00:02 Hello everyone. My topic is normal

00:06 delivery and it is one of the

00:09 centerpiece topics in the whole um

00:13 subject of obstetrics and it is

00:15 something that is very important for you

00:18 to learn because all doctors are

00:22 expected to be able to perform a normal

00:25 delivery on a lowrisk pregnant patient.

00:32 Okay, but first of all you I would like

00:35 to remind all of you that these are the

00:37 patients that you have to refer to an

00:39 OB/GYN.

00:41 These are the patients that cannot

00:43 deliver in a primary care facility. No.

00:46 So pregnant women in the extremes of

00:49 ages should be referred to the

00:51 specialist in the next level of um

00:54 health care. All multigravid more than

00:58 um G4 should be referred if the patient

01:01 has a previous cesarian section,

01:03 previous gynecologic surgery, if she has

01:06 medical complications

01:08 or history of a still birth. Um if the

01:12 patient has any coorbidities no like

01:14 hypertension, heart disease, uh

01:17 diabetes, asthma, thyroid conditions

01:20 etc. If the patient presented with

01:23 pre-lor rupture of membrane or she has

01:27 malpresentation of her fetus or multiple

01:30 pregnancy no so more than a singleton

01:33 pregnancy you can no longer manage that

01:36 in a primary care facility. If the

01:38 patient presents with pre-term labor,

01:40 you have to refer to the next level of

01:43 health care, vaginal bleeding,

01:45 hypertension, and other risk factors

01:48 that would make the pregnancy high risk.

01:51 As I mentioned earlier, uh all general

01:54 practitioners, all primary care

01:56 physicians can actually take care of

02:00 lowrisk pregnant patients only. they can

02:02 actually deliver low-risk pregnant

02:04 patients but all the rest of the

02:06 gravidas should be referred to

02:09 obsetrications.

02:11 Okay, before I proceed also to normal

02:14 delivery I would like to review no um

02:18 some important concepts in um labor. Now

02:22 first uh we have to be very familiar

02:25 with the cardinal movements of labor.

02:28 Remember at the start of labor no when

02:30 the patient starts labor meaning she

02:33 experiences regular painful uterine

02:36 contractions that would lead to cervical

02:39 dilotation. So that's the definition of

02:41 true labor no onset of regular painful

02:45 uterine contractions that would lead to

02:47 cervical dilation

02:49 the baby will undergo no or will perform

02:52 some cardinal movements in order for it

02:55 to be delivered. The first would be

02:57 engagement.

02:59 Engagement is when the biparital

03:02 diameter has traversed the pelvic inlet.

03:05 So engagement is when the fetal head

03:07 enters the pelvis of the mother. No. And

03:11 the definition is when the biparital

03:13 diameter has passed through the inlet

03:16 and then when with continued contraction

03:19 of the uterus, it will continue to push

03:21 the baby so that the head will descend.

03:25 So that's the second cardinal movement

03:27 descent. So it will descend into the

03:29 pelvis with a continued contraction of

03:31 the uterus and then when the fetal head

03:34 encounters the pelvic floor it will

03:37 perform the third cardinal movement

03:39 which which is flexion. The baby's head

03:43 needs to flex so that it can be it will

03:46 be able to navigate no the pelvis and go

03:49 out and be delivered.

03:52 After flexion, the fetal head head will

03:56 undergo internal rotation

03:58 and then the next cardinal movement is

04:00 extension. No, the baby's head will use

04:04 the symphysis pubis as its fulcrum as it

04:07 extends. So that's the time you will see

04:10 the head being delivered through the

04:12 entritus cuz it will extend and then

04:15 after extension

04:17 it will perform external rotation and

04:21 then if you are the one attending you

04:22 will deliver the anterior shoulder and

04:24 the posterior shoulder and then deliver

04:26 the baby. So remember those cardinal

04:29 movements and I also want to emphasize

04:32 that [clears throat]

04:33 um engagement, descent, flexion,

04:36 internal rotation, most of the time you

04:38 won't be able to see those. What you

04:41 will be able to see no when you're

04:42 actually delivering a baby is that is

04:45 extension.

