8.Normal delivery. Stages of labor. Flashcards
Labour is called normal if?
spontaneous onset , vertex presentation , no prolongation , natural termination with minimal aids , without having any complications affecting the health of the mother
describe false labour ?
more in primigravidae
prior to the onset of true labor pain by 1 or 2 weeks in primigravidae and by a few days in multiparae
no changes in cervix dull in nature , not in frequent intervals confined to lower abdomen and groin , not associated with hardening of uterus , relived by enema and sedation
what is true labour ?
painless BRAXTON Hicks contractions occur with hardening of uterus with no effect on dilatation of the cervix
then false labour
===becoming true labour ===
painful contraction at regular intervals
frequency, duration and intensity of contraction increase
said to be good - intervals at 3–5 minutes and at the height of contraction the uterine wall cannot be indented by the fingers
associated with SHOW, due to progressive effacement and dilation of cervix ( expulsion of the thick mucus plug blocking the cervical canal with blood)
descent of presenting part
bag of waters - stretching of the lower uterine segment, the membranes are detached
lower pole of the fetal membranes becomes unsupported and tends to bulge into the cervical canal. As it contains liquor, which has passed below the presenting part, it is called “bag of waters”.
not relived by enema or sedatives
where is the pace maker of these contraction
tubal ostia
pain of uterine contractions are mainly due to
compression of nerve ganglion distributed along cutaneous nerve T10 - L1
other cause of pain -
myometrial hypoxia ,
stretching of peritoneum over fundus ,
stretching of cervix during dilation
how many stages of labour are there and describe them
1st stage - onset of true labour - complete dilation of the cervix
further subdivided into the latent and the active phase
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2nd stage of labour - from the complete dilation of the cervix - delivery of fetus
has subdivision
The propulsive phase—starts from full dilatation to the descent of the presenting part to the pelvic floor.
The expulsive phase -mother sires to bearing down with her abdominal muscles to expel the fetus
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3rd stage of labour - end of delivery of fetes to delivery of placenta
describe the latent phase of first stage of labour
1)Effacement is the process by which the muscular fibers of the cervix are pulled upward and merges with the fibers of the lower uterine segment
cervix is dilated / thinning and mucus plug will come off - “show” .
In primigravidae, effacement precedes dilatation of the cervix, whereas in multiparae, both occur simultaneously
2) regular uterine contractions- causes cervix to be further dilated and increase in intrauterine pressure
what happens if the amniotic fluid does not rupture and there has already been show ?
amniotic fluid does not rupture because there is weak uterine contractions
perform amniotomy which is artificial rupture of the amniotic sac
this will induce labour
when is amniotomy contraindicated ?
baby is in breech , placental prevae - where placeta is lying over the cervix
describe the active phase in the first stage of labour
4) once the cervix is over 3 cm dilated we are in the active phase , the cervix is constantly pulling up and it become part of the lower uterine wall .
5) uterine contraction continue with increasing intensity and regularly until cervix is fully dilated
6) With the full dilatation of the cervix, the membranes usually rupture and there is escape of good amount of liquor amnii
check if the amniotic fluid is clear - this is normal
green or smelly - indicates meconium - dangerous because meconium would go into the foetus lungs - aspiration - cause respiratory problems
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wall of upper segment of uterus is thick , while the passive lower segment is thin - the junction between the two is called the PHYSIOLOGICAL RETRACTION RING (not pathological retraction ring - feature obstructed by labour- bandyl)
the first stage of labour can be very long in whom ?
nullipara (no delivery of fetus) women
normally the latent stage of stage 1 in nullipara women should take ?
less than 20 hours - longer indicate failure to progress
dilation should continue at what rate after 3 cm in nullipara
enter active phase
should continue every 1.2 cm/hr atleast – slower than this failure to progress
the latent stage for multipara women is how long
less than 14 hours - more than this failure to progress
dilation should continue at what rate after 3 cm effacement in multipara
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active phase is split into ?
less than 1.5cm /hr after 4cm dilation- failure to progress
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acceleration =3-4 in 2hrs
phase of maximum - 4-9cm in 2hrs
deceleration = 9-10cm in 2hrs
what is the clinical management of first stage
maternal monitoring - check freq /intensity / duration of contractions
In primigravidae, the cervix may be completely effaced, feeling like a paper although not dilated to admit a fingertip. It may be mistaken for one that is fully dilated.
anterior lip of the cervix is the last to be effaced!!
-check blood pressure , temp , fluid intake and output
check fetal heart rate every 15-30 mins
analgesia if needed
amniotomy if needed
second stage of labour begin when ? and what happens to the uterus shape during contractions ?
cervix is 10cm dilated
The uterus becomes elongated during contraction, while the anteroposterior and transverse diameters are reduced.
The elongation is partly due to the contractions of the circular muscle fibers of the uterus to keep the fetal axis straight.
the 7 cardinal movement in the second stage of labour only occur when ?
