NORMAL LABOR AND ITS MANAGEMENT
Definition of Labour
Labor:
The series of events that take place in the genital organs to bring out the viable product of conception into the outer world through expulsion from the uterus (womb) is called “labour”.
A woman who is in labor is called a “parturient”.
And
The process of giving birth is called “Parturization”.
Normal labor is also called eutoshia.
Normal labor is said when the following criteria can be fulfilled.
1) The onset of labor should be spontaneous and at term (37 to 48 weeks).
2) Vertex presentation of fitus (the occiput of the head of the fitus is in the lower part of the uterine cavity and the chin of the fitus is tucked with its chest).
should be.
3) Duration of labor should not be long (ie if primary gravida mother then average duration of labor should be 12 hours and if multipara mother then average duration of labor should be 6 hours)
4) Birth should be natural with minimum assistance.
5) There should be no complications affecting the health of mother and baby
5 “P” Factors Affecting Duration of Labor:
1) Passenger (Fitus)
2) Passage (Birth Canal)
3) Power (contractions)
4) Placenta
5) Psychological State of Women
•>
1) Passenger (Fitus):
It involves presentation of fitus (breech, transverse), position of fitus, and size of fitus.
2) Passage (Birth Canal):
It involves maternal pelvis, birth canal resistance and fetopelvic diameter, and woman’s parity.
3) Power (Contractions):
Frequency, intensity and duration of contractions.
4) Placenta:
Site of implantation
5) Psychological State of Women:
Maternal psychological response, maternal anxiety, emotional factors and amount of sedation.
Stages of Labour:
The stages of labor are divided into four stages.
1) First Stage of Labour,
2) Second Stage of Labour,
3) Third Stage of Labour,
4) Fourth stage of labor
1) First Stage of Labor (Cervical Stage):
The first stage of labor is the initial phase of childbirth. In which the cervix gradually opens (dilate) and thins (effacement). Due to this, the baby can pass from the uterine cavity into the birth canal (vagina). In which regular and rhythmic uterine contractions are seen and the frequency, intensity and duration of uterine contractions gradually increase.
The first stage of labor starts with true labor pain and lasts until full dilatation of the cervix (10 cm). This stage is also called the “cervical stage”.
The first stage of labor is further divided into 3 stages:
First Stage No Time Period:
Primigravida:=12-16 hours, and
Multigravida:=6-8 hours, no.
The first stage of labor is divided into three phases.
1) Latent Phase,
2) Active Phase,
3) Transitional phase
1) Latent Phase,
The latent phase is known as “prodomal labor” or “pre-labor”.
Cervical dilatation of 1-4 cm centimeters occurs in this stage.
Contractions in this phase repeat every 15-30 minutes and last for 15-30 seconds.
Mother is talkative in this phase.
2) Active Phase,
Active phase is also known as dilatation phase.
In this second phase, the cervix a
5 – 7 cm dilated. And the contractions are repeated every 3-5 minutes and
Seen for 45 – 60 seconds.
In this stage mother feels restlessness.
3) Transitional phase
In the transitional phase, the dilatation of the cervix is 8-10 cm.
Contractions are repeated every 2-3 minutes and last for 60 to 90 seconds.
Overall, the first stage of labor is the critical period in which, after the cervix opens, the uterus prepares for delivery by providing the proper position of the baby in the uterine cavity. Continuous monitoring by health care providers is important to improve the condition and well-being of the mother and fetus during this stage.
2) Second Stage of Labor (Expulsion of Fits):
The period from full dilatation of the cervix to the birth of the baby through the birth canal is called the second stage of labor.
its duration,
In primi gravida: 1-2 hrs
In multigravida: 20-30 minutes.
The second stage of labor is further divided into two phases:
1) Propulsive phase,
2) Explosive phase.
1) Propulsive Phase:
The propulsive phase starts from full dilatation of the cervix until the presenting part of the fitus descends to the pelvic floor (+4 +5 stations).
2) Explosive Phase:
This is the expulsive phase until the baby is completely expelled from the uterine cavity along with the mother’s bearing down efforts.
3) Third Stage of Labor (Expulsion of Placenta):
This stage is the period from the expulsion of the baby to the expulsion of the placenta and membranes is called the third stage.
Its time duration is 15 minutes in primi gravida and multigravida
4) Fourth Stage of Labor (Observation Stage):
The observation stage after the birth of the baby is called the 4th stage of labor. During this stage, the general condition of the mother and the condition of the newborn and the behavior of the uterus are carefully monitored.
Its time duration is 1 hour.
Thus, the time duration of all four stages of total labor (1st stage + 2nd stage + 3rd stage + 4th stage) is 13-15 hours in primigravida and 6-8 hours in multigravida.
Reasons for onset of labor:
No exact cause of labor is known but it is said that many factors are responsible for the onset of labor such as,
1) Mechanical Cause,
2) Hormonal causes,
3)Neurological causes
1) Mechanical Cause,
ama,
Heightened reflex irritability of the uterus,
uterine distention,
Menstrual Period Suppression,
Prolonged pressure of fits.
2) Hormonal causes:
1) Phyto-placental contribution
Fetal hypothalamus is triggered to produce releasing factors.
The anterior pituitary gland releases adrenotrophic hormone due to these factors
( ACTH) is stimulated to produce.
Adrenotrophic hormone
(ACTH) stimulates the fetal adrenal gland to secrete cortisol.
Cortisol causes changes in placental hormones.
Ex:=
Estrogen levels increase,
Progesterone levels decrease.
2) Estrogen hormone:
Estrogen increases the chances of the following mechanisms:
1) Increases release of oxytocin from maternal pituitary.
2) Stimulates myometrial receptors to synthesize oxytocin, prostaglandins.
3) Synthesis of prostaglandins by decidual and amnion cells is increased.
4) Myometrial contraction stimulates the synthesis of the protein actomyosin.
3) Progesterone
Progesterone has a relaxant effect on the uterus.
Progesterone is produced first by the corpus luteum and then by the placenta.
It inhibits uterine contractility.
Fetal production of dehydroepiandrosterone sulfate (DHEA-S) and increased cortisol inhibits the conversion of fetal pregnenolone to progesterone.
Hence progesterone levels fall down before labor while estrogen levels rise.
Then the progesterone level falls down which is associated with the synthesis of prostaglandin.
4) Oxytocin:
The hormone oxytocin is released from the mother’s posterior pituitary gland.
As the level of estrogen increases, it helps in increasing the level of oxytocin.
Oxytocin receptors in the decidual vera are increased at the end of pregnancy. Oxytocin acts directly on the myometrium and causes contraction of the uterus.
It also acts on endometrial tissues to release prostaglandins.
5) Prostaglandins
The major sites of prostaglandin formation are the placenta, fetal membranes, decidual cells, and myometrium.
It is said that due to the release of estrogen, the uterine decidua releases prostaglandins which act on the uterine muscles causing the uterine muscles to contract.
3) Neurological causes
Labor can be initiated through a nerve pathway.
Both ‘α’ and ‘β’ adrenergic receptors are present in the myometrium.
Estrogen acts on the ‘α’ receptor and progesterone acts on the ‘β’ receptor.
1)’α’:=’α’ adrenergic receptor Stimulate ‘α’ receptor.
