MANAGEMENT OF LABOUR

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MANAGEMENT OF LABOUR

• SALWA NEYAZI
• CONSULTANT OBSTETRICIAN GYNECOLOGIST
• PEDIATRIC ADOLESCENT GYNECOLOGIST

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MANAGEMENT OF LABOUR

• WHAT IS LABOUR?
• Regular frequent uterine contractions
• Cx changes (dilatation effacement)
• or
• SROM
• WHAT ARE THE GOALS OF LABOUR MNAGEMENT?
• To reduce maternal mortality morbidity
  resulting from complications of labour/delivery
  postpartum
• To reduce intrapartum fetal mortality
• To reduce birth aspyxia
• To reduce the cesarean section rate
• To improve maternal satisfaction of the birthing
  experience
• To relieve maternal anxiety pain during labour

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PHASES OF LABOUR

• FRIEDMANS CURVE

10-
DECELRATION PHASE
8-
Cervical dilatation
6-
ACCELRATION PHASE
4-
???????LATENT PHASE???????
2-
??ACTIVE PHASE??
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8
10
2
4
Duration of labour
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LABOUR TIME FRAMES
Phases/ Stages of labour Phases/ Stages of labour Nulliparous Multiparous
Latent phase Mean time 6.4 h 4.8 h
Latent phase Longest normal 20.1 h 13.6 h
Active phase Mean rate 3 cm/h 5.7cm/h
Active phase Slowest normal 1.2cm/h 1.5cm/h
2nd Stage Mean time 1.1 h 0.4 h
2nd Stage Longest normal 2.9 h 1.1 h
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MANAGEMENT OF LABOUR

• 1- Labour preparation ? Prenatal educational
  classes
• ? amount of analgesia used in labour
• Improve maternal stisfaction
• 2-Birthing companion ? A supportive companion
  with experience of labour (not trained in health
  discipline) ? faster progress less dystocia
• 3-Ambulation
• ? the incidence of dystocia ?? augmentation ?
  operative delivery
• ? pain percieved by the woman ? ? analgesia
  epidural
• Supine position ? antroposterior compression of
  the pelvis/ ? the size of the passage

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MANAGEMENT OF LABOUR

• 4-Analgesia
• Epidural
• Nitrous oxide
• Narcotics

? pain anxiety
? Catecholamines
Dystocia
?Uterine Contraction strength
?Uterine blood flow
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• 5-Contiuous assessment of progress of labour
• THE PARTOGRAM

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MANAGEMENT OF LABOUR

• 6-Amniotomy
• Routine early use of amniotomy after 3 cm
  dilatation ?
• Shortens the average length of labour
• Does not ? the incidence of CS
• 7-Fetal size
• ? fetal size ? ? duration of labour

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FACTORS INFLUENCING LABOUR

• WHAT IS DYSTOCIA?
• 4 hrs of lt 0.5 cm/ hr dilatation
• 1 hr with no descent
• Dystocia cannot be diagnosed before the onset of
  labour
• WHAT ARE THE CAUSES OF DYSTOCIA?
• 3 Ps
• POWERS ? Hypotonic contractions
• PASSENGER ? Fetal position
• Fetal size
• PASSAGE ?Boney pelvis
• Soft tissue

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• How to assess these factors?
• Adequate powers ? contractions that
• -last for 60 sec
• -reach 20-30 mmHg of pressure
• -occur every 1-2 min
• Hypotonic contractions are responsible for 2/3 of
  nulliparous dystocia
• If powers are adequate ? check Passage for size
  abnormal shape and check the Passenger for size
  malpresentation
• What is the importance of diagnosing dystocia?
• Dystocia elective repeat CS account for the
  majority of CS indications
• There has been dramatic ?in CS rate with ? in
  maternal mortality, morbidity, neonatal morbidity
  health care costs, reducing Dystocia ? ? CS rate

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PHILPOTTS CERVICOGRAPH

• Cervicograph should not be used until active
• labour has been established 3-4 cm dilatation

10-
8-
Action line
Cervical dilatation
6-
Alert line
4-
2-
6

8
10
2
4
Time (hr)
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TREATMENT OF DYSTOCIA

• 1-Oxytocin 2-Active management of labour
• 3-Instrumental deliveries 4-CS

ADVERSE EFFECTS OF OXYTOCIN
ADVERSE EFFECTS MECHANISM PREVENTION
Fetal compromise Hyperstimulation Correct dose
Uterine rupture Hyperstimulation Correct dose
Hypotension Vasodilatation Low dose infusion
Water intoxication ADH effect Limit free water
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PRINCIPLES OF ACTIVE MANAGEMENT

• Accurate diagnosis of labour
• Continuous assessment of the progress of labour
• One to one nursing care
• Early amniotomy
• Oxytocin
• Benefits of active management
• Significant reduction in dystocia instrumental
  deliveries CS rate
• No increase in birth asphyxia or perinatal
  mortality

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ACTIVE MANAGEMENT OF LABOUR
Active Control
Labour gt12 hrs 7 20
Forceps 19.4 29
CS 4.3 13
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PREVENTION OF DYSTOCIA

• Avoid unnecessary inductions
• Induction is associated with increase
  incidence of Dystocia DX in the latent phase of
  labour increase in obstetric interventions
• Admit only women inactive labour
• Encourage prenatal classes labour companion
• Ambulate in labour
• Use appropriate analgesia
• Active management of labour

