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Antenatal Care,

Normal Labor and


Delivery

Dr. dr. I Nyoman Bayu Mahendra, SpOG(K)

Department Obstetric and Gynaecology


of Medical Faculty Udayana University
Definition of ANC

An examination and a management of pregnant


woman with aims to prepare the pregnant
woman and the baby in healthy state as
physically and mentally and safe both of them
during pregnancy, labor and puerperium
Aims of ANC
• Pregnant woman in healthy state
• Treat her if there is any diseases during
pregnancy
• Deliver without any complications
• Baby and mother in healthy state until post
partum
Examination of ANC
• The better frequent of ANC is at least 4 times during
pregnancy which arrange as one time in 1st trimester,
one time in 2nd trimester and two times in 3rd
trimester.
• Suggestion:
– Till 7 months gestational age might be controlled every
monthly
– Beyond 7 month gestational age might be controlled twice
in a month
– And from 36 week until delivery might be controlled every
week.
What is evaluated in ANC?

Anamnesis

Physical examinations
generally

Obstetrics examinations

Supported investigations
Anamnesis

• A. Last menstrual period (LMP) that’s can


predict due date or estimation date of delivery
(EDD)
– The role to count EDD is date added with 7 days,
month extracted with 3 months and year added
with 1 year.
• Example: If the LMP is 23-06-2016  EDD is 30-03-
2017
Anamnesis
• B. Previous pregnancies history
– Mode of deliveries: normal vaginal delivery or
instrumental (ventouse, forceps), CS.
– Are there any history of post-partum hemorrhage
?
– How about out come of babies? How many
vigorous babies? How old the baby/babies
currently? Is there any stillbirth history? Sex of
baby/babies. And birth weight.
Physical Examination Generally

• Vital signs: BP, pulse, respirations rate, temperature


• Mother weight. Total gain until term over 10 to 12
kg since 16 weeks pregnancy
• Eyes: pale anemia
• Thyroid gland
• Mammae: nipple  inverted?
• Heart: murmur or abnormal heart sounds?
• Lung: wheezing?, ronchi?
• Liver and spleen: hepato-splenomegaly?
• Extremities: edema?, varicose?
Obstetrics Examinations

• If the gestational age is less than 12 week might be


confirmed by vaginal examination. Exceptionally if
the patient does not allow it.
• If pregnancy is 12 to 20 week  fetal heart beat
should be detected by doppler.
• The ballottement sign should be positive and fetal
heart beat should be detected in 20 to 28 week
pregnant.
• If more than 28 week the baby head is establish in
lower abdomen of mother.
• The baby head already engaged in 36 week or after.
The Supported Investigations
• Laboratory investigations:
– Routine of HGB, leukocyte, urinalysis, serologist
screening: HBsAg.
– In Caucasian woman, blood group for rhesus must
be examined because approximately 15 % with Rh
negative. In African or black women the incidence
is 3 % to 8 %. In Indonesian is over 0.5 %).
• If any indication might be examined blood
sugar level, serologist of TORCH, etc.
The Supported Investigations
• Ultrasound imaging (USG)
– Performed with indication such as threatened
miscarriage, antepartum bleeding, to confirm
viability in less than 10 week pregnant, suspected
IUGR, morphologic scan for congenital anomaly in
18 – 20 week, etc.
• X-Ray:
– Abdomen in suspected anencephaly
– Chest in mother with suspected lung tuberculosis
Communication, Information and Education

• Hygienist of cloths, body and environment


• Nutrition: complete and balance as a motto:”
complete of four then perfect of five”. Enough of
protein, carbohydrate, fat, avoid smoking, minimize
drink coffee
• Medicine: vitamins, mineral: Fe,calcium, vitamin B12,
folic acid, etc
• Beware to consume medicines in 1st trimester such
as tetracycline, prednisone, tranquilizer, etc
Exercise in pregnancy

• To maintain pregnant woman health


• To introduce and teach pregnant woman
about physiologic position and simulation
during in labor
• Not allowed pregnant woman with:
– Preterm contractions, bleeding, history of
recurrent miscarriage, PPROM
Addition
• Immunization: TT
• Needed an establish state of physically and
mentally
Pregnant woman is categorized by

Obstetrics complication such as toxemia, Low risk


High risk pregnancy
mal-presentation, multiple pregnancy. pregnancy

Bad obstetrics history:


Post partum hemorrhage, IUFD, CS, instrumental
delivery

Medical problems: GDM, cardiac disease

Grande-multi pregnancy

Mother age more than 35 years


NORMAL LABOR
AND DELIVERY
Labor Physiology
• Definition
– Partus: delivery process of viable conception by vaginal
delivery route
– Partus immaturus: 20-<28 weeks (500 - < 1000 gram)
– Partus prematurus: 28 -<37 weeks (correlated to organ
function maturation)
– Partus postmaturus: >42 weeks
– Gravida: pregnant woman
– Primigravida: woman who is in the first pregnancy
• Para: woman who have deliver viable baby
• Abortus: the spontaneous or induced termination of
pregnancy before fetal viability
• Inlabor: the process that leads to childbirth
• NORMAL LABOR: baby born with occiput
presentation without asissted technique and no
morbidity happen to the mother, and almost
finished less than 24 hours
Parturition Initiation

