Managing normal labor

1. Managing normalManaging normal
labourlabour

2. Managing normal labourManaging normal labour
Normal labourNormal labour –– is spontaneous inis spontaneous in
onset and remaining so throughoutonset and remaining so throughout
labour and delivery; low-risklabour and delivery; low-risk
pregnancy group, the infant is bornpregnancy group, the infant is born inin
the vertex position between 37 andthe vertex position between 37 and
42 completed weeks of pregnancy42 completed weeks of pregnancy;;
after the delivery both birth motherafter the delivery both birth mother
and infant are in good conditionand infant are in good condition..

3. I. Theories of the causes ofI. Theories of the causes of
labor.labor.
1. Prostaglandin release is the most1. Prostaglandin release is the most
important in the spontaneous onset ofimportant in the spontaneous onset of
labor. Prostaglandins are known to causelabor. Prostaglandins are known to cause
the uterine contraction in every form ofthe uterine contraction in every form of
pregnancy. Prostaglandin (Pg)pregnancy. Prostaglandin (Pg)
administered both intravenously andadministered both intravenously and
vaginally induces uterine contraction.vaginally induces uterine contraction.
Estrogens and Calcium are also known asEstrogens and Calcium are also known as
factors increasing prostaglandin synthesis.factors increasing prostaglandin synthesis.

4. 2 Fetal cortisol level2 Fetal cortisol level. It is possible that fetal. It is possible that fetal
cortisol levels and the proper functioning of thecortisol levels and the proper functioning of the
fetal adrenal gland influence the spontaneousfetal adrenal gland influence the spontaneous
onset of labor.onset of labor.
3 Progesterone.3 Progesterone. Increased fetal production ofIncreased fetal production of
dehydroepiandrosterone (DHEAS) and cortisoldehydroepiandrosterone (DHEAS) and cortisol
may inhibit the conversion of fetal pregnenolonemay inhibit the conversion of fetal pregnenolone
to progesterone, thereby altering the estrogento progesterone, thereby altering the estrogen
progesterone ratio.progesterone ratio.
It is probably the alteration in the estrogenIt is probably the alteration in the estrogen
progesterone ratio rather than the fall in theprogesterone ratio rather than the fall in the
absolute concentration of progesterone thatabsolute concentration of progesterone that
influences the spontaneous onset of labor.influences the spontaneous onset of labor.

5. SponsoredSponsored
Medical Lecture Notes –Medical Lecture Notes – All SubjectsAll Subjects
USMLE Exam (America) –USMLE Exam (America) – PracticePractice

6. 4.4. Feto-placental contribution.Feto-placental contribution. It hasIt has
been postulated that due to unknownbeen postulated that due to unknown
factors, fetal pituitary is stimulated prior tofactors, fetal pituitary is stimulated prior to
onset of labor, this results in increasedonset of labor, this results in increased
release of adrenocorticotrophic hormonerelease of adrenocorticotrophic hormone
which stimulates fetal adrenals, thenwhich stimulates fetal adrenals, then
cortisol secretion is increased whichcortisol secretion is increased which
results in accelerated production ofresults in accelerated production of
estrogen and prostaglandin from theestrogen and prostaglandin from the
placenta.placenta.

7. Estrogen is probable to:Estrogen is probable to:
- increase the release of oxytocin from maternal- increase the release of oxytocin from maternal
pituitary;pituitary;
- activate the receptors for oxytocin in the- activate the receptors for oxytocin in the
myometrium and deciduas;myometrium and deciduas;
- accelerate lysosomal disintegration inside the- accelerate lysosomal disintegration inside the
deciduas cells that results in increaseddeciduas cells that results in increased
prostaglandin synthesis;prostaglandin synthesis;
- stimulates synthesis of myometrial contraction- stimulates synthesis of myometrial contraction
with protein-actomyosin through activation ofwith protein-actomyosin through activation of
adenosine triphosphatase; increases theadenosine triphosphatase; increases the
excitability of the myometrial cell membranes.excitability of the myometrial cell membranes.

8. 5. Oxytocin5. Oxytocin It is known that endogenouslyIt is known that endogenously
produced oxytocin plays a role in theproduced oxytocin plays a role in the
spontaneous onset of labor.spontaneous onset of labor.
Oxytocin influences the presence ofOxytocin influences the presence of
oxytocin receptors in the myometrium.oxytocin receptors in the myometrium.
Myometrial contraction depends on itsMyometrial contraction depends on its
own readiness to oxytocin action, and thisown readiness to oxytocin action, and this
readiness depends on the level ofreadiness depends on the level of
estrogen in blood.estrogen in blood.
6. Nervous factors6. Nervous factors..

