Labor, delivery : Guidelines, reviews, statements, recommendations, standards

Obstetrics Simplified - Diaa M. EI-Mowafi

Active Management of Normal Labour

Aims

• To achieve delivery of a normal healthy child with minimal physical and psychological maternal effects.
• Early anticipation, recognition and management of any abnormalities during labour course.

Antenatal Preparation

• Maternal education: about the physiology of labour and symptoms of impending labour.
• Breathing exercise: adapt the mother to breathing during labour to guard against respiratory alkalosis caused by hyperventilation.

First Stage of Labour

• History:
  • Complete obstetric history.
  • History of present pregnancy:
    • Duration of pregnancy.
    • Medical disorders during this pregnancy.
    • Complications during this pregnancy as antepartum haemorrhage.
  • History of present labour:
    • Labour pains: onset, frequency and duration.
    • Passage of "show", fluid or blood per vaginum.
    • Sensation of foetal movement.
• Examination:
  • General examination:
    • Height and built.
    • Maternal vital signs: pulse, temperature and blood pressure.
    • Chest and heart examination.
    • Lower limbs for oedema.
  • Abdominal examination:
    • Fundal level.
    • Fundal grip.
    • Umbilical grip.
    • Pelvic grips.
    • FHS.
    • Scar of previous operations (e.g. C.S, myomectomy or hysterotomy).
  • Pelvic examination:
    • Cervix:
      • Dilatation: the diameter of the external os is measured by the finger (s) during P/V examination and expressed in cm, one finger = 2 cm, 2 fingers = 4 cm and the distance resulted from their separation is added to the 4 cm in more dilatation.
      • Effacement.
      • Position (posterior, midway, central).
    • Membranes: ruptured or intact. If ruptured exclude cord prolapse and meconium stained liquor.
    • Presenting part and its position.
    • Station: of the presenting part.
    • Pelvic capacity.
  • Investigations: If not done before or if indicated:
    • Blood group-Rh typing.
    • Urine for albumin and sugar. 
    • Hb%. 
    • Ultrasonography.
• Active procedures:
  • Evacuation of the rectum by enema to;
    • avoid uterine inertia,
    • help the descent of the presenting part,
    • avoid contamination by faeces during delivery.
  • Evacuation of the bladder:
    • ask the patient to micturate every 2-3 hours, if she cannot use a catheter.
    • It prevents uterine inertia and helps descent of the presenting part.
  • Preparation of the vulva:
    • Shave the vulva, clean it with soap and warm water from above downwards, swab it with antiseptic lotion and apply a sterile pad.
  • Nutrition:
    • When labour is established no oral feeding is allowed, but sips of water.
    • 15 ml magnesium trisilicate is given every 2 hours as an oral antacid to guard against bronchospasm occurs if the acid vomitus is inhaled during general anaesthesia "Mendelson’s syndrome". Antacid injections may be used instead.
    • If labour is delayed more than 8 hours, IV drip of glucose 5% or saline-glucose solution is given.
  • Posture:
    • Patient is allowed to walk during the early first stage particularly with intact membranes.
    • If rest is needed the patient lies on her left lateral position to prevent inferior vena cava compression and hence placental insufficiency and foetal distress.
  • Analgesia:
    • Pethidine 100 mg IM,
    • trilene inhalation, or 
    • epidural anaesthesia are the most common use.
    • N.B. Patient should not bear down during the first stage as this is useless, exhausts the patient and predisposes to genital prolapse.
  • The partogram:
    • It is the graphic recording of the course of labour including the following observations:
      • The mother:
        • Pulse every 30 minutes,           
        • blood pressure every 2 hours,
        • temperature every 4 hours,
        • uterine contractions: frequency, strength and duration every 30 minutes by manual palpation or better by tocography if available,
        • cervical dilatation,   
        • fluid input and output,
        • drugs including oxytocins.
      • The foetus
        • FHR every 15 minutes by Pinard’s stethoscope or better by doptone,
        • descent of the presenting part,
        • degree of moulding.
    • Cardiotocography if available is more valuable for continuous monitoring of both uterine contractions and FHR particularly in high risk pregnancy.
    • The advantages of the partogram:
      • Allows right intervention in the proper time e.g. oxytocin usage, instrumental delivery or C.S.
      • Allows different staff shifts to manage the case successively.
      • A document for labour events.

Second Stage of Labour

Its beginning is identified by:

• The patient feels the desire to defecate.
• The contractions become more prolonged and painful.
• Reflex desire to bear down during the contractions.
• The expulsive effort is accompanied by sustained expiratory grunt.
• Rupture of membranes, although this is not specific as it may occur earlier even before start of labour " prelabour rupture of membranes" or later even to the degree that the foetus is delivered in an intact sac.
• Full dilatation of the cervix (10 cm) in between uterine contractions is the most sure sign.

Delivery room

• The patient is transferred on a wheel or trolley to the delivery room.
• Put her in the lithotomy position.
• The lower abdomen, upper parts of the thighs, vulva and perineum are swabbed with antiseptic lotion.
• Sterile legs and towels are applied.

Bearing down

Ask the patient to bear down during contractions and relax in between.

