Comprehensive Admission Procedures for Labor and Delivery in High-Risk Pregnancies

2. Admission procedures Dr. F Mostajeran MD

3. Admission procedures • Urged to report early in labor • Early admittance to labar , delivery unit • especially high risk pregnancy • accurat diagnosis of labar • Falsely diagnosed , inappropriate in terrention • Not diagnosed (remot from medical personnel medical facilities)

4. Definition of labor • Uterine contractions that bring effacement and dilatation of cervix. • Painful contractions become regular • onset of labor as beginning at the time of admission to the labor unit • Admission for labor based on dilatations accompanied by painful contractions .

5. D. Diagnasis between false and true labor is difficult • Contractions of true labor • Regular intervals • Intervals gradually shorten • Intensity gradually increases • Discomfort back , abdomen • Cervix dilates • Discomfort is not stopped by sedation

6. Contractions of false labor • Irregular intervals • Intervals long • Intensity unchanged • Discomfort lawer abdomen • Cervix not dilate • Relieved by sedation

7. Pregnant woman who is having Cantractions • Emergency condition • Labor is defined as process of childbirth beginning • Latent phase delivery placenta

8. Electronic admission testing • Recommend NST or CST on all patient • (labar – delivery unit) • Fetal admission test • identify unsuspected cases

9. Vaginal examination • Amnionic fluid effacement • Cervix dilatation position • Presenting part • Station • Pelvic architecture

10. Detection of ruptured membranes • Leakage of fluid • Prolapse cord • Labor occur • Serious intra uterine infection • Nitrazine paper (PH= 7.0 – 7.5) • Arborization or ferning • Alpha – fetoprotein • Injection various dyes

11. Vital signs and review of pregnancy record • Physical examination • Preparation of vulva and perineum • Inspection and cleaning of the vulva , perineum , mini – shave - enema

12. Friedman • Three functional divisions of labor • Preparatory division: Little cervical dilatation Considerable change • Dilatational division : Most rapid rate • pelvic division: Deceleration phase of cervix - dilatation Cardinal fetal movements

13. Cervical dilatation • Latent phase (14-20h) • Active phase: acceleration ,phase of maximum slope , deceleration phase

16. Management first stage of labor • Remainder of general physical exam is completed • HCT HB protein - glocose • average duration first stage of labor • 7 hours in nulliparous w • 4 hours in parous w

18. Fetal monitoring during labar • Contractions and response FH • Suitable stethoscopc , doppler ultrasonic devices • FH should be checked after contractions • every 30 minutes (15) • Second stage every 15 minutes (5) • Cantinous electronic monitoring

19. MATERNAL MONITORING • Vital signs • T , pulse , BP every 4/h • PROM temprature every 1/h • 18 h of PROM antimicrobial

20. Subsequent vaginal examinations • When membrans rupture if head was not Defenetly engaged • fetal H immediately and during the next uterine contraction • (occult umbilical cord compression) • periodic examinations at 2-3 hours interval

21. Oral intake • Gastric emptying time prolanged (food – medication remain in the stomach – not absorbed may be vomited) • Food should be withheld • Intravenous fluids • Infusion system routine early labar (IV line) • Longer labors glucose sodium water 60-120 ml/hr

22. Maternal position during labor • normal laboring woman • Not be confined to bed • Comfortable chair • In bed position most comfortabl (lateral recumbend)

23. Analgesia • Is initiated on the basis of maternal discomfort • vaginal examination befor administration of analgesia (delivering a depressed infant) • Timing , method and size of initial and subsequent dose , interval of time until delivery

24. Amniotomy • There is a great temptation • Benefits: rapid labor detection of meconium staining • Internal fetal M • Aseptic technique • Head must be well applied to the cerxin

25. Urinary bladder function • Bladder distention avoid • Abstracted labor • Subsequent bladdes hypotonia, infection • Suprapubic region shauld be visualized , palpated detect filling bladder • If could not void on a bedpan • Intermittent catheterization

26. Management of second stage labor • Full dilatation of the cervix • Begins to bear dawn • 50 minutos in nulliparous • 20 minutos in multiparous

27. Higher parity 2-3 expulsive efforts may suffice Complete the delivery of the infant • FHR • Low – risk 15 H.risk 5

28. Fetal H.R • Contraction – maternal expulsive efforts • FHR are not consequence of head compression • Descent fetus and reduction in uterine volume • some degree of premature separation placenta

29. tighten a loop or loops of umbilical cord • Around the fetus umbilical blood flow • Prolonged uninterrupted maternal expulsive efforts dangerous to the fetus

