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Labor. This is the process by which products of conception (fetus, placenta, cord and membranes) are expelled from the uterus. It is defined as the progressive effacement and dilatation of the uterine cervix, resulting from rhytmic contarctions of the uterine musculature.

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labor

Labor

This is the process by which products of conception (fetus, placenta, cord and membranes) are expelled from the uterus. It is defined as the progressive effacement and dilatation of the uterine cervix, resulting from rhytmic contarctions of the uterine musculature

changes in late pregnacy which prognosticate labor
Changes in late pregnacy which prognosticate labor:
  • Braxton-Hick’s contractions
  • lightening
  • bloody show
slide3

Uterine contractions without effacement and dilatation of the cervix occur normally in the third trimester of pregnancy and are termed Braxton-Hicks contractions. Their number and intensity becomes greater as the patient approaches term. Sometimes they result in the patient’s perception of discomfort and cause so called „false labor” which doesn’t change the status of the cervix (its length and dilatation)

each contraction has three phases
Each contraction has three phases:
  • increment - the intensity of the contraction increases
  • acme - the contraction is at its high
  • decrement - the intensity of the contraction diminshes
slide5

Lightening - (2-3 weeks before labor) It is the result of fetal head descending into the pelvis. The patient reports a change in the shape of her abdomen and the sensation that the baby has gotten less heavy. As the bladder is compressed by the fetal head there may be more frequent urination. The patient may also notice an easier time breathing, because there is less pressure on the diaphragm.

slide6

Bloody show - (1-2 days before labor) this is the passage of blood-tinged (pink) mucus from vagina which is the result of begining of the cervical effacement and extrusion of mucus from the endocervical glands.

lie situs it is the relation of the long axis of the fetus with the maternal long axis
LIE = SITUSIt is the relation of the long axis of the fetus with the maternal long axis
  • longitudinal (99%) when the axes are parallel
  • transverse when the axes cross at 90° angle
  • oblique when the axes cross at 45° angle
slide8

Presentationis determined by „the presenting part” i.e. the portion of the fetus lowest in the birth canal

In longitudinal lie, the presenting part is either cephalic (96%) or breech (3%)

position
Position
  • it is the relation of the fetal presenting part to the right or left side of the maternal pelvis or
  • it is the relation of fetal spine to the right or left side of mother’s body Position I - left Position A – anterior Position II - right Position B - posterior
slide10

The pelvis is formed by five bones: the ilium, the ischium, the pubis, the sacrum, the coccyx and the ligaments connecting them.The ilium, the ischium and the pubis form the lateral and anterior boundaries of the pelvis. The sacrum and coccyx form the posterior wall of the pelvis.

slide11

The pelvis may be divided into:1.The false pelvis - the upper part - which is seldom involved in the problems of labor2.The true pelvis - the lower part - which formes the bony canal through which the baby must pass during deliveryThe pelvis inlet divides the false pelvis from the true pelvis

patient ought to come to the hospital if
Patient ought to come to the hospital if:
  • uterus contractions occur approximately every 10 minutes for at least two hours
  • there is a sudden gush of fluid or a constant leakage of fluid (rupture of membranes)
  • there is some bleeding
  • there is significant decrease in fetal movements
at the time of initial evaluation at the hospital the physician must
At the time of initial evaluation at the hospital the physician must:
  • at first auscultate fetal heart tones
  • determine the nature and frequency of the uterus contractions
  • determine the possibility of spontaneous rupture of membranes
  • examine the gravid abdomen by Leopold maneuvers
  • perform the vaginal examination
at the time of initial evaluation at the hospital the physician must reviev the prenatal records to
At the time of initial evaluation at the hospital the physician must reviev the prenatal records to:
  • identify complications of pregnancy up to that point
  • confirm gestational age to differentiate preterm labor from labor at term, if necessary by use of USG
  • review laboratory informations
slide15

1.The first Leopold maneuver determines what occupies the fundus(it helps to determine the lie and presentation)

2.The second Leopold maneuverdetermines location of small parts

(it is used to determine the position)

Using one hand to steady the fetus, the fingers of the other hand are used to palpate either the firm, long fetal spine or the various shapes and movements indicating fetal small parts (hands and feet)

slide16

3.The third Leopold maneuver identifies descent of presenting partSuprapubic palpation identifies the presenting part as the fetal head which is relatively mobile, or a breech which moves the entire body

