Normal labor and delivery is defined as the spontaneous expulsion of a single, mature fetus through the birth canal within 3-18 hours without complications to the mother or fetus. Labor involves 3 stages - the first stage is cervical dilation, the second stage is baby's descent and birth, and the third stage involves delivery of the placenta. Uterine contractions increase in frequency and strength during the first stage to dilate the cervix by 1 cm per hour. The fetal head engages and descends through the birth canal during the second stage before birth. The third stage sees delivery of the placenta within 30 minutes.
It is a composite graphical recording of cervical dilatation and descent of head against duration of labour in hours.
It also gives information about fetal and maternal condition that are all recorded on single sheet of paper.
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.
It is a composite graphical recording of cervical dilatation and descent of head against duration of labour in hours.
It also gives information about fetal and maternal condition that are all recorded on single sheet of paper.
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 second stage of labor begins when the cervix is completely dilated (open), and ends with the birth of your baby. Contractions push the baby down the birth canal, and you may feel intense pressure, similar to an urge to have a bowel movement. Your health care provider may ask you to push with each contraction.
The second stage of labor begins when the cervix is completely dilated (open), and ends with the birth of your baby. Contractions push the baby down the birth canal, and you may feel intense pressure, similar to an urge to have a bowel movement. Your health care provider may ask you to push with each contraction.
a detail study on normal labour ( definition, stages of labour, management ,p...martinshaji
The World Health Organization (WHO) defines normal birth as follows: The birth is spontaneous in onset and low risk at the start of labor and remains so throughout labor and delivery. The infant is born spontaneously in the vertex position between 37 and 42 weeks of pregnancy. this is study on detailed study on physiology and stages of normal labour .
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physiology of labor includes the contraction and retraction of the muscles of uterus. I hope this presentation will help the persons of concerned subject.
This presentation contains :-
1.Introduction of normal labour
2. Definiation of normal labour
3.Criteria of normal labour
4. Physiology of normal labour
5. Pathophysiology of labor
6.Estrogen
7. Prostaglandin
8. Oxytocin
9. True labor and false labor difference
10. Uterine contraction in labor
11. Stages of labour
12. Management of 1 st stage
13. management of 2 nd stage
14. mamagement of 3 rd stage of labor
15. Cervix dilation
16. Friedman's curve
17. Fetal skull
18. Diameter of fetal skull
19. Sutures in fetal head
20. Moulding
21. Mechanism of labour
Normal Labour & Nursing Management of First stage of LabourNeha Parmar
Definition of normal labor, Terminology , events of labour, causes of labour, signs , stages of labour , signs and symptoms of labour, diagnosis in first stage of labour, Partograph, difference between true labour and false labour ,nursing management of first stage of labour.
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.
Consolidated guidelines on
the Use of Antiretroviral
Drugs for Treating and
Preventing HIV Infection
Summary of key features and recommendations
JUNE 2013
Ureteric injury in Gyenec Surgery, Serious complication of gynecologic surgery
Significant morbidity and long-term sequelae
Uncommon in benign gynecologic surgery
Vaginal hysterectomy has the lowest rate of ureteral injury
Laparoscopic hysterectomy has the highestThe ureters are the muscular ,thick walled narrow tubes(Right and Left)
Each measures 25-30 cm in length and extends from renal pelvis to its entry in the bladder.The ureter are located retroperitonealy and run from the renal pelvic to urinary bladder.
First part –Enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel and run downwards along with greater sciatic notch & reaches ischial spine.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
2. CONTENTS
1. Definition of normal labour
2. Factors influencing progress of labour
3. Diagnosis of labour
4. Stages of labour
5. Mechanisms of labour
6. Management of labour
3. LABOUR
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
4. 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
7. THE NORMAL FEMALE PELVIS
1. The female pelvis provides the basic
framework of the birth canal.
2. The obstetric pelvis is divided into false and
true pelvis by the pelvic brim or inlet
3. The true pelvis is important, for it is
through this confined space that the fetus
must pass on its journey through the birth
canal.
4. The true pelvis is composed of inlet, cavity
and outlet.
5. Types of female pelvis – gynaecoid,
anthropoid, android and platypelloid
Outlet
Cavity
Inlet
8. NORMAL FEMALE PELVIS
1. The brim is slightly oval transversely.
2. The sacral promontory is not prominent.
3. The transverse diameter is slightly longer than
the anteroposterior.
4. The sidewalls are parallel and straight.
5. The ischial spines are not prominent.
6. The sacrosciatic notches are wide.
7. The sacrum has a good curve.
8. The pubic arch angle are wide, i.e. more than 90
9. Inter tuberous diameter is wide
The ideal normal female gynaecoid pelvis:
9. THE NORMAL FEMALE PELVIS
The important diameters of the female pelvis:
Anteroposterior Oblique Transverse
BRIM 11 12 13
CAVITY 12 12 12
OUTLET 13 12 11
Diameters
(cm)
11. THE FETAL SKULL
1. Sagittal suture: - The sagittal suture lies
between the parietal bones. It runs in an
anteroposterior direction between the anterior
and posterior fontanelles.