• Parturition initation ~ complex theory


• Prostaglandin theory
• Uterine sirculation
• Nerve effect (pressure to cervical ganglion of
frankenhauser plexus)
• Nutrition (placental degeneration)
• Decrease of progesterone level
Normal parturition phase

Divided into fourth stage:


1. 1st stage of labor: clinical onset of the labor, cervical
dilation below 10 cm
2. 2nd stage of labor: fetal descent, the baby born
because of uterine power and mother
3. 3rd stage of labor: delivery of the placenta and the
membrane
4. 4th stage of labor: puerperial phase, especially 2
hours after placenta born
1st stage of labor

• Inlabor sign: (min. 2 from 3 signs)


– Uterine contraction
– Bloody show
– Cervical dilatation
• Divided to 2 phase:
– Laten phase (cervical dilatation <4 cm)
– Active phase (cervical dilatation 4 cm-complete)
• Latent phase:
– Duration ~ 8 hours
– Slow cervical dilatation
• Active phase:
– Average cervical
dilatation 1 cm/hour
– Manage by WHO
Partograph
• Cervical dilatation mechanism in primigravida:
OUI opened, continued by OUE
• Multigravida: OUI already opened, dilatation
and effacement occurred at the same time
• Amniotic membrane ruptured when CD
complete or almost complete
WHO Partograph

• Simple, one sheet of paper (2 pages)


• Contained all information about parturition
• Alert line, Action line
• When do consultation or referral
• Never occurred prolonged labor and
neglected labor
• Part of clean and safe labor
Definition
• Assisted method to monitor progress of the labor,
mother and baby condition
• Active phase
• Condition will be record?
– Progress of labor
– Mother and baby condition
– Caring during labor and delivery
– Complication detection
– Appropriate and correct management
When we used?

• All of labor
• Active phase
• All of medical facilities
• All of medical staff
Latent Phase

• CD less than 4 cm
• Record separately (mother care card/KMS)
• FHB: @ ½ hour
• UC: @ ½ hour
• Mother pulse: @ ½ hour
• CD: @ 4 hours
• BP and temp: @ 4 hours
Active Phase
• Use WHO partograph
• A. Mother general information:
– Name, age, gravida (Para? Abortus?), medical record
number, admitted sate, time of ROM
• B. Fetal condition:
– FHB, AF, moulage
• C. Progress of labor:
– CD, descent, alert/action line
– * Time (@hour)
– Time of active phase initiation
– Time of examination
• E. Uterine contraction:
– Frequency and duration (in 10 minutes)
• F. Drugs
– Oxytovin, etc
• G. Mother condition:
– Pulse, BP, temperature
– Urine
• H. Caring, monitoring and clinical management
– Write down in the blank space
Fetal Condition

• FHB
• Record @ 30 minutes, small cubicle=30 minutes
• Number at left of the graphic = FHB
• Fill with dot symbol and connect
• Alert at 120-160x/minutes of FHB
• Colour and AF condition
• Moulage (sagital suture):
– 0 : separately
– 1 : close each other
– 2 : overlap, and can separate manually
– 3 : overlap, can not separate manually
Progress of Labor

• Vertical : 10 cubicle
• 1 cubicle = 1 cm, and
30 minutes
• Cubicle = dilatation
and head descent
• @ 4 hours, mark with
X symbol at the
appropriate graph
• Descent of fetal
presentation:
• Record the lowest part
@ 4 hours.
• Mark with “O” symbol
, exp: if 4/5 write down
at 4 (vertical).
Alert and Action Line
Alert line:
• Started at 4 cm-
complete CD, if the
progress 1 cm/hour
• Record of active phase,
started at alert line
• If the progress
appropriate at right of
alert line carefully
• If the progress cut off
action line  need
further management
Uterine Contraction
• Filled in the cubicle
below time column
• Contraction @10
minutes
• 1 cubicle = 1
contraction
• If the contraction
frequency 3 times in
10 menit  3 cubicle
2nd stage of labor

• UC become adequate
• Complete CD
• Powerfull pressure by lowest part of the fetal to
pelvic floor  clinically the mother will have
sensation to bear down
• Pressure to the rectum  sensation to defecation
• Perineal bulge and opened anal spinchter
• Primigravida ~ 2 hours, multigravida ~ 1 hour
3rd stage of labor

• Uterine contraction although the baby have


born  placenta separate from it insertion at
uterine wall
• 6-15 minutes after the baby born
• No longer than 30 minutes  placental
retention
4th stage of labor

• Monitoring 2 hours after delivery


• Mother general condition
• Education
• Postpartum hemorrhage
• Uterine contraction!!!
NORMAL DELIVERY MANAGEMENT
Thank you

Make a pregnancy as a blessing

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