SlideShare uma empresa Scribd logo
1 de 91
Baixar para ler offline
NORMAL LABOUR
AND
DELIVERY
Dr Jograjiya PG Student
Department of Obstetrics and Gynecology, ESIC-PGIMSR, Basaidarapur, New Delhi
CONTENTS
1. Definition of normal labour
2. Factors influencing progress of labour
3. Diagnosis of labour
4. Stages of labour
5. Mechanisms of labour
6. Management of labour
LABOUR
Labour is defined as the onset of regular painful
Contractions with progressive cervical effacement and
dilatation of the cervix accompanied by
descent of the presenting part.
DEFINITIONS
NORMAL LABOUR
 Spontaneous expulsion,
 of a single,
 mature fetus (37 completed weeks – 42 weeks),
 presented by vertex,
 through the birth canal (i.e. vaginal delivery),
 within a reasonable time (not less than 3 hours or more than
18 hours),
 without complications to the mother,
 or the fetus.
The following criteria should be present
NORMAL LABOUR
Understanding the process of
labour is importance
• problems can be identified
• correctly managed
IMPORTANCE
LABOUR AND DELIVERY
FACTORS THAT INFLUENCE
PROGRESS OF LABOUR
Passenger Passage
Power
THE NORMAL FEMALE PELVIS
1. The female pelvis provides the basic
framework of the birth canal.
2. The obstetric pelvis is divided into false and
true pelvis by the pelvic brim or inlet
3. The true pelvis is important, for it is
through this confined space that the fetus
must pass on its journey through the birth
canal.
4. The true pelvis is composed of inlet, cavity
and outlet.
5. Types of female pelvis – gynaecoid,
anthropoid, android and platypelloid
Outlet
Cavity
Inlet
NORMAL FEMALE PELVIS
1. The brim is slightly oval transversely.
2. The sacral promontory is not prominent.
3. The transverse diameter is slightly longer than
the anteroposterior.
4. The sidewalls are parallel and straight.
5. The ischial spines are not prominent.
6. The sacrosciatic notches are wide.
7. The sacrum has a good curve.
8. The pubic arch angle are wide, i.e. more than 90
9. Inter tuberous diameter is wide
The ideal normal female gynaecoid pelvis:
THE NORMAL FEMALE PELVIS
The important diameters of the female pelvis:
Anteroposterior Oblique Transverse
BRIM 11 12 13
CAVITY 12 12 12
OUTLET 13 12 11
Diameters
(cm)
THE FETAL SKULL
1. Sutures
2. Diameters
THE FETAL SKULL
1. Sagittal suture: - The sagittal suture lies
between the parietal bones. It runs in an
anteroposterior direction between the anterior
and posterior fontanelles.
2. Coronal sutures: - The suture uniting the
parietal bones to the frontal bones is called the
coronal suture. It’s extend transversely from the
anterior fontanels and lies between the parietal
and frontal bone.
3. Frontal suture: - The frontal suture is between
the two frontal bones. It is an anterior
continuation of the sagittal suture.
4. Lambdoidal suture: - Is between the parietal
and occiptal bones.
SUTURES
THE FETAL SKULL
MOULDING OF THE FETAL SKULL
MOULDING is the ability of the
fetal head to change its shape and
so to adapt itself to the unyielding
maternal pelvis during the
progress of labour.
This property is of the greatest
value in the progress of labour.
THE FETAL SKULL
Diameters of the fetal skull – anterior posterior diameters
A
B
C
D
E
F
G AB ~ Suboccipto bregmatic – 9.5
-Vertex
AC ~ Submento bregmatic – 9.5
-Face
DE ~ Occipito frontal ~ 11-12
FG ~ Mento vertical – 13.5
-Brow
POWER ► Contractions + Maternal
pushing
Uterine contractions:
1. Initiate by pacemakers ~ uterotubal junction
2. Contraction waves meet at the fundus
3. Contraction waves progress downward
 Shortening of muscle fibres
 Retractions
 intra uterine pressure
EXPULSION OF THE FETUS
Additional force
“maternal pushing”
Intra abdominal pressure
UTERINE CONTRACTION
NORMAL CONTRACTION
1. Frequency ~ one in every 2 – 3 min with at least 1
minute interval
2. Intensity ~ strong (> 50 mmHg)
3. Duration ~ 45 – 60 sec
Uterine contractions
LABOUR AND DELIVERY
WHAT INITIATE LABOUR
“ONSET OF LABOUR”
NORMAL LABOUR
 Hormonal factors
1) Estrogen theory
2) Progesterone withdrawal theory
3) Prostaglandins theory
4) Oxytocin theory
5) Fetal cortisol theory
 Mechanical factors
1) Uterine distension theory
2) Stretch of the lower uterine segment by the presenting near term
Causes of Onset of Labour:
- It is unknown but the following theories were postulated:
Normal labour and delivery
Normal labour and delivery
Normal labour and delivery
LABOUR AND DELIVERY
DIAGNOSIS OF LABOUR
NORMAL LABOUR AND DELIVERY
 Painful regular uterine contractions
– as evidence by contraction at least
one in ten minutes
 Show – as evidence by mucus mixed
with blood
 Rupture of membranes – as
evidence by leaking liquor
SYMPTOMS AND SIGNS OF LA
Before labour begins, women usually notice one or more premonitory, or
warnings, signs that labour is about to begin.
They are:
LABOUR AND DELIVERY
DESCRIBE THE STAGES OF
LABOUR
NORMAL LABOUR AND DELIVERY
STAGES OF LABOUR
FIRST STAGE SECOND
STAGE
THIRD STAGE
It begins with the onset of true
labour contractions and ends
when the cervix is fully dilated
(10 cm).
Cervical effacement and
dilatation occur in the first stage
First stage of labour consists of
two phases:- latent and active.
The first stage of labour is the
longest for both nulliparous and
parous women.
The second stage of labour
begins with complete dilatation
of the cervix and ends with the
birth of the baby.
The duration is about 1 to 1½
hours in nulliparas and about 30
to 45 minutes in parous women.
The third stage is that of
separation and expulsion of
placenta and membranes and also
involves the control of bleeding.
It begins after the birth of the
baby and ends with the expulsion
of the placenta and membranes.
This is the shortest stage, lasting
up to 30 minutes, with an average
length of 5 to 10 minutes. There
is no difference in duration for
nulliparous and parous.
Labour can be divided into three stages, which are unequal in length.
FIRST STAGE OF
LABOUR
NORMAL LABOUR AND DELIVERY
PHASES OF THE FIRST STAGE OF LABOU
Divided into:
Latent phase – begins with onset of contracts and ends when cervix is 3 cm dilated and effaced
Active phase – begins after the cervix is 3 cm dilated
NORMAL LABOUR AND DELIVERY
PHASES OF THE FIRST STAGE OF LABOU
LATENT Phase ACTIVE Phase
1. Begins with onset of contractions
2. Slow progress
3. Little cervical dilatation
4. Progressive cervical effacement
5. Ends once the cervix reaches 3
cm dilatation
6. Durations
~ 8 hours for nulliparae
~ 6 hours for multiparae
1. Active process
2. Begins after 3 cm of cervical
dilatation
3. Period of active cervical
dilatation (average rate 1 cm/hr)
4. S-shaped curve which is used to
define progress of labour
5. It has 3 component
a) acceleration - slow
b) maximum - fast
c) deceleration - slow
NORMAL LABOUR AND DELIVERY
WHAT HAPPEN DURING
THE FIRST STAGE OF LABOUR
NORMAL LABOUR AND DELIVERY
WHAT HAPPEN DURING THE FIRST STAG
1. Contractions:
CONTRACTIONS
1: Regular
2: Increasing in frequency
3: Stronger
NORMAL LABOUR AND DELIVERY
WHAT HAPPEN DURING THE FIRST STAG
2. Cervical dilatation and effacement:
Causes of cervical dilatation:
Contraction and retraction of uterine musculature
Mechanical pressure by the bulging membrane (fore
water)
The descend of the presenting part
Phases of cervical dilatation
Latent phase – the first 3 cm of dilatation; a slow
process (8 hours in nulliparous and 3 hours
in multiparous
Active phase – this is active process of cervical
dilatation; the normal rate is 1 cm/hour
NORMAL LABOUR AND DELIVERY
WHAT HAPPEN DURING THE FIRST STAG
3. Engagement of the presenting part:
NORMAL LABOUR AND DELIVERY
Do Uterine Contractions Affect Fetal Heart Rate?
Uterine contractions can affect fetal heart rate by increasing or
decreasing that rate in association with any given contraction.
The three primary mechanisms by which uterine contractions can
cause a decrease in fetal heart rate are compression of:
· Fetal head
· Umbilical cord
· Uterine myometrial vessels
FETAL HEART CHANGES
NORMAL LABOUR AND DELIVERY
PROGRESS OF FIRST STAGE OF LABOUR
Findings suggestive of satisfactory progress in first stage of labour are:
- regular contractions of progressively increasing frequency and duration;
- rate of cervical dilatation at least 1 cm per hour during the active phase of
labour (cervical dilatation on or to the left of alert line);
Findings suggestive of unsatisfactory progress in first stage of labour
are:
- irregular and infrequent contractions after the latent phase;
- OR rate of cervical dilatation slower than 1 cm per hour during the active
phase of labour (cervical dilatation to the right of alert line);
SECOND STAGE OF
LABOUR
NORMAL LABOUR AND DELIVERY
SECOND STAGE OF LABOUR
1. Begins with FULL DILATATION and ends with DELIVERY OF
THE BABY.
2. It have TWO Phases
a) Propulsive phase – from full dilatation until presenting part has
descended
to the pelvic floor
b) Expulsive phase which ends with the delivery of the baby
Features of expulsive phase – 1) mother’s irresistible desire to bear
down
2) distension of perineum
3) dilatation of the anus
3. Average length
a) Primigravidae – 40 minutes
b) Multigravidae – 20 minutes
NORMAL LABOUR AND DELIVERY
PROGRESS OF SECOND STAGE OF LABOUR
Findings suggestive of satisfactory progress in second stage
of labour are:
- steady descent of fetus through birth canal;
- onset of expulsive (pushing) phase.
Findings suggestive of unsatisfactory progress in second
