2 TYPES OF PHYSIOLOGY

1.UTERINE ACTION

2.MECHANICAL ACTION.

NON-INTERFERENCE

WITH WATCHFUL EXPECTANCY

MONITOR CAREFULLY

TO

 GENERAL
BOWEL REST DIET BLADDER

AND AMBULATION

CARE RELIEF OF PAIN ASSESSMENT OF PROGRSS OF LABOR AND PARTOGRAPH RECORDING

IT IS A COMPOSITE GRAPHICAL RECORD OF

CERVICAL DIALATATION AND DESCEND OF

THE HEAD AGAINST DURATION OF LABOUR IN

HOURS

 The

partograph can be used by health workers with adequate training in midwifery who are able to : - observe and conduct normal labour and delivery. - Perform vaginal examination in labour and assess cervical diltation accurately - plot cervical diltation accurately on a graph against time There is no place for partograph in deliveries at home conducted by attendants other than those trained in midwifery

early detection of abnormal progress of a labour prevention of prolonged labour recognize cephalopelvic disproportion before obstructed labour assist in early decision on transfer , augmentation , or termination of labour increase the quality and regularity of all observations of mother and fetus early recognition of maternal or fetal problems the partograph can be highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture) and for the newborn (death, anorexia, infections, etc.).

Part 1 : fetal condition PArt 11 : progress of labour Part 111 : maternal condition Outcome :

( at top ) ( at middle ) ( at bottom )

This part of the graph is used to monitor and assess fetal condition 1 - Fetal heart rate 2 - membranes and liquor 3 moulding of the fetal skull bones

Basal fetal heart rate? < 160 beats/mi =tachycardia > 120 beats/min = bradycardia >100 beats/min = severe bradycardia

intact membranes .I ruptured membranes + clear liquor ..C ruptured membranes + meconium- stained liquor ..M ruptured membranes + blood stained liquor B ruptured membranes + absent liquor....A

Molding is an important indication of how adequately the pelvis can accommodate the fetal head. separated bones . sutures felt easily ..O bones just touching each other ..+ overlapping bones ( reducible ) ...++ severely overlapping bones ( non reducible ..+++

 Cervical

diltation Descent of the fetal head Fetal position Uterine contractions

This section of the paragraph has as its central feature a graph of cervical diltation against time it is divided into a latent phase and an active phase

 it

starts from onset of labour until the cervix reaches 3 cm diltation once 3 cm diltation is reached , labour enters the active phase lasts 8 hours or less each contraction lasting < 20 sceonds at least 2/10 min contractions

 Contractions

at least 3 / 10 min each lasting < 40 seconds The cervix should dilate at a rate of 1 cm / hour or faster

 The

alert line drawn from 3 cm diltation represents the rate of diltation of 1 cm / hour Moving to the right or the alert line means referral to hospital for extra vigilance

 The

action line is drawn 4 hour to the left of the alert line and parallel to it This is the critical line at which specific management decisions must be made at the hospital

 It

is the most important information and the surest way to assess progress of labour. when progress of labour is normal and satisfactory , plotting of cervical dilatation remains on the alert line. if a woman arrives in the active phase of labour , recording of cervical dilatation starts on the alert line

 It

should be assessed by abdominal examination immediately before doing a vaginal examination, using the rule of fifth to assess engagement The rule of fifth means the palpable fifth of the fetal head are felt by abdominal examination to be above the level of symphysis pubis

 Observations

of the contractions are made every hour in the latent phase and every half-hour in the active phase frequency how often are they felt ? Assessed by number of contractions in a 10 minutes period duration how long do they last ? Measured in seconds from the time the contraction is first felt abdominally , to the time the contraction phases off Each square represents one contraction

Less than 20 seconds: Between 20 and 40 seconds: More than 40 seconds:

Name / DOB /Gestation Medical / Obstetrical issues Assess maternal condition regularly by monitoring : drugs , IV fluids , and oxytocin , if labour is augmented pulse , blood pressure Temperature Urine volume , analysis for protein and acetone

SINGLE SHEET OF PAPER CAN PROVIDE DETAILS OF NECESSARY INFORMATION. NO NEED TO RECORD THE LABOUR EVENT REPEATEDLY. IT CAN PREDICT DEVIATION FROM NORMAL DURATION OF LABOUR EARLY. CAN REDUCE THE INCIDENCE OF PROLONGED LABOUR AND CAESAREAN RATE.

 SEDATIVES

AND ANALGESICS INHALATION AGENTS REGIONAL ANALGESIA PATIENT CONTROLLED ANALGESIA (PCA) PSYCHOPROPHYLAXIS TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION GENERAL ANESTHESIA

 The

threshold of pain. Primi or multi. Maturity of the fetus.

 Pethadine:

Strong sedatives but less analgesic efficiency. Used in the first phase of labor The initial dose is 100mg IM.
effects For mother- nausea, vomiting, delayed gastric empting. For fetus- respiratory and sucking depression.

