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The Bishop score can also be used as a means to predict the success of an induction of labour. During effacement, the cervix becomes incorporated into the lower segment of the uterus.

During a contraction, uterine muscles contract causing shortening of the upper segment and drawing upwards of the lower segment, in a gradual expulsive motion.

A standard duration of the latent first stage has not been established and can vary widely from one woman to another.

However, the duration of active first stage from 5 cm until full cervical dilatation usually does not extend beyond 12 hours in first labours "primiparae" , and usually does not extend beyond 10 hours in subsequent labours "multiparae".

The median duration of active first stage is four hours in first labours and three hours in second and subsequent labours.

Dystocia of labor , also called "dysfunctional labor" or "failure to progress", is difficult labor or abnormally slow progress of labor, involving progressive cervical dilatation or lack of descent of the fetus.

Friedman's Curve, developed in , was for many years used to determine labor dystocia. However, more recent medical research suggests that the Friedman curve may not be currently applicable.

The expulsion stage begins when the cervix is fully dilated, and ends when the baby is born. As pressure on the cervix increases, a sensation of pelvic pressure is experienced, and, with it, an urge to begin pushing.

At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has passed below the level of the pelvic inlet.

The fetal head then continues descent into the pelvis, below the pubic arch and out through the vaginal introitus opening.

This is assisted by the additional maternal efforts of "bearing down" or pushing, similar to defecation. The appearance of the fetal head at the vaginal orifice is termed the "crowning".

At this point, the mother will feel an intense burning or stinging sensation. When the amniotic sac has not ruptured during labour or pushing, the infant can be born with the membranes intact.

This is referred to as "delivery en caul ". The second stage varies from one woman to another. In first labours, birth is usually completed within three hours whereas in subsequent labours, birth is usually completed within two hours.

The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labour or the involution stage.

Placental expulsion begins as a physiological separation from the wall of the uterus. The average time from delivery of the baby until complete expulsion of the placenta is estimated to be 10—12 minutes dependent on whether active or expectant management is employed.

Placental expulsion can be managed actively or it can be managed expectantly, allowing the placenta to be expelled without medical assistance.

Active management is the administration of a uterotonic drug within one minute of fetal delivery, controlled traction of the umbilical cord and fundal massage after delivery of the placenta, followed by performance of uterine massage every 15 minutes for two hours.

Delaying the clamping of the umbilical cord for at least one minute or until it ceases to pulsate, which may take several minutes, improves outcomes as long as there is the ability to treat jaundice if it occurs.

For many years it was believed that late cord cutting led to a mother's risk of experiencing significant bleeding after giving birth, called postpartum bleeding.

However a recent review found that delayed cord cutting in healthy full-term infants resulted in early haemoglobin concentration and higher birthweight and increased iron reserves up to six months after birth with no change in the rate of postpartum bleeding.

The "fourth stage of labour" is the period beginning immediately after the birth of a child and extending for about six weeks.

The terms postpartum and postnatal are often used for this period. The World Health Organization WHO describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most deaths occur during the postnatal period.

Following the birth, if the mother had an episiotomy or a tearing of the perineum , it is stitched.

This is also an optimal time for uptake of long-acting reversible contraception LARC , such as the contraceptive implant or intrauterine device IUD , both of which can be inserted immediately after delivery while the woman is still in the delivery room.

The first passing of urine should be documented within six hours. Vaginal discharge, termed "lochia", can be expected to continue for several weeks; initially bright red, it gradually becomes pink, changing to brown, and finally to yellow or white.

Most authorities suggest the infant be placed in skin-to-skin contact with the mother for 1—2 hours immediately after birth, putting routine cares off until later.

Until recently babies born in hospitals were removed from their mothers shortly after birth and brought to the mother only at feeding times. Mothers were told that their newborn would be safer in the nursery and that the separation would offer the mother more time to rest.

As attitudes began to change, some hospitals offered a "rooming in" option wherein after a period of routine hospital procedures and observation, the infant could be allowed to share the mother's room.

However, more recent information has begun to question the standard practice of removing the newborn immediately postpartum for routine postnatal procedures before being returned to the mother.

Beginning around , some authorities began to suggest that early skin-to-skin contact placing the naked baby on the mother's chest may benefit both mother and infant.

Using animal studies that have shown that the intimate contact inherent in skin-to-skin contact promotes neurobehaviors that result in the fulfillment of basic biological needs as a model, recent studies have been done to assess what, if any, advantages may be associated with early skin-to-skin contact for human mothers and their babies.

A medical review looked at existing studies and found that early skin-to-skin contact, sometimes called kangaroo care , resulted in improved breastfeeding outcomes, cardio-respiratory stability, and a decrease in infant crying.

