Supervisor : dr. Fadjrir, SpOG Mentor : dr. Juhriani M.

Lubis Presenter : Winson Wawan Harimawan Fairuz Syarifuddin

Definition
Spontaneous vaginal delivery is the proses of birth of a viable newborn with a vertex presentation due to the contraction of the uterus and and maternal efforts, without any assistance of tool within 24 hours

Parturition

Parturition
1.

Phase I a. Uterine quiescence b. Cervical softening Phase II : Preparation of labor a. Myometrial changes b. Cervical ripening

2.

Parturition
3.

Phase III : Labor First stage labor a. Uterine labor contraction b. Uterine shape changes c. Effacement and dilatation of cervix Second stage labor: fetal descent Third stage labor : delivery of placenta and membrane Phase IV : Puerperium

4.

Sign and Symptom in Labor

Preparatory stage of labor : Lightening Pollakiuria False labor contraction Softening of the cervix Bloody show discharge In labor: Frequent, forceful, prolonged and reguler contraction Increase of bloody show discharge On vaginal examination, found cervix effacement and dilatation

Examination
1. Abdominal Palpation (Leopolds maneuvers)

2. Vaginal Examination

a. Pelvic adequacy b. bishop score (consisitency, direction, effacement, dilatation, fetal station c. Progress of labor 3. Sonography

Mechanisms of Labor
Cardinal movement : Engagement Flexion Decent Internal rotation Extension External rotation Expulsion

Stages of Labor
1.

1. 2. 3.

First stage: interval between onset of labor until complete cervical dilatation a. latent phase b. active phase Second stage: From complete cervical dilatation until delivery of newborn Third stage: From delivery of infant until delivery of placenta Forth stage: immediate postpartum periode of approximately 2 hours after delivery of placenta

Partograph
Graphic recording of the progress of labour Recording of salient conditions of the mother and

fetus Uses o To detect labour that is not progressing normally o To indicate when augmentation of labour is appropriate o To recognize CPD long before obstruction occurs

Who should not have a Partograph?

Women with problems which are identified before labour starts or during labour which need special attention

Observations charted on the Partograph

Fetal condition Fetal heart rate Membranes and liquor Moulding of the fetal skull The Progress of labour Cervical dilatation Descent of fetal head Uterine contractions duration, frequency Maternal condition Pulse/ BP / Temp Urine volume, acetone, protein Drugs & IV Fluids Oxytocin regime

Normal Delivery Care

Comprised of 60 steps for complete and appropriate

care in spontaneous vaginal delivery. The 60 steps are divided as follows :

Observation of second stage delivery Preparation for delivery assistance

Confirmation of complete dilatation with normal fetal

condition Preparing family and mother to assist with straining process Preparation for baby delivery

 Assisting delivery of baby Delivery of head Delivery of shoulder Management of the newborn Active management of third stage Injection of oxytocin Controlled Cord Traction Uterine massage Haemorrhage evaluation

 Postpartum Evaluation / Fourth Stage Clean-up Documentation

 Preparation for delivery assistance

Wearing apron and assistant sanitary Wearing sterile handgloves Preparing oxytocin injection and put on partus set

Confirmation of complete dilatation with normal fetal

condition Vulva and perineum hygiene with sublimat cotton Performing vaginal examination to ensure complete dilatation Evaluate fetal heart rate and documenting in partograph Preparing family and mother to assist with straining process Inform condition to mother and positioning the mother Performing delivery guidance

 Preparation for baby delivery

Preparing towels to hold the baby and to hold perineum in head

delivery Open partus set, prepare all tools and drugs

Delivery of head
When head stretch vulva with 5-6 cm diameter, asisstant holds

perineum with one hand and the other hand put on head. With gentle pressure and not inhibit expulsion of the head, assist head to move outward slowly. After delivery of the head, Wipe face, mouth and nose with sterile gauze or towel. Evaluate if theres entrapment of umbilical cord on the neck, do a gently traction and release from upper side of head. Wait for head to perform external rotation

