Transcript Document

Diameters of superior aperture of lesser
pelvis (female).
fetus over bony pelvis
in normal presentation
for birth
Linea Nigra
Leopold's Maneuvers
Leopolds' maneuvers are used
to determine the orientation
of the fetus through
abdominal palpation.
Using two hands and
compressing the maternal
abdomen, a sense of fetal
direction is obtained
(vertical or transverse).
The sides of the uterus are
palpated to determine the
position of the fetal back
and small parts.
The presenting part (head) is
palpated above the
symphysis and degree of
engagement is determined
The fetal occipital
prominence determined.
Head Palpation
Doppler
Normal Labor
Is the process by which a single full term
living viable fetus is expelled from the
natural passage within reasonable hours.
in which the fetus presents by the vertex
and which terminates naturally without
artificial aid and without complications.
Calculation of the date of labor:
A calculation based on the date of the last menstrual
period is the method in common use. It is the most
accurate method. The average duration of pregnancy is
ten lunar months, forty weeks or 280 days from the 1st
day of the last menstruation.
The onset of the labor:
Is recognised by:
(1) painful uterine contractions (labor pains).
(2) Blood stained cervical mucus ‘the show'.
(3) Commencing dilatation of the cervical os .
(4) Formation of the bag of fore-water.
Symptoms and Signs
• Cervix not dilated
Stage
False labor/
Phase
Not in
labor
Table C-8
Diagnosis of stage and phase of labour
a
• Cervix dilated less than 4
cm
First
Latent
• Cervix dilated 4–9 cm
• Rate of dilatation
typically 1 cm per hour or
more
• Fetal descent begins
First
Active
• Cervix fully dilated (10
cm)
• Fetal descent continues
• No urge to push
Second
Early (non-expulsive)
• Cervix fully dilated (10
cm)
• Presenting part of fetus
reaches pelvic floor
• Woman has the urge to
Second
Late(expulsive)
Effacement and dilatation of the cervix
Abdominal
palpation for
descent of the
fetal head
Vaginal examination
vaginal examination may be
used to assess descent by
relating the level of the fetal
presenting part to the ischial
spines of the maternal pelvis .
Note:
When there is a significant
degree of caput or moulding,
assessment by abdominal
palpation is more useful than
assessment by vaginal exam.
Assessing descent of the fetal head by vaginal
examination.0 station is at the level of the ischial
spine .
Presentation and position
Determine the presenting part
The most common presenting part is the vertex of
the fetal head. If the vertex is not the presenting
part, it is called malpresentation.
If the vertex is the presenting part, use
landmarks on the fetal skull( occiput) to
determine the position of the fetal head in
relation to the maternal pelvis.
Landmarks of the fetal skull
Determine the position of the fetal head
The fetal head normally engages in the maternal
pelvis in an occiput transverse position, with the
fetal occiput transverse in the maternal pelvis.
With descent, the fetal head rotates so that the fetal
occiput is anterior in the maternal pelvis (occiput
anterior positions), Failure of an occiputotransverse
position to rotate to an occiputo- anterior position
should be managed as an occiputo- posterior position
An additional feature of a normal presentation
is a well-flexed vertex with the occiput lower in
the vagina than the sinciput.
Well-flexed vertex
Assessment of progress of labor
Once diagnosed, progress of labor is assessed by:
-Measuring changes in cervical effacement and
dilatation during the latent phase.
-Measuring the rate of cervical dilatation and fetal
descent during the active phase.
-Assessing further fetal descent during the second
stage.
Plot a simple graph of cervical dilatation (centimetres)
on the vertical axis against time (hours) on the
horizontal axis.
Vaginal examinations
Vaginal examinations should be carried out at least once
every 4 hours during the first stage of labor and after
rupture of the membranes. At each vaginal examination,
record the following:
-Color of amniotic fluid;
- Cervical dilatation;
-Descent of the presenting part (can also be assessed
abdominally).
Cervical dilatation
Assessing descent of the fetal head by vaginal
examination.0 station is at the level of the
ischial spine .
In the second stage of labor, perform vaginal
examinations once every hour.
USING THE PARTOGRAPH
The WHO partograph has been modified to make it
simpler and easier to use.
The latent phase has been removed and plotting on the
partograph begins in the active phase when the cervix
is 4 cm dilated.
The modified WHO Partograph
Labor pains
Regular, frequent, uterine contractions which
lead to progressive dilatation of the cervix.
Braxton-Hicks contractions
Uterine contractions occurring prior to the onset
of labor. They are normal and can be
demonstrated early in the middle trimester of
pregnancy. These innocent contractions can be
painful, regular, and frequent, although they
usually are not effective.
