Normal Labour

Question 1

What is labour

Answer 1

Labour is the process by which regular painful contractions bring about effacement and dilatation of the cervix and
descent of the presenting part, ultimately leading to expulsion of the fetus, membranes and placenta from the mother

Question 2

Criteria for normal labor

Answer 2

 Normal Labor (Eutocia): Labor is called normal if it fulfils the following criteria.
 Spontaneous in onset and at term.
 With vertex presentation.
 Without undue prolongation.
 Natural termination with minimal aids.
 Without having any complications affecting the health of the mother and/or the baby

Question 3

What are true labor pains

Answer 3

True labor pains are characterized by:
i) Uterine contractions at regular intervals
ii) Frequency of contractions increase gradually
iii) Intensity and duration of contractions increase progressively
iv) Associated with “show”
v) Progressive effacement and dilatation of cervix
vi) Descent of presenting part
vii) Formation of “bag of forewaters”
viii) Not relieved by enema or sedatives.

Question 4

False labour pains

Answer 4

False labor pains (Syn: false labor, spurious labor): More common in primigravidae than in parous women and
appears prior to onset of true labor pain, by 1 or 2 wks in primigravidae and by a few days in multiparae, due to
stretching of cervix and lower uterine segment with consequent irritation of neighboring ganglia.
 They are:
a. Dull in nature
b. Confined to lower abdomen and groin
c. Not associated with hardening of uterus
d. They have no other features of true labor pains
e. Usually relieved by enema or sedative

Question 5

Dystocia

Answer 5

Abnormal Labor (Dystocia): Any deviation from definition of normal labor is
called abnormal labor, e.g. presentation other than vertex or having some
complications even with vertex presentation affecting course of labor or modifying
nature of termination or adversely affecting maternal and/or fetal prognosis.

Question 6

What is prelabour?

Answer 6

Prelabor (Syn: premonitory stage): may begin 2–3 wks before onset of true labor in primigravidae and a few days
before in multiparae. Features are inconsistent and may consist of the following:
 “Lightening”: Diminishing of fundal height, few wks prior to onset of labor esp in primigravidae, as presenting
part sinks into true pelvis due to active pulling up of lower pole of uterus around presenting part-signifies
incorporation of lower uterine segment into wall of uterus. That relieves pressure on diaphragm, & mechanical
cardiorespiratory embarrassment, but ↑ micturition or constipation due to
mechanical factor
 Cervical changes: Few days prior to onset of labor, cervix becomes ripe- soft,
less than 1.5 cm in length, admits a finger easily and is dilatable.