stage of labour are:
- lack of descent of fetus through birth canal;
- failure of expulsion during the late (expulsive) phase.
THIRD STAGE OF
LABOUR
NORMAL LABOUR AND DELIVERY
THIRD STAGE OF LABOUR
1. Begins after DELIVERY of the baby and ends with DELIVERY
OF THE PLACENTA / MEMBRANES.
2. It have TWO Phases
a) Separation phase
b) Expulsion phase
3. Duration – usually 15 minutes or less (if actively managed).
4. Average blood loss – 150 to 250 ml.
NORMAL LABOUR AND DELIVERY
PHYSIOLOGICAL EFFECTS OF LABOU
FIRST STAGE SECOND STAGE THIRD STAGE
ON THE MOTHER
1. Minimal effects 1. Pulse increases
2. Systolic BP
slightly
increased due
to pain and
anxiety
3. Minor injuries
to the birth
canal
1. Blood loss from
the placental site
(200 ml)
2. Blood loss from
laceration and
perineum (100
ml)
ON THE FETUS
1. Moulding – overlapping of the vault bones
2. Caput succedaneum – it is a soft swelling of the most dependent
part of the
fetal head
MANAGEMENT
OF
LABOUR
AIMS IN THE MANAGEMENT OF LABOUR
To achieve delivery of a normal healthy
child
To anticipate, recognize and treat
potential abnormal conditions before
significant hazard develops for the mother
or the fetus.
PRINCIPLES IN THE MANAGEMENT OF LABOUR
Diagnosis of labour
Monitoring the progress of labour
Ensuring maternal well-being
Ensuring fetal well-being.
NORMAL LABOUR AND DELIVERY
MANAGEMENT
FIRST STAGE OF
LABOUR
MANAGEMENT OF THE FIRST STAGE OF LABOUR1
 On admission:
When the women presents at hospital, the woman’s antenatal record is
reviewed to discover whether there have been any abnormalities
during her pregnancy. When there are no records of antenatal care a
complete history must be taken.
 General examination of the mother
a) General conditions – evaluate the mother general health condition.
Look for pallor, edema, abdominal scar (LSCS) and maternal height.
b) Vital signs – Blood pressure, pulse, respiration and temperature are
taken and recorded
c) Heart and lungs
d) Urine analysis – for protein, sugar and ketones
MANAGEMENT OF THE FIRST STAGE OF LABOUR2
 Abdominal examination:
a) A detailed abdominal examination should be carried out and recorded.
b) Determine the presentation and position of the fetus and also the
engagement
c) Auscultate the fetal heart
d) Evaluate the uterine contraction
Vaginal examination – the purpose is to
a) To make a positive diagnosis of labour
b) To make a positive identification of presentation
c) To determine whether the fetal head is engaged in case of doubt
d) To ascertain whether the fore waters have ruptured or to rupture them
artificially
e) To exclude cord prolapse after rupture of the fore waters
f) To confirm the degree of cervical dilatation and position of the presenting
part
g) To assess progress of labour.
h) To assess the adequacy of the pelvis.
MANAGEMENT OF THE FIRST STAGE OF LABOUR3
 Bowel preparation:
If there has been no bowel action for 24 hours or the rectum feels loaded on vaginal
examination an enema is given.
 Bladder care
A full bladder may initially prevent the fetal head from entering the pelvic brim and
later impede descent of the fetal head. It will also inhibit effective uterine action.
The woman should be encouraged to empty her bladder every 1½ - 2 hours during
labour.
The quantity of urine passed should be measured and recorded and a specimen
obtained for testing.
 Nutrition in early labour
No food is permitted after labour is established – to prevent regurgitation and
aspiration
It is important to maintain adequate hydration - via intravenous routes
MANAGEMENT OF THE FIRST STAGE OF LABOUR4
 Position of labouring mother:
As long as the patient is healthy, the presentation normal, the presenting part
engaged, and the fetus in good condition, the patient may walk about or may be in
bed, as she wishes
 Monitoring the progress of labour
Once labour has become established, all events during labour should be recorded on
a partogram.
a) The well-being of the fetus
b) The well-being of the mother
c) The progress of the labour
 Pain relief
When the pains are severe an analgesic preparation may be given.
a) Opiate drugs – e.g. Pethidine given intramuscularly every 4 hour
b) Inhalational analgesia – e.g. Entonox
c) Epidural analagesia
NORMAL LABOUR AND DELIVERY
 Pain in labour
The pain experienced by the woman in labour is caused by the:
1): Uterine contractions and uterine ischaemia.
2): Cervical dilatation. Dilatation and stretching of the cervix and
lower uterine segment stimulate nerve ganglia and are a major
source of pain.
3): Distention of the vagina and perineum. Marked distention of the
vagina and perineum occurs with fetal descent, especially during the
second stage.
LABOUR PAIN – causes1
NORMAL LABOUR AND DELIVERY
 Pain in labour
LABOUR PAIN – causes2
Table 1: PAIN DURING THE STAGES OF LABOUR
STAGES OF LABOUR SORCES OF PAIN
FIRST STAGE
Pain is caused mainly by uterine contractions, thinning of the lower
segment of the uterus, and dilatation of the cervix.
SECOND STAGE
Pain result from two sources:
1.The stretching of the vagina, vulva and perineum.
2.The contraction of the myometrium.
THIRD STAGE
Pain is caused by the passage of the placenta through the cervix, plus that
produced by the uterine contractions.
NORMAL LABOUR AND DELIVERY
PAIN RELIEF IN LABOUR – types
Three methods are in common use during labour:
1. Analgesic drugs (narcotics, e.g. pethidine)
which are given by intramuscularly injection.
2. Inhalation analgesia (e.g. Entonox).
3. Regional anaesthesia (e.g. epidural, spinal)
that blocks the sensory pain pathways.
NORMAL LABOUR AND DELIVERY
MONITORING FETAL HEART
How Do Uterine Contractions Affect Fetal Heart Rate?
Uterine contractions can affect fetal heart rate by increasing or decreasing
that rate in association with any given contraction.
The three primary mechanisms by which uterine contractions can cause
a decrease in fetal heart rate are compression of:
· Fetal head
· Umbilical cord
· Uterine myometrial vessels
NORMAL LABOUR AND DELIVERY
MONITORING FETAL HEART
How To Monitor The Fetal Heart Rate?
 Auscultation methods
 Electronic monitoring ~ CTG
NORMAL LABOUR AND DELIVERY
MONITORING FETAL HEART
To detect fetal hypoxia
NORMAL
ABNORMAL
RECORDING THE
PROGRESS OF LABOUR
NORMAL LABOUR AND DELIVERY
RECORDING THE PROGRESS OF LABOUR
PATIENT INFORMATION
FETAL INFORMATION
~ fetal well being
LABOUR INFORMATION
~ Dilatation
~ Descent
~ Contraction
MEDICATIONS
MATERNAL INFORMATION
~ Well being
NORMAL LABOUR AND DELIVERY
RECORDING THE PROGRESS OF LABOUR - Partogram
Patient information: Fill out name,
gravida, para, hospital number, date and
time of admission and time of ruptured
membranes.
Fetal heart rate: Record every half hour.
Amniotic fluid: Record the colour of
amniotic fluid at every vaginal
examination:
I: membranes intact;
C: membranes ruptured, clear fluid;
M: meconium-stained fluid;
B: blood-stained fluid.
Moulding:
1: sutures apposed;
2: sutures overlapped but reducible;
3: sutures overlapped and not reducible.
NORMAL LABOUR AND DELIVERY
RECORDING THE PROGRESS OF LABOUR - Partogram
Cervical dilatation: Assessed at every
vaginal examination and marked with a
cross (X). Begin plotting on the partograph
at 3 cm.
Station : recorded as a circle (O) at every
vaginal examination.
Contractions: Chart every half hour;
palpate the number of contractions in 10
minutes and their duration in seconds.
Less than 20 seconds:
Between 20 and 40 seconds:
More than 40 seconds:
Assess the progress of labour:
NORMAL LABOUR AND DELIVERY
RECORDING THE PROGRESS OF LABOUR - Partogram
Oxytocin: Record the amount of oxytocin
every 30 minutes when used.
Drugs given: Record any additional
drugs given – e.g. Pethidine
Pulse: Record every 30 minutes and
mark with a dot (●).
Blood pressure: Record every 4 hours
and mark with arrows ( )
Temperature: Record every 2 hours.
Protein, acetone and volume: Record
every time urine is passed.
Progress of maternal well being:
NORMAL LABOUR AND DELIVERY
MANAGEMENT
SECOND STAGE O
LABOUR
MANAGEMENT OF THE SECOND STAGE OF LABOUR1
 Maternal position:
With the exception of avoiding supine position, the mother
may assume any comfortable position for effective bearing
down.
The semi-recumbent or supported sitting position, with the
thighs abducted, is the posture most commonly adopted
 Bearing down
With each contraction, the mother should be encouraged to
bear down with expulsive efforts
Once the onset of the second stage has been confirmed
a woman should not be left without attendance.
Accurate observation of progress is vital, for the
unexpected can always happen.
MANAGEMENT OF THE SECOND STAGE OF LABOUR2
 Observation during the second stage:
Four factors determine whether the second stage may be safely continued and
these must be carefully monitored throughout the second stage of labour.
1. Maternal conditions
Observation includes an appraisal of the mother’s ability to cope emotionally as
well as an assessment of her physical wellbeing. A maternal pulse rate is usually
recorded quarter-hourly and bloods pressure hourly
2. Fetal conditions - During the second stage, the fetal heart should be monitored
either continuously or after each contraction. stage may be associated with fetal
distress.
The liquor amnii is observed for signs of meconium staining.
3. Uterine contractions - The strength, length and frequency of contractions should