While the uterine contractions of labor are usually
painful, they are sometimes mildly painful, in the early
stages of labor. Occasionally, they are painless.
Cervical dilatation alone does not confirm labor,
since many women will demonstrate some
dilatation (1-3 cm) for weeks or months prior to
the onset of labor.
Thus, labor will be determined by observing the
patient over time and demonstrating progressive
cervical changes, in the presence of regular,
frequent, painful uterine contractions.
Latent Phase Labor
The first stage can be divided functionally into two phases: the
latent phase and the active phase.
Latent phase of labor (also known as prodromal labor)
precedes the active phase of labor.
Women in latent phase labor
Are less than 4 cm dilated.
Have regular, frequent contractions that may be painful.
The contractions wax and wane
Cervix dilate only very slowly
Can usually talk or laugh during their contractions
May find this phase of labor lasting days or longer
Active Phase Labor
Active phase labor is a time of rapid change in
cervical dilatation, effacement, and station.
Active phase labor lasts until the cervix is completely
dilated.
Women in active phase labor:
Are at least 4 cm dilated.
Have regular, frequent contractions that are usually
moderately painful.
Demonstrate progressive cervical dilatation of at
least 1.2-1.5 cm per hour.
Usually are not comfortable with talking or laughing
during their contractions
Progress of Labor
For a woman experiencing her first baby, labor
usually lasts about 12-14 hours. In multigravida,
labor is generally quicker, lasting about 6-8 hours.
These averages are only approximate, and there is
considerable variation from one woman to the next, and from
one labor to the next.
During labor, the cervix dilates (opens) and effaces
(thins). This process has been likened to the process
of pulling a turtleneck sweater over your head. The
collar opens (dilates) to allow your head to pass
through, and also thins (effaces) as your head
passes through.
The process of dilatation and
effacement occurs for mechanical
&biochemical reasons.
The force of the contracting
uterus naturally seeks to dilate
and thin the cervix. However, the
cervix to be respond to these
forces requires it to be "ready.“
The process of readying the
cervix on a cellular level usually
takes place over days to weeks
preceding the onset of labor
(ripening).
Descent
means that the fetal head descends through the
birth canal.
The "station" of the fetal head describes how far it
has descended through the birth canal.
This station is determined relative to the maternal
ischial spines( bony prominences on each side of
the maternal pelvic sidewalls).
"0 Station" means that the top of the fetal head
descended through the birth canal just to the level of
the maternal ischial spines.
-This means that the fetal head is "fully" engaged (or
"completely engaged"), because the widest portion of
the fetal head has entered the opening of the birth
canal (the pelvic inlet).
- If the fetal head not reached the ischial spines, this
is indicated by negative numbers, such as -2 (the top
of the fetal head is 2 cm above the ischial spines).
-If the fetal head has descended further than the
ischial spines, this is indicated by positive numbers,
such as +2 (the top of the head is 2 cm below the
ischial spines).
Negative numbers above -3 indicate the fetal
head is unengaged (floating).
Positive numbers beyond +3 (+4 or +5) indicate
that the fetal head is crowning and about to
deliver.
Primigravida demonstrate deep engagement (0 or
+1) days to weeks prior to the onset of labor.
Multiparous woman not engage below -2 or -3
until they are in labor, and nearly completely
dilated.
Uterine Contractions
The onset of labor may be sudden or gradual, and is
defined as regular uterine activity in the presence of
cervical dilatation.
During a contraction the long muscles of the uterus
contract, starting at the top of the uterus and working
their way down to the bottom (Fundal dominence).
At the end of the contraction, the muscles relax to a
state shorter than at the beginning of the contraction.
This draws the cervix up over the baby's head.
Each contraction dilates the cervix until it becomes
completely dilated (10+ cm in diameter).
gradual onset with slow cervical change towards 3
cm (just over 1 inch) dilation is referred to as the
"latent phase".
A woman is said to be in "active labor" when
contractions have become regular in frequency (3-4
in 10 minutes) and about 60 seconds in duration.
The powerful contractions are accompanied by
cervical effacement and dilation greater than 3 cm.
The labor may begin with a rupture of the amniotic
sac, the paired amnion and chorion( rupture of bag
of fore water).
. In
the "transition phase" from 8 cm–10 cm
of dilation, the contractions often come every
two minutes & lasting 70–90 seconds.
The duration of labor varies widely, but
averages some 13 hours for primiparae 8
hours for multiparae.
Electronic fetal
monitoring
Cervical dilatation assessed at every vaginal
examination and marked with a cross (X). Begin
plotting on the partograph at 4 cm.
Alert line: A line starts at 4 cm of cervical dilatation to
the point of expected full dilatation at the rate of 1 cm
per hour.
Action line: Parallel and 4 hours to the right of the
alert line.