4.The fourth Leopold maneuveridentifies the cephalic prominence

As long as the cephalic prominence is easily palpable, the vertex is not likely to have descended to 0 station (linea interspinalis, level of ischial spines)

vaginal examination consists of speculum examination digital examination

Vaginal examination consists of:- speculum examination- digital examination

!!! In every case of vaginal bleeding the vaginal examination should be done with extreme care, only by use of speculum, because of the risk of disrupting a placenta previa !!!

the digital portion of vaginal examination allows the examiner to determine
The digital portion of vaginal examination allows the examiner to determine :
  • - the degree of cervical effacement (from 3 to 0 cm)
  • - the degree of cervical dilatation (from 0 to 10 cm)
  • - the consistency of the cervix (firm, medial, soft)
  • the position of the cervix in vagina (anterior, medial, posterior)
  • the fetal station determined by identifying the foremost point of the fetal presenting part relative to the level of the ischial spines
the degree of engagement in cm relative to the level of ischial spines
The degree of engagement (in cm relative to the level of ischial spines)
  • If the leading point of the presenting part is palpable at the pelvic inlet or above, it is called -4 station(floating)
  • If the leading point of the presenting part is palpable lower but above the level of ischial spines it is called respectively -3, -2 or -1 station(fixed)
  • If the leading point of the presenting part has reached the level of the ischial spines, it is termed 0 station. The largest diameter of presenting part is in the inlet(engaged)
the degree of engagement in cm relative to the level of ischial spines1
The degree of engagement (in cm relative to the level of ischial spines)
  • Descent of the leading point of the presenting part below the line of ischial spines is defined respectively as +1, +2, +3 . The largest diameter of presenting part is between the inlet plane and maximum depth of pelvis(midplane)
  • If the presenting part is deep in pelvis and its leading point +4 or +5 it is calledon perineum
slide21

The clinical significance of the fetal head presenting at 0 station is that the biparietal diameter of the fetal head (9,5-10 cm - the greatest transverse diameter of the fetal skull), has negotiated the pelvic inlet

stages of labor
Stages of labor
  • The first stage (the period of dilatation and effacement) is the interval between the onset of labor (from the begining of regular contracions which occur every 10 minutes, from the moment of rupture of membranes) and full cervical dilatation (10 cm) - the latent phase which comprises cervical

effacement and early cervical dilatation (to 3-4 cm) - the accelerated phase (from 5 to 7 cm) - the transition phase (from 8 to 10 cm)

stages of labor1

Stages of labor

The second stage(the period of expulsion)lasts from complete cervical dilatation till the delivery of the infant

The third stage(the placental stage) begins immediately after delivery of the infant and ends with the delivery of the placenta

The fourth stage is defined as the early postpartum period of approximately 2 hours after delivery of the placenta. During this period the patient undergoes significant physiologic adjustment and must be under close medical control

slide24

During the first stage of labor frequency of contractions rises from 1/10 min. to 5/10 min.The contractions gradually become more frequent and regular. They also become longer (60 s) and stronger

slide25

As the contractions continue through the first stage of labor, a pull is exerted on the cervix. The pressure of the baby’s presenting part (head) against the cervix stimulates the release of the hormone oxytocin, which in turn stimulates further contractions. As the upper portion of the uterus contracts, the lower portion relaxes, allowing the baby to descend further toward the vagina.

slide26

If the fetal membranes don’t rupture spontaneously, sometimes (often) in the active phase of labor (dilatation > 4-5 cm) we perform amniocentesis :

  • to intensify uterine contractions
  • to insert intrauterine pressure catheter or a fetal scalp monitor
  • to state the presence or absence of meconium in amniotic fluid
  • to state the presence of blood in amniotic fluid
slide27

Sometimes sponatneous (and rarely artificial rupture of membranes) may cause some risk:- umbilical cord prolapsemay occur if rupture of the membranes takes place before engagement of the presenting fetal part (fetal heart tones should be assesed after rupture of membranes in any case)- icidence of infection may be increased if labor is prolonged, because there is an entry for bacteria- in some cases abruption of the placenta occurs

slide28

Mechanism of labor refers to the changes of the position of the fetus and movements of its head during the passage through the birth canal.These movements are accomplished by the forceful contractions of the uterus.The long diameter of the inlet of the pelvis is side to side. The long diameter of the outlet is from front to back. Therefore, the baby’s head must turn 90 degrees to emerge from the outlet. During normal cephalic labor the occipital portion of the fetal head is the lower-most part in maternal pelvis and rotates toward symphysis pubis.

