Midwifery Module: Labor and Delivery

Module Information

• Module Name: Labor and Delivery
• Year Level: 3rd year
• Students: Midwifery students
• Instructor: Kerebih Abere (BSc, MSc)
• Email: [email protected]
• Date: October, 2023

Part One: Normal Labor and Delivery - Outline

• Introduction/Overview of the Module
• Physiology of Labor
• Mechanism of Labor
• Normal Labor
• Stages of Labor
• Management of Normal Labor
• Immediate Newborn Care (Day 7)
• Demonstration on Management of Normal Labor

Introduction...cont

• Maternal and child death rates are high in Ethiopia.
• Maternal death is defined as the death of a woman during pregnancy, childbirth, or within 42 days of the termination of pregnancy, regardless of the duration or site of the pregnancy. This includes deaths from any cause related to or aggravated by the pregnancy or its management.
• In 2020, 401 maternal deaths occurred per 100,000 live births.
• In 2020, 47 child deaths occurred per 1,000 live births.
• In 2020, 41 neonatal deaths occurred per 1,000 live births.
• Other health concerns in Ethiopia include reproductive health, gender violence, and STIs.

Cause of Onset of Labor

• The exact cause is unknown, but progressive hormonal changes, progressive mechanical changes, and other triggering factors are suspected.

Progressive Hormonal Changes

• Increased estrogen to progesterone ratio: near term, estrogen secretion increases, while progesterone secretion remains constant or decreases.
• Progesterone relaxes the uterus during pregnancy; its decrease allows the uterine muscles to contract.
• Increased oxytocin production near term stimulates uterine contractions and labor.
• Increased synthesis of prostaglandin in the decidua softens and ripens the cervix, facilitating cervical dilation and initiating labor.
• Mature fetus secretes cortisol, which decreases progesterone levels and raises estrogen and prostaglandin levels, stimulating labor.

Progressive Mechanical Changes

• Stretch of uterine musculature: as the baby grows, it stretches the uterine muscle. This stretching increases muscle excitation and stimulates prostaglandin production.
• Twins are often born 3 weeks earlier than singleton pregnancies due to a marked increase in uterine stretch.
• Stretch or irritation of the cervix: the baby's head or presenting part pushing against the cervix leads to cervical dilation and stimulates uterine contractions.

Other Triggering Factors

• Placental maturation: As the placenta ages, its efficiency in supporting the baby decreases.
• Biochemical factors: Biochemical shifts in the balance of enzymes, proteins, and other factors.
• Maternal stress and physical activity: some research suggests that maternal stress can influence labor onset.

Physiology of Labour

• Labor: the process that prepares the body for childbirth, involving uterine contractions.
• Delivery: the actual process of giving birth.
• Physiology of labor refers to the biological and physiological processes during childbirth, involving hormonal, muscular, and neural changes.

Myometrial Changes

• Myometrial Changes (Prelabor): Increased contractility: Myometrium becomes more responsive to stimuli, particularly to oxytocin and prostaglandins.
• Braxton Hicks Contractions: Irregular, painless uterine contractions.
• Progesterone Withdrawal: Progesterone levels decrease, reducing its relaxing effect.
• Estrogen Increase: Rising estrogen levels promote muscle contraction.
• Myometrial Changes (During Labor): Coordination of contractions, increase in oxytocin receptors, increased calcium influx, prostaglandin release to soften the cervix.

Uterus

• Weight increases from 60gm to 1000gm at term
• Size: Becomes enlarged
• Consistency: Becomes softer due to increased vascularity and presence of amniotic fluid.
• Capacity: Increases from 4ml to 4000ml
• Contractility: Braxton Hicks contractions increase, irregular and painless contractions from the first trimester till delivery.

Braxton Hicks Contraction

• It is often called "practice contractions" or "false labor."
• Begins in early pregnancy, but most commonly felt in the second or third trimester.
• Become more frequent in the third trimester.
• Preparing the uterus for actual labor, helping the body prepare for childbirth.

