Management of labor stages

Management of 1st ,2nd and 3rd stages of

labor

DR. Ahmed Walid Anwar Morad Assistant Professor of OBS&GYN

FACULTY OF MEDECINE BENHA UNIVERISITY

2014

Normal LaborNormal Labor

Process by which …… Process by which …… regular regular

uterine contractionsuterine contractions —›—›

progressive progressive effacement and effacement and

dilatationdilatation of the cervix of the cervix —›—› delivery delivery

of theof the fetus fetus and the and the placentaplacenta at or at or

beyond age of fetal viability.beyond age of fetal viability.

1 LNMP 24 W 28 W 37 W 40W 42W

PTL

Term Labour

Labour can occur at:Labour can occur at:

prolongedprolonged

Stages of laborStages of labor Stage Stage 11stst 22ndnd 33rdrd 44thth

Onset Onset Onset of Onset of true true uterine uterine contractiocontractionsns

Full cx Full cx dilatationdilatation

Fetal Fetal expulsionexpulsion

Placental Placental deliverydelivery

End End Full cx Full cx dilatationdilatation

Fetal Fetal expulsionexpulsion

Placental Placental deliverydelivery

2h 2h observatioobservations for ns for PPHge PPHge and any and any complicaticomplicationsons

Time Time oPG =12-14 PG =12-14 hhoMG = 6-8 hMG = 6-8 h

oPG = 1-2 hPG = 1-2 hoMG = ½- 1 MG = ½- 1 hh

PG &MG PG &MG = 10-30 = 10-30 minmin

Management of stages of labor

How to deal

Diagnosis

Preparations

Monitoring

Procedures

Management of the Management of the First Stage of LabourFirst Stage of Labour

Diagnosis Diagnosis {{made within one hour of admission}made within one hour of admission}A.A. symptoms:symptoms:1.1. True labour painsTrue labour pains – colicky pain in the abdomen and – colicky pain in the abdomen and

back are characterized byback are characterized by:: charactercharacter True labour painTrue labour pain False labour painFalse labour pain

contractionscontractions regularregular IrregularIrregular

Interval between Interval between contractions and contractions and intensityintensity

Progressive Progressive (increase in (increase in

frequency and frequency and intensity)intensity)

Short duration, not Short duration, not progressiveprogressive

Changes in the Changes in the cervixcervix

Associated with Associated with effacement and effacement and dilation of the dilation of the

cervixcervix

Not associated with Not associated with effacement and effacement and

dilation of the cervixdilation of the cervix

Membranes Membranes Associated with Associated with bulging of bulging of

membranesmembranes

Not associated with Not associated with bulging of bulging of

membranesmembranes

Response to Response to analgesiaanalgesia

Not relieved by Not relieved by sedation sedation

Relieved by sedationRelieved by sedation

Labour Labour Followed by labourFollowed by labour Not followed by labourNot followed by labour

Patient preparations:Patient preparations:

Full Full historyhistory and clinical and clinical examinationexamination

PositionPosition: Encourage any non-: Encourage any non-supine position and movement supine position and movement throughout labor and childbirth.throughout labor and childbirth.

DietDiet:: nothing by mouth, IV fluid, or nothing by mouth, IV fluid, or light diet but fat ,proteins are not light diet but fat ,proteins are not allowed at all.allowed at all.

IV lineIV line : recommended. : recommended.

Patient preparations:Patient preparations:

Rectum:Rectum: no evidence that routine no evidence that routine enema is beneficial .enema is beneficial .

BladderBladder: : – Encouraged patient to empty her bladder Encouraged patient to empty her bladder

regularly. regularly. – Urinary catheter only when woman is Urinary catheter only when woman is

unable to void. unable to void. Pain Control: Pain Control: antenatal women education antenatal women education

about pain relief techniques- epidural anesthesia about pain relief techniques- epidural anesthesia ―› satisfaction.―› satisfaction.

2.2. Show – blood stained mucous.Show – blood stained mucous.

3.3. SROMSROM

B.B. Signs:Signs:o palpable or recorded uterine palpable or recorded uterine

contractioncontractiono effacement and dilation of the cervixeffacement and dilation of the cervixo formation of forewater formation of forewater

What is a partogram

(partograph) ?

PARTOGRAMPARTOGRAM

Def:Def: diagrammatic record of the diagrammatic record of the

events of labour.events of labour.

