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From
the Latin word labor: troublesome effort or suffering parturire: to be ready to bear young partus: to produce
physiologic process that begins with the onset of rhythmic contractions which brings about changes in the biochemical connective tissue resulting in gradual effacement and dilation of the cervix and ends with expulsion of the product of conception
Uterine
Documented
Cervical
Cervical
effacement of >70-80%
Dilation >3 cm
TRUE LABOR
Regular Contractions Decreasing intervals (shortened) Increasing intensity
FALSE LABOR
Irregular Contractions Irregular and long intervals Same intensity or go away spontaneously Lower abdomen discomfort
Cervical Dilation
Depends
on:
Fetal
Lie
Longitudinal Lie
Transverse Lie
Oblique Lie
Fetal
Presentation
Compound Presentation
Cephalic Presentation
Vertex (SOB)-9.5cm
Sinciput (OF)-11.5cm
Breech Presentation
Complete Breech Frank Breech Incomplete Breech Single Footling Breech Double Footling Breech
Fetal
Attitude or Posture
Head flexed Chin close to chest Extremities close to the body Back curved
Fetal
Cephalic Presentation Occiput anterior (OA) Right Occiput Anterior(ROA) Left Occiput Anterior(LOA) Right Occiput Transverse (ROT) Left Occiput Transverse(LOT) Right Occiput Posterior (ROP) Left Occiput Posterior(LOP) Occiput Posterior(OP)
Breech Presentation Sacrum Anterior (SA) Left Sacrum Anterior (LSA) Right Sacrum Anterior (RSA) Right Sacrum Transverse (RST) Left Sacrum Transverse (LST) Right Sacrum Posterior (RSP) Left Sacrum Posterior (LSP) Sacrum Posterior (SP)
Fetal
Station: degree of descent of the presenting part of the fetus from the ischial spines
Number
of fetuses
of fetal anomalies
Presence Fetal
size
Consists of the bony pelvis and soft tissues of the birth canal
pelvic outlet can result in cephalopelvic disproportion for assessment
Small
Pelvimetry:
Leopolds
Involves
Positional
the fetus
Passage
of the widest diameter of the fetal presenting part below the plane of the pelvic inlet due to lateral inclination of the fetal
Asynclitism:
head
Anterior Asynclitism (Naegeles Obliquity) Sacrum Posterior Asynclitism (Fritzmanns Obliquity) Symphisis Pubis
Pressure
of the amniotic fluid Direct pressure of the fundus upon the breech with contractions Bearing down efforts of maternal abdominal muscles Extension and straightening of the fetal body
Resistance
Descent
will not occur without it Sagittal suture is now oriented anteroposteriorly (occiput is anteriorly oriented)
Head
up in extension 2 forces:
Force exerted by the fundus Force exerted by the resistance of the pelvic floor and the symphysis pubis, anteriorly
The
head back to its original position One shoulder is anterior behind the symphysis pubis and the other is posterior
Almost
immediately after external rotation The perineum thins out As the shoulder passes out, the rest of the body follows
1ST
STAGE: onset of labor until full cervical dilation (Latent and Active Phase)
STAGE: from full cervical dilation of 10 cm until delivery of the baby STAGE: from delivery of the baby up to the delivery of the placenta STAGE: the next 2 hours following the delivery of the placenta.
2ND
3RD
4TH
Preparatory
Division
Dilatational
Division
Pelvic
Division
Deceleration Phase Second Stage concurrent with the phase of maximum slope
Latent
Active
Phase
Phase
Complete
history and PE Abdominal Exam Pelvic Exam (Speculum Exam) Internal Examination
Cervical dilation and effacement Position of the cervix Cervical dilation and effacement Fetal Station Status of the fetal membrane
Vital
Induction
of Labor: an intervention designed to artificially initiate contractions leading to progressive dilation and effacement of the cervix and birth of the baby (RCOG,2002)
Confirmation of Parity Confirmation of Gestational Age Presentation Bishops Score Uterine Activity Non stress Test
FACTOR
Closed
1-2
3-4
>=5
0-30
40-50
60-70
>80
-3 Firm posterior
-2 Medium midposition
-1 soft Anterior
+1, +2
Gestational HTN Pre eclampsia, eclampsia Prelabor rupture of the membranes Maternal medical indications Gestational >= 41 1/7weeks Evidence of fetal compromise Intraamniotic infection Fetal demise Logistic factors for term pregnancy
Contraindications:
Malpresentation Absolute cephalopelvic disproportion Placenta Previa Previous major uterine surgery or classical CS Invasive carcinoma of the cervix Cord presentation Active genital herpes Gynecological, obstetrical, or medical conditions that prelude vaginal birth Obstetricians convenience
OXYTOCIN
Oxytocin augmentation is a major intervention and should only be implemented on a valid indication. (Level I, Grade C) When induction of labor is undertaken with oxytocin, the recommended regimen is a starting dose of 1-2 mU/min and is increased at intervals of 30 mins or more. The minimum dose should be used and this should be titrated against uterine contractions aiming for maximum of 3-4 contractions every 10 mins. (RCOG, Grade C) Regular observations of uterine contractions and FHT should be recorded every 15 to 30 minutes and with each incremental increase of Oxytocin.
