APRIL 2005

DEPARTMENT OF OBST & GYNAE RCMP

NORMAL LABOUR AND DELIVERY

Prof Dr MOHD AZHAR MN

ROYAL COLLEGE OF MEDICINE PERAK

APRIL 2005

DEPARTMENT OF OBST & GYNAE RCMP

NORMAL LABOUR AND DELIVERY

CONTENTS
1. 2. 3. 4. 5. 6. Definition of normal labour Factors influencing progress of labour Diagnosis of labour Stages of labour Mechanisms of labour Management of labour

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

WHAT IS NORMAL LABOUR ?

APRIL 2005

DEPARTMENT OF OBST & GYNAE RCMP

NORMAL LABOUR

DEFINITIONS
Labour is defined as the onset of regular painful contractions with progressive cervical effacement and dilatation of the cervix accompanied by descent of the presenting part.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR
The following criteria should be present to call it normal labour Spontaneous expulsion, of a single, mature fetus (37 completed weeks 42 weeks), presented by vertex, through the birth canal (i.e. vaginal delivery), within a reasonable time (not less than 3 hours or more than 18 hours), without complications to the mother, or the fetus

APRIL 2005

NORMAL LABOUR
IMPORTANCE
DEPARTMENT OF OBST & GYNAE RCMP

Understanding the process of labour is importance problems can be identified correctly managed

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

WHAT FACTORS INFLUENCE PROGRESS OF LABOUR ?

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

LABOUR AND DELIVERY

FACTORS THAT INFLUENCE PROGRESS OF LABOUR
Power

Passenger

Passage

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

THE NORMAL FEMALE PELVIS

1. The female pelvis provides the basic framework of the birth canal.

2. The obstetric pelvis is divided into false and true pelvis by the pelvic brim or inlet
3. The true pelvis is important, for it is through this confined space that the fetus must pass on its journey through the birth canal. 4. The true pelvis is composed of inlet, cavity and outlet. Cavity Outlet 5. Types of female pelvis gynaecoid, anthropoid, android and platypelloid

Inlet

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

THE NORMAL FEMALE PELVIS

The ideal normal female gynaecoid pelvis:
1. The brim is slightly oval transversely. 2. The sacral promontory is not prominent. 3. The transverse diameter is slightly longer than the anteroposterior. 4. The sidewalls are parallel and straight. 5. The ischial spines are not prominent. 6. The sacrosciatic notches are wide. 7. The sacrum has a good curve. 8. The pubic arch angle are wide, i.e. more than 90 9. Inter tuberous diameter is wide

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

THE NORMAL FEMALE PELVIS

The important diameters of the female pelvis:
Diameters (cm) Anteroposterior Oblique Transverse

BRIM

11 11.5

12

12.5

CAVITY 12

12

12

OUTLET 12.5

12

11- 11.5

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

THE FETAL SKULL

1. Sutures 2. Diameters

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

THE FETAL SKULL

SUTURES
1. Sagittal suture: - The sagittal suture lies between the parietal bones. It runs in an anteroposterior direction between the anterior and posterior fontanelles.

2.

Coronal sutures: - The suture uniting the parietal bones to the frontal bones is called the coronal suture. Its extend transversely from the anterior fontanels and lies between the parietal and frontal bone.
Frontal suture: - The frontal suture is between the two frontal bones. It is an anterior continuation of the sagittal suture. Lambdoidal suture: - Is between the parietal and occiptal bones.

3.

4.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

THE FETAL SKULL

MOULDING OF THE FETAL SKULL

MOULDING is the ability of the fetal head to change its shape and so to adapt itself to the unyielding maternal pelvis during the progress of labour. This property is of the greatest value in the progress of labour.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

THE FETAL SKULL

Diameters of the fetal skull anterior posterior diameters
A G D E
AB ~ Suboccipto bregmatic 9.5 AC ~ Submento bregmatic 9.5

F C

DE ~ Occipito frontal ~ 11.0

FG ~ Mento vertical 13.5

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

POWER Contractions + Maternal pushing

Uterine contractions:

1. Initiate by pacemakers ~ uterotubal junction 2. Contraction waves meet at the fundus 3. Contraction waves progress downward
Shortening of muscle fibres Retractions intra uterine pressure