9. Clinical principles of managingClinical principles of managing
normal labournormal labour::
-- estimate prognosed risk degree forestimate prognosed risk degree for
development of maternal and perinataldevelopment of maternal and perinatal
pathology in order to determine necessarypathology in order to determine necessary
clinical responseclinical response;;
-- determine delivery plan and discuss thedetermine delivery plan and discuss the
suggested plan with the womansuggested plan with the woman;;
-- document maternal and fetal assessment ondocument maternal and fetal assessment on
the partogram in the course of labourthe partogram in the course of labour;;
-- use anaesthesia when it is indicateduse anaesthesia when it is indicated;;
-- assess the newborn’s condition, provideassess the newborn’s condition, provide
routine initial newborn care, encourage earlyroutine initial newborn care, encourage early
breastfeedingbreastfeeding..

10. STAGES OF LABORSTAGES OF LABOR
-- The FirstThe First stage. It starts from the onset of labor painstage. It starts from the onset of labor pain
and ends with full dilatation of the cervix. It is in otherand ends with full dilatation of the cervix. It is in other
words the "cervical stage" of labor.words the "cervical stage" of labor.
Its average duration is about 12 hours.Its average duration is about 12 hours.
-- The Second stageThe Second stage. It starts from the full dilatation of. It starts from the full dilatation of
the cervix (not from the rupture of the membranes) andthe cervix (not from the rupture of the membranes) and
ends with expulsion of the fetus from the birth canal. Itsends with expulsion of the fetus from the birth canal. Its
average duration is 2 hours in primigravidae and 30average duration is 2 hours in primigravidae and 30
minutes in multiparae.minutes in multiparae.
-- The ThirdThe Third stage. It begins after expulsion of thestage. It begins after expulsion of the
fetus and ends with expulsion of the placenta andfetus and ends with expulsion of the placenta and
membranes (afterbirth). Its average duration is about 30membranes (afterbirth). Its average duration is about 30
minutes. The duration however, is reduced to 5 minutesminutes. The duration however, is reduced to 5 minutes
in active management.in active management.

11. Diagnosis and confirmation ofDiagnosis and confirmation of
labourlabour::
-- the woman has intermittent abdominal or back painthe woman has intermittent abdominal or back pain
after 37 weeks gestation with blood-stained mucusafter 37 weeks gestation with blood-stained mucus
discharge or watery vaginal discharge (amniotic fluid)discharge or watery vaginal discharge (amniotic fluid);;
-- there have been birth pangs lasting 15-20 secondsthere have been birth pangs lasting 15-20 seconds
every 10 minutesevery 10 minutes;;
-- cervical effacement and change of placement – thecervical effacement and change of placement – the
progressive shortening and thinning of the cervix.progressive shortening and thinning of the cervix.
Cervical dilatation -Cervical dilatation - the increase in diameter of thethe increase in diameter of the
cervical opening measured in centimetrescervical opening measured in centimetres;;
-- gradual descent of the fetal head towards pelvis minorgradual descent of the fetal head towards pelvis minor
relative to the entrance area to the pelvis minor.relative to the entrance area to the pelvis minor.

12. PrelaborPrelabor (syn: premonitory(syn: premonitory
stage).stage).
This stage may begin two or threeThis stage may begin two or three
weeks before the onset of trueweeks before the onset of true
labor in primigravidae and a fewlabor in primigravidae and a few
days before in multiparae.days before in multiparae.

13. The features are inconsistentThe features are inconsistent
and may comprise the following:and may comprise the following:
1) Lightening: a few weeks prior to the1) Lightening: a few weeks prior to the
onset of labor especially in primigravidaeonset of labor especially in primigravidae
the presenting part sinks into the truethe presenting part sinks into the true
pelvis. It is due to active pulling up ofpelvis. It is due to active pulling up of thethe
lower pole of the uterus around tiielower pole of the uterus around tiie
presenting part.presenting part.
2) Cervical changes: the cervix may2) Cervical changes: the cervix may
become soft, patulousbecome soft, patulous and shortened,and shortened,
specially in primigravidae.specially in primigravidae.

14. 3) Appearance of false pain. False pain has the3) Appearance of false pain. False pain has the
following features:following features:
a) dull in nature and usually confined to the lowera) dull in nature and usually confined to the lower
abdomen and groin;abdomen and groin;
b) continuous and unrelated with contractions ofb) continuous and unrelated with contractions of
the uterus;the uterus;
c) without any effect on dilatation of the cervix;c) without any effect on dilatation of the cervix;
d) usually relieved by enemad) usually relieved by enema and administration ofand administration of
a sedative therapy.a sedative therapy.

