1. Labour ,it s mechanism and management
Dr Hiba Ahmed Suhail M.B. Ch. B./F.I.B.O.G. College of medicine University of Mosul

2. Aims:
1-To achieve delivery of a normal healthy child with minimal physical and psychological maternal effects. 2-Early anticipation, recognition and management of any abnormalities during labour course. .

3. Antenatal Preparation
Maternal education: about the physiology of labour and symptoms of impending labour. .

4. Management during first stage
The first stage of labour is timed from the diagnosis of onset of labour to full dilatation of the cervix.

5. First Stage of Labour:
(I) History:
(1)Complete obstetric history.
(2)History of present pregnancy:
- Duration of pregnancy.
- Medical disorders during this pregnancy.
Complications during this pregnancy as antepartum haemorrhage.
(3)History of present labour:
Labour pains : onset, frequency and duration.
- Passage of " show", fluid or blood per vagina
- Sensation of fetal movement.

6. (II)Examination: (1) General examination: - Height and built
(II)Examination: (1) General examination: - Height and built. - Maternal vital signs : pulse, temperature and blood pressure. - Chest and heart examination. - Lower limbs for odema. (2) Abdominal examination: - Fundal level. - Fundal grip. - Umbilical grip. - Pelvic grips. - Fetal Heart Sound . - Scar of previous operations.

7. (3) Pelvic examination:
a-Cervix: -Dilatation : the diameter of the external os is measured by the finger (s) during P/V examination and expressed in cm, one finger = 2 cm , 2 fingers = 4 cm -Effacement. - Position (posterior, midway , central). b- Membranes: ruptured or intact. If ruptured exclude cord prolapse and meconium stained liquor c- Presenting part and its position.

8. Investigations: If not done before or if indicated: 1- Blood group-Rh typing. 2- Urine for albumin and sugar. 3- Hb concentration . 4- Ultrasound of pregnancy .

9. Management during the latent phase :
Women who are in the latent phase of labour should be encouraged to mobilize and should be managed away from the labour suite
Intervention during this phase is best avoided unless there are identified risk factors.
Simple analgesics are used
no restriction of eating and drinking, although lighter foods and clear fluids maybe better tolerated.
Vaginal examinations are usually performed every 4 hours to determine when the active phase has been reached (approximately 4cm dilatation and full effacement).
The frequency of pelvic examination may be increased if the progress is unusually slow or fast.

10. Management during the active phase:
#Once the active phase has been reached, the lower limit of normal progress is 1cm dilatation every 2 hours. # Descent of the presenting part through the pelvis is another crucial component of progress and should be recorded at each vaginal examination. #During the first stage, the membranes may be intact, may have ruptured spontaneously or may have been ruptured artificially. #Maternal and fetal observations are carried out, and recorded on the partogram. #Women may drink and take light diet if no risk of anesthesia during established labour # Intravenous fluids to those who are becoming dehydrated to prevent ketosis, which impair uterine contractility. #Active management of labour( early artificial rupture of membrane and use of oxytocin augmentation if progress less than 1 cm dilatation per hour for more than 2hours) .

11. #Evacuation of the bladder ask the patient to micturate every 2-3 hours, if she cannot use a catheter Itprevents uterine inertia Pethidine 100 mg IM,inhalational anesthesia or epidural anaesthesia are the most common use. #Oral antacids need only be given to women with risk factors for complications and helps to guard against bronchospasm occurs if the acid vomitus is inhaled during general anaesthesia ( Mendelson’s syndrome). #Posture Patient is allowed to walk during the early first stage particularly with intact membranes.If rest is needed the patient lies on her left lateral position to prevent inferior vena cava compression. #Emotional support to the mother

12. The partogram :
It is the graphic recording of the course of labour including the following
observations:
(I) The maternal informations:
- Pulse every 30 minutes,
-blood pressure every 2 hours,
- temperature every 4 hours,
- uterine contractions : frequency , strength and
duration every 30 minutes by manual palpation
or better by tocography if available
- cervical dilatation.
- fluid input and output
- drugs including oxytocins

13. (II) The fetal informations :
*FHR every 15 minutes by Pinard’s stethoscope
*descent of the presenting part
*degree of moulding
Cardiotocography if available is more valuable for continuous monitoring of both uterine contractions and FHR particularly in
high risk pregnancy

15. The advantages of the partogram
1-Allows right intervention in the proper time e.g. oxytocin usage, instrumental delivery or C.S. 2- A document for labour events

16. Second Stage of Labour:
(1) Its beginning is identified by: the first sign of the second stage is an urge to push experienced by the mother. The patient feels the desire to The contractions become more prolonged and painful. Reflex desire to bear down during the contractions. The expulsive effort is accompanied by sustained expiratory effort. Full dilatation of the cervix (10 cm ) in between uterine contractions is the most sure sign.

17. (2) Delivery room:
1-The patient is transferred on a wheel or trolley to the delivery room. 2- Put her in the lithotomy position 3-The lower abdomen, upper parts of the thighs and perineum are swabbed with antiseptic lotion. (3) Bearing down: Ask the patient to bear down during contractions and relax in between.