be assessed continuously.
4. The progress of descent - The progress should be recorded approximately every
30 minutes during the second stage.
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
 CONDUCTING THE DELIVERY1:
When delivery is imminent, the patient is usually placed in the dorsal
position, and the skin over the lower abdomen, vulva, anus and upper
thigh is cleansed with antiseptic solution and draped.
DELIVERY OF THE HEAD
1) Control the delivery of the head to prevent laceration
2) Performed episiotomy if requires
3) Performed Ritgen’s method
4) Cleared the airway after delivery of the had
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
 PERFORMING AN EPISIOTOMY:
"..is a surgical incision into the perineum to enlarge the space at the
outlet
EPISIOTOMY
IS EPSIOTOMY REALLY NEEDED?
Episiotomies are said to provide the following benefits:
1. Speed up the birth
2. Prevent Tearing
3. Protects against incontinence
4. Protects against pelvic floor relaxation
5. Heals easier than tears
medical research has not proven
any of these benefits
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
 PERFORMING AN EPISIOTOMY:
Episiotomies are not always necessary
Episiotomy should be considered only in the case of:
• Complicated vaginal delivery (breech, shoulder
dystocia, forceps,
vacuum);
• Scarring of the perineum;
• Fetal distress.
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
 PERFORMING AN EPISIOTOMY:
Episiotomy Types
Midline episiotomy Mediolateral episiotomy J-shaped episiotomy
Incision of episiotomy
The three major types of
episiotomy
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
 PERFORMING AN EPISIOTOMY:
Infiltrate perineum with
local anaesthetic agent
Making an incision
Wait until:
1) the perineum is thinned
out;
and
2) 3–4 cm of the baby’s head
is visible during a
contraction.
Performing an episiotomy will
cause bleeding. It should not,
therefore, be done too early.
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
 CONDUCTING THE DELIVERY2:
DELIVERY OF THE SHOULDERS
Delivery of the anterior shoulder is aided by
gentle downward traction on the head.
The posterior shoulder is delivered by
elevating the head.
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
 CONDUCTING THE DELIVERY3:
DELIVERY OF THE TRUNK
 After the delivery of the shoulders the baby is grasped
around the chest to aid the birth of the trunk.
 Finally, the body is slowly extracted by traction on the
shoulders and lifts the baby towards the mother’s abdomen.
 The time of delivery is noted.
CUTTING THE UMBILICAL CORD
 After delivery, it is therefore usual to wait 15 to 20 seconds
before clamping and cutting the umbilical cord.
 After cutting the cord a plastic crushing clamp is placed on
the cord 1 to 2 cm from the umbilicus and the cord is cut again 1
cm beyond the clamp.
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
 CONDUCTING THE DELIVERY4:
IMMEDIATE CARE OF THE NEW BORN
Once the baby is breathing normally he should be dried and
warmly wrapped to prevent cooling and handle to the mother
to hold, cuddle and enjoy.
If spontaneous respiration is not established soon
after birth, resuscitation is the immediate priority.
The Apgar’s score of the baby should be noted
and recorded.
LABOUR AND DELIVERY
THE MECHANISMS OF
NORMAL LABOUR
- Occiput anterior -
NORMAL LABOUR AND DELIVERY
Occiput anterior (OA)
Anterior
Pubis
Sacrum
Posterior
Right Left
Occipital bone
NORMAL LABOUR AND DELIVERY
Occiput anterior positions
NORMAL LABOUR AND DELIVERY
MECHANISM OF LABOUR for occiput ante
The “mechanism of labour” refers to the sequencing of
events related to posturing and positioning that allows the
baby to find the “easiest way out”.
For a normal mechanism of labour to occur, both the fetal
and maternal factors must be harmonious.
DEFINITION:
NORMAL LABOUR AND DELIVERY
MECHANISM OF LABOUR for occiput anter
Events of mechanism of labour:
F: Flexion and descent
I: Internal rotation of the fetal head
C: Crowning
E: Extension
R: Restitution
I : Internal rotation of the shoulders
E: External rotation of the fetal head
L: Lateral flexion of the body
NORMAL LABOUR AND DELIVERY
MECHANISM OF LABOUR for occiput anterior (OA
Descend
Flexion
Internal rotation
Crowning
Extension
Restitution
Internal rotation of shoulder
External rotation of head
Lateral flexion of body
LOA
LOA
OA
LOA
OA
OA
LOT
Delivery
F
I
C
E
R
I
E
L
NORMAL LABOUR AND DELIVERY
MANAGEMENT
THIRD STAGE OF
LABOUR
MANAGEMENT OF THE THIRD STAGE OF LABOUR
 BIRTH OF THE PLACENTA1:
Delivery of the placenta occurs in two stages:
(1) separation of the placenta from the wall of the uterus and
into the lower uterine segment and/or the vagina, and
(2) actual expulsion of the placenta out of the birth canal.
THE THIRD STAGE OF LABOUR
 MECHANISM OF PLACENTA SEPARATION1:
Two mechanisms of placental separation occurs:
1- Mathews-Duncan mechanism
The leading edge of the placenta
separates first and the placenta is
delivered with its raw surface
exposed.
2- Schultz mechanism
If the placenta is inserted at the
fundus and central area separates
first, the placenta inverts and draws
the membranes after it, covering the
raw surface (inverted umbrella)
LABOUR AND DELIVERY
WHAT ARE THE SIGNS OF
PLACENTA SEPARATION
MANAGEMENT OF THE THIRD STAGE OF LABOUR
 BIRTH OF THE PLACENTA2:
CLINICAL SIGNS OF PLACENTAL SEPARATION
Placental separation takes place within 5 minutes after the delivery of the
infant. Signs suggesting that detachment or separation has taken place
include:
1. The uterus becomes globular and hard. This sign is the earliest to appear.
2. There is often a sudden gush of blood
3. The uterus rises in the abdomen because the placenta,
having separated, passes down into the lower segment
and vagina, where its bulk pushes the uterus upward
4. Cord lengthening. This is the most reliable clinical sign
of placental separation.
MANAGEMENT OF THE THIRD STAGE OF LABOUR
 BIRTH OF THE PLACENTA2:
After the placental separation takes place the
placenta can be delivered by the:
1. Passive management – wait for spontaneous
expulsion of placenta
2. Active management
LABOUR AND DELIVERY
ACTIVE MANAGEMENT OF
THE THIRD STAGE OF LABOUR
MANAGEMENT OF THE THIRD STAGE OF LABOUR
ACTIVE MANAGEMENT OF THE THIRD STAGE
Active management of the third stage (active delivery of the
placenta) helps prevent postpartum haemorrhage.
Active management of the third stage of labour includes:
~ use of oxytocin
~ controlled cord traction, and
~ uterine massage.
MANAGEMENT OF THE THIRD STAGE OF
LABOUR
ACTIVE MANAGEMENT OF THE THIRD STAGE
~ Use of oxytocin
Oxytocic drugs should be given with the birth of the anterior shoulder.
Syntocinon is the most used oxytocic known to be effective; the
addition of ergometrine may reduce blood loss.
SYNTOMETRINE (oxytocin 5 IU + ergometrine 0.5 mg) – widely
used
MANAGEMENT OF THE THIRD STAGE OF LABOUR
 BIRTH OF THE PLACENTA3:
EXPULSION OF THE PLACENTA BY ACTIVE
MANAGEMENT
When these signs have appeared the placenta is ready for
expression. If the patient is awake, she is asked to bear down while
gentle traction is made on the umbilical cord.
The popular and effective method of delivering the placenta is by
Brandt-Andrews method.
MANAGEMENT OF THE THIRD STAGE OF LABOUR
 BIRTH OF THE PLACENTA4:
BRANDT’S ANDREW METHOD
Once the signs of placental separation have occurred the obstetrician
assists delivery of the placenta by controlled cord traction as described
by Brandt-Andrews’ method.
A) Placenta separation B) Controlled cord traction C) Delivery of the membranes
MANAGEMENT OF THE THIRD STAGE OF LABOUR
 BIRTH OF THE PLACENTA5:
EXAMINATION OF THE PLACENTA
The placenta, membranes, and umbilical cord should be examined
for completeness and for anomalies.
EXAMINATION OF THE PERINEUM
At the same time, the perineal region, vulva outlet, vaginal canal, and
the cervix should be carefully examined for lacerations.
If the perineum has been torn or an episiotomy made, tear or incision
should be repaired immediately.
MANAGEMENT OF THE THIRD STAGE OF LABOUR
 REPAIR OF EPISIOTOMY:
Note: It is important that absorbable sutures be used for closure.
Continuous sutures Interrupted sutures Interrupted suture or
subcuticular
Vaginal mucosa
1. Identify apex
2. Begin suturing
1.0 cm above apex
3. Continuous sutures
4. Ends at the level of
vaginal opening
MANAGEMENT AFTER
DELIVERY
IMMEDIATE MANAGEMENT AFTER THE
DELIVERY
 EARLY POSTPARTUM MANAGEMENT:
The hours immediately following delivery and the birth of the placenta are a critical
period as postpartum haemorrhage can occurs due the relaxation of the uterus.
The patient is kept in the delivery suite for 1 hour postpartum under close
observation. She is check for bleeding, the blood pressure is measured, and the pulse
is counted.
Before discharging the patient from the delivery suit it is mandatory:
 To check the uterus frequently to make sure it is firm and not relaxing.
 To remove any presence of intrauterine blood clots. The presence of these clots will
interfere with retraction and the normal haemostatic mechanism of the uterus.
 To look at the introitus to see that there is no haemorrhage.
 To keep the bladder empties because full bladder can also interfere with uterine
retraction.
 To examine the baby to be certain that it is breathing well and that the colour and
tone are normal.
Normal labour and delivery

