Managment of labor for undergraduate

Management of Normal Management of Normal LaborLabor

Management on Management on AdmissionAdmission

Full historyFull history::1-Complete obstetric history.1-Complete obstetric history.

2-History of the present pregnancy.2-History of the present pregnancy.

3-History of the present labor ( e.g.: labor 3-History of the present labor ( e.g.: labor pains, vaginal bleeding, gush of fluid& fetal pains, vaginal bleeding, gush of fluid& fetal movement).movement).

General Examination:General Examination:Vital signs ( pulse , B.P. , temperature,Vital signs ( pulse , B.P. , temperature,

…etc.)…etc.)

2-Abdominal 2-Abdominal examinationexamination

Fundal levelFundal level

Fundal gripFundal grip

Umbilical gripUmbilical grip

Second pelvic gripSecond pelvic grip

PalpationPalpation

AuscultationAuscultation

3-Pelvic examination:3-Pelvic examination:

CervixCervix : dilatation (c.m.), effeacemet (%) , : dilatation (c.m.), effeacemet (%) , position & consistency.position & consistency.

membrane:membrane: intact or ruptured ( if intact or ruptured ( if ruptured exclude cord prolapse).ruptured exclude cord prolapse).

--Amniotic fluidAmniotic fluid ( after R.O.M.): either ( after R.O.M.): either clear , meconium stained or blood stained.clear , meconium stained or blood stained.

-Presenting part -Presenting part , , position ,station & moulding.position ,station & moulding.

--Assessment of pelvic capacity Assessment of pelvic capacity

Cervical dilatationCervical dilatation It is the surest way to assess progress of labourIt is the surest way to assess progress of labour

Assessment of pelvic Assessment of pelvic capacitycapacity

PartographPartograph a graphical record of the a graphical record of the

observations made observations made

of a women in labor of a women in labor

For progress of labor and For progress of labor and conditions of the mother conditions of the mother and and

the fetus the fetus

History Of PartogramHistory Of Partogram Friedman'sFriedman's partogram partogram

latent phase latent phase

Starts from Starts from onset of labour onset of labour until the until the cervix cervix reaches 3 cm dilatationreaches 3 cm dilatation

lasts 8 hours or lesslasts 8 hours or less

Contractions Contractions at least 2/10 min at least 2/10 min contractionscontractions

each lastingeach lasting < < 20 seconds20 seconds

Active phase :Active phase :

The cervix should dilate at a rate of 1 The cervix should dilate at a rate of 1 cm / hour or fastercm / hour or faster

Contractions at least 3 / 10 min each Contractions at least 3 / 10 min each lasting lasting << 40 seconds 40 seconds

Closed cervix vs Closed cervix vs effecedeffeced vs vs dilated Cxdilated Cx

Components of the Components of the partographpartograph

Part 1 : fetal condition Part 1 : fetal condition ( at ( at top )top )

Part 2 : progress of labour Part 2 : progress of labour ( at ( at middle )middle )

Part 3 : maternal condition ( at Part 3 : maternal condition ( at bottom )bottom )

Part 1 : Fetal condition Part 1 : Fetal condition Recording fetal heart Recording fetal heart

raterate

Membranes and liquorMembranes and liquor

Dilated cervix with bag of fore water

I: intactC : clearM : muconiumB : blood stained

Molding the fetal skull Molding the fetal skull bonesbones

. Increasing molding with the head high in the pelvis . Increasing molding with the head high in the pelvis is an ominous sign of Cephalopelvic disproportion.is an ominous sign of Cephalopelvic disproportion.

separated bones . sutures felt easilyseparated bones . sutures felt easily……………….O.O bones just touching each otherbones just touching each other…………………………..+..+ overlapping bones …………… overlapping bones …………… ……………………...++...++ severely overlapping bones ( notable ) severely overlapping bones ( notable ) …………..+++..+++

Part 2 – progress of labourPart 2 – progress of labour . . Cervical dilatation: it is divided into a latent Cervical dilatation: it is divided into a latent

phase and an active phasephase and an active phase Descent of the fetal headDescent of the fetal head Uterine contractions Uterine contractions

Descent of the fetal Descent of the fetal headhead

The rule of fifth BY abdominal The rule of fifth BY abdominal examinationexamination

Assessing descent of the fetal PV;Assessing descent of the fetal PV; 0 station is at the level of the 0 station is at the level of the

ischial spine ischial spine

Engagment Engagment

Normal progress in Normal progress in labor labor

Alert line ( health facility Alert line ( health facility line )line )

The alert line drawn from 3 cm The alert line drawn from 3 cm dilatation represents the rate of dilatation represents the rate of dilatation of 1 cm / hour dilatation of 1 cm / hour

Moving to the right or the alert line Moving to the right or the alert line means referral to hospital for extra means referral to hospital for extra carecare

Action line ( hospital Action line ( hospital line )line )

