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Introductory lecture for M3 Clerkship in Obstetrics & Gynecology. Addresses APGO Educational Objectives, 8th Edition, Educational Topics 11 and 22.
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Intrapartum Care Intrapartum Care & Abnormal Labor& Abnormal Labor
Francis S. Nuthalapaty, MD
Medical Student Lecture SeriesDepartment of Obstetrics & GynecologyDepartment of Obstetrics & GynecologyGreenville Hospital System University Greenville Hospital System University Medical CenterMedical CenterGreenville, South CarolinaGreenville, South Carolina
Learning ObjectivesLearning ObjectivesAPGO ET-11: Intrapartum Care
Understanding the process of normal labor and delivery allows optimal
care and reassurance for the parturient and timely recognition of
abnormal events.
APGO Medical Student Educational Objectives 8th Ed. 2004
Learning Objectives Learning Objectives ET-11ET-11
Objective Level of Competence
List the signs and symptoms of labor KH
Describe the three stages of labor and recognize common abnormalities
KH
Describe the steps of a vaginal delivery SH
Describe the different methods of delivery with the indications and contraindications of each
KH
Describe the evaluation of common puerperal complications
KH
APGO Medical Student Educational Objectives 8th Ed. 2004
Learning ObjectivesLearning ObjectivesAPGO Educational Topic 22:
Abnormal LaborLabor is expected to progress in an
orderly and predictable manner. Careful observation of the mother and fetus during labor will allow
early detection of abnormalities so that management can be directed to
optimize outcome.APGO Medical Student Educational Objectives 8th Ed. 2004
Learning Objectives ET-Learning Objectives ET-2222
ObjectiveLevel of
Competence
List abnormal labor patterns K
Describe methods of fetal surveillance K
Discuss fetal and maternal complications of abnormal labor
K
List indications and contraindications for oxytocin administration
K
APGO Medical Student Educational Objectives 8th Ed. 2004
Learning Objectives ET-Learning Objectives ET-2222
ObjectiveLevel of
Competence
List indications for VBAC K
Discuss strategies for emergency management of breech, shoulder dystocia and cord prolapse
K
APGO Medical Student Educational Objectives 8th Ed. 2004
TerminologyTerminology• Gravidity
–#of current and completed pregnancies of any kind
• Parity–# of completed pregnancies ≥ 20 weeks
–not delivered infants (e.g. twins)
TerminologyTerminology
•Nullipara
•Primipara
•Multipara
•Grand Multipara
TerminologyTerminology
• TPAL Nomenclature:T = Term deliveries ≥ 37 wksP = Preterm deliveries < 37 wksA = Abortions (< 20 wks)L = Living children
• G3/P1-0-1-1:
TerminologyTerminology
• G3/P1-0-1-1:
–3rd Pregnancy
–1 Term delivery
–0 Preterm deliveries
–1 Abortion
–1 Living child
TerminologyTerminology
• G5/P2-1-1-0:
TerminologyTerminology
• G5/P2-1-1-0:
–5th Pregnancy
–2 Term deliveries
–1 Preterm delivery
–1 Abortion
–0 Living children
TerminologyTerminology
• G2/P0-2-0-3:
TerminologyTerminology
• G2/P0203:
–2nd Pregnancy
–0 Term deliveries
–2 Preterm deliveries
–0 Abortions
–3 Living children
TerminologyTerminology
•Fetal Presentation•Attitude•Fetal Lie•Fetal Position•Fetal Station
TerminologyTerminology
Designates the fetal part over the pelvic inlet
Fetal PresentationFetal Presentation
Presentation % Incidence
Cephalic 96.8---Breech 2.7 1:36Transverse 0.3 1:335Compound 0.1 1:1000Face 0.051:2000Brow 0.011:10,000
Williams Obstetrics, 21st Ed. 452.
Fetal PresentationFetal Presentation
Cephalic Presenting Cephalic Presenting DiametersDiameters
FACE
SINCIPUTMILITARY
BROW VERTEXFLEXED
Figure 9-2 Lateral view of the fetal skull showing the prominent landmarks and the anteroposterior diameters.