18. (4) Delivery of the head:
The main aim during delivery of the head is to prevent perineal lacerations
through the following instructions:
1-Support of the perineum:
When the perineum start to separate by the head, a sterile pad is placed
over the perineum and press on it with the right hand during uterinecontractions. Soon after this the baby's head will be seen at the out let of birth canal at the peak of each contraction. Between contractions, the elastic tone of the perineal muscles will push the head back into the pelvic cavity.
This is continued until crowning occurs to maintain flexion of the head
- Crowning:is the permanent distension of the introit us by the fetal head like
a crown on the head. The head does not recede back in between uterine contractions.
When the head no longer recedes between contractions (crowning), this indicates that it has passed through the pelvic floor, and delivery is imminent this means that the biparietal diameter is just passed the vaginal out let .
-Ritgen manoeuvre: upward pressure on the perineum by the right hand and downward pressure on the occiput by the left hand to control the extension of the head and the occipital prominence escapes under the symphysis pubis.

20. 4-Coils of the umbilical cord :
2-Episiotomy:
It is done at crowning when the perineum is stretched to the degree that it is about to tear.
3-Swab and aspirate:
The mouth and nose once the head is delivered before respiration is initiated and
the liquor, meconium or blood is inhaled.
4-Coils of the umbilical cord :
Once the fetal head is born, a check is made to see whether the cord is tight around the neck, thereby making delivery of the body difficult. The cord may need to be clamped and divided before delivery of the rest of the body.

21. (5) Delivery of the shoulders:
With the next contraction, there is external rotation of the head and the shoulders can be delivered
To aid delivery of the shoulders, the head should be pulled gently downwards and forwards until the anterior shoulder appears beneath the pubis. The head is then lifted gradually until the posterior shoulder appears over the perineum and the baby is then swept upwards to deliver the body and legs.
Immediate care of the neonate

22. (6) Delivery of the remainder of the body: Usually slips without difficulty otherwise gentle traction is applied to complete delivery. (7) Clamping the cord: The baby is held by its ankles with the head downwards at a lower level than its mother for few seconds, this may be enhanced by milking the cord towards the baby, to add about 100 ml of blood to its circulation. The cord is divided between 2 clamps to avoid bleeding from a possible 2 nd twin

23. Third Stage of Labour: (I)Delivery of the placenta Separation of placenta occurs because of reduction of volume of uterus due to uterine contraction&retraction so it lies free in the lower segment of uterine cavity. The mother will become aware of its presence on the pelvic floor &by straining expel it through vagina.

24. Signs of placental separation and descent
1-The body of the uterus becomes smaller, harder and globular. 2-The fundal level rises as the upper segment overrides the lower uterine segment which is now distended with the placenta. 3-Suprapubic bulge due to presence of the placenta in the lower uterine segment. 4-Elongation of the cord particularly on pressing on the uterine fundus and it does not recede back into the vagina on relieving the pressure.. 5. Gush of blood from the vagina.

26. Physiological management of the third stage is
Traditionally it was considered prudent to await signs of placental separation then expelling it by pressure on the fundus which is associated with risk of postpartum hemorrhage.
The placenta is delivered by maternal effort, and no uterotonic drugs are given.
but can used in women who are not at risk of postpartum haemorrhage
It is associated with heavier bleeding.
If hemorrhage, or if the placenta remains un delivered after 60 minutes of physiological management, active management should be done.

27. The active management of third stage
The modern management which involve a procedure called controlled cord traction [Brandt-Andrews’ method].
This technique as follows:
1-Synthetic oxytocin 10 iu or syntometrin [5iu oxytocin,0.5 mg ergometrine] is given by intramuscular injection following delivery of anterior shoulder .
2-After delivery of the baby the attendant should place the left hand on the uterus to identify when a contraction has occurred .During this time the perineum should be observed for any hemorrhage.

28. The cord should be double clamped approximately 1-2 minutes after delivery of baby.
3-When a contraction is felt the left hand should be moved suprapubically &the fundus is elevated with the palm facing towards the mother.
4-At the same time the right hand should grasp the cord &exert steady tractions that the placenta separates &delivered gently ,care being taken to peel off all membranes usually with a twisting motion.

30. (II) Routine examinations:
(1) Examination of the placenta and membranes:
by exploring it on a plain surface to be sure that it is complete. If there is missed part, exploration of the uterus is done under general anesthesia.
(2) Explore the genital tract:
The perineum of the mother should be inspected for any tears or lacerations.
Minor tears do not require suturing, but tears extending into the' perineal muscles or an episiotomy will require careful repair. (III) Repair of episiotomy

31. Retained placenta :
In 2 per cent of cases, the placenta will not be expelled by controlled cord traction
If no bleeding occurs, a further attempt at controlled cord traction should be made after 10 minutes.
If this fails, the placenta is 'retained' and will require manual removal under general or regional anesthesia in the operating theatre.

32. Care of The Newborn
*The newborn is placed in supine position with the head lower down. rubber or disposable plastic catheter is used to aspirate the mucus from the pharynx and mouth directly by attach it to an electric suction pump.
*Crying of the baby is usually occurs within seconds, if delayed slapping its soles, flexion and extension of the legs and rubbing the back
*A disposable plastic umbilical clamp is applied about 5 cm from the umbilicus to avoid the possibility of tying an umbilical hernia then cut
about 1.5 cm distal to the clamp and inspect it for bleeding.