NORMALLABOUR

AHMAD FURQAN BIN NOOR AZMISYAZA SYAZANA BINTI NORDIN

STRUCTURE OF MYOMETRIUM• Myometrium located in the middle between perimetrium and endometrium• Consist mainly of uterine smooth muscle (uteromyocytes).• Has 3 types of smooth muscle :

• Longitudinal• Circular• Oblique

CONTRACTION OF UTERINE MYOCYTES

MECHANISM OF MYOMETRIUM CONTRACTION

In myometrium, the thick and thin filaments(actin and

myosin) are found in long, random bundles throughout

the cells

Hormone such as oxytoxin and prostaglandin are the

agent for activation the calcium channel and allow

calcium to enter the uterine myocyte.

The interaction of actin and myosin with calcium and

adenosine triphosphate(ATP) will causes contraction of

uterine myocyte

The cell membrane also contain gap juction that allow communication from cell to

cell to provide synchronization contraction

Synchronization of myometrium smooth muscle cell by diff type of vegetative NS causes strong myometrial

contraction during labour

FUNCTION OF MYOMETRIUM• To contract during process of labour by a

positive feedback effect on “ferguson reflex”

WHAT IS FERGUSON REFLEX????

• Contraction of uterus after the cervix has been stimulated

• Impulse generated due to NS and humoral factor (oxytocin)

• Ferguson reflex created the urge to push during labour.

WHAT?

LABOUR DELIVERY “HARD WORK” “WITH HELP”

Fully normal natural process of giving birth process through normal which involves active birth canal. management and medical

helps.

CAUSES OF LABOUR

HORMONAL FACTOR

• FETO-PLACENTA DISTRIBUTION• -CRH → pituitary,ACTH → fetal adrenal gland,glucocorticoid →

accelerated production of estrogen and prostaglandins from placenta → reduce progesterone production

• Increase oestrogen (increase exitabiliity of myometrium membrane and increase synthesis of prostaglandin)

• Increase prostaglandin (maintain labour)

• Decrease progesterone (increase contractility)

MECHANICAL FACTOR

• UTERINE DISTENTION• Due to extra strength : when uterus distended to a certain limit, it

start to contract to evacuate its contents.

SIGN OF LABOURREGULAR CONTRACTION With pain and uterine get tighten Oxytoxin will be release when true labour occur. Oxytoxin is a

hormone that induce contraction of myometrium Contraction usually start at the back and move around to the front.

The contraction can be felt as a cramping or tightening sensation

SIGN OF LABOURPASSING THE MUCUS PLUGThe cervix is plugged with a thick

piece of mucous that helps protect fetus during pregnancy by blocking the entrance to the uterus

When the cervix effaces and dilates, the mucus plug will be release

Labour is usually starts several hours to few days after that.

BACK LABOURBack labor refers to the intense lower back pain

that many women feel during contractions when they're giving birth.

The position of baby such as occiput anterior can causes pressure from the baby’s head to be applied to the mother sacrum

BRAXTON’S HICKS• Cervix is a part of uterus.• False contraction to prepare for cervix ripening before onset of the labour.• Usually pain is felt at night.

CERVIX RIPENING.• Cervical canal become short and wider• Palpation consistency : soft

TRUE LABOUR

• Regular interval last about 30-70s

• As time goes by, they get stronger , longer and closer

• Pain is felt at the back to the abdomen.

FALSE LABOR / BRAXTON HICKS

• Irregular contraction and doesn’t get close together.

• Pain stop when pt take a walk/change position

• Contraction usually weak and doesn’t get stronger

• Pain is felt only in front of abdomen / pelvis

STAGES OF LABOUR

FIRST STAGE

SECOND STAGE

THIRD STAGE

FIRST STAGE OF LABOUR

LATENT PHASE -Start with regular uterine contraction and ends with the beginning of cervical dilation and effacement

ACTIVE PHASE-Increase velocity of cervical dilatation in short duration( hours) from 3cm to 7cm-Uterine contraction become intensively increase, more frequuent longer and stronger

DECELERATION PHASE-Decrease velocity of cervix dilatation from 7cm to maximun dilatation 10cm and full effacement-It occurs because the head descend and is it contract with the cervix . It give force to cervix to dilate more-Causes cervix to dilate until full dilatation

based on velocity of cervical dilatation

GRAPH OF VELOCITY OF CERVICAL DILATATION.

