Management Of Normal Labour PDF

**MANAGEMENT OF NORMAL LABOUR** In the past, they planned → passive (expectant) tit of labour but now (since O'Driscoll 1979) → concept of active management of labour: **Definition:** Is close observation and anticipation of patient's progress in labour which is recorded on partogram, for early di...

**MANAGEMENT OF NORMAL LABOUR** In the past, they planned → passive (expectant) tit of labour but now (since O'Driscoll 1979) → concept of active management of labour: **Definition:** Is close observation and anticipation of patient's progress in labour which is recorded on partogram, for early diagnosis and management of any dysfunctional labour. **Advantages:**\ 1- Prolonged labour is less common.\ 2- ↓Maternal distress (e.g. dehydration and ketosis).\ 3- ↓ Fetal distress\ 4- ↓ Load on nursing and medical staff. **Components of active management of labour:**\ I- Antenatal education.\ II- Active management of 1st stage.\ III- Active management of second stage.\ IV- Active management of 3rd stage.\ V- Care of newborn. **I -- Antenatal education:** 1- Maternal health education about the physiology of labour.\ 2- Aim: to prepare mother physically and emotionally to ↓ both physical and mental stress during process of labour. **II- Active management of 1st stage of labour:** **I) History:** 1- Complete obstetric history : e.g. previous c.s.\ 2- History of present pregnancy.\ 3- History of present labour: Labour pains, vaginal bleeding, gush of fluid, fetal movement (F.M.) **II) Examination:** 1- General exam.: Vital signs: (Mention)\ 2- Abdominal exam : Abdominal grips, F.H.S.\ 3- PV:\ a- Cx: dilatation, effacement, position, consistency.\ b- Membranes: Intact or ruptured if ruptured exclude cord prolapse.\ c- Presenting part and position, station and moulding.\ e- Pelvic capacity and tests for cephalopelvic disproportion.\ 4- Investigation, if not done before: Blood gp and Rh typing, urine analysis, Hb%, U/S **III) Active procedures:** 1- Evacuation of bladder and rectum:\ 2- Preparation of vulva: (cleaning). Shave vulva → clean it with soap and warm H2OH2​O from above down.\ 3- Nutrition\ 4- Posture.\ 5- Analgesia and/or Anaesthesia.\ → Analgesia: pethidine 50-100 mg I.M.\ → Anaesthesia: - Epidural anesthesia.\ - Mask: trilene inhalation or N2O+O2N2​O+O2​\ 6) Monitoring of labour: (Intrapartum monitoring):\ - clinical monitoring = Partogram\ - electronic = monitor of F.H.S\ - biochemical = scalp sampling of fetus **III- Active management of second stage:** 1- Diagnosis of onset of second stage (mention).\ 2- Patient transfer to delivery room and put in lithotomy position.\ 3- Complete asepsis:\ o Female.\ o Attendants and obstetric\ o Instruments: - Autoclave - Boiling\ 4- Analgesia or anaesthesia: 5- Bearing down: ask patient to beardown during contraction and relax in between.\ 6- Delivery of fetus:\ A) Delivery of fetal head: The main task of doctor is to prevent perineal laceration during delivery of head this occurs by:\ 1- Before crowning: (crowning: passage of BPD of head through vulval ring and head does not recede in between contractions):\ Before crowning: support perineum\ 2- AT crowning: do episiotomy.\ 3- After crowning: →→ controlled head extension (Ritgen manoeuvre)\ ○ If head is delivered, the eye lids, nose and mouth are gently swabbed to remove mucus and blood to avoid inhalation by baby (i.e. fetal resuscitation starts once head is delivered.\ B) Delivery of shoulder and body:\ ○ When anterior shoulder hinges below symphysis pubis, the head is gently lifted anteriorly to deliver posterior shoulder then posteriorly to deliver anterior shoulder\ ○ Delivery of the remainder of body is slowly extracted by gentle traction on shoulder and head\ C) After deliver of fetus:\ ○ Hold fetus by its ankles with head down (unless preterm baby or baby suspect of intracranial hge. →→ hold fetus horizontally).