MANAGEMENT OF MANAGEMENT OF LABOURLABOUR

SALWA NEYAZISALWA NEYAZICONSULTANT OBSTETRICIAN GYNECOLOGISTCONSULTANT OBSTETRICIAN GYNECOLOGIST

PEDIATRIC & ADOLESCENT GYNECOLOGISTPEDIATRIC & ADOLESCENT GYNECOLOGIST

MANAGEMENT OF LABOURMANAGEMENT OF LABOUR

WHAT IS LABOUR?WHAT IS LABOUR? Regular frequent uterine contractionsRegular frequent uterine contractions

++ Cx changes (dilatation & effacement)Cx changes (dilatation & effacement)

oror SROMSROM

WHAT ARE THE GOALS OF LABOUR MNAGEMENT?WHAT ARE THE GOALS OF LABOUR MNAGEMENT? To reduce maternal mortality & morbidity resulting from To reduce maternal mortality & morbidity resulting from

complications of labour/delivery & postpartum complications of labour/delivery & postpartum To reduce intrapartum fetal mortalityTo reduce intrapartum fetal mortality To reduce birth aspyxiaTo reduce birth aspyxia To reduce the cesarean section rateTo reduce the cesarean section rate To improve maternal satisfaction of the birthing experienceTo improve maternal satisfaction of the birthing experience To relieve maternal anxiety & pain during labourTo relieve maternal anxiety & pain during labour

PHASES OF LABOURPHASES OF LABOUR

FRIEDMAN’S CURVEFRIEDMAN’S CURVE

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LATENT PHASELATENT PHASE

ACTIVE PHASEACTIVE PHASE

ACCELRATION PHASEACCELRATION PHASE

DECELRATION PHASEDECELRATION PHASE

Duration of labourDuration of labour

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LABOUR TIME FRAMESLABOUR TIME FRAMES

Phases/ Stages of labourPhases/ Stages of labourNulliparousNulliparousMultiparousMultiparous

Latent phaseLatent phaseMean timeMean time 6.4 h6.4 h 4.8 h4.8 h

Longest Longest normalnormal

20.1 h 20.1 h 13.6 h13.6 h

Active phaseActive phaseMean rateMean rate 3 cm/h3 cm/h 5.7cm/h 5.7cm/h

Slowest Slowest normalnormal

1.2cm/h1.2cm/h 1.5cm/h1.5cm/h

22ndnd Stage StageMean timeMean time 1.1 h1.1 h 0.4 h0.4 h

Longest Longest normalnormal

2.9 h2.9 h 1.1 h1.1 h

MANAGEMENT OF LABOURMANAGEMENT OF LABOUR

1- Labour preparation1- Labour preparation Prenatal educational classes Prenatal educational classes amount of analgesia used in labour amount of analgesia used in labour Improve maternal stisfaction Improve maternal stisfaction

2-Birthing companion2-Birthing companion A supportive companion with A supportive companion with experience of labour (not trained in health discipline) experience of labour (not trained in health discipline) faster progress & less dystociafaster progress & less dystocia

3-Ambulation3-Ambulation the incidence of dystocia the incidence of dystocia augmentation augmentation operative operative

deliverydelivery pain percieved by the woman pain percieved by the woman analgesia & epidural analgesia & epidural Supine position Supine position antroposterior compression of the pelvis/ antroposterior compression of the pelvis/

the size of the passagethe size of the passage

MANAGEMENT OF LABOURMANAGEMENT OF LABOUR

4-Analgesia4-Analgesia EpiduralEpidural Nitrous oxideNitrous oxide NarcoticsNarcotics

↑ ↑ pain pain

& anxiety& anxiety

↑ ↑ CatecholaminesCatecholamines

Uterine Uterine

blood flowblood flow

Uterine Uterine

ContractionContraction

strengthstrength

DystociaDystocia

5-Contiuous assessment 5-Contiuous assessment of progress of labourof progress of labour

THE PARTOGRAMTHE PARTOGRAM

MANAGEMENT OF LABOURMANAGEMENT OF LABOUR

6-Amniotomy6-Amniotomy Routine early use of amniotomy after 3 cm Routine early use of amniotomy after 3 cm

dilatation dilatation Shortens the average length of labourShortens the average length of labour Does not Does not the incidence of CS the incidence of CS

7-Fetal size7-Fetal size ↑ ↑ fetal size fetal size ↑ duration of labour ↑ duration of labour

