Labor and Delivery Dr.Zahra Awad Warsame

DEFINITION Labor is a physiological event. It involves a sequential, integrated set of changes within the myometrium, decidua, and uterine cervix. Occurs sometimes gradually over a period of days to weeks and sometimes rapidly over minutes to hours and culminates in delivery of the fetus

Cont….  Uterine contractions during active labor have two major functions: to dilate the cervix to push the fetus through the birth canal. interaction of three mechanical variables, known as the "three Ps": the powers, the passenger, and the passage is important for a normal successful delivery.

Powers (uterine contractions) This refers to the force generated by the uterine musculature during contractions. Uterine activity can be assessed qualitatively by simple observation of the mother and palpation of the fundus of the uterus through the abdomen or by external tocodynamometry.

Cont….. the occurrence of three to five contractions in 10 minutes has been used to define adequate labor, and is observed in about 95 percent of women in spontaneous labor at term.

Passenger (fetus) There are several fetal variables that can affect the course of labor, Fetal size Lie (the long axis of the fetus relative to the longitudinal axis of the uterus). Fetal lie can be longitudinal, transverse, or oblique Presentation (the fetal part that directly overlies the pelvic inlet). Presentation is usually vertex or breech; shoulder, compound (e.g., vertex and hand), and funic (umbilical cord) presentations are other possibilities

Cont… Attitude (degree of flexion/extension of the fetal head). The fetal head is in flexion when the chin approaches the chest and in extension when the occiput nears the back Number of fetuses Presence of fetal anomalies (eg, sacrococcygeal teratoma)

Cont…. Position (relationship of a nominated site of the presenting part to a denominating location on the maternal pelvis, eg, right occiput anterior). Station (degree of descent of the leading edge of the presenting part of the fetus, typically measured as distance in centimeters between the leading bony edge of the fetus and the ischial spines)

Cont… A small fetus in longitudinal lie, with vertex presentation, a flexed head in anterior position that has passed through the pelvic inlet is the ideal candidate for negotiating the maternal pelvis.

Passage (pelvis)  The passage consists of the bony pelvis and the soft tissues of the birth canal (cervix, pelvic floor musculature), both of which offer varying degrees of resistance to fetal expulsion. The bony pelvis is assessed by pelvimetry (i.e., quantitative measurement of pelvic capacity), which can be performed clinically or via imaging studies

Symptoms and signs of the onset of labor Painful uterine contraction a show effacement and dilation of the cervix rupture of membranes

STAGES   Although labor is a continuous process, it has traditionally been divided into three stages to facilitate study and to assist in clinical management.

First stage This refers to the interval between the onset of labor and full cervical dilatation. It has been subdivided into three phases according to the rate of cervical dilatation. Latent phase — The period between the onset of labor and the point at which a change in the slope of the rate of cervical dilatation is noted. It is characterized by slow cervical dilatation, and is of variable duration.

Cont…. Active phase — This phase is associated with a faster rate of cervical dilatation and usually begins by 2 to 4 cm of cervical dilatation.

Contractions onset, frequency, duration, intensity increase in frequency and duration uterus can be felt to harden during contraction lasting about 30-45 seconds interval between contractions to be 5 min’ Intensity (slight, middle, heavy) the pain of labor is a character

CARDINAL MOVEMENTS OF LABOR Seven discrete cardinal movements of the fetus occur over the course of labor and delivery: engagement, descent, flexion, internal rotation, extension, external rotation or restitution, expulsion.

Engagement  This refers to the passage of the widest diameter of the presenting part to a level below the plane of the pelvic inlet. In the cephalic presentation with a well-flexed head, the largest transverse diameter of the fetal head is the biparietal diameter (9.5 cm) In the breech presentation, the widest diameter is the bitrochanteric diameter.

Descent  this refers to the downward passage of the presenting part through the pelvis.

Flexion  Flexion of the fetal head occurs passively as the head descends due to resistance related to the shape of the bony pelvis and by the soft tissues of the pelvic floor. complete flexion usually only occurs during the course of labor. With the head completely flexed, the fetus presents the smallest diameter of its head (suboccipito-bregmatic diameter thereby allowing optimal passage through the pelvis.

Internal rotation this is the rotation of the presenting part from its original position (usually transverse with regard to the birth canal) to the antero posterior position as it passes through the pelvis.

Extension  this occurs once the fetus has descended to the level of the introitus. This descent brings the base of the occiput into contact with the inferior margin of the symphysis pubis. At this point, the birth canal curves upwards. The fetal head is delivered by extension and rotates around the symphysis pubis.

External rotation (restitution) After the fetal head deflexes (extends), it rotates to the correct anatomic position in relation to the fetal torso; left or right rotation depends on the orientation of the fetus.

Expulsion this refers to delivery of the body of the fetus. After delivery of the head and external rotation, further descent brings the anterior shoulder to the level of the symphysis pubis. The anterior shoulder rotates under the symphysis pubis, after which the rest of the body usually delivers without difficulty.