movements of the fetal head during its passage through the birth canal
Movements of the fetal head during its passage through the birth canal
  • engagement
  • descent
  • flexion
  • internal rotation
  • extension
  • external rotation
  • expulsion
slide30

Engagementis defined as descent of the biparietal diameter of the head to the level of the pelvic inlet. Clinically it is diagnosed by palpation of the leading point of the presenting part in the level of ischial spines (0 station). In multiparas engagement sometimes does not occur until dilatation of the cervix begin. In primiparas it often occurs in the last days of pregnancy causing the feel of lightening (2-3 weeks)

slide31

Descent of the presenting partis a necessary for the successful completion of passage through the birth canal.It is the continous progress of the fetus as it passes through the birth canal. It is brought about by the downward pressure of uterine contractions.The greatest rate of descent occurs during the latter portions of the first stage of labor and during the second stage of labor

slide32

Flexion of the fetal headallows for the smallest diameters of the fetal head (suboccipito-bregmatic plane 32 cm of circumference)to present to the maternal pelvis. Flexion occurs when fetus descends and the head encounters resistance. During flexion the head of the fetus is bent forward causing its chin to rest on its sternum (breastbone). Flexion is important because the narrowest part of the head must enter the pelvic outlet.

slide33

Internal rotationfacilities presentation of the optimal diameters of the fetal head to the bony pelvis. It is the rotating of the head of the fetus 90 degrees from the transverse to the long diameter of the pelvis.In normal labor the head rotates with its occiput toward symphysis pubis.This movement takes place mainly during the second stage of labor.

slide34

Extension of the fetal headoccurs as it reaches the introitus and is stopped under the pubic arch. To accomodate to the upward curve of the birth canal, the flexed head now extendsExternal rotationoccurs after delivery of the head as the head rotates back 90 degrees from the long to the transverse diameter of the pelvis relative to its shouldersExpulsion is the final delivery of the fetus from the birth canal. It is delivery of the shoulders and the rest of the body

management of labor general rules

Management of labor - general rules

- the patient shouldn’t be left without care for any significant length of time

- supporting person may be allowed to remain with the patient throughout the labor and delivery process in most cases

management of labor
Management of labor
  • maternal vital signs should be taken at least every 30 minutes in the first stage of labor (pulse, blood pressure, respiratory rate, temperature, urine output)
  • the patient should be given nothing by mouth except for sips of water or other clear liquids
  • an intravenous line is always inserted at the admission to the delivery room to provide hydration or give drugs
management of labor1
Management of labor
  • during labor, descent of the presenting part of the fetus causes elevation of the bladder which results in the patient having difficulty urine voiding. Therefore the patient should be encouraged to void frequently. In the end of the first stage or in the second stage of labor catheterisation of the bladder may be necessery
  • the use of cleansing enema to empty the lower part of the digestive tract is indicated but not obligatory
management of labor2
Management of labor
  • in the first stage of labor the position of the patient depends on her choice (sitting, lying or walking)
  • in the second stage of labor we prefer „lying on the back” position
management of labor3
Management of labor
  • in the first stage of labor auscultation of the FHR should be performed at least every 15 minutes by stetoscope or UDT. In our Clinic we generally use periodical electronic fetal monitoring (KTG) in low-risk pregnancies. In the cases of high risk we perform continious fetal monitoring
  • in the second stage of labor fetal heart rate auscultation should be performed after each uterine contraction !!
management of labor drugs
Management of labor - drugs
  • analgesic and anestetic agents may affect the latent stage of labor - they should generally not be used until the active phase of labor
  • when they are used in the end of the first stage of labor they may couse neonatal depresion
management of labor4
Management of labor
  • evaluation of the patients progress of labor is accomplished by means of a series of pelvic examinations with average for every two hours
  • before every vaginal examination the perineum is cleansed with sterile solution and the examination is performed with sterile glove
vaginal examination during labor should identify
Vaginal examination during labor should identify
  • cervical dilatation
  • cervical effacement
  • station of the presenting part
  • position of the presenting part
  • status of the membranesThese findings should be noted graphillicaly on the hospital record (partogram)
slide43

