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NORMAL LABOR AND
DELIVERY
WHAT IS LABOR?
From the Latin word labor: “troublesome effort or suffering
parturire: “to be ready to bear youngpartus: “to produce”
WHAT IS LABOR? A physiologic process that begins with
the onset of rhythmic contractions which brings about changes in the biochemical connective tissue resulting in gradual effacement and dilation of the cervix and ends with expulsion of the product of conception
CRITERIA FOR THE DIAGNOSIS OF LABOR Uterine Contractions (at least 1 in 10
mins or 4 in 20 mins) by direct observation or electronically
Documented progressive changes in cervical dilation and effacement
Cervical effacement of >70-80%
Cervical Dilation >3 cm
TRUE LABOR VS. FALSE LABOR
TRUE LABOR FALSE LABOR
Regular Contractions Irregular Contractions
Decreasing intervals (shortened)
Irregular and long intervals
Increasing intensity Same intensity or go away spontaneously
Lower abdomen and low back pain
Lower abdomen discomfort
Cervical Dilation No cervical change or cervix does not dilate
PROGRESS OF LABOR 12-14 hours: first delivery 6-hours: succeeding deliveries Cervical Dilatation: opening of the
cervix Cervical Effacement: shortening of
the cervix and thinning of the cervical walls 0%: normal100%: completely thinned
LABOR SUCCESS Depends on:
Power
Passenger
Passageway
PASSENGER Fetal Lie
Longitudinal Lie
Transverse Lie
Oblique Lie
PASSENGER Fetal Presentation
Compound Presentation
PASSENGERCephalic Presentation
Vertex Sinciput Brow Face (SOB)-9.5cm (OF)-11.5cm (OM)-12.5cm (SMB)-9.5cm
Breech Presentation Complete Breech Frank Breech Incomplete Breech
Single Footling BreechDouble Footling Breech
PASSENGER Fetal Attitude or Posture
Head flexed Chin close to chest Extremities close to the body Back curved
Fetal Position: chosen portion of the fetal presenting part Occiput – in cephalic presentation Sacrum – breech presentation Chin/mentum – face presentation Acromion/scapula – shoulder presentation
Cephalic PresentationOcciput anterior (OA)Right Occiput Anterior(ROA)Left Occiput Anterior(LOA)Right Occiput Transverse (ROT)Left Occiput Transverse(LOT)Right Occiput Posterior (ROP)Left Occiput Posterior(LOP)Occiput Posterior(OP)
Breech PresentationSacrum Anterior (SA)Left Sacrum Anterior (LSA)Right Sacrum Anterior (RSA)Right Sacrum Transverse (RST)Left Sacrum Transverse (LST)Right Sacrum Posterior (RSP)Left Sacrum Posterior (LSP)Sacrum Posterior (SP)
PASSENGER Fetal Station: degree of descent of the
presenting part of the fetus from the ischial spines
PASSENGER Number of fetuses
Presence of fetal anomalies
Fetal size
PASSAGEWAY Consists of the bony pelvis and soft
tissues of the birth canal
Small pelvic outlet can result in cephalopelvic disproportion
Pelvimetry: for assessment
PELVIMETRY
DIAGNOSIS OF FETAL PRESENTATION Leopold’s Maneuver Internal Examination Auscultation Imaging Studies
MECHANISM OF LABOR Involves the cardinal movements of
labor:Engagement DescentFlexion Internal rotationExtensionExternal rotationexpulsion
Positional changes in the presenting part of the fetus
MECHANISM OF LABOR: ENGAGEMENT
Passage of the widest diameter of the fetal presenting part below the plane of the pelvic inlet
Asynclitism: due to lateral inclination of the fetal headAnterior Asynclitism (Naegele’s Obliquity)– Sacrum Posterior Asynclitism (Fritzmann’s Obliquity) –
Symphisis Pubis
MECHANISM OF LABOR: DESCENT Pressure of the amniotic fluid Direct pressure of the fundus upon the
breech with contractions Bearing down efforts of maternal
abdominal muscles Extension and straightening of the fetal
body
MECHANISM OF LABOR: FLEXION Resistance of the birth canal on descent Shorter suboccipitobregmatic
diameter(9.5 cm)
MECHANISM OF LABOR: INTERNAL ROTATION Descent will not occur without it Sagittal suture is now oriented antero-
posteriorly (occiput is anteriorly oriented)
MECHANISM OF LABOR: EXTENSION Head up in extension 2 forces:
Force exerted by the fundusForce exerted by the resistance of the
pelvic floor and the symphysis pubis, anteriorly
MECHANISM OF LABOR:EXTERNAL ROTATION The head back to its original position One shoulder is anterior behind the
symphysis pubis and the other is posterior
MECHANISM OF LABOR:EXPULSION Almost immediately after external
rotation The perineum thins out As the shoulder passes out, the rest of
the body follows
4 STAGES OF LABOR 1ST STAGE: onset of labor until full cervical
dilation (Latent and Active Phase)
2ND STAGE: from full cervical dilation of 10 cm until delivery of the baby
3RD STAGE: from delivery of the baby up to the delivery of the placenta
4TH STAGE: the next 2 hours following the delivery of the placenta.
