Normal labour

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NORMAL LABOUR BY Dr SHANZA AUROOJ

Transcript of Normal labour

  • 1.Dr shanza aurooj FCPS part-II trainee Under Prof Dr Naila Ehsan

2. Table of contents: Defination of labour Female pelvis and fetal head diameters Physiology of labour Stages of labour First stage of labour Second stage of labour Third stage of labour 3. LABOUR IS A CLINICAL DIAGNOSIS CHARACTERIZED BY REGULAR PHASIC UTERINE CONTRACTIONS INCREASING IN FREQUENCY AND INTENSITY RESULTING IN DILATATION AND EFFACEMENT OF UTERINE CERVIX,AND ENDS WITH THE DELIVERY OF THE BABY AND EXPULSION OF THE PLACENTA 4. THE BIRTH CANAL: The bony pelvis Joints & ligaments Pelvic muscles 5. Represented by a prominent line starting from the upper border of pubic symphysis, passing over iliopectineal the anterior aspect of ala of sacrum, ending at the upper border of first sacral vertebrea called promontory False pelvis: Above the pelvis brim,having no obstetric importance True pelvis: Below the pelvic brim,related to child birth A typical female pelvis with optimal configuration for easy vaginal delivery is called gynecoid pelvis,It is comprised of 1. Pelvic inlet 2. Pelvic cavity 3. Pelvic outlet 6. Pelvic inlet: Anteroposterior diameter (true conjugate)=12 cm,from upper border of pubic symphysis to sacral promontory Obstetric conjugate Shortest AP diameter=11.5 cm,from posterior surface of pubic symphysis to sacral promontory Diagonal conjugate Measured from the lower border of pubic symphysis to sacral promontary=12.5 cm Transverse diameter: Between the farthest two points on iliopectineal line,largest=13 cm 7. The true conjugate can be measured only on radiographic films The obstetric conjugate is measured indirectly by subtracting 1-2 cm from diagonal conjugate.The diagonal conjugate is the most easily and commonly assessed. By deeply inserting the wrist, the promontory may be felt by the tip of the second finger as a projecting bony margin. the vaginal hand is elevated until it contacts the pubic arch. The immediately adjacent point on the index finger is marked.The distance between the mark and the tip of the second finger is the diagonal conjugate. 8. Pelvic cavity: Lies between outlet & inlet,bounded in front by pubic symphysis and behind by sacrum AP diameter : midlevel of pubic symphysis & junction of 2nd & 3rd sacral vertebrae=13 cm Transverse diameter: Measured at the level of ischial spines(interspinous diameter)=11.5 cm 9. Pelvic outlet Transverse diameter: Between ischial tuberosities=11 cm Anteroposterior diameter: From lower border of pubic symphysis to coccyx = 13 cm 10. Caldwell moloy classification of female pelvis: Gyneacoid pelvis (50%) Anthropoid pelvis( 25%) Android pelvis (20%) Platypelloid pelvis(5%) 11. Round inlet & cavity with oval outlet,most suitable for vaginal delivery Oval inlet & outlet with round cavity,delayed engagement of head ,OCP Heart shaped inlet,narrow cavity (prominent spines)& oval outlet with narrow subpubic angle,most troublesome pelvis,persistent OCP & deep transverse arrest Kidney shaped.Flat inlet,reduced true conjugate,wide subpubic angle,delay in head engagement 12. Fetal diameters: Fetal skull diameters Transverse Anteroposterior Fetal body diameters Biacromial (11.5-12cm)distance between the acromial processes of scapula,if large may cause shoulder dystocia Bitrochanteric (10 cm) distance between the greater trochanters of femur 13. Bones of fetal skull: 14. Fetal diameters: biparietal diameter(9.5 cm),between two parietal eminence Bitemporal diameter(8cm),between the farthest points of coronal suture 15. SOB,from base of occipit to bregma.most favourable as it is shortest,fully flexed head in vertex presentation OPF,from occipital protruberence to nasion,slightly defled head,favours OCP SMB,from junction of chin &neck to bregma, hyperextended head with face presentation VM,from point of chin to centre of saggital suture,largest & most unfavourable,BROW presentation 16. PHYSIOLOGY OF LABOUR: oestriol oestradoil dehydroepiandrosterone pregnenolone cholestrol Placental oxytoxcin Prostaglandins Placental CRH hypothalamus Posterior pituatry oxytoxcin Oxytoxcin receptors SROM LABOUR hypothalamus anterior pituatry ACTH ADRENAL