Advantages:Advantages:

– MonitoringMonitoring the progress of labour, the progress of labour, maternal and fetal wellbeing maternal and fetal wellbeing

– Early detectionEarly detection and management of and management of

labour abnormalities.labour abnormalities.

Fetal Fetal

cervicalcervical

Descent Descent

Uterine Uterine

MaternaMaternal l

Timing observations of different parameters of partogram in the the1st stage of labor

Parameter

Ideal

in both phases

)hrs(

Minimum acceptable

Latent phase

Active phase

Vaginal examination 4 8 4Descent of head 4 8 4Contractions ½ 4 2Fetal heart beats ½ 4 1Temperature, PR, BP, urine 4 4 4

Phases of cervical dilatationPhases of cervical dilatation

The alert line: The alert line: DrawnDrawn from 3 cm dilatationfrom 3 cm dilatation ( at rate of dilatation ( at rate of dilatation

of 1 cm / hour).of 1 cm / hour).

Represents the rate of dilatation of the slowest 10 % of Represents the rate of dilatation of the slowest 10 % of

labours in primigravidae. labours in primigravidae.

Crossing the alert lineCrossing the alert line suggests that the patient should be suggests that the patient should be

transferred to a hospital for extra care. transferred to a hospital for extra care.

The action lineThe action line : : parallel and 2 (4) hours to the right of the alert line; parallel and 2 (4) hours to the right of the alert line;

crossing the action linecrossing the action line suggests the need for intervention suggests the need for intervention

(eg, artificial rupture of the membranes, administration of (eg, artificial rupture of the membranes, administration of

oxytocics.oxytocics.

Vaginal examination:Vaginal examination: single individual to minimize single individual to minimize

interobserver variationsinterobserver variations

Indications:Indications:

On admission On admission

At one to four hour intervals in the At one to four hour intervals in the first stage first stage

At At rupture of membranesrupture of membranes to evaluate for cord prolapse to evaluate for cord prolapse

Feeling the Feeling the urge to pushurge to push to determine whether the to determine whether the

cervix is fully dilated cervix is fully dilated

If the If the FHRFHR falls, to evaluate for conditions such as cord falls, to evaluate for conditions such as cord

prolapse or uterine rupture. prolapse or uterine rupture.

Vaginal examination:Vaginal examination:

Disadvantages:Disadvantages:

– Increases woman’s anxiety.Increases woman’s anxiety.

– Increasing numbers vaginal examinations in Increasing numbers vaginal examinations in

(PROM) increases neonatal sepsis (PROM) increases neonatal sepsis

Effacement and dilation of the cervixEffacement and dilation of the cervix

Assessing descent of the fetal head by Assessing descent of the fetal head by vaginal examination;vaginal examination;

0 station is at the level of the ischial 0 station is at the level of the ischial

spine (Sp). spine (Sp). 

Palpate number of contraction in ten minutes and duration of each contraction in

seconds

• Less than 20 seconds: 

• Between 20 and 40 seconds:

• More than 40 seconds:

Fetal heart rateFetal heart rate   Intermittent auscultation of the fetal heartIntermittent auscultation of the fetal heart ( for low ( for low

risk patients): after a contraction should occur for at risk patients): after a contraction should occur for at

least 1 minute, at least every 15 minutes.least 1 minute, at least every 15 minutes.

– Method : Doppler ultrasound or Pinard stethoscope.Method : Doppler ultrasound or Pinard stethoscope.

Continuous intrapartum FHR monitoringContinuous intrapartum FHR monitoring for : for :

((External and InternalExternal and Internal))

– High-risk patients ,High-risk patients ,

– When FHR below 110 or over 160 BPMWhen FHR below 110 or over 160 BPM

Active management of Active management of laborlabor

AmniotomyAmniotomy

Oxytocin Oxytocin

administrationadministration

for dilation rates for dilation rates

of <1 cm/hourof <1 cm/hour

Management of second stage

of labour

Onset of second stageOnset of second stage

Full cervical dilatation (sure) Full cervical dilatation (sure)

Involuntary Bearing downInvoluntary Bearing down

The urge to defecate and urinate.The urge to defecate and urinate.

Contractions becomes more prolonged.Contractions becomes more prolonged.

Expiratory grunting with expulsive efforts.Expiratory grunting with expulsive efforts.