\ ○ Massage the cord towards the umblicus to add 100 cc blood to infant's circulation.\ ○ The cord is cut between 2 clamps **IV- Management of 3rd stage:** I- We have 2 methods:\ a- Conservative Method:\ \< Put the ulnar border of left hand just above fundus to detect any bleeding inside uterus due to uterine inertia manifested by rise of level of atonic fundus.\ \< Wait signs of separation and descent of placenta (mention).\ \< Massage uterus to help it to contract to stop any bleeding.\ \< Ask patient to strain to help descent of placenta.\ \< Hold placenta between 2 hands and roll it, in order not to miss a part of membranes inside uterus.\ \< Inspect placenta and membrane to sure that they are complete and no parts intrauterine.\ \< Give ergometrine or syntocinon (oxytocin) after delivery of placenta to help uterine contraction. b\) The active method:\ \< With the delivery of anterior shoulder, ergometrine is given to help separation of placenta.\ \< The uterus usually contracts strongly after delivery of fetus and placenta separates at once.\ \< -When the uterus hardens, the placenta is delivered by Brandt -- Andrews method (controlled cord traction).\ \< As placenta appears → it's hold by 2 hands and rolled and inspect after delivery.\ \< The active method is preferred by many because amount of blood loss during 3rdrd stage ↓ however there is ↑ incidence of contraction ring in uterus and retained placenta. **V- Care of the new born:** 1- Best by pediatrician and starts once head is delivered by mouth wash of any mucus or blood.\ 2- Aspiration of mucus in mouth and throat by mucus catheter.\ 3- Ligate umbilical cord by plastic sterile clamp and cut the cord distal to clamp, paint the stump by alcohol.\ 4- Take neonatal measures (weight, height,........)\ 5- Inspect infant for any congenital anomalies.\ 6- Put penicillin drops in the eyes to avoid ophthalmia neonatorum. **Apgar score:** is a clinical assessment of the degree of new born asphyxia using 5 clinical features: H.R., respiratory effort, muscle tone, reflex irritability, and colour either O, 1, 2 is given for each clinical feature a score of (7-10) → good condition\ Score (4-6) → moderate asphyxia\ Score \< 4 → severe asphyxia\ Apgar score should be done at (1) and (5) min. after birth Clinical feature 0 1 2 --------------------------------------------- -------------- ---------------------------- ----------------- H.R. (bpm) Absent Below 100 Over 100 Respiratory effort: Absent Slow or irregular Good cry Muscle tone: Absent Some flexion of limb Active movement Reflex (response to a catheter in nostrils) No response Grimace Cough or sneeze Colour Blue or pale Body pink and limbs → blue All pink **Neonatal Asphyxia:** 2 types of Asphyxia\ I- Asphyxia livida:\ 1- Blue colour.\ 2- Strong heart beats.\ 3- +ve respiration.\ 4- +ve Muscle tone.\ 5- +ve Reflexes.\ 6- It has good prognosis. II- Asphyxia pallida\ 1- White colour.\ 2- Weak heart beats.\ 3- Absent respiration.\ 4- Absent muscle tone.\ 5- Absent reflexes.\ 6- It has bad prognosis. **Management of neonatal asphyxia:**\ a- Prophylaxis:\ 1- Proper antenatal and intranatal care including careful observation of F.H.S.\ 2- No morphine during delivery.\ 3- Proper oxygenation during anaesthesia.\ 4- Vit. K. to the mother and episiotomy to all premature.\ 5- Clear air passage of fetus immediately after deliver. b- Care of the new born: 1. Respiration:\ (a) clear air way passage: by\ 1- Holding the infant from its feet.\ 2- Aspirate the mucus by suction apparatus.\ (b) Oxygen supply:\ 1- Oxygen mask in front of mouth and nose (Ambo bag).\ 2- Mouth to Mouth breathing.\ 3- Endotracheal tube with intermittent positive pressure O2O2​ 2. Circulation: (a) external cardiac massage\ (b) Adrenaline either in umbilical vein or intracardiac 3. C.N.S.: (a) if hypoxia due to morphine give nalloxane.\ (b) : C.N.S. stimulants e.g. couramine injection. 4. Acidosis: we give Na HCO33​ 5. Heat: avoid cooling.