Download Labour management issues & referral System

Normal Labour
PROFESSOR RAZIA MUSTAFA ABBASI
Labour
 It is the process by which regular pain full uterine
contraction bring about effacement and dilatation
of cervix and decent of presenting part leading to
explosion of the fetus and placenta from the mother
Labour can occur at:
Term
Labour
PTL
1 LNMP
prolonged
24 W 28 W 37 W 40W 42W
Normal labour:
 Spontaneous
expulsion, through the natural
passages (birth canal) of a single, mature (37-42
completed weeks of pregnancy) alive
fetus,
presenting by vertex, within a reasonable time,
without fetal or maternal complications.
Physiology of labour
Mechanical theories: - uterine distension
Hormonal theories:
1. Maternal :
o
progesterone withdrawal
o
oxytocin stimulation
o
prostaglandins
o
serotonin
2. fetal:
o
fetal cortisol
o
fetal membranes
3. Neuronal factors:
o
sympathetic- alpha receptor stimulation
STAGE OF LABOUR.
STAGES OF LABOUR:
I-The First stage: stage of cervical effacement and
dilatation
Definition :the first stage of labour refers to the
period from the onset of true uterine contractions to
the fully dilation of the cervix, when the diameter of
the cervical os measures 10cm.
Duration:
o
primigravida = 8-12 h
o
multigravida = 6-8 h
Phases of the first stage:
 Latent phase: started when the cervix dilatated
slowly and reached to about 3cm.
A. in primigravida = 8h
B. in multigravida = 4h
 - Active phase: rapid dilatation of the cervix to
reach 10cm
A. in primigravda = 4h
B. in multigravida =2h
The active phase is divided into:
1. Accelerative phase
2. Slopping phase
3. Decelerative:
A. prolonged active phase
B. primary dysfunction: dilation in active
phase of<1cm/hr
C. secondary arrest: active phase dilation
stops or slow significantly.
N.B – in primigravida the cervix dilates from
above downwards, in multigravida
dilatation of the internal os, taking up of
the cervix and dilatation of the external os
occurs simultaneously.
Factors affecting cervical dilatation:
1.
2.
3.
4.
5.
Contraction and retraction of the uterus.
The bag of fore-water.
Absence of membranes.
Fitting of the presenting part to the lower
segment and the cervix.
Pre-labour changes in the cervix (eg,
softening)
II-The Second stage of labour:
stage of delivery of the fetus.
Definition: the second stage of labour refers
to the period from complete cervical
dilatation to the birth of the fetus.
Duration:
A.in primigravida =1 h
B.in multigravida = ½ h
however the timing of the second stage is
very different to determine and controversial
and can be extended as much as there is
progress in descent and no harm to the
mother or fetus
The second stage of labour had two phases:
1. Passive phase – stage of descent of the
presenting part and dilatation of the vagina
– due to contraction and retraction of the
uterine muscle.
2. Expulsive phase – stage of bearing down –
due to contraction and retraction of the
uterine muscle and voluntary efforts by
diaphragm and abdominal muscles.
A-Delivery of the fetal head:
Enter the pelvis by flexion
Engagement
Increased flexion
Internal rotation
DESCENT
Crowning
Extension
Restitution
External rotation
Delivery of the fetal head
B-Delivery of the shoulder and body:
Mechanism of labour in vertex presentation:
Definition: The spontaneous adjustments of the
fetal position and attitude to affect efficient passage
of the fetus through the pelvis, marked by
progressive descent until delivery of the fetus.
Delivery of the fetal head:
A- Descent: is a continuous movement throughout
the process of delivery, however it becomes more
rapid in the second stage of labour, it is caused by:
o-Uterine contraction and retraction.
o-bearing down effort – mainly in the second stage of
labour
In normal pelvis, the fetal head enters with
the sagittal suture in the transverse
diameter (or occasionally oblique diameter
of the brim). If the sagittal suture in
between the symphysis pubis and sacral
promontory – both parietal bones are felt
vaginally at the same level – the head is said
to be (synclitic). In such case the biparietal
diameter (9.5cm) is the diameter of
engagement. However some degree of
lateral inclination of the head over the
shoulder – (Asynclitism) is present
normally as the head enters the pelvic inlet.