Cervix

• Becomes more vascular
• Hypertrophied and soft
• Clothed by a thick mucous plug (operculum).
• Increased blood flow
• Becomes soft near term

Cervical Ripening (Near Labor)

• Softening and effacement: cervical ripening and softening.
• Hormonal changes: Increased estrogen, decreased progesterone.
• Vasodilation: increased blood flow and edema (swelling) of cervical tissue.
• Endocervical gland secretion: throughout pregnancy, the cervix secretes mucus; during labor, the mucous plug is expelled (bloody show).

Cervical Dilation (During Labor)

• Endothelial cell activation: Increased mechanical pressure from uterine contractions stretches and dilates the cervix.
• Inflammatory response: Cytokines and enzymes (matrix metalloproteinases) breakdown cervical collagen, facilitating dilation.
• Contraction-induced stretching: Increasing intensity of uterine contractions mechanically stretches the cervix.

Premonitory Signs of Labour

• Lightening: Feeling of the uterus dropping lower into the pelvis, relieving pressure on lungs and stomach.
• Frequent micturition: increased urination due to pressure on the bladder.
• False pains: Irregular uterine pain.
• Slight taking up of the cervix
• Bloody show (blood + white mucus) occurring due to leakage of operculum
• Braxton Hicks Contractions stronger.

Normal Labour/Eutocia - Learning Objectives

• Define the meaning of labor.
• Describe signs of labor.
• List and describe the stages of labor.
• Explain the physiology of labor.
• Describe the mechanism of labor.
• Demonstrate the management of normal labor.
• Plot a partograph accurately.

Normal Labour

• When the fetus is born at term (>37 weeks).
• Presentation- by vertex
• Spontaneous onset
• Commenced within 18 hours (not prolonged)
• No complication arises (maternal & fetal)
• If the mode of delivery is vaginal (SVD)

True Labor

• Painful, rhythmic uterine contractions
• Progressive dilation of the cervix (>2cm)
• Contractions unaffected by sedation
• Discomfort in the back and abdomen
• Show (blood + white mucus)

False Labor

• Irregular uterine contractions
• No progressive dilation of cervix
• Contractions affected by sedation
• Discomfort only in lower abdomen
• No show

Mechanism of Labour

• The ability of the fetus to negotiate the pelvis during labor and delivery depends on the complex interactions of: the power (uterine contractions); the passenger (the fetus); the passage (the pelvis & birth canal); and the psychology of the woman.

Stages of Labour

• First stage: from onset of labor to full dilation of the cervix
  • Latent phase: from onset of labor up to cervical dilation of 4cm, Duration = 6-8hrs in primigravida and 4-6hrs in multigravida.
  • Active phase: from 4cm to full dilation of cervix /10cm, Duration = 4-6hrs in primigravida and 2-4hrs in multigravida.
• Second stage: from full dilation to delivery of the baby
  • Duration: 1-2 hours (primigravida); 30 minutes - 1 hour (multigravida)
• Third stage: from delivery of the fetus to expulsion of placenta with the cord
  • Duration: 15-30 minutes
• Fourth stage: 1-2 hours after placenta delivery

Based on Gestational Age

• Preterm labor: labor onset before 37 weeks
• Term labor: labor onset within 37-42 weeks
• Post-term labor: labor after 42 weeks

Events in 1st Stage of Labour

• Contractions with retraction
• Formation of upper and lower segment
• Development of retraction ring
• Taking up of the cervix
• Dilation and effacement of cervix
• Show
• Formation of bag of waters
• Rupture of membranes

Contraction and Retraction

• The contraction starts from the fundus and goes downward, assisting cervix dilation
• Upper pole: strong contraction & retraction to become short and thicker
• Lower pole: slight contraction and strong dilation that becomes thin and distensible
• Retraction ring: ring structure made to meet upper and lower segments
• Bandls ring: visible retraction ring which is a pre-rupture sign

Admission Procedure

• Well-coming the mother and her partner on arrival
• Greeting the mother
• Introducing oneself
• Informing relatives to wait

Admission Criteria

• Confirming true labor
• Checking for show
• Rupture of membranes
• Regular uterine contractions
• Cervical dilation
• Danger signs

