Download - Normal Labor&Delivery
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Normal Labor & DeliveryNormal Labor & Delivery
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Why labor pains ?Why labor pains ?
LaborLabor-- because much energy is expendedbecause much energy is expended
during this timeduring this time
PainsPainsbecause contractions of labor are painfulbecause contractions of labor are painful
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Mechanisms Cited for Pain in LaborMechanisms Cited for Pain in Labor
Hypoxia of the contractedHypoxia of the contracted myometriummyometrium
Compression of nerve ganglia in the cervix andCompression of nerve ganglia in the cervix and
lower uterus by the interlocking muscle bundleslower uterus by the interlocking muscle bundles
Stretching of the cervix during dilatationStretching of the cervix during dilatation
Stretching of the peritoneum overlying theStretching of the peritoneum overlying the
fundusfundus
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Stages OfStages Of LabourLabour
Stage 1Stage 1
Cervical Effacement and DilatationCervical Effacement and Dilatation
Stage 2Stage 2
Full cervical dilatation to expulsion ofFull cervical dilatation to expulsion of
fetusfetus
Stage 3Stage 3
Placental separation andexpulsionPlacental separation andexpulsion
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EffacementEffacement:: taking up of thecervixtaking up of thecervix
or obliteration of thecervical canalor obliteration of thecervical canal
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Nulli ara Multi ara
Cervical
Effacementand
dilatation
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Cardinal MovementsCardinal Movementsof Laborof Labor
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The fetus is in theThe fetus is in the occiputocciput or vertex inor vertex in
approximately 97% of laborsapproximately 97% of labors
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Engagement
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion
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Conduct of Labor andConduct of Labor andDeliveryDelivery
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Signs of LaborSigns of Labor
HypogastricHypogastric andand lumbosacrallumbosacral painspains
(contractions)(contractions)
Bloody vaginal discharge or bloodyBloody vaginal discharge or bloody
showshow
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True LaborTrue Labor False LaborFalse Labor
Contractions regularContractions regular
Intervals shortenIntervals shorten
Intensity increasesIntensity increases
Discomfort in back &Discomfort in back &abdomenabdomen
CervixdilatesCervixdilates
IrregularIrregular
Remain longRemain long
UnchangedUnchanged
Lower abdomenLower abdomen
No dilatationNo dilatation
Relieved by sedationRelieved by sedation
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Admission Vaginal ExamAdmission Vaginal Exam
If there are NO contraindications, note:If there are NO contraindications, note:
Amniotic fluidAmniotic fluid
CervixCervix
Presenting partPresenting part
StationStation
Pelvic architecturePelvic architecture
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StationStation
Degree of descent of the presenting part intoDegree of descent of the presenting part into
the birth canalthe birth canal
Landmark:Ischial spinesLandmark:Ischial spines
Described in centimeters above or below spinesDescribed in centimeters above or below spines
((--5 to +5)5 to +5)
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Ischial spines
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Management of FirstS
tageManagement of FirstS
tageLaborLabor
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First stageFirst stage
-- from onset of regularfrom onset of regularcontractions to full cervicalcontractions to full cervical
dilatationdilatation
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First stage:Admission ProceduresFirst stage:Admission Procedures
History
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First Stage:Admission ProceduresFirst Stage:Admission Procedures
2. Physical Examination2. Physical Examination
General survey, vital signsGeneral survey, vital signs
a. Abdominal Examinationa. Abdominal Examination
InspectionInspection
PalpationPalpation
AuscultationAuscultation
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Identify which pole
occupies thefundus
Determine onwhich side the
back and soft partsare
What presenting
part overlies theinlet; attitudeExtent of descent
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First stage:Admission ProceduresFirst stage:Admission Procedures
3. Baseline3. Baselinecardiotocogramcardiotocogram
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First stage: Maternal MonitoringFirst stage: Maternal Monitoring
Subsequent vaginal examinationsSubsequent vaginal examinations
AnalgesiaAnalgesia
Vital signs every 1Vital signs every 1--2 hours2 hours
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Management ofManagement of
SecondStage of LaborSecondStage of Labor
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SecondStageSecondStage
Mean duration:Mean duration:
2020 minsmins.. -- multiparamultipara
5050 minsmins.. -- nulliparanullipara
IdentificationIdentification
--Woman starts to bear downWoman starts to bear down
-- Urge to defecateUrge to defecate-- Uterinecontractions longer, restUterinecontractions longer, restintervals shorterintervals shorter
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Second stage:Second stage:
Preparation for DeliveryPreparation for Delivery
PositionPosition
-- DorsalDorsal lithotomylithotomy
-- StirrupsStirrups
-- Legs not too wide openLegs not too wide open
--Poplit
ealPoplit
eal r
egion shoul
drest
comfortablyr
egion shoul
drest
comfortablyonon leg holderleg holder
-- Cleansing anddrapingCleansing anddraping
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LITHOTOMY POSITION
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Delivery of the HeadDelivery of the Head
CrowningCrowning
largest headlargest head
diameter encircleddiameter encircled
by theby the vulvarvulvar ringring
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Delivery of the HeadDelivery of the Head
EpisiotomyEpisiotomy
Incision of the pudendaIncision of the pudenda
Not universally doneNot universally done
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EpisiotomyEpisiotomy
Substitutes a jagged laceration for a cleanSubstitutes a jagged laceration for a clean
cut woundcut wound
TypesTypes
-- medianmedian
-- mediolateralmediolateral
