MODERATOR: Dr Rita Mittal PRESENTED BY:Dr.

Ekawali

STAGES OF LABOUR
Dynamic

and continuous process Divided into three functional stages for the purpose of management

First stage: starts with the onset of true labour pains and ends with full dilatation of the cervix Second stage: starts from the full dilatation of the cervix and ends with the expulsion of the fetus from the birth canal Third stage: begins with expulsion of the fetus and ends with expulsion of the placenta and membranes

FUNCTIONAL DIVISION OF LABOUR

Friedman developed the concept of three functional divisions of labor to describe their physiological objectives The preparatory division during which although the cervix dilates little, its connective tissue components change considerably. It includes latent phase and acceleration phase of active phase

During the dilatational division the dilatation proceeds at its most rapid rate. It occupies the phase of maximum slope. The pelvic division commences with the deceleration phase of cervical dilatation and includes 2nd stage of labor as well.

CLINICAL COURSE OF FIRST STAGE

Also called cervical stage of labour Lasts for 12 hours in primigravidae and 6 hours in multiparae On the basis of rate of cervical dilatation it is divided into 2 phases- latent and active

LATENT PHASE
The latent phase corresponds to the preparatory division As defined by Friedman the onset of latent labor is the point at which the mother perceives regular contractions It ends at between 3 to 4 cms for most women

In PGR the latent phase is 8 hours long during which effacement occurs and dilatation occurs later at a rate of 0.35 cm/hr In multiparae the latent phase is about 4 hrs long and dilatation and effacement occur simultaneously

Prolonged latent phase: lasts for more than 14 hours in multiparae and more than 20 hours in primigravidae. Factors which affect the prolongation include excessive sedation, epidural analgesia, thick uneffaced and undilated cervix.

In Active phase cervix dilates from 3 to 4 cms to full dilatation During the peak of the active phase of labour cervix dilates at a rate of 1cm/hr in primigravidae and 1.5 cm/hr in multiparae

Disorders of active phase include protraction and arrest disorders Protraction is defined as either slow rate of cervical dilatation(<1cm/hr in PGR and < 1.5cm/hr in multigravidae) or slow rate of descent( < 1cm/hr in PGR and <2cm/hr in multigravidae)

Arrest disorders are defined as complete cessation of cervical dilatation for atleast 2 hours or complete cessation of descent for 1 hour

PRINCIPLES OF MANAGEMENT
Rapid initial assessment Reassessment and intervention if labor becomes abnormal Close monitoring of the fetal and maternal condition Adequate pain relief Adequate hydration Emotional support

1. 2. 3. 4. 5. 6.

When a woman reports with labor she should be admitted and diagnosis of labor is confirmed True labor is characterised by Regular pain with hardening of uterus Increasing frequency increasing intensity discomfort occuring mainly in the back and abdomen not affected with sedation associated with cervical changes

INITIAL ASSESSMENT

It includes detailed history, general physical examinatiopn, state of hydration, per abdomen, per speculum and per vaginum and basic investigations

    

Height of uterus Lie and Presentation Level of presenting part in fifths Contractions in 10 minute period ( frequency, duration and intensity) Fetal heart sound- after the contraction for a minimum period of 1 minute every 30 minutes in 1st stage(ACOG 2007)

LEVEL OF PRESENTING PART

PER SPECULUM
Abnormal discharge Evidence of rupture of membrane( on coughing, ph test, nitrazine test) Colour of amniotic fluid

PER VAGINUM

Bishop score and pelvic assessment is performed.

BISHOPS SCORE
PARAMETER S DILATATION 0 1 2 3 CLOSED 1-2 3-4 5+

CERVICAL LENGTH CONSISTEN CY POSITION STATION

2 MEDIUM MIDLINE -2

1 SOFT ANTERIOR -1,0

FIRM POSTERIOR -3

+1,+2

PELVIC ASSESSMENT
Empty the bladder Lithotomy position Sacral promontory Curve of sacrum from above downwards and side to side Sacrosciatic notch Ischial spines and inter ischial diameter Sidewalls

Ileopectineal lines Posterior surface of pubis symphysis Pubic arch and pubic angle Transverse diameter of the outlet

INVESTIGATIONS
Haemoglobin Blood group and type Urine for proteins, sugar

After the initial assessment if the membranes are intact and contractions are adequate nothing active is to be done except for hydration If membranes have ruptured and contractions are adequate the patient is to be given antibiotics with iv fluids If there is premature rupture of membrane the patient is started on antibiotics with active management of labor

