Normal Labor and Delivery Valerie Robinson D.O.
Contractions • Become regular • Increase in strength and frequency • Cervical change: Dilation and Effacement • Normal is >1.2cm/hour in P0, >1.5cm/hour in P>0 • 0% effacement is 3-4cm thick • ROM may be spontaneous or assisted • 3 factors affecting successful labor and delivery are the Power, Passenger, and Passage Definition of Labor
#1: Onset to full Dilation • #2: full Dilation to Delivery • Mom wants to bear down • May feel rectal pressure • May have N/V • #3: Delivery to Placental expulsion 3 Stages
Latent – Onset of labor and slow cervical dilation • Active – Rapid cervical dilation. Usu begins at 2-4 cm • After • Involution – Empty uterus contracts to become smaller and hard. Stops bleeding. 4 Phases
Tocodynamometer (TOCO) measures length and strength of contractions • May also use IUPC after ROM • Adequate contractions for labor are 3-5 per 10 minutes Power
Size • Presentation: breech, vertex, transverse • Position: LOA, etc • Movements • FHR • How many babies are there? Passenger
Engagement – widest diameter is below pelvic inlet • Descent • Flexion • Internal Rotation – rotation into the AP dimension • Extension – occiput contacts the pubic symphysis • External Rotation – head rotates to correct anatomy • Expulsion 7 cardinal movements
Baseline – average FHR over 10 minutes. 110-160 • Variability – Fluctuations in FHR amplitude • Absent • Minimal - <5 BPM • Moderate - 6-25 BPM • Marked - >25 BPM • Accelerations – increase from baseline • Normal is a 15 BPM increase lasting at least 15 seconds, <2 minutes • If it lasts >10 minutes, it is a baseline change • Decelerations – decrease in FHR with return to baseline • Early • Late • Variable • Prolonged - >2 minutes Fetal heart monitor
Is the pelvic outlet large enough? • Infections such as GBS, herpes, hepatitis Passage
Check cervical D/E/S • Dilation: 0-10 cm • Effacement: 0-100% • Station: – 5-+5cm above-below ischial spines • Check presentation and position • Check for ROM; color and quantity • Check vitals • Apply TOCO and Doppler transducer • Review prenatal chart Initial Assessment
IV fluids are not necessary • IV access should be gained for emergency, labor augmentation, antibiotics • Restriction of drink is not necessary, but food may be restricted due to risk of aspiration pneumonitis • Pain control • Encouragement and reassurance • An anterior cervical lip lasting >30 minutes may be normal or may indicate a malposition L&D Care
Nurse or doctor will check labor progression by monitoring TOCO and checking Dilation/Effacement/ Station • Allowing passive descent instead of pushing at 10cm increased chance of SVD, decreased chance of instrument assistance, decreased pushing time • Pushing: Reflexive, or Valsalva. 10x3 in contraction • May use hands to support the perineum or fetal head and reduce risk of tearing. • May do a manual reduction of an anterior cervical lip • Episiotomy is only used when there is a risk of severe perineal laceration • Watch for and reduce a nuchal cord Delivery
Deliver anterior shoulder, use downward traction on the head in concert with contractions • Then upward traction to deliver posterior shoulder • Suctioning may be performed but has not been shown to have any benefit except in babies with obvious secretory obstruction or who will be on a ventilator • Cord clamping can take place immediately, but there is some benefit to delaying it so the placenta can deliver more blood to the baby. 75% of available blood is transfused in the first minute following delivery. • Cord blood can be collected for diagnostic purposes • Cord blood pH is measured by needle aspiration of artery Delivery cont.
Uterus contracts, placenta separates, cord lengthens • WHO suggests that placenta is retained after 1 hour • Retained placenta increases risk of hemorrhage • More commonly retained in preterm delivery • Active management includes: Prophylactic oxytocin, Cord traction, and Uterine massage • When providing cord traction, support the fundus to prevent inversion • Slowly rotate the placenta as it is delivered, so you can get the attached membranes out intact. Stage 3
Check incision if C/S • Birth control • Screen for depression • Breast-feeding? Post-Partum
Costanzo, Linda S. Physiology. 3rd Ed. Saunders/Elsevier: Philadelphia, PA. 2007. pp. 456-460 • Gordon, John David MD, Et al. Obstetrics, Gynecology, and Infertility: Handbook for Clinicians. 6th Ed. Scrub Hill Press: Arlington, VA. 2007. pp 87-88. • http://www.gynaeonline.com/perineal_tear.htm • Funai Et al. Management of normal labor and delivery.UpToDate. Updated 5/18/12. • Funai Et al. Mechanism of normal labor and delivery. UpToDate. Updated 10/19/11. References