3. Each myometrial
cell has proteins
plasma
membrane
involved in the
process of ion
transport and
compose the
receptor sites for
endogenous and
exogenous
substances.
Besides containing the
normal cellular
organelles, the smooth
muscle cells of the
myometrium contain
myofilaments consist of
actin and myosin. The
interaction of these two
proteins with calcium
and adenosine triphosph
ate (ATP) is the pathway
that causes the smooth
muscle cell to contract.
The cell
membrane also
contains gap
junctions that
allow
communication
from cell to cell
and provide
synchronization
during labor.
The
transmembrane
junction consists
of two protein
hemichannels
connexons.
Each of them
composed of six
connexin subunit
protein.
Synchonization
of myometrium
smooth muscle
cells cause
powerful waves
of myometrial
contraction
During labor
4. - During the process of labor, The myometrium contracts
by a positive feedback effect on
the "Ferguson reflex"),
- Strong contraction of the myometrium are influenced
by the action of the hormone oxytocin secreted by the
posterior pituitary and hormone prostaglandins from
placenta.
-Contractions of the uterus after the cervix
has been stimulated.
-During labor, the urge to push is created
by the Ferguson reflex.
-The urge to push is caused when the baby
is pressed onto the Ferguson Plexus of
nerves.
- These contractions expel the fetus from the uterus into
vagina and also constrict the blood supply to the
placenta.
-After delivery, the myometrium contracts to expel
the placenta and reduce blood loss; where the
crisscrossing fibres of middle layer compress the blood
vessels.
5. Natural resistance force
of pelvic floor and
uterine contraction
‘’HARD WORK’’
FULLY NORMAL NATURAL
PROCESS
THROUGH NORMAL
BIRTH CANAL
DUE TO NATIVE
EXPULSION FORCE
‘’WITH HELP’’
THE PROCESS OF GIVING BIRTH
WHICH REQUIRES MEDICAL HELPS
For example :
OPERATIONAL DELIVERY
(CAESAREAN -Section)
6. 1.
Feto-placental contribution :
- CRH Pituitary, ACTH Fetal adrenal
gland,glucocorticoid accelerated
production of estrogen and prostaglandins
from placenta reduce progesterone
production
2.
Increase oestrogen (increase excitability
of myometrium membranes and increase
synthesis of Prostagladin)
3.
Increase Prostaglandin (maintain labor)
4.
Decrease Progestrone (increase
contractility)
1.
Uterine distention :
- Stretching effect of the myometrium
by the growing fetus and liquor
amnii on the uterus.
7. REGULAR CONTRACTION
false labour,
It should be infrequent,
irregular, and involve
only mild cramping.
- Contraction occur when the uterine muscles tighten and
relax.
- When true labor begins, the pituitary gland releases
oxytocin. Oxytocin is a hormone that stimulates
contractions.
- True labor contractions are different from
Braxton Hicks because they make labor progress.
- Contractions usually start in the back and move around
to the front. The contractions can be felt as a cramping or
tightening sensation.
8. PASSING OF THE MUCUS PLUG
-The cervix is "plugged" with a thick piece of mucous
that helps protect fetus during pregnancy by blocking
the entrance to the uterus.
- As cervix effaces and dilates, the mucus
plug will be released.
- The mucus is discharged into the vagina and may be
clear, pink, or slightly bloody.
Time to labor?
-Few days to hours.
9. BACK LABOR
- "Back labor" refers to the pain and discomfort that
laboring women experience in their lower back
- A frequent cause of back labor is the position of the baby.
Positions such as occiput posterior (when baby is facing
the mother’s abdomen) can cause pressure from the
baby’s head to be applied to the mother’s sacrum (the
tailbone).
- The result can be intense
discomfort during labor.
10.
11.
12.
13. Starts with
Regular uterine
contractions
and ends with
beginning of
cervical dilatation
and effacement.
-Increase velocity of cervical dilatation
in short duration (4 hourts) from 3cm
to 7cm
.
