Transcript Normal Labor and Childbirth

Normal Labor and Childbirth
Objectives of Care During
Labor and Childbirth
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Protect the life of the mother and newborn
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Support the normal labor and detect and treat complications in
timely fashion
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Support and respond to needs of the woman, her partner and
family during labor and childbirth
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Definition
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Labor is the process by which contractions of the
gravid uterus expel the fetus.
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A term pregnancy delivers between 37 and 42 weeks
from the last menstrual period (LMP).
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Preterm labor is that occurring before 37 weeks of
gestational age.
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Postdate pregnancy occurs after 42 weeks gestation
and requires careful monitoring.
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Termination of pregnancy before 20 weeks of
gestation is defined as either spontaneous or
elective abortion.
Premonitory signs of labor
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Cervical changes
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softening and dilation with descent of the presenting part into the
pelvic. This stage occurs one month to one hour before actual labor.
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The cervix becomes shortened and thinned segment
Premonitory signs of labor
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Lightening: occurs when the fetal presenting part begins
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to descend into the maternal pelvic. The uterus lowers and
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moves into a more anterior position. this change will cause:
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Breathing becomes easier
Increased pelvic pressure
Cramping and low backache
Lower extremities edema
Increased vaginal secretion
More frequent urination
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In PG it occurs 2 weeks ore more before labor.
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In MP it occurs during labor
Premonitory signs of labor
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Increased energy level : many women will
focus this energy in preparation by cleaning,
cooking, preparing the nursery…it is usually occur
24-48 hours before labor.
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Bloody show: the mucus plug of the cervical
canal during pregnancy is expelled as a result of
cervical softening and increased pressure of the
presenting part. The exposed cervical capillaries
release a small amount of blood that mix with the
mucus, resulting in bloody show.
Premonitory signs of labor
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Braxton Hicks Contraction: these contractions aid
in moving the cervix from the posterior position to
the anterior position, they also help in ripining and
softening of the cervix.
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The contractions are irregular and diminished by
walking, voiding, eating, increasing fluid intake, or
changing position.
Premonitory signs of labor
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Spontaneous rupture of membrane: one in four
women experience SROM before onset of labor. This
reduces the capacity of the uterus, thickens the
uterine wall, and increases uterine irritability. Labor
usually follows.
At term, 90% will be in labor within 24 h after
membrane rupture.
If labor does not begin in 24 h, the case must be
considered complicated by prolonged rupture of the
membranes because of the increased risk of
ascending infection.
True versus false labor:
Differentiating True Labor and False Labor
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Factors
True labor
False labor
Contractions
timing
Regular intervals, becoming close together, usually 4-6 minutes apart,
lasting 30-60 seconds.
Irregular intervals,
not occurring close
together
Contraction
strength
Becomes stronger with time, vaginal pressure is usually felt
Frequently weak,
not getting strong
with time
Contraction
discomfort
Start in the back and radiates around toward the front of the abdomen
Usually felt in the
front of the
abdomen
Position changes
Contractions continue no matter what positional changes is made
Contraction may
stop or slow down
with walking or
changing position
Effect of analgesia
Not terminated by sedation
Frequently
abolished by
sedation
Cervical change
Progressive effacement and dilation
No change
Partograph and Criteria for Active Labor
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Label with patient
identifying information
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Note fetal heart rate, color
of amniotic fluid, presence
of moulding, contraction
pattern, medications given
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Plot cervical dilation
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Alert line starts at 4 cm-from here, expect to dilate
at rate of 1 cm/hour
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Action line: If patient does
not progress as above,
action is required
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Support of Woman
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Give woman as much information and explanation as she
desires
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Provide care in labor and childbirth at a level where woman
feels safe and confident
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Provide empathic support during labor and childbirth
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Facilitate good communication between caregivers, the woman
and her companions
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Continuous empathetic and physical support is associated
with shorter labor, less medication and epidural analgesia and
fewer operative deliveries
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Clean Delivery
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Infection accounts for 14.9% of all maternal deaths
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These deaths can be avoided with infection prevention
practices
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Infection Prevention Practices
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Use disposable materials once and decontaminate reusable
materials throughout labor and childbirth
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Wear gloves during vaginal examination, during birth of newborn
and when handling placenta
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Wear protective clothing (shoes, apron, glasses)
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Wash hands
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Wash woman’s perineum with soap and water and keep it clean
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Ensure that surface on which newborn is delivered is kept clean
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High-level disinfect instruments, gauze and ties for cutting cord
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Best Practices: Labor and Childbirth
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Use non-invasive, non-pharmacological methods of pain relief
during labor (massage, relaxation techniques, etc.):
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Less use of analgesia OR 0.68 (CI 0.58–0.79)
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Fewer operative vaginal deliveries OR 0.73 (95% CI 0.62–
0.88)
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Less postpartum depression at 6 weeks OR 0.12 (CI 0.04–
0.33)
Offer oral fluids throughout labor and childbirth
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Position in Labor and Childbirth
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Allow freedom in position and movement throughout labor and
childbirth
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Encourage any non-supine position:
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Side lying
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Squatting
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Hands and knees
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Semi-sitting
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Sitting
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Position in Labor and Childbirth
(continued)
Use of upright or lateral position compared with supine or
lithotomy position is associated with:
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Shorter second stage of labor (5.4 minutes, 95% CI 3.9–6.9)
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Fewer assisted deliveries (OR 0.82, CI 0.69–0.98)
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Fewer episiotomies (OR 0.73, CI 0.64–0.84)
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Fewer reports of severe pain (OR 0.59, CI 0.41–0.83)
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Less abnormal heart rate patterns for fetus (OR 0.31, CI
0.11–0.91)
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More perineal tears (OR 1.30, CI 1.09–1.54)
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Blood loss > 500 mL (OR 1.76, CI 1.34–3.32)
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Restricted Use of Episiotomy:
Objectives and Design
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Objective: To evaluate possible benefits, risks and costs of
restricted use of episiotomy vs. routine episiotomy
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Design: Meta analysis of six randomized control trials
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Restricted Use of Episiotomy:
Maternal Outcomes Assessed
.