FACTORS INFLUENCING LABOURFACTORS INFLUENCING LABOUR

WHAT IS DYSTOCIA?WHAT IS DYSTOCIA? ≥ ≥ 4 hrs of 4 hrs of < 0.5 cm/ hr dilatation< 0.5 cm/ hr dilatation ≥ ≥ 1 hr with no descent1 hr with no descent Dystocia cannot be diagnosed before the onset of Dystocia cannot be diagnosed before the onset of

labourlabourWHAT ARE THE CAUSES OF DYSTOCIA?WHAT ARE THE CAUSES OF DYSTOCIA? 3 P’s3 P’s POWERS POWERS Hypotonic contractionsHypotonic contractions PASSENGER PASSENGER Fetal positionFetal position Fetal sizeFetal size PASSAGE PASSAGE Boney pelvisBoney pelvis Soft tissueSoft tissue

How to assess these factors?How to assess these factors? Adequate powers Adequate powers contractions that contractions that

-last for 60 sec-last for 60 sec

-reach 20-30 mmHg of pressure-reach 20-30 mmHg of pressure

-occur every 1-2 min-occur every 1-2 min Hypotonic contractions are responsible for 2/3 of Hypotonic contractions are responsible for 2/3 of

nulliparous dystocianulliparous dystocia If powers are adequate If powers are adequate check Passage for size & check Passage for size &

abnormal shape and check the Passenger for size & abnormal shape and check the Passenger for size & malpresentationmalpresentation

What is the importance of diagnosing dystocia?What is the importance of diagnosing dystocia? Dystocia & elective repeat CS account for the majority Dystocia & elective repeat CS account for the majority

of CS indicationsof CS indications There has been dramatic There has been dramatic ↑↑in CS rate with in CS rate with ↑ ↑ in in

maternal mortality, morbidity, neonatal morbidity & maternal mortality, morbidity, neonatal morbidity & health care costs, reducing Dystocia health care costs, reducing Dystocia CS rate CS rate

PHILPOTT’S CERVICOGRAPHPHILPOTT’S CERVICOGRAPH

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Time (hr)Time (hr)

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Alert lineAlert lineAction lineAction line

Cervicograph should not be used until active Cervicograph should not be used until active

labour has been established 3-4 cm dilatationlabour has been established 3-4 cm dilatation

TREATMENT OF DYSTOCIATREATMENT OF DYSTOCIA

1-Oxytocin 2-Active management of labour1-Oxytocin 2-Active management of labour

3-Instrumental deliveries 4-CS3-Instrumental deliveries 4-CS

ADVERSE EFFECTSADVERSE EFFECTSMECHANISMMECHANISMPREVENTIONPREVENTION

Fetal compromiseFetal compromiseHyperstimulationHyperstimulationCorrect doseCorrect dose

Uterine ruptureUterine ruptureHyperstimulationHyperstimulationCorrect doseCorrect dose

HypotensionHypotensionVasodilatationVasodilatationLow dose infusionLow dose infusion

Water intoxicationWater intoxicationADH effectADH effectLimit free waterLimit free water

ADVERSE EFFECTS OF OXYTOCINADVERSE EFFECTS OF OXYTOCIN

PRINCIPLES OF ACTIVE MANAGEMENTPRINCIPLES OF ACTIVE MANAGEMENT

Accurate diagnosis of labourAccurate diagnosis of labour Continuous assessment of the progress of labourContinuous assessment of the progress of labour One to one nursing careOne to one nursing care Early amniotomyEarly amniotomy OxytocinOxytocin

Benefits of active managementBenefits of active management Significant reduction in dystocia instrumental Significant reduction in dystocia instrumental

deliveries & CS ratedeliveries & CS rate No increase in birth asphyxia or perinatal No increase in birth asphyxia or perinatal

mortalitymortality

ActiveActiveControlControl

Labour >12 Labour >12 hrshrs

7%7%20%20%

ForcepsForceps19.4%19.4%29%29%

CSCS4.3%4.3%13%13%

ACTIVE MANAGEMENT OF LABOUR ACTIVE MANAGEMENT OF LABOUR

PREVENTION OF DYSTOCIAPREVENTION OF DYSTOCIA

Avoid unnecessary inductionsAvoid unnecessary inductions

Induction is associated with increase incidence of Induction is associated with increase incidence of Dystocia DX in the latent phase of labour & Dystocia DX in the latent phase of labour & increase in obstetric interventionsincrease in obstetric interventions

Admit only women inactive labourAdmit only women inactive labour Encourage prenatal classes & labour companionEncourage prenatal classes & labour companion Ambulate in labourAmbulate in labour Use appropriate analgesiaUse appropriate analgesia Active management of labourActive management of labour

