Optimal care for both mother and child requires collaboration between obstetricians and mid-wifes.

  • There are approximately 100 000 normal deliveries / year in Sweden
  • 25% Instrumental (sectio and obstetrical vacuum extraction, VE)
  • 5% before week 37 + 0 (= premature)
  • 4% > 41 + 6 days (overdue; have to evaluate if induction have to be made to prevent complications)

Definition of a normal delivery:

  • Pregnancy length 37 + 0 – 41 + 6
  • Single birth, vertex presentation (head down)
  • No medical risk factors in the mother / fetus
  • Spontaneous labor
  • No complications during delivery or after delivery

Why does the delivery start?

  • Oxytocin receptors
  • Changed balance between alfa and beta receptors in the myometrium
  • Growth and stretching of muscle cells
  • Progesterone levels decreases
  • Fetal cortisone increases
  • Prostaglandine F2-alfa increases

Delivery

Latent phase (hours-days-weeks)

Active phase (9-10 hours for first time delivery; 7-11 hours for second time delivery)

– Opening period

– Extraction

– Delivery

 Definition of the Latent Phase

  •  Contractions: Pre-labor, Braxton-Hicks, false-labor, standstill labor
  • Non or little change in the opening of the cervix
  • The latent phase of labour, from the start of the uterine contractions until progressive dilatation of the cervix commences, is poorly understood, and the duration of this phase is particularly difficult to measure (RCOG-Midwifery practical guidelines)

The best thing is if the delivery starts by itself. These women should be held away from the delivery ward to prevent the staff from inducing the delivery artificially.

Questions to ask the pregnant woman; Has the water broke? Contractions every 20 minutes? Does the baby kick normally? If the water has broken with contractions every 5 minutes then she should come in.

 

Care – latent phase

  • Good education antenatally (Mvc) and especially about week 36.
  • Good access to “verbal support” and encouragement
  • Should be encouraged to stay at home and continue normal activities
  • Shower
  • Continuity in the counseling (same mid-wife)

Care – Prolonged latent phase

  • Benign condition
  • Psychological support, individual care
  • Anxiety and worry for the upcoming delivery has to be alleviated before other relaxation methods are practiced

Care on the delivery ward should not be conducted

  • This leads more interventions (Holmes-01, Mcniven -98)
  • Labour assessment area

-shorter delivery time, less EDA, less S-drip and a more positive delivery experience (Walsh-00)

Delivery start

Common early symptoms

  • Mucus plug sheds
  • Bleeding (vessels breaks in the cervix; BUT! this doesn’t give rise to a profound bleeding. If there’s a profound bleeding, the patient must seek the delivery ward immediately. This could indicate that the placenta is misplaced. A discharged placenta gives rise  to profound bleeding and pain. 1 deciliter placenta-bleeding means 1/3 of the child’s blood volume.

Active Phase -Def

  • Regularly, painful contractions (3-4/ 10 min, duration 20-45 sec)
  • The water breaking
  • The cervix opens 3-4 cm
2 of the above-mention criteria must be met; if not then it’s still a latent-phase.
1 finger is approximately 1,5 cm.
All water breakage must seek the delivery ward. If the water is contaminated with feces, it indicates that the child is stressed. If one have to deliver the baby, cortisone is given to stimulate lung maturation.

At the delivery ward

  • Evaluate the patients status, general condition, labour, outer palpation, auscultate the fetus heart rate, vaginal exam
  • Connect the CTG
  • Read the Mvc journal
  • Blood tests, blood pressure, urine
  • Red/green patient?

Note! Be careful with palpating the vagina if the water has broke due to the infection risk!

Process

  • Cervix opens 1 cm / hour
  • Ffd (HU) works itself down through the pelvis channel, especially if the cervix is over 8 cm open.
  • Palpate (outer palpation and inner palpation)

Normal delivery

Partograph and “Action Line”

  • The partogram is an action line with 2-4 hours delay
  • Vaginal exam shouldn’t be made less than every 4 hours
  • General evaluation:

– Abdominal palpation!

