Normal labour and delivery

NORMAL LABOUR

AND

DELIVERY

Dr Jograjiya PG Student

Department of Obstetrics and Gynecology, ESIC-PGIMSR, Basaidarapur, New Delhi

http://www.focusonbrevard.com/City/CentralCity/CivicCntr/Floor2.htm


http://www.perakmed.edu.my/index.php

http://www.perakmed.edu.my/index.php



CONTENTS

1. Definition of normal labour

2. Factors influencing progress of labour

3. Diagnosis of labour

4. Stages of labour

5. Mechanisms of labour

6. Management of labour

LABOUR

Labour is defined as the onset of regular painful

Contractions with progressive cervical effacement and

dilatation of the cervix accompanied by

descent of the presenting part.

DEFINITIONS

NORMAL LABOUR

Spontaneous expulsion,

of a single,

mature fetus (37 completed weeks – 42 weeks),

presented by vertex,

through the birth canal (i.e. vaginal delivery),

within a reasonable time (not less than 3 hours or more than

18 hours),

without complications to the mother,

or the fetus.

The following criteria should be present

NORMAL LABOUR

Understanding the process of

labour is importance

• problems can be identified

• correctly managed

IMPORTANCE

LABOUR AND DELIVERY

FACTORS THAT INFLUENCE

PROGRESS OF LABOUR

Passenger Passage

Power

THE NORMAL FEMALE PELVIS

1. The female pelvis provides the basic

framework of the birth canal.

2. The obstetric pelvis is divided into false and

true pelvis by the pelvic brim or inlet

3. The true pelvis is important, for it is

through this confined space that the fetus

must pass on its journey through the birth

canal.

4. The true pelvis is composed of inlet, cavity

and outlet.

5. Types of female pelvis – gynaecoid,

anthropoid, android and platypelloid

Outlet

Cavity

Inlet

NORMAL FEMALE PELVIS

1. The brim is slightly oval transversely.

2. The sacral promontory is not prominent.

3. The transverse diameter is slightly longer than

the anteroposterior.

4. The sidewalls are parallel and straight.

5. The ischial spines are not prominent.

6. The sacrosciatic notches are wide.

7. The sacrum has a good curve.

8. The pubic arch angle are wide, i.e. more than 90

9. Inter tuberous diameter is wide

The ideal normal female gynaecoid pelvis:

THE NORMAL FEMALE PELVIS

The important diameters of the female pelvis:

Anteroposterior Oblique Transverse

BRIM 11 12 13

CAVITY 12 12 12

OUTLET 13 12 11

Diameters

(cm)

THE FETAL SKULL

1. Sutures

2. Diameters

http://courses.washington.edu/vertebra/453/photos/skull_photos/fetal_lateral.jpg


THE FETAL SKULL

1. Sagittal suture: - The sagittal suture lies

between the parietal bones. It runs in an

anteroposterior direction between the anterior

and posterior fontanelles.

2. Coronal sutures: - The suture uniting the

parietal bones to the frontal bones is called the

coronal suture. It’s extend transversely from the

anterior fontanels and lies between the parietal

and frontal bone.

3. Frontal suture: - The frontal suture is between

the two frontal bones. It is an anterior

continuation of the sagittal suture.

4. Lambdoidal suture: - Is between the parietal

and occiptal bones.

SUTURES

THE FETAL SKULL

MOULDING OF THE FETAL SKULLMOULDING is the ability of the

fetal head to change its shape and

so to adapt itself to the unyielding

maternal pelvis during the

progress of labour.

This property is of the greatest

value in the progress of labour.