The action line is drawn 4 hour to the The action line is drawn 4 hour to the right of the alert line and parallel to right of the alert line and parallel to itit

This is the critical line at which This is the critical line at which specific management decisions must specific management decisions must be made at the hospitalbe made at the hospital

When labor goes from latent to active phase , When labor goes from latent to active phase , plotting of the dilatation is immediately plotting of the dilatation is immediately transferred from the latent phase area to the transferred from the latent phase area to the alert linealert line

Normal labor progress Normal labor progress

At At addmision addmision

Then after Then after 4h 4h

Abnormal labor progress Abnormal labor progress

Recording uterine Recording uterine contractioncontraction

PART 3:Recording of PART 3:Recording of maternal conditionmaternal condition

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Management of the Management of the first stagefirst stage

Ambulating and position in Ambulating and position in labor labor

Walking may be more comfortable than Walking may be more comfortable than being supine during early laborbeing supine during early labor

The left lateral position keeps the uterus The left lateral position keeps the uterus off the inferior vena cava; off the inferior vena cava; this prevent this prevent (supine hypotensive syndrome)(supine hypotensive syndrome)

Evaluation of fetal well-Evaluation of fetal well-beingbeing

Measurement of the Measurement of the fetal heart fetal heart raterate

By hand-held Doppler, or By CTGBy hand-held Doppler, or By CTG

Late in first stageLate in first stage patients may report the urge to patients may report the urge to

push.push. This may indicate significant descent This may indicate significant descent

of the fetal head with pressure on of the fetal head with pressure on the perineum.the perineum.

Management of the Management of the second stagesecond stage

Diagnosis of the onset of the Diagnosis of the onset of the 2nd stage2nd stage

Feeling a desire to evacuate the Feeling a desire to evacuate the bladder or rectumbladder or rectum

Reflex desire to bear down during Reflex desire to bear down during contractions. contractions.

The uterine contractions are more The uterine contractions are more prolonged and vigorous. prolonged and vigorous.

Full cervical dilatation Full cervical dilatation

(the surest sign).(the surest sign).

Transport the lady to the Transport the lady to the delivery room.delivery room.

. . (A)Position(A)Position:: - Lithotomy - Lithotomy position or Dorsal position.position or Dorsal position.

((B)Paint vulva & perineumB)Paint vulva & perineum with antiseptic solution.with antiseptic solution.

((C)Apply sterile leggings and C)Apply sterile leggings and towelstowels

((D)Evacuate the bladderD)Evacuate the bladder by by catheter catheter (if not evacuated before)(if not evacuated before)

Litotomy positionVS dorsal Litotomy positionVS dorsal positionposition

F)Ask the lady to bear down F)Ask the lady to bear down during uterine contractions and during uterine contractions and relax in between.relax in between.

J). V oxytocin drip J). V oxytocin drip in glucose in glucose solution 5% solution 5% may be given.may be given.

4)The main task of 4)The main task of the obstetrician is the obstetrician is to prevent perineal to prevent perineal lacerationslacerations, , how?how?

When the labia start toWhen the labia start to

be separated by the head, be separated by the head,

put a sterile dressing on put a sterile dressing on

the perineum the perineum and press on it during and press on it during uterine Contractions.uterine Contractions.

A. Support of the perineum A. Support of the perineum till crowning occurstill crowning occurs

Crowning: Crowning: The B.P.D passes The B.P.D passes through the vulval ring during through the vulval ring during

contraction and the head does not contraction and the head does not recede inbetween uterine recede inbetween uterine

contractionscontractions..

EpisiotomyEpisiotomy

when the perineum is when the perineum is maximally stretched and about maximally stretched and about to tearto tear

Problems arising from Problems arising from EpisiotomyEpisiotomy

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PainPain EdemaEdema BleedingBleeding InfectionInfection Defects in woundDefects in wound

Before Crowning Before Crowning After After

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B. After crowningB. After crowning,, Prevent straining after Prevent straining after

crowning.crowning. Allow gradual and slow extension Allow gradual and slow extension

only inbetween uterine contractions. only inbetween uterine contractions. by doing by doing ""Rtigen maneuver“Rtigen maneuver“

Examine neck for looped umbilical cordExamine neck for looped umbilical cord

.. If a loop of cord is coiled If a loop of cord is coiled

around the neck Try to slip it.around the neck Try to slip it. If several loops, If several loops,

apply double clampingapply double clamping

and cut the cord and cut the cord

inbetween.inbetween.

Support infant’s head as it rotates for Support infant’s head as it rotates for shoulder presentationshoulder presentation

..

