management of labor stages
Post on 14-Jun-2015
487 Views
Preview:
DESCRIPTION
TRANSCRIPT
Management of 1st ,2nd and 3rd stages of
labor
DR. Ahmed Walid Anwar Morad Assistant Professor of OBS&GYN
FACULTY OF MEDECINE BENHA UNIVERISITY
2014
Normal LaborNormal Labor
Process by which …… Process by which …… regular regular
uterine contractionsuterine contractions —›—›
progressive progressive effacement and effacement and
dilatationdilatation of the cervix of the cervix —›—› delivery delivery
of theof the fetus fetus and the and the placentaplacenta at or at or
beyond age of fetal viability.beyond age of fetal viability.
1 LNMP 24 W 28 W 37 W 40W 42W
PTL
Term Labour
Labour can occur at:Labour can occur at:
prolongedprolonged
Stages of laborStages of labor Stage Stage 11stst 22ndnd 33rdrd 44thth
Onset Onset Onset of Onset of true true uterine uterine contractiocontractionsns
Full cx Full cx dilatationdilatation
Fetal Fetal expulsionexpulsion
Placental Placental deliverydelivery
End End Full cx Full cx dilatationdilatation
Fetal Fetal expulsionexpulsion
Placental Placental deliverydelivery
2h 2h observatioobservations for ns for PPHge PPHge and any and any complicaticomplicationsons
Time Time oPG =12-14 PG =12-14 hhoMG = 6-8 hMG = 6-8 h
oPG = 1-2 hPG = 1-2 hoMG = ½- 1 MG = ½- 1 hh
PG &MG PG &MG = 10-30 = 10-30 minmin
Management of stages of labor
How to deal
Diagnosis
Preparations
Monitoring
Procedures
Management of the Management of the First Stage of LabourFirst Stage of Labour
Diagnosis Diagnosis {{made within one hour of admission}made within one hour of admission}A.A. symptoms:symptoms:1.1. True labour painsTrue labour pains – colicky pain in the abdomen and – colicky pain in the abdomen and
back are characterized byback are characterized by:: charactercharacter True labour painTrue labour pain False labour painFalse labour pain
contractionscontractions regularregular IrregularIrregular
Interval between Interval between contractions and contractions and intensityintensity
Progressive Progressive (increase in (increase in
frequency and frequency and intensity)intensity)
Short duration, not Short duration, not progressiveprogressive
Changes in the Changes in the cervixcervix
Associated with Associated with effacement and effacement and dilation of the dilation of the
cervixcervix
Not associated with Not associated with effacement and effacement and
dilation of the cervixdilation of the cervix
Membranes Membranes Associated with Associated with bulging of bulging of
membranesmembranes
Not associated with Not associated with bulging of bulging of
membranesmembranes
Response to Response to analgesiaanalgesia
Not relieved by Not relieved by sedation sedation
Relieved by sedationRelieved by sedation
Labour Labour Followed by labourFollowed by labour Not followed by labourNot followed by labour
Patient preparations:Patient preparations:
Full Full historyhistory and clinical and clinical examinationexamination
PositionPosition: Encourage any non-: Encourage any non-supine position and movement supine position and movement throughout labor and childbirth.throughout labor and childbirth.
DietDiet:: nothing by mouth, IV fluid, or nothing by mouth, IV fluid, or light diet but fat ,proteins are not light diet but fat ,proteins are not allowed at all.allowed at all.
IV lineIV line : recommended. : recommended.
Patient preparations:Patient preparations:
Rectum:Rectum: no evidence that routine no evidence that routine enema is beneficial .enema is beneficial .
BladderBladder: : – Encouraged patient to empty her bladder Encouraged patient to empty her bladder
regularly. regularly. – Urinary catheter only when woman is Urinary catheter only when woman is
unable to void. unable to void. Pain Control: Pain Control: antenatal women education antenatal women education
about pain relief techniques- epidural anesthesia about pain relief techniques- epidural anesthesia ―› satisfaction.―› satisfaction.
2.2. Show – blood stained mucous.Show – blood stained mucous.
3.3. SROMSROM
B.B. Signs:Signs:o palpable or recorded uterine palpable or recorded uterine
contractioncontractiono effacement and dilation of the cervixeffacement and dilation of the cervixo formation of forewater formation of forewater
What is a partogram
(partograph) ?
PARTOGRAMPARTOGRAM
Def:Def: diagrammatic record of the diagrammatic record of the
events of labour.events of labour.