Additional force

maternal pushing

Intra abdominal pressure

EXPULSION OF THE FETUS

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

UTERINE CONTRACTION

Uterine contractions

NORMAL CONTRACTION
1. 2. 3. Frequency ~ one in every 2 3 min with at least 1 minute interval Intensity ~ strong (> 50 mmHg) Duration ~ 45 60 sec

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

LABOUR AND DELIVERY

WHAT INITIATE LABOUR ONSET OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR
Causes of Onset of Labour:
- It is unknown but the following theories were postulated:

Hormonal factors
1) Estrogen theory 2) Progesterone withdrawal theory 3) Prostaglandins theory 4) Oxytocin theory 5) Fetal cortisol theory

Mechanical factors
1) Uterine distension theory 2) Stretch of the lower uterine segment by the presenting near term

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

LABOUR AND DELIVERY

DIAGNOSIS OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

SYMPTOMS AND SIGNS OF LAB

Before labour begins, women usually notice one or more premonitory, or warnings, signs that labour is about to begin.
They are:

Painful regular uterine contractions as evidence by contraction at least one in ten minutes Show as evidence by mucus mixed with blood Rupture of membranes as evidence by leaking liquor

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

LABOUR AND DELIVERY

DESCRIBE THE STAGES OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

STAGES OF LABOUR
Labour can be divided into three stages, which are unequal in length.

FIRST STAGE
It begins with the onset of true labour contractions and ends when the cervix is fully dilated (10 cm). Cervical effacement and dilatation occur in the first stage

SECOND STAGE
The second stage of labour begins with complete dilatation of the cervix and ends with the birth of the baby. The duration is about 1 to 1 hours in nulliparas and about 30 to 45 minutes in parous women.

THIRD STAGE
The third stage is that of separation and expulsion of placenta and membranes and also involves the control of bleeding. It begins after the birth of the baby and ends with the expulsion of the placenta and membranes. This is the shortest stage, lasting up to 30 minutes, with an average length of 5 to 10 minutes. There is no difference in duration for nulliparous and parous.

First stage of labour consists of two phases:- latent and active. The first stage of labour is the longest for both nulliparous and parous women.

APRIL 2005

DEPARTMENT OF OBST & GYNAE RCMP

FIRST STAGE OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

PHASES OF THE FIRST STAGE OF LABOUR

Divided into:
Latent phase begins with onset of contracts and ends when cervix is 3 cm dilated and effaced Active phase begins after the cervix is 3 cm dilated

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

PHASES OF THE FIRST STAGE OF LABOUR

LATENT Phase
1. 2. 3. 4. 5. 6.

ACTIVE Phase
1. 2.

Begins with onset of contractions Slow progress Little cervical dilatation Progressive cervical effacement Ends once the cervix reaches 3 cm dilatation Durations ~ 8 hours for nulliparae ~ 6 hours for multiparae

3.
4. 5.

Active process Begins after 3 cm of cervical dilatation Period of active cervical dilatation (average rate 1 cm/hr) S-shaped curve which is used to define progress of labour It has 3 component a) acceleration - slow b) maximum - fast c) deceleration - slow

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

WHAT HAPPEN DURING THE FIRST STAGE

1. Contractions:
CONTRACTIONS

1: Regular 2: Increasing in frequency 3: Stronger

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

WHAT HAPPEN DURING THE FIRST STAGE

2. Cervical dilatation and effacement:
Causes of cervical dilatation:
Contraction and retraction of uterine musculature Mechanical pressure by the bulging membrane (fore water) The descend of the presenting part

Phases of cervical dilatation

Latent phase the first 3 cm of dilatation; a slow process (8 hours in nulliparous and 3 hours in multiparous
Active phase this is active process of cervical dilatation; the normal rate is 1 cm/hour

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

WHAT HAPPEN DURING THE FIRST STAGE

3. Engagement of the presenting part:

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

FETAL HEART CHANGES Do Uterine Contractions Affect Fetal Heart Rate?
Uterine contractions can affect fetal heart rate by increasing or decreasing that rate in association with any given contraction.