Mais conteúdo relacionado

Mais procurados (20)

Prolonged labour -gihs
Prolonged labour -gihsProlonged labour -gihs
Prolonged labour -gihs
 
03 Active management of third stage of labour
03 Active management of third stage of labour03 Active management of third stage of labour
03 Active management of third stage of labour
 
Abnormal+labour
Abnormal+labourAbnormal+labour
Abnormal+labour
 
Rupture uterus
Rupture uterusRupture uterus
Rupture uterus
 
Multiple pregnancy
Multiple pregnancyMultiple pregnancy
Multiple pregnancy
 
Antepartum hemorrhage
Antepartum hemorrhageAntepartum hemorrhage
Antepartum hemorrhage
 
Inversion Of Uterus
Inversion Of UterusInversion Of Uterus
Inversion Of Uterus
 
POLYHYDRAMINOS
POLYHYDRAMINOSPOLYHYDRAMINOS
POLYHYDRAMINOS
 
Prolonged labour
Prolonged labourProlonged labour
Prolonged labour
 
Prom and pprom
Prom and ppromProm and pprom
Prom and pprom
 
Breech presentation
Breech presentationBreech presentation
Breech presentation
 
Physiology of labour
Physiology of labourPhysiology of labour
Physiology of labour
 
Cervical ripening and the bishop score
Cervical ripening and the bishop scoreCervical ripening and the bishop score
Cervical ripening and the bishop score
 
Induction of labor
Induction of laborInduction of labor
Induction of labor
 
Normal Labour
Normal LabourNormal Labour
Normal Labour
 
Aph
AphAph
Aph
 
Cord Prolapse
Cord ProlapseCord Prolapse
Cord Prolapse
 
Caesarean section
Caesarean sectionCaesarean section
Caesarean section
 
Puerperal Pyrexia
Puerperal PyrexiaPuerperal Pyrexia
Puerperal Pyrexia
 
Operative procedure in obstetric
Operative procedure in obstetricOperative procedure in obstetric
Operative procedure in obstetric
 

Semelhante a Normal labour and delivery

Normal physiology of labour and delivery .pptx
Normal physiology of labour and delivery .pptxNormal physiology of labour and delivery .pptx
Normal physiology of labour and delivery .pptxEndex Tam
 
a detail study on normal labour ( definition, stages of labour, management ,p...
a detail study on normal labour ( definition, stages of labour, management ,p...a detail study on normal labour ( definition, stages of labour, management ,p...
a detail study on normal labour ( definition, stages of labour, management ,p...martinshaji
 
4 normal labour and delivery
4 normal labour and delivery4 normal labour and delivery
4 normal labour and deliveryMohd Hanafi
 
Normal labour and delivery
Normal labour and deliveryNormal labour and delivery
Normal labour and deliveryDr. Rubz
 
Normal labour and its physiology
Normal labour and its physiologyNormal labour and its physiology
Normal labour and its physiologyAtul Yadav
 
Normal Labour & Nursing Management of First stage of Labour
Normal Labour & Nursing Management of First stage of LabourNormal Labour & Nursing Management of First stage of Labour
Normal Labour & Nursing Management of First stage of LabourNeha Parmar
 
Normal labour and delivery
Normal labour and deliveryNormal labour and delivery
Normal labour and deliverySornpiseth Khut
 
Stages of labour.pptx
Stages of labour.pptxStages of labour.pptx
Stages of labour.pptxvincenttobi1
 
Physiology of labor. Anaesthesia in labor
Physiology of labor. Anaesthesia in laborPhysiology of labor. Anaesthesia in labor
Physiology of labor. Anaesthesia in laborberbets
 
Labour and its stages
Labour and its stagesLabour and its stages
Labour and its stagesShrooti Shah
 
NORMAL LABOUR& Mechanism.pptx
NORMAL LABOUR& Mechanism.pptxNORMAL LABOUR& Mechanism.pptx
NORMAL LABOUR& Mechanism.pptxIram Chaudhry
 
NORMAL LABOR. WARDA
NORMAL LABOR.  WARDANORMAL LABOR.  WARDA
NORMAL LABOR. WARDAOsama Warda
 

Semelhante a Normal labour and delivery (20)

Normal physiology of labour and delivery .pptx
Normal physiology of labour and delivery .pptxNormal physiology of labour and delivery .pptx
Normal physiology of labour and delivery .pptx
 
2_2018_12_03!06_49_40_PM.ppt
2_2018_12_03!06_49_40_PM.ppt2_2018_12_03!06_49_40_PM.ppt
2_2018_12_03!06_49_40_PM.ppt
 
a detail study on normal labour ( definition, stages of labour, management ,p...
a detail study on normal labour ( definition, stages of labour, management ,p...a detail study on normal labour ( definition, stages of labour, management ,p...
a detail study on normal labour ( definition, stages of labour, management ,p...
 
