MANAGEMENT OF LABOUR

SALWA NEYAZI
CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

MANAGEMENT OF LABOUR
WHAT IS LABOUR? Regular frequent uterine contractions

Cx changes (dilatation & effacement)

or

SROM

WHAT ARE THE GOALS OF LABOUR MNAGEMENT? To reduce maternal mortality & morbidity resulting from complications of labour/delivery & postpartum To reduce intrapartum fetal mortality To reduce birth aspyxia To reduce the cesarean section rate To improve maternal satisfaction of the birthing experience To relieve maternal anxiety & pain during labour

PHASES OF LABOUR
FRIEDMANS CURVE

10-

DECELRATION PHASE

Cervical dilatation

8-

6-

ACCELRATION PHASE
4-

LATENT PHASE
2-

ACTIVE PHASE

| 2

| 4

| 6

|| 8

| 10

Duration of labour

LABOUR TIME FRAMES

Phases/ Stages of labour Latent phase Mean time Longest normal Nulliparous 6.4 h 20.1 h Multiparous 4.8 h 13.6 h

Active phase

Mean rate
Slowest normal

3 cm/h
1.2cm/h 1.1 h 2.9 h

5.7cm/h
1.5cm/h 0.4 h 1.1 h

2nd Stage

Mean time Longest normal

MANAGEMENT OF LABOUR
1- Labour preparation Prenatal educational classes amount of analgesia used in labour Improve maternal stisfaction 2-Birthing companion A supportive companion with experience of labour (not trained in health discipline) faster progress & less dystocia

3-Ambulation the incidence of dystocia augmentation operative delivery pain percieved by the woman analgesia & epidural Supine position antroposterior compression of the pelvis/ the size of the passage

MANAGEMENT OF LABOUR
4-Analgesia Epidural Nitrous oxide Narcotics
Dystocia pain & anxiety

Catecholamines

Uterine Contraction strength

Uterine blood flow

5-Contiuous assessment of progress of labour

THE PARTOGRAM

MANAGEMENT OF LABOUR
6-Amniotomy Routine early use of amniotomy after 3 cm dilatation Shortens the average length of labour Does not the incidence of CS 7-Fetal size fetal size duration of labour

FACTORS INFLUENCING LABOUR

WHAT IS DYSTOCIA? 4 hrs of < 0.5 cm/ hr dilatation 1 hr with no descent Dystocia cannot be diagnosed before the onset of labour WHAT ARE THE CAUSES OF DYSTOCIA? 3 Ps POWERS Hypotonic contractions PASSENGER Fetal position Fetal size PASSAGE Boney pelvis Soft tissue

How to assess these factors? Adequate powers contractions that -last for 60 sec -reach 20-30 mmHg of pressure -occur every 1-2 min Hypotonic contractions are responsible for 2/3 of nulliparous dystocia If powers are adequate check Passage for size & abnormal shape and check the Passenger for size & malpresentation What is the importance of diagnosing dystocia? Dystocia & elective repeat CS account for the majority of CS indications There has been dramatic in CS rate with in maternal mortality, morbidity, neonatal morbidity & health care costs, reducing Dystocia CS rate

PHILPOTTS CERVICOGRAPH

Cervicograph should not be used until active labour has been established 3-4 cm dilatation
10-

Cervical dilatation

8-

6-

Alert line

Action line

4-

2-

| 2

| 4

| 6

|| 8

| 10

Time (hr)

TREATMENT OF DYSTOCIA
1-Oxytocin 2-Active management of labour 3-Instrumental deliveries 4-CS
ADVERSE EFFECTS OF OXYTOCIN

ADVERSE EFFECTS Fetal compromise Uterine rupture Hypotension Water intoxication

MECHANISM Hyperstimulation Hyperstimulation Vasodilatation ADH effect

PREVENTION Correct dose Correct dose Low dose infusion Limit free water

PRINCIPLES OF ACTIVE MANAGEMENT

Accurate diagnosis of labour Continuous assessment of the progress of labour One to one nursing care Early amniotomy Oxytocin

Benefits of active management Significant reduction in dystocia instrumental deliveries & CS rate No increase in birth asphyxia or perinatal mortality

ACTIVE MANAGEMENT OF LABOUR

Active Control

Labour >12 hrs Forceps

7%

20%

19.4%

29%

CS

4.3%

13%

PREVENTION OF DYSTOCIA

Avoid unnecessary inductions Induction is associated with increase incidence of Dystocia DX in the latent phase of labour & increase in obstetric interventions Admit only women inactive labour Encourage prenatal classes & labour companion Ambulate in labour Use appropriate analgesia Active management of labour

