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Labor Review. Petrenko N., MD,PhD. Critical Factors in Labor. 5 critical factors Birth passage Fetus Relationship of Maternal Pelvis and Presenting Part Physiologic forces of labor Psychosocial considerations. 1 Birth Passage. Four different types of pelvises, but frequently mixed types.

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Labor review

Labor Review

Petrenko N., MD,PhD


Critical factors in labor

Critical Factors in Labor

  • 5 critical factors

    • Birth passage

    • Fetus

    • Relationship of Maternal Pelvis and Presenting Part

    • Physiologic forces of labor

    • Psychosocial considerations


1 birth passage

1 Birth Passage

  • Four different types of pelvises, but frequently mixed types

anthrapoid

android

gynaecoid

platypelloid


2 fetus

2 Fetus

Lambdoidal suture

  • Sutures:

    • Frontal

    • Sagittal

    • Coronal

    • Lambdoidal

Sagittal suture

Coronal suture

Frontal suture

Note: sutures are actually membranous spaces that meet at fontanels


Fetus

Fetus

  • ☺Fontanelles: intersection of sutures, allows for molding, helps identify position of head

    • Anterior (bregma)

      • Diamond shaped

      • Approx 2-3 cm

      • Ossifies in ~12-18 months

    • Posterior

      • Triangle shaped

      • Smaller

      • Closes in 8-12 weeks


Fetus1

Fetus

  • Other landmarks on the fetal head

    • Mentum

    • Sinciput

    • Vertex

    • occiput


Fetus2

Fetus

  • Fetal attitude

    • Relation of fetal parts to one another

    • Normal: mod flexion of head, flexion of arms onto chest, flexion of legs onto abdomen

  • Changes in attitude can contribute to longer, more difficult labor or Cesarean Section


Fetus3

Fetus

  • Fetal lie

    • Relationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom

    • Longitudinal: parallel

    • Transverse: right angle

    • Oblique: acute abgle


Fetus fetal lie

Fetus Fetal lie

Longitudinal

Transverse


Fetus4

Fetus

  • Fetal presentation

    • Body part entering the pelvis (presenting part)

      • Cephalic

      • Breech

      • Shoulder


Fetus fetal lie1

Fetus Fetal lie

Cephalic

  • Breech

Shoulder


Fetus5

Fetus

  • Fetal presentation: Cephalic

    • ☺Vertex presentation

      • Most common

      • Head completely flexed on chest

      • Suboccipitobregmatic (Smallest diameter)

      • Occiput in presenting part


Fetus6

Fetus

  • Fetal presentation: Cephalic

    • Military presentation

      • Fetal head neither flexed nor extended

      • Occipitofrontal diameter presents

      • Top of the head is presenting part


Fetus7

Fetus

  • Fetal presentation: Cephalic

    • Brow presentation

      • Fetal head partially extended

      • Occipitomental diameter presents

      • Sinciput is presenting part


Fetus8

Fetus

  • Fetal presentation: Cephalic

    • Face presentation

      • Head hyperextended

      • Submentobregmatic diameter presents

      • Face is presenting part


Fetal presentations

Fetal presentations


Fetus9

Fetus

  • Fetal presentation: Breech

    • Sacrum is the landmark

    • Complete breech

      • Knees and hips are flexed, thighs on abdomen (“fetal position”)

      • Buttocks and feet are presenting parts


Fetus10

Fetus

  • Fetal presentation: Breech

    • Sacrum is the landmark

    • Frank breech

      • Hips flexed, knees extended

      • Buttocks is presenting part


Fetus11

Fetus

  • Fetal presentation: Breech

    • Sacrum is the landmark

    • Footling breech

      • Hips and legs extended

      • Feet are presenting parts (single vs double)


Fetus12

Fetus

  • Fetal presentation: Shoulder

    • Acromion process of shoulder is presenting part


Station

Station

􀂉In Gynaecoid & Android pelvis distance between ischial spine to brim is ~5 cm.