 Delivery of shoulder After external rotation, place two hands in biparietal position. Telling mother to strain in next contraction. With gentle pressure pull downwards and outward to deliver the anterior shoulder and pull upwards to deliver posterior shoulder After both of the shoulders delivered, follow through the hand to deliver elbow and hand and one hand follow to deliver all body

 Management of the newborn Evaluate newborn quickly the put over mothers abdomen, with head position slightly under the body. Do a resuscitation if theres sign of neonatal asphyxia Wrap head and body with towel and maintain a skin contact with mother. Clamp umbilical cord about 3 cm from babys side. And clamp 2 cm from that point to the mothers side. Cut in between Wipe the baby, change the towel and wrap baby with clean and dry towel. Give the baby to the mother and recommend the mother to contact with the baby and began lactation.

 Active management of third stage Check abdomen for second child. Begin management of third stage Inject 10 IU oxytocin intramuscular Perform controlled cord traction. One hand place over and slightly upper symphisis to palpate for contraction. One hand holds umbilical cord with clamp. Wait for contraction and pull gently outward while the other hand press dorsocranially to prevent invertio uteri. If theres no contraction, stimulate the nipple to induce contraction. After placenta detached, continue traction according to passage and change clamp position every 5-10 cm.

 After placenta is sighted at introitus vagina, continue

delivery of the placenta with both hands holding membrane and rotating clockwise until membrane encapsulated the placenta and then gently pull out the placenta. Evaluate weight and number of cotyledons. Perform a uterine massage with hand on fundal and massage circularly until contractions are established.

 Haemorrhage evaluation Examine the placenta and contraction. Evaluate bleeding. Check for laceration and do suture repair if lacerations existed. Postpartum Evaluation / Fourth Stage Observing contractions, bleeding, and mothers vital sign every 30 minutes for 2 hours Clean-up Documentation

Supervisor : dr. Fadjrir, SpOG Mentor : dr. Juhryani M. Lubis Presenter : Winson Wawan Harimawan Fairuz Syarifuddin

PATIENT IDENTITY

Name Age Religion Occupation Ethnicity Education Address Admission Date Admission Time MR number

: Dewi Paraguna Sitompul : 27 years old : Moslem : Housewife : Batak : Senior High School : Jl. Pelajar Timur Gg. Ikhlas Medan : June 11th, 2013 : 21.00 WIB : 88.64.36

HISTORY TAKING
Mrs. D, 27 years old, G2P1A0, Moslem, Batak, Senior High School, Housewife, wife of Mr. A, 26 years old, Moslem, Batak, Senior High School, entrepreneur, came to ER Dr. Pirngadi General Hospital with Chief Complain : Labor Contraction Description : It has been experienced by the patient since June 11th, 2013 at 07.00 AM, with bloody show since June 11th, 2013 07.00 AM. History of water broke since June 11th, 2013 09.00 AM. The water was clear and odorless. At 10.oo AM patient went to midwife and was discharged home due to dilatation was minimal. History of fever in pregnancy is not found. Micturition is normal. Defecation is normal. History of Previous Illness : Diabetes Mellitus (-), Hypertension (-) History of Previous Treatment : -

Menstrual History

Menstrual Cycle Cycle Length Menstrual Duration Menstrual Volume Complain during menstruation Last Menstrual Period Expected Date of Delivery Antenatal Care 1st Trimester 2nd Trimester 3rd Trimester

: Regular : 28 days : 6-7 days : 1-2 menstrual pad / days : dismenorrhea (-) : September 15th, 2012 : June 22nd, 2013 : Midwife , 3 times : once : once : once

Labor History
Male, term, Spontaneous Vaginal Delivery, doctor,

hospital, 3000 grams, 2,5 years old, alive. This pregnancy

Present State
Sensorium

: compos mentis Blood Pressure : 120/80 mmHg Pulse : 88 bpm Respiratory Rate : 20 tpm Temperature : 36,80C

Obstetric Examination
Abdomen SFH Stretch Bottom Movement Contraction FHR EBW

: enlarged asimmetrically : 3 fingers below xyphoid process (32cm) : left : head (3/5) : (+) : 2 x 30/ 10 : 144 bpm : 2945 grams

