Created by: HANIFA INSANI KAMAL M.

ZAIDI IMAWAN RINALDI

SUPERVISOR: Dr. Fadjrir, Sp.OG

 From

the Latin word labor: troublesome effort or suffering parturire: to be ready to bear young partus: to produce

physiologic process that begins with the onset of rhythmic contractions which brings about changes in the biochemical connective tissue resulting in gradual effacement and dilation of the cervix and ends with expulsion of the product of conception

 Uterine

Contractions (at least 1 in 10 mins or 4 in 20 mins) by direct observation or electronically

progressive changes in cervical dilation and effacement

Documented

Cervical
Cervical

effacement of >70-80%
Dilation >3 cm

TRUE LABOR
Regular Contractions Decreasing intervals (shortened) Increasing intensity

FALSE LABOR
Irregular Contractions Irregular and long intervals Same intensity or go away spontaneously Lower abdomen discomfort

Lower abdomen and low back pain

Cervical Dilation

No cervical change or cervix does not dilate

 Depends

on:

Power Passenger Passageway

 Fetal

Lie

Longitudinal Lie

Transverse Lie

Oblique Lie

 Fetal

Presentation

Compound Presentation

Cephalic Presentation

Vertex (SOB)-9.5cm

Sinciput (OF)-11.5cm

Brow Face (OM)-12.5cm (SMB)-9.5cm

Breech Presentation

Complete Breech Frank Breech Incomplete Breech Single Footling Breech Double Footling Breech

 Fetal

Attitude or Posture

Head flexed Chin close to chest Extremities close to the body Back curved

Fetal

Position: chosen portion of the fetal presenting part

Occiput in cephalic presentation Sacrum breech presentation Chin/mentum face presentation Acromion/scapula shoulder presentation

Cephalic Presentation Occiput anterior (OA) Right Occiput Anterior(ROA) Left Occiput Anterior(LOA) Right Occiput Transverse (ROT) Left Occiput Transverse(LOT) Right Occiput Posterior (ROP) Left Occiput Posterior(LOP) Occiput Posterior(OP)

Breech Presentation Sacrum Anterior (SA) Left Sacrum Anterior (LSA) Right Sacrum Anterior (RSA) Right Sacrum Transverse (RST) Left Sacrum Transverse (LST) Right Sacrum Posterior (RSP) Left Sacrum Posterior (LSP) Sacrum Posterior (SP)

 Fetal

Station: degree of descent of the presenting part of the fetus from the ischial spines

 Number

of fetuses
of fetal anomalies

Presence Fetal

size

Consists of the bony pelvis and soft tissues of the birth canal
pelvic outlet can result in cephalopelvic disproportion for assessment

Small

Pelvimetry:

 Leopolds

Maneuver Internal Examination Auscultation Imaging Studies

 Involves

the cardinal movements of labor:

Engagement Descent Flexion Internal rotation Extension External rotation expulsion

Positional

changes in the presenting part of

the fetus

 Passage

of the widest diameter of the fetal presenting part below the plane of the pelvic inlet due to lateral inclination of the fetal

Asynclitism:

head

Anterior Asynclitism (Naegeles Obliquity) Sacrum Posterior Asynclitism (Fritzmanns Obliquity) Symphisis Pubis

 Pressure

of the amniotic fluid Direct pressure of the fundus upon the breech with contractions Bearing down efforts of maternal abdominal muscles Extension and straightening of the fetal body

 Resistance

of the birth canal on descent Shorter suboccipitobregmatic diameter(9.5 cm)

 Descent

will not occur without it Sagittal suture is now oriented anteroposteriorly (occiput is anteriorly oriented)

 Head

up in extension 2 forces:

Force exerted by the fundus Force exerted by the resistance of the pelvic floor and the symphysis pubis, anteriorly

 The

head back to its original position One shoulder is anterior behind the symphysis pubis and the other is posterior

 Almost

immediately after external rotation The perineum thins out As the shoulder passes out, the rest of the body follows

 1ST

STAGE: onset of labor until full cervical dilation (Latent and Active Phase)
STAGE: from full cervical dilation of 10 cm until delivery of the baby STAGE: from delivery of the baby up to the delivery of the placenta STAGE: the next 2 hours following the delivery of the placenta.