Question 7

Theories of onset of labour

Answer 7

Theories of onset of labour
 Uterine distension: Like any body hollow organ, when the uterus in distended to a certain limit, it starts to contract
to evacuate its contents. This explains the preterm labour in case of multiple pregnancy and polyhydramnios.
 Stretching effect on myometrium by growing fetus and liquor amnii can explain onset of labor at least in twins
or polyhydramnios. Uterine stretch increases gap junction proteins, receptors for oxytocin and specific
contraction associated proteins (CAPS).
 Stretch of the lower uterine segment: by the presenting part near term.
 Fetoplacental contribution: Cascade of events activate
fetal hypothalamic pituitary adrenal axis prior to onset of
labor → increased CRH → increased release of ACTH
→ fetal adrenals → increased cortisol secretion →
accelerated production of estrogen and prostaglandins
from the placenta
 Hormonal factors
 Oestrogen theory:
 During pregnancy, most of the oestrogens are
present in a bound form. During the last trimester,
more free oestrogen appears increasing the excitability of the myometrium and prostaglandins synthesis.
 Probable modes of action of oestrogen:
a) Increase release of oxytocin from maternal pituitary
b) Promotes synthesis of receptors for oxytocin in myometrium and decidua- by 100–200 folds), PGs &
increase in gap junctions in myometrial cells.
c) Accelerates lysosomal disintegration inside the cells resulting in increased PG synthesis
d) Stimulates synthesis of myometrial contractile protein –actomyosin via activation of adenosine triphosphate
e) Increase the excitability of the myometrial cell membranes
 Progesterone withdrawal theory:
 Before labour, there is a drop in progesterone synthesis leading to predominance of excitatory action of
oestrogens. Increased fetal production of dehydroepiandrosterone sulfate (DHEA-S) and cortisol inhibits the
conversion of fetal pregnenolone to progesterone.
 It is the alteration in estrogen: progesterone ratio rather than the fall in the absolute concentration of
progesterone which is linked with prostaglandin synthesis
 Progesterone-binding protein increases at term: due to tissue effects of progesterone decrease
 Suppression of myometrial excitability by progesterone decrease
 Reduction of stimulation of beta receptor activity
 This relative fall promotes the release of arachidonic acid
 Prostaglandins theory:
 Mainly produced by decidua. Prostaglandins E2 and F2α are
powerful stimulators of uterine muscle activity.
 PGF2α is increased in maternal and fetal blood as well as the
amniotic fluid late in pregnancy and during labour.
 PG are important factors which initiate and maintain labor.
Major sites of synthesis are- amnion, chorion, decidual cells
and myometrium and synthesis is triggered by- rise in
estrogen level, glucocorticoids, mechanical stretching in late
pregn, increase in cytokines (IL–1, 6, TNF), infection,
v/exam, membrane sweeping or ROM. PGs enhance gap
junction (intermembranous gap betwn 2 cells via which
stimulus flows) formation
 Oxytocin theory:
 Though oxytocin is a powerful stimulator of uterine contraction, its natural role in onset of labour is doubtful
 Secretion of oxytocinase enzyme from the placenta is decreased near term due to placental ischemia leading
to predominance of oxytocin’s action.
 Fetal cortisol theory: Increased cortisol production from the fetal adrenal gland
before labour may influence its onset by increasing oestrogen production from the
placenta.

Question 8

Sutures of fetal skull

Answer 8

Sutures:
 Saggital suture —separates parietal bones
 Frontal suture—-separates frontal bones.
 Coronal suture—separates frontal & parietal
bones
 Lambdoid suture—separates parietal & occipital bones

Question 9

Fontanelles of the fetal skull

Answer 9

Fontanelles- are the junctions of the various sutures.
 Anterior fontanelle (Bregma): Is diamond shaped. Junction of the sagittal, frontal
and coronal sutures.
 Posterior fontanelle: triangular shaped. Found at the meeting of the sagittal suture
and lambdoidal sutures
 Fontanelles and sutures allow a process called ‘moulding’ but severe moulding
can be a sign of cephalopelvic disproportion

Question 10

Diameters of the fetal skull

Answer 10

Diameters of the fetal skull
1. Sub-occipito bregmatic, SOB - 9.5 cm-
 Measured from below the occipital
protuberance to the centre of the anterior
fonatannelle or bregma
2. Sub-occipito frontal, SOF - 10cm
 Measured from below occipital protuberance
to the centre of the frontal suture
3. Occipitofrontal, OF – 11.5 cm
 Measured from the occipital protuberance to glabella
4. Mento-vertical, MV – 13.5cm
 Measured from the point of the chin to the highest
point on the vertex.
5. Sub-mentovertical, SMV - 11.5 cm
 Measured from point where the chin joins the neck to
the highest point on the vertex suture
6. Sub-mento bregamatic, SMB - 9.5cm
 Measured from the point where the chin joins the neck to the centre of the bregma
7. Biparietal diameter - 9.5 cm
 Diameter between the two parietal eminences
8. Bitemporal diameter - 8.5 cm
 Diameter between the two furthest points (anteroinferior ends) of the coronal suture

Question 11

Presenting diameters of fetal skull

Answer 11

Presenting diameters
Vertex:
 Well flexed – Sub-occipitobregmatic diameter (9.5cm) and
biparietal diameter (9.5cm) present .
 Deflexed – Occipitofrontal (11.5cm) and BPD present. This
often arises when occiput is in a posterior position.
Face: Complete extension –
 Submentobregmatic (9.5cm) and bitemporal diameter.
Brow: Head is partially extended –
 Mentovertical diameter (13.5cm) and bitemporal diameter
present. If this presentation persists , vaginal birth is unlikely

