tren === Factors Influencing Labour : Power & Passenger «=== Lasour te Myometrium in pregnancy undergoes - Hyperplasia & Hypertrophy Definition v © Series of events which takes place in Female baaiiligy cles genital tract. in order to expel the products of conception into the outer world is called labour @ (N) Labour is called Eutocia © Criteria of Normal labour: WY (Spontaneous in onset & term (37-42 w) Pulls the cervix & Lover uterus v (2) with vertex presentation Opening ofthe cervix (2) without undue protongation (8 hrs) (4) Natural termination with minimal aids BRAXTON HICKS CONTRACTION (5) Without having any complication affecting the + Start early in the pregnancy & present throughout health of the mother and / OR the baby. Painless & Irregular Regular contractions 3P of Labour Lp. > Fundal predominance over 2. Passage > Progress Fundocervical at 2 cm / see & fomenge > Pacemaker - Cornu(Fallopian tube attaching 40 the uterus) Rt cornu > Lt cornu wees bat > Contractions are painful ~ 1S mm Hg (Uterine pressure) Uterine contractions i called power © Contr dlahs o'S mmig > Fundus cannot be indented - 40 mm Hg f > 1 stage of Labour ~ 40 to 50 mm Hg > 2” stage of Labour - 3 layers of myometrium tractie property ae Laka 00 Fe een - Active Space .Denominator - Mentum © Hard, curved, Globular, Balloteble Fetal postion - Right Hento Anterior v Fetal Head(Breech presentation) ‘© Empty ~ Transverse tie Leopard's 2 > Lateral Grip / umbilical Grip ‘© Smooth curvilinear Resistance -> Fetal back @ Hultiple knob like structure > Limbs Leopard's 3 > Pawliks Grip \ ‘© Presenting part a © Hovable > Not engaged © Not movable > Engaged Presentation - Cephalic PP ~Vertex Leopard's 4 > To confirm 3rd maneuver Denominator - Occiput Left occipitoposterior ‘¢ Hands converging - PP nat engaged '* Hands diverging - PP engaged LeopoLo MANEUVERS 46:01 «Gives the attitude of the PP (by determining the Sinciput and occiput. Leopard's 4 > Funda Grip Complete flexion - sinciput > occiput ~Deflected head - sinciput = occiput ‘© Broad, Soft, Irregular - Buttocks ~+Complete flexion - occiput > sinciput - Active Space .SSeS Stages of Labour SSS STAGES OF LABOUR 00:14 ANSWER: (b) © stages of Labour © Fstage = Onset of true labour pains to full dilatation (40cm) ‘© 2 stage - Full dilation to expulsion of fetus © 3° stage - Expulsion of placenta © 4 stage - 4 hour observation, post-delivery Bag of water helps in effacement and dilatation of cervix (physiological chills are observed) True Labour Pain False Labour Pain © Regular © Irregular Q) Second stage of labor is from ? © Aseinintensity, © Non progressive frequency Onset of contraction tc f ib 2. Onset of contraction to rupture of membranes 5 sasceean Be b. Onset of contractions to full dilation cervical changes cx dilates c. Rupture of membranes to delivery of fetus Show (o) 4. Full dilation to delivery of fetus ‘© Formation of bag of water ANSWER: (d) © Seen in lower abd © Lower abd radiates to medical. aspect of thigh and back Q) True Labor pain includes all, except (PGI June 12) © Not relieved with © Relieved with medication medication a. Painful uterine contraction b. Short Vagina x Formation of the bag of waters 7 fom d. Cervical dilation ¥ e. Progressive descent of presenting part Cervic — Active Space =Effacement v Thining ofthe cervix Cervical length > Oom (Gem > Oem) 1ST STAGE OF LABOUR ACTIVE PHASE. 4._Dilation of cervix __|2._ Descent of Fetal Head bilation te Dilation 0 > 10 Pri Hulti 1.5 em / br 2om/ br imi rate - 4.2 cm/br tem / he 11:55 WHO 4.