Normal Delivery

makmur sitepu

Divisi FetoMaternal
Departemen Obgin FK-USU/RS. HAM
 Duration of Pregnancy

• Average 280 days or 40 weeks (9 months

10 days)
• Estimated Date of Confinement (EDC)
• Nagele’s rule
• Date of first day of LMP
• Subtract 3 months
• Add 7 days
• Accurate to plus or minus 2.5 weeks
36
32,40
28
24

Fundal height measurement

3
Fundal Height
 Inpartu

is
regular uterine contraction frequency
and
cervical changes (dilation and Flattening)
 Labor is divided into 4 stages

• First stage:coordinated contractions

leading to dilation of cervical os 10 cm
• Second stage:Begins with complete dilation
of the cervix and delivery of fetus
• Third stage:Begins after delivery of baby
and ends with delivery of the placenta
• Fourth Stage: delivery of placenta – 1 hour
 First Stage of Labor
• Begins with onset of coordinated contractions
leading to dilation of cervical os and ends with
complete dilation (10 cm) of the cervical os.
• False Labor (Braxton Hicks contractions)
• Cervix fails to dilate greater than 2 cm
• Duration of first stage -
• Primigravida: 13 hours
• Multiparous: 7 hours or less
 First Stage
• His and bloody show
• Primigravida: OUI open, flat and thin cervical → OUE open.
• Multigravida: Opening, flattening, thinning simultaneously.
Phase of First stage
1. The latent phase is from 0–4 cm dilatation and It
should normally not last longer than 8 hours.
2. The active phase is from 4–10 cm dilatation which
should be at the rate of at least 1 cm/hour.
Source: WHO/UNFPA/UNICEF/WORLD BANK. IMPAC-Managing Complications in Pregnancy and
Childbirth: A Guide for Midwives and Doctors. WHO 2000 (WHO/RHR/ 00.7)
 Second Stage II
• His stronger and faster every 2-3 minutes.
Head pressing the pelvic floor muscles → straining and
defecation
Perinium prominent and wide and the anal opening →
labia open, visible head of the fetus in the vulva.
Born under the head with suboccipito bregmatika.

• Primigravida: 1.5 hours

• multi: 0.5 hours.
 Stage III

• Lasted 6-15 minutes, the placenta

separated spontaneously or with little
emphasis on the fundus uteri.
Stage IV
• Observe whether there are post partum
haemorrhage.
 The 5 “Ps” of Labor:

• Passenger (fetus)
• Powers (uterine contractions)
• Passage (the pelvis & maternal soft parts)
• Position (maternal)
• Psyche (maternal psychological status)
 Minimal contraction

• Duration 20 – 40 second
• Occur 2 times / 10 minutes
His adequate
Contractions that ..
• 60 seconds duration
Pressure reached 50-60 mm Hg
• Occur every 2-3 minutes
or
Produce good labor progress
 Passenger

Fetal size

Fetal presentation

Fetal position

Moulding
Passenger
Moulding of the fetal skull bones
0 bones are separated and the sutures can be felt easily.
+ bones are just touching each other.
++ bones are overlapping but can be separated easily
+++ bones are overlapping but cannot be separated easily
 Passages

Maternal pelvis

Inlet

Outlet
 Birth canal ( passage)
• Inlet
• diagonal conjugate diameter > 12 cm
• Mid pelvis
• interspinous diameter > 10 cm
• Outlet
• subpubic angle > 90 0

• intertuberosity diameter > 10 cm

23
25
HODGE

H1: above symph -

Promontorium
HII: Lower Shymph
HIII: Spina Isachiadica
HIV: Cocygeus
Station
• 8 Cardinal Movements: (in an anterior
occiput position)
1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. Restitution
7. External rotation of the shoulders
8. Expulsion
 Third stage
• Delivery of placenta
• sign of placental separation (uterine
sign, vulva sign, cord sign)
• Modified Crede,
• Brandt Andrew
• Controlled cord traction

38
Controlled cord traction
Delivery of the placenta :Brandt-Andrew Maneuver
Delivery of the placenta : Modified Crede’s maneuver
Active Management Third Stage

1. Prophylactic Oxytocic at delivery ant.

Shoulder or delivery of baby.
2. Uterine massage.
3. Controlled cord traction.
 Breastfeeding

“Breastfeeding is neither easy nor

automatic.”

