Child birth Dr. Miada Mahmoud Rady

Labor the miracle of life Labor : the process by which the product of conception are expelled out side uterus at term. It occurs in three stages. The length of time for each stage depends on whether the woman primipara or multipara. First signs of labor (which often go unnoticed): Lightening : Relief of pressure in the upper abdomen. Increase of pressure in the pelvis. Bloody show (a plug of mucus sometimes mixed with blood).

First stage of labor It begins with onset of regular uterine contractions and ends with full cervical effacement and dilation. Early contractions come at 5 and 15 minute intervals. Effacement : the lower segment of the uterus is pulled upward over the presenting part, resulting in effacement (thinning and shortening) of the cervix. Dilation : cervix stretches until wide enough to accommodate the fetus passing through. Averages about 12 hours in a nullipara up to 8 hours in a multipara at the end of the stage, the amniotic sac often ruptures.

Second stage of labor It Begins with full cervical dilation (10 cm) and complete effacement , and ends with baby’s birth. During the second stage the fetus undergoes series of position changes to adapt and pass through the birth canal. It ends with complete delivery of the fetus .

Mechanisms of Labor/ Cardinal Movements Descent Flexion Internal Rotation Extension External Rotation 25. Explain the positional changes /cardinal movements of stage 2 and why they occur in this order? Expulsion

Third stage of labor The placenta separates from the uterine wall and is expelled. Uterine contractions squeeze shut the exposed blood vessels from where the placenta was separated from the uterine wall.

Maternal Response to Labour Increased workload of the heart leading to increased blood pressure, pulse, and cardiac output. Increased breathing rate to accommodate the increased oxygen demand and also due to pain from labor and perineal stretching. Increased WBC production in response to stress and exertion of labor. Preservation of fluids and electrolytes by the renal system. Protein breakdown and increased temperature from physical exertion. Short notes on maternal response to labour? True or false and correct the false : During labour the following occurs → Increased workload of the heart , pulse , blood pressure and cardiac out put. Decreased respiratory rate . Loss ( excretion ) of fluid and electrolytes . Fetal acidosis.

The fetal responses to labor Result from powerful uterine contractions on the fetal body. Fetal responses include : Decrease in the amount of oxygen and nutrients to the fetus . Insufficient removal of waste from the fetus . Decreased fetal heart rate . Fetal acidosis : from hypoxia and a build up of lactic acid caused by : Nuchal cord ,shoulder dystocia and abnormal fetal position . Multiple births . Respiratory conditions . Short essay on fetal response to labour ? What are causes of fetal acidosis? Fetal acidosis result from …………………….. And is caused by …………………………………………. ,………………………….. And ………………………… True or false and correct false : increased heart rate and fetal oxygen . Remember placenta does it all.

Preparing for delivery birthing positions. OB kit and preparing for delivery . Assisting labour. Post partum care.

Semi-fowler’s position Birthing positions Standing birth Semi-fowler’s position Free movement. Take advantage of the force of gravity . Fetal head is moved away from sacrum when the back is arched. Patient sits in semi-fowler or high fowler position . Helps some women with pushing because they can lie back to rest between contractions .

Side-lying position Kneeling birth Left sided position, with the upper torso supported with pillows. Ensures the uterus and fetus are moved away from the inferior aorta. Fewer perineal tears with this method. The woman kneels with her buttocks in the air and resting on her elbows. Allows her to arch her back to assist delivery. Allows the fetal head to move away from the sacrum.

OB kit and preparing for delivery Open the sterile OB Wash hands thoroughly. Put on sterile gloves. Maintain standard precautions. Drape the woman in sterile towels.

Safe and controlled delivery occurs primarily over the draping if there is no time. Attend to the emotional needs of the patient and bystanders. Have your partner at the woman’s head to help keep her calm and administer oxygen if needed. Encourage the woman to rest between contractions and to resist bearing down until you can assist with delivery.

Assisting delivery and care of new born

Cutting umbilical cord Assisting delivery Care of new born Apgar scoring Cutting umbilical cord Delivery of placenta

Assisting delivery Control the delivery : When crown begins, place gentle pressure on the head to prevent it from delivering too quickly and tearing the vagina. Support the newborn’s head as it emerges from the vagina and begins to turn ,Do not pull the newborn out. If membranes cover the head, tear the amniotic sac with fingers or forceps so the newborn can breathe. Slip a middle finger alongside the head to check for nuchal cord.