􀂉In Anthropoid pelvis distance is ~7 cm

􀂉In Platypelloid pelvis distance is ~3 cm

Station of the head in

relation to ischial spines


Relationship of maternal pelvis and presenting part

Relationship of maternal pelvis and presenting part


Relationship of maternal pelvis and presenting part1

Relationship of maternal pelvis and presenting part

  • OA most common, easiest to deliver

  • Other positions are considered malpositions

  • Position influences labor and birth

  • Largest diameter in posterior position: back pain, longer 2nd stage

  • Can tell position by palpation of abdomen and Vaginal Examination


2 fetus1

2 Fetus

Lambdoidal suture

  • Sutures:

    • Frontal

    • Sagittal

    • Coronal

    • Lambdoidal

Sagittal suture

Coronal suture

Frontal suture

Note: sutures are actually membranous spaces that meet at fontanels


Fetus13

Fetus

  • ☺Fontanelles: intersection of sutures, allows for molding, helps identify position of head

    • Anterior (bregma)

      • Diamond shaped

      • Approx 2-3 cm

      • Ossifies in ~12-18 months

    • Posterior

      • Triangle shaped

      • Smaller

      • Closes in 8-12 weeks


Fetus14

Fetus

  • Other landmarks on the fetal head

    • Mentum

    • Sinciput

    • Vertex

    • occiput


Fetus15

Fetus

  • Fetal attitude

    • Relation of fetal parts to one another

    • Normal: mod flexion of head, flexion of arms onto chest, flexion of legs onto abdomen

  • Changes in attitude can contribute to longer, more difficult labor or Cesarean Section


Fetus16

Fetus

  • Fetal lie

    • Relationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom

    • Longitudinal: parallel

    • Transverse: right angle

    • Oblique: acute abgle


Fetus fetal lie2

Fetus Fetal lie

Longitudinal

Transverse


Fetus17

Fetus

  • Fetal presentation

    • Body part entering the pelvis (presenting part)

      • Cephalic

      • Breech

      • Shoulder


Fetus fetal lie3

Fetus Fetal lie

Cephalic

  • Breech

Shoulder


Fetus18

Fetus

  • Fetal presentation: Cephalic

    • ☺Vertex presentation

      • Most common

      • Head completely flexed on chest

      • Suboccipitobregmatic (Smallest diameter)

      • Occiput in presenting part


Fetus19

Fetus

  • Fetal presentation: Cephalic

    • Military presentation

      • Fetal head neither flexed nor extended

      • Occipitofrontal diameter presents

      • Top of the head is presenting part


Fetus20

Fetus

  • Fetal presentation: Cephalic

    • Brow presentation

      • Fetal head partially extended

      • Occipitomental diameter presents

      • Sinciput is presenting part


Fetus21

Fetus

  • Fetal presentation: Cephalic

    • Face presentation

      • Head hyperextended

      • Submentobregmatic diameter presents

      • Face is presenting part


Fetal presentations1

Fetal presentations


Fetus22

Fetus

  • Fetal presentation: Breech

    • Sacrum is the landmark

    • Complete breech

      • Knees and hips are flexed, thighs on abdomen (“fetal position”)

      • Buttocks and feet are presenting parts


Fetus23

Fetus

  • Fetal presentation: Breech

    • Sacrum is the landmark

    • Frank breech

      • Hips flexed, knees extended

      • Buttocks is presenting part


Fetus24

Fetus

  • Fetal presentation: Breech

    • Sacrum is the landmark

    • Footling breech

      • Hips and legs extended

      • Feet are presenting parts (single vs double)


Fetus25

Fetus

  • Fetal presentation: Shoulder

    • Acromion process of shoulder is presenting part


Station1

Station

􀂉In Gynaecoid & Android pelvis distance between ischial spine to brim is ~5 cm.

