Antepartum haemorrhage

It is defined as bleeding from or into the genital tract after the 28th week of pregnancy but before the birth of baby. The first and second stage of labour are thus included. The 28th week is taken arbitarily as the lower limit of fetal viability.

Causes -
The causes of antepartum haemorrhage fall into the following categories. On an average, the incidence of placenta praevia, abruptio placentae and indeterminate group is almost same.

Effect of excessive vomiting in pregnancy

1. Metabolic changes -
- Inadequate intake of food results in glycogen depletion. For the energy supply, the fat
  reserve is broken down.
- Due to low carbohydrate, there is incomplete oxidation of fat and accumulation of ketone
  bodies in the blood.
- The acetone is ultimately excreted through the kidneys and in the breath.
- There is also increase in endogenous tissue protein metabolism resulting in excessive
  excretion of non-protein nitrogen in the urine.
- Water and electrolyte metabolism are seriously affected leading to biochemical and
  circulatory changes.

2. Biochemical changes - 
- Loss of water and salts in the vomitus resulting in fall in plasma sodium, potassium
  and chlorides.
- The urinary chloride may be well below the normal 5 gm/litre or may even be absent.
- Hepatic dysfunction results in acidosis and ketosis with rise in blood urea and uric acid ,
  hypoglycaemia, hypoproteinaemia, and hypovitaminosis.

3. Circulatory changes - 
There is haemoconcentration leading to rise in haemoglobin percentage, RBC count and
haematocrit values. There is slight increase in the white cell count with increase in eosinophils.
There is concomitant reduction of extracellular fluid.

Hyperemesis gravidarum during pregnancy

It is a severe type of vomiting of pregnancy which has got deleterious effect on the health 
of the mother and/or incapacitates her in day to day activities.

Incidence - Less than 1 in 1000 pregnancy.

Etiology -
The etiology is obscure but the following are the known facts :
- It is mostly limited to the first trimester.
- It is more common in first pregnancy.
- It has got a familial history -mother and sister also suffer from the same manifestation.
- It is more prevalent in multiple pregnancy.
- It is more common in unplanned pregnancies.

Causes -
The exact causes are not known. There are some theories for hyperemesis gravidarum.
1. Hormonal - Progesterone excess leading to relaxation of the cardiac sphincter and
    simultaneous retention of gastric fluids due to impaired gastric motility.
2. Psychogenic - It probably aggravates the nausea once it begins. But neurogenic element
    sometimes plays a role, as evidenced by its subsidence after shifting the patient from the
    home surroundings.
3. Dietary deficiency - Probably due to low carbohydrate reserve, as it happens after a night
    without food.
4. Allergic or immunological basis.
5. Decrease gastric motility is found to cause nausea.

Sign and symptoms -
- Dry coated tongue.
- Sunken eyes.
- Acetone smell in breath.
- Tachycardia.
- Hypotension.
- Rise in temperature.
- Oliguria.
- Epigestric pain.
- Constipation.

Management -
Principles -
- To control vomiting.
- To correct the fluids and electrolytes.
- To prevent or to detect complications at earliest stage.

Hospitalization - 
Whenever a patient is stamped as a case of hyperemesis gravidarum, she is admitted in hospital.

Fluids - 
Oral feeding is withheld for at least 24 hours after the cessation of vomiting. During this period,
fluid is given through intravenous drip method. The amount of fluid to be infused in 24 hours is
approximate 3 litres, of which half is 5% dextrose and half is Ringer's solution.

Drugs -
a) Antiemetics drugs
- Promethazine (Phenargan) 25 mg
- Prochlorperazine (Stemetil) 5 mg
- Triflupromazine (Siquil) 10 mg
may be administered twice or thrice daily IM.
b) Nutritional support with vitamin B1, B6, B12 and vitamin C are given.

Diet -
- At first, dry carbohydrate foods like biscuit, bread and toast are given.
- Small but frequent feeds are recommended.

Complications -
- Neurological complications such as peripheral neuritis.
- Stress ulcer in stomach.
- Esophageal tear or rupture.
- Jaundice.
- Deep vein thrombosis.

Vomiting in pregnancy (morning sickness)

Vomiting is a symptoms which may be related to pregnancy or may be a manifestation of
some medical-surgical-gynaecological complications which can occur at any time during
pregnancy. It commonly occur between 5 to 18 weeks of pregnancy.

Causes -
The causes of vomiting is not clear. Several theroies such as increased level of the stomach
contents, increased hormone level, acute fulminating preeclampsia and psycological factors
have been proposed.

Types -
The vomiting related to pregnant state and depending upon the severity, it is classified as :
a) Simple vomiting of pregnancy
b) Hyperemesis gravidarum


                   Simple vomiting (morning sickness or emesis gravidarum)
The patient complains of nausea and occasional sickness on rising in the morning. Slight
vomiting is so common in early pregnancy (about 50% of women) that it is considered as
a symptom of pregnancy. The vomitus is small and clear or bile stained.
It does not produce any impairment of health or restrict the normal activities of the women. 
The features disappears with  or without treatment by 12-14th week of pregnancy.

Management -
- Taking of dry toast or biscuit and avoidance of fatty and spicy foods are enough to relieve
  the symptoms in majority.
- Avoiding food or not eating may actually make nausea worse. Try eating to avoid an empty 
  stomach, which may aggravate nausea.
- Antiemetic drugs- trifluoperazine 1 mg twice daily.
- Patient is advised to take plenty of fluids and fruit juice.


                                        Hyperemesis gravidarum 
It is a severe type of vomiting of pregnancy which has got deleterious effect on the health of
the mother and/or incapacitates her in day to day activities. For details about hyperemesis
gravidarum, visit the following page :
http://pregnancyandlabour.blogspot.in/2014/01/hyperemesis-gravidarum-during-pregnancy.html

Management of normal puerperium

Immediately following delivery, the patient should be closely observed. She may be given
a drink of her choice or something to eat, if she is hungry.