Descent assessed by abdominal palpation: At 0/5,
the sinciput (S) is at the level of the symphysis
pubis.
Bl p: Record every 4 hours and mark with arrows.
Temperature: Record every 2 hours.
Protein, acetone and urine volume: Record every time
urine is passed
STAGES OF NORMAL LABOUR
Normal Labour is the process of expulsion of
a mature foetus with the placenta and
membranes. It is divided into three stages:
Stage I lasts from the onset of labor to full dilatation
of the cervix.
In primigravida
this stage lasts for about 10 to 12 hours.
In multipara
it lasts from 6 to 8 hours.
A typical childbirth will begin the onset of the first
stage of labour
The First Stage is divided into three phases:
Phase I: is the longest and least painful phase of labour.
It starts from the time when the cervix first starts to dilate
to the time when the cervix is 4 cm dilated. It is also called
'Latent phase' of labor. It can last for days and can occur
with only the mildest discomfort to the pregnant woman.
Phase II: This is a more active phase of labor. The cervix
dilates from 4 cm to 8 cm during this phase. The
contractions are more painful , of longer duration and
come more regularly. It is also called the 'middle phase ' of
labour.
Phase III: During this phase, the cervix dilates from 8 cm
to 10 cm, the cervix is fully dilated and the baby's head can
come out of the uterus safely and easily. This phase is
also called the 'transition phase' of labour since it marks
the transition of the First stage to the Second stage.
Stage II : lasts from the full dilatation
of the cervix to the expulsion of the
baby. In a first pregnancy, it lasts for
about 1- 2 hour, in subsequent
pregnancies, it lasts for about ½ hour.
This stage is a stage when the baby's
head is travelling down the vaginal
canal to be delivered.
The contractions are very painful,
appearing to produce continuous pain.
The second stage of labor starts at the end of
the first stage when the cervix is fully dilated to
10 cm.
In the Mother:
Contraction and Retraction
Painful, involuntary contractions as well as
retractions occur in the uterine muscles.
Contraction of the Accessory Muscles:
As the second stage starts, the abdominal
muscles and diaphragm contract forcefully to
expel the fetus (bearing down pains).
The woman in labor holds her breath after
taking a deep inspiration thereby fixing the
diaphragm in a lower position and contracts
the abdominal muscles
This action increases the intra- abdominal
pressure, compressing the uterus and helps in
increasing the expulsive force. in the later part
of second stage, the urge and the pressure
becomes involuntary and synchronises with
the uterine contractions.
Changes in the Surrounding Organs:
As the fetus moves into the vagina it dilating the
vaginal cavity.
The structures in front ( the bladder and the urethra )
pushed upwards and forwards. This results in
inability to pass urine by woman in labor.
The structures behind the uterus ( the rectum, the
anus and the perineum ) displaced downwards and
backwards. So the woman gets a desire to pass
stool , the perineum becomes stretched and thinned
out. The anus opens up as the head descends
In the Baby:
The baby undertakes a series of movements
and changes in position during its passage
through the vaginal canal to the vaginal outlet.
In a normal labor, the baby faces the mothers
back and delivers in this position (with the face
towards the mother's back).
Engagement:
means that the largest transverse diameter of
the fetal head is at the level of the smallest
diameter of the mother's pelvis (ischial spine).
Descent with Flexion: The baby descends deeper
into the mother's pelvis. At the same time, the flexion of
its body ( the arms folded in front of the chest, the legs
tucked in front of the abdomen, and the chin touching the
chest wall )increases, so that the overall size of the baby
becomes smaller and can fit into the pelvis.
When the head of the baby reaches the lowest point of
the pelvic floor, it presses against the perineum causing
it to bulge slowly.
The head of the baby is now seen at the vaginal opening.
Initially, the head retracts back when the uterine
contraction decreases. Later, the head remains at the
opening even when there is no uterine contraction. This
is called 'Crowning‘.
Descent: As the fetal head
engages and descends, it
assumes an occiput
transverse position because
it is the widest pelvic
diameter available for the
widest part of the fetal head.
Flexion: While descending, the
head flexes so the fetal chin is
touching the chest. The occipital
(posterior fontanel) slides into the
center of the birth canal and the
anterior fontanel becomes more
remote and difficult to feel. Fetal
position remains occiputotransverse.
Internal Rotation:
With further descent, the
occiput rotates anteriorly and
the fetal head assumes an
oblique orientation. In some
cases, the head may rotate
completely to the occipitoanterior position.
Extension:
The curve of the hollow of
the sacrum favors extension
of the fetal head as further
descent occurs. This means
that the fetal chin is not
touching the fetal chest
External Rotation:
The shoulders rotate into an oblique or frankly
anterio-posterior orientation with further
descent. This encourages the fetal head to
return to its transverse position. This is also
known as Restitution .