2ND

3RD

4TH

 Preparatory

Division

Latent Phase Acceleration Phase

Dilatational

Division

Phase of Maximum Slope

Pelvic

Division

Deceleration Phase Second Stage concurrent with the phase of maximum slope

 Latent
Active

Phase
Phase

Acceleration Phase Phase of Maximum Slope Deceleration Phase

 Complete

history and PE Abdominal Exam Pelvic Exam (Speculum Exam) Internal Examination

Cervical dilation and effacement Position of the cervix Cervical dilation and effacement Fetal Station Status of the fetal membrane

ROM Character of fluid

 Vital

Signs Uterine Contractions Cervical Changes Fetal Heart Tones

 Induction

of Labor: an intervention designed to artificially initiate contractions leading to progressive dilation and effacement of the cervix and birth of the baby (RCOG,2002)

Confirmation of Parity Confirmation of Gestational Age Presentation Bishops Score Uterine Activity Non stress Test

FACTOR

Cervical Dilation (in cm)

Cervical Effacement (%) Station Cervical Consistency Cervical Position

Closed

1-2

3-4

>=5

0-30

40-50

60-70

>80

-3 Firm posterior

-2 Medium midposition

-1 soft Anterior

+1, +2

It should only be implemented on a valid indication (Level I, Grade C)

Gestational HTN Pre eclampsia, eclampsia Prelabor rupture of the membranes Maternal medical indications Gestational >= 41 1/7weeks Evidence of fetal compromise Intraamniotic infection Fetal demise Logistic factors for term pregnancy

Contraindications:

Malpresentation Absolute cephalopelvic disproportion Placenta Previa Previous major uterine surgery or classical CS Invasive carcinoma of the cervix Cord presentation Active genital herpes Gynecological, obstetrical, or medical conditions that prelude vaginal birth Obstetricians convenience

OXYTOCIN

Oxytocin augmentation is a major intervention and should only be implemented on a valid indication. (Level I, Grade C) When induction of labor is undertaken with oxytocin, the recommended regimen is a starting dose of 1-2 mU/min and is increased at intervals of 30 mins or more. The minimum dose should be used and this should be titrated against uterine contractions aiming for maximum of 3-4 contractions every 10 mins. (RCOG, Grade C) Regular observations of uterine contractions and FHT should be recorded every 15 to 30 minutes and with each incremental increase of Oxytocin.

 MEMBRANE

SWEEPING/STRIPPING

Increases local production of prostaglandins

AMNIOTOMY

Artificial rupture of the membranes

 Continued

lack of progression into the active

phase
Nulliparous

women could safely remain in the latent phase for 12 hours is not reasonable to allow up to 18 hours of latent labor before recommending CS.

It

 Duration:

50 minutes: Nullipara 20 minutes: Mutlipara

Fetal

Heart Tones: every 15 minutes Ritgen Maneuver

 Molding
Caput

fusion of the parietal bones

- swelling

 Placental

Separation

Calkins Sign Sudden gush of blood Uterus rises in the abdomen(tilted) The umbilical cord rises

Mechanism

of Placental Separation

Duncan: peripheral separation Schulze: central separation

 Lacerations

of the Birth Canal

1st degree: fourchette, perineal skin, vaginal mucosa 2nd degree: above + fascia and muscles of the perineum 3rd degree: above + anal sphincter 4th degree: above + rectal mucosa

 Purpose:

to facilitate the 2nd stage of labor to improve maternal and neonatal outcome
Maternal Benefit

Reduced risk of perineal trauma, subsequent floor dysfunction and prolapse, urinary and fecal incontinence, and sexual dysfunction Shortened 2nd stage of labor

Fetal Benefit

Timing

Too early: increased blood loss Late: laceration may not be prevented

 Indications

Expedite delivery in the 2nd stage When spontaneous laceration is likely Maternal or fetal distress Assisted forceps delivery Large Baby Maternal exhaustion

 Kinds

of Episiotomy

 Routine

vs. Restrictive Episiotomy

repair of laceration

Episiorrhaphy:

Suture Materials and Technique

2 layered closure can improve postpartum pain and healing complications vs a 3 layered closure. There is good evidence to support the use of Fast Absorbing Polyglactin 910 as a material of choice for perineal closure. (Level I, Grade A) Continuous Suturing vs. Interrupted

 Recommendations:

Administration of prophylactic uterotonin within one minute after the delivery of the baby and prior to the delivery of the placenta Early cord clamping and cutting

Clamping: never above the introitus Delaying the clamping? 3:80:60

Controlled cord traction to deliver the placenta

Giving Uterotonins -> increased uterine contractions/retraction -> total detachment and expulsion of the placenta -> optimal occlusion of the myometrial vessels -> PPH prevented The use of combination preparation (Oxytocin and Ergometrine) appears to be associated with a statistically significant reduction in the risk of PPH when compared to oxytocin alone where blood loss is less than 1000mL. (Level I, Grade B).

 Administration

of oxytocin alone is as effective as the use of oxytocin plus ergometrine in the prevention of PPH, but is associated with a significantly lower rate of unpleasant maternal side effects (nausea, vomiting and hypertension). (Level II, Grade B)

 Recommended

Dose:

Ergometrine 200-250 mcg IM OR 100-125 mcg IV bolus Oxytocin 10 u/500mL NSS (20 u/1000mL NSS)

Continuous IV drip OR 5 u IV bolus

 Recommendations

Oxytocin is effective as 1st line prophylactic uterotonic during the 3rd stage of labor in the prevention of PPH and is safe to use in all patients. (Level I) Use of ergot alkaloid and Ergometrine-Oxytocin are valid alternatives in the absence of Oxytocin. Their use have to be weighed against maternal adverse effects. (Level I) Use of ergot alkaloid and Ergometrine Oxytocin combination have to be avoided in hypertensive patients. (Level I)

 Critical

period

Uterotonics Uterine Massage Ice pack

Breast

feeding

 Williams
POGS

Obstetrics, 22nd ed.

Clinical Guidelines on Normal Labor and Delivery, April 2009

IDENTITY
: Mrs.D : 33 years old : Housewife : Moeslem : Padang : Desember, 07th 2013 : 11.20 AM : Desember, 09th 2013

Name Age Occupation Religion Ethnic Date of arrival Time of arrival Date of out

 History

Taking

Mrs. D. 33 years old, with G3 P2 A0, padang, moeslim, housewife, as a wife Mr. R. 38 years old, java, Muslim, self-employee, come to Emergency unit Pirngadi hospital at Desember 07th,2013 at 11.28 with : Chief Complain : labour pain Explanation : it happened since Desember 07th,2013, at 05.00 P..M. Bloody show (+) in Desember 07th,2013 at 06.30 P.M. Water discharge (-), Urinary (+) normal, bowel (+) normal. Past medical history : Unclear History of Medication : Unclear Last menstruation periode Estimated date of delivery Ante natal care : 17-03-2013 : 24-12-2013 : - Bidan 6 x - Obstetrician 2 x

Physical Examination

Present Status
Sensorium Blood Preassure Heart Rate Respiration Rate Temperature : : : : : Compos mentis 130/80 mmHg 80 x/i 20 x/i 36,8 oC
Anemic Ikteric Syanotic Dyspnoe Oedema

: : : : :

Localize status
Head: Neck Thorax Eyes : Konj.palp.inf.pale (-/-) Sklera ikterik (-/-) : Limph node (-) : Respiration Sound : Vesikuler (+) Additional Sound : wheezing (-/-) : Asimetris enlargement : 4 fingers under proc.Cypoideus (30 cm) : Right : Head : (+) : (+) 2x30/10 : (+) 136 x/i, reguler : 3000 3200 gr.

Abdomen Fundal Height Streched Part Lower Part Movement Uterus contraction Foetal heart rate Estimated Baby Weight

VT : serviks sacral, eff 80%, Amnion sack (-), Hodge I ST : Bloody show (-), Amnion fluid (-).

