Labor
Labor
Labor
Labour: is the processes by which regular painful contraction bring about effacement and dilatation of
cervix and desend of the presenting part, ultimately leading to expulsion of the fetus and the placenta
from the mother.
2. Second stage: The time from full dilatation of cervix to delivery of fetus.
This also subdivided into 2 phases
a- The 1st phase (passive phase): the time between fully dilated to the onset of involuntary expulsive
contraction (there is no maternal urge to push and the fetal head is relatively high in pelvic)
b- The 2nd phase (Active phase): there is a maternal urge to push because the fetal head is low causing a
reflex need to bear down.
▩ The normal active 2nd stage should last no longer than 2 hours in primiparous
and 1 hours in multipara.
3. Third stage: is the time from delivery of the fetus to delivery of the placenta.
▩ This stage lasts no more than 30 minute.
Terms
This refer as change in the position and attitude that the fetus undergo during its passage through the
birth cannal.
lie: The relation between the long axis of the fetus to that of the mother.
• Fetal and maternal axes may cross at a 45 degree forming an oblique lie ,
• Predisposing factors for transverse lie include
- multiparity,
- placenta previa and
- uterine anomalies.
Presentation: is the portion of the fetal body that either foremost within the birth cannal
or in close proximity to it.
Attitude or posture: the relation between the different parts of the fetus.
Fetal position: relation between an arbitrarily chosen portion of the fetal presenting part to a fixed
point to the birth cannal .
So with each presentation there may be 4 position –>right or left, anterior or posterior (the fetal occiput
,chin (mentum),and sacrum are the determined points in the vertex ,face and breech presentation.
Engagement: The greatest transverse diameter (biparietal diameter) passes through the pelvic inlet
- When the head is 2/5 palpable per abdomen
- When head Is at the ischial spine (at zero station)
Station: degree of descent of the presenting part of the fetus, measured in centimeters from the
ischial spines
left occipito- anterior (ROP) is more common than Right occipito-anterior (LOP)
Right occipito-posterior (ROP) is more common than left occipito-posterior (LOP)
because: The left oblique diameter is reduced by the presence of sigmoid colon.
The mechanism of labour:
1- Engagement: it occurs when the widest part of the presenting part has passed successfully
through the inlet.
The number of fifth of the fetal head palpable abdominally has taken place if more than 2/5 of fetal
head is palpable abdominally, the head is not engaged.
2- Descend: refers to the downward passage of the presenting part through the bony pelvis
- This is needed during the first stage and 1st phase of the 2nd stage of labour, and it occur due to
uterine contraction and in the active 2nd phase of the 2nd stages are helped by voluntary use of
abdominal musculature and Valsalva maneuver (pushing).
3- Flexion: occurs Passively as the head descends meets resistance of pelvic floor, cervix and walls
of pelvic
- This occur to minimizing the presenting diameter of the fetal head (Complete flexion places the
shorter suboccipito-begmatic diameter to substituted the longer occipito-frontal diameter)
4- Internal rotation: This movement consist of a turning of the head in such a manner that
the occiput gradually moves toward the symphysis pubis anteriorly from its original position or
less commonly toward the hallow of the sacrum so that the saggital suture now lie in the A-p
diameter of the pelvic inlet.
5- Extension: Following completion of internal rotation, the occiput is underneath the symphysis pubis
and the bregma near the lower border of the sacrum so the well flexed head now extended and the
occiput escape from underneath the symphysis pubis and distended the vulva (crowing the head).
7- External rotation: rotation of the occiput through a further one eighth of a circle to the
transverse position.
LEFT occipit-anterior
Management of normal labor
The first stage of labour:
1- History:
The following are important to note in the history:
A- Details of previous birth, the size of previous
babies and the previous Caesarean
B- Gestational age
2- EXAMINATION: ﻣﻠﺰﻣﺔ
General examination: This include
VITAL SIGNS (temperature, pulse and blood pressure)
Abdominal examination:
First Inspection to see if there is scar,
Then Palpation
→ Fundal height + (Leopold's maneuvers : fundal grip, umbilical (lateral )grip,
pawlik’s grip , pelvic grip…) to see
- The lie of baby determined (longitudinal, transverse, oblique), also
- The presenting part are determined (cephalic, breech) and
- The degree of engagement.
→ also, the uterine contractions are assessed for frequency, duration and strength.
Then auscultation (110-160 bpm)
→ In breech presentations: the heart sounds will often be heard above the umbilicus
→ In Head (vertex) presentations: the heart sounds will often be heard below umbilicus.
The fetal heart sounds are listened at a point midway between the anterior superior
iliac spine & the umbilicus on the back of the baby (usually in the right if the
presentation is cephalic)
Vaginal Examination:
The index and middle figure are passed to the top of the vagina and cervix and the
following parameters are determined (Bishop’s score)
a- The cervix is examined for
- Length (effacement)
- Dilatation
- Consistency
- Position
[It is usually performed every 4 hours to determine when the active phase
has been reached (approximately 4 cm dilatation and full effacement).
The lower limit of normal progress is 1 cm dilatation every 2 hours once
the active phase has been reached]
b- The Membrane is examined for
- The condition of the membrane should also be determined (ruptured or not) and also
- The color (clear, blood stain, meconium) and amount of liquor is determined.
[During the first stage, the membranes may be intact, may have ruptured
spontaneously or may have been ruptured artificially. Generally speaking,
if the membranes are intact, it is not necessary to rupture them if the
progress of labour is satisfactory.]
c- The presenting part:
- Determine the presenting part (head, buttock, legs, …)
- The position: In normal labour the vertex will be presented and the position can be
determined by located the occiput (this identified by feeling for the triangular posterior
fontanelle,
- Engagement: The relation of the lowest part of the head to the ischial spine will be
estimated
- Station and descend: The d escend is crucial component of progress and should be
recorded at each vaginal examination.