Principles - 
- To give all out attention in to restore the health status of the mother.
- To prevent infection.
- To take care of the breasts, including promotion of lactation and nursing of the child.
- To motivate the mother for contraception.

General management -

Rest and ambulance -
It is indeed difficult to categories an uniform period of rest. After a good resting period,
the patient becomes fresh and can breast feed the baby or moves out of bed to go to the
toilet. Early ambulation is encouraged.

Que. - What is the benefits of early ambulation after delivery ?
Ans. -  Advantages of early ambulation are:
           - Provide a sense of well-being.
           - Bladder complications and constipation are reduced.
           - Facilitates uterine drainage.
           - Hastens involution of uterus.
           - Lessens puerperal venous thrombosis and embolism.

Hospital stay -
Early discharge from the hospital is an almost universal procedure. If adequate supervision
by trained health visitors is provided, there is no harm in early discharge.

Diet -
The patient should be on normal diet of her choice. If the patient is lactating, high calories,
adequate protein, fat, plenty of fluids, minerals and vitamins are to be given.

Care of the bladder -
The patient is encouraged to pass urine following delivery as soon as convenient. If the patient
fails to pass urine, catheterisation should be done. Catheterisation is also indicated in case of
incomplete emptying of bladder.

Care of the bawel -
The problem of constipation is much less because of early ambulation and liberalisation of the
dietary intake. A diet containing sufficient roughage and fluids is enough to move the bowel.
If necessary, mild laxative such as Igol (isopgol husk) two teaspoons may be given at bed time.

Sleep -
The patient is in need of rest, both physical and mental. So she should be protected against
worries and undue fatigue. Sleep is ensured providing adequate physical and emotional support.

Care of the vulva and episiotomy -
Shortly after delivery, the vulva and buttocks are washed with soapwater down over the anus
and a sterile pad is applied. The patient should look after personal cleanliness of the vulval
region. The perineal wound should be dressed with spirit and antiseptic power after each act
micturition and defaecation or at least twice a day.

Care of the breast -
The nipple should be washed with sterile water before each feeding. It should be cleaned
and kept dry after the feeding is over. Nipple soreness is avoided by frequent short feeding
rather than the prolonged feeding, keeping the nipple clean and dry.

Lactation suppression

Suppression of lactation becomes necessary if the baby is born dead or dies in the neonatal
period or if breast feeding is contraindicated.

Mechanical method for lactation suppression -
It may be used in cases where the lactation is to be suppressed after the establishment of
milk secretion.
i) The patient should stop breast feeding.
ii) She should not express or pump out the milk from the breast.
iii) A tight compression bandage is applied for about 2-3 days.
iv) Analgesic tablet containing aspirin and ice packs are given to given to relieve pain and
    breast engorgement.

Drugs for lactation suppression - 
Bromocriptine (dopamine agonist that inhibits prolactin) 2.5 mg, 1 tablet daily for 10-14 days
may be given (with caution).
Side effects are:
- Hypertension
- Rebound breast engorgement
- Myocardial infarction
- Puerperal stroke.
Puerperal breast engorgement though painful, is never fatal.

Milk production

A healthy mother will produce about 500-800 ml of milk a day to feed her infant with
about 500 Kcal/day. This requires about 600 Kcal/day for the mother which must be
made up from the mother's diet or from her body store. For this purpose a store of
about 5 kg of fat during pregnancy is essential to make up any nutritional deficit during
lactation. With the exception of iron and calcium, almost all other nutrients are provided
in a well balanced diet.

Stimulation of lactation -
Mother is motivated as regard the benefits of breast feeding since the early pregnancy.
No prelacteal feeds (honey, water) are given to the infant.
Following delivery important steps are -
- To put the baby to the breast at 2-3 hours interval from the first day.
- Plenty of fluids to drink.
- To avoid breast engorgement .
- Early and exclusive breast feeding in correct position are encouraged.

Que. - What is the cause of lactation failure or inadequate milk production ?
Ans. - It may be due to infrequent suckling or due to endogenous suppression of prolactin
          (pyridoxin, diuretics or retained placental bits). Unrestricted feeding at short interval
          is helpful in milk production.

Drugs to improve milk production -
Metoclopramide (10 mg thrice daily) increases milk volume about 60-100% by increasing
prolactin levels. Sulpuride (dopamine antagonist) has also been found effective.

Scheme of amenorrhoea in lactating mother

Lactation after delivery

For the first two days following delivery, no further anatomic changes in the breasts occur. The secretion from the breast called colostrum which starts during pregnancy becomes more abundant.

                 Percentage composition of colostrum and breast milk

	Protein	Fat	Carbohydrate	Water
Colostrum   Breast milk	8.6      1.2	2.3      3.2	3.2          7.5	86       87

Advantages -
- The antibodies provides immunological defence to new born.
- It has laxative action on the baby because of large fat globules.

Physiology of lactation -
Although lactation starts following delivery, the preparation for effective lactation starts during pregnancy. The physiological basis of lactation is divided into four phages:
a) Preparation of breast (Mammogenesis).
b) Synthesis and secretion from the breast alveoli (Lactogenesis).
c) Ejection of milk (Galactokinesis).
d) Maintenance of lactation (Galactopoiesis).

Mammogenesis -
Pregnancy is associated with a remarkable growth of both the ductal and lobulo-alveolar systems. An intact nerve supply is not essential for the growth of the mammary gland during pregnancy.

Lactogenesis -
Milk secretion actually starts on 3rd or 4th day after delivery. Around this time, the breasts become engorged, tense, tender and feel warm. Inspite of a high prolactine level during pregnancy, milk secretion is kept in abeyance. Probably, the steroids estrogen and progesterone circulating during pregnancy make the breast tissue unresponsive to prolactin. When the estrogen and progesterone are withdrawn following delivery, prolactin begins its milk secretory activity in previously fully developed mammary glands.

