MANAGEMENT OF LABOUR

1. MANAGEMENT OF LABOUR SALWA NEYAZI CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

2. MANAGEMENT OF LABOUR WHAT IS LABOUR? Regular frequent uterine contractions + Cx changes (dilatation & effacement) or SROM WHAT ARE THE GOALS OF LABOUR MNAGEMENT? To reduce maternal mortality & morbidity resulting from complications of labour/delivery & postpartum To reduce intrapartum fetal mortality To reduce birth aspyxia To reduce the cesarean section rate To improve maternal satisfaction of the birthing experience To relieve maternal anxiety & pain during labour

3. PHASES OF LABOUR FRIEDMAN�S CURVE

4. LABOUR TIME FRAMES

5. MANAGEMENT OF LABOUR 1- Labour preparation ? Prenatal educational classes ? amount of analgesia used in labour Improve maternal stisfaction 2-Birthing companion ? A supportive companion with experience of labour (not trained in health discipline) ? faster progress & less dystocia 3-Ambulation ? the incidence of dystocia ?? augmentation ? operative delivery ? pain percieved by the woman ? ? analgesia & epidural Supine position ? antroposterior compression of the pelvis/ ? the size of the passage Management of patients in the labour ward & postnatal ward 1-Management of labour T1-A supportive companion in labour will have a positive influence on the progress of labour by shortening labour & reducing dystocia F2-Ambulation during labour will increase the pain percieved by the woman & increase the cesarean section rateManagement of patients in the labour ward & postnatal ward 1-Management of labour T1-A supportive companion in labour will have a positive influence on the progress of labour by shortening labour & reducing dystocia F2-Ambulation during labour will increase the pain percieved by the woman & increase the cesarean section rate

6. MANAGEMENT OF LABOUR 4-Analgesia Epidural Nitrous oxide Narcotics

7. 5-Contiuous assessment of progress of labour THE PARTOGRAM T 3-The partogram should be used for all patients in active labourT 3-The partogram should be used for all patients in active labour

8. MANAGEMENT OF LABOUR 6-Amniotomy Routine early use of amniotomy after 3 cm dilatation ? Shortens the average length of labour Does not ? the incidence of CS 7-Fetal size ? fetal size ? ? duration of labour T 4-Amniotomy after 3 cm dilatation will shorten the Average length of labour T 4-Amniotomy after 3 cm dilatation will shorten the Average length of labour

9. FACTORS INFLUENCING LABOUR WHAT IS DYSTOCIA? = 4 hrs of < 0.5 cm/ hr dilatation = 1 hr with no descent Dystocia cannot be diagnosed before the onset of labour WHAT ARE THE CAUSES OF DYSTOCIA? 3 P�s POWERS ? Hypotonic contractions PASSENGER ? Fetal position Fetal size PASSAGE ?Boney pelvis Soft tissue

10. How to assess these factors? Adequate powers ? contractions that -last for 60 sec -reach 20-30 mmHg of pressure -occur every 1-2 min Hypotonic contractions are responsible for 2/3 of nulliparous dystocia If powers are adequate ? check Passage for size & abnormal shape and check the Passenger for size & malpresentation What is the importance of diagnosing dystocia? Dystocia & elective repeat CS account for the majority of CS indications There has been dramatic ?in CS rate with ? in maternal mortality, morbidity, neonatal morbidity & health care costs, reducing Dystocia ? ? CS rate T5-Inadequare uterine contractions may result in failure to progress in labour 2-Dystocia T1- It is the most common indication for cesarean section T 2-Hypotonic contractions are responsible for 2/3 of nulliparous dystociaT5-Inadequare uterine contractions may result in failure to progress in labour 2-Dystocia T1- It is the most common indication for cesarean section T 2-Hypotonic contractions are responsible for 2/3 of nulliparous dystocia

12. TREATMENT OF DYSTOCIA 1-Oxytocin 2-Active management of labour 3-Instrumental deliveries 4-CS

13. PRINCIPLES OF ACTIVE MANAGEMENT Accurate diagnosis of labour Continuous assessment of the progress of labour One to one nursing care Early amniotomy Oxytocin Benefits of active management Significant reduction in dystocia instrumental deliveries & CS rate No increase in birth asphyxia or perinatal mortality T 3-Active management of labour will reduce the incidence of dystocia, instrumental deliveries & cesarean section rate F 4-Active management of labour will increase birh asphyxia T 5- Induction of labour is associated with increased incidence of dystocia T 3-Active management of labour will reduce the incidence of dystocia, instrumental deliveries & cesarean section rate F 4-Active management of labour will increase birh asphyxia T 5- Induction of labour is associated with increased incidence of dystocia

15. PREVENTION OF DYSTOCIA Avoid unnecessary inductions Induction is associated with increase incidence of Dystocia DX in the latent phase of labour & increase in obstetric interventions Admit only women inactive labour Encourage prenatal classes & labour companion Ambulate in labour Use appropriate analgesia Active management of labour

16. MANAGEMENT OF POSTPARTUM PATIENTS

17. PUERPERIUM It is the period after delivery during which there is rapid return to normal health & the normal prepregnancy body physiology . It lasts around six wk There is a high prevelance of maternal morbidity in the immediate postpartum period (85%) , in the 1st 8 wk postpartum 87% & continuing problem in 47-76% Maternal mortality & most maternal morbidity except for piles & stress incontinence are more after CS Vacuum extraction results in less maternal trauma & pain than forceps without increasing the need for CS Puerperium T1- There is a high prevelance of maternal morbidity in the immediate postpartum periodPuerperium T1- There is a high prevelance of maternal morbidity in the immediate postpartum period

