The document discusses normal labour and delivery, defining it as the spontaneous expulsion of a single, mature fetus between 37-42 weeks of gestation through the birth canal without complications. It describes the stages of labour as first, second and third stage. The first stage involves cervical dilation and effacement in latent and active phases. Contractions increase in frequency and strength during this stage. The second stage begins with full dilation and ends with baby's birth. The third stage involves delivery of the placenta. Factors influencing labour progress like passenger, passage and power are also summarized.

1. NORMAL LABOUR AND DELIVERY Prof Dr MOHD AZHAR MN ROYAL COLLEGE OF MEDICINE PERAK APRIL 2005 DEPARTMENT OF OBST & GYNAE RCMP

2. NORMAL LABOUR AND DELIVERY APRIL 2005 DEPARTMENT OF OBST & GYNAE RCMP Definition of normal labour Factors influencing progress of labour Diagnosis of labour Stages of labour Mechanisms of labour Management of labour CONTENTS

3. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY WHAT IS NORMAL LABOUR ?

4. NORMAL LABOUR APRIL 2005 DEPARTMENT OF OBST & GYNAE RCMP Labour is defined as the onset of regular painful contractions with progressive cervical effacement and dilatation of the cervix accompanied by descent of the presenting part . DEFINITIONS

5. NORMAL LABOUR Spontaneous expulsion, of a single, mature fetus (37 completed weeks – 42 weeks), presented by vertex, through the birth canal (i.e. vaginal delivery), within a reasonable time (not less than 3 hours or more than 18 hours), without complications to the mother, or the fetus The following criteria should be present to call it normal labour Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY

6. NORMAL LABOUR APRIL 2005 DEPARTMENT OF OBST & GYNAE RCMP Understanding the process of labour is importance problems can be identified correctly managed IMPORTANCE

7. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY WHAT FACTORS INFLUENCE PROGRESS OF LABOUR ?

8. LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY FACTORS THAT INFLUENCE PROGRESS OF LABOUR Passenger Passage 3 "P" Power

9. THE NORMAL FEMALE PELVIS Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY The female pelvis provides the basic framework of the birth canal. The obstetric pelvis is divided into false and true pelvis by the pelvic brim or inlet The true pelvis is important, for it is through this confined space that the fetus must pass on its journey through the birth canal. The true pelvis is composed of inlet , cavity and outlet . Types of female pelvis – gynaecoid , anthropoid, android and platypelloid Outlet Cavity Inlet

10. THE NORMAL FEMALE PELVIS Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY The brim is slightly oval transversely. The sacral promontory is not prominent. The transverse diameter is slightly longer than the anteroposterior. The sidewalls are parallel and straight. The ischial spines are not prominent. The sacrosciatic notches are wide. The sacrum has a good curve. The pubic arch angle are wide, i.e. more than 90  Inter tuberous diameter is wide The ideal normal female gynaecoid pelvis :

11. THE NORMAL FEMALE PELVIS Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY The important diameters of the female pelvis : Anteroposterior Oblique Transverse BRIM 11 – 11.5 12 12.5 CAVITY 12 12 12 OUTLET 12.5 12 11- 11.5 Diameters (cm)

12. THE FETAL SKULL Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY Sutures Diameters

13. THE FETAL SKULL Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY Sagittal suture: - The sagittal suture lies between the parietal bones. It runs in an anteroposterior direction between the anterior and posterior fontanelles. Coronal sutures: - The suture uniting the parietal bones to the frontal bones is called the coronal suture. It’s extend transversely from the anterior fontanels and lies between the parietal and frontal bone. Frontal suture: - The frontal suture is between the two frontal bones. It is an anterior continuation of the sagittal suture. Lambdoidal suture: - Is between the parietal and occiptal bones. SUTURES

14. THE FETAL SKULL Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY MOULDING OF THE FETAL SKULL MOULDING ’ is the ability of the fetal head to change its shape and so to adapt itself to the unyielding maternal pelvis during the progress of labour. This property is of the greatest value in the progress of labour.