¢m / hr 4em/ he ‘Friedman curve Monitoring - by partogr Phase of deceleration ring = *Y om (9 t00m) PROTRACTED / PROLONGED ACTIVE PHASE Phase of ‘max" supply 4-2} Rate of dilatation Rate of descent Primi <12 om/hr <[Link]/r Phase of acceleration alti <15 om/hr <2om/ne (3-4em) wo <1 om/hr 0to3em > 3 t0 40cm Power Aigner ne ube Arlt te mertanes Hodified WHO Partogram > Otohem > to 10cm om Willems 25° € (cect) sronannvene 3 > 0toSem =6 to em 63 OP wn (00% can - Retain soi arene ACTIVE PHASE ARREST Average _| Prolonged Primi__| 10-12 hours | > 20 hows « Prerequisite - cervix should be diated > Gem or rat | Cabos | Rhos membranes should be ruptured Causes for prolonged latent cervix ‘+ Insp of good uterine contractions © Unriped cervix v Excess sedation If no dilatation for 4 hrs eat ; Inadequate contractions 4 Early epidural analgesia v Active SpaceGive oxytocin v If no dilatation for 6 hrs & R-CS 2" STAGE OF LABOUR From full Dilatation to Expulsion of Fetus ‘Ag prong 2" Stage Pri = es | 33h ave Lap tlm _| R= Station oft Head Win Ep» thr = above +2 + CS bebo + 2 intramental Forcepshaccum Management - RITGEN's maneuver —Fiex the fetal Head to prevent the urethral tear "+ Support the perineum & prevent the perineal tear bole » —i= | Gelvan wih midine apsiotomy assisted Vagina byrne gen manenver 29:00 EPISIOTOMY In and stage, at the height of crowring episiotomy can be given. Planned incision on the perineum to increase the perineal outlet for easy passage of Fetus Not mandatory Depends on the perined tears Types - Midine episiotomy & Mediolaterd episiotomy Active Space Hidline Episiotomy —_Hediolaterat Episiotomy(Miost. comm Advantage © Less blood loss Easy to repair + Less sphincter Heals faster ‘Tears Less painful. Less dyspareunia | Disadvantage : '* Hore blood loss Disadvantage ‘© Hore painful © Cannotbe extended | © Takes more time to © AP Risk of sphincter | Heat. TearsMEDIOLATERAL EPISIOTOMY 35:30 © 2° degree perineat tear ‘© At crouning, on stretched perineum - Is given at an angle of 60° from midline ‘© Post delivery on unstretched perineum - It appears to be 45° from midline STRUCTURES CUT IN THE EPISIOTOMY ‘© Bulbospongiosus © Part of Levatorani ‘© Superficial & deep transverse perinei ‘© Branches of pudenal nerve & vessels. Episiotomy is Repaired - in 3 Layers with chromic catgut OR Vieryl Rapid PERINEAL TEAR 38:47 1 degree - Skin is cut 2* degree ~ Skin + Muscle cut 31 degree - Skin + Muscle + Anal sphincter cut 3a = < 80% of extandl sphincter aut 3b = >50% of EAS cut 36- EAS + AS cut Ws degree - Rectal mucosa cut 318 4" degree - Operated in OT under spinal anaesthesia 31 End to End Anastomosis Post repair - NPO for 24-48 hrs -> Semi-Solid Diet > On Laxatives Q) Timing of Repair -> 3° / 4” Perineat Tear ~ Detected at Labour oR Within 24 hrs, v Repair immediately ~ Detected beyond 24 hours v Repair after 3 months Active Spacemes 8" Stage of Management qx THIRD STAGE 00:28 Uterus is globular, 4S ses in height > Schroder’s ‘© Expulsion of placenta sign On pushing uterus back cord does not receed TYPES OF SEPARATION 00:41 Kustner's sign * Supropubic bulge +ve 1. Mathew - 2. Schultze ames ik ie posit is PLANE OF PLACENTAL SEPARATION 05:40 The leading edge of | insertedat the fundus Decihus spongiesom, the placenta and central orea separates first and separates first, the MANAGEMENT OF PLACENTAL SEPARATION 06:30 ‘the placenta surface | placenta inverts and is delivered