04:46 Sometimes you will be able to see

04:48 internal rotation but most of the time

04:51 is extension and then you will be able

04:54 to see external rotation and then you

04:56 will deliver the baby already.

04:59 I would also like to have a quick review

05:02 of the labor curve. So this is the

05:04 normal labor curve. This is how we

05:06 monitor the progress of labor of our

05:08 patients. So uh in this particular grid

05:12 on the left yaxis would be the cervical

05:15 dilotation in centimeters and then on

05:18 the right of the y-axis uh would be the

05:21 stations of the presenting part. No with

05:25 zero as the meaning the most dependent

05:28 portion of the presenting part is is at

05:31 the level of the iskll spine divide at

05:32 station zero and then on the x axis

05:36 would be the hours of labor. So this is

05:39 a typical labor curve that is a normal

05:42 uh labor curve and I would like to

05:44 review you quickly on the different

05:48 stages, phases and divisions of labor.

05:52 Okay. Okay. First, what are the

05:55 different stages of labor? We actually

05:58 have four stages. The first stage of

06:01 labor is from the onset of painful ut

06:05 regular painful uterine contractions up

06:08 to full cervical dilotation. So in this

06:11 particular uh slide it is shaded blue.

06:14 No from 0 to 10 because 10 cm is full

06:19 cervical dilotation. So from 0 to 10

06:22 that's the first stage of labor and then

06:25 after that so from full cervical

06:28 dilotation up to the delivery of the

06:31 baby that's the second stage of labor

06:34 and then from the delivery of the baby

06:37 it's colored yellow h second stage and

06:40 then from the delivery of the baby to

06:42 the delivery of the placenta that's

06:45 colored green here that's the third

06:47 stage of labor and then you fourth stage

06:50 stage of labor is the early postpartum

06:53 period. So that's the fourth stage. So

06:57 you have to be able to understand this

06:59 clearly so that you will be able to

07:01 understand abnormal labor. This is

07:04 normal labor that I'm discussing.

07:07 Understand it well so that you will be

07:09 able to understand abnormal labor. So

07:12 let first stage of labor 0 to 10 onset

07:16 of labor up to full cervical dilotation.

07:19 Second stage of labor, full cervical

07:22 dilotation up to delivery of the baby.

07:24 Third stage of labor, delivery of the

07:27 baby up to um delivery of the placenta.

07:31 Fourth stage of labor is um the

07:35 immediate postpartum period. Okay. What

07:38 about the different phases of labor or

07:41 it merices

07:44 recently? Okay. The latent phase of

07:48 labor is from the onset of labor up to

07:52 six cm. Before cas it was up to four cm

07:58 only. But with additional um analysis of

08:02 many other uh women giving birth um and

08:05 then studying all of their labor curves.

08:08 The recommendation now is to consider

08:10 the active phase as starting at 6 cm.

08:15 So

08:17 latent phase now covers it early active

08:21 phase. So it is from 0 to 6 cm. Meaning

08:28 we enter the true active phase at 6 cm.

08:33 Okay. So 0 to 6 cm is considered latent

08:37 phase. And then when the patient is

08:40 already 6 cm that's the time we say that

08:43 she has entered the true active phase.

08:47 Now

08:49 um graph I pegged the start of the

08:52 deceleration phase at 8 cms but the

08:56 recommendation now

08:59 and I can't edit my my slide. The

09:03 recommendation now is to consider the

09:05 deceleration phase as starting at 9 cm.

09:10 So 9 cms start deceleration phase and

09:15 then

09:17 naman second stage of labor is from full

09:19 cervical dilotation to delivery of the

09:21 baby and then third stage from delivery

09:24 of the baby to delivery of the placenta.

09:26 So I'll summarize latent phase now is

09:30 from 0 to 6 cms. Active phase is from 6

09:35 to 9 cms. Deceleration phase from 9 to

09:39 10 cms.

09:41 Okay.

