Admission procedures

Dr. F Mostajeran MD

Admission procedures

Urged to report early in laborEarly admittance to labar , delivery unit especially high risk pregnancyaccurat diagnosis of labarFalsely diagnosed , inappropriate in terrentionNot 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 .

D. Diagnasis between false and true labor is difficult

Contractions of true labor

Regular intervals

Intervals gradually shorten

Intensity gradually increases

Discomfort back , abdomen

Cervix dilates

Discomfort is not stopped by sedation

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

Electronic admission testing

Recommend NST or CST on all patient

(labar – delivery unit)

Fetal admission test

identify unsuspected cases

Vaginal examination1. Amnionic fluid effacement2. Cervix dilatation position3. Presenting part4. Station5. Pelvic architecture

Detection of ruptured membranes

Leakage of fluidProlapse cordLabor occurSerious intra uterine infectionNitrazine paper (PH= 7.0 – 7.5)Arborization or ferningAlpha – fetoproteinInjection various dyes

Vital signs and review of pregnancy recordPhysical examinationPreparation of vulva and perineumInspection 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

Latent phase (14-20h)

Active phase:

acceleration ,phase of maximum slope

, deceleration phase

Cervical dilatationCervical dilatation

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 intakeGastric emptying time prolanged

(food – medication remain in the stomach – not absorbed may be vomited)

Food should be withheld

Intravenous fluidsInfusion system routine early labar (IV line)

Longer labors glucose sodium water 60-120 ml/hr

Maternal position during labornormal laboring woman

Not be confined to bed

Comfortable chair

In bed position most comfortabl (lateral recumbend)

AnalgesiaIs initiated on the basis of maternal

discomfortvaginal 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 temptationBenefits: rapid labor detection of meconium staining Internal fetal MAseptic techniqueHead must be well applied to the cerxin

Urinary bladder functionBladder 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

FHRLow – 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 deliveryVariety 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 headContraction perineum bulgesVulvovaginal opening becomes more dilatedGradually circular opening This encirclement of the largest headBy the vulvar ring is known as crowning

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 nasopharynxMinimize aspiration AF – debris , bloodonce 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 cord4-5 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 infant80ml 50mg Iron , Iron deficiency

anemiaMaternal alloimmunization our policy after cleaning airway 30" cord clamp

Management of the third stage

After delivery of the infantHeight uterine fundusUterus firm , no unusual bleedingWaiting until placentac separat – no massageHand 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

delivery of the placentaTraction on the umbilical cord must not be used inversion

Manaol removal of placentaoccasionally placenta will not separatAt any time brisk bleeding and , placenta can not be deliveredActive management of the third stage5 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 15

Oxytocic AgentsOxytocin (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 effectsDeleterious effects follow IV bolusAntidiuresisrare maternal convulsion antidiuretic actionWater intoxication (20,40mu/minut )Concentration should be increared rather than rate of flowNormal 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

ProstaglandinsNot 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

ClassifiedFirst fourchette , perineal skin vaginal mucousSecond fascia and muscles of perineal bodyThird anal sphincterFourth retal mucosa

Episiotomy and repair

Incision of pudendaPerineotomy incision of perineuEpisiotamy synonymously with penineotomyBegin in midline :Directed laterally mediolateralDirected down ward midline

Timing of episiotomyPerform when head is visible during contraction 3-4After application of bladesTiming of repairMost common practice repair until placenta deliveredTechniqueHemostasisAnatomical restoration without excessive suturingChromic 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 presentationMost commonly ascertained ab – examConfirmed V.Examination before or at the onset of laborSagitlal suture in the transrevse pelvic diameterLOT , ROT , LOA , ROAROP , 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

EngagementBiparietal 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 laborFurther descent until onset of the second stageIn multiparous descent usually begins with engagement

Descent is brought by one or more of four forces

1. Pressure of amnionic fluid

2. Direct pressure of fondus with cont ractions

3. Bearing down efforts abdominal muscles

4. Extension and straightening of fetal body

FLEXION

As soon as descending head meets resistanceCervix , walls of the pelvis , pelvic floorThe chin is braught into more intimate contact Fetal thorox suboccipitobreg matic occipitafrontal

Internal rotation

occiput gradually moves from original position toward symphysis pubisLess commonly posteriorlyInternal rotation essential completion of laborIt always associated with descent and acomplished after engagement

ExtensionAfter in-rotation sharply flexed head reaches the vulvaUndergoes extension which essential to birthVulvar outlet directed upward , for wardExtension 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 rotationdelivered 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)

ExpulsionImmediatly after external rotation

Anterior shoulder under symphysis pubis

Posterior shoulder distended perineum

After delivery of the shoulders

Rest of body quickly extruded