THE FETAL SKULL

Diameters of the fetal skull – anterior posterior diameters

A

BC

D

E

F

G AB ~ Suboccipto bregmatic – 9.5

-Vertex

AC ~ Submento bregmatic – 9.5

-Face

DE ~ Occipito frontal ~ 11-12

FG ~ Mento vertical – 13.5

-Brow

POWER ► Contractions + Maternal

pushingUterine contractions:

1. Initiate by pacemakers ~ uterotubal junction

2. Contraction waves meet at the fundus

3. Contraction waves progress downward

Shortening of muscle fibres

Retractions

intra uterine pressure

EXPULSION OF THE FETUS

Additional force

“maternal pushing”

Intra abdominal pressure

UTERINE CONTRACTION

NORMAL CONTRACTION

1. Frequency ~ one in every 2 – 3 min with at least 1

minute interval

2. Intensity ~ strong (> 50 mmHg)

3. Duration ~ 45 – 60 sec

Uterine contractions

LABOUR AND DELIVERY

WHAT INITIATE LABOUR

“ONSET OF LABOUR”

NORMAL LABOUR

Hormonal factors

1) Estrogen theory

2) Progesterone withdrawal theory

3) Prostaglandins theory

4) Oxytocin theory

5) Fetal cortisol theory

Mechanical factors

1) Uterine distension theory

2) Stretch of the lower uterine segment by the presenting near term

Causes of Onset of Labour:

- It is unknown but the following theories were postulated:

LABOUR AND DELIVERY

DIAGNOSIS OF LABOUR

NORMAL LABOUR AND DELIVERY

Painful regular uterine contractions

– as evidence by contraction at least

one in ten minutes

Show – as evidence by mucus mixed

with blood

Rupture of membranes – as

evidence by leaking liquor

Progressive shortening and

SYMPTOMS AND SIGNS OF LABOURBefore labour begins, women usually notice one or more premonitory, or

warnings, signs that labour is about to begin.

They are:

LABOUR AND DELIVERY

DESCRIBE THE STAGES OF

LABOUR


STAGES OF LABOUR

FIRST STAGE SECOND

STAGE

THIRD STAGE

It begins with the onset of true

labour contractions and ends

when the cervix is fully dilated

(10 cm).

Cervical effacement and

dilatation occur in the first stage

First stage of labour consists of

two phases:- latent and active.

The first stage of labour is the

longest for both nulliparous and

parous women.

The second stage of labour

begins with complete dilatation

of the cervix and ends with the

birth of the baby.

The duration is about 1 to 1½

hours in nulliparas and about 30

to 45 minutes in parous women.

The third stage is that of

separation and expulsion of

placenta and membranes and also

involves the control of bleeding.

It begins after the birth of the

baby and ends with the expulsion

of the placenta and membranes.

This is the shortest stage, lasting

up to 30 minutes, with an average

length of 5 to 10 minutes. There

is no difference in duration for

nulliparous and parous.

Labour can be divided into three stages, which are unequal in length.

FIRST STAGE OF

LABOUR


PHASES OF THE FIRST STAGE OF LABOURDivided into:

Latent phase – begins with onset of contracts and ends when cervix is 3 cm dilated and effaced

Active phase – begins after the cervix is 3 cm dilated


PHASES OF THE FIRST STAGE OF LABOURLATENT Phase ACTIVE Phase

1. Begins with onset of contractions

2. Slow progress

3. Little cervical dilatation

4. Progressive cervical effacement

5. Ends once the cervix reaches 3

cm dilatation

6. Durations

~ 8 hours for nulliparae

~ 6 hours for multiparae

1. Active process

2. Begins after 3 cm of cervical

dilatation

3. Period of active cervical

dilatation (average rate 1 cm/hr)

4. S-shaped curve which is used to

define progress of labour

5. It has 3 component

a) acceleration - slow

b) maximum - fast

c) deceleration - slow


WHAT HAPPEN DURING

THE FIRST STAGE OF LABOUR


WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR

1. Contractions:

CONTRACTIONS

1: Regular

2: Increasing in frequency

3: Stronger



2. Cervical dilatation and effacement:

Causes of cervical dilatation:

Contraction and retraction of uterine musculature

Mechanical pressure by the bulging membrane (fore

water)

The descend of the presenting part

Phases of cervical dilatationLatent phase – the first 3 cm of dilatation; a slow

process (8 hours in nulliparous and 3 hours

in multiparous

Active phase – this is active process of cervical

dilatation; the normal rate is 1 cm/hour



3. Engagement of the presenting part:


Do Uterine Contractions Affect Fetal Heart Rate?