Decrease velocity of cervix dilatation
from 7cm to maximum dilation (10cm)
and to full effacement : maternal os
-
It occurs because. the head descend and
is in contact with the cervix.It gives force
to cervix to dilate more (because presenting
part of fetus 9.5cm and cervical dilatation
only 7cm)
-
Cause cervix to dilate until full dilatation
- Uterine contractions become
intensively increase – more frequent,
longer, and stronger.
14. -
During active labor,the uterine divisions that are initiated phase 2 of parturition (Preparation of
Labor) become increasely evident.
-
During contraction : - upper segment becomes firm
- lower segment becomes softer,distended and more passive
-
Physiological retraction ring is formed between the upper and lower segment of the uterus.
-
Functions of lower and upper uterine segment during 1st stage of labor : the upper segment
contract,retracts and expels the fetus.In response to these contractions,the softened lower
uterine segment and cervix dilate and thereby form a greatly expanded,thinned out.
-
Fetus can pass through lower segment.
-
The upper uterine segment does not relax to its original lentgh after contraction,it becomes
relatively fixed at shorter length (retraction) : to maintain and gain expulsive force of fetus
15. -
Cervical effacement occurs because of increased myometrial activity during
uterine preparation for labor just after cervix is ripened.
-
The cervix gradually softens, shortens and becomes thinner. It is called cervical
effacement.
-
The muscular fibres at about the level of the internal cervical os are pulled
upward,or ‘taken up’,into the lower uterine segment.The condition of the external
os remains unchanged.
-
The presenting part, applied to the cervix and forming lower uterine segment
-
Because the lower uterine segment and cervix have lesser resistance during a
contraction,the uterine contraction cause pressure on the membranes and
hydrostatic action of amniotic sac in turn dilates the cervical canal.
It is called cervical dilatation.
16.
17. -
Start when cervical dilatation is complete
and end with the expulsion of the fetus
head of fetus descend passes through the muscular birth canal
PUSH (voluntary movement) occurs.
the head of fetus pressed on the muscle of pelvis causing
increase sensitivity on the stretch receptor on pelvic muscle and
cause mother to have the urge to push the fetus out from the
vagina
As the fetal head continue descend, the vaginal opens and the
fetal scalp appears.
At first, it appears slit-like then becomes oval and then circular.
This is called crowning.
As she continue pushes, using her abdominal muscles to aid the
involuntary uterine contractions, the fetus is pushed out of the
birth canal.
18. -
Occurs immediately after delivery of the
fetus.Happen 30 minutes to prevent excessive
bleeding
There are 4 classes of blood loss:
> 500 ml
= high blood loss
1L
= mild bleeding
-
250-300 ml = average blood loss
> 1.5 L
= severe bleeding
Two separate phases are involved:
•
placental separation
the placenta descent to the lower segment
and finally expulsed with the membrane
•
placental expulsion
occurs by being forced out by the effective
contraction and retraction of the uterus with
the voluntary contraction of abdominal
muscles.
19. -Occurs from the moment of the birth until 6th weeks
(If prolongation occur,it is called delay period)
-Events occur during this period :
1. There is sustained uterine contraction to prevent postpartum
hemorrhage
2. Lactogenesis (breastfeeding)
3. Uterine involution and cervical repair ( to enable the reproductive
organs to return to non-preggy state)
4. Resumption of ovulation
3 phases of postpartum period :
-The initial
or acute period
involves the first 6–12 hours postpartum. This is a time of rapid
change to occurs such as postpartum hemorrhage, uterine inversion,
amniotic fluid embolism, and eclampsia.
-The second phase (subacute postpartum period)
lasts 2–6 weeks. the changes are less rapid than in the acute
postpartum phase and the patient is generally capable of selfidentifying problems.
The third phase (delayed postpartum period)
can last up to 6 months. Changes during this phase are extremely
gradual, and pathology is rare.
20.