Galactogenesis -
Discharge of milk from the mammary glands depends not only on the suction exerted by the baby during suckling but also on the contractile mechanism which expresses the milk from the alveoli into the ducts.
During suckling, a conditioned reflex is set up. The ascending tackle impulses from the nipple and areola pass via hypothalamus to synthesize and transport oxytocin to the posterior pituitary. Oxytocin produces contraction of the myopithelial cells of the alveoli and the ducts containing the milk. This is the 'milk ejection' or 'milk let down' reflex the milk is forced down into the ampulla of the lactiferous ducts, wherefrom it can be expressed by the mother or sucked out by the baby.

Galactopoiesis -
Prolactin appears to be the single most important galactopoietic hormone. For maintenance of effective and continuous lactation, suckling is essential. It is not only essential for the removal of milk from the glands, but it also causes the release of prolactin. Secretion is a continuous process unless suppressed  by congestion or emotional disturbances. Milk pressure reduces the rate of production and hence periodic breast feeding is necessary to relieve the pressure which in turn maintains the secretion.

Breast milk for premature infant is beneficial by many ways (psychological, nutritional and immunological). Metabolic disturbances like azotemia, hyper amnioacidemia and metabolic acidosis are less with breast milk compared to formula. It gives immunological protection to the premature infant.

Physiological changes after delivery

Pulse -
For a few hours after normal delivery, the pulse rate is likely to be raised,
which settles down to normal during the second day. However, the pulse rate
often rises with after-pain or excitement.

Temperature - 
The temperature should not be above normal temperature within first 24 hours.
Genito-urinary tract infection should be excluded if there is rise of temperature.

Urinary tract -
Dilated ureters and renal pelvis return to normal size within 8 weeks. 'Clean catch'
sample of urine should be collected and sent for examination and contamination
with lochia should be avoided.

Gastro-intestinal tract - 
Increased thirst in early puerperium is due to loss of fluid during labour, in the
lochia, diuresis and perspiration. Slight intestinal paresis leads to constipation.

Weight gain - 
In addition to the weight loss as a consequence of the expulsion of the uterine
contents, a further loss of about 2 kg occurs during puerperium chiefly caused
by diuresis.

Fluid loss - 
There is a net fluid loss of at least 2 litres during the first week. The amount of loss
depends on the amount retained during pregnancy, dehydration during labour and
blood loss during delivery.

Blood values - 
Immediately following delivery, there is slight decrease of blood volume due to
dehydration and blood loss. The blood volume returns to the non-pregnant level
by the second week. RBC volume and haematocrit values returns to normal by
the end of first week.

Menstruation and ovulation -
- The onset of the first menstrual period following delivery is very variable and
  depends on lactation.
- If the woman does not breast feed her baby, the menstruation returns by 6th week 
  following delivery in about 40% and by 12th week in 80% of cases.
- A woman who is exclusively breastfeeding, the contraceptive protection is about
  98% upto 6 months after delivery.
- Non-lactating mother should use contraceptive measures after 3 weeks and the 
  lactating mother after 3 months of delivery.

Lochia: Normal bleeding and discharge after birth

                                                LOCHIA

It is the vaginal discharge for the first fortnight during puerperium. The discharge
originates from the uterine body, cervix and vagina.

Odour and reaction -
It has got a particular offensive fishy smell. Its reaction is alkaline tending to becomes
acid toward the end.

Composition -
Depending upon the variation of the colour of the discharge, it is named as

Name	Colour	Duration	Composition
Lochia rubra	Red	1-4 days	Blood, shreds of fetal membranes and deciduas, vernix caseosa, lanugo and meconium
Lochia serosa	Yellowish or pink	5-9 days	Leucocytes, wound exudates, mucous from the cervix and micro-organisms
Lochia alba	Pale white	10-15 days	Decidual cells, leucocytes, mucous, cholestrin crystals, fatty and granular epithelial cells and micro-organisms

Amount -
The average amount of discharge for the first 5-6 days, is estimated to be 250 ml.

Normal duration -
It may extend up to 3 weeks.

Clinical importance -
The character of the lochial discharge gives useful information about the abnormal
puerperal state. The vulval pads are to be inspected daily to get information.

• Odour :- If offensive, indicates infection.
• Amount :- Scanty or absent - signifies infection. If excessive - indicates infection.
• Colour :- Persistence of red colour beyond the normal limit signifies subinvolution                      or retained bits of conceptus.
• Duration :- Duration of the lochia alba beyond 3 weeks suggests genital lesion.

Puerperium period (Involution of uterus)

Puerperium is the period following childbirth during which the body tissues,
specially the pelvic organs revert back approximately to the pre-pregnant state
both anatomically and physiologically.

Duration -
Puerperium begins as soon as the placenta is expelled and lasts for approximately
6 weeks when the uterus becomes regressed almost to the non-pregnant size.
The period is arbitrarily divided into -
a) Immediate - within 48 hours
b) Early - upto 7 days
c) Remote - upto 6 weeks.

Involution of the uterus - 

Anatomical consideration - 
Uterus -
Immediately following delivery, the uterus becomes firm and retracted with
alternative hardening and softening. The uterus measures about 20*12*7.5 cm
(length, breadth & thickness) and weight about 1000 gm. At the end of 6 weeks,
its measurement is almost similar to that of the non-pregnant state and weight
about 60 gm.

Lower uterine segment -
Immediately following delivery, the lower segment becomes a thin, flabby,
collapsed structure. It takes a few weeks to revert back to the normal shape
and size of the uterus, that is the part between the body of the uterus and
internal opening (os) of the cervix.

Cervix - 
The cervix contracts slowly; the external os admits two fingers for a few days
but by the end of first week, narrow down to admit the tip of finger only.

Physiological consideration - 
The physiological process of involution is most marked in the body of the uterus.
Changes occur in following component -
a) Muscles
b) Blood vessel
c) Endometrium.

