1. Evaluate volume of vaginal bleeding as stable or unstable per the patients vital signs and uterine response . Stable : vital signs within 20% of patients average readings and uterus remains firm between assessment or quickly firms after fundal massage Unstable : vital signs vary greater than 20% from the patients average readings or repetitive blood pressure readings below 90/60 mm Hg , pulse more than 110/min , respiration 24 to 26 / min accompanied by continuous bleeding and a boggy uterine tone INCREASE PULSE RATE IS THE FIRST SIGN OF THE HYPOVOLUMIA AND VHYPOTENSION IS LATE . If bleeding continues and uterus is firm , notify health care provider for evaluation of laceration or retained placental fragments . AUTOTRANSFUSION 1

2. SEMINAR WHAT IS MEANT BY THE SEMINAR ? A SMALL GROUP OF ADVANCED STUDENTS IN A COLLEGE OR GRADUATE SCHOOL ENGAGED IN ORGINAL RESEARCH OR INTENSIVE STUDY UNDER THE GUIDANCE OF PROFESOR WHO MEET REGULARLY WITH THEM TO DISCUSS THEIR REPORTS AND FINDINGS . 2 3. MANAGEMENT OF PHASES OF LABOUR BHUSHAN RHISHIKESH JOSHI ( IIIRD B.BSC. NSG ) 3 4. CONTENTS OBJECTIVES INTRODUCTION TO TOPIC PHASES OF LABOUR MANAGEMENT OF FIRST STAGE MANAGEMENT OF SECOND STAGE CARE OF NEW BORN MANAGEMENT OF THIRD STAGE 1. EXPECTANT 2. ACTIVE ( PREFERRED) MANAGEMENT OF FOURTH STAGE SUMMARY 4 5. OBJECTIVES DEFINE LABOR . DESCRIBE EVENTS OCCURING IN STAGES OF LABOR . HIGHLIGHT PRINCIPLES AND OBJECTIIVES OF MANAGEMENT OF LABOR . DISCUSS MANAGEMENT OF FIRST STAGE OF LABOUR ELLABORATE MANAGEMENT OF SECOND STAGE OF LABOR . EXPLAIN IMMEDIATE CARE OF NEW BORN . DESCRIBE MANAGEMENT OF THIRD STAGE OF LABOR . DISCUSS MANAGEMENT OF FOURTH STAGE OF LABOR SUMMERIZATION OF TOPIC . 5 6. THE CHALLENGE IS, CAN YOU PROVIDE VIGILANCE WITHOUT INTERVENTION. You are the only one , who can help you in best way . 6 7. DEFINING LABOR SERIES OF EVENTS THAT TAKES PLACE IN THE GENITAL ORGANS IN AN EFFORT TO EXPEL THE VIABLE PRODUCT OF CONCEPTION OUT OF THE WOMB THROUGH VAGINA INTO THE OUTER WORLD IS CALLED AS LABOR . NORMAL LABOR (EUTOCIA) LABOR IS CALLED AS NORMAL IF IT FULFILS FOLLOWING CRITERIA 1. SPONTANEOUS IN ONSET AND AT TERM 2. WITH VERTEX PRESENTATION 3. WITHOUT UNDUE PROLONG 4. NATURAL TERMINATION WITH MINIMAL AIDS 5. WITHOUT HAVING ANY COMPLICATIONS AFFECTING THE HEALTH OF THE MOTHER AND/OR THE BABY . ABNORMAL LABOR (DYSTOCIA) ANY DEVIATION FROM THE DEFINATION OF NORMAL LABOR IS CALLED ABNORMAL LABOR 7 8. FACTORS INITIATING LABOR THEORETICAL MATERNAL FACTORS PROGESTERONE ESTROGEN OXYTOCIN PROSTAGLANDIN PSYCHE FETAL FACTORS FETAL CORTISOL