As of , early postpartum skin-to-skin contact is endorsed by all major organizations that are responsible for the well-being of infants, including the American Academy of Pediatrics.

The WHO suggests that any initial observations of the infant can be done while the infant remains close to the mother, saying that even a brief separation before the baby has had its first feed can disturb the bonding process.

They further advise frequent skin-to-skin contact as much as possible during the first days after delivery, especially if it was interrupted for some reason after the delivery.

In many cases and with increasing frequency, childbirth is achieved through induction of labour or caesarean section. Caesarean section is the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth.

In , Therefore, many guidelines recommend against non-medically required induced births and elective cesarean before 39 weeks. A large review of methods of induction was published in The American Congress of Obstetricians and Gynecologists ACOG guidelines recommend a full evaluation of the maternal-fetal status, the status of the cervix, and at least a 39 completed weeks full term of gestation for optimal health of the newborn when considering elective induction of labour.

Per these guidelines, the following conditions may be an indication for induction, including:. Induction is also considered for logistical reasons, such as the distance from hospital or psychosocial conditions, but in these instances gestational age confirmation must be done, and the maturity of the fetal lung must be confirmed by testing.

The ACOG also note that contraindications for induced labour are the same as for spontaneous vaginal delivery, including vasa previa , complete placenta praevia , umbilical cord prolapse or active genital herpes simplex infection.

Deliveries are assisted by a number of professionals including: obstetricians , family physicians and midwives. For low risk pregnancies all three result in similar outcomes.

Eating or drinking during labour is an area of ongoing debate. While some have argued that eating in labour has no harmful effects on outcomes, [81] others continue to have concern regarding the increased possibility of an aspiration event choking on recently eaten foods in the event of an emergency delivery due to the increased relaxation of the esophagus in pregnancy, upward pressure of the uterus on the stomach, and the possibility of general anesthetic in the event of an emergency cesarean.

They additionally acknowledge that not eating does not mean there is an empty stomach or that its contents are not as acidic. They therefore conclude that "women should be free to eat and drink in labour, or not, as they wish.

At one time shaving of the area around the vagina , was common practice due to the belief that hair removal reduced the risk of infection, made an episiotomy a surgical cut to enlarge the vaginal entrance easier, and helped with instrumental deliveries.

It is currently less common, though it is still a routine procedure in some countries even though a systematic review found no evidence to recommend shaving.

Another effort to prevent infection has been the use of the antiseptic chlorhexidine or providone-iodine solution in the vagina.

Evidence of benefit with chlorhexidine is lacking. A review of the active management in low-risk women found that when compared to routine care there were no differences in the use of medications for pain, maternal or neonatal complications, or rates of assisted vaginal deliveries.

There was a slight reduction in the caesarean section rate, however active management was seen as "highly prescriptive and interventional. Active management of labour consists of a number of principles that aim to improve outcomes with prolonged labour.

This include antenatal classes, early diagnosis of labour by senior midwives , amniotomy when membranes are intact before the onset of labour, selective use of oxytocin for slow progress only in first time mothers , and one-to-one support from midwives and obstetricians.

There is some debate about the effectiveness of active management of labour on caesarean section rates. Some women prefer to avoid analgesic medication during childbirth.

Psychological preparation may be beneficial. Relaxation techniques, immersion in water, massage, and acupuncture may provide pain relief.

Acupuncture and relaxation were found to decrease the number of caesarean sections required. Most women like to have someone to support them during labour and birth; such as a midwife, nurse, or doula ; or a lay person such as the father of the baby, a family member, or a close friend.

Studies have found that continuous support during labor and delivery reduce the need for medication and a caesarean or operative vaginal delivery, and result in an improved Apgar score for the infant [95] [96].

Different measures for pain control have varying degrees of success and side effects to the woman and her baby. Popular medical pain control in hospitals include the regional anesthetics epidurals EDA , and spinal anaesthesia.

Epidural analgesia is a generally safe and effective method of relieving pain in labour, but is associated with longer labour, more operative intervention particularly instrument delivery , and increases in cost.

Augmentation is the process of stimulating the uterus to increase the intensity and duration of contractions after labour has begun.

Several methods of augmentation are commonly been used to treat slow progress of labour dystocia when uterine contractions are assessed to be too weak.

Oxytocin is the most common method used to increase the rate of vaginal delivery. The WHO does not recommend the use of antispasmodic agents for prevention of delay in labour.

Perineal tears can occur during childbirth, most often at the vaginal opening as the baby's head passes through, especially if the baby descends quickly.

Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. While making a cut to the opening of the vagina, known as an episiotomy is common, it is generally not needed.

A Cochrane review compared episiotomy as needed restrictive with routine episiotomy to determine the possible benefits and harms for mother and baby.