Uterine contractions can affect fetal heart rate by increasing or

decreasing that rate in association with any given contraction.

The three primary mechanisms by which uterine contractions can

cause a decrease in fetal heart rate are compression of:

· Fetal head

· Umbilical cord

· Uterine myometrial vessels

FETAL HEART CHANGES


PROGRESS OF FIRST STAGE OF LABOUR

Findings suggestive of satisfactory progress in first stage of labour are:

- regular contractions of progressively increasing frequency and duration;

- rate of cervical dilatation at least 1 cm per hour during the active phase of

labour (cervical dilatation on or to the left of alert line);

Findings suggestive of unsatisfactory progress in first stage of labour

are:

- irregular and infrequent contractions after the latent phase;

- OR rate of cervical dilatation slower than 1 cm per hour during the active

phase of labour (cervical dilatation to the right of alert line);

SECOND STAGE OF

LABOUR


SECOND STAGE OF LABOUR

1. Begins with FULL DILATATION and ends with DELIVERY OF

THE BABY.

2. It have TWO Phases

a) Propulsive phase – from full dilatation until presenting part has

descended

to the pelvic floor

b) Expulsive phase which ends with the delivery of the baby

Features of expulsive phase – 1) mother’s irresistible desire to bear

down

2) distension of perineum

3) dilatation of the anus

3. Average length

a) Primigravidae – 40 minutes

b) Multigravidae – 20 minutes


PROGRESS OF SECOND STAGE OF LABOUR

Findings suggestive of satisfactory progress in second stage

of labour are:

- steady descent of fetus through birth canal;

- onset of expulsive (pushing) phase.

Findings suggestive of unsatisfactory progress in second

stage of labour are:

- lack of descent of fetus through birth canal;

- failure of expulsion during the late (expulsive) phase.

THIRD STAGE OF

LABOUR


THIRD STAGE OF LABOUR

1. Begins after DELIVERY of the baby and ends with DELIVERY

OF THE PLACENTA / MEMBRANES.

2. It have TWO Phases

a) Separation phase

b) Expulsion phase

3. Duration – usually 15 minutes or less (if actively managed).

4. Average blood loss – 150 to 250 ml.


PHYSIOLOGICAL EFFECTS OF LABOURFIRST STAGE SECOND STAGE THIRD STAGE

ON THE MOTHER

1. Minimal effects 1. Pulse increases

2. Systolic BP slightly increased due to pain and anxiety

3. Minor injuries to the birth canal

1. Blood loss from

the placental site

(200 ml)

2. Blood loss from

laceration and

perineum (100

ml)

ON THE FETUS

1. Moulding – overlapping of the vault bones

2. Caput succedaneum – it is a soft swelling of the most dependent

part of the

fetal head

MANAGEMENT

OF

LABOUR

AIMS IN THE MANAGEMENT OF LABOUR

To achieve delivery of a normal healthychild

To anticipate, recognize and treatpotential abnormal conditions beforesignificant hazard develops for the motheror the fetus.

PRINCIPLES IN THE MANAGEMENT OF LABOUR

Diagnosis of labour

Monitoring the progress of labour

Ensuring maternal well-being

Ensuring fetal well-being.


MANAGEMENT

FIRST STAGE OF

LABOUR

MANAGEMENT OF THE FIRST STAGE OF LABOUR1

On admission:

When the women presents at hospital, the woman’s antenatal record isreviewed to discover whether there have been any abnormalitiesduring her pregnancy. When there are no records of antenatal care acomplete history must be taken.

