Normal Labor&Delivery

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Normal Labor & DeliveryNormal Labor & Delivery


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Why labor pains ?Why labor pains ?

LaborLabor-- because much energy is expendedbecause much energy is expended

during this timeduring this time

PainsPainsbecause contractions of labor are painfulbecause contractions of labor are painful


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Mechanisms Cited for Pain in LaborMechanisms Cited for Pain in Labor

Hypoxia of the contractedHypoxia of the contracted myometriummyometrium

Compression of nerve ganglia in the cervix andCompression of nerve ganglia in the cervix and

lower uterus by the interlocking muscle bundleslower uterus by the interlocking muscle bundles

Stretching of the cervix during dilatationStretching of the cervix during dilatation

Stretching of the peritoneum overlying theStretching of the peritoneum overlying the

fundusfundus


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Stages OfStages Of LabourLabour

Stage 1Stage 1

Cervical Effacement and DilatationCervical Effacement and Dilatation

Stage 2Stage 2

Full cervical dilatation to expulsion ofFull cervical dilatation to expulsion of

fetusfetus

Stage 3Stage 3

Placental separation andexpulsionPlacental separation andexpulsion


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EffacementEffacement:: taking up of thecervixtaking up of thecervix

or obliteration of thecervical canalor obliteration of thecervical canal


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Nulli ara Multi ara

Cervical

Effacementand

dilatation


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Cardinal MovementsCardinal Movementsof Laborof Labor


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The fetus is in theThe fetus is in the occiputocciput or vertex inor vertex in

approximately 97% of laborsapproximately 97% of labors


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Engagement

Descent

Flexion

Internal Rotation

Extension

External Rotation

Expulsion


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Conduct of Labor andConduct of Labor andDeliveryDelivery


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Signs of LaborSigns of Labor

HypogastricHypogastric andand lumbosacrallumbosacral painspains

(contractions)(contractions)

Bloody vaginal discharge or bloodyBloody vaginal discharge or bloody

showshow


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True LaborTrue Labor False LaborFalse Labor

Contractions regularContractions regular

Intervals shortenIntervals shorten

Intensity increasesIntensity increases

Discomfort in back &Discomfort in back &abdomenabdomen

CervixdilatesCervixdilates

IrregularIrregular

Remain longRemain long

UnchangedUnchanged

Lower abdomenLower abdomen

No dilatationNo dilatation

Relieved by sedationRelieved by sedation


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Admission Vaginal ExamAdmission Vaginal Exam

If there are NO contraindications, note:If there are NO contraindications, note:

Amniotic fluidAmniotic fluid

CervixCervix

Presenting partPresenting part

StationStation

Pelvic architecturePelvic architecture


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StationStation

Degree of descent of the presenting part intoDegree of descent of the presenting part into

the birth canalthe birth canal

Landmark:Ischial spinesLandmark:Ischial spines

Described in centimeters above or below spinesDescribed in centimeters above or below spines

((--5 to +5)5 to +5)


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Ischial spines


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Management of FirstS

tageManagement of FirstS

tageLaborLabor


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First stageFirst stage

-- from onset of regularfrom onset of regularcontractions to full cervicalcontractions to full cervical

dilatationdilatation


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First stage:Admission ProceduresFirst stage:Admission Procedures

History


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First Stage:Admission ProceduresFirst Stage:Admission Procedures

2. Physical Examination2. Physical Examination

General survey, vital signsGeneral survey, vital signs

a. Abdominal Examinationa. Abdominal Examination

InspectionInspection

PalpationPalpation

AuscultationAuscultation


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Identify which pole

occupies thefundus

Determine onwhich side the

back and soft partsare

What presenting

part overlies theinlet; attitudeExtent of descent


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First stage:Admission ProceduresFirst stage:Admission Procedures

3. Baseline3. Baselinecardiotocogramcardiotocogram


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First stage: Maternal MonitoringFirst stage: Maternal Monitoring

Subsequent vaginal examinationsSubsequent vaginal examinations

AnalgesiaAnalgesia

Vital signs every 1Vital signs every 1--2 hours2 hours


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Management ofManagement of

SecondStage of LaborSecondStage of Labor


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SecondStageSecondStage

Mean duration:Mean duration:

2020 minsmins.. -- multiparamultipara

5050 minsmins.. -- nulliparanullipara

IdentificationIdentification

--Woman starts to bear downWoman starts to bear down

-- Urge to defecateUrge to defecate-- Uterinecontractions longer, restUterinecontractions longer, restintervals shorterintervals shorter


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Second stage:Second stage:

Preparation for DeliveryPreparation for Delivery

PositionPosition

-- DorsalDorsal lithotomylithotomy

-- StirrupsStirrups

-- Legs not too wide openLegs not too wide open

--Poplit

ealPoplit

eal r

egion shoul

drest

comfortablyr

egion shoul

drest

comfortablyonon leg holderleg holder

-- Cleansing anddrapingCleansing anddraping


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LITHOTOMY POSITION


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Delivery of the HeadDelivery of the Head

CrowningCrowning

largest headlargest head

diameter encircleddiameter encircled

by theby the vulvarvulvar ringring


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Delivery of the HeadDelivery of the Head

EpisiotomyEpisiotomy

Incision of the pudendaIncision of the pudenda

Not universally doneNot universally done


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EpisiotomyEpisiotomy

Substitutes a jagged laceration for a cleanSubstitutes a jagged laceration for a clean

cut woundcut wound

TypesTypes

-- medianmedian

-- mediolateralmediolateral


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Median episiotomy


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Mediolateral episiotomy


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Benefits(?) of EpisiotomyBenefits(?) of Episiotomy

