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Management of labor�Intranatal care

Vd. Sushma J. Rathod

M.S (Ayu)

Associate professor & H.O.D

Prasutitantra & Streeroga

GAC vadodara

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Aims

Maximal observation with minimal active intervention
To maintain the normalcy and to detect any deviation from normal at the earliest possible movement
Reduces maternal and perinatal mortalities & morbidity

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�

Issues

Is the patient in labour? to be kept in labour room or not?
To be augmented or not?
Monitoring protocols - what are to be adopted?
Labour assistance – in what way?

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Is the patient in labour?

A Dilemma - Wide variations in the clinical spectrum

Regular uterine contractions

Progressive dilatation of cervix

Show

Latent or active?

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Place of conduction of labour

Ayurveda says

Stay navama masa onwards
Newly built for each pt
Away from population
Wooden
Gomaya lipta & dhoopita.
Prajanana kushala,anurakta paricharika.
All necessary instruments & medications stored in.
Outsiders not allowed.

Present scenario is

Admission at onset of labour
Common for all
Within the city.
Well fumigated
Trained nursing staff
Equipped with all necessary things.
Admission restricted.

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Phases / Stages of labour

First stage of labour from onset of true labour pains to full dilatation of cervix
Second stage delivery of head, expulsion of the body
Third stage complete expulsion of the after births.
Fourth stage observation for one hour for vitals & bleeding.

Prajayini
Asanna prasava

Prasavotsuka

Parivartita garbha

Latent
Active
pelvic

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Latent phase

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Active phase

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1^st stage

Admission – when she is in true labor
Record card (booked / Unbooked)
General & obstetrics examination

(maternal well being, N presentation 7position, No CPD, N FHR)

Psychological & emotional support by attendant or caregiver
Pt Care ( Shaving of the vulva, vulva & perineum are washed with detol solution)
Enema with soap & Water
Bladder evacuation or catheterization

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Things to be considered in first examination �in labour room

Per abdominal

To confirm the gestational age and size of the fetus

To reconfirm the presentation, presenting part and its entry into the pelvis.

To see the contractility of uterus.

To confirm the fetal well being.

Per vaginal

Note the color of the show or discharges

To see the condition of cervix,

To know the presence of membranes,

To confirm presenting part and its descent,

Pelvic adequacy estimation

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General care of the labouring woman

Monitoring of vitals
Ambulation norms
Diet
Bladder and bowel care
Part preparation
Pre labour counseling
Companion

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�What is new - Acharyas suggested�

Krita swasti vachana and mangala karma
Bhoomi shayana
Mridu aastharana
Prajanana kushala stree parivritta
Ashwasana
Swaabhyakta – ushna jala parishikta
Aakanta yavagu paana
Inhalation of fine powders of Chira bilwa, shimshapa, ela langali vacha etc

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Care in first stage

Watch for the progress of labour
Early detection of the deviations from normalcy
Observation and active interference
Monitoring of Fetal wellbeing
Monitoring of maternal wellbeing

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Assessment of uterine contractions

Interval
Duration
Intensity – quantification

- manual

- tocometer

- intra uterine catheters

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Early detection of problems

Anticipated in latent phase –

watchful expectancy and masterly inactivity – as may last

from hours to days;

if no indication may allow physiology to take over.

mean duration is 4.8 to 13.6 hours in multi and in primi 6.4 to 20.6 hours.

Anticipated in Active phase – protraction,

- arrest;

- hypotonic ,

- hypertonic dysfunctions;

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Active management of labour

No patient must be in labor for more than 12 hours

No admission to labour ward before established labor

cx 4cms dilatation

Rupture of membranes

100% effacement

show

ARM and Starting oxytocin drip with 6mIu/l

Increase by 6mIu every 15 min up to max 40 mIu

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Monitoring of Fetal well being � � - Doppler� - Cardio tocograph

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Documentations and their importance

Bishops score – indicative of favorability of cervix or ripening.
Partogram .

Graphical recording of the events
Gives a good record of the maternal and fetal wellbeing
Promptly identifies the problems
Useful in medico legal aspects

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Parivritta garbha�

Paryankamena aropayeth
Vishikhantaram anulomam anusukham abhyagya
Yonim punah punah prasarayeth
Vamakarne mantram japayeth
Pravahitum upakramet
Akaale maa pravahishya
Pravahayeth shaneihi shaneihi in initial phase, pragadam garbha nirgame, yonimukham prapanne gaadha tamam avishalya bhavat.
Akala pravahane shwasa kasa pleeha prasakta……..

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Birthing positions –

In absence of any other complications comfortable position for mother can be opted for.

Birth cushion
Sitting
Squatting
Kneeling
Upright
Water births

Reports say that it results in cutting short 2nd stage, better patient co-operation and more intact perineum.

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Posture – latent phase – moving, walking, seating

-active phase- in bed –lt lateral postion

Antiseptic &Aseptic precaution (during vaginal examination & conduction of labor)
Vaginal examination ( 1^st d/b senior doctor to be more reliable & informative)
food – sips of water by mouth
Analgesic and tranquiliser

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Partograph

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

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Degree of cervical dilation in centimeter
Effacement (25%, 50%, 100%)
Membrane status (if rupture color of the liquor- clear / meconium stain/blood stain)
Presenting part and its position
Station of the head
contraction

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2^nd stage

Aim – to assist the natural expulsion of the fetus

- to prevent perineal injuries

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Pain – intensity of pain increased

- comes at intervals of 2- 3 min & last for about 1- 1 ½ min

Bearing down efforts appears during 2^nd stage of labor
Descent of the fetus

By abd exam- FHR shifted downwards & medially

Vaginal –descent of the head in relation to ischial spines

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Episiotomy
Care following delivery of the head
removal of mucus and blood fm mouth & pharynx
Eyelids are wiped with sterile cotton

3. Prevention of perineal laseration

4. Delivery of the shoulders

5. Immediate care of newborn

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3^rd stage

Separation , descent & expulsion of the placenta with membranes
Pain for short time or no pain soon after the delivery of the baby
Air passage should be clear
APGAR rating (at 1^st min & 5 min & 15 min)
Clamping and ligature of the cord

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The uterus is massaged
Examination of the placenta membrane and cord
Vulva , vagina & perineum are inspected
Watch maternal condition

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Management after delivery

Apara patana a normal phenomena
Retention is abnormal and lady cant be considered as completed labour .
Anaha ,adhmana, mala mootra sanga are the complications

Management

Vatahara upachara
Sudden jerks
Sudden raise of intra abdominal pressure
In case of failure hasta nishkasana with full antiseptic precautions.

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Care in third stage of labour

Watchful expectancy and active management
Examination of placenta and identifying the problems
Examination and repair of genital tract injuries
Maternal assessment
Neonatal assessment
Alertness to identify the complications

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Complications of third stage

Retention of placenta
Atonicity of the uterus
Injuries to the genital tract
Inversion of uterus
Pulmonary embolism
Hematomas

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Care in fourth stage of labour

General condition
Behavior of the uterus
Bleeding
Bladder care
Rest and ambulation

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