Relationship between cervical dilatation and fetal descent

UTERINE CONTRACTION AND RETRACTION UTERINE SEGMENT

• During contraction upper segment become firm and lower segment become softer,distended and more passive

• Refraction ring form between the upper and lower segment of the uterus• During first stage of labour the upper segment contract,refracts and

expels the fetus and in respond to these contraction, lower segment become softened

• The upper segment does not relax to its original length after contarction,it become relatively fixed at shorter length in order to maintain and gain expulsive force of fetus

CERVICAL EFFACEMENT AND DILATATION

• Cervical effacement occur because of increase myometrial activity during uterine preparation for labour just after cervix is ripened

• The cervix gradually softens, shorten and become thinner. It is called cervical effacement

• The muscular fibre at about level of the internal cervical os are pulled upward ot taken up into lower uterine segment. The condition of the external os remain unchaged

• The presenting part ,applied to the cervix and forming lower uterine segment• Because the lower uterine segment and cervix have lesser resistance during a

contraction, the uterine contraction cause pressure on the membrane and hydrostatic action of amniotic sac in turn dilates the cervical canal. It is called cervical dilatation.

RUPTURE OF MEMBRANE

• Occur during full dilatation

• “EARLY MEMBRANE RUPTURE” When it occur at 6cm of dilatation

• “PRETERM MEMBRANE RUPTURE”When it occur before the onset of labour.

SECOND STAGE(FETAL EXPULSION)

• Start when cervical dilatation is complete and end with the expulsion of the fetus• All the mechanism of labour happen in this stage.

Head of the fetus decent passes through the muscular birth canal (pelvic inlet)

PUSH(voluntary movement)The head of the fetus pressed on the muscle of pelvis causing increase sensitivity on the stretch receptor on pelvic muscle and causes mother to have the urge to push fetus out

As the fetal head continue descend ,the vagina open and the fetal scalp appears. At first it appears slit like then become oval then circular . This is called crowning

As she continue pushes,using her adominal muscle to aid the involuntary uterine contraction ,the fetus is pushed out of the birth canal

• During this stage : mother start to feel the new event.

1. Labour : uterine contraction2. Pushing

Voluntary : sense at anterior abdominal muscle and pelvic

muscle.involuntary

THIRD STAGE(PLACENTAL SEPARATION AND EXPULSION) Occurs immediately after delivery of the

fetus. The management of placenta expulsion

only occur 30 mins to prevent excessive bleeding/hemorrhage.

If not,manual separation and removal of placenta will be done.

2 types : Marginal separation Central separation

Mechanism : -contraction continue after the

fetus is expulsed to help with the membrane separation.-contraction also continue toprovide spasm of vessel to prevent bleeding.

MANAGEMENT OF NORMAL LABOURADMINISTRATION PROCEDURE.1. IDENTIFICATION OF LABOR• To differentiate true/false labor2. CERVICAL EXAMINATION• Cervical effacement • Cervical dilation• Level of station (distance between fetal part in birth canal and inshial spine)

3. VAGINAL EXAMINATIONThe function of vaginal examination are to:

• Identify the fetal presentation and position• 4 movement of vaginal examination1. Insert 2 finger into vaginal2. Fingers directed posteriorly and then swept forward over the

fetal head toward maternal symphysis. During the movement ,the fingers should cross the saggital suture.

3. The position of 2 fontanel are ascertained,the fingers are passed to most anterior extension of saggital suture ,and fontanel there is examined and identified. Then with a sweeping motion the fingers pass along the suture to other end of head until the other fontanel is felt and differentiated

4. The station or extent to which the presenting part has descended into the pelvis, can also be established at this time

4. DETECTION OF RUPTURED MEMBRANE• Diagnosed when amniotic fluid is seen

MANAGEMENT OF THE FIRST STAGE OF LABOUR

Cardiotocography • Monitor fetal heart rate at least every 30 mins (1st stage), each 15 mins (2nd stage)

Intravenous Fluids

An intravenous infusion system is advantageous during the immediate puerperium to administer oxytocin prophylactically and at times therapeutically when uterine atony persists.

Moreover, with longer labors, the administration of glucose, sodium, and water to the otherwise fasting woman at the rate of 60 to 120 mL/hr prevents dehydration and acidosis.

MANAGEMENT OF THE FIRST STAGE OF LABOUR

PARTOGRAM A graphical representation that record the observation and information from the monitoring of the mother and fetusConsist

• Maternal status• Fetal heart rate• Dilation and descent• Uterine contraction

MANAGEMENT OF THE FIRST STAGE OF LABOUR

ANALGESIC.The pain of childbirth is likely to be most severe pain that a women experience during her lifetimeAnalgesia that usually used:

• Meperidine = 25-50 mg every 1-2 hours or 50-100mg every 2-4 hours • Fentanyl = 50-100mcg every hours • Nalbuphine = 10 mg IV or IM every 3 hours • Butorphanol = 1-2 mg IV or IM every 4 hours• Morphine, 2-5 mg IV or 10 mg IM every 4 hours

As an alternative ,regional anesthesia may be given. Anesthesia option include:• Epidural• Spinal• Combined spinal-epidural

MANAGEMENT OF THE FIRST STAGE OF LABOURACTIVE MANAGEMENT

ACTIVE MANAGEMENT OF LABOUR (AML) IS A STRUCTURED PROTOCOL • with the aim of reducing prolonged labour. ( to keep labour to fewer

than 12 hours and to a minimum operative delivery rates. )

• Two of its components are performed : -Amniotomy -Oxytocin

• When dilation is not increased by 1cm per hour,amniotomy is performed.After 2 hours,high dose oxytocin infused if still not dilated.

