Management of Normal
Labour
Aim
1-to achieve
delivery of a normal healthy child with minimal physical
discomfort and maximum psychological satisfaction for
the parents
2-To anticipate,
recognize and treat potentially abnormal conditions
before significant hazard develops for the mother or the
fetus
Conduct of the first
stage
1-Admission with
history and examination.(see table)
Identify high risk
patients (see high-risk pregnancy)
2-Most women will
desire to have shower or bath
3-Routine shaving
and administration of an enema are unnecessary.
Occasionally the mother requests suppositories or an
enema because she fears embarrassment if she
subsequently soils the linen later in labor
4-Mother should be
free to walk around and should be encouraged to do this
unless there is overriding medical reason for her to be
in bed
5-If no EFM, avoid
supine position for fear of aortocaval compression with
hypotension and decrese in placental perfusion
6-No food or drink
should be taken with exception of sips of iced waater
7-Magnesium
trisilicate, 15 ml every 2 hours to reduce the risk of
aspiration pneumonia should general anesthesia be
required subsequently
8-Encourage mother
to empty the bladder at least every 2 hours and before
vaginal examination. Catherization may be required if
the bladder becomes palpable and the mother is unable to
void voluntarily. This is particularly likely with
epidural analgesia.
Assessment (see
partograph)
*General
examination with recording of pulse,temperature and
blood pressure
-elevated BP
suggests preeclampsia
-elevated
temperature suggests infection
-Rapid pulse may
indicate hypovolumia(normally pulse rate may reach
100bpm)
*Leopold’s
maneuvers used to determine the orientation of the fetus
through abdominal palpation. lie, presentation and
engagement of the presenting part.
The head is
determined in 5/5 above pelvic brim .
*Vaginal examination
-Timing
1-Immediately
following admission
2-Immediately
following rupture of membranes
3-At 2-4 hours
intervals when labor is established
4-If any relevant
adverse event supervene e.g meconium staining of AF or
abnormalities in FHR
Procedure
-The procedure
should be explained to the mother and she should be
encouraged to void urine before the examination
-The vulva is
cleaned with antiseptic solution and a sterile glove
lubricated with antiseptic cream is used.
N.B Ritual scrubing,
sterile gowning and draping are quite unnecessary.
Features to note on
vaginal examination
1-the condition of
external genitalia
is noticed e.g bleeding,discharge..etc.
2-Assessment of
pelvic a dequacy.subpubic
angle, ischial spines,promontory and sacral curvatures
3-Cervix
*Position is
recorded. usually posterior position indicates early or
no labour
*dilatation and
effacement
-Dilatation is
usually expressed in centimeters, as general the fingers
can estimate the cervical dialatation:
1.5cm:one finger
fits tightly through the cervix and touches the fetal
head
2cm:one finger fits
loosely inside the cervix,but cervix can not fit two
fingers
3cm:two fingers fit
tightly inside the cervix
4cm:two fingers fit
loosely inside the cervix
6cm:there is still
2cm of cervix still palpable on both sides of the cervix
8cm:there is only
1cm of the cervix still palpable on both sides of the
cervix
9cm:Not even 1cm is
left laterally,or there is an anterior lip of the cervix
10cm:cervix could
not be felt anywhere around the fetal head.
-Effacement is
easiest to measure in terms of centimeters of thickness
i.e 1cm thick, 1,5cm thick etc. Alternatively it could
be expressed in percent of an uneffaced cervix..i.e
50%,90%.This expression presumes a good knowledge of
what an uneffaced cervix should fell like
4-Membranes should
be felt between fingers and record if intact or
ruptured. If ruptured the colour and consistency of AF
should be noted.
5-Presenting Part
-nature e.g vertex,
buttock..etc
-position e.g
LOT,ROP..etc
-station..its
relation to ischial spines..-1,-2 or +2
-moulding..the
overlap of bones of the skull
-Caput..edema of
the scalp..indicates some degree of CPD
6-Abnormalities e.g
cord presentation or prolapse, tumor, septa..etc
These observations
are recorded in the partograph.
*If necessary a
scalp electrode and/or intrauterine catheter can be
inserted and if these are already being used their
position and function should be checked on completion of
the examination and adjusted or reapplied as required.
