KANMANI.

S 12TH BATCH MSc (N)

NORMAL LABOUR

Series of events that takes place in the genital organs in an effort to expel the viable products of conception out of the womb through the vagina into the outer world Is called labor.

Cont---- Labor

is called normal (eutocia) if it fulfils the following criteria. 1. Spontaneous in onset and at term, 2. With vertex presentation, 3. Without undue prolongation, 4. Natural termination with minimal aids, 5. Without having any complications affecting the health of the mother or the baby.

Events in the second stage of labor

The second stage begins with the complete dilatation of the

cervix and ends with the expulsion of the fetus. This stage is concerned with the descent and delivery of the fetus through the birth canal. With the full dilatation of the cervix , the membrane usually rupture and there is escape of good amount of liquor amnii. uterine contraction and retraction become stronger. The uterus becomes elongated during contraction. The elongation is partly due to straightening , of the fetus and partly due to stretching of the lower uterine segment.

Contin--- Delivery of the fetus is accomplished by the

downward thrust offered by uterine contractions supplemented by voluntary contraction of abdominal muscles against the resistance offered by bony and soft tissues of the birth canal. There is always a tendency to push the fetus back into the uterine cavity by the elastic recoil of the tissue of the vagina and the pelvic floor. This is effectively counterbalanced by the power of retraction.

Contin--- Thus, with increasing contraction and

retraction, the upper segment becomes more and more thicker with corresponding thinning of lower segment. The expulsive force of uterine contractions is added by voluntary contraction of the abdominal muscles called bearing down efforts.

CLINICAL COURSE OF SECOND STAGE OF LABOR

Three phases: the latent

the descent the transition phases. Each phase is characterized by maternal verbal and nonverbal behaviors, uterine activity, the urge to bearing down, and fetal descent.

 The latent phase is a period of rest and relative calm. The

urge to bearing down is not well established and is experienced primarily during the time of contraction. The descent phase is characterized by strong urges to bearing down as Fergusons reflex is activated when the presenting part presses on the stretch receptors of the pelvic floor. In the transition phase, the presenting part is on the perineum and bearing down efforts are most effective for promoting birth. The woman may be more verbal about the pain she is experiencing; and may act out of control.

Pain and bearing down efforts

Pains: The intensity of the pain increases. The pains come

at intervals of 2-3 minutes and lasts for about 1-1.5 minutes.

BEARING DOWN EFFORTS(Fergusons reflux)

It is the additional voluntary expulsive efforts that appear in the late second stage (expulsive phase). It is initiated by nerve reflexes set up due to stretching of the vagina by the presenting part. This stimulation causes the release of oxytocin from the posterior pituitary glands, which provokes stronger expulsive uterine contractions.

Contin--- MEMBRANES STA TUS Membranes may rupture with a gush of liquor per

vaginam. Rarely, spontaneous rupture may not takes place at all, allowing the baby to be born in a caul DESCENT OF THE FETUS Abdominal findings are- progressive descent of the head, assessed in relation to the brim, rotation of the anterior shoulder to the midline and change in position of the fetal heart rate shifted downwards and medially. Internal examination reveals descent of the head in relation to the Ischial spines and gradual rotation of the head evidenced by position of the sagittal suture and the occiput in relation to the quadrants of the pelvis.

 VAGINAL SIGNS

As the head descends down, it distends the perineum, the vulval opening looks like a slit through which the scalp hairs are visible. During each contraction, the perineum is markedly distended with the overlying skin tense and glistening and the vulval opening becomes circular. The maximum diameter of the head stretches the vulval outlet and there is no recession even after the contraction passes off. This is called crowning of the head. The head is born by the extension. Immediately after the delivery of shoulders and trunk, a gush of liquor(hind waters) follows, often tingled with blood.

Crowning of head

 MATERNAL SIGNS There are features of exhaustion.

Respiration is, slowed down with increased perspiration. During the bearing down efforts, the face becomes congested with neck veins prominent. Immediately following the expulsion of the fetus, the mother heaves a sigh of relief. FETAL EFFECTS Bradycardia during contractions is very much prominent which often continues because of quick successive contractions.

MANAGEMENT OF SECOND STAGE OF LABOUR

PRINCIPLES
To assist in the natural expulsion of the fetus slowly

and steadily. To prevent perineal injuries.

 GENERAL MEASURES The patient should lie down in bed Constant supervision_ (a) to note FHR at 5 minutes interval, (b)

to note the maternal pulse and blood pressure at 15minutes interval,(c) to give assurance, advice and instruction to patient so as to keep up the morale and to avail maximum co-operation during voluntary expulsion of the fetus. To administer inhalation analgesics Vaginal examination is done at the beginning of the second stage not only to confirm its onset but to detect accidently cord prolapse, if any. Position and station of the head and progressive descent of the head can be ensured. Nothing is given by mouth, except sips of water or ice.