Muscles -
There is marked hypertrophy and hyperplasia of muscle fibers during pregnancy
and the individual muscle fiber enlarges to the extent of 10 times in length and
5 times in breadth. During puerperium, the number of muscle fibers is not
decreased but there is number of muscle fibers is not decreased but there is
substantial reduction of the myometrial call size.

Blood vessels -
The changes of the blood vessels are pronounced at the placental site. The arteries
are constricted by contraction of its way and thickening of the intima followed by
thrombosis. New blood vessels grow inside the thrombi.

Endometrium -
Following delivery, the major part of the decidua is cast off with the expulsion of
the placenta and the membranes, more at the placental site. The endometrium left
behind varies in thickness from 2-5 mm. The superficial part containing the
degenerated decidua, blood cells and bits of fetal membranes becomes necrotic
and is cast off in lochia. Regeneration occurs from the epithelium of the uterine
gland mouths and interglandular stromal cells. Regeneration of the epithelium is
completed by 10th day and the entire endometrium is restored by the day 16,
except the placental site it takes about 6 weeks.

Clinical assessment of involution -
The rate of involution of the uterus can be assessed clinically by noting the height
of the fundus of the uterus in relation to the symphysis pubis. The measurement
should be taken carefully at fixed time every day, preferably by the same observer.
Bladder must be emptied beforehand and preferably the bowel too, as the full
bladder and the loaded bowel may raise the level of the fundus of the uterus.
The uterus is to be centralised and with a measuring tape, the fundal height is
measured above the symphysis pubis. Following delivery, the fundus lies about
13.5 cm above the symphysis pubis. During the first 24 hour, the level remains
constant, thereafter there is a steady decrease in height by 1.25 cm in 24 hours,
so that by the end of second week the uterus becomes a pelvic organ.

Episiotomy procedure

A surgically planned incision on the perineum and posterior wall during
the second stage of labour is called episiotomy.

Objectives :-
- To enlarge the vaginal introitus for safe delivery.
- To minimise overstretching of perineal muscles.
- To reduce the stress and strain on the fetal head.

Indication :-
- To in-elastic perineum.
- Big baby.
- Breech delivery.
- Shoulder dystocia.
- Face to pubis delivery.
- Operative delivery.
- Previous perineal surgery.

Timing :-
Just prior to crowning.

Advantages :-
- A clear controlled incision is easy to repair and heal.
- Reduction in the duration of second stage.
- Reduction of trauma to pelvic floor muscles.
- It minimise intracranial injuries of fetus.

Types :-
It has four types -
1. Medio-lateral episiotomy
2. Median episiotomy
3. Lateral episiotomy
4. 'J' shaped episiotomy
Mostly used episiotomy is medio-lateral.

Steps of medio-lateral episiotomy :-
Step 1 (preliminaries) :- Perineum is swabbed with antiseptic lotion.
Step 2 (incision) :-  The incision is made by a sharp scissors.
Step 3 (repair) :- The repair is done soon after expulsion of placenta.

Equipments for normal delivery

For mother -

Sterile delivery pack containing - 

1. Articles for cutting and suturing an episiotomy

- Episiotomy scissors 

- Artery clamps - 3

- Tissue forceps - 1

- Needle holder - 1

- Syringe and needle for infiltration - 10 ml

2. Scissors for cutting the cord

3. Bowl for cleaning solution
4. Basin to receive placenta
5. Cotton balls
6. Gauze pieces
7. Towel to cover the hand supporting the perineum
8. Sterile gown
9. Leggings for mother
10. Apron, gloves and mask for staff

For new born -
1. Baby blanket or flannel cloths - 2
  - One to receive and dry the baby of excess secretion and another to wrap the baby.
2. Neonatal resuscitation equipment
3. Oxygen cylinder with tubing
4. Suction apparatus and mucous extraction
5. Cord clamps
6. Bulb syringe for nasal oropharyngeal suctioning of the baby

Other articles -
- Antiseptic lotion - savlon or dettol
- Suture material
- Perineal pads for mother
- Sterile gloves
- Methergin
- Lignocaine 2%

Mechanism of birth

The series of movements that occur on the head in the process of adaptation,
during its journey through the pelvis, is called mechanism of labour.
The principle movements are :-
  1. Engagement
  2. Discent
  3. Flexion
  4. Internal rotation
  5. Crowning
  6. Extension
  7. Restitution
  8. External rotation of the head and internal rotation of the shoulder
  9. Delivery of the shoulder and trunk.

Engagement -
The fetus head enters in brim (inlet) is called engagement. In primigravidae,
engagement occurs before the onset of labour while in multiparae, engagement
occurs in late first stage with the rupture of membranes.

Descent -
Provided there is no undue bony or soft tissue obstruction, descent is a continuous
process. It is slow in first stage but pronounced in second stage. It is completed
with the expulsion of the fetus. Factors facilitating are
- Uterine contraction and retraction.
- Bearing down efforts.

Flexion -
As the head meets the resistance of the birth canal during descent, full flexion is
achieved. Flexion is achieved either due to the resistance offered by the unfolding
cervix, the walls of the pelvis or by the pelvic floor.

Internal rotation -
It is a movement of great importance without which there will be no further descent.
It is probably due to slope of pelvic floor, pelvic shape and inequalities in flexibility
of component parts of the fetus. Torsion of the neck is an inevitable phenomenon
during internal rotation of head. There is no movement of the shoulders from the
oblique diameter as the neck sustains a torsion of only 1/8th of a circle.

Crowning -
After internal rotation of the head , further descent occurs until the subocciput lies
underneath the pubic arch. At this stage, the maximum diameter of the head
(biparietal diameter) stretches the vulval outlet without any recession of the
head even after the contraction is over - called ''crowning of the head''.

Extension -
Delivery of the head takes place by extension through 'couple of force' theory.
The driving force pushes the head in a downward direction while the pelvic floor
offers a resistance in the upward and forward direction. The downward and upward
forces neutralise and remaining forward thrust helping in extension.

