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2 TYPES OF PHYSIOLOGY
1.UTERINE ACTION
2.MECHANICAL ACTION.
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NON-INTERFERENCE WITH
WATCHFUL EXPECTANCY
TO MONITOR CAREFULLY
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GENERAL
BOWEL
REST AND AMBULATION
DIET BLADDER CARE
RELIEF OF PAIN
ASSESSMENT OF PROGRSS OF LABOR ANDPARTOGRAPH RECORDING
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IT IS A COMPOSITE GRAPHICAL RECORD OF
CERVICAL DIALATATION AND DESCEND OF
THE HEAD AGAINST DURATION OF LABOUR IN
HOURS
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The partograph can be used by healthworkers with adequate training in midwiferywho are able to :
- observe and conduct normal labour and
delivery.- Perform vaginal examination in labour andassess cervical diltation accurately
- plot cervical diltation accurately on a graph
against time There is no place for partograph in deliveries
at home conducted by attendants other thanthose trained in midwifery
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early detection of abnormal progress of a labour prevention of prolonged labour
recognize cephalopelvic disproportion beforeobstructed labour
assist in early decision on transfer ,augmentation , or termination of labour
increase the quality and regularity of allobservations of mother and fetus
early recognition of maternal or fetal problems the partograph can be highly effective in
reducing complications from prolonged labor forthe mother (postpartum hemorrhage, sepsis,uterine rupture) and for the newborn (death,anorexia, infections, etc.).
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Part 1 : fetal condition ( at top )
PArt 11 : progress of labour ( at middle )
Part 111 : maternal condition ( at bottom ) Outcome :
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This part of the graph is used to monitor
and assess fetal condition
1 - Fetal heart rate
2 - membranes and liquor3 moulding of the fetal skull bones
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Basal fetal heart rate? < 160 beats/mi =tachycardia
> 120 beats/min = bradycardia
>100beats/min = severe bradycardia
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intact membranes .I
ruptured membranes + clear liquor ..C
ruptured membranes + meconium- stained liquor
..M
ruptured membranes + blood stained liquor
B
ruptured membranes + absent
liquor....A
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Molding is an important indication of how
adequately the pelvis can accommodate the
fetal head.
separated bones . sutures felt easily ..O
bones just touching each other ..+
overlapping bones ( reducible ) ...++
severely overlapping bones ( non reducible
..+++
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Cervical diltation
Descent of the fetal head
Fetal position
Uterine contractions
This section of the paragraph has as itscentral feature a graph of cervical
diltation against timeit is divided into a latent phase and anactive phase
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it starts from onset of labour until thecervix reaches 3 cm diltation
once 3 cm diltation is reached , labourenters the active phase
lasts 8 hours or less
each contraction lasting < 20 sceonds
at least 2/10 min contractions
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Contractions at least 3 / 10 min
each lasting < 40 seconds
The cervix should dilate at a rate of 1 cm
/ hour or faster
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The alert line drawn from 3 cm diltation
represents the rate of diltation of 1 cm /
hour
Moving to the right or the alert line meansreferral to hospital for extra vigilance
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The action line is drawn 4 hour to the left of
the alert line and parallel to it
This is the critical line at which specific
management decisions must be made at thehospital
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It is the most important information andthe surest way to assess progress oflabour.
when progress of labour is normal andsatisfactory , plotting of cervicaldilatation remains on the alert line.
if a woman arrives in the active phase oflabour , recording of cervical dilatationstarts on the alert line
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It should be assessed by abdominal
examination immediately before doing a
vaginal examination, using the rule of
fifth to assess engagementThe rule of fifth means the palpable fifth
of the fetal head are felt by abdominal
examination to be above the level of
symphysis pubis
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Observations of the contractions aremade every hour in the latent phase andevery half-hour in the active phase
frequency how often are they felt ?
Assessed by number of contractions in a10 minutes period
duration how long do they last ?
