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Normal Labor & DeliveryIntrapartum
Management Post Partum Care
WHO definition of "normal birth"
-Spontaneous onset
-Low risk at the start and remaining throughtout
-Infant is born spontaneously in vertex position between 37-42 weeks
-After birth, mother and baby are in good condition.
Definition of labor
-Uterine contractions that result in cervical dilation and effacement over time and descent of the presenting part -Membrane rupture can support dx, but not defined as such
Stages of Labor
- 1st : Latent and active phase
- 2nd : From full dilation to delivery "pushing phase"
- 3rd : Separation and expulsion of the placenta
- 4th : First hour after delivery
1st Stage of Labor
Latent and active phase
2nd Stage of Labor
From full dilation to delivery "pushing phase"
3rd Stage of Labor
Separation and expulsion of the placenta
4th Stage of Labor
First hour after delivery
Fetal Lie
Orientation of the fetus to the long axis of the uterys
Fetal position
-Position of the fetal presenting part relative to the maternal pelvis
-I.E. OA
Fetal presentation
-Fetal part presenting at the pelvic outlet
-E.g. Breech, cephalic, compound
Attitude
Flexion or extension of the fetal head relative to the shoulders
TERM
Biparietal 9.5cm
LOCATION
TERM
Lamboid suture
LOCATION
TERM
Coronal suture
LOCATION
TERM
Anterior frontanel
LOCATION
- Engagement
- Descent
- Internal rotation
- Extension
- External rotation (restitution)
- Expulsion- delivery of anterior shoulder
- Expulsion- delivery of posterior shoulder
True labor
-Contractions at regular intervals -Interval gradually shortens -Intensity gradually increases -Pain is in back and abd -Cervix dilates -Pain is not stopped by sedation
False labour
-Contractions at irregular intervals -Interval remains long -Intensity remains the same -Pain is mainly in lower abd -Cervix does not change -Pain is relieved by sedation
Latent phase of labor
-Patient perceives regular contractions
-Ends for most women b/w 3-5cm dilated
-Try to avoid admitting to case room
When does the latent phase end in most women?
-B/w 3-5cm dilated
What is a prolonged latent phase?
-Greater than 20hrs in nullipara and greater than 14hrs in multipara
What is a prolonged latent phase in nullipara?
20hrs
What is a prolonged latent phase in multipara?
14hrs
What should you avoid doing during the latent phase of labor?
-Admitting pt to the case room
Active phase of labor
-Cervical dilation of 3-5cm or more w/ regular uterine contractions
-Admit to case room!
What should you do w/ a pt in the active phase of labor
Accelerations in baseline fetal HR
/= 15 bpm above baseline lasting at least 15 secs
Decelerations in baseline fetal HR
-Early and variable are normal -Late may be abnormal
A major goal of intrapartum care is...
Management of labor pain
Effects of higher pain in labor
Increased anxiety and catecholamine levels, leading to dysfunctional uterine contractions and altered uterine blood flow
Spinal roots responsible for uterine contractions
T10-L
Spinal roots responsible for perineal pain
S2-S
Non-pharmacologic methods for pain management
- Maternal movement and position change
- Counter pressure
- Activating peripheral sensory receptors (e.g. heat/cold, immersion in water, touch and massage, acupuncture/acupressure)
- Enhancing descending inhibitory pathways (e.g. attention focusing and distraction, hypnosis and self-hypnosis, music, biofeedback)
Pharmacologic methods for pain management
-Entonox (nitrous oxide), -Narcotics (Meperidine for long duration, but morphine tends to be used at HSC) -Pudendal nerve blocks -Perineal infiltration -Epidural blocks
Pudendal nerve block
-Regional block of S2, S3, S -Effective for 2nd stage of labor
What are pudendal nerve blocks useful for?
-SVD -Episiotomies -Some outlet and low OVD
Pudendal nerve block procedure
-Use of an Iowa trumpet w/ 20-gauge needle -Inject local anesthetic just below ischial spines
-Prepare ephedrine for IV injection (30mg diluted in 9mg of saline or water)
- Infusion of epidural solution 6-12ml/hr
Labor dystocia
-Abnormal progression of labor
Most common problem associated w/ labor
Labor dystocia (i.e. abnormal progression of labor)
Labor dystocia in active labor
4hrs of less than 0.5cm/hr dilatation
Labor dystocia in active second stage
1hr of active pushing and no descent of the presenting part
Labor dystocia is associated w/ increased...
-Maternal stress and anxiety -Maternal infection -Postpartum hemorrhage -Increased C/S rate
Etiology of dystocia
4 P's
- Power : Contractions, maternal expulsive efforts
- Passenger : Fetal position, attitude, size, abnormalities (i.e. hydrocephalus)
- Passage : Pelvic structure, soft tissue factors (e.g. full bladder/rectum, tumours, vaginal septum)
- Psyche : Maternal pain, anxiety
2nd stage of labor
-Most women begin pushing when the cervix is fully dilated -However, may allow for passive decent in pt w/ normal FHR and good pain control -Pt may push in any position comfortable (e.g. squatting, kneeling, on side, or supine)
Which position for pushing should we try to avoid?
Full supine
What should we reassess frequently in the 2nd stage of labor?
1)Effective pushin
- Pain control
- strength and frequency of contractions
Episiotomy (ACOG 2006)
-One of the most commonly performed procedure in obs -Incision in the perineal area to enlarge the vaginal orifice
What is one of the most commonly performed procedures in obstetrics?
-Episiotomy
Episiotomy procedure
-Little data to support or refute benefit
Position of fetus in delivery during second stage
-Fetal occiput then turns to a transverse position (restitution; external rotation) -Sides of fetal head then grasped -Gentle downward traction is applied w/ maternal effort for delivery of anterior shoulder -Upward movement to deliver posterior shoulder
Following the delivery of the baby, next...
-Slide hand along fetal back to grasp baby at ankles ( avoid the stomach area)
-At the time of delivery, routine suction at the perineum is not typically done
- Place baby on mother’s belly if baby vigorous
-Cord then doubly clamped and divided
Active management of the 3rd stage of labor
-Oxytocin bolus -Controlled gentle traction on umbilical cord w/ other hand supporting uterus
Procedures in the 3rd stage of labor
-May take sample for cord gases -Cord blood collection -Typically allow up to 30min for delivery of placenta
Signs of placental separation
-Uterus globular and firm -Sudden gush of blood -Uterus rises in the abdomen as placenta moves into lower uterine segment and vagina -Lengthening of umbilical cord
Management of the 4th stage of labor
-Following delivery examination of perineum, vagina, cervix, and placenta -Ensure adequate analgesia -Monitor bleeding
Leading cause of maternal mortality
-Postpartum hemorrhage
Postpartum hemorrhage
500 ml blood loss after vaginal delivery
1000 ml after CS -Leading cause of maternal mortality -Primary and secondary
Postpartum hemorrhage as defined for vaginal delivery