*If the sagittal suture lies close to the sacrum
and the anterior patietal bone lies over the
inlet (Anterior parietal bone presentation) Anterior asynclitism.
*If the sagittal suture lies close to the
symphysis pubis and the posterior parietal
bone lies over the inlet (posterior parietal
bone presentation) – posterior asynclitism.
Increased flexion :
As the head descends, it meets resistance from
the pelvic walls and floor and this leads to
increased flexion of the head. As the head
flexed it brings the shortest longitudinal
diameter of the head (sub-occipito-bregmatic
– 9.5cm) to pass through the birth canal.
Flexion is explained by the (two armed lever
theory).
D-Internal rotation:
The internal rotation occurs as the head descends
through the pelvic cavity. As the head enters the
pelvic inlet in transverse diameter will rotate 3/8 of
the cycle to pass through the pelvic outlet in anteroposterior diameter.
The rotation is favoured by the slopping shape of the
pelvic floor, angling the leading point of the head
(occiput) in downward and forward direction, by the
effect of the contraction and retraction of the uterus.
E-Crowning, extension and delivery of the
fetal head:
The combined effect of descent and internal rotation
bring the presenting diameter to the plane of the
pelvic outlet, with the occiput lying under the pubic
arch and the sinciput at the lower border of the
sacrum or coccyx.
When the widest diameter of the fetal head is
embraced by the distended vulva, it is said to be
crowned.
The occiput remains under the pubic arch but the
sinciput sweeps forwards as the neck extends.
The head is acted upon by:
1. The downward and forward force of the uterine
contraction and retraction.
2. The upward and forward force offered by pelvic
floor resistance so the head passes forwards i.e.
extends vertex, forehead, and face come out
successively.
Frequently, especially in primigravida, the soft
tissues are not able to distend equally so that
tearing of the perineum and adjacent tissues may
occur unless steps are taken to avoid it by making
a formal incision (episiotomy).
F-Restitution and external rotation:
Following delivery of the head the occiput
rotates to the lateral position, in the opposite
direction of internal rotation to correct the twist
of the head on the shoulders produced by
internal rotation. The internal rotation of the
shoulders inside the pelvis transmitted to the
delivered head which in turn move one eight of a
circle outside the pelvis, in the same direction as
that of the restitution, so at the end the occiput
is towards one thigh and the face is towards the
other thigh.
Delivery of the shoulder and body:
The widest diameter of the shoulders,( the biacromial diameter), pass the pelvic brim at the time
when the anterior rotation of the head is occurring.
Thus the anterior rotation of the occiput is
favourable for both the head and the shoulders.
Similarly external rotation of the head is associated
with rotation of the shoulders to bring them into
the antero-posterior diameter of the outlet. With
further descent, the anterior shoulder delivered
first from under the pubic arch, followed by
posterior shoulder, during which time lateral
flexion of the trunk is occurring. The trunk and
buttocks follow with the same or the next
contraction.
Even in the course of normal delivery, there
are many variations of the mechanisms,
dependent on the variation in the size and
shape of the pelvis and of the fetal head.
III-The Third stage of labour :the stage
of expulsion of the placenta and membranes.
Duration: up to 30 minutes, however the average
length of the third stage of labour is 10
minutes.
Mechanism: the third stage is made of two
phases:
1. The first phase: phase of placental separation
occurs through the spongiosa layer of the
decidua at the time of expulsion of the baby or
very soon afterwards. The shearing force
responsible for the separation is the contraction
and retraction of the uterus, reducing the
uterine volume and the area of the placental
site, as the fetus is expelled.
2. The second phase: phase of placental expulsion
– The separated placenta descends from the
upper (active) segment into lower (passive)
uterine segment, cervix, and vagina by two
mechanisms:
A.-Schultze mechanism:(80%)
The placenta delivered as an inverted umbrella
with it’s fetal surface presenting first followed by
the membranes with retro-placental haematoma.
