physiology of 1st stage of labor

7/28/2019 Physiology of 1st Stage of Labor

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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.

physiology of 1st stage of labor

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