General examination of the mother

a) General conditions – evaluate the mother general health condition. Look for pallor, edema, abdominal scar (LSCS) and maternal height.

b) Vital signs – Blood pressure, pulse, respiration and temperature are taken and recorded

c) Heart and lungs

d) Urine analysis – for protein, sugar and ketones


Abdominal examination:

a) A detailed abdominal examination should be carried out and recorded.

b) Determine the presentation and position of the fetus and also theengagement

c) Auscultate the fetal heart

d) Evaluate the uterine contraction

Vaginal examination – the purpose is to

a) To make a positive diagnosis of labour

b) To make a positive identification of presentation

c) To determine whether the fetal head is engaged in case of doubt

d) To ascertain whether the fore waters have ruptured or to rupture them artificially

e) To exclude cord prolapse after rupture of the fore waters

f) To confirm the degree of cervical dilatation and position of the presenting part

g) To assess progress of labour.

h) To assess the adequacy of the pelvis.


Bowel preparation:

If there has been no bowel action for 24 hours or the rectum feels loaded on vaginalexamination an enema is given.

Bladder care

A full bladder may initially prevent the fetal head from entering the pelvic brim and later impede descent of the fetal head. It will also inhibit effective uterine action.

The woman should be encouraged to empty her bladder every 1½ - 2 hours during labour.

The quantity of urine passed should be measured and recorded and a specimen obtained for testing.

Nutrition in early labour

No food is permitted after labour is established – to prevent regurgitation and aspiration

It is important to maintain adequate hydration - via intravenous routes


Position of labouring mother:

As long as the patient is healthy, the presentation normal, the presenting partengaged, and the fetus in good condition, the patient may walk about or may be inbed, as she wishes

Monitoring the progress of labour

Once labour has become established, all events during labour should be recorded on a partogram.

a) The well-being of the fetus

b) The well-being of the mother

c) The progress of the labour

Pain relief

When the pains are severe an analgesic preparation may be given.

a) Opiate drugs – e.g. Pethidine given intramuscularly every 4 hour

b) Inhalational analgesia – e.g. Entonox

c) Epidural analagesia


Pain in labour

The pain experienced by the woman in labour is caused by the:

1): Uterine contractions and uterine ischaemia.

2): Cervical dilatation. Dilatation and stretching of the cervix and

lower uterine segment stimulate nerve ganglia and are a major

source of pain.

3): Distention of the vagina and perineum. Marked distention of the

vagina and perineum occurs with fetal descent, especially during the

second stage.

LABOUR PAIN – causes1


Pain in labour

LABOUR PAIN – causes2

Table 1: PAIN DURING THE STAGES OF LABOUR

STAGES OF LABOUR SORCES OF PAIN

FIRST STAGE

Pain is caused mainly by uterine contractions, thinning of the lower segment of the uterus, and dilatation of the cervix.

SECOND STAGE

Pain result from two sources:1.The stretching of the vagina, vulva and perineum.2.The contraction of the myometrium.

THIRD STAGE

Pain is caused by the passage of the placenta through the cervix, plus that produced by the uterine contractions.


PAIN RELIEF IN LABOUR – types

Three methods are in common use during labour:

1. Analgesic drugs (narcotics, e.g. pethidine)

which are given by intramuscularly injection.

2. Inhalation analgesia (e.g. Entonox).

3. Regional anaesthesia (e.g. epidural, spinal)

that blocks the sensory pain pathways.


MONITORING FETAL HEARTHow Do Uterine Contractions Affect Fetal Heart Rate?

Uterine contractions can affect fetal heart rate by increasing or decreasing

that rate in association with any given contraction.

The three primary mechanisms by which uterine contractions can cause

a decrease in fetal heart rate are compression of:

· Fetal head

· Umbilical cord

· Uterine myometrial vessels


MONITORING FETAL HEART

How To Monitor The Fetal Heart Rate?

