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Normal labour
Normal labour
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Labor

  1. 1. NORMAL LABOR Balemlay S (MD) March 2018
  2. 2. Labor • Outline Definition of labor Physiology of labor Mechanism of labor Management of labor Partograph Reference 4/27/2018 Balemlay S (MD) 2
  3. 3. labor  Labor is the physiological process by which a fetus is expelled from the uterus to the outside world. Labor is a clinical diagnosis, classically defined by the triad of: 1 regular painful uterine contractions, 2 progressive cervical effacement and dilatation 3 show (bloody discharge). 4/27/2018 3Balemlay S (MD)
  4. 4. Diagnosis of labor - At least two contraction per 20 minutes lasting 20 seconds, and - Cervical dilatation of 3-4 cm or more - Cervical effacement of 80% or more - Show - Rupture of membranes At least two criterias needed to make the diagnosis. 44/27/2018 Balemlay S (MD)
  5. 5. Remember…… 1) Show should be disregarded if there is a membrane rupture or digital PV exam done with in 48 hours prior to show. 2) Rupture of the membranes without presence of painful uterine contractions is PROM, 3) Cervical change without presence of painful uterine contractions is either cervical incompetence, or a normal finding in most multiparous woman. 4/27/2018 5Balemlay S (MD)
  6. 6. WHO definition of normal labor and delivery:  spontaneous in onset & at term  low-risk at the start of labor and remaining so throughout labor and delivery.  The infant is born spontaneously  in the vertex position & single ton  After birth, mother and infant are in good condition  within a reasonable time (not less than 3 hours or more than 18 hours) 4/27/2018 6Balemlay S (MD)
  7. 7. Physiology of labor • The physiology of labor initiation has not been completely elucidated. • Labor is species specific, mechanism in humans is unique. 1. Hormonal factors: a. Estrogen theory: During pregnancy, most estrogens are in binding state. • more free estrogen appears increasing the excitability of the myometrium and prostaglandins synthesis. 4/27/2018 7Balemlay S (MD)
  8. 8. Physiology- cont’d b. Progesterone withdrawal theory c. Prostaglandins theory: PGF2a was found to be increased in maternal and fetal blood as well as the amniotic fluid late in pregnancy and during labor. d. Oxytocin theory: The secretion of oxytocinase enzyme from the placenta is decreased near term due to placental ischemia leading to predominance of oxytocin’s action e. Fetal cortisol theory: Increased cortisol production by adrenal increases estrogen production. 84/27/2018 Balemlay S (MD)
  9. 9. Physiology- cont’d 2. Mechanical factors: a. Uterine distension theory: explains the preterm labor in case of multiple pregnancy and polyhydramnios. b. Stretch of the lower uterine segment by the presenting part at term 94/27/2018 Balemlay S (MD)
  10. 10. Phases of labor • Phase 0 (Phase of quiescence): - Refers the time in utero before onset of labor. - Uterine activity is suppressed • Phase 1 (Activation phase): - Estrogen facilitates expression of myometrial receptors for PGs and oxytocin- Gap junctions - Prepares the uterus for subsequent stimulation phase 104/27/2018 Balemlay S (MD)
  11. 11. Phases-cont’d • Phase 2 (Stimulation phase): - Uterotonics, particularly PGs and oxytocin stimulate regular uterine contractions • Phase 3 (Uterine involution): - After delivery, mainly mediated by oxytocin. 114/27/2018 Balemlay S (MD)
  12. 12. Phases of labor 4/27/2018 12Balemlay S (MD)
  13. 13. Mechanisms of labor • It is also known as the cardinal movements, described in relation to a vertex presentation • cardinal movement refers to the changes in position of fetal head during its passage through the birth canal. • Because of asymmetry in fetal head and maternal pelvis, such rotations are needed for negotiation. • Although labor and delivery occurs in a continuous fashion, the cardinal movements are described as 7 discrete sequences. 134/27/2018 Balemlay S (MD)