Measured in seconds from the time thecontraction is first felt abdominally , tothe time the contraction phases off
Each square represents one contraction
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Less than 20 seconds:
Between 20 and 40 seconds:
More than 40 seconds:
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Name / DOB /Gestation
Medical / Obstetrical issues
Assess maternal condition regularly by
monitoring :drugs , IV fluids , and oxytocin , if labour
is augmented
pulse , blood pressureTemperature
Urine volume , analysis for protein and
acetone
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A SINGLE SHEET OF PAPER CAN PROVIDE
DETAILS OF NECESSARY INFORMATION.
NO NEED TO RECORD THE LABOUR EVENT
REPEATEDLY.
IT CAN PREDICT DEVIATION FROM NORMAL
DURATION OF LABOUR EARLY.
CAN REDUCE THE INCIDENCE OF PROLONGED
LABOUR AND CAESAREAN RATE.
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SEDATIVES AND ANALGESICS
INHALATION AGENTS
REGIONAL ANALGESIA
PATIENT CONTROLLED ANALGESIA (PCA) PSYCHOPROPHYLAXIS
TRANSCUTANEOUS ELECTRICAL NERVE
STIMULATION
GENERAL ANESTHESIA
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The threshold of pain.
Primi or multi.
Maturity of the fetus.
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Pethadine: Strong sedatives but less
analgesic efficiency.
Used in the first phase of labor
The initial dose is 100mg IM.
Side effects
For mother- nausea, vomiting, delayedgastric empting.
For fetus- respiratory and sucking
depression.
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Meptazinol :
It has got similar analgesic
and sedative property as that of
pethadine. It cause lessrespiratory depression of the baby
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Pentazecin (Fortwin):
it is given IM in a dose of 30-40mg its duration is shorter and causes
some respiratory depression and
also drug dependency naloxone is an efficient and
reliable antagonist.
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Diazepam :
It is well tolerated by the patient.
It doesnot produce vomiting and help in the
dilatation of the cervix. It is metabolized in the liver.
The usual dose is 5-10mg.
It may be used in larger dose in the
management of pre-eclampsia.
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Midazolam :
More potent and neonatal side effectare less compare to diazepam.
It is cleared from the tissue more
rapidly.
Dose of 0.05 mg/kg is given IV.
C bi i f i d
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Combination of narcotics and
tranquilisers :
Narcotics may be used incombination with promethazine,
chlorpromazine or promazine.
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Nitrous oxide and air: This is used in thesecond phase. Now a day, this is not usedbecause this produce fetal hypoxia.
Premixed nitrous oxide and oxygen: cylinders
containing 50% nitrous oxide and 50% oxygenmixture. Endonox apparatus has beenapproved for use by midwives. It can be selfadministered
Trichloroethylene (Trilene): This is an usefuldrug in labor with high analgesic effect. Itgives better result in nervous women thannitrous oxide. It is no longer used.
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methoxyflurane, isoflurane,
enfluran: they are good analgesicagent and more effective than
trichloroethylene.
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Continuous lumbar epidural block
Contraindications
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Contraindications
Sepsis at the site of injection
Hemorrhage
Supine hypotensionHypovolaemia
Neurologic disease.
Spinal deformity or chronic back pain.
Complications
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Complications
Hypotension
Pain at the insertion site
Post spinal headache due to leakage of
cerebrospinal fluid.
Injury to nerves.
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Caudal epidural analgesia:
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Paracervical nerve block
Pudental nerve block
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Pudental nerve block
S i l th i
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Spinal anesthesia
Ad t
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Advantages
less fetal hypoxiaEasy technique
No inhalation anesthesia is required
Disadvantages
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Disadvantages
Hypotension
Respiratory depression to the baby
Post-spinal head ache
Transient or permanent paralysis
Toxic reaction of local anesthetic drug.Nausea and vomiting
Urinary retention.
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CONSIDERATIONS
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ELECTIVE OR EMERGENCY PROCEDURE
PATIENT SHOULD BE ON NIL BY MOUTH.
DRUGS MAY CAUSE FETAL DEPRESSION.VOLATILE ANESTHESIA DIMINISHES UTERINE CONTRACTILITY EG:
EATHER, HALOTHANE.