􀂉In Anthropoid pelvis distance is ~7 cm

􀂉In Platypelloid pelvis distance is ~3 cm

Station of the head in

relation to ischial spines


Relationship of maternal pelvis and presenting part2

Relationship of maternal pelvis and presenting part


Relationship of maternal pelvis and presenting part3

Relationship of maternal pelvis and presenting part

  • OA most common, easiest to deliver

  • Other positions are considered malpositions

  • Position influences labor and birth

  • Largest diameter in posterior position: back pain, longer 2nd stage

  • Can tell position by palpation of abdomen and Vaginal Examination


Physiologic forces of labor

Physiologic forces of labor

  • Primary: uterine muscles (causes dilation and effacement)

  • Secondary: abdominal muscles (for 2nd stage)


Physiologic forces of labor1

Physiologic forces of labor

  • Phases of contractions

    • Increment

    • Acme

    • Decrement

  • Relaxation

    • Uterine muscle rest

    • Rest for mom

    • Restores oxygenation to baby


Physiologic forces of labor2

Physiologic forces of labor

Frequency

Duration

Intensity


Physiologic forces of labor3

Physiologic forces of labor

Intensity:

indirect (subjective): palpation: mild, moderate, strong,

direct (objective): mmHg pressure with IUPC (intauterine)


Physiologic forces of labor4

Physiologic forces of labor

Early labor: mild, short duration, irregular

As labor progresses: stronger, longer, more regular, closer together


Physiologic forces of labor5

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles


Stages of labor

Stages of Labor☺

  • Stage 1

    • Onset of regular contractions to complete dilatation

  • Stage 2

    • Complete dilatation to birth

  • Stage 3

    • Birth of infant to birth of placenta

  • Stage 4

    • Birth of placenta to 1-4 hrs recovery


Stages of labor1

Stages of Labor☺

  • Stage 1 divided into 3 phases

    • 1 Latent phase: 0-3 cm

      • Primip 8.6 hrs

      • Multip 5.3 hrs

      • May have irregular contractions, short, mild – moderate

      • Excited, talkative, smiling

    • 2 Active phase: 4-7 cm

      • Primip 4.6 hrs; dilation at least 1.2 cm/hr

      • Multip 2.4 ; dilation at least 1.5 cm/hr

      • Uterus contraction through 2-5 min, by 40-60 sec, mod – strong

      • ↑ anxiety, sense of hopelessness, fear of loss of control


Stages of labor2

Stages of Labor☺

  • Stage 1 divided into 3 phases cont…

  • 3 Transition phase: 8-10 cm

    • Primip 3.6 hrs

    • Multip variable

    • Uterus contraction through 1 ½ - 2 min; 60-90 sec, mod – strong

    • Acutely aware of intensity of uterus contraction, significant anxiety, restless, can’t get comfortable, fears being alone, yet may not want anyone to touch her, hot-cold, apprehensive

  • As dilation progresses, ↑ bloody show, ROM. As gets to closer to complete, ↑ rectal pressure, splitting feeling, urge to push


Stages of labor3

Stages of Labor☺

  • 2nd stage

    • Usually <2 hrs (less in multips)

    • Affected by epidural, maternal pushing, position of presenting part, size of pelvis

    • As head approaches perineum, labia separate, may see presenting part with pushing, then recede. Rectum bulges and flattens

    • Crowning


Stages of labor4

Stages of Labor


Stages of labor5

Stages of Labor☺

  • 3rd stage

    • Usually will induced 5 mins. May be up to 30 mins. Retained after 30 mins.

    • Signs of separation

      • Globular shaped uterus

      • Rise in fundus

      • Sudden gush or heavy trickle of blood

      • Lengthening of cord from vagina

    • Shiny schultze

    • Dirty duncan


Stages of labor6

Stages of Labor☺

  • 4th stage

    • Blood loss normal up to 500mL (vag del)

    • Hemodynamic changes  ↓ BP, ↑ pulse pressure, tachycardia

    • Uterus contracted and midline ~1/2 way between symphysis and umbilicus. Within 1st hour about level with umbilicus

    • Shaking, hunger, thirst

    • Bladder is hypotonic


Post term pregnancy

Post-term Pregnancy

  • > 42 completed weeks

  • Cause of true post-term is unknown; often incorrect dates

  • Maternal Risks:

    • Large baby and associations

    • Psychologic ills

  • Fetal-Neonatal Risks:

    • Placental changes  insufficiencies

    • Oligohydramnios

    • macrosomia birth trauma, glucose maintenance problems

    • Meconmium stained fluid (aspiration)