The review found that restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. Obstetric forceps or ventouse may be used to facilitate childbirth.

In cases of a head first-presenting first twin, twins can often be delivered vaginally. In some cases twin delivery is done in a larger delivery room or in an operating theatre, in the event of complication e.

Obstetric care frequently subjects women to institutional routines, which may have adverse effects on the progress of labour.

Supportive care during labour may involve emotional support, comfort measures, and information and advocacy which may promote the physical process of labour as well as women's feelings of control and competence, thus reducing the need for obstetric intervention.

The continuous support may be provided either by hospital staff such as nurses or midwives, doulas , or by companions of the woman's choice from her social network.

A Cochrane review examined debriefing interventions for women who perceived childbirth as being traumatic but failed to find any evidence to support routine debriefing as a needed intervention after childbirth.

Continuous labour support may help women to give birth spontaneously, i. Continuous labour support may also reduce women's use of pain medication during labour and reduce the risk of babies having low five-minute Agpar scores.

For monitoring of the fetus during childbirth, a simple pinard stethoscope or doppler fetal monitor " doptone " can be used.

A method of external noninvasive fetal monitoring EFM during childbirth is cardiotocography CTG , using a cardiotocograph that consists of two sensors: The heart cardio sensor is an ultrasonic sensor , similar to a Doppler fetal monitor , that continuously emits ultrasound and detects motion of the fetal heart by the characteristic of the reflected sound.

The pressure-sensitive contraction transducer, called a tocodynamometer toco has a flat area that is fixated to the skin by a band around the belly.

The pressure required to flatten a section of the wall correlates with the internal pressure, thereby providing an estimate of contraction.

The WHO states: "In countries and settings where continuous CTG is used defensively to protect against litigation, all stakeholders should be made aware that this practice is not evidence-based and does not improve birth outcomes.

A mother's water has to break before internal invasive monitoring can be used. It can also involve fetal scalp pH testing. Per figures retrieved in , since there has been a 44 per cent decline in the maternal death rate.

However, according to figures women die every day from causes related to pregnancy or childbirth and for every woman who dies, 20 or 30 encounter injuries, infections or disabilities.

Most of these deaths and injuries are preventable. In , noting that each year more than , women die of complications of pregnancy and childbirth and at least seven million experience serious health problems while 50 million more have adverse health consequences after childbirth, the World Health Organization WHO has urged midwife training to strengthen maternal and newborn health services.

To support the upgrading of midwifery skills the WHO established a midwife training program, Action for Safe Motherhood. The rising maternal death rate in the US is of concern.

In the US ranked 12th of the 14 developed countries that were analyzed. However, since that time the rates of every country have steadily continued to improve while the US rate has spiked dramatically.

While every other developed nation of the 14 analyzed in shows a death rate of less than 10 deaths per every , live births, the US rate has risen to By comparison, the United Kingdom ranks second highest at 9.

Compared to other developed nations, the United States also has high infant mortality rates. The Trust for America's Health reports that as of , about one-third of American births have some complications; many are directly related to the mother's health including increasing rates of obesity, type 2 diabetes, and physical inactivity.

The U. Centers for Disease Control and Prevention CDC has led an initiative to improve woman's health previous to conception in an effort to improve both neonatal and maternal death rates.

The second stage of labour may be delayed or lengthy due to poor or uncoordinated uterine action, an abnormal uterine position such as breech or shoulder dystocia , and cephalopelvic disproportion a small pelvis or large infant.

Prolonged labour may result in maternal exhaustion, fetal distress, and other complications including obstetric fistula.

Eclampsia is the onset of seizures convulsions in a woman with pre-eclampsia. Pre-eclampsia is a disorder of pregnancy in which there is high blood pressure and either large amounts of protein in the urine or other organ dysfunction.

Pre-eclampsia is routinely screened for during prenatal care. Onset may be before, during, or rarely, after delivery.

Around one percent of women with eclampsia die. A puerperal disorder or postpartum disorder is a complication which presents primarily during the puerperium, or postpartum period.

The postpartum period can be divided into three distinct stages; the initial or acute phase, six to 12 hours after childbirth; subacute postpartum period, which lasts two to six weeks, and the delayed postpartum period, which can last up to six months.

Postpartum bleeding is the leading cause of death of birthing mothers in the world, especially in the developing world. Globally it occurs about 8.

Uterine atony, the inability of the uterus to contract, is the most common cause of postpartum bleeding.

Following delivery of the placenta, the uterus is left with a large area of open blood vessels which must be constricted to avoid blood loss. Retained placental tissue and infection may contribute to uterine atony.

Heavy blood loss leads to hypovolemic shock , insufficient perfusion of vital organs and death if not rapidly treated.