Delivery by Extension: As the fetal head reaches
the maternal symphysis pubis it hitches under
the bone.
The pressure by the uterine contractions causes
the neck of the baby to get extended .
The forehead appears first, then the eyes and
nose and lastly the mouth as the neck extends
more and more.
The baby's nose and mouth is suctioned of any
secretions at this time to clear up the respiratory
tract and help the baby to breathe properly.
Normal Delivery Traction
Childbirth Stage 2
Vaccum extraction
Forceps
Delivery of the Shoulders: Once the head is out, the
contractions may or may not decrease in intensity for
some time.
Then the contractions increase once again, the anterior
shoulder (the shoulder just under the symphysis pubis)
hitches under the bone and the posterior shoulder (the
shoulder towards the rectum) is delivered first.
The body of the baby now slides smoothly out of the
vaginal canal.
The delivery of the baby signifies the end of the second
stage and the beginning of the 'Third Stage'
Steps of management of the second stage
of labor : The principles of management of this
stage are: (a) to ensure birth of a healthy baby
(b) to prevent damage to the maternal tissues.
Labor monitoring – The maternal pulse and blood
pressure are recorded. Fetal heart rate is counted
and recorded after every contraction. Uterine
contractions are checked.
Position during delivery – The standard position
for the delivery of the baby is the lithotomy position
(the patient lies on her back, legs flexed on the
hips, knees flexed and spread wide apart).
Cleansing of the vulva & the surrounding parts with
sterile solutions.
Catheterisation of the bladder is done if the patient
cannot pass urine.
The patient is encouraged to bear down with every
pain.
Crowning of the head - The head is said to be
crowned when it distends the vaginal opening,
without retracting inside the vagina after the episode
of pain is over.
Episiotomy –doctors prefer to do an episiotomy
when the head is crowned to prevent injury to the
perineum.
Episiotomy increases the size of the vaginal opening.
The head is delivered slowly, preventing sudden
extension of the head at the neck.This can cause
injury and tearing of the maternal perineum.
The perineum is supported by the left palm of the
doctor during delivery of the head.
After the head is delivered, the eyes are swabbed
with sterile cotton swabs, mouth and nostrils are
aspirated and a hand passed over the neck to check
for the presence of cord around the neck.
Next pains bring on the delivery of shoulders and
trunk.
Baby is held in a head down position while the cord is
clampedThe baby is then handed over to the
paedetrician.
Third stage: placenta
Breastfeeding during and after the third stage
In this stage, the uterus expels the placenta
(afterbirth). Breastfeeding the baby will help to
cause this.
The mother normally loses less than 500 mL of
blood. Blood loss will be greater if the umbilical
cord is used to tug on the placenta.
It is essential that the placenta be examined to
ensure that it was expelled whole. Remaining
parts can cause postpartum bleeding or
infection.
Stage III lasts from the birth of the baby to the
expulsion of the placenta and the membranes. It lasts
for about 15 - 20 minutes in both first and later
pregnancies.
The third stage is comparatively less painful
and is characterised by a gush of bleeding at
the time the placenta separates
The uterus contracts to become a As soon as the
baby is delivered, The uterus firm globular organ
reaching up to the umbilicus
•Through the vagina, the cervical os is seen
to become partially closed.
•The baby's umbilical cord is seen snaking
out of the os towards the vaginal opening.
An injection of ergometrine just after the
baby is delivered to stimulate the uterus to
contract better. This helps to prevent any
excess bleeding.
Signs that the placenta is beginning to
separate:
A sudden gush of blood
Lengthening of the visible portion of the umbilical cord.
The uterus, which is usually soft and flat immediately
after delivery, becomes round and firm.
The uterus, the top of which is usually about half-way
between the pubic bone and the umbilicus, seems to
enlarge and approach the umbilicus.
As the placenta separates, the
woman will again feel painful
uterine cramps.
As the placenta descends
through the birth canal, she will
again feel the urge to bear down
and push out the placenta.
If the placenta is not promptly
expelled, this is called "retained
placenta" and it should be
manually removed.
After delivery of the placenta, the uterus normally
contracts firmly, closing off the open blood vessels
which supplied the placenta,without this contraction
rapid blood loss will occur.
To encourage the uterus to firmly contract,
oxytocin 10 mIU IM can be given after delivery.
Breast feeding the baby or nipple stimulation will
cause the mother's pituitary gland to release oxytocin
internally, causing similar, but milder effects.
simple way to encourage firm uterine contraction is
uterine massage.
Massaging the
uterus often
causes the uterus
to contract
Oxytocin usually
is given IV to
stimulate uterine
contractions.