Observations During
labor
1-Maternal pulse rate
every 30 minutes
2-Maternal BP every 2
hours, more frequently if indicated
3-Maternal temperature
recorded every 4 hours
4-Drainage of amniotic
fluid, amount and character are recorded every 30
minutes
5-Descent of the head
recorded every 2 hours
6-Uterine contractions
every 30 minutes
7-Fetal heart rate every
15 minutes
Monitoring maternal
Contractions
1-Clinical palpation
In absence of
tocography, record frequency, strength, duration as
judged by palpation and the mother’s responses at least
every 30 minutes. Contractions usually occurs 3 in 10
minutes,lasting 45-60 seconds.
2-Electronic Monitoring
of contraction(Tocography)
a-External
tocography gives semiquantitative feature
b-Intra-uterine
catheter may be required in special situations e.g with
use of oxytocine infusion, but is rarely necessary in
normal labor
1-Contractility:
effective contractions should have an amplitude of
50-75mmhg, duration of 45-90 seconds and frequency every
3-5 minutes.
2-Resting tone:
spontaneous labor it is 5-15 mmhg and with oxytocine it
reaches to 15-20mmhg.
3-Rythmicity:
presence of coupling or tripling may represent
hyperstimulation
4-Configuration:
typically it is bell-shaped, may become rectangle during
pushing
N.B
*the area under the
curve when an internal transeducer is used may be
calculated to determine the adequacy of uterine
contractions
*if
hypercontractility present:(coupling,or duration
>90seconds)
a-Discontinue
oxytocine if it is in use
b-give subcutaneous
terbutaline 0.25mg if there is sings FHR abnormalities
Fetal Heart Monitoring
1-Auscultation by
Doppler every 30 minutes during first stage and every 5
minutes during second stage
2-Electronic FHR
monitoring
a-External
Cardiotocography using ultrasound
b-Internal
Monitoring: Scalp electrode usually provides more
complete information and can be applied when membranes
rupture
Appropriate monitoring
in an uncomplicated pregnancy
1)
for women who is healthy
and has had an otherwise uncomplicated pregnancy,
intermittent auscultation should be offered and
recommended in labor to monitor fetal heart :
-In the active phase ,
intermittent auscultation should be offered after a
contraction for a minimum of 60 seconds and at least:
-every 15 minutes in the first stage
-every 5 minutes in the second stage
2)Continuous EFM should be offered and recommended
if intermittent auscultation shows:
a-baseline less than 110bpm or >160bpm
b-any evidence of decelerations
Indications for EFM
1-maternal diseases associated with uteroplacental
insufficiency:
a-hypertension b-DM c-heart disease d-severe
anemia e-renal disease
2-Preterm labor
3-postterm labor
4-IUGR
5-If during labour:
a-there is meconium staining of AF b-oxytocine is
used
c-failure to progress d-excessive vaginal bleeding
e-if intermittent auscultation is not satisfactory
N.BCurrent evidence does not support the use of
admission cardiotocography in low-risk pregnancy and it
is therefore not recommended.
Interpretation of FHR
tracing
1-Baseline FHR
1)Normal baseline 120-160bpm
2)Tachycardia: >160bpm
a-Fetal hypoxia
b-Maternal fever
c-Hyperthyrodism
d-Drugs e.g
parasympatolytic or parasympathomimetic
3)Bradycardia: <120bpm
a-Fetal Asphyxia
b-Anaesthetics
c-Fetal cardiac conduction
defect(usually benign)
Baseline FHR=140bpm
2-Variability
Two types of variability can be seen
1)short-term variability: Beat-to-beat variations is
normally 5-10bpm, this is reliably assessed with
internal monitoring
2)long-term variability: waviness of the FHR tracing
which normally has a frequency of 3-10cycles/minute and
amplitude of 10-25bpm
Decreased variability
1-Fetal sleep cycles
2-CNS depression secondary to:
a-Hypoxia
b-Extreme prematurity
c-congenital anomalies
d-drugs e.g parasympatholytic agents
N.B Loss of variability is usually associated with
high incidence of fetal acidosis and low Apgar score.