• Should be initiated within 1 hour after

delivery
• Feed baby every 2-3 hrs to stimulate milk
production
• Production should be established by 36-96 hrs
Biology of labor

MAKMURS
 Parturition
• Normal Pregnancy
• Uterine quiescence Fetus

• Immature fetus
• Closed cervix
• Parturition
Placenta
• Coordinated uterine activity
Membranes
Mother

• Maturation of the fetus

• Maternal lactation
• Progressive cervical dilation
 Initiation of Labor
• Fetus
• Sheep
• Fetal ACTH and cortisol
• Placental 17 α hydroxylase
•  Estradiol
•  Progesterone
• Placental production of oxytocin, PGF2 α
• Humans
• Fetal increased DHEA
• Placental conversion to estradiol
• Increased decidual PGF2 and gap junctions
• Increased oxytocin and PG receptors
• Decreased progesterone receptors
47
 Initiation of labor
• Oxytocin
• Peptide hormone
• Hypothalamus-posterior pituitary
• Fetal production
• Maternal serum increase in second stage of labor
• Oxytocin receptors
• Fundal location
• 100-200 x during pregnancy
• Actions
• Stimulate uterine contractions
• Stimulate PG production from amnion/decidua
48
 Theories of labor

• Progesteron withdrawal.
 Has quieting effect on uterus
 Counterbalance estrogen.

• Oxytocin production
 Posterior pituitary
 As pregnancy progresses oxytocin receptor↑↑
• Prostaglandin production↑

• Endothelin production↑
 Contraction smooth muscle.
 High level in amniotic fluid.

• Estrogen stimulation > 34 – 35 weeks.

 Promotes oxytocin production in myometrium.

• Fetal cortisol.

• Distention of uterus.
Exact couse of onset labor not clear.

Most current belief is that of

A PROSTAGLANDIN CASCADE.
Maternal and Fetal Endocrine Systems Involved in
Increased Placental Production of CRH.
 Oxytocin receptor Extracellular
Calcium channel

Intracellular
Phospholipase C

cAMP

Ca+ MLCK
+ Oxytocin
+ Prostaglandin Ca store

Uterine contractions
54
Contraction Prostaglandin
Fetal membranes

Rupture
KASUS
Ny. DL, usia 28 tahun, G1P0A0
HPHT = 20 November 2009
• Pemeriksaan 4 jam kemudian diperoleh :
• Status present : dalam batas normal
• Status obstetricus : His = 3x30 detik/10 menit
• DJJ = 148x/i, regular
• Dilatasi servik : 6 cm
• Penurunan kepala : 2/5
• Penyusupan : +2
• Ketuban masih utuh

• Dua jam kemudian Ny.DL mengalami pembukaan lengkap.

• Penurunan Kepala : 1/5
• Penyusupan : +2
• His : 4 x 50 detik/ 10 menit
• Djj : 150x/1, regular.
• ketuban pecah dan timbul rasa ingin mengedan.
 Kasus dengan TFU 34 cm

• Kepala 3/5  minus station  -13

• EBW : 155 x (34 - 13) = 3255 gram.
• HPHT: 20 November 2009
• TTP: 27 agustus 2010
• Usia Kehamilan saat ini 39 minggu.
• Kepala Sudah memasuki PAP
• Taksiran berat janin JT : 3255 gram.
 Introduction
• A Cardiotocograph (CTG) is a
record of the fetal heart rate
(FHR) either measured from a
transducer on the abdomen or
a probe on the fetal scalp. In
addition to the fetal heart rate
another transducer measures
the uterine contractions over
the fundus
• Abbreviation:
CTG = Cardiotocograph

• What does "Cardiotocograph"

mean?
Cardio = heart
Toco = contractions (of uterus
during labour)
Graph = machine to record
• Cardiotocograph = machine to
record the heart rate (fetal
heart) and contractions of
uterus during labour
 Physiology
• During labour the fetus can
become stressed. The heart rate
of the fetus is monitored
throughout labour so stress can
be detected early. The
contractions are monitored also
so that the midwife and mother
know when the contraction is
occurring and also to check for
fetal distress during the
contraction.
 Units of measurement

• Fetal heart rate: BPM (beats per minute)

• Contractions: contractions\ 10 minutes.

• IUP: mmHg
 Typical values
• Fetal heart rate: 100 –
160 BPM

• Contractions:
3-4contractions \10min.

• IUP: 0 - 70 mmHg