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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

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

anthrapoid

android

gynaecoid

platypelloid


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

  • ☺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


Fetus

  • Other landmarks on the fetal head

    • Mentum

    • Sinciput

    • Vertex

    • occiput


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


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

Longitudinal

Transverse


Fetus

  • Fetal presentation

    • Body part entering the pelvis (presenting part)

      • Cephalic

      • Breech

      • Shoulder


Fetus Fetal lie

Cephalic

  • Breech

Shoulder


Fetus

  • Fetal presentation: Cephalic

    • ☺Vertex presentation

      • Most common

      • Head completely flexed on chest

      • Suboccipitobregmatic (Smallest diameter)

      • Occiput in presenting part


Fetus

  • Fetal presentation: Cephalic

    • Military presentation

      • Fetal head neither flexed nor extended

      • Occipitofrontal diameter presents

      • Top of the head is presenting part


Fetus

  • Fetal presentation: Cephalic

    • Brow presentation

      • Fetal head partially extended

      • Occipitomental diameter presents

      • Sinciput is presenting part


Fetus

  • Fetal presentation: Cephalic

    • Face presentation

      • Head hyperextended

      • Submentobregmatic diameter presents

      • Face is presenting part


Fetal presentations


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


Fetus

  • Fetal presentation: Breech

    • Sacrum is the landmark

    • Frank breech

      • Hips flexed, knees extended

      • Buttocks is presenting part


Fetus

  • Fetal presentation: Breech

    • Sacrum is the landmark

    • Footling breech

      • Hips and legs extended

      • Feet are presenting parts (single vs double)


Fetus

  • Fetal presentation: Shoulder

    • Acromion process of shoulder is presenting part


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

  • 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 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

  • ☺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


Fetus

  • Other landmarks on the fetal head

    • Mentum

    • Sinciput

    • Vertex

    • occiput


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


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

Longitudinal

Transverse


Fetus

  • Fetal presentation

    • Body part entering the pelvis (presenting part)

      • Cephalic

      • Breech

      • Shoulder


Fetus Fetal lie

Cephalic

  • Breech

Shoulder


Fetus

  • Fetal presentation: Cephalic

    • ☺Vertex presentation

      • Most common

      • Head completely flexed on chest

      • Suboccipitobregmatic (Smallest diameter)

      • Occiput in presenting part


Fetus

  • Fetal presentation: Cephalic

    • Military presentation

      • Fetal head neither flexed nor extended

      • Occipitofrontal diameter presents

      • Top of the head is presenting part


Fetus

  • Fetal presentation: Cephalic

    • Brow presentation

      • Fetal head partially extended

      • Occipitomental diameter presents

      • Sinciput is presenting part


Fetus

  • Fetal presentation: Cephalic

    • Face presentation

      • Head hyperextended

      • Submentobregmatic diameter presents

      • Face is presenting part


Fetal presentations


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


Fetus

  • Fetal presentation: Breech

    • Sacrum is the landmark

    • Frank breech

      • Hips flexed, knees extended

      • Buttocks is presenting part


Fetus

  • Fetal presentation: Breech

    • Sacrum is the landmark

    • Footling breech

      • Hips and legs extended

      • Feet are presenting parts (single vs double)


Fetus

  • Fetal presentation: Shoulder

    • Acromion process of shoulder is presenting part


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

  • 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

  • Primary: uterine muscles (causes dilation and effacement)

  • Secondary: abdominal muscles (for 2nd stage)


Physiologic forces of labor

  • Phases of contractions

    • Increment

    • Acme

    • Decrement

  • Relaxation

    • Uterine muscle rest

    • Rest for mom

    • Restores oxygenation to baby


Physiologic forces of labor

Frequency

Duration

Intensity


Physiologic forces of labor

Intensity:

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

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


Physiologic forces of labor

Early labor: mild, short duration, irregular

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


Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles


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 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 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 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 Labor


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 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

  • > 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

  • 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

  • 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 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 Malpresentation

  • Shoulder

    • Version may be attempted

    • C/S

  • Compound presentation


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

  • Umbilical cord precedes presenting part

  • May be visible or occult

  • More common with

    • Abnormal lie

    • Low birth weight

    • > previous births

    • Amniotomy

    • Long cord


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 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)

  • 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 (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)

  • 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.


PROMSigns of Infection

  • Maternal fever

  • Fetal tachycardia

  • Foul-smelling vaginal discharge


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


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


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

  • 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

  • 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

  • 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 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

  • Corticosteroids

    • Help mature fetal lungs

    • Betamethasone or dexamethasone

    • Most effective if 24 hours has elapsed before delivery


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 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 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


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

  • 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 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)


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

  • 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


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

  • 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 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

  • 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 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 Birth


Cesarean Birth


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 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 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 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)

  • 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

  •  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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