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Normal labour and delivery ppt
- 1. NORMAL LABOUR AND DELIVERY RHEA MARCANO 413003930
- 2. CONTENTS • 1. Definition of normal Labour • 2. Factors influencing progress of Labour • 3. Diagnosis of Labour • 4. Stages of Labour • 5. Management of Labour
- 3. LABOUR DEFINITION LABOUR IS DEFINED AS THE ONSET OF REGULAR PAINFUL CONTRACTIONS WITH PROGRESSIVE EFFACEMENT AND DILATATION OF THE CERVIX ACCOMPANIED BY DECENT OF THE PRESENTING PART LEADING TO EXPULSION OF THE FETUS OR FETUSES AND PLACENTA FROM THE MOTHER.
- 4. FACTORS TO HELP DETERMINE IF LABOUR IS NORMAL • Mature Fetus 37-42 weeks • Spontaneous expulsion • Vertex is the presenting part • Vaginal Delivery • Time ( not < 3hour but not >18 hours) • Complications??
- 5. INFLUENTIAL FACTORS OF THE PROGRESS OF LABOUR • 3P’s • Power • Passenger • Passage
- 6. FEMALE PELVIS • Basic framework for the birth canal • True Pelvis- Inlet, cavity and Outlet ( The fetus must pass through all three in order for labour to be sucessful) • Types of Pelvis- Gynaecoid, Anthropoid, Android and Platypelloid
- 9. MOULDING The bones of the fetal head can move closer together or overlap to help the head fit through the pelvis. Parietal bones overlap occipital and frontal bones. Moulding can be staged from +1 to +4, +1-+3 being normal and +4 being cause for some concern.
- 10. DIAMETERS OF THE SKULL
- 12. CAUSES OF THE ONSET OF NORMAL LABOUR • It is unknown but the following theories are proposed: • Hormonal Factors • Oestrogen Theory • Progesterone withdrawal theory • Prostaglandin Theory • Oxytocin Theory • Fetal Cortisol Theory • Mechanical Factors • Uterine Distension Theory • Stretch of the lower uterine segment
- 15. Friedman’s Curve
- 16. DIAGNOSIS OF LABOUR • Signs that can clue you into the onset of Labour • Show- evidence by mucus mixed with blood or mucus plug • Rupture of membranes- look for leaking liquor • panful, regular uterine contractions, atleast (1:10)
- 18. • ON ADMISSION: Review antenatal record Complete history if record isn't available • GENERAL EXAMINATION OF MOTHER General condition- pallor, oedema, abdominal scars, maternal height Vital signs- Blood pressure, Pulse, respiration, temperature (measured and recorded) Heart and Lungs Urinalysis- protein, sugar, ketones
- 19. • Abdominal Examination: Detail examination, determine fetal presentation, position and engagement Auscultate fetal heart sound Evaluate uterine contractions Attach Carditocography (CTG) for 20 min trace
- 20. • VAGINAL EXAMINATION Confirm degree of dilatation and effacement Identify the presenting part Fetal head engagement if any doubt Confirm or artificially rupture if necessary (ROM) Exclude cord prolapse • BLADDER/BOWEL CARE Administer an Enema allow to empty bladder ever 1 1/2 - 2 hours
- 21. • NUTRITION IN EARLY LABOUR No food after labour is established to prevent regurgitation and aspiration Place IV to start administration of fluids • POSITIONING OF LABOURING MOTHER Once everything is well with mom and baby, patient may ambulate or lay in bed as the feel comfortable • MONITORING, PROGRESS OF LABOUR • PAIN RELIEF Opiate drugs- Pethidine given IM q4hrly Epidural analgesia
- 22. PARTOGRAM • A cartogram is a composite graphical record of key data (maternal & fetal) during labour entered against time on a single sheet of paper. • Relevant measurements such as cervical dilatation, fetal heart rate, duration of labour and vital signs • Monitors progress of Labour
- 24. COMPONENTS OF A PARTOGRAM • Patient Identification • Time (recorded in 1hr intervals) • Fetal Heart Rate • State of Membranes • Cervical Dilatation • Uterine Contractions • Drugs & Fluids • BP (2hr intervals) • Pulse Rate (30min intervals) • Oxytocin • Urinalysis • Temperature
- 25. STAGES OF LABOUR
- 27. First Stage Second Stage Third Stage Begins with the onset of true labour contractions and ends when the cervix is fully dilated (10cm). Cervical effacement and dilatation occurs in this stage 2 Phase: Latent & Active Latent: From diagnosis of labour to 3cm dilatation Active: From 3cm to ful dilatation (10cm) The second stage of labour begins with complete dilatation and ends with the birth of the baby. Approximately 2 hours in a nulliparous and 1 hour in a multiparae woman Begins after birth and ends with the expulsion of the placenta and membranes Shortest stage: After birth, up to 30 minutes
- 28. FIRST STAGE WHAT HAPPENS AND HOW TO MANAGE!