The three primary mechanisms by which uterine contractions can cause a decrease in fetal heart rate are compression of: Fetal head Umbilical cord Uterine myometrial vessels

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

PROGRESS OF FIRST STAGE OF LABOUR Findings suggestive of satisfactory progress in first stage of labour are: - regular contractions of progressively increasing frequency and duration; - rate of cervical dilatation at least 1 cm per hour during the active phase of labour (cervical dilatation on or to the left of alert line);

Findings suggestive of unsatisfactory progress in first stage of labour are: - irregular and infrequent contractions after the latent phase; - OR rate of cervical dilatation slower than 1 cm per hour during the active phase of labour (cervical dilatation to the right of alert line);

APRIL 2005

DEPARTMENT OF OBST & GYNAE RCMP

SECOND STAGE OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

SECOND STAGE OF LABOUR
1. Begins with FULL DILATATION and ends with DELIVERY OF THE BABY. 2. It have TWO Phases a) Propulsive phase from full dilatation until presenting part has descended to the pelvic floor b) Expulsive phase which ends with the delivery of the baby
Features of expulsive phase 1) mothers irresistible desire to bear down 2) distension of perineum 3) dilatation of the anus

3. Average length a) Primigravidae 40 minutes b) Multigravidae 20 minutes

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

PROGRESS OF SECOND STAGE OF LABOUR

Findings suggestive of satisfactory progress in second stage of labour are: - steady descent of fetus through birth canal; - onset of expulsive (pushing) phase. Findings suggestive of unsatisfactory progress in second stage of labour are: - lack of descent of fetus through birth canal; - failure of expulsion during the late (expulsive) phase.

APRIL 2005

DEPARTMENT OF OBST & GYNAE RCMP

THIRD STAGE OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

THIRD STAGE OF LABOUR
1. Begins after DELIVERY of the baby and ends with DELIVERY OF THE PLACENTA / MEMBRANES. 2. It have TWO Phases a) Separation phase b) Expulsion phase 3. Duration usually 15 minutes or less (if actively managed). 4. Average blood loss 150 to 250 ml.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY PHYSIOLOGICAL EFFECTS OF LABOUR

FIRST STAGE
1.

SECOND STAGE
1. 2.

THIRD STAGE
1.

Minimal effects

ON THE MOTHER

3.

Pulse increases Systolic BP slightly increased due to pain and anxiety Minor injuries to the birth canal

2.

Blood loss from the placental site (200 ml) Blood loss from laceration and perineum (100 ml)

ON THE FETUS

1. 2.

Moulding overlapping of the vault bones Caput succedaneum it is a soft swelling of the most dependent part of the fetal head

MANAGEMENT OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

AIMS IN THE MANAGEMENT OF LABOUR
The AIMS include:

To achieve delivery of a normal healthy child To anticipate, recognize and treat potential abnormal conditions before significant hazard develops for the mother or the fetus.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

PRINCIPLES IN THE MANAGEMENT OF LABOUR
The principles include: Diagnosis of labour Monitoring the progress of labour Ensuring maternal well-being Ensuring fetal well-being.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT FIRST STAGE OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE FIRST STAGE OF LABOUR1
On admission:
When the women presents at hospital, the womans antenatal record is reviewed to discover whether there have been any abnormalities during her pregnancy. When there are no records of antenatal care a complete history must be taken.

General examination of the mother

a) General conditions evaluate the mother general health condition. Look for pallor, edema, abdominal scar (LSCS) and maternal height. b) Vital signs Blood pressure, pulse, respiration and temperature are taken and recorded

c) Heart and lungs

d) Urine analysis for protein, sugar and ketones

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE FIRST STAGE OF LABOUR2
Abdominal examination:
a) A detailed abdominal examination should be carried out and recorded. b) Determine the presentation and position of the fetus and also the engagement c) Auscultate the fetal heart d) Evaluate the uterine contraction

Vaginal examination the purpose is to

a) To make a positive diagnosis of labour b) To make a positive identification of presentation c) To determine whether the fetal head is engaged in case of doubt d) To ascertain whether the fore waters have ruptured or to rupture them artificially e) To exclude cord prolapse after rupture of the fore waters f) To confirm the degree of cervical dilatation and position of the presenting part g) To assess progress of labour. h) To assess the adequacy of the pelvis.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE FIRST STAGE OF LABOUR3
Bowel preparation:
If there has been no bowel action for 24 hours or the rectum feels loaded on vaginal examination an enema is given.