MANAGEMENT OF POSTPARTUM PATIENTS

PUERPERIUM

It is the period after delivery during which there is rapid return to normal health & the normal prepregnancy body physiology . It lasts around six wk There is a high prevelance of maternal morbidity in the immediate postpartum period (85%) , in the 1st 8 wk postpartum 87% & continuing problem in 47-76% Maternal mortality & most maternal morbidity except for piles & stress incontinence are more after CS Vacuum extraction results in less maternal trauma & pain than forceps without increasing the need for CS

PROBLEMS THAT MAY BE ENCOUNTERED IN POSTNATAL WARD

1-Afterpains due to myometrial contractions with breast feeding Improve with NSAID 2-Post partum hemorrhage (5-10%) -Routine use of oxytocics in the third stage of labour blood loss by 30-40% -It is more likely to occur in the delivery room & the first 12 hrs after delivery - Most commonly due to suboptimal contractions of the uterus or abnormal implantation site of the placenta (low laying ) at which bleeding can not be controlled by uterine contractions -RPOC & endometritis can result in PPH several days after delivery

What can we do if a Pt has PPH in the postnatal ward? Start IV line Send blood for CBC/X-matching /Coagulation Feel the level of the fundus normally midway between umbilicus & symphesis pubis may be distended with blood clots inside it inadequate uterine contraction Uterine massage Start IV syntocinon drip/ ergometrin PG F2 NALODOR IM /IV or intramyometrial U/S to R/O RPOC Check for unnoticed perineal, vaginal or cevical lacerations Exploration under GA

3-Anemia (25-30%) 4-Fever Common causes of fever -Breast engorgement -UTI 2-5 days after delivery -Endometritis Prophylactic antibiotics at the time of CS serious infections , febrile morbidity & wound infection PROM predispose to endometritis 5- RH ve mothers with RH +ve babies should receive Anti-D 300 gm within 72 hrs of delivery

6-Thrombosis & pulmonary embolism Accounts for 23% of direct maternal deaths After CS 69% / after ND 48% Risk factors obesity, immobilization, previous thromboembolism, increasing maternal age & operative delivery Prophylaxis for the high risk gp reduces the risk May appear after the 3rd day & death occur 7th D in 2/3 of cases Pelvic thrombophlebitis following endometritis Causes pain & fever Dx by exclusion Rx Ab & Heparin

7-PET & ECLAMPSIA 35% of eclampsia can occur for the 1st time in the postnatal period Close monitering of BP & proteinurea should continue after delivery for Pt with PET or eclampsia & appropriate measures taken if the problem persists We should ignore alarming symptoms like headache , vomitting & epigastric pain 8- BOWEL PROBLEMS Constipation 20% Local acting laxatives high fiber diet Hemorrhoids 18% 70% last more than 1 year Avoid constipation Xyloproct suppositories Inability to control flatus or faeses 4%

9-PERINEAL CARE

Perineal pain occur in 42% of women after delivery & persists beyond the 1st 2 M in 8-10% after SVD Mediolateral episiotomy causes more pain than median episiotomy 50% dyspareunia on 1st restarting intercourse & 15% continue to have it 3 Y later After assissted vaginal delivery 84% will have perineal pain 30% after the 1st 2 M The choice of suture material has a long term effect on dyspareunia Analgesics should be used for relief of perineal pain Paracetamol/ Brufen/ Ponstan Sitz bath for pain relief To keep the area clean & dry Pelvic examination to R/O hematoma

10-URINARY TRACT PROBLEMS

Urinary retention is mainly due to bladder edema & hyperemia -Perineal pain can add to the problem by causing reflex retention -Paralyzing effect of the epidural If the Pt does not void for 6-8 hrs or has frequent small voids cathterization UTI -especially if the Pt has been catheterized in labour -2ry to urine retension Urinary frequency Stress incontinence 20% 3M after delivery of them still incontinent after 1 year

11-DEPRESSION & TIREDNESS

Depression 10-15% within the 1st year Tiredness 42% in hospital 54% at home 1st 2 months Supportive care & counseling

12-BREAST PROBLEMS Nipple pain / engorgement/ cracks & bleeding 66% -Rx To teach the mother the correct way of BFeeding Local heat Analgesics Breast feeding/pumping to reduce engorgement Keeping the nipple clean Applying emollients Bepanthene cream/ breast milk Nipple shield Mastitis/breast abscess not contraindication to breast feeding -Usually 2-3 wk after delivery -Requires Antibiotics & continued breast feeding or pumping