Labor and delivery
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Labor and Delivery. CAPT Mike Hughey, MC, USNR. Labor. Regular, frequent, leading to progressive cervical effacement and dilatation Braxton-Hicks contractions May be painful and regular, but usually are not Do not lead to cervical change Labor diagnosis usually made in retrospect.

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Labor and Delivery

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Labor and delivery

Labor and Delivery

CAPT Mike Hughey, MC, USNR



  • Regular, frequent, leading to progressive cervical effacement and dilatation

  • Braxton-Hicks contractions

    • May be painful and regular, but usually are not

    • Do not lead to cervical change

  • Labor diagnosis usually made in retrospect.

  • Cause of labor is unknown

Latent phase labor

Latent Phase Labor

  • <4 cm dilated

  • Contractions may or may not be painful

  • Dilate very slowly

  • Can talk or laugh through contractions

  • May last days or longer

  • May be treated with sedation, hydration, ambulation, rest, or pitocin

Active phase labor

Active Phase Labor

  • At least 4 cm dilated

  • Regular, frequent, usually painful contractions

  • Dilate at least 1.2-1.5 cm/hr

  • Are not comfortable with talking or laughing during their contractions

Progress of labor

Progress of Labor

  • Lasts about 12-14 hours (first baby)

  • Lasts about 6-8 hours (subsequent babies)

  • Considerable variation.

  • Effacement (thinning)

  • Dilatation (opening)

  • Descent (progress through the birth canal)



  • Fetal head descends through the birth canal

  • Defined relative to the ischial spines

  • 0 station = top of head at the spines (fully engaged)

  • +2 station = 2 cm past (below) the ischial spines

Cardinal movements of labor

Cardinal Movements of Labor

  • Engagement (0 Station)

  • Descent

  • Flexion (fetal head flexed against the chest)

  • Internal rotation (fetal head rotates from transverse to anterior

  • Extension (head extends with crowning)

  • External rotation (head returns to its’ transverse orientation)

  • Expulsion (shoulders and torso of the baby are delivered)

Watch a delivery

Watch a Delivery

Placental separation

Placental Separation

  • Signs of separation:

    • Increased bleeding

    • Lengthening of the cord

    • Uterus rises, becoming globular instead of discoid

    • Uterus enlarges, approaching the umbilicus

  • Normally separates within a few minutes after delivery

Initial labor management

Initial Labor Management

  • Risk assessment

  • Contractions: frequency, duration, onset

  • Membranes: Ruptured, intact

  • Status of cervix: dilatation, effacement, station

  • Position of the fetus: vertex, transverse lie, breech

  • Fetal status: fetal heart rate, EFM



  • Dilatation: How far has the cervix opened (in cm)

  • Effacement: How thin is the cervix (in cm or %)

Status of membranes

Status of Membranes

  • Nitrazine paper turns blue in the presence of alkaline amniotic fluid (“nitrazine positive”)

  • Vaginal secretions are nitrazine negative (yellow) because of their acidity

  • Pooling of amniotic fluid in the vaginal vault is a reliable sign

Orientation of fetus

Orientation of Fetus

  • Vertex, breech or transverse lie

  • Palpate vaginally

  • Leopold’s Maneuvers

Management of early labor

Management of Early Labor

  • Ambulation OK with intact membranes

  • If in bed, lie on one side or the other…not flat on her back

  • Check vital signs every 4 hours

  • NPO except ice chips or small sips of water

Monitor the fetal heart

Monitor the Fetal Heart

  • During early labor, for low risk patients, note the fetal heart rate every 1-2 hours.

  • During active labor, evaluate the fetal heart every 30 minutes

  • Normal FHR is 120-160 BPM

  • Persistent tachycardia (>160) or bradycardia (<120, particularly <100) is of concern

Electronic fetal monitors

Electronic Fetal Monitors

  • Continuously records the instantaneous fetal heart rate and uterine contractions

  • Patterns are of clinical significance.

  • Use in high-risk patients.

  • Use in low-risk patients optional

Normal patterns

Normal Patterns

  • Normal rate

  • Short term variability (3-5 BPM)

  • Long term variability (15 BPM above baseline, lasting 10-20 seconds or longer)

  • Contractions every 2-3 minutes, lasting about 60 seconds



  • >160 BPM

  • Most are not suggestive of fetal jeopardy

  • Associated with:

    • Fever, Chorioamnionitis

    • Maternal hypothyroidism

    • Drugs (tocolytics, etc.)

    • Fetal hypoxia

    • Fetal anemia

    • Fetal arrythmia



  • Sustained <120 BPM

  • Most are caused by increased in vagal tone

  • Mild bradycardia (80-90) with retention of variability is common during 2nd stage of labor

  • <80 BPM with loss of BTBV may indicate fetal distress

Late decelerations

Late Decelerations

  • Repetive, non-remediable slowings of the fetal heartbeat toward the end of the contraction cycle

  • Reflect utero-placental insufficiency

Early decelerations

Early Decelerations

  • Periodic slowing of the FHR, synchronized with contractions

  • Rarely more than 20-30 BPM below the baseline

  • Innocent

  • Associated with fetal head compression

Variable decelerations

Variable Decelerations

  • Variable in onset, duration and depth

  • May occur with contractions or between them

  • Sudden onset/recovery

  • Increased vagal tone, usually due to some degree of cord compression

Severe variable decelerations

Severe Variable Decelerations

  • Below 60 BPM for at least 60 seconds

  • If persistent, can be threatening to fetal well-being, with progressive acidosis

Prolonged decelerations

Prolonged Decelerations

  • Last > 60 seconds

  • Occur in isolation

  • Associated with:

    • Maternal hypotension

    • Epidural

    • Paracervical block

    • Tetanic contractions

    • Umbilical cord prolapse

Pain relief

Pain Relief

  • Narcotics

  • Continuous Lumbar Epidural

  • Paracervical Block

  • 50/50 nitrous/oxygen

  • Psychoprophylaxis (Lamaze breathing)

  • Hypnosis

Anesthesia during delivery

Anesthesia During Delivery

  • Local

  • Pudendal Block

  • Epidural

  • Caudal

  • Spinal

  • 50/50 nitrous/oxygen



  • Avoids lacerations

  • Provides more room for obstetrical maneuvers

  • Shortens the 2nd Stage Labor

  • Midline associated with greater risk of rectal lacerations, but heals faster

  • Many women don’t need them.

Clamp and cut the cord

Clamp and Cut the Cord

  • Clamp about an inch from the baby’s abdomen

  • Use any available instruments or usable material

  • Check the cord for 3-vessels, 2 small arteries and one larger vein

Inspect the placenta

Inspect the Placenta

  • Make sure it is complete

  • Look for missing pieces

  • Look for malformations

  • Look for areas of adherent blood clot

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