- 29. • 1. Contractions • Regular • Increasing Frequency • Stronger • 2. Cervical Dilatation and Effacement • 3. Engagement of the presenting part
- 30. MANAGEMENT • Continuity of care • Observation of progress of Labour • Monitoring fetal & maternal well-being • Adequate pain relief (according to mothers wishes) • Adequate hydration to prevent Ketosis Lactate ringer solution
- 31. SECOND STAGE WHAT HAPPENS AND HOW TO MANAGE?
- 32. SECOND STAGE • First sign of the second stage is the urge to push • Full Dilatation to Delivery of the fetus • Signs to look for:- • (1) Distention of the perineum • (2) Dilatation of the anus • Satisfactory progress:- steady descent of the fetus through the birth canal & onset of the expulsive phase
- 33. MANAGEMENT • Continuous monitoring during this phase • Maternal Position, usually semi-recumbent or supported sitting position with thighs abducted but any comfortable position expect supine for an uncomplicated pregnancy • Encourage to bear down with the contractions
- 34. MANAGEMENT (CONT’D) • Maternal condition - BP and PR measured every 15- 30mins and after contractions • Fetal Condition- Fetal heart rate, measured continuously or after contractions • Uterine Contractions- strength, length and frequency continuously assessed • Progress of descent- recorded every 30 mins
- 35. CONDUCTING THE DELIVERY • position patient • antiseptic solution to clean skin of lower abdomen, vulva, anus and upper thigh, then drape • DELIVERY OF THE HEAD • Control delivery of the head • Perform episiotomy if required • Perform Ritgen’s Maneuver • Clear the airways after delivery of the head
- 36. CONDUCTING THE DELIVERY (CONT’D) • DELIVERY OF THE SHOULDERS • Anterior shoulder assisted by gentle downward traction of the head • Posterior shoulder is delivered by elevating the head.
- 37. CONDUCTING THE DELIVERY • DELIVERY OF THE TRUNK • Grasp baby around the chest after shoulders delivered to help with birth of trunk • Baby swept unto mother’s abdomen • Note time of delivery • CUTTING THE UMBILICAL CORD • wait 15-20 seconds then clamp • plastic crushing clip placed 1-2cm above umbilicus and cut 1cm beyond the clamp
- 38. IMMEDIATE CARE OF THE NEWBORN • Assess baby • Health baby with spontaneous respiration place on mother’s abdomen, dry& cover baby • No spontaneous respiration or respiratory problems then resuscitate baby • APGAR scores
- 39. EVENTS OCCURRING DURING LABOUR • Flexion and Descent • Internal Rotation of the fetal head • Crowning • Extension • Restitution • Internal rotation of the shoulders • External rotation of the fetal body • Lateral flexion of the body
- 41. THIRD STAGE WHAT HAPPENS AND HOW TO MANAGE?
- 42. THIRD STAGE • Begins with fetus delivery and ends with delivery of the placenta/membranes • Two phases: Separation and Expulsion • 30 mins or less • Average blood loss 150-250 mld
- 43. MANAGEMENT • BIRTH OF THE PLACENTA • Two (2) stages:- • Separation of the placenta from the wall of the uterus and into the lower uterine segment or vagina • Actual expulsion of the placenta out of the birth canal
- 44. TWO MECHANISMS OF SEPARATION • Mathews-Duncan mechanism (raw surface exposed when delivered) • Schultz Mechanism (placenta inserted at fundus, placenta inverts and covers the raw surface)
- 45. SIGNS OF SEPARATION • Globular and hard uterus • Sudden gush of blood • Cord Lengthening (Most reliable clinical sign)
- 46. BIRTH OF THE PLACENTA • Two methods: • Passive Management (wait for spontaneous expulsion of the placenta) • Active Management
- 47. ACTIVE MANAGEMENT OF THE THIRD STAGE • Help prevent postpartum hemorrhage • Includes:- • Use of oxytocin (given around the time of the anterior shoulder delivery, 10 units) • Controlled cord traction • Uterine massage
- 48. ACTIVE PLACENTA DELIVERY • Brandt’s Andrew method • Placenta separation • Controlled cord traction • Delivery of the membranes • Examination of the Placenta:- placenta, membranes & umbilical cord for completeness and anomalies
- 49. • EXAMINATION OF THE PERINEUM • look for lacerations, also vulva outlet, vaginal canal & cervix should be inspected • Repair lacerations or episiotomies immediately
- 50. IMMEDIATE MANAGEMENT AFTER THE DELIVERY • EARLY POSTPARTUM MANAGEMENT • Monitor for postpartum hemorrhage, keep for atlas 1 hour in delivery suite (bleeding- ask to report any sudden gushes of blood, bp and pulse) • Before discharging from delivery suite • Check uterus frequently to ensure it is firm • Remove intrauterine clots • Look at introitus for NO hemorrhage • Keep bladder empty • Ensure baby is breathing well, pink and well flexed
- 51. REFERENCES • Obstetrics ten teacher • Various online resources