2)’β’:=’β’ adrenergic receptor Stimulate ‘β’ receptor.
A contractile response from the ‘α’ receptors of the prostaglandin nerve fibers located in and around the uterus and in the lower part of the uterus is initiated when progesterone reduces.
So the reasons for starting this labor are as follows.
Sign of Onset of Labour:
1) Painful Uterine Contraction (Labor Pain)
2) The show
3) Progressive dilatation and effacement of cervix
4) Formation of “bag of water”
1) Painful Uterine Contraction (Labor Pain):
Throughout pregnancy, painless Braxton Hicks contractions occur with simultaneous hardening of the uterus. There are changes in the character of these contractions, they are more powerful, intermittent and associated with more pain.
The pain usually fills in the front of the abdomen and radiates backward. Contractions are the first sign of labor pain. At first, women experience one or two contractions per hour that increase more regularly (these are tolerable at first).
Contractions may intensify over a period of 6-8 hours. After that, the active phase of labor begins. In this, contractions become more intense and occur every 2-3 minutes and last for 45 to 60 seconds. Women find it very difficult to relax during this period as the intense nature of the pain is accompanied by rapid dilatation of the cervix.
Additionally, contractions are not as frequent but are more intense. Finally, women experience intense contractions lasting between 60-90 seconds. And more regularly every 2-3 minutes. This is the stage of labor called hard labor where the cervix dilates to 10 cm.
2)Show:
An operculum (cervical mucus plug) forms in pregnancy and comes out in the form of a blood stained mucoid discharge a few hours before or with labor called a “show”.
Rupture of the capillary vessels of the cervix and stretching of the lower uterine segment leads to blood oozing from the raw decidual surface.
3) Progressive dilatation and effacement of cervix:
The effective force of the first stage is painful uterine contractions. These painful uterine contractions lead to progressive dilatation and effacement of the cervix.
10 cm dilatation of cervix occurs.
The muscle fibers surrounding the internal os are pulled upwards by the retracted upper segment thereby shortening the cervix and then merging with the lower uterine segment and becoming part of it and gradual effacement of the cervix.
4) Formation of “bag of water”:
The dilatation of the lower uterioid segment causes the chorion to detach. The loose part of the fluid bulges into the dilating internal os. The amniotic fluid in front of the head is fixed in the cervix called fore water. Water maintains a uniform pressure in the uterus during uterine contractions thus providing some degree of protection to the fetus and placenta thus the pressure for water during contractions is not increased which is called general fluid pressure.
Eg: When the membranes are intact, the pressure of uterine contractions is applied to the fluid and remains the same throughout the uterus.
True Labor and False Labour:
1) Uterine contraction:
True Labour:
Contractions are always present in it.
Contractions are regular and increase in frequency, intensity and duration.
Its duration is up to 60 seconds.
It causes abdominal tightening (hardening of uterus), discomfort or pain.
The discomfort starts from the back and starts in the abdomen.
Walking increases the intensity of contractions.
The pain caused by it is not relieved by enemas or sedatives.
False Labour:
Uterine contractions are not always present in false labor.
It has irregular and inefficient uterine contractions.
Its time duration is for three to four minutes.
The contractions are not painful every day and the uterus is not hard.
The discomfort is primarily in the abdomen.
Contractions can be relieved by walking.
Pain is relieved by providing it and sedatives.
2) Cervix
True Labour:
There is effacement and dilatation of the cervix.
False labor
Cervical changes are not seen in it.
3) Membrane:
True Labour:
Tenses fill during contractions and a ‘bag of water’ is formed.
False Labour:
Tens does not fill and formation of ‘bag of water’ does not take place.
4) show:
True Labour:
A true labor ma show is mostly present.
False Labour:
False labor is not a show to watch.
5) Fits:
True Labour:
In it, the fitus descends progressively.
False Labour:
The fit does not descend progressively.
Physiologic Events of First Stage of Labor:
The first stage of labor starts with the preparation of the birth canal and provides a place for the expansion of the placenta.
First Stage of Labor (Cervical Stage:
The first stage of labor is the initial phase of childbirth. In which the cervix gradually opens (dilate) and thins (effacement). Due to this, the baby can pass from the uterine cavity into the birth canal (vagina). In which regular and rhythmic uterine contractions are seen and the frequency, intensity and duration of uterine contractions gradually increase.
The first stage of labor starts with true labor pain and lasts until full dilatation of the cervix (10 cm). This stage is also called the “cervical stage”.
The first stage of labor is further divided into 3 stages:
First Stage No Time Period:
Primigravida:=12-16 hours, and
Multigravida:=6-8 hours, no.
The first stage of labor is divided into three phases.
1) Latent Phase,
2) Active Phase,
3) Transitional phase
1) Latent Phase,
The latent phase is known as “prodomal labor” or “pre-labor”.
Cervical dilatation of 1-4 cm centimeters occurs in this stage.
Contractions in this phase repeat every 15-30 minutes and last for 15-30 seconds.
Mother is talkative in this phase.
2) Active Phase,
Active phase is also known as dilatation phase.
In this second phase, the cervix a
5 – 7 cm dilated. And the contractions are repeated every 3-5 minutes and
Seen for 45 – 60 seconds.
In this stage mother feels restlessness.
3) Transitional phase
In the transitional phase, the dilatation of the cervix is 8-10 cm.
Contractions are repeated every 2-3 minutes and last for 60 to 90 seconds.
The first stage of overall labor is the critical period in which, after the cervix opens, the uterus prepares for delivery by providing the proper position of the baby in the uterine cavity. During this stage it is important to continuously monitor the mother and fetus to improve their condition and well-being.
••> Mainly three phases are seen in the events of the first stage of labour:
1) Dilatation of cervix
2)Effacement of cervix
3) Formation of lower uterine segment
1) Dilatation of Cervix:
a) Uterine contraction and retraction:
Uterine contractions are involuntary, regular and rhythmic, gradually increasing in intensity, the contraction interval being 15 minutes at the beginning of the first stage and 2 to 3 minutes by the end of the second stage.
Contractions in the uterine muscles are not complete, instead of complete relaxation after the contraction, some contraction remains in the muscle fibers, thus the upper segment of the uterus becomes short and thick, and the cavity becomes smaller, thus helping the progressive expulsion of the fetus.
Contractions start from a pacemaker (tubal ostia) located in the cornua of the uterus. All contractions originate from one of these pacemakers and pass into the uterus. The concept is similar to the pacemaker of the heart. Each contraction is an inward and downward pass through the uterus. This causes the entire uterus to contract.
In normal action the intensity is higher near the pacemaker i.e. in the upper uterine segment and lower in the lower uterine segment. The upper segment contracts and retracts powerfully while the lower segment contracts and dilates slightly and the uterus relaxes between the two contractions. stays
The upper segment of the uterus is composed of longitudinal muscle fibers while the lower segment of the uterus is composed of circular muscle fibers. Thus, a structure like bucket holding fashion is formed between the upper part and lower part of the uterus. Contraction of the fundus and cervical dilatation are somewhat coordinated, called the polarity of the uterus, which is usually controlled by the local nervous system. Polarity is the neuromuscular harmony between the two segments of the uterus that persists throughout labor. The upper segment of the uterus contracts and retracts strongly to expel the placenta while the lower segment contracts slightly and dilates to expel the placenta.
b) Fital axis pressure:
Every uterine contraction, if the baby is in a longitudinal and flexed attitude, then this uterine contraction comes to the fetus. Due to these contractions, the fetus descends towards the lower pole of the uterus. Thus, the cervix dilates more due to the pressure of the presenting part of the fetus. happens
c) Bag of Membrane (Formation of Upper and Lower Uterine Segment):
Usually in late pregnancy the uterus is divided into two segments namely upper uterine segment and lower uterine segment while the lower segment extends from the isthmus of the uterus to the cervix and is thin and distensible and has a length of 7.5 to It is about 10 centimeters
Amniotic fluid surrounds the fetus Due to continuous contraction of the uterus, the amniotic fluid is usually divided into two parts viz.
