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Management of labor Dr.Sabet

Management of labor Dr.Sabet. Spontaneous in onset/low risk during labor/37-42 w/vertex position/after birth, mother and infant are in good condition. Indication of hospitalization:. 1- painful regular uterine contractions+active phase 2- ROM 3- passage of blood-stained mucus

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Management of labor Dr.Sabet

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  1. Management of labor Dr.Sabet

  2. Spontaneous in onset/low risk during labor/37-42 w/vertex position/after birth, mother and infant are in good condition.

  3. Indication of hospitalization: 1- painful regular uterine contractions+active phase 2- ROM 3- passage of blood-stained mucus 4- other maternal or fetal complications

  4. Indication of induction 1- PROM + lung maturity2- PIH3- ROM without labor4- Chorioamnionitis5- severe IUGR6- Maternal medical problems (DM-SLE-renal dis)7- fetal demise

  5. 8- post term9- oligo, polyhydramnios10- non-reassuring antepartum fetal testing11-chronic HTN12- Chronic pulmonary dis13- Cholestasis of pregnancy14- Psychologic factors15- Risk of rapid labor16- far distance from hospital 17- previous still birth

  6. 8- prolapsed umblical cord9- macrosomia10- suspected CPD11- prior classic uterine incision12- prior rupture of uterus13- pelvic structural deformities14- inability to adequetely monitor of FHR during labor15- multiple pregnancy 16- grand multiparity ( >= 5 previous pregnancies > 20 w)

  7. Management of the first stage of labor 1- Diagnosis of onset of labor and hospitalization 2- Complete physical exam/check of PNC HX 3- Assess of PMH/PSH/PDH/risk factors 4- Digital exam - on admission - latent phase: q4h - prior to administering analgesia - active phase: q2h - when the patient feels to push - if FHR abnormalities occur

  8. 5- NST 6- VS (q 1h) 7- perineal shaving 8- Enema 9- nurse-midwife care assessment 10- 11- BG/Rh, Hb 11-HIV, HBS, IDC, VDRL if was not done 12- restrict consumption of solid foods/ allow clear liquid at low risk of C/S 13- IV-administration

  9. 14- Stress dose of corticostroids if prednisone 5-20 mg/day > 3w 15- No routinely antiacid is advised 16- Upright position 17- Assessment of uterine contractions 18- Induction or augmentation if indicated 19- Amniotomy if indicated 20- Continuous electronic FHR monitoring during induction of labor or in high risk pregnancy (suspected IUGR/preeclampcia/abruption/ DM1)

  10. 21- Frequent check of FHR, Cont(q30 -60’ at latent phase , q 30’ at active phase ) in low risk women with spontaneous labor 22- Assessment of persistent anterior cervical lip 23- Pain reduction methods 24- Partogram

  11. Active management of the second stage 1- Control of VS at least one time 2- Continuous electronic FHR monitoring with document q5’ during induction of labor or in high risk pregnancy (suspected IUGR/preeclampcia/abruption/ DM1) 3- Frequent check of FHR, Cont( q 15’) in low risk women with spontaneous labor 4- upright position (no supine)5- pain reduction methods

  12. 6- delayed pushing 7- time of transferring to delivery room 8- Episiotomy 9- ABG of neonate if Apgar < 710- Suction if indicated 11- Time of cord clamping12- early breast feeding

  13. Management of the third stage 1- Control of VS 2- Gentle umblical cord traction 3- Prophylactic administration of uterotonic medication 4- Prophylactic administration of misoprostol in high risk patient for PPH 5- Early breast feeding

  14. 6- If no delivery of placenta after 30-40’ - 10u oxy IM - active breast feeding - bladder catheterization - repeat of gentle umblical cord traction - misoprostol 800 Mg R/sl

  15. Management of the forth stage 1- Control of VS - q15’ until 1h - q30’ until 1h - q1h for 4h - q6h until discharge 2- Gentle massage of the uterine after delivery of placenta 3- administration of uterotonic medication 4- Prophylactic administration of misoprostol in high risk patient for PPH 5- Early breast feeding