3 FUNCTIONAL DIVISIONS OF LABOR Preparatory Division
Latent PhaseAcceleration Phase
Dilatational DivisionPhase of Maximum Slope
Pelvic DivisionDeceleration PhaseSecond Stage concurrent with the phase of
maximum slope
2 PHASES OF CERVICAL DILATION Latent Phase
Active PhaseAcceleration PhasePhase of Maximum SlopeDeceleration Phase
ASSESSMENT OF A PATIENT IN LABOR
ASSESSSMENT Complete history and PE Abdominal Exam Pelvic Exam (Speculum Exam) Internal Examination
Cervical dilation and effacementPosition of the cervixCervical dilation and effacementFetal StationStatus of the fetal membrane
ROM Character of fluid
MANAGEMENT OF THE STAGES OF
LABOR
1ST STAGE OF LABOR Vital Signs Uterine Contractions Cervical Changes Fetal Heart Tones
1ST STAGE OF LABOR Induction of Labor: an intervention
designed to artificially initiate contractions leading to progressive dilation and effacement of the cervix and birth of the baby (RCOG,2002)Confirmation of ParityConfirmation of Gestational AgePresentationBishop’s ScoreUterine ActivityNon stress Test
BISHOP’S PREINDUCTION CERVICAL SCORE SYSTEM
FACTOR 0 1 2 3
Cervical Dilation (in cm)
Closed 1-2 3-4 >=5
Cervical Effacement (%)
0-30 40-50 60-70 >80
Station -3 -2 -1 +1, +2
Cervical Consistency
Firm Medium soft
Cervical Position
posterior midposition Anterior
1ST STAGE:INDUCTION OF LABOR
It should only be implemented on a valid indication (Level I, Grade C) Gestational HTN Pre eclampsia, eclampsia Prelabor rupture of the membranes Maternal medical indications Gestational >= 41 1/7weeks Evidence of fetal compromise Intraamniotic infection Fetal demise Logistic factors for term pregnancy
1ST STAGE:INDUCTION OF LABOR
Contraindications: Malpresentation Absolute cephalopelvic disproportion Placenta Previa Previous major uterine surgery or classical CS Invasive carcinoma of the cervix Cord presentation Active genital herpes Gynecological, obstetrical, or medical conditions
that prelude vaginal birth Obstetrician’s convenience
1ST STAGE:INDUCTION OF LABOR (METHODS)
OXYTOCIN Oxytocin augmentation is a major intervention and
should only be implemented on a valid indication. (Level I, Grade C)
When induction of labor is undertaken with oxytocin, the recommended regimen is a starting dose of 1-2 mU/min and is increased at intervals of 30 mins or more. The minimum dose should be used and this should be titrated against uterine contractions aiming for maximum of 3-4 contractions every 10 mins. (RCOG, Grade C)
Regular observations of uterine contractions and FHT should be recorded every 15 to 30 minutes and with each incremental increase of Oxytocin.
1ST STAGE:INDUCTION OF LABOR (METHODS) MEMBRANE SWEEPING/STRIPPING
Increases local production of prostaglandins
AMNIOTOMYArtificial rupture of the membranes
1ST STAGE:FAILED INDUCTION Continued lack of progression into the
active phase
Nulliparous women could safely remain in the latent phase for 12 hours
It is not reasonable to allow up to 18 hours of latent labor before recommending CS.
