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Normal Labor and Delivery. Midwifery Division Department of OB/GYN University of North Carolina School of Medicine. OBJECTIVES. Describe the maternal factors in birth List the various fetal positions and presentations Review the 7 Cardinal Movements Define the 4 stages of labor

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normal labor and delivery

Normal Labor and Delivery

Midwifery Division

Department of OB/GYN

University of North Carolina

School of Medicine

objectives
OBJECTIVES
  • Describe the maternal factors in birth
  • List the various fetal positions and presentations
  • Review the 7 Cardinal Movements
  • Define the 4 stages of labor
  • Describe a normal fetal heart rate pattern
  • Discuss the factors affecting the US C/S rate and VBAC rate.
normal labor delivery definitions
NORMAL LABOR & DELIVERYDefinitions
  • Labor: progressive dilatation of the cervix in association with uterine contractions
  • Term : > 37 weeks gestation
  • Preterm: < 37 weeks gestation
    • 11% of all US births in 1997
    • 80% of preterm births between 34 - 36 weeks
    • Preterm delivery < 35 weeks: 3.5%
obstetrical pelvic exam
Obstetrical Pelvic Exam
  • Dilation (dilatation): patency of the internal cervical os
    • 0 = “closed”
    • 10 cm = “complete”
  • Effacement: shortening of the cervical length
    • 0% = “thick”
    • 100% = “fully effaced”
obstetrical pelvic exam6
Obstetrical Pelvic Exam
  • Station: level of presenting part (bony portion) in relation to the maternal ischial spines
    • Ischial spines = O station
    • Above spines: -5 to -1
    • Below spines: +1 to +5
obstetrical pelvic exam8
Obstetrical Pelvic Exam
  • Presentation: fetal part closet to pelvic inlet
    • vertex
    • brow
    • face
    • breech
    • shoulder
  • Position: relationship of particular point on the presenting part of the fetus and the vertical and horizontal planes of the maternal pelvis
    • Vertex: occiput for orientation
    • Breech: sacrum
    • Face: mentum
slide9

Vertex

Parietal

Brow

Face

obstetrical pelvic exam11
Obstetrical Pelvic Exam
  • Lie: relationship between the long axis of the fetus and the mother
    • Longitudinal
    • Transverse
  • Asynclitism: anterior or posterior parietal bone precedes the sagittal suture
    • Anterior
    • Posterior
cardinal movements of labor
Cardinal Movements of Labor
  • Engagement: descent of biparietal diameter to the level of the ischial spines (0 station)
    • Often occurs before onset of labor in nulliparous patients
  • Descent
  • Flexion: presenting diameters of fetal head presenting to maternal pelvis are optimized
cardinal movements of labor15
Cardinal Movements of Labor
  • Internal rotation: fetal occiput rotates from transverse to AP
  • Extension: head rotates under symphysis pubis
  • External rotation (restitution): occiput and spine assume same position
  • Expulsion: fetal body delivers
normal labor delivery stages of labor
NORMAL LABOR & DELIVERYStages of Labor
  • First stage: Onset of labor to full dilation (10m cm)
  • Second stage: Full cervical dilation to delivery of infant
  • Third stage: Delivery of infant to delivery of placenta
  • Fourth stage: First hour after birth
slide22

Ritgen Maneuver

Erb’s palsey

normal labor delivery phases of labor
NORMAL LABOR & DELIVERYPhases of Labor
  • Latent phase: onset of contractions until active phase
  • Active phase: 3 cm dilation in nulliparas; 4 cm dilation in multiparas to deceleration phase
  • Deceleration phase: 8 – 9 cm dilation to complete dilation
post partum hemorrhage
POST PARTUM HEMORRHAGE
  • Not a diagnosis but a consequence of an event
    • Atony of the uterus
    • Placenta problem
    • Laceration

Defined as greater than 500 ml.

Estimated as 5 % of vaginal births.

Average EBL with C/S = 1000ml.

treatment for pph
TREATMENT FOR PPH
  • Find the cause and treat promptly
  • Active management of the third stage
  • Med: Pitocin

Cytotec

Methergine

Hemabate

Repair lacerations promptly

abnormal latent phase of labor
Abnormal Latent Phase of Labor
  • > 20 hours in nulliparas
  • > 14 hours in multiparas
  • Treatment
    • Therapeutic rest
      • Morphine (10- 20 mg)
      • Hypnotic (Ambien)
    • 85% proceed into active phase of labor
    • 10% - no contractions
    • 5% - may need oxytocin
primary dysfunctional labor
Primary Dysfunctional Labor