Management of 1st Stage Labour

• Taking a full history
  • Time of onset of contraction
  • Status of fetal membranes and time of rupture
  • Presence/absence of vaginal bleeding (show)
  • Presence of fetal movement
  • Symptoms of severe preeclampsia
  • History of allergy
  • Time of last ingestion of food or fluid
  • Use of any medication
  • Presence of ANC follow-up & any problems
• Performing physical examinations
  • Observing general condition of the mother
  • Assessing for signs of anemia and dehydration
  • Taking vital signs
  • Abdominal examination
  • Inspecting for 5's (scar, size, skin, shape)
  • Palpating fetal lie & presentation
  • Measuring fundal height
  • Checking fetal heart rate and assessing frequency & duration of contractions (use Leopold maneuvers)

Vaginal Examination in Labour

• Indications: To decide if a woman is in labor, and when in doubt regarding presentation/position, to assess the progress of labor, and to assess the size and shape of the pelvis.
• Reducing vaginal examinations: careful abdominal examination, finding useful information during procedure, and recording findings
• Equipment & procedures: sterile gauze/cotton swabs, sponge forceps, antiseptic solution, sterile gloves, receiver

Vaginal Examination

• Ask the patient to empty her bladder
• Put the patient in lithotomy position
• Wash hands & wear sterile gloves
• Clean the vulva in 3-4 ways
• Go straight to the presenting part because it is sterile.

Findings on V/E

• Presenting part: which part of the fetus comes first (occiput), caput (swelling of fetal skull molding (0, +1, +2, +3), position (OA, OP & OL), station (-2,-1,0,+1,+2) relative to ischial spine. Example; if head touches ischial spine, station =0. Station − location of fetal head in relation to ischial spine.
• Membranes: Intact, ruptured, bulge, flat. If ruptured, observe color: clear straw-normal, green-meconium (Grade 1, 2, 3), golden-hemolytic disease, Milky-infection, feel cord for prolapsed/presentation.
• Cervix: dilation in cm (1 finger = 1.5−2cm), effacement-shortening & thinning of cervix- hard, soft, edematous thick or thin, Pelvis: promontory of the sacrum — reachable/side walls, straight, convergent, divergent, ischial spines − blunt, prominent
• Sacral curvature, Pubic arch, Bituberous diameter, Vagina, Perineum, Vulva

Management of Latent Labour

• Cx-dilation <4cm, check vital sign every 4 hours
• Do V/E (Cx dilation/other) every 4 hours, diet-fluid
• No need for sleeping in bed
• She can move/rest in nearest to health institution.

Partograph/Labour Graph

• Used to follow labor progress
• Advantage: shows time taken in first stage of labor, easy to understand miss-managements, simple for communication, used for research & teaching aid, and quick & time saving
• The graph has 3 sections: Fetal part, Maternal part, and labor progress
  • Descent
  • Contraction
  • Cx-dilation

Patient Information for Partograph

• Name, gravida, para, hospital number
• Date and time of admission
• Time of ruptured membranes
• Fetal heart rate (record every half hour, mark with dot (.))—Normal 120−160 beat/min; max (100−180)

Amniotic Fluid

• Record the color of amniotic fluid at every vaginal examination (4 hours).
• Membranes intact (I)
• Membranes ruptured − clear fluid (R(C))
• Blood-stained fluid (R(B))
• Meconium-stained fluid (R(m);(grade:1,2,3))
• Grade 1: Good volume of liquor, lightly meconium stained
• Grade 2: Reasonable volume with heavy suspension of meconium
• Grade 3: Dark, thick meconium which is undiluted

Molding

• Normal separation/can feel sutures (0)
• Bones meet together, not overlap (+1)
• Overlapping can be pushed back/reducible (+2)
• Overlapping can't be separated/not reducible (+3)

Station

• Descent by vaginal examination; -2,-1,0,+1,+2
• At ischial spine (0)
• Below ischial spine (+)
• Head is above ischial spine (−)
• Hours: Time elapsed since onset of active phase of labor
• Time: Record actual time
• Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration (length, strength & frequency).