HYPOXIA AND HYPERCAPNIA MAY OCCUR.
CAN CAUSE DEPRESSION IN APGAR SCORE.
Complications of GA
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Co pl cat o s o G
Aspiration of gastric content (mendelsons
syndrome).Failure in intubation and ventilation.
Nausea, vomiting and sore throat.
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PREVENTION
KEEP THE PATIENT NBM.
H2 BLOCKER BEFORE NIGHT AND 1 HOUR BEFORE ADMINISTERING GA.
METOCLOPROMIDE 10MG IV IS GIVEN AFTER MINIMUM 3 MINUTE BEFORE
OXYGENATION TO DECREASE GASTRIC VOLUME AND TO INCREASE THETONE OF LOWER ESOPHAGEAL SPHINCTER.
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It t t f th f ll dil t ti
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It starts from the full dilatation
till the expulsion of the fetus.
It has got two phases and
duration is 2hours in primi and
30min in multiparae.
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Propulsive phase: Starts from fulldilatation till the descent of the
presenting part to the pelvic floor
Expulsive phase: From the maternalbearing down effort till the delivery of
the fetus.
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Descent of the presenting part, whichbegan during the 1st stage of labor and
reached its maximum speed towards the
end of the first stage of labor, continues
through the second stage of labor until
reaching the pelvic floor.
The average maximum rate of descend is
1.6cm per hour in nulliparas and 5.4cmper hour in multiparas.
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Contraction during the second stage
are frequent, strong, and slightly
longer that is approximately every 2
minutes, lasting 60-90 seconds,
allowing both mother and baby
regular recovery period.
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The membrane often ruptures
spontaneously at the onset of the secondstage.
The consequent drainage of liquor allows
the hard, round fetal head to be directlyapplied to the vaginal tissue and aid
distention.
As the fetus further descend into the
vagina, pressure from the presenting partstimulates nerve receptors in the pelvic
floor and the mother experience the need
to push.
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As the hard fetal head descend, the soft tissuesof the pelvis become displaced.
Anteriorly the bladder is pushed upwards into
the abdomen where it is at risk of injury during
the fetal descent. Posterior, the rectum becomes flattened into the
sacral curve and the pressure of the advancing
head expels the residual fecal matter.
The fetal head become visible at the vulva,advancing with each contraction and receding
during the resting phase until crowning takes
place and the head is born.
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The women verbal expression my baby iscoming often signals an imminent delivery.
It is possible for a woman to feel strong
desire to push before full dilation.
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Membranes normally rupture at the onset ofsecond stage.
However this may occur at any time during
labor.
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Deep engagement of the presenting part andpremature maternal effort may produce this
sign during the latter part of the first stage.
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Excessive moulding may result in theformation of the large caput succedaneum,
which can protrude through the cervix prior
to the full dilatation
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This is the loss of blood stained mucus, whichoften accompanies rapid dilatation towards
the end of the first stage.
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to assist in the natural expulsion of the fetusslowly and steadily
to prevent the perineal injury
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the patient should lie down in the bed
constant supervision by the medical
attendant is mandatory (BP, maternal pulse
and FHR)
Administration of inhalation analgesic
vaginal Examination is done at the beginning
of the second stage
nothing is given by mouth.
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Shifting to labor table
Positioning of the patient: position of the
woman during delivery may be lateral or
partial sitting. Dorsal position with 15 degree
left lateral tilt is commonly favored as itavoids aortocaval compression and facilitates
pushing effort.
Scrubbing of the staff: puts on sterile gown,
mask and gloves and stands on the right side
of the table
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Toileting the external genitalia and inner side
of the thighs is done with cotton swabs
soaked in savlon or dettol solution. catheterize the bladder
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Delivery is divided in to threephases:
Delivery of head
Delivery of shoulder
Delivery of trunk
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The principles which should befollowed is
-maintain flexion of head
-to prevent early extension
-to regulate slow escape of the
vulval outlet
h d f h b
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The patient is encouraged for the bearing
down effect during contraction which
facilitate the descend of head.