15. The First stage of laborThe First stage of labor
The main events tiiat occur in the lThe main events tiiat occur in the l
stage are:stage are:
dilatation and taking up of thedilatation and taking up of the
cervix;cervix;
full formation of the lower uterinefull formation of the lower uterine
segmentsegment..

16. Predisposing factors whichPredisposing factors which
favour smooth dilatation are:favour smooth dilatation are:
softening of the cervix;softening of the cervix;
fibro-musculo-glandular hypertrophy;fibro-musculo-glandular hypertrophy;
increased vascularity;increased vascularity;
accumulation of fluid in betweenaccumulation of fluid in between
collagen fibres.collagen fibres.
These are under the action of hormones:These are under the action of hormones:
estrogen, progesterone and relaxin.estrogen, progesterone and relaxin.

17. The first stage of labor may be dividedThe first stage of labor may be divided
into 3 phases depending on theinto 3 phases depending on the
character of pain:character of pain:
Latent phase.Latent phase. During the latent phase, theDuring the latent phase, the
uterine contractions are typically infrequent,uterine contractions are typically infrequent,
somewhat uncomfortable, and, in some cases,somewhat uncomfortable, and, in some cases,
not very strong, but they generate sufficientnot very strong, but they generate sufficient
force to cause slow dilation and someforce to cause slow dilation and some
effacement of the cervix.effacement of the cervix.
Latent phase of labor begins from the onset ofLatent phase of labor begins from the onset of
regular labor pain to 4 cm opening of the cervix,regular labor pain to 4 cm opening of the cervix,
the duration of which is about 5 hours inthe duration of which is about 5 hours in
multiparaemultiparae and 6,5 hours in primigravidae. Theand 6,5 hours in primigravidae. The
rate of the cervix dilatation is about 0.35 cm/hourrate of the cervix dilatation is about 0.35 cm/hour

18. Active phase.Active phase. This phase follows theThis phase follows the
latent phase and is characterized by alatent phase and is characterized by a
progressive cervical dilation,progressive cervical dilation,
progressive labor pains.progressive labor pains.
The duration is about 1.5 - 3 hours. ItThe duration is about 1.5 - 3 hours. It
takes place from 4 to 8 cm opening oftakes place from 4 to 8 cm opening of
the cervix.the cervix.
The rate of the opening is aboutThe rate of the opening is about
1.5 — 2 cm/h in multiparae1.5 — 2 cm/h in multiparae

19. Slowing down phaseSlowing down phase.. This phase follows theThis phase follows the
second phase and is characterized by somesecond phase and is characterized by some
decreasing of pain intensity.decreasing of pain intensity.
It begins soon after the 8 cm cervix opening tillIt begins soon after the 8 cm cervix opening till
the full opening of the cervix.the full opening of the cervix.
The labor pain begins not too strong andThe labor pain begins not too strong and
intensive, the intervals between the pains areintensive, the intervals between the pains are
rather short.rather short.
For example, the duration of pain is about 45 —For example, the duration of pain is about 45 —
50 sec., and intervals are about 2 – 2,5 min. The50 sec., and intervals are about 2 – 2,5 min. The
duration of this phase is about 1-2 hour, the rateduration of this phase is about 1-2 hour, the rate
of the cervix opening is 1-1,5 cm/h.of the cervix opening is 1-1,5 cm/h.

20. Management of the first stage ofManagement of the first stage of
laborlabor
1.1. Fetal monitoring. Any device shouldFetal monitoring. Any device should
monitor the fetal heart tones immediatelymonitor the fetal heart tones immediately
after the uterine contraction.after the uterine contraction.
One should know that sudden drop to lessOne should know that sudden drop to less
than 120 beats per minute (bpm) orthan 120 beats per minute (bpm) or
increase to above 160 bpm may be anincrease to above 160 bpm may be an
indication of fetal distress.indication of fetal distress.
The normal tones are clear and rhythmic.The normal tones are clear and rhythmic.

21. 2.2. Observing of mother's condition:Observing of mother's condition:
- the pulse rate;- the pulse rate;
- the blood pressure;- the blood pressure;
- the temperature.- the temperature.
3.3. Monitoring of labor pain. Labor painMonitoring of labor pain. Labor pain
should be increasing in character duringshould be increasing in character during
the l phase of labor.the l phase of labor.