Normal Labour by Dr Salman
Normal Labour by Dr SalmanNormal Labour by Dr Salman
Normal Labour by Dr Salman
 
4 normal labour and delivery
4 normal labour and delivery4 normal labour and delivery
4 normal labour and delivery
 
Normal labour and delivery
Normal labour and deliveryNormal labour and delivery
Normal labour and delivery
 
Normal labour.pptx
Normal labour.pptxNormal labour.pptx
Normal labour.pptx
 
L31 Normal Labor & Delivery
L31 Normal Labor & DeliveryL31 Normal Labor & Delivery
L31 Normal Labor & Delivery
 
Normal labor and physical therapy role
Normal labor and physical therapy role Normal labor and physical therapy role
Normal labor and physical therapy role
 
Normal labour and its physiology
Normal labour and its physiologyNormal labour and its physiology
Normal labour and its physiology
 
Normal Labour & Nursing Management of First stage of Labour
Normal Labour & Nursing Management of First stage of LabourNormal Labour & Nursing Management of First stage of Labour
Normal Labour & Nursing Management of First stage of Labour
 
Normal labour and delivery
Normal labour and deliveryNormal labour and delivery
Normal labour and delivery
 
Stages of labour.pptx
Stages of labour.pptxStages of labour.pptx
Stages of labour.pptx
 
Normal labor
Normal laborNormal labor
Normal labor
 
Physiology of labor. Anaesthesia in labor
Physiology of labor. Anaesthesia in laborPhysiology of labor. Anaesthesia in labor
Physiology of labor. Anaesthesia in labor
 
Labour and its stages
Labour and its stagesLabour and its stages
Labour and its stages
 
NORMAL LABOUR& Mechanism.pptx
NORMAL LABOUR& Mechanism.pptxNORMAL LABOUR& Mechanism.pptx
NORMAL LABOUR& Mechanism.pptx
 
NORMAL LABOR. WARDA
NORMAL LABOR.  WARDANORMAL LABOR.  WARDA
NORMAL LABOR. WARDA
 
Normal labor for undergraduate
Normal labor for undergraduateNormal labor for undergraduate
Normal labor for undergraduate
 
Normal labour newest
Normal labour newestNormal labour newest
Normal labour newest
 

Mais de Jograjiya Gelabhai Raghubhai (9)

Vault prolapse, Pelvic organ Prolapse, Supports Of Uterus
Vault   prolapse, Pelvic organ Prolapse, Supports Of UterusVault   prolapse, Pelvic organ Prolapse, Supports Of Uterus
Vault prolapse, Pelvic organ Prolapse, Supports Of Uterus
 
Prevention and treatment of hiv infection in pregnancy
Prevention and treatment of hiv infection in pregnancyPrevention and treatment of hiv infection in pregnancy
Prevention and treatment of hiv infection in pregnancy
 
Torch, fetal infections
Torch, fetal infectionsTorch, fetal infections
Torch, fetal infections
 
Ureteric injury in Gyenec Surgery
Ureteric injury in Gyenec SurgeryUreteric injury in Gyenec Surgery
Ureteric injury in Gyenec Surgery
 
Diabetes in pregnancy
Diabetes in pregnancyDiabetes in pregnancy
Diabetes in pregnancy
 
Pelvic inflammatory disease (pid)
Pelvic inflammatory disease (pid)Pelvic inflammatory disease (pid)
Pelvic inflammatory disease (pid)
 
Urinary incontinence
Urinary incontinenceUrinary incontinence
Urinary incontinence
 
Antenatal doppler
Antenatal dopplerAntenatal doppler
Antenatal doppler
 
Induction and augmentation of labour by dr jograjiya
Induction and augmentation of labour by dr jograjiyaInduction and augmentation of labour by dr jograjiya
Induction and augmentation of labour by dr jograjiya
 

Último

Understanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsUnderstanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsNeha Sharma
 
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHY
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHYCECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHY
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHYRMC
 
Three Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and LaborThree Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and LaborHealth Catalyst
 
person with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxperson with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxMUKESH PADMANABHAN
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxPamela McKinney
 
21 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 202421 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 2024Traumasoft LLC
 
ACCA Version of AI & Healthcare: An Overview for the Curious
ACCA Version of AI & Healthcare: An Overview for the CuriousACCA Version of AI & Healthcare: An Overview for the Curious
ACCA Version of AI & Healthcare: An Overview for the CuriousKR_Barker
 
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfAnatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfhezamzaki1
 
Hematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of HematinicsHematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of Hematinicsnetraangadi2
 
Pharmacovigilance audits inspections.pptx
Pharmacovigilance audits inspections.pptxPharmacovigilance audits inspections.pptx
Pharmacovigilance audits inspections.pptxCliniminds India
 
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLiving Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLyons Health
 
Eating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports PsychologyEating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports Psychologyshantisphysio
 
Diseases of the Respiratory System (J00-J99),.pptx
Diseases of the Respiratory System (J00-J99),.pptxDiseases of the Respiratory System (J00-J99),.pptx
Diseases of the Respiratory System (J00-J99),.pptxEMADABATHINI PRABHU TEJA
 
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
LARYNGEAL CANCER.pptx  Prepared by Neha KewatLARYNGEAL CANCER.pptx  Prepared by Neha Kewat
LARYNGEAL CANCER.pptx Prepared by Neha KewatNehaKewat
 
EYE CANCER.pptx prepared by Neha kewat digital learning
EYE CANCER.pptx prepared by  Neha kewat digital learningEYE CANCER.pptx prepared by  Neha kewat digital learning
EYE CANCER.pptx prepared by Neha kewat digital learningNehaKewat
 
Artificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementArtificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementIris Thiele Isip-Tan
 
Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)bishwabandhuniraula
 

Último (20)

Understanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsUnderstanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common Locations
 
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHY
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHYCECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHY
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHY
 
Three Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and LaborThree Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and Labor
 
person with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxperson with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptx
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptx
 
21 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 202421 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 2024
 
ACCA Version of AI & Healthcare: An Overview for the Curious
ACCA Version of AI & Healthcare: An Overview for the CuriousACCA Version of AI & Healthcare: An Overview for the Curious
ACCA Version of AI & Healthcare: An Overview for the Curious
 
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfAnatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
 
Hematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of HematinicsHematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of Hematinics
 
Pharmacovigilance audits inspections.pptx
Pharmacovigilance audits inspections.pptxPharmacovigilance audits inspections.pptx
Pharmacovigilance audits inspections.pptx
 
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLiving Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
 
Eating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports PsychologyEating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports Psychology
 
The Power of Active listening - Tool in effective communication.pdf
The Power of Active listening - Tool in effective communication.pdfThe Power of Active listening - Tool in effective communication.pdf
The Power of Active listening - Tool in effective communication.pdf
 
Diseases of the Respiratory System (J00-J99),.pptx
Diseases of the Respiratory System (J00-J99),.pptxDiseases of the Respiratory System (J00-J99),.pptx
Diseases of the Respiratory System (J00-J99),.pptx
 
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
LARYNGEAL CANCER.pptx  Prepared by Neha KewatLARYNGEAL CANCER.pptx  Prepared by Neha Kewat
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
 
SCOPE OF CRITICAL CARE ORGANIZATION
SCOPE OF CRITICAL CARE ORGANIZATIONSCOPE OF CRITICAL CARE ORGANIZATION
SCOPE OF CRITICAL CARE ORGANIZATION
 
EYE CANCER.pptx prepared by Neha kewat digital learning
EYE CANCER.pptx prepared by  Neha kewat digital learningEYE CANCER.pptx prepared by  Neha kewat digital learning
EYE CANCER.pptx prepared by Neha kewat digital learning
 
Artificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementArtificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes Management
 
Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)
 
Painting Rats White Angers Them to No End
Painting Rats White Angers Them to No EndPainting Rats White Angers Them to No End
Painting Rats White Angers Them to No End
 

