1. Normal Labour
By:
Dr. Radwa M. Yehia

2. Objectives?

3. Objectives At the end of this lecture the student will be able to:
Describe the role of P.T. for alleviating labour pain by the use of different physical therapy modalities.
Use efficiently and safely the relevant training equipments during labour.
Considering effectively clinical diagnosis and investigations during labour.

4. Obstetrics concerns itself with pregnancy, labour, delivary &the care of the mother after child birth Gynaecology is the study of disease associated with women which in effect means condition involving the female genital tract.

5. Normal anatomy of female pelvis

6. What is normal labour from your point of view?

7. What happen in normal labour?

8. Normal Labour
Spontaneous expulsion, through the natural passages (birth canal) of a single, mature (37-42 completed weeks of pregnancy) alive fetus, presenting by vertex, within a reasonable time, without fetal or maternal complications.

9. Post-mature pregnancy
Duration of pregnancy is 42 weeks or more.
Prolonged Labour
Duration of labour lasting more than 24 h.
Causes:
Uterine inertia (commonest).
Occipito-posterior presentation.
Rigid perineum (elderly).
Full bladder & rectum.

10. Precipitate Labour
Duration of labour lasting less than 3 h. It is common in multiparas.
Causes:
Strong uterine contraction.
No obstruction in the birth canal.
Lack of soft tissues resistance.

11. Cause of Onset of labour:
Mechanical theories:
Hormonal theories:
1) Maternal :
Oestrogen theory
Progesterone withdrawal theory
Prostaglandins theory
Oxytocin theory
2) Foetal:Foetal cortisol

12. Signs of onset of labour:
1. Show:
Discharge of mucoid blood (mucous plug) due to effacement of the cervix.
2. Uterine contractions (True labour pains):
Contraction followed by retraction (partial sustained cont.).
3. Ruptured membranes:
Rupture of the amniotic sac resulting in a sudden or gradual loss of amniotic fluid.
Functions of Liquor amnii:

13. Characteristics of true & false labour pains:
True Labour Pains
False Labour Pains
Regular, increase gradually in ammplitude, frequency & duration.
Irregular in ammplitude, frequency & duration.
Hardening of the uterus.
No hardening of the uterus.
Progressive dilatation and
effacement of the cervix.
No effect on the cervix.
Membranes are bulging during
contractions.
No bulging of the membranes.
Discomfort in back & abdomen.
Discomfort in lower abdomen.
Accompanied by progressive
diltation of the cervix.
No progressive diltation of the cervix.
Not affected by sedatives.
Affected by sedatives.
Enhanced by enema.
Not enhanced by enema.

14. Rupture of membranes:
Associated by gush of amniotic fluid (liquor amnii).
It is the last sign occur but in some cases pre-mature rupture occur.
In this case, ask the woman to lie down to prevent cord prolapse.
Liquor amnii is alkaline fluid about 1 L.

15. Forces of labour
Uterine force: primary
Auxiliary forces: secondary

16. Stages of labour

18. 1st stage (cervical dilatation)
Start at onset of labour & ends at full cervical dilatation.
In primigravida …… 8-12 h.
In multigravida …… 6-8 h.

20. Factors detrmining duration of 1st stage :
(A) Parity
(B) Frequency, intensity & duration of contractions.
(C) Ability of cervix to dilate.
(D) Fetal presentation & position.

21. 2nd stage (foetal expulsion)

23. Duration of 2nd stage
From full cervical dilatation to fetal expulsion.
Its duration is about 1 hour in primigravida and ½ hour in multipara

24. Factors detrmining duration of 2nd stage:
(A) Parity (resistance of soft tissue).
(B) Frequency, intensity & duration of contractions.
(C) Fetal presentation & position.
(D) Feto-pelvic relationship
(E) Efficacy of maternal voluntary expulsive force.

25. 3rd stage:
It is the stage of expulsion of the placenta and membranes.
Begins after delivery of the foetus and ends with expulsion of the placenta and membranes.
Its duration is about minutes in both primi and multipara.
4thr stage ( 1st h. after delivery).
During which careful observation for the patient, particularly for signs of postpartum haemorrhage is essential. Routine uterine massage is usually done every 15 minutes during this period.

27. Management of 1st stage
Encourage mother to breathe deeply and prevent straining.
Walking around is useful.
Control pain by using electrical modalities like TENS (Fig. 2).