22. 4 Observing of the cervix dilatation and4 Observing of the cervix dilatation and
effacement.effacement.
It is necessary to do the vaginalIt is necessary to do the vaginal
examination when the patient is admittedexamination when the patient is admitted
(or with the onset of regular pains), then(or with the onset of regular pains), then
every 4 hours to understand theevery 4 hours to understand the
changing of the cervix.changing of the cervix.
The rupture of the water membrane isThe rupture of the water membrane is
the indication for vaginal examination,the indication for vaginal examination,
too.too.

23. The Second stage of laborThe Second stage of labor
The second stage lasts forThe second stage lasts for
approximately 50 minutes in theapproximately 50 minutes in the
primigravida and approximately 20primigravida and approximately 20
minutes in the multigravida.minutes in the multigravida.
However, the second stage lasting 2However, the second stage lasting 2
hours, especially in the primigravida,hours, especially in the primigravida,
is not uncommon.is not uncommon.

24. The main signs of the secondThe main signs of the second
stage of labor are:stage of labor are:
- Rupture of the bag of membranes with- Rupture of the bag of membranes with
escape of liquor amnii;escape of liquor amnii;
- Increasing intensity of uterine- Increasing intensity of uterine
contractions;contractions;
- Appearing of bearing down efforts;- Appearing of bearing down efforts;
- Complex dilatation of the cervix as- Complex dilatation of the cervix as
evidenced on vaginal examination.evidenced on vaginal examination.

25. Management of the second stageManagement of the second stage
of laborof labor
The main thing is:The main thing is:
To assist in the naturalTo assist in the natural
expulsion of the fetus slowlyexpulsion of the fetus slowly
and steadily.and steadily.
To prevent perineal injuries.To prevent perineal injuries.

26. Manual care during the secondManual care during the second
stage of labourstage of labour
During the second stage of labourDuring the second stage of labour
the woman should be encouragedthe woman should be encouraged
to assume a position comfortableto assume a position comfortable
both for her and for the medicalboth for her and for the medical
staffstaff..

28. Medical supervision and supportiveMedical supervision and supportive
care during labour and childbirthcare during labour and childbirth
In order to perform dynamic and graphicIn order to perform dynamic and graphic
monitoring of the course of labour and themonitoring of the course of labour and the
condition of the woman and fetus, as wellcondition of the woman and fetus, as well
as to prevent possible labouras to prevent possible labour
complications all findings are documentedcomplications all findings are documented
in thein the partogram.partogram.

29. The partogramThe partogram consists of three mainconsists of three main
components which are recorded in 7 tablescomponents which are recorded in 7 tables::
І –І – fetal conditionfetal condition –– heart rateheart rate,, fetal bladder andfetal bladder and
amniotic fluid condition, configuration of the fetalamniotic fluid condition, configuration of the fetal
headhead ((see tablessee tables. 1, 2).. 1, 2).
ІІ -ІІ - labourlabour –– cervix dilatation ratecervix dilatation rate,, descent ofdescent of
fetal headfetal head,, uterine contractionsuterine contractions,, oxytocin dosingoxytocin dosing
regimenregimen ((see tablessee tables 3, 4, 5).3, 4, 5).
ІІІ –ІІІ – maternal conditionmaternal condition –– pulse, arterialpulse, arterial
pressure, temperature, urinalysis (volume,pressure, temperature, urinalysis (volume,
protein, acetone), medicines administeredprotein, acetone), medicines administered
during labourduring labour ((tablestables 6, 7).6, 7).

30. The passport part of the partogramThe passport part of the partogram
contains information about:contains information about:

surname, name and patronymic of thesurname, name and patronymic of the
woman;woman;

number of pregnancies;number of pregnancies;

parity/number of births;parity/number of births;

name of the hospital;name of the hospital;

date and time of admission;date and time of admission;

time of rupture of membranes;time of rupture of membranes;

№№ of labour historyof labour history..

31. І –І – Fetal conditionFetal condition
Heart rateHeart rate
TableTable 11 is used for recordingis used for recording the heart rate ofthe heart rate of
the fetus.the fetus.
The heart rate is measured and recorded in theThe heart rate is measured and recorded in the
partogram every 15 minutes during the 1st stagepartogram every 15 minutes during the 1st stage
of labour; during the 2nd stage of labour theof labour; during the 2nd stage of labour the
heart rate is measured every 5 minutes after aheart rate is measured every 5 minutes after a
birth pang and recorded in the partogram everybirth pang and recorded in the partogram every
15 minutes15 minutes..