Oral intake should ideally be restricted because of chances of vomiting, gastric aspiration and Mendelsons syndrome should general anesthesia be required But it contributes to dehydration and ketosis It is therefore ideal for women to take clear fluids and clear soups An enema is also given in early stage

Women should not be confined to bed in early labour dorsal position causes aortocaval compression and should be discouraged

Patient is encouraged to pass urine by herself ( full bladder inhibits descent of head and bladder hypotonia) If she cant go to toilet she is given a bed pan

IV FLUIDS
Labor increased energy consumption ketosis impaired myometrial function dysfunctional labor 60-120ml/ hr Ringer lactate- Na 130, K 4, Ca 3, Cl 109, HCO3- 28 ( Total 273) 0.9% NaCl- Na154, Cl 154 ( Total 308)

ANALGESIA AND ANESTHESIA

PROGRAMMED LABOR: protocol for labor management (Daftary et al 1977, 2001, 2003) with the dual objective of providing pain relief during labor and reaching the goals of safe motherhood by optimizing obstetric outcome Rests on 3 pillars of: 1. Ensuring adequate uterine contractions Active management of labor. 2. Providing optimum pain reliefUse of analgesics and antispasmodics. 3. Close clinical monitoring of labor events Maintaining a PARTOGRAM.

Dilute an ampoule of 30 mg pentazocine or Fortwin with a diluent like normal saline/distilled water Dilute an ampoule of diazepam in 10 ml of diluent. Administer 1/5 of each drug, i.e. 6.0 mg of Fortwin and 2.0 mg of diazepam, slowly in bolus form through the tubing of the infusion line (Ganla et al 2000, Guseck 1952).

Administer inj. Tramadol in the dose of 1 mg/kg body wt. intramuscularly an antispasmodic like Inj. Drotin 40 mg,(other alternatives include Inj.Buscopan, or Epidosin, as per clinicians choice

MANAGEMENT OF ACTIVE PHASE

PARTOGRAPH-It is a pictorial representation of the key events in labour presented chronologically on a single page 3 COMPONENTS-maternal, fetal and progress of labor Maternal-hydration, pulse, blood pressure. Respiratory rate, temperature, urine output and urine for albumin, sugar and ketones

Fetal-heart rate Progress of labor-dilatation, effacement, station, uterine contractions

A line of acceptable progress is drawn on the partograph called the alert line. It has conventionally been based on the slowest tenth percentile rate of cervical dilatation observed in women who progress without intervention and deliver normally( 1cm/hr) Another line is drawn parallel and 2-4 hrs to the right of this alert line called the action line

On admission the cervical dilatation should be plotted on the partograph provided the diagnosis of labour is made along with all other parameters If the progress of labour falls to the right of the action line amniotomy alone or oxytocin may be needed to correct the progress( active management of labor)

ACTIVE MANAGEMENT OF LABOUR

Developed by ODriscoll in Dublin who pioneered the concept that a disciplined, standardized labor management protocol reduced the number of cesarean delivery-it is now referred to as active management of labor Two of its components are amniotomy and oxytocin

oxytocin

Oxytocin titration technique

drops/min 2units in 500 ml, at 20 drops/minute 40 drops 60 drops 8 units in 500 ml, at 20 drops/ minute 40 drops 60 drops mu/min 4 8 16 16 32 64

Amniotomy
  

C/I-chronic hydramnios Procedure empty the bladder Lithotomy position Full asepsis two fingers are introduced in the cervical canal with palmar surface upwards Long kochers with hooks closed is introduced upto the membranes along the palmar aspect

Blades open to hold the membranes and torn by twisting movement If head not engaged the head should be pushed to the brim to prevent cord prolapse FHS should be recorded before and after the procedure Hazards-cord prolapse, abruption, injury to cervix, amnionitis

INTRAPARUM FETAL MONITORING

Goal is to detect hypoxia in labour and initiate management Either by intermittent auscultation or electrical fetal monitoring by CTG Intermittent auscultation is done using a stethoscope every 30 minutes in 1st stage and every 5 minutes in 2nd stage(ACOG) However information on baseline variability is not possible and detection of late decelerations may not be reliable

Continuous electronic fetal monitoring is done using ultrasound transducers one of which monitors FHS and the other duration and frequency of uterine contractions The fetal heart at term beats at a rate of 110-160bpm with baseline variability of 5-25 bpm and atleast 2 accelerations of 15bpm each of 15 seconds in 20 minute period

