labour

  CLINICAL COURSE OF FIRST STAGE OF LABOR

The first symptom to appear is intermittent painful uterine contractions followed by expulsion of               bloodstained mucus (show) per vaginam.

 Only few drops of blood mixed with mucus is expelled and any excess should be considered abnormal

PAIN:-

 Pains are felt more anteriorly with simultaneous hardening of the uterus.

Clinically pains are said to be good if they come at intervals of 3–5 minutes and at the height

of contraction the uterine wall cannot be indented (दांतेदार बना हुआ) by the fingers.

DILATATION AND EFFACEMENT OF THE CERVIX: -

(Effacement is the thinning and shortening of the cervix. It happens at the end of pregnancy in preparation for childbirth. A pregnant person must be 100% effaced for a vaginal delivery)

Progressive anatomical changes in the cervix, such as dilatation and effacement, are recorded                       following each vaginal examination.

Cervical dilatation is expressed either in terms of fingers—1, 2, 3 or fully dilated or better in terms         of centimeters (10 cm when fully dilated). It is usually measured with fingers but recorded in                 centimeters.

 One finger equals to 1.6 cm on average. Simultaneously, effacement of the cervix is expressed in              terms of percentage, i.e. 25%, 50% or 100% (cervix less than 0.25 cm thick). The term “rim” is                 used when the depth of the cervical tissue surrounding the os is about 0.5–1 cm.

Partograph 

 Friedman (1954) first devised it.

 Partograph is a composite graphical record of cervical dilatation and descent of head against                  duration of labor in hours.

 It also gives information about fetal and maternal condition, which are all  recorded on a single              sheet of paper.

Cervical dilatation is a sigmoid curve and the first stage of labor has got two phases—

(1) Latent phase and

(2) Active phase

STATUS OF THE MEMBRANES: 

Membranes usually remain intact until full dilatation of the cervix or sometimes even beyond in the       second stage. 

However, it may rupture any time after the onset of labor but before full dilatation of cervix—when        it is called early rupture. When the membranes rupture before the onset of labor, it is called                       premature rupture

. As it has got some influence on the obstetric outcome, जैसा कि प्रसूति परिणाम पर इसका कुछ प्रभाव   पड़ा है,

An intact membrane is best felt with fingers during uterine contraction when it becomes tense and          bulges out through the cervical opening.

MATERNAL SYSTEM: 

General condition remains unaffected; although, a feeling of transient fatigue appears following a          strong contraction 

Pulse rate is increased by 10–15 beats per minute during contraction, which settles down to its               previous rate in between contractions.

 Systolic blood pressure is raised by about 10 mm Hg during contraction.

Temperature remains  unchanged.

FETAL EFFECT:

 As long as the membranes are intact, there is hardly any adverse effect on the fetus .

 However, during  contraction, there may be slowing of fetal heart rate by 10–20 beats per minute            which soon  returns to its normal rate of about 140 per minute as the intensity of contraction                   diminishes provided the fetus is not compromised.

CLINICAL COURSE OF SECOND STAGE OF LABOR

Second stage begins with full dilatation of the cervix and ends with expulsion of the fetus.

PAIN: The intensity of the pain increases. 

The pain comes at intervals of 2–3 minutes and lasts for about 1–1½ minutes. It becomes                   successive with increasing intensity in the second stage.

BEARING-DOWN EFFORTS:

 It is the additional voluntary expulsive efforts that appear during the second stage of labor  (expulsive phase).

MEMBRANES STATUS:

 Membranes may rupture with a gush of liquor per vaginam.

 Rupture may occasionally be delayed till the head bulges out through the introitus.(vagina)

Rarely, spontaneous rupture may not take place at all, allowing the baby to be “born in a caul”.: Membranes may rupture with a gush of liquor per vaginam. 

Rupture may occasionally be delayed till the head bulges out through the introitus. 

Rarely, spontaneous rupture may not take place at all, allowing the baby to be “born in a caul”

भ्रूण झिल्ली.

DESCENT OF THE FETUS: Features of descent of the fetus are evident from abdominal and vaginal examinations.

Abdominal assessment of progressive descent of the head (using fifth formula)

Progressive descent of the head can be usefully assessed abdominally by estimating the number of

“fifths” of the head above the pelvic brim (Crichton). The amount of head felt suprapubically in finger

breadth is assessed by placing the radial margin of the index finger above the symphysis pubis successively

until the groove of the neck is reached. When one-fifth above, only the sinciput can be felt abdominally

and nought-fifth represents a head entirely in the pelvis with no poles felt abdominally

CLINICAL COURSE OF THIRD STAGE OF LABOR

Third stage includes separation, descent and expulsion of the placenta with its membranes.

PAIN: For a short time, the patient experiences no pain. However, intermittent discomfort in the lower

abdomen reappears, corresponding with the uterine contractions.

BEFORE SEPARATION: Per abdomen—Uterus becomes discoid in shape, firm in feel and nonballottable.

Fundal height reaches slightly below the umbilicus.

Per vaginam: There may be slight trickling of blood. Length of the umbilical cord as visible from

outside remains static.

AFTER SEPARATION: It takes about 5 minutes in conventional management for the placenta to

separate.

Per abdomen:

1. Uterus becomes globular, firm, and ballottable.

2. The fundal height is slightly raised as the separated placenta comes down in the lower segment

and the contracted uterus rests on top of it.

3. Slight bulging in the suprapubic region due to distension of the lower segment by the separated

placenta.

Per vaginum:

4. Slight gush of vaginal bleeding.

5. Permanent lengthening of the cord is established. This can be elicited by pushing down the

fundus when a length of cord comes outside the vulva, which remains permanent even after the

pressure is released. Alternatively, on suprapubic pressure upward by the fingers, there is no

indrawing of the cord and the same lies unchanged outside the vulva.

EXPULSION OF PLACENTA AND MEMBRANES: The expulsion is achieved either by voluntary bearingdown

efforts or more commonly aided by manipulative procedure. The afterbirth delivery is soon followed

by slight to moderate bleeding amounting to 100–250 mL.