B.Mattews – Duncan mechanism: (20%)
The placenta delivered side way and it presents
with it’s inferior surface first.
Issues in the management of labour
 Review of antenatal record if available
 Diagnosis of labour
 Non engagement of presenting part
 Problems of first stage
 Problems of second stage
 Problem of third stage
 Contraception
 Breast feeding
High risk pregnancy
 Age:<20 or >35
 Parity: Primigravida or Grand multipara
 Previous obstetric out come and mode of delivery
 Any medical disorder: hypertension/ diabetes
/epilepsy/autoimmune disorder
 Any obstetric problem in previous pregnancy:
difficult delivery/ instrument delivery
/PPH/Perineal tears
Diagnosis
A.
symptoms:
1.
True labour pains – colicky pain in the abdomen and back
are characterized by:
character
True labour pain
contractions
regular
Interval between
contractions and
intensity
Changes in the cervix
Progressive (increase in
frequency and
intensity)
False labour pain
Irregular
Short duration, not
progressive
Associated with
effacement and dilation
of the cervix
Not associated with
effacement and dilation
of the cervix
Membranes
Associated with bulging of
membranes
Not associated with
bulging of membranes
Response to analgesia
Not relieved by sedation
Relieved by sedation
Labour
Followed by labour
Not followed by labour
Causes of non-engagement:
 Erroneous dates (primigravida)
 Extra-uterine:
A. full bladder or loaded rectum
B. Pelvic tumours
C. Pendulous abdomen and marked lumbar lordosis.
D. High angle of inclination of the pelvis.
E. Contracted pelvis.
 -Uterine:
A. Poor uterine tone.
B. Congenital deformities.
C. Fibromyomata.
D. Placenta previa.
 -Fetal:
A. polyhydramnios.
B. Short umbilical cord(acutal or relative,
due to entanglement)
C. Large baby.
D. Deflexion attitude, and malposition.
E. Multiple pregnancy.
F. Hydrocephalus.
Engagement – can be assessed by abdominal
station in fifths during antenatal period,
and by abdominal and vaginal stations
during labour.
Partogram - Maternal
Name / DOA /Gestation
Medical / Obstetrical issues
HR / BP/ Temp
Urinanalysis
Partogram - Fetal
 Fetal heart rate
Colour of liquor
 Moulding
Moulding of the skull:
 means obliteration of the suture line between
the bones and overlapping of the un-united
bones of the fetal skull, and is measured by
degree.
Degree
Clinical finding
+
++
+++
Suture line closed, no overlap
Overlap of suture line reducible
Overlap of suture line irreducible
As the degree of moulding increase- means there is CPD
Partogram - Progress
Uterine contractions
Cervical dilatation
Descent of presenting part
Caput / Moulding
Fetal position
FRIEDMAN’S CURVE
Problem of first stage
10
9
8
7
6
5
4
3
2
1
0
Dilatation
2
4
6
8
10
12
Problem of first stage
10
9
8
7
6
5
4
3
2
1
0
Dilatation
6
8
10
12
14
Problem of second stage
10
9
8
7
6
5
4
3
2
1
0
Dilatation
6
8
10
12
14
16
What can go wrong?
Powers
Poor contractions/Maternal effort
Passages
Small pelvis/Pelvic shape
Passenger
Big baby/Presentation/Malposition
Abnormal powers
 Artificial rupture of membranes
 Oxytocin infusion
 Change position
 Encouragement
 Review after four hours if no improvement refer for
operative delivery.
Problem in passenger/pelvis
Refer for operative delivery if there is problem with
passenger/ passage
Passenger
 Good size baby
 Malpresentation
 Malposition
 Congenital abnormalities
 Multiple pregnancies
Problem in passenger/pelvis
 Contracted pelvis
 CPD
 Congenital abnormalities of pelvis
Problem of third stage
 Post partum haemorrhage
 Retained placenta
 Morbidly adherent placenta
 Uterine inversion
 Uterine rapture
REFERRAL FORMS
Management of labour
The management of labour should be commenced
during the antenatal period, and the women should
be classified as high or low risk pregnancy. The
medical or surgical problems should be corrected
as in case of (anaemia, hypertension, urinary tract
infection), vaccination should be given if necessary,
and all investigations should be performed and
prepared such as (HIV, HCV, Hbs Ag, blood
grouping…….etc).
