OBG509 — Labour and its Complications, Operative Obstetrics, Newborn Baby, Puerperium and its Abnormalities, Safe Motherhood: Lecture Note

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la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Course code: OBG 509 Course title: Labour and its Complications, Operative Obstetrics, Newborn Baby, Puerperium and its Abnormalities, Safe Motherhood Course credit load: 3 Units Series 1: Physiology and Management of Labour • Part 1.1: Physiology of Labour o Sub Part 1.1.1: Onset and phases of normal labour o Sub Part 1.1.2: Uterine contractions and cervical change o Sub Part 1.1.3: Mechanism of labour • Part 1.2: Management of Labour and the Partogram o Sub Part 1.2.1: First stage management o Sub Part 1.2.2: Second and third stage management o Sub Part 1.2.3: Use of the partogram • Part 1.3: Post-term Pregnancy o Sub Part 1.3.1: Definition, incidence, and recurrence of post-term pregnancy o Sub Part 1.3.2: Physiological changes and complications of post-term pregnancy o Sub Part 1.3.3: Accurate pregnancy dating and membrane sweeping • Part 1.4: Induction of Labour o Sub Part 1.4.1: Definition and indications for induction of labour o Sub Part 1.4.2: Methods of induction of labour o Sub Part 1.4.3: Induction versus expectant management in post-term pregnancy • Part 1.5: Managing Induction and its Challenges o Sub Part 1.5.1: Failed induction of labour o Sub Part 1.5.2: Foetal surveillance during induction and post-term pregnancy o Sub Part 1.5.3: Complications of induction of labour

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Introduction Picture a woman in the final weeks of pregnancy, uncertain whether to wait for labour to begin naturally or to accept the offer of induction as her due date passes. Behind that seemingly simple decision lies a genuinely rich body of physiology and evidence: how labour actually begins and progresses, how it is safely monitored, and what happens when a pregnancy extends beyond term. This Series lays the essential foundation for the whole of this course, beginning with the physiology and management of normal labour before turning to post-term pregnancy and induction, the first of many clinical decisions that shape the course of childbirth. The aim of this Series is to equip you with a thorough understanding of the physiology and management of normal labour, and the definition, causes, complications, and management of post-term pregnancy and induction of labour. We shall commence this Series by examining the physiology of normal labour. Next, we will consider the management of labour, including the use of the partogram. Following that, our attention turns to post-term pregnancy, its incidence, physiological changes, and complications. We will then explore induction of labour and its methods. Finally, we will conclude by examining failed induction and the role of foetal surveillance. Series Learning Outcomes Upon completing this Series, you should be able to: • SLO 1.1: describe the physiology of normal labour, • SLO 1.2: describe the management of labour, including use of the partogram, • SLO 1.3: define post-term pregnancy and induction of labour, • SLO 1.4: describe the incidence and recurrence of post-term pregnancy, • SLO 1.5: enumerate the physiological changes and complications associated with post-term pregnancy, • SLO 1.6: describe interventions to reduce post-term pregnancy, including accurate pregnancy dating and membrane sweeping, • SLO 1.7: discuss the management of post-term pregnancy, including induction versus expectant management, and • SLO 1.8: describe failed induction of labour and the role of foetal surveillance. 1.1 Physiology of Labour