with its | draws the membranes Passive management Active management Faw sufoce P0363 | ter it, covering the © Primi and multi © Within S minutes raw surface (inverted jincecinsgursies faite within 15 minutes If placenta is maintained » 30 mins > prolonged 3° stage retained placenta Marginal / Hathew Central / Schultze Duncan ‘© Placenta separates in Placenta separates | centre flloved by COMPONENTS OF ACTIVE MANAGEMENT OF THE fron ie lye to] ad THIRD STAGE OF LABOUR (AMTSL) 08:13 edges another edge. ‘© Fetal surface of © Haternd. surface of | placentas at vulval 1081 - Mneumonic Placenta is at vulval | outlet 4. Immediate administration of uterotonic drug outlet ‘© Retro placental elot 2 fried 2. Delayed cord camping 3. Controlled cord traction / Brandt Andrew method SIGNS OF PLACENTAL SEPARATION 03:20 4. Intermittent uterine tone assessment ‘© Sudden gush of bleeding ‘© Lengthening of cord . Active Space -UTEROTONIC DRUGS 08:51 4. Uterotonics: Injection oxytocin - administer 40 units: |M immediately after the delivery of the baby, 2. Oral misoprostol 600 meg is the preferred alternative to oxytocin particularly for home. delivery 3. Hethergine ~ 0.2 mg im/iv Serge ‘son. [Steet | naan | “ey SPSS = cen = ‘at |tOvse| 24min | 20m [Neve ave | 16-20°C faeces feara| one] BE TRE mw | DELAYED CORD CLAMPING 10:20 ‘© Delay clamping the cord for at least 1-3 minutes to reduce rates of infant anemia ‘© Advantage: Extra 80 ml blood to fetus INDICATION OF EARLY CORD CLAMPING 10:51 © Fetal hypoxia ‘© Cord circulation not intact Abruption Placenta previa ‘Vasa previa Cord avulsion 1UGR with abnormal Doppler findings ‘© Mother hemodynamically unstable ‘© Rhnegative mother © HIV delayed © Preterm 00000 CONTROLLED CORD TRACTION 12:44 '* Brandt Andrew method + Improper methods can lead to uterine inversion INTERMITTENT UTERINE TONE ASSESSMENT 13:20 v Uterine relaxed v Uterine massage Active Spacenee Breech Presentation exes MALPRESENTATION 00:29 ‘* Presentation - Part of the baby occupying the lover uterine segment ‘© Host common presentation - cephalic, baby's head in the lower uterine segment, ‘© Holpresentation - Any part of the baby, opart ‘from head, present in the Lover uterine segment ‘© Baby's Legs and buttocks Lie in the Lower uterine segment ‘* Host common malpresentation - Breech '* Holpresentation cannot be seen until 12 weeks of Incidence of breech at 28 weeks - 25% © Approach to mather ~ counsel her that the baby will rotate © ATO weeks - 4% ‘© Ifthe baby does not rotate at 36 weeks ~ manual rotation - External cephalic version ‘© If successful ~ baby is delivered vaginally ‘© If not successful - assisted vaginal breech delivery ‘© Space compromise inside the uterine cavity - baby cannot rotate, causing breech TYPES OF BREECH 06:28 Frank Breech Complete Breech Footing Breech ‘© Host common type of breech - Frank breech, aka gestation extended breech © Nothing is felt around 12 weeks of © Flexedat hip gestation © Extended at knee. ‘+ Presentation can be observed after 28 weeks of ‘© Complete breech (least common)slexedat hip and gestation knee ‘+ Leopold maneuvers - to examine and give the ‘© Footling breech: extended at hip and knee presentation - Active Space .