The degree of flexion a fetus assumes during labor or the relation of the fetal parts to
each other
Fetal AttitudeFetal Attitude
Variations in Fetal Variations in Fetal AttitudeAttitude
SINCIPUT, MILITARY BROW FACEVERTEX, FLEXED
Fetal LieFetal Lie•Refers to the relation of the long axis of
fetus (back) to the long axis of the mother:
------ Transverse ------ -------------- Longitudinal ----------------
Diagnosis of Fetal Diagnosis of Fetal PresentationPresentation
•Abdominal Palpation– - Leopold’s Maneuvers
Diagnosis of Fetal Diagnosis of Fetal PresentationPresentation
•Abdominal Palpation– - Leopold’s Maneuvers
•Vaginal Examination•Auscultation•Sonography
Fetal PositionFetal PositionRefers to the relation of an
arbitrarily chosen portion of the fetal presenting part to the right or left side of the maternal birth
canal
• Reference points (denominators) are:
Fetal occiput
Fetal chin (mentum)
Fetal sacrum
Fetal Head: Fetal Head: LandmarksLandmarks
Figure 9-1 Superior view of the fetal skull showing the sutures, fontanelles, and transverse diameters.
Occiput PresentationOcciput Presentation
Fetal Position Fetal Position
OP
LOT
OA
ROT
LOPROP
LOAROA
•LOT: 40%•ROT: 20%•OP: 20%
Fetal Position Fetal Position
?????
Fetal Position Fetal Position
Left OcciputAnterior
Fetal Position Fetal Position
?????
Fetal Position Fetal Position
Right Occiput
Posterior
Fetal Position Fetal Position
?????
Fetal Position Fetal Position
Left OcciputTransver
se
The relationship of the fetal presenting part to the level
of the ischial spines
Fetal StationFetal Station
Fetal StationFetal Station
World Health Organization: Managing Complications in Pregnancy and Childbirth World Health Organization: Managing Complications in Pregnancy and Childbirth www.who.int/reproductivehealth/impac/Clinical_Principles/Normal_labour_C57_C76.htmlwww.who.int/reproductivehealth/impac/Clinical_Principles/Normal_labour_C57_C76.html
Clinical CorrelationClinical Correlation
• Correct identification of fetal position relative to the birth canal is critical!
• Document the following:– Fetal Lie – Fetal Presentation – Fetal Position– Fetal Station
LaborLabor
TerminologyTerminology• False Labor (Braxton-Hicks ctx)
– May be present from first trimester
– Irregular, nonrhythmic
• True Labor
– Rhythmic contractions with cervical
change
Essential Factors of LaborEssential Factors of Labor(The 3 P’s)(The 3 P’s)
• Passage
• Powers
• Passenger
The 3 P’s of LaborThe 3 P’s of LaborPassagePassage
PassagePassage
•Bony Pelvis–inlet
–midpelvis
–outlet
•Soft Tissue
Caldwell-Moloy Caldwell-Moloy ClassificationClassification
A
P
Gynecoid
A
P
Android
P
A
Platypelloid
P
A
Anthropoid
Caldwell-Moloy ClassificationCaldwell-Moloy Classification
• Gynecoid = 40 – 50% (10-15% AA)
• Android = 30%
• Anthropoid = 20% (40% in AA)
• Platypelloid = 2- 5%
Gynecoid PelvisGynecoid Pelvis• Round at the inlet, with the widest
transverse diameter only slightly greater than the anteroposterior diameter
• Side walls straight• Ischial spines of average prominence• Well-rounded sacrosciatic notch• Well-curved sacrum• Spacious subpubic arch, with an angle
of approximately 90 degrees
Android PelvisAndroid Pelvis• Triangular inlet with a flat
posterior segment and the widest transverse diameter closer to the sacrum than in the gynecoid type
• Convergent side walls with prominent spines
• Shallow sacral curve• Long and narrow sacrosciatic notch• Narrow subpubic arch
Anthropoid PelvisAnthropoid Pelvis• A much larger AP than transverse
diameter, creating a long narrow oval at the inlet
• Side walls that do not converge• Ischial spines that are not prominent but
are close, owing to the overall shape• Variable, but usually posterior,
inclination of the sacrum• Large sacrosciatic notch• Narrow, outwardly shaped subpubic arch
Pelvic Landmarks - Pelvic Landmarks - InletInlet
•Sacral promontory
•Illiopectineal line
•Symphysis pubis
mywebpages.comcast.net/wnor/pelvis.htm --Wesley Norman, PhD, DSc Georgetown University
Pelvic Landmarks - Pelvic Landmarks - InletInlet
Pelvic Landmarks - Pelvic Landmarks - InletInlet
Vaginal Examination to Vaginal Examination to Determine the Diagonal Determine the Diagonal
ConjugateConjugate
Pelvic Landmarks - Pelvic Landmarks - MidMid
•Ischial spines
•Sacrum
•Sacrosciatic notch
mywebpages.comcast.net/wnor/pelvis.htm --Wesley Norman, PhD, DSc Georgetown University
Pelvic Landmarks - Pelvic Landmarks - MidMid
Assessment of Mid-Assessment of Mid-pelvispelvis
Pelvic Landmarks - Pelvic Landmarks - OutletOutlet
•Pubic arch
•Ischial tuberosities
•Sacrococcygeal joint
Pelvic Landmarks - Pelvic Landmarks - OutletOutlet
Figure 9-4 Pelvic outlet and its diameters.