?Clean cut wound?Clean cut wound

?prevents pelvic relaxation?prevents pelvic relaxation

cystocelecystocele

rectocelerectocele

urinary incontinenceurinary incontinence

Surgical judgment andcommon senseSurgical judgment andcommon sense


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Timing of EpisiotomyTiming of Episiotomy

Too earlyToo early

-- Bleeding from the incisionBleeding from the incision

Too lateToo late-- Excessive stretching of muscles of theExcessive stretching of muscles of the

perinealperineal floor; defeats the purpose of thefloor; defeats the purpose of theprocedureprocedure

Ideally: when head is visible atIdeally: when head is visible at introitusintroitus duringduringa contraction to aa contraction to a 33--44 cm. diametercm. diameter


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Median MediolateralMedian Mediolateral

Easy to repairEasy to repair More difficultMore difficult

Rare faulty healingRare faulty healing More commonMore common

Less postLess post--op painop pain More commonMore commonExcellent anatomicExcellent anatomic Faulty at timesFaulty at times

resultsresults

Less blood lossLess blood loss More blood lossMore blood lossDyspareuniaDyspareunia rarerare OccasionalOccasional

Extension commonExtension common RareRare


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Ritgen

Maneuver


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Clearing of the NasopharynxClearing of the Nasopharynx

Aspirate amnionic fluidAspirate amnionic fluid

debris and blooddebris and blood

Wipe face quicklyWipe face quickly


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Delivery of theShouldersDelivery of theShoulders

After delivery of the head, the fetus comesAfter delivery of the head, the fetus comesin contact with the anusin contact with the anus

If shoulders do not appear at the vulvaIf shoulders do not appear at the vulvaspontaneously after external rotation,spontaneously after external rotation,sides of the head are grasped and gentlesides of the head are grasped and gentle

downward traction is applied. Bodydownward traction is applied. Bodyfollows.follows.


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DOWNWARD

THEN

UPWARD


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NuchalNuchal cordcord

Finger should be passed around the neck toFinger should be passed around the neck to

check forcheck for nuchalnuchal cordscords

If looseIf loose just slide over infants headjust slide over infants head

If tightIf tight cut between 2 clampscut between 2 clamps


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Clamping the cord between 2 clamps

Nuchal cord


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Management of theThirdStageManagement of theThirdStage


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Third stage of laborThird stage of labor

Placental separation andexpulsionPlacental separation andexpulsion


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Delivery of the PlacentaDelivery of the Placenta

Should not be forced until signs of placentalShould not be forced until signs of placentalseparation appearseparation appear

DANGERDANGER::Uterine inversion !!!Uterine inversion !!!


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Signs of Placental SeparationSigns of Placental Separation

Uterus becomes globularUterus becomes globular

Sudden gush of bloodSudden gush of blood

Uterus rises in the abdomenUterus rises in the abdomen

Umbilical cord lengthensUmbilical cord lengthens

Within 1Within 1--3 minutes3 minutes


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PLACENTA


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Sudden g

ush of blood


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Lengthening of the cord


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Expression ofthe Placenta


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Delivery of the placenta


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Inspectionofthe Placenta


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Inspection of placenta


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Too much traction on thecordcan lead to UTERINE INVERSION


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UTERINE INVERSION

PLACENTA

UTERUS


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Manual Removal of the PlacentaManual Removal of the Placenta

Performed if the placenta does not separatePerformed if the placenta does not separate

promptlypromptly


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OxytocicOxytocic AgentsAgents

After deliveryAfter delivery hemostasishemostasis is achieved byis achieved by

vasoconstriction of the placental sitevasoconstriction of the placental site

Agents which promotecontraction of theAgents which promotecontraction of the

myometriummyometrium::

-- OxytocinOxytocin

-- ErgonovineErgonovine maleatemaleate

-- MethylergonovineMethylergonovine maleatemaleate


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Fourth Stage of LaborFourth Stage of Labor

Maternal vital signsMaternal vital signs

Gentle uterine massage and ice packs toGentle uterine massage and ice packs to

stimulatecontractionsstimulatecontractions

Bladder should becheckedBladder should bechecked

Clots in the uterinecavityClots in the uterinecavity

HematomasHematomas


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Lacerations of Vagina & PerineumLacerations of Vagina & Perineum

First degreeFirst degree

-- FourchetteFourchette,, perinealperineal skin vaginal mucosa butskin vaginal mucosa but

not the underlying fascia and musclenot the underlying fascia and muscle

Second degreeSecond degree

-- Fascia & muscles of theFascia & muscles of the perinealperineal body but notbody but notthe anal sphincterthe anal sphincter


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ThirddegreeThirddegree

--Vaginal mucosa,Vaginal mucosa, perinealperineal skin, fascia, upskin, fascia, up

to the rectal sphincter but not the rectalto the rectal sphincter but not the rectal

mucosamucosa

Fourth degreeFourth degree

-- Extension up to the rectal mucosaExtension up to the rectal mucosa


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Pain after EpisiotomyPain after Episiotomy

Persistence of pain may indicate thePersistence of pain may indicate the

presence of a HEMATOMA:presence of a HEMATOMA:

--vulvarvulvar

--vulvovaginalvulvovaginal

--ischiorectalischiorectal


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Good day!Good day!

Normal Labor&Delivery

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