33. Amniotic fluid and moulding of the fetal headAmniotic fluid and moulding of the fetal head
TableTable 22 is used for recording the following parametersis used for recording the following parameters::
а)а) integrity of the membranesintegrity of the membranes ((I – intact membranesI – intact membranes))
and the condition of amniotic fluid after rupture of theand the condition of amniotic fluid after rupture of the
membranes:membranes:
- C – clear amniotic fluid;- C – clear amniotic fluid;
- M- M –– meconium-stained fluidmeconium-stained fluid;;
- B- B –– blood-stained fluid.blood-stained fluid.
б)б) moulding of the fetal head:moulding of the fetal head:
-- II degreedegree –– the cranial bones are apposed bythe cranial bones are apposed by
connecting tissue, the cranial sutures are easilyconnecting tissue, the cranial sutures are easily
palpable;palpable;
-- IIII degreedegree –– cranial bones are overlapping, sutures arecranial bones are overlapping, sutures are
not distinguishable;not distinguishable;
-- IIIIII degreedegree –– cranial bones are overlapping, notcranial bones are overlapping, not
apposed, pronounced fetal head mouldingapposed, pronounced fetal head moulding..

34. The moulding degrees are recordedThe moulding degrees are recorded
in the partogram with the followingin the partogram with the following
signs:signs:

I degree - (-);I degree - (-);

II degree – (+);II degree – (+);

III degree – (++).III degree – (++).

35. ІІ –ІІ – The course of labourThe course of labour
Cervix dilatation and descent of the fetalCervix dilatation and descent of the fetal
headhead
TableTable 33 is used for recordingis used for recording:: thethe dynamics of cervix dilatation anddynamics of cervix dilatation and
descent of the fetal head. These are assessed during every vaginaldescent of the fetal head. These are assessed during every vaginal
examination on admission to the maternity department, afterexamination on admission to the maternity department, after
discharge of amniotic fluid or every 4 hours during labourdischarge of amniotic fluid or every 4 hours during labour..
Alert lineAlert line (1)(1) - A line starts at 3 cm of cervical dilatation to the point- A line starts at 3 cm of cervical dilatation to the point
of expected full dilatation at the rate of 1 cm per hour.of expected full dilatation at the rate of 1 cm per hour.
Action lineAction line (2(2)) – Parallel and 4 hours to the right of the alert line.– Parallel and 4 hours to the right of the alert line.
In the course of normal labour the graphical depiction of cervicalIn the course of normal labour the graphical depiction of cervical
dilatation is not plotted to the right of the alert line.dilatation is not plotted to the right of the alert line.
If this happens, the medical personnel should perform criticalIf this happens, the medical personnel should perform critical
assessment of the reason for unsatisfactory rate of cervicalassessment of the reason for unsatisfactory rate of cervical
dilatation and take a decision on treatment of this conditiondilatation and take a decision on treatment of this condition..
When a woman is admitted to the hospital in the active phase of theWhen a woman is admitted to the hospital in the active phase of the
first stage of labour the degree of cervical dilatation is plotted on thefirst stage of labour the degree of cervical dilatation is plotted on the
alert line. Provided the findings indicate satisfactory progress of thealert line. Provided the findings indicate satisfactory progress of the
labour, the cervical dilatation will be plotted on the alert line or to thelabour, the cervical dilatation will be plotted on the alert line or to the
left of it.left of it.
In cases when the latent phase of labour lasts less than 8 hours theIn cases when the latent phase of labour lasts less than 8 hours the
labour depiction is immediately transferred from the latent phase onlabour depiction is immediately transferred from the latent phase on
the alert line in the active phase with a dotted line.the alert line in the active phase with a dotted line.

36. TableTable 4.4. EveryEvery check box corresponds to onecheck box corresponds to one
contractioncontraction.. The contractions are assessedThe contractions are assessed
every hour during the latent phase and every 30every hour during the latent phase and every 30
minutes during the active phaseminutes during the active phase..
The frequency of contractions is measured inThe frequency of contractions is measured in
seconds during ten minutes of observation.seconds during ten minutes of observation.
The duration of contractions is measured fromThe duration of contractions is measured from
the point of onset in the abdominal cavity to thethe point of onset in the abdominal cavity to the
end of contraction.end of contraction.
The duration is measured in seconds, theThe duration is measured in seconds, the
appropriate number of check boxes is shadedappropriate number of check boxes is shaded
correspondingly.correspondingly.

37. TableTable 55 is used to record data in caseis used to record data in case
of augmentation of labourof augmentation of labour..
Every 30 minutes the amount ofEvery 30 minutes the amount of
Oxytocin in drops per minute shouldOxytocin in drops per minute should
be recorded, as well as dosage andbe recorded, as well as dosage and
mode of administration of themode of administration of the
uterotonic agentuterotonic agent..