Auscultation methods

Electronic monitoring ~ CTG


MONITORING FETAL HEART

To detect fetal hypoxia

NORMAL

ABNORMAL

RECORDING THE

PROGRESS OF LABOUR


RECORDING THE PROGRESS OF LABOUR

PATIENT INFORMATION

FETAL INFORMATION

~ fetal well being

LABOUR INFORMATION

~ Dilatation

~ Descent

~ Contraction

MEDICATIONS

MATERNAL INFORMATION

~ Well being


RECORDING THE PROGRESS OF LABOUR - Partogram

Patient information: Fill out name,

gravida, para, hospital number, date and

time of admission and time of ruptured

membranes.

Fetal heart rate: Record every half hour.

Amniotic fluid: Record the colour of

amniotic fluid at every vaginal

examination:

I: membranes intact;

C: membranes ruptured, clear fluid;

M: meconium-stained fluid;

B: blood-stained fluid.

Moulding:

1: sutures apposed;

2: sutures overlapped but reducible;

3: sutures overlapped and not reducible.



Cervical dilatation: Assessed at every

vaginal examination and marked with a

cross (X). Begin plotting on the partograph

at 3 cm.

Station : recorded as a circle (O) at every

vaginal examination.

Contractions: Chart every half hour;

palpate the number of contractions in 10

minutes and their duration in seconds.

Less than 20 seconds:

Between 20 and 40 seconds:

More than 40 seconds:

Assess the progress of labour:



Oxytocin: Record the amount of oxytocin

every 30 minutes when used.

Drugs given: Record any additional

drugs given – e.g. Pethidine

Pulse: Record every 30 minutes and

mark with a dot (●).

Blood pressure: Record every 4 hours

and mark with arrows ( )

Temperature: Record every 2 hours.

Protein, acetone and volume: Record

every time urine is passed.

Progress of maternal well being:


MANAGEMENT

SECOND STAGE OF

LABOUR

MANAGEMENT OF THE SECOND STAGE OF LABOUR1

Maternal position:

With the exception of avoiding supine position, the mothermay assume any comfortable position for effective bearingdown.

The semi-recumbent or supported sitting position, with thethighs abducted, is the posture most commonly adopted

Bearing down

With each contraction, the mother should be encouraged tobear down with expulsive efforts

Once the onset of the second stage has been confirmed

a woman should not be left without attendance.

Accurate observation of progress is vital, for the

unexpected can always happen.


Observation during the second stage:

Four factors determine whether the second stage may be safely continued andthese must be carefully monitored throughout the second stage of labour.

1. Maternal conditions

Observation includes an appraisal of the mother’s ability to cope emotionally as well as an assessment of her physical wellbeing. A maternal pulse rate is usually recorded quarter-hourly and bloods pressure hourly

2. Fetal conditions - During the second stage, the fetal heart should be monitored either continuously or after each contraction. stage may be associated with fetal distress.

The liquor amnii is observed for signs of meconium staining.

3. Uterine contractions - The strength, length and frequency of contractions should be assessed continuously.

4. The progress of descent - The progress should be recorded approximately every 30 minutes during the second stage.


CONDUCTING THE DELIVERY1:

When delivery is imminent, the patient is usually placed in the dorsalposition, and the skin over the lower abdomen, vulva, anus and upperthigh is cleansed with antiseptic solution and draped.

DELIVERY OF THE HEAD

1) Control the delivery of the head to prevent laceration

2) Performed episiotomy if requires

3) Performed Ritgen’s method

4) Cleared the airway after delivery of the had


PERFORMING AN EPISIOTOMY:

"..is a surgical incision into the perineum to enlarge the space at the

outlet

EPISIOTOMY

IS EPSIOTOMY REALLY NEEDED?