1) For water
2) Hind water
When the presenting part of the fetus enters the pelvic brim, the amniotic fluid passes through the presenting part but remains inside the membrane. This passed amniotic fluid bulges in front of the presenting part of the fetus and is called forewater. And the amniotic fluid that is present in the upper segment of the uterus is called hind water.
As the contraction starts, the hydrostatic pressure exerted on the fore-water also helps in the dilatation of the fore-water service.
2) effacement of cervix
It is the process of thinning of the cervix which is completed during or before the 1st stage of labor in primigravida.
In primigravida, effacement occurs before dilatation of cervix whereas in multipara, both i.e. dilatation and effacement of cervix occur simultaneously. The expulsion and compression effect of mucus also helps to thin the cervix.
This thinning and shortening of the cervical canal is due to the lengthening of the muscular fibers surrounding the internal orifice.
In primigravida, this occurs before the onset of labor while in multigravida it occurs with cervical dilatation.
3) Formation of Lower Uterine Segment:
There is no anatomical or functional division of the uterus before the labor process starts. But after the onset of labor, the upper segment of the uterus becomes progressively thicker while the lower segment of the uterus becomes progressively thinner and this process is maximally observed during the second stage of labour.
At the junction of the uterus i.e. between the upper segment and the lower segment of the uterine cavity, a distinct ridge is formed, called the physiological retraction ring.
Event of Second Stage of Labor:
Second Stage of Labor (Expulsion of Fits):
The second stage of labor starts with full (10 cm) dilatation of the cervix and ends with full expulsion of the placenta.
The period from the full dilatation of the cervix to the birth of the baby through the birth canal is called the second stage of labor.
its duration,
In primi gravida: 1-2 hrs
In multigravida: 20-30 minutes.
The second stage of labor is further divided into two phases:
1) Propulsive phase,
2) Explosive phase.
1) Propulsive Phase:
The propulsive phase starts from full dilatation of the cervix until the presenting part of the fitus descends to the pelvic floor (+4 +5 stations).
2) Explosive Phase:
This is the expulsive phase until the baby is completely expelled from the uterine cavity along with the mother’s bearing down efforts.
Description
The second stage of labor starts with the complete dilatation of the cervix and ends with the complete expulsion of the placenta.
This stage is associated with continuous descent of the fetus down and delivery of the fetus through the birth canal.
Full uterine contractions lead to rupture of the membranes leading to expulsion of amniotic fluid (like amniotic fluid) from the birth canal. Due to the expulsion of this amniotic fluid, the volume of the uterine cavity decreases and the uterine contractions also become stronger.
Due to uterine contractions, the uterus is stretched while the anterior-posterior and transverse diameters of the uterus are reduced. Stretching of the uterine cvt is usually seen partly due to stretching of the fitus and partly due to stretching of the lower segment of the uterine cvt.
Continuous uterine contractions push the fetus up and the fetus descends continuously.
Due to uterine contraction and retraction, the upper segment of the uterine cavity becomes thicker while the lower segment of the uterine cavity becomes thinner.
Continuous uterine contractions and the bearing down of the mother causes a downward force from the uterine cavity while an upward force from the pelvic floor. Thus, due to downward and upward forces, a forward force is exerted on the fitus,
Thus, due to the force exerted on the continuous placenta, the fetus is expelled from the uterine cavity.
Events of Third Stage of Labor:
Third Stage of Labor (Expulsion of Placenta):
This stage starts with the expulsion of the placenta and the period till the expulsion of the placenta and membranes is called the third stage. Its time duration is 15 minutes in primi gravida and multigravida
The events of the third stage of labor usually involve three phases.
1) Separation of the placenta from the uterine wall.
2) Descend down of placenta.
3) Expulsion of placenta
1) Separation of placenta from uterine wall:
In this stage the placenta starts separating from the decidua basalis, the deep spongy layer of the decidua.
Condition of uterus before separation of placenta:
The uterus is discoid in shape.
Utrus is a firm
The uterus lies below the umbilicus.
are non-ballotable.
Kundal height is found slightly below the umbilicus.
Two methods are usually involved to separate the placenta.
1) Central Separation (Schultz Method)
2) Marginal Separation (Matthews Duncan Method)
1) Central Separation (Schultz Method):
Usually, the main factor for separation of the placenta is uterine contraction and retraction, mainly due to the retraction ability of the muscle fibers of the uterine cavity, the separation of the placenta starts. Because the uterine cavity retracts with the expulsion of the fetus, in this retracted uterine cavity, the discoid-shaped placenta does not remain attached normally and due to this, the placenta is banded and its separation starts.
Thus, in central separation, the placenta separates from the central part, and with each uterine contraction and retraction, the separation increases, and the placenta bends, and as the placenta separates from the central part, the placenta and the site of implantation. Blood collection starts. This is called retroplacental hematoma. Because the accumulation of blood occurs in the posterior part of the placenta and the blood is not visible in it.
2) Marginal Separation (Mathews Duncan Method):
Generally the placenta is thin at its margin site while thick at its central part. Because of the contraction and retraction ability of the muscle fibers, the margin of the placenta can easily separate, so with every contraction and retraction in marginal separation, the placenta starts to separate from the margin site and the placenta starts to separate, along with the blood. It is visible.
Thus, there are generally two methods of separating the placenta.
2) Descend down of placenta:
After separation of the placenta, uterine contractions and contractions cause the placenta to fall into the lower uterine segment or upper vaginal part and cause the clinical signs of separation:
Sign of Placental Separation:
Dark blood rushes from each of the antroites.
The umbilical cord extends downward 3 inches or more from the vaginal area and increases in length.
The shape of the uterus changes from discoid to globular and contracts.
3) Expulsion of placenta:
After the placenta descends into the lower part of the uterine cavity, expulsion of the placenta occurs due to the voluntary bearing down effects of the mother’s abdominal muscles or through manipulative procedures.
Events Fourth Stage of Labor (Observation Stage):
The observation stage after the birth of the baby is called the 4th stage of labor. During this stage, the general condition of the mother and the condition of the newborn and the condition of the uterus are carefully monitored.
The fourth stage is 1 hour after birth of the placenta. This is an important period that requires close observation of the mother and the mother should be kept under continuous close monitoring for 1 hour after delivery.
Assessing whether the mother is bleeding in the fourth stage of labor due to which the condition of post partum haemorrhage (PPH) arising in the mother can be prevented by measuring the blood pressure of the mother and counting her pulse properly. Assessing the mother’s welling including palpating the uterus from the mother’s abdomen to properly assess whether the uterus is firm and filled with blood.