- 54. • Engagement: The fetus is engaged if the widest leading part (typically the widest circumference of the head) is negotiating the inlet. • Station: Relationship of the bony presenting part of the fetus to the maternal ischial spines. If at the level of the spines it is at “0 (zero)” station, if it passed it by 2cm it is at “+2” station. • Attitude: Relationship of fetal head to spine: flexed, neutral (“military”), or extended attitudes are possible. • Position: Relationship of presenting part to maternal pelvis, i.e. ROP=right occiput posterior, or LOA=left occiput anterior. • Presentation: Relationship between the leading fetal part and the pelvic inlet: cephalic, breech (complete, incomplete, frank or footling), face, brow, mentum or shoulder presentation. • Lie: Relationship between the longitudinal axis of fetus and long axis of the uterus: longitudinal, oblique, and transverse. • Caput or Caput succedaneum: oedema typically formed by the tissue overlying the GLOSSARY
- 55. Pelvic types Traditional obstetrics characterizes four types of pelvises: • Gynecoid: Ideal shape, with round to slightly oval (obstetrical inlet slightly less transverse) inlet: best chances for normal vaginal delivery. • Android: triangular inlet, and prominent ischial spines, more angulated pubic arch. • Anthropoid: the widest transverse diameter is less than the anteroposterior (obstetrical) diameter. • Platypelloid: Flat inlet with shortened obstetrical diameter.
Hinweis der Redaktion
- Usually only know after the delivery, near impossible to predict before. But can clue us into high risk or low risk patients
- The ideal pelvis the brim is slightly oval transversely, sacral promontory isn't prominent, transverse diameter slightly larger than the AP, sidewalls parallel and straight, ischial spines not prominent, sacrosciatic notches not wide, sacrum has a good curve, pubic arch angle is wide.
- https://stratog.rcog.org.uk/tutorial/easi-resource/moulding-4947
- In 1955, Dr Friedman, from Columbia University, published a study he had undertaken of 500 first time mothers who had given birth at full term. The doctor plotted their labours on a graph, and calculated the average time it took a woman to dilate each centimetre. This graph is known as the Friedman’s Curve, used as the gold standard for rates of cervical dilation and fetal descent during active labour for the past 60 years. The graph showed the average rate of cervical dilation was about 1 centimetre per hour. The rate of dilation varied within the total time of labour, but was broken into the following sections: Length of time it took to dilate from 0cm to 4cm was 8.6 hours From 4cm to 10cm the average dilation time was about 5 hours. Because labour appeared to speed up after 4cm, this was considered to be the active stage of labour. When dilation reached 9cm, there was a slight slowing down until 10cm was reached Pushing took an average of 1 hour. How Is It Applied During Labour? The Friedman’s curve is one of the first pieces of obstetric knowledge maternity care providers learn. When a woman comes into hospital with contractions, she is usually required to have a vaginal examination, to check cervical dilation and confirm if she is in active labour (4cm dilation or more). If her cervix is not dilated 4cm or more, she is often sent home until contractions pick up. After being admitted to the maternity ward, the woman is then expected to dilate an average 1cm per hour. Most hospitals have a policy of routine vaginal examinations every 3-4 hours to check progress. A dilation rate of less than 1cm per hour is considered abnormal and labelled a ‘failure to progress’. More monitoring might be suggested and, depending on how baby is coping, augmentation might be offered. This could be breaking the waters or administering artificial oxytocin via a drip, to speed up contractions. It isn’t surprising that a cascade of intervention might begin at this stage. The mother is likely to have continuous fetal monitoring belts attached and will be unable to move freely, limiting her ability to manage contractions. The baby might not be able to move into an optimal birth position, or begin to show signs of distress. By this time, it’s very likely the mother is feeling stressed and tired. Her body begins to respond by releasing adrenaline, which will reduce levels of oxytocin, the hormone responsible for uterine contractions. Again, labour might appear to slow or stall, causing care providers to intervene further. Failure to progress is responsible for around 30% of all c-sections performed on first time mothers. It isn’t surprising that a cascade of intervention might begin at this stage. The mother is likely to have continuous fetal monitoring belts attached and will be unable to move freely, limiting her ability to manage contractions. The baby might not be able to move into an optimal birth position, or begin to show signs of distress. By this time, it’s very likely the mother is feeling stressed and tired. Her body begins to respond