Normal Delivery

makmur sitepu

Divisi FetoMaternal
Departemen Obgin FKUSU/RS. HAM

Duration of Pregnancy
Average 280 days or 40 weeks (9
months 10 days)
Estimated Date of Confinement (EDC)
Nageles 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 04 cm dilatation and It
should normally not last longer than 8 hours.
2. The active phase is from 410 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)

Powers

Minimal contraction
Duration 20 40 second
Occur 2 times / 10 minutes

Powers

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

intertuberosity diameter > 10 cm

25

HODGE
H1: above symph
- Promontorium
HII: Lower
Shymph
HIII: Spina
Isachiadica
HIV: Cocygeus

Station

 8 Cardinal Movements: (in an

anterior occiput position)
1.
2.
3.
4.
5.
6.
7.
8.

Engagement
Descent
Flexion
Internal rotation
Extension
Restitution
External rotation of the shoulders
Expulsion

Third stage
Delivery of placenta
sign of placental separation (uterine
sign, vulva sign, cord sign)
Modified Crede,
Brandt Andrew

Controlled cord traction

Controlled cord
traction

Delivery of the placenta :BrandtAndrew Maneuver

Delivery of the placenta : Modified Credes

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 3696 hrs

Biology of labor
MAKMURS

Parturition
Normal Pregnancy
Uterine quiescence
Immature fetus
Closed cervix

Parturition
Coordinated uterine activity
Maturation of the fetus
Maternal lactation
Progressive cervical dilation

Initiation of Labor

Fetus

Sheep
Fetal ACTH and cortisol
Placental 17 hydroxylase
Estradiol
Progesterone
Placental production of oxytocin, PGF2

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
1 Progesteron withdrawal.
Has quieting effect on uterus
Counterbalance estrogen.

2. Oxytocin production
Posterior pituitary
As pregnancy progresses oxytocin
receptor

3 Prostaglandin production
4 Endothelin production
Contraction smooth muscle.
High level in amniotic fluid.

5 Estrogen stimulation > 34 35 weeks.

Promotes oxytocin production in myometrium.

6 Fetal cortisol.
7 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

Calcium channel

Extracellular

Intracellular

Phospholipase C

cAMP
Ca+

+ Oxytocin
+ Prostaglandin

MLCK

Ca
store

Uterine contractions

Contraction

Prostaglandin
Fetal membranes

Rupture

KASUS

Ny. DL, usia 28 tahun, G1P0A0

HPHT = 20 November 2009
Pemeriksaan 4 jam kemudian diperoleh :

Status present
Status obstetricus

: dalam batas normal

: 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.

CARDIOTOCOGRAPH/CTC
ELECTRONIC FETAL
MONITORING

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. 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. can be
detected early by heart rate
The contractions also are
monitored

Units of measurement
Fetal heart rate: BPM (beats per
minute)
Contractions: contractions / 10
minutes.
Intra uterine pressure : mmHg

Typical values
Fetal heart rate:
100 160 BPM
Contractions:
3-4contractions /
10min.
IUP: 0 - 70 mmHg

Indications for continuous CTG/EFM

Any pregnancy considered high risk

Induction or augmentation of
labor
Decreased fetal movement
Premature labor
Premature rupture of membranes

Oligohydramnios
Hypertension
Abnormal fetal heart rate
Fetal malpresentation in
labor
IDDM
Multiple Gestation
Previous C/S
Trauma
Meconium

Interpretation
The CTG trace generally shows
two lines. The upper line is a
record of the fetal heart rate in
beats per minute.
The lower line is a recording of
uterine contractions from the
toco.

Baseline Rate
This should be between 100 and
160 beats per minute (BPM) and is
indicated by the FHR when stable
(with
accelerations
and
decelerations absent)
It should be taken over a period of
5 - 10 minutes

Bradycardia
This is defined as a baseline heart
rate of less than 110 bpm. If
between 110 and 100 it is suspicious
whereas below 100 it is pathological.
A steep sustained decrease in rate is
indicative of fetal distress and if the
cause cannot be reversed the fetus
should be delivered

Tachycardia
A suspicious tachycardia is
defined as being between 160
and 170 whereas a pathological
pattern is above 170.
Tachycardias can be indicative of:
1. fever
2. fetal infection
3. epidural

Baseline variations
The short term variations in
the baseline should be
between 10 and 15 bpm
(except during intervals of
fetal sleep which should be no
longer than 60 minutes)

Accelerations
This is defined as a transient
increase in heart rate of greater
than 15 bpm for at least 15
seconds. Two accelerations in 20
minutes is considered a reactive
trace/ reassuring.
Accelerations are a good sign

Decelerations
These may either be normal or
pathological. Early decelerations
occur at the same time as uterine
contractions and are usually due to fetal
head
Late decelerations persist after the
contraction has finished and suggest
fetal distress.

Takes home massage

A normal CTG is a good sign
but a poor CTG does not
always suggest fetal distress.
A more definitive diagnosis
may be made ex: fetal blood
sampling

Thankyou for listening