09:43 Why do we have to to label them as

09:45 stages, phases, etc.? Um you just have

09:48 to trust me. You just have to understand

09:50 it now. Hopefully you can memorize it,

09:53 right? because you will need this

09:55 information when you discuss abnormal

09:58 labor or dystocia. Okay. Laten phase 0

10:02 to6 active phase 6 to9 deceleration

10:06 phase 9 to 10 cms. Okay. So

10:12 now there al there is also such a thing

10:14 as divisions of labor. um

10:19 clinical use but I would just like to

10:21 mention it.

10:23 Um the divisions of labor are the

10:26 preparatory division, dilotational

10:29 division and pelvic division. Okay. The

10:34 preparatory division is um coincides

10:38 with the latent phase. So 0 to 6 cm per

10:42 dilotational division is 6 to 9 cms

10:47 8 cm 6 to 9 and then the pelvic division

10:51 is from 9 up to st the second stage of

10:55 labor delivery baby

11:00 10 cms delivery of the baby

11:05 exam preparatory division 0 to cm.

11:10 Dilotational division 6 to 9 cm.

11:15 And then pelvic division is from 9 cms

11:18 up to delivery of the baby. So kasama

11:21 second stage.

11:23 Okay. So I hope

11:26 different stages, phases, divisions of

11:28 labor.

11:30 Okay.

11:32 Now

11:34 uh these are some of the newest

11:36 recommendations l on how to care for the

11:38 first stage of labor. So we admit the

11:40 patient during the active phase 6 cm

11:47 earlier

11:49 hospital and then the the p there should

11:52 be a companion of choice

11:58 labor room. We should allow the patient

12:00 to be mobile or assume the upright

12:03 position during labor. We should allow

12:05 the patient to eat and drink during

12:08 labor.

12:09 NPO use the partraph to monitor the

12:12 progress of labor. At sana we limit the

12:15 IE to five or less. Recommended

12:19 perennial shaving recommended routine

12:21 enema. We don't recommend anymore

12:25 placing the patient on NPO or inserting

12:27 an IV line recommended routine amnotomy

12:31 and routine oxytocin augmentation.

12:34 Okay. So we now go to the management of

12:37 the second stage of labor and I'll be

12:39 discussing uh all the recommendations as

12:43 regards delivery and then later on

12:45 you'll be watching two videos. No, after

12:48 this lecture of mine, you'll be watching

12:50 two videos on normal delivery and EIN C.

12:55 Okay.

12:56 Okay. During the second stage of labor,

12:59 meaning full cervical dilotation, the

13:01 patient is already in the delivery room.

13:03 The patient is about to deliver. We

13:05 should continue close monitoring of the

13:07 patient and the baby. Check the uterine

13:10 contractions, fetal heart rate, mood and

13:12 behavior of the patient. continue

13:15 recording in the ptograph cuz there

13:17 might be some indications to do an

13:18 emergency CS. No. So we should clean

13:21 your hands, wear double gloves, clean we

13:24 should clean the delivery surface.

13:26 Uh clean cutting and care of the cord to

13:29 avoid infection of the umbilical cord

13:32 and then make sure that the patient's

13:34 bladder is empty

13:37 upright position or supine position

13:39 during delivery and then allow her to

13:42 push as she wishes. You don't have to

13:44 coach the patient to push. That's

13:46 something new cuz when I was a resident,

13:48 we would always coach the patient. No,

13:51 on how to push.

13:53 Um, no funal pressure. Of course, you

13:56 wait until the head is visible and the

13:57 perennium is distending already. Do not

14:01 massage or stretch the pinium.

14:04 We sometimes do that also before, but

14:06 not anymore. Okay. Of course, you have

14:09 to p practice universal precaution.

14:13 Of course, we have to ensure that the

14:15 delivery room is clean and warm um and

14:20 controlled on temperature.

14:22 Um cuz um we have to thermorreulate the

14:25 baby when it is delivered already. Okay.