  • As pregnancy approached term, fetal well-being studies done


Fetal malposition

Fetal Malposition

  • OP position:

    • Fetus must rotate 135° or occasionally born in OP position

    • If born OP, increased risk of 3rd or 4th degree laceration, broken symphysis

    • May use forceps or manual rotation

    • Positioning: knee chest, pelvic rocking


Fetal malpresentation

Fetal Malpresentation

  • Brow

    • Usually C/S recommended

    • Perinatal morbidity and mortality:

      • Trauma: cerebral and neck compression; damage to trachea and larynx

    • Tx: pelvimetry, oxytocin?, C/S

  • Face

    • Perinatal morbidity and mortality:

      • Risk of prolonged labor, fetal edema, swelling of neck and internal structures, petechiae, ecchymosis

    • Tx: C/S in no progress


Fetal malpresentation1

Fetal Malpresentation

  • Breech

    • Most common malpresentation

    • Frank breech most common

    • Risk of cord prolapse; fetal anomolies 3x higher

    • If vag del: head trauma, fetal entrapment

    • Tx: external version (50-60% success), if vag del: epidural, double set-up


Fetal malpresentation2

Fetal Malpresentation

  • Shoulder

    • Version may be attempted

    • C/S

  • Compound presentation


Macrosomia

Macrosomia

  • >4500 g

  • Obese 3-4x more likely to have macrosomic baby

  • ↑risk of perineal lacerations, infection

  • Most significant problem is shoulder dystocia

    • OB emergency permanent injury of brachial plexus, fx clavicle, asphyxia, neurologic damage

    • Tx:

      • Assessment of adequacy of pelvis

      • Suprapubic pressure

      • Intentional breaking of clavicle

      • ?C/S


Prolapsed cord

Prolapsed Cord

  • Umbilical cord precedes presenting part

  • May be visible or occult

  • More common with

    • Abnormal lie

    • Low birth weight

    • > previous births

    • Amniotomy

    • Long cord


Prolapsed cord1

Prolapsed Cord

  • Key interventions

    • Relieve pressure on cord

      • Trendelberg or knee chest position

      • Oxygen to increase maternal oxygen saturation

      • Pressure on the presenting part

    • Call for help, but do not leave mother

    • Expedite delivery


Prolapsed cord2

Prolapsed Cord

  • Maternal Risk

    • No direct risk

  • Fetal-Neonatal Risk

    • Cord compression  ↓O2  possible death or neurologic compromise

  • Tx

    • Prevention!

    • If palpated, keep pressure off cord

    • ☺When ROM occurs, listen to FHTs for full minute; if decel heard, do vag exam to r/o cord prolapse


Intrauterine fetal demise iufd

Intrauterine Fetal Demise (IUFD)

  • May be found prior to coming to hosp or at time of admission

  • May be unexplained or r/t materanal disease process or fetal insult

  • May be induced right away or wait for spontaneous labor. C/S not automatically done

  • Pain med give freely


Intrauterine fetal demise iufd1

Intrauterine Fetal Demise (IUFD)

  • Provide privacy for families

  • Listen

  • Avoid inappropriate consolations

  • Give accurate info

  • Obtain mementos

  • Allow opportunity to see and hold

  • Provide information re: burial options

  • Provide support information


Premature rupture of membrane prom

Premature Rupture of Membrane(PROM)

  • Spontaneous break in the amniotic sac before onset of regular contractions

  • Mother at risk for chorioamnionitis, especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

  • Risk of fetal infection, sepsis and perinatal mortality increase with prolonged ROM.

  • Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus.


Prom signs of infection

PROMSigns of Infection

  • Maternal fever

  • Fetal tachycardia

  • Foul-smelling vaginal discharge


Prom detecting amniotic fluid

PROM Detecting Amniotic Fluid

  • Nitrazine

  • Ferning: Place a smear of fluid on a slide and allow to dry. Check results. If fluid takes on a fernlike pattern, it is amniotic fluid.