28. 5) Modified side lying as a comfortable position.
4) Firm kneading and effleurage massage on back and abdomen should be applied.
5) Modified side lying as a comfortable position.
6) Empty rectum with enema.
7) Empty bladder each 2 hours.

29. 8) Check matrnal BP, (PR) & temperature every 2-4 hours, then hourly as labour advances.
9) Check foetal heart rate (FHR), normal FHR values ( beat/min) above 160 beat/min or below 100 beat/min is an early sign of foetal distress.

31. Management of 2nd stage Put the pregnant woman in lithotomy position.
Ask her to take Deep breaths bear down during contractions to increase the power of expulsion of the foetus and relax in between them.

32. 3) Sternal breathing should be applied at crowning to prevent perennial laceration.
4) At crowning the mother will asked to stop bearing down and pant in and out softly and easily with opened mouth.
5) Control pain by using electrical modalities like TENS.

33. Management of 3rd stage
Management, which may be passive or active, consists of ensuring the complete separation and safe delivery of the placenta, and monitoring and controlling haemorrhage where necessary.

34. Electrical modalities during labour (TENS)
Mechanism of Action:
The type of stimulation delivered by the TENS unit aims to excite (stimulate) the sensory nerves, and by so doing, activate specific natural pain relief mechanisms.
Pain Gate Mechanism
Endogenous Opiods System

35. Parameters of TENS 1) Frequency rate:
-During cont. use high TENS, freq. : HZ.
In between cont. use burst TENS, freq. : 2 HZ.
2) Pulse width:150 µs.
3) Intensity: determined by the woman & can be increased with increased pain or accomodation.

36. Electrode placement in 1st stage
- Proximal pair electrodes: upper 1/3 (T10-L1)
- Distal pair electrodes: lower 1/3 (S2-S4)

37. TENS for 2nd stage Proximal pair electrodes: T10-L1
- Distal pair electrodes: lower abdomen in “V” shape

38. Management of 3rd stage Avoid fundus pressure to prevent pelvic floor dysfunction later on.

39. Common postpartum physical problems
Symphysis pubis pain.
Backache/neckache.
Haemorrhoids.
After pains.
Breast engorgement, mastitis, block ducts & cracked nipples.
Scanty of milk production.
Oedema in feet.
Perineal pain.

40. Episiotomy
What is episiotomy?

41. Electrical modalities during postnatal period
a) Acute perineal trauma:
Pelvic floor muscle exercises: pumping action------venous and lymphatic drainage and the removal of traumatic exudate, relieving stiffness, restoring function &stimulate the production of opiates .
Functional Activity----pressure-relieving cushions.
Ice------technique + effects
I.R------technique + effects
U.S------technique + effects
Pulsed electromagnetic energy (PEME) or short wave diathermy (SWD) technique + effects
Low level laser therapy

42. b) Chronic perineal healing:
Stretching: of the perineal body.
U.S: Using continuous mode (5 minutes).

43. Post partum ex. program 1st day. Breathing ex. Circulatory ex.
Relaxation on face.
Static abd. cont.
2nd day.
Leg ex.
Pelvic floor ex.
Arm ex.

44. 3rd day.
Pelvic rocking ex.
4th day.
Hip shrugging.
Pelvic rotation.
Posture correction.
5th day.
First step of trunk flexion.
6th day.
First step of trunk rotation.

45. 7th day.
Other steps of trunk flexion.
Other steps of trunk rotation.
8th day – 40th day.
Repeate each previous ex. in form of sets (each up to 20 times).

46. Episiotomy Definition: Timing:
known as perineotomy, is the surgical enlargement of the vaginal orifice by an incision of the perineum (the area between the vagina and anus) during the last part of the second stage of labour or delivery.
Timing:

47. Indications of episiotomy
Absolute indications:
Previous perineal reconstructive surgery.
Previous pelvic floor surgery.
Relative indications:
Cervical dystocia.
Rigid perineum.
Foetal distress.
An instrumental or breech delivery.

48. 1) Medianor vertical incision.
Types
1) Medianor vertical incision.
2) Lateral.
3) Mdedio-lateral (J-shape).
Advantages(Median)
Disadvantages (Median)
Minimal bleeding.
Easier to repair.
Heals well and quicker compared with the medi- olateral episiotomy.
There is less pain in the postpartum period.
The incidence of dyspareunia is less.
It is associated with more 3rd and 4thdegree tears because of the straight easy extension into the anus.