Laboratorium report before delivery, 07th 2013:

Hb Ht Leukosit Trombosit : 12,3 gr/dl : 36,5 % : 10.000 /mm : 292.000 /mm

Desember,

Diagnosis : Multigravida + Intra uterin pregnancy (36-38) week + Head presentation + live fetal + Inpartu

Therapy

: -IVFD RL

20 drips/i

Planning : - Lead to labour - Monitoring vital sign, fetal heart rate, uterus contracttion

Normal labor and delivery report. In Desember 07th, 2013 at 07.00 PM, born a baby (male), weight 2900 gr, Lenght 45 cm, A/S : 8/9, Anal (+).

Patient lied at ginecology bed in Mc Robert position. In adequate uterus contraction, show head up and down in introitus vagina. and then fixed in adequate uterus contraction. Next, lead patien for straining. with subociput as hiponuklion, labour fontanela minor, fontanela mayor, fore head, face and all head, with biparietal holding, pulling down head to delivery front shoulder and pull up to delivery rear shoulder. Delivery a baby (male),weight 2900 gr, height 45 cm, A/S : 8/9, Anus (+), NBS : 37 match with (36-38) week pregnancy. The umbilical cord was clamp in 2 place and cut in the middle of. The placenta delivery by controling umbilical cord and impression complete. Evaluated the way born,show a laceration second grade and it repair.

Evaluated bleeding after repaired

clear.

Condition of the patient after spontaneous vaginal birth : well.

NEONATUS

Born status Date of birth Condition of the baby APGAR Score Ventilator Sex Weight Lenght Congenital anomali Trauma

: Single : Desember 07th, 2013 at 07.00 PM : Life and Health : 8/9 : Negative : Male : 2900 gram : 45 cm : Negative : Negative

Th/ :

- IVFD RL + oksitosin 10 IU - Amoxicilin 3 x 500 mg - Mefenamic acid 3 x 500 mg - B.complek 2 x 1

20 gtt/i

P/

- Blood test after 2 hour normal labor and delivery - monitoring vital sign, uterus contraction, haemorraghic status

Laboratorium result after 2 hour normal labor and delivery: Hb : 12,1 gram % Ht : 36,0 % Leukosit : 16.000 /mm Trombosit : 261.000 /mm

Stage IV
Time 20.15 20.45 BP 130/90 130/90 HR 80 86 RR 22 20 Uterus Contraction Strong Strong Urinary Sac Empty Empty Bleeding -

21.15
21.45 22.15

130/80
130/80 130/80

88
84 84

20
20 20

Strong
Strong Strong

Empty
Empty Empty

10cc 10cc

 Follow

up (Desember 08th, 2013)

(-) Sensorium: CM Blood Pressure :100/70 mmHg HR : 80 x/I RR :20 x/I Temp : 36,8 c Abdomen : soepel, peristaltik (+) Uteria fundal height :2 cm under umbilical Vaginal bleeding : (-) Urinate (+) Defecation (-) Post Spontaneus Vaginal Birth d/t Occipital Persentation + 2nd poerpurium day Amoxicilin 3 x 500 mg Mefenamat acid 3 x 500 mg B.Comp 2 x1

Chief Complain Vital Sign

Localize Status

Diagnosa Treatment

Case Analysis
Theory

Case

Sign of inpartu include bloody show and patient came with chief complain labour pain happened since Desember 07th,2013 contraction intensity gradually increase . with bloody show

Partus dibagi menjadi 4 kala. Pada kala I Pada pasien ini, keempat kala berhasil serviks membuka sampai terjadi dilakukan dengan baik. Pada pasien ini kala

pembukaan 10 cm. Kala I dinamakan kala II berlangsung selama 30 menit. pembukaan. Kala II disebut pula kala pengeluaran, oleh karena berkat kekuatan his dan kekuatan mengedan janin didorong ke luar sampai lahir. Pada primigravida kala II berlangsung 1,5 2 jam, sedangkan pada multigravida berlangsung 30 menit 1 jam. Dalam kala III atau kala uri plasenta

Post partum hemorage (PPH) is the lose 500 cc or more blood from the genital tract during 24 hours after birth a baby. It caused by 4T : - Tonus - Tissue - Trauma - Thrombin

In this patients we found laceration second grade of the perineum, and it has been repaired properly.

Problem List

As a general doctor in puskesmas, what can we do to avoid bleeding complication after delivery for mother with multigravida? What kind of contraception is the most suitable to this patient can we recommend?