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Ch 13. CONDUCT OF NORMAL LABOR AND DELIVERY


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Ch 13. CONDUCT OF NORMAL LABOR AND DELIVERY. 부산백병원 산부인과 R1 서 영 진. The ideal conduct of labor and delivery - Birthing is recognized as a normal physiological process that most women experience without complication

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Ch 13. CONDUCT OF NORMAL LABOR AND DELIVERY

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Ch 13 conduct of normal labor and delivery

Ch 13. CONDUCT OF NORMAL LABOR AND DELIVERY

부산백병원 산부인과

R1 서 영 진


Ch 13 conduct of normal labor and delivery

  • The ideal conduct of labor and delivery

    - Birthing is recognized as a normal physiological

    process that most women experience without

    complication

    - Intrapartum complications can arise very quickly

    and unexpectedly


Admission procedures

ADMISSION PROCEDURES

  • Identification of labor

    -One of the most critical diagnoses in obstetrics

    is the accurate diagnosis of labor

    -Hx, PEx, V/S (BP, PR, BT)

    -Uterine contraction (duration, frequency, intensity)

    -fetus (presentation, heart rate, size)

    -fetal membrane, vaginal bleeding & leakage

    ->The fetal heart rate should be checked, especially

    at the end of a contraction and immediately,

    thereafter, to identify pathological slowing of the

    heart rate


Admission procedures1

True labor

-regular interval

-gradually shorten

-intensity: increase

-discomfort

back & abdomen

-cervix: dialte

-discomfort:

not stopped

by sedation

False labor

-irregular interval

-remian long

-intensity: unchanged

-discomfort

low abdomen

-cervix: not dilate

-discomfort:

usually relieved

by sedation

ADMISSION PROCEDURES


Admission procedures2

ADMISSION PROCEDURES

  • Federal requirements for

    inter-hospital transfer of laboring women

    -all Medicare-participating hospitals with emergency

    services must provide an appropriate medical

    screening examination for any pregnant women

    -LABOR: the precess of childbirth beginning with

    the latent phase of labor continuing

    through delivery of the placenta

    -penalty; $50,000


Admission procedures3

ADMISSION PROCEDURES

  • Electronic admission testing

    -NST (nonsterss test)

    :an assessment of fetal heart rate accelerations

    or lack of the same with fetal movement

    -CST (contraction stress test)

    : an assessment of fetal heart rate before, during,

    and following a uterine contraction if the patient

    is in labor

    -fetal heart rate: variability and variable deceleration

    with fetal acoustic stimulation


Admission procedures4

ADMISSION PROCEDURES

  • Vaginal examination

    -aseptic conditions

    1) amnionic fluid: membrane rupture

    posterior vaginal fornix

    (vernix or meconium) , swab

    2) cervix: softness, effacement, dilatation, location

    presentation , presence of membrane

    3) presenting part


Ch 13 conduct of normal labor and delivery

4)station: the degree of descent

high level- fundal pressure

5)pelvic architecture: diagonal conjugate

ischial spine, pelvic sidewall

sacrum


Admission procedures5

ADMISSION PROCEDURES

  • Cervical effacement

    - the length of the cervical canal compared to that

    of an uneffaced cervix

    -reduced by one half: 50 % effaced

    completely: 100 % effaced

  • Cervical dilatation

    -the average diameter of the cervical opening

    -dilated fully: 10cm


Admission procedures6

ADMISSION PROCEDURES

  • Position of the cervix

    -the relationship of the cervacal os to the fetal head

    -posterior, modposition, or anterior

    (ex. preterm labor: posterior)

  • Station

    -the presenting part in the birth canal in relationship

    to the ischial spine

    -ischial spine: halfway between the pelvic inlet and

    the pelvic outlet


Ch 13 conduct of normal labor and delivery

-the lowermost portion of the fetal presenting part

is at the level of the ischial spine: ZERO (0)

engagement

-divided into third

->ACOG (1988) divided into fifth

(-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5)

-If the head is unusually molded, of if there is an

extensive caput formation, or both, engagement

might not have taken place even through the

head appears to be at 0 station


Admission procedures7

ADMISSION PROCEDURES

  • Detection of ruptured membranes

    -Ruptere of membrane

    1) if not fixed in the pelvis, prolapse & cmpression

    of umbilical cord is greatly increased

    2) if the pregnancy is at or near term, labor is likely

    to occur soon

    3) if delivery is delayed for 24 hours or more after

    membranes rupture, serious intrauterine

    infection


Ch 13 conduct of normal labor and delivery

-diagnosis of rupture of the membrane

: pooling in the posterior fornix or passing from

the cervical canal of the amnionic fluid

: testing of pH – normal (4.5~5.5)

amnionic fluid (7.0~7.5)