18. PROBLEMS THAT MAY BE ENCOUNTERED IN POSTNATAL WARD 1-Afterpains ? due to myometrial contractions ? with breast feeding Improve with NSAID 2-Post partum hemorrhage (5-10%) -Routine use of oxytocics in the third stage of labour ? ? blood loss by 30-40% -It is more likely to occur in the delivery room & the first 1-2 hrs after delivery - Most commonly due to suboptimal contractions of the uterus or abnormal implantation site of the placenta (low laying ) at which bleeding can not be controlled by uterine contractions -RPOC & endometritis can result in PPH several days after delivery T2-Postpartum hemorrhage is most likely to occur in the delivery room & the first 1-2 hours after deliveryT2-Postpartum hemorrhage is most likely to occur in the delivery room & the first 1-2 hours after delivery

19. What can we do if a Pt has PPH in the postnatal ward? Start IV line Send blood for CBC/X-matching /Coagulation Feel the level of the fundus ? normally midway between umbilicus & symphesis pubis ? may be distended with blood clots inside it ? inadequate uterine contraction Uterine massage Start IV syntocinon drip/ ergometrin PG F2a NALODOR IM /IV or intramyometrial U/S to R/O RPOC Check for unnoticed perineal, vaginal or cevical lacerations Exploration under GA

20. 3-Anemia (25-30%) 4-Fever Common causes of fever -Breast engorgement -UTI 2-5 days after delivery -Endometritis Prophylactic antibiotics at the time of CS ? ? serious infections , febrile morbidity & wound infection PROM predispose to endometritis 5- RH �ve mothers with RH +ve babies should receive Anti-D 300 �gm within 72 hrs of delivery T 3- Thrombosis & pulmonary embolism are more likely to occur after cesarean section than normal deliveryT 3- Thrombosis & pulmonary embolism are more likely to occur after cesarean section than normal delivery

21. 6-Thrombosis & pulmonary embolism Accounts for 23% of direct maternal deaths After CS 69% / after ND 48% Risk factors ? obesity, immobilization, previous thromboembolism, increasing maternal age & operative delivery Prophylaxis for the high risk gp reduces the risk May appear after the 3rd day & death occur 7th D in 2/3 of cases Pelvic thrombophlebitis ? following endometritis Causes pain & fever Dx by exclusion Rx Ab & Heparin

22. 7-PET & ECLAMPSIA 35% of eclampsia can occur for the 1st time in the postnatal period Close monitering of BP & proteinurea should continue after delivery for Pt with PET or eclampsia & appropriate measures taken if the problem persists We should ignore alarming symptoms like headache , vomitting & epigastric pain 8- BOWEL PROBLEMS Constipation 20% ? Local acting laxatives high fiber diet Hemorrhoids 18% ? 70% last more than 1 year ? Avoid constipation Xyloproct suppositories Inability to control flatus or faeses 4% F 4- 80% of eclampsia occur for the first time in the postnatal period F 4- 80% of eclampsia occur for the first time in the postnatal period

23. 9-PERINEAL CARE Perineal pain occur in 42% of women after delivery & persists beyond the 1st 2 M in 8-10% after SVD Mediolateral episiotomy causes more pain than median episiotomy 50% dyspareunia on 1st restarting intercourse & 15% continue to have it 3 Y later After assissted vaginal delivery ? 84% will have perineal pain 30% after the 1st 2 M The choice of suture material has a long term effect on dyspareunia Analgesics should be used for relief of perineal pain ? Paracetamol/ Brufen/ Ponstan Sitz bath for pain relief To keep the area clean & dry Pelvic examination ? to R/O hematoma F5- Perineal pain is uncommon in the post partum periodF5- Perineal pain is uncommon in the post partum period

24. 10-URINARY TRACT PROBLEMS Urinary retention is mainly due to bladder edema & hyperemia -Perineal pain can add to the problem by causing reflex retention -Paralyzing effect of the epidural If the Pt does not void for 6-8 hrs or has frequent small voids ? cathterization UTI ? -especially if the Pt has been catheterized in labour -2ry to urine retension Urinary frequency Stress incontinence 20% 3M after delivery � of them still incontinent after 1 year T 1-urinary retention following normal delivery is due to edema & hyperemia of the bladder or due to the effect of the epidural F2-Stress incontinence is more common after cesarean sectionT 1-urinary retention following normal delivery is due to edema & hyperemia of the bladder or due to the effect of the epidural F2-Stress incontinence is more common after cesarean section

25. 11-DEPRESSION & TIREDNESS Depression 10-15% within the 1st year Tiredness 42% in hospital 54% at home 1st 2 months Supportive care & counseling 12-BREAST PROBLEMS Nipple pain / engorgement/ cracks & bleeding ?66% -Rx ? To teach the mother the correct way of BFeeding ? Local heat Analgesics Breast feeding/pumping to reduce engorgement Keeping the nipple clean Applying emollients Bepanthene cream/ breast milk Nipple shield Mastitis/breast abscess ? not contraindication to breast feeding -Usually 2-3 wk after delivery -Requires Antibiotics & continued breast feeding or pumping T4-Correct positioning of the baby�s mouth during breast feeding will reduce nipple pain cracks & bleeding T 5-Nonsteroidal antiinflammatory drugs are not helpful in relieving episiotomy pain T4-Correct positioning of the baby�s mouth during breast feeding will reduce nipple pain cracks & bleeding T 5-Nonsteroidal antiinflammatory drugs are not helpful in relieving episiotomy pain