Contractions

• Less than- 20 seconds
• Between 20−40 seconds: moderate
• More than 40−60 seconds: strong
• Adequate contraction: >=3 strong contraction within 10 minute
• Oxytocin: Record amount per volume IV fluids in drops/min. every 30min when used.
• Drugs given: Record any additional drugs given.
• Temperature: Record every 2 hours
• Pulse: Record every 30 minutes and mark with a dot (•)
• Blood pressure: Record every 4 hours and mark with arrows ()
• Urine: Protein, acetone, and volume, record every time urine is passed.

Descent

• Assessed by abdominal palpation
• Part of head palpable above the symphysis pubis: Recorded as a circle (O) at every vaginal examination
• At 0/5, head is below the symphysis pubis, e.g. 2/5 = 0 station, 2/5 means 3 fingers inter to brim
• Alert line: Start at 4 cm of cervical dilation to the point of expected full dilation at the rate of 1 cm/hr
• Action line: Parallel and 4 hours to the right of the alert line

Active Phase

• Cervical dilation is plotted on the alert line (4cm)
• If progress is satisfactory, the plotting of cervical dilation will remain to the left of the alert line.
• The latent phase is from 0-3 cm dilation, should not last longer than 8 hours
• The active phase is from 4-10 cm, & dilation should be at the rate of at least 1 cm/hr

When Labor Progresses Well

• Dilation should not move to the right of the alert line
• If admission to the hospital takes place in the active phase, the cervical dilation is immediately plotted on the alert line.
• Cx moves right of the alert line; poor progress and indicates some problems. Cx crosses action line – danger, take immediate action.

Examples (Partograph Plottings)

• Case examples including patient details, time of admission, cervical dilation, descent, molding, urine, blood pressure, pulse, temperature, fetal heart rate, membranes, contractions, and more details for plotting.
• Multiple case examples illustrating various scenarios are provided.

Take Aways

• Definition of Labor
• Normal Labor criteria
• Labor can be (true/false). Cases of labor onset
  • Hormonal factors
  • Mechanical factors
• Mechanism of Labor − interaction b/n 4Ps
• Stages of Labor: labor has 4 stages
• Admission criteria: 6 criteria to admit. Management of first-stage labor with events in first stage of labor

Second Stage of Labor

• From full dilation to the delivery of the baby.
• Positive signs: No cervix felt on V/E
• Probable signs: Stronger contractions, mother wants to push, membranes rupture, anal and vulvar gaping, perineum bulging.

Physiology of 2nd Stage

• Contractions are shorter and more frequent.
• Abdominal muscles and diaphragm act as expulsive mechanisms.
• Pelvic floor is displaced.
• The fetus is expelled.
• Mother wants to push.

Mechanism of Labor

• A series of passive movements of the fetus through the birth canal, involving: Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation (Restitution), Expulsion.

Preparation for Delivery

• Equipment and materials needed: Suction apparatus, Oxygen, Antiseptic solution, Gloves, Cotton & Gauze swabs, Uterotoxic drugs (Oxytocin), Protective (gown, apron, cap, goggles, long shoes), and IP materials (decontaminants)
  • Vitamin K, Cord tie
  • Delivery set, Epi-set
• Position − (Lithotomy) as mother's preference
• Explain procedure
• Talk to her — verbal anesthesia
• Patient preparation — position the mother (lithotomy or), encourage her to push, explain what's happening, put on personal protective equipment, arrange & check equipment, keep constant contact with mother.

