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MANAGEMEN

T OF NORMAL
LABOUR

Under
supervision
of
prof;Doaa
Aeft

MANAGEMENT OF NORMAL
LABOUR

Defination:
Labour is a physiologic
process during which the
fetus, membranes, umbilical
cord, and placenta are
expelled from the uterus.

CRITERIA FOR CALLING IT


NORMAL LABOUR:
1- Spontaneous expulsion, of a single and mature
foetus .
2- presentedby vertex and through the birth canal.
3-presentation within a reasonable time (not less than
3 hours or more than 18 hours)
4- without complications to the mother and or the
foetus.

CLINICAL PELVIMETRY
OBSTETRICAL CONJUGATE

anterior
symphysis pubis
posterior
sacral promontory
lateral
lineaterminalis

Diagonal conjugate
(clinical)
inferior border of
s.pubis
tos.promontory
Interspinous
Bi ischial diameter

Clinical Picture OfLabour


(A) Prodromal (pre - labour) stage:
(1) Shelfing:
(2) Lightening:
(3) Pelvic pressure symptoms:
(4) Increased vaginal discharge.
(5) False labour pain:
(B) Onset of Labour:
(1) True labour pain.
(2) The show:
(3) Dilatation of the cervix:
(4) Formation of the bag of fore waters:

PAIN CONTROL

Non pharmaceutical
Some women prefer to avoidanalgesicmedication during
childbirth. Psychological preparation may be beneficial.A
recent Cochrane overview of systematic reviews on nondrug interventions found that relaxation techniques,
immersion in water, massage, andacupuncturemay provide
pain relief.

Some women like to have someone to


support them during labour and birth; such
as a midwife, nurse, ordoula; or a lay person
such as the father of the baby, a family
member, or a close friend. Studies have
found that continuous support during labor
and delivery reduce the need for medication
and a caesarean or operative vaginal
delivery, and result in an improved
Apgar scorefor the infant.
The injection of small amounts of sterile
water into or just below the skin at several
points on the back has been a method tried
to reduce labour pain, but no good evidence
shows that it actually helps.

Pharmaceutical
1-inhalednitrous oxidegas for pain control,
especially as 53% nitrous oxide, 47% oxygen,
known asEntonox.
2-Opioidssuch as fentanylmaybe used, but if
given too close to birth there is a risk of
respiratory depression in the infant.
3-regional anestheticsepidurals(EDA), and
spinal anaesthesia. Epidural analgesia is a
generally safe and effective method of relieving
pain in labour, but is associated with longer
labour, more operative intervention (particularly
instrument delivery), and increases in cost.

Augmentation
Augmentation is the process of facilitating further
labour.Oxytocinhas been used to increase the rate of
vaginal delivery in those with a slow progress of labour.

Oxytocin facilitates labour and will follow apositive feedbackloop.


Administration of antispasmodics (e.g. hyoscine butylbromide) is not
formally regarded as augmentation of labour;
however, there is weak evidence that they may shorten labour. There is not
enough evidence to make conclusions
about unwanted effects in mothers or babies.

Active Managementof Normal


Labour
consists of a number of care
principles, including frequent
assessment of cervical dilatation. If
the cervix is not dilating, oxytocin is
offered. This management results in a
slightly reduced number of caesarean
births, but does not change how many
women have assisted vaginal births.
75% of women report that they are
very satisfied with either active

First Stage of Labour


- It is the stage of cervical dilatation.
Starts with the onset of true labour pain and endswith full dilatation of the cervix i.e. 10 cm in
. diameter
It takes about 10-14 hours in primi-gravida andabout 6-8 hours in multipara
:History
.Complete obstetric history
:History of present pregnancy
. Duration of pregnancy
.Medical disorders during this pregnancy
Complications during this pregnancy as antepartum
:History of present labour
.haemorrhage

.Labour pains: onset, frequency and duration


.Passage of "show", fluid or blood per vaginum
.Sensation of foetal movement

Examination

:General examination

.Height and built


Maternal vital signs: pulse, temperature and
.blood pressure
.Chest and heart examination
.Lower limbs for oedema

:Abdominal examination

.Fundal level
.Fundal grip
.Umbilical grip
.Pelvic grips
. FHS
Scar of previous operations (e.g. C.S,
.myomectomy or hysterotomy)

:Pelvic examination
:Cervix
Dilatation: the diameter of the external os is
measured by the finger (s) during P/V
examination and expressed in cm, one finger =
2 cm, 2 fingers = 4 cm and the distance
resulted from their separation is added to the 4
.cm in more dilatation
. Effacement
.Position (posterior, midway, central)
Membranes: ruptured or intact. If ruptured
exclude cord prolapse and meconium stained
.liquor
. Presenting part and its position
. Station: of the presenting part

