stage of labour:
• An estimated fetal weight, assessed
on abdominal examination, of 4 kg or
more.
• A patient with poor progress in the
first stage of labour before eventually
reaching full cervical dilatation.
• A patient who progressed normally
during the active phase of the first stage
7. THE SECOND STAGE OF LABOUR 79
of labour, but whose progress was slower must give the midwife or doctor her full
from 7 or 8 cm until full dilatation. co-operation.
2. The patient should be moved so that her
buttocks are over the edge of the bed to
Slow progress in the first stage of labour may be allow good downward traction on the
followed by a prolonged second stage of labour. fetal head. This can be done rapidly by
removing the end of the bed or by turning
the patient across the bed.
MANAGEMENT OF 3. The patient’s hips and knees must be fully
flexed so that her knees almost touch
IMPACTED SHOULDERS her shoulders. The midwife or doctor
must hold the infant’s head between both
hands and firmly pull the head down
4-23 Which patients are at high risk of
(posteriorly) while an assistant must at
developing impacted shoulders?
the same time press firmly just above the
The same patients who are at high risk of a patient’s symphysis pubis. The amount
prolonged second stage of labour are also at of downward traction applied should be
high risk for impacted shoulders (shoulder gradually increased until a reasonable
dystocia), i.e. women who probably have a amount of traction is used. This reduces the
large infant. risk of a brachial plexus injury as opposed
to traction applied as a jerk. The suprapubic
4-24 What signs during the second pressure must be firm enough to allow
stage of labour indicate that the the assistant’s hand to pass behind the
shoulders are impacted? symphysis pubis. This procedure helps to get
the infant’s anterior shoulder to pass under
1. Normally the infant’s head is delivered the symphysis pubis. The patient must bear
by extension. However, with impacted down as strongly as possible during these
shoulders the head is held back, does attempts to deliver the shoulders.
not distend the perineum and does not This procedure to deliver impacted
undergo the normal rotation. shoulders is called the MacRobert’s method.
2. The size of the infant’s head and cheeks at 1. If the infant is not delivered after two
delivery indicate that the infant is big and attempts, you should deliver the posterior
fat. Usually the patient is also fat. shoulder:
3. Attempts at external rotation, lateral • The midwife or doctor should place a
flexion and traction fail to deliver the right hand (if right-handed) or a left
shoulders. hand (if left-handed) posterior to the
The earlier these signs of impacted shoulders fetus in the vagina to reach the infant’s
are recognised, the better is the chance that shoulder. The cavity of the sacrum is
this complication will be successfully managed. the only area which provides space for
manipulation.
4-25 How should a patient with • The posterior arm of the infant should
impacted shoulders be managed? be followed until the elbow is reached.
The arm must be flexed at the elbow
The following management should be carefully and then pulled anteriorly over the
followed in a step-by-step manner: chest and out of the vagina. Delivery
1. The patient must be told that a serious of the posterior arm also delivers the
complication has developed and that she posterior shoulder.
8. 80 INTRAPAR TUM CARE
• The anterior shoulder can now be suctioned. If necessary hold the shoulders
freed by pulling the infant’s head down back until the airways have been cleared.
(posteriorly). Always suction the mouth first before
• If the anterior shoulder cannot be clearing the nose.
released, the infant must be rotated 2. With clear liquor: Suctioning the infant’s
through 180 degrees. During the airways is not necessary before delivering
rotation the infant’s head and freed the shoulders. After delivery suctioning is
arm should be firmly held. The freed only needed if the infant does not breathe
arm will indicate the direction of the well.
rotation, i.e. turn the infant so that the
shoulder follows the freed arm. Once 4-27 What is the immediate management
the anterior shoulder has been rotated of the infant after a vaginal delivery?
into the hollow of the sacrum, the
trapped shoulder can be released by Dry the infant very well and assess whether
inserting a hand posteriorly, flexing the the infant cries or breathes well. If the
arm at the elbow and pulling the arm infant breathes well, leave the infant on the
out of the vagina. mother’s abdomen and only clamp and cut the
umbilical cord after two to three minutes. If
The rules of delivering impacted shoulders the infant does not breathe well, clamp and cut
must be followed carefully without panicking. the cord immediately and move the infant to a
If the infant is delivered within five minutes of convenient place for resuscitation.
detecting the complication, no brain damage
should occur. While the above management
helps to reduce the risk of birth injury, fracture CASE STUDY 1
of the clavicle or humerus may occur with
delivery of the posterior shoulder. This is
A multiparous patient presents in labour at
preferable to an Erb’s palsy (brachial plexus
18:00. The fetal head is palpable 3/5 above
injury). Time should not be wasted trying
the pelvic brim and the cervix is found to
other methods which are not effective. The
be 7 cm dilated. The vaginal examination is
management of impacted shoulders should
repeated at 21:00 when the alert line indicates
regularly be practised on mannequins.
that the cervix should be fully dilated. The
examination confirms that the cervix is
Impaction of the shoulders is a serious fully dilated. However, the fetal head is still
complication and requires fast and effective not engaged. Preparations are made for the
management according to a clear plan. patient to start bearing down.
1. Do you agree that the patient should
MANAGING THE start bearing down now that she has
reached full dilatation of the cervix?
NEWBORN INFANT No. She should not start bearing down until
the fetal head is engaged and has reached the
perineum.
4-26 Should you suction the
infant’s airways at delivery?
2. What symptoms and signs would
1. With meconium-stained liquor: Once indicate to you that the patient
the infant’s head has been delivered, do should start bearing down?
not carry on with the delivery until the
infant’s mouth and throat have been well The patient will have an uncontrollable urge to
bear down. In addition the fetal head will be
9. THE SECOND STAGE OF LABOUR 81
engaged on abdominal examination and the palpable above the pelvic brim while 3+
fetal head will distend the perineum when the moulding is found on vaginal examination.
patient bears down. The patient wants to bear down with
contractions.