MANAGEMENT OF MANAGEMENT OF POSTPARTUM PATIENTSPOSTPARTUM PATIENTS

PUERPERIUMPUERPERIUM It is the period after delivery during which there is It is the period after delivery during which there is

rapid return to normal health & the normal rapid return to normal health & the normal prepregnancy body physiology . It lasts around prepregnancy body physiology . It lasts around six wksix wk

There is a high prevelance of maternal morbidity There is a high prevelance of maternal morbidity in the immediate postpartum period (85%) , in in the immediate postpartum period (85%) , in the 1the 1stst 8 wk postpartum 87% & continuing 8 wk postpartum 87% & continuing problem in 47-76%problem in 47-76%

Maternal mortality & most maternal morbidity Maternal mortality & most maternal morbidity except for piles & stress incontinence are more except for piles & stress incontinence are more after CSafter CS

Vacuum extraction results in less maternal Vacuum extraction results in less maternal trauma & pain than forceps without increasing trauma & pain than forceps without increasing the need for CSthe need for CS

PROBLEMS THAT MAY BE PROBLEMS THAT MAY BE ENCOUNTERED IN POSTNATAL WARDENCOUNTERED IN POSTNATAL WARD

1-Afterpains 1-Afterpains due to myometrial contractionsdue to myometrial contractions

↑ ↑ with breast feedingwith breast feeding

Improve with NSAIDImprove with NSAID

2-Post partum hemorrhage (5-10%)2-Post partum hemorrhage (5-10%)

-Routine use of oxytocics in the third stage of labour -Routine use of oxytocics in the third stage of labour blood loss by 30-40%blood loss by 30-40%

-It is more likely to occur in the delivery room & the first 1-2 -It is more likely to occur in the delivery room & the first 1-2 hrs after deliveryhrs after delivery

- Most commonly due to suboptimal contractions of the - Most commonly due to suboptimal contractions of the uterus or abnormal implantation site of the placenta (low uterus or abnormal implantation site of the placenta (low laying ) at which bleeding can not be controlled by uterine laying ) at which bleeding can not be controlled by uterine contractionscontractions

-RPOC & endometritis can result in PPH several days after -RPOC & endometritis can result in PPH several days after deliverydelivery

What can we do if a Pt has PPH in the postnatal What can we do if a Pt has PPH in the postnatal ward? ward?

Start IV line Start IV line Send blood for CBC/X-matching /CoagulationSend blood for CBC/X-matching /Coagulation Feel the level of the fundus Feel the level of the fundus normally midway normally midway

between umbilicus & symphesis pubis between umbilicus & symphesis pubis may be may be distended with blood clots inside it distended with blood clots inside it inadequate inadequate uterine contractionuterine contraction

Uterine massageUterine massage Start IV syntocinon drip/ ergometrinStart IV syntocinon drip/ ergometrin PG F2PG F2αα NALODOR IM /IV or intramyometrial NALODOR IM /IV or intramyometrial U/S to R/O RPOCU/S to R/O RPOC Check for unnoticed perineal, vaginal or cevical Check for unnoticed perineal, vaginal or cevical

lacerationslacerations Exploration under GAExploration under GA

3-Anemia (25-30%)3-Anemia (25-30%)

4-Fever4-Fever

Common causes of fever Common causes of fever

-Breast engorgement -Breast engorgement

-UTI 2-5 days after delivery-UTI 2-5 days after delivery

-Endometritis-Endometritis Prophylactic antibiotics at the time of CS Prophylactic antibiotics at the time of CS serious serious

infections , febrile morbidity & wound infectioninfections , febrile morbidity & wound infection PROM predispose to endometritisPROM predispose to endometritis

5- RH –ve mothers5- RH –ve mothers with RH +ve babies should receive with RH +ve babies should receive Anti-D 300 µgm within 72 hrs of deliveryAnti-D 300 µgm within 72 hrs of delivery

6-Thrombosis & pulmonary embolism6-Thrombosis & pulmonary embolism Accounts for 23% of direct maternal deathsAccounts for 23% of direct maternal deaths After CS 69% / after ND 48% After CS 69% / after ND 48% Risk factors Risk factors obesity, immobilization, previous obesity, immobilization, previous

thromboembolism, increasing maternal age & thromboembolism, increasing maternal age & operative delivery operative delivery

Prophylaxis for the high risk gp reduces the riskProphylaxis for the high risk gp reduces the risk May appear after the 3May appear after the 3rdrd day & death occur 7 day & death occur 7thth D D

in 2/3 of casesin 2/3 of cases Pelvic thrombophlebitis Pelvic thrombophlebitis following endometritis following endometritis