14:29 Now when we are delivering the baby now

14:32 we should be able to control the

14:34 delivery of its head cuz a fast delivery

14:36 will cause lacerations in the pinium. So

14:39 we have to keep uh one hand on the head

14:41 as it advances no during maternal uh

14:45 push and contraction. Uh we have to

14:48 prevent the the head from coming out too

14:50 quickly. And then we support the pinium

14:52 with the other hand. This is the

14:53 modified wit gun procedure.

14:57 And then when the baby's head is about

15:00 to be delivered, we can ask the woman to

15:02 stop pushing already. Now to prevent

15:05 that baby that head from lacerating the

15:07 perennium and then we should gently

15:09 deliver the rest of the baby and call

15:11 out the sex in time of the delivery

15:14 right away. It's very important to call

15:16 out the sex huh because the nurses they

15:18 would put a bracelet right away on that

15:21 baby indicating if that baby is a boy or

15:24 a girl. So you have to mention it no boy

15:28 or girl baby. Okay. So summary lang

15:33 recommendations the new recommendations

15:34 for the second stage of labor. So

15:37 upright position during delivery

15:40 or supine no ensure that the bladder is

15:43 empty. We follow universal precautions

15:46 provide physical and emotional support

15:48 to the partant

15:50 and then make sure that there is

15:52 perinial support and control delivery of

15:54 the head to prevent laceration. As I

15:57 said recommended coach mother to push

16:01 It's not recommended to do perennial

16:03 massage that that won't prevent any

16:06 laceration.

16:07 Fundal pressure is not recommended. No,

16:10 you pushing at the fundus to help

16:12 deliver the baby. No, that's no longer

16:14 recommended because it can lead to

16:16 uterine rupture and then episotomy is no

16:20 longer routine. So our episotomy when we

16:23 cut the pinium that should be indicated

16:25 only no only if there is an indication

16:28 to do it like The pennial body is too

16:31 small, the head is too big.

16:35 Okay. And then during the third stage of

16:38 labor, third stage of labor, now deliver

16:41 baby. And now you're waiting for the

16:43 placenta to be delivered. You have to

16:45 place the baby prone on the mother's

16:47 abdomen. And then sa abdomen, dry baby.

16:50 No. Um

16:53 but well, it's it would be the

16:55 pediatrician who will do that. Um they

16:58 they make sure that they do not wipe off

17:00 the verix because that will help in

17:02 thermmorreulation. No. Um and then

17:06 discard the wet towel. Make sure that

17:07 the baby is in skin-to-skin contact with

17:10 the mother. We cover the baby with a

17:12 fresh dry linen and then put a bonnet.

17:15 No. For thermo regulation,

17:18 we exclude a second baby. No. By

17:20 palpating the mother's abdomen. So you

17:22 can palpate the mother's abdomen. You

17:23 can also do your IE to make sure that

17:25 there's no second baby undiagnosed twin.

17:28 When and then when we're sure that

17:30 there's no second baby, we give the

17:32 oxytocin 10 international units or one

17:35 vial intramuscularly

17:37 within a minute of the baby's birth. No,

17:40 that will prevent postpartum hemorrhage.

17:43 And then we wait until the cord

17:46 pulsations have stopped usually 1 to 3

17:49 minutes before clamping and cutting the

17:51 cord. No, again this is the new

17:54 recommendation based on EINC.

17:57 So when the pulsations have stopped,

17:59 clap clamp the cord using a sterile

18:02 plastic clamp 2 cm from the umbilical

18:05 base and then another clamp you 5 cm

18:09 from the base. So m 3 cms away from the

18:12 first clamp and then that's the time you

18:14 cut the cord close to the plastic clamp.

18:19 Okay.

18:21 recommendation as a care of the cord. Do

18:23 not milk the cord towards the baby. When

18:25 I was a student, when I was arrested, we

18:27 were told that we should milk the cord

18:29 towards the baby. Now, we no longer have

18:31 to do that. And then observe for the

18:33 oozing of blood cuz if there is blood

18:36 oozing out, you have to tie it to make

18:38 sure that the baby will not bleed out.

