labour petr velebil. first stage of labour u clinical intervention should not be offered or advised...

LabourLabour

Petr VelebilPetr Velebil

First stage of labourFirst stage of labour

Clinical intervention should not be offered or Clinical intervention should not be offered or advised where labour isadvised where labour is progressing normally progressing normally and the woman and baby are welland the woman and baby are well

In all stages of labour, women who have left the In all stages of labour, women who have left the normal care pathway due tonormal care pathway due to the development of the development of complications can return to it if/when the complications can return to it if/when the complication iscomplication is resolved resolved


Latent first stage of labour – a period of time, not Latent first stage of labour – a period of time, not necessarily continuous, when:necessarily continuous, when: there are painful contractions, andthere are painful contractions, and there is some cervical change, including cervical there is some cervical change, including cervical

effacement and dilatation upeffacement and dilatation up to 4 cm to 4 cm Established first stage of labour – when:Established first stage of labour – when:

there are regular painful contractions, andthere are regular painful contractions, and there is progressive cervical dilatation from 4 cmthere is progressive cervical dilatation from 4 cm


Duration of the first stageDuration of the first stage the length of established first stage ofthe length of established first stage of labour labour

varies between womenvaries between women first labours last on average 8 hours and arefirst labours last on average 8 hours and are

unlikely to last over 18 hoursunlikely to last over 18 hours ssecond and subsequent labours last on averageecond and subsequent labours last on average

5 hours and are unlikely to last over 12 hours5 hours and are unlikely to last over 12 hours

Delay in the First stage of labourDelay in the First stage of labour

A diagnosis of delay in the established first stage of A diagnosis of delay in the established first stage of labour needs to take intolabour needs to take into consideration all aspects of consideration all aspects of progress in labour and should include:progress in labour and should include: cervical dilatation of less than 2 cm in 4 hours for first cervical dilatation of less than 2 cm in 4 hours for first

labourslabours cervical dilatation of less than 2 cm in 4 hours or a cervical dilatation of less than 2 cm in 4 hours or a

slowing in the progress of labourslowing in the progress of labour for second or for second or subsequent labourssubsequent labours

descent and rotation of the fetal headdescent and rotation of the fetal head changes in the strength, duration and frequency of changes in the strength, duration and frequency of

uterine contractionsuterine contractions


Where delay in the established first stage is Where delay in the established first stage is suspected the following should besuspected the following should be considered: considered: parityparity cervical dilatation and rate of changecervical dilatation and rate of change uterine contractionsuterine contractions station and position of presenting partstation and position of presenting part the woman's emotional statethe woman's emotional state


If delay in the established first stage of labour is If delay in the established first stage of labour is suspected, amniotomy shouldsuspected, amniotomy should be considered for be considered for all women with intact membranesall women with intact membranes

Whether or not a woman has agreed to an Whether or not a woman has agreed to an amniotomy, all women withamniotomy, all women with suspected delay in suspected delay in the established first stage of labour should be the established first stage of labour should be advised toadvised to have a vaginal examination 2 hours have a vaginal examination 2 hours later, and if progress is less than 1 cm alater, and if progress is less than 1 cm a diagnosis of delay is madediagnosis of delay is made


When delay in the established first stage of When delay in the established first stage of labour is confirmed in nulliparouslabour is confirmed in nulliparous women, the women, the use of oxytocinuse of oxytocin should be consideredshould be considered

TThe woman should be informed that the use of he woman should be informed that the use of oxytocinoxytocin following spontaneous or artificial following spontaneous or artificial rupture of the membranes will bring forwardrupture of the membranes will bring forward her her time of birth but will not influence the mode of time of birth but will not influence the mode of birth or other outcomesbirth or other outcomes


Where a diagnosis of delay in the established Where a diagnosis of delay in the established first stage of labour is madefirst stage of labour is made continuous EFM continuous EFM should be offeredshould be offered

Continuous EFM should be used when oxytocin Continuous EFM should be used when oxytocin is administered foris administered for augmentation augmentation

Second stage of labourSecond stage of labour

Passive second stage of labour:Passive second stage of labour: the finding of full dilatation of the cervix prior to or in the the finding of full dilatation of the cervix prior to or in the

absence ofabsence of involuntary expulsive contractions involuntary expulsive contractions Onset of the active second stage of labour:Onset of the active second stage of labour:

the baby is visiblethe baby is visible expulsive contractions with a finding of full dilatation of expulsive contractions with a finding of full dilatation of

the cervix or otherthe cervix or other signs of full dilatation of the cervixsigns of full dilatation of the cervix active maternal effort following confirmation of full active maternal effort following confirmation of full

dilatation of the cervix indilatation of the cervix in the absence of expulsive the absence of expulsive contractionscontractions