21. 1. IDENTIFICATION OF LABOR
To differentiate True and False Labor
Characteristics
True Labour
False Labour
Contraction
Regular and gradually short
interval
Irregular and unchanged interval
Cervical Dilatation
Yes
No
Discomfort
Back and abdomen
Lower abdomen
2. CERVICAL EXAMINATION
- Cervical effacement
- Cervical dilation
- level of station (distance between fetal part in birth canal and inshial spine)
22. 3. VAGINAL EXAMINATION
The functions of a vaginal examination are to:
•
Identify the fetal presentation and position
4 movements of vaginal examination:
1) Insert 2 fingers into vagina
2) Fingers directed posteriorly and then swept forward over the fetal head toward maternal
symphysis. During the movement, the fingers should cross the saggital suture
3)The position of 2 fontanels are ascertained.the fingers are passed to most anterior
extension of saggital suture , and fontanel there is examined and identified. Then
with a sweeping motion the fingers pass along the suture to other end of head until
the other fontanel is felt and differentiated.
4) The station, or extent to which the presenting part has descended into the pelvis, can
also be established at this time.
4. DETECTION OF RUPTURED MEMBRANE
-
Diagnosed when amniotic fluid is seen
pH determination of vagina fluid
Indicator used : Nitrazine
Vaginal fluid
pH
Amniotic fluid
4.5 – 5.5
7.0 – 7.5
23. Monitoring fetal well-being during labor
-Monitoring the fetal heart rate by using Cardiotocography (CTG)
at least every 30 minutes in first stage and then every 15
minutes during second stage.
24. Subsequent Vaginal Examination
Intravenous Fluids
-An intravenous infusion system is advantageous during the immediate puerperium to
administer oxytocin prophylactically and at times therapeutically when
uterine atony persists.
-Moreover, with longer labors, the administration of glucose, sodium, and water
to the otherwise fasting woman at the rate of 60 to 120 mL/hr prevents dehydration
and acidosis.
25. PARTOGRAM
a graphical representation that
record the observation and information
from the monitoring of the mother and
fetus.
Consists :
Maternal status
Fetal heart rate
Dilatation & descent
Uterine contractions
26. analgesia
-The pain of childbirth is likely to be the most severe pain that a
woman experiences during her lifetime.
-Analgesic that we use :
Meperidine, 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4
hours
Fentanyl, 50-100 mcg IV every hour
Nalbuphine, 10 mg IV or IM every 3 hours
Butorphanol, 1-2 mg IV or IM every 4 hours
Morphine, 2-5 mg IV or 10 mg IM every 4 hours
As an alternative, regional anesthesia may be given. Anesthesia
options include the following:
Epidural (common)
Spinal
Combined spinal-epidural
27. ACTIVE MANAGEMENT
Active management of labour (AML) is a structured protocol
for the management of all parturients in labour
with the aim of reducing prolonged labour. Its aim was to keep labour
to fewer than 12 hours and operative delivery rates to a minimum.
Two of its components are performed :
-Amniotomy
-Oxytocin
When dilation is not increased by 1cm per hour,amniotomy is
performed.After 2 hours,high dose oxytocin infused if still not dilated.
ARM, (Artificial rupture of the membranes) AMNIOTOMY
-breaking the membranes that surround the baby and releasing the amniotic fluid before
it breaks naturally itself.
-This is performed with the use of a long sharp hook similar to a crochet hook that is inserted
through vagina and cervix and used to make a small nick in the membranes allowing the
waters to escape. Patient will be required to lay on her back with her legs open while this procedure
is preformed.
-ARM’s are used to either help start labour before it is ready to started itself, or speed up a labour
that is not moving fast enough for either the care provider or the mother.
28. PREPARATION FOR DELIVERY
•
•
Positions that a woman may
adopt during childbirth
Once the cervix is fully dilated and the
woman is in the expulsive phase of the
second stage, encourage the woman to
assume the position she prefers and
encourage her to push
Most widely used is dorsal lithotomy
position.