ASSESSMENT
In 1st stage
Dilatation and effacement of cervix Sudden appearance of bloody show

An episode of vomiting
Increased bloody show Shaking of extremities

Increased restlessness
Involuntary bearing down efforts

Assessment in the second stage of labor

The frequency, strength, and duration of uterine contractions;

the duration of uterine relaxation; and the fetal response. Monitor fetal heart rate-including variability, acceleration and deceleration pattern; low risk birth-FHR in every 15mins;high risk birth-FHR in every 5 mins Maternal pulse and blood pressure Status of bladder( especially in case of epidural block) Status of show and character of amniotic fluid Maternal energy level Emotional response of woman and partner towards 2nd stage of labor Fetal descent

Duration of

nd 2

stage

A second stage of more than 2 hours in a1st pregnancy

and of 1.5 hours in subsequent pregnancies may be considered prolonged in women without regional analgesia .

In the case of prolonged second stage Nursing diagnosis

Risk for injury to mother and fetus related to

persistent use of Valsalvas maneuver Situational low self esteem related to knowledge deficit regarding normal beneficial effects of vocalization during bearing down efforts, / inability to carry out birth plan for birth without medication Ineffective individual coping related to coaching that contradicts womans physiologic urge to push Pain related tobearing down efforts and distention of the perineum

In the case of prolonged second stage Nursing diagnosis

Anxiety related to inability to control defecation when

bearing down / knowledge deficit regarding and inexperience with perineal sensations associated with the urge to bear down. Risk for injury to mother related to inappropriate positioning of mothers legs in stirrups Risk for infections related to prolonged rupture of membranes/ perineal incision(episiotomy) / perineal lacerations Situational low self esteem, partner or father, related to inability to support mother during second stage of labor.

CONDUCTION OF DELIVERY
Delivery is divided into three phases

Delivery of the head Delivery of the shoulder Delivery of the trunk

Delivery of the head: The principles to be followed are to maintain flexion of the head, to prevent its early extension and to regulate its slow escape out

of the vulval outlet.

BEARING DOWN EFFORTS

 Care following delivery of the head

The mucus and blood in the mouth and pharynx are to be

wiped with sterile gauze piece on little finger. Or by using bulb syringe The eye lids are then wiped with sterile cotton swabs.(from medial to the lateral canthus) The neck is then palpated to exclude the presence of any loop of cord(20-25%)

Contin-- Delivery of the shoulders

Wait for the uterine contractions to come and for the movements of restitution and external rotation of the head to occur. Traction on the head should be gentle to avoid excessive stretching of the neck causing injury to the brachial plexus, hematoma of the neck or fracture of the clavicle Delivery of the trunk After the delivery of the shoulders, the fore finger of each hand are inserted under the axillae and the trunk is delivered gently by lateral flexion.

Immediate care of new born

Soon after the delivery of the baby, it should be placed in a tray covered with sterile linen. The tray is placed between the legs of the mother and should be at a lower level than the uterus to facilitate gravitation of blood from the placenta to the fetus.

Air passage should be cleared of mucus by sucker.

Apgar rating at 1 to 5 minutes is to be recorded

Contin-- Clamping and ligature of the cord--- cord is to be clamped and

divided as soon as convenient following birth of the baby. But early clamping should be done in cases of Rh incompatibility (to prevent antibody transfer), neonatal asphyxia, preterm babies, IUGR babies. The cord is clamped by two Kochers forceps, the near one is placed 5cm away from the umbilicus and is cut in between. Quick check method is made to detect any gross abnormality and the baby is wrapped in cotton or warm material. The identification tape is tied both on the wrist of the baby and the mother in hospital confinement and after showing the baby to the mother, the baby is transferred to the nursery for further management and care.

EPISIOTOMY

A surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labor is called episiotomy.

Objectives
To enlarge the vaginal introitus
To prevent perineal tears

A neat surgical incision is easier to repair than a ragged tear May prevent pelvic relaxation and vaginal wall prolapsed

Indications
oAnticipating perineal
Inelastic perineum

Manipulative delivery
To cut short second

Fetal interest fetal distress, pre mature baby, breech presentation

Timing of episiotomy
Bulging thinned perineum during contraction just prior to crowning

is the ideal time

Types
Medio-lateral episiotomy
Midline episiotomy

Lateral episiotomy
J shaped episiotomy

Contin-- Medio-lateral: the incision is made

downwards and outwards from the midpoint of the fourchette either to the right or left. Midline: the incision commences from the centre of the fourchette and extends posteriorly along the midline for about 2.5cm

Contin-- Lateral: the incision starts from about 1cm

away from the centre of the fourchette and extends laterally. J shaped: the incision begins in the centre of the fourchette and is directed posteriorly along the midline for about 1.5cm and then directed downwards and outwards along 5 or7 o clock position to avoid the anal sphincter.

Post operative care

Dressing : Comfort: Ambulance: Removal of stitche

Complications
Immediate
Extension of the incision Vulval haematoma Infection Wound dehiscence

contin--Remote
Dyspareunia: Chance of perineal lacerations

Advantages of episiotomy
Maternal: -- Easy to repair and heals

properly. --Preserves the strength of pelvic floor -- Lacerations of rectum can be avoided --Shortening of second stage

 Fetal: -- It minimizes intracranial injuries

-- Reduces fetal asphyxia and acidosis.

EQUIPMENTS NEEDED FOR NORMAL VAGINAL DELIVERY

sponge holding forceps

Long straight scissors perineorraphy scissors

or

Kochers haemostatic forceps

Cord clamp

Needle holder

Suture needle with holder

Catgut suture

suture needle with holder

THANKS

THANKS