Assisting delivery With the head supported, clear the airway by suctioning with a bulb syringe. Gently guide the head downward so the upper shoulder can deliver and then gently guide the head upward to allow delivery of the lower shoulder. The trunk and legs will follow rapidly. Grasp and support the newborn as it emerges. Remember ; Newborns are wet and slippery.

Suction to clear air way Gently guide the head down Gently guide the head up

Assisting delivery Once delivered, maintain the newborn at the same level as the vagina to prevent blood drainage. Wipe blood or mucus from the newborn’s nose and mouth with sterile gauze. Suction the mouth and nostrils with the bulb syringe. Dry the newborn with sterile towels, and wrap in a dry blanket. Record the time of birth for the report.

Apgar score Used to evaluates the newborn’s vital functions immediately after birth Five parameters are given score from 0 to 2 is given at 60 seconds and again at 5 minutes after birth: i. Heart rate ii. Respiratory effort iii. Muscle tone iv. Reflex irritability v. Color Most newborns have a total score of 7 to 10. A score of 4 to 6 will need resuscitation. Give short account on Apgar scoring ? True or false and correct false : Apgar scoring is done on 4 parameters. each parameters is given score from 0 to 2 done at 60 seconds and 5 mints after birth new born with Apgar score of 5 will need no resuscitation.

Pathophysiology, Assessment, and Management of Complications of Labor

Precipitous labor and birth Means the newborn has been delivered prior to paramedic arrival. Uncommon in primigravida , common in multipara and risk increases with increase in the number of deliveries. More common in women with previous precipitous labour. The entire labor time and birth usually occurs in less than 3 hours. Contractions are usually more intense and more effective.

Fetal adverse affects are usually minor and includes Facial bruising and more than usual misshaped head Management : Address ABCs. Mange shock . Fetal monitoring . Rapid transport .

Post-term pregnancy Definition : The fetus has not been born after 42 weeks. Risk factors include: Previous post term pregnancy. Irregular menstrual cycles (increased chance of due date miscalculation). Complication : Malnutrition of the fetus due to impaired function of placenta. Meconium aspiration. Longer labour and complicated delivery . C.S is usually the method of delivery

Meconium staining Definition : abnormal staining of amniotic fluid with meconium at time of delivery. Meconium : first stool of the baby , Odorless, greenish-black, with a tar-like consistency and sterile. Pathophysiology : The fetus passively ingests elements while in utero (mucus, amniotic fluid) which become baby's first stool In fetal distress, or from the stress of labor and delivery, meconium may be voided into the amniotic fluid.

Know only after rupture of amniotic sac. Color : Yellow tint suggests meconium in the amniotic fluid for some time. Greenish-black color suggests recent meconium passage (sign of danger).

Complication : May cause chemical pneumonia in the newborn : Meconium viscosity can partially or completely block the airway  The respiratory tract may be irritated If respiratory depression is seen with meconium in the airway, perform tracheal suctioning through an endotracheal tube.

Fetal macrosomia Definition : known as “big baby syndrome;” refers to a large fetus that weighs more than 4,500 grams . Risk factors include: Gestational diabetes or diabetes that is not properly controlled. Male fetus and some genetic conditions in the fetus. Post term pregnancy. Obesity and excessive weight gain during pregnancy .

Treatment should focus on: Supporting the woman and providing rapid transport for possible cesarean section If field delivery: Encourage breastfeeding. Check newborn’s blood glucose level because of the increased risk of hypoglycemia.

Multiple gestation Delivery of more than one baby . Consider the possibility of multiples if: The first newborn is small. The abdomen is still large after the birth. The second newborn is usually born within 45 minutes, with contractions beginning about 10 minutes after the first birth.

Management The procedure is the same as a single birth : Always prepare for more than one resuscitation and call for assistance. The procedure is the same as a single birth : Clamp and cut the cord of the first newborn as soon as delivery is complete. The second newborn may or may not deliver before the placenta. Check if there are one or two cords coming out of the placenta when it delivers : If there are two cords in one placenta, the twins are identical. If there is one cord in the placenta, there will be another placenta, and the twins are non identical.

Record the time of birth for each newborn. Multiples may be so small that they look premature. Identify the first newborn delivered as “Baby A,” loosely tying an extra length of tape around a foot.

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