2ND STAGE OF LABOR Duration:
50 minutes: Nullipara20 minutes: Mutlipara
Fetal Heart Tones: every 15 minutes Ritgen Maneuver
2ND STAGE OF LABOR Molding – fusion of the parietal bones
Caput - swelling
3RD STAGE OF LABOR Placental Separation
Calkin’s SignSudden gush of bloodUterus rises in the abdomen(tilted)The umbilical cord rises
Mechanism of Placental SeparationDuncan: peripheral separationSchulze: central separation
3RD STAGE OF LABOR: USE OF EPISIOTOMY AND REPAIR
Lacerations of the Birth Canal1st degree: fourchette, perineal skin, vaginal
mucosa2nd degree: above + fascia and muscles of the
perineum3rd degree: above + anal sphincter4th degree: above + rectal mucosa
3RD STAGE: USE OF EPISIOTOMY AND REPAIR Purpose: to facilitate the 2nd stage of labor
to improve maternal and neonatal outcome Maternal Benefit
Reduced risk of perineal trauma, subsequent floor dysfunction and prolapse, urinary and fecal incontinence, and sexual dysfunction
Fetal Benefit Shortened 2nd stage of labor
Timing Too early: increased blood loss Late: laceration may not be prevented
3RD STAGE: USE OF EPISIOTOMY AND REPAIR
IndicationsExpedite delivery in the 2nd stageWhen spontaneous laceration is likelyMaternal or fetal distressAssisted forceps deliveryLarge BabyMaternal exhaustion
3RD STAGE: USE OF EPISIOTOMY AND REPAIR Kinds of Episiotomy
3RD STAGE: USE OF EPISIOTOMY AND REPAIR
3RD STAGE: USE OF EPISIOTOMY AND REPAIR Routine vs. Restrictive Episiotomy
Episiorrhaphy: repair of lacerationSuture Materials and Technique
2 layered closure can improve postpartum pain and healing complications vs a 3 layered closure.
There is good evidence to support the use of Fast Absorbing Polyglactin 910 as a material of choice for perineal closure. (Level I, Grade A)
Continuous Suturing vs. Interrupted
3RD STAGE: ACTIVE MANAGEMENT
Recommendations:Administration of prophylactic uterotonin
within one minute after the delivery of the baby and prior to the delivery of the placenta
Early cord clamping and cutting Clamping: never above the introitus Delaying the clamping?
3:80:60
Controlled cord traction to deliver the placenta
3RD STAGE:ACTIVE MANAGEMENT TO PREVENT PPH
Giving Uterotonins -> increased uterine contractions/retraction -> total detachment and expulsion of the placenta -> optimal occlusion of the myometrial vessels -> PPH prevented
The use of combination preparation (Oxytocin and Ergometrine) appears to be associated with a statistically significant reduction in the risk of PPH when compared to oxytocin alone where blood loss is less than 1000mL. (Level I, Grade B).
3RD STAGE:ACTIVE MANAGEMENT TO PREVENT PPH
Administration of oxytocin alone is as effective as the use of oxytocin plus ergometrine in the prevention of PPH, but is associated with a significantly lower rate of unpleasant maternal side effects (nausea, vomiting and hypertension). (Level II, Grade B)
3RD STAGE:ACTIVE MANAGEMENT TO PREVENT PPH
Recommended Dose:Ergometrine – 200-250 mcg IM OR 100-125
mcg IV bolus
Oxytocin – 10 ‘u’/500mL NSS (20 ‘u’/1000mL NSS) Continuous IV drip OR 5 ‘u’ IV bolus
3RD STAGE: DRUGS Recommendations
Oxytocin is effective as 1st line prophylactic uterotonic during the 3rd stage of labor in the prevention of PPH and is safe to use in all patients. (Level I)
Use of ergot alkaloid and Ergometrine-Oxytocin are valid alternatives in the absence of Oxytocin. Their use have to be weighed against maternal adverse effects. (Level I)
Use of ergot alkaloid and Ergometrine – Oxytocin combination have to be avoided in hypertensive patients. (Level I)
4TH STAGE Critical period
UterotonicsUterine Massage Ice pack
Breast feeding
REFERENCES: Williams Obstetrics, 22nd ed.
POGS Clinical Guidelines on Normal Labor and Delivery, April 2009
THANK YOU!