Normal Labor

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Normal Labor Delivery
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Why labor pains ?

• Labor - because much energy is expended during
  this time
• Pains because contractions of labor are painful

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Mechanisms Cited for Pain in Labor

• Hypoxia of the contracted myometrium
• Compression of nerve ganglia in the cervix and
  lower uterus by the interlocking muscle bundles
• Stretching of the cervix during dilatation
• Stretching of the peritoneum overlying the fundus

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Stages Of Labour

• Stage 1
• Cervical Effacement and Dilatation
• Stage 2
• Full cervical dilatation to expulsion of fetus
• Stage 3
• Placental separation and expulsion

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Effacement taking up of the cervix or
obliteration of the cervical canal
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Cervical Effacement and dilatation
Nullipara Multipara
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Cardinal Movements of Labor
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• The fetus is in the occiput or vertex in
  approximately 97 of labors

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• Engagement
• Descent
• Flexion
• Internal Rotation
• Extension
• External Rotation
• Expulsion

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Conduct of Labor and Delivery
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In labor or not?
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Signs of Labor

• Hypogastric and lumbosacral pains (contractions)
• Bloody vaginal discharge or bloody show

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True Labor False Labor

• Contractions regular
• Intervals shorten
• Intensity increases
• Discomfort in back abdomen
• Cervix dilates
• Unaffected by sedation

• Irregular
• Remain long
• Unchanged
• Lower abdomen
• No dilatation
• Relieved by sedation

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Admission Vaginal Exam

• If there are NO contraindications, note
• Amniotic fluid
• Cervix
• Presenting part
• Station
• Pelvic architecture

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Station

• Degree of descent of the presenting part into the
  birth canal
• Landmark Ischial spines
• Described in centimeters above or below spines
  (-5 to 5)

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Ischial spines
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• Management of First Stage Labor

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• First stage
• - from onset of regular contractions to full
  cervical dilatation

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First stage Admission Procedures
History
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First Stage Admission Procedures

• 2. Physical Examination
• General survey, vital signs
• a. Abdominal Examination
• Inspection
• Palpation
• Auscultation

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Identify which pole occupies the fundus
Determine on which side the back and soft parts
are
What presenting part overlies the inlet attitude
Extent of descent
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First stage Admission Procedures

• 3. Baseline cardiotocogram

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First stage Maternal Monitoring

• Subsequent vaginal examinations
• Analgesia
• Vital signs every 1-2 hours

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• Management of
• Second Stage of Labor

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• Second stage
• - From full cervical dilatation to expulsion of
  the fetus

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Second Stage

• Mean duration
• 20 mins. - multipara
• 50 mins. - nullipara
• Identification
• - Woman starts to bear down
• - Urge to defecate
• - Uterine contractions longer, rest intervals
  shorter

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Second stage Preparation for Delivery

• Position
• - Dorsal lithotomy
• - Stirrups
• - Legs not too wide open
• - Popliteal region should rest comfortably on
  leg holder
• - Cleansing and draping

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LITHOTOMY POSITION
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Delivery of the Head

• Crowning
• largest head
• diameter encircled
• by the vulvar ring

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Delivery of the Head

• Episiotomy
• Incision of the pudenda
• Not universally done

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Episiotomy

• Substitutes a jagged laceration for a clean cut
  wound
• Types
• - median
• - mediolateral

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Median episiotomy
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Mediolateral episiotomy
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Benefits(?) of Episiotomy

• ?Clean cut wound
• ?prevents pelvic relaxation
• cystocele
• rectocele
• urinary incontinence
• Surgical judgment and common sense

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Timing of Episiotomy

• Too early
• - Bleeding from the incision
• Too late
• - Excessive stretching of muscles of the
  perineal floor defeats the purpose of the
  procedure
• Ideally when head is visible at introitus during
  a contraction to a 3-4 cm. diameter

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Median Mediolateral

• Easy to repair More difficult
• Rare faulty healing More common
• Less post-op pain More common
• Excellent anatomic Faulty at times
• results
• Less blood loss More blood loss
• Dyspareunia rare Occasional
• Extension common Rare

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Ritgen Maneuver
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Clearing of the Nasopharynx

• Aspirate amnionic fluid debris and blood
• Wipe face quickly

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Delivery of the Shoulders

• After delivery of the head, the fetus comes in
  contact with the anus
• If shoulders do not appear at the vulva
  spontaneously after external rotation, sides of
  the head are grasped and gentle downward traction
  is applied. Body follows.

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DOWNWARD THEN UPWARD
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Clamping of the cord

• After delivery, infant is placed below the level
  of the vaginal introitus for about 3 minutes
• 80 cc. of blood gives about 50 mg. More of iron
  to the infant
• Cord clamped about 5 cm. from abdomen

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Nuchal cord

• Finger should be passed around the neck to check
  for nuchal cords
• If loose just slide over infants head
• If tight cut between 2 clamps

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Nuchal cord
Clamping the cord between 2 clamps
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• Management of the Third Stage

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Third stage of labor

• Placental separation and expulsion

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Delivery of the Placenta

• Should not be forced until signs of placental
  separation appear
• DANGER Uterine inversion !!!

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Signs of Placental Separation

• Uterus becomes globular
• Sudden gush of blood
• Uterus rises in the abdomen
• Umbilical cord lengthens
• Within 1-3 minutes

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PLACENTA
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Sudden gush of blood
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Lengthening of the cord
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Expression of the Placenta
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Delivery of the placenta
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Inspection of the Placenta
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Inspection of placenta
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Too much traction on the cord can lead to UTERINE
INVERSION
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UTERUS
PLACENTA
UTERINE INVERSION
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Manual Removal of the Placenta

• Performed if the placenta does not separate
  promptly

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Oxytocic Agents

• After delivery hemostasis is achieved by
  vasoconstriction of the placental site
• Agents which promote contraction of the
  myometrium
• - Oxytocin
• - Ergonovine maleate
• - Methylergonovine maleate

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Fourth Stage of Labor

• The hour immediately after delivery
• Uterus is frequently evaluated to detect
  excessive bleeding

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Fourth Stage of Labor

• Maternal vital signs
• Gentle uterine massage and ice packs to
  stimulate contractions
• Bladder should be checked
• Clots in the uterine cavity
• Hematomas

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Lacerations of Vagina Perineum

• First degree
• - Fourchette, perineal skin vaginal mucosa but
  not the underlying fascia and muscle
• Second degree
• - Fascia muscles of the perineal body but not
  the anal sphincter

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• Third degree
• - Vaginal mucosa, perineal skin, fascia, up to
  the rectal sphincter but not the rectal mucosa
• Fourth degree
• - Extension up to the rectal mucosa

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Pain after Episiotomy

• Persistence of pain may indicate the presence of
  a HEMATOMA
• -vulvar
• -vulvovaginal
• -ischiorectal

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• Good day!