Management of normal labor The first stage: education, eating, walking, position(sitting, reclining, recumbent) monitoring of the fetal heart rate , Palpation of cervix ( effacement ,dilation) uterus contractions (palpation or electronic monitoring) Analgesia and anesthesia

Delivery Commences at second stage From full dilatation to delivery of baby and placenta. Baby moves through the pelvis as contractions become more stronger Takes different positions as it negotiates the bony pelvis *check fetal heart every 5minutes in 2nd stage 4/14/2017

Signs of 2nd stage Increase in bloody show Maternal desire to bear down with each contraction Feeling of pressure on rectum and desire to defecate Onset of nausea and vomiting 4/14/2017

The cervix is totally taken up into the uterus so that the uterus and birth canal are continuous. Dilatation and effacement are complete. Contractions are 45-90 seconds long, 2 to 5 minutes apart . Each contraction pushes the baby further down the birth canal The baby is pushed underneath the pubic bone at which point the head crown.

Crowning of the head Extension At this point, you can also suction the nose for secretions

Advise patient to stop pushing and check for the umbilical cord. Contractions may slow down and change character. An urge to push is felt, pressure to the rectum and pelvic floor, stretching of the perineum which causes a stinging sensation as the baby's head emerges With the onset of a contraction, there’s a tendency to take several, rapid, deep breaths. Most women can get three or four pushes into a single contraction

Delivery cont…. During the delivery, the fetal head emerges through the vaginal opening, usually facing toward the woman's rectum. As the fetal head delivers, support the perineum to reduce the risk of perineal laceration from uncontrolled, rapid delivery. Allow time for the fetal shoulders to rotate. This allows the birth canal to squeeze the fetal chest, forcing amniotic fluid out of the baby's nose and mouth.

Delivery of the head

After a reasonable pause (15-30 seconds), have the woman bear down again, delivering the shoulders and torso of the baby

Delivery positions Semi-recumbent position, preferred for most women. with both knees drawn to the chest Supine position push…. more effectively if her knees are pulled back towards her shoulders. Standing position…. Lessens chances of perineal tears Sitting or squatting position. The Sims position…deliver on one side, with one knee drawn up and the other leg straightened

Standing position

Duration of the second stage…usually an hour or two for a PG. For a mother having a subsequent baby, the second stage is usually shorter, less than an hour.

Cutting the cord Clamp and Cut the Umbilical Cord. Can delay cord clamping as you dry the baby and suction. Put two clamps on the umbilical cord, about an inch (3 cm) from the baby's abdomen. Use scissors to cut between the clamps

Clamping the cord Cutting the cord, btn the clamps

During the transition from intrauterine to extra uterine life, the umbilical cord will continue, for a short time, to provide oxygenated blood to the fetus. Once the baby is breathing, then blood is shunted to its lungs where it receives much better oxygenated blood than it was getting from the placenta. While the cord remains intact, elevation of the fetus above the level of the placenta (eg resting on the mother's abdomen) results in some pooling of newborn blood within the placenta and can make the baby somewhat anemic.

Holding the baby below the level of the placenta results in pooling of placental blood within the newborn, because the rapid hemolysis of the fetal hemoglobin can worsen neonatal jaundice. It is better to keep the baby more or less level with the placenta until the cord is clamped. If the baby is not breathing well after delivery and needs resuscitation, immediately clamp and cut the cord so you can move the baby to the resuscitation area.

3rd stage Time between delivery of the baby to total expulsion of the placenta. Can last a few minutes to an hour. Completely expelled placenta being examined 4/14/2017

Signs of placental separation A sudden gush of blood Lengthening of the visible portion of the umbilical cord. The uterus, which is usually soft and flat immediately after delivery,  becomes round and firm.

Two Methods of Third Stage Management 4/14/2017 Two Methods of Third Stage Management Active Management of ThirdStage of Labor Physiologic (“expectant”) management Oxytocics are not used Placenta is delivered by gravity and maternal effort Cord is clamped after delivery of the placenta Active Management Oxytocic is given Cord is clamped Placenta delivered by controlled cord traction (CCT) with counter-traction on the fundus Fundal massage

Physiologic Management: Advantages and Disadvantages 4/14/2017 Physiologic Management: Advantages and Disadvantages Active Management of Third Stage of Labor Advantages Does not interfere with normal labor process Does not require special drugs/supplies Disadvantages Increases length of third stage Increases risk of postpartum hemorrhage (PPH)

Active Management: Advantages and Disadvantages 4/14/2017 Active Management: Advantages and Disadvantages Active Management of Third Stage of Labor Advantages Decreases length of third stage Decreases risk of PPH Disadvantages Requires oxytocics and items needed for injection Requires a birth attendant with skills in: Observation Giving an injection CCT Active management reduces the duration of the third stage and reduces postpartum hemorrhage.

Procedure for Active Management 4/14/2017 Procedure for Active Management Active Management of Third Stage of Labor Oxytocin Within 1 minute of birth, palpate abdomen to rule out presence of another baby Give oxytocin CCT Await strong uterine contraction (2–3 minutes) Apply controlled cord traction while applying countertraction above pubic bone If placenta does not descend, stop traction and await next contraction WHO recommends giving oxytocin within 2 minutes to give provider time to give injection Continuous gentle traction Uterine massage every 15 minutes for 2 hours

Oxytocic Drugs: Syntometrine 4/14/2017 Oxytocic Drugs: Syntometrine Active Management of Third Stage of Labor Advantages Combined effect of rapid action of oxytocin and sustained action of ergometrine Disadvantages Increased risk of hypertension, nausea and vomiting Not heat stable

Active Management of Third Stage of Labor 4/14/2017 Summary Active Management of Third Stage of Labor Active management of third stage includes: Oxytocin Controlled cord traction Fundal massage Ensuring supply of oxytocin is a priority Reduces risk of PPH Retained placenta Need for therapeutic oxytocics

Asante saana