Investigations:
If not done before or if
:indicated
. Blood group-Rh typing
.Urine for albumin and sugar
%. Hb
.Ultrasonography

:Active procedures
;Evacuation of the rectum by enema to
,avoid uterine inertia
, help the descent of the presenting part
.avoid contamination by faeces during delivery
:Evacuation of the bladder
ask the patient to micturate every 2-3 hours, if
.she cannot use a catheter
It prevents uterine inertia and helps descent of
.the presenting part
:Preparation of the vulva
Shave the vulva, clean it with soap and warm
water from above downwards, swab it with
antiseptic lotion and apply a sterile pad.

:Nutrition
When labour is established no oral feeding is
. allowed, but sips of water
ml magnesium trisilicate is given every 2 15
hours as an oral antacid to guard against
bronchospasm occurs if the acid vomitus is
inhaled during general anaesthesia
"Mendelsons syndrome". Antacid injections
.may be used instead
If labour is delayed more than 8 hours, IV drip
of glucose 5% or saline-glucose solution is
.given
: Posture
Patient is allowed to walk during the early first
.stage particularly with intact membranes

:Analgesia

,Pethidine 100 mg IM
trilene inhalation, or
epidural anaesthesia are the most
.common use
N.B. Patient should not bear down
during the first stage as this is useless,
exhausts the patient and predisposes to
genital prolapse

The partogram

It is the graphic recording of the course of


:labour including the following observations
:The mother
, Pulse every 30 minutes
,blood pressure every 2 hours
,temperature every 4 hours
uterine contractions: frequency, strength and
duration every 30 minutes by manual palpation
,or better by tocography if available
, cervical dilatation
, fluid input and output
drugs including oxytocin

The foetus
FHR every 15 minutes by Pinards stethoscope
,or better by doptone
,descent of the presenting part
.degree of moulding
Cardiotocography if available is more valuable
for continuous monitoring of both uterine
contractions and FHR particularly in high risk
.pregnancy
:The advantages of the partogram
Allows right intervention in the proper time
e.g. oxytocin usage, instrumental delivery or
. C.S
Allows different staff shifts to manage the case

Second Stage of Labour


- It is the stage of expulsion of the
. foetus
Begins with full cervical dilatationand ends with the delivery of the
. foetus
Its duration is about 1 hour inprimigravida and hour in
multipara.
-(ACOG) has suggested that a
prolonged second stage of labor
should be considered when the
second stage of labor exceeds 3

:Its beginning is identified by

. The patient feels the desire to defecate


The contractions become more prolonged and
.painful
Reflex desire to bear down during the
. contractions
The expulsive effort is accompanied by
.sustained expiratory grunt
Rupture of membranes, although this is not
specific as it may occur earlier even before
start of labour " prelabour rupture of
membranes" or later even to the degree that
.the foetus is delivered in an intact sac
Full dilatation of the cervix (10 cm) in
between uterine contractions is the most sure

Delivery room
The patient is transferred on a wheel or
.trolley to the delivery room
.Put her in the lithotomy position
The lower abdomen, upper parts of the
thighs, vulva and perineum are swabbed
.with antiseptic lotion
.Sterile legs and towels are applied
Bearing down
Ask the patient to bear down during
.contractions and relax in between
Delivery of the head

The main aim during delivery of the head


is to prevent perineal lacerations through
:the following instructions
:i) Support of the perineum
When the labia start to separate by the
head, a sterile pad is placed over the
perineum and press on it with the right
hand during uterine contractions. This is
continued until crowning occurs to
.maintain flexion of the head

:Crowning

is the permanent distension of the vulval ring by the


foetal head like a crown on the head. The head does not
.recede back in between uterine contractions
This means that the biparietal diameter is just passed
the vulval ring and the occipital prominence escapes
.under the symphysis pubis
After crowning, allow slow extension of the head so the
vulva is distended by the suboccipito frontal diameter 10
.cm
If the head is allowed to extend before crowning the
vulva will be distended by the occipito-frontal 11.5 cm
.increasing the incidence of perineal lacerations
Ritgen manoeuvre: upward pressure on the perineum by
the right hand and downward pressure on the occiput by
. the left hand to control the extension of the head

Episiotomy

It is done at crowning when the


perineum is stretched to the degree that
.it is about to tear
:Swab and aspirate
the mouth and nose once the head is
delivered before respiration is initiated
and the liquor, meconium or blood is
.inhaled
:Coils of the umbilical cord
if present around the neck are slipped
over the head but if tight or multiple they
.are cut between 2 clamps