Vaginal Examination
Axial Cervix Cervix Diameter 4 cm Effacement 80%, Membrane (-) SRM 12 hours ago Head in HI-II Posterior fontanella 3 oclock direction Gloves : bloody show (+), water (+) clear

USG : TRANSABDOMINAL SONOGRAPHY

Singleton, head presentation, living Fetal movement (+), Fetal heart rate (+) BPD = 88,2 mm FL

= 73,0 mm AC = 301 mm Placenta corpus anterior grade III Conclusion : Intrauterine Pregnancy (38-39) weeks + Head Presentation + Alive

Laboratory Results

DIAGNOSIS SG + IUP (38 3/7) weeks + Head Presentation + Living + In Labor THERAPY IVFD Ringers Lactate 20 drips/ minute Amoxicillin tab 3x500mg PLANNING Monitor vital sign , FHR, dan labor progression with partograph

Spontaneous Vaginal Delivery Report

At 01.25 AM, June 11th, 2013 patient felt longer, stronger, and closer contractions and the urge to strain, vaginal examination was done with complete dilatation. Labor management was started : The patient was laid in gynecologic bed with Mc Robert position Bladder was emptied and vulva hygiene was done. With adequate contraction, head of fetus was sighted in introitus vagina and stayed.

 With subsequent adequate contraction, patient was

encouraged to strain and head was born started with posterior fontanella, anterior fontanella, forehead, face, chin and the rest of head. After external rotation, with the helpers hand on biparietal, head is pulled gently downwards to deliver anterior shoulder and pulled upwards to deliver posterior shoulder. Then the head was held on one hand and the other hand following along on the back simultaneously to deliver the body.

 At 01.45 AM was born a female baby, with weigh 3080

grams, body length 48 cm, head circumference 32 cm, Apgar Score : 9/10, anal verge positive, and with New Ballard Score 35 (38-40 weeks) AGA.

 Umbilical cord was clamped in two point, then cut in

between. Then Oxytocin 10 IU intramuscular was injected on lateral thigh After 5-10 minutes, placenta was delivered with controlled umbilical cord stretching, intact, weigh 500 grams, with 16 cotyledons (all intact). The passage was evaluated, found perineal laceration grade I Then the laceration was sutured with chromic catgut 2-0 Evaluation of bleeding : 150 cc Patients condition after SVD : stable

 THERAPY IVFD Ringers Lactate + Oxytocin 10 IU drip 20

drips/minute Amoxicillin tab 3 x 500mg Vitamin B complex tab 2 x 1

Fourth Stage Observation

Time 02.00 02.30 03.00 03.30 04.00 Blood Pressure 110/70 mmHg 110/70 mmHg 110/70 mmHg 120/80 mmHg 120/80 mmHg Pulse 80 bpm 80 bpm 86 bpm 84 bpm 82 bpm Respiratory Contraction Rate 18 tpm 18 tpm 20 tpm 20 tpm 20 tpm strong strong strong strong strong Bleeding 5 cc 10 cc 15 cc 15 cc 15 cc

Laboratory results 2 hours after SVD

Follow up (June 12th, 2013)

S : fever (-) O : Status presens Sensorium Blood Pressure Pulse RR Temperature Localized State Abdomen SFH Pervaginal Bleeding Micturition Defecation : compos mentis : 120/80 mmHg : 80 bpm : 22 tpm : 36,80C : Soft, peristaltic (+) normal : 3 fingers below umbilicus, contraction (+) strong : (-), Lochia rubra (+) : (+) normal : (+) normal

A : Post Spontaneous Vaginal Delivery due to Posterior Occipital Presentation + Puerperium day 1 P: Amoxicillin tab 3x500mg Mefenamic Acid tab 3x500mg Ferrous Sulphate tab 1x1 Vitamin B complex tab 2xI Discharged for outpatient care

