introduction
Labor is the process that begins
with repeated, forceful uterine
contractions. Uterine contractions
supply the power that makes birth
possible. Contractions
cause the
3
cervix to dilate and help move the
baby through the birth canal .
Labor
ABNORMAL LABOR(DYSTOCIA)
FIRST STAGE
It starts from the onset of true labor pain, and
ends with the full dilatation of the cervix. Its
average duration is 12 hrs. in primigravidae and
6 hrs in multiparae1.1.
FIRST STAGE comprises of 3 phases
Latent phase
Active phase
Transitional phase
SECOND STAGE
THIRD STAGE
Fourth stage
Duration
Uterine actions
(a) Fundal dominance
(b) Polarity
(c) Contractions and retraction
(d) Formation of upper and lower uterine
segment
(e) The retraction ring
(f) Cervical effacement
(g) Cervical dilatation
Mechanical factors
(a) Formation of the forewaters
(b) Rupture of the membranes
(c) Fetal axis pressure
DURATION
Uterine actions
FUNDAL DOMINANCE
Each uterine contraction starts in the
fundus near one of the cornua and
spreads across and downwards.
contraction lasts longest in the fundus
where it is also more intense and
contraction fades from all parts
together.
This pattern permits the cervix to
dilate and the strongly contracting
fundus to expel the fetus.
POLARITY
Polarity is the term used to describe
the neuromuscular hormony that
prevails between the two poles or
segments of the uterus through out
the labor.
polarity disorganized = labor inhibited
Contractions AND
RETRACTION
contraction
Contraction is the
temporary reduction in the
length of the fibers
Retraction
Effects of retraction
Help
Bandls ring
Effacement ( taking up of
cervix)
Here cervix is drawn up and gradually
merges in to the lower uterine
segment.
In the primiparous women it may
result in complete effacement.
In multiparous women perceptible
canal may remain.
EFFACEMENT OF
CERVIX
No changes to cervix
0% Effaced
50% Effaced
Cervix is completely
thinned out
100% Effaced
Cervical dilatation
Closed cervix
Mechanical factors
Formation of forewaters
The sac of amniotic fluid is described as
having two sections the forewaters (in front
4
of babys head) and the hind waters (behind
babys head).
During labor forewaters are formed as the lower
segment of the uterus stretches and the chorion
4 from it .
(the external membrane) detaches
The well flexed babys head fits into the
cervix and cuts off the fluid in front of the head
4
(forewaters) from the fluid behind (hind
waters) .
PRINCIPLES
Non
To
preliminaries
This consist of basic evaluation of the
current clinical condition.
Inquiry is to be made about the onset of
labor pains or leakage of water, if any.
Thorough general and obstetrical
examinations including vaginal
examinations are to be carried out and
recorded.
Records of antenatal visits, investigation
reports and any specific treatment given, if
available, are to be reviewed.
Actual management
Environment
Emotional support
Prevention
of infection
Skin
and membranes :
Rest
Antiseptics
and asepsis:
Position of mother :
Remaining
upright and
leaning forward reduces this
pressure while allowing the
babys head to constantly
bear down on the cervix.
The result? Dilation tends to
occur more quickly.
Nutrition
Bladder care :
Vital
signs :
Vaginal examination
preliminaries
Toileting hands and forearms should be
washed, a scrubbing brush should be used for
fingernails.
Sterile pair of gloves is to be put on.
Vulval toileting should be performed and same
solution is poured over the vulva by separating
the labia minora by the fingers of left hand.
Gloved middle and index finger of the right
hand smeared with antiseptic cream introduced
in to vagina after separating the labia by two
fingers of the left hand.
Fetal monitoring
Pain management
Non
pharmacological methods :
Hypnosis
Pharmacological
Sedative
methods :
and analgesics :
The sedative given were usually the chloral
derivatives. Analgesics which are used in early
labor are in mild to moderate analgesic range
e.g. paracetamol.
Narcotics : A narcotic is a strong analgesic drug
with some sedative properties. These include
pethidine, morphine, naloxone, pentazocine.
Inhalation analgesia : They offer effective
pain relief for the majority, of women with the
adnvantage that all their effects are short lived
and they donot give rise to any complication in
the neonate. The agent used is Entonox. Entonox
is the trade name used to describe an equal
mixture of oxygen and nitrous oxide.
Physiology in the
second stage of
labor
hoursininPrimi-gravida
Primi-gravida
22hours
30
minutes
in
multi30 minutes in multigravida
gravida
Physiology changes :
1.
Uterine actions :
contractions becomes stronger and
longer but may be less frequent affording
mother and fetus a recovery period
during the resting phase.
There are progressive, continued
contractions and retractions of the upper
uterine segment while the lower segment
and cervix passively dilate and thin. The
membrane often rupture spontaneously
at the onset of second stage.
2) Soft tissue
replacement :
As the fetal head descends, the soft tissue of
the pelvic become displaced. Anteriorly the
bladder is pushed upwards in to the
abdomen where it is at less risk of injury
during descent .
Posteriorly the rectum becomes flattened in
to the sacral curve and the pressure of the
advancing head expels any residual fecal
matter. The fetal head become visible at the
vulva, advancing with each contraction and
receding during the resting phase until
crowning take place and the head is born
The
Mechanism
of normal labor
CARDINAL MOVEMENTS
OF LABOR i
Station of head
Asynclitism
:The
head
usually
engages in the pelvis in a synclitic
position, one that is parallel to the
anteroposterior plane of the pelvis.
Frequentlyasynclitismoccurs
(the
head
is
deflected
anteriorly
or
posteriorly in the pelvis), which can
facilitate descent because the head is
being positioned to accommodate to the
pelvic
cavity.
However,
extreme
asynclitism can cause cephalopelvic
disproportion, even in a normal-size
pelvis, because the head is positioned
so that it cannot descend.
Crowning
ROLE OF NURSE
SPONTANEOUS DELIVERY
Delivery of the head : crowning
encirclement of the largest head
diameter by the vulval ring.
- one hand: a towel-draped, gloved hand
may exert forward pressure on the chin of
the fetus through the perineum just in
front of the coccyx
- with other hand: exerts pressure superiorly
against the occiput.
SPONTANEOUS DELIVERY
Delivery of shoulder
The occiput : Turns toward one of the
maternal thigh
Fetal head: Transverse position
sucking the nasopharynx or checking for a
cord.
Timing
of cord clmaping
THIRD STAGE
Active Management
Oxytocic is given
Cord is clamped
Placenta delivered by controlled cord traction
(CCT) with counter-traction on the fundus
Fundal massage or pressure
Details of Physiologic
Management
Try not to give oxytocic
Try not to use CCT or any manual interference
with uterus at fundus
Try to encourage mother to concentrate on
feeling for next contraction or urge to push
When mother feels contraction or urge or there
are signs of separation, encourage mother and
help her change posture
If placenta does not deliver spontaneously,
wait, try putting baby to breast and encourage
maternal effort
Active
management
Uterotonic agent
Uterus
Assessment of size
Assessment of size
and tone after delivery and tone after delivery
Cord traction
None
controlled cord
traction when uterus
contracted
Cord clamping
Variable
Early
Recommendations Concerning
Selection of Oxytocic
Uterine
exploration:
- No longer recommended for
normal deliveries or those
following previous cesarean
delivery.
- Is justified in patients with
bleeding originating high in the
genital tract.
- The cervix should be visualized
after all forceps deliveries
Fourth stage
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Thank you