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Normal Labor and Delivery

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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 ... – PowerPoint PPT presentation

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Title: Normal Labor and Delivery


1
Normal Labor and Delivery
  • Midwifery Division
  • Department of OB/GYN
  • University of North Carolina
  • School of Medicine

2
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.

3
NORMAL LABOR DELIVERYDefinitions
  • Labor progressive dilatation of the cervix in
    association with uterine contractions
  • Term gt 37 weeks gestation
  • Preterm lt 37 weeks gestation
  • 11 of all US births in 1997
  • 80 of preterm births between 34 - 36 weeks
  • Preterm delivery lt 35 weeks 3.5

4
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

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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

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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

9
Vertex
Parietal
Brow
Face
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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

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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

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Cardinal Movements of Labor
  1. Internal rotation fetal occiput rotates from
    transverse to AP
  2. Extension head rotates under symphysis pubis
  3. External rotation (restitution) occiput and
    spine assume same position
  4. Expulsion fetal body delivers

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18
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

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22
Ritgen Maneuver
Erbs palsey
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24
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

25
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.

26
TREATMENT FOR PPH
  • Find the cause and treat promptly
  • Active management of the third stage
  • Med Pitocin
  • Cytotec
  • Methergine
  • Hemabate
  • Repair lacerations promptly

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Abnormal Latent Phase of Labor
  • gt 20 hours in nulliparas
  • gt 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

29
Primary Dysfunctional Labor
  • Slow rate of dilation in the active phase of
    labor
  • lt 1.2 cm/hr in nulliparas
  • lt 1.5 cm/hr in multiparas

30
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

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Disorders of the Second Stage
  • Protracted Descent
  • lt 1 cm/hr in nulliparas
  • lt 2 cm/hr in multiparas
  • Prolonged
  • Nulliparas
  • With epidural 3 hours
  • No epidural 2 hours
  • Multiparas
  • With epidural 2 hours
  • No epidural 1 hour

33
Abnormalities of Labor THE 5 P
  • Passageway maternal pelvis
  • Powers uterine contractions
  • Passenger fetus
  • Placenta profusion
  • Psyche mothers readiness

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Uterine Contractions
  • External tocodynamometry
  • Less accurate
  • 3-5 contractions/10 minutes
  • Internal tocodynamometry
  • Measures mm Hg
  • 180 220 Montevido units/10 minutes

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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

38
INDUCTION OF LABORBishop Score
0 1 2 3
Dilation Closed 1 - 2 3 4 gt 5
Effacement 0 30 40 50 60 70 gt 80
Station -3 -2 -1 1, 2
Consistency Firm Medium Soft
Position Posterior Mid Anterior
39
INDUCTION OF LABORMisoprostol (Cytotec)
  • PO tablet FDA approved to prevent gastric
    ulceration in patients taking NSAIDs
  • 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

40
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

41
NORMAL LABOR DELIVERYAnesthesia
  • Cesarean section
  • Spinal
  • Epidural
  • General (more risky in obstetrics)
  • Vaginal delivery
  • Local
  • Pudendal
  • Epidural
  • Combined spinal/epidural

42
Pudendal Block
43
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

44
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

45
First degree
External sphincter
External sphincter
Second degree
Third degree
46
NORMAL LABOR DELIVERYCesarean Delivery
  • Skin incisions
  • Vertical
  • Pfannensteil
  • Uterine incisions
  • Low cervical transverse (Kerr)
  • Low vertical or T shaped
  • Classical

47
NORMAL LABOR DELIVERYCesarean Delivery
48
USA TRENDS
49
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

50
BREECH
Complete breech
Frank breech
Incomplete breech
51
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

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53
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

54
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

55
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

56
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

57
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 200096141-5.
58
NORMAL LABOR DELIVERYEstimated Fetal Weight
  • Leopolds maneuvers (palpation of the maternal
    abdomen)
  • Ultrasound estimate of fetal weight (error of 10
    15)
  • Maternal estimate of fetal weight (best)

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Forceps Assisted Vaginal Delivery
  • Outlet forceps
  • Scalp visible at the introitus w/o parting the
    labia
  • Sagittal suture lt 45 degrees
  • Low forceps
  • Leading point of skull at 2 or below
  • lt 45 degrees
  • gt 45 degrees
  • Mid-forceps
  • Head is engaged but presenting part is above 2
    station
  • Rarely done

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Mitivac vacuum
63
NORMAL LABOR DELIVERYVacuum vs Forceps
  • Forceps
  • More maternal trauma
  • Minimal fetal trauma (bruising)
  • Vacuum
  • Less maternal trauma
  • Potential for increased fetal trauma (subgaleal
    bleeding)

64
UnderstandingFetal Monitoring (Parameters)
  • Baseline rate
  • Variability
  • Presence of accelerations
  • Presence of decelerations
  • Changes or trends of FHR patterns over time

65
Fetal Heart Rate Baseline
  • 10 minute window
  • Duration at least 2 minutes
  • Bradycardia lt 110 bpm
  • Tachycardia gt 170 bpm

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Fetal Monitoring (Variability)
  • Concept of long-term variability dropped
  • Absent undetectable
  • Minimal undetectable - lt 5 bpm
  • Moderate 6 - 25 bpm
  • Marked gt 25 bpm

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Fetal Monitoring (Accelerations)
  • Onset to peak lt 30 seconds
  • gt 32 weeks gt15 bpm X gt15 secs
  • lt 32 weeks gt 10 bpm X gt 10 secs
  • gt 2 minutes in duration prolonged
  • gt 10 minutes in duration change in baseline

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DECELERATIONSFetal Monitoring (Variables)
  • Onset to nadir lt 30 secs
  • gt 15 bpm below baseline
  • Duration gt 15 seconds
  • lt 2 minutes from onset to return to baseline

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DECELERATIONSFetal Monitoring (Variables)
  • Treatment
  • Pelvic exam (rule out prolapsed cord)
  • Maternal oxygen
  • Change maternal position
  • Stop pushing
  • Amnioinfusion

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Fetal Monitoring (Early Decelerations)
  • Onset to nadir gt 30 secs
  • Coincident in timing with UC
  • Nadir occurring simultaneously with the peak of
    the contraction

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Fetal Monitoring (Late Decelerations)
  • Onset to nadir gt 30 secs
  • Delayed in timing
  • Nadir occurring after the peak of the contraction
  • Reoccuring can be ominous

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Fetal Monitoring(Late Decelerations)
  • Treatment
  • Correct hypotension or other maternal
    conditions
  • Maternal oxygen
  • Scalp stimulation
  • Cesarean delivery if repetitive

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Cord Blood Gases
  • Defensive medicine (not used clinically)
  • Clamp cord segment at all deliveries
  • Obtain arterial sample for 5 minute Apgar score
    lt 7

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NORMAL LABOR DELIVERYCord Blood Gases
  • Umbilical artery (No labor)
  • Acidemia pH lt 7.15
  • Metabolic base excess gt -11 mmol/L and pCO2 lt
    65 mm
  • Respiratory base excess lt 11 mmol/L and pCO2 gt
    65 mm
  • Mixed base excess gt -11 mmol/L and pCO2 gt 65
    mm

86
NORMAL LABOR DELIVERYCord Blood Gases
  • Umbilical artery (No labor)
  • Clinically significant acidemia is probably
    represented by an umbilical arterial pH of lt 7.0
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