2. 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.
3. Frontal suture: - The frontal suture is between
the two frontal bones. It is an anterior
continuation of the sagittal suture.
4. Lambdoidal suture: - Is between the parietal
and occiptal bones.
SUTURES
12. THE FETAL SKULL
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.
13. THE FETAL SKULL
Diameters of the fetal skull – anterior posterior diameters
A
B
C
D
E
F
G AB ~ Suboccipto bregmatic – 9.5
-Vertex
AC ~ Submento bregmatic – 9.5
-Face
DE ~ Occipito frontal ~ 11-12
FG ~ Mento vertical – 13.5
-Brow
14. POWER ► Contractions + Maternal
pushing
Uterine contractions:
1. Initiate by pacemakers ~ uterotubal junction
2. Contraction waves meet at the fundus
3. Contraction waves progress downward
Shortening of muscle fibres
Retractions
intra uterine pressure
EXPULSION OF THE FETUS
Additional force
“maternal pushing”
Intra abdominal pressure
15. UTERINE CONTRACTION
NORMAL CONTRACTION
1. Frequency ~ one in every 2 – 3 min with at least 1
minute interval
2. Intensity ~ strong (> 50 mmHg)
3. Duration ~ 45 – 60 sec
Uterine contractions
17. 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:
- It is unknown but the following theories were postulated:
22. 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
SYMPTOMS AND SIGNS OF LA
Before labour begins, women usually notice one or more premonitory, or
warnings, signs that labour is about to begin.
They are:
24. NORMAL LABOUR AND DELIVERY
STAGES OF LABOUR
FIRST STAGE SECOND
STAGE
THIRD STAGE
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.
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.
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.
Labour can be divided into three stages, which are unequal in length.
26. NORMAL LABOUR AND DELIVERY
PHASES OF THE FIRST STAGE OF LABOU
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
27. NORMAL LABOUR AND DELIVERY
PHASES OF THE FIRST STAGE OF LABOU
LATENT Phase ACTIVE Phase
1. Begins with onset of contractions
2. Slow progress
3. Little cervical dilatation
4. Progressive cervical effacement
5. Ends once the cervix reaches 3
cm dilatation
6. Durations
~ 8 hours for nulliparae
~ 6 hours for multiparae
1. Active process
2. Begins after 3 cm of cervical
dilatation
3. Period of active cervical
dilatation (average rate 1 cm/hr)
4. S-shaped curve which is used to
define progress of labour
5. It has 3 component
a) acceleration - slow
b) maximum - fast
c) deceleration - slow
28. NORMAL LABOUR AND DELIVERY
WHAT HAPPEN DURING
THE FIRST STAGE OF LABOUR
29. NORMAL LABOUR AND DELIVERY
WHAT HAPPEN DURING THE FIRST STAG
1. Contractions:
CONTRACTIONS
1: Regular
2: Increasing in frequency
3: Stronger
30. NORMAL LABOUR AND DELIVERY
WHAT HAPPEN DURING THE FIRST STAG
2. 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
31. NORMAL LABOUR AND DELIVERY
WHAT HAPPEN DURING THE FIRST STAG
3. Engagement of the presenting part:
32. NORMAL LABOUR AND 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
33. NORMAL LABOUR AND 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);
35. NORMAL LABOUR AND DELIVERY
SECOND STAGE OF LABOUR
1. Begins with FULL DILATATION and ends with DELIVERY OF
THE BABY.
2. 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
3. Average length
a) Primigravidae – 40 minutes
b) Multigravidae – 20 minutes
36. NORMAL LABOUR AND 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.
38. NORMAL LABOUR AND DELIVERY
THIRD STAGE OF LABOUR
1. Begins after DELIVERY of the baby and ends with DELIVERY
OF THE PLACENTA / MEMBRANES.
2. It have TWO Phases
a) Separation phase
b) Expulsion phase
3. Duration – usually 15 minutes or less (if actively managed).
4. Average blood loss – 150 to 250 ml.
39. NORMAL LABOUR AND DELIVERY
PHYSIOLOGICAL EFFECTS OF LABOU
FIRST STAGE SECOND STAGE THIRD STAGE
ON THE MOTHER
1. Minimal effects 1. Pulse increases
2. Systolic BP
slightly
increased due
to pain and
anxiety
3. Minor injuries
to the birth
canal
1. Blood loss from
the placental site
(200 ml)
2. Blood loss from
laceration and
perineum (100
ml)
ON THE FETUS
1. Moulding – overlapping of the vault bones
2. Caput succedaneum – it is a soft swelling of the most dependent
part of the
fetal head
41. AIMS IN THE MANAGEMENT OF LABOUR
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.
42. PRINCIPLES IN THE MANAGEMENT OF LABOUR
Diagnosis of labour
Monitoring the progress of labour
Ensuring maternal well-being
Ensuring fetal well-being.
