Management of normal labour

Note that the characteristics of normal labour include:

-No pregnancy complication that may affect the labour

-Spontaneous onset of labour between 37 and 42 weeks of gestational age

-Clear liquor

-Normal maternal observations

-No intrapartum bleeding

-Acceptable rate of cervical dilatation

-No fetal or maternal distress.

-Normal delivery within 1 hour of good expulsive effort unless delivery is imminent (e.g in shoulder dystocia , in which the 1 hour duration can not be used)

-Intact perineum, first or second degree tear.

-Total post partum blood loss of less than 500 ml for vaginal delivery

____________________________________________________________________________

Outline

1.Onset of labour

2.Phases of labour

3.Management of latent phase of labour

-Monitoring

4.Management of active phase of labour

-Amniotomy

-Stages of labour

-Analgesia

-Monitoring using partogram and CTG tracing

-Mechanism of labour

-Conducting a labour

-Position

-Crowning

-Delivery of head

-Delivery of shoulder

-Delivery of whole body

-Cord clamping

-Episiotomy

-Placenta separation

-Controlled cord traction

-Repair episiotomy wound

____________________________________________________________________________

1.Onset of labour

Labour is characterized by regular uterine contraction leading to progressive effacement and dilatation of cervix followed by expulsion of fetus. Note that the labour process starts with regular uterine contraction.

Therefore, when patient came with regular contraction pain, and there is regular contraction during per abdomen assessment, we should treat patient as in labour.

Cervical effacement will occur first followed by cervical dilatation

____________________________________________________________________________

2.Phases of labour

When patient is diagnosed as in labour, we should determine in what phase of labour she is. There are 2 phases of labour 1)Early/latent phase 2)Active phase. Early phase of labour starts from the onset of labour until the beginning of active phase of labour. Active phase of labour starts from the cervix is 3 cm dilated to full dilatation, that is 10 cm, with regular uterine contraction.

Phases of labour

____________________________________________________________________________

3.Management of latent phase of labour

Patient in early phase of labour should be managed in antenatal ward. In ward regular monitoring should be done. Monitoring should include : 1)Vital signs 2)pad chart 3)uterine contraction 4)Vaginal examination, when clinically indicated such as strong contraction 5)Fetal heart rate 6)Fetal kick chart 7)CTG

Once patient has entered active phase of labour, she should be sent to labour room.

____________________________________________________________________________

4.Management of active phase of labour

Patient is sent to labour room. Patient history and problems are reviewed. Abdominal examination is done and CTG probes are attached to patient abdomen. Vaginal examination is also done. Amniotomy is done if the amniotic membrane still intact.

Amniotomy / artificial rupture of membrane done using amniotic hook

Determine which stage of labour patient in. There are 3 stages of labour. First stage of labour starts from onset of labour umtil full dilatation of cervix that is 10 cm. Second stage starts once cervix is fully dilated until fetal delivery. Third stage begins once the fetus is delivered until delivery of placenta..

Stages of labour

Patient in first stage of labour is monitored using partogram and CTG tracing. Analgesia usually required during this stage.

Partograph

Example plotted partograph of one patient

Normal CTG

CTG machine

Once patient entered second stage of labour, patient is encouraged to bear down with each contraction. Delivery is conducted in proper techniques, based on the mechanism of labour.

Mnemonic for mechanism of labour (a lil dirty but you will remember it) : Every Damn
Female I Eat Returns Eagerly (Engagement, Descent, Flexion, Internal rotation, Extension,
Restitution, External rotation), followed by deliver of anterior shoulder,
posterior shoulder and whole body

Once patient entered second stage, she is put in lithotomy position as in this picture,
and encourage to bear down. This picture also showing 'crowning', which occur when
the widest part of fetal head is encircled by vulvar ring. Episiotomy is done during this time

Episiotomy is usually done in order to avoid extensive perineal tear, which is more difficult to repair, and has more complication. It is done during crowning.

Episiotomy

Delivery of head. Ritgen's menouver can be used to guard and guide
the perineum during delivery of head. This technique can facilitate
the head delivery and reduce risk of extensive perineal tear.

Ritgen's menouver. The fingers of right hand, pressing posterior to rectum,
are used to extend the head while counterpressure is applied to the occiput
by the left hand to allow for a more controlled delivery of the fetal head.

Once the head delivered, let the head turn to one side spontaneously
as restitution occur, in which the fetal head realign with the shoulder

Once the whole body is delivered, the cord is clamped

Third stage of labour begins once whole fetus is delivered. However in the second stage, the management should be started already, which is syntometrine administration, given after delivery of anterior shoulder.

Before the placenta is delivered, look for signs of placenta separation.1)Uterus become globular. 2)lengthening of cord. 3)Gushing of blood.

Once there is signs of placenta separation, the placenta can be delivered using controlled cord traction technique