When the scalp is visible for about 5 cm
in diameter, flexion of the head is
maintained during the contraction ,bypushing the occiput downward and
backward by the thumb and index finger
of the left hand while pressing the
perineum by the right palm.
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Episiotomy can be done at this stage when
perineum got bulged out
Sudden escape of the head during
contraction at this stage is to be prevented
Slow delivery of the head in between thecontractions is to be regulated.
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The mucus, blood in the mouth has to bewiped
Eyelids are wiped with sterile dry cotton
swabs. Each eye starting from the medial to
the lateral canthus.
The neck is then palpated to exclude the
presence of any loop of cord
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Wait for the uterine contraction to come andfor movements of restitution and external
rotation of head.
If there is a delay, the head is grasped by
both hand and is gently drawn posteriorlyuntil the anterior shoulder is released from
the pubis.
Traction on the head should be gentle to
avoid excessive stretching of the neck
causing injury to the brachial plexus.
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After the delivery of the shoulder, the forefingers of each hand are inserted under the
axilla and the trunk is delivered gentle by
lateral flexion.
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Delivery of the early extension is to beavoided
Spontaneous forcible delivery of the head is
to be avoided
To deliver the head in between contractions
To perform timely episiotomy
To take care during the delivery of the
shoulder
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STAGE STARTS FROM THE
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EXPULSION OF THE FETUS
TILL THE EXPULSION OF THEPLACENTA.
DURATION IS 15 MIN BOTH IN
PRIMI AND MULTI.IT COMPRISES THE PHASE OF
PLACENTAL SEPERATION, ITS
DESCENT TO THE SEGMENTAND FINALLY ITS EXPULSIONWITH THE MEMBRANE.
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DETACHMENT STARTS AT THECENTRE.
ACCUMULATION OF BLOOD BEHINDTHE PLACENTA
(RETROPLACENTAL HAEMATOMA).
INCREASE CONTRACTION , INCREASE
DETACHMENT .
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STARTS FROM MARGINAL.
PROGRESSIVE UTERINECONTRACTION, MORE AND MORE
AREA OF THE PLACENTA GET
SEPERATED.
FREQUENT ONE.
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Sudden gush of blood.Lengthening of the umbilical cord
visible.
Change the position of the uterus asit rises the abdomen, because the
bulk of the placenta is in the lower
uterine segment or upper uterinesegment.
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EXPELLED OUT BY EITHERVOLUNTARY CONTRACTION
MUSCLES OR BYMANIPULATIVE
PROCEDURE.
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-to ensure strict vigilanceand to follow the
management guidelinesstrictly in practice so as to
prevent the complications,
the important one being is
PPH.
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Minimal assistance may be given for theplacental expulsion if it needed.
Constant watch
Change mother position from lateral to
dorsal A hand is placed over the fundus
To recognize the sign of separation ofplacenta.
To note the state of uterine activity-contraction and relaxation.
To detect cupping of the fundus, which is anearly evidence of inversion of the uterus.
EXPULSION OF PLACENTA:
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TRADITIONAL METHOD
DESCENT--- CONFIRMATION.
CAN WAIT TIL 10MT IF THERE IS NO BLEEDING
INTRA ABDOMINAL PRESSURE WILL FACILITATE
FOR THE EXPEL OF THE PLACENTA.
AS SOON AS THE PLACENTA PASSES THROUGHTHE INTROITUS GRASP IT BY THE HAND AND
TWIST ROUND AND ROUND WITH GENTLE
TRACTION.
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CONTROLLED CORD TRACTION FUNAL PRESSURE
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IT IS ALSO CALLED MODIFIED BRANDT-ANDREWS METHOD.
THIS PROCESS IS ADOPTED ONLY WHEN THE
UTERUS IS HARD AND CONTRACTED
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Principle:-to excite powerful uterine
contractions following birth of
the anterior shoulder by parent
oxytocin which facilitates not
only early separation of the
placenta but produces effective
uterine contraction following its
separation.
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To minimise blood loss inthird stage approximately
to 1/5th
To shorten the duration of
third stage to half.
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Slight increasedincidence of retained
placenta.