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Normal Labour, DeliveryNormal Labour, Delivery
andand
Postnatal CarePostnatal Care
AIMS
• Understand the process of normal labour
• Understand what Active Management of the
Third Stage of Labour (AMTSL) is and it’s
importance
• Knowledge of evidence based practices
When is a Woman in Labour?
• Diagnosis of Labour
 2-3 uterine contractions in 10mins
 Progressive shortening and thinning of the
cervix during labour and
 Cervical dilatation
 4cm or more dilated
Normal Labour
• Stages of Labour
 First Stage: onset of labour pains to full dilatation
of the cervix
 Second Stage: full dilatation of the cervix to the
delivery of the baby
 Third Stage: starts after the delivery of the baby
ending with the delivery of the placenta
 Immediate postpartum (‘Fourth Stage’): frequent
monitoring in the one hour following delivery
Supportive Care
• Many providers continue to use, untimely,
inappropriate and/or unnecessary interventions,
leading to complications
• Example: immobilising women, not allowing
eating and drinking
Supportive Care
• Supportive care during labour is the most
important thing to help the woman tolerate
labour pains and facilitate the progress of
labour
Supportive Care
• Support from a birth partner or companion.
• Good communication and building trust with
staff.
• Encourage walking around and changing
positions frequently.
• Encourage adequate intake of food and drinks
• Monitor maternal and fetal wellbeing using
the partograph
Care that is of no proven benefit
• Routine shaving of the pudendal area.
• Giving an enema.
• Routinely cutting episiotomy for delivery.
• Application of fundal pressure
Management of Labour
• Not in active labour
(cx 0-3cm, contraction <2/10)
- Monitor every hour: contractions, FHR
- Monitor every 4 hours: HR, BP, temp
• In active labour
(cx 4cm or more)
- START partograph
- Monitor every 30 min: contractions, FHR,
presence of any danger signs
- Monitor every 4 hours: cervical dilatation, HR,
BP, temp
Assessing Progress in Labour
- Assessing changes in cervical dilatation and
effacement (PV examination)
- Foetal descent (PV and Abdominally)
Normal labor   amtsl
5ths
of Head palpable above symphysis pubis
Second Stage
• Once the cervix is fully dilated, encourage the
woman to assume the position she prefers to
push only with a contraction.
 Squatting, sitting and standing positions may
make pushing easier
 Avoid routine catheterization which may lead to
infections.
 When delivery is imminent the women may be
put in dorsal lithotomy position for the actual
conduct of delivery
Second Stage
Delivery of the head:
 Control birth of the head to keep it flexed.
 Gently support the perineum as the baby’s
head delivers.
 Feel around the baby’s neck for the umbilical
cord:
- if the cord is loose, slip it over the baby’s head
- if the cord is tight clamp and cut it.
[!] NO routine episiotomy
Second Stage
Completion of delivery :
• Allow the baby’s head to turn spontaneously.
• Deliver one shoulder at a time - anterior then
posterior.
• Support the rest of the baby’s body as it slides out.
• Dry and wrap baby, assess breathing
• Ensure the baby is kept warm and in skin-to-skin
contact on the mother’s chest/abdomen.
Third stage of labor
The classical expectant management
• Wait for the natural forces of labor to bring
about 3rd
stage contraction and placental
separation
• Look for the signs of placental separation
• Controlled cord traction to expel the placenta
and membranes
• Optional administration of Oxytocics
Active management of 3rd
stage
• Oxytocic administration immediately after
delivery of the baby so that the uterine
contractions and placental separation is not
left to the natural uncertain forces of labor
• Controlled cord traction on perception of a
strong uterine contraction with out waiting for
the actual signs of placental separation
• Uterine massage to maintain the contraction
Active Management of the Third
Stage
As practiced
• Palpate the abdomen to rule out the presence of
an additional baby(s)
• Give Oxytocin: 10 units
• Clamp and cut the umbilical cord
• Controlled cord traction on perception of a
strong uterine contraction with out waiting for
the actual signs of placental separation
• Uterine massage to maintain the contraction
Controlled Cord Traction
• Should be done only when the uterus is
felt to have contracted strongly
• Make sure the bladder is empty
• Hold the clamped cord in one hand and
with the other hand apply counter
traction on the uterus. Keep slight
tension on the cord and await a
contraction.
Controlled Cord Traction
Cont
• Pull downward on the cord to deliver the
placenta, applying counter traction to the
uterus with the other hand
• If it does not succeed at first attempt wait for
some more time for a stronger uterine
contraction
• Stress on a complete examination of the
placenta for any retained placental fragments
Third Stage
• As the placenta delivers, gently turn it until
the membranes are twisted and slowly pull
to complete the delivery.
• Check the placenta to be sure none of it is
missing.
• Examine the woman carefully and repair any
tears to the cervix or vagina or repair the
episiotomy.
[ ! ] NO routine packing of vagina while attempting a repair.
Immediate PNC - Mother
• Routine observations
• Regular checks for vaginal bleeding and contraction of
uterus.
• Examine perineum for tears.
• Pain relief
• Encourage the mother to eat, drink and rest
• Consider IUD insertion
• Identify any signs of complications, stabilise and REFER
Observations
• 1-2 hours: every 15 minutes
• 3-5 hours: every 30 minutes
• >5 hours: every 4 hours
• Length of stay in health facility: Advise
observation for 24hours
Immediate PNC - Newborn
• Encourage early breastfeeding
• Keep warm, check temp every 15min by feeling the feet
• Examine for any malformation or abnormality > REFER
• Care of the cord, check for bleeding
• Give VIT K 1mg IM.
• Delay baby’s first bath to beyond 24 hours of birth
[!] Avoid separating mother from baby whenever possible. Do not leave
mother and baby unattended at any time.