30. Preparation for delivery • Variety of positions • Dorsal lithotomy position • For beter exposure legholders stirrups • Cramps in the legs (brief massage – changing position) • Preparation for delivery entails vulvar and perineal cleansing

31. Spontaneous delivery • Delivery of the head • Contraction perineum bulges • Vulvovaginal opening becomes more dilated • Gradually circular opening • This encirclement of the largest head • By the vulvar ring is known as crowning

32. Perineum is extremely thin • Episiotomy , laceration • Episiotomy risk tear external anal – rectum • Episiotomy - anterior tear urethra , labia

33. Ritgen manover • Vaginal introitus 5 cm • Towel – draped , gloved hand forward pressure • on the chin of the fetus • other hand exerts pressure superiorly against occiput

34. Cleaning the nasopharynx • Minimize aspiration AF – debris , blood • once thorax is delivered • face quickly wiped nause , mouth are aspirated

35. Following delivery of anterior shoulder • Finger should be passed to the neck • Nuchal cords 25% + • Drawn down , loose – slipped over the head • Clamping the cord • 4-5 cm , 2-3 cm fetal abdomen two clamps • Plastic cord clamp

36. Timing of cord clamping • Infant is placed at or below vaginal interoitus 3 , 80ml of blood shifted from placenta to infant • 80ml 50mg Iron , Iron deficiency anemia • Maternal alloimmunization • our policy after cleaning airway 30" cord clamp

37. Management of the third stage • After delivery of the infant • Height uterine fundus • Uterus firm , no unusual bleeding • Waiting until placentac separat – no massage • Hand rest on the fundus (atonic – filled with blood)

38. Signs of placental separation • uterus becames globular firm • Sudden gush of blood • Uterus rises (placenta separated , passes dawn to lower u-segment • Its balk pushes uterus upward • Umbilical cord protrudes forther out

39. delivery of the placenta • Traction on the umbilical cord must not be used inversion • Manaol removal of placenta • occasionally placenta will not separat • At any time brisk bleeding and , placenta can not be delivered • Active management of the third stage • 5 units oxytocin +0.5 ergometrine • reductian in the length of third stage

40. Fourth stage of labor • Exam placenta , membranes , umbilical cord • Completeness , anomalies • Hour immediately fallowing delivery • Critical fourth stage of labor • uterine atony , BP , pulse every 15

41. Oxytocic Agents • Oxytocin (pitocin , syntocinon) • Methylergo novine maleat (methergine) • Reduce blood loss by stimuloting myometrial contraction • Iml 10IU half – lifc IV 3 • Inapropriate dose kill the fetus ,rupture uterus

42. Cardiovascular effects • Deleterious effects follow IV bolus • Antidiuresis • rare maternal convulsion antidiuretic action • Water intoxication (20,40mu/minut ) • Concentration should be increared rather than rate of flow • Normal saline are lactated ringer solution

43. Ergonovine and methylergonavine • IV – IM – orally no differenc in actions • Sensitivity of pregnant uterus is very great • In pregnancy 0.1my IV , 0.25my oral tetanic Uterine contraction • Tetanic effect prerention , control PPH • IV administration sometimes tram sient , severe hypertension

44. Prostaglandins • Not used routinely • Manage ment PPH • PG F2x 250ng IM (15-90" ) 8does 88% successful • 20% side effects diarrhea ,hypertension vomiting , Fever , flushing , tachycandia • PG E2 20-mg suppositories

45. Lacerat ons of the Birth canal • Classified • First fourchette , perineal skin vaginal mucous • Second fascia and muscles of perinealbody • Third anal sphincter • Fourth retal mucosa

46. Episiotomy and repair • Incision of pudenda • Perineotomy incision of perineu • Episiotamy synonymously with penineotomy • Begin in midline : • Directed laterally mediolateral • Directed down ward midline

47. Timing of episiotomy • Perform when head is visible during contraction 3-4 • After application of blades • Timing of repair • Most common practice repair until placenta delivered • Technique • Hemostasis • Anatomical restoration without excessive suturing • Chromic catgut 3-0

48. Fourth – degree laceration • Various techniques remcommend • Esential approximat torn edges rectal mucosa • With muscularis sutures 0.5cm apart • Muscular layer covered with a layer of fascia

49. Labor with occiput presentations • 95% fetus occiput or vertex presentation • Most commonly ascertained ab – exam • Confirmed V.Examination before or at the onset of labor • Sagitlal suture in the transrevse pelvic diameter • LOT , ROT , LOA , ROA • ROP , LOP (narrow forepelvis , anterior placentation