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Severe vaginal/perineal trauma
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Need for suturing
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Posterior/anterior perineal trauma
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Perineal pain
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Dyspareunia
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Urinary incontinence
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Healing complications
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Perineal infection
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Indicated Use of Episiotomy:
Reviewer’s Conclusions
.
.
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Implications for practice: Clear evidence to restrict use of
episiotomy in normal labor
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Implications for research: Further trials needed to assess use
of episiotomy at:
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Assisted delivery (forceps or vacuum)
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Preterm delivery
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Breech delivery
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Predicted macrosomia
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Presumed imminent tears (threatened 3rd degree tear or
history of 3rd degree tear with previous delivery)
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Best Practices: Third Stage of Labor
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Active management of third stage for ALL women:
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Oxytocin administration
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Controlled cord traction
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Uterine massage after delivery of the placenta to keep the
uterus contracted
Routine examination of the placenta and membranes
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22% of maternal deaths caused by retained placenta
Routine examination of vagina and perineum for lacerations
and injury
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Best Practices: Postpartum
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Close monitoring and surveillance during first 6 hours
postpartum
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Parameters:
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– Blood pressure, pulse, vaginal bleeding, uterine
hardness
Timing:
– Every 15 minutes for 2 hours
– Every 30 minutes for 1 hour
– Every hour for 3 hours
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Presence of Female Relative
During Labor: Results
Randomized controlled trial in Botswana: 53 women with relative;
56 without
Labor Outcome
Experimental
Group (%)
Control
Group (%)
p
Spontaneous vaginal
delivery
91
71
0.03
Vacuum delivery
4
16
0.03
Cesarean section
6
13
0.03
Analgesia
53
73
0.03
Amniotomy
30
54
0.01
Oxytocin
13
30
0.03
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Presence of Female Relative
During Labor: Conclusion
Support from female relative improves labor outcomes
.
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Harmful Routines
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Use of enema: uncomfortable, may damage bowel, does not
change duration of labor, incidence of neonatal infection or
perinatal wound infection
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Pubic shaving: discomfort with regrowth of hair, does not
reduce infection, may increase transmission of HIV and
hepatitis
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Lavage of the uterus after delivery: can cause infection,
mechanical trauma or shock
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Manual exploration of the uterus after delivery
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Harmful Practices
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Examinations:
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Rectal examination: Similar incidence of puerperal
infection, uncomfortable for woman
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Routine use of x-ray pelvimetry: Increases incidence of
childhood leukemia
Position:
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Routine use of supine position during labor
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Routine use of lithotomy position with or without stirrups
during labor
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Harmful Interventions
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Administration of oxytocin at any time before delivery in such
a way that the effect cannot be controlled
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Sustained, directed bearing down efforts during the second
stage of labor
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Massaging and stretching the perineum during the second
stage of labor (no evidence)
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Fundal pressure during labor
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Inappropriate Practices
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Restriction of food and fluids during labor
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Routine intravenous infusion in labor
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Repeated or frequent vaginal examinations, especially by more
than one caregiver
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Routinely moving laboring woman to a different room at onset
of second stage
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Encouraging woman to push when full dilation or nearly full
dilation of cervix has been diagnosed, before woman feels
urge to bear down
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Inappropriate Practices
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Rigid adherence to a stipulated duration of the second stage of
labor (e.g., 1 hour) if maternal and fetal conditions are good
and there is progress of labor
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Liberal or routine use of episiotomy
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Liberal or routine use of amniotomy
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Practices Used for Specific
Clinical Indications
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Bladder catheterization
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Operative delivery
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Oxytocin augmentation
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Pain control with systemic agents
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Pain control with epidural analgesia
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Continuous electronic fetal monitoring
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Normal Labor and Childbirth:
Conclusion
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Have a skilled attendant present
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Use partograph
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Use specific criteria to diagnose active labor
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Restrict use of unnecessary interventions
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Use active management of third stage of labor
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Support woman’s choice for position during labor and
childbirth
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Provide continuous emotional and physical support to woman
throughout labor
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