MEMBRANE
SWEEPING/STRIPPING
AMNIOTOMY
Continued
phase
Nulliparous
women could safely remain in the latent phase for 12 hours is not reasonable to allow up to 18 hours of latent labor before recommending CS.
It
Duration:
Fetal
Molding
Caput
- swelling
Placental
Separation
Calkins Sign Sudden gush of blood Uterus rises in the abdomen(tilted) The umbilical cord rises
Mechanism
of Placental Separation
Lacerations
1st degree: fourchette, perineal skin, vaginal mucosa 2nd degree: above + fascia and muscles of the perineum 3rd degree: above + anal sphincter 4th degree: above + rectal mucosa
Purpose:
to facilitate the 2nd stage of labor to improve maternal and neonatal outcome
Maternal Benefit
Reduced risk of perineal trauma, subsequent floor dysfunction and prolapse, urinary and fecal incontinence, and sexual dysfunction Shortened 2nd stage of labor
Fetal Benefit
Timing
Too early: increased blood loss Late: laceration may not be prevented
Indications
Expedite delivery in the 2nd stage When spontaneous laceration is likely Maternal or fetal distress Assisted forceps delivery Large Baby Maternal exhaustion
Kinds
of Episiotomy
Routine
Episiorrhaphy:
Recommendations:
Administration of prophylactic uterotonin within one minute after the delivery of the baby and prior to the delivery of the placenta Early cord clamping and cutting
Giving Uterotonins -> increased uterine contractions/retraction -> total detachment and expulsion of the placenta -> optimal occlusion of the myometrial vessels -> PPH prevented The use of combination preparation (Oxytocin and Ergometrine) appears to be associated with a statistically significant reduction in the risk of PPH when compared to oxytocin alone where blood loss is less than 1000mL. (Level I, Grade B).
Administration
of oxytocin alone is as effective as the use of oxytocin plus ergometrine in the prevention of PPH, but is associated with a significantly lower rate of unpleasant maternal side effects (nausea, vomiting and hypertension). (Level II, Grade B)
Recommended
Dose:
Ergometrine 200-250 mcg IM OR 100-125 mcg IV bolus Oxytocin 10 u/500mL NSS (20 u/1000mL NSS)
Recommendations
Oxytocin is effective as 1st line prophylactic uterotonic during the 3rd stage of labor in the prevention of PPH and is safe to use in all patients. (Level I) Use of ergot alkaloid and Ergometrine-Oxytocin are valid alternatives in the absence of Oxytocin. Their use have to be weighed against maternal adverse effects. (Level I) Use of ergot alkaloid and Ergometrine Oxytocin combination have to be avoided in hypertensive patients. (Level I)
Critical
period
Breast
feeding
Williams
POGS
IDENTITY
: Mrs.D : 33 years old : Housewife : Moeslem : Padang : Desember, 07th 2013 : 11.20 AM : Desember, 09th 2013
Name Age Occupation Religion Ethnic Date of arrival Time of arrival Date of out
History
Taking
Mrs. D. 33 years old, with G3 P2 A0, padang, moeslim, housewife, as a wife Mr. R. 38 years old, java, Muslim, self-employee, come to Emergency unit Pirngadi hospital at Desember 07th,2013 at 11.28 with : Chief Complain : labour pain Explanation : it happened since Desember 07th,2013, at 05.00 P..M. Bloody show (+) in Desember 07th,2013 at 06.30 P.M. Water discharge (-), Urinary (+) normal, bowel (+) normal. Past medical history : Unclear History of Medication : Unclear Last menstruation periode Estimated date of delivery Ante natal care : 17-03-2013 : 24-12-2013 : - Bidan 6 x - Obstetrician 2 x
Physical Examination
Present Status
Sensorium Blood Preassure Heart Rate Respiration Rate Temperature : : : : : Compos mentis 130/80 mmHg 80 x/i 20 x/i 36,8 oC
Anemic Ikteric Syanotic Dyspnoe Oedema
: : : : :
Localize status
Head: Neck Thorax Eyes : Konj.palp.inf.pale (-/-) Sklera ikterik (-/-) : Limph node (-) : Respiration Sound : Vesikuler (+) Additional Sound : wheezing (-/-) : Asimetris enlargement : 4 fingers under proc.Cypoideus (30 cm) : Right : Head : (+) : (+) 2x30/10 : (+) 136 x/i, reguler : 3000 3200 gr.
