Transcript Admission pracedurws - Isfahan University of Medical Sciences

Admission procedures
Dr. F Mostajeran MD
Admission procedures
Urged to report early in labor
Early admittance to labar , delivery unit
especially high risk pregnancy
accurat diagnosis of labar
Falsely diagnosed , inappropriate in
terrention
Not diagnosed (remot from medical
personnel medical facilities)
Definition of labor
Uterine contractions that bring effacement
and dilatation of cervix.
Painful contractions become regular
onset of labor as beginning at the time of
admission to the labor unit
Admission for labor based on dilatations
accompanied by painful contractions .
D. Diagnasis between false
and true labor is difficult
Contractions of true labor
Regular intervals
Intervals gradually shorten
Intensity gradually increases
Discomfort back , abdomen
Cervix dilates
Discomfort is not stopped by sedation
Contractions of false labor
Irregular intervals
Intervals long
Intensity unchanged
Discomfort lawer abdomen
Cervix not dilate
Relieved by sedation
Pregnant woman who is having
Cantractions
Emergency condition
Labor is defined as process of
childbirth beginning
Latent phase
delivery placenta
Electronic admission testing
Recommend NST or CST on all
patient
(labar – delivery unit)
Fetal admission test
identify unsuspected cases
Vaginal examination
1. Amnionic fluid
effacement
2. Cervix dilatation
position
3. Presenting part
4. Station
5. Pelvic architecture
Detection of ruptured
membranes
Leakage of fluid
Prolapse cord
Labor occur
Serious intra uterine infection
Nitrazine paper (PH= 7.0 – 7.5)
Arborization or ferning
Alpha – fetoprotein
Injection various dyes
Vital signs and review of pregnancy
record
Physical examination
Preparation of vulva and perineum
Inspection and cleaning of the vulva
, perineum , mini – shave - enema
Friedman
Three functional divisions of labor
Preparatory division:
Little cervical dilatation
Considerable change
Dilatational division :
Most rapid rate
pelvic division:
Deceleration phase of cervix - dilatation
Cardinal fetal movements
Cervical dilatation
Latent phase (14-20h)
Active phase:
acceleration ,phase of maximum slope
, deceleration phase
Management first stage of
labor
Remainder of general physical exam
is completed
HCT HB protein - glocose
average duration first stage of labor
7 hours in nulliparous w
4 hours in parous w
Fetal monitoring during labar
Contractions and response FH
Suitable stethoscopc , doppler ultrasonic
devices
FH should be checked after contractions
every 30 minutes (15)
Second stage every 15 minutes (5)
Cantinous electronic monitoring
MATERNAL MONITORING
Vital signs
T , pulse , BP every 4/h
PROM temprature every 1/h
18 h of PROM antimicrobial
Subsequent vaginal
examinations
When membrans rupture if head
was not Defenetly engaged
fetal H immediately and during the
next uterine contraction
(occult umbilical cord compression)
periodic examinations at 2-3 hours
interval
Oral intake
Gastric emptying time prolanged
(food – medication remain in the stomach – not
absorbed may be vomited)
Food should be withheld
Intravenous fluids
Infusion system routine early labar (IV line)
Longer labors glucose sodium water 60-120
ml/hr
Maternal position during labor
normal laboring woman
Not be confined to bed
Comfortable chair
In bed position most comfortabl
(lateral recumbend)
Analgesia
Is initiated on the basis of maternal
discomfort
vaginal examination befor
administration of analgesia
(delivering a depressed infant)
Timing , method and size of initial and
subsequent dose , interval of time until
delivery
Amniotomy
There is a great temptation
Benefits: rapid labor detection of
meconium staining
Internal fetal M
Aseptic technique
Head must be well applied to the
cerxin
Urinary bladder function
Bladder distention avoid
Abstracted labor
Subsequent bladdes hypotonia, infection
Suprapubic region shauld be visualized ,