18:41 Dry cord care is currently recommended.

18:43 And do not apply any substance on the

18:45 cord. And then after you clamp the cord,

18:48 you now focus on delivering the

18:50 placenta.

18:52 Okay. When you deliver your placenta,

18:55 you place the palm of the other hand on

18:57 the lower abdomen to feel for strong

19:00 uterine contractions. And then you have

19:02 to perform a CCT, controlled cord

19:05 traction with counter traction of the

19:07 uterus. So you left hand as you can see

19:09 in the picture the left hand is trying

19:11 to you know push gently push the uterus

19:14 away while performing controlled cord

19:17 traction that's a right hand picture on

19:20 the cord. Do not pull on the cord too

19:23 tightly because you might um avulse it.

19:27 You might break the cord and avulse it

19:29 from the placenta. So how will you get

19:31 the placenta? You will perform p a

19:32 manual extraction if you do that. That's

19:35 a no no.

19:37 So as the placenta is delivered, support

19:39 it with both hands and gently move the

19:41 membranes up and down until it is

19:43 delivered. And then you massage the

19:45 uterus.

19:47 Okay.

19:49 And then we ensure that we practice we

19:52 practice the active management of the

19:54 third stage of labor or AMTSL.

20:00 So what is involved in AMTSL? I have

20:03 another slide for this. We'll discuss it

20:05 again later. But it involves the

20:07 administration of ioterotonic like

20:09 oxytocin within a minute from the

20:11 delivery of the head after palpating the

20:13 abdomen to rule out a second baby and

20:16 then doing controlled core traction with

20:18 counterattraction on the uterus and then

20:20 performing uterine massage. So th that

20:22 those are the components of AMTSL or

20:25 active management of the third stage of

20:27 labor. Okay. In the fourth stage of

20:30 labor that's the immediate postpartum

20:32 period. No, the patient will be already

20:34 wheeled into the recovery room. So, you

20:36 have to monitor both the mother and the

20:37 newborn. Remember, there's

20:39 non-separation. That's ec non-separation

20:42 of the baby from the mother. So, the

20:44 baby is holding the mother um on her

20:47 chest. So, you have to monitor

20:51 mom because she's exhausted. So, you

20:53 have to monitor make sure that the mom

20:55 is awake so that the baby will not fall

20:57 from the chest to the floor. No. Um,

21:02 so you have to monitor well, monitor the

21:05 vital signs of the mom, check for

21:07 vaginal bleeding, examine the lower

21:09 vagina and the pinium if there's

21:10 bleeding. Check check check for tears

21:12 and bleeding. Um, clean the woman, make

21:15 her feel comfortable, and then you check

21:17 the vital signs regularly.

21:21 Okay. Okay. This is our um e- poster for

21:24 the active management of the third stage

21:26 of labor that we should be doing for all

21:29 of our patients. Now so overlap with

21:32 DINC but we have to perform all of them

21:35 to ensure that uh there will be no post

21:37 postpartum hemorrhage. So you have to

21:40 number one place the baby's skin-to-skin

21:42 contact on the abdomen. So par ec naman.

21:46 Okay. And then administer a uterotonic a

21:49 minute after birth. And then delayed

21:51 cord clamping number three.

21:55 And then you place the infant directly

21:57 in the mother's chest. Number four, with

21:59 the newborn skin touching the mother's

22:01 skin, hopefully mag initiate

22:03 breastfeeding. And then number five,

22:06 perform controlled core traction at the

22:08 same time supporting the uterus. And

22:11 then once the placenta is delivered,

22:13 massage the uterus immediately after

22:14 delivery of the placenta and membrane

22:16 until it is firm. We have to make sure

22:18 that the that the uterus is firm. No.

22:21 And we have to instruct the patient to

22:22 maintain it now firm. No. to prevent

22:25 postpartum hemorrhage.