Postpartum infections, also known as childbed fever and puerperal fever, are any bacterial infections of the reproductive tract following childbirth or miscarriage.

Signs and symptoms usually include a fever greater than The infection usually occurs after the first 24 hours and within the first ten days following delivery.

Infection remains a major cause of maternal deaths and morbidity in the developing world. The work of Ignaz Semmelweis was seminal in the pathophysiology and treatment of childbed fever and his work saved many lives.

Childbirth can be an intense event and strong emotions, both positive and negative, can be brought to the surface. Abnormal and persistent fear of childbirth is known as tokophobia.

Most new mothers may experience mild feelings of unhappiness and worry after giving birth. Babies require a lot of care, so it is normal for mothers to be worried about, or tired from, providing that care.

The feelings, often termed the "baby blues" , affect up to 80 percent of mothers. They are somewhat mild, last a week or two, and usually go away on their own.

Postpartum depression is different from the "baby blues". With postpartum depression, feelings of sadness and anxiety can be extreme and might interfere with a woman's ability to care for herself or her family.

Because of the severity of the symptoms, postpartum depression usually requires treatment. The condition, which occurs in nearly 15 percent of births, may begin shortly before or any time after childbirth, but commonly begins between a week and a month after delivery.

Childbirth-related posttraumatic stress disorder is a psychological disorder that can develop in women who have recently given birth. Examples of symptoms include intrusive symptoms , flashbacks and nightmares , as well as symptoms of avoidance including amnesia for the whole or parts of the event , problems in developing a mother-child attachment , and others similar to those commonly experienced in posttraumatic stress disorder PTSD.

Many women who are experiencing symptoms of PTSD after childbirth are misdiagnosed with postpartum depression or adjustment disorders.

These diagnoses can lead to inadequate treatment. Postpartum psychosis is a rare psychiatric emergency in which symptoms of high mood and racing thoughts mania , depression, severe confusion, loss of inhibition, paranoia, hallucinations and delusions set in, beginning suddenly in the first two weeks after childbirth.

The symptoms vary and can change quickly. The most severe symptoms last from two to 12 weeks, and recovery takes six months to a year.

Five causes make up about 80 percent of newborn deaths. They include prematurity and low-birth-weight, infections, lack of oxygen at birth, and trauma during birth.

Stillbirth is typically defined as fetal death at or after 20 to 28 weeks of pregnancy. Worldwide prevention of most stillbirths is possible with improved health systems.

Worldwide in there were about 2. Preterm birth is the birth of an infant at fewer than 37 weeks gestational age. It is estimated that one in 10 babies are born prematurely.

Premature birth is the leading cause of death in children under five years of age though many that survive experience disabilities including learning defects and visual and hearing problems.

Causes for early birth may be unknown or may be related to certain chronic conditions such as diabetes, infections, and other known causes.

The World Health Organization has developed guidelines with recommendations to improve the chances of survival and health outcomes for preterm infants.

Newborns are prone to infection in the first month of life. The organism S. The baby contracts the infection from the mother during labor.

In it was estimated that about one in newborn babies have GBS bacterial infections within the first week of life, usually evident as respiratory disease, general sepsis , or meningitis.

Untreated sexually transmitted infections STIs are associated with congenital and infections in newborn babies, particularly in the areas where rates of infection remain high.

The majority of STIs have no symptoms or only mild symptoms that may not be recognized. Mortality rates resulting from some infections may be high, for example the overall perinatal mortality rate associated with untreated syphilis is 30 percent.

Perinatal asphyxia is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain.

Hypoxic damage can occur to most of the infant's organs heart , lungs , liver , gut , kidneys , but brain damage is of most concern and perhaps the least likely to quickly or completely heal.

Risk factors for fetal birth injury include fetal macrosomia big baby , maternal obesity , the need for instrumental delivery, and an inexperienced attendant.

Specific situations that can contribute to birth injury include breech presentation and shoulder dystocia.

In the first post of this Delivery Reporting Series I discussed some of the agreements that a delivery team needs to decide on when it comes to entering data to track their work through a sprint in the delivery.

Azure DevOps Dashboard is built on widgets for visualisations, and the data displayed by the widgets are based on the queries built and saved in the team project.

Note that the query shows all work items and their current states in Azure DevOps. However at the time of writing this post, it is not possible to do a basic query within Azure DevOps to see all the work items and their states based on a snapshot from 1 week ago.

This means it is impossible to track changes in time for e. In the first post I mentioned that a project team should consider tracking work items and the relationships between work items e.

This query returns all user stories and their children tasks and bugs linked to the parent user stories. Suppose you now want to compare estimates versus real effort for each parent User Stories in the iteration.

In the next post I will take a look at this connector and the functionalities provided to report on statistics from Azure DevOps using Power BI.

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