Rupture of membranes (suggestive)Rupture of membranes (suggestive)

Position: Position: Patient is put in dorsal Lithotomy position and Patient is put in dorsal Lithotomy position and the legs are half-flexed the legs are half-flexed

Patient is properly Patient is properly draped draped AsepsisAsepsis: : DietDiet Bladder and rectumBladder and rectum Pain reliefPain relief Patient is asked to take Patient is asked to take deep breathdeep breath & breath held then & breath held then

exerts downward pressure at the time of uterine exerts downward pressure at the time of uterine contraction and relax in betweencontraction and relax in between

Preparation for deliveryPreparation for delivery

Fetal heart rate monitoringFetal heart rate monitoring

Low risk:Low risk: every 15 min every 15 min High risk:High risk: every 5 min every 5 min

Slowing of the FHR may occur due to Slowing of the FHR may occur due to fetal head compressionfetal head compression

Obstetrical roleObstetrical role Bearing down only during contraction.Bearing down only during contraction. Delivery of the headDelivery of the head

– Crowning Crowning – The main role of obstetrician is the The main role of obstetrician is the

prevention of perineal tearsprevention of perineal tears Before crowningBefore crowning After crowningAfter crowning) ) Ritgen maneuver )Ritgen maneuver ) EpisiotomyEpisiotomy

– Once head delivered clear upper air way. Once head delivered clear upper air way.

Ritgen maneuverRitgen maneuver

Posterior shoulderPosterior shoulderAnterior shoulderAnterior shoulderDelivery of shoulderDelivery of shoulder

The rest of the body almost always follows the shoulder The rest of the body almost always follows the shoulder

without difficultywithout difficulty

Management of third stage of

labour

aimed at:

1-Complete delivery of the after birth

(placenta and membranes).

2-Prevention of acute inversion of the

uterus.

3-prevention of postpartum

haemorrhage

Management of third stage of labour

a-Conservative method:

•The left hand is placed just above the fundus to detect any

change in the fundal level, shape and consistency of the

uterus which indicate atony.

• Wait for signs of placental separation and decent,

•Massage uterus to contract

•The patient is asked to bear down to deliver the placenta

spontaneously.

• Ergometrine 0.5mg or Syntometrine(5 units syntocinon +

0.5mg Ergometrine) to be given intravenouslly.

Delivery of the placenta and membranes: uterus should be examined for the presence of second baby

Signs of separation and decent of the

placenta:

1. -The body of the uterus becomes smaller, harder, and

globular.

2. -The fundal level rises in the abdomen because the

lower segment becomes distended by the placenta.

3. -Suprapubic bulge may appear due to presence of the

placenta in the lower segment.

4. -Elongation of the cord out side the vulva.

5. -Sudden gush of blood from the vagina.

b-Active methods (prophylaxis against postpartum haemorrhage)

1-Give Methargine 0.5 mg IM or Syntometrine (5units

oxytocin+0.5mg Methargine), at the time of the anterior

shoulder is free from symphysis pubis or as soon as possible

thereafter.

2-Deliver the placenta and membranes by control cord traction by

right hand, and the left hand is placed on the suprapubic

region, pushing the uterus upwards.

N.B. USE SYNTOCINON RATHER THAN METHARGINE

IN CARDIAC AND HYPERTENSIVE CASES.

Controlled Controlled

cord tractioncord traction Delivery of Delivery of the placentathe placenta

IV-Post Delivery:

1-examine the placenta for their completeness,

anomalies, length, and number of vessels in the

cord and record the placental weight.

2-Suture the episiotomy or any laceration.

3-Estimate blood loss, count swabs, and take cord

blood for Hb, blood group, Rh, bilirubin, and

coomb’s test for Rh negative mother.

IV-Post Delivery:

4-Check BP, P, T, Lochia and firmness of the uterus

before transferring the patient.

5-Continue an infusion of syntocinon through the first

hour if necessary.

6-Allow no food during the first hour, sips of water

may be taken, encourage nursing.

Seven Cardinal Seven Cardinal MovementsMovements

EngagementEngagement– descent of BPD to a level below the plane of descent of BPD to a level below the plane of

the pelvic inletthe pelvic inlet

DescentDescent FlexionFlexion Internal rotationInternal rotation ExtensionExtension RestitutionRestitution External rotationExternal rotation ExpulsionExpulsion

InductionInduction

Assess adequacy of pelvis and Assess adequacy of pelvis and cervical examcervical exam

Bishop scoreBishop score

Bishop score Bishop score

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