Bladder care
A full bladder may initially prevent the fetal head from entering the pelvic brim and later impede descent of the fetal head. It will also inhibit effective uterine action.
The woman should be encouraged to empty her bladder every 1 - 2 hours during labour. The quantity of urine passed should be measured and recorded and a specimen obtained for testing.

Nutrition in early labour

No food is permitted after labour is established to prevent regurgitation and aspiration It is important to maintain adequate hydration - via intravenous routes

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE FIRST STAGE OF LABOUR4
Position of labouring mother:
As long as the patient is healthy, the presentation normal, the presenting part engaged, and the fetus in good condition, the patient may walk about or may be in bed, as she wishes

Monitoring the progress of labour

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

Pain relief
When the pains are severe an analgesic preparation may be given. a) Opiate drugs e.g. Pethidine given intramuscularly every 4 hour b) Inhalational analgesia e.g. Entonox c) Epidural analagesia

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

LABOUR PAIN causes1
Pain in labour
The pain experienced by the woman in labour is caused by the: 1): Uterine contractions and uterine ischaemia. 2): Cervical dilatation. Dilatation and stretching of the cervix and lower uterine segment stimulate nerve ganglia and are a major source of pain. 3): Distention of the vagina and perineum. Marked distention of the vagina and perineum occurs with fetal descent, especially during the second stage.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

LABOUR PAIN causes2
Pain in labour
Table 1: PAIN DURING THE STAGES OF LABOUR

STAGES OF LABOUR

SORCES OF PAIN Pain is caused mainly by uterine contractions, thinning of the lower segment of the uterus, and dilatation of the cervix. Pain result from two sources: [Link] stretching of the vagina, vulva and perineum. [Link] contraction of the myometrium. Pain is caused by the passage of the placenta through the cervix, plus that produced by the uterine contractions.

FIRST STAGE

SECOND STAGE

THIRD STAGE

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

PAIN RELIEF IN LABOUR types
Three methods are in common use during labour: 1. Analgesic drugs (narcotics, e.g. pethidine) which are given by intramuscularly injection. 2. Inhalation analgesia (e.g. Entonox). 3. Regional anaesthesia (e.g. epidural, spinal) that blocks the sensory pain pathways.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MONITORING FETAL HEART

How Do Uterine Contractions Affect Fetal Heart Rate?
Uterine contractions can affect fetal heart rate by increasing or decreasing that rate in association with any given contraction.

The three primary mechanisms by which uterine contractions can cause a decrease in fetal heart rate are compression of: Fetal head Umbilical cord Uterine myometrial vessels

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MONITORING FETAL HEART

How To Monitor The Fetal Heart Rate? Auscultation methods Electronic monitoring ~ CTG

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MONITORING FETAL HEART

To detect fetal hypoxia

ABNORMAL

NORMAL

APRIL 2005

DEPARTMENT OF OBST & GYNAE RCMP

RECORDING THE PROGRESS OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

RECORDING THE PROGRESS OF LABOUR
PATIENT INFORMATION

FETAL INFORMATION ~ fetal well being

LABOUR INFORMATION ~ Dilatation ~ Descent ~ Contraction

MEDICATIONS

MATERNAL INFORMATION ~ Well being

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

RECORDING THE PROGRESS OF LABOUR - Partogram
Patient information: Fill out name, gravida, para, hospital number, date and time of admission and time of ruptured membranes.
Fetal heart rate: Record every half hour.

Amniotic fluid: Record the colour of amniotic fluid at every vaginal examination: I: membranes intact; C: membranes ruptured, clear fluid; M: meconium-stained fluid; B: blood-stained fluid.
Moulding: 1: sutures apposed; 2: sutures overlapped but reducible; 3: sutures overlapped and not reducible.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

RECORDING THE PROGRESS OF LABOUR - Partogram
Assess the progress of labour:
Cervical dilatation: Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 3 cm.
Station : recorded as a circle (O) at every vaginal examination. Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds. Less than 20 seconds: Between 20 and 40 seconds: More than 40 seconds:

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

RECORDING THE PROGRESS OF LABOUR - Partogram
Progress of maternal well being:
Oxytocin: Record the amount of oxytocin every 30 minutes when used. Drugs given: Record any additional drugs given e.g. Pethidine Pulse: Record every 30 minutes and mark with a dot (). Blood pressure: Record every 4 hours and mark with arrows ( ) Temperature: Record every 2 hours. Protein, acetone and volume: Record every time urine is passed.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT SECOND STAGE O LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE SECOND STAGE OF LABOUR1
Once the onset of the second stage has been confirmed a woman should not be left without attendance. Accurate observation of progress is vital, for the unexpected can always happen. Maternal position:
With the exception of avoiding supine position, the mother may assume any comfortable position for effective bearing down. The semi-recumbent or supported sitting position, with the thighs abducted, is the posture most commonly adopted

Bearing down
With each contraction, the mother should be encouraged to bear down with expulsive efforts

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE SECOND STAGE OF LABOUR2
Observation during the second stage:
Four factors determine whether the second stage may be safely continued and these must be carefully monitored throughout the second stage of labour. 1. Maternal conditions Observation includes an appraisal of the mothers ability to cope emotionally as well as an assessment of her physical wellbeing. A maternal pulse rate is usually recorded quarterhourly and bloods pressure hourly 2. Fetal conditions - During the second stage, the fetal heart should be monitored either continuously or after each contraction. stage may be associated with fetal distress. The liquor amnii is observed for signs of meconium staining.

3. Uterine contractions - The strength, length and frequency of contractions should be assessed continuously.
4. The progress of descent - The progress should be recorded approximately every 30 minutes during the second stage.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE SECOND STAGE OF LABOUR3
CONDUCTING THE DELIVERY1:
When delivery is imminent, the patient is usually placed in the dorsal position, and the skin over the lower abdomen, vulva, anus and upper thigh is cleansed with antiseptic solution and draped.

DELIVERY OF THE HEAD 1) Control the delivery of the head to prevent laceration 2) Performed episiotomy if requires 3) Performed Ritgens method 4) Cleared the airway after delivery of the had

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE SECOND STAGE OF LABOUR3
PERFORMING AN EPISIOTOMY:
EPISIOTOMY "..is a surgical incision into the perineum to enlarge the space at the outlet IS EPSIOTOMY REALLY NEEDED?
Episiotomies are said to provide the following benefits: 1. 2. 3. 4. 5. Speed up the birth Prevent Tearing Protects against incontinence Protects against pelvic floor relaxation Heals easier than tears

medical research has not proven any of these benefits

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE SECOND STAGE OF LABOUR3
PERFORMING AN EPISIOTOMY:
Episiotomies are not always necessary
Episiotomy should be considered only in the case of: Complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum); Scarring of the perineum; Fetal distress.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE SECOND STAGE OF LABOUR3
PERFORMING AN EPISIOTOMY:
Incision of episiotomy

Episiotomy Types

Midline episiotomy

Mediolateral episiotomy

J-shaped episiotomy

The three major types of episiotomy

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE SECOND STAGE OF LABOUR3
PERFORMING AN EPISIOTOMY:
Making an incision
Performing an episiotomy will cause bleeding. It should not, therefore, be done too early.

Wait until: 1) the perineum is thinned out; and 2) 34 cm of the babys head is visible during a contraction.

Infiltrate perineum with local anaesthetic agent

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE SECOND STAGE OF LABOUR3
CONDUCTING THE DELIVERY2:
DELIVERY OF THE SHOULDERS Delivery of the anterior shoulder is aided by gentle downward traction on the head.

The posterior shoulder is delivered by elevating the head.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE SECOND STAGE OF LABOUR3
CONDUCTING THE DELIVERY3:
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 mothers abdomen. The time of delivery is noted.

CUTTING THE UMBILICAL CORD

After delivery, it is therefore usual to 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.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE SECOND STAGE OF LABOUR3
CONDUCTING THE DELIVERY4:
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 Apgars score of the baby should be noted and recorded.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

LABOUR AND DELIVERY

THE MECHANISMS OF NORMAL LABOUR - Occiput anterior -

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

Occiput anterior (OA)

Anterior
Pubis

Occipital bone

Right

Left

Sacrum Posterior

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

Occiput anterior positions

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MECHANISM OF LABOUR for occiput anterio

DEFINITION:

The mechanism of labour refers to the sequencing of events related to posturing and positioning that allows the baby to find the easiest way out. For a normal mechanism of labour to occur, both the fetal and maternal factors must be harmonious.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MECHANISM OF LABOUR for occiput anterior