Slow rate of dilation in the active phase of labor

  • < 1.2 cm/hr in nulliparas
  • < 1.5 cm/hr in multiparas
disorders of the active phase
Disorders of the Active Phase
  • Secondary Arrest: cessation of previously normal rate of dilation for two hours
  • Combined Disorder: cessation of dilation when patient has previously exhibited a primary dysfunctional labor
disorders of the second stage
Disorders of the Second Stage
  • Protracted Descent:
    • < 1 cm/hr in nulliparas
    • < 2 cm/hr in multiparas
  • Prolonged:
    • Nulliparas
      • With epidural – 3 hours
      • No epidural – 2 hours
    • Multiparas
      • With epidural – 2 hours
      • No epidural – 1 hour
abnormalities of labor the 5 p
Abnormalities of Labor THE 5 “P”
  • Passageway: maternal pelvis
  • Powers: uterine contractions
  • Passenger: fetus
  • Placenta: profusion
  • Psyche: mother’s readiness
uterine contractions
Uterine Contractions
  • External tocodynamometry
    • Less accurate
    • 3-5 contractions/10 minutes
  • Internal tocodynamometry
    • Measures mm Hg
    • 180 – 220 Montevido units/10 minutes
induction of labor oxytocin
INDUCTION OF LABOROxytocin
  • Peptide from posterior pituitary
  • Usually given IV; can be given IM
  • IV bolus = hypotension
  • 10 units/ml; dilute in 1000 cc LR
  • Routine dose: Start at 2mu/min,
  •  2 mu/min every 15-30 minutes to 36 IU/min
  • Active management of labor: start at 6 mu/min,  by 6 mu/min every 15 minutes to 36 mu/min
  • High doses – ADH effect = water intoxication
induction of labor misoprostol cytotec
INDUCTION OF LABORMisoprostol (Cytotec®)
  • PO tablet FDA approved to prevent gastric ulceration in patients taking NSAID’s
  • PGE1
  • 25 mcg (1/4 of 100mcg tablet) in vagina Q 4 hours X 4 doses
  • Wait 6 hours after last dose to start oxytocin
  • Contraindicated with uterine eschar
normal labor delivery foley bulb
NORMAL LABOR & DELIVERYFoley Bulb
  • Place special foley through cervix and inflate balloon to 30 cc
  • Tape to thigh – remove by 12 hours
  • Used when Cytotec contraindicated – uterine eschar
  • Mechanism: mechanical/local release of prostaglandins
  • Frequently used with pitocin
normal labor delivery anesthesia
NORMAL LABOR & DELIVERYAnesthesia
  • Cesarean section
    • Spinal
    • Epidural
    • General (more risky in obstetrics)
  • Vaginal delivery
    • Local
    • Pudendal
    • Epidural
    • Combined spinal/epidural
normal labor delivery lacerations
NORMAL LABOR & DELIVERYLacerations
  • Cervical (use clock to describe location)
  • Vaginal (left or right)
  • Periurethrael
  • Clitoral
  • Perineal
    • 1st degree: skin only involved
    • 2nd degree: skin and subcutaneous tissue
    • 3rd degree: external rectal sphincter
    • 4th degree: rectal mucosa not intact
normal labor delivery episiotomy
NORMAL LABOR & DELIVERYEpisiotomy
  • Types
    • Midline
    • Mediolateral
    • Proctoepisiotomy
  • Originally thought to protect perineum
  • Now thought to result in more 3rd and 4th degree extensions
  • More perineal pain
  • At UNC less that 3% of patients
slide45

First degree

External sphincter

External sphincter

Second degree

Third degree

normal labor delivery cesarean delivery
NORMAL LABOR & DELIVERYCesarean Delivery
  • Skin incisions
    • Vertical
    • Pfannensteil
  • Uterine incisions
    • Low cervical transverse (Kerr)
    • Low vertical or “T” shaped
    • Classical
vbac trial of labor
VBAC/Trial of Labor
  • One previous LUT incision (1% rate of rupture)
  • Two previous LUT incisions (2% rupture)
  • Unknown incision (up to 7% rupture)
  • Success of TOLAC = VBAC (vaginal birth after cesarean section): 60 – 80%
breech
BREECH

Complete breech

Frank breech

Incomplete breech

normal labor delivery breech presentation
NORMAL LABOR & DELIVERYBreech Presentation
  • 37 weeks gestation – external cephalic version (50% success)
    • Ultrasound
    • Non-stress test
    • IV/subcut terbutaline for tocolysis
    • Ultrasound monitoring
    • Repeat non-stress test/
    • K-B stain prn
  • Cesarean section vs vaginal birth
multiple gestation
Multiple Gestation
  • Twins
    • Vertex/vertex – vaginal delivery
    • Vertex/breech or transverse lie – breech extraction of 2nd twin
    • Breech/other – Csection (locked twins)
  • Triplets or higher order gestation
    • Cesarean delivery indicated
gbs epidemiology
GBS Epidemiology
  • 10-30% of pregnant women colonized
  • Vertical transmission may occur
  • Neonatal invasive GBS infection decreased 21% from 1993 to 1998.
  • In 2000 rate was .23 per 1000 live births
  • Early onset infection
    • Antibiotics in labor will reduce
    • Prevents 225 newborn deaths per year
  • Late onset infection
gbs protocol
GBS Protocol
  • Routine culture at 35-37 weeks
  • Culture lower 1/4 vaginal and peri anal area
  • Culture stable up to 96 hours in Amies transport media
  • If patient allergic to penicillin, get suscepibility testing
gbs protocol56
GBS Protocol
  • Treat with intravenous penicillin
  • Attempt to achieve 2 doses to prevent invasive evaluation of neonate
  • PCN 6 million units IV load, then 3 million units q 4 hours
gbs protocol57
GBS Protocol

