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Normal Labor
Kingdom of Saudi Arabia
Ministry of Higher Education
King Faisal University
College of Medicine
By/ Fahad AlHulaibi Mansour Al Omair Ahmed Al Awwad Abdulaziz Al Barrak
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Objectives
By end of this Tutorial, you will be able to :
Diagnose The Onset Of Labor .
Define Stages Of Labor.
Understand The Mechanism Of
Normal Labor.
Monitoring The Mother & The Fetus During
Labor.
Understand Management Of Normal
Labor.
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30 months
-
24 months
=
6 months
Or
24 weeks “age of viability”
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Definition
Labor:
Is the process whereby the product of conception are
expelled from uterian cavity after 24th week of
gestation.
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Definition
Premature labour:
labour occurring before the commencement of the 37th
week of gestation
Prolonged labour:
labour lasting in excess of:
24 hours in a primigravida
&16 hours in a multigravida.
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Onset of labour
The onset of labour is defined as the time of onset of regular, painful uterine contractions, which produce progressive effacement and dilatation of the cervix.
false labour: where the onset of painful contractions is not associated with progressive dilatation of the cervix.
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The clinical signs of the onset of labour include:
1. The onset of regular, painful contractions that
produce progressive cervical dilatation.
2. The exhibition of a vaginal show - the passage of
blood stained mucus.
3. Rupture of the fetal membranes - may occur at the
time of onset of contractions or it may be delayed
until the delivery of the fetus.
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Stages of labour
The First Stage
• onset of labour start
• Cervix reached full dilatation end
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The Second Stage
• Cervix reached full
dilatation start
• expulsion of the fetus end
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The Third Stage “Placenta Stage “
• delivery of the child. start
• expulsion of placenta. end
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The classic signs of placental separation :
1. show of bright blood.
2. apparent lengthening of the umbilical cord
3. elevation of the uterine fundus within the abdominal
cavity .
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MECHANISM OF
NORMAL LABOUR
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Mechanism of Normal labour
Engagement of the head normally occurs before the
onset of labour in the primigravid woman but may not
occur until labour is well established in a multipara.
Only 2/5th of the head will be palpable per
abdomen
Zero station on vaginal examination
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Mechanism of labour
1. Descent of the head provides a measure of the
progress of labour
Descent occurs throughout
labour
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2. Flexion of the head occurs as it descends and meets the pelvic floor, bringing the chin into contact with the fetal thorax.
Flexion produces
a smaller diameter
of presentation
(suboccipitobregmatic
diameter)
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3. Internal rotation:
The head rotates as it reaches pelvic floor and the
occiput normally rotates anteriorly from the lateral
position towards the
pubic symphysis
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4. Extension: The acutely flexed head descends to
distend the pelvic floor and the vulva, and the base
of the occiput comes into contact with the inferior
rami of the pubis.
The head now extends until
it is delivered. Maximal
distension of the perineum
and introitus accompanies
the final expulsion of the
head, a process that is
known as crowning.
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5. Restitution:
Following delivery of the head, it rotates back to be
in line with its normal relationship to the fetal
shoulders
6. External rotation: When the
shoulders reach the pelvic floor,
they rotate into the
anteroposterior diameter of the
pelvis. This is accompanied by
rotation of the fetal head so that
the face looks laterally at the
maternal thigh.
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7. Delivery of the shoulders: The anterior shoulder
is delivered first by traction posteriorly on the fetal
head so that the shoulder emerges under the pubic
arch.
The posterior shoulder is
delivered by lifting the head
anteriorly over the perineum.
This is followed by rapid
delivery of the remainder of
the trunk and the lower limbs
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INTRAPARTUM
MONITORING
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What to monitor?
Mother
Temperature
Pulse rate
Blood pressure
Urine
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Fetus
Auscultation
Fetal CTG
Fetal ECG
Scalp stimulation test
Acid-Base balance
Others
Partogram
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Mother Intrapartum monitoring
Temperature
Normal Temperature
36.2°-37.2°
Frequency
Every 4 hours
Pyrexia; Causes
Infection
Maternal exhaustion: Dehydration cause pyrexia.
Risks
Mother
fetus
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Cont.
Pulse Rate
Normal Range
70-100 beats per min
Frequency
Hourly
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Blood Pressure
Normal Range
100/60 mm Hg to 140/90 mm Hg
Frequency
hourly
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Urine
Items
Volume
Protein
Ketones
Frequency
Every 2 hours
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Fetal Monitoring
Auscultation
Fetal CTG
Fetal ECG
Acid-Base balance
Scalp stimulation test
Others
Vibroacoustic stimulation
Fetal oxygen saturation
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Auscultation
The heart rate should be recorded every 15 minutes
in the first stage and after each contraction in the
second stage, using a Pinard fetal stethoscope
Cardiotocography is not required when the labour
is classified as low risk.
However, there are specific indications for electronic
fetal monitoring.
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Indications for continuous electronic
fetal monitoring
Maternal
Previous caesarian section
Pre-eclampsia
Post-term pregnancy
Prolonged rupture of the membranes
Induced labour
Diabetes
Antepartum haemorrhage Other maternal medical
diseases
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Cont.