Delay in the Second stageDelay in the Second stage

Nulliparous women:Nulliparous women: Birth would be expected to take place within 3 Birth would be expected to take place within 3

hours of the start of the active secondhours of the start of the active second stage in stage in most womenmost women

A diagnosis of delay in the active second stage A diagnosis of delay in the active second stage should be made when it has lastedshould be made when it has lasted 2 hours and if 2 hours and if birth is not imminentbirth is not imminent


Parous women:Parous women: Birth would be expected to take place within 2 Birth would be expected to take place within 2

hours of the start of the active secondhours of the start of the active second stage in most women.stage in most women. A diagnosis of delay in the active second stage A diagnosis of delay in the active second stage

should be made when it has lastedshould be made when it has lasted 1 hour and women should be referred to a 1 hour and women should be referred to a

healthcare professional trained tohealthcare professional trained to undertake an operative vaginal birth if birth is not undertake an operative vaginal birth if birth is not

imminent.imminent.


IIn a woman without epiduraln a woman without epidural analgesiaanalgesia and and withoutwithout an urge to push an urge to push after full dilatation after full dilatation, , further assessment shouldfurther assessment should take place after 1 take place after 1 hourhour


Where there is delay in the second stage of Where there is delay in the second stage of labour, or if the woman islabour, or if the woman is excessively distressed, excessively distressed, support and sensitive encouragement and the support and sensitive encouragement and the woman‘swoman‘s need for analgesia/anaesthesia are need for analgesia/anaesthesia are particularly importantparticularly important

In nulliparous women, if after 1 hour of active In nulliparous women, if after 1 hour of active second stage progress issecond stage progress is inadequate, delay is inadequate, delay is suspectedsuspected

Following vaginal examination, amniotomyFollowing vaginal examination, amniotomy should be offered if the membranes are intactshould be offered if the membranes are intact


Following initial obstetric assessment for women Following initial obstetric assessment for women with delay in the secondwith delay in the second stage of labour, ongoing stage of labour, ongoing obstetric review should be maintained everyobstetric review should be maintained every15–15–30 minutes30 minutes

Instrumental birth and delayed Instrumental birth and delayed second stagesecond stage

Instrumental birth should be considered if there is Instrumental birth should be considered if there is concern about fetalconcern about fetal wellbeing, or for prolonged wellbeing, or for prolonged second stagesecond stage

On rare occasions, the woman's need for help in On rare occasions, the woman's need for help in the second stage may be anthe second stage may be an indication to assist indication to assist by offering instrumental birth when supportive by offering instrumental birth when supportive care has notcare has not helped helped

The choice of instrument depends on a balance The choice of instrument depends on a balance of clinical circumstance andof clinical circumstance and practitioner practitioner experienceexperience

Instrumental birth and delayed Instrumental birth and delayed second stagesecond stage

Instrumental birth is an operative procedure that should Instrumental birth is an operative procedure that should be undertaken withbe undertaken with anaesthesia anaesthesia

If a woman declines anaesthesia, a pudendal block If a woman declines anaesthesia, a pudendal block combined with localcombined with local anaesthetic to the perineum can anaesthetic to the perineum can be used during instrumental birthbe used during instrumental birth

Where there is concern about fetal compromise, either Where there is concern about fetal compromise, either tested effectivetested effective anaesthesia or, if time does not allow anaesthesia or, if time does not allow this, a pudendal block combined withthis, a pudendal block combined with local anaesthetic local anaesthetic to the perineum can be used during instrumental birthto the perineum can be used during instrumental birth

Caesarean section should be advised if vaginal birth is Caesarean section should be advised if vaginal birth is not possiblenot possible

Intrapartum interventions to Intrapartum interventions to reduce perineal traumareduce perineal trauma

Perineal massage should not be performed by Perineal massage should not be performed by healthcare professionals in thehealthcare professionals in the second stage of second stage of labourlabour

Either the 'hands on' (guarding the perineum and Either the 'hands on' (guarding the perineum and flexing the baby's head) orflexing the baby's head) or the 'hands poised' the 'hands poised' (with hands off the perineum and baby's head but (with hands off the perineum and baby's head but inin readiness) technique can be used to facilitate readiness) technique can be used to facilitate spontaneous birthspontaneous birth

Lidocaine spray should not be used to reduce Lidocaine spray should not be used to reduce pain in the second stage ofpain in the second stage of labour labour