  16. PPH criteria 1- Scant: blood < 10 cc or bloody pad < 5 cm 2- Light : blood 10-25ncc or bloody pad 5-10 cm 3- Mod: blood 25-50 cc or bloody pad 10-15 cm 4- urge/ heavy : blood 50-800 cc or complete bloody pad during 2h 5- Excessive : complete bloody pad during 15’

  17. Abnormal progress of labor 1- protraction disorders - latent phase (primiparous >=20h & multiparous >= 14h) , Rx : MS 15-20 mg , bed rest , DW 5% - active phase (primiparous: Dil < 1.2 cm/h , des < 1cm/h & multiparous : Dil < 1.5 cm/h , des < 2cm/h) Rx: oxy + amniotomy at Dil >= 6cm C/S in suspected CPD

  18. - second stage : - if uterine activity is low : oxy - if uterine activity is good : observe until progression or Dx of arrest

  19. 2- Arrest disordered - active phase : no cervical Dil after 2h or no descent after 1h management : CPD suspected : CS No CPD suspected : assessment of uterine activity → if low: oxy → if adequate: observe

  20. - if no cervical change in 4h (Mvu>=200) → CS • or no cervical change in 6h (Mvu<200) - second stage : Primiparous no progress after >= 4h with EA or >= 3h without EA Multiparous no progress after >= 3h with EA or >= 2h without EA Management : if high station or contraindication of operative delivery or CPD suspected : CS - if low station and no contraindication: operative delivery

  21. Failed induction : ROM (Spontaneous or artificial) and oxy stimulation for 12-18 h without entering to active phase → CS

  22. Operative delivery (vacuum) Indications: - arrest of second stage of labor - non-reassuring fetal status - maternal cardiac or neurological dis

  23. Contraindication • Prematurity (<34w) • No dilated CX • Malpresentation / malposition of fetus • High station • Fetal CTD • Fetal bleeding diatheses • Suspected CPD • No engagement

  24. Technique 1- bladder should be empty 2- lithotomy position 3- anesthesia 4- cup in the flexion point 5- the angle of traction is down ward 6- the axis of traction is then extended upward to a 45 degree angle to the floor 7- max pressure 600 mmg

  25. Fundal pressure (Kristeller maneuver) 1- controversial 2- complications : increased incidence of large vaginal lacerations, abdominal pain, RDS, uterine rupture, rib fracture, liver rupture, spleen rupture, dyspareunia and perineal pain, third and forth degree perineal lacerations, increased postpartum hemorrhage, shoulder dystocia, neonatal injuries included brachial plexus damage, femor and clavicle Fx, thoracic spinal cord injury, alternations in fetal cerebral blood flow which associated with development of Cp and asphyxia, increase of intracranial pressure, compression of umblical cord, hypoxemia, subgaleal hemorrhage 3- there is no significant in urinary and anal incontinence, genital prolapse, pelvic floor dysfunction.

  26. Risk factors for uterine rupture due to fundal pressure • grand multiparity • induction of labor in a previously scared uterus • Uterine anomalies • Inappropriate PG and oxy usage • Previous instrumental abortion • Vacuum extraction or forceps delivery • Vigorous fundal pressure

  27. Indication • Primiparous or low parity patients without risk factors with fetal distress or with maternal exhaustion at second stage when there is no operative delivery possibility for shortening the second stage • Fetal scalp sampling to assess base excess

  28. technique • Gentle placing a hand on the uterine fundus which creates a longitudinal force toward a 30-45 degree angle of the pelvis toward the pelvic outlet during uterine contractions and avoiding pressure on the spine

  29. There is a baby-guard system consists of a disposable ergonomic 3-chamber inflatable belt and a detector of electro-physiologic signals of myographic uterine activity from the maternal abdomen to create controlled pressure on uterus for decreasing second stage with lower risk than uncontrolled fundal pressure

  30. baby-guard system

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