Case Analysis
Theory Preparatory labor signs are including: lightening, abdominal distention, pollakiuria, false labor pain, softening of cervix and bloody show. Labor signs are including : stronger, frequent and reguler contractions, bloody show, with signs of ruptured membrane, and dilatation of cervix in vaginal examination Case Patient came with chief complaint of Labor contraction , experienced by the patient since June 11th, 2013 at 07.00 AM, with bloody show since June 11th, 2013 07.00 AM. History of water broke since June 11th, 2013 09.00 AM. The water was clear and odorless. From obstetric examination was found regular contraction, with duration 2x30/10 and from vaginal examination found cervix dilatation 4 cm and effacement 80%

Theory In active delivery, duration of contraction can vary between 30 to 90 seconds.

Case In this patient, the duration of contraction over time is as follows: 21.00 & 21.30: 2x30/10 22.00 & 22.30: 3x20-40/10 23.00-01.00 : 4x>40/10 At 09. o0 PM the dilatation was 4 cm and at 01.25 AM the dilatation was complete, so rate of dilatation is 1,44 cm/hours At 01.25 AM we found complete dilatation and the baby was born at 01.45 AM. Duration of second stage is 20 minutes.

In multiparity, the average rate of dilatation is 1,5 cm / hour

In multiparity, duration of second stage is less than one hour.

Theory Duration of third stage is usually less than 15 minutes after second stage.

Case Placenta was delivered 10 minutes after baby was born. With controlled umbilical cord stretching, placenta was delivered, intact, weigh 500 grams, with 16 cotyledons. In this patient we found grade I laceration on perineum and we did a repair with suture. Fourth Stage bleeding observation was 60 cc.

Post partum haemorrhage is define as bleeding over 500 cc after delivery, which caused by 4T, tonus (in atonia uteri), tissue (in retensio placenta), trauma (laceration of passage) and thrombin (coagulation disorder)

Clinical Summary
Mrs. D, 27 years old, G2P1A0, Moslem, Batak, Senior

High School, Housewife, wife of Mr. A, 26 years old, Moslem, Batak, Senior High School, entrepreneur, came to ER Dr. Pirngadi General Hospital with Chief Complain Labor Contraction 2013 at 07.00 AM, with bloody show since June 11th, 2013 07.00 AM. History of water broke since June 11th, 2013 09.00 AM. The water was clear and odorless. At 10.oo AM patient went to midwife and was discharged home due to dilatation was minimal.

It has been experienced by the patient since June 11th,

 Last menstrual period of the patient is September 15th,

2013 and Expected Date of Delivery June 22nd, 2013 with antenatal care by midwife , 3 times. With labor history first kid is male, term, spontaneous vaginal delivery, doctor, hospital, 3000 grams, 2,5 years old, alive.

Vital signs are within normal limit. Obstetric examination

showed abdomen enlarged asimmetrically, with SFH 3 fingers below xyphoid process (32 cm), stretch left, bottom head, movement positive, contraction 2 x 30/ 10, FHR 144 bpm, and EBW: 2945 grams

 From vaginal examination, the findings are axial

cervix, with dilatation of 4 cm, effacement 80%, membrane (-), SRM 12 hours ago, Head in HI-II , posterior fontanella 3 oclock direction, Gloves : bloody show (+), water (+) clear, with USG TAS showing Intrauterine Pregnancy (38-39) weeks + Head Presentation + Alive

The patient was diagnosed SG + IUP (38 3/7) weeks +

Head Presentation + Living + In Labor

 The patient was then monitored with partograph and

planned for spontaneous vaginal delivery At 01.25 AM, June 11th, 2013 patient felt longer, stronger, and closer contractions and urge to strain, vaginal examination was done with complete dilatation. Labor management was started. At 01.45 PM was born a female baby, with weigh 3080 grams, body length 48 cm, head circumference 32 cm, Apgar Score : 9/10, anal verge positive, with New Ballard Score 35 (38-40 weeks) AGA. Patients condition after SVD : stable The patient was then monitored for one day with stable condition and then discharged as outpatient the day after.

Problems
Is the patient diagnosed correctly ? Are the treatment on this patient appropriate to

protocol ?