Mechanisms of labor

Mechanisms of labor Lie presentation Attitude and position Fetal lie: Longitudinal Oblique

F . Presentation
Cephalic Breech Shoulder (preria-septum)

Relationship head and body classified

Chin contact thorax

vertex, occiput
face

presentation occiput and back contact ,

presentation F. head position between these

partially flexed , fontanel (bregma) , sinciput presentation partially extended , brow

Breech presentation
Frank Complete Footling

 Fetal attitude or posture Fetus forms an avoid Back Head Legs Arms

Position :
Presenting part Vertex occiput Face mentum Breech sacrum Lo Ro oA oP

Diagnosis presentation position

Abdominal palpation:

Leopold maneuvers First maneuver Second maneuver fetal fole Third maneuver thumb fingers ,movable Fourth maneuver First three fingers Direction of axis pelvic inlet

 V. E xamination
Sutures Fontanels

 Auscultation reinforce V.S Radiography

 Labor with occiput presentation vertex presentation 40% LOT 20% ROT 20% OP OP (placenta anterior narrow fore pelvis)

 Cardinal morement of labor Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

 Changes in shape of the head Caput succedaneum Vertex head change shape labor forces Fetal scalp forming swelling prevent differentiation sutures fontanels

Molding Head shape change external compressive forces possibly Braxton hicks cont

Admission procedures
Urged to report early in labor Early admittance to labar , delivery unit especially high risk pregnancy accurat diagnosis of labar Falsely diagnosed , inappropriate in terrention Not diagnosed (remot from medical personnel medical facilities)

Definition of labor
Uterine contractions that bring effacement and dilatation of cervix. Painful contractions become regular onset of labor as beginning at the time of admission to the labor unit Admission for labor based on dilatations accompanied by painful contractions .

Contractions of true labor Regular intervals Intervals gradually shorten Intensity gradually increases Discomfort back , abdomen Cervix dilates Discomfort is not stopped by sedation

D. Diagnasis between false and true labor is difficult

Contractions of false labor

Irregular intervals Intervals long Intensity unchanged Discomfort lawer abdomen Cervix not dilate Relieved by sedation

Pregnant woman who is having Cantractions Emergency condition Labor is defined as process of childbirth beginning Latent phase delivery placenta

Vaginal examination
1. Amnionic fluid effacement 2. Cervix dilatation position 3. Presenting part 4. Station 5. Pelvic architecture

Detection of ruptured membranes

Leakage of fluid
Prolapse cord Labor occur Serious intra uterine infection Nitrazine paper (PH= 7.0 7.5) Arborization or ferning Alpha fetoprotein Injection various dyes

Vital signs and review of pregnancy record Physical examination Preparation of vulva and perineum Inspection and cleaning of the vulva , perineum , mini shave enema

Friedman
Three functional divisions of labor Preparatory division: Little cervical dilatation Considerable change Dilatational division : Most rapid rate pelvic division: Deceleration phase of cervix dilatation Cardinal fetal movements

Cervical dilatation
Latent phase (14-20h) Active phase: acceleration ,phase of maximum slope , deceleration phase

Management first stage of labor

Remainder of general physical exam is completed HCT HB protein - glocose average duration first stage of labor 7 hours in nulliparous w 4 hours in parous w

Fetal monitoring during labar Contractions and response FH Suitable stethoscopc , doppler ultrasonic devices FH should be checked after contractions every 30 minutes (15) Second stage every 15 minutes (5) Cantinous electronic monitoring

MATERNAL MONITORING
Vital signs T , pulse , BP every 4/h PROM temprature every 1/h 18 h of PROM antimicrobial

Subsequent vaginal examinations

When membrans rupture if head was not Defenetly engaged fetal H immediately and during the next uterine contraction (occult umbilical cord compression) periodic examinations at 2-3 hours interval

Oral intake
Gastric emptying time prolanged (food medication remain in the stomach not absorbed may be vomited) Food should be withheld

Intravenous fluids
Infusion system routine early labar (IV line) Longer labors glucose sodium water 60120 ml/hr