  • Speculum exam


Fernlike pattern

fernlike pattern


Prom treatment

PROM Treatment

  • Depends on fetal age and risk of infection

  • In a near-term pregnancy, induction within 12-24 hours of membrane rupture

  • In a preterm pregnancy (28 -34 weeks), the woman is hospitalized and observed for signs of infection. If an infection is detected, labor is induced and an antibiotic is administered


Prom nursing interventions

PROMNursing Interventions

  • Explain all diagnostic tests

  • Assist with examination and specimen collection

  • Administer IV Fluids

  • Observe for initiation of labor

  • Offer emotional support

  • Teach the patient with a history of PROM how to recognize it and to report it immediately


Signs of preterm labor

Signs of Preterm Labor

  • Rhythmic uterine contraction producing cervical changes before fetal maturity

  • Onset of labor 20 – 37 weeks gestation.

  • Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies.

  • There is no known prevention except for treatment of conditions that might lead to preterm labor.


Treatment of preterm labor

Treatment of Preterm Labor

  • Used if tests show premature fetal lung development, cervical dilation is less than 4 cm, & there are no that contraindications to continuation of pregnancy.

  • Bed rest, drug therapy (if indicated) with a tocolytic


Preterm labor pharmacotherapies

Preterm Labor Pharmacotherapies

  • Terbutaline (Brethine), a beta-adrenergic blocker, is the most commonly used tocolytic

  • Side effects: maternal & fetal tachycardia, maternal pulmonary edema, tremors, hyperglycemia or chest pain, and hypoglycemia in the infant after birth

  • Ritodrine (Yutopar) is less commonly used.


Preterm labor pharmacotherapies1

Preterm Labor Pharmacotherapies

  • Magnesium Sulfate

    • Acts as a smooth muscle relaxant and leads to decreased blood pressure

    • Many side effects including flushing, nausea, vomiting and respiratory depression

    • Should not be used in women with cardiac or renal impairment

    • Excreted by the kidneys


Perterm labor pharmacotherapies

Perterm Labor Pharmacotherapies

  • Corticosteroids

    • Help mature fetal lungs

    • Betamethasone or dexamethasone

    • Most effective if 24 hours has elapsed before delivery


Nursing interventions with preterm labor

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor

  • Observe for signs of fetal or maternal distress

  • Administer medications as ordered

  • Monitor the status of contractions, and notify the physician if they occur more than 4 times per hour.


Nursing interventions with preterm labor1

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor

  • Encourage patient to lie on her side

  • Bed rest encouraged but not proven effective

  • Provide guidance about hospital stay, potential for delivery of premature infant and possible need for neonatal intensive care


Nursing interventions with preterm labor2

Nursing Interventions with Preterm Labor

Discharge teaching for home care:

  • Avoid sex in any form

  • Take medications on time

  • Teach to recognize the signs of preterm labor and what to do


Birth related procedures

Birth Related Procedures


Procedures

Procedures

  • Version

    • External

    • Internal

  • Cervical Ripening

    • Cervidil

    • Cytotec

  • Amnioinfusion

    • ~250-500 mL warmed saline or LR is infused into uterus via IUPC over 20-30 min

    • Used to correct variables, dilute mec stained fluid


Labor induction

Labor Induction

  • Stimulation of U/C before spontaneous onset of labor

  • Prior to starting induction

    • Verification of gestation age

    • Confirmation of fetal presentation

    • Assessment of risk factors

    • Well-being assessment of mom and baby

    • Cervical Assessment


Labor induction1

Labor Induction

  • Cervical Assessment (Bishop’s Score)

    • Higher the score, more successful the induction will be

    • Favorable cervix is most important criteria for successful induction


Bishop s score

Bishop’s Score)


Labor induction2

Labor Induction

  • Methods

    • Stripping membranes

    • Oxytocin

      • ☺Always given via IV pump (may be given IM after del)

      • Site closest to insertion

      • Continuous EFM

      • Risks

        • Hyperstimulation

        • Uterine rupture

        • Water intoxication

        • Fetal risks associated with maternal problems, hyperbilirubinemia, trauma from rapid birth


Episiotomy

Episiotomy

  • Decline over the years

  • May make it more likely will have deep tears

  • Lacerations heal more quickly in absence of epis

  • 3rd or 4th degree lacerations more likely with epis


Episiotomy1

Episiotomy

  • Midline

    • from vag orifice to fibers of rectal sphincter

    • Less blood loss, easier to repair, heals with less discomfort

  • Mediolateral

    • From midline of posterier forchette to 45° angle to right or left

    • Provides more room but has > blood loss, longer healing time and more discomfort

  • Tx

    • Pain relief measures

    • Ice

    • Inspect!