Normal labour and delivery

  • 1. NORMAL LABOUR AND DELIVERY Dr Jograjiya PG Student Department of Obstetrics and Gynecology, ESIC-PGIMSR, Basaidarapur, New Delhi
  • 2. CONTENTS 1. Definition of normal labour 2. Factors influencing progress of labour 3. Diagnosis of labour 4. Stages of labour 5. Mechanisms of labour 6. Management of labour
  • 3. LABOUR Labour is defined as the onset of regular painful Contractions with progressive cervical effacement and dilatation of the cervix accompanied by descent of the presenting part. DEFINITIONS
  • 4. NORMAL LABOUR  Spontaneous expulsion,  of a single,  mature fetus (37 completed weeks – 42 weeks),  presented by vertex,  through the birth canal (i.e. vaginal delivery),  within a reasonable time (not less than 3 hours or more than 18 hours),  without complications to the mother,  or the fetus. The following criteria should be present
  • 5. NORMAL LABOUR Understanding the process of labour is importance • problems can be identified • correctly managed IMPORTANCE
  • 6. LABOUR AND DELIVERY FACTORS THAT INFLUENCE PROGRESS OF LABOUR Passenger Passage Power
  • 7. THE NORMAL FEMALE PELVIS 1. The female pelvis provides the basic framework of the birth canal. 2. The obstetric pelvis is divided into false and true pelvis by the pelvic brim or inlet 3. The true pelvis is important, for it is through this confined space that the fetus must pass on its journey through the birth canal. 4. The true pelvis is composed of inlet, cavity and outlet. 5. Types of female pelvis – gynaecoid, anthropoid, android and platypelloid Outlet Cavity Inlet
  • 8. NORMAL FEMALE PELVIS 1. The brim is slightly oval transversely. 2. The sacral promontory is not prominent. 3. The transverse diameter is slightly longer than the anteroposterior. 4. The sidewalls are parallel and straight. 5. The ischial spines are not prominent. 6. The sacrosciatic notches are wide. 7. The sacrum has a good curve. 8. The pubic arch angle are wide, i.e. more than 90 9. Inter tuberous diameter is wide The ideal normal female gynaecoid pelvis:
  • 9. THE NORMAL FEMALE PELVIS The important diameters of the female pelvis: Anteroposterior Oblique Transverse BRIM 11 12 13 CAVITY 12 12 12 OUTLET 13 12 11 Diameters (cm)
  • 10. THE FETAL SKULL 1. Sutures 2. Diameters
  • 11. THE FETAL SKULL 1. Sagittal suture: - The sagittal suture lies between the parietal bones. It runs in an anteroposterior direction between the anterior and posterior fontanelles. 2. Coronal sutures: - The suture uniting the parietal bones to the frontal bones is called the coronal suture. It’s extend transversely from the anterior fontanels and lies between the parietal and frontal bone. 3. Frontal suture: - The frontal suture is between the two frontal bones. It is an anterior continuation of the sagittal suture. 4. Lambdoidal suture: - Is between the parietal and occiptal bones. SUTURES
  • 12. THE FETAL SKULL MOULDING OF THE FETAL SKULL MOULDING is the ability of the fetal head to change its shape and so to adapt itself to the unyielding maternal pelvis during the progress of labour. This property is of the greatest value in the progress of labour.
  • 13. THE FETAL SKULL Diameters of the fetal skull – anterior posterior diameters A B C D E F G AB ~ Suboccipto bregmatic – 9.5 -Vertex AC ~ Submento bregmatic – 9.5 -Face DE ~ Occipito frontal ~ 11-12 FG ~ Mento vertical – 13.5 -Brow
  • 14. POWER ► Contractions + Maternal pushing Uterine contractions: 1. Initiate by pacemakers ~ uterotubal junction 2. Contraction waves meet at the fundus 3. Contraction waves progress downward  Shortening of muscle fibres  Retractions  intra uterine pressure EXPULSION OF THE FETUS Additional force “maternal pushing” Intra abdominal pressure
  • 15. UTERINE CONTRACTION NORMAL CONTRACTION 1. Frequency ~ one in every 2 – 3 min with at least 1 minute interval 2. Intensity ~ strong (> 50 mmHg) 3. Duration ~ 45 – 60 sec Uterine contractions
  • 16. LABOUR AND DELIVERY WHAT INITIATE LABOUR “ONSET OF LABOUR”
  • 17. NORMAL LABOUR  Hormonal factors 1) Estrogen theory 2) Progesterone withdrawal theory 3) Prostaglandins theory 4) Oxytocin theory 5) Fetal cortisol theory  Mechanical factors 1) Uterine distension theory 2) Stretch of the lower uterine segment by the presenting near term Causes of Onset of Labour: - It is unknown but the following theories were postulated:
  • 22. NORMAL LABOUR AND DELIVERY  Painful regular uterine contractions – as evidence by contraction at least one in ten minutes  Show – as evidence by mucus mixed with blood  Rupture of membranes – as evidence by leaking liquor SYMPTOMS AND SIGNS OF LA Before labour begins, women usually notice one or more premonitory, or warnings, signs that labour is about to begin. They are:
  • 23. LABOUR AND DELIVERY DESCRIBE THE STAGES OF LABOUR
  • 24. NORMAL LABOUR AND DELIVERY STAGES OF LABOUR FIRST STAGE SECOND STAGE THIRD STAGE It begins with the onset of true labour contractions and ends when the cervix is fully dilated (10 cm). Cervical effacement and dilatation occur in the first stage First stage of labour consists of two phases:- latent and active. The first stage of labour is the longest for both nulliparous and parous women. The second stage of labour begins with complete dilatation of the cervix and ends with the birth of the baby. The duration is about 1 to 1½ hours in nulliparas and about 30 to 45 minutes in parous women. The third stage is that of separation and expulsion of placenta and membranes and also involves the control of bleeding. It begins after the birth of the baby and ends with the expulsion of the placenta and membranes. This is the shortest stage, lasting up to 30 minutes, with an average length of 5 to 10 minutes. There is no difference in duration for nulliparous and parous. Labour can be divided into three stages, which are unequal in length.
  • 26. NORMAL LABOUR AND DELIVERY PHASES OF THE FIRST STAGE OF LABOU Divided into: Latent phase – begins with onset of contracts and ends when cervix is 3 cm dilated and effaced Active phase – begins after the cervix is 3 cm dilated
  • 27. NORMAL LABOUR AND DELIVERY PHASES OF THE FIRST STAGE OF LABOU LATENT Phase ACTIVE Phase 1. Begins with onset of contractions 2. Slow progress 3. Little cervical dilatation 4. Progressive cervical effacement 5. Ends once the cervix reaches 3 cm dilatation 6. Durations ~ 8 hours for nulliparae ~ 6 hours for multiparae 1. Active process 2. Begins after 3 cm of cervical dilatation 3. Period of active cervical dilatation (average rate 1 cm/hr) 4. S-shaped curve which is used to define progress of labour 5. It has 3 component a) acceleration - slow b) maximum - fast c) deceleration - slow
  • 28. NORMAL LABOUR AND DELIVERY WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR
  • 29. NORMAL LABOUR AND DELIVERY WHAT HAPPEN DURING THE FIRST STAG 1. Contractions: CONTRACTIONS 1: Regular 2: Increasing in frequency 3: Stronger
  • 30. NORMAL LABOUR AND DELIVERY WHAT HAPPEN DURING THE FIRST STAG 2. Cervical dilatation and effacement: Causes of cervical dilatation: Contraction and retraction of uterine musculature Mechanical pressure by the bulging membrane (fore water) The descend of the presenting part Phases of cervical dilatation Latent phase – the first 3 cm of dilatation; a slow process (8 hours in nulliparous and 3 hours in multiparous Active phase – this is active process of cervical dilatation; the normal rate is 1 cm/hour
  • 31. NORMAL LABOUR AND DELIVERY WHAT HAPPEN DURING THE FIRST STAG 3. Engagement of the presenting part:
  • 32. NORMAL LABOUR AND DELIVERY Do Uterine Contractions Affect Fetal Heart Rate? Uterine contractions can affect fetal heart rate by increasing or decreasing that rate in association with any given contraction. The three primary mechanisms by which uterine contractions can cause a decrease in fetal heart rate are compression of: · Fetal head · Umbilical cord · Uterine myometrial vessels FETAL HEART CHANGES
  • 33. NORMAL LABOUR AND DELIVERY PROGRESS OF FIRST STAGE OF LABOUR Findings suggestive of satisfactory progress in first stage of labour are: - regular contractions of progressively increasing frequency and duration; - rate of cervical dilatation at least 1 cm per hour during the active phase of labour (cervical dilatation on or to the left of alert line); Findings suggestive of unsatisfactory progress in first stage of labour are: - irregular and infrequent contractions after the latent phase; - OR rate of cervical dilatation slower than 1 cm per hour during the active phase of labour (cervical dilatation to the right of alert line);
  • 35. NORMAL LABOUR AND DELIVERY SECOND STAGE OF LABOUR 1. Begins with FULL DILATATION and ends with DELIVERY OF THE BABY. 2. It have TWO Phases a) Propulsive phase – from full dilatation until presenting part has descended to the pelvic floor b) Expulsive phase which ends with the delivery of the baby Features of expulsive phase – 1) mother’s irresistible desire to bear down 2) distension of perineum 3) dilatation of the anus 3. Average length a) Primigravidae – 40 minutes b) Multigravidae – 20 minutes
  • 36. NORMAL LABOUR AND DELIVERY PROGRESS OF SECOND STAGE OF LABOUR Findings suggestive of satisfactory progress in second stage of labour are: - steady descent of fetus through birth canal; - onset of expulsive (pushing) phase. Findings suggestive of unsatisfactory progress in second stage of labour are: - lack of descent of fetus through birth canal; - failure of expulsion during the late (expulsive) phase.