Restitution -
It is visible passive movement of the head due to untwisting of the neck sustained
during internal rotation.

External rotation -
It is movement of rotation of the head visible externally due to internal rotation
of the shoulders.

Birth of shoulders and trunk -
After the shoulders are positioned in antero-posterior diameter of the outlet, further
descent takes place until the anterior shoulder escapes below the symphysis pubis
first. By a movement of lateral flexion of the spine, the posterior shoulder sweeps
over the perineum. Rest of the trunk is then expelled out by lateral flexion.

Fourth stage of labour

It is not included in labour process. It is only observational stage in which 
the condition of the patient is observed after the delivery of the baby. 
Pulse, blood pressure, behaviour of the uterus and any abnormal vaginal bleeding
is to be watched at least for one hour after delivery. When fully satisfied that
the general condition is good, pulse and blood pressure are steady, the uterus
is well contracted and there is no abnormal vaginal bleeding, the patient is sent
to the ward.

If the placenta is not delivered

Expulsion of placenta -
Only when the features of placental separation and its descent into the lower segment
are confirmed, the patient is asked to bear down simultaneously with the hardening of
the uterus. The raised intra-abdominal pressure is often adequate to expel the placenta. 
If the patient fails to expel. one can wait safely upto 10 minutes if there is no bleeding.
As soon as the placenta passes through the introitus, it is grasped by the hands and
twisted round and round with gentle traction so that the membranes are stripped intact.
If the membranes threaten to tear, they are caught hold of by sponge holding forceps and
in similar twisting movements the rest of the membranes are delivered.

If the spontaneous expulsion fails or is not practicable, because of delivery under 
anaesthesia, any one of the following methods can be used to expendite expulsion.

i) Controlled cord traction -
The palmar surface of the fingers of the left hand is placed (above the symphysis pubis)
approximately at the junction of upper and lower uterine segment. The body of the uterus
is pushed upwards and backwards, towards the umbilicus while by the right hand steady
tension (but not too strong traction) is given in downward and backward direction holding
the clamp until the placenta comes outside the introitus. The procedure is to be adopted
only when the uterus is hard and contracted.

ii) Fundal pressure -
The fundus is pushed downwards and backwards after placing four fingers behind the
fundus and the thumb in front using the uterus as a sort piston. The pressure must be
given only when the uterus becomes hard. If it is not, then make it hard by gentle rubbing.
The pressure is to be withdrawn as soon as the placenta passes through the introitus.
The uterus is massaged to make it hard, which facilitates expulsion of retained clots if any.
Injection of oxytocin (5-10) I.V. or methergin 0.2 mg is given intramuscularly.
Oxytocin is more stable and has lesser side effects.

Management of third stage of labour

Third stage is the most crucial stage of labour. Previously uneventful first and second
stage can become abnormal within a minute with disastrous consequences.

Principles -
To ensure strict vigilance and to follow the management guidelines strictly in practice
so as to prevent the complications, the important one being postpartum haemorrhage.

Steps of management -
Two methods of management are

• Expectant management
• Active management

1. Expectant management (traditional) -
In this management, the placental separation and its descent into the vagina are allowed to
occur spontaneously. Minimal assistance may be given for the placental expulsion if it needed.
- Constant watch is mandatory and the patient should not be left alone.
- If the mother is delivered in the lateral position, she should be changed to dorsal position to
  note features of placental separation and to assess the amount of blood loss.
- A hand is placed over the fundus -
   a) to recognise the signs of separation of placenta.
   b) to note the state of uterine activity - contraction and retraction.
   c) to detect, though rare, cupping of the fundus which is an early evidence of intervention
      of the uterus.
- Placenta is separated within minutes following birth of the baby. A watchful expectancy can
  be extended up to 15-20 minutes. In some institutions, ''no touch'' or ''hands off'' police is
  employed. The patient is expected to expel the placenta within 20 minutes with the aid of gravity.

Expulsion of placenta -
When the placenta descent into the lower uterine segment, the patient is asked to bear down
simultaneously with the hardening of the uterus. The raised intra-abdominal pressure is often
adequate to expel the placenta.

Examination of the placenta, membrane and cord -
The placenta is placed in a tray and is washed out in running tap water to remove the blood
and clots. The maternal surface is first inspected for its completeness and anomalies.
The maternal surface is covered with greyish decidua (spongy layer of decidua basalis).
Normally the cotyledons are placed in close approximation and any gap indicates a missing
cotyledon. The membranes - chorion and amnion are to be examined carefully for completeness
and presence of abnormal vessels indicative of succenturiate lobe. The amnion is shiny but the 
chorion is shaggy. The cut end of the cord is inspected for number of blood vessels. Normally,
there are two umbilical arteries and one umbilical vein.
Vulva, vagina and perineum are inspected carefully for injuries and to be repaired, if any.
The episiotomy wound is now sutured.

2. Active management of third stage -

Advantages -
- To minimise blood loss in third loss.
- To shorten the duration of third stage.

Procedures -
Inj. ergometrine 0.25 mg or methergin 0.2 mg is given intravenously following the birth of
anterior shoulder. If administered prior to this, there is chance of imprisonment of the shoulder
behind the symphysis pubis. If the placenta is not delivered, it should be delivered  by
controlled cord traction technique.

Mechanism of separation of placenta

Marked retraction reduces effectively the surface area at the placental
site to aboutits half. But as the placenta is inelastic, it can not keep pace
with such an extent of diminution resulting in its buckling. A shearing force 
is instituted between the placenta and the placental site which bring about 
its ultimate separation. The plane of separation runs through deep spongy
layer of decidua basahs so that a variable thickness of decidua covers the
maternal surface of separated placenta.

There are two way of separation of placenta.

1. Central separation - 

Detachment of placenta from its uterine attachment starts at the centre
resulting in opening up of few uterine sinuses and accumulation of blood
behind the placenta (retroplacental haematoma). With increasing contraction,
more and more detachment occurs facilitated by weight of the placenta and
retroplacental blood until whole of the placenta gets detached.

