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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

Labor and Delivery

CAPT Mike Hughey, MC, USNR

labor
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.
  • 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)
descent
Descent
  • 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)
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
cervix
Cervix
  • 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
tachycardia
Tachycardia
  • >160 BPM
  • Most are not suggestive of fetal jeopardy
  • Associated with:
    • Fever, Chorioamnionitis
    • Maternal hypothyroidism
    • Drugs (tocolytics, etc.)
    • Fetal hypoxia
    • Fetal anemia
    • Fetal arrythmia
bradycardia
Bradycardia
  • 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
episiotomy
Episiotomy
  • 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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