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DIAGNOSIS OF LABOUR

 

FIRST STAGE

  • Latent phase
    • Cervix less than 4 cm dilated
  • Active phase
    • Cervix between 4 cm and 10 cm dilated

 

 

SECOND STAGE

  • Early phase(non-expulsive)
    • Cervix fully dilated (10 cm)
    • Fetal descent continues
    • Patient has no urge to push
  • Late phase(expulsive)
    • Presenting part of fetus reaches the pelvic floor and the patient has the urge to push
    • Typically lasts less than 1 hour in primigravida women and less than 30 minutes in multigravida women

 

Carry out vaginal examinations at least once every 4 hours in the first stage of labour and plot the findings on the partograph.

The partograph is very helpful in monitoring the progress of labour and in the early detection of abnormal labour patterns.

DIAGNOSIS OF VAGINAL BLEEDING IN EARLY PREGNANCY1

Typical Symptoms and Signs Occasional Symptoms and Signs Probable Diagnosis
  • Light* bleeding
  • Closed cervix
  • Uterus corresponds to dates
  • Cramping/lower abdominal pain
  • Uterus softer than normal
    Threatened abortion
  • Light bleeding
  • Abdominal pain
  • Closed cervix
  • Uterus slightly larger than normal
  • Uterus softer than normal
  • Fainting
  • Tender adnexal mass
  • Amenorrhea
  • Cervical motion tenderness
    Ectopic pregnancy
  • Light bleeding
  • Closed cervix
  • Uterus smaller than dates
  • Uterus softer than normal
  • Light cramping/lower abdominal pain
  • History of expulsion of products of conception
    Complete abortion
  • Heavy** bleeding
  • Dilated cervix
  • Uterus corresponds to dates
  • Cramping/lower abdominal pain
  • Tender uterus
  • No expulsion of products of conception
    Inevitable abortion
  • Heavy bleeding
  • Dilated cervix
  • Uterus smaller than dates
  • Cramping/lower abdominal pain
  • Partial expulsion of products of conception
    Incomplete abortion
  • Heavy bleeding
  • Dilated cervix
  • Uterus larger than dates
  • Uterus softer than normal
  • Partial expulsion of products of conception resembling grapes
  • Nausea/vomiting
  • Spontaneous abortion
  • Cramping/lower abdominal pain
  • Ovarian cysts (easily ruptured)
  • Early-onset pre-eclampsia
  • No evidence of a fetus
    Molar pregnancy

* Light bleeding: takes longer than 5 minutes for a clean pad or cloth to be soaked
** Heavy bleeding: takes less than 5 minutes for a clean pad or cloth to be soaked

 

DIAGNOSIS OF VAGINAL BLEEDING IN LATE PREGNANCY1

Typical Symptoms and Signs Occasional Symptoms and Signs Probable Diagnosis
  • Bleeding after 22 weeks gestation (may be retained in the uterus)
  • Intermittent or constant abdominal pain
  • Shock
  • Tense/tender uterus
  • Decreased/absent fetal sounds
  • Fetal distress or absent fetal heart sounds
    Abruptio placentae
  • Bleeding (intra-abdominal and/or vaginal)
  • Severe abdominal pain (may decrease after rupture)
  • Shock
  • Abdominal distention/free fluid
  • Abnormal uterine contour
  • Tender abdomen
  • Easily palpable fetal parts
  • Absent fetal movements and fetal heart sounds
  • Rapid maternal pulse
    Ruptured uterus
  • Bleeding after 22 weeks gestation
  • Painless
  • Shock
  • Bleeding may be precipitated by intercourse
  • Relaxed uterus
  • Fetal presentation not in pelvic/lower uterine pole feels empty
  • Normal fetal position
    Placenta previa

MANAGEMENT OF BLEEDING IN LATE PREGNANCY, LABOUR AND POSTPARTUM HEMORRHAGE

1. Monitor blood loss, vital signs and urine output and treat appropriately. Remember bleeding can recur.
2. After bleeding is controlled (24 hours after bleeding stops), determine hemoglobin or hematocrit to check for anemia and treat appropriately.
3. Record details or problems and procedures carried out.
4. Inform the woman about these and provide her with a written summary. Provide counselling and advise on prognosis for fertility and childbirth.
5. Schedule a follow-up visit at 4 weeks.

DIAGNOSIS AND MANAGEMENT OF ABORTION COMPLICATIONS

Symptoms and Signs Complication Management
  • Lower abdominal pain
  • Rebound tenderness
  • Tender uterus
  • Prolonged bleeding
  • Malaise
  • Fever
  • Foul-smelling vaginal discharge
  • Purulent cervical discharge
  • Cervical motion tenderness
  • Infection
  • Sepsis
    Begin antibiotics* as soon as possible before attempting manual vacuum aspiration
  • Cramping abdominal pain
  • Rebound tenderness
  • Abdominal distention
  • Rigid (hard and tense) abdomen
  • Shoulder pain
  • Nausea/vomiting
  • Fever
  • Uterine, vaginal or bowel injuries
    Perform a laparotomy to repair the injury and perform manual vacuum aspiration simultaneously. Seek assistance, if required

*Give antibiotics until the woman is fever-free for 48 hours

 

  • Ampicillin                2 gm IV every 6 hours
  • Plus gentamicin        5 mg/kg IV every 24 hours
  • Plus metronidazole   500 mg IV every 8 hours

 

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