Also the patient should be advised to attend the
antenatal class (parenterful class) and visit the
hospital including the labour ward to be familiar to
the place and staff.
Once labour is commenced and the patient arrived
to the admission room the following to be done:
A. -Taking history or reviewing the antenatal file.
1-Last menstrual period – expected date of confinement.
2-Time of onset of labour.
3-Frequency and duration of contraction (3-4cm/10min).
4-Presence or absence of amniotic fluid leakage.
5-Presence or absence of show or vaginal bleeding.
6-Past obstetric history especially mode of previous
delivery, presentation, mode of delivery, and weight
of previous children.
7-Past medical or surgical history that may affect labour
or delivery, especially diabetes, heart disease,
respiratory disease allergies, and any medication.
B-Examination:
1. .General:
a-pallor, oedema, varicosities, height, and built.
b-Vital signs (BP, P, T)
c-Examination of heart, lungs, breast and other
organs if necessary
2. .Abdominal Examination:
a-To determine fundal height in cm using tape
measure (to determine gestational age
clinically), fetal lie, presentation, engagement
in fifths, size of the fetus, amount of liquor,
fetal heart rate.
b-The frequency and duration of the contraction.
3. .Vaginal Examination: to assess the following.
a-Cervical dilatation in cm and effacement in %.
b-Length of the cervix.
c-Consistency of the cervix
d-Position of the cervix
e-State of the membranes, amount and colour of
liquor.
f-fetal presentation, position and station.
g-pelvic architecture.
DO NOT DO VAGINAL EXAMINATION IN
CASES OF VAGINAL BLEEDING BEFORE THE
PLACENTA PREVIA IS EXCLUDED.
DO STERIL SPECULUM EXAMINATION IF
SUSPECTED PLROM, IF THE WOMAN IS NOT
IN LABOUR.
If the woman diagnosed as having active labour –
to be admitted to labour ward.
N.B- active labour means –regular strong and
frequent uterine contraction 3-4/10min lasting 4550 sec, and the cervix is fully effaced and 2.5-3cm
dilated.
Arrival to the labour ward:
I-first stage of labour:
1-Ensure patient’s privacy by covering her with
sheaths or blankets.
2-Reassure and show great sympathy and interest.
3-Record maternal vital signs every hour (BP, P, T).
4-Take blood for grouping and cross match for high
risk patients.
5-Monitor:
a-high risk patients should have a continuous
electronic fetal heart monitoring.
b-low risk patients should have brief electronic fetal
heart monitoring if NORMAL, to be followed by
intermittent auscultation:
-first stage every 15min
-second stage every 5min
6-Limit oral intake to small amount of clear fluid or
frozen pineapple.
7-Give all patients in active labour Ranitidine
(Zentac) 150mg orally / 6hourly.
8-Nurse the patient in:
a-left lateral position for mediated patients.
b-sitting or semi-reclining for unmediated patients.
9-Encourage spontaneous voiding, catheterization
may be necessary.
10-Test all urine specimen for proteins, sugar, and
acetone.
11-Give IV fluids during labour to avoid
dehydration
a-0.9%
Nacl or hartmann’s solution at 80125ml/hr
b-Supplementation with 5% dextrose to prevent
ketosis and hypoglycemia.
12-Give analgesia/anesthesia as required.
a-Pethidine (50-150mg)IM.
b-Diamorphin (5-10mg)IM. Every 3-4 hours.
*avoid giving it too early in labour < 3-4cm
cervical dilation or too late when the delivery is
expected within 1-2hours.
*if given too late:
-inform the pediatrician
-give Naloxon (Narcon) 0.02mg IM to the neonate.
c-Use Entonox (NO2 50%+O2 50%) by mask if
available.
d-Use epidural analgesia in selected cases if
available such as Breech, Twins, preterm delivery.
e-Give anti-emetics such as Metoclopromide (510mg)IM if necessary, but should not be routine.