If the uterus is soft and boggy, it indicates a condition of a hytopic uterus that cannot contract properly. If the uterus is firm, it indicates a condition of effective hemostasis.
Proper inspection of the placental membrane and umbilical cord after delivery of the placenta and proper assessment of any retained bits of placenta in the uterine cavity. Because of this, the condition of post partum hemorrhage can be prevented, after assessing whether there are proper vessels in the umbilical cord and properly checking whether there are any abnormalities. To check mother’s vital sign properly. Then properly examining the newborn baby and properly assessing its breathing pattern, after providing proper rest to the mother, advising the mother to provide breast feeding to the baby. And to provide a properly comfortable environment for the mother.
Fetus in utero:
The relationship of the fitus to the uterus and pelvis is described in certain terms.Understanding these terms can identify which part of the fitus enters the pelvic brim first.
Mainly 6 parts are involved in it.
1) Lye,
2) Presentation,
3) Presenting part,
4) Attitude,
5) Denominator,
6) Position
1) Lye:
The relationship of the long axis of the fitus to the long axis of the maternal spine is called “lie”.
Lies are usually longitudinal but can sometimes be transverse and oblique.
1) Longitudinal:
It has the long axis of the fitus parallel to the long axis of the maternal spine. This means that the fitus is in either a head-down (cephalic) or feet-down (breech) position. This is the most optimal fital position for delivery.
2) Transverse:
Transverse lie in obstetrics involves the position of the fitus where the fitus is in a horizontal (horizontal) position across the mother’s uterus rather than parallel to the mother’s spine. In this position, the fetus’s head is on one side of the uterus and its buttocks or legs are on the opposite side. This condition is not conducive to delivery in the vaginal canal and often requires a cesarean section.
3) Oblique:
Oblique lie occurs when the fetus is positioned at an angle in the uterine cavity, with both the head and buttocks of the fetus tilted to one side of the mother. This position is neither longitudinal nor transverse but rather at a diagonal angle. This type of lye is not ideal for vaginal delivery.
2) Presentation:
The part occupied by the fetus in the lower pole of the uterus (pelvic brim) is called the presentation of the fetus.
Generally three presentations are involved viz.
1) Cephalic presentation (96.5 %) including,
Vertex Presentation,
bro presentation,
Includes face presentation.
2) Podilek/breech presentation (3%),
3) Solder and other like, compound presentation (0.5%)
1) Cephalic presentation (96.5 %):
Cephalic presentation involves the position of the fetus during childbirth where the head of the fetus is down towards the birth canal. It is the most common and ideal presentation for vaginal delivery.
2) Podilek/breech presentation (3%):
Podalic presentation is a type of breech presentation in which the first leg of the fitus or buttux is at the lower pole of the uterus, with the fitus or buttux being the presenting part in the birth canal. In this presentation, the buttocks or legs of the fitus are toward the cervix, and the head is usually positioned at the top of the uterus.
3) Solder and other like, compound presentation (0.5%):
Solder Presentation:
When the fetus is in the urine cavity and solder is placed in the lower pole of the uterus as its presenting part, it is called solder presentation.
Compound Presentation:
When more than one body part is present in the lower pole of the uterus, it is called a compound presentation.
3) Presenting Part:
In obstetrics, the “presenting part” involves the part of the fetus that is closest to the cervix and is entering or has entered the birth canal.
Presenting part means the body part of fetus which fills above the internal os during examination through cervical opening through finger is called presenting part.
1) Head (Vertex Presentation):
Most common and ideal for delivery through the vaginal canal, where the head or top part is the presenting part.
2) Buttocks (breech presentation):
In a breech presentation, the buttocks are the presenting part.
3)Feet (Footling Breach):
Ama, the leg is the presenting part, it is a type of breech presentation.
4) Shoulder (Shoulder Presentation):
If the solder is a presenting part, it usually means that the fit is in a transverse lie.
4) Attitude:
The relation of the different body parts of Fitus to each other is called “Attitude”. The universal attitude of Fits is well flexed.
Attitude is the relationship of the body’s trunk with its limbs and head. His attitude should be well flexed. Fits no back part is bent, head well bent and touching the chest. Arms are well bent, crossed along the chest, thighs on the abdomen and legs on the thighs. A fitus is an ovoid mass that fits snugly into the uterine cavity. Such an attitude makes it easy to expel fits during the labor process
is helpful.
Deviation from the normal attitude of flexion is called deflection, extension or hyperextension, especially in vertex presentation a well flexed head (vertex) will have the smallest presenting diameter and efficient uterine axon. Labor will be most effective when, abnormal attitude creates difficulties in labour.
5) Denominator:
Generally, the denominator is the bony part of the fetus that comes in relation to the different quadrants of the maternal pelvis as the presenting part is called the denominator.
such as,
Vertex/cephalic presentation has occiput as denominator.
Face presentation has the mentum (chin) as the denominator.
Brow presentation has the frontal eminence as the denominator.
A breech presentation has the sacrum as the denominator.
The solder presentation has the acromion process of the scapula as the denominator.
6) Position:
The relation of the denominators in the different quadrants of the maternal pelvis is called the position.
Theoretically, each segment has eight positions divided into equal parts of 45° to place the denominator.
1) L.O.A.(Left Occipito Anterior)
Most common and called 1st vertex position. Occiput points to left iliopectineal eminence, sagittal suture is in right oblique diameter of pelvis.
2)R.O.A (Right Occipito Anterior):
2nd is the vertex position. Its occiput is towards the rightiliopectineal eminence and sinciput is pointed towards the left sacroiliac joint while the sagittal suture lies in the left oblique diameter of the pelvis.
3) R.O. P. (Right Occipito Posterior) :
3rd vertex is the position. It has the occiput pointing towards the right sacro-iliac joint while the sinciput is towards the left iliopectineal eminence and the sagittal suture lies in the right oblique diameter of the pelvis.
4)l.O.P.(Left Occipito Posterior):
4th vertex is the position. It has the occiput pointed towards the left sacroiliac joint and the sagittal sutures lie in the left oblique diameter of the pelvis.
5)R.O.T (Right Occipito Transverse):
The occiput points to the right iliopectinal line between the iliopectineal eminence and the sacro-iliac joint, the sagittal sutures being in the transverse diameter of the pelvis.
6)L.O.T (Left Occipito Transverse):
The occiput points to the left iliopectinal line between the iliopectinal eminence and the sacro-iliac joint, the sagittal sutures are in the transverse diameter of the pelvis.
7) O.A.(Occipito Anterior):
The occiput points to the symphysis pubis, the synciput points to the sacrum, the sagittal sutures are in the anterior posterior diameter of the pelvis.
8)O.P.(Occipito Posterior):
The occiput points to the sacrum, the synciput points to the symphysis pubis, the sagittal suture is in the anterior posterior diameter of the pelvis.
Mechanism of Labor (Cardinal Movements of Normal Labour):
The series of passive movements of the fetus through the birth canal is called the mechanism of labor. In this the principal movements are of the head. Changes in fetal head position during passage of the fetus through the birth canal are called cardinal movements. And this cardinal movement is usually seen during the second stage of labor.