Episiotomies are said to provide the following benefits:

1. Speed up the birth

2. Prevent Tearing

3. Protects against incontinence

4. Protects against pelvic floor relaxation

5. Heals easier than tears

medical research has not proven

any of these benefits



Episiotomies are not always necessary

Episiotomy should be considered only in the case of:

• Complicated vaginal delivery (breech, shoulder

dystocia, forceps,

vacuum);

• Scarring of the perineum;

• Fetal distress.



Episiotomy Types

Midline episiotomy Mediolateral episiotomy J-shaped episiotomy

Incision of episiotomy

The three major types of

episiotomy



Infiltrate perineum with

local anaesthetic agent

Making an incision

Wait until:

1) the perineum is thinned

out;

and

2) 3–4 cm of the baby’s head

is visible during a

contraction.

Performing an episiotomy will

cause bleeding. It should not,

therefore, be done too early.



DELIVERY OF THE SHOULDERS

Delivery of the anterior shoulder is aided by

gentle downward traction on the head.

The posterior shoulder is delivered by

elevating the head.



DELIVERY OF THE TRUNK

After the delivery of the shoulders the baby is grasped around the chest to aid the birth of the trunk.

Finally, the body is slowly extracted by traction on the shoulders and lifts the baby towards the mother’s abdomen.

The time of delivery is noted.

CUTTING THE UMBILICAL CORD

After delivery, it is therefore usual to wait 15 to 20 seconds before clamping and cutting the umbilical cord.

After cutting the cord a plastic crushing clamp is placed on the cord 1 to 2 cm from the umbilicus and the cord is cut again 1 cm beyond the clamp.



IMMEDIATE CARE OF THE NEW BORN

Once the baby is breathing normally he should be dried and warmly wrapped to prevent cooling and handle to the mother to hold, cuddle and enjoy.

If spontaneous respiration is not established soon

after birth, resuscitation is the immediate priority.

The Apgar’s score of the baby should be noted

and recorded.

LABOUR AND DELIVERY

THE MECHANISMS OF

NORMAL LABOUR

- Occiput anterior -


Occiput anterior (OA)Anterior

Pubis

Sacrum

Posterior

Right Left

Occipital bone


Occiput anterior positions


MECHANISM OF LABOUR for occiput anterior

The “mechanism of labour” refers to the sequencing of

events related to posturing and positioning that allows the

baby to find the “easiest way out”.

For a normal mechanism of labour to occur, both the fetal

and maternal factors must be harmonious.

DEFINITION:


MECHANISM OF LABOUR for occiput anterior

Events of mechanism of labour:

F: Flexion and descent

I: Internal rotation of the fetal head

C: Crowning

E: Extension

R: Restitution

I : Internal rotation of the shoulders

E: External rotation of the fetal head

L: Lateral flexion of the body


MECHANISM OF LABOUR for occiput anterior (OA)

Descend

Flexion

Internal rotation

Crowning

Extension

Restitution

Internal rotation of shoulder

External rotation of head

Lateral flexion of body

LOA

LOA

OA

LOA

OA

OA

LOT

Delivery

F

I

C

E

R

I

E

L


MANAGEMENT

THIRD STAGE OF

LABOUR

MANAGEMENT OF THE THIRD STAGE OF LABOUR

BIRTH OF THE PLACENTA1:

Delivery of the placenta occurs in two stages:

(1) separation of the placenta from the wall of the uterus andinto the lower uterine segment and/or the vagina, and

(2) actual expulsion of the placenta out of the birth canal.

THE THIRD STAGE OF LABOUR

MECHANISM OF PLACENTA SEPARATION1:

Two mechanisms of placental separation occurs:

1- Mathews-Duncan mechanism

The leading edge of the placenta

separates first and the placenta is

delivered with its raw surface

exposed.