A routine episiotomy should not be carried out during A routine episiotomy should not be carried out during spontaneous vaginalspontaneous vaginal birth birth

Where an episiotomy is performed, theWhere an episiotomy is performed, the rrecommended technique is aecommended technique is a mediolateral episiotomy mediolateral episiotomy

An episiotomy should be performed if there is a An episiotomy should be performed if there is a clinical need such asclinical need such as instrumental birth or suspected instrumental birth or suspected fetal compromisefetal compromise

EEffective analgesia should be provided prior to ffective analgesia should be provided prior to carrying out ancarrying out an episiotomy, except in an emergency episiotomy, except in an emergency due to acute fetal compromisedue to acute fetal compromise


Women with a history of severe perineal trauma Women with a history of severe perineal trauma should be informed that theirshould be informed that their risk of repeat risk of repeat severe perineal trauma is not increased in a severe perineal trauma is not increased in a subsequent birth,subsequent birth, compared with women having compared with women having their first babytheir first baby

Episiotomy should not be offered routinely at Episiotomy should not be offered routinely at vaginal birth following previousvaginal birth following previous third- or fourth- third- or fourth-degree traumadegree trauma


In order for a woman who has had previous third- In order for a woman who has had previous third- or fourth-degree trauma toor fourth-degree trauma to make an informed make an informed choice, discussion with her about the future mode choice, discussion with her about the future mode of birthof birth should encompass: should encompass: current urgency or incontinence symptomscurrent urgency or incontinence symptoms the degree of previous traumathe degree of previous trauma risk of recurrencerisk of recurrence the success of the repair undertakenthe success of the repair undertaken the psychological effect of the previous traumathe psychological effect of the previous trauma management of her labourmanagement of her labour

Third stage of labourThird stage of labour

The third stage of labour is the time from the birth The third stage of labour is the time from the birth of the baby to the expulsion of theof the baby to the expulsion of the placenta and placenta and membranesmembranes

Active management of the third stage involves a Active management of the third stage involves a package of care which includes allpackage of care which includes all of these three of these three components:components: routine use of uterotonic drugsroutine use of uterotonic drugs early clamping and cutting of the cordearly clamping and cutting of the cord controlled cord tractioncontrolled cord traction

Third stage of labourThird stage of labour

Physiological management of the third stage Physiological management of the third stage involves a package of care whichinvolves a package of care which includes all of includes all of these three components:these three components: no routine use of uterotonic drugsno routine use of uterotonic drugs no clamping of the cord until pulsation has ceasedno clamping of the cord until pulsation has ceased delivery of the placenta by maternal effortdelivery of the placenta by maternal effort

Prolonged third stageProlonged third stage

The third stage of labour is diagnosed as The third stage of labour is diagnosed as prolonged if not completed withinprolonged if not completed within

30 minutes of the birth of the baby with active 30 minutes of the birth of the baby with active management and management and

60 minutes60 minutes with physiological management with physiological management

Physiological and active Physiological and active management of the third stagemanagement of the third stage

Active management of the third stage is Active management of the third stage is recommended, which includes the userecommended, which includes the use of oxytocin, of oxytocin, followed byfollowed by early clamping and cutting of the cord early clamping and cutting of the cord and controlled cord tractionand controlled cord traction

Women should be informed that active Women should be informed that active management of the third stage reducesmanagement of the third stage reduces the risk of the risk of maternal haemorrhage and shortens the third stagematernal haemorrhage and shortens the third stage

Women at low risk of postpartum haemorrhage Women at low risk of postpartum haemorrhage who request physiologicalmanagement of the third who request physiologicalmanagement of the third stage should be supported in their choicestage should be supported in their choice

Physiological and active Physiological and active management of the third stagemanagement of the third stage

Changing from physiological management to Changing from physiological management to active management of the thirdactive management of the third stage is indicated stage is indicated in the case of:in the case of: haemorrhagehaemorrhage failure to deliver the placenta within 1 hourfailure to deliver the placenta within 1 hour the woman's desire to artificially shorten the third the woman's desire to artificially shorten the third

stagestage

Treatment of women with a Treatment of women with a retained placentaretained placenta

Intravenous access should always be secured in Intravenous access should always be secured in women with a retainedwomen with a retained placenta placenta

Intravenous infusion of oxytocin should not be Intravenous infusion of oxytocin should not be used to assist the delivery of theused to assist the delivery of the placenta placenta

For women with a retained placenta oxytocin For women with a retained placenta oxytocin injection into the umbilical veininjection into the umbilical vein with 20 IU of with 20 IU of oxytocin in 20 ml of saline is recommended, oxytocin in 20 ml of saline is recommended, followed by proximalfollowed by proximal clamping of the cord clamping of the cord


If the placenta is still retained 30 minutes after If the placenta is still retained 30 minutes after oxytocin injection, or sooner ifoxytocin injection, or sooner if there is concern there is concern about the woman's condition, women should be about the woman's condition, women should be offered anoffered an assessment of the need to remove the assessment of the need to remove the placenta. placenta.