Question 12

Braxton Hicks contractions

Answer 12

Throughout pregnancy there is irregular involuntary spasmodic uterine contractions which are painless (Braxton-
Hicks) and have no effect on dilatation of the cervix

Question 13

True uterine contractions

Answer 13

True uterine contractions are characterized by being:
 Involuntary, Intermittent, with increase in amplitude, frequency & duration as labour advances.
 Associated with forewater bulging, felt abdominally with fundal dominance.
 Effective contractions are :
 3-5/10min in frequency- intervals gradually shorten with advancement
of labor until in 2nd stage, when it comes every 2–3 minutes.
 40-60 sec in duration- gradually increase with progress of labor.
 35-50 mmhg amplitude
 < 10 mmhg resting uterine tone between

Question 14

Uterine retraction and contraction

Answer 14

 Retraction is a phenomenon of the uterus in labor in which muscle fibers
are permanently shortened. Results in permanent shortening of fibers once & for all.
 Contraction is a temporary reduction in length of muscle fibers, which attain their full length during relaxation.

Question 15

Formation of upper and lower segments of the uterus

Answer 15

Formation of upper and lower segments
 Anatomically distinct. Upper segment formed from the body of the fundus, is mainly concerned with contraction and
retraction. It’s thick and muscular.
 Lower uterine segment is formed from isthmus & cervix & is
about 8-10 cm in length. This is to prepare for distension and
dilatation.
 Muscle content reduces from fundus to cervix
 But before onset of labor, there is no complete anatomical or
functional division of the uterus.
 During labor, the demarcation of an active upper segment & a
relatively passive lower segment is more pronounced.
 The wall of upper segment becomes progressively thickened with progressive thinning of the lower segment
 A distinct ridge is produced at the junction of the two, called physiological retraction ring

Question 16

First stage of labour

Answer 16

First stage – Time from onset or diagnosis of labour to full dilatation
 Divided into
 ‘Latent phase’ (from onset of labour to 4cm cervical dilatation). Cervix becomes fully effaced and ‘
 ‘Active phase’ (from 4cm cervical dilatation (end of latent phase) to full dilatation)
 Effacement is a process by which cervix shortens in length as it becomes included into lower segment of uterus.
Muscular fibers of the cervix are pulled upwards and merges with the fibers of the lower uterine segment.
 First stage is mainly concerned with preparation of birth canal to facilitate expulsion of the fetus in 2nd stage.
 Main events are—(a) Dilatation and Effacement of the cervix and (b) full formation of lower uterine segment.
 Duration: Latent phase: 8 hours
Active phase: between 2 and 6 hours

Question 17

Second stage of labour

Answer 17

Second stage - from full cervical dilatation to expulsion/delivery of the fetus
 Subdivided into 2 phases-
1. Passive phase / Propulsive - from full dilatation until head touches the pelvic floor and onset of involuntary
expulsive contractions. No maternal urge to push as fetal head is relatively high.
2. Active second stage / Expulsive –from onset of involuntary maternal urge to push (as fetal head is low,
which causes a reflex need to ‘bear down’) to baby delivery. Mother has irresistable desire to ‘bear down’.
 Stage is concerned with the descent and delivery of the fetus through the birth canal.
Duration: Primigravida < 2 hours Multigravida <1 hour

Question 18

Third stage of labour

Answer 18

Third stage – from delivery of the fetus or fetuses until delivery of the placenta.
 Placenta separation is facilitated partly by uterine contraction & mostly by wgt of
placenta as it descends down from active part.
 It’s a phase of placental separation; its descent to lower segment & finally its
expulsion with membranes.
 There are 2 ways of separation of placenta
1. Central separation (Schultze): placenta detachment from its uterine
attachment starts at the center resulting in opening up of few uterine sinuses &
accumulation of bld behind placenta (retroplacental hematoma).
2. Marginal separation (Mathews-Duncan): separation starts at the margin as it is mostly unsupported.
Marginal separation is found more frequently.
 Duration: < 30 min.
 Mechanism of control of bleeding: After placental separation, torn sinuses
with free blood circulation from uterine and ovarian vessels are obliterated,
by occlusion effect of arterioles by complete retraction , as they tortuously
pass via interlacing intermediate layer of myometrium, are literally clamped

