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CONDUCT OF

NORMAL
LABOR
Presentor:
Clerk SEMJON TSYRLIN

Objectives
To present a case of a normal
conduct of labor
To discuss the normal conduct of
labor
To discuss the management of
normal conduct of labor

General Data

B. J., 20 yr. old


G2P1 (1001)
Single
Filipino
Roman Catholic
Residing in Binan, Laguna
Admitted for the 2nd time
December 7, 2012 at around 6:54am

Chief Complaint
Bloody Mucoid Discharge

Past Medical History

(-)
(-)
(-)
(-)
(-)

DM
HPN
Asthma
Thyroid Disease
Hospitalization

Family Medical History

(-) HPN
(-) Diabetes Mellitus
(-)CA
(-) Thyroid disease

Personal & Social History


Housewife
Living with a partner, 25 years old,
payroll clerk, for 2 years
Non smoker
Non alcoholic beverage drinker
No known allergies to food and
drugs.

Menstrual History
Menarche at 11 years old lasted for
3-5 days
Interval: 28-30 days
3-5 days duration
1-2 moderately soaked regular
pads/day
Denies dysmenorrhea.

Sexual History

1st coitus: 18 years old


Single sexual partner
No post coital bleeding
No dyspareunia

Contraceptive History
No history of contraceptive use

Gynecological History
(-) Leucorrhea
(-) Vaginal pruritus
(-) Pap smear done

Obstetrical History
G2P1 (1001)
YEAR

ROUT INDICATI PLACE OF


BIRTH
E
ON FOR DELIVERY WEIGHT
CS
2011 F- Term NSD
None
UPHDJGTM
3kgs
C
prese pregnan
nt
cy

G
1
G
2

SEX

LMP: March 16, 2012


PMP: February 16, 2012
AOG: 38 weeks
EDC: December 23, 2012

COMPLICATIO
NS
none

Prenatal History
At 8 weeks amenorrhea
Suspected pregnancy
No consult done
No medications taken

At 16 weeks AOG
Quickening was noted
No consult done

At 20 weeks AOG
Consult at Private OB
Ultrasound confirmed pregnancy

Prenatal History
At 21-27 wks AOG- irregular PNCU at
Health center
At 28 weeks AOG
First prenatal check-up at Jonelta OPD
Laboratories ordered:

CBC with platelet count


Urinalysis
VDRL
HbsAg

Prescriptions:
Multivitamins
Folic acid

Prenatal History
At 30 weeks AOG
Laboratory results from 2 weeks prior:

CBC with platelet count - normal


Urinalysis UTI
VDRL - nonreactive
HbsAg - nonreactive

Prescriptions:
Cefalexin 500mg, QID, for 7 days

At 32 weeks AOG
Repeat U/A was normal- UTI resolved
Repeat CBC showed anemia
Patient was again prescribed MVTs OD, FeSO4
BID and Ascorbic acid OD.

Prenatal History
At 33-35 weeks AOG- regular PNCU and
regular intake of Multivitamins and
supplements
At 36 weeks AOG
Patients anemia resolved
Advised weekly prenatal checkups and fetal
health monitoring

At 37 weeks AOG
Unremarkable findings
Good fetal movement, FHT 140s, FH 32cm.

History
of
Pregnancy/Illness:
3 hours PTA
(+) labor pains
(-) watery vaginal discharge
(-) bloody show
no consult done

1 hour PTA
(+) labor pains
(+) bloody show

Thus seeking consult, and


subsequently admitted

Present

Review of Systems
CNS: (-) Loss of consciousness (-)
Dizziness (-) Headache
CVS: (-) Chest pain (-) easy
fatigability
Respiratory: (-) DOB (-) cough (-)
colds
GIT: (-) Vomiting (-) Nausea (-)
Constipation
GUT: (-)Dysuria (-) Polyuria (-)
Hematuria

PHYSICAL
EXAMINATION

General Survey:
Ambulatory, conscious, coherent, afebrile, not in
cardiorespiratory distress

Vital Signs:

