ABC of labour care Yasser Orief By Lecturer of Obs.& Gyn., Alexandria University. Fellow, Lübeck University, Germany. DOGE, Auvergne University, France.

Agenda Normal Labour ? Initial Evaluation of a Woman in Labor Active management of labour Newborn care

Normal Labour ???

Normal Labour ? ? Spontaneous Single Full term Viable Vertex Natural Passages Reasonable time Without interference Without complications

Initial Evaluation of a Woman in Labor

Initial Evaluation of a Woman in Labor Performed to: Evaluate the current health status of the mother and baby, Identify risk factors which could influence the course or management of labor, and Determine the labor status of the mother.

Initial Evaluation of a Woman in Labor 1 History 2. Examination 3. Investigations

Initial Evaluation of a Woman in Labor History Personal Menstrual Obstetrical Medical Surgical Family

Initial Evaluation of a Woman in Labor Examination Vital signs Blood Pressure.. > 140/90 Pulse .. > 100 bpm Temperature .. > 38 C°

Initial Evaluation of a Woman in Labor Examination Contractions Check the frequency and duration of any uterine contractions. Manual electronic fetal monitor

Initial Evaluation of a Woman in Labor Examination Contractions

Initial Evaluation of a Woman in Labor Examination Fetal Heart Rate How? Fetal Doppler device, Electronic fetal monitor, Ultrasound Pinard stethoscope. What? Tic Tac rhythm Regular 120-160 BPM

Initial Evaluation of a Woman in Labor Examination Fetal Heart Rate Electronic fetal monitoring

Initial Evaluation of a Woman in Labor Abdominal Examination (Leopold's Maneuvers ) 1. Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse).

Initial Evaluation of a Woman in Labor Abdominal Examination (Leopold's Maneuvers ) 2. The sides of the uterus are palpated to determine the position of the fetal back and small parts.

Initial Evaluation of a Woman in Labor Abdominal Examination (Leopold's Maneuvers ) 3. The presenting part (head or butt) is palpated above the symphysis and degree of engagement determined

4. The fetal occipital prominence is determined.. Initial Evaluation of a Woman in Labor Abdominal Examination (Leopold's Maneuvers ) 4. The fetal occipital prominence is determined..

Initial Evaluation of a Woman in Labor Vaginal Examination Fetal Orientation Cervical dilatation and effacement Status of fetal membranes Assessment of maternal pelvis

Fetal Orientation Cephalic Initial Evaluation of a Woman in Labor Abdominal and Vaginal Examination Fetal Orientation Cephalic

Fetal Orientation Breech Initial Evaluation of a Woman in Labor Abdominal and Vaginal Examination Fetal Orientation Breech

Fetal Orientation Complex Transverse Initial Evaluation of a Woman in Labor Abdominal and Vaginal Examination Fetal Orientation Complex Transverse

Initial Evaluation of a Woman in Labor Vaginal Examination Cervical dilatation and effacement

Initial Evaluation of a Woman in Labor Vaginal Examination Status of Fetal Membranes Intact or ruptured

Initial Evaluation of a Woman in Labor Vaginal Examination Status of Fetal Membranes Intact or ruptured Vaginal secretions are normally slightly acid, turning Nitrazine paper yellow. Amniotic fluid, in contrast, is a weak base, and will turn the Nitrazine paper a dark blue.

Initial Evaluation of a Woman in Labor Vaginal Examination Assessment of maternal pelvis This is frequently performed prenatally, but can also be done at the initial evaluation of a patient in labor. Android Anthropoid Platypoid Gynecoid

Initial Evaluation of a Woman in Labor Investigations Urine for Protein and Glucose Proteinura (1+ or greater) can suggest the presence of pre-eclampsia. glucosuria (1+ to 2+ or greater) can suggest the presence of diabetes.

Initial Evaluation of a Woman in Labor Investigations Ultrasound Number Viability Congenital anomalies Orientation Placenta Amniotic fluid

Active management of labour

Is she actually in labour ?? progressive cervical changes, in the presence of regular, frequent, painful uterine contractions. Anything else → False labour

Stages of labour 1st stage: Labour pain → Full cx dilatation From to 1st stage: Labour pain → Full cx dilatation 2nd stage: Full cx dilatation → Fetal expulsion 3rd stage: Fetal expulsion → After birth expul. 4th stage: next 24 hours

Ist stage of labour 2 phases Latent phase Are less than 4 cm dilated. Have regular, frequent contractions that may or may not be painful. Dilate only very slowly Can usually talk or laugh during their contractions May find this phase of labor lasting hours to days or longer.

Ist stage of labour 2 phases Active phase Are at least 4 cm dilated. Have regular, frequent contractions that are usually moderately painful. Demonstrate progressive cervical dilatation of at least 1.2-1.5 cm per hour. Usually are not comfortable with talking or laughing during their contractions.

Effacement and dilatation of the cervix Ist stage of labour Progress of labour Effacement and dilatation of the cervix 

Ist stage of labour Progress of labour Descent

Ist stage of labour Progress of labour Descent

Ist stage of labour USING THE PARTOGRAPH Patient information Fetal heart rate: Record every half hour. Amniotic fluid: Record the colour of amniotic fluid at every vaginal examination Moulding: Cervical dilatation: Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 4 cm. Alert line: A line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm per hour.

USING THE PARTOGRAPH Action line: Parallel and 4 hours to the right of the alert line. Time: Record actual time. Contractions: Chart every half hour Oxytocin Drugs given: Record any additional drugs given. Pulse: Record every 30 minutes and mark with a dot (●). Blood pressure: Record every 4 hours Temperature: Record every 2 hours. Protein, acetone and volume:

Sample Prtogram

Normal Prtogram

Abnormal Prtogram

Normal Prtogram

Normal Prtogram

2nd stage of labour (Baby delivery) It begins with complete dilatation and ends when the baby is completely out of the mother. Primigravida → 1- 2 hours Multipara → 30 minutes

2nd stage of labour (Baby delivery) Delivery of the head Ask the woman to pant or give only small pushes with contractions as the baby’s head delivers. Gently support the perineum as the baby’s head delivers.  Once the baby’s head delivers, ask the woman not to push. Suction the baby’s mouth and nose. Feel around the baby’s neck for the umbilical cord

2nd stage of labour (Baby delivery) Episiotomy  should be considered only in the case of: complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum); scarring from female genital mutilation or poorly healed third or fourth degree tears; fetal distress.

2nd stage of labour (Baby delivery) Clamp and Cut the Umbilical Cord Once the baby is breathing, put two clamps on the umbilical cord, about an inch (3 cm) from the baby's abdomen. Use scissors to cut between the clamps. It is better to keep the baby level more or less with the placenta until the cord is clamped.

3rd stage of labour (Placenta delivery) Primigravida → 30 minutes Multipara → 10minutes

3rd stage of labour (Placenta delivery) Signs of placental separation A sudden gush of blood Lengthening of the visible portion of the umbilical cord. The uterus  becomes round and firm. Carefully inspect the placenta

Newborn care

Newborn care provide routine initial newborn care Check for congenital anomalies skin-to-skin contact with the mother early breastfeeding.

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