Management of normal labour

Question 1

What are the warning symptoms during pregnancy?

Answer 1

1- fever
2- persistent headache
3- blurring of vision
4- persistent vomiting
5- edema of face & hands
6- itching in palms of hands & soles of feet
7- abdominal or epigastric pain
8- diminished fetal movement
9- vaginal bleeding
10- gush of fluid

Question 2

Why is a PV exam during labour important?

Answer 2

1- exclude contracted pelvis
2- check dilatation & effacement of the cervix
3- check fetus for attitude, lie, presentation, & position
4- rupture of the membranes +- meconium
5- pelvic station (engagement)

Question 3

When should a PV examination be preformed during labour?

Answer 3

At least twice:
1- at start of labour
2- when membranes rupture to exclude cord prolapse

• If membranes are intact -> every 1 hour to check dilatation & effacement
• if membranes are ruptured -> every 2 hours to assess progress of labour

Question 4

What is the cause of false labour pains?

Answer 4

Braxton Hicks contraction
- after 20 weeks
- irregular

Question 5

How is the 1st stage of labour managed?

Answer 5

1- antisepsis
2- record maternal observations -> vital signs, uterine contractions, cervical dilatation, pelvic station, rupture of membranes
3- record fetal observations -> FHR 110 - 160 beats/min
4- Nutrition -> sugary fluids early but NPO in active phase, if labour is prolonged (> 8 hrs) give IV fluids with glucose 5%
5- pain relief
6- if membranes are ruptured -> rest in lateral position
7- if membranes are intact -> walking is allowed between contractions
8- avoid straining so it doesn’t exhaust the patient & cause genital prolapse

Question 6

What are the methods of pain relief during the first stage of labour?

Answer 6

1- Pethidine 50mg IM -> should be stopped 2 hours before 2nd stage of labour
2- phenothiazine derivatives
3- nitrous oxide + O2
4- epidural analgesia -> can continue it to 2nd stage

Question 7

Why should pethidine be stopped 2 hours before the 2nd stage of labour?

Answer 7

May cause fetal respiratory depression

Antidote -> Naloxone

Question 8

How is the 2nd stage of labour identified?

Answer 8

1- full dilatation of cervix -> 10cm or 5 fingers
2- desire of patient to evacuate her rectum
3- desire to bear down
4- bearing down accompanied by exploratory grunt
5- rupture of membranes

Question 9

What position is the patient placed in during the 2nd stage of labour?

Answer 9

Lithotomy or dorsal position

Question 10

When do perineal tears occur?

Answer 10

Before crowning
- extension of fetal head will over distend the vulva
- occipito-frontal diameter 11.5cm

Perineal support when the head appears in the vulva to prevent extension before crowning

Question 11

How should delivery of the fetal head be done?

Answer 11

• slow
• in between uterine contractions
• without bearing down
• aided by Ritgen maneuver

Question 12

What should be done after delivery of head?

Answer 12

1- clearance of air passages by swabbing & aspiration
2- coils of the umbilical cord around fetal neck
- one loop is slipped
- several loops are doubly clamped & the cord is cut in between

Question 13

How should the delivery of the shoulder & body be done?

Answer 13

1- traction on the head till anterior shoulder appears under symphysis pubis
2- head is lifted to deliver posterior shoulder first
3- head is lifted downwards to deliver anterior shoulder

Question 14

When should lifting the fetus from the ankles be avoided after delivery?

Answer 14

• asphyxia
• suspicion of intracranial hemorrhage
• preterm fetuses

Question 15

When is milking of the cord contraindicated?

Answer 15

• Rh-incompatibility
• Preterm fetuses -> to avoid circulatory overload

Question 16

How is the 3rd stage of labour managed?

Answer 16

1- exclude bleeding & uterine atony (rise in fundal level of a lax uterus points to bleeding)

Conservative
2- placenta is delivered by gravity & bearing down or fundal pressure

Active
3- Uterine stimulants with delivery of anterior shoulder -> oxytocin
4- Brandt-Andrew method -> left hand is Supra-pubic & pushes them uterus upwards during contraction while the other hand is gently pulling the cord

Question 17

What are the signs of separation of the placenta?

Answer 17

1- fundal level rises
2- body of the uterus becomes smaller, harder & globular
3- Supra-pubic bulge due to presence of placenta in lower uterine segment
4- elongation of the cord without receding
5- gush of blood from vagina (expulsion of retroplacental clot)

Question 18

When is delivery of the placenta by fundal pressure contraindicated?

Answer 18

When uterus is lax -> may cause inversion of the uterus

Question 19

What are the advantages of active placental delivery?

Answer 19

• less duration & blood loss
• reduction in post-parturition hemorrhage

Question 20

What are the disadvantages of conservative & active methods of placental delivery?

Answer 20

Conservative
- takes longer time
- risk of postpartum hemorrhage is 5%

Active
- rupture of the cord
- acute inversion of the uterus if done on a lax uterus

Question 21

What should be done in the 4th stage of labour?

Answer 21

1st 24hrs after delivery In which PPH is most probable

• uterine massage every 15 minutes for 2 hours