13-Do vaginal examination to:
a-assess progress of labour every 2-4hr
b-or immediately after rupture of membranes
c-FHR abnormalities.
14-Recall all the observations in labour in
Partogram.
15-Consider augmentation with syntocinon if
progress of labour is slow (partogram).
-1000 ml Hartmann’s solution or normal saline +
10 units syntocinon (pitocin)
-Begin the infusion using a pump at 4 milliunits per
minute and double the dose every 20 minutes to a
maximum of 32 milliunits/min.
-Or begin with 15 drops / min and increase the
rate by 10 drops every 30 minutes untill adequate
contractions.
II-second stage of labour:
Once the patient reach the second stage of labour and have
the desire to push down then:
1-Put the patient in lithotomy position or other positions clean
the vulva, and perineum with antiseptic solution.
2-Encourage organized pushing down which she is feeling to
do so
3. -Monitor the uterine contraction and fetal heart more
frequent.
4. -Use syntocinon if progress is slow and no contractions.
5. -When the head appears at the vulva, the perineum is
supported during uterine contraction by sterile pad to
promote flexion and prevent premature extension of the
head by pressing up on the sinciput until crowning occur.
6. -After crowning the head is allowed to be
delivered by extension slowly in between the
contractions by sliding the perineum over the
face.
7. -DO episiotomy if necessary under local
anaesthetic ( 10-20 ml) of 1% lignocain, but
should not be routine.
8. -Wait for the next contraction to deliver the
shoulder and trunks.
9. -Clamp and deliver the cord and baby to be
handled to pediatrician.
III-Third stage of labour:
The management of third stage is aimed at:
1-Complete delivery of the after birth
(placenta and membranes).
2-Prevention of acute inversion of the
uterus.
3-prevention of postpartum haemorrhage
A-Delivery of the placenta and membranes:
a-Conservative method: the left hand is
placed over the abdomen to detect any
change in the level of the fundus or sign of
placental separation and decent are
detected, the patient is asked to bear down
to deliver the placenta spontaneously.
Ergometrine 0.5mg or Syntometrine(5 units
syntocinon + 0.5mg Ergometrine) to be
given intravenouslly.
Signs of separation
placenta:
and
decent
of
the
1. -The body of the uterus becomes smaller, harder,
and globular.
2. -The fundal level rises in the abdomen because
the lower segment becomes distended by the
placenta.
3. -Suprapubic bulge may appear due to presence
of the placenta in the lower segment.
4. -Elongation of the cord out side the vulva.
5. -Sudden gush of blood from the vagina.
b-Active methods(prophylaxis against postpartum
haemorrhage)
1-Give Methargine 0.5 mg IM or Syntometrine
(5units oxytocin+0.5mg Methargine), at the
time of the anterior shoulder is free from
symphysis pubis or as soon as possible
thereafter.
2-Deliver the placenta and membranes by control
cord traction by right hand, and the left hand is
placed on the suprapubic region, pushing the
uterus upwards.
N.B. USE SYNTOCINON RATHER
METHARGINE
IN
CARDIAC
HYPERTENSIVE CASES.
THAN
AND
IV-Post Delivery:
1-examine the placenta for their completeness,
anomalies, length, and number of vessels in the
cord and record the placental weight.
2-Suture the episiotomy or any laceration.
3-Estimate blood loss, count swabs, and take cord
blood for Hb, blood group, Rh, bilirubin, and
coomb’s test for Rh negative mother.
4-Check BP, P, T, Lochia and firmness of the uterus
before transferring the patient.
5-Continue an infusion of syntocinon through the
first hour if necessary.
6-Allow no food during the first hour, sips of water
may be taken, encourage nursing.
V-Care of the new born infant:
1. -Clearance of the new passages.
2. -Determine the Apgar score one and five minutes
- heart rate
- respiratory rate
- muscle tone
- colour
- reflex irritability
3-Care of the umbilical cord stump
4-General assessment of the infant to exclude any
congenital anomalies.
5-Identification of weight, estimate the gestational
age, dress it and put a mask to identify it.
6-Protect the baby against cold.