ARTIFICIAL CERVICAL EXAM STRIPPING OF MEMBRANES PROSTAGLANDINS ARTIFICIAL RUPTURE OF MEMBRANES SEX NIPPLE STIMULATION 8 EVENTS OCCURRING IN STAGES OF LABOR 9. EVENTS IN FIRST STAGE OF LABOR CHIEFLY CONCERNED WITH PREPARATION OF BIRTH CANAL SO AS TO FACILITATE EXPULSION OF FETUS IN SECOND STAGE .MAIN EVENTS THAT OCCURS IN THIS STAGE ARE : DILATION AND TAKING UP OF CERVIX THERE ARE DIFFERENT FEACTORS WHICH PREDISPOSE SMOOTH DILATION OF CERVIX : a) UTERINE CONTRACTION AND RETRACTION CRVIX BECOMES SHORTENED AND RETRACTED IN BUCKET HOLDING FASHION . b) BAG OF MEMBRANE EFFACEMENT OR TAKING UP OF THE CERVIX : IS A PROCESS OF THINNING OUT . NOTE THE FOLLOWING : DILATION : HOW FAR THE CEVIX HAS BEEN OPENED ( IN CM ) EFFACEMENT : HOW THIN IS THE CERVIX ( IN CM OR % ) FULL FORMATION OF LOWER UTERINE SEGMENT 9 IN NULLIPARA THE FIRST STAGE MAY BE PROLONG UP TO 12 HOURS WHILE IN MULTIPARA IT GET COMPLETED IN 4 6 HOURS . 10. CERVICAL DILATION AND EFFACEMENT 11. EVEN TS IN SECOND STAGE OF LABOR THIS STAGE IS CONCERNED WITH THE DESCENT AND DELIVERY OF THE FETUS THROUGH THE BIRTH CANAL , CERVICAL DILATION CONTINUES , WITH FULL DILATION OF CERVIX , THE MEMBRANES USUALLY RUPTURE AND THERE IS ESCAPE OF GOOD AMOUNT OF LIQUOR AMNII . UTERINE CONTRACTION AND RETRACTION BECOMES MORE STRONGER EXPULSIVE FORCE OF UTERINE CONTRACTION IS ADDED BY CONTRACTION OF THE ABDOMINAL MUSCLES CALLED BEARING DOWN EFFORTS . THE SECOND STAGE MAY LAST FROM 1 TO 4 HOURS IN NULLIPARA AND LESS THAN 1 HOUR IN MULTIPARA . 11 12. EVENTS IN THIRD STAGE OF LABOR THE THIRD STAGE OF LABOR COMPRISES THE PHASE OF PLACENTAL SEPARATION ITS DECENT TO LOWEAR SEGMENT AND FINALY ITS EXPULSION WITH MEMBRANES . PLACENTAL SEPARATION : AFTER THE BIRTH SHAPE OF UTERUS BECOMES DISCOID AND CAVITY IS MUCH REDUCED(20CMX10CM) . AS THE PLACENTA IS INELASTIC IT CAN NOT KEEP PACE WITH SUCH EXTENT OF RETRACTION AND RESULTS IN BUCKLING . SEPARATION MAY BE MARGINAL MAY BE CENTRAL . SEPARATION OF THE MEMBRANES AFTER THE SEPARATION OF PLACENTA IT GET EXPELLED OUT . THE THIRD STAGE MAY LAST FROM A FEW MINUTES TO 30 MINUTES . 12 13. PRINCIPLES AND OBJECTIIVES OF MANAGEMENT OF LABOR . NON INTERFERENCE WITH WATCHFUL EXPECTANCY FOR NATURAL BIRTH . MONITOR CAREFULLY SO AS TO DETECT ANY INTRAPARTUM COMPLICATION . ASSIST IN THE NATURAL EXPULSION OF THE FETUS SLOWLY AND STEADILY . TO PREVENT PERINEAL INJURIES . IMMEDIATE CARE OF NEWBORN . ENSURE STRICT VIGILANCE . TO FOLLOW THE MANAGEMENT GUIDELINES STRICTLY IN PRACTICE 13 14. MANAGEMENT OF FIRST STAGE OF LABOR PRELIMINARIES BASIC EVALUATION OF CURRENT CLINICAL CONDITIONS. OBSTETRICAL AND GENERAL EXAMINATION INCLUDING VAGINAL EXAMINATION TO EXCLUDE ANY ABNORMALITIES. RECORDS OF ANTE NATAL VISITS , INVESTIGATION REPORTS AND ANY SPECIFIC TREATMENT GIVEN ARE TO BE REVIEWED . 