Management of

normal labour

Prof. Aboubakr Elnashar Benha university Hospital, Egypt

elnashar53@hotmail.com ABOUBAKR ELNASHAR

Contents Introduction Definitions

Mechanism

Aims

Principles

1st stage

2nd stage

3rd stage

4th stage

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Definitions Labour:

Regular involuntary coordinated, painful uterine contractions associated with cervical effacement and dilatation

• Regular frequent uterine contractions

+ • Cx changes (dilatation & effacement)

or • SROM

Delivery:

Expulsion of the product of the conception after fetal viability.

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Anterior

Pubis

Right Left

Occipital bone

MECHANISMS OF NORMAL LABOUR

Occiput anterior

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Occiputo anterior positions

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D: Descent

F: Flexion

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

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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

D

F

I

C

E

R

I

E

L

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Cardinal movements of Labor

Cardinal movements of labour (LOA)

Head is delivered

by Extension Restitution

External rotation

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CROWNING OF THE HEAD

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Head is delivered by EXTENSION

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RESTITUTION

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EXTERNAL ROTATION

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• Delivery of a normal healthy child

• To anticipate, recognize and treat potential abnormal conditions before significant hazard develops for the mother or the fetus.

AIMS

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• Diagnosis of labour

• Monitoring the progress of labour • Ensuring maternal well-being • Ensuring fetal well-being.

PRINCIPLES

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MANAGEMENT 1st STAGE

OF LABOUR

I. Assessment

II. Preparation and care

III. Partogram

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I. Assessment 1. History: 1. Woman’s antenatal record is reviewed

2. No records of antenatal care: complete history .

2. Examination

a. General a) Pallor, edema, abdominal scar (LSCS)

b) Vital signs: BP, pulse, RR and T

c) Heart and lungs

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b. Abdominal examination:

a. Presentation and position and engagement

b. Auscultate the fetal heart

c. Evaluate the uterine contraction

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c. Vaginal examination –

i) PP:

Presentation

Engagement, station

Position

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ii) Membranes

Intact or absent: exclude cord prolapse after ROM

iii) Cx

Consistency, position

Dilatation

Effacement,

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iv) Pelvis Adequacy.

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Do not do vaginal examination:

vaginal bleeding before the placenta previa is

excluded.

Sterile speculum examination:

suspected ROM, if the woman is not in labour.

Admission to labour ward:

Active labour:

Regular painful contractions and

cervical dilatation 3 cm

{less time in the labor ward

less intrapartum oxytocics

less analgesia} ABOUBAKR ELNASHAR

3. Investigation Urine: Protein Sugar ketones Blood: CBC RBS Grouping cross match for high risk patients.

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II. Preparation and care 1. Bowel preparation:

Indicated:

No bowel action for 24 h or

Rectum feels loaded on vaginal examination

similar length of labor and most maternal and

neonatal outcomes

generates discomfort in women

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2. Bladder care Encourage to empty bladder /1½ - 2 h. {A full bladder: prevent the fetal head from entering the pelvic brim impede descent of the fetal head. inhibit effective uterine action}. The quantity of urine should be measured and recorded

and a specimen obtained for testing.

3. Nutrition No food is permitted after labour is established {prevent regurgitation and aspiration} Small amount of clear fluid or frozen pineapple, Ice chips

to moisten the mouth

Maintain adequate hydration via intravenous routes

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4. Perineal shaving

No

{is associated with similar maternal febrile

morbidity, wound infection, and neonatal

infection compared with just selective clipping of

hair}

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Routine early ARM

Not recommended

{decrease duration of labor( 60 min, mostly

because of shorter 1st stage),

decrease use of oxytocin,

similar incidence of NRFHR monitoring

similar neonatal outcomes compared with

selective (later or no) AROM

26% increase in CD}

should be reserved for failure to progress

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5. Position:

Walk about or

in bed, as she wishes

As long as the

patient is healthy

presentation normal

presenting part engaged

fetus in good condition

6. Pain relief Severe: an analgesic

a) Opiate drugs. e.g. Pethidine IM/4 h

b) Inhalational analgesia e.g. Entonox

c) Epidural analagesia

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III. Monitoring the progress of labour

Once labour has become established, all events during labour should be recorded on a partogram. a) Well-being of the fetus b) Well-being of the mother c) Progress of the labour

Patient information:

name, gravida, para, hospital number, date and time

of admission and time of ruptured membranes.