15. THE FETAL SKULL Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY Diameters of the fetal skull – anterior posterior diameters A B C D E F G AB ~ Suboccipto bregmatic – 9.5 AC ~ Submento bregmatic – 9.5 DE ~ Occipito frontal ~ 11.0 FG ~ Mento vertical – 13.5

16. POWER ► Contractions + Maternal pushing Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY Uterine contractions: Initiate by pacemakers ~ uterotubal junction Contraction waves meet at the fundus Contraction waves progress downward Shortening of muscle fibres Retractions  intra uterine pressure EXPULSION OF THE FETUS Additional force “ maternal pushing”  Intra abdominal pressure

17. UTERINE CONTRACTION Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY NORMAL CONTRACTION Frequency ~ one in every 2 – 3 min with at least 1 minute interval Intensity ~ strong (> 50 mmHg) Duration ~ 45 – 60 sec Uterine contractions

18. LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY WHAT INITIATE LABOUR “ ONSET OF LABOUR”

19. NORMAL LABOUR Hormonal factors 1) Estrogen theory 2) Progesterone withdrawal theory 3) Prostaglandins theory 4) Oxytocin theory 5) Fetal cortisol theory Mechanical factors 1) Uterine distension theory 2) Stretch of the lower uterine segment by the presenting near term Causes of Onset of Labour: Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY - It is unknown but the following theories were postulated:

20. LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY DIAGNOSIS OF LABOUR

21. NORMAL LABOUR AND DELIVERY Painful regular uterine contractions – as evidence by contraction at least one in ten minutes Show – as evidence by mucus mixed with blood Rupture of membranes – as evidence by leaking liquor Progressive shortening and dilatation of the cervix Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” SYMPTOMS AND SIGNS OF LABOUR Before labour begins, women usually notice one or more premonitory, or warnings, signs that labour is about to begin. They are:

22. LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY DESCRIBE THE STAGES OF LABOUR

23. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” STAGES OF LABOUR Labour can be divided into three stages , which are unequal in length. The third stage is that of separation and expulsion of placenta and membranes and also involves the control of bleeding. It begins after the birth of the baby and ends with the expulsion of the placenta and membranes. This is the shortest stage, lasting up to 30 minutes, with an average length of 5 to 10 minutes. There is no difference in duration for nulliparous and parous . The second stage of labour begins with complete dilatation of the cervix and ends with the birth of the baby. The duration is about 1 to 1½ hours in nulliparas and about 30 to 45 minutes in parous women. It begins with the onset of true labour contractions and ends when the cervix is fully dilated (10 cm). Cervical effacement and dilatation occur in the first stage First stage of labour consists of two phases:- latent and active . The first stage of labour is the longest for both nulliparous and parous women. THIRD STAGE SECOND STAGE FIRST STAGE

24. APRIL 2005 DEPARTMENT OF OBST & GYNAE RCMP FIRST STAGE OF LABOUR

25. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” PHASES OF THE FIRST STAGE OF LABOUR Divided into: Latent phase – begins with onset of contracts and ends when cervix is 3 cm dilated and effaced Active phase – begins after the cervix is 3 cm dilated

26. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” PHASES OF THE FIRST STAGE OF LABOUR Active process Begins after 3 cm of cervical dilatation Period of active cervical dilatation (average rate 1 cm/hr) S-shaped curve which is used to define progress of labour It has 3 component a) acceleration - slow b) maximum - fast c) deceleration - slow Begins with onset of contractions Slow progress Little cervical dilatation Progressive cervical effacement Ends once the cervix reaches 3 cm dilatation Durations ~ 8 hours for nulliparae ~ 6 hours for multiparae ACTIVE Phase LATENT Phase

27. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR

28. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR Contractions : CONTRACTIONS 1: Regular 2: Increasing in frequency 3: Stronger

29. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR Cervical dilatation and effacement : Causes of cervical dilatation: Contraction and retraction of uterine musculature Mechanical pressure by the bulging membrane (fore water) The descend of the presenting part Phases of cervical dilatation Latent phase – the first 3 cm of dilatation; a slow process (8 hours in nulliparous and 3 hours in multiparous Active phase – this is active process of cervical dilatation; the normal rate is 1 cm/hour

30. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR Engagement of the presenting part :

31. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” Do Uterine Contractions Affect Fetal Heart Rate? Uterine contractions can affect fetal heart rate by increasing or decreasing that rate in association with any given contraction. The three primary mechanisms by which uterine contractions can cause a decrease in fetal heart rate are compression of: · Fetal head · Umbilical cord · Uterine myometrial vessels FETAL HEART CHANGES

32. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” PROGRESS OF FIRST STAGE OF LABOUR Findings suggestive of satisfactory progress in first stage of labour are: - regular contractions of progressively increasing frequency and duration; rate of cervical dilatation at least 1 cm per hour during the active phase of labour (cervical dilatation on or to the left of alert line); Findings suggestive of unsatisfactory progress in first stage of labour are: - irregular and infrequent contractions after the latent phase; OR rate of cervical dilatation slower than 1 cm per hour during the active phase of labour (cervical dilatation to the right of alert line);

33. APRIL 2005 DEPARTMENT OF OBST & GYNAE RCMP SECOND STAGE OF LABOUR

34. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” SECOND STAGE OF LABOUR Begins with FULL DILATATION and ends with DELIVERY OF THE BABY. It have TWO Phases a) Propulsive phase – from full dilatation until presenting part has descended to the pelvic floor b) Expulsive phase which ends with the delivery of the baby Features of expulsive phase – 1) mother’s irresistible desire to bear down 2) distension of perineum 3) dilatation of the anus Average length a) Primigravidae – 40 minutes b) Multigravidae – 20 minutes

35. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” PROGRESS OF SECOND STAGE OF LABOUR Findings suggestive of satisfactory progress in second stage of labour are: - steady descent of fetus through birth canal; onset of expulsive (pushing) phase. Findings suggestive of unsatisfactory progress in second stage of labour are: - lack of descent of fetus through birth canal; - failure of expulsion during the late (expulsive) phase.

36. APRIL 2005 DEPARTMENT OF OBST & GYNAE RCMP THIRD STAGE OF LABOUR

37. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” THIRD STAGE OF LABOUR Begins after DELIVERY of the baby and ends with DELIVERY OF THE PLACENTA / MEMBRANES. It have TWO Phases a) Separation phase b) Expulsion phase Duration – usually 15 minutes or less (if actively managed). Average blood loss – 150 to 250 ml.

38. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” PHYSIOLOGICAL EFFECTS OF LABOUR Moulding – overlapping of the vault bones Caput succedaneum – it is a soft swelling of the most dependent part of the fetal head ON THE FETUS Blood loss from the placental site (200 ml) Blood loss from laceration and perineum (100 ml) Pulse increases Systolic BP slightly increased due to pain and anxiety Minor injuries to the birth canal Minimal effects ON THE MOTHER THIRD STAGE SECOND STAGE FIRST STAGE

39. MANAGEMENT OF LABOUR

40. NORMAL LABOUR AND DELIVERY To achieve delivery of a normal healthy child To anticipate, recognize and treat potential abnormal conditions before significant hazard develops for the mother or the fetus. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” AIMS IN THE MANAGEMENT OF LABOUR The AIMS include:

41. NORMAL LABOUR AND DELIVERY Diagnosis of labour Monitoring the progress of labour Ensuring maternal well-being Ensuring fetal well-being. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” PRINCIPLES IN THE MANAGEMENT OF LABOUR The principles include:

42. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT FIRST STAGE OF LABOUR

43. NORMAL LABOUR AND DELIVERY On admission : When the women presents at hospital, the woman’s antenatal record is reviewed to discover whether there have been any abnormalities during her pregnancy. When there are no records of antenatal care a complete history must be taken. General examination of the mother a) General conditions – evaluate the mother general health condition. Look for pallor, edema, abdominal scar (LSCS) and maternal height. b) Vital signs – Blood pressure, pulse, respiration and temperature are taken and recorded c) Heart and lungs d) Urine analysis – for protein, sugar and ketones Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE FIRST STAGE OF LABOUR 1

