ABC of labour careABC of labour care

By

Yasser OriefLecturer of Obs.& Gyn., Alexandria University.

Fellow, Lübeck University, Germany.DOGE, Auvergne University, France.

AgendaAgenda

• Normal Labour ?• Initial Evaluation of a

Woman in Labor • Active management of labourActive management of labour• Newborn careNewborn care

Normal Labour ? ?Normal Labour ? ?• SpontaneousSpontaneous• SingleSingle• Full termFull term• ViableViable• VertexVertex• Natural PassagesNatural Passages• Reasonable timeReasonable time• Without interferenceWithout interference• Without complicationsWithout complications

Initial Evaluation of a Woman in Labor

Performed to:• Evaluate the current health status of the

mother and baby, • Identify risk factors which could influence the

course or management of labor, and • Determine the labor status of the mother.

Initial Evaluation of a Woman in Labor

• 1 History1 History• 2. Examination2. Examination• 3. Investigations3. Investigations

Initial Evaluation of a Woman in Labor

HistoryHistory• Personal Personal • Menstrual Menstrual • Obstetrical Obstetrical • MedicalMedical• SurgicalSurgical• FamilyFamily

Initial Evaluation of a Woman in LaborExamination

Vital signs

• Blood Pressure.. > 140/90• Pulse .. > 100 bpm• Temperature .. > 38 C°

Initial Evaluation of a Woman in LaborExamination

ContractionsContractions

Check the Check the frequency frequency and durationand duration of any of any uterine contractions.uterine contractions.

• ManualManual• electronic fetal electronic fetal

monitormonitor

Initial Evaluation of a Woman in LaborExamination

ContractionsContractions

Initial Evaluation of a Woman in LaborExamination

Fetal Heart RateHow?• Fetal Doppler device,• Electronic fetal monitor,• Ultrasound• Pinard stethoscope.What? • Tic Tac rhythm• Regular• 120-160 BPM

Initial Evaluation of a Woman in LaborExamination

Fetal Heart RateFetal Heart Rate

Electronic fetal monitoringElectronic fetal monitoring

Initial Evaluation of a Woman in LaborAbdominal Examination (Leopold's Maneuvers )

1. Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse).

Initial Evaluation of a Woman in LaborAbdominal Examination (Leopold's Maneuvers )

2. The sides of the 2. The sides of the uterus are palpated uterus are palpated to determine the to determine the position of the fetal position of the fetal back and small parts.back and small parts.

Initial Evaluation of a Woman in LaborAbdominal Examination (Leopold's Maneuvers )

3. The presenting part 3. The presenting part (head or butt) is (head or butt) is palpated above the palpated above the symphysis and degree symphysis and degree of engagement of engagement determineddetermined

Initial Evaluation of a Woman in LaborAbdominal Examination (Leopold's Maneuvers )

4. The fetal occipital 4. The fetal occipital prominence is prominence is determined..determined..

Initial Evaluation of a Woman in LaborVaginal Examination

• Fetal OrientationFetal Orientation• Cervical dilatation and effacementCervical dilatation and effacement• Status of fetal membranesStatus of fetal membranes• Assessment of maternal pelvisAssessment of maternal pelvis

Initial Evaluation of a Woman in LaborAbdominal and Vaginal Examination

Fetal OrientationFetal Orientation CephalicCephalic

Initial Evaluation of a Woman in LaborAbdominal and Vaginal Examination

Fetal Orientation Fetal Orientation BreechBreech

Initial Evaluation of a Woman in LaborAbdominal and Vaginal Examination

Fetal OrientationFetal Orientation Complex TransverseComplex Transverse

Initial Evaluation of a Woman in LaborVaginal Examination

Cervical dilatation and Cervical dilatation and effacementeffacement

Initial Evaluation of a Woman in LaborVaginal Examination

Status of Fetal MembranesStatus of Fetal MembranesIntact or rupturedIntact or ruptured

Initial Evaluation of a Woman in LaborVaginal Examination

Status of Fetal MembranesStatus of Fetal MembranesIntact or rupturedIntact or ruptured

Vaginal secretionsVaginal secretions are normally are normally slightly slightly acidacid, turning Nitrazine , turning Nitrazine paper paper yellow.yellow.

Amniotic fluidAmniotic fluid,, in contrast, is a weak in contrast, is a weak basebase, and will turn the Nitrazine , and will turn the Nitrazine paper a paper a dark blue.dark blue.

Initial Evaluation of a Woman in LaborVaginal Examination

Assessment of maternal pelvisAssessment of maternal pelvis

This is frequently performed prenatally, but can This is frequently performed prenatally, but can also be done at the initial evaluation of a also be done at the initial evaluation of a patient in labor. patient in labor.

GynecoidGynecoidPlatypoid Anthropoid Android

Initial Evaluation of a Woman in LaborInvestigations

Urine for Protein and Glucose

• ProteinuraProteinura (1+ or greater) can suggest the presence of pre-eclampsia.

• glucosuria glucosuria (1+ to 2+ or greater) can suggest the presence of diabetes.

Initial Evaluation of a Woman in LaborInvestigations

Ultrasound

• Number • Viability• Congenital anomalies• Orientation• Placenta• Amniotic fluid

Is she actually in labour ??Is she actually in labour ??

• progressive cervical changes, in the presence of regular, frequent, painful uterine contractions.