  14. 14. Cardinal movements - cont’d 1. Engagement: the passage of widest diameter of presenting part to a level below the plane of pelvic inlet. On the pelvic examination, the presenting part is at 0 station, or at the level of the maternal ischial spines. 2. Descent: downward passage of presenting part through the birth canal - This occurs intermittently with contractions. - Greatest descent occurs in deceleration phase (late active stage) & second stage 144/27/2018 Balemlay S (MD)
  15. 15. Cont’d 3. Flexion: Occurs passively - Helps to present the smallest presenting diameter (i.e. from occipitofrontal (11.0 cm) to suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis.). 4. Internal rotation: Passive movement due to shape of pelvis and pelvic musculature. - Rotation of the presenting part from its original position to AP position & in line with the AP diameter of the pelvic outlet. 5. Extension: Occurs once fetus descended to a level of interoitus - Is because of force of uterine contraction versus muscles of the pelvic floor. the result is delivery of the head 154/27/2018 Balemlay S (MD)
  16. 16. Cont’d 6. External rotation: also called as restitution - Return of fetal head to the correct postion in relation to fetal torso. - Passive movement - Results from maternal bony pelvis & its musculature and basal tone of fetal musculature 7. Expulsion: Delivery of rest of fetus. 164/27/2018 Balemlay S (MD)
  17. 17. 174/27/2018 Balemlay S (MD)
  18. 18. STAGES OF LABOR • Four arbitrary stages of labor: to facilitate study and to assist in clinical management. - First stage of labor: onset of labor till full(10cm) cervical dilatation Latent phase: onset of labor to 3 cm cervical dilatation. Active phase: 4 cm – 10 cm cervical dilatation. • Rate of cervical dilatation is 1.2cm/hr in primi & 1.5 cm/hr for multi • Average duration of first stage is 12 hrs in primi and 6 hrs in multi. 4/27/2018 18Balemlay S (MD)
  19. 19. Second stage  from full cervical dilatation of cervix to delivery of fetus. Second stage lasts an hour in primi and 20 minutes in multi. Rate of descent is 1cm/ hr in primi & 2cm/hr for multi. 4/27/2018 19Balemlay S (MD)
  20. 20. Third stage • Third stage of labor: from delivery of fetus till delivery of placenta. • Average duration is 15 minutes for both. • FOURTH STAGE: first one to two hours after delivery of placenta, where PPH is high. - This stage is a critical time for monitoring of vital signs and observe for blood loss & uterine contractility. 4/27/2018 20Balemlay S (MD)
  21. 21. Success of labor determined by 3P’S • POWER • PASSENGER • PASSAGE 4/27/2018 Balemlay S (MD) 21
  22. 22. Labor - Mechanics 1 Powers (uterine contractions) It has two major goals: • To dilate cervix • To push the fetus through the birth canal • Assessment: - Simple observation - Manual palpation - External objective assessment-tocodynamometer - Direct measurement by intrauterine pressure catheter 4/27/2018 22Balemlay S (MD)
  23. 23. Power(ctd) • Adequate uterine contraction 3-5 contractions in a 10 minute period 200-250 Montevideo ???Hyper stimulation, tachysystole, hypertonus. 4/27/2018 23Balemlay S (MD)
  24. 24. 2 Passenger (fetus) 1. Fetal size 2. Fetal Lie – longitudinal, transverse or oblique 3. Fetal presentation – vertex, breech, shoulder, compound 4. Attitude – degree of flexion or extension of the fetal head 5. Position _ Depending on the reference point or denominator 6. Station – degree of descent of the presenting part of the fetus, measured in centimeters from the ischial spines 7. Number of fetuses 8. Presence of fetal anomalies – hydrocephalus, sacrococcygeal teratoma 4/27/2018 24Balemlay S (MD)
  25. 25. 3 Passage (pelvis) • Consists of the bony pelvis and soft tissues of the birth canal. • Bony pelvis can be measured by pelvimetry but it is not accurate and it has been replaced by a clinical trial of labor. 4/27/2018 25Balemlay S (MD)