The Fits in Utero:
Lai: Longitudinal,
Presentation: Cephalic,
Presenting part: Vertex,
Attitude : Flexion,
Denominator: Occiput,
Position: Right Occipito Anterior (R.O.A) or Left Occipito Anterior (L.O.A).
Diameter of Engagement of Pelvis:
Inlet : Transverse diameter ( 13 Cm).
Diameters of Engagement of Skull:
Sub-occipito bragmatic diameter: 9.5 cm.
Sub-occipito frontal:10 cm.
Mechanism:
In normal labor the head is entered in the greater common available transverse diameter. A left occipito anterior position (L.O.A.) is more common than a right occipito posterior (R.O.P.) position. Anterior-posterior diameter of head is suboccipito-pragmatic 9.5 cm or slightly deflection suboccipito-frontal diameter 10 cm. An occipito-anterior position is common in this,
The following mechanisms are observed such as:
1) Engagement,
2) descent down,
3) Flexon,
4) Internal rotation,
5) Crowning,
6) Extension,
7) Restitution,
8) External rotation of head with internal rotation of solder,
9) Birth of shoulder and trunk by lateral flexion.
1) Engagement:
At L.O.A, when the head of the fetus enters the pelvic brim, the occiput lies on the left iliopectineal eminence, the syncyput in the right sacroiliac joint and the sagittal suture on the right oblique diameter of the mother’s pelvis. The engaging antero-posterior diameter of the head is either suboccipito- bragmatic 9.5 cm or suboccipito-frontal 10 cm. Engaging transverse diameter is biparietal diameter 9.5 cm.
2) Descent Down:
Descent down is a continuous process that is slow in the first stage but more pronounced in the second stage. which ends with the expulsion of the fetus. Factors such as continuous contraction and retraction of the uterine cavity and maternal bearing down helps the fit to descend.
In primigravida there is already head engagement, there is practically no descent in the first stage, while in multigravida the descent of the head takes place with the engagement of the fitus head with the onset of labor. When the cervix is fully dilated, the head of the fetus reaches the pelvic floor.
Factors that help in descent like,
1) Uterine contraction and retraction,
2) Bearing Down Feet,
3) Due to straightening of spine of fetus especially after membrane rupture.
3) Flexion:
Flexion is continuous during the labor process due to which the diameter of the presenting part of the fetus becomes small so that the presenting part can easily pass through the maternal pelvis. If the maternal pelvis is adequate, flexion is an unfolding cervix, pelvic wall or pelvis. If the pelvis is adequate, the resistance of the maternal soft tissues promotes full flexion of the head.
4) Internal Rotation:
As the head continues to descend, the front of the fitus head pushes down on the pelvic floor. When contractions subside, the pelvic floor rebounds causing the occiput to slide forward. The occiput is rotated 1/8th of a circle (45 degrees) and comes under the pubic arch. Torsion (twisting) of the neck of the fitus occurs when this internal rotation occurs.
5) Crowning:
After the internal rotation of the head, the subocciput descends till it comes below the pubic arch. At this stage, the maximum diameter of the head i.e. the biparietal diameter stretches the vulval outlet and after the contraction the head does not move back, it is called “crowning of head”. ” is called.
6) Extension:
Delivery of the head is by extension, i.e. by “couple of forces”. Driving force to head in downward direction while pelvic floor provides resistance in upward and forward direction thus neutralizing downward force and upward force and remaining forward force helps in extension of head of fitus. The fetal head is born from the vulval outlet as are the vertex, brow and face. After the chin is exposed, the head drops down and the chin approaches the maternal anal opening.
7) Restitution:
After extension of the head, visible movement is observed in which the twisting of the neck in the internal rotation of the head is untwisted in the restitution. is Hence comes the maternal side.
8) External rotation of head with internal rotation of solder:
In this phase there is internal rotation of the solder and external rotation of the head outwards and the solder is now at the widest diameter of the pelvic outlet, i.e. antero-posteriorly. The anterior solder reaches the levator ani muscles anteriorly and rotates anteriorly to lie beneath the symphysis pubis. This movement is clearly visible, at the same time, the head also rotates externally in the same direction as the restitution in a 1/8 circle.
9) Birth of shoulder and trunk by lateral flexion:
After the shoulder comes into the anterior-posterior diameter of the outlet, the anterior descent continues until the anterior solder escapes below the symphysis pubis. Lateral flexion movement of the spine sweeps the posterior solder from the perineum and then the remaining trunk is delivered through lateral flexion.
Management of First Stage of Labour:
Comprehensive care is involved in the nursing management of the first stage of labor. Its aim is to support the mother physically, emotionally and educationally and closely monitor the progress of labor.
assessment
To properly monitor the progress of labor, the condition of the mother and the condition of the fetus.
Inquire about when the labor pains started.
Any type of liker should be inquired whether it is leaking or not.
Proper examination of the mother.
Perform proper obstetric examination.
Vaginal examination of the mother.
To properly check the antenatal records of the mother.
Maternal Assessment
Regular monitoring of the mother’s vital signs, such as
temperature,
pulse,
Respiration,
And to assess blood pressure properly.
To properly assess the intensity, frequency, duration, and resting tone of uterine contractions of pregnant women by palpation method.
Properly assess cervical dilatation and effacement by pervaginal examination.
Properly and accurately documenting and charting cervical dilatation and effacement.
Fetal assessment
Continuous monitoring of fetal heart rate by electronic fetal monitoring (EFM).
Properly assess the fetal heart rate pattern.
Proper documentation of fetal heart rate and any abnormality should also be properly documented.
Support and comfort measures
Providing a properly comfortable position to the mother due to which the comfort level of the mother can also increase and the labor process can also progress like walking, standing, sitting etc.
Advising the mother on relaxation techniques such as deep breathing exercises, and mind diversional therapy etc.
Provide emotional support, reassurance and psychological support to the mother to reduce her anxiety.
Hydration and nutrition
Advise the mother to have moderate fluid intake.
Continuously monitor the mother’s intake output chart to properly maintain the mother’s hydration status.
Advise the mother to take adequate amount of light food and take plain food to maintain the nutritional status of the mother.
Like plain water,
Salty Lemon Water,
Soup, and fruit juice etc.
Antiseptic and aseptic
Applying proper antiseptic dressing on the genital area, due to which cleanliness can be maintained.
Education and Communication
To provide education to mother and her supporters about mother’s condition and progress of labour.
Care of Bowel
Provide proper enema to clear mother’s bowel and increase uterine contractions.
Care of Bladder
Advise pregnant women to empty the bladder frequently as a full bladder inhibits contracture.
Relief of Pain:
Provide proper analgesic medication to the mother to relieve the pain condition of the mother.
such as,
Inj. Pethidine 100 mg IM should be provided when the survey is dilated to a2 finger and repeated every four hours if needed.
Noting the Progress of Labour:
Proper recording of partograph to assess the process of labor so that labor progress can be assessed properly.
Partograph
Definition:
Partograph A Cervical dilatation,
A graphic recording and tool for fetal head descent and labor progress and the condition of the mother and fetus. Partograph provides immediate and relevant information about the condition of the mother and fetus.
It recognizes the need to take action for appropriate time and timely referral. Morbidity and mortality rate of mother and fetus can also be improved through partograph.
Objectives or Advantages:
1) To record observations during labor properly.
2) To understand the latent and active phase of labour.