Question 19

Methods of Placenta separation

Answer 19

 There are 2 ways of separation of placenta
1. Central separation (Schultze): placenta detachment from its uterine
attachment starts at the center resulting in opening up of few uterine sinuses &
accumulation of bld behind placenta (retroplacental hematoma).
2. Marginal separation (Mathews-Duncan): separation starts at the margin as it is mostly unsupported.
Marginal separation is found more frequently.

Question 20

Fourth stage of labor

Answer 20

Fourth stage: stage of observation for at least 1 hour after expulsion of the after-births. During this period,
general condition of the patient and the behavior of the uterus are carefully monitored

Question 21

Diagnosis of the onset of labour

Answer 21

Symptoms: Abdominal pain. Backache
 Passage of show : passage of cervical mucous plug as the cervix dilates
 Signs: Regular uterine contractions
 Dilatation & effacement of the cervix
 Formation of bag of forewater

Question 22

Cervical effacement

Answer 22

Cervical effacement: It is progressive taking up of the cervix and its
incorporation into lower uterine segment is detected clinically by the progressive
thinning of the cervix.

Question 23

Cervical dilation

Answer 23

Cervical dilatation: It is due to uterine contractions& retractions. Fetal axis
pressure, pressure of bag of forewater
 Latent phase Slow cervical dilatation ( to 3cm)
 Active phase
- Phase of acceleration (4cm to 5cm)
- Phase of maximum slope (5-8cm)
- Phase of decceleration (8cm to full dilatation)
- In PG effacement preceeds dilatation, while in MG they both occur together

Question 24

Movement involved in the mechanism of labour

Answer 24

Mechanism of labour – Vertex presentation
 Refers to the series of changes in position and attitude that the fetus undergoes during its passage through the birth
canal. Relation of the fetal head and body to the maternal pelvis changes as the fetus descends through the pelvis
 Principal movements are: (1) Engagement (2) Descent (3) Flexion (4) Internal rotation (5) Crowning (6)
Extension (7) Restitution (8) External rotation & (9) Expulsion of trunk.

Question 25

Engagement

Answer 25

Engagement – Head enters the pelvis in the transverse position. Occurs in majority of nulliparous women prior to labour. In majority of multips, it occurs in labour.  Due to lateral inclination of the head, sagittal suture does not strictly correspond with the available transverse diameter of inlet but deflected anteriorly toward the symphysis pubis or posteriorly towards sacral promontory. Such deflection of head in relation to pelvis is called asynclitism  Diagnosis of engagement: History Lightening, reappearance of urinary symptoms.  O/E: 2/5 head palpable abdominally  V/E: Head station zero.

Question 26

Descent

Answer 26

Descent – Occurs throughout and is needed before flexion, internal rotation and extension occur.  In 1st stage and passive phase 2nd stage, it is secondary to uterine contractions, but in active phase of the 2nd stage it is helped by voluntary use of abdominal muscles and the Valsalva maneuver.  Provided there is no undue bony or soft tissue obstruction, descent is a continuous process & completed with expulsion of fetus.  Factors facilitating descent are- (1) uterine contraction & retraction, (2) bearing down efforts and (3) straightening of fetal ovoid especially after rupture of membranes.

Question 27

Flexion

Answer 27

Increased flexion – Occurs as the head enters the narrower mid-cavitydue to surrounding structures and is reduces the presenting diameter  As head meets resistance of birth canal during descent, full flexion is achieved.  In adequate pelvis, flexion is achieved either due to resistance by unfolding cervix, walls of pelvis or by pelvic floor.

Question 28

Internal rotation

Answer 28

Internal rotation – Occiput leading point in a well flexed head and on reaching the sloping gutter of levator ani muscles, its encouraged to rotate anteriorly so that the sagittal suture now lies in the AP diameter of the pelvic outlet  Prerequisites of anterior internal rotation of head are; well flexed head, efficient uterine contraction, favourable shape at midpelvic plane & tone of levator ani M.  Movement of great importance without which there will be no further descent.