2. Marginal separation - 

Separation starts at the margin as it is mostly unsupported. With progressive
uterine contraction, more and more areas of the placenta gets separated.
Marginal separation is found mare frequently.

Mechanism of control of bleeding - 
The normal volume of blood flow through the placental site is 500-800 ml/min. 
At the placental separation, this has to be arrested within seconds to prevent
serious haemorrhage. Retraction of the oblique uterine muscle fibres in the
upper uterine segment through which tortuous blood vessels intertwin. The
resultant thickening of muscle exert pressure on the torn vessels action on
clamps thus securing a ligature action.

Events in third stage of labour

The third stage of labour comprises the phase of placental separation; its descent to
the lower segment and finally its expulsion with the membranes. The main events in
the third stage of labour are -
              a) Separation of the placenta
              b) Expulsion of the placenta and membrane

Placental separation -
After the birth of the baby, the uterus measures about 20 cm vertically and 10 cm
antero-posteriorly, the shape becomes discoid. The wall of the upper segment is much
thickened, while the thin and flabby lower segment is thrown into folds. The cavity is
much reduced to accommodate only the after-births. A shearing force is instituted 
between the placenta and the placental site which bring about its ultimate separation.

Separation of the membranes - 
The membranes which are attached loosely in the active part (upper uterine segment)
are thrown into multiple folds. Those attached to the lower segment are already
separated during its stretching. The separation is facilitated partly by uterine contraction 
and mostly by weight of the placenta as it descends down from the active part .

Expulsion of placenta - 
After complete separation of the placenta, it is forced down into the flabby lower uterine
segment or upper part of the vagina by effective contraction and retraction of the uterus.
Thereafter, it is expelled out by either voluntary contraction of abdominal muscles (bearing
down efforts) or by manipulative procedure.

Delivery of the baby

Conduction of delivery -
It divided into three phases -
                - Delivery of the head
                - Delivery of the shoulders
                - Delivery of the trunk

Delivery of the head - 
The principles to be followed are
- to maintain flexion of the head.
- to prevent its early extension.
- to regulate its slow escape out of the vulval outlet.

General measures -
- The patient is encouraged for the bearing down efforts during uterine contractions.
  This facilitates descent of the head.
- When the scalp is visible for about 5 cm in diameter, flexion of the head is maintained
  during contractions.
- At this stage, the maximum diameter of the head (biparietal diameter) stretches the vulval
  outlet without any   recession of the head even after the contraction is over and it is called
  ''crowning of the head''.
- When the perineum is fully stretched, episiotomy is done.
- Slow delivery of the head in between the contractions is to be regulated.
- The forehead, nose, mouth and the chin are thus born successively over the stretched
  perineum by extension.

Care following delivery of the head -
- Immediately following delivery of the head, the mucus and blood in the mouth and pharynx
  are to be wiped   with sterile gauze piece on a little finger. Alternatively, mechanical or
  electrical sucker may be used.
- The eyelids are then wiped with sterile dry cotton swabs using one for each eye starting
  from the medial to the lateral canthus to minimize contamination of the conjunctival sac.
- The neck is then palpated to exclude the presence of any loop of cord.

Prevention of perineal laceration -
More attention should be paid not to the perineum but to the controlled delivery of head.
- Delivery by early extension is to be avoided.
- Spontaneous forcible delivery of the head is to be avoided.
- To deliver the head in between contractions.
- To perform timely episiotomy.
- To take care during delivery of the shoulders.

Delivery of the shoulders -
- Do not be hasty in delivery of the shoulders. Wait for the uterine contractions to come
  and for the movements of restitution and external rotation of the head to occur.
- External rotation shows that the shoulders are rotating into the antero-posterior diameter
  of the pelvic outlet, which is largest space.
- During the next contraction, the anterior shoulder is born behind the symphysis. If there is
  delay, the head is grasped by both hands and is gently drawn posteriorly until the anterior
  shoulder is released from under the pubis.

Delivery of the trunk -
After the delivery of the shoulders, the fore finger of each hand are inserted under the axillae
and the trunk is delivered gently by lateral flexion.

Management of second stage of labour

Principles -
1. To assist in the natural expulsion of the fetus slowly and steadily.
2. To prevent perineal injuries.

General measures -
- The patient should be in bed.
- Constant supervision is mandatory and the FHR is recorded at every minutes.
- To administer inhalation analgesics, if available, in the form of Gas  N2O  and  O2  to
  relieve pain during contractions.
- Vaginal examination is done at the beginning of the second stage not only to conform
  its onset but to detect any accidental cord prolapse.

Preparation for delivery -
- Position :- Positions of the woman during delivery may be lateral or dorsal.
- The accoucheur scrubs up and puts on sterile gown, mask and gloves and stands on
  the right side of table.
- Toileting the external genitalia and inner side of the thighs is done with cotton swabs
  soaked in Savlon and or Dettol solution.
- Essential aseptic procedures are remembered as 3 'C's -
                       - Clean hands  
                       - Clean surface
                       - Clean cutting and ligaturing of the cord
- To catheterise the bladder, if it is full.

Conduction of delivery -
The assistance required in spontaneous delivery. It divided into three phases -
                       - Delivery of the head
                       - Delivery of the shoulders
                       - Delivery of the trunk
For details, visit the page Delivery of the baby.

Immediate care of the newborn -
-  Soon after the delivery of the baby, it should be placed on a tray covered with clean dry
   linen with the head slightly downwards. It facilitates drainage of the mucus accumulated
   in the trachco-bronchial tree by gravity. The tray is placed between the legs of the mother
   and should be at a lower level than the uterus to facilitate gravitation of blood from the 
   placenta to the infant.
-  Air passage should be cleared of mucus and liquor by gentle suction.
-  Apgar rating at one minute and at five minutes is to be recorded.
-  Clamping and ligature of the cord - The cord is clamped by two Kocher's forceps, the near
   one is placed 5 cm away from the umbilicus and is cut in between. The cut end is then
   covered with sterile gauze piece after making sure that there is no bleeding. The purpose 
   of clamping the cord on the maternal end is to prevent soiling of the bed with blood.