44. NORMAL LABOUR AND DELIVERY Abdominal examination : a) A detailed abdominal examination should be carried out and recorded. b) Determine the presentation and position of the fetus and also the engagement c) Auscultate the fetal heart d) Evaluate the uterine contraction Vaginal examination – the purpose is to a) To make a positive diagnosis of labour b) To make a positive identification of presentation c) To determine whether the fetal head is engaged in case of doubt d) To ascertain whether the fore waters have ruptured or to rupture them artificially e) To exclude cord prolapse after rupture of the fore waters f) To confirm the degree of cervical dilatation and position of the presenting part g) To assess progress of labour. h) To assess the adequacy of the pelvis. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE FIRST STAGE OF LABOUR 2

45. NORMAL LABOUR AND DELIVERY Bowel preparation : If there has been no bowel action for 24 hours or the rectum feels loaded on vaginal examination an enema is given. Bladder care A full bladder may initially prevent the fetal head from entering the pelvic brim and later impede descent of the fetal head. It will also inhibit effective uterine action. The woman should be encouraged to empty her bladder every 1½ - 2 hours during labour. The quantity of urine passed should be measured and recorded and a specimen obtained for testing. Nutrition in early labour No food is permitted after labour is established – to prevent regurgitation and aspiration It is important to maintain adequate hydration - via intravenous routes Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE FIRST STAGE OF LABOUR 3

46. NORMAL LABOUR AND DELIVERY Position of labouring mother : As long as the patient is healthy, the presentation normal, the presenting part engaged, and the fetus in good condition, the patient may walk about or may be in bed, as she wishes Monitoring the progress of labour Once labour has become established, all events during labour should be recorded on a partogram. a) The well-being of the fetus b) The well-being of the mother c) The progress of the labour Pain relief When the pains are severe an analgesic preparation may be given. a) Opiate drugs – e.g. Pethidine given intramuscularly every 4 hour b) Inhalational analgesia – e.g. Entonox c) Epidural analagesia Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE FIRST STAGE OF LABOUR 4

47. NORMAL LABOUR AND DELIVERY Pain in labour The pain experienced by the woman in labour is caused by the: 1): Uterine contractions and uterine ischaemia. 2): Cervical dilatation. Dilatation and stretching of the cervix and lower uterine segment stimulate nerve ganglia and are a major source of pain. 3): Distention of the vagina and perineum. Marked distention of the vagina and perineum occurs with fetal descent, especially during the second stage. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” LABOUR PAIN – causes 1

48. NORMAL LABOUR AND DELIVERY Pain in labour Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” LABOUR PAIN – causes 2 Pain is caused by the passage of the placenta through the cervix, plus that produced by the uterine contractions. THIRD STAGE Pain result from two sources: The stretching of the vagina, vulva and perineum. The contraction of the myometrium. SECOND STAGE Pain is caused mainly by uterine contractions, thinning of the lower segment of the uterus, and dilatation of the cervix. FIRST STAGE SORCES OF PAIN STAGES OF LABOUR Table 1: PAIN DURING THE STAGES OF LABOUR

49. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” PAIN RELIEF IN LABOUR – types Three methods are in common use during labour: Analgesic drugs (narcotics, e.g. pethidine) which are given by intramuscularly injection. Inhalation analgesia (e.g. Entonox). Regional anaesthesia (e.g. epidural, spinal) that blocks the sensory pain pathways.

50. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MONITORING FETAL HEART How Do Uterine Contractions Affect Fetal Heart Rate? Uterine contractions can affect fetal heart rate by increasing or decreasing that rate in association with any given contraction. The three primary mechanisms by which uterine contractions can cause a decrease in fetal heart rate are compression of: · Fetal head · Umbilical cord · Uterine myometrial vessels

51. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MONITORING FETAL HEART How To Monitor The Fetal Heart Rate? Auscultation methods Electronic monitoring ~ CTG

52. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MONITORING FETAL HEART To detect fetal hypoxia NORMAL ABNORMAL

53. APRIL 2005 DEPARTMENT OF OBST & GYNAE RCMP RECORDING THE PROGRESS OF LABOUR

54. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” RECORDING THE PROGRESS OF LABOUR PATIENT INFORMATION FETAL INFORMATION ~ fetal well being LABOUR INFORMATION ~ Dilatation ~ Descent ~ Contraction MEDICATIONS MATERNAL INFORMATION ~ Well being PARTOGRAM

55. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” RECORDING THE PROGRESS OF LABOUR - Partogram Patient information : Fill out name, gravida, para, hospital number, date and time of admission and time of ruptured membranes. Fetal heart rate : Record every half hour. Amniotic fluid : Record the colour of amniotic fluid at every vaginal examination: I: membranes intact; C: membranes ruptured, clear fluid; M: meconium-stained fluid; B: blood-stained fluid. Moulding : 1: sutures apposed; 2: sutures overlapped but reducible; 3: sutures overlapped and not reducible.

56. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” RECORDING THE PROGRESS OF LABOUR - Partogram Cervical dilatation : Assessed at every vaginal examination and marked with a cross ( X ). Begin plotting on the partograph at 3 cm. Station : recorded as a circle ( O ) at every vaginal examination. Contractions : Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds. Less than 20 seconds: Between 20 and 40 seconds: More than 40 seconds: Assess the progress of labour:

57. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” RECORDING THE PROGRESS OF LABOUR - Partogram Oxytocin : Record the amount of oxytocin every 30 minutes when used. Drugs given : Record any additional drugs given – e.g. Pethidine Pulse : Record every 30 minutes and mark with a dot (●). Blood pressure : Record every 4 hours and mark with arrows ( ) Temperature : Record every 2 hours. Protein, acetone and volume: Record every time urine is passed. Progress of maternal well being:

58. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT SECOND STAGE OF LABOUR

59. NORMAL LABOUR AND DELIVERY Maternal position : With the exception of avoiding supine position, the mother may assume any comfortable position for effective bearing down. The semi-recumbent or supported sitting position, with the thighs abducted, is the posture most commonly adopted Bearing down With each contraction, the mother should be encouraged to bear down with expulsive efforts Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE SECOND STAGE OF LABOUR 1 Once the onset of the second stage has been confirmed a woman should not be left without attendance. Accurate observation of progress is vital, for the unexpected can always happen.

60. NORMAL LABOUR AND DELIVERY Observation during the second stage : Four factors determine whether the second stage may be safely continued and these must be carefully monitored throughout the second stage of labour. Maternal conditions Observation includes an appraisal of the mother’s ability to cope emotionally as well as an assessment of her physical wellbeing. A maternal pulse rate is usually recorded quarter-hourly and bloods pressure hourly Fetal conditions - During the second stage, the fetal heart should be monitored either continuously or after each contraction. stage may be associated with fetal distress. The liquor amnii is observed for signs of meconium staining. Uterine contractions - The strength, length and frequency of contractions should be assessed continuously. The progress of descent - The progress should be recorded approximately every 30 minutes during the second stage. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE SECOND STAGE OF LABOUR 2

61. NORMAL LABOUR AND DELIVERY CONDUCTING THE DELIVERY 1 : When delivery is imminent, the patient is usually placed in the dorsal position, and the skin over the lower abdomen, vulva, anus and upper thigh is cleansed with antiseptic solution and draped. DELIVERY OF THE HEAD 1) Control the delivery of the head to prevent laceration 2) Performed episiotomy if requires 3) Performed Ritgen’s method 4) Cleared the airway after delivery of the had Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE SECOND STAGE OF LABOUR 3

62. NORMAL LABOUR AND DELIVERY PERFORMING AN EPISIOTOMY : Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE SECOND STAGE OF LABOUR 3 "..is a surgical incision into the perineum to enlarge the space at the outlet EPISIOTOMY IS EPSIOTOMY REALLY NEEDED? Episiotomies are said to provide the following benefits: Speed up the birth Prevent Tearing Protects against incontinence Protects against pelvic floor relaxation Heals easier than tears medical research has not proven any of these benefits

63. NORMAL LABOUR AND DELIVERY PERFORMING AN EPISIOTOMY : Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE SECOND STAGE OF LABOUR 3 Episiotomies are not always necessary Episiotomy should be considered only in the case of : Complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum); Scarring of the perineum; Fetal distress.