Question 29

Crowning

Answer 29

Crowning: After internal rotation of head, further descent occurs until occiput is underneath the symphysis pubis and the bregma is near the lower border of the sacrum.  Subocciput lies underneath pubic arch.  At this stage, maximum diameter of head (biparietal diameter) stretches / distends vulval outlet without any recession of head even after contraction is over. is known as ‘crowning’ of the head

Question 30

Extension

Answer 30

Extension: Delivery of the head takes place by extension through “couple of force” theory.  Well-flexed head now extends and the occiput escapes from underneath the symphysis pubis and the vulva. This.  Further head extends and the occiput underneath the symphysis pubis acts as a fulcrum point as the bregma, face and chin appear in succession over the posterior vaginal opening and perineal body.

Question 31

Restitution

Answer 31

Restitution – Head aligns itself with the shoulders which are in oblique position. Rotates through one eighth.  When head is delivering, occiput is directly anterior.  As soon as it escapes from vulva, head aligns itself with shoulders, which have entered pelvis in oblique position.  The slight rotation of occiput through one-eighth of the circle is called‘restitution’.

Question 32

External rotation

Answer 32

External rotation – Shoulders rotate into the direct AP plane.  Occiput then rotates through a further one-eighth of a circle to transverse position

Question 33

Delivery of shoulders and body

Answer 33

Delivery of the shoulders and fetal body – Shoulders are in the AP position.  Anterior shoulder is under the symphysis pubis and delivers first.  Gently downward tractions is exerted. Posterior shoulder is then delivered.

Question 34

Hx taking of labour

Answer 34

History  Note the following important points on admission:  Detailed review of prenatal data: Previous obstetric/ gynaecological/ current pregnancy history  H/O previous deliveries and size of previous babies, e.g. a previous H/O C/section, especially if the indication was a mechanical problem, is an adverse feature.  Labour Details;  Onset of abdominal pains, Frequency, duration and perception of strength of the contractions.  Time of rupture of membranes and, if so, the colour and amount of amniotic fluid lost.  Presence of abnormal vaginal discharge or bleeding or show  Fetal recent activity.  Any medical issues that may influence labour & delivery, e.g. pregnancy-induced HTN, fetal growth restriction.  Assess for any special requirements, e.g. an interpreter, or particular emotional/psychological needs?  Her expectations of the labour and delivery.  Her birth plan?  Her hope for pain relief use

Question 35

General exam of labour

Answer 35

General examination  Body mass index- if raised may complicate management of labour.  Vital signs; temperature, pulse and blood pressure and record  Urinalysis- tested for protein, blood, ketones, glucose and nitrates.  Abdominal examination  Inspection- for scars indicating previous surgery  Measure the SFH  Determine the fetal lie (longitudinal, transverse or oblique)  Nature of presenting part (cephalic or breech)  Degree of engagement- If presenting part is a cephalic presentation  A high (five-fifths palpable) and unengaged head is a poor prognostic sign for successful delivery.  Assess reason for high head (e.g. OP position, deflexed head, placenta praevia, fibroid, etc.) using U/S  Assess uterine contractions (take at least 10 mins), by direct uterine palpation and not checking tocograph  FHS- singleton / multiple  Vaginal examination  Done with the pt. lying in dorsal position, under aseptic technique  Should be restricted to the minimum (interval of 3–4 hours) to avoid risks of infection esp after ROM  Explain procedure and purpose to the pt. and obtain verbal consent  Ensure adequate privacy as V/E is distressing to any women Cervical findings- effacement/position/dilatation  Other findings which should be recorded  Presenting part and its position  Station of the head in relation to ischial spines  Status of membranes and if ruptured- colour of the liquor  Caput or moulding of the head  Assessment of the pelvis specially in primigravidae

Question 36

Indications of V/E in labour

Answer 36

Indication of V/E a) At onset of labor  To confirm onset of labor and precisely determine the presenting part and its position.  Pelvic assessment esp. in primigravidae. b) Assess progress of labor by periodic V/E noting; cervical dilatation and descent of the head. c) After ROM- exclude cord prolapse esp. in unengaged head. d) Whenever any interference is contemplated. e) To confirm full cervical dilatation and to vividly diagnose onset of 2nd stage.