38. ІІІ –ІІІ – Condition of the womanCondition of the woman
TableTable 66 is used to record findings in case otheris used to record findings in case other
medicines are administeredmedicines are administered..
TableTable 77 is used to record:is used to record:

arterial blood pressure (assessed every 2 hours);arterial blood pressure (assessed every 2 hours);

pulse rate (every 2 hours marked withpulse rate (every 2 hours marked with ●)●);;

body temperaturebody temperature ((marked every 4 hoursmarked every 4 hours));;

urine volumeurine volume ((every 4 hoursevery 4 hours));;

urine protein and acetone (provided there areurine protein and acetone (provided there are
indications)indications)..

40. The Third stage of laborThe Third stage of labor
Management of the third stage of labourManagement of the third stage of labour
Within one minute of delivery of the baby oxytocin 10Within one minute of delivery of the baby oxytocin 10
units IM is administered in order to prevent bleeding.units IM is administered in order to prevent bleeding.
Controlled cord traction is performed if there areControlled cord traction is performed if there are
signs of placental separation from the uterussigns of placental separation from the uterus..
During this process the obstetrician holds theDuring this process the obstetrician holds the
clamped cord and performs controlled cordclamped cord and performs controlled cord
traction with one hand; the other hand is placedtraction with one hand; the other hand is placed
just above the woman’s pubic bone to stabilizejust above the woman’s pubic bone to stabilize
the uterus by applying counter traction in orderthe uterus by applying counter traction in order
to prevent inversion of the uterus.to prevent inversion of the uterus.
If there are no signs of placental separation orIf there are no signs of placental separation or
external bleeding within 30 – 40 seconds ofexternal bleeding within 30 – 40 seconds of
delivery, the placenta and placental fragmentsdelivery, the placenta and placental fragments
are removed manuallyare removed manually..

41. The fundus of the uterus is massaged throughThe fundus of the uterus is massaged through
the woman’s abdomen immediately afterthe woman’s abdomen immediately after
placental separation. After this the woman isplacental separation. After this the woman is
encouraged to empty the bladder. If there areencouraged to empty the bladder. If there are
indications the bladder should be catheterized.indications the bladder should be catheterized.
After placental separation it is necessary toAfter placental separation it is necessary to
ensure that no placental fragments orensure that no placental fragments or
membranes of the urinary bladder remain andmembranes of the urinary bladder remain and
the uterus is contractedthe uterus is contracted..

42. During the early postnatal period theDuring the early postnatal period the
following procedures should befollowing procedures should be
performed:performed:

monitoring the general condition of themonitoring the general condition of the
mother;mother;

uterine activity;uterine activity;

blood discharge rate every 15 minutesblood discharge rate every 15 minutes
during 2 hours after birth in the deliveryduring 2 hours after birth in the delivery
room.room.

43. Central separation (Schults).Central separation (Schults).
Detachment of the placenta from its uterineDetachment of the placenta from its uterine
attachment starts in the centre resulting inattachment starts in the centre resulting in
opening up of few uterine sinuses andopening up of few uterine sinuses and
accumulation of blood behind the placenta (retroaccumulation of blood behind the placenta (retro
placental hematoma).placental hematoma).
With increasing contraction, more and moreWith increasing contraction, more and more
detachment occurs facilitated by weight of thedetachment occurs facilitated by weight of the
placenta and retro placental blood until theplacenta and retro placental blood until the
whole of the placenta gets detached.whole of the placenta gets detached.
There is no any hemorrhage until delivering ofThere is no any hemorrhage until delivering of
the whole placenta.the whole placenta.

44. Marginal separation (Duncan).Marginal separation (Duncan).
Separations starts a the margin, as itSeparations starts a the margin, as it
is mostly unsupported. Withis mostly unsupported. With
progressive uterine contraction, moreprogressive uterine contraction, more
and more areas of the placenta getand more areas of the placenta get
separated.separated.
There is some bleeding during theThere is some bleeding during the
separation of the placenta.separation of the placenta.

45. One should know the volume ofOne should know the volume of
physiological hemorrhage, which takesphysiological hemorrhage, which takes
place in the normal third period. It isplace in the normal third period. It is
about 0.5% of body weight, but not moreabout 0.5% of body weight, but not more
than 400 ml.than 400 ml.
Failure to comply with even one of theseFailure to comply with even one of these
points may result in the baby beingpoints may result in the baby being
threatened with hypothermia, developmentthreatened with hypothermia, development
of hypoglycemia, metabolic acidosis,of hypoglycemia, metabolic acidosis,
infection, respiratory disorders, CNSinfection, respiratory disorders, CNS
affection (hemorrhage, convulsions).affection (hemorrhage, convulsions).

