01, LABOUR

Page 1

Title and Editor

  • No. 3 Obstetrics January 2024

  • Edited by: Rasheed Mohammed

Page 2

Stages of Labour

  • Definitions:

    • Labour: Process where regular uterine contractions result in cervical effacement and dilatation, leading to delivery.

    • Normal Labour: Delivery of a singleton baby presenting vertex, through the birth canal, without complications.

    • Duration of Normal Labour:

      • Primigravida: 12 – 18 hours

      • Multigravida: 6 – 10 hours

  • Physiologic Changes Before Labour Onset:

    • Increased oxytocin and PGL levels; receptor multiplication.

    • Formation of gap junctions in myometrial cells for communication.

    • Lower uterine segment (LUS) formation with myometrial tone increase.

    • Cervical changes: softening, effacement, and dilatation.

  • Onset of Labour:

    • Exact cause unknown; theories include progesterone withdrawal and increased PGL levels.

    • Uterine distension and increased fetal cortisol may also contribute.

  • Characteristics of True Labour Pains:

    • Start in the UUS, low amplitude, increase in frequency and duration.

    • Pain results from ischemia, nerve compression, and stretching during contractions.

Page 3

The Stages of Labour

  • Stages of Labour:

    1. First Stage: Cervical effacement and dilatation, ends with complete cervical dilatation (10 cm).

    2. Second Stage: Delivery of the fetus.

    3. Third Stage: Delivery of the placenta.

    4. Fourth Stage: First 1-2 hours post-delivery.

First Stage Phases

  • Latent Phase:

    • Cervical dilatation to ~4 cm, slow process.

    • Average duration: 6.5 hours (primigravida) and 4.5 hours (multigravida).

  • Active Phase:

    • Defined by rapid cervical dilatation (4-5 cm to 10 cm).

    • Cardinal movements of delivery occur.

Second Stage

  • Begins with full dilatation, ends with fetal expulsion.

  • Duration: 1-2 hours (primigravida) and < 1 hour (multigravida).

Third Stage

  • Starts with fetal delivery, ends with placenta expulsion.

  • Duration: 10-30 minutes (both types of gravida).

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Management of Normal Labour

  • Overview:

    • Comprehensive patient data collection for risk assessment.

    • Patient preparation includes reassurance, nutrition advice, and pain relief options.

    • Monitor progress via a partogram.

    • Fetal surveillance; auscultation or continuous monitoring.

First Stage Management

  1. Patient Preparation: Evacuate bladder and cleanse.

  2. Pain Relief Options:

    • IM injections of Pethidine or Epidural Analgesia.

  3. Nutrition: Light diet and oral fluids.

  4. Education: Avoid bearing down during the first stage.

  5. Monitoring Progress: Use partogram.

  6. Intrapartum Fetal Surveillance: Intermittent or continuous monitoring based on risk.

Second Stage Management

  1. Place of Delivery: Transfer to an equipped delivery room.

  2. Maternal Position: Lithotomy position.

  3. Prepare for Delivery: Analyze bladder status and sterilize area.

  4. Maternal Bearing Down: Encourage during contractions.

  5. Delivery Techniques: Manage head and shoulder delivery with care.

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Management of the Third Stage of Labour

  1. Wait for Placental Separation Signs:

    • Gush of blood, elongation of cord.

  2. Uterine Massage: Gentle massage to promote contractility.

  3. Controlled Traction: For placental expulsion.

  4. Ecbolics Administration: Ensure rapid placental separation.

  5. Inspection of Placenta: Check for completeness.

  6. Episiotomy Repair: Address lacerations after expulsion.

Fourth Stage of Labour

  • Observation of complications post-delivery including shock, retained placentas, PPH, and uterine inversions.

Care of the Newborn

  1. Warmth: Ensure adequate thermal care.

  2. Clear Airways: Suctioning of secretions.

  3. APGAR Score: Immediate assessment at 1 & 5 minutes.

  4. Identification: Baby needs identifier bands.

  5. Vitamin K Administration: Prevents hemorrhagic disease of the newborn.

  6. Eye Care: Use antibiotic drops for prophylaxis.

Page 6

Obstetric Emergencies: Shoulder Dystocia

  • Definition: Anterior shoulder impacted against the symphysis pubis post-head delivery.

  • Incidence: Complicates 1% of vaginal deliveries.

  • Emergency Status: Requires immediate intervention due to fetal distress.

  • Risk Factors: Previous history, fetal macrosomia, high BMI, diabetes, post-term pregnancies, and lack of progress in the second stage.

Complications

  • Fetal:

    • Birth asphyxia, brachial plexus injuries, and rarely fetal death.

  • Maternal:

    • PPH, uterine rupture, lacerations, and severe perineal tears.

Management Mechanism

  1. HELPER Maneuver: A systematic approach to relieve shoulder dystocia:

    • H: Call for assistance.