3. If the abdominal examination
shows that the fetal head is not 1. What complications would you expect
engaged what conditions must be when you consider the patient’s progress
met when deciding to wait before during the first stage of labour?
allowing the patient to bear down?
A prolonged second stage of labour as the
Fetal distress must be excluded by making patient’s progress in labour was slower than
sure that there are no late fetal heart rate expected between 7 cm and full dilatation.
decelerations. Cephalopelvic disproportion
must also be excluded by finding 2+ moulding 2. What would be the most likely cause of
or less on vaginal examination. a prolonged second stage in this patient?
Cephalopelvic disproportion as indicated by
4. How long is it safe to wait for
an unengaged fetal head and 3+ moulding.
the fetal head to engage?
The patient should be examined again after 3. Do you agree with the decision
an hour. If the head is still not engaged, you to allow the patient to bear down
can wait for a further hour provided that because she is fully dilated?
there are still no signs of either cephalopelvic
disproportion or fetal distress. Thereafter, No. As the patient has cephalopelvic
the patient must be evaluated for an assisted disproportion, a Caesarean section must be
delivery. If the conditions for an assisted performed.
delivery cannot be met, a Caesarean section
must be done. 4. How should this patient be managed
further if she is at a clinic?
5. Would you manage a primigravid She must be referred to a hospital with
patient in the same way as a muligravida facilities to perform a Caesarean section.
if she reached full cervical dilatation
without engagement of the fetal head? 5. What arrangements must be
Usually primigravidas only reach full made to make the transfer of this
cervical dilatation after the fetal head patient as safe as possible?
has engaged. Therefore, there is a greater The patient must lie on her side and an
chance of cephalopelvic disproportion in intravenous infusion must be started. If there
a primigravida than in a multigravida who are no contraindications, the contractions
may reach full cervical dilatation with an must be stopped with intravenous
unengaged fetal head. hexoprenaline (Ipradol) or oral nifedipine
(Adalat). If there is any concern about the
condition of the fetus, the patient must be
CASE STUDY 2 given face mask oxygen.
A patient who progressed normally during
the first stage of labour until a cervical
dilatation of 7 cm reaches full dilatation of
the cervix after a further five hours. At the
last examination 3/5 of the fetal head is still
10. 82 INTRAPAR TUM CARE
CASE STUDY 3 5. How would you have managed this
patient if the prolonged labour was due
to poor co-operation and ineffective
A primigravida patient has still not delivered
attempts at bearing down by the patient?
after her cervix has been fully dilated for
45 minutes. The fetal head is not palpable Good communication between the staff
abdominally and bulges the perineum when and the patient during the first stage of
the patient bears down with contractions. A labour should have established a trusting
prolonged second stage is diagnosed and a relationship. The patient should have been
decision made to proceed with an assisted told exactly what she should do during the
delivery. second stage. She should also have beeen
supported, encouraged and praised.
1. Do you agree with the diagnosis
of prolonged second stage?
This will depend on when the patient started
CASE STUDY 4
to bear down and whether her attempts at
bearing down were effective. The diagnosis is A multigravid patient weighing 110 kg
correct if she has been bearing down well for progresses to full cervical dilatation. After
45 minutes. 30 minutes in the second stage of labour, the
infant’s head is delivered with difficulty. The
head is held back and does not distend the
2. What should your management
perineum while rotation of the head does not
be if the patient has been bearing
occur.
down well for 45 minutes?
As the head is not palpable abdominally and 1. What complication has occurred
is distending the perineum, an episiotomy during the second stage of labour?
should be done. Thereafter, if the infant has
not been delivered after a few contractions Impaction of the shoulders (i.e. shoulder
with the patient bearing down well, the patient dystocia).
must be evaluated for an assisted delivery.
2. How could this complication
3. Should an episiotomy be done at have been predicted?
the delivery of all primigravidas? An overweight patient is at risk for developing
No. Only if there is a definite indication for impacted shoulders as infants born to these
an episiotomy. In this case an episiotomy is patients are often very big.
indicated as the second stage is prolonged and
delivery would probably be rapidly achieved 3. How should this patient
with an episiotomy. be further managed?
The patient’s buttocks must be moved to the
4. The infant is delivered just before an edge of the bed so that good posterior traction
episiotomy is done and after the birth it can be applied to the infant’s head. This can
is noticed that the patient has a second be done quickly if the end of the bed can
degree perineal tear. Would it have been be removed or if the patient can be swung
preferable to have done an episiotomy? around across the bed. The patient’s hips
No. A second degree tear is preferable to an and knees should be flexed so that her knees
episiotomy. A second degree tear is easier to almost reach her shoulders. The infant’s head
repair, heals faster and causes less pain and should be firmly held between both hands
discomfort than an episiotomy. and pulled downwards (posteriorly) while an
11. THE SECOND STAGE OF LABOUR 83
assistant, at the same time, presses down over
the suprapubic area. The amount of downward
traction applied should be gradually increased
until a reasonable amount of traction is used.
4. What should the further management
be if these attempts to deliver the
shoulders are not successful?
An immediate attempt must be made to
deliver the infant’s posterior arm. The person
conducting the delivery must place a hand
posterior to the fetus in the vagina, flex the
infant’s posterior arm at the elbow and pull
it out anteriorly over the chest. When the
arm is pulled out the posterior shoulder will
automatically be delivered as well. The anterior
shoulder can now be released by pulling the
infant’s head downwards.