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Median episiotomy
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Mediolateral episiotomy
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Benefits(?) of EpisiotomyBenefits(?) of Episiotomy
?Clean cut wound?Clean cut wound
?prevents pelvic relaxation?prevents pelvic relaxation
cystocelecystocele
rectocelerectocele
urinary incontinenceurinary incontinence
Surgical judgment andcommon senseSurgical judgment andcommon sense
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Timing of EpisiotomyTiming of Episiotomy
Too earlyToo early
-- Bleeding from the incisionBleeding from the incision
Too lateToo late-- Excessive stretching of muscles of theExcessive stretching of muscles of the
perinealperineal floor; defeats the purpose of thefloor; defeats the purpose of theprocedureprocedure
Ideally: when head is visible atIdeally: when head is visible at introitusintroitus duringduringa contraction to aa contraction to a 33--44 cm. diametercm. diameter
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Median MediolateralMedian Mediolateral
Easy to repairEasy to repair More difficultMore difficult
Rare faulty healingRare faulty healing More commonMore common
Less postLess post--op painop pain More commonMore commonExcellent anatomicExcellent anatomic Faulty at timesFaulty at times
resultsresults
Less blood lossLess blood loss More blood lossMore blood lossDyspareuniaDyspareunia rarerare OccasionalOccasional
Extension commonExtension common RareRare
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Ritgen
Maneuver
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Clearing of the NasopharynxClearing of the Nasopharynx
Aspirate amnionic fluidAspirate amnionic fluid
debris and blooddebris and blood
Wipe face quicklyWipe face quickly
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Delivery of theShouldersDelivery of theShoulders
After delivery of the head, the fetus comesAfter delivery of the head, the fetus comesin contact with the anusin contact with the anus
If shoulders do not appear at the vulvaIf shoulders do not appear at the vulvaspontaneously after external rotation,spontaneously after external rotation,sides of the head are grasped and gentlesides of the head are grasped and gentle
downward traction is applied. Bodydownward traction is applied. Bodyfollows.follows.
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DOWNWARD
THEN
UPWARD
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NuchalNuchal cordcord
Finger should be passed around the neck toFinger should be passed around the neck to
check forcheck for nuchalnuchal cordscords
If looseIf loose just slide over infants headjust slide over infants head
If tightIf tight cut between 2 clampscut between 2 clamps
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Clamping the cord between 2 clamps
Nuchal cord
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Management of theThirdStageManagement of theThirdStage
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Third stage of laborThird stage of labor
Placental separation andexpulsionPlacental separation andexpulsion
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Delivery of the PlacentaDelivery of the Placenta
Should not be forced until signs of placentalShould not be forced until signs of placentalseparation appearseparation appear
DANGERDANGER::Uterine inversion !!!Uterine inversion !!!
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Signs of Placental SeparationSigns of Placental Separation
Uterus becomes globularUterus becomes globular
Sudden gush of bloodSudden gush of blood
Uterus rises in the abdomenUterus rises in the abdomen
Umbilical cord lengthensUmbilical cord lengthens
Within 1Within 1--3 minutes3 minutes
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PLACENTA
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Sudden g
ush of blood
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Lengthening of the cord
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Expression ofthe Placenta
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Delivery of the placenta
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Inspectionofthe Placenta
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Inspection of placenta
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Too much traction on thecordcan lead to UTERINE INVERSION
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UTERINE INVERSION
PLACENTA
UTERUS
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Manual Removal of the PlacentaManual Removal of the Placenta
Performed if the placenta does not separatePerformed if the placenta does not separate
promptlypromptly
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OxytocicOxytocic AgentsAgents
After deliveryAfter delivery hemostasishemostasis is achieved byis achieved by
vasoconstriction of the placental sitevasoconstriction of the placental site
Agents which promotecontraction of theAgents which promotecontraction of the
myometriummyometrium::
-- OxytocinOxytocin
-- ErgonovineErgonovine maleatemaleate
-- MethylergonovineMethylergonovine maleatemaleate
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Fourth Stage of LaborFourth Stage of Labor
Maternal vital signsMaternal vital signs
Gentle uterine massage and ice packs toGentle uterine massage and ice packs to
stimulatecontractionsstimulatecontractions
Bladder should becheckedBladder should bechecked
Clots in the uterinecavityClots in the uterinecavity
HematomasHematomas
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Lacerations of Vagina & PerineumLacerations of Vagina & Perineum
First degreeFirst degree
-- FourchetteFourchette,, perinealperineal skin vaginal mucosa butskin vaginal mucosa but
not the underlying fascia and musclenot the underlying fascia and muscle
Second degreeSecond degree
-- Fascia & muscles of theFascia & muscles of the perinealperineal body but notbody but notthe anal sphincterthe anal sphincter
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ThirddegreeThirddegree
--Vaginal mucosa,Vaginal mucosa, perinealperineal skin, fascia, upskin, fascia, up
to the rectal sphincter but not the rectalto the rectal sphincter but not the rectal
mucosamucosa
Fourth degreeFourth degree
-- Extension up to the rectal mucosaExtension up to the rectal mucosa
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Pain after EpisiotomyPain after Episiotomy
Persistence of pain may indicate thePersistence of pain may indicate the
presence of a HEMATOMA:presence of a HEMATOMA:
--vulvarvulvar
--vulvovaginalvulvovaginal
--ischiorectalischiorectal
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Good day!Good day!