by releasing adrenaline, which will reduce levels of oxytocin, the hormone responsible for uterine contractions. Again, labour might appear to slow or stall, causing care providers to intervene further. Failure to progress is responsible for around 30% of all c-sections performed on first time mothers. Is Friedman’s Curve Relevant Today? The women in Doctor Friedman’s study averaged 20 years of age, and over 95% of the women were sedated during labour, as it was the era of ‘twilight sleep'. More than 50% of the women had forceps assisted delivery and around 14% were induced or had their labour augmented with artificial oxytocin (Pitocin or Syntocinon). These factors had the potential to change the pace of labour outside a woman’s normal and individual dilation pattern. Since the 1950s, labour practices, and women, have changed. Women are no longer routinely sedated during labour – epidurals are much more common. Artificial oxytocin for labour induction and augmentation is also used more commonly and forceps are no longer routinely used. Women having their first baby are more likely to be older, on average, than women 60 years ago. A great deal has changed, yet the same expectation of cervical dilation is applied. A study in 2002 showed Friedman’s curve is an inaccurate description of normal labor progression. A large study in 2010 looked at the labour records of nearly 62,500 women from 19 hospitals across the US. The research found a wide variation in cervical dilation, and the average labour was much longer than those in Friedman’s original research. On average, women began active labour at 6cm, instead of 3cm as Dr Friedman reported in 1955. The average time it took to dilate during active labour was about 30 minutes for each centimetre. Around 95% of women took less than 2 hours to dilate 1cm during active labour. Fifteen years of research has shown the average rate of cervical dilation accelerates after 6cm rather than 4cm. Care providers who are aware of this, and don’t intervene before 6cm of dilation, will limit the use of unnecessary interventions and potentially reduce the number of c-sections occurring as a result. When choosing a care provider, find out how they base cervical dilation, and whether they are aware of the more recent research showing a slower rate of dilation up to 6cm. Choosing your care provider carefully will help avoid unnecessary interventions.
- Admission Management
- Antenatal record will be able to cue you into abnormalities that may complicate labour
- Advantages[edit] • Provides information on single sheet of paper at a glance • No need to record labour events repeatedly • Prediction of deviation from normal progress of labour • Improvement in maternal morbidity, perinatal morbidity and mortality
- 1. Patient identification 2. Time: It is recorded at an interval of one hour. Zero time for spontaneous labour is time of admission in the labour ward and for induced labour is time of induction. 3. Fetal heart rate: It is recorded at an interval of thirty minutes. 4. State of membranes and colour of liquor: "I" designates intact membranes, "C" designates clear and "M" designates meconium stained liquor. 5. Cervical dilatation and descent of head 6. Uterine contractions: Squares in vertical columns are shaded according to duration and intensity. 7. Drugs and Fluids 8. Blood pressure: It is recorded in vertical lines at an interval of 2 hours. 9. Pulse rate: It is also recorded in vertical lines at an interval of 30 minutes. 10. Oxytocin: Concentration is noted down in upper box; while dose is noted in lower box. 11. Urine analysis
- First Stage: The latent phase can take up to 8 hour in a nulliparae woman and 6 hours in a multiparae woman. The active phase occurs much faster approximately 1cm/hour
- Uterine contractions can cause a decrease in heart rate or an increase in heart rate. 3 primary mechanisms by which uterine contractions decrease fetal heart rate are compression of: (1) Fetal Head (2) Umbilical Cord (3) Uterine myometrial vessels Beware of irregular or infrequent contractions after the latent phase and/or the rate of cervical dilatation slower than 1cm during the active phase
- Stage 2 - what happens and how to manage Stage 3- what happens and how to manage Freedman curve?? Reading and understanding the CTG - Add link Partogram, understanding how to use it- Provide Link
- Ritgen’s Maneuver is an obstetric procedure used to control delivery of the fetal head. It involves applying upward pressure from the coccygeal region to extend the head during actual delivery, thereby protecting the musculature of the perineum. 2nd Definition Delivery of a child’s head by pressure on the perineum while controlling the speed of the delivery by pressure wit the other hand on the head.
- Oxytocin Syntocinon Syntometrine (oxytocin 5IU + ergometrine 0.5mg)