Advantages:Advantages:
– MonitoringMonitoring the progress of labour, the progress of labour, maternal and fetal wellbeing maternal and fetal wellbeing
– Early detectionEarly detection and management of and management of
labour abnormalities.labour abnormalities.
Fetal Fetal
cervicalcervical
Descent Descent
Uterine Uterine
MaternaMaternal l
Timing observations of different parameters of partogram in the the1st stage of labor
Parameter
Ideal
in both phases
)hrs(
Minimum acceptable
Latent phase
Active phase
Vaginal examination 4 8 4Descent of head 4 8 4Contractions ½ 4 2Fetal heart beats ½ 4 1Temperature, PR, BP, urine 4 4 4
Phases of cervical dilatationPhases of cervical dilatation
The alert line: The alert line: DrawnDrawn from 3 cm dilatationfrom 3 cm dilatation ( at rate of dilatation ( at rate of dilatation
of 1 cm / hour).of 1 cm / hour).
Represents the rate of dilatation of the slowest 10 % of Represents the rate of dilatation of the slowest 10 % of
labours in primigravidae. labours in primigravidae.
Crossing the alert lineCrossing the alert line suggests that the patient should be suggests that the patient should be
transferred to a hospital for extra care. transferred to a hospital for extra care.
The action lineThe action line : : parallel and 2 (4) hours to the right of the alert line; parallel and 2 (4) hours to the right of the alert line;
crossing the action linecrossing the action line suggests the need for intervention suggests the need for intervention
(eg, artificial rupture of the membranes, administration of (eg, artificial rupture of the membranes, administration of
oxytocics.oxytocics.
Vaginal examination:Vaginal examination: single individual to minimize single individual to minimize
interobserver variationsinterobserver variations
Indications:Indications:
On admission On admission
At one to four hour intervals in the At one to four hour intervals in the first stage first stage
At At rupture of membranesrupture of membranes to evaluate for cord prolapse to evaluate for cord prolapse
Feeling the Feeling the urge to pushurge to push to determine whether the to determine whether the
cervix is fully dilated cervix is fully dilated
If the If the FHRFHR falls, to evaluate for conditions such as cord falls, to evaluate for conditions such as cord
prolapse or uterine rupture. prolapse or uterine rupture.
Vaginal examination:Vaginal examination:
Disadvantages:Disadvantages:
– Increases woman’s anxiety.Increases woman’s anxiety.
– Increasing numbers vaginal examinations in Increasing numbers vaginal examinations in
(PROM) increases neonatal sepsis (PROM) increases neonatal sepsis
Effacement and dilation of the cervixEffacement and dilation of the cervix
Assessing descent of the fetal head by Assessing descent of the fetal head by vaginal examination;vaginal examination;
0 station is at the level of the ischial 0 station is at the level of the ischial
spine (Sp). spine (Sp).
Palpate number of contraction in ten minutes and duration of each contraction in
seconds
• Less than 20 seconds:
• Between 20 and 40 seconds:
• More than 40 seconds:
Fetal heart rateFetal heart rate Intermittent auscultation of the fetal heartIntermittent auscultation of the fetal heart ( for low ( for low
risk patients): after a contraction should occur for at risk patients): after a contraction should occur for at
least 1 minute, at least every 15 minutes.least 1 minute, at least every 15 minutes.
– Method : Doppler ultrasound or Pinard stethoscope.Method : Doppler ultrasound or Pinard stethoscope.
Continuous intrapartum FHR monitoringContinuous intrapartum FHR monitoring for : for :
((External and InternalExternal and Internal))
– High-risk patients ,High-risk patients ,
– When FHR below 110 or over 160 BPMWhen FHR below 110 or over 160 BPM
Active management of Active management of laborlabor
AmniotomyAmniotomy
Oxytocin Oxytocin
administrationadministration
for dilation rates for dilation rates
of <1 cm/hourof <1 cm/hour
Management of second stage
of labour
Onset of second stageOnset of second stage
Full cervical dilatation (sure) Full cervical dilatation (sure)
Involuntary Bearing downInvoluntary Bearing down
The urge to defecate and urinate.The urge to defecate and urinate.
Contractions becomes more prolonged.Contractions becomes more prolonged.
Expiratory grunting with expulsive efforts.Expiratory grunting with expulsive efforts.
