Sunday, May 20, 2012

Normal Labour


Case: A 24 year old G2P1, a booked case of your hospital comes to you in labour. She tells you that she has been having labour pain for almost 5 hours now.  On abdominal palpation, you can feel 3 strong uterine contractions every 10 mins. The head is engaged. On PS, cervix is 4cm dilated with effacement. On PV, the head is felt at “0” station. How will you manage the case now? 



What is labour? 

Expulsion of fetus through uterus after the age of viability


What is normal labour ?
  • Vertex presentation
  • Spontaneous onset of labour at term
  • Natural termination through vagina
  • Without any assistance 
  • Without any complications

Onset of labour
  • Fetus – Anterior pituitary and adrenal gland
  • Placenta – Hormones
  • Mother – Uterus, Hormone and Prostaglandins

At term- Increased release of ACTH from the Ant Pituitary
                                    ↓
Increased secretion of cortisol
                 ↓
Increased in oestrogen
                 ↓
Increased oxytocin receptors in the myometrium
                  
Increased prostaglandin synthesis

Prostaglandins
  • Decidua
  • Membranes
  • Placenta
  • Liquor

Diagnosis of onset of labour
  • Painful intermittent uterine contractions 
  • Show
  • Dilatation of cervix
  • Formation of bag of water



Characteristics of uterine contractions

  • Intermittent
  • Regular interval
  • Relaxation in between
  • Followed by retraction




Starts from cornua – descends down
Fundal dominance
Synchronous
Intra amniotic pressure rise to > 20mm Hg
1st stage – 40-50 mm Hg
2nd stage – 100-120 mm Hg 


Characteristics of cervical dilatation

  • Progressive 1cm per hour in primi
  • 1.5 cm per hour in multi
  • Effacement – progressive shortening of cervix due to gradual merging up of upper part of cervix to the lower segment
  • May occur before dilatation of cervix in primi
  • Occurs together with dilatation during labour




Stages of labour

1st stage – Onset of labour to full dilatation of cervix = 10 cm
2nd stage- full dilatation of cervix to delivery of fetus
3rd stage- delivery of fetus to expulsion of placenta

Duration of labour

Total duration 
1st stage -  Primi 8-16 hrs (average 12 hrs)
                -  Multi 4- 8 hrs (average 6 hrs)
2nd stage- Primi 1-2 hrs
                - Multi 1 hr
3rd stage – 5 to 15 min  


Mechanism of labour

  • Engagement
  • Engaging diameter – sub-occipito-bregmatic (9.4 cm)
  • Descent with flexion
  • Internal rotation
  • Crowning
  • Extension
  • Restitution and External rotation
  • Delivery of trunk






Management of 1st stage of labour

1st stage – latent stage and active stage 
General care
Monitor labour

General care

  • Support and care 
  • Mobilization
  • Nutrition
  • Evacuation of bladder
  • Antiseptic and asepsis



Monitor Progress of Labour

Maintain partograph


Components of partograph


  • Mother’s identification
  • Fetal heart rate
  • Color of liquor and moulding
  • Rate of cervical dilatation and descent of head
  • Frequency in 10 min, duration and strength of uterine contraction
  • Vitals = pulse, BP, Temp
  • Oxytocin infusion
  • Drugs and I/V fluids
  • Urine for acetone, albumin and volume





    Management of 2nd stage
    • Position
    • Bearing down during contraction
    • Episiotomy need
    • Support perineum
    • Suction baby’s mouth and nose
    • Keep the baby on mother’s abdomen
    • Dry the baby by wiping
    • Clamp and cut the cord
    • Keep the baby warm
    • Skin to skin contact

    Active Management of 3rd stage
    • Oxytocin 10 units I/M after delivery of fetus
    • Controlled cord traction (CCT) 
    • Uterine massage every 15 min for 2 hrs



    Mechanism of control of bleeding
    Signs of separation of placenta 
    • Hardening of uterus
    • Gush of blood per vaginum
    • True lengthening of cord
    • Rise of fundal height


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