palpated detect filling bladder
If could not void on a bedpan
Intermittent catheterization
Management of second stage
labor
Full dilatation of the cervix
Begins to bear dawn
50 minutos in nulliparous
20 minutos in multiparous
Higher parity 2-3 expulsive efforts
may suffice Complete the delivery of
the infant
FHR
Low – risk 15 H.risk 5
Fetal H.R
Contraction – maternal expulsive efforts
FHR are not consequence of head
compression
Descent fetus and reduction in uterine
volume
some degree of premature separation
placenta
tighten a loop or loops of umbilical
cord
Around the fetus umbilical blood
flow
Prolonged uninterrupted maternal
expulsive efforts
dangerous to
the fetus
Preparation for delivery
Variety of positions
Dorsal lithotomy position
For beter exposure legholders stirrups
Cramps in the legs (brief massage – changing
position)
Preparation for delivery entails vulvar and
perineal cleansing
Spontaneous delivery
Delivery of the head
Contraction perineum bulges
Vulvovaginal opening becomes more
dilated
Gradually circular opening
This encirclement of the largest head
By the vulvar ring is known as crowning
Perineum is extremely thin
Episiotomy , laceration
Episiotomy risk tear external anal –
rectum
Episiotomy - anterior tear urethra ,
labia
Ritgen manover
Vaginal introitus 5 cm
Towel – draped , gloved hand
forward pressure
on the chin of the fetus
other hand exerts pressure
superiorly against occiput
Cleaning the nasopharynx
Minimize aspiration AF – debris ,
blood
once thorax is delivered
face quickly wiped nause , mouth
are aspirated
Following delivery of anterior shoulder
Finger should be passed to the neck
Nuchal cords 25% +
Drawn down , loose – slipped over the head
Clamping the cord
4-5 cm , 2-3 cm fetal abdomen two clamps
Plastic cord clamp
Timing of cord clamping
Infant is placed at or below vaginal
interoitus 3 , 80ml of blood shifted
from placenta to infant
80ml 50mg Iron , Iron deficiency
anemia
Maternal alloimmunization
our policy after cleaning airway 30"
cord clamp
Management of the third stage
After delivery of the infant
Height uterine fundus
Uterus firm , no unusual bleeding
Waiting until placentac separat – no
massage
Hand rest on the fundus (atonic – filled
with blood)
Signs of placental
separation
1. uterus becames globular firm
2. Sudden gush of blood
3. Uterus rises (placenta separated ,
passes dawn to lower u-segment
4. Its balk pushes uterus upward
5. Umbilical cord protrudes forther out
delivery of the placenta
Traction on the umbilical cord must not be
used inversion
Manaol removal of placenta
occasionally placenta will not separat
At any time brisk bleeding and , placenta can
not be delivered
Active management of the third stage
5 units oxytocin +0.5 ergometrine
reductian in the length of third stage
Fourth stage of labor
Exam placenta , membranes ,
umbilical cord
Completeness , anomalies
Hour immediately fallowing delivery
Critical fourth stage of labor
uterine atony , BP , pulse every 15
Oxytocic Agents
Oxytocin (pitocin , syntocinon)
Methylergo novine maleat (methergine)
Reduce blood loss by stimuloting
myometrial contraction
Iml 10IU half – lifc IV 3
Inapropriate dose kill the fetus ,rupture
uterus
Cardiovascular effects
Deleterious effects follow IV bolus
Antidiuresis
rare maternal convulsion antidiuretic
action
Water intoxication (20,40mu/minut )
Concentration should be increared rather
than rate of flow
Normal saline are lactated ringer solution
Ergonovine and methylergonavine
IV – IM – orally no differenc in actions
Sensitivity of pregnant uterus is very great
In pregnancy 0.1my IV , 0.25my oral tetanic
Uterine contraction
Tetanic effect prerention , control PPH
IV administration sometimes
tram sient , severe hypertension
Prostaglandins
Not used routinely
Manage ment PPH
PG F2x 250ng IM (15-90" ) 8does
88% successful
20% side effects diarrhea ,hypertension
vomiting , Fever , flushing ,
tachycandia