Guide infant’s head downward to deliver Guide infant’s head downward to deliver anterior shoulderanterior shoulder

7)Deliver posterior 7)Deliver posterior shoulder first , then the shoulder first , then the

anterior shoulder anterior shoulder when the anterior shoulder appears when the anterior shoulder appears under the pubic arch,the head is under the pubic arch,the head is lifted upwards to deliver the lifted upwards to deliver the posterior shoulder, then downwards posterior shoulder, then downwards to deliver the anterior shoulder.to deliver the anterior shoulder.

The rest of the body The rest of the body usually slips easilyusually slips easily

8)Hold the fetus from its 8)Hold the fetus from its feetfeet

ContraindicationsContraindications

1-Premature baby1-Premature baby

2-Fetal asphyxia2-Fetal asphyxia 3-Suspected presence3-Suspected presence

of intracranial hemorrhage.of intracranial hemorrhage.

9)Milking the cord9)Milking the cord TTowards the fetal umbilicus add l00 cc owards the fetal umbilicus add l00 cc

of blood to fetal circulation of blood to fetal circulation Alternatively, the infant is held about Alternatively, the infant is held about

half minute below the level of the half minute below the level of the vaginal introitus before clamping the vaginal introitus before clamping the cord. cord.

In cases of Rh In cases of Rh incompatibilityincompatibility

The cord should be clamped The cord should be clamped immediately with no milking to immediately with no milking to avoid addition of more bilirubin avoid addition of more bilirubin from destructed R.B.Cs to fetal from destructed R.B.Cs to fetal circulation →more circulation →more hyperbilirubinaemiahyperbilirubinaemia

10)Clamp the cord by 2 10)Clamp the cord by 2 ring forceps and cut ring forceps and cut

inbetweeninbetweenAfter delivery and evaluation of infant, clamp and cut cord

D- D- Management of Management of the 3rd Stage:the 3rd Stage:

Normally the placenta is expelled within 10 minutes, if expelled between 10- 30 minutes (delayed delivery of placenta). If not expelled within 30 minutes (Retained placenta).

Active management of 3Active management of 3rdrd stage stage of labor.of labor.

AA

CONTROLLED CORD TRACTION

Guarding the UterusGuarding the Uterus

Controlled cord tractionControlled cord traction

Delivering the Delivering the MembranesMembranes

Physiological Physiological ManagementManagement

Passive or expectant managementPassive or expectant management No prophylactic No prophylactic oxytocicsoxytocics

Cord clamped afterCord clamped afterdelivery of placentadelivery of placenta

No Controlled Cord Traction (CCTNo Controlled Cord Traction (CCT))

11)Episiotomy repair 11)Episiotomy repair

check placenta and check placenta and membranesmembranes

for completeness for completeness

and normalityand normality

THANK YOUTHANK YOU

Active Management Active Management Of LabourOf Labour

The aim of active The aim of active management of labour is management of labour is

toto ensure that the primigravida will ensure that the primigravida will

deliver a healthy baby in less than deliver a healthy baby in less than 12 hours12 hours

Benefits of Active Benefits of Active Management of LabourManagement of Labour

It avoids prolonged labour which It avoids prolonged labour which can lead to: can lead to:

Maternal distress and emotional Maternal distress and emotional upset.upset.

Fetal hypoxia and distress.Fetal hypoxia and distress.

Exhaustion of the medical and Exhaustion of the medical and nursing staff.nursing staff.

The Principles of Active The Principles of Active Management of LabourManagement of Labour

1-Antenatal education1-Antenatal education ::The mother is informed about the physiology of The mother is informed about the physiology of

labour and assured that labour will take less than labour and assured that labour will take less than 12 hours. In this way, she can cope better with 12 hours. In this way, she can cope better with the stress of labour.the stress of labour.

2-Strict diagnosis of onset of 2-Strict diagnosis of onset of labour.labour.

Onset of regular involuntary Onset of regular involuntary coordinated, painful uterine coordinated, painful uterine contractions associated with cervical contractions associated with cervical effacement and dilatationeffacement and dilatation

3-Regular follow-Up of 3-Regular follow-Up of the Patient during the Patient during

LabourLabour : PV is done on admission to the labor. : PV is done on admission to the labor.

This will be repeated every 1-2 hoursThis will be repeated every 1-2 hours

Examination recoreded in Examination recoreded in partographpartograph

4-Correction of Abnormal 4-Correction of Abnormal ProgressProgress

The rate of cervical dilatation should The rate of cervical dilatation should not be less than 1 cm per hour in the not be less than 1 cm per hour in the active phase of labour. active phase of labour.

If the cervix is not dilating properly, If the cervix is not dilating properly, amniotomy or pitocin dripamniotomy or pitocin drip

Normal vs.Prolonged Normal vs.Prolonged latent phaselatent phase

5-Personal Attention:5-Personal Attention:

one nurse face to face for each one nurse face to face for each patient patient ..

6-Diet6-Diet

Nothing is allowed by mouth.Nothing is allowed by mouth.

7-Provision of suitable 7-Provision of suitable analgesia.analgesia.