3-Common periodic
Patterns
1-Acceleration
periodic increase in FHR>160bpm
*Reassuring if
associated with fetal movement
*may be compensatory before or after deceleration
2-Decelerations
periodic decrease in FHR <120bpm
3 types of decelerations are encountered early, late
and variable decelerations.
1)Early deceleration
occur coincidentally with uterine contractions and
are associated with fetal head compression.
Cause:vagal nerve stimulation
Pattern: start early in the contraction phase, reach
their lowest point at the peak of contraction and return
to baseline levels as contraction finish
2-Late Deceleration
Transient but repetitive decelerations of FHR
observed to occur late in the contraction phase, reaches
its lowest point after the acme of contraction and
returns to baseline once the contraction is over
Cause: Result from fetal hypoxia and indicates
uteroplacental insufficiency and are always considered
ominous.
3- Varaible
deceleration
Characterized by variable duration,timing in relation
to contraction and intensity.
This is a reflex pattern, typically secondary to
umbilical cord compression.
Poor prognostic signs:
1-association with poor FHR baseline variability
2-Lack of pre-deceleration and post-deceleration
accelerations
3-Slow return to baseline or failure to return to
baseline
a-biphasic shape (W) sign=knot of cord
b-prolonged duration>120seconds can be seen with:
1-maternal hypotension
2-maternal hypoxia
3-tetanic contractions
4-prolapsed cord
5-fetal scalp procedures (vagal)
6-paracervical or epidural analgesia
N.B prolonged deceleration after severe variable
deceleration may signal impending fetal demise
General measures to
manage FHR abnormalities
1-turn the patient to left lateral position to
alleviate vena cava compression
2-Discontinue oxytocin
3-Apply 100% oxygen at a rate 8-10L/min by face mask
4-Correct maternal hypotension
5-Vaginal examination to rule out cord prolapse and
estimate duration of labor
6-Consider fetal scalp blood sampling for pH
determination
7-decreased variability, try fetal scalp stimulation,
if return to normal it is reassuring, if unresponsive
follow other measures
8-prolonged progressive late deceleration with pH
<7.20 proceed to CS. In some cases with severe late
deceleration, there is no time to perform fetal scalp
pH, proceed to CS to save the baby.
9-consider terbutaline 0,25mg SC if there is titanic
contraction
10-consider amnioinfusion in cases with variable
deceleration in absence of cord prolapse
Fetal stimulation
test
When the scalp is stimulated and there is an
acceleration of 15bpm lasting 15 seconds, it denotes
fetal pH value of 7.22 or greater , the reverse is not
true.
Fetal Scalp Blood
sample
*Units employing EFM should have ready access to
fetal blood sampling facilities.
*Fetal scalp blood sampling is indicated whenever
there is persistent abnormality of FHR
Contraindications
1-maternal infection e.g HIV,hepatitis,herpes simplex
2-fetal bleeding disorders e.g hemophalia
3-Prematurity <34 weeks
*Fetal blood
sampling should be undertaken with the patient in left
lateral position.
Interpertations of
results:
|
FBS Results |
Subsequent
action |
|
1->7.25
2-7.21-7.24
3-<7.20 |
1-Repeat
samples if FHR abnormalities persists
2-repeat FBS
within 30 minutes or consider rapid delivery if
there is rapid fall since last sample
3-Immediate
delivery |
Conduct of second
stage of labor
The second stage begins at full dilatation of cervix,
but usually the mother is asked to push only when she
feels involuntary bearing down which occurs a result of
reflex action when the head press on the pelvic floor
muscles.
It is important not to let the mother push until she
has the urge to bear down even with fully dilated cervix
to avoid maternal exhaustion.
Observation
Maternal
1-contractions
2-pulse and blood pressure with level of hydration
3-vaginal examination to assess the descent of head
if delivery is not imminent 30 minutes after pushing
down
Fetus
1-fetal heart every 5 minutes
2-descent of the head
Position in delivery
Traditionally mothers are usually delivered in left
lateral position, dorsal position or lithotomy position,
however, mother can take any position she prefers as
long as it does not increase the risk of trauma.
Delivery procedure
*Aim is to allow natural progress and expulsion as
far as possible
*To minimize perineal trauma some control of the
delivery of the head and shoulders is advisable and an
episiotomy may be required if tearing seems imminent.