In the second stage of labor patients report the need of push which accompanies the contractions. During the contraction voluntary maternal effort (pushing) can be added to the involuntary contractile forces of the uterus to facilitate delivery of the fetus.At the pik of each contraction, the mother is encouraged to take a deep breath, hold it and push (perform extended Valsalva maneuver) so that abdominal muscules contract and help to expell the fetus. This increase in intra-abdominal pressure aids in fetal descent through the birth canal and this is the indispensable condition of deliveryThe second stage of labor shouldn’t last longer than two hours !!

slide44

The position of the patient for delivery most preferred by physicians is the dorsal lithotomy position (on the patient’s back). This allows the physician to have better control of the delivery and facilitates subsequent surgical repair after deliveryIn every succesive contraction, the maternal force correlated with uterine contractions cause more of the fetal scalp to be visiable at the introitus.

slide45

In this moment: at the top of the contraction,

andafter local injection of anesthetic substance

(1% xylocaine)episiotomy (an incision of the perineum) is performed (in our Clinic mediolateral)- obligatory in primiparas - in some cases in multiparas

The main role of episiotomy is to enlarge the vaginal outlet and to facility delivery(especially indicated in cases of instrumental delivery)

the episiotomy serves several purposes
The episiotomy serves several purposes:
  • it is a straight, clean surgical incision, not ragged laceration which otherwise is likely to occur
  • it spares the baby’s head from perineal resistance
  • it shortens the duration of the second stage of labor
slide47

Then the physician performs a modified Ritgen maneuver. One hand is placed over the vertex while the other exerts pressure through the perineum onto the fetal chin. The chin can then be delivered slowly, with control applied by the hand. A sterile towel is used to avoid contamination of this hand by contact with the anus.

slide48

After delivery of the head the neck should be evaluated for the possible presence of a umbilical cord, which should be reduced over the fetal head if possible. If the cord is tight, it may be doubly clumped and cut.After delivery of the head , the shoulders descend and rotate from transverse to the anteposterior diameter of the pelvis.The attendant’s hands are placed on the occiput and vertex, applying gentle downword pressure, thus delivering the anterior shoulder.The posterior shoulder is then delivered by upward traction on the fetal head. The rest of the fetal body deliveries easily.

slide49

After delivery nasal and oral suction is performed.It is especially important in case of presence meconium in amniotic fluid because of the possibility of MAS (meconium aspiration syndrom).After clumping the umbilical cord the newborn is attended to the neonatologist.

slide50

Immediately after delivery of the infant, the uterus significantly decreases in size. This is the cause of separation of the placenta in the third stage of labor.The classic signs of placental separation are:- rise of the uterus in abdomen and its globular configuration- a gush of blood- lengthening of the umbilical cord

there are two modes of management in the third stage of labor

There are two modes of management in the third stage of labor:

1.Waiting for spontaneous extrusion of the placenta, even up to 30 minutes

2. Giving immediately after the delivery of the fetal head a bolus of Oxytocin for making a strong contraction of the uterus

slide52

If spontaneous placental separation does not occur it is necessery to to remove the placenta manually.This is accomplished by passing a hand into the uterine cavity and using the palm of the hand to separate the placenta from the uterine wall.

slide53

After delivery of the placenta the evaluation of its surface must be performed. If there are any lacks the revision of the uterine cavity by excochleation must be done.

slide54

Then, inspection of the birth canal should be accomplished. It includes control of:- lacerations of the introitus, vulvar area and periurethral area- lacerations of vagina and extensions of the episiotomy- lacerations of the cervixRepair of these lacerations and the episiotomy is accomplished with an absorbable suture in local block.

classification of perineum rupture
Classification of perineum rupture:
  • 1° - involves the vaginal mucosa or perineal skin, but not the underlying tissue
  • 2° - involves the underlying subcutaneous tissue, but not the rectal sphincter or rectal mucosa
  • 3° - extends through the rectal sphincter but not into the rectal mucosa
  • 4° - extends into the rectal mucosa
fourh stage of labor

Fourh stage of labor

For the first (especially two) hours aftere delivery there is the graetest risk of postpartum complications.

Postpartum uterine hemorrhage occurs in 1% of deliveries. It is more likely to occur in cases of:

- rapid labor

- protracted labor

uterine enlargement (large fetus, polihydramnios,

gemelli)

- prolonged use of betamimetic agent

slide57

In the fourth stage of labor the uterine palpation by abdominal wall must be repeated in frequent intervals to accertain uterine tone. The amount of blood loss must be observed.It is also necessary to observe the pulse and blood pressure.