Events in second stage of labour

The second stage begins with the complete dilatation of the cervix and ends with
the expulsion of the fetus. This stage is concerned with
                       a) The descent
                       b) Delivery of the fetus through the birth canal

The descent -
Descent of the fetal presenting part, which begin during the first stage of labour and
reached its maximum speed towards the end of the first stage, continuous its rapid
pace through the second stage of labour. The average maximum rate of descent is
1.6 cm/hour in nullipara and 5.4 cm/hour in multipara.

Delivery of the fetus through the birth canal -
With the full dilatation of the cervix, the membranes usually rupture and there is escape
of good amount of liquor amnii. The volume of the uterine cavity is thereby reduced.
Simultaneously, uterine contraction and retraction become stronger.
                      Delivery of the fetus is accomplished by the downward thrust offered by
uterine contractions supplemented by voluntary contraction of abdominal muscles against
the resistance offered by bony and soft tissue of the birth canal. Endowed with power of
retraction, the fetus is gradually expelled from the uterus against the resistance offered by
the pelvic floor.
                      The expulsive force of uterine contractions is added by voluntary contraction
of the abdominal muscles called ''bearing down'' efforts.


Que. - What is bearing down efforts ?
Ans. -  It is an additional voluntary expulsive efforts that appear during the second stage
          of labour (expulsive phage). It is initiated by nerve reflex set up due to stretching of
          the vagina by the presenting part. In majority, this expulsive effort start spontaneously
          with the full dialatation of the cervix. Along with uterine contraction, the woman, the
          woman is instructed to exert downward pressure as done during straining at stool.
          There may be slowing of the FHR during pushing and it should come back to normal
          once the contraction is over.

Management of first stage of labour

Principles -

1. Non-interference with watchful expectancy so as to prepare the patient for natural birth.

2. To monitor carefully the progress of labour, maternal conditions and fetal behaviour so 
    as to detect any intrapartum complication early.

Actual management -
General -

- Antiseptic dressing.
- Encouragement and assurance are given to keep up the morale.
- Constant supervision is ensured.

Bowel - 
An enema with soap and water or glycerine suppository is traditionally given in early stage. 
This may be given if the rectum feels loaded on vaginal examination. But enema neither 
shortens the duration of labour nor reduces the infection rate.

Rest and ambulation -
If the membranes are intact, the patient is allowed to walk about. Ambulation can reduce
the duration of labour.

Perineal shave -
The purpose of perineal shave is to prevent infection, preparation of perineum involving
the shaving of mons pubis, vulva and anal region provide for cleanliness and early viewing
of perineum.

Diet -
A woman in labour, even in early stage, should not eat solid food. Gastric contents are really
dangerous if aspirated following general anaesthesia. So food is withheld during active labour.

Bladder care -
Patient is encouraged to pass urine by herself as full bladder often inhibits uterine contraction
and may lead to infection. If the woman can not go to the toilet, she is given a bed pan.
Privacy must be maintained and comfort must be ensured. If the patient fails to pass urine
specially in late stage, catheterisation is to be done with strict aseptic precaution.

Relief of pain -
The common analgesic drug used is pethidine 50-100 mg intramuscularly (IM) when the pain
are well established in the active phase of labour. Pethidine is an effective analgesic as well as
a sedative. The drug should not be given if delivery is anticipated within two hours.

Assessment of progress of labour and partograph recording -
Information in the partograph include -
1. Maternal vital signs - Temperature, pulse and BP.
2. Uterine activity - Duration and frequency of contractions.
3. Fetal heart rate.
4. Vaginal examination findings -
    - Cervical dilatation in cm.
    - Cervical effacement.
    - Descent/ station of presenting part.
    - Status of membranes.
    - Status of the liquor amini.
5. Fluid examination.
6. Urine analysis.
7. Drug administration.

Fetal heart rate (FHR) -
FHR along with its rhythm and intensity should be noted every half hour in the first stage
and every 15 min in second stage or following rupture of the membrane. To avoid confusion 
of maternal and fetal heart rates, maternal pulse should be counted. Otherwise maternal
tachycardia may be wrongly treated as fetal heart rate. Normal fetal heart rate ranges
from 110-150 per minute.

Que. - What is partograph recording ?
Ans. -  Partograph is a graphic recording of the silent feature of labour status. In the management 
           of woman in labour, partograph search to validated the normal progress of labour and to 
           facilitate early identification of deviation from normal pattern. The number of contraction
           in 10 min and duration of each contaction in second are recorded in the partograph.

Management of normal labour

General considerations -
labour events have got great psychological, emotional and social impact to the woman and her family. She experiences stress, physical pain and fear of dangers. The caregiver should be tactful, sensitive and respectful to her. The woman is allowed to have her chosen companion (family member). Privacy must be maintained.

Management of normal labour aims at maximal observation with minimal active intervention. The idea is to maintain the normalcy and to detect any deviation from the normal at the earliest possible moment.

Antiseptics and aspesis -
Scrupulous surgical cleanliness and asepsis on the part of the patient and the attendants involved in the delivery process are to be maintained.

Patient care -
- Shaving or hair clipping of the vulva is done. The vulva and the perineum are washed liberally
   with soap and water and then with 10% dettol solution.
- The woman take a shower or bath, wear laundered gown and stay mobile.
- Antiseptic and aseptic precautions are to be taken during vaginal examination and during
   conduction of delivery.

Vaginal examination -
- First vaginal examination should be done by a senior doctor to be more reliable and informative.
  The examination is done with the patient lying in dorsal position.
- Whatever aseptic technique is employed, there is always some chance of introducing infection
   specially after rupture of the membranes. Hence vaginal examination should be restricted to
   a minimum.