POSITIONING FOR DELIVERY
29. PERINEUM CLEANING
-Need 6 swab balls
-Clean sequentially as shown by the numbers
-Clean according to the direction shown by the
Arrows
-Delivery must be sterile and antiseptic procedure
CREATE A STERILE FIELD
AROUND THE VAGINAL OPENING
30. EPISIOTOMY
•
Note:
–
Not a routine procedure and are
considered preventing tear
–
Associated with
• an increase of 3rd & 4th degree tears
• subsequent anal sphincter muscle
dysfunction.
Considered only in:
Do not decrease
• perineal damage
• future vaginal prolapse
• urinary incontinence
–
•
–
complicated vaginal delivery
• breech
• shoulder dystocia
• forceps
• vacuum
–
scarring from female genital mutilation or
poorly healed third or fourth degree tears
–
fetal distress.
31. ASSISTING WITH DELIVERY
•
•
•
Ritgen Maneuver is performed
As crowning occurs, place a hand on the top of the
baby’s head and apply light pressure
Instruct the mother to focus on her breathing. Have her
“pant like a dog” to help her stop pushing and prevent
a forceful birth.
DELIVERY OF THE HEAD
•
•
•
Ask the woman to pant or give only small pushes
with contractions as the baby’s head delivers
To control birth of the head, place the fingers of
one hand against the baby’s head to keep it
flexed (bent)
Continue to gently support the perineum as the
baby’s head delivers
DELIVERY OF THE
HEAD
32. DELIVERING OF THE SHOULDERS
•
•
The side of the head are grasped with two hands and gentle
traction is applied until anterior shoulder appears
Upward movement until posterior shoulder is delivered
SUCTION THE BABY’S MOUTH AND NOSE
•
Once the baby’s head delivers, ask the woman not to push
•
Suction the baby’s mouth and nose
Nuchal Cord
If the cord is around the neck, attempt to slip it over the baby’s
head
Feel around the
baby’s neck
for the umbilical cord
33. ASSISTING WITH DELIVERY
As the head
emerges, the baby will turn to one side
(for easier passage of shoulders through birth canal)
Check to see if the umbilical
cord is looped around
the baby’s neck. If so, gently slip it over the head
Use
a clean towel to catch the baby
BABY DELIVERED
FIRST BODY CONTACT OF MOTHER AND
BABY AND CORD CLAMPING
CLAMPING, CUTTING AND TYING
OF
UMBILICAL CORD
34. Expectant management
•
Talk to the woman and tell her
that you will deliver her placenta
•
Wash your hands and put on
your sterile gloves
•
After having the signs of placental separation, hold
the clamp close to the perineum with one hand.
•
Deliver the placenta by putting one hand just above
the pubic bone.
•
Tell the mother that she can strain when there is
uterine contraction
4 signs of pacental
separation :
-Uterus becomes globular
and firm
-Sudden gush of blood
-Uterus rise in the
abdomen and placenta pass
down into vagina
-Umbilical cord protrudes
farther out of vagina
35. Expectant management
•
Gently guide the placenta downward and
outward by holding on the cord.
•
Be gentle because a hard pull can tear or
break the cord and even worst, turn the
uterus inside out
•
As the uterus stays in place and the cord gets
longer , continue to guide gently until the
placenta is delivered
•
When the bulk of the placenta is out,hold it with
your two hands
•
Rotate the placenta like twisting a rope until
delivered so that the fetal membranes will come
out.
36. Expectant management
•
Feel the uterus from the abdomen
and massage it to keep it contracted.
•
Inject an oxytocin drug
intramuscularly to control bleeding.
•
The best time to inject oxytocin during
the 3rd stage of labor:
A.
After the delivery of the baby
B.
After the delivery of the placenta
38. • Went to medical university
followed by 3 years of internship
• Specialized in pregnancy and
birth with different
complications.
• Majority of Certified Nurse
Midwives
• Midwife usually only available for
woman who are healthy and with
low-risk pregnancies.
• Able to share more on emotions
• Available for home birth
• Normally only provide medical
advice
• Usually don’t provide home birth
• Cannot perform C-Sections
care.
• Able to perform C-Sections.