• Anything else → Anything else → False False labourlabour

Stages of labourStages of labour

From to

• 1st stage: Labour pain → Full cx dilatation• 2nd stage: Full cx dilatation → Fetal expulsion• 3rd stage: Fetal expulsion → After birth expul.• 4th stage: next 24 hours

Ist stage of labour 2 phases Ist stage of labour 2 phases

Latent phaseLatent phase• Are less than 4 cm dilated. Are less than 4 cm dilated. • Have regular, frequent Have regular, frequent

contractions that may or may not contractions that may or may not be painful. be painful.

• Dilate only very slowly Dilate only very slowly • Can usually talk or laugh during Can usually talk or laugh during

their contractions their contractions • May find this phase of labor May find this phase of labor

lasting hours to days or longer.lasting hours to days or longer.

Ist stage of labour 2 phases Ist stage of labour 2 phases

Active phaseActive phase• Are at least 4 cm dilated. Are at least 4 cm dilated. • Have regular, frequent contractions Have regular, frequent contractions

that are usually moderately painful. that are usually moderately painful. • Demonstrate progressive cervical Demonstrate progressive cervical

dilatation of at least 1.2-1.5 cm per dilatation of at least 1.2-1.5 cm per hour. hour.

• Usually are not comfortable with Usually are not comfortable with talking or laughing during their talking or laughing during their contractions.contractions.

Ist stage of labourIst stage of labour

Progress of labour Progress of labour Effacement and dilatation of the cervix Effacement and dilatation of the cervix 

Ist stage of labourIst stage of labour

Progress of labour Progress of labour DescentDescent

Ist stage of labourIst stage of labour

Progress of labour Progress of labour DescentDescent

Ist stage of labourIst stage of labour

USING THE PARTOGRAPH USING THE PARTOGRAPH • Patient informationPatient information• Fetal heart rate:Fetal heart rate: Record every half hour. Record every half hour. • Amniotic fluid:Amniotic fluid: Record the colour of amniotic fluid at Record the colour of amniotic fluid at

every vaginal examinationevery vaginal examination• Moulding: Moulding: • Cervical dilatation:Cervical dilatation: Assessed at every vaginal examination Assessed at every vaginal examination

and marked with a cross (X). Begin plotting on the and marked with a cross (X). Begin plotting on the partograph at 4 cm. partograph at 4 cm.

• Alert line:Alert line: A line starts at 4 cm of cervical dilatation to the A line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm per point of expected full dilatation at the rate of 1 cm per hour.hour.

USING THE PARTOGRAPHUSING THE PARTOGRAPH• Action line:Action line: Parallel and 4 hours to the right of the alert Parallel and 4 hours to the right of the alert

line. line. • Time:Time: Record actual time. Record actual time. • Contractions:Contractions: Chart every half hour Chart every half hour• OxytocinOxytocin• Drugs given:Drugs given: Record any additional drugs given. Record any additional drugs given. • Pulse:Pulse: Record every 30 minutes and mark with a dot (●). Record every 30 minutes and mark with a dot (●). • Blood pressure:Blood pressure: Record every 4 hours Record every 4 hours• Temperature:Temperature: Record every 2 hours. Record every 2 hours. • Protein, acetone and volume:Protein, acetone and volume:

Sample Prtogram Sample Prtogram

Normal Prtogram Normal Prtogram

Abnormal Prtogram Abnormal Prtogram

Normal Prtogram Normal Prtogram

Normal Prtogram Normal Prtogram

2nd stage of labour (Baby delivery)2nd stage of labour (Baby delivery)

It begins with complete dilatation and ends It begins with complete dilatation and ends when the baby is completely out of the when the baby is completely out of the mother.mother.

PrimigravidaPrimigravida → 1- 2 hours Multipara Multipara → 30 minutes

2nd stage of labour (Baby delivery)2nd stage of labour (Baby delivery)Delivery of the head • Ask the woman to pant or give only

small pushes with contractions as the baby’s head delivers.

• Gently support the perineum as the baby’s head delivers. 

• Once the baby’s head delivers, ask the woman not to push.

• Suction the baby’s mouth and nose. • Feel around the baby’s neck for the

umbilical cord

2nd stage of labour (Baby delivery)2nd stage of labour (Baby delivery)

Episiotomy  should be considered only in the case of:

• complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum);

• scarring from female genital mutilation or poorly healed third or fourth degree tears;

• fetal distress.

2nd stage of labour (Baby delivery)2nd stage of labour (Baby delivery)

Clamp and Cut the Umbilical CordClamp and Cut the Umbilical Cord• Once the baby is breathing, put two

clamps on the umbilical cord, about an inch (3 cm) from the baby's abdomen. Use scissors to cut between the clamps.

• It is better to keep the baby level more or less with the placenta until the cord is clamped.

3rd stage of labour (Placenta delivery)3rd stage of labour (Placenta delivery)

PrimigravidaPrimigravida → 30 minutes

Multipara Multipara → 10minutes

3rd stage of labour (Placenta delivery)3rd stage of labour (Placenta delivery)

Signs of placental separationSigns of placental separation• A sudden gush of blood • Lengthening of the visible portion

of the umbilical cord. • The uterus  becomes round and

firm.

Carefully inspect the placentaCarefully inspect the placenta

Newborn careNewborn care

provide routine initial newborn care Check for congenital anomalies skin-to-skin contact with the mother early breastfeeding.

THANK YOU