46. Thermal protectionThermal protection..
1) Warm maternity ward1) Warm maternity ward..
The ward should be clean and warm, withoutThe ward should be clean and warm, without
draughts, open windows or air conditioners.draughts, open windows or air conditioners.
The optimal temperature for the mother andThe optimal temperature for the mother and
the newborn isthe newborn is 25-28° С.25-28° С. All the equipmentAll the equipment
for thermal protection of the newborn shouldfor thermal protection of the newborn should
be prepared and warmed up beforehandbe prepared and warmed up beforehand
(blankets, baby’s cap, crawlers, loose jacket,(blankets, baby’s cap, crawlers, loose jacket,
booties, nappies)booties, nappies)..

47. 2) Immediate drying of the newborn2) Immediate drying of the newborn..
Immediately on delivery (before clamping ofImmediately on delivery (before clamping of
the cord) the midwife/obstetrician shouldthe cord) the midwife/obstetrician should
thoroughly wipe the head and the body of thethoroughly wipe the head and the body of the
newborn with sterile, dry, warmed-up blanketnewborn with sterile, dry, warmed-up blanket..
Place the baby on the mother’s abdomen andPlace the baby on the mother’s abdomen and
complete dryingcomplete drying.. Cover the baby’s head with aCover the baby’s head with a
clean hat, put clean booties on the baby andclean hat, put clean booties on the baby and
cover its body with a dry warmed-up blanket.cover its body with a dry warmed-up blanket.

48. 3)Skin to skin contact.3)Skin to skin contact.
This is necessary to prevent heat loss andThis is necessary to prevent heat loss and
facilitates colonization of the baby’s organismfacilitates colonization of the baby’s organism
with maternal florawith maternal flora.. The baby should spendThe baby should spend
two hours in skin-to-skin contact with thetwo hours in skin-to-skin contact with the
mother, after which both mother and the babymother, after which both mother and the baby
should be transferred to the postnatal ward.should be transferred to the postnatal ward.
To monitor thermal protection theTo monitor thermal protection the
temperature of the baby is first measuredtemperature of the baby is first measured
30 minutes following delivery30 minutes following delivery..

49. 4)Breastfeeding4)Breastfeeding..
It is vital to initiate breastfeeding as earlyIt is vital to initiate breastfeeding as early
as possible, within the first hour of theas possible, within the first hour of the
baby’s life, when the baby appearsbaby’s life, when the baby appears
readyready.. It is not advisable to force theIt is not advisable to force the
baby to the breast if there are no signsbaby to the breast if there are no signs
that the baby is readythat the baby is ready..

50. 5)Delayed weighing and bathing5)Delayed weighing and bathing..
Weighing and bathing the baby immediatelyWeighing and bathing the baby immediately
following birth results in heat lossfollowing birth results in heat loss.. AnyAny
meconium or blood should be partially wipedmeconium or blood should be partially wiped
from the baby’s skin after deliveryfrom the baby’s skin after delivery.. TheThe
remaining vernix caseosa must not be removed.remaining vernix caseosa must not be removed.
It is recommendable to give the baby its firstIt is recommendable to give the baby its first
bath at homebath at home..
The weighing and anthropometry should beThe weighing and anthropometry should be
performed after skin-to-skin contact beforeperformed after skin-to-skin contact before
transferring the mother and the newborn to thetransferring the mother and the newborn to the
postnatal wardpostnatal ward..

51. 6) Correct dressing and swaddling of6) Correct dressing and swaddling of
the babythe baby..
Tight swaddling is harmful for theTight swaddling is harmful for the
newborn, as it reduces efficiency of heatnewborn, as it reduces efficiency of heat
maintenance by the baby, restrictsmaintenance by the baby, restricts
respiratory and muscular movements ofrespiratory and muscular movements of
the babythe baby.. For this reason the baby shouldFor this reason the baby should
be dressed in clean warm crawlers, abe dressed in clean warm crawlers, a
loose jacket, a cap and booties, andloose jacket, a cap and booties, and
covered with a warm blanketcovered with a warm blanket..