Assessment of Pelvic Assessment of Pelvic OutletOutlet
Minimum PelvimetricsMinimum PelvimetricsPelvic
Plane DiameterLength
(cm)
Inlet Diagonal conjugate
11.5
Midplane Bispinous 10.5*
Outlet Bituberous 8* Average measurement, no minimum defined
The 3 P’s of LaborThe 3 P’s of LaborPowersPowers
PowersPowers
•50 mm Hg or more
•Contractions occur q 2-3
minutes
•Upper uterus more active with
pacemakers at cornual
The 3 P’s of LaborThe 3 P’s of LaborPassengerPassenger
PassengerPassenger• Head is typically the largest
structure
• Molding
• Smallest diameter of head:– suboccipitobregmatic
• Abnormal lie or size or presentation can cause problems
Passenger: Fetal Head Passenger: Fetal Head ConsiderationsConsiderations
• Bones in face fused but cranial vault has movable bones
• Molding is when bones overlap under pressure
• Sutures are membranous spaces between bones
• Fontanelles or “soft spots” are the intersections between sutures
MoldingMolding
Relationship between the passage and the fetus
Engagement Station Fetal position
Passage and Passenger Passage and Passenger RelationshipRelationship
• Engagement –the fetal head is thru the pelvic inlet when fetal BPD reaches the ischial spines
Relationship between the passage and the fetus
Engagement Station Fetal position
Passage and Passenger Passage and Passenger RelationshipRelationship
• Station - descent of the fetal BPD, relative to the level of the ischial spines.
COURSE OF NORMAL COURSE OF NORMAL LABORLABOR
Labor DefinitionLabor Definition
The physiologic process by which the gravid uterus evacuates its contents at or near term by a mechanism involving coordinated sequence of periodic contractions of the myometrium effecting progressive cervical dilatation and fetal descent through the birth canal.
- Emanuel A. Friedmin
First Stage of LaborFirst Stage of Labor• Onset of true labor until cervix
fully dilated:
Latent Phase Active Phase
First Stage of LaborFirst Stage of Labor
First Stage of LaborFirst Stage of Labor
Second Stage of LaborSecond Stage of Labor
• Complete dilatation to delivery of the infant
Cardinal Movements Cardinal Movements of Laborof Labor
• Engagement, descent, flexion
• Internal rotation
• Complete rotation with beginning of extension
• Complete extension
• External Rotation (Restitution)
• External rotation with delivery of Anterior shoulder
• Expulsion with delivery of Posterior shoulder
Third Stage of LaborThird Stage of Labor
• Delivery of the infant to delivery of the placenta
Third Stage of LaborThird Stage of Labor• Placental separation:
– Uterus becomes firmer
– Gush of blood– Uterus rises in
abdomen as placenta passes into lower segment
– Lengthening of umbilical cord
Stages: cont’d
Third stage Placental separation Placental delivery
Fourth stage 1-4 hours
Power: Forces of Power: Forces of LaborLabor
• First Stage of Labor– Primary Forces = Uterine ctx to dilate cervix
to 10 cm
• Second Stage of Labor– Secondary Forces = Abdominal muscles to
push fetus out after cervix is fully dilated
• Third Stage of Labor- Primary Forces = Uterine ctx to deliver
placenta
INTRAPARTUM INTRAPARTUM MANAGEMENTMANAGEMENT
Fetal Heart Rate Fetal Heart Rate MonitoringMonitoring
• External:
Indirect - Doppler ultrasound
• Internal:
Direct – Scalp electrode
Fetal Heart Rate Fetal Heart Rate MonitoringMonitoring
• External:
– Assessment of:
• baseline, variability, accelerations,
decelerations
– Limitations:
• Maternal Body Habitus
• Maternal/Fetal Movement Artifact
Fetal Heart Rate Fetal Heart Rate MonitoringMonitoring
• Internal:– Assessment of:
• baseline, variability, accelerations, decelerations
– Limitations:
• Membranes must be ruptured
• Minimally invasive
• Increase risks of Hep B/HIV if mother +
• Maternal HR detected if FHR absent
Contraction Contraction MonitoringMonitoring
• External:
– Indirect: Abdominal pressure
electrode
• Internal:
– Direct: IUPC with pressure sensor
Contraction Contraction MonitoringMonitoring
• External:
- Can detect presence and interval of ctx,
but not strength
- Limitations:
Maternal Body Habitus
Maternal/Fetal Movement Artifact
Factitious contractions
Contraction Contraction MonitoringMonitoring
• Internal:
- Assessment of BOTH frequency
and
intensity of contractions
- Limitations:
Membranes must be ruptured
Minimally invasive
Intrapartum MonitorsIntrapartum Monitors
Fetal Heart Rate Fetal Heart Rate InterpretationInterpretationAssessmentAssessment
• Quality of tracing
• Baseline fetal heart rate
• Describe overall variability
• Presence of accelerations?