Rupture of membranes (suggestive)Rupture of membranes (suggestive)
Position: Position: Patient is put in dorsal Lithotomy position and Patient is put in dorsal Lithotomy position and the legs are half-flexed the legs are half-flexed
Patient is properly Patient is properly draped draped AsepsisAsepsis: : DietDiet Bladder and rectumBladder and rectum Pain reliefPain relief Patient is asked to take Patient is asked to take deep breathdeep breath & breath held then & breath held then
exerts downward pressure at the time of uterine exerts downward pressure at the time of uterine contraction and relax in betweencontraction and relax in between
Preparation for deliveryPreparation for delivery
Fetal heart rate monitoringFetal heart rate monitoring
Low risk:Low risk: every 15 min every 15 min High risk:High risk: every 5 min every 5 min
Slowing of the FHR may occur due to Slowing of the FHR may occur due to fetal head compressionfetal head compression
Obstetrical roleObstetrical role Bearing down only during contraction.Bearing down only during contraction. Delivery of the headDelivery of the head
– Crowning Crowning – The main role of obstetrician is the The main role of obstetrician is the
prevention of perineal tearsprevention of perineal tears Before crowningBefore crowning After crowningAfter crowning) ) Ritgen maneuver )Ritgen maneuver ) EpisiotomyEpisiotomy
– Once head delivered clear upper air way. Once head delivered clear upper air way.
Ritgen maneuverRitgen maneuver
Posterior shoulderPosterior shoulderAnterior shoulderAnterior shoulderDelivery of shoulderDelivery of shoulder
The rest of the body almost always follows the shoulder The rest of the body almost always follows the shoulder
without difficultywithout difficulty
Management of third stage of
labour
aimed at:
1-Complete delivery of the after birth
(placenta and membranes).
2-Prevention of acute inversion of the
uterus.
3-prevention of postpartum
haemorrhage
Management of third stage of labour
a-Conservative method:
•The left hand is placed just above the fundus to detect any
change in the fundal level, shape and consistency of the
uterus which indicate atony.
• Wait for signs of placental separation and decent,
•Massage uterus to contract
•The patient is asked to bear down to deliver the placenta
spontaneously.
• Ergometrine 0.5mg or Syntometrine(5 units syntocinon +
0.5mg Ergometrine) to be given intravenouslly.
Delivery of the placenta and membranes: uterus should be examined for the presence of second baby
Signs of separation and decent of the
placenta:
1. -The body of the uterus becomes smaller, harder, and
globular.
2. -The fundal level rises in the abdomen because the
lower segment becomes distended by the placenta.
3. -Suprapubic bulge may appear due to presence of the
placenta in the lower segment.
4. -Elongation of the cord out side the vulva.
5. -Sudden gush of blood from the vagina.
b-Active methods (prophylaxis against postpartum haemorrhage)
1-Give Methargine 0.5 mg IM or Syntometrine (5units
oxytocin+0.5mg Methargine), at the time of the anterior
shoulder is free from symphysis pubis or as soon as possible
thereafter.
2-Deliver the placenta and membranes by control cord traction by
right hand, and the left hand is placed on the suprapubic
region, pushing the uterus upwards.
N.B. USE SYNTOCINON RATHER THAN METHARGINE
IN CARDIAC AND HYPERTENSIVE CASES.
Controlled Controlled
cord tractioncord traction Delivery of Delivery of the placentathe placenta
IV-Post Delivery:
1-examine the placenta for their completeness,
anomalies, length, and number of vessels in the
cord and record the placental weight.
2-Suture the episiotomy or any laceration.
3-Estimate blood loss, count swabs, and take cord
blood for Hb, blood group, Rh, bilirubin, and
coomb’s test for Rh negative mother.
IV-Post Delivery:
4-Check BP, P, T, Lochia and firmness of the uterus
before transferring the patient.
5-Continue an infusion of syntocinon through the first
hour if necessary.
6-Allow no food during the first hour, sips of water
may be taken, encourage nursing.
Seven Cardinal Seven Cardinal MovementsMovements
EngagementEngagement– descent of BPD to a level below the plane of descent of BPD to a level below the plane of
the pelvic inletthe pelvic inlet
DescentDescent FlexionFlexion Internal rotationInternal rotation ExtensionExtension RestitutionRestitution External rotationExternal rotation ExpulsionExpulsion
InductionInduction
Assess adequacy of pelvis and Assess adequacy of pelvis and cervical examcervical exam
Bishop scoreBishop score
Bishop score Bishop score
E.mail:::ahwalid2004@yahoo.com
top related