64. NORMAL LABOUR AND DELIVERY PERFORMING AN EPISIOTOMY : Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE SECOND STAGE OF LABOUR 3 Episiotomy Types Midline episiotomy Mediolateral episiotomy J-shaped episiotomy Incision of episiotomy The three major types of episiotomy

65. NORMAL LABOUR AND DELIVERY PERFORMING AN EPISIOTOMY : Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE SECOND STAGE OF LABOUR 3 Infiltrate perineum with local anaesthetic agent Making an incision Wait until: the perineum is thinned out; and 3–4 cm of the baby’s head is visible during a contraction. Performing an episiotomy will cause bleeding. It should not, therefore, be done too early.

66. NORMAL LABOUR AND DELIVERY CONDUCTING THE DELIVERY 2 : DELIVERY OF THE SHOULDERS Delivery of the anterior shoulder is aided by gentle downward traction on the head. The posterior shoulder is delivered by elevating the head. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE SECOND STAGE OF LABOUR 3

67. NORMAL LABOUR AND DELIVERY CONDUCTING THE DELIVERY 3 : DELIVERY OF THE TRUNK After the delivery of the shoulders the baby is grasped around the chest to aid the birth of the trunk. Finally, the body is slowly extracted by traction on the shoulders and lifts the baby towards the mother’s abdomen. The time of delivery is noted. CUTTING THE UMBILICAL CORD After delivery, it is therefore usual to wait 15 to 20 seconds before clamping and cutting the umbilical cord. After cutting the cord a plastic crushing clamp is placed on the cord 1 to 2 cm from the umbilicus and the cord is cut again 1 cm beyond the clamp. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE SECOND STAGE OF LABOUR 3

68. NORMAL LABOUR AND DELIVERY CONDUCTING THE DELIVERY 4 : IMMEDIATE CARE OF THE NEW BORN Once the baby is breathing normally he should be dried and warmly wrapped to prevent cooling and handle to the mother to hold, cuddle and enjoy. If spontaneous respiration is not established soon after birth, resuscitation is the immediate priority. The Apgar’s score of the baby should be noted and recorded. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE SECOND STAGE OF LABOUR 3

69. LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY THE MECHANISMS OF NORMAL LABOUR - Occiput anterior -

70. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” Occiput anterior (OA) Anterior Pubis Sacrum Posterior Right Left Occipital bone

71. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” Occiput anterior positions

72. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MECHANISM OF LABOUR for occiput anterior The “mechanism of labour” refers to the sequencing of events related to posturing and positioning that allows the baby to find the “easiest way out”. For a normal mechanism of labour to occur, both the fetal and maternal factors must be harmonious. DEFINITION:

73. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MECHANISM OF LABOUR for occiput anterior Events of mechanism of labour: F: Flexion and descent I: Internal rotation of the fetal head C: Crowning E: Extension R: Restitution I : Internal rotation of the shoulders E: External rotation of the fetal head L: Lateral flexion of the body

74. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MECHANISM OF LABOUR for occiput anterior (OA) Descend Flexion Internal rotation Crowning Extension Restitution Internal rotation of shoulder External rotation of head Lateral flexion of body LOA LOA OA LOA OA OA LOT Delivery F I C E R I E L

75. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT THIRD STAGE OF LABOUR

76. NORMAL LABOUR AND DELIVERY BIRTH OF THE PLACENTA 1 : Delivery of the placenta occurs in two stages: (1) separation of the placenta from the wall of the uterus and into the lower uterine segment and/or the vagina, and (2) actual expulsion of the placenta out of the birth canal. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE THIRD STAGE OF LABOUR

77. NORMAL LABOUR AND DELIVERY MECHANISM OF PLACENTA SEPARATION 1 : Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” THE THIRD STAGE OF LABOUR Two mechanisms of placental separation occurs: 1- Mathews-Duncan mechanism The leading edge of the placenta separates first and the placenta is delivered with its raw surface exposed. 2- Schultz mechanism If the placenta is inserted at the fundus and central area separates first, the placenta inverts and draws the membranes after it, covering the raw surface (inverted umbrella)

78. LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY WHAT ARE THE SIGNS OF PLACENTA SEPARATION

79. NORMAL LABOUR AND DELIVERY BIRTH OF THE PLACENTA 2 : CLINICAL SIGNS OF PLACENTAL SEPARATION Placental separation takes place within 5 minutes after the delivery of the infant. Signs suggesting that detachment or separation has taken place include: The uterus becomes globular and hard. This sign is the earliest to appear. There is often a sudden gush of blood The uterus rises in the abdomen because the placenta, having separated, passes down into the lower segment and vagina, where its bulk pushes the uterus upward. Cord lengthening . This is the most reliable clinical sign of placental separation. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE THIRD STAGE OF LABOUR

80. NORMAL LABOUR AND DELIVERY BIRTH OF THE PLACENTA 2 : After the placental separation takes place the placenta can be delivered by the: Passive management – wait for spontaneous expulsion of placenta Active management Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE THIRD STAGE OF LABOUR

81. LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR

82. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE THIRD STAGE OF LABOUR ACTIVE MANAGEMENT OF THE THIRD STAGE Active management of the third stage (active delivery of the placenta) helps prevent postpartum haemorrhage . Active management of the third stage of labour includes: ~ use of oxytocin ~ controlled cord traction, and ~ uterine massage .

83. NORMAL LABOUR AND DELIVERY Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE THIRD STAGE OF LABOUR ACTIVE MANAGEMENT OF THE THIRD STAGE ~ Use of oxytocin Oxytocic drugs should be given with the birth of the anterior shoulder. Syntocinon is the most used oxytocic known to be effective; the addition of ergometrine may reduce blood loss. SYNTOMETRINE (oxytocin 5 IU + ergometrine 0.5 mg) – widely used

84. NORMAL LABOUR AND DELIVERY BIRTH OF THE PLACENTA 3 : EXPULSION OF THE PLACENTA BY ACTIVE MANAGEMENT When these signs have appeared the placenta is ready for expression. If the patient is awake, she is asked to bear down while gentle traction is made on the umbilical cord. The popular and effective method of delivering the placenta is by Brandt-Andrews method. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE THIRD STAGE OF LABOUR

85. NORMAL LABOUR AND DELIVERY BIRTH OF THE PLACENTA 4 : BRANDT’S ANDREW METHOD Once the signs of placental separation have occurred the obstetrician assists delivery of the placenta by controlled cord traction as described by Brandt-Andrews’ method. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE THIRD STAGE OF LABOUR A) Placenta separation B) Controlled cord traction C) Delivery of the membranes

86. NORMAL LABOUR AND DELIVERY BIRTH OF THE PLACENTA 5 : EXAMINATION OF THE PLACENTA The placenta, membranes, and umbilical cord should be examined for completeness and for anomalies. EXAMINATION OF THE PERINEUM At the same time, the perineal region, vulva outlet, vaginal canal, and the cervix should be carefully examined for lacerations. If the perineum has been torn or an episiotomy made, tear or incision should be repaired immediately. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE THIRD STAGE OF LABOUR

87. NORMAL LABOUR AND DELIVERY REPAIR OF EPISIOTOMY : Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” MANAGEMENT OF THE THIRD STAGE OF LABOUR Note : It is important that absorbable sutures be used for closure. Continuous sutures Interrupted sutures Interrupted suture or subcuticular Vaginal mucosa Identify apex Begin suturing 1.0 cm above apex Continuous sutures Ends at the level of vaginal opening

88. APRIL 2005 DEPARTMENT OF OBST & GYNAE RCMP MANAGEMENT AFTER DELIVERY

89. NORMAL LABOUR AND DELIVERY EARLY POSTPARTUM MANAGEMENT : The hours immediately following delivery and the birth of the placenta are a critical period as postpartum haemorrhage can occurs due the relaxation of the uterus. The patient is kept in the delivery suite for 1 hour postpartum under close observation. She is check for bleeding, the blood pressure is measured, and the pulse is counted. Before discharging the patient from the delivery suit it is mandatory : To check the uterus frequently to make sure it is firm and not relaxing. To remove any presence of intrauterine blood clots. The presence of these clots will interfere with retraction and the normal haemostatic mechanism of the uterus. To look at the introitus to see that there is no haemorrhage. To keep the bladder empties because full bladder can also interfere with uterine retraction. To examine the baby to be certain that it is breathing well and that the colour and tone are normal. Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY” IMMEDIATE MANAGEMENT AFTER THE DELIVERY

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