Episiotomy

• Def: An incision into the perineal body during the second stage of labor to widen the vulval orifice.
• It is a second-degree tear.
• Indications: Prevent tear in tight perineum, prevent cerebral damage in preterm & after coming head in breech delivery, widen outlet in instrumental delivery, in second-stage delay (to facilitate), prevent previous tears from recurring.
• Types: Medio-lateral (commonly used, fast healing), median (dangerous, may extend to third-degree tear), J-shaped (repair & healing difficult), lateral (may affect Bartholin's glands).
• How to perform: Perform at the height of contraction (Should not be more than 3 cm), Inject local anesthesia (10 ml), Wait 1-2 minutes, Insert two figures behind perineum to protect the head, Insert scissors and point to the side, Perform single deliberate cut at the height of contraction.
• Repair: Repair within one hour of anesthesia, start at the apex (end point of scissor), Clean the perineum & change the upper glove, Suture in three layers (mucosa, muscle & skin), suture vaginal wall (mucosa) in continuous, Suture the muscle & skin with separate sutures/intrapted, Insert small gloved finger into the perineum after closure
• Delivery: Assess labor progress via V/E, Perform episiotomy if perineum is tight, Put one hand over fetal head to maintain flexion and prevent fast delivery, Place gauze or pad on perineum to prevent tear & contamination from stool, After head delivery, check for cord around the neck, and cut, Hold head with left hand and clean eye & mouth with right hand using gauze, Wait for rotation of shoulders, deliver baby down wards, then upwards, slip hand over the body and lift, dry baby, cover with cloth, assess breathing

3rd Stage of Labour

• Begins immediately after delivery of the baby and lasts when the placenta is expelled
• Usual length: 5−15 minutes
• Retained placenta: If it lasts more than 30 minutes; up to 1 hour is normal.
• Physiology of 3rd stage of labor: Separation of placenta, Descent of the placenta, Expulsion of the placenta, Control of bleeding (by living ligature)
• Signs of placental separation: Uterus rises to the level of the umbilicus; Gash of blood; Cord seems to lengthen, Cord will not return back on supra-pubic pressure. At the end of 3rd stage: Uterus is midway b/n the Sp and umbilicus, no bleeding, bladder empty.
• Expulsion of the placenta: By the action of living ligature, Contraction of d/t fibers (like crisscross, longitudinal & circular fiber), Other clotting mechanism, Oxytocic drugs, Contraction & relaxation of uterine muscles
• Method of placental expulsion
  • Maternal effort
  • Fundal pressure
  • Controlled cord traction with out oxytocin
  • Active management of 3rd stage of labor/AMSTL—Administration of oxytocic drugs with in 1 minute of birth of the baby then controlled cord traction (CCT) with first uterine contraction.
• Benefits of AMTSL: Shorter duration of third stage of labor, less maternal blood loss, less need for oxytocin in postpartum period, less anemia in postpartum period.
• Procedures of AMTSL: Palpate the mother's abdomen to rule out additional baby, give 10 IU of oxytocin IM, Clamp the cord close to perineum, Apply supra-pubic pressure, Wait, gently pull downward. When the placenta is visible pull upward.

4th Stage of Labour

• The first 1-2 hours after the delivery of the placenta
• Monitoring the woman and her baby's condition
• Checking uterus, every 15 minutes (4 times in 1st hour and two more times), V/S and condition of baby frequently
• Observing for and taking care of bleeding, Encouraging her to pass urine, Breast feeding within 1 hour of delivery

Neonatal Assessment

• General examination − Appearance, activity, breathing, cyanosis, jaundice, pallor, temperature, & APGAR score
• Weight (2.5-3.9 kg, low birth weight [1.5-2.5 kg], very low birth weight [<1.5 kg])
• Length (48-52 cm)
• Head circumference (32-34 cm)
• Chest circumference (30-33 cm)

APGAR Score

• Score done at 1st and 5th minute of birth
• Normal score: >8 from a total of 10—Asphyxia neonaterum, failure of the newborn to breathe at birth
  • Severe (1−3 APGAR)
  • Moderate (4−5 APGAR)
  • Mild (6−7 APGAR)

Immunization (for newborns)

• BCG (better to give as early as possible, but can be given till 45 days)
• OPV0 (before 14 days of birth)
• Store vaccine at 2-8°C
• BCG should not be given for HIV+ neonates
• Do not give vaccine with infection/illness; continue after recovery
• Give IM injection; deep IM is better to reduce SE
• BCG: superficial is good to reduce SE