15. ACTUAL MANAGEMENT General ANTISEPTIC DRESSING ENCOURAGEMENT , EMOTIONAL SUPPORT AND ASSURANCE CONSTANT SUPERVISION REST AND AMBULATION BOWEL :ENEMA WITH SOAP AND WATER OR GLYCERINE SUPPOSITORY DIET: FOOD IS WITH HELD DURING ACTIVE LABOUR. BECAUSE DELAYED EMPTYING OF THE STOMACH AND LOW PH OF GASTRIC CONTAIN IS REAL DANGER IF ASPIRATED FOLLOWING GENERAL ANESTHESIA WHEN NEEDED UNEXPECTEDLY . BLADDER CARE : ENCOURAGED TO PASS URINE BY HERSELF . IF PATIENT FAILS TO PASS URINE SPECIALLY IN LATE FIRST STAGE , CATHETERIZATION SHOULD BE DONE WITH STRICT ASEPTIC PRECAUTIONS . 15 16. MANAGEMENT OF LABOR PAIN PAIN IS SUBJECTIVE , COMPLEX INTERACTION OF INFLUENCES : a. PHYSIOLOGIC b. PSYCHOSOCIAL c. CULTURAL d. ENVIRONMENTAL NATURE OF LABOR PAIN 1ST STAGE VISCERAL PAIN DIFFUSE ABDOMINAL CRAMPING UTERINE CONTRACTIONS 17. NONPHARMACOLOGICAL PAIN RELIEF 1. CONTINUOUS LABOR SUPPORT INCREASINGLY AVAILABLE AT HOSPITALS & BIRTH CENTERS RECENT SURVEY (2002 - WHO) 6% OF WOMEN USED WARM WATER BATHS 49% FOUND THEM VERY HELPFUL 2. WARM WATER BATHS LABOR MAY SLOW IF USED IN EARLY LABOR LESS THAN 5CM DILATION 3. STERILE-WATER INJECTIONS INTRADERMAL INJECTIONS OF STERILE WATER IN THE SACRAL AREA CAUSES A BURNING SENSATION COUNTERIRRITATION DECREASES BACK PAIN FOR 45-90 MINS. 4 .POSITIONS, TOUCH, & MASSAGE 18. 18 NON-MEDICAL CARE BY A TRAINED PERSON DIFFERENT DEFINITIONS/CRITERIA DEPENDING ON STUDIES: a) MINIMUM OF 80% PRESENCE b) PRESENCE WITHOUT INTERRUPTION, EXCEPT FOR TOILETING VARIOUS TERMS: DOULA, LABOR ASSISTANT, BIRTH COMPANION, MONITRICE MAY REFER TO HUSBAND OR UNTRAINED FEMALE COMPANION CONTINUOUS LABOR SUPPORT 19. EFFECTS OF PSYCHOLOGICAL SUPPORT DURING LABOUR Continuous Labor Support: Mechanism of Action from Hodnett (2007) Negative experiences may impede labor Negative experiences may impede adjustment to motherhood Mitigates potentially harsh environment Positive impact of companionship on mom woman uses gravity & position changes fetopelvic relationship is enhanced Mobility encouraged by support person fewer abnormal FHR patterns preserves uterine contractility stress hormones (epinephrine) may be reduced Support person decreases anxiety of mom Physiologic impact of continuous labor support 19 20. WHY ARE WE LOOKING TO DECREASE THE USE OF MEDICATION? THE THEORY NATURAL BIRTH : BODY PRODUCES ENDORPHINS TO COPE WITH PAIN . BABYS