Side

Meptazinol : It has got similar analgesic and sedative property as that of pethadine. It cause less respiratory depression of the baby

Pentazecin (Fortwin):
it is given IM in a dose of 30-40mg its duration is shorter and causes some respiratory depression and also drug dependency naloxone is an efficient and reliable antagonist.

 Diazepam

: It is well tolerated by the patient. It doesnot produce vomiting and help in the dilatation of the cervix. It is metabolized in the liver. The usual dose is 5-10mg. It may be used in larger dose in the management of pre-eclampsia.

Midazolam :
More potent and neonatal side effect are less compare to diazepam. It is cleared from the tissue more rapidly. Dose of 0.05 mg/kg is given IV.

Combination of narcotics and tranquilisers : Narcotics may be used in combination with promethazine, chlorpromazine or promazine.

 Nitrous

oxide and air: This is used in the second phase. Now a day, this is not used because this produce fetal hypoxia. Premixed nitrous oxide and oxygen: cylinders containing 50% nitrous oxide and 50% oxygen mixture. Endonox apparatus has been approved for use by midwives. It can be self administered Trichloroethylene (Trilene): This is an useful drug in labor with high analgesic effect. It gives better result in nervous women than nitrous oxide. It is no longer used.

methoxyflurane, isoflurane, enfluran: they are good analgesic agent and more effective than trichloroethylene.

Continuous lumbar epidural block

Contraindications Sepsis at the site of injection Hemorrhage Supine hypotension Hypovolaemia Neurologic disease. Spinal deformity or chronic back pain.

Complications Hypotension Pain at the insertion site Post spinal headache due to leakage of cerebrospinal fluid. Injury to nerves.

 Caudal

epidural analgesia:

 Paracervical nerve block

Pudental nerve block

 Spinal anesthesia

Advantages
less fetal hypoxia Easy technique No inhalation anesthesia is required

Disadvantages
Hypotension Respiratory depression to the baby Post-spinal head ache Transient or permanent paralysis Toxic reaction of local anesthetic drug. Nausea and vomiting Urinary retention.

CONSIDERATIONS
ELECTIVE OR EMERGENCY PROCEDURE PATIENT SHOULD BE ON NIL BY MOUTH. DRUGS MAY CAUSE FETAL DEPRESSION. VOLATILE ANESTHESIA DIMINISHES UTERINE CONTRACTILITY EG: EATHER, HALOTHANE. HYPOXIA AND HYPERCAPNIA MAY OCCUR. CAN CAUSE DEPRESSION IN APGAR SCORE.

Complications of GA Aspiration of gastric content (mendelsons syndrome). Failure in intubation and ventilation. Nausea, vomiting and sore throat.

PREVENTION
KEEP THE PATIENT NBM. H2 BLOCKER BEFORE NIGHT AND 1 HOUR BEFORE ADMINISTERING GA. METOCLOPROMIDE 10MG IV IS GIVEN AFTER MINIMUM 3 MINUTE BEFORE OXYGENATION TO DECREASE GASTRIC VOLUME AND TO INCREASE THE TONE OF LOWER ESOPHAGEAL SPHINCTER.

It starts from the full dilatation till the expulsion of the fetus. It has got two phases and duration is 2hours in primi and 30min in multiparae.

 Propulsive

phase: Starts from full dilatation till the descent of the presenting part to the pelvic floor Expulsive phase: From the maternal bearing down effort till the delivery of the fetus.

 Descent

of the presenting part, which began during the 1st stage of labor and reached its maximum speed towards the end of the first stage of labor, continues through the second stage of labor until reaching the pelvic floor. The average maximum rate of descend is 1.6cm per hour in nulliparas and 5.4cm per hour in multiparas.

Contraction

during the second stage are frequent, strong, and slightly longer that is approximately every 2 minutes, lasting 60-90 seconds, allowing both mother and baby regular recovery period.

 The

membrane often ruptures spontaneously at the onset of the second stage. The consequent drainage of liquor allows the hard, round fetal head to be directly applied to the vaginal tissue and aid distention. As the fetus further descend into the vagina, pressure from the presenting part stimulates nerve receptors in the pelvic floor and the mother experience the need to push.

As the hard fetal head descend, the soft tissues of the pelvis become displaced. Anteriorly the bladder is pushed upwards into the abdomen where it is at risk of injury during the fetal descent. Posterior, the rectum becomes flattened into the sacral curve and the pressure of the advancing head expels the residual fecal matter. The fetal head become visible at the vulva, advancing with each contraction and receding during the resting phase until crowning takes place and the head is born.

 The

women verbal expression my baby is coming often signals an imminent delivery.

is possible for a woman to feel strong desire to push before full dilation.

It

 Membranes

normally rupture at the onset of second stage. However this may occur at any time during labor.

 Deep

engagement of the presenting part and premature maternal effort may produce this sign during the latter part of the first stage.