Preliminaries -
- Toileting - The hands and forearms should be washed with soap and running water.
- Sterile pair of gloves is to be put on.
- Vulva should once more be swabbed from before backwards with antiseptic lotion.
- Vaginal examination should be kept as minimum as possible to avoid risks of infection.

Events in first stage of labour

The first stage is chiefly concerned with the preparation of the birth
canal so as to facilitate expulsion of the fetus in the second stage.
The main events that occur in the first stage are -

             a) Dilatation and effacement of the cervix.

             b) Full formation of lower uterine segment.

Dilatation of the cervix - 

Dilation of cervix is the process of enlargement of the external cervical os
(opening) from an orifice of a few mm to an opening large enough for the baby
to pass through. Dilatation is clinically evaluated by measuring the diameter of
the cervical opening in cm, with '0' (zero) cm being a closed external cervical os
(opening) and 10 cm complete dilatation.

Actual factors responsible are -

i) Uterine contraction and retraction -: The longitudinal muscle fibers of the upper
segment are attached with circular muscle fibers of the lower segment and upper
part of the cervix in a bucket holding fashion. Thus, with each uterine contraction,
not only the canal is opened up from above down but it also becomes shortened
and retracted. There is some co-ordination between fundal contraction and cervical
dilatation called ''polarity of uterus''.
ii) Bag of membranes -: The membranes (amnion and chorion) are attached loosely to
the decidua lining the uterine cavity except over the internal os. In vertex presentation,
the girdle of contact of the head (that part of the circumference of the head which first
comes in contact with the pelvic brim) being spherical, may well fit with the wall of the
lower uterine segment. Thus the amniotic cavity is divided into two compartments.
The part above the girdle of contact contains the fetus with bulk of the liquor called
hindwaters and the one below it containing small amount of liquor called forewaters.
iii) Fetal axis pressure -: During each contraction the uterus rears forward (become upright)
and the force of fundal contraction is transmitted to the upper pole of the uterus,
down the long axis of the fetus is applied by the presenting part of the cervix. This is
known as fetal axis pressure. It becomes more significant after rupture of the membrane
and during the second stage of labour.
iv) Vis-a-tergo -: The final phage of dilatation and retraction of the cervix is achieved by
download thrust of the presenting part of the fetus and upward pull of the cervix over
the lower segment.

Effacement or taking up of cervix -
Effacement is the process by which the muscular fibers of the cervix are pulled upward 
and merge with the fibers of the lower uterine segment. The cervix becomes thin during
the first stage of labour or even before that in primigravidae. In primigravidae, effacement
precedes dilatation of the cervix, whereas in multiparae, both occur simultaneously.
Expulsion of mucus plug is caused by effacement.

Physiology of normal labour

Physiology of normal labour complete into two steps -

                1. Uterine contraction.
                2. Retraction.

Uterine contraction -
During contraction, uterus becomes hard and somewhat pushed anteriorly
to make the long axis of the uterus in the line with that of pelvic axis.
Simultaneously, the patient experiences pain which is situated more on the
hypogastric region, often radiating to the thighs.
Probable cause of pain are -
   - Myometrial hypoxia during contractions.
   - Stretching of the peritoneum over the fundus.
   - Stretching of the cervix during dilatation.
   - Compression of the nerve ganglion.
The pain of uterine contractions is distributed along the cutaneous nerve
distribution of T10 to L1.

Intensity - The intensity of uterine contractions describes the degree of uterine
systole. The intensity gradually increases with advancement of labour until it
becomes maximum in the second stage during delivery of the baby. Intrauterine
pressure is raised to 40-50 mm Hg during first stage and about 100-120 mm Hg
in the second stage of labour during contractions.

Duration - In the first stage, the contractions last for about 30 second initially but
gradually increases in duration with the progress of labour. Thus in the second stage,
the contractions last longer than in the first stage.

Frequency - In the early stage of labour, the contractions come at intervals of ten to
fifteen minutes. The intervals gradually shorten with advancement of labour until in
the second stage, when it comes every two or three minutes.

Retraction -
Retraction is a phenomenon of the uterus in labour in which the muscle fibers are
permanently shortened. Unlike any other muscle of the body, the uterine muscles
have this property to become shortened once and for all. Contraction is a temporary
reduction in length of the fibers, which attain their full length during relaxation. In contrast,
retraction results in permanent shortening and the fibers are shortened once and for all.
The net effect of retraction on normal labour are -
- Essential property in the formation of lower uterine segment and dilatation and 
   effacement up of the cervix.
- To maintain the advancement of the presenting part made by the uterine contractions 
   and to help in ultimate expulsion of the fetus.
- To reduce the surface area of the uterus favouring separation of placenta.
- Effective haemostasis after the separation of the placenta.

Stages of labour

Stages of labour :-
There are 3 stages in labour -

1st stage - 
It starts from onset of true labour pain and ends with full dilatation of the cervix.
In other words, it is ''cervical stage'' of labour. Average duration of this stage is
about 12 hour in primigravidae and 6 hour in multiparae.

2nd stage - 
It starts from the full dilatation of the cervix and ends with expulsion of fetus
from the birth canal. It has got two phages -
a) The propulsive phase - starts from full dilatation upto the descent of the
presenting part to the pelvic floor.
b) The expulsive phase - is distinguished by maternal bearing down efforts and
ends with delivery of the baby.
Average duration of this stage is 2 hour in primigravidae and 30 min in multigravidae.

3rd stage - 
It begins after expulsion of fetus and ends with the expulsion of the placenta and membranes.
It's average duration is 15 min in both gravidae. The duration is, however, reduced to
5 min in active management.

4th stage - 
It is not include in labour. It is only a observational stage. Duration of this stage is
at least one hour after the expulsion of placenta. During this period, general condition
of the patient and the behaviour of the uterus are to be carefully watched.

Note:-
Primigravidae : Woman who is pregnent first time. 
Multigravidae : Woman who is pregnent multi times.