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PATIENT INFORMATION FETAL INFORMATION FHR Am fluid Moulding LABOUR INFORMATION Dilatation Descent Contraction MEDICATIONS syntocinon drugs IV fluids MATERNAL INFORMATION Pulse, BP, T Urine: alb, ketones, vol

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A. Condition of the fetus

I. FHR: every half hour.

II. Memb & Liq: every vaginal examination

I= intact,

A= abscent

C= clear,

M= meconium

B= blood,

III. Moudling:

0 (separated)

+ (touching)

++(overlap)

+++ (severe overlap)

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Monitor FHR Auscultation methods Electronic monitoring: CTG

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NORMAL

ABNORMAL

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B. Progress of labour

I. Cervical dilatation (cm).

every vaginal examination

Plot x

In active phase

Alert line: drawn at a rate of 1 cm /h cervical dil

The mean rate of the slowest 10% of normal PG Action line: drawn 4 h to the right of alert line. Intervention should take place II. Descend:

every vaginal examination Plot O (amount of head palpable

above pelvic brim) and Position

III. Contractions:

every half hour

Frequency/10 m, Duration & Intensity:

stippled (<20 sec, weak);

striped (20-40 sec, moderate);

complete (>40 sec, strong).

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Recording the progress of labour

frequency of cervical examinations.

Most studies: every 2 h.

{risk of chorioamnionitis increases with the increasing

number of examinations}.

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C. Condition of the mother

I. Medications:

Oxytocin: amount /30 min

Drugs

IV Fluids

II. V/S:

B.P: /4 h

mark with arrows ( )

P: /30 min

mark with a dot (●).

T: /2 hours.

III. Urine:

every time urine is passed.

Vol, alb, ketones

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WHO partogram, 2002

Simple & easy to use.

The latent phase has been removed .

Plotting on begins in the active phase when the cervix

is 4 cm dilated.

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MANAGEMENT 2nd

STAGE OF

LABOUR I. Preparation

II. Observation

III. Conduct of delivery

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I. Preparation 1. Maternal position: With the exception of avoiding supine position, the

mother may assume any comfortable position for effective bearing down.

Semi-recumbent or

Supported sitting position, with the thighs abducted

2. PERINEAL CLEANSING

When delivery is imminent skin over the lower abdomen, vulva, anus and upper thigh is cleansed with antiseptic solution and draped.

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POSITIONING FOR DELIVERY

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PERINEAL CLEANSING

Need 6 swab balls

Clean sequentially

as shown by the

numbers

Clean according to

the direction

shown by the

Arrows

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CREATE A STERILE FIELD

AROUND THE VAGINAL OPENING

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II. Observation 1.Maternal conditions

Emotional condition

pulse quarter-hourly

bloods pressure hourly

2.Fetal conditions

FHR: either continuously or after each contraction.

Liquor: meconium staining.

3.Uterine contractions

Strength

Duration

Frequency, assessed continuously.

4.The progress of descent

every 30 minutes

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III. CONDUCTING THE DELIVERY 1. DELIVERY OF THE HEAD

1) Control the delivery of the head to prevent laceration

2) Episiotomy if required

3) Ritgen’s method

4) Clear the airway after delivery of the had

Modified Ritgen Maneuver

As crowning occurs: exert forward pressure on the chin of the

fetus through the perineum just in front of the coccyx.

Concurrently, the other hand exerts pressure superiorly against

the occiput ABOUBAKR ELNASHAR

• Instruct the mother to focus on her breathing. Have her

“breathe heavily” to help her stop pushing and prevent a

forceful birth.

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• Ask the woman to pant or give

only small pushes with

contractions as the baby’s

head delivers

• To control birth of the head,

place the fingers of one hand

against the baby’s head to

keep it flexed (bent)

• Continue to gently support the

perineum as the baby’s head

delivers

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DELIVERY OF THE HEAD

Head is delivered by extension ABOUBAKR ELNASHAR

• Once the baby’s

head delivers, ask

the woman not to

push

• Suction the baby’s

mouth and nose

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CORD AROUND THE NECK

Feel around the baby’s

neck for the umbilical cord

If the cord is around the

neck, attempt to slip it over

the baby’s head

If the cord is tight around

the neck, doubly clamp

and cut it before unwinding

it from around the neck

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As the head emerges,

the baby will turn to one

side (for easier passage

of shoulders through

birth canal)

Note the time, if

possible

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• Allow the baby’s head to turn spontaneously.

• After the head turns, place a hand on each side of the baby’s head.

• Tell the woman to push gently with the next contraction.

• Reduce tears by delivering one shoulder at a time

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DELIVERY OF FETAL HEAD WITH

ROL POSITION

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2. Delivery of the anterior shoulder by gentle downward traction on the head.

In the direction of the axis of the body

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3. DELIVERY OF POSTERIOR SHOULDER

by elevating the head.

Support the rest of the baby’s body with one hand as

it slides out

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4. 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.

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BABY DELIVERED

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FIRST BODY CONTACT OF MOTHER AND

BABY AND CORD CLAMPING

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5. CLAMING AND CUTTING THE UMBILICAL CORD

After delivery

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.