Delivery of the shoulders


Gentle downward traction is applied to the head till the
anterior shoulder slips under the symphysis pubis. The
head is lifted upwards to deliver the posterior shoulder
.first then downwards to deliver the anterior shoulder
Delivery of the remainder of the body
Usually slips without difficulty otherwise gentle
.traction is applied to complete delivery
Clamping the cord
The baby is held by its ankles with the head
downwards at a lower level than its mother for few
:seconds. This is contraindicated in
. Preterm babies
. Erythroblastosis foetalis
.Suspicion of intracranial haemorrhage
This may be enhanced by milking the cord towards the
.baby, to add about 100 ml of blood to its circulation
The cord is divided between 2 clamps to avoid bleeding

Third Stage of Labour


- It is the stage of expulsion of the placenta
. and membranes
Begins after delivery of the foetus andends with expulsion of the placenta and
. membranes
Its duration is about 10-20 minutes in. both primi and multipara
A-Expectant management of the third stage
of labor involves spontaneous delivery of
. the placenta

Delivery of the placenta


:Conservative method
Put the ulnar border of the left hand just above the
fundus at the level of the umbilicus to detect any
bleeding inside the uterus known by rising level of the
.atonic uterus
Wait for signs of placental separation and descent but
.do not massage the uterus
As soon as they are detected massage the uterus to
induce its contraction, ask the patient to bear down and
.push the uterus downwards to deliver the placenta
Hold the placenta between the two hands and roll it to
make the membranes like a rope in order not to miss a
.part of it
Give ergometrine 0.5 mg or oxytocin 5 units IM after
delivery of the placenta to help uterine contraction and
minimise blood loss. These may be given before
.delivery of the placenta

:Signs of placental separation and descent


The body of the uterus becomes smaller,
.harder and globular
The fundal level rises as the upper segment
overrides the lower uterine segment which is
.now distended with the placenta
Suprapubic bulge due to presence of the
.placenta in the lower uterine segment
Elongation of the cord particularly on pressing
on the uterine fundus and it does not recede
.back into the vagina on relieving the pressure
.Gush of blood from the vagina

:The active method (Brandt- Andrews method)


With delivery of the anterior shoulder, 0.5 mg
ergometrine or syntometrine (0.5 mg
.ergometrine + 5 units oxytocin) is given IM
When the uterus contracts, put the left hand
suprapubic and push the uterus upwards while
gentle downward and backward traction is
applied on the cord by the right hand when the
placenta is delivered it is rolled as in the
.conservative method
.Advantage: reduction of the blood loss
:Disadvantages
Constriction ring may occur with retention of
.the placenta
Avulsion of the cord if undue pressure is

Routine examinations
Examination of the placenta and
:membranes
by exploring it on a plain surface to
be sure that it is complete. If there
is missed part, exploration of the
uterus is done under general
.anaesthesia
:Explore the genital tract
For any lacerations that should be
.immediately repaired
Repair of episiotomy

Fourth Stage of Labour


Observation for the patient particularly atony of
.the uterus and vaginal bleeding
Care of The Newborn
Clearance of the air passages
The newborn is placed in supine position with
the head lower down. A metal, rubber or better
disposable plastic catheter is used to aspirate
the mucus from the pharynx and mouth directly
by the physicians mouth or by attach it to an
.electric suction pump
Crying of the baby is usually occurs within
seconds, if delayed slapping its soles, flexion and
extension of the legs and rubbing the back
.usually stimulate breathing

Apgar score
Is calculated at 1 and 5 minutes and further
steps of resuscitation are arranged according
.to it (see later)
The umbilical cord
A disposable plastic umbilical clamp is
applied about 5 cm from the umbilicus to
avoid the possibility of tying an umbilical
hernia then cut about 1.5 cm distal to the
clamp. Inspect for bleeding and paint it with
.alcohol
If the plastic umbilical clamp is not available,
. 2 ligatures of silk are applied instead of it
The umbilical stump is painted daily with an

Congenital anomalies
The newborn is examined for injuries or congenital
anomalies as imperforate anus, hypospadias (not to be
circumcised as the cut skin will be used in the repair
.later on), cyanotic heart diseases.... etc
:Weight
.the newborn and record it
Dressing
Dressing as well as all previous procedures should be
done in a warm place better under radiant warmer to
prevent heat loss which occurs rapidly after delivery
.increasing the metabolism and acidosis
Care of the eyes
An antibiotic eye drops as chloramphenicol are instilled
into the eyes as a prophylaxis against ophthalmia
.neonatorum
:Identification
of the baby by a plastic bracelet on which its mothers

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