Causes pain & feverCauses pain & fever

Dx by exclusionDx by exclusion

Rx Ab & Heparin Rx Ab & Heparin

7-PET & ECLAMPSIA7-PET & ECLAMPSIA 35% of eclampsia can occur for the 135% of eclampsia can occur for the 1stst time in the time in the

postnatal periodpostnatal period Close monitering of BP & proteinurea should Close monitering of BP & proteinurea should

continue after delivery for Pt with PET or continue after delivery for Pt with PET or eclampsia & appropriate measures taken if the eclampsia & appropriate measures taken if the problem persistsproblem persists

We should ignore alarming symptoms like We should ignore alarming symptoms like headache , vomitting & epigastric painheadache , vomitting & epigastric pain

8- BOWEL PROBLEMS8- BOWEL PROBLEMS Constipation 20% Constipation 20% Local acting laxatives Local acting laxatives high fiber diethigh fiber diet Hemorrhoids 18% Hemorrhoids 18% 70% last more than 1 year 70% last more than 1 year

Avoid constipationAvoid constipation Xyloproct suppositories Xyloproct suppositories Inability to control flatus or faeses 4% Inability to control flatus or faeses 4%

99--PERINEAL CAREPERINEAL CARE

Perineal pain occur in 42% of women after delivery & Perineal pain occur in 42% of women after delivery & persists beyond the 1persists beyond the 1stst 2 M in 8-10% after SVD 2 M in 8-10% after SVD

Mediolateral episiotomy causes more pain than median Mediolateral episiotomy causes more pain than median episiotomyepisiotomy

50% dyspareunia on 150% dyspareunia on 1stst restarting intercourse & 15% restarting intercourse & 15% continue to have it 3 Y latercontinue to have it 3 Y later

After assissted vaginal delivery After assissted vaginal delivery 84% will have perineal 84% will have perineal pain pain

30% after the 130% after the 1stst 2 M 2 M The choice of suture material has a long term effect on The choice of suture material has a long term effect on

dyspareunia dyspareunia Analgesics should be used for relief of perineal pain Analgesics should be used for relief of perineal pain

Paracetamol/ Brufen/ PonstanParacetamol/ Brufen/ Ponstan Sitz bath for pain relief Sitz bath for pain relief To keep the area clean & dry To keep the area clean & dry Pelvic examination Pelvic examination to R/O hematoma to R/O hematoma

1010--URINARY TRACT PROBLEMSURINARY TRACT PROBLEMS

Urinary retention is mainly due to bladder edema & Urinary retention is mainly due to bladder edema & hyperemia hyperemia

-Perineal pain can add to the problem by causing reflex -Perineal pain can add to the problem by causing reflex retention retention

-Paralyzing effect of the epidural -Paralyzing effect of the epidural If the Pt does not void for 6-8 hrs or has frequent small If the Pt does not void for 6-8 hrs or has frequent small

voids voids cathterization cathterization UTI UTI -especially if the Pt has been catheterized in labour -especially if the Pt has been catheterized in labour

-2ry to urine retension-2ry to urine retension Urinary frequency Urinary frequency Stress incontinence 20% 3M after deliveryStress incontinence 20% 3M after delivery ¾ of them still incontinent after 1 year¾ of them still incontinent after 1 year

11-DEPRESSION & TIREDNESS11-DEPRESSION & TIREDNESS Depression 10-15% within the 1Depression 10-15% within the 1stst year year Tiredness 42% in hospitalTiredness 42% in hospital 54% at home 154% at home 1stst 2 months 2 months Supportive care & counseling Supportive care & counseling

12-BREAST PROBLEMS12-BREAST PROBLEMS Nipple pain / engorgement/ cracks & bleedingNipple pain / engorgement/ cracks & bleeding 66%66% -Rx -Rx To teach the mother the correct way of BFeeding To teach the mother the correct way of BFeeding Local heat Local heat AnalgesicsAnalgesics Breast feeding/pumping to reduce engorgementBreast feeding/pumping to reduce engorgement Keeping the nipple clean Keeping the nipple clean Applying emollients Bepanthene cream/ breast milkApplying emollients Bepanthene cream/ breast milk Nipple shield Nipple shield Mastitis/breast abscess Mastitis/breast abscess not contraindication to breast not contraindication to breast

feedingfeeding -Usually 2-3 wk after delivery-Usually 2-3 wk after delivery -Requires Antibiotics & continued breast feeding or -Requires Antibiotics & continued breast feeding or

pumpingpumping