52. 7)Twenty-four-hour rooming-in7)Twenty-four-hour rooming-in..
Provided there are no contraindicationsProvided there are no contraindications
the newborn should constantly be with itsthe newborn should constantly be with its
mothermother.. Staying together ensures theStaying together ensures the
baby is breastfed on demand, preventsbaby is breastfed on demand, prevents
hypothermia and hospital-acquiredhypothermia and hospital-acquired
infectioninfection..

53. 8) Thermal protection during8) Thermal protection during
transferringtransferring..
In case it is necessary to transfer theIn case it is necessary to transfer the
baby to another department the medicalbaby to another department the medical
personnel must maintain the bodypersonnel must maintain the body
temperature and constantly monitor it intemperature and constantly monitor it in
order to prevent hypothermiaorder to prevent hypothermia..
In case of cesarean delivery the newbornIn case of cesarean delivery the newborn
is covered with a warm blanket andis covered with a warm blanket and
transported in a couveuse.transported in a couveuse.

54. 9)Thermal protection during9)Thermal protection during
resuscitationresuscitation..
Newborns with asphyxia are not able toNewborns with asphyxia are not able to
generate sufficient amount of heat, whichgenerate sufficient amount of heat, which
increases the risk of hypothermiaincreases the risk of hypothermia.. For thisFor this
reason it is necessary to ensure thatreason it is necessary to ensure that
resuscitation activities are performed inresuscitation activities are performed in
warm conditions.warm conditions.

55. 10)Further training and professional10)Further training and professional
developmentdevelopment..
All medical personnel must have relevantAll medical personnel must have relevant
qualifications and skills to provide thermalqualifications and skills to provide thermal
protectionprotection.. The family members should beThe family members should be
informed about the necessity to maintaininformed about the necessity to maintain
normal body temperature of the babynormal body temperature of the baby..

56. Assessment of the newborn’s conditionAssessment of the newborn’s condition
on deliveryon delivery,, routine initial newborn care,routine initial newborn care,
and early breastfeedingand early breastfeeding
1. The umbilical cord is clamped and cut within1. The umbilical cord is clamped and cut within
one minute. If it is necessary the mucus isone minute. If it is necessary the mucus is
removed from the oral cavity with a rubber bulbremoved from the oral cavity with a rubber bulb
or an electric suction pump.or an electric suction pump.
2. The condition of the newborn according to the2. The condition of the newborn according to the
Apgar score is assessed on the 1st and the 5thApgar score is assessed on the 1st and the 5th
minute on deliveryminute on delivery..
3. In order to prevent ophtalmia 0.5%3. In order to prevent ophtalmia 0.5%
erythromycin ointment or 1% tetracyclineerythromycin ointment or 1% tetracycline
ointment are administered to all newborns withinointment are administered to all newborns within
1 hour after delivery in accordance with the1 hour after delivery in accordance with the
instructions.instructions.

57. Labour pain relief by consent ofLabour pain relief by consent of
the woman.the woman.
If the pregnant woman is suffering from painful birthIf the pregnant woman is suffering from painful birth
pangs or contractionspangs or contractions::
-- ensure that the woman receives psychological andensure that the woman receives psychological and
emotional supportemotional support;;
-- encourage the woman to change position (Fig.1)encourage the woman to change position (Fig.1);;
- encourage the woman to move about freely;- encourage the woman to move about freely;
- suggest that the birth partner massage the woman’s- suggest that the birth partner massage the woman’s
back, hold her hand and wipe her with a wet sponge inback, hold her hand and wipe her with a wet sponge in
the intervals between pangsthe intervals between pangs;;
- encourage the woman to apply special breathing- encourage the woman to apply special breathing
techniques (breathe in deeply, breathe out slowly) – intechniques (breathe in deeply, breathe out slowly) – in
most cases these techniques relieve feelings of painmost cases these techniques relieve feelings of pain;;
- it is acceptable to use music, aromatherapeutic- it is acceptable to use music, aromatherapeutic
essences and other non-invasive, non pharmacologicalessences and other non-invasive, non pharmacological
methods of pain relief (shower, bath, massage)methods of pain relief (shower, bath, massage)..

58. NoninhalationNoninhalation (systemic) and inhalation(systemic) and inhalation
anesthetic agents and regional anesthesiaanesthetic agents and regional anesthesia
may be used for pain reliefmay be used for pain relief..
During physiological labour systemicDuring physiological labour systemic
analgetics, opioid alkaloids (when cervixanalgetics, opioid alkaloids (when cervix
dilatation is not more than 5-6cm),dilatation is not more than 5-6cm),
phenothiazine derivatives and analgeticsphenothiazine derivatives and analgetics
of other groups are used for this purposeof other groups are used for this purpose..