2- Schultz mechanism

If the placenta is inserted at the

fundus and central area separates

first, the placenta inverts and draws

the membranes after it, covering the

raw surface (inverted umbrella)

LABOUR AND DELIVERY

WHAT ARE THE SIGNS OF

PLACENTA SEPARATION



CLINICAL SIGNS OF PLACENTAL SEPARATION

Placental separation takes place within 5 minutes after the delivery of theinfant. Signs suggesting that detachment or separation has taken placeinclude:

1. The uterus becomes globular and hard. This sign is the earliest to appear.

2. There is often a sudden gush of blood

3. The uterus rises in the abdomen because the placenta,

having separated, passes down into the lower segment

and vagina, where its bulk pushes the uterus upward

4. Cord lengthening. This is the most reliable clinical sign

of placental separation.



After the placental separation takes place theplacenta can be delivered by the:

1. Passive management – wait for spontaneous expulsion of placenta

2. Active management

LABOUR AND DELIVERY

ACTIVE MANAGEMENT OF

THE THIRD STAGE OF LABOUR


ACTIVE MANAGEMENT OF THE THIRD STAGE

Active management of the third stage (active delivery of the

placenta) helps prevent postpartum haemorrhage.

Active management of the third stage of labour includes:

~ use of oxytocin

~ controlled cord traction, and

~ uterine massage.

MANAGEMENT OF THE THIRD STAGE OF

LABOUR

ACTIVE MANAGEMENT OF THE THIRD STAGE

~ Use of oxytocin

Oxytocic drugs should be given with the birth of the anterior shoulder.

Syntocinon is the most used oxytocic known to be effective; the

addition of ergometrine may reduce blood loss.

SYNTOMETRINE (oxytocin 5 IU + ergometrine 0.5 mg) – widely

used



EXPULSION OF THE PLACENTA BY ACTIVEMANAGEMENT

When these signs have appeared the placenta is ready forexpression. If the patient is awake, she is asked to bear down whilegentle traction is made on the umbilical cord.

The popular and effective method of delivering the placenta is byBrandt-Andrews method.



BRANDT’S ANDREW METHOD

Once the signs of placental separation have occurred the obstetricianassists delivery of the placenta by controlled cord traction as describedby Brandt-Andrews’ method.

A) Placenta separation B) Controlled cord traction C) Delivery of the membranes



EXAMINATION OF THE PLACENTA

The placenta, membranes, and umbilical cord should be examinedfor completeness and for anomalies.

EXAMINATION OF THE PERINEUM

At the same time, the perineal region, vulva outlet, vaginal canal, andthe cervix should be carefully examined for lacerations.

If the perineum has been torn or an episiotomy made, tear or incisionshould be repaired immediately.


REPAIR OF EPISIOTOMY:

Note: It is important that absorbable sutures be used for closure.

Continuous sutures Interrupted sutures Interrupted suture or

subcuticular

Vaginal mucosa

1. Identify apex

2. Begin suturing

1.0 cm above apex

3. Continuous sutures

4. Ends at the level of

vaginal opening

MANAGEMENT AFTER

DELIVERY

IMMEDIATE MANAGEMENT AFTER THE

DELIVERY

EARLY POSTPARTUM MANAGEMENT:

The hours immediately following delivery and the birth of the placenta are a criticalperiod as postpartum haemorrhage can occurs due the relaxation of the uterus.

The patient is kept in the delivery suite for 1 hour postpartum under closeobservation. She is check for bleeding, the blood pressure is measured, and the pulseis counted.

Before discharging the patient from the delivery suit it is mandatory:

To check the uterus frequently to make sure it is firm and not relaxing.

To remove any presence of intrauterine blood clots. The presence of these clots will interfere with retraction and the normal haemostatic mechanism of the uterus.

To look at the introitus to see that there is no haemorrhage.

To keep the bladder empties because full bladder can also interfere with uterine retraction.

To examine the baby to be certain that it is breathing well and that the colour and tone are normal.

Normal labour and delivery

Healthcare

Transcript of Normal labour and delivery