Ch 13. CONDUCT OF NORMAL LABOR AND DELIVERY

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Ch 13. CONDUCT OF NORMAL LABOR AND
DELIVERY

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• 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

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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
• -gtThe fetal heart rate should be checked,
  especially
• at the end of a contraction and
  immediately,
• thereafter, to identify pathological
  slowing of the
• heart rate

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ADMISSION PROCEDURES

• 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

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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

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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

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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

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• 4)station the degree of descent
• high level- fundal pressure
• 5)pelvic architecture diagonal conjugate
• ischial spine,
  pelvic sidewall
• sacrum

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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

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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

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• -the lowermost portion of the fetal presenting
  part
• is at the level of the ischial spine ZERO
  (0)
• 
  engagement
• -divided into third
• -gtACOG (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

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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

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• -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 (4.55.5)
• amnionic fluid
  (7.07.5)
• Nirazine test
• false-positive
  blood, semen
• 
  bacterial vaginosis
• false-negative
  minimal fluid
• Nitrazine test insert sterile cotton
  tip-gttouching it
• to a strip-gt
  comparering the color
• -arborization, ferning pattern or AFP of
  amnionic fluid

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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

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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)

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MANAGEMENT OF FIRST STAGE OF LABOR

• The average duration of the first stage
• -nulliparous 7 hours
• -parous 4 hours
• -gtindividual variations
• The physician can best reach a conclusion
  about
• the normalicy of the pregnancy when all
• examinations ,including record and
  laboratory
• review, are completed

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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.

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• 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

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• -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

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• 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

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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 (gt18 hrs)
• antibiotics (preventtion of group B
  streptococcus)

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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

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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

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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)

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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

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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

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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

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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