3) Interpreting the partograph to identify any deviation from normal and take appropriate action.
4) To know the progress of labor so that action can be taken and referred at the right time.
5) Records can be seen at a glance in a single seat and easily handed over.
6) To avoid having to record the event of labor repeatedly.
7) To prolong labor and reduce the rate of education.
Observation Charted on Partograph:
1) Pregnant Woman Information:
A) Name,
B) GTPAL score
G: gravida,
T:=Tommy Birth,
P:=mercury,
A:= Abortion,
L:= Living Children.
C) Name of Hospital,
D) Hospital Registration Number,
E) Date and time of admission,
F) Time of membrane rupture,
G) Period of Gestation,
H) Date and time of onset of labour.
2) Fittal condition:
A) Fetal heart rate,
B) amniotic fluid,
C) Molding.
3) Progress of Labour
A) Cervical dilatation,
B) Descent of head,
C) uterine contractions.
4) Maternal condition
A) Oxytocin, drugs and I.v. fluid administration
B) pulse,
C) blood pressure,
D) Temperature,
E) Urine volume, acetone and protein.
All this information is filled in a partograph.
Points to keep in mind while filling partograph:
1) Partograph maintenance should be started when the woman reaches the active phase of labor and the pregnant woman should not be left alone.
2) The fetal heart rate should be counted and recorded every half hour.
Fetal heart sounds should be accounted for for a full 1 minute and should be counted immediately after uterine contractions are detected.
3) Monitor uterine contracture frequency, intensity, duration, pulse, fetal heart rate every 30 minutes when dilatation of cervix is 4 cm or more.
4) Monitor blood pressure and cervical dilatation (in cm) every two hours.
5) Monitor descent of head and temperature every four hours.
1) Patient Identification Data
In this, the woman’s name, age, GTPAL score, date and time of admission, registration number, time of rupture of membranes and time and date of onset of labor are marked.
2) Fittal condition
Counting and recording the vital heart rate every half hour.
To account for the full 1 minute of the fittal heart rate.
To count fetal heart rate immediately after uterine contractions.
If Fetal Heart Sound (FHS) is < 120/Minutes or if
(FHS) >160/Minutes indicates fetal distress. If there is a condition of fetal distress, immediate action should be taken.
A vertical column in each small box represents that half-hour interval.
2) Condition of membrane
Record condition of amniotic membrane and color of amniotic fluid every 30 minutes along with fetal condition.
A) If Amniotic Membrane is Intact := I (Intact),
B) If Liker is Clear: = C( Clear),
C) If Liker is Absent := A( Absent) ,
D) If the amniotic membrane is ruptured := R (Rupture),
E) If meconium stained liquor:= M( meconium),
F) If blood is present in the liquid: B (Blood)
Thus, marking the condition of amniotic membrane and amniotic fluid in the partograph.
3) Molding (The bones of the fetal head are separated by sutures and fontanelles, but while passing through the birth canal, the bones of the fetal head overlap each other and the gap of the head changes for some time due to which the fetal head is a (The condition can easily pass through the birth canal is called molding.)
Moldings are recorded by grade to record.
A) 0 -> If bones are separated and sutures are easily felt.
B) + -> When the bones just touch each other.
C) ++ -> When bones are overlapping but easily separated.
D) +++ -> Bones are severely fixed when overlapping.
4) Progress of Labour
Start plotting labor progression on the partograph only after the woman is in active labor.
Active labor A cervical dilatation of 4 cm or greater and the athlete having two good contractions every 10 minutes should start plotting on the partograph.
Recording cervical dilatation in cm every four hours.
Record the onset of cervical dilatation starting from the left luteal line (when the mother is in active labour). Normally the graph line is continuous above the left alert line to show the proper time each time.
If the alert line is crossed i.e. if the graph moves to the right of the alert line then it indicates prolonged labor. Hence the midwife should be immediately alerted that there is something abnormal in the labour. Noting the time the alert line is crossed and immediately initiating measures for immediate treatment or referral.
When the graph crosses the action line i.e. if the action moves to the right side of the line, start treatment immediately or refer the mother to appropriate medical services.
The gap between alert and action line is 4 hours.
5) Uterine contractions
Recording uterine contractions every half hour Contractions twice in ten minutes indicate good uterine contractions.
Marking it as follows in the box of the partograph.
Mild uterine contractions < 20 seconds,
Moderate uterine contractions 20 – 40 seconds,
Strong uterine contractions > 40 seconds.
6) Cervical dilatation and descent of fetal head
The descent of the fitter head down through out the labor process coincides with cervical dilatation.
Until the cervix is 7 cm, the descent of the fetal head is assessed by abdominal palpation with the fifth (5) number of the fetal head above the pelvic brim.
In the partograph, cervical dilatation is plotted by (x) while descent of the fetal head is plotted by (O).
7) Maternal condition
Maternal pulse every half hour
is recorded on the partograph and is plotted in the partograph by a dot(•).
Maternal blood pressure is recorded every 4 hours with both systolic blood pressure and diastolic blood pressure indicated by vertical arrows ( ↕ ) with the upper end of the arrow indicating systolic BP. While the arrow no lower end shows the diastolic blood pressure.
Recording maternal temperature every four hours on a partograph.
Proper recording of maternal urine volume, urine acetone and protein level on partograph.
If any drug or oxytocin medication is given to the mother during the labor process, properly recording the dose route and time of administration.
Thus, early, quick and relevant information about labor progress and condition of mother and fetus can be obtained through Partograph.
Documentation
After assessing the condition of the mother and fetus, properly document it and maintain the partograph properly.
Properly documenting all assessments, interventions, observations, in the mother’s medical record.
Properly record maternal vital sign, uterine contraction pattern, cervical dilatation and effacement, fetal heart sound and labor progress.
Collaboration and Advocacy
Collaborating with other health care personnel such as obstetricians, midwives and nurses to make decisions about the condition of the mother properly by communicating the condition of the mother’s labor.
Thus, by properly managing the first stage of labor, complications in the mother and fetus can be prevented and the first stage of labor can be properly maintained.
Documentation
After assessing the condition of the mother and fetus, properly document it and maintain the partograph properly.
Properly documenting all assessments, interventions, observations, in the mother’s medical record.
Properly record maternal vital sign, uterine contraction pattern, cervical dilatation and effacement, fetal heart sound and labor progress.
Collaboration and Advocacy
Collaborating with other health care personnel such as obstetricians, midwives and nurses to make decisions about the condition of the mother properly by communicating the condition of the mother’s labor.
Thus, by properly managing the first stage of labor, complications in the mother and fetus can be prevented and the first stage of labor can be properly maintained.
Second Stage of Labor Management:
The transition from the first stage of labor to the second stage occurs due to the following features.
Due to increase in intensity and frequency of uterine contractions.
Due to increase in mother’s bearing down aftors.
Diffusion occurs with the descent of the presenting part of the fetters.
Complete dilatation of cervix occurs.
Principles of Second Stage of Labor
Accustoming the fetus to be expelled slowly and naturally.
Preventing perineal injury.
General Measures:
Advise the patient to lie down on a proper bed.
Constantly observe the patient for the following signs such as,
Continuous monitoring of fetal heart rate (FHR) at every five minutes interval.