Fetal
Fetal growth restriction
Prematurity
Oligohydramnios
Multiple pregnancy
Meconium-stained liquor
Breech presentation
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Cardiotocogram
Components:
Base line fetal heart rate
Base line variability
Accelerations
Decelerations
Uterine Contractions
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Fetal Heart Rate
Normal Range
110-160 beats/min
More than 160 is tachycardia
Less than 110 is bradycardia
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Baseline Variability
Normal Range
6-25
Increased (more than 25)
Early Hypoxia
Prolonged pregnancy
Decreased (less than 6)
Late hypoxia
Sleep
Vibro-acoustic stimulation
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Accelerations
Transient increase in heart rate more than or equal
to 15 beats for more 15 seconds.
Assuring of good fetal health if present
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Decelerations
Transient decrease in heart rate more than or equal
to 15 beats for more 15 seconds.
Normally not present.
Types (in relation to uterine contractions)
Early
Late
Variable
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Early Decelerations
They are synchronous with uterine contractions.
The nadir of the deceleration occurs at the peak of
the contraction and the decrease in heart rate is
generally less than 40 beats/min.
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Cont.
These decelerations are generally due to head
compression and are commonly considered to be
physiological.
They are a common form of deceleration seen in
labour
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Late Decelerations
The onset of the slowing of heart rate occurs well
after the contraction is established and does not
return to the normal baseline until at least 20
seconds after the contraction is completed.
They are indicative of fetal hypoxia.
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Variable Decelerations
Variable decelerations vary in timing and
amplitude, hence their name.
An early deceleration where the heart rate falls by
more than 40 beats/min is also classified as a
variable deceleration.
Types:
Mild: Total duration is >30 sec, or FHR >80 bpm
Moderate: FHR 80-70 bpm
Severe: FHR <70 bpm for more than 1 min
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Cont.
The commonest cause is cord compression and the
changes may be considered to be pathological if
the cord compression is persistent
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Uterine Contractions
Tocodynamometer
A pressure-sensitive tocodynamometer is placed around
the maternal abdomen.
The tocodynamometer measures only the frequency of
contractions, not their intensity or strength.
Intrauterine pressure catheter (IUPC).
This method allows internal monitoring of contractions.
IUPC measures both the frequency and strength of
contractions.
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Electrocardiogram
The fetal electrocardiogram (ECG) can be recorded
from scalp electrodes or by the placement of
maternal abdominal electrodes.
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Two items are important:
Acidosis (T wave and QRS height)
Asphyxia (PR interval and RR interval)
The fetal ECG can also be used to identify the
nature of fetal arrhythmias.
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Scalp stimulation test
The examiner rubs the fetal scalp during a digital
examination.
An acceleration is usually seen in the FHR tracing of the
uncompromised, nonacidotic fetus. The presence of an
acceleration is associated with an intact ANS and a
fetal scalp blood pH greater than 7.20.
If an acceleration is not obtained after scalp
stimulation, fetal scalp blood can be sampled to
measure the fetal pH or one can progress to immediate
surgical delivery.
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Fetal scalp blood sampling
The fetal scalp is visualized through the dilated cervix, and blood is collected in heparinized capillary tubes
The normal fetal capillary pH is 7.25 to 7.35 in the first stage of labor.
A fetal scalp pH greater than or equal to 7.20 is reassurance that the fetus is not acidotic. Labor can proceed for 20 to 30 minutes.
A pH of less than 7.20 may represent significant acidosis. Delivery is thus indicated by vaginal delivery, if possible, or cesarean delivery.
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Others
Vibroacoustic stimuli (VAS). Fetus is stimulated by noise
for 1 second.
The presence of fetal accelerations in response to VAS is
considered reassuring.
The fetus is restimulated if no accelerations occur within 10
seconds. The VAS test may be repeated up to four times.
Normal fetal oxygen saturation: ranges between 35%
and 75%, If the fetal oxygen saturation remains above
30% during labor, fetal metabolic acidosis is excluded.
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Partogram
Partogram is a graphical record of key data
(maternal and fetal) during labour entered against
time on a single sheet of paper.
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Components
Fetal Parameters:
FHR
Status of membranes or Amniotic Fluid
Moulding
Caput
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Progress of Labor:
Cervical dilatation
Station of head
Uterine contractions: Frequency & Duration
Oxytocin:
Concentration / L
Infusion rate
Any other medicine & IV fluid
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Maternal Parameters:
Vital data:
Pulse
BP
Temparature
Urine:
Output
Acetone
Protein / Glucose
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MANAGEMENT OF
NORMAL LABOUR
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General principles of the management of
the first stage of labour :
• Observation and intervention if the labour becomes
abnormal by partogram .
• Pain relief during labour and emotional support for
the mother ( Narcotic agents , inhalational analgesia
and regional analgesia )
• Adequate hydration throughout labour.
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Fetal monitoring in labour
• Fetal cardiotocography
• Basal heart rate
• Transitory changes
• The fetal electrocardiogram
• Fetal acid-base changes
• Scalp blood sampling
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Management of the second stage
Delivery of the head .
Controlled descent .
Minimizing perineal damage.
Clamping the cord .
Evaluation of Apgar score.
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Evaluation of the Apgar score
2 1 0
Pink Blue White Colour
Normal Rigid Flaccid Tone
>100 <100
beats/min
Impalpable Pulse
beats/min
Regular Irregular Absent Respiration
Normal Poor Absent Response
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Management of the third stage
Recognition of placental separation.
Assisted delivery of the placenta with cord traction.
Routine use of oxytocic agents with crowning of the head.
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References:
Essential Obstetrics and Gynaecology, 4th Ed
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Thank
you