Maternal position during labor

normal laboring woman Not be confined to bed Comfortable chair In bed position most comfortabl (lateral recumbend)

Analgesia
Is initiated on the basis of maternal discomfort vaginal examination befor administration of analgesia (delivering a depressed infant) Timing , method and size of initial and subsequent dose , interval of time until delivery

Amniotomy
There is a great temptation Benefits: rapid labor detection of meconium staining Internal fetal M Aseptic technique Head must be well applied to the cerxin

Urinary bladder function

Bladder distention avoid Abstracted labor Subsequent bladdes hypotonia, infection Suprapubic region shauld be visualized , palpated detect filling bladder If could not void on a bedpan Intermittent catheterization

Management of second stage labor

Full dilatation of the cervix Begins to bear dawn 50 minutos in nulliparous 20 minutos in multiparous

Higher parity 2-3 expulsive efforts may suffice Complete the delivery of the infant

FHR
Low risk 15 H.risk 5

Fetal H.R Contraction maternal expulsive efforts FHR are not consequence of head compression Descent fetus and reduction in uterine volume some degree of premature separation placenta

tighten a loop or loops of umbilical cord Around the fetus umbilical blood flow Prolonged uninterrupted maternal expulsive efforts dangerous to the fetus

Preparation for delivery

Variety of positions Dorsal lithotomy position For beter exposure legholders stirrups Cramps in the legs (brief massage changing position) Preparation for delivery entails vulvar and perineal cleansing

Spontaneous delivery
Delivery of the head Contraction perineum bulges Vulvovaginal opening becomes more dilated Gradually circular opening This encirclement of the largest head By the vulvar ring is known as

Perineum is extremely thin Episiotomy , laceration Episiotomy risk tear external anal rectum Episiotomy - anterior tear urethra , labia

Ritgen manover
Vaginal introitus 5 cm Towel draped , gloved hand forward pressure on the chin of the fetus other hand exerts pressure superiorly against occiput

Cleaning the nasopharynx Minimize aspiration AF debris , blood once thorax is delivered face quickly wiped nause , mouth are aspirated

Following delivery of anterior shoulder Finger should be passed to the neck Nuchal cords 25% + Drawn down , loose slipped over the head

Clamping the cord

4-5 cm , 2-3 cm fetal abdomen two clamps Plastic cord clamp

Timing of cord clamping

Infant is placed at or below vaginal interoitus 3 , 80ml of blood shifted from placenta to infant 80ml 50mg Iron , Iron deficiency anemia Maternal alloimmunization our policy after cleaning airway 30" cord clamp

Management of the third stage

After delivery of the infant Height uterine fundus Uterus firm , no unusual bleeding Waiting until placentac separat no massage Hand rest on the fundus (atonic filled with blood)

Signs of placental separation

1. uterus becames globular firm 2. Sudden gush of blood 3. Uterus rises (placenta separated , passes dawn to lower u-segment 4. Its balk pushes uterus upward 5. Umbilical cord protrudes forther out

Traction on the umbilical cord must not be used inversion

delivery of the placenta

Manaol removal of placenta

occasionally placenta will not separat At any time brisk bleeding and , placenta can not be delivered Active management of the third stage 5 units oxytocin +0.5 ergometrine reductian in the length of third stage

Fourth stage of labor

Exam placenta , membranes , umbilical cord Completeness , anomalies Hour immediately fallowing delivery Critical fourth stage of labor uterine atony , BP , pulse every

Oxytocic Agents
Oxytocin (pitocin , syntocinon) Methylergo novine maleat (methergine) Reduce blood loss by stimuloting myometrial contraction Iml 10IU half lifc IV 3 Inapropriate dose kill the fetus ,rupture uterus

Cardiovascular effects
Deleterious effects follow IV bolus Antidiuresis rare maternal convulsion antidiuretic action Water intoxication (20,40mu/minut ) Concentration should be increared rather than rate of flow Normal saline are lactated ringer solution