FETUS PERFOMS 7 CARDINAL MOVEMENTS OF LABOUR ONLY PRESENT IN VERTEX POSITION
what are the 7 cardinal movement in the second stage of labour
1 ) Engagment
2) descend
3) Flexion
4) Internal rotation
5) Extension
6) External rotation / resuscitation
7) expulsion
what is engagement ?
fetus is said to be engaged when the widest part of the fetal head (biparital diameter) has passed through the pelvic inlet commonly the transverse diameter or less commonly the oblique
The engaging transverse diameter is biparietal 9.5 cm
The engaging anteroposterior diameter of the head is either suboccipitobregmatic (fully flexed) 9.5 cm
in slight deflexion—the suboccipitofrontal - 10.5cm
fully deflexed face - ocipitofrontal - 11.5cm
ocipitolateral is the most common
due to the head facing laterally the sagittal suture does not strictly correspond with the available transverse diameter of the inlet. Instead, it is either deflected anteriorly toward the symphysis pubis or posteriorly toward the sacral promontory causing asynclinitism - mild degrees are common but severe not
what is descent ?
in multiparae, descent starts with engagement.
in primipare engagemnet in first stage and descend
Head is expected to reach the pelvic floor by the time the cervix is fully dilated
progression of fetal head is measured in -10 to +10
The negative indicate the presenting part is getting proximal from the maternal’s narrowest area the ischial spines
And positives indicates the presenting part is getting distal from the mothers ischial spines
what is flexion ?
resistance by the soft tissues such as the cervix or the pelvis walls and floor
- the chin meets the chest , now the smallest diameter of the babies head -
has to know go
go to the suboccipitobregmatic plane =9.5cm in AP
what is internal rotation
because the shape of the pelvis is downwards forwards and medially - internal rotation occurs
from the ocipitolateral position 2/8 of a circle anterior rotation
in oblique ocipitoanterioir - 1/8
placing the occiput behind the symphysis pubis- fetal in occipital anterioir position
prerequisites of anterior internal rotation : well-flexed head, efficient uterine contraction, favorable shape at the midpelvic plane, and good tone of the levator ani muscles
rotation of the head seen by by position of the sagittal suture, and the occiput
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rotation of the shoulders in the same direction of one-eighth of a circle placing the shoulders to lie in the oblique diameter with one-eighth of torsion in the neck
what is extension ?
subocciput lies underneath the pubic arch. At this stage, the maximum diameter of the head (biparietal diameter) stretches the vulval outletnd there is no recession even after the contraction passes off
before extension in dutta there is crowning
EXTENSION- as fetal head passes under subpubiic arch - releasing the brow , face and chin as the nape pivots underneath the arch
what is external rotation
restitution
rotating the head through one-eighth of a circle in the direction opposite to that of internal rotation (1/8 posterioir rotation )
The occiput thus points to the maternal thigh
the is so the anterior shoulder can give birth .the anterior shoulder rotates toward the symphysis pubis from the oblique diameter, The shoulders now lies in the anteroposterior diameter
what is expulsion ?
After the shoulders are positioned in anteroposterior diameter of the outlet
maternal pushing bring the anterior shoulder under symphysis pubis
lateral flexion of the spine, the posterior shoulder sweeps over the perineum. Rest of the trunk is then expelled out by lateral flexion
duration of second stage
nullipara?
30mins -3hours
if it takes longer forceps or c section is needed
duration of second stage multipara ?
5-60 mins
if it takes longer forceps or c section is needed
what is the clinical management in second stage
PATIENT IS TAUGHT TO ONLY bear down during contractions - spontaneous forcible delivery of the head is avoided because it can damage the perineum
fetal monitoring - heat heart rate deceleration due to head or cord compression
Normal fetal heart rate ranges from 110 to 150 per minute
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when delivery is about to happen patient placed in lithotomy position and skin over lower abdomen , vulva , anus and upper thighs is cleansed with antiseptic solution
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When scalp is visible for about 5 cm in diameter, flexion of the head is maintained during contractions -by pushing the occiput downward and backward using thumb and index fingers of the left hand while pressing the perineum by the right palm
repeated during subsequent
contractions until the subocciput is placed under the
symphysis pubis.
At this stage, the maximum diameterof the head (biparietal diameter) stretches the vulval
outlet without any recession of the head
= when crowning of head seen - episiotomy may be performed to prevent perineal lacerations
Bulging thinned out perineum is a better criterion
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RITEGEN manoeuvre is performed when the suboccipitofrontal diameter emerges out.