To properly note the mother’s vital signs mainly pulse and blood pressure at 15 minute intervals.
Provide proper reinsurance to the mother so that the mother’s moral support can be properly maintained.
Proper examination of the vaginal area at the beginning of the second stage to confirm the onset of labor and prevent accidental coda prolapse.
Properly assess the position and station of the fetal head.
Preparation for Delivery:
To prepare the patient for delivery when “OS” shows signs of dilatation such as,
Uterine contractions are strong and frequent,
vulval gapping,
anus pouting,
Thinning and bulging of the perineum.
When the presenting part of the fitus in primi gravida is weighed until it reaches 4 to 5 cm in the vulva.
After that you have to provide the position to the woman properly.
Wearing gloves, gown and mask to maintain proper aseptic technique and then standing on the right side of the patient.
Now after painting the external genital organs properly with cotton swab and Dettol then keep one sterile sheet under the patient’s buttocks and one sheet over the abdomen.
Then to maintain aseptic technique the three “c’s” should be kept properly viz.
clean hands,
clean surface,
Clean cutting and ligature of code.
If the bladder is inflated, catheterize it and empty it properly.
Then to confirm whether the membrane has ruptured, if not, do Artificial Rupture of Membrane (ARM).
Then conduct the delivery proper in which the main delivery is conducted in three phases:
1) Delivery of the head,
2) Delivery of the shoulder,
3) Delivery of the trunk
1) Delivery of the head:
The following principles should be followed while delivering the head, viz.
Maintain proper flexion of the head.
Preventing early extension of the head.
The head should slowly escape out of the vulval outlet.
If the mother’s uterine contractions are poor, properly fit a venous line, then add 5 units of oxytocin in 5% dextrose to start her drips.
Then advise the woman to wear bearing down afts with each contraction and provide her with small amounts of water intake in between.
Allow the fetal head to descend slowly before crowning.
Perineal infiltration and episiotomy
Properly place episiotomy to prevent perineal tear when perineum is broad, tough and stretching.
Administer 5 to 10 ml of 1% xylocaine into the perineum during uterine contractions.
Before the crowning stage, episiotomy is started by scissors at the mid point of the forechette followed by mediolateral episiotomy at 7:30 clock (right side) or 4:30 clock (left side placement).
Preventing sudden escape of the head after placing an episiotomy.
Properly monitoring the slow delivery of the head between contractions usually involves properly pushing the chin of the fitus with the right hand covered by a sterile gauze pad and placing the right hand on the anococcygeal region and applying pressure on the occiput with the left hand. to do
Then the forehead, nose, mouth and chin are born from the stretched perineum.
Care after delivery of head:
Immediately after delivery of the head, clean the head, mouth and fairings of the fit with a litter finger covered with properly sterile gauze.
Then the eyelids should be properly cleaned using a sterile and dry cotton swab, in which to prevent contamination of the conjunctival sac, clean the ice starting from the medial canthus to the lateral canthus.
Then palpate and assess the neck of the fetus to check if any loop of code is present. Then if the loop is present and it is loose, slip it from the shoulder and if it is tight, apply two couture forceps and cut it from the middle.
Delivery off shoulder:
Do not rush while delivering the solder.
Wait until uterine contraction and restitution and external rotation.
Now, the anterior shoulder is seen below the pubis after which the head of the fetus is properly placed between the two pairs and lifted towards the mother’s abdomen leading to the delivery of the posterior shoulder first followed by the delivery of the anterior shoulder.
If the anterior shoulder is not free below the pubis, the head is depressed to bring the anterior shoulder below the pubis.
Delivery of Trunk:
After the delivery of the shoulder, insert the four fingers of both hands into the axilla and then deliver the truck through lateral flexion.
Immediate care of newborn after delivery
Immediate newborn care involves properly assessing and stabilizing the newborn.
Immediate newborn care is crucial for stabilizing the fetus from intrauterine life to extrauterine life.
Goal of immediate newborncare
1) Respiration of newborn is done to establish, maintain and provide support.
2) To prevent newborn from vomiting and hypothermia.
3) To prevent infection in the newborn.
4) To provide safety to the newborn and prevent him from injury.
5) To provide immediate treatment by early identification of any actual or potential problem in the newborn.
Immediate newborn care is provided.
Immediate Newborn Care
1) Establishment of Respiration
Immediately patent the newborn’s airway and clear the airway properly when the newborn is received. Due to which the newborn can effectively breathe.
As soon as the newborn’s head is born, wipe the mouth and nose and suction the mouth and nose so that the newborn can breathe properly. Saxon should be done through the mouth first and then through the nose to prevent aspiration of secretions.
2) Initiation of cry
Normally up to 99% of newborns cry immediately and spontaneously after delivery, this cry is recognized as a good sign for newborn breathing.
If the newborn does not cry properly, follow the steps below:
a) If the baby does not cry spontaneously or if the cry is weak then slightly simulating the baby to cry.
b) Lightly rub the soles of the baby’s feet instead of slapping them on the bum to stimulate the baby’s cry. Stimulate the baby to start crying after removing the newborn’s secretions.
C) Newborn’s cry is usually loud and husky and proper monitoring of newborn if there is any abnormal cry like,
Hypitch cry: = due to hypoglycemia and increased intracranial pressure,
Weak cry:= prematurity,
Hosacry:= laryngeal stridor
3) Care of Code
Cord care is important immediate care of the newborn.
A newborn’s cord should be clamped within 30 seconds of birth and then properly cut.
After the newborn is delivered, keep the newborn on the mother’s abdomen.
Then properly clamp the cord from two opposite sites by cord clamp.
The first clamp should be placed 5 cm from the umbilicus and the second clamp should be placed 2.5 cm from the first camp.
Then cut the cord properly between the two clamps.
Do not apply anything to the cord, let it dry and fall naturally.
The code folds down naturally within seven to ten days after birth.
Prevent the cord from getting wet by water and urine.
If any kind of discharge and bleeding is present in the cord, immediately assess the cord clamp and then loosen it properly.
Immediately if the following signs and symptoms are observed in the coda
To report such as,
Foul smell coming from the cord,
Seeing any discharge,
Redness around the cord,
The cord is wet,
If the cord does not fall down in 7-10 days,
inflammation,
Fever etc.
4) Maintain position of the newborn
During the first 12-18 hours after birth, a newborn is prone to choking, phlegm and gagging of mucus. So providing proper position to the newborn.
In which proper side lining position should be provided to the fitters due to which the mucus can be removed and drainage.
5) Identification and banding
After the baby is born, proper identification band should be applied to the baby so that the baby can be properly identified.
6) Eyecare
Clean the newborn’s ice from inner canthers to outer canthers with properly sterile gauze.
Apply erythromycin or tetracycline ointment from the lower lead in ice if needed.
7) Attachment and attachment (bonding)
After the birth of the baby, placing the baby on the mother’s abdomen, due to which bonding with the mother and proper skin-to-skin contact can take place, due to which the attachment of the mother and the baby can occur and the baby can be prevented from hypothermia.
8) APGAR score
APGAR score is the most important parameter of immediate newborn care.
APGAR score should be assessed at 1 minute and 5 minutes after birth.
In APGAR score,
A:= Appearance (Skin Color),
P:=Pulse (hotrate),
G:= grimace (reflux irritability),
A:=activity (muscle tone),
R:= Respiration (Respiratory Efforts)
is assessed.