22:28 Okay. So, what are the recommendations

22:30 for the third and fourth stages of

22:32 labor? As I mentioned a while ago,

22:34 monitor properly, examine the lower

22:37 vagina perinium, check for tears and

22:39 bleeding, clean the woman, and monitor

22:41 the vital signs. Recommended

22:45 manual exploration of the uterus unless

22:48 you avulse the cord and you have to go

22:50 after the placenta. So, no yun. I the

22:54 routine use of ice packs over the

22:57 hypogastrium to prevent hemorrhage is no

23:00 longer recommended.

23:02 Recommended oral methyl erometrin malate

23:06 or methin brand

23:10 helps you to to make the uterus

23:12 contracted routine. If you practice

23:15 AMTSL or active management of the third

23:17 stage of labor, then we won't need to to

23:20 give an oral uterotonic.

23:24 Okay.

23:27 Okay. Four core steps in essential

23:30 newborn care because this is something

23:32 that we have to practice for all

23:34 deliveries in our institution. This is

23:36 mandated by the department of health.

23:38 May overlap with AMT TSL. So

23:44 as long as you'll be able to do all of

23:45 the steps. So four core steps would be

23:48 immediate and thorough drying on the

23:50 maternal chesta. Then early skin to

23:54 abdomen abdomen baby dry and then

23:58 skin-to-skin contact maternal chest and

24:00 then properly time cord clamping. You

24:03 wait for the possessions to stop and

24:04 then you know now how to clamp 2 cms

24:07 away and then 5 cms away and then

24:10 nonseeparation

24:11 of the baby from the mother for early

24:13 breastfeeding. EINC has been proven

24:16 already to prevent neonatal death to

24:20 promote exclusive breastfeeding and to

24:23 promote uh prolonged breastfeeding no

24:25 more than six months. Remember, never

24:29 leave the mother and baby unattended.

24:32 Baby, monitor the mother and baby every

24:34 15 minutes for the first 1 to two hours.

24:37 Assess warmth and breathing of the baby.

24:40 Advise the mother to move her baby

24:42 toward her breast when the baby shows

24:44 breastfeeding cues. Sorry. Initiate

24:47 breastfeeding within an hour when the

24:49 baby is ready and allow the baby to have

24:52 a full breastfeed before doing routine

24:55 newborn care.

24:58 routine newborn care. So when you do it

25:00 right away,

25:02 the baby will not feed anymore. You will

25:04 irritate the baby, when you do all of

25:05 these things, no, you will apply

25:08 ointment on the eyes. You will inject

25:11 the baby with vitamin K. You will inject

25:14 the baby with hepatitis B and BCG

25:16 vaccines. That baby will be irritated

25:19 and it will no longer breastfeed. So the

25:22 recommendation is breastfeed the baby

25:24 first before you do all of these things

25:26 to that baby and then do not interrupt

25:29 the breastfeeding for any of these

25:30 reasons. If the baby is breastfeeding

25:32 already, do not interrupt the baby by

25:35 doing all the other steps.

25:38 Okay. So this is the summary of the

25:41 essential newborn care. No, that you

25:43 have to remember. Immediate drying,

25:47 skin-to-skin contact, non-separation of

25:50 the baby from the mother and

25:51 breastfeeding initiation. You

25:53 nonsepparation at least s 90 minutes,

25:56 one and a half hours and then proper

25:59 cord clamping and cutting. Okay, that's

26:03 the end of my brief lecture, but you

26:06 will be watching two videos. The first

26:09 video is uh a video of a delivery. No, I

26:12 I think it it was filmed in an African

26:15 nation.

26:17 um but they're not practicing eially

26:43 studied. It has been proven that it is

26:46 effective in preventing postpartum

26:48 hemorrhage, preventing neonatal death

26:51 and promoting breastfeeding. So it is

26:53 required by the department of health. So

26:55 if we're not performing it, then we are

26:58 violating the instructions of DOA. So

27:01 that's something we have to do. That's

27:03 something all doctors should know how to

27:06 perform. So please uh watch uh well,

27:09 watch carefully and learn it because

27:12 when you are already delivering babies

27:14 in your clerkship, you should be able to

27:17 practice that ei

27:24 watching two videos. Thank you.