BP: 120/80 mmHg


T: 36.9C
CR: 88 bpm
RR: 19cpm

Skin:
Warm to touch, good skin turgor

HEENT:
Pink palpebral conjunctiva, anicteric sclerae, no
nasoaural discharge, moist lips and oral mucosa

Chest/Lungs:
Symmetric chest expansion, no retraction, clear breath
sounds

Heart:
Adynamic precordium, normal rate, regular rhythm, no
murmur

Abdomen & Pelvic Exam (on next slide)


Extremities:

Abdomen
&
Examination
Abdomen:

Pelvic

Globular
FH: 28cm
FHT: 140s LLQ EFW: 2.48kgs
2-3 mild to moderate contractions in 15 mins
LEOPOLDS MANEUVER:
L1: breech
L2: Fetal small parts Right; Fetal back - Left
L3: cephalic
L4: Not engaged
Pelvic Exam
I: Parous introitus
SE: Cervix violaceous, (+) bloody mucoid discharge
IE: 5cm, 70% effaced, cephalic, (+) BOW, st-2

Initial Assessment

G2P1 (1001) PREGNANCY


UTERINE 38 WEEKS AOG,
CEPHALIC IN LABOR

COURSE IN THE WARD

UPON ADMISSION
Plan:
Stable vital signs
Good fetal movement
FHT 140s
NPO
IVF: D5LR 1L x 8hours

Medications:

Ampicillin 1g TIV
10 units of Oxytocin
incorporated to present IVF
For NSD barring complications
regulated at 8-10 gtts/min
Nalbuphine 10mg IM
Diagnostics:
Methylergometrine
CBC with platelet count
1 amp IM/IV Medications:
(Leukocytosis)
Ampicillin 1g TIV
Urinalysis (Normal)
Monitor progress of labor, vital
signs, FHT and contractions

BASELINE
CARDIOTOCOGRA
M:
Shows reassuring
fetal heart rate
pattern

After 5 hours of Labor


Patient went in to full cervical dilatation
and delivered spontaneously a live baby
girl full term, cephalic, birth weight 3.0kg,
Appropriate for gestational age.

Postpartum orders:
DAT
IVF with oxytocin incorporation
was continued
Medications were:
- Cefuroxime 500 mg/cap BID
- Mefenamic acid 500 mg/cap TID
PRN
- Methylergometrine 1 tablet TID for

On the 1st Postpartum day:

Stable vital signs


No abdominal pain
No bleeding
Well contracted uterus
Voiding freely
Minimal lochial
discharge
May go home
Advised ff up at Jonelta
OPD

Home Rx

Cefuroxime 500 mg/tab 1


tab BID for 7 days
Mefenamic acid 500 mg/tab
1 tab TID as needed on full
stomach
Methylergometrine maleate
tab TID x 7 more doses
Ferrous Sulfate 1 tab every
day for one month
Ascorbic Acid 1 tab every
day for one month

Final Assessment
G2P2 (2002) PREGNANCY
UTERINE, DELIVERED FULL
TERM, CEPHALIC, LIVE BABY
GIRL, BIRTHWEIGHT 3.0KG,
APPROPRIATE FOR GESTATIONAL
AGE, NORMAL SPONTANEOUS
DELIVERY, RIGHT MEDIOLATERAL
EPISIOTOMY & REPAIR, 2ND
DEGREE, UNDER IV SEDATION.

Normal
Conducti
on of
Labor

LABOR
Period from the onset of regular
uterine contractions until expulsion
of the placenta

Normal Labor and Delivery


True Vs. False Labor
True Labor

False Labor

Contractions

Regular

Irregular

Interval

Regular

Irregular

Intensity

Shorter

Long

Discomfort

Back and Abdomen

Chiefly lower
abdomen

Cervical
Dilatation

Increases

Unchanged

Sedation

No relief*

With relief

Mechanism of Labor
Fetal position within the uterine
cavity at the onset of labor with
respect to the birth canal
critical to the route of delivery
Fetal Orientations:

Lie
Presentation
Attitude
Position

Fetal Lie
The relation of the long axis of the
fetus to that of the mother
Longitudinal (99%)
Transverse
Predisposing factors:

Multiparity
Placenta Previa
Hydramnios
Uterine Anomalies

Oblique

Fetal Presentation
Portion of the fetal body that is either
foremost within the birth canal or in
closest proximity to it
Longitudinal lies
Fetal head : Cephalic presentation
Breech : Breech presentation

Transverse lies
Shoulder presentation

Cephalic Presentation

BREECH PRESENTATION
Breech presentation
Frank breech- thighs are flexed with legs
extended
Complete breech- thighs flexed, legs flexed
Footling one or both thighs are extended

Fetal Attitude or Posture


fetus assumes a characteristic posture
described as attitude or habitus
fetus forms an ovoid mass that
corresponds roughly to the shape of the
uterine cavity
In all cephalic presentations, the arms are
usually crossed over the thorax or become
parallel to the sides, and the umbilical
cord lies in the space between them and
the lower extremities.

Fetal Position
Position refers to the relationship of
an arbitrarily chosen portion of the
fetal presenting part to the right or
left side of the maternal birth canal

Abdominal Palpation
Leopold Maneuvers
First Maneuver
This maneuver permits identification
of which fetal polethat is, breech or
headoccupies the uterine fundus.
The breech gives the sensation of a
large, nodular mass, whereas the
head feels hard and round and is
more mobile and ballottable.

Second Maneuver
Palms are placed on either side of the
maternal abdomen, and gentle but deep
pressure is exerted. On one side, a hard,
resistant structure is feltthe backand
on the other, numerous small, irregular,
mobile parts are feltthe fetal extremities

Third Maneuver
Using the thumb and fingers of one
hand, the lower portion of the
maternal abdomen is grasped just
above the symphysis pubis. If the
presenting part is not engaged, a
movable mass will be felt, usually the
head. The differentiation between
head and breech is made as in the
first maneuver

Fourth Maneuver
The examiner faces the mother's feet
and, with the tips of the first three
fingers of each hand, exerts deep
pressure in the direction of the axis
of the pelvic inlet.

Cardinal movements of labor


1. Engagement- the mechanism by which
the biparietal diameter, the greatest
transverse diameter of the fetal head in
occiput presentations, passes through the
pelvic inlet
2.Descent- this is the first requisite for
birth of the newborn
-brought about by:
(1) pressure of the amnionic fluid,
(2) direct pressure of the fundus upon the
breech with
contractions,
(3) bearing down efforts of maternal
abdominal muscles,

Cardinal movements of labor


3.Flexion
- occurs as the descending head meets
resistance, whether from the cervix, walls of the
pelvis, or pelvic floor
- the chin is in contact with the fetal thorax, and
the appreciably shorter suboccipitobregmatic
diameter is substituted for the longer
occipitofrontal diameter
4. Internal Rotation
- consists of a turning of the head in such a
manner that the occiput gradually moves toward
the symphysis pubis anteriorly from its original
position or, less commonly, posteriorly toward the
hollow of the sacrum

Cardinal movements of labor


5.Extension
this brings the base of the occiput into direct
contact with the inferior margin of the symphysis
pubis
6.External Rotation
corresponds to rotation of the fetal body, serving
to bring its bisacromial diameter into relation with
the anteroposterior diameter of the pelvic outlet
7. Expulsion
occurs almost immediately after external rotation,
the anterior shoulder appears under the
symphysis pubis, and the perineum soon
becomes distended by the posterior shoulder.
After delivery of the shoulders, the rest of the

First Stage of Labor: Clinical Onset


of Labor
forceful uterine contractions that effect cervical
dilatation, fetal descent and delivery begin
suddenly without warning
average duration: nullipara- 8 hrs
multipara- 5 hrs
Uterine contractions characteristic of labor
stimulated by:
hypoxia of the contracted myometrium
Compression of nerve ganglia in the cervix and
lower uterus by the interlocking muscle
bundles
stretching of the cervix during dilatation