Question 37

Management of first stage of labour

Answer 37

Management of Stage 1 of labour  Establish diagnosis of labour through history (at term).  Patient will present with intermittent lower abdominal pain and backache.  Show may be present with or without draining.  O/E uterine contractions and descent are palpable abdominally.  VE: assess; cervical dilatation and effacement, state of membranes, position, station, signs of obstruction (caput) and umbilical cord  Review the obstetrics records for any risk  If in latent phase, admit to Antenatal ward and orient patient around the ward.  Position of the patient - Before ROM allow mobility to aid cervical dilatation. - Ambulation can reduce duration of labor, need of analgesia and improves maternal comfort. - Should be in bed if labor is being monitored electronically or epidural analgesia was given - After ROM better in left lateral position to prevent venacaval compression  Psychological reassurance, encouragement and emotional support  Analgesia- IM fentanyl 50-100 mg when the pain is in well established active phase of labor.  Pethidine should not be given if delivery is anticipated within 2 hours as it crosses the placenta and is a respiratory depressant to the neonate  Give IM Metoclopramide 10 mg to combat vomiting due to pethidine.  Ensure regular rectal/bladder emptying to encourage descent and discourage PPH due to uterine atony  Urine ouput is recorded for volume, protein or acetone.  Diet counselling i.e. liquids and semi-solid foods in early labour, but avoid solids  Food is withheld during active labor.  Give IVF (dextrose) only if indicated/, IVF R/L if any intervention is anticipated or pt is under regional anesthesia.  Monitor for progress of labour and FHR closely and open a partograph once active phase of labour commences  Electronically by CTG for high risk groups ( routine in some countries)  Do vitals- TPR + BP and record accordingly on partograph frequantly  Avoid unnecessary vaginal examination  Prepare the baby’s linen  OBTAIN CONSET FOR UNDERAGE PATIENTS IN CASE OF A C/S

Question 38

Management of stage 2 of labour

Answer 38

PRINCIPLES: a) To assist in the natural expulsion of the fetus slowly and steadily, b) To prevent perineal injuries.  Diagnosis of onset of the 2nd stage of labour:  Symptoms: Involuntary bearing down, desire of defecate  Signs: Perineal bulge, Full cervical dilatation 10 cm  Choose preferred position (Lithotomy is most preferred)  Analgesia- if available, give inhalation analgesics, N2O and O2 to relieve pain during contraction Continue monitoring is mandatory and record FHR at every 5 minutes.  V/E- done at onset of 2nd stage not only to confirm its onset, R/O any accidental cord prolapse. The position and the station of the head are once more to be reviewed and the progressive descent of the head is ensured.  Once crowning is evident, tell pt. to push in tandem with contractions (Maternal effort and uterine contractions)  Delivery of the head: applying perineal support with pads and cover the anal orifice while simultaneously flexing or gently pressing the head of the baby down to reduce presenting diameter when crowning occurs  Extension is then allowed gradually in between contractions  Crowning is the passage of the biparietal diameter just outside of vulval ring and subboccipital region is fixed below the symphysis pubis, clinically identified by that the head does not receed in between contractions.  Do episiotomy at this time if perineum is fully, stretched and threatens to tear specially in primigravidae, after prior infiltration of 10 mL of 1% lignocaine, extends from vaginal fourchette in a mediolateral direction, usually to the right, via the perineum and incorporating lower vaginal wall  Slow regulated delivery of the head in between the contractions is done  Ritzen maneuver- forehead, nose, mouth and the chin are born successively over stretched perineum by extension.  Wipe the baby’s face (suction is optional) and check for the cord around the neck. If it is present, double clamp it and cut it  Delivery of the shoulders: Wait for restitution and external rotation of the head to occur  Apply gentle downward traction to deliver anterior shoulder followed by posterior shoulder  Traction on the head should be gentle to avoid excessive stretching of the neck causing injury to the brachial plexus, hematoma of the neck or fracture of the clavicle.  Delivery of the trunk: After the delivery of the shoulders, the fore finger of each hand are inserted under the axillae and the trunk is delivered gently by lateral flexion. Sweep baby over and place on mother’s abdomen (Immediate skin-to-skin contact between mother and baby helps bonding, and promote further release of oxytocin, to encourage uterine contractions).