• Presence of decelerations?
• Contraction frequency/intensity
Fetal Heart Rate TracingFetal Heart Rate Tracing
Fetal Monitoring Fetal Monitoring GuidelinesGuidelines
Normal Labor Normal Labor ParametersParameters
Source: Modified from Friedman EA. Labor: Clinical Evaluation and Management, 2nd ed. New York. Appletion-Century-Cronz 1370.43
Nulliparous Labor
MeanLower Limit
(95%)
Latent 8.6 h 20.6 h
Active 4.9 h 11.5 h
Deceleration 54 min 3.3 h
Maximum Slope 3.0 cm/h 1.2 cm/h
Second Stage 57 min 2.5 h
Normal Labor Normal Labor ParametersParameters
Source: Modified from Friedman EA. Labor: Clinical Evaluation and Management, 2nd ed. New York. Appletion-Century-Cronz 1370.43
Multiparous Labor
MeanLower Limit
(95%)
Latent 5.3 h 13.6 h
Active 2.2 h 5.2 h
Deceleration 14 min 53 min
Maximum Slope 5.7 cm / h 1.5 cm/h
Second Stage 14 min 50 min
Abnormal Labor Abnormal Labor Assessment Assessment Clinical Caveat
Labor dystocia requires a close assessment of the 3-P’s to determine the etiology and
implement appropriate management changes to address
the problem identified.
Adequate LaborAdequate Labor• Defined as > 200 Montevideo
units (MVU) as measured by IUPC
• MVU = Sum of contraction strength for each contraction occurring over 10 minutes
MVUs = ????MVUs = ????
MVUs = 270MVUs = 270“Adequate Labor”“Adequate Labor”
7 Labor Dysfunctions7 Labor Dysfunctions1. Prolonged Latent Phase
– Definition:• > 20 hours nullipara• > 14 hours multipara
– Treatment:• “Therapeutic rest” = sedatives
– 85% awaken in 6-10 hours and progress to active phase
– 10% have stopped contracting– 5% continue to contract without progression,
requiring uterine stimulation.
• Oxytocin
7 Labor Dysfunctions7 Labor Dysfunctions2. Protracted Active Phase
– Definition:• Cervical dilation < 1.2 cm/h nullipara• Cervical dilation < 1.4 cm/h multipara
– Treatment:• Evaluate passenger, passageway, power• IUPC to calculate MVU (goal > 200)• Oxytocin augmentation
7 Labor Dysfunctions7 Labor Dysfunctions3. Protracted Deceleration Phase
– Definition:• > 3 hours nullipara• > 1 hour multipara
– Treatment:• Same as for protracted active phase• Evaluate passenger, passageway, power• IUPC to calculate MVU (goal > 200)• Oxytocin augmentation
7 Labor Dysfunctions7 Labor Dysfunctions4. Secondary Arrest of Dilatation
in Active phase– Definition:
• Absence of cervical change over 2 hours*• MVU > 200
– Treatment:• Cesarean delivery
* Extension to 4 hours results in higher rate of vaginal delivery (92%) and is also acceptable
7 Labor Dysfunctions7 Labor Dysfunctions5. Protracted Descent
– Definition:• < 1 cm/h nullipara• < 2 cm/h multipara
– Treatment:• Same as for protracted active phase• Evaluate passenger, passageway, power• IUPC to calculate MVU (goal > 200)• Oxytocin augmentation
7 Labor Dysfunctions7 Labor Dysfunctions7. Arrest of Descent in Second
Stage– Definition:
• No descent of presenting part in:• > 2 hours (or > 3 hours with CLE) nullipara• > 1 hour (or > 2 hours with CLE) multipara
– Treatment:• Continued observation• Operative vaginal delivery• Cesarean delivery
7 Labor Dysfunctions7 Labor Dysfunctions6. Failure of Descent
– Definition:• No descent in > 1 hour nullipara• No descent in > 30 min multipara
– Treatment:• Same as for protracted active phase• Evaluate passenger, passageway, power• IUPC to calculate MVU (goal > 200)• Oxytocin augmentation
Labor Assessment Labor Assessment Case 1Case 1
• 32 yo G1P0 36 weeks presented with contractions. Looks uncomfortable, and is contracting every 3 minutes but cervix is 2 cm and 50% effaced. Was seen the previous day with similar complaints and findings.
