Normal Labour

Posted: July 15, 2010 by gerardloh in O & G

Normal Labour

Definition:-

the process whereby there is a spontaneous onset of painful, regular contractions at term which followed by effacement and dilatation of cervix and descent of the presenting part which resulted in birth of a normal fetus and expulsion of the placenta

—        3 stages

1st : cervical dilation fr 0-10cm

> Latent phase (0-3cm)

> Active phase (3-10cm)

2nd : fr full dilation to delivery of fetus

3rd : fr delivery of fetus to delivery of

placenta

1st stage ( Latent phase)

Dx

—        Regular  painful contractions

—        Significant cervical effacement

—        Cervical dilation up to 3cm

Duration

PRIMI: 20 hrs(mean 8 hrs)

MULTIPARA: 14 hrs ( mean 6 hrs)

DDx: FALSE LABOUR-

ü      Contractions – irregular and intensity varies

ü      Contractions may be painless

ü      If painful, intensity  same

ü      Painful contractions are relieved by sedation

ü      No progression in cervical effacement and dilatation

ü      No evidence of fetal compromise

ü      Patient should be reassured that she is not in labour and allowed discharge.

Management

—        V/s (BP,PR,T) monitoring of the maternal condition 4Hourly

—        Fetal monitoring 4H ~ CTG or pinard

—        Abdomen examination, time contraction within 10min

—        R/v VE on strong and regular contractions

—        Consider pain relief as required by patient

Active phase

MANAGEMENT

  1. R/V History and problem
  2. V/S monitoring
  3. Abd examination,time contraction (aim contraction for 3-4:10min)
  4. VE (on strong n regular contraction)
  5. ARM
  6. Start partogram
  7. CTG monitoring  2hr-ly  for  20min( if normal CTG+good contraction,consider IM Pethidine 75mg +IM Phenergen 25mg)
  8. Time for next R/V

<6cm at 1ST VE-next 4 hrs

>6cm next VE when full dilation is expected

Ix

  1. FBC
  2. UFEME
  3. GSH (for all in labour)

GXM (for high risk labour)

2ND STAGE

—        Catetherise patient

—        Check position of patient

—        Continuous monitoring of uterine contraction

—        Encourage pt to push with each contraction (chin to chest,look to abd,take deep breath n push)

—        When no contraction,ask pt to stop pushing. Monitor FHR

—        Sweep vulva gently

—        Perineal guarding n push head down

—        Usually episiotomy at ‘crowning’

—        Delivery of head

—        Check for any cord around neck⃰

—        Fetus head pull biparietally downward with mother’s effort

—        Delivery of ant. Shoulder and then post. shoulder

—        Delivery of whole baby.

—        Clamping and cutting of cord*

—        Wipe and suction of newborn

—        Cord blood- TSH,G6PD*

—        Syntometrine/syntocinon IM on maternal thigh

—        1st touch btw mother n child

3rd : PLACENTA DELIVERY

—        Interval between period after delivery of fetus and complete delivery of placenta

—        Ask mother to relax and don’t try to push during this stage!!!

SIGNS  OF PLACENTAL SEPARATION:

  1. Gushing of blood
  2. lengthening of cord
  3. elevation of fundus as the uterus contracts(globulation)

ACTIVE MANAGEMENT- Syntometrine/Syntocinon

CCT

—        give 1ml syntometrine IM (syntocinon + ergometrine) the patient’s thigh for healthy patient.

—        Patient with PIH & heart problem only can be given 10 units syntocinon IM

CCT-

—        Left hand is placed suprapubically over uterus Press uterus backwards towards the mother.

—        Grasp cord  by clamp with right hand and apply gentle traction  (1st slightly downwards,then upwards)

—        When placenta is seen,deliver it with both hands in rotation movement

—        Clamp the coming membrane n remove slowly in rotation movement too.

—        massage of fundus of uterus

—        Remove blood clot by right hand (position of hand- VE position)

—        Use cotton to clean up the vaginal area

—        Check if present tears???

v      If after ½ hour (30 minutes) the placenta still not delivered, inform specialist. Usually will do MRP(manual removal of placenta)

MANUAL REMOVAL OF PLACENTA (MRP)

Preparation:

—        Antibiotic cover (see Antibiotic guidelines)

—        Adequate analgesia, preferably under GA or regional anaesthesia, if patient is already on epidural, procedure can be carried out in the LR

—        Put patient in lithotomy position and apply perineal sheet (sterile)

—        The operator should be scrubbed and gowned with MRP gloves.

  1. 1. Introducing one hand into vagina along the cord
  2. 2. Grasping fundus with other hand,while detaching the placenta with sideways slicing movement of the fingers
  3. 3. Grasp placenta in the palm of hand
  4. 4. Examination of placenta for completeness

—        It is important to re-explore the uterine cavity to make sure no placental tissue is left behind.

—        Once the uterus is confirmed empty:

ü      intravenous infusion of  oxytocin 40units at 60-80mls/ hour.

ü      Uterine massage

ü      manual compression

PLACENTA CHECKING

1.Check the umbilical cord

—        2 arteries & 1 vein

—        Measure length of cord (normally 40-60cm) –use finger to estimate, end of middle finger till end of thumb à15cm

—        Colour of cord

—        Where the cord planted on placenta – center or lateral

—        Present of knot or not. If yes, distinguish either true or false knot

2. Check the placenta

  • Opening of membrane (normally 1)

If > than 1 – may be because of tear of  the membrane, may be some part of                                                     membrane left inside

  • Cotiledon   – colour

– lobes (norm:18-20 )

INFARCT -dead of tissues (caused by decrease O2

supplyàdecrease fx of placenta)

-common in post-date delivery

how to know?

-feel it by hand – sandy-like

-white spot on cotiledon

(use cotton to clean up the

cotiledon)

—        Membrane layers

1) amnion layer (fetus’ side-inner)

-translucent

-thin,shiny

-high in tensile  strength

2) chorion layer (mother’s side-outer)  -easy to break,shaggy

—        3. Measure blood loss volume

-include the blood clots

– < 500ml

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