  • 38. NORMAL LABOUR AND DELIVERY THIRD STAGE OF LABOUR 1. Begins after DELIVERY of the baby and ends with DELIVERY OF THE PLACENTA / MEMBRANES. 2. It have TWO Phases a) Separation phase b) Expulsion phase 3. Duration – usually 15 minutes or less (if actively managed). 4. Average blood loss – 150 to 250 ml.
  • 39. NORMAL LABOUR AND DELIVERY PHYSIOLOGICAL EFFECTS OF LABOU FIRST STAGE SECOND STAGE THIRD STAGE ON THE MOTHER 1. Minimal effects 1. Pulse increases 2. Systolic BP slightly increased due to pain and anxiety 3. Minor injuries to the birth canal 1. Blood loss from the placental site (200 ml) 2. Blood loss from laceration and perineum (100 ml) ON THE FETUS 1. Moulding – overlapping of the vault bones 2. Caput succedaneum – it is a soft swelling of the most dependent part of the fetal head
  • 41. AIMS IN THE MANAGEMENT OF LABOUR To achieve delivery of a normal healthy child To anticipate, recognize and treat potential abnormal conditions before significant hazard develops for the mother or the fetus.
  • 42. PRINCIPLES IN THE MANAGEMENT OF LABOUR Diagnosis of labour Monitoring the progress of labour Ensuring maternal well-being Ensuring fetal well-being.
  • 43. NORMAL LABOUR AND DELIVERY MANAGEMENT FIRST STAGE OF LABOUR
  • 44. MANAGEMENT OF THE FIRST STAGE OF LABOUR1  On admission: When the women presents at hospital, the woman’s antenatal record is reviewed to discover whether there have been any abnormalities during her pregnancy. When there are no records of antenatal care a complete history must be taken.  General examination of the mother a) General conditions – evaluate the mother general health condition. Look for pallor, edema, abdominal scar (LSCS) and maternal height. b) Vital signs – Blood pressure, pulse, respiration and temperature are taken and recorded c) Heart and lungs d) Urine analysis – for protein, sugar and ketones
  • 45. MANAGEMENT OF THE FIRST STAGE OF LABOUR2  Abdominal examination: a) A detailed abdominal examination should be carried out and recorded. b) Determine the presentation and position of the fetus and also the engagement c) Auscultate the fetal heart d) Evaluate the uterine contraction Vaginal examination – the purpose is to a) To make a positive diagnosis of labour b) To make a positive identification of presentation c) To determine whether the fetal head is engaged in case of doubt d) To ascertain whether the fore waters have ruptured or to rupture them artificially e) To exclude cord prolapse after rupture of the fore waters f) To confirm the degree of cervical dilatation and position of the presenting part g) To assess progress of labour. h) To assess the adequacy of the pelvis.
  • 46. MANAGEMENT OF THE FIRST STAGE OF LABOUR3  Bowel preparation: If there has been no bowel action for 24 hours or the rectum feels loaded on vaginal examination an enema is given.  Bladder care A full bladder may initially prevent the fetal head from entering the pelvic brim and later impede descent of the fetal head. It will also inhibit effective uterine action. The woman should be encouraged to empty her bladder every 1½ - 2 hours during labour. The quantity of urine passed should be measured and recorded and a specimen obtained for testing.  Nutrition in early labour No food is permitted after labour is established – to prevent regurgitation and aspiration It is important to maintain adequate hydration - via intravenous routes
  • 47. MANAGEMENT OF THE FIRST STAGE OF LABOUR4  Position of labouring mother: As long as the patient is healthy, the presentation normal, the presenting part engaged, and the fetus in good condition, the patient may walk about or may be in bed, as she wishes  Monitoring the progress of labour Once labour has become established, all events during labour should be recorded on a partogram. a) The well-being of the fetus b) The well-being of the mother c) The progress of the labour  Pain relief When the pains are severe an analgesic preparation may be given. a) Opiate drugs – e.g. Pethidine given intramuscularly every 4 hour b) Inhalational analgesia – e.g. Entonox c) Epidural analagesia
  • 48. NORMAL LABOUR AND DELIVERY  Pain in labour The pain experienced by the woman in labour is caused by the: 1): Uterine contractions and uterine ischaemia. 2): Cervical dilatation. Dilatation and stretching of the cervix and lower uterine segment stimulate nerve ganglia and are a major source of pain. 3): Distention of the vagina and perineum. Marked distention of the vagina and perineum occurs with fetal descent, especially during the second stage. LABOUR PAIN – causes1
  • 49. NORMAL LABOUR AND DELIVERY  Pain in labour LABOUR PAIN – causes2 Table 1: PAIN DURING THE STAGES OF LABOUR STAGES OF LABOUR SORCES OF PAIN FIRST STAGE Pain is caused mainly by uterine contractions, thinning of the lower segment of the uterus, and dilatation of the cervix. SECOND STAGE Pain result from two sources: 1.The stretching of the vagina, vulva and perineum. 2.The contraction of the myometrium. THIRD STAGE Pain is caused by the passage of the placenta through the cervix, plus that produced by the uterine contractions.
  • 50. NORMAL LABOUR AND DELIVERY PAIN RELIEF IN LABOUR – types Three methods are in common use during labour: 1. Analgesic drugs (narcotics, e.g. pethidine) which are given by intramuscularly injection. 2. Inhalation analgesia (e.g. Entonox). 3. Regional anaesthesia (e.g. epidural, spinal) that blocks the sensory pain pathways.
  • 51. NORMAL LABOUR AND DELIVERY MONITORING FETAL HEART How Do Uterine Contractions Affect Fetal Heart Rate? Uterine contractions can affect fetal heart rate by increasing or decreasing that rate in association with any given contraction. The three primary mechanisms by which uterine contractions can cause a decrease in fetal heart rate are compression of: · Fetal head · Umbilical cord · Uterine myometrial vessels
  • 52. NORMAL LABOUR AND DELIVERY MONITORING FETAL HEART How To Monitor The Fetal Heart Rate?  Auscultation methods  Electronic monitoring ~ CTG
  • 53. NORMAL LABOUR AND DELIVERY MONITORING FETAL HEART To detect fetal hypoxia NORMAL ABNORMAL
  • 55. NORMAL LABOUR AND DELIVERY RECORDING THE PROGRESS OF LABOUR PATIENT INFORMATION FETAL INFORMATION ~ fetal well being LABOUR INFORMATION ~ Dilatation ~ Descent ~ Contraction MEDICATIONS MATERNAL INFORMATION ~ Well being
  • 56. NORMAL LABOUR AND DELIVERY RECORDING THE PROGRESS OF LABOUR - Partogram Patient information: Fill out name, gravida, para, hospital number, date and time of admission and time of ruptured membranes. Fetal heart rate: Record every half hour. Amniotic fluid: Record the colour of amniotic fluid at every vaginal examination: I: membranes intact; C: membranes ruptured, clear fluid; M: meconium-stained fluid; B: blood-stained fluid. Moulding: 1: sutures apposed; 2: sutures overlapped but reducible; 3: sutures overlapped and not reducible.
  • 57. NORMAL LABOUR AND DELIVERY RECORDING THE PROGRESS OF LABOUR - Partogram Cervical dilatation: Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 3 cm. Station : recorded as a circle (O) at every vaginal examination. Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds. Less than 20 seconds: Between 20 and 40 seconds: More than 40 seconds: Assess the progress of labour:
  • 58. NORMAL LABOUR AND DELIVERY RECORDING THE PROGRESS OF LABOUR - Partogram Oxytocin: Record the amount of oxytocin every 30 minutes when used. Drugs given: Record any additional drugs given – e.g. Pethidine Pulse: Record every 30 minutes and mark with a dot (●). Blood pressure: Record every 4 hours and mark with arrows ( ) Temperature: Record every 2 hours. Protein, acetone and volume: Record every time urine is passed. Progress of maternal well being:
  • 59. NORMAL LABOUR AND DELIVERY MANAGEMENT SECOND STAGE O LABOUR
  • 60. MANAGEMENT OF THE SECOND STAGE OF LABOUR1  Maternal position: With the exception of avoiding supine position, the mother may assume any comfortable position for effective bearing down. The semi-recumbent or supported sitting position, with the thighs abducted, is the posture most commonly adopted  Bearing down With each contraction, the mother should be encouraged to bear down with expulsive efforts Once the onset of the second stage has been confirmed a woman should not be left without attendance. Accurate observation of progress is vital, for the unexpected can always happen.
  • 61. MANAGEMENT OF THE SECOND STAGE OF LABOUR2  Observation during the second stage: Four factors determine whether the second stage may be safely continued and these must be carefully monitored throughout the second stage of labour. 1. Maternal conditions Observation includes an appraisal of the mother’s ability to cope emotionally as well as an assessment of her physical wellbeing. A maternal pulse rate is usually recorded quarter-hourly and bloods pressure hourly 2. Fetal conditions - During the second stage, the fetal heart should be monitored either continuously or after each contraction. stage may be associated with fetal distress. The liquor amnii is observed for signs of meconium staining. 3. Uterine contractions - The strength, length and frequency of contractions should be assessed continuously. 4. The progress of descent - The progress should be recorded approximately every 30 minutes during the second stage.
