1. Normal Delivery For LU7

2. Objectives  To outline the conduct of normal labor and delivery  To define personnel requirements

3. Ideal Situation

4. How big should OBAS be?

5. Accurate Diagnosis of Labor  Contractions occur at regular intervals  Intervals shorten  Intensity increases  Discomfort in back and abdomen  Cervix dilates  Discomfort not stopped by sedation

6. Transfer of patients  “A woman in true labor is considered unstable for interhospital transfer purposes until the child and placenta are delivered … unless the risks of transfer are outweighed by benefits of treatment at another facility…violation (carries) civil penalties of up to $50,000…” (Williams, 2001)

7. Electronic Admissions Testing  Non stress test is performed before patient is discharged from admitting of labor unit..

8. Vaginal examination  Not performed if bleeding in excess of bloody show  Amniotic fluid egress examined using sterile speculum to check for pooling  Cervix softness, effacement, dilatation, position  Presenting part  Station  Pelvimetry

9. Monitoring in 1 st stage  Fetal heart rate every 15 to 30 min (110-170 beats per minute)  Uterine contractions by intervals, duration and intensity  Maternal vital signs at least every 4 hours (hourly for hypertensives)  Vaginal examinations every 2 to 3 hours (hourly if in active phase)

10. Monitoring during 2 nd stage  Fetal heart rate every 15 min for low risk and every 5 min for high risk  Positioning in lithotomy and prepping

11. Episiotomy  Not routine  Increases the risk of tears through the rectum  Done once fetal head bulges through the perineum

12. Delivery of head  Crowning is when the largest diameter of the fetal head is encircled by the peritoneum

13. Ritgen’s maneuver  Forward pressure on chin of fetus in direct occiput anterior position once perineum is distended 5 cm or more  Favors extension of head

17. Delivery of shoulders  Head in transverse position and bisacromial diameter in AP  Sides of head are grasped and gentle traction exerted downward to deliver anterior shoulder from under symphysis pubis

18. Handling the nuchal cord

19. Delivery of placenta  4 signs of separation Globular uterus Gush of blood Uterus rises Lenghtening of cord

20. Active management of 3 rd stage  Oxtyocin drip 5 to 10 units after cord clamping  Methyl ergometrine 0.5 mg IM after placenta is delivered (deferred for hypertensive patients)

21. Management of 4 th stage of labor  Involution of uterus  Postpartum hemorrhage >500 cc assessed (laceration, atony, etc.)  Uterine massage and uterotonics given (including misoprostol)

22. Repair of episiotomy  Features median vs. mediolateral episiotomy  Assess extent of tears Cervical lacertaion Urethral, periurethral Vaginal side walls Sphincter tears Rectal mucosal tears

23. Episorraphy  Goal is to control hemorrhage and restore anatomy without excessive suturing  Sutures used are chromic 2-O and vicryl 2-O with big round needle

24. Thank you!