Events of mechanism of labour: F: I: C: E: R: I: E: L: Flexion and descent Internal rotation of the fetal head Crowning Extension Restitution Internal rotation of the shoulders External rotation of the fetal head Lateral flexion of the body

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY MECHANISM OF LABOUR for occiput anterior (OA)
F I C E R I E L
Descend LOA LOT

Internal rotation of shoulder

External rotation of head LOA Restitution

Flexion
LOA

OA

Internal rotation

Extension Lateral flexion of body OA

Crowning

OA

Delivery

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT THIRD STAGE OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA1:
Delivery of the placenta occurs in 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.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

THE THIRD STAGE OF LABOUR
MECHANISM OF PLACENTA SEPARATION1:
Two mechanisms of placental separation occurs:
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)

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

LABOUR AND DELIVERY

WHAT ARE THE SIGNS OF PLACENTA SEPARATION

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA2:
CLINICAL SIGNS OF PLACENTAL SEPARATION Placental separation takes place within 5 minutes after the delivery of the infant. Signs suggesting that detachment or separation has taken place include: 1. The uterus becomes globular and hard. This sign is the earliest to appear. 2. There is often a 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. This is the most reliable clinical sign of placental separation.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA2:

After the placental separation takes place the placenta can be delivered by the: 1. Passive management wait for spontaneous expulsion of placenta 2. Active management

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

LABOUR AND DELIVERY

ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE THIRD STAGE OF LABOUR
ACTIVE MANAGEMENT OF THE THIRD STAGE Active management of the third stage (active delivery of the placenta) helps prevent postpartum haemorrhage. Active management of the third stage of labour includes: ~ use of oxytocin ~ controlled cord traction, and ~ uterine massage.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE THIRD STAGE OF LABOUR
ACTIVE MANAGEMENT OF THE THIRD STAGE ~ Use of oxytocin
Oxytocic drugs should be given with the birth of the anterior shoulder. Syntocinon is the most used oxytocic known to be effective; the addition of ergometrine may reduce blood loss. SYNTOMETRINE (oxytocin 5 IU + ergometrine 0.5 mg) widely used

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA3:
EXPULSION OF THE PLACENTA BY ACTIVE MANAGEMENT When these signs have appeared the placenta is ready for expression. If the patient is awake, she is asked to bear down while gentle traction is made on the umbilical cord. The popular and effective method of delivering the placenta is by Brandt-Andrews method.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA4:
BRANDTS ANDREW METHOD 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.

A) Placenta separation

B) Controlled cord traction

C) Delivery of the membranes

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE THIRD STAGE OF LABOUR
BIRTH OF THE PLACENTA5:
EXAMINATION OF THE PLACENTA The placenta, membranes, and umbilical cord should be examined for completeness and for anomalies.

EXAMINATION 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.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

MANAGEMENT OF THE THIRD STAGE OF LABOUR
REPAIR OF EPISIOTOMY:
Note: It is important that absorbable sutures be used for closure.
Vaginal mucosa 1. 2. Identify apex Begin suturing 1.0 cm above apex Continuous sutures Ends at the level of vaginal opening

3. 4.

Continuous sutures

Interrupted sutures

Interrupted suture or subcuticular

APRIL 2005

DEPARTMENT OF OBST & GYNAE RCMP

MANAGEMENT AFTER DELIVERY

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

NORMAL LABOUR AND DELIVERY

IMMEDIATE MANAGEMENT AFTER THE DELIVERY
EARLY POSTPARTUM MANAGEMENT:
The hours immediately following delivery and the birth of the placenta are a critical period as postpartum haemorrhage can occurs due the relaxation of the uterus. The patient is kept in the delivery suite for 1 hour postpartum under close observation. She is check for bleeding, the blood pressure is measured, and the pulse is counted. Before discharging the patient from the delivery suit it is mandatory: To check the uterus frequently to make sure it is firm and not relaxing. To remove any presence of intrauterine blood clots. The presence of these clots will interfere with retraction and the normal haemostatic mechanism of the uterus. To look at the introitus to see that there is no haemorrhage. To keep the bladder empties because full bladder can also interfere with uterine retraction. To examine the baby to be certain that it is breathing well and that the colour and tone are normal.