Ergonovine and methylergonavine IV IM orally no differenc in actions Sensitivity of pregnant uterus is very great In pregnancy 0.1my IV , 0.25my oral tetanic Uterine contraction Tetanic effect prerention , control PPH IV administration sometimes tram sient , severe hypertension

Prostaglandins
Not used routinely Manage ment PPH PG F2x 250ng IM (15-90" ) 8does 88% successful 20% side effects diarrhea ,hypertension vomiting , Fever , flushing , tachycandia PG E2 20-mg suppositories

Lacerat ons of the Birth canal

Classified
First fourchette , perineal skin vaginal mucous Second fascia and muscles of perineal body Third anal sphincter Fourth retal mucosa

Episiotomy and repair

Incision of pudenda Perineotomy incision of perineu Episiotamy synonymously with penineotomy Begin in midline : Directed laterally mediolateral Directed down ward midline

Timing of episiotomy
Perform when head is visible during contraction 3-4 After application of blades Timing of repair Most common practice repair until placenta delivered Technique Hemostasis Anatomical restoration without excessive suturing Chromic catgut 3-0

Fourth degree laceration

Various techniques remcommend Esential approximat torn edges rectal mucosa With muscularis sutures 0.5cm apart Muscular layer covered with a layer of fascia

Labor with occiput presentations

95% fetus occiput or vertex presentation Most commonly ascertained ab exam Confirmed V.Examination before or at the onset of labor Sagitlal suture in the transrevse pelvic diameter LOT , ROT , LOA , ROA ROP , LOP (narrow forepelvis , anterior placentation

OCCCIPUT ANTERIOR PRESENTATION

Irregular shape pelvic canal Large dimensions fetal head Adoptation or accommodation of suitable Portions of head to the varius segment of the pelvis is required

Cardinal movements of labar

Engagement Descent Flexion Internal rotation Extension External rotation expulsion

Concomitantly , uterine cantractions Important modifications in fetal attitude straightening of the fetus loss dorsal convexity , closer application of the extremities to the body , fetal ovoid cylinder

Engagement
Biparietal diameter greatest transverse diameter F.Head passes thraugh the pelvic inlet Lost few weeks of pregnancy Until after cammencement of labor In many multiparous , some nulliparous At onset of labor head freely movable above inlet Referred floating

Asynclitism
Sagittal suture remaining parallel to transverse axis may not lie exactly midway Between symphysis and sacral promontory Sagitlal suture deflected posteriorly or anteriorly

Asynclitism anteror or posterior Moderat degree of asynclitism are the rule in normal labor Severe asynclitism may lead to cephalopelvic disproportion even with an normal sized pelvis

DESCENT
First requisit for birth infant In nulli parus take place befor the onset of labor Further descent until onset of the second stage In multiparous descent usually begins with engagement

1. 2. 3. 4.

Descent is brought by one or more of four forces Pressure of amnionic fluid Direct pressure of fondus with cont ractions Bearing down efforts abdominal muscles Extension and straightening of fetal body

FLEXION
As soon as descending head meets resistance Cervix , walls of the pelvis , pelvic floor The chin is braught into more intimate contact Fetal thorox suboccipitobreg matic occipitafrontal

Internal rotation
occiput gradually moves from original position toward symphysis pubis Less commonly posteriorly Internal rotation essential completion of labor It always associated with descent and acomplished after engagement

Extension
After in-rotation sharply flexed head reaches the vulva Undergoes extension which essential to birth Vulvar outlet directed upward , for ward Extension must occur before head can pass through it

Head born by further extension occiput , bregma , fore head , nose mouth Finally chin pass Head drops down ward chin lies over anal region

External rotation
delivered head under goes restitution occiput toward the left rotates left ischial tuberosity occiput toward the right rotates right ischial tuberosity Bisacromial diameter in to relation anteroposterior diameter of the pelbic outlet shoulders (anteriar posterior)

Expulsion
Immediatly after external rotation Anterior shoulder under symphysis pubis Posterior shoulder distended perineum After delivery of the shoulders Rest of body quickly extruded