  26. 26. 4/27/2018 26Balemlay S (MD)
  27. 27. True labor Vs False labor True labor pain False labor pain Regular Irregular Increase progressively not Lower abdomen & back Lower abdomen Dilatation & effacement of cervix No effect on cervix Not relieved by sedatives & antispasmodics Relieved 27
  28. 28. MANAGEMENT OF NORMAL LABOR  Admission criteria for labor 1. All women with diagnosis of labor ( latent and active) with ruptured membranes, or 2. All women with diagnosis of labor ( latent and active) with known risk factor, or 3. All women with diagnosis of active labor (i.e. cervix dilation is ≥ 4 cms with complete or 100% effacement) with/without presence of rupture of membranes or risk factor 4/27/2018 28Balemlay S (MD)
  29. 29. MANAGEMENT OF NORMAL LABOR(ctd) • Psychosocial issues - emotional support - Inform about maternal & fetal conditions • Evaluation: - Review prenatal record for medical & obstetrical condition - check development of new disorder - Thorough history & physical examination 4/27/2018 29Balemlay S (MD)
  30. 30. MANAGEMENT OF NORMAL LABOR(ctd) • Laboratory Studies BG &Rh ,Hct /Hgb ,HIV test, Urine analysis • Position: can assume any position except supine. • Diet: fluid diet, intravenous hydration when indicated 4/27/2018 30Balemlay S (MD)
  31. 31. Management of the First Stage of Labor FHB every 30 minutes in low risk & every 15 minutes in high risk - FHB has to be counted for a full minute just after contraction. - Uterine contraction every 30 minutes, monitor for 10 minutes - Pelvic evaluation every 4 hrs unless indicated. - Maternal vital signs: every 2-4 Hrs 4/27/2018 31Balemlay S (MD)
  32. 32. Management of the Second Stage of Labor -FHB every 15 minutes in low risk & 5 minutes in high risk mothers. - Monitor descent hourly. - Expulsive Efforts:instruct to exert downward pressure as though she were straining at stool during contraction. - DELIVERY: use aseptic technique Reduce risk of maternal perineal injury Prevent fetal injury Provide initial support to newborn 4/27/2018 32Balemlay S (MD)
  33. 33. Active management of the third Stage of Labor(AMTSL) • use of utertonics, • controlled cord traction and • uterine massage Who should get AMTSL? What are benefits of AMTSL? 4/27/2018 33Balemlay S (MD)
  34. 34. Partograph • It is the graphic recording of the progress of labor and the salient condition of the mother & fetus. • Designed by WHO for use in developing countries. • It serves as an “early warning system” . 4/27/2018 34Balemlay S (MD)
  35. 35. Partograph(ctd) Components: 4 - Patient information - Fetal condition - Progress of labor - Maternal condition 4/27/2018 35Balemlay S (MD)
  36. 36. 4/27/2018 36Balemlay S (MD)
  37. 37. • Sample Partograph for Normal Labor 37
  38. 38. 38
  39. 39. Advantages of partograph • Early detection of abnormal labor and prevention of prolonged labor • ↓ maternal - perinatal morbidity & mortality • Pictorial (graphic or clear) display of events of labor: - Clarifies recordings - Avoids lengthy written notes - Facilitates recognition of any omissions - Saves time → Companionship 4/27/2018 39Balemlay S (MD)
  40. 40. Advantages of partograph(ctd) • Low cost, feasible • All interrelated variables of labor can be seen on a single paper. • Hand over of patients 4/27/2018 Balemlay S (MD) 40
  41. 41. Reference 4/27/2018 Balemlay S (MD) 41
  42. 42. THANK YOU 4/27/2018 Balemlay S (MD) 42
  43. 43. Quiz on Review of labor 1 What is labor? 2 What are the diagnostic criteria of labor? 3 List down criterias for of normal labor. 4 What are determinant factors for success labor? 5 What are the admision criterias of labor? 6 List down cardinal movements in their order. 7 Who should get AMTSL? 8 What are benefits of AMTSL? 9 How do differentiat true from false labor? 10 List down component & advantages of partograph. 4/27/2018 Balemlay S (MD) 43

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