44. MANAGEMENT OF THE FIRST STAGE OF LABOUR1
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
45. MANAGEMENT OF THE FIRST STAGE OF LABOUR2
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.
46. MANAGEMENT OF THE FIRST STAGE OF LABOUR3
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
47. MANAGEMENT OF THE FIRST STAGE OF LABOUR4
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
48. 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.
LABOUR PAIN – causes1
49. NORMAL LABOUR AND DELIVERY
Pain in labour
LABOUR PAIN – causes2
Table 1: PAIN DURING THE STAGES OF LABOUR
STAGES OF LABOUR SORCES OF PAIN
FIRST STAGE
Pain is caused mainly by uterine contractions, thinning of the lower
segment of the uterus, and dilatation of the cervix.
SECOND STAGE
Pain result from two sources:
1.The stretching of the vagina, vulva and perineum.
2.The contraction of the myometrium.
THIRD STAGE
Pain is caused by the passage of the placenta through the cervix, plus that
produced by the uterine contractions.
50. NORMAL LABOUR AND DELIVERY
PAIN RELIEF IN LABOUR – types
Three methods are in common use during labour:
1. Analgesic drugs (narcotics, e.g. pethidine)
which are given by intramuscularly injection.
2. Inhalation analgesia (e.g. Entonox).
3. Regional anaesthesia (e.g. epidural, spinal)
that blocks the sensory pain pathways.
51. NORMAL LABOUR AND 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
52. NORMAL LABOUR AND DELIVERY
MONITORING FETAL HEART
How To Monitor The Fetal Heart Rate?
Auscultation methods
Electronic monitoring ~ CTG
53. NORMAL LABOUR AND DELIVERY
MONITORING FETAL HEART
To detect fetal hypoxia
NORMAL
ABNORMAL
55. NORMAL LABOUR AND DELIVERY
RECORDING THE PROGRESS OF LABOUR
PATIENT INFORMATION
FETAL INFORMATION
~ fetal well being
LABOUR INFORMATION
~ Dilatation
~ Descent
~ Contraction
MEDICATIONS
MATERNAL INFORMATION
~ Well being
56. NORMAL LABOUR AND 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.
57. NORMAL LABOUR AND 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:
58. NORMAL LABOUR AND 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:
60. MANAGEMENT OF THE SECOND STAGE OF LABOUR1
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
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.
61. MANAGEMENT OF THE SECOND STAGE OF LABOUR2
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.
1. 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
2. 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.
3. Uterine contractions - The strength, length and frequency of contractions should
be assessed continuously.
4. The progress of descent - The progress should be recorded approximately every
30 minutes during the second stage.
62. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
CONDUCTING THE DELIVERY1:
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
63. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
PERFORMING AN EPISIOTOMY:
"..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:
1. Speed up the birth
2. Prevent Tearing
3. Protects against incontinence
4. Protects against pelvic floor relaxation
5. Heals easier than tears
medical research has not proven
any of these benefits
64. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
PERFORMING AN EPISIOTOMY:
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.
65. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
PERFORMING AN EPISIOTOMY:
Episiotomy Types
Midline episiotomy Mediolateral episiotomy J-shaped episiotomy
Incision of episiotomy
The three major types of
episiotomy
66. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
PERFORMING AN EPISIOTOMY:
Infiltrate perineum with
local anaesthetic agent
Making an incision
Wait until:
1) the perineum is thinned
out;
and
2) 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.
67. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
CONDUCTING THE DELIVERY2:
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.
68. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
CONDUCTING THE DELIVERY3:
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.
69. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
CONDUCTING THE DELIVERY4:
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.
73. NORMAL LABOUR AND DELIVERY
MECHANISM OF LABOUR for occiput ante
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:
74. NORMAL LABOUR AND DELIVERY
MECHANISM OF LABOUR for occiput anter
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
75. NORMAL LABOUR AND 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
77. MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA1:
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.
78. THE THIRD STAGE OF LABOUR
MECHANISM OF PLACENTA SEPARATION1:
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)
80. MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA2:
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:
1. The uterus becomes globular and hard. This sign is the earliest to appear.
2. There is often a sudden gush of blood
3. 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
4. Cord lengthening. This is the most reliable clinical sign
of placental separation.
81. MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA2:
After the placental separation takes place the
placenta can be delivered by the:
1. Passive management – wait for spontaneous
expulsion of placenta
2. Active management
83. 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.
84. 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
85. MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA3:
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.
86. MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA4:
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.
A) Placenta separation B) Controlled cord traction C) Delivery of the membranes
87. MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA5:
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.
88. MANAGEMENT OF THE THIRD STAGE OF LABOUR
REPAIR OF EPISIOTOMY:
Note: It is important that absorbable sutures be used for closure.
Continuous sutures Interrupted sutures Interrupted suture or
subcuticular
Vaginal mucosa
1. Identify apex
2. Begin suturing
1.0 cm above apex
3. Continuous sutures
4. Ends at the level of
vaginal opening
90. IMMEDIATE MANAGEMENT AFTER THE
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.