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS 1.1.1 Onset and phases of normal labour Labour is the physiological process by which the products of conception, the foetus, placenta, and membranes, are expelled from the uterus, marked by the onset of regular, painful uterine contractions accompanied by progressive cervical effacement and dilatation, distinguishing true labour from the irregular, non-progressive Braxton Hicks contractions that commonly occur throughout the later weeks of pregnancy without leading to cervical change. Labour is traditionally divided into three stages: the first stage, from the onset of regular painful contractions to full cervical dilatation, further subdivided into a slower latent phase and a faster active phase; the second stage, from full dilatation to delivery of the baby; and the third stage, from delivery of the baby to delivery of the placenta and membranes, each stage governed by distinct physiological processes and having a different expected duration and pattern of progress. Fill in the blank: True labour is distinguished from Braxton Hicks contractions by progressive cervical effacement and ________. The first stage of labour is subdivided into a slower latent phase and a faster ________ phase. 1.1.2 Uterine contractions and cervical change Effective uterine contractions in labour arise from coordinated, synchronised contraction of the myometrium, spreading from pacemaker sites near the uterine cornua in a wave that sweeps downward, with the fundus contracting more strongly and for longer than the lower segment, a phenomenon known as fundal dominance, essential for effective cervical dilatation and descent of the presenting part. Cervical effacement (progressive shortening and thinning of the cervix, typically preceding significant dilatation in a primigravida but occurring simultaneously with dilatation in a multigravida) and cervical dilatation (progressive opening of the cervical os) together reflect the softening, remodelling effect of prostaglandins and mechanical pressure from the presenting part, with the rate of cervical dilatation in the active phase used as the principal objective marker of labour progress. Fill in the blank: Stronger, longer contraction of the fundus compared with the lower segment is known as fundal ________. The rate of cervical dilatation in the active phase is used as the principal objective marker of labour ________. 1.1.3 Mechanism of labour The mechanism of labour describes the sequence of positional changes the foetus undergoes as it negotiates the maternal pelvis during the second stage, comprising engagement, descent, flexion (bringing the smallest diameter of the foetal head to present), internal rotation (aligning the head with the widest pelvic diameter at each level), extension (as the head delivers beneath the pubic symphysis), and restitution and external rotation (as the shoulders rotate into the anteroposterior diameter).

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Each step of this mechanism reflects the foetal head and body adapting passively to the changing shape and dimensions of the successive pelvic planes it must pass through, a process that, in a normal labour with an appropriately sized foetus and adequate uterine contractions, proceeds without active intervention, though recognising deviation from this expected sequence is an essential skill in identifying labour that is not progressing normally. Fill in the blank: Flexion of the foetal head brings the ________ diameter of the head to present during labour. Internal rotation aligns the foetal head with the widest ________ diameter at each level of the pelvis. Figure 1.1: The three stages of labour and the mechanism of normal labour. Pilot questions 1.1 1. Distinguish true labour from Braxton Hicks contractions. (Linked to SLO 1.1) 2. Describe the three stages of labour and their subdivisions. (Linked to SLO 1.1) 3. Explain the concept of fundal dominance and its importance. (Linked to SLO 1.1) 4. Distinguish cervical effacement from cervical dilatation. (Linked to SLO 1.1) 5. Describe the mechanism of normal labour. (Linked to SLO 1.1)

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS 1.2 Management of Labour and the Partogram 1.2.1 First stage management Management of the first stage of labour includes regular maternal observations (pulse, blood pressure, and temperature), assessment of contraction frequency and strength, intermittent auscultation or continuous electronic monitoring of the foetal heart depending on the woman's risk category, and regular vaginal examination to assess cervical dilatation and descent of the presenting part, with the frequency of each observation guided by local protocol and the woman's individual risk status. Supportive care throughout the first stage, including appropriate analgesia, encouragement of mobility where safe and desired, adequate hydration, and continuous emotional support, meaningfully contributes to a positive labour experience and, in some circumstances, to more efficient labour progress, reflecting the recognition that management of labour extends well beyond clinical observation alone to encompass the woman's overall wellbeing and experience of childbirth. Fill in the blank: Assessment of cervical dilatation and descent of the presenting part is performed by regular ________ examination. Supportive care throughout the first stage includes analgesia, mobility, hydration, and emotional ________. 1.2.2 Second and third stage management Management of the second stage involves continued maternal and foetal monitoring, guidance and support of maternal pushing efforts once full dilatation is confirmed, and preparation for delivery, with the duration of the second stage monitored against locally defined time limits that vary according to parity and the use of regional analgesia, prompting consideration of instrumental or operative delivery if progress becomes inadequate. Active management of the third stage (prophylactic uterotonic administration, controlled cord traction, and cord clamping) is now recommended as routine practice for the great majority of deliveries, given robust evidence that it substantially reduces the risk of postpartum haemorrhage compared with expectant, physiological management of this final stage of labour. Fill in

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