GLAND CRH DHEA CORTISOL Fetal lung maturity 17. Stages of labour: STAGES DEFINATION DIVISION DURATION First stage Begins with the onset of regular , phasic & co- ordinate uterine contractions & end s with full cervical dilatation(10cm) Latent phase: Begins at onset of labour & lasts till cervix is 3 cm dilated Active phase: Begins at 3 cm dilatation till cervix is fully dilated 8 hrs in Nulliparous,5 hrs in multiparous 5 hrs in nulliparous,2 hrs in multiparous Total duration is 14 hrs in nulliparous,7 hrs in multiparous Second stage Interval between full cervical dilatation & delivery of infant 2 hrs in nulliparous,1 hr in multiparous Third stage Delivery of the placenta & fetal membranes 30 minutes in either 18. First stage of labour: 0 2 4 6 8 10 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 hours of labour hours of labour Active phase Dilatationincms Latent phase Freidmans graph of labour 19. Management of first stage of labour: DIAGNOSIS INITIAL EVALUATION GENERAL MEASURES DETERMINATION OF PROGRESS OF LABOUR MATERNAL MONITORING FETAL MONITORING MAINTAINING PARTOGRAM DOSE OF OXYTOXCIN PAIN RELIEF DURING FIRST STAGE 20. DIAGNOSIS OF LABOUR: HISTORY labour pains Show Sudden loss of fluid from vagina ABDOMINAL EXAMINATION Uterine contractions Frequency(3/10) Duration(40-60 s) Severity(pressure>80 mmhg) PELVIC EXAMINTAION Cervical dilatation Effacement Consistency position Level of presenting part Diagnosis of labour is confirmed when in the presence of regular & painful uterine contractions,the cervix is more than 2 cm dilated or more than 80% effaced 21. INITIAL EVALUATION: BOOKED PATIENT Antenatal record review Admission test CTG Vitals/urine analysis Usual management& Monitoring of labour UNBOOKED PATIENT Detailed history/examinat ion Routine investigations(an tenatal visit) Usual management & monitoring 22. General measures: ENEMA/ GLYCERINE SUPPOSITORIES IV line position Oral intake Bladder care Prophylactic antibiotics 23. Determination of progress of labour Descent of the presenting part On P/A examination (Chrictons technique)(number of fifths head is palpable) 5/5=free floating 4/5,3/5=entering brim 2/5=fixed,1/5=engaged On p/v examination(level of head in relation to ischial spine) -1,-2,-3 no of centimters above ischial spines,0=ischial spines & +1,+2,+3 below the ischial spine 1/5 0 Cervical dilatation Roughly assessed by fingers,1 finger=1.5 cm P/V examination Latent phase=3 hourly Active phase=hourly 24. VITALS (4 hourly) Intake/output chart Level of hydration MATERNAL Detection of passage of meconium Fetal cardiac behaviour Fetal blood sampling FETAL 25. DETECTION OF PASSAGE OF MECONIUM GRADE THREE Meconium dominates over liquor passed as semisolid material or black paste Immediate delivery is indicated GRADE TWO both liquor & meconium are drained in equal amounts giving it a dark green appearance Fetal distress,labour allowed in selected cases only GRADE ONE small amount of meconium staining liquor light green or Yellow LABOUR can be allowed to progress 26. Fetal blood sampling Normal PH=7.25-7.30 Suspicious=7.2 -7.25 abnormal= 40 min (3) Variability > 25 bpm (4) No accelerations > 40 min (5) Sporadic mild decelerations of any type (6) Variable deceleratopms Antepartum - (1) - (5) any one / combination Intrapartum - (1) - (4) & (6) any one / combination C. Pathological : Antepartum (1) Baseline < 100 or > 170 bpm (2) Variability < 5 bpm for > 40 min (3) repeated decelerations of any type (4) Sporadic noncurrent severe variable, prolonged or late decelerations (5) Sinusoidal pattern Any one or in combination 40. Interpretations of result: Reactive/normal CTG: low risk,Intermittent fetal heart rate monitoring required Suspicious CTG: High risk,require continous fetal heart rate monitoring Abnormal CTG: High risk,require EmLSCS 41. PARTOGRAM Partogram is a composite graphical record of key data (maternal and fetal) during labour entered against time on a single sheet of paper Advantages Provides information on single sheet of paper at a glance Prediction of deviation from normal progress of labour 42. Patients data Fetal heart rate Liqour/membranes I C cervical dilatation Descent of presenting part Uterine contractions Frequency=no of contractions in 10 min Dots