  • 62. MANAGEMENT OF THE SECOND STAGE OF LABOUR3  CONDUCTING THE DELIVERY1: When delivery is imminent, the patient is usually placed in the dorsal position, and the skin over the lower abdomen, vulva, anus and upper thigh is cleansed with antiseptic solution and draped. DELIVERY OF THE HEAD 1) Control the delivery of the head to prevent laceration 2) Performed episiotomy if requires 3) Performed Ritgen’s method 4) Cleared the airway after delivery of the had
  • 63. MANAGEMENT OF THE SECOND STAGE OF LABOUR3  PERFORMING AN EPISIOTOMY: "..is a surgical incision into the perineum to enlarge the space at the outlet EPISIOTOMY IS EPSIOTOMY REALLY NEEDED? Episiotomies are said to provide the following benefits: 1. Speed up the birth 2. Prevent Tearing 3. Protects against incontinence 4. Protects against pelvic floor relaxation 5. Heals easier than tears medical research has not proven any of these benefits
  • 64. MANAGEMENT OF THE SECOND STAGE OF LABOUR3  PERFORMING AN EPISIOTOMY: Episiotomies are not always necessary Episiotomy should be considered only in the case of: • Complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum); • Scarring of the perineum; • Fetal distress.
  • 65. MANAGEMENT OF THE SECOND STAGE OF LABOUR3  PERFORMING AN EPISIOTOMY: Episiotomy Types Midline episiotomy Mediolateral episiotomy J-shaped episiotomy Incision of episiotomy The three major types of episiotomy
  • 66. MANAGEMENT OF THE SECOND STAGE OF LABOUR3  PERFORMING AN EPISIOTOMY: Infiltrate perineum with local anaesthetic agent Making an incision Wait until: 1) the perineum is thinned out; and 2) 3–4 cm of the baby’s head is visible during a contraction. Performing an episiotomy will cause bleeding. It should not, therefore, be done too early.
  • 67. MANAGEMENT OF THE SECOND STAGE OF LABOUR3  CONDUCTING THE DELIVERY2: DELIVERY OF THE SHOULDERS Delivery of the anterior shoulder is aided by gentle downward traction on the head. The posterior shoulder is delivered by elevating the head.
  • 68. MANAGEMENT OF THE SECOND STAGE OF LABOUR3  CONDUCTING THE DELIVERY3: DELIVERY OF THE TRUNK  After the delivery of the shoulders the baby is grasped around the chest to aid the birth of the trunk.  Finally, the body is slowly extracted by traction on the shoulders and lifts the baby towards the mother’s abdomen.  The time of delivery is noted. CUTTING THE UMBILICAL CORD  After delivery, it is therefore usual to wait 15 to 20 seconds before clamping and cutting the umbilical cord.  After cutting the cord a plastic crushing clamp is placed on the cord 1 to 2 cm from the umbilicus and the cord is cut again 1 cm beyond the clamp.
  • 69. MANAGEMENT OF THE SECOND STAGE OF LABOUR3  CONDUCTING THE DELIVERY4: IMMEDIATE CARE OF THE NEW BORN Once the baby is breathing normally he should be dried and warmly wrapped to prevent cooling and handle to the mother to hold, cuddle and enjoy. If spontaneous respiration is not established soon after birth, resuscitation is the immediate priority. The Apgar’s score of the baby should be noted and recorded.
  • 70. LABOUR AND DELIVERY THE MECHANISMS OF NORMAL LABOUR - Occiput anterior -
  • 71. NORMAL LABOUR AND DELIVERY Occiput anterior (OA) Anterior Pubis Sacrum Posterior Right Left Occipital bone
  • 72. NORMAL LABOUR AND DELIVERY Occiput anterior positions
  • 73. NORMAL LABOUR AND DELIVERY MECHANISM OF LABOUR for occiput ante The “mechanism of labour” refers to the sequencing of events related to posturing and positioning that allows the baby to find the “easiest way out”. For a normal mechanism of labour to occur, both the fetal and maternal factors must be harmonious. DEFINITION:
  • 74. NORMAL LABOUR AND DELIVERY MECHANISM OF LABOUR for occiput anter Events of mechanism of labour: F: Flexion and descent I: Internal rotation of the fetal head C: Crowning E: Extension R: Restitution I : Internal rotation of the shoulders E: External rotation of the fetal head L: Lateral flexion of the body
  • 75. NORMAL LABOUR AND DELIVERY MECHANISM OF LABOUR for occiput anterior (OA Descend Flexion Internal rotation Crowning Extension Restitution Internal rotation of shoulder External rotation of head Lateral flexion of body LOA LOA OA LOA OA OA LOT Delivery F I C E R I E L
  • 76. NORMAL LABOUR AND DELIVERY MANAGEMENT THIRD STAGE OF LABOUR
  • 77. MANAGEMENT OF THE THIRD STAGE OF LABOUR  BIRTH OF THE PLACENTA1: Delivery of the placenta occurs in two stages: (1) separation of the placenta from the wall of the uterus and into the lower uterine segment and/or the vagina, and (2) actual expulsion of the placenta out of the birth canal.
  • 78. THE THIRD STAGE OF LABOUR  MECHANISM OF PLACENTA SEPARATION1: Two mechanisms of placental separation occurs: 1- Mathews-Duncan mechanism The leading edge of the placenta separates first and the placenta is delivered with its raw surface exposed. 2- Schultz mechanism If the placenta is inserted at the fundus and central area separates first, the placenta inverts and draws the membranes after it, covering the raw surface (inverted umbrella)
  • 79. LABOUR AND DELIVERY WHAT ARE THE SIGNS OF PLACENTA SEPARATION
  • 80. MANAGEMENT OF THE THIRD STAGE OF LABOUR  BIRTH OF THE PLACENTA2: CLINICAL SIGNS OF PLACENTAL SEPARATION Placental separation takes place within 5 minutes after the delivery of the infant. Signs suggesting that detachment or separation has taken place include: 1. The uterus becomes globular and hard. This sign is the earliest to appear. 2. There is often a sudden gush of blood 3. The uterus rises in the abdomen because the placenta, having separated, passes down into the lower segment and vagina, where its bulk pushes the uterus upward 4. Cord lengthening. This is the most reliable clinical sign of placental separation.
  • 81. MANAGEMENT OF THE THIRD STAGE OF LABOUR  BIRTH OF THE PLACENTA2: After the placental separation takes place the placenta can be delivered by the: 1. Passive management – wait for spontaneous expulsion of placenta 2. Active management
  • 82. LABOUR AND DELIVERY ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR
  • 83. MANAGEMENT OF THE THIRD STAGE OF LABOUR ACTIVE MANAGEMENT OF THE THIRD STAGE Active management of the third stage (active delivery of the placenta) helps prevent postpartum haemorrhage. Active management of the third stage of labour includes: ~ use of oxytocin ~ controlled cord traction, and ~ uterine massage.
  • 84. MANAGEMENT OF THE THIRD STAGE OF LABOUR ACTIVE MANAGEMENT OF THE THIRD STAGE ~ Use of oxytocin Oxytocic drugs should be given with the birth of the anterior shoulder. Syntocinon is the most used oxytocic known to be effective; the addition of ergometrine may reduce blood loss. SYNTOMETRINE (oxytocin 5 IU + ergometrine 0.5 mg) – widely used
  • 85. MANAGEMENT OF THE THIRD STAGE OF LABOUR  BIRTH OF THE PLACENTA3: EXPULSION OF THE PLACENTA BY ACTIVE MANAGEMENT When these signs have appeared the placenta is ready for expression. If the patient is awake, she is asked to bear down while gentle traction is made on the umbilical cord. The popular and effective method of delivering the placenta is by Brandt-Andrews method.
  • 86. MANAGEMENT OF THE THIRD STAGE OF LABOUR  BIRTH OF THE PLACENTA4: BRANDT’S ANDREW METHOD Once the signs of placental separation have occurred the obstetrician assists delivery of the placenta by controlled cord traction as described by Brandt-Andrews’ method. A) Placenta separation B) Controlled cord traction C) Delivery of the membranes
  • 87. MANAGEMENT OF THE THIRD STAGE OF LABOUR  BIRTH OF THE PLACENTA5: EXAMINATION OF THE PLACENTA The placenta, membranes, and umbilical cord should be examined for completeness and for anomalies. EXAMINATION OF THE PERINEUM At the same time, the perineal region, vulva outlet, vaginal canal, and the cervix should be carefully examined for lacerations. If the perineum has been torn or an episiotomy made, tear or incision should be repaired immediately.
  • 88. MANAGEMENT OF THE THIRD STAGE OF LABOUR  REPAIR OF EPISIOTOMY: Note: It is important that absorbable sutures be used for closure. Continuous sutures Interrupted sutures Interrupted suture or subcuticular Vaginal mucosa 1. Identify apex 2. Begin suturing 1.0 cm above apex 3. Continuous sutures 4. Ends at the level of vaginal opening
  • 90. IMMEDIATE MANAGEMENT AFTER THE DELIVERY  EARLY POSTPARTUM MANAGEMENT: The hours immediately following delivery and the birth of the placenta are a critical period as postpartum haemorrhage can occurs due the relaxation of the uterus. The patient is kept in the delivery suite for 1 hour postpartum under close observation. She is check for bleeding, the blood pressure is measured, and the pulse is counted. Before discharging the patient from the delivery suit it is mandatory:  To check the uterus frequently to make sure it is firm and not relaxing.  To remove any presence of intrauterine blood clots. The presence of these clots will interfere with retraction and the normal haemostatic mechanism of the uterus.  To look at the introitus to see that there is no haemorrhage.  To keep the bladder empties because full bladder can also interfere with uterine retraction.  To examine the baby to be certain that it is breathing well and that the colour and tone are normal.