    • E: Perform episiotomy to facilitate manoeuvres.

    • L: Positioning legs (McRoberts’ maneuver).

    • P: Suprapubic pressure to dislodge shoulder.

    • E: Internal maneuvers to rotate shoulders.

    • R: Release of the posterior arm.

  2. Methods of Last Resort:

    • Symphysiotomy: Increase pelvic outlet size.

    • Cleidotomy: Surgical division of the fetal clavicle.

    • Zanvanelli Maneuver: Manual replacement; consider emergency CS if unsuccessful.

Page 7

Cord Prolapse

  • Definition: Protrusion of the umbilical cord below the presenting part after ROM.

  • Effects: Compression of vessels, risk of fetal acidemia, and potential neurological issues.

Predisposing Factors

  • Transverse lie, multiple pregnancies, polyhydramnios, and ruptured membranes.

Diagnosis

  • Identification of cord loops via PV examination.

  • Check for fetal pulsations to exclude IUFD.

Management

  1. Call for help immediately.

  2. Prevent further compression via:

    • Position changes, bladder filling, or manual support.

  3. Use tocolytics for uterine relaxation.

  4. Check fetal heart sounds and deliver fetus expeditiously based on viability and labor stage.

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Uterine Inversion

  • Overview: Rare but serious complication occurring in about 1:2000-3000 deliveries.

  • Risk Factors: Strong traction on the cord, short umbilical cord, abnormal placenta adherence, and previous inversions.

Signs and Symptoms

  • Hemorrhage, severe abdominal pain in the third stage, and signs of shock.

Management

  1. Call for help and prepare for resuscitation.

  2. Immediate fluid replacement and manual reduction techniques.

  3. Continuous monitoring of vitals post-event.

  4. Surgical intervention if manual reduction fails.

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Uterine Rupture

  • Overview: Life-threatening emergency possibly leading to severe maternal morbidity and mortality.

  • Types of Rupture: Complete and scar dehiscence.

  • Incidence: Varies based on type; higher in patients with prior surgical scars.

Presentation & Risk Factors

  • Sudden severe abdominal pain, vaginal bleeding, and hypovolemic shock signs.

  • Contributing factors include prior uterine surgeries, multiparity, and malpresentations.

Management

  1. Call for immediate assistance.

  2. ABCD approach and emergency laparotomy if required.

  3. Repair ruptures and manage any bleeding.

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Amniotic Fluid Embolism

  • Definition: Presence of amniotic fluid or fetal debris in maternal circulation, causing fatal reactions.

  • Incidence and Characteristics: Rare with high mortality; occurs during labor or shortly after delivery.

Risk Factors

  • Older maternal age, multiple pregnancies, and history of various pregnancy complications.

Diagnosis

  • Diagnosis is primarily clinical with exclusion of other conditions.

Management

  1. Immediate resuscitation and CPR.

  2. Fluid resuscitation for hemodynamic support.

  3. Delivery within 5 minutes of cardiac arrest if possible.

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Postpartum Hemorrhage

  • Definition: Blood loss exceeding defined limits with significant timeframes post-delivery.

  • Primary Causes: 4Ts (Uterine atony, Trauma, Thrombin, Tissue).

Uterine Atony

  • Most common cause; various risk factors include previous atony, grand multiparity, and uterine overdistension.

Management

  1. Resuscitation and monitoring.

  2. Uterine massage and oxytocin infusion as first-line treatments.

  3. Prepare for surgical intervention if conservative measures fail.

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Genital Tract Trauma

  • Pathogenesis: Second most common cause.

  • Management: Immediate exploration and suturing of lacerations, surgical intervention for ruptures.

Retained Products of Conception

  • Common Causes: Retained placenta due to atony or abnormal adherence.

  • Management: Manual removal, administration of oxytocin, and potential surgical evacuation.

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Coagulopathy

  • Etiology: Various pre-existing conditions and overlapping issues.

  • Management: Resuscitation, fresh blood transfusion, and addressing underlying causes.

Secondary PPH

  • Common Causes & Management: Address retained tissue and focus on resuscitation as needed.

Page 14

Clinical Picture and Examination of PPH

  • General Examination: Signs of shock; assess uterine tone.

Complications of PPH

  • Major Risks: Hypovolemic shock effects and delayed management consequences.

General Management Approach

  1. Call for assistance across relevant departments.

  2. Implement resuscitation measures and monitor.

  3. Identify uterine tone and act swiftly.

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Prevention of PPH

  • Key Steps: Appropriate prenatal care and risk assessment, management of labor stages, and effective postpartum practices to minimize hemorrhage risks.

Page 16

Summary of Treatments in PPH

  • Management Steps: Focused on contraction restoration, assistance for hemorrhage, and surgical options as needed.

Page 17

Overall Recommendations

  • Active prenatal and labor management to prevent complications.

  • Continuous vigilance during and post-delivery for early identification of risk factors.