Penicillin allergy:

- Kefzol 2 grams IV load, then 1 gram q 8 hrs if not at high risk of anaphylaxis

  • Clindamycin – 900 mg IV q 8 hrs
    • 15-20% of isolates resistant
  • Vancomycin – 1 gram IV q 12 hours, doses given over 30 minutes

Hager et al. Obstet Gynecol 2000;96:141-5.

normal labor delivery estimated fetal weight
NORMAL LABOR & DELIVERYEstimated Fetal Weight
  • Leopold’s maneuvers (palpation of the maternal abdomen)
  • Ultrasound estimate of fetal weight (error of 10 – 15%)
  • Maternal estimate of fetal weight (best)
forceps assisted vaginal delivery
Forceps Assisted Vaginal Delivery
  • Outlet forceps:
    • Scalp visible at the introitus w/o parting the labia
    • Sagittal suture < 45 degrees
  • Low forceps:
    • Leading point of skull at +2 or below
      • < 45 degrees
      • > 45 degrees
  • Mid-forceps:
    • Head is engaged but presenting part is above +2 station
    • Rarely done
normal labor delivery vacuum vs forceps
NORMAL LABOR & DELIVERYVacuum vs Forceps
  • Forceps
    • More maternal trauma
    • Minimal fetal trauma (bruising)
  • Vacuum
    • Less maternal trauma
    • Potential for increased fetal trauma (subgaleal bleeding)
understanding fetal monitoring parameters
UnderstandingFetal Monitoring (Parameters)
  • Baseline rate
  • Variability
  • Presence of accelerations
  • Presence of decelerations
  • Changes or trends of FHR patterns over time
fetal heart rate baseline
Fetal Heart Rate Baseline
  • 10 minute window
  • Duration: at least 2 minutes
  • Bradycardia: < 110 bpm
  • Tachycardia: > 170 bpm
fetal monitoring variability
Fetal Monitoring (Variability)
  • Concept of long-term variability dropped
  • Absent: undetectable
  • Minimal: undetectable - < 5 bpm
  • Moderate: 6 - 25 bpm
  • Marked: > 25 bpm
fetal monitoring accelerations
Fetal Monitoring (Accelerations)
  • Onset to peak: < 30 seconds
  • > 32 weeks: >15 bpm X >15 secs
  • < 32 weeks: > 10 bpm X > 10 secs
  • > 2 minutes in duration: prolonged
  • > 10 minutes in duration: change in baseline
decelerations fetal monitoring variables
DECELERATIONSFetal Monitoring (Variables)
  • Onset to nadir < 30 secs
  • > 15 bpm below baseline
  • Duration: > 15 seconds
  • < 2 minutes from onset to return to baseline
decelerations fetal monitoring variables75
DECELERATIONSFetal Monitoring (Variables)

Treatment

  • Pelvic exam (rule out prolapsed cord)
  • Maternal oxygen
  • Change maternal position
  • Stop pushing
  • Amnioinfusion
fetal monitoring early decelerations
Fetal Monitoring (Early Decelerations)
  • Onset to nadir > 30 secs
  • Coincident in timing with UC
  • Nadir occurring simultaneously with the peak of the contraction
fetal monitoring late decelerations
Fetal Monitoring (Late Decelerations)
  • Onset to nadir > 30 secs
  • Delayed in timing
  • Nadir occurring after the peak of the contraction
  • Reoccuring can be ominous
fetal monitoring late decelerations81
Fetal Monitoring(Late Decelerations)

Treatment

  • Correct hypotension or other maternal conditions
  • Maternal oxygen
  • Scalp stimulation
  • Cesarean delivery if repetitive
cord blood gases
Cord Blood Gases
  • Defensive medicine (not used clinically)
  • Clamp cord segment at all deliveries
  • Obtain arterial sample for 5 minute Apgar score < 7
normal labor delivery cord blood gases
NORMAL LABOR & DELIVERYCord Blood Gases

Umbilical artery (No labor)

  • Acidemia: pH < 7.15
  • Metabolic: base excess > -11 mmol/L and pCO2< 65 mm
  • Respiratory: base excess < 11 mmol/L and pCO2> 65 mm
  • Mixed: base excess > -11 mmol/L and pCO2> 65 mm
normal labor delivery cord blood gases86
NORMAL LABOR & DELIVERYCord Blood Gases

Umbilical artery (No labor)

Clinically significant acidemia is probably represented by an umbilical arterial pH of < 7.0