APGAR score has a total score of 0-10.
APGAR score at 1 minute after birth:
If the Apgar score is 7-10 then it is called normal i.e. no depression in which the baby is provided with normal post delivery routine care.
If the APGAR score is between 4-6, it indicates mild depression in which the child requires assistance for breathing.
If the APGAR score is between 0-3, it indicates severe depression requiring resuscitation of the child.
APGAR score at 5 minutes after birth:
An APGAR score between 7-10 is considered normal, but if the Apgar score is below 7, the baby needs to be monitored for another half hour.
9) Vitamin K:
A newborn’s intestine is sterile for some time after birth i.e. the bacteria responsible for manufacturing vitamin K is not present in the intestine which is why the newborn cannot manufacture vitamin K i.e. vitamin k a clotting factor. The factor responsible for this is that if this vitamin K is not present in the body of the newborn, then there are chances of building in the newborn, so as a preventive measure, artificial injection of vitamin K is provided to the newborn baby.
Dose:=
In pre term:=0.5 ml,
Full term:= 1 mg.
Intra muscularly (IM) is provided on the vastus lateralis (lateral anterior thigh).
Immediate newborn care after birth is provided as follows.
Then cover the baby with proper cloth to prevent hypothermia condition and apply proper identification band then transfer the baby to nursery for further care and observation.
2) Delivery of the shoulder,
3) Delivery of the trunk
Management of Third Stage of Labour:
Management of the third stage is most crucial because it involves separation and expulsion of the placenta from the uterine cavity, and to prevent complications of postpartum hemorrhage in the third stage.
Management of the third stage requires strict vigilance of the placenta to prevent complications of postpartum hemorrhage.
Step of Management
At present, two methods are used in the management of the third stage.
1) Expectant (watchful) management
2) Active management
1) Expectant (watchful) management
In this management, separation of the placenta and its descent into the vagina is allowed to occur spontaneously.
For this management, placental expulsion is minimally assisted.
In this stage mother is constantly watched i.e. mother is not left alone even for a short period of time.
If the mother is in a lateral position, placing her in a dorsal position will allow a proper understanding of the sign of placental separation and the extent of blood loss.
In this management, only placenta separation, descent and expulsion are properly watched.
One hand is placed on the fundus so that,
a) Separation of placenta can be realized.
b) State of uterine activity i.e. contraction and relaxation can be understood.
Separation of placenta
The placenta begins to separate from the uterine wall within minutes of the baby’s birth, so wait 15 to 20 minutes for the placenta to separate on its own.
No touch technique is used in this.
Ama has a “no touch policy” ie the placenta is expelled by gravity within 15-20 minutes ie no massaging of the fundus.
Do not use any type of uterotonic and do not use any manual method for expulsion of placenta.
Expulsion of placenta
Following points to follow when placenta is expelled:
Advise the patient to put beer down after the uterus when the uterus becomes hard.
Raised intra-abdominal pressure is important to expel the placenta.
And the placenta may be expelled on its own.
2) Active management
1) Use of uterotonic
Oxytocin is not the drug of choice in the management of the third stage of labor.
In the management of the third stage, 10 units of oxytocin should be provided IM (intracellular).
Oxytocin enhances uterine contractions and helps expel the placenta.
2) CCT (Control Cord Traction)
Control cold traction uses a manual method in which the umbilical cord is tracked and gently pulled downwards and backward to allow the placenta to separate from the uterine wall and then be expelled, but control cord traction is performed when uterine contractions are present. The hand is placed on the suprapubic area and then performed.
3) Fundal pressure:
Push the fundus downwards and backwards by placing the four fingers behind the fundus and keeping the thumb in front of the uterus as a piston. Stopping the pressure immediately When the baby is macerated or premature, this method is more useful as the tensile strength of the coda is low. If any clots remain inside, massaging the uterus helps in its expulsion.
4) Delay code cutting
After delivery of fits, wait for one to three minutes and then cut the umbilical cord. This technique is more useful in term newborns. Because the newborn can receive an adequate amount of blood from the placenta, the condition of anemia can be prevented.
But in pre-term babies, the liver is immature and the red blood cells break down in excess and if delayed coda cutting is done, due to this, the condition of hyperbilirubinemia (jaundice) may arise in the newborn.
5) Post partum vigilance
Proper inspection of placenta after delivery of placenta including proper assessment of cotylodon, lobe and maternal and fetal site and membrane followed by fundal massage after delivery of placenta so that uterine contractions can continue and if there are retained bits of placenta Can be expelled properly. And the condition of Post Partum Hemorrhage (PPH) occurring in the mother can be prevented.
Management of Fourth Stage of Labour:
Immediate Post Natal Care
After the expulsion of the placenta, the time up to one hour (1 hour) is called the fourth stage of labor in which the general condition of the patient and the behavior of the uterus are monitored.
Observation of Women
It contains vital sign of mother like,
temperature,
pulse,
Respiration and blood pressure are properly monitored if mildly elevated, usually due to fatigue and dehydration, and vital signs are checked every 15 minutes for the next 1 to 2 hours until the patient is stable.
Then assess the condition of the uterus in which the uterus is firmly contracted and in mid line.
Assess the condition of bladder and bowel properly.
After that check the condition of lokia in which color and amount of lokia should be assessed every fifteen minutes for 1 to 2 hours.
Then assess the perineum every 15 minutes for the first one to two hours in which (REEDA) assess for redness, swelling, ecchymosis, discharge and Wood’s approximation.
Care of Women:
Prevention of Hemorrhage:
The fundus of the uterus should be palpated frequently every fifteen minutes if firm, massage to check the pad properly and monitor the perineum and blood loss for hematoma in the vagina and monitor the mother’s fluid level.
Provide care of the perineum:
If there is manual manipulation of the perineum during episiotomy or fourth degree labor, apply an ice pack to the perineum and provide a clean perineal pad to reduce swelling.
Prevention of Bladder Distention:
Palpate for bladder distention, anchor the woman to void naturally Provide a bed pan or apply water to the perineum or anchor her to void naturally.
Maintenance of Safety:
After observing the mother for blood pressure, pulse, blood loss, analgesic or anesthetic medication, assist for ambulation and observe for orthostatic hypotension.
Maintenance of Comfort:
Because of the contractions, the woman feels discomfort, so it is called after pain, for this, the bladder should be emptied. Provide blankets and analgesic drugs as per prescription and encourage women to do relaxation and breathing exercises.
Maintenance of Cleanliness:
After properly cleaning the mother’s perineum, dry the buttocks properly and provide a sterile pad.
Maintenance of Fluid Balance and Nutrition:
Advise the woman to take a small amount of fluid, if there is severe bleeding, provide her with intravenous fluid.
Psychosocial Needs:
Reassure the mother properly.
Anchorage to hold the newborn properly.
Anchoring the newborn to provide skin-to-skin contact with the mother to promote mother-baby bonding.
Anchoring mother to give early best feeding to baby.
Complete physical and neurological assessment of the newborn baby.
Then when the general condition of the patient is fully satisfied,
Transfer the patient to the ward when the woman’s pulse and blood pressure are within the proper normal range and the uterus is well contracted and there is no abnormal vaginal bleeding.