Women should be informedWomen should be informed that this assessment that this assessment can be painful and they should be advised to can be painful and they should be advised to havehave analgesia or even anaesthesia for this analgesia or even anaesthesia for this assessmentassessment


If manual removal of the placenta is required, this If manual removal of the placenta is required, this must be carried out undermust be carried out under effective regional effective regional anaesthesia (or general anaesthesia when anaesthesia (or general anaesthesia when necessary)necessary)

Risk factors for postpartum Risk factors for postpartum haemorrhagehaemorrhage

Antenatal risk factors:Antenatal risk factors: previous retained placenta or postpartum haemorrhageprevious retained placenta or postpartum haemorrhage maternal haemoglobin level below 8.5 g/dlmaternal haemoglobin level below 8.5 g/dl body mass index greater than 35 kg/m2body mass index greater than 35 kg/m2 grand multiparity (parity 4 or more)grand multiparity (parity 4 or more) antepartum haemorrhageantepartum haemorrhage overdistention of the uterus (multipleoverdistention of the uterus (multiples,s, polyhydramnios polyhydramnios or or

macrosomia)macrosomia) existing uterine abnormalitiesexisting uterine abnormalities low-lying placentalow-lying placenta maternal age (35 years or older)maternal age (35 years or older)

Risk factors for postpartum Risk factors for postpartum haemorrhagehaemorrhage

Risk factors in labour:Risk factors in labour: inductioninduction prolonged first, second or third stage of labourprolonged first, second or third stage of labour oxytocin useoxytocin use precipitate labourprecipitate labour operative birth or caesarean sectionoperative birth or caesarean section

Management of postpartum Management of postpartum haemorrhagehaemorrhage

Immediate treatment for postpartum Immediate treatment for postpartum haemorrhage should include:haemorrhage should include: calling for appropriate helpcalling for appropriate help uterine massageuterine massage intravenous fluidsintravenous fluids UterotonicsUterotonics

No particular uterotonic drug can be No particular uterotonic drug can be recommended over another for therecommended over another for the

treatment of postpartum haemorrhagetreatment of postpartum haemorrhage


Treatment combinations for postpartum Treatment combinations for postpartum haemorrhage might include repeathaemorrhage might include repeat bolus of oxytocin (intravenous), ergometrine bolus of oxytocin (intravenous), ergometrine

(intramuscular, or cautiously(intramuscular, or cautiously intravenously), intravenously), intramuscular oxytocin with ergometrine intramuscular oxytocin with ergometrine (Syntometrine),(Syntometrine),

misoprostol, oxytocin infusion (Syntocinon) or misoprostol, oxytocin infusion (Syntocinon) or carboprost (intramuscular).carboprost (intramuscular).


Additional therapeutic options for the treatment of Additional therapeutic options for the treatment of postpartum haemorrhagepostpartum haemorrhage include tranexamic acid (intravenous) and include tranexamic acid (intravenous) and rarely, in the presence of otherwiserarely, in the presence of otherwise normal clotting normal clotting

factors, rFactor VIIa, after seeking advice from afactors, rFactor VIIa, after seeking advice from a haematologisthaematologist

No particular surgical procedure can be No particular surgical procedure can be recommended above another for therecommended above another for the treatment of treatment of postpartum haemorrhagepostpartum haemorrhage

Perineal care - Perineal care - trauma caused by trauma caused by either tearing or episiotomyeither tearing or episiotomy

first degree – injury to skin onlyfirst degree – injury to skin only second degree – injury to the perineal muscles but not the second degree – injury to the perineal muscles but not the

anal sphincteranal sphincter third degree – injury to the perineum involving the anal third degree – injury to the perineum involving the anal

sphincter complex:sphincter complex: 3a – less than 50% of external anal sphincter thickness torn3a – less than 50% of external anal sphincter thickness torn 3b – more than 50% of external anal sphincter thickness torn3b – more than 50% of external anal sphincter thickness torn 3c – internal anal sphincter torn3c – internal anal sphincter torn

fourth degree – externalfourth degree – external and internal and internal sphincter sphincter and anal and anal epitheliumepithelium


Perineal trauma should be repaired using aseptic Perineal trauma should be repaired using aseptic techniquestechniques

