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MANAGEMENT OF LABOUR

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Title: MANAGEMENT OF LABOUR


1
MANAGEMENT OF LABOUR
  • SALWA NEYAZI
  • CONSULTANT OBSTETRICIAN GYNECOLOGIST
  • PEDIATRIC ADOLESCENT GYNECOLOGIST

2
MANAGEMENT OF LABOUR
  • WHAT IS LABOUR?
  • Regular frequent uterine contractions
  • Cx changes (dilatation effacement)
  • or
  • SROM
  • WHAT ARE THE GOALS OF LABOUR MNAGEMENT?
  • To reduce maternal mortality morbidity
    resulting from complications of labour/delivery
    postpartum
  • To reduce intrapartum fetal mortality
  • To reduce birth aspyxia
  • To reduce the cesarean section rate
  • To improve maternal satisfaction of the birthing
    experience
  • To relieve maternal anxiety pain during labour

3
PHASES OF LABOUR
  • FRIEDMANS CURVE

10-
DECELRATION PHASE
8-
Cervical dilatation
6-
ACCELRATION PHASE
4-
???????LATENT PHASE???????
2-
??ACTIVE PHASE??
6

8
10
2
4
Duration of labour
4
LABOUR TIME FRAMES
Phases/ Stages of labour Phases/ Stages of labour Nulliparous Multiparous
Latent phase Mean time 6.4 h 4.8 h
Latent phase Longest normal 20.1 h 13.6 h
Active phase Mean rate 3 cm/h 5.7cm/h
Active phase Slowest normal 1.2cm/h 1.5cm/h
2nd Stage Mean time 1.1 h 0.4 h
2nd Stage Longest normal 2.9 h 1.1 h
5
MANAGEMENT OF LABOUR
  • 1- Labour preparation ? Prenatal educational
    classes
  • ? amount of analgesia used in labour
  • Improve maternal stisfaction
  • 2-Birthing companion ? A supportive companion
    with experience of labour (not trained in health
    discipline) ? faster progress less dystocia
  • 3-Ambulation
  • ? the incidence of dystocia ?? augmentation ?
    operative delivery
  • ? pain percieved by the woman ? ? analgesia
    epidural
  • Supine position ? antroposterior compression of
    the pelvis/ ? the size of the passage

6
MANAGEMENT OF LABOUR
  • 4-Analgesia
  • Epidural
  • Nitrous oxide
  • Narcotics

? pain anxiety
? Catecholamines
Dystocia
?Uterine Contraction strength
?Uterine blood flow
7
  • 5-Contiuous assessment of progress of labour
  • THE PARTOGRAM

8
MANAGEMENT OF LABOUR
  • 6-Amniotomy
  • Routine early use of amniotomy after 3 cm
    dilatation ?
  • Shortens the average length of labour
  • Does not ? the incidence of CS
  • 7-Fetal size
  • ? fetal size ? ? duration of labour

9
FACTORS INFLUENCING LABOUR
  • WHAT IS DYSTOCIA?
  • 4 hrs of lt 0.5 cm/ hr dilatation
  • 1 hr with no descent
  • Dystocia cannot be diagnosed before the onset of
    labour
  • WHAT ARE THE CAUSES OF DYSTOCIA?
  • 3 Ps
  • POWERS ? Hypotonic contractions
  • PASSENGER ? Fetal position
  • Fetal size
  • PASSAGE ?Boney pelvis
  • Soft tissue

10
  • How to assess these factors?
  • Adequate powers ? contractions that
  • -last for 60 sec
  • -reach 20-30 mmHg of pressure
  • -occur every 1-2 min
  • Hypotonic contractions are responsible for 2/3 of
    nulliparous dystocia
  • If powers are adequate ? check Passage for size
    abnormal shape and check the Passenger for size
    malpresentation
  • What is the importance of diagnosing dystocia?
  • Dystocia elective repeat CS account for the
    majority of CS indications
  • There has been dramatic ?in CS rate with ? in
    maternal mortality, morbidity, neonatal morbidity
    health care costs, reducing Dystocia ? ? CS rate

11
PHILPOTTS CERVICOGRAPH
  • Cervicograph should not be used until active
  • labour has been established 3-4 cm dilatation

10-
8-
Action line
Cervical dilatation
6-
Alert line
4-
2-
6

8
10
2
4
Time (hr)
12
TREATMENT OF DYSTOCIA
  • 1-Oxytocin 2-Active management of labour
  • 3-Instrumental deliveries 4-CS

ADVERSE EFFECTS OF OXYTOCIN
ADVERSE EFFECTS MECHANISM PREVENTION
Fetal compromise Hyperstimulation Correct dose
Uterine rupture Hyperstimulation Correct dose
Hypotension Vasodilatation Low dose infusion
Water intoxication ADH effect Limit free water
13
PRINCIPLES OF ACTIVE MANAGEMENT
  • Accurate diagnosis of labour
  • Continuous assessment of the progress of labour
  • One to one nursing care
  • Early amniotomy
  • Oxytocin
  • Benefits of active management
  • Significant reduction in dystocia instrumental
    deliveries CS rate
  • No increase in birth asphyxia or perinatal
    mortality

14
ACTIVE MANAGEMENT OF LABOUR
Active Control
Labour gt12 hrs 7 20
Forceps 19.4 29
CS 4.3 13
15
PREVENTION OF DYSTOCIA
  • Avoid unnecessary inductions
  • Induction is associated with increase
    incidence of Dystocia DX in the latent phase of
    labour increase in obstetric interventions
  • Admit only women inactive labour
  • Encourage prenatal classes labour companion
  • Ambulate in labour
  • Use appropriate analgesia
  • Active management of labour