FEATURE

BASELINE

VARIABILITY

DECELERATI ONS

ACCELERATI ONS

REASSURING 110-160

NONE

PRESENT

NON100-109 REASSURING 161-180

<5 or >40 FOR < 90 MINUTES

EARLY AND VARIABLE SINGLE PROLONGED DECELERATI ON< 3MIN VARIABLE AND LATE PROLONGED DECELERATI ON >3 MIN

ABSENCE WITH OTHERWISE CTG IS OF UNCERTAIN SIGNIFICANC E

ABNORMAL

<100 >180 SINUSOIDAL PATTERN>10 MIN

<5 FOR > 90 MINUTES

CTG has low specificity so its verification is done using fetal blood sampling It is done using a vaginal amnioscope and requires ruptured membrane with atleast 3 cm cervical dilatation- scalp wiped clean-liquor excluded from sample with mother in left lateral position

The sample is analysed for acid base balance and base deficit which is interpreted as follows 7.25 it should be repeated if FHS abnormality persist 7.21-7.24 repeat after 30 minutes 7.20 immediate delivery indicated

REPEAT VAGINAL EXAMINATION

Following rupture of membrane During active phase every 4 hours If any intervention is contemplated To confirm onset of second stage

CLINICAL COURSE OF SECOND STAGE

Begins with full dilatation of cervix and ends with expulsion of fetus The labour pains increase in intensity , duration and come at intervals of 2-3 minutes Additional voluntary expulsive effort appears called bearing down effort Membrane may rupture with gush of liquor

On per abdomen there is progressive descent of the head and change in position of FHS more midline and downwards On per vaginum there is descent of head in relation to ischial spines With descent of head there is distention of perineum and vulval opening looks like a slit with scalp hair visible through it

Gradually the vulval opening becomes more circular Adjacent anal sphincter is stretched and stool may come out The head recedes after the contraction When the maximum diameter of head stretches the vulval outlet and there is no recession of head it is referred to as crowning

The head is born by extension followed by delivery of shoulders and trunk After that a gush of hind water follows often tinged with blood

MANAGEMENT OF 2nd STAGE

 

PRINCIPLES To assist in natural expulsion of fetus slowly and steadily To prevent perineal injury

GENERAL MEASURES Patient should be in bed FHS is monitored every 5 minutes Per vaginum is done to confirm the onset of 2nd stage, to rule out cord prolapse and to assess progress of labour

  

PREPARATION The patient should ideally be placed in dorsal position with 15 degree left lateral tilt The external genitalia and inner side of thigh is toileted with cotton swabs soaked in septic solution One sterile sheet is placed beneath buttocks and one on abdomen and sterile leggings are put Bladder is emptied if full

Conduction of delivery is divided into delivery of head, shoulders and trunk DELIVERY OF HEAD Principles: Maintain flexion Prevent early extension Regulate its slow escape out of vulval outlet in between the pains Patient is encouraged to bear down

  

When the scalp is visible for 5 cm flexion is maintained by pushing occiput downwards and backwards by using thumb and index finger of left hand while giving good perineal support by right palm with sterile vulval pad When the perineum is fully stretched and threatens to tear episiotomy is given after perineal infiltration with 10 ml of 1% lignocaine

RITZEN MANEUVER

Slow delivery of the head in between contractions is accomplished by pushing chin with sterile towel covered fingers while left hand exerts pressure on occiput( ritzen maneuver) The forehead, nose, mouth and pharynx is wiped with gauze or mechanical or electrical sucker may be used Eyelids are wiped with sterile wet cotton swabs Neck is then palpated for presence of cord

If the cord is loose it should be slipped over head and shoulders If the cord is tight it is cut in between two pairs of kochers forceps placed one inch apart

DELIVERY OF SHOULDERS
Do not be in haste Wait for restitution and external rotation During the next contraction anterior shoulder is born behind symphysis followed by the posterior shoulder which is delivered out of perineum Delivery of the shoulders is followed by delivery of the trunk

Cord is clamped by two kochers forceps one 5 cm from umbilicus, 1 inch apart and cut

Role of episiotomy
   

To enlarge the introitus To minimise overstretching and rupture of perineal muscles To reduce stress and strain on fetal head INDICATIONSRigid perineum Anticipating perineal tear eg big baby, breech, shoulder dystocia Operative delivery Previous perineal surgery

Mediolateral- from midpoint of fourchette, downwards and outwards, 2.5 cms away from anus Medial- centre of fourchette, along midline for about 2.5 cms

THANK YOU