– Leopolds grip; position/posture/presentation

– Pain reaktion, bleeding, bear down etc

– Long-drawn deliveries shall avoided

When the cervix opens 4 cm, it means that the delivery process has begun. It then opens about 1 cm / hour. If there are good contractions, the cervix will open nicely. But if the mother has contraction-weakness the cervix might not open 1 cm/ hour. Some women have labor-paus and that’s why there’s two lines. The other line is 3 hours later. But the delivery process is not allowed to pass the other, later line. Active action must be taken if it does, e.g. induction of delivery

Contraction weakness

  • Delayed cervix dilatation with 2-3 hours in active phase (see action line)
  • Risk factor for both mother and child; infection, fetal hypoxia, operative delivery

Contraction weakness- measurement

  • Prophylaxis – prevent contraction weakness
  • Therapy – intervene
  • Prophylaxis and therapy: active management of labor

Prophylaxis – routine early amniotomy

  • Don’t affect sectio frequency
  • Shortens the delivery time by 60-120 min
  • Decreased the amount of prolonged deliveries
  • Less children with low Apgar
  • More analgesia and more cases with fetal sounds affect but these are not deep or serious

Therapy – amniotomy and subsequent S-drip

  • Decreases the delivery process
  • The recommended method in Sweden

Active management of labor

  • Criteria for diagnosis “active delivery”
  • Partogram with “action line”
  • Routine early amniotomy
  • Syntocinon-drip when there’s a contraction-weakness tendency
  • A mid-wife should continuously be available

Active management of labor lead to:

  • Shorter delivery time
  • Less prolonged deliveries (>12h)
  • Less amount of chorioamnionites
  • Less amount of sectio (in some studies)
  • No difference in neonatal morbidity
  • More patients content with their delivery

Extraction phase (2 phases)

  • 2-3 hours for first time mothers
  • 1/2 – 1 hour for second time mothers

Ground rule: The mother shouldn’t press for more than 2 hours

Partus

  • Prostrate vertex presentation 95%
  • Defl-posture: parietal, forehead, face presentation 1-2%
  • Breech presentation 3%
  • Vertical presentation 3-4% (1,5% after rotation/turn attempt)

– Episiotomy, profylax sphincter rupture , then cut the umbilicus, mother-child contact.

– Apgar score, acid-base status

Note! The placenta contains blood which is good if it is delivered to the child. If you wait a bit before cutting the umbilicus, you can prevent anemia in the child.

Acid-base status can be taken from the child’s scalp and later on, after partus, from the placenta from both the arterial and venous part.

Third labor stage

= the time between the child’s birth and the breed of the placenta.

  • Syntocinon 10E (So that the uterus contracts)
  • After 5-10 minutes comes the placenta
  • Globally there’s a big maternal morbidity and mortality due to bleeding
  • Medicine (Syntocinon, cytotec etc.) gives rise to less bleeding, shorter third stage, decreased infection risk

Fetal monitoring

Opening stage – normally there’s no change in the child’s acid-base status
  • CTG, initially intermittent in the active phase but it should be continuous when there’s a suspicion of complication
  • Interpretation, basal frequency, variability, acceleration, deceleration, pain frequency (Dr C Bravado)
  • Risk-pregnancy: contact scapl-ctg, scalp test, STAN (ST-Analysis)

Fetal monitoring – extraction phase

  • Phase 1: Cervix fully expanded to when is rotated and pushed down the pelvis
  • Phase 2: Pushing to extraction, often CTG
When pushing, the childs acid-base status decreases physiologically but can affect fetuses that have spare reserve and in babies with hypoxia and acidosis. It it therefore not good to have prolonged pushing phase.

Pain relief

  • Laughing gas 70%
  • Pethidin, ketogan (the child will be affected; shouldn’t therefore not be given to mothers expected to give birth within 3 hours.
  • EDA >25%
  • Spinal
  • PCB (<5%)
  • Pudendus (<5%) (Pelvic anesthesia)
  • Infiltration (around the vagina)

Puerperium

  • 6-8 weeks postpartum
  • Uterus involution
  • Bloody discharge, brown, pink

After control

8-12 weeks postpartum

Last Updated:  30/8-2012

 

 

 

 

 

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