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MANAGEMENT OF POSTPARTUM PATIENTS
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PUERPERIUM

• It is the period after delivery during which
  there is rapid return to normal health the
  normal prepregnancy body physiology . It lasts
  around six wk
• There is a high prevelance of maternal morbidity
  in the immediate postpartum period (85) , in the
  1st 8 wk postpartum 87 continuing problem in
  47-76
• Maternal mortality most maternal morbidity
  except for piles stress incontinence are more
  after CS
• Vacuum extraction results in less maternal trauma
  pain than forceps without increasing the need
  for CS

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PROBLEMS THAT MAY BE ENCOUNTERED IN POSTNATAL WARD

• 1-Afterpains ? due to myometrial contractions
• ? with breast feeding
• Improve with NSAID
• 2-Post partum hemorrhage (5-10)
• -Routine use of oxytocics in the third stage
  of labour ? ? blood loss by 30-40
• -It is more likely to occur in the delivery
  room the first 1-2 hrs after delivery
• - Most commonly due to suboptimal contractions
  of the uterus or abnormal implantation site of
  the placenta (low laying ) at which bleeding can
  not be controlled by uterine contractions
• -RPOC endometritis can result in PPH several
  days after delivery

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• What can we do if a Pt has PPH in the postnatal
  ward?
• Start IV line
• Send blood for CBC/X-matching /Coagulation
• Feel the level of the fundus ? normally midway
  between umbilicus symphesis pubis ? may be
  distended with blood clots inside it ? inadequate
  uterine contraction
• Uterine massage
• Start IV syntocinon drip/ ergometrin
• PG F2a NALODOR IM /IV or intramyometrial
• U/S to R/O RPOC
• Check for unnoticed perineal, vaginal or cevical
  lacerations
• Exploration under GA

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• 3-Anemia (25-30)
• 4-Fever
• Common causes of fever
• -Breast engorgement
• -UTI 2-5
  days after delivery
• -Endometritis
• Prophylactic antibiotics at the time of CS ? ?
  serious infections , febrile morbidity wound
  infection
• PROM predispose to endometritis
• 5- RH ve mothers with RH ve babies should
  receive Anti-D 300 µgm within 72 hrs of delivery

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• 6-Thrombosis pulmonary embolism
• Accounts for 23 of direct maternal deaths
• After CS 69 / after ND 48
• Risk factors ? obesity, immobilization,
  previous thromboembolism, increasing maternal age
  operative delivery
• Prophylaxis for the high risk gp reduces the
  risk
• May appear after the 3rd day death occur 7th D
  in 2/3 of cases
• Pelvic thrombophlebitis ? following endometritis
• Causes pain fever
• Dx by exclusion
• Rx Ab Heparin

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• 7-PET ECLAMPSIA
• 35 of eclampsia can occur for the 1st time in
  the postnatal period
• Close monitering of BP proteinurea should
  continue after delivery for Pt with PET or
  eclampsia appropriate measures taken if the
  problem persists
• We should ignore alarming symptoms like headache
  , vomitting epigastric pain
• 8- BOWEL PROBLEMS
• Constipation 20 ? Local acting laxatives
• high fiber
  diet
• Hemorrhoids 18 ? 70 last more than 1 year ?
  Avoid constipation
• Xyloproct suppositories
• Inability to control flatus or faeses 4

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9-PERINEAL CARE

• Perineal pain occur in 42 of women after
  delivery persists beyond the 1st 2 M in 8-10
  after SVD
• Mediolateral episiotomy causes more pain than
  median episiotomy
• 50 dyspareunia on 1st restarting intercourse
  15 continue to have it 3 Y later
• After assissted vaginal delivery ? 84 will have
  perineal pain
• 30 after the 1st 2 M
• The choice of suture material has a long term
  effect on dyspareunia
• Analgesics should be used for relief of perineal
  pain ? Paracetamol/ Brufen/ Ponstan
• Sitz bath for pain relief
• To keep the area clean dry
• Pelvic examination ? to R/O hematoma

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10-URINARY TRACT PROBLEMS

• Urinary retention is mainly due to bladder edema
  hyperemia
• -Perineal pain can add to the problem by
  causing reflex retention
• -Paralyzing effect of the epidural
• If the Pt does not void for 6-8 hrs or has
  frequent small voids ? cathterization
• UTI ? -especially if the Pt has been catheterized
  in labour
• -2ry to urine retension
• Urinary frequency
• Stress incontinence 20 3M after delivery
• ¾ of them still incontinent after 1 year

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11-DEPRESSION TIREDNESS

• Depression 10-15 within the 1st year
• Tiredness 42 in hospital
• 54 at home 1st 2 months
• Supportive care counseling
• 12-BREAST PROBLEMS
• Nipple pain / engorgement/ cracks bleeding
• ?66
• -Rx ? To teach the mother the correct way of
  BFeeding
• ? Local heat
• Analgesics
• Breast feeding/pumping to reduce
  engorgement
• Keeping the nipple clean
• Applying emollients Bepanthene
  cream/ breast milk
• Nipple shield
• Mastitis/breast abscess ? not contraindication to
  breast feeding
• -Usually 2-3 wk after delivery
• -Requires Antibiotics continued breast
  feeding or pumping