Abdomen Fundal Height Streched Part Lower Part Movement Uterus contraction Foetal heart rate Estimated Baby Weight
VT : serviks sacral, eff 80%, Amnion sack (-), Hodge I ST : Bloody show (-), Amnion fluid (-).
Desember,
Diagnosis : Multigravida + Intra uterin pregnancy (36-38) week + Head presentation + live fetal + Inpartu
Therapy
: -IVFD RL
20 drips/i
Planning : - Lead to labour - Monitoring vital sign, fetal heart rate, uterus contracttion
Normal labor and delivery report. In Desember 07th, 2013 at 07.00 PM, born a baby (male), weight 2900 gr, Lenght 45 cm, A/S : 8/9, Anal (+).
Patient lied at ginecology bed in Mc Robert position. In adequate uterus contraction, show head up and down in introitus vagina. and then fixed in adequate uterus contraction. Next, lead patien for straining. with subociput as hiponuklion, labour fontanela minor, fontanela mayor, fore head, face and all head, with biparietal holding, pulling down head to delivery front shoulder and pull up to delivery rear shoulder. Delivery a baby (male),weight 2900 gr, height 45 cm, A/S : 8/9, Anus (+), NBS : 37 match with (36-38) week pregnancy. The umbilical cord was clamp in 2 place and cut in the middle of. The placenta delivery by controling umbilical cord and impression complete. Evaluated the way born,show a laceration second grade and it repair.
clear.
NEONATUS
Born status Date of birth Condition of the baby APGAR Score Ventilator Sex Weight Lenght Congenital anomali Trauma
: Single : Desember 07th, 2013 at 07.00 PM : Life and Health : 8/9 : Negative : Male : 2900 gram : 45 cm : Negative : Negative
Th/ :
20 gtt/i
P/
- Blood test after 2 hour normal labor and delivery - monitoring vital sign, uterus contraction, haemorraghic status
Laboratorium result after 2 hour normal labor and delivery: Hb : 12,1 gram % Ht : 36,0 % Leukosit : 16.000 /mm Trombosit : 261.000 /mm
Stage IV
Time 20.15 20.45 BP 130/90 130/90 HR 80 86 RR 22 20 Uterus Contraction Strong Strong Urinary Sac Empty Empty Bleeding -
21.15
21.45 22.15
130/80
130/80 130/80
88
84 84
20
20 20
Strong
Strong Strong
Empty
Empty Empty
10cc 10cc
Follow
Localize Status
Diagnosa Treatment
Case Analysis
Theory
Case
Sign of inpartu include bloody show and patient came with chief complain labour pain happened since Desember 07th,2013 contraction intensity gradually increase . with bloody show
Partus dibagi menjadi 4 kala. Pada kala I Pada pasien ini, keempat kala berhasil serviks membuka sampai terjadi dilakukan dengan baik. Pada pasien ini kala
pembukaan 10 cm. Kala I dinamakan kala II berlangsung selama 30 menit. pembukaan. Kala II disebut pula kala pengeluaran, oleh karena berkat kekuatan his dan kekuatan mengedan janin didorong ke luar sampai lahir. Pada primigravida kala II berlangsung 1,5 2 jam, sedangkan pada multigravida berlangsung 30 menit 1 jam. Dalam kala III atau kala uri plasenta
Post partum hemorage (PPH) is the lose 500 cc or more blood from the genital tract during 24 hours after birth a baby. It caused by 4T : - Tonus - Tissue - Trauma - Thrombin
In this patients we found laceration second grade of the perineum, and it has been repaired properly.
Problem List
As a general doctor in puskesmas, what can we do to avoid bleeding complication after delivery for mother with multigravida? What kind of contraception is the most suitable to this patient can we recommend?