PG E2 20-mg suppositories
Lacerat ons of the Birth canal
Classified
First fourchette , perineal skin vaginal
mucous
Second fascia and muscles of perineal
body
Third anal sphincter
Fourth retal mucosa
Episiotomy and repair
Incision of pudenda
Perineotomy incision of perineu
Episiotamy synonymously with
penineotomy
Begin in midline :
Directed laterally mediolateral
Directed down ward midline
Timing of episiotomy
Perform when head is visible during
contraction 3-4
After application of blades
Timing of repair
Most common practice repair until
placenta delivered
Technique
Hemostasis
Anatomical restoration without excessive
suturing
Chromic catgut 3-0
Fourth – degree laceration
Various techniques remcommend
Esential approximat torn edges
rectal mucosa
With muscularis sutures 0.5cm apart
Muscular layer covered with a layer
of fascia
Labor with occiput
presentations
95% fetus occiput or vertex presentation
Most commonly ascertained ab – exam
Confirmed V.Examination before or at the
onset of labor
Sagitlal suture in the transrevse pelvic
diameter
LOT , ROT , LOA , ROA
ROP , LOP (narrow forepelvis , anterior
placentation
OCCCIPUT ANTERIOR
PRESENTATION
Irregular shape pelvic canal
Large dimensions fetal head
Adoptation or accommodation of
suitable
Portions of head to the varius
segment of the pelvis is required
Cardinal movements of labar
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation expulsion
Concomitantly , uterine cantractions
Important modifications in fetal
attitude
straightening of the fetus loss dorsal
convexity , closer application of the
extremities to the body , fetal ovoid
cylinder
Engagement
Biparietal diameter – greatest
transverse diameter F.Head passes
thraugh the pelvic inlet
Lost few weeks of pregnancy
Until after cammencement of labor
In many multiparous , some nulliparous
At onset of labor head freely movable
above inlet
Referred “floating”
Asynclitism
Sagittal suture remaining parallel to
transverse axis may not lie exactly
midway
Between symphysis and sacral
promontory
Sagitlal suture deflected posteriorly
or anteriorly
Asynclitism anteror or posterior
Moderat degree of asynclitism are
the rule in normal labor
Severe asynclitism may lead to
cephalopelvic disproportion
even with an normal – sized pelvis
DESCENT
First requisit for birth infant
In nulli parus take place befor the
onset of labor
Further descent until onset of the
second stage
In multiparous descent usually
begins with engagement
1.
2.
3.
4.
Descent is brought by one or more of four
forces
Pressure of amnionic fluid
Direct pressure of fondus with
cont ractions
Bearing down efforts abdominal muscles
Extension and straightening of fetal body
FLEXION
As soon as descending head meets
resistance
Cervix , walls of the pelvis , pelvic
floor
The chin is braught into more
intimate contact Fetal thorox
suboccipitobreg matic
occipitafrontal
Internal rotation
occiput gradually moves from
original position toward symphysis
pubis
Less commonly posteriorly
Internal rotation essential
completion of labor
It always associated with descent
and acomplished after engagement
Extension
After in-rotation sharply flexed head
reaches the vulva
Undergoes extension which essential
to birth
Vulvar outlet directed upward , for
ward
Extension must occur before head
can pass through it
Head born by further extension
occiput , bregma , fore head , nose
mouth
Finally chin pass
Head drops down ward chin lies
over anal region
External rotation
delivered head under goes restitution
occiput toward the left rotates left
ischial tuberosity
occiput toward the right rotates
right ischial tuberosity
Bisacromial diameter in to relation
anteroposterior diameter of the pelbic
outlet shoulders (anteriar – posterior)
Expulsion
Immediatly after external rotation
Anterior shoulder under symphysis
pubis
Posterior shoulder distended
perineum
After delivery of the shoulders
Rest of body quickly extruded