Change in Uterine Shape During


1st Stage Labor
Becomes longer, narrower
Fetal axis pressure
the decrease in horizontal diameter produces a
straightening of the fetal vertebral column, and
the lower pole is thrust farther downward and
into the pelvis

Cervical changes induced during the 1st


stage of labor
1.Cervical effacement - obliteration/ taking up of
the cervix is the shortening of the cervical
canal from a length of about 2 cm to a mere
circular orifice with almost paper- thin edges

2nd Stage of Labor: Fetal Descent


-begins when cervical dilatation is
complete
-ends with fetal delivery
-median duration: nulliparas- 50
minutes
multiparas- 20 minutes

3rd Stage of Labor: Delivery of


Placenta & Membrane
begins immediately after delivery of the fetus
cleavage of the placenta is facilitated greatly by the
nature of the loose structure of the spongy deciduas
Signs of Placental Separation (usually 1-5 mins after
delivery)
1. The uterus becomes globular and firmer.
2. There is a sudden gush of blood.
3. The uterus rises in the abdomen.
4.The umbilical cord protrudes farther out of the
vagina, indicating that the placenta has descended.

Delivery of the Placenta


Traction on the umbilical cord must not be used to
pull the placenta out of the uterus to prevent
inversion of the uterus.
As downward pressure toward the vagina is
applied to the body of the uterus, the umbilical
cord is kept slightly taut. The uterus is then lifted
cephalad with the abdominal hand.
As the placenta passes through the introitus,
pressure on the uterus is stopped. The placenta is
then gently lifted away from the introitus.
The maternal surface of the placenta should be
examined carefully to ensure that no placental
fragments are left in the uterus.

Management of Labor and Delivery

1st Stage Labor


Monitoring Fetal Well-Being - CTG
Uterine Contractions firmness
Maternal Vital Signs
-If fetal membranes have been ruptured
for many hours before the onset of labor,
or if there is a borderline temperature
elevation, the temperature is checked
hourly, else q4hours.

Management of Labor and Delivery

2nd Stage Labor


Maternal Expulsive Efforts
Preparation
Delivery of the Head
Ritgen Maneuver
Delivery of the Shoulders
Clearing of the Nasopharynx
Clamping of the Cord

Management of Labor and Delivery

3rd Stage Labor


Oxytocin
Induces and promotes labor
Stimulates milk ejection

Methylergometrine
Promotes uterine
contractions
Prevents uterine atony

Lacerations of the Birth Canal


1. First Degree- involves the fourchette,
perineal skin and vaginal mucous
membrane
2. Second Degree- involves, in addition
to skin and mucous membrane, the fascia
and muscles of the perineal body
3. Third Degree- involves the skin,
mucous membrane, perineal body, involve
the anal sphincter
4. Fourth Degree- extends through the
rectal mucosa to expose the lumen of
the rectum. Tears in the region of the

EPISIOTOMY AND REPAIR


1. Prevents pelvic relaxationcystocele,
rectocele, and urinary incontinence
2. Lower rates of posterior perineal trauma,
surgical repair, and healing complications
3. Variables include the timing of the incision,
the type of incision, and techniques for repair.
4. If performed unnecessarily early, bleeding
from the episiotomy may be considerable during
the interim between incision and delivery.
5. If it is performed too late, lacerations will
not be prevented. It is common practice to
perform episiotomy when the head is visible
during a contraction to a diameter of 3 to 4 cm.
With forceps delivery, most practitioners perform
an episiotomy after application of the blades.

Characteristic

Midline

Mediolateral

Surgical repair

Easy

More difficult

Faulty healing

Rare

More common

Postoperative pain

Minimal

Common

Anatomical results

Excellent

Occasionally faulty

Blood loss

Less

More

Dyspareunia

Rare

Occasional

Extensions

Common

Uncommon

Fetal Heart Rate Monitoring


Periodic intrapartum heart rate
changes include:
Accelerations:
Peak within 30 seconds
Usually reassuring
Absence is not necessarily nonreassuring

Decelerations
Early: physiologic
Variable: usually due to cord head
compression
May be physiologic or pathologic

SALAMAT PO, SA INYONG LAHAT!!!