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Clamping, cutting and tying Of

umbilical cord

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EPISIOTOMY Surgical incision into the perineum to enlarge

the space at the outlet

Benefits:

1.Speed up the birth

2.Prevent Tearing

3.Protects against incontinence

4.Protects against pelvic floor relaxation

5.Heals easier than tears

Not proven

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No decrease

perineal damage

future vaginal prolapse

urinary incontinen

Increase 3rd & 4th degree tears

anal sphincter muscle dysfunction.

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Indications Not routine

1. Sizeable babies with anticipation of shoulder

dystocia.

2. Shoulder dystocia.

3. Instrumental delivery (according to judgement)

4. Breech

5. Scarring from female genital mutilation or poorly

healed third or fourth degree tears

6. Fetal distress.

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Types

Mediolateral rather than midline

(less 3rd and 4th degree perennial tear).

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Good analgesia

(infiltration with xylocain )

Timing:

cause bleeding: not be

done too early. Wait

until perineum is

thinned out and

3–4 cm of the baby’s

head is visible during

contraction.

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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.

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Nonoperative interventions to decrease

operative birth in systematic reviews (FIGO, 2012):

1. Continuous support for women during

childbirth by one-to-one birth attendants

2. Use of upright or lateral positions during

delivery compared with supine or lithotomy

3. Delaying pushing for 1–2 hours or until the

woman has a strong urge to push reduces the

need for rotational and midcavity interventions

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Recommendations FIGO (2012)

• Delivery facilities must offer everywoman

privacy and allow her to be accompanied by her

choice of a supportive person (husband, friend,

mother, relative, TBA)

• Psychosocial support, education,

communication, choice of position,

and pharmacological methods appropriately

used during the first stage are all useful in

relieving pain and distress in the second stage

of labor.

• Monitoring of FHR must be continued during

2nd stage to allow early detection of bradycardia.

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• Routine episiotomy is harmful and should not

be practiced.

• Women should not be forced or encouraged to

push until they feel an urge to push.

• Fetal heart auscultation after every contraction.

• Local anesthetic should always be given for

any episiotomy, episiotomy/ laceration repair, or

forceps delivery.

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MANAGEMENT 3rd

STAGE OF

LABOUR I. Delivery of placenta

II. Examination of placenta and perineum

III. Repair of episeotomy

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I. Delivery OF THE PLACENTA

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.

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MECHANISM OF PLACENTA SEPARATION1:

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)

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SIGNS OF PLACENTALSEPARATION

within 5 minutes after the delivery of the infant.

1.The uterus becomes globular and hard. =earliest

to appear.

2.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.

=most reliable clinical

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. . . Physiological Management

Active Management

Uterotonic None or after placenta delivered

With delivery of anterior shoulder or baby

Uterus Assessment of size and tone

Assessment of size and tone

Cord traction None Application of controlled cord traction* when uterus contracted

Cord clamping Variable Early

*Gentle downward cord traction with countertraction on the uterine body ABOUBAKR ELNASHAR

ACTIVE MANAGEMENT OF THE THIRD STAGE

Helps prevent postpartum haemorrhage.

includes:

1. use of oxytocin

2. controlled cord traction, and

3. uterine massage.

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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.

If the patient is awake, she is asked

to bear down while gentle

traction is made on the umbilical

cord.

A) Placenta separation

B) Controlled cord traction

C) Delivery of the membranes ABOUBAKR ELNASHAR

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II. EXAMINATION 1. OF THE PLACENTA

The placenta, membranes, and umbilical cord should be examined for completeness and for anomalies.

2. 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.

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III. REPAIR OF EPISIOTOMY Suture as soon as possible after delivery to avoid bleeding and infection (RCOG) Start just above the apex Use 3 layer technique, vaginal mucosa, perennial muscle and perineal skin Synthetic, absorbable (rapidly absorbable polyglactin 910) VICRYL RAPIDE begins to fall off 7-10 days post-operatively reduced post partum perineal pain, dyspareunia, although increased suture removal up to 3/12 For each layer use loose continuous non locking suturing this will reduce pain and dyspareunia.

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1. Identify apex

2. Begin suturing

1.0 cm above apex

3. Continuous sutures

4. Ends at the level of

vaginal opening

Continuous sutures Interrupted sutures Interrupted suture or

subcuticular ABOUBAKR ELNASHAR

MANAGEMENT 4th stage of labour

I. Observe II. Check

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The 2 hours after delivery

critical period {postpartum haemorrhage can

occurs due the relaxation of the uterus}.

I. Observation in delivery suite

Bleeding

blood pressure

pulse .

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II. Check before discharging the patient from the

delivery

1. Uterus:

Frequently to make sure it is firm and not relaxing.

Remove any presence of intrauterine blood clots. {clots

interfere with retraction and the normal haemostatic

mechanism of the uterus}.

2. Introitus

to see that there is no hge.

3. Bladder

empty {full bladder can also interfere with uterine retraction}.

4. Baby

breathing well and that the colour and tone are normal. ABOUBAKR ELNASHAR

Thank you Aboubakr elnashar

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