16
MANAGEMENT OF POSTPARTUM PATIENTS
17
PUERPERIUM
  • It is the period after delivery during which
    there is rapid return to normal health the
    normal prepregnancy body physiology . It lasts
    around six wk
  • There is a high prevelance of maternal morbidity
    in the immediate postpartum period (85) , in the
    1st 8 wk postpartum 87 continuing problem in
    47-76
  • Maternal mortality most maternal morbidity
    except for piles stress incontinence are more
    after CS
  • Vacuum extraction results in less maternal trauma
    pain than forceps without increasing the need
    for CS

18
PROBLEMS THAT MAY BE ENCOUNTERED IN POSTNATAL WARD
  • 1-Afterpains ? due to myometrial contractions
  • ? with breast feeding
  • Improve with NSAID
  • 2-Post partum hemorrhage (5-10)
  • -Routine use of oxytocics in the third stage
    of labour ? ? blood loss by 30-40
  • -It is more likely to occur in the delivery
    room the first 1-2 hrs after delivery
  • - Most commonly due to suboptimal contractions
    of the uterus or abnormal implantation site of
    the placenta (low laying ) at which bleeding can
    not be controlled by uterine contractions
  • -RPOC endometritis can result in PPH several
    days after delivery

19
  • What can we do if a Pt has PPH in the postnatal
    ward?
  • Start IV line
  • Send blood for CBC/X-matching /Coagulation
  • Feel the level of the fundus ? normally midway
    between umbilicus symphesis pubis ? may be
    distended with blood clots inside it ? inadequate
    uterine contraction
  • Uterine massage
  • Start IV syntocinon drip/ ergometrin
  • PG F2a NALODOR IM /IV or intramyometrial
  • U/S to R/O RPOC
  • Check for unnoticed perineal, vaginal or cevical
    lacerations
  • Exploration under GA

20
  • 3-Anemia (25-30)
  • 4-Fever
  • Common causes of fever
  • -Breast engorgement
  • -UTI 2-5
    days after delivery
  • -Endometritis
  • Prophylactic antibiotics at the time of CS ? ?
    serious infections , febrile morbidity wound
    infection
  • PROM predispose to endometritis
  • 5- RH ve mothers with RH ve babies should
    receive Anti-D 300 µgm within 72 hrs of delivery

21
  • 6-Thrombosis pulmonary embolism
  • Accounts for 23 of direct maternal deaths
  • After CS 69 / after ND 48
  • Risk factors ? obesity, immobilization,
    previous thromboembolism, increasing maternal age
    operative delivery
  • Prophylaxis for the high risk gp reduces the
    risk
  • May appear after the 3rd day death occur 7th D
    in 2/3 of cases
  • Pelvic thrombophlebitis ? following endometritis
  • Causes pain fever
  • Dx by exclusion
  • Rx Ab Heparin

22
  • 7-PET ECLAMPSIA
  • 35 of eclampsia can occur for the 1st time in
    the postnatal period
  • Close monitering of BP proteinurea should
    continue after delivery for Pt with PET or
    eclampsia appropriate measures taken if the
    problem persists
  • We should ignore alarming symptoms like headache
    , vomitting epigastric pain
  • 8- BOWEL PROBLEMS
  • Constipation 20 ? Local acting laxatives
  • high fiber
    diet
  • Hemorrhoids 18 ? 70 last more than 1 year ?
    Avoid constipation
  • Xyloproct suppositories
  • Inability to control flatus or faeses 4

23
9-PERINEAL CARE
  • Perineal pain occur in 42 of women after
    delivery persists beyond the 1st 2 M in 8-10
    after SVD
  • Mediolateral episiotomy causes more pain than
    median episiotomy
  • 50 dyspareunia on 1st restarting intercourse
    15 continue to have it 3 Y later
  • After assissted vaginal delivery ? 84 will have
    perineal pain
  • 30 after the 1st 2 M
  • The choice of suture material has a long term
    effect on dyspareunia
  • Analgesics should be used for relief of perineal
    pain ? Paracetamol/ Brufen/ Ponstan
  • Sitz bath for pain relief
  • To keep the area clean dry
  • Pelvic examination ? to R/O hematoma

24
10-URINARY TRACT PROBLEMS
  • Urinary retention is mainly due to bladder edema
    hyperemia
  • -Perineal pain can add to the problem by
    causing reflex retention
  • -Paralyzing effect of the epidural
  • If the Pt does not void for 6-8 hrs or has
    frequent small voids ? cathterization
  • UTI ? -especially if the Pt has been catheterized
    in labour
  • -2ry to urine retension
  • Urinary frequency
  • Stress incontinence 20 3M after delivery
  • ¾ of them still incontinent after 1 year

25
11-DEPRESSION TIREDNESS
  • Depression 10-15 within the 1st year
  • Tiredness 42 in hospital
  • 54 at home 1st 2 months
  • Supportive care counseling
  • 12-BREAST PROBLEMS
  • Nipple pain / engorgement/ cracks bleeding
  • ?66
  • -Rx ? To teach the mother the correct way of
    BFeeding
  • ? Local heat
  • Analgesics
  • Breast feeding/pumping to reduce
    engorgement
  • Keeping the nipple clean
  • Applying emollients Bepanthene
    cream/ breast milk
  • Nipple shield
  • Mastitis/breast abscess ? not contraindication to
    breast feeding
  • -Usually 2-3 wk after delivery
  • -Requires Antibiotics continued breast
    feeding or pumping
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