‘+ Kneeling presentation (rare): presenting part ‘© Footling breech (highest risk) and kneeling breech are associate with cord prolapse ‘© Least chance of cord prolapse - Frank breech ‘© Best for vaginal delivery ~ Frank breech © Good dilator of cervix as it is regular and conical ‘© Footling & kneeling breech - direct LSCS ‘+ Complete breech has highest chance of reversion to cephalic REGARDING BREECH PRESENTATION: ‘A)_ The incidence at term is 40% - FALSE 8) At 26-32 weeks approximately 40-50% of all presentations are breech ~ FALSE C) Only 2% of breech presentations at 29 weeks will convert spontaneously to cephalic presentation by term - FALSE D) Fetuses in the flexed (complete) presentation are more Likely to spontaneously convert to cephalic ‘han extended (Frank) - TRUE E) The incidence of congenital abnormalities is higher ‘han in cephalic presentations ~ TRUE = Controcted Neural tube | © Cornufundal pelvis & defects attachment ccephalo pelvic |» Congenital of placenta disproportion | myotonic Uterine dystrophy malformations Prematurity ‘= Pelvic tumors | (most ‘© Uterine fibroid | common ‘© Huttiparous couse) + Polyhydraminos QUESTION: Host common cause of breech presentation is? A) Prematurity 8) Contracted pelvis CC) Otigohydramnios D) Placenta previa ‘ANSWER: (A) DIAGNOSIS OF BREECH 22:00 1) Clinical: Leopold maneuvers (© Fundel grip - hard curved & globular and ballotable 2) Confirmed by USG: © On auscultation, FHR is heard around the CAUSES OF BREECH 16:39 umblicus PERVAGINAL EXAMINATION: ao Frank Breech: Presenting part -fetal buttocks, @/Placenta sacrum and external genitalia previa ‘© Complete Breech: Presenting part - fetal buttocks, | © Short cord sacrum, external genitalia and feet Active Space‘+ Kneeling Breech: Presenting part - knee ‘+ Footting Breech: Presenting part ~ foot BREECH Ischia scrum Ischia tuberosity tuberosity Face: Halar prominence Hentum MANAGEMENT 2727 External. Cephalic Version (ECV): + Success rate 50% + Done under continuous fetal monitoring + Subcutaneous terbutline before procedure relaxes the uterus + InRh ve mothers - AntiD given prior to ECV REGARDING EXTERNAL CEPHALIC VERSION {ecy): A) The success rate is greatest inthe second ‘rimester - FALSE 18) The success rate after 37 weeks gestation is 90% - FALSE C) It carries a significant risk of fetal mortality - TRUE 1) Fetal morbidity i usully associated with placenta ‘bruption cord entanglement - TRUE PREREQUISITES FOR ECV: ‘© Hembrane should be intact ‘+ Liquor shouldbe adequate ‘+ Done between gestational age 36 weeks to ferm Singleton fetus (in case of twins - single baby should be present inside) ‘+ Pelvis should be adequate ‘* There shouldbe no obstetric indication for Cesorean section © Done in: © Primi - 36 weeks © Multi - 37 weeks extemal Cephatie Version (ECV) @ oO fay in tween postion Your pyscanfesing me heat dram athe baby enersly a “ Torn 9 sppving Baby icapha procera, (pessueexenaly” enaged neg vad) ‘vagal Solver, —___@Forward roll ABSOLUTE CONTRAINDICATIONS 36:11 © Itis contraindicated if vagina delivery is not an option, such as with placenta previa © Hultifetal gestation © Relative contraindications are: Early labor Otigahydramrinos (or) Rupture of membranes Known nuchal cord Structural uterine abnormalities Fetal growth restriction and Prior abruption or its risks Prior cesarean delivery a contraindication 02000000 COMPLICATIONS OF ECV © Cord entanglement © Cord compression © Fetal distress 37:51 #———_—_____—_ Active Space INDICATIONS OF LSCS IN BREECH ASSISTED BREECH DELIVERY (2) - backward flip Fetal death Abruption Preterm labor PROM - can initiate Labor early 39:37 Lack of operator experience Patient not willing for vaginal detivery Baby ueight >3.8Kg - 4Kg Baby weight <1.5kg, preterm, IUGR => Skull bones soft - risk of IVH Footling breach & kneeling breeching Star gazing breech Fetal anomalies incompatible with vaginal deliveries Prior neonatal birth trauma or prior intrauterine death Contracted pelvis Placenta previa Previous LSCS Primi with breech - relative indication 47:52 Principle: masterly inactive (hands off) The following points are important for the safe conduct of a breech delivery: © Denot be in hurry (© Never pull from below and let the mother expel. ‘the fetus by her oun effort with uterine contractions © Always keep the fetus with its back anterior© Keep a pair of obstetrics forceps ready should it become necessary assist the aftercoming head © Anesthetist and pediatrician should attend the delivery © Inform the operation theater, if C/S is needed ‘© Always hold the baby by femoro pelvie grip MECHANISM OF LABOR IN BREECH 50:05 1) Buttocks 2) Shoulders 3) Head CARDINAL MOVEMENTS AT BUTTOCK '* Engaging diameter - bitrochanteric diameter ‘© Diameter of engagement: Left oblique of inlet i Descent Anterior buttock touches levator ani Internal rotation of anterior buttock through 1/8" of Circle placing it behind pubic symphysis Delivery of trunk by lateral flexion 1 Restitution Buttocks rotate to original position CARDINAL MOVEMENTS AT SHOULDER © ED~ Bisacromial diameter (12cm) ‘Diameter of engagement - left oblique 4 Descent 1 Internal rotation of shoulders So bisacromial diameter Lies in AP diameter 1 Delivery of posterior shoulder followed by anterior shoulder 1 Restitution ‘Anterior shoulder will be towards right thigh in LSA eee Active Space =CARDINAL MOVEMENTS AT HEAD ‘© Engagement occurs through opposite oblique diameter ‘¢ Engaging diameter - Suboccipito frontal (10 cm) © LSA right oblique 1 Descent 1 Internal rotation occiput Lies below pubic symphysis 1 Head is born by flexion ASSISTED VAGINAL BREECH DELIVERY [Link] © Hands off till umbilicus © Baby's bock should always be anterior ‘Anterior back with arrested Lover Limb - Pinard's maneuver ‘© Nuchal displacement or extended arm - Lovset's maneuver + After coming head of breech - suprapubic pressure from up © Pronated hand + malar flexion + shoulder ‘tractions ‘* Burn marshal technique hold the baby at ankle, pull up vertically as an are © Pipers forceps is used PINNARD'S METHOD [Link], © For arrested Lower limb ‘© Finger in the popliteal fossa ‘* Flex the knee and pull the leg out LovseT’s MANEUVER [Link] © @ ‘© Nuchal displacement of arm / extended arm ‘© Baby held by femora pelvic grip and rotated by 180° ‘© So posterior shoulder comes below pubic symphysis Active Space . \NEEIIIEUEEE~ _—_______MODIFIED MAURICEAU-SMELLIE-VEIT MANEUVER [Link] ‘+ After coming head of breech '® Suprapubic pressure + malar flexion + shoulder WIGARD MARTIN METHOD [Link] © No shoulder traction ‘© Only suprapubic pressure + malar flexion BURN MAR SHALL [Link] ray vd ‘© Nape ofthe neck is visible —> baby held up the ankle and pulled up vertically as an are DORSO POSTERIOR BREECH [Link] a Modified prag maneuver PIPERS FORCEPS. SS< “S Long shank with perineal ‘© Best - after coming head of breech ‘© Inindia, alternate to pipers forceps - Long das forceps ENTRAPPED HEAD © Seen in preterm breech © Baby head is stuck through undiated cervix © Cervix incised at 2 o'clock position and 10 o'clock position ~ Druhhsen’s incision DECREASE IN FETAL HEART RATE © Onrotation > 1 FHR - stop the procedure & re~ rotate the fetus 1 JFHR— LSCS Active Space =