Question 39

Immediate care of the newborn

Answer 39

 Place neonate on a tray covered with clean dry linen with head slightly downwards (15°), to facilitate drainage of mucus by gravity.  Start by suction of mouth & nose once head is delivered- to clear air passage (oropharynx) of mucus and liquor  Stimulate respiration by the rubbing of the back  Apgar score at 1 & 5 minutes- assessed (colour, pulse rate, grimace, muscle tone& respiratory effort)  Examine for sex & apparent congenital malformations.  Clamp cord with two Kocher’s forceps, and cut it between 2 clamps  Take neonatal measurements (weight, length, head circumference )  Quick check to R/O any gross abnormality and then wrap baby with a dry warm towel.  Tie an identification tape both on the wrist of baby and mother  Encourage initiation of breastfeeding within the first hour

Question 40

Management of 3rd stage of labour

Answer 40

Principles; to ensure strict vigilance and to follow the management guidelines to prevent the complications, such as postpartum hemorrhage  Stage of placental delivery. Normally takes between 5 and 10 minutes.  If longer than 30 minutes, it should be regarded as prolonged. Two methods of management 1. Expectant management (traditional):  Placental separation and its descent into the vagina are allowed to occur spontaneously.  Minimal assistance may be given for the placental expulsion  Constant watch for the pt is mandatory  Place hand over the fundus to- a) To recognise the signs of separation of placenta, b) Note state of uterine activity- contraction and relaxation, c) Detect, though rare, cupping of fundus (early evidence of inversion of uterus)  Then placenta expulsion only when features of placental separation and its descent into lower segment are confirmed, asked pt. to bear down simultaneously with uterine contraction  Assisted expulsion: Controlled cord traction (modified Brandt- Andrews method) or  Fundal pressure- Fundus is pushed downwards and backwards after placing four fingers behind the fundus and the thumb in front  Examine placenta, membranes & cord: for missing cotyledons or a succenturiate lobe.  Inspect vulva for any tears or lacerations. NB: Desire to fiddle with fundus or massage uterus is strongly to be condemned. 2. Active management (preferred) Principle; To elicit powerful uterine contractions within one minute of delivery Merits; a) Minimizes blood loss in 3rd stage approximately to 1/5 th . b) Shortens the duration of 3rd stage to half. Demerit: slightly increase incidence of retained placenta & so increase incidence of manual removal.  Reduces the incidence of postpartum haemorrhage from 15 to 5%.  Constant watch is mandatory and the patient should not be left alone.  Give Inj. oxytocin 10 units IM (preferred) or methergin 0.2 mg IM, within 1 min of delivery of baby  Massage the uterus to expedite contractions with or without signs of placental separation  After placental separation, use CCT (Brandt-Andrews) technique to expedite placental delivery.  Controlled cord traction (CCT)- Sustained upward/downward traction of the cord with counter traction (left hand pushing down on uterus supra-pubically to prevent uterine retroversion  If 1st attempt fails, reattempt after 2–3 minutes, and then 3rd attempt at 10 minutes, if still no success, do manual removal.  When placenta reaches the vulva, twist the membrane to ensure complete separation  Inspect the vagina for any tears, then inspect placenta and membrane

Question 41

Signs of placenta separation

Answer 41

Signs of separation are: 1. Lengthening of the cord protruding from the vulva; 2. A small gush of blood from the placental bed, which normally stops quickly 3. Rising of the uterine fundus to above the umbilicus 4. Placenta in the vagina 5. Fundus becomes hard and globular compared to the broad, softer fundus prior to separation