Equipment should be checked and swabs and Equipment should be checked and swabs and needles counted before and after theneedles counted before and after the procedure procedure

Good lighting is essential to see and identify the Good lighting is essential to see and identify the structures involvedstructures involved

Difficult trauma should be repaired by an Difficult trauma should be repaired by an experienced practitioner in theatre underexperienced practitioner in theatre under regional or regional or general anaesthesia. An indwelling catheter should general anaesthesia. An indwelling catheter should be inserted forbe inserted for 24 hours to prevent urinary retention24 hours to prevent urinary retention


Good anatomical alignment of the wound should be Good anatomical alignment of the wound should be achieved, and considerationachieved, and consideration given to the cosmetic given to the cosmetic resultsresults

Rectal examination should be carried out after Rectal examination should be carried out after completing the repair to ensure thatcompleting the repair to ensure that suture material suture material has not been accidentally inserted through the rectal has not been accidentally inserted through the rectal mucosamucosa

Following completion of the repair, an accurate Following completion of the repair, an accurate detailed account should bedetailed account should be documented covering the documented covering the extent of the trauma, the method of repair and theextent of the trauma, the method of repair and the materials usedmaterials used


Information should be given to the woman Information should be given to the woman regarding the extent of the trauma, painregarding the extent of the trauma, pain relief, relief, diet, hygiene and the importance of pelvic-floor diet, hygiene and the importance of pelvic-floor exercisesexercises

Prelabour rupture of the Prelabour rupture of the membranes at termmembranes at term

There is no reason to carry out a speculum There is no reason to carry out a speculum examination with a certain historyexamination with a certain history of rupture of of rupture of the membranes at termthe membranes at term

Women with an uncertain history of prelabour Women with an uncertain history of prelabour rupture of the membranesrupture of the membranes should be offered a should be offered a speculum examination to determine whether theirspeculum examination to determine whether their membranes have rupturedmembranes have ruptured

Digital vaginal examination in the absence ofDigital vaginal examination in the absence of contractions should be avoidedcontractions should be avoided

Prelabour rupture of the Prelabour rupture of the membranes at termmembranes at term

Women presenting with prelabour rupture of the Women presenting with prelabour rupture of the membranes at term should bemembranes at term should be advised that: advised that: the risk of serious neonatal infection is 1% rather the risk of serious neonatal infection is 1% rather

than 0.5% for women with intactthan 0.5% for women with intact membranes membranes 60% of women with prelabour rupture of the 60% of women with prelabour rupture of the

membranes will go into labour withinmembranes will go into labour within 24 hours 24 hours induction of labour is appropriate approximately 24 induction of labour is appropriate approximately 24

hours after rupture of thehours after rupture of the membranes membranes

Meconium-stained liquorMeconium-stained liquor

Continuous EFM should be advised for women Continuous EFM should be advised for women with significant meconiumstainedwith significant meconiumstained liquor, which is liquor, which is defined as either dark green or black amniotic fluid defined as either dark green or black amniotic fluid thatthat is thick or tenacious, or any meconium-stained is thick or tenacious, or any meconium-stained amniotic fluid containing lumpsamniotic fluid containing lumps of meconium of meconium

Continuous EFM should be considered for women Continuous EFM should be considered for women with light meconium-stainedwith light meconium-stained liquor depending on a liquor depending on a risk assessment which should include as a risk assessment which should include as a minimumminimum their stage of labour, volume of liquor, their stage of labour, volume of liquor, parity, the FHRparity, the FHR

Complicated labour: monitoring Complicated labour: monitoring babies in labourbabies in labour

Normal Normal FHR trace in which all four features are classified as FHR trace in which all four features are classified as

reassuringreassuring Suspicious Suspicious

FHR trace with one feature classified as non-FHR trace with one feature classified as non-reassuring and the remainingreassuring and the remaining features classified as features classified as reassuringreassuring

PathologicalPathological FHR trace with two or more features classified as FHR trace with two or more features classified as

non-reassuring or one ornon-reassuring or one or more classified as abnormal more classified as abnormal

MALPOSITIONS AND MALPOSITIONS AND MALPRESENTATIONSMALPRESENTATIONS

Malpositions are abnormal positions of the vertex Malpositions are abnormal positions of the vertex of the fetal head (with theof the fetal head (with the occiput as the occiput as the reference point) relative to the maternal pelvisreference point) relative to the maternal pelvis

Malpresentations are all presentations of the Malpresentations are all presentations of the fetus other than vertex.fetus other than vertex.

labour petr velebil. first stage of labour u clinical intervention should not be offered or advised...

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