Presentation on theme: "The course and conduct of normal labor and delivery"— Presentation transcript:
1 The course and conduct of normal labor and delivery
2 A definition of laborProgressive dilatation of the uterine cervix in association with repetitive uterine contractions.Spontaneous or inducedTerm or preterm
3 Important termsLie- relationship between the long axis of the fetus and that of the mother (longitudinal, transverse or oblique).Presentation- the fetal part that lies closest to the pelvic inlet (cephalic - vertex, face; breech; shoulder).Attitude- relationship of the fetal parts to each other, usually head and trunk (flexion or extension of the neck).
4 Onset of laborRegular uterine contractions - from at least 1/2 hr, frequency at least every 10 minutesBleedingRupture of membranes
5 Stages of the labor I - shortening and dilatation of the cervix II - delivery of the fetusIII - delivery of the placenta with the umbilical cord and membranesIV - about two hours after delivery (inspection and surgical help)
7 Dilatation of the cervix Nullipara:I - shorteningII - dilatation of external osIII - dilatation of internal osMultipara:phases I, II and III occur together
8 Mechanisms of laborThe special labor mechanisms is due to asymmetry of the shape of both the fetal head and maternal pelvis.Changes in the position of the fetal head are required for the average size fetus to accomplish passage through the birth canal.The rotations are accomplished by the propulsive force of uterine activity.
9 Important! Pelvic planes and diameters of the pelvic inlet Diameters of fetal skullLeopold’s maneuvers(Data in each manual of obstetrics)
10 Examination External (Leopold’s maneuvers) Internal cervix - length and dilatationmembranes - intact or not, color of the amniotic fluidfetus - presentation, attitude, rotationpelvis - size
11 Cardinal movements of labor movements of the headengagementdescent1. flexion2. internal rotation3. extension4. external rotationexpulsion
12 EngagementIt is the descent of the largest transverse diameter of fetal head (BPD) to a level below the plane of the pelvic inlet.Then the head is engaged.
13 Flexion (I movement of the head) - placement of the fetal chin on the thorax Internal rotation (II movement) - rotation from the transverse position towards symphysis.
14 Extension - III movement Begins at the level of maternal vulvaThe fetal head is delivered by extension from the flexed to the extended position rotating around the symphysis pubis
15 External rotation - IV movement After delivery of the head the forces exerted on the head by the maternal pelvic musculature are relived and the fetus resumes its normal face-forward position.Its face begins to „look” at one of mother’s leg.
17 ExpulsionDelivery of the shoulders - first the anterior one (under the symphysis pubis) and then the posterior one.The rest of the body is usually quickly delivered.
18 Assisted spontaneous delivery Lateral episiotomyPrevention of rapid delivery of the headDelivery of the shoulders and bodyAspiration of the mucus from the fetal mouth, pharynx and noseCord clamping
19 Episiotomy A lateral incision of perineum before delivery of the head Why?to enlarge the area of the outlet easier delivery of the head prevention of intraventricular hemorrhageprevention of lacerationsprevention of late complications - relaxation of pelvic muscles and urine incontinence
20 Episiotomy Prophylactic - nulliparas, some multiparas Mandatory in instrumental delivery, like forceps or vacuum extractorin abnormal presentations, like breechin preterm deliveries
21 Monitoring of fetal well-being Continuous fetal heart rate and contractions monitoring (CTG) - external or directbaseline FHRFHR variabilityperiodic FHR changesdecelerations (early, late, variable)accelerationssinusoidal FHR patternFetal capillary scalp blood sampling
22 Baseline FHR between 110 and 150 bpm < bradycardia (e.g. hypoxia)> tachycardia (e.g. infection)
23 FHR variability short-term, a beat-to-beat variability normal ranges: bpm from the basis< 5 - loss of variability (silent)> 25 - exaggerated variability
24 Deceleration Decrease in FHR of at least 15 bpm lasting 15 s or longer early - begins with the beginning of contraction, reaches its lowest point just with the peak of contractionlate - occurs in the late phase of contraction, its lowest point is after contractionvariable - no association with contractions
25 Decelerationearly - due to pressure of fetal head as it moves down the birth canal, reflex mediated by the vagus nervelate - result of fetal hypoxia (uteroplacental insufficiency)variable - effect of umbilical cord compression (cord around the neck, arm or between some part of the fetus and the uterine wall)
26 Acceleration Increase in FHR of at least 15 bpm lasting 15 s or longer associated with contractions or fetal movementsindicator that fetus is adequately oxygenated
27 Anesthesia for labor Psychoprophylaxis - very important teaching about physiologybreathingstress controlhusband participationNarcotic drugs - attention: risk of respiratory depression in newbornSubarachnoidal block