[!] NO routine suction of throat and nose

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Normal labor amtsl

  • 1. Normal Labour, DeliveryNormal Labour, Delivery andand Postnatal CarePostnatal Care
  • 2. AIMS • Understand the process of normal labour • Understand what Active Management of the Third Stage of Labour (AMTSL) is and it’s importance • Knowledge of evidence based practices
  • 3. When is a Woman in Labour? • Diagnosis of Labour  2-3 uterine contractions in 10mins  Progressive shortening and thinning of the cervix during labour and  Cervical dilatation  4cm or more dilated
  • 4. Normal Labour • Stages of Labour  First Stage: onset of labour pains to full dilatation of the cervix  Second Stage: full dilatation of the cervix to the delivery of the baby  Third Stage: starts after the delivery of the baby ending with the delivery of the placenta  Immediate postpartum (‘Fourth Stage’): frequent monitoring in the one hour following delivery
  • 5. Supportive Care • Many providers continue to use, untimely, inappropriate and/or unnecessary interventions, leading to complications • Example: immobilising women, not allowing eating and drinking
  • 6. Supportive Care • Supportive care during labour is the most important thing to help the woman tolerate labour pains and facilitate the progress of labour
  • 7. Supportive Care • Support from a birth partner or companion. • Good communication and building trust with staff. • Encourage walking around and changing positions frequently. • Encourage adequate intake of food and drinks • Monitor maternal and fetal wellbeing using the partograph
  • 8. Care that is of no proven benefit • Routine shaving of the pudendal area. • Giving an enema. • Routinely cutting episiotomy for delivery. • Application of fundal pressure
  • 10. • Not in active labour (cx 0-3cm, contraction <2/10) - Monitor every hour: contractions, FHR - Monitor every 4 hours: HR, BP, temp
  • 11. • In active labour (cx 4cm or more) - START partograph - Monitor every 30 min: contractions, FHR, presence of any danger signs - Monitor every 4 hours: cervical dilatation, HR, BP, temp
  • 12. Assessing Progress in Labour - Assessing changes in cervical dilatation and effacement (PV examination) - Foetal descent (PV and Abdominally)
  • 14. 5ths of Head palpable above symphysis pubis
  • 15. Second Stage • Once the cervix is fully dilated, encourage the woman to assume the position she prefers to push only with a contraction.  Squatting, sitting and standing positions may make pushing easier  Avoid routine catheterization which may lead to infections.  When delivery is imminent the women may be put in dorsal lithotomy position for the actual conduct of delivery
  • 16. Second Stage Delivery of the head:  Control birth of the head to keep it flexed.  Gently support the perineum as the baby’s head delivers.  Feel around the baby’s neck for the umbilical cord: - if the cord is loose, slip it over the baby’s head - if the cord is tight clamp and cut it. [!] NO routine episiotomy
  • 17. Second Stage Completion of delivery : • Allow the baby’s head to turn spontaneously. • Deliver one shoulder at a time - anterior then posterior. • Support the rest of the baby’s body as it slides out. • Dry and wrap baby, assess breathing • Ensure the baby is kept warm and in skin-to-skin contact on the mother’s chest/abdomen.
  • 18. Third stage of labor
  • 19. The classical expectant management • Wait for the natural forces of labor to bring about 3rd stage contraction and placental separation • Look for the signs of placental separation • Controlled cord traction to expel the placenta and membranes • Optional administration of Oxytocics
  • 20. Active management of 3rd stage • Oxytocic administration immediately after delivery of the baby so that the uterine contractions and placental separation is not left to the natural uncertain forces of labor • Controlled cord traction on perception of a strong uterine contraction with out waiting for the actual signs of placental separation • Uterine massage to maintain the contraction
  • 21. Active Management of the Third Stage As practiced • Palpate the abdomen to rule out the presence of an additional baby(s) • Give Oxytocin: 10 units • Clamp and cut the umbilical cord • Controlled cord traction on perception of a strong uterine contraction with out waiting for the actual signs of placental separation • Uterine massage to maintain the contraction
  • 22. Controlled Cord Traction • Should be done only when the uterus is felt to have contracted strongly • Make sure the bladder is empty • Hold the clamped cord in one hand and with the other hand apply counter traction on the uterus. Keep slight tension on the cord and await a contraction.
  • 23. Controlled Cord Traction Cont • Pull downward on the cord to deliver the placenta, applying counter traction to the uterus with the other hand • If it does not succeed at first attempt wait for some more time for a stronger uterine contraction • Stress on a complete examination of the placenta for any retained placental fragments
  • 24. Third Stage • As the placenta delivers, gently turn it until the membranes are twisted and slowly pull to complete the delivery. • Check the placenta to be sure none of it is missing. • Examine the woman carefully and repair any tears to the cervix or vagina or repair the episiotomy. [ ! ] NO routine packing of vagina while attempting a repair.
  • 25. Immediate PNC - Mother • Routine observations • Regular checks for vaginal bleeding and contraction of uterus. • Examine perineum for tears. • Pain relief • Encourage the mother to eat, drink and rest • Consider IUD insertion • Identify any signs of complications, stabilise and REFER
  • 26. Observations • 1-2 hours: every 15 minutes • 3-5 hours: every 30 minutes • >5 hours: every 4 hours • Length of stay in health facility: Advise observation for 24hours
  • 27. Immediate PNC - Newborn • Encourage early breastfeeding • Keep warm, check temp every 15min by feeling the feet • Examine for any malformation or abnormality > REFER • Care of the cord, check for bleeding • Give VIT K 1mg IM. • Delay baby’s first bath to beyond 24 hours of birth [!] Avoid separating mother from baby whenever possible. Do not leave mother and baby unattended at any time. [!] NO routine suction of throat and nose