 Excessive

moulding may result in the formation of the large caput succedaneum, which can protrude through the cervix prior to the full dilatation

 This

is the loss of blood stained mucus, which often accompanies rapid dilatation towards the end of the first stage.

 to

assist in the natural expulsion of the fetus slowly and steadily to prevent the perineal injury

 the

patient should lie down in the bed constant supervision by the medical attendant is mandatory (BP, maternal pulse and FHR) Administration of inhalation analgesic vaginal Examination is done at the beginning of the second stage nothing is given by mouth.

 Shifting

to labor table Positioning of the patient: position of the woman during delivery may be lateral or partial sitting. Dorsal position with 15 degree left lateral tilt is commonly favored as it avoids aortocaval compression and facilitates pushing effort. Scrubbing of the staff: puts on sterile gown, mask and gloves and stands on the right side of the table

 Toileting

the external genitalia and inner side of the thighs is done with cotton swabs soaked in savlon or dettol solution. catheterize the bladder

Delivery is divided in to three phases: Delivery of head Delivery of shoulder Delivery of trunk

The

principles which should be followed is -maintain flexion of head -to prevent early extension -to regulate slow escape of the vulval outlet

 The

patient is encouraged for the bearing down effect during contraction which facilitate the descend of head. When the scalp is visible for about 5 cm in diameter, flexion of the head is maintained during the contraction ,by pushing the occiput downward and backward by the thumb and index finger of the left hand while pressing the perineum by the right palm.

Episiotomy can be done at this stage when perineum got bulged out

Sudden

escape of the head during contraction at this stage is to be prevented Slow delivery of the head in between the contractions is to be regulated.

 The

mucus, blood in the mouth has to be wiped Eyelids are wiped with sterile dry cotton swabs. Each eye starting from the medial to the lateral canthus. The neck is then palpated to exclude the presence of any loop of cord

 Wait

for the uterine contraction to come and for movements of restitution and external rotation of head. If there is a delay, the head is grasped by both hand and is gently drawn posteriorly until the anterior shoulder is released from the pubis. Traction on the head should be gentle to avoid excessive stretching of the neck causing injury to the brachial plexus.

 After

the delivery of the shoulder, the fore fingers of each hand are inserted under the axilla and the trunk is delivered gentle by lateral flexion.

 Delivery

of the early extension is to be

avoided Spontaneous forcible delivery of the head is to be avoided To deliver the head in between contractions To perform timely episiotomy To take care during the delivery of the shoulder

STAGE

STARTS FROM THE EXPULSION OF THE FETUS TILL THE EXPULSION OF THE PLACENTA. DURATION IS 15 MIN BOTH IN PRIMI AND MULTI. IT COMPRISES THE PHASE OF PLACENTAL SEPERATION, ITS DESCENT TO THE SEGMENT AND FINALLY ITS EXPULSION WITH THE MEMBRANE.

DETACHMENT STARTS AT THE CENTRE.

ACCUMULATION OF BLOOD BEHIND THE PLACENTA (RETROPLACENTAL HAEMATOMA).

INCREASE CONTRACTION , INCREASE DETACHMENT .

STARTS

FROM MARGINAL.

PROGRESSIVE

UTERINE CONTRACTION, MORE AND MORE AREA OF THE PLACENTA GET SEPERATED. ONE.

FREQUENT

 Sudden

gush of blood. Lengthening of the umbilical cord visible. Change the position of the uterus as it rises the abdomen, because the bulk of the placenta is in the lower uterine segment or upper uterine segment.

EXPELLED

OUT BY EITHER VOLUNTARY CONTRACTION MUSCLES OR BY MANIPULATIVE PROCEDURE.

to ensure strict vigilance and to follow the management guidelines strictly in practice so as to prevent the complications, the important one being is PPH.

 Minimal

assistance may be given for the placental expulsion if it needed. Constant watch Change mother position from lateral to dorsal A hand is placed over the fundus To recognize the sign of separation of placenta. To note the state of uterine activitycontraction and relaxation. To detect cupping of the fundus, which is an early evidence of inversion of the uterus.

EXPULSION OF PLACENTA: TRADITIONAL METHOD DESCENT--- CONFIRMATION. CAN WAIT TIL 10MT IF THERE IS NO BLEEDING INTRA ABDOMINAL PRESSURE WILL FACILITATE FOR THE EXPEL OF THE PLACENTA. AS SOON AS THE PLACENTA PASSES THROUGH THE INTROITUS GRASP IT BY THE HAND AND TWIST ROUND AND ROUND WITH GENTLE TRACTION.

 CONTROLLED

CORD TRACTION FUNAL PRESSURE

 IT

IS ALSO CALLED MODIFIED BRANDTANDREWS METHOD. THIS PROCESS IS ADOPTED ONLY WHEN THE UTERUS IS HARD AND CONTRACTED

Principle:

-to excite powerful uterine contractions following birth of the anterior shoulder by parent oxytocin which facilitates not only early separation of the placenta but produces effective uterine contraction following its separation.

To

minimise blood loss in third stage approximately to 1/5th To shorten the duration of third stage to half.

Slight

increased incidence of retained placenta.