ARM, (Artificial rupture of the membranes) AMNIOTOMY • Breaking the membranes that surround the baby and releasing the

amniotic fluid before it breaks naturally itself. • This is performed with the use of a long sharp hook similar to a

crochet hook that is inserted through vagina and cervix and used to make a small nick in the membranes allowing the waters to escape. Patient will be required to lay on her back with her legs open while this procedure is preformed.

• ARM’s are used to either help start labour before it is ready to started itself, or speed up a labour that is not moving fast enough for either the care provider or the mother.

MANAGEMENT OF SECOND STAGE OF LABOUR

Once cervix is fully dilated and the women is in the expulsive phase of the second stage ,encourage her to assume the position she prefer and encourage her to push

PERINEUM CLEANING• Need 6 swab balls• Clean sequentially as shown by the numbers• Clean according to the direction by the arrow • Delivery must be sterile and antiseptic

procedure

CREATE STERILE FIELD AROUND THE VAGINAL OPENING

EPISIOTOMY

• Not a routine procedure and are considered preventing tearDo not decrease:• Perineal damage• Future vaginal prolapse• Urinary incontinenceAssociated with • An increase of 3rd and 4th degree tears• Subsequent anal sphincter muscle dysfunctionConsidered only in:• Complicated vaginal deliveryBreechForceps Vacuum

• Scarring from female genital mutilation or poorly heald 3rd or 4th degree tear

MANAGEMENT OF THE SECOND STAGE OF LABOUR

•Ritgen Maneuver is performed •As crowning occurs, place a hand on the top of the baby’s head and apply light pressure •Instruct the mother to focus on her breathing. Have her “pant like a dog” to help her stop pushing and prevent a forceful birth.

DELIVERY OF THE HEAD •Ask the woman to pant or give only small pushes with contractions as the baby’s head delivers •To control birth of the head, place the fingers of one hand against the baby’s head to keep it flexed (bent) •Continue to gently support the perineum as the baby’s head delivers

MANAGEMENT OF THE SECOND STAGE OF LABOUR

DELIVERING OF THE SHOULDERS

•The side of the head are grasped with two hands and gentle traction is applied until anterior shoulder appears

•Upward movement until posterior shoulder is delivered

SUCTION THE BABY’S MOUTH AND NOSE•Once the baby’s head delivers, ask the woman not to push

•Suction the baby’s mouth and nose

NUCHAL CORD If the cord is around the neck, attempt to slip it over the baby’s

head. Feel around the

baby’s neck for the umbilical cord

ASSISTING WITH DELIVERY• As the head emerges, the baby will turn to one side (for easier passage of

shoulders through birth canal)• Check to see if the umbilical cord is looped around the baby neck. If so,

gently slip it over the head

Baby delivered First body contact of mother and baby and cord clamping

Clamping,cutting and tying of umbilical cord

MANAGEMENT OF 3RD STAGE OF LABOR• Talk to the women and tell her that you will be deliver the placenta• Wash your hand and put on your sterile glove• After having the signs of placental separation, hold the clamp close to the

perineum with one hand. • Gently guide the placenta downward and outward by holding on the cord• Be gentle and do not pull as it can tear or break the cord• When the bulk of placenta is out, hold it with 2 hands• Rotate the placenta like twisting a rope until delivered so that fetal membranes will

come out

4 SIGNS OF PlACENTAL SEPARATION -Uterus becomes globular and firm -Sudden gush of blood -Uterus rise in the abdomen and placenta pass down into vagina -Umbilical cord protrudes farther out of vagina

MANAGEMENT OF THE THIRD STAGE OF LABOUR

EXPECTANT MANAGEMENT

• Feel the uterus from the abdomen and massage it to keep in contracted

• Injected an oxytoxin drug intramusculary to control bleeding

• The best time to inject oxytoxin during 3rd stage of labour

A. After delivery of babyB. After delivery of the placenta

MANAGEMENT OF THE THIRD STAGE OF LABOUR

• Repair episiotomy

• Controlled cord traction

• Massage of uterus

ROLE OF :

• To detect any sign of possible complications.• To prevent complications.

doctor

• Performed manual assistant during normal labor to prevent injury to mother. ( laceration of birth canal soft tissue )

midwives

THANK YOU