When the head starts to distend the vulva:
1-
A rectal pad is placed
over the anus with the right hand
2-the advancing head is controlled with the palm and
fingers of the left hand, with the fingers placed evenly
over the vertex.
Head should be delivered towards the end of
contraction
3-Episiotomy is performed if there is undue perineal
stretching
4-Flexion of the head is maintained until the occiput
and parietal eminence are free. The later is then
gripped between fingers and thumb to aid extension of
the head
5-When the chin is free the rectal pad is discarded
and mucus is wiped from the baby’s face and nose
6-The head is supported by one hand whilst the other
is used to explore for loops around the neck.If the cord
is tightly round the neck two clapms are applied and the
cord is cut before delivery of the shoulders
7-Delivery of shoulders
usually takes place with the next contraction. The
anterior shoulder is assisted by placing the hands on
the head, with the fingers towards the neck exerting
gentle pressure towards the anus.
8-When the anterior shoulder is delivered the head is
guided upwards towards the the mother’s abdomen,
allowing the posterior shoulder to sweep the perineum
9-shoulders are supported with the right hand and the
buttocks with the left hand as the trunk is delivered
10-syntometrine (ergometrin maleate 0.5mg+oxytocin 5
units) is given I.M by the assistant during this
process, preferably at the time of the anterior shoulder
is delivered
11-the time of delivery is noted
12-the baby is positioned with the head dependent
(lower than chest) and clear mucus is wiped from the
mouth and nostrils
13-The umbilical cord is clamped approximately 10cm
from umbilicus with two clamps and is divided between
clamps
14-the baby is given to the mother as soon as
possible to fondle
15-A recervior is placed close to the vulva to
receive the placenta and any blood clots
Conduct of the third
stage
To minimize PPH delivery of placenta is aided
pharmacologically by injection of syntometrine and
mechanically by controlled cord traction
If syntometrine is not given at the time of anterior
shoulder it should be given as soon as possible.
When the uterus contracts expulsion of placenta is
assisted as follows:
1-The left hand is used to support the fundus of the
uterus by suprapubic pressure
2-the fingers are pressed firmly backwards
immediately above the symphysis pubis, thus supporting
the uterus and tending to pull it downwards
3-At the same time steady cord traction is applied
with the right hand
4-As the placenta is expelled from the vulval orfice
both hands are used to complete the delivery of the
placenta and membranes into the reservoir
Expectant management
If no syntometrine used watchful waiting for signs of
placental separation.
No attempts should be made to pull the cord otherwise
inversion of uterus will occur.
The uterus is palpated to make sure it is firm and
signs of placental separation are observed:
1-Uterus become globular and firm, the earliest sign
2-there is often a sudden gush of blood
3-the uterus rises in the abdomen because the
placenta passes down into the lower segment and vagina
where its bulk pushes the uterus upwards
4-suprapubic bulge felt when placenta occupies the
lower segment
5-The umbilical cord protrudes farther out of the
vagina, indicating that the placenta has descended
these signs appear within about a minute after
delivery of the infant and usually within 5 minutes.
When placental descend signs appear the physician
first ascertains that the uterus is firmly contracted.
The mother ,if not ansethesized, is asked to push down
to deliver the placenta,
If this fails the physician after confirming that the
uterus is firm and contracted ,firmly exerts pressure
with the hand on the fundus and propel the detached
placenta into the vagina. As the placenta passes through
the interiotus fundal pressure is stopped, then placenta
is gently lifted away from the interiotus. If membranes
are torn they are clamped and gently pulled .
N.B Traction on the cord must not be used to pull the
placenta out of uterus
Placenta, membranes and cord should be carefully
examined to make sure it is complete.
Fourth stage
The hour immediately after delivery of the placenta
is a critical period as postpartum hemorrhage due to
uterine relaxation is most likely to occur in this
period.
It is mandatory that the uterus be evaluated very
frequently throughout this period by a competent
attendant who keeps a and on the fundus ad massages it
at the slightest sign of relaxation. At the same time
vagina and perineal region is also frequently inspected
for any bleeding.
see
Labor1
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