Management of Normal Labour


Maximum observation with minimal active intervention.

Aim:

Non intereference with watchful expectancy  so  as  to prepare  the  patient  for natural birth.
To monitor carefully the progress  of  labour, maternal condition and fetal behaviour so as to detect any intrapartum complication early.


General Principle:

-Initial assessment
-Observation and intervention if labour becomes abnormal
-close monitoring of the fetal  and maternal condition
-Adequate pain relief
-Emotional support
-Adequate hydration

Initial Assessment:

- Detailed History
- Clinical Examination
- Basic investigation
Aim:
 - To identify as high risk before the onset of labour


O/E:
Vitals 
General sign
Chest/CVS

P/A:
Fundal Height
Lie
Presentation
Engagement
Contraction
FHS



V/I:
P/V:- Dilatation,Effacement,Consistency,Position,Station,
    Membrane Status ,CPD

Investigation:


Diagnosis and Confirmation of Labour:

Admission
1.Encouragement and Assurance
2.Maintain cleanliness of women and her enviroment
3.Rest and ambulation
4.Diet(Liquid and a few biscuits, I/V fluid)
5.Bladder(Encourage women to empty regularly)
6.Bowel(Donot give  enema routinely)
7.Relief of pain:
 - Suggest change of position
 - Encourage mobility
 - Massage her back
 - Encourage breathing exercise
 - If necessary pethidine 1 mg/kg body weight or morphine 0.1 mg/kg IM
 - Epidural
8.Assessment of progression of labour by partograph
 - Patient information 
 - FHR every 30 minutes
 - Amniotic fluid:Record the color of amniotic fluid at every P/V.

I: Membrane intact
C: Clear fluid
M:  Meconium stained fluid
B: Blood stained fluid

Moulding:

1.Sutures apposed
2.Sutures overlapped but reducible
3.Suture overlapped but not reducible


Cervix Dilatation:
-Assess at every vaginal examination and marked with a cross 
-Begin plotting on the partograph  at 4 cm

Alert line:
A line starts at 4 cm of cervical dilatation to the point of expected full dilatation  at the rate of 1 cm/hr.

Action line: Parallel and 4 hrs to the right of the alert line.
Descent: Assessed by P/A. Head divided into five parts. Refers to the part of the head palpable above the s.pubis.
Hours: Refers to the time elapsed since onset of ASOL.
Time: Record actual time

Contraction: Chart every half and hourly.Palpate the no.of contraction in every 10 min.and duration in sec.
< 20 sec: mild
20-40 sec : moderate
>40 sec : Strong
Oxytocin: Amount ofoxytocin/ltr, Drops/min

  • Drugs: Record if additional  drugs given 
  • Pulse: Half hourly
  • B.P: Every 4 hourly
  • Temperature: 2 Hrly
  • Protein,Acetone volume:  Record every time urine is passed

Protraction - as a slow rate of cervical dilatation or descent
 Primiparas - less than 1.2 cm dilatation per hour or less than 1 cm descent per hour.  
 multiparas - less than 1.5 cm dilatation per hour or less than 2 cm descent per hour.  


   Arrest disorders - as a complete cessation of dilatation or descent. Arrest of dilatation  is defined as 2 hours with no cervical change,  Arrest of descent as 1 hour without fetal descent. 

SECOND STAGE OF LABOUR

Progress of second stage of labour:
1.Increasing intensity of uterine contraction
2.Appearance of bearing down effort
3.Urge to defecate with descent of presenting part 
4.Complete dilatation of cervix as evidenced by P/V

AIM

1.To assist in the natural expulsion of the fetus slowly and steadily.
2.To prevent perineal  injury


General measures:

Pt should be in bed
Constant supervision for progress of fetal  &  maternal  condition.
Fetal condition:
If  there  is  FHS  less than 100 or  more than 160 suspect  fetal distress.
Position & presentation: other than occiput  anterior with well flexed head  are considered malposition.   

Maternal  conditions:
Evaluate the women for sign of distress:
Pulse: If the women’s pulse’s  increased ,she
may be dehydrated or  in pain.
BP: If BP decreased suspect APH.
Acetone: If acetone is present in the
urine,suspect poor hydration & nutrition and give dextrose IV.

Preperation for delivary:
 once the cervix is fully
dilated & the women in expulsive
phase,encourage  to assume  position she
prefers & encourage to push.
  • Clean hand:
  • Clean surface:
  • Clean cutting & ligating of the cord:

Delivery of Head
  • Ask the women to pant or give only small pushes with contractions as the baby’s head delivers.
  • To control birth of the head, place the fingers of one against the baby’s head to keep it flexed(bent).
  • Continue to gently support the perineum as the baby’s head delivers.
  • Once the baby’s head delivers, ask the women not to push.
  • Suction the baby’s mouth and nose.



Feel around the baby’s neck for the umbilical cord:
    - If the cord is around the neck but is loose,slip it over the baby’s head;
    - If the cord is tight around the neck,doubly clamp and cut it before unwinding it from around the neck.
 Hooking the fingers in the axillae should be avoided  - injure the nerves of the upper extremity, producing a transient or possibly even a permanent paralysis. 
  Immediately after delivery of the newborn, there is usually a gush of amnionic fluid, often tinged with blood but not grossly bloody.

Delivery of shoulder
Completion of delivery


Clamping the Cord
The umbilical cord is cut between two umbilical cord clamps –
  -  one clamp at 4 to 5 cm from the fetal abdomen,  
  -  other clamp at 2 to 3 cm from the fetal abdomen.  

Timing of Cord Clamping
If after delivery, the newborn is placed at or below the level of the vaginal introitus for 3 minutes and the fetoplacental circulation is not immediately occluded by clamping the cord, an average of 80 mL of blood may be shifted from the placenta to the neonate.
  This provides about 50 mg of iron, which reduces the frequency of iron deficiency anemia later in infancy.
    The risk of circulatory overloading from gross hypervolemia is high, especially in preterm and growth-retarded neonates.
  


Management of the Third Stage of Labor

Immediately after delivery of the newborn, the size of the uterine fundus and its consistency are examined.
 If the uterus remains firm and there is no unusual bleeding, watchful waiting until the placenta separates is the usual practice. 
Massage is not employed, but the fundus is frequently palpated to make certain that the organ does not become atonic and filled with blood from placental separation.
When the placenta has separated, it should be determined that the uterus is firmly contracted.
 The mother may be asked to bear down, and the intra-abdominal pressure may be adequate to expel the placenta. 
If these efforts fail, or if spontaneous expulsion is not possible,  then after  pressure is exerted with the hand on the fundus to propel the detached placenta into the vagina 


FOURTH  STAGE:  usually about 1-2 hrs after delivery

Vital signs
BP , Pulse
Full Bladder
Trauma
Uterine  Relaxation / Atony
Sudden Collapse / Shock

VULVAL HAEMATOMA / RUPTURED UTERUS
pains -  Analgesia if needed

Transfer to inpatient if all signs are normal