Delivery of the head

The main aim during delivery of the head is to prevent perineal lacerations through the following instructions:

• i) Support of the perineum:
  • When the labia start to separate by the head, a sterile pad is placed over the perineum and press on it with the right hand during uterine contractions. This is continued until crowning occurs to maintain flexion of the head.
• Crowning:
  • is the permanent distension of the vulval ring by the foetal head like a crown on the head. The head does not recede back in between uterine contractions.
  • This means that the biparietal diameter is just passed the vulval ring and the occipital prominence escapes under the symphysis pubis.
  • After crowning, allow slow extension of the head so the vulva is distended by the suboccipito frontal diameter 10 cm.
  • If the head is allowed to extend before crowning the vulva will be distended by the occipito-frontal 11.5 cm increasing the incidence of perineal lacerations.
  • Ritgen manoeuvre: upward pressure on the perineum by the right hand and downward pressure on the occiput by the left hand to control the extension of the head.
• Episiotomy:
  • It is done at crowning when the perineum is stretched to the degree that it is about to tear.
• Swab and aspirate:
  • the mouth and nose once the head is delivered before respiration is initiated and the liquor, meconium or blood is inhaled.
• Coils of the umbilical cord:
  • if present around the neck are slipped over the head but if tight or multiple they are cut between 2 clamps.

Delivery of the shoulders

Gentle downward traction is applied to the head till the anterior shoulder slips under the symphysis pubis. The head is lifted upwards to deliver the posterior shoulder first then downwards to deliver the anterior shoulder.

Delivery of the remainder of the body

Usually slips without difficulty otherwise gentle traction is applied to complete delivery.

Clamping the cord

The baby is held by its ankles with the head downwards at a lower level than its mother for few seconds. This is contraindicated in:

• Preterm babies.
• Erythroblastosis foetalis.
• Suspicion of intracranial haemorrhage.

This may be enhanced by milking the cord towards the baby, to add about 100 ml of blood to its circulation.

The cord is divided between 2 clamps to avoid bleeding from a possible 2nd uniovular twin.

Third Stage of Labour

Delivery of the placenta

Conservative method:

• Put the ulnar border of the left hand just above the fundus at the level of the umbilicus to detect any bleeding inside the uterus known by rising level of the atonic uterus.
• Wait for signs of placental separation and descent but do not massage the uterus.
• As soon as they are detected massage the uterus to induce its contraction, ask the patient to bear down and push the uterus downwards to deliver the placenta.
• Hold the placenta between the two hands and roll it to make the membranes like a rope in order not to miss a part of it.
• Give ergometrine 0.5 mg or oxytocin 5 units IM after delivery of the placenta to help uterine contraction and minimise blood loss. These may be given before delivery of the placenta.

Signs of placental separation and descent:

• The body of the uterus becomes smaller, harder and globular.
• The fundal level rises as the upper segment overrides the lower uterine segment which is now distended with the placenta.
• Suprapubic bulge due to presence of the placenta in the lower uterine segment.
• Elongation of the cord particularly on pressing on the uterine fundus and it does not recede back into the vagina on relieving the pressure.
• Gush of blood from the vagina.

The active method (Brandt- Andrews method):

• With delivery of the anterior shoulder, 0.5 mg ergometrine or syntometrine (0.5 mg ergometrine + 5 units oxytocin) is given IM.
• When the uterus contracts, put the left hand suprapubic and push the uterus upwards while gentle downward and backward traction is applied on the cord by the right hand when the placenta is delivered it is rolled as in the conservative method.
• Advantage: reduction of the blood loss.
• Disadvantages:
  • Constriction ring may occur with retention of the placenta.
  • Avulsion of the cord if undue pressure is applied.
  • Inversion of the uterus if fundus is pressed while the uterus is lax.

Routine examinations

• Examination of the placenta and membranes:
  • by exploring it on a plain surface to be sure that it is complete. If there is missed part, exploration of the uterus is done under general anaesthesia.
• Explore the genital tract:
  • For any lacerations that should be immediately repaired.

Repair of episiotomy

Fourth Stage of Labour

Observation for the patient particularly atony of the uterus and vaginal bleeding.

Care of The Newborn

Clearance of the air passages

• The newborn is placed in supine position with the head lower down. A metal, rubber or better disposable plastic catheter is used to aspirate the mucus from the pharynx and mouth directly by the physician’s mouth or by attach it to an electric suction pump.
• Crying of the baby is usually occurs within seconds, if delayed slapping its soles, flexion and extension of the legs and rubbing the back usually stimulate breathing.

Apgar score

Is calculated at 1 and 5 minutes and further steps of resuscitation are arranged according to it (see later).

The umbilical cord

• A disposable plastic umbilical clamp is applied about 5 cm from the umbilicus to avoid the possibility of tying an umbilical hernia then cut about 1.5 cm distal to the clamp. Inspect for bleeding and paint it with alcohol.
• If the plastic umbilical clamp is not available, 2 ligatures of silk are applied instead of it.
• The umbilical stump is painted daily with an antiseptic till its fall within 10 days.

Congenital anomalies

The newborn is examined for injuries or congenital anomalies as imperforate anus, hypospadias (not to be circumcised as the cut skin will be used in the repair later on), cyanotic heart diseases.... etc.

Weight:

the newborn and record it.

Dressing

Dressing as well as all previous procedures should be done in a warm place better under radiant warmer to prevent heat loss which occurs rapidly after delivery increasing the metabolism and acidosis.

Care of the eyes

An antibiotic eye drops as chloramphenicol are instilled into the eyes as a prophylaxis against ophthalmia neonatorum.

Identification

Identification of the baby by a plastic bracelet on which its mother’s name is written.