They can be remembered with the mnemonic: Call PEDS For Parturition =
Cervical Position, Effacement, Dilation, Softness; Fetal Station.
The examiner assigns a score to each component of 0 to 2 or 0 to 3. The highest possible score
is 13 and the lowest possible score is 0.
Women in FIRST STAGE of labor
• The frequency of contraction every 30 minute and
• her pulses determined hourly and
• Their temperature and blood pressure every 4 hours,
• A vaginal examination every 4 hours (Unless other factors suggest more frequent examination) .
Once the SECOND STAGE is reached,
• The blood pressure, pulse, and vaginal examination should be performed hourly .
3- Investigation:
- Sample of urine tested for (protein, blood, glucose, ketone and nitrate)
- Sample of blood tested for (blood group, cross matching, Hb level)
4- Procedures:
Encouraged to mobilize AND reassurance:
- Women who are in the latent phase of labor should be encouraged to mobilize
and should be managed away from the labor suite where possible. Indeed, they
may well go home, to return later when the contractions are stronger or more
frequent.
- Encouragement and reassurance are extremely important.
- Intervention during this phase is best avoided unless there are identified risk
factors.
Diet and Dehydration:
- Latent phase: here is no reason to restrict eating and drinking, although lighter
foods and clear fluids may be better tolerated
- Active phase: Women may drink during established labor and those who are
becoming dehydrated may benefit from intravenous fluids to prevent ketosis,
which can impair uterine contractility. Light diet is acceptable if they have no
obvious risk factors for needing a general anesthetic and if they have not had
pethidine or diamorphine for pain relief.
Analgesics: Simple analgesics (pethidine) are preferred over nitrous oxide and
epidurals.
Evacuation of the bladder (foley’s catheter) and rectum (enema) +
preparation of vulva:
- Shaving and enemas are unnecessary and antacids need only be given to women
with risk factors for complications, or to those who have had opioid analgesia.
Partogram: Maternal and fetal observations are carried out as described previously,
and recorded on the partogram.
ACTIVE MANAGEMENT OF LABOUR:
It’s a collection of intervention to maximized the chance of a normal birth. It include
• One-to-one midwifery care, (A variaty of study failed to show any benefit of active
management except one-to-one care)
• 2 hourly vaginal examination and
• Augmentation: Early artificial rupture of membrane and use of oxytocin augmentation
if progress fell for more than 2 hours behind the schedule of 1 cm per hour.
The Second stage of labour:
Diagnosis the onset of the second stage:
If the labor has been normal, the first sign of the second phase of the second
stage is likely to be an urge to push experienced by the mother. The woman
will get an expulsive reflex with each contraction, and will generally take a deep
breath, hold it, and strain down (the Valsalva manoeuvre).
Full dilatation of the cervix should be confirmed by a vaginal examination if the
head is not visible.
Positioning + partogram + pushing panting:
Positioning: Women should be discouraged from lying supine, or semisupine, and
should adopt any other position that they find comfortable. Lying in the left
lateral position and squatting are particularly effective options.
Partogram: Maternal and fetal surveillance intensifies in second stage, as
described previously. The development of fetal acidemia may accelerate, and
maternal exhaustion and ketosis increase in line with the duration of active
pushing.
The pushing should be organized with the contractions to be effective.
Once the head has crowned, the woman should be discouraged from bearing
down by telling her to take rapid, shallow breaths (‘panting’).
(in mediolateral episiotomy, first three complications are more yet the extension
to the sphincter is less than the way it is with midline episiotomy, a reason for
making the mediolateral more preferable.)
To aid delivery of the shoulders, the head should be pulled gently downwards
and forwards until the anterior shoulder appears beneath the pubis. The head is
then lifted gradually until the posterior shoulder appears over the perineum and
the baby is then swept upwards to deliver the body and legs.
If the infant is large and traction is necessary to deliver the body, it should be
applied to the shoulders only, and not to the head.
Immediate care of the neonate:
After the infant is born, it lies between the mother’s legs or is delivered directly on
to the maternal upper abdomen. The baby will usually take its first breath within
seconds. There is no need for immediate clamping of the cord, and indeed about 80
mL of blood will be transferred from the placenta to the baby before cord
pulsations cease, reducing the chances of neonatal anaemia and iron deficiency.
The baby’s head should be kept dependent to allow mucus in the respiratory tract
to drain, and oropharyngeal suction should only be applied if really necessary. After
clamping and cutting the cord, the baby should have an Apgar score calculated at 1
minute of age (see Chapter 19, Neonatology) which is then repeated at 5 minutes.
Immediate skin-to-skin contact between mother and baby will help bonding, and
promote the further release of oxytocin, which will encourage uterine contractions.
The baby should be dried and covered with a warm blanket or towel, maintaining
this contact. Initiation of breastfeeding should be encouraged within the first hour
of life, and routine newborn measurements of head circumference, birthweight and
temperature are usually performed soon after this hour has elapsed. Before being
taken from the delivery room, the first dose of vitamin K should be given (if
parental consent has been given) and the infant should have a general examination
for abnormalities and a wrist label attached for identification.
Third stage of labour
It’s the time from delivery of the baby to the expulsion of the placenta and the
membrane. This normally take between 5 to 10 minutes.
Separation of the placenta occur because of the reduction in the volume of the
uterus due to uterine contraction and retraction (shortening of the the myometrial
muscle fibers).
A cleavage plane develops within the decidua basalis and the separated placenta
lies free in the lower segment of the uterine cavity.