ENDORPHINS RAISE WHEN MOMS ENDORPHINS RAISE . MEDICATIONS DECREASE NATURAL ENDORPHINS FOR BOTH .IT ALSO STIMULATES THE BABYS ADRENAL GLANDS . FIGHT OR FLIGHT HELPS TO ADAPT TO LIFE OUTSIDE OF THE UTERUS . IT INCREASES BLOOD FLOW TO BABY . STIMULATES IMMUNE SYSTEM (INCREASED WBCS) . MAKING BABY MORE ALERT FACILITATES BONDING . OXYTOCIN PEAKS JUST AFTER AN UNMEDICATED BIRTH AND STIMULATES MATERNAL BEHAVIORS . OPIODS AND NARCOTICS CONTINUOUS LUMBAR EPIDURAL PARACERVICAL BLOCK 50 / 50 NITROUS / OXYGEN PSYCHOPROPHYLAXIS HYPNOSIS PHARMACOLOGICAL PAIN RELIEF 21. PARENTERAL OPIOIDS : MOTHER LESS PAIN RELIEF AND SATISFACTION WITH PAIN RELIEF (ALL STAGES) LOWER RATE OF OXYTOCIN AUGMENTATION SHORTER STAGES OF LABOR FEWER CASES OF MALPOSITION FEWER INSTRUMENT-ASSISTED DELIVERIES PARENTERAL OPIOIDS - INFANT NEONATAL RESPIRATORY DEPRESSION DECREASED ALERTNESS INHIBITION OF SUCKING LOWER NEUROBEHARIORAL SCORES DELAY IN EFFECTIVE FEEDING LONG-TERM EFFECTS CANNOT BE EXCLUDED 22. EPIDURAL ANALGESIA BALANCE BETWEEN PAIN RELIEF AND OTHER GOALS 1. WALKING (1ST STAGE) 2. PUSHING EFFECTIVELY (2ND STAGE) 3. MINIMIZING SIDE EFFECTS MATERNAL AND NEONATAL WALKING EPIDURAL INTRATHECAL OPIOID INJECTION BEFORE CONTINUOUS EPIDURAL INFUSION *OFTEN ARE UNABLE TO WALK 1. SUBSTANTIAL MOTOR BLOCKADE 2. NEED CONTINUOUS FETAL MONITORING ADVANTAGES: 1. RAPID ONSET OF PAIN RELIEF 2. POTENTIAL FOR THE INTRATHECAL MEDICATION TO SUFFICE 3. LIKELY TO DELIVER IN 2-3 HOURS 23. EPIDURAL ANALGESIA - EFFECTS SLOWS LABOR (1ST AND 2ND STAGES) INCREASES USE OF PITOCIN OXYTOCIN AUGMENTATION INCREASED PERINEAL TEARS INCREASED INSTRUMENT-ASSISTED DELIVERY FORCEPS/VACUUM EXTRACTION INCREASED CESAREAN (?) ESPECIALLY WHEN ADMINISTERED EARLY MATERNAL FEVER EPIDURAL SIDE EFFECTS COMMON: HYPOTENSION IMPAIRED MOTOR FUNCTION (INABILITY TO WALK) NEED FOR CATHETERIZATION UNCOMMON (60% FINLAND AND UNITED KINGDOM b) 50/50 BLEND NITROUS OXIDE AND OXYGEN FULL EFFECT 50 SECONDS AFTER INHALATION USUALLY SELF-ADMINISTERED AS NEEDED NITROUS OXIDE SIDE EFFECTS NAUSEA ,VOMITING ,POOR RECALL OF LABOR 1. NITRAZINE PAPER TURNS BLUE IN THE PRESENCE OF ALKALINE AMNIOTIC FLUID . 2. VAGINAL SECERITIONS ARE NITRAZINE NEGATIVE AS THEY ARE ACIDIC . 3. POOLING OF THE AMNIOTIC FLUID IN THE VAGINAL VAULT IS A RELIABLE SIGN . STATUS OF MEMBRANES 25. MONITORING FOR FETAL WELL-BEING: THE EVIDENCE 25 EARLY LABOR, FOR LOW RISK PATIENTS, NOTE THE FETAL HEART RATE EVERY 1-2 HOURS. DURING ACTIVE LABOR, EVALUATE THE FETAL HEART EVERY 30 MINUTES NORMAL FHR IS 120-160 BPM PERSISTENT TACHYCARDIA (>160) OR BRADYCARDIA (