Nirazine test

false-positive: blood, semen

bacterial vaginosis

false-negative: minimal fluid

#Nitrazine test: insert sterile cotton tip->touching it

to a strip-> comparering the color

-arborization, ferning pattern or AFP of amnionic fluid


Admission procedures8

ADMISSION PROCEDURES

  • Vital signs and review of the pregnancy record

  • Preparation of vulva and perineum

    -cleansing and scrubbing

    -clipping or mini-shaving or hair (But. not routinely)

  • Vaginal examination

    -sterile gloves

    -avoid the anal region

    -the number of vaginal exam: infectious morbidity

    especially rupture


Admission procedures9

ADMISSION PROCEDURES

  • Enema

    -to minimize subesquent contaminaton by feces

    during the second stage

    -not routinely at Parkland hospital

  • Larboratory

    -Hb, Hct: recheck

    -blood type, UA (pretein, glucose)

    -syphilis, hepatitis B, HIV

    (ex. Routine in TEXAS)


Management of first stage of labor

MANAGEMENT OF FIRST STAGE OF LABOR

  • The average duration of the first stage

    -nulliparous: 7 hours

    -parous: 4 hours

    ->individual variations

    #The physician can best reach a conclusion about

    the normalicy of the pregnancy when all

    examinations ,including record and laboratory

    review, are completed


Management of first stage of labor1

MANAGEMENT OF FIRST STAGE OF LABOR

  • Monitoring fetal well-being during labor

    -The frequency, intensity, and duration of uterine

    contraction, and the response of the fetal heart

    rate to the contracton, are of considerable

    concern.


Ch 13 conduct of normal labor and delivery

# Fetal heart rate

-change in the fetal heart rate that most likely are

ominous almost always are detectable immediately

after a uterine contraction

- To avoid confusing maternal and fetal heart rates.

the maternal pulse should be counted as the fetal

heart rate is counted

- fetal jeopardy, compromise, or distress

; FHR below 110 bpm after a contracton


Ch 13 conduct of normal labor and delivery

-fetal jeopardy very likely exists if the rate is heard

to be less than 100 per minute, even though there

is recovery to a rate in the 110 to 160 bpm range

before the next contraction

-any abnormalities: every 30 minute in the 1st stage

every 15 minite in the 2nd stage

at risk: every 15 minutes in the 1st stage

every 5 minitus in the 2nd stage


Ch 13 conduct of normal labor and delivery

# Uterine contraction

-with the palm of the hand lightly on the uterus, the

examiner determines the time of onset of the

contraction

-It is best to quantify the contractions as regards

the degree of firmness or resistance to indentation


Maternal monitoring and management during labor

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

  • Maternal vital signs

    -temperature, pulse, blood pressure

    : at least every 4 hours

    (if membrane rupture or high temperature: hourly)

    -prolonged membrane rupture (>18 hrs)

    :antibiotics (preventtion of group B streptococcus)


Maternal monitoring and management during labor1

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

  • Subsequent vaginal examination

    -the status of the cervix

    the station & position of the presenting part

    -at 2- to 3-hour intervals

    -sterile, water-soluble lubricants

    avoid povidone-iodine and hexachlorophene

    -if membrane rupture before engage

    :fetal heart rate should be checked

    vaginal exam-umbilical cord compression


Maternal monitoring and management during labor2

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

  • Oral intake

    - food should be withheld during active labor

    and delivery

    - in labor & analgesics are administered

    :gastric emptying time is prolonged

    :not absorbed ,vomited, and aspiration

    -sips of clear liquids, occasional ice chips, and

    lip moisturizers are permitted


Maternal monitoring and management during labor3

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

  • Intravenous fluids

    -there is seldom any real need for such in the

    normally pregnant at least until analgesia

    is administered

    -advantage: oxitocin prophylactically (atony persist)

    administration of glucose, Na, water

    (prevent dehydration & acidosis)


Maternal monitoring and management during labor4

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

  • Maternal position during labor

    -need not be confined to bed early in labor

    -a comfortable chair may be beneficial

    -lateral recumbency

    must not be restricted to lying supine


Maternal monitoring and management during labor5

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

  • Analgesia

    -depend on the needs and desires of the women

    -the timing, method of the administration, and

    size of initial and subsequent doses are based

    to a considerable degree on the anticipated

    interval of the time until delivery

    -a repeat vaginal exam before administering analgesia


Maternal monitoring and management during labor6

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

  • Amniotomy

    -aseptic technique

    -the fetal head must not be dislodged from the

    pelvis: prevents umbilical cord prolapse

    -more rapid labor

    early detection of meconeum staining

    the opportunity to apply an electrode to the fetus

    insert a pressure catheter


Maternal monitoring and management during labor7

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

  • Urinary bladder function

    -bladder distention should be avoided

    : obstructed labor

    subsequent bladder hypotonia and infection

    -ambulation: self voiding

    if not, intermittent catheterization