Delivery by early extension is to be avoided to prevent perineal tea
right hand draped with sterile towel exerts upward pressure to to chin of baby one the perineum near coccyx - the other hand exerts pressure on the occiput backwards
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once head delivered air way is cleared of blood and amniotic fluid using bulb suction device - after that neck palpated to check if umbilical cord is around the neck - if so usually they can be easily untangled manually if not it can be cut between two kosher forceps
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delivery of the anterior shoulder ONLY AFTER RESUCUITATION AND EXTERNAL ROTATION
aided by gentle downward and posterioir traction of the head - brachial plexus may be damaged if excessive pressure used
the posterior shoulder is delivered by elevating and anterior traction of the head
then the whole body is extracted by index finger under the axilla and delivered by lateral flexion
cord is clamped and cut
usually the cord is clamped and cut within ?
1-3 minutes
delayed cord clamping leads to ?
neonatal hyperbilirubinemia as additional blood is transferred from placenta to newborn
what is the 3rd stage of labour ?
delivery of placenta
in third stage of labour immediately after the delivery of the baby what should be checked ?
cervix and vagina should be thoroughly inspected for lacerations and surgical repair
After birth of baby uterus measures to ?
after expulsion - uterine cavity is permanently reduced in size only to accommodate the afterbirths
about 20 cm vertically and 10 cm anteroposteriorly
after the birth of the baby what is the uterus shape ?
becomes discoid - upper segment much thickened and while the thin flabby lower segments is in folds
the plane of separation of the placenta is through what ?
plane of separation - runs through deep spongy layer of DECIDUA BASALIS - so when the placenta is extracted there is a variable thickness of decidua attached to it
seperation of the placenta fro the uterus should occur within ?
2-10 mins after the end of second stage labour
why is Squeezing of fundus to accelerate the process 3rd stage of labour not recommenced ?
increases passage of fetal cells into maternal circulation
what are the signs of placental separation in 3rd stage you should look for ?
umbilical cord permanently lengthens outside the vagina
per abdomen - Uterus becomes globular, firm, and ballottable
The fundal height is slightly raised
Slight bulging in the suprapubic region due to distension of the lower segment by the separated placenta.
per vaginum
fresh flow of blood from vagina
elicited by pushing down the
and the length of the cord remains permanent even after the pressure is released. Alternatively, on suprapubic upward pressure by the fingers,
only when the signs of placental separation is met can we deliver the placenta and how do we deliver the placenta ?
Manual removal extracts the placenta from the Decidua basalaris - with general anaesthesia not recommended
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physiological management
oxytocin’s not given
placenta delivered by gravity and maternal efforts
Or
ACTIVE MANAGEMNTE - recommended for all women
Clamp the cord
oxytocin is given -routine to add 20IU of oxytocin in intravenous infusion after the baby has been delivered to avoid pph
apply gentle traction on the cord
Use the other hand place it between the fundus and symphysis and apply counter pressure to stop the descend of the uterus
the chorioamnitoc membrane is also delivered with the placenta
there are two ways the placenta can separate and be delivered what are they ?
central seperation - dettachment of placenta starts from the centre
uterine sinuses open - and accumulation of blood behind the placenta - RETROPLACENTAL HEMATOMA
with contraction, weight of placental and retroplacental hematoma the whole placenta gets detached
marginal seperation - more frequent , more area of placenta seperated as uterine contracts
following delivery of the placenta what should be assessed ?
if there is any uterine bleeding
can be reduced through by massaging by cup it between both hands and avoided if routine oxytocin has been administered
then placenta should be examined for missing condyletons of pathology of fatal membranes and cord and placenta
what are the cord abnormalities that should be checked
Thin cord
FLAT cord
varicosity of umbilical vessels
cord knots
lateral cord insertion- not of clinical significance
battledore cord -not of clinical significance
velamentous cord insertion
what is a flat cord ?
reduced amount of Wartons jelly
what is the definition of a thin cord ?
if the diameter of the vein is less than 7 cm it is also described as a thin cord - the blood flow was compromised
what is varicosity of umbilical veins and what causes it ?
vessels dilated and show blood clots due to compression of cords -
due to prolapse or head compression , fetal hyper coagulation(due to sepsis or thrombophilia)
Abdominal assessment of progressive descent of the head (using fifth formula) ?
the width of the 5 fingers is a guide to the expression in fifths
. A head that is mobile above the brim will accommodate the full width of 5 fingers - above the pelvic brim
As the head descends, the portion of the head remaining above the brim will be represented by fewer fingers (4/5, 3/5,
generally accepted that the head is engaged when the portion above the brim is represented by 2 fingers width or less
two types of episiotomy which can occur what are they ?
a midline or mediolateral
what is the advantge of epistiotmy
if incase a tear occurs we can control the direction of the tear by doing the epistiotomy and because we do not want the tear to occur medially where the sphincter muscles are - we manipulate it
how to do a epstiotomy ?
Two fingers enter the vagina along the proposed line for the episiotomy, to protect the presenting part, episiotomy at a 60 degree angle;
episcissors guided and cut is made