Operative assisted deliveries

Operative Assisted Deliveries

  • Forceps

    • Maternal complications

      • Trauma

      • Increased pain in pp period

      • Weakening of the pelvic floor

    • Fetal-neonatal complications

      • Caput

      • Caphalohematoma

      • Transient facial paralysis

      • trauma


Operative assisted deliveries1

Operative Assisted Deliveries

  • Vacuum Extractor

    • Longer duration of suction, more likely scalp injury

    • Maternal complications

      • Perineal trauma

      • Edema

      • Genital tract and anal sphincter probs (< than with forceps)

    • Neonatal complications

      • Scalp lacerations

      • Bruising/subdural hematoma

      • Cephalohematoma

      • Jaundice

      • Fx clavicle

      • Retinal hemorrhage

      • death


Cesarean birth

Cesarean Birth

  • 1970 - ~5%

  • 1988 – 24.7%

  • 2001 – 21%

  • 2005 - ? But higher

  • Indications

    • Failure to progress/descend

    • Previa/abruption/prolapse cord

    • Non-reassuring fetal status

    • Malpresentation

    • Previous C/S

  • Maternal morbidity and mortality is > than vag delivery


Cesarean birth1

Cesarean Birth

  • Technique

    • NOTE: Skin incision NOT indicative of uterine incision

    • Transverse (Pfannenstiel)-lower uterine segment

      • Adv: below pubic hair line, less bleeding, better healing

      • Disadv: difficult to extend if needed, requires more time, if adipose fold difficult to keep clean and dry

    • Vertical-between naval and symphysis

      • Adv: quicker, more room

      • Disadv: scar obvious, longer


Cesarean birth2

Cesarean Birth


Labor review

Cesarean Birth


Cesarean birth3

Cesarean Birth

  • Technique

    • Uterine incision (type depends on need for C/S)

    • Transverse-lower uterine segment

      • Adv: thinnest  less blood loss, only mod dissection of bladder, easier to repair, site less likely to rupture during subsequent pregnancies, less chance of adherence of bowel or omentum to incision line

      • Disadv: takes longer, limited in size due to major blood vessels, greater tendency to extend into uterine vessels


Cesarean birth4

Cesarean Birth

  • Technique

    • Lower Uterine Segment Vertical Incision

      • Preferred for multiple gestation, abnormal presentation, previa, preterm, macrosomia

      • Adv: more room

      • Disadv: may extend into cx, more extensive dissection of the bladder is necessary, if extends upward hemostasis and closure more difficult, higher risk of rupture in subsequent pregnancies


Cesarean birth5

Cesarean Birth

  • Technique

    • Classic incision

      • Upper uterine segment

      • Adv: more room, quicker to do

      • Disadv: more blood loss, difficult to repair, higher risk of rupture in subsequent pregnancies


Cesarean birth6

Cesarean Birth

  • Prep for C/S (time dependent)

    • Permits NPO

    • IV Oral/IV antacids, H2 inhibitors

    • FoleyTeaching

    • Shave

  • Immediate PP care

    • Freq vs (q 5-10 min) Lungs

    • Check dressingI&O

    • Lochia and uterus Anesthetic level


Vbac vaginal birth after cesarean

VBAC (vaginal birth after cesarean)

  • That was then, this is now

  • Specific criteria

  • Must sign consent

  • Contraindications

    • Classic incision or previous fundal uterine surgery

  • Most common risk is hemorrhage and uterine rupture


Placental accreta

Placental accreta

  •  occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle. Placenta accreta is the most common accounting for approximately 75% of all cases.

  •  Approximately 1 in 2,500 pregnancies experience placenta accreta, increta or percreta.

  • There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall.


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