Normal Labour .pdf

Normal labour DR. NOHA AHMED FOUAD  LECTURER OF PHYSICAL THERAPY WOMAN HEALTH DEPARTMENT FACULTY OF PHYSICAL THERAPY BADR UNIVERSITY ACADEMIC YEAR 2022-2023  Objectives By the end of this lecture each student should be...

Normal labour DR. NOHA AHMED FOUAD  LECTURER OF PHYSICAL THERAPY WOMAN HEALTH DEPARTMENT FACULTY OF PHYSICAL THERAPY BADR UNIVERSITY ACADEMIC YEAR 2022-2023  Objectives By the end of this lecture each student should be able to: 1- Define all definitions related to normal labour 2- Know onset and stages of labour 3- Integrate physical therapy program through different stages of labour 4- Design physical therapy program post partum  Definitions Labour: it is act of expulsion of featus and placenta from uterus. Normal Labour: It is an expulsion of single mature fetus, presenting by the vertex through birth canal within 24 hours, process of labour terminates spontaneously without foetal and maternal complications. Post Mature Labour: duration of pregnancy is 42 weeks or more.  Cont: Definitions Prolonged labour: Duration of Labour last more than 24 hours due to:  Uterine inertia ( insufficient uterine contractions)  Occipito-posterior position.  Rigid perineum especially in elderly  Full bladder and rectum. Precepitate labour: Duration of Labour lasts less than 3 hours due to:  Strong uterine contractions  No obstruction in birth canal  Lack of resistance of soft tissues  The onset of labour 1-Show: Discharge of mucous mixed with blood due to dilatation of cervix  2-True labour Pain: characterized by:  Regular, increase in amplitude, frequency and duration.  Accompanied by hardening of the uterus.  Discomfort in bith back and abdomen  Accompanied by progressive dilatation of cervix.  Contractions are not affected by sedation.  Enhanced by enema.  Cont: The onset of labour  False labour pain: women complains of painful uterine contractions while progressive dilatation of cervix fails to occurs.  characterized by:  Irregular contraction  Intensity of contraction remains the same  Discomfort in lower abdomen only.  Contractions are usually relieved and stopped by sedation.  Pain don’t cause progressive dilatation of cervix.  Cont: The onset of labour 3- Rupture of membrane:  Associated by gush of amniotic fluid ( liquor amnii)  liquor amnii is slightly alkaline fluid and about one liter.  Women should go to hospital immediately because of danger of cord prolapse.  The functions of amniotic fluid are:  Protection of the fetus.  Medium for free movement of foetus.  Keep fetal temperature constant.  Medium for foetal exertion.  After rupture of membrane acts as anti septic fluid for birth canal  Stages of labour Divided into 3 stages  First stage (stage of cervical dilatation):  Begins with the onset of labour and ends with complete cervical dilatation ( about 10 cm or 5 fingers), duration of 1st stages is about 8-12 hours in primegravida and 6-8 hours in multigravida. ( longest stage)  Management of first stage of labour:  1- The mother is asked to choose preferable relaxed position each time contraction begins.  2-Deep breathing exercise as a key of relaxation (diaphragmatic breathing). 3- Prevent straining because this will predispose to prolapse and exhaustion. 4- Walk in intervals between pain. 5- Once the membrane rupture mother should lie down to avoid leakage of liquor amnii. 6- If the mother complaining from backache firm massage from modified sideling position 7- Mother should be asked to empty bladder and rectum every 2 hours. 8- TENS used as a modality for pain control reduce length of labour and decrease dependence on narcotics during and after labour. Placement of electrodes: over site of pain or paravertebrally over nerve root. Top set over T10- L1 area that provides uterine nerve supply Lower set placed over S2-S4 For sever back pain Parameters of TENS : Frequency :  80-120 Hz. During uterine contraction.  2 Hz Between uterine contraction. Pulse width: 150 micro-second. Intensity : according to each women until feeling tingling.  Cont: Stages of labour Second stage ( stage of expulsion of the fetus) : Extends from full dilatation of cervical to complete birth of the infant, duration of 2nd stage ranged from few minutes to one hour. Management of 2nd stage of labour: 1- The mother lies in lithotomy position. 2- Instruct mother to take deep breath and bear down during uterine contractions (to increase the expulsive force) and relax in-between ( to regain her strength and recover from the last effort). 3- Perineum must be supported with uterine contraction to avoid perineal laceration. 4- At crowning the mother is asked to stop bearing down and pant in and out softly and easily with open mouth. 