• Diagnosis:
• Management:
Labor Assessment Labor Assessment Case 1Case 1
• 32 yo G1P0 36 weeks presented with contractions. Looks uncomfortable, and is contracting every 3 minutes but cervix is 2 cm and 50% effaced. Was seen the previous day with similar complaints and findings.
• Diagnosis:– Prolonged latent phase
• Management:– “Therapeutic Rest”
Labor Assessment Labor Assessment Case 2Case 2
• 24 yo P1001 39 weeks presented in labor. Contracting every 3 minutes but looks comfortable. Progressed from 4 to 6 centimeters in 6 hours. Membranes intact. Estimated fetal weight – 3000 grams. Pelvis adequate on examination. Vertex presentation.
• Diagnosis:
• Management:
Labor Assessment Labor Assessment Case 2Case 2
• 24 yo P1001 39 weeks presented in labor. Contracting every 3 minutes but looks comfortable. Progressed from 4 to 6 centimeters in 6 hours. Membranes intact. Estimated fetal weight – 3000 grams. Pelvis adequate on examination. Vertex presentation.
• Diagnosis:– Protracted active phase likely secondary to
inadequate labor (insufficient power)• Management:
– Amniotomy, Oxytocin augmentation +/- IUPC
Labor Assessment Labor Assessment Case 3Case 3
• 32 yo P0000 Class C diabetic at 40 weeks undergoing labor induction. Contracting every 2-3 minutes. 7 cm dilation x 4 hours. Confirmed adequate labor with intrauterine pressure catheter. Membranes ruptured, Estimated fetal weight – 4200 grams. Pelvis adequate on examination. Vertex presentation.
• Diagnosis:
• Management:
Labor Assessment Labor Assessment Case 3Case 3
• 32 yo P0000 Class C diabetic at 40 weeks undergoing labor induction. Contracting every 2-3 minutes. 7 cm dilation x 4 hours. Confirmed adequate labor with intrauterine pressure catheter. Membranes ruptured, Estimated fetal weight – 4200 grams. Pelvis adequate on examination. Vertex presentation.
• Diagnosis:– Arrest of dilatation likely secondary to cephalopelvic
disproportion/fetal macrosomia (Passenger too big for pelvis)
• Management: Cesarean Delivery
Labor Assessment Labor Assessment Case 4Case 4
• 28 yo P0101 at 42 weeks presented in labor. History of previous MVA with pelvic fracture. Contracting every 2-3 minutes. 6 cm dilation x 4 hours. Confirmed adequate labor with intrauterine pressure catheter. Membranes ruptured, Estimated fetal weight – 3200 grams. Constricted pelvic inlet with non-engaged fetal head. Vertex presentation.
• Diagnosis:
• Management:
Labor Assessment Labor Assessment Case 4Case 4
• 28 yo P0101 at 42 weeks presented in labor. History of previous MVA with pelvic fracture. Contracting every 2-3 minutes. 6 cm dilation x 4 hours. Confirmed adequate labor with intrauterine pressure catheter. Membranes ruptured, Estimated fetal weight – 3200 grams. Constricted pelvic inlet with non-engaged fetal head. Vertex presentation.
• Diagnosis: – Arrest of dilatation likely secondary to cephalopelvic
disproportion/abnormal pelvis (Pelvis too small for pelvis)
• Management: Cesarean Delivery