5- Episiotomy should be done at proper time ( perineal stretched) to avoid perineal tear. 6- TENS: The lower set is transferred to the anterior aspect of the lower abdomen in a V shape to relieve supra pubic pain.  Cont: Stages of labour Third stage ( stage of expulsion of placenta and membrane) : Is the period from the birth of the infant to delivery of placenta and membrane. Management of 3rd stage of labour: 1-Massaging the uterus during separation and descend of the placenta to help it to contract to stop bleeding. 2-Inspect the external genitalia and perineum so that any laceration of the perineum should be repaired. 3- Observe the mother carefully for one hour for fear of post partum hemorrhage. Contraindications for post partum exercise Post partum heamorrhage Nephritis Puerperal fever  Values of post partum exercise I-Prophylactic:  Guard against respiratory complications.  Guard against circulatory complications (thrombosis and embolism).  Guard against pelvic floor dysfunctions. ( genital prolapse and SI)  Cont: Values of post partum exercise  2-Curative:  Restore muscle tone ( abdominal and pelvic floor).  Help involution of the uterus.  Re-education of postural sense.  Help micturation and defecation.  3-Lactational:  Improve blood supply in pectoral region and increase milk secretion.  Prevent breast sagging.  Post Partum Exercises First Day: Circulatory Exercises  Respiratory exercises  Static abdominal contraction  Relaxation on face ( Daily time rest ) Second Day: Repeat previous exercises and add  Leg exercises  Pelvic floor exercises  Arm exercises Third Day: Repeat previous exercises and add Pelvic rocking exercises Fourth Day: Repeat previous exercises and add Hip shrugging exercises Pelvic rotation exercises Postural correction exercises Fifth Day: Repeat previous exercises and add First step of trunk flexion Sixth Day: Repeat previous exercises and add First step of trunk rotation Seventh Day: Repeat previous exercises and add  Other steps of trunk flexion  Other steps of trunk rotation  Eighth Day: Increase repetition of previous exercises up to 20 times till the end of puerperium.  Episiotomy  It is an incision of the perineum aiming to widen the vaginal enteroitus and facilitate passage of the fetus (It is the most common operation in obstetrics)  Values of episiotomy  Prevent perineal lacerations  Relieves compression on the foetal head so Prevent injures of the fetal skull.  Prevent Stretch of pelvic floor and subsequent pelvic floor dysfunction.  Surgical incision repaired more successfully than jagged tear. Types of Episiotomy  Median episiotomy : extends posterior along mid line of the perineum.  Medio -lateral episiotomy: extends laterally to either side of the perineum. Management of Post natal case with Episiotomy  Aim of physical therapy after episiotomy: 1- Relieve pain at the site of incision. 2- Promote healing of incision. 3- Positioning Physical Therapy Modalities  Ice Application  To relieve edema of the perineum and subsequently relief perineal pain.  Ice packs or crushed ice applied to the painful area for 4-5 minutes.  OR Ice cubes for 2-3 minutes.  Ultrasonic Pulsed ultrasonic of low intensity (0.5-1 w/cm2) is applied for 3- 5 minutes depending on the length of the incision. If improvement doesn’t occurs increase intensity or duration. Applied under water or water filled codon.  Pulsed ElectroMagnetic Energy (PEME) It should be held as close as possible to the incision without actual contact to the skin. To decrease swelling and inflammation. To increase fibrin and collagen deposition. Parameters of PEME used to relief perineal pain are as follow **Frequency 27 MHZ **Pulse rate=100/second, **Pulse width 40-65 micro-sec., **Duration from10-15 minutes. Low level LASER Therapy It is applied from a distance of about 1 cm. from the incision and the parameters depend on the aim of treatment. To promote wound healing: Use wave length from 600-750 nm.& frequency< 1000 Hz, Intensity 0.5-4 JCm2 To relief pain : Use wave length> 600nm. & frequency > 1000Hz, Intensity 0.5-4 JCm2 Inhibition or treatment of scare: Use wave length from 750- 905 nm.& frequency > 1000 Hz, Intensity 4- 6 JCm2 Comfortable position SUPINE WITH CROSSED LEGS.  Advices for postnatal case 1- Ask mother to repeat this exercises as a daily routine. 2-lactate your baby in the first 3 days ( collustrum ) which also stimulate involution of the uterus. 3-Avoid backlying position for long period to prevent R.V.F. 4- Don’t carry heavy objects and pushing heavy object to avoid increase intra- abdominal pressure 5-Avoid constipation by eating fresh vegetables and fruits , Increase fluid intake and avoid fats & carbohydrates 6-Bladder training to train levator ani muscle. 7-Avoid squatting and cross-sitting positions to avoid stretch at the site of incision 