cpg on normal labor and delivery

8/10/2019 CPG on Normal Labor and Delivery

1/59

CPG on Normal Labor

and Dellivery

Prepared by: Jaramillo, Neptune S.

MSU COM, CLASS 2012


2/59

In Latin, the word labormeans a troublesome effortor suffering. Another term for labor isparturition

which comes from the Latin word Parturireto beready to bear young and is related topartustoproduce. To labor in this sense is to produce.

a physiologic process that begins with the onset of

rhythmic contractions which bring about changes inthe biochemical connective tissue resulting gradualeffacement and dilatation of the cervix and ends withthe expulsion of the product of conception

DEFINITION OF LABOR


3/59

a clinical diagnosis

criteria for the diagnosis of labor include: Uterine contractions (at least 1 in 10 minutes or 4 in 20

minutes) by direct observation or electronically usinga cardiotocogram

Documented progressive changes in cervical dilatationand effacement

Cervical effacement of > 70-80%

Cervical dilatation > 3 cm

DEFINITION OF LABOR


4/59

goal of intrapartum fetalsurveillance to detect potentialfetal decompensation and to

allow timely and effectiveintervention


5/59

aims to identify hypoxia before it is

sufficient to lead to long term poorneurological outcome for babies

done at regular intervals using a handheld Doppler device

MONITORING OF FETAL WELL-BEING DURING NORMAL LABOR


6/59

intermittent auscultation be undertaken every15-30 minutes in the 1ststage of labor and

every 5 minutes in the 2ndstage of labor at least30 seconds after each contraction

cardiotocography (CTG) is not recommended

for healthy women at term in labor in theabsence of risk factors for adverse perinataloutcome

Recommendations:


7/59

Continuous EFM should be recommendedwhen either risk factors for fetal compromisehave been identified antenatally, at the onsetor during labor

Recommendations:


8/59

defined as an intervention

designed to artificially initiateuterine contractions leading toprogressive dilatation and

effacement of the cervix and birthof the baby.

INDUCTION OF LABOR


9/59

Assessment with documentation prior tostarting the induction should include:

Confirmation of parityPresentationBishops scoreConfirmation of gestational ageUterine activityNonstress test

Recommendations:


10/59

Confirmation of gestational age

Confirmation of Term Gestation

American College of Obstetrics and Gynecology (ACOG)

Practice Bulletin #230, November 1996

Fetal heart tones have been documented for 20 weeks by

nonelectronic fetoscope or for 30 weeks by Doppler

The passage of 36 weeks since a serum or urine humn chorionic

gonadotropin (HCG) pregnancy test was found to be positive Ultrasound measurement of the crown-rump length at 6-11 weeks

gestational age (GA) that support a current GA equal =/> 39 weeks

Ultrasound measurements at 13-20 weeks GA supports a clinically

determined GA equal =/> 39 weeks.


11/59

Induction of labor should be

administered only in a hospital setting,particularly in a labor room under theresponsibility of an obstetrician

Assess cervical ripening with the use ofBishops preinduction score system

Recommendations:


12/59

FACTOR SCORE

0 1 2 3

CervicalDilatation

(in cm)

Closed 1-2 3-4 5

Cervical

Effacement

(%)

0-30 40-50 60-70 >80

Station -3 -2 -1 +1,+2Cervical

ConsistencyFirm Medium Soft

Cervical Position

Posterior Midposition Anterior

Bishops Preinduction

Cervical Score System


13/59

Gestational hypertension

Preeclampsia, eclampsiaPrelabor rupture of membranes

Maternal medical conditions (e.g.,

diabetes mellitus, renal disease, chronichypertension)

Gestation 41 1/7 weeks

Induction is indicated when the continuance ofpregnancy may no longer be advisable in the

following clinical circumstances:


14/59


15/59

Malpresentation (e.g., transverse,

breech)Absolute cephalopelvic disproportion

Placenta previa

Previous major uterine surgery orclassical cesarean section

Contraindications for

Labor Induction


16/59

Invasive carcinoma of the cervix

Cord presentationActive genital herpes

Gynecological, obstetrical, or medical

conditions that preclude vaginal birthObstetricians convenience

Contraindications for

Labor Induction


17/59

OXYTOCIN

MEMBRANE SWEEPING /STRIPPING

AMNIOTOMY

Methods of Induction of Labor


18/59

seeks to provide adequate hydration andnutrition while maintaining safety for themother and the baby

Many obstetricians restrict oral food andfluid intake during active labor because of

the possible riskincidence of aspiration of gastric contents has

always been low and therefore plays a verysmall role as a cause of maternal death

INTRAPARTUM NUTRITION


19/59

thought to decrease the risk puerperal

and neonatal infections

Recommendation:

There is no evidence to support the routineuse of enemas during labor

ENEMA DURING LABOR


20/59

Friedmans Curve

MONITORING THE

PROGRESS OF LABOR


21/59

1. Latent phase: up to 3-4 cm dilatation (approximately 8 hrs

long)

2. Active Phase

a. Acceleration phase-not always present

b. Phase of Maximum Slope

- Occurs at approximately 9 cm. dilatation

- Fetus is considered fully descended as it falls one station

below the ischial spine (+1)

c. Deceleration- always present

DILATATION CURVE


22/59

ends at 3-4 cm dilatation

( approx. 8 hrs long)

Extends from the onset of labor,

time from the onset of the regularuterine contractions, to thebeginning of the active phase.

Latent phase


23/59

The point when the curve becoming more steeplyinclined.

ends at full cervical dilatation when the cervix is nolonger palpable.

The active phase may be further subdivided in tothree distinctive phase:

Acceleration phase Phase of maximum slope

Deceleration phase

Active Phase


24/59

1. Latent phase- no fetal descent occurs

- Extends beyond dilatational phase of descent curve

1. Active Phase- come much later

a. Acceleration

b. Phase of maximum descent

- Occurs at around 9 cm dilatation

- Corresponds to the deceleration of dilatation

- Fetus fully descended at +1 (station below level of ischial

spines)

Fetal Descent


25/59

o The pattern of descent follows a hyperbolic curve, it too

has its phases as follows:

1. The Latent Phase - corresponds to the latent and

acceleration phase of cervical dilatation (the preparatory

division of labor). At this time, little if at all, fetal head

descent takes place.

2. The Accelaration Phase - corresponds to the phase of

maximum slope (the dilatation division of labor) of

cervical dilatation. This is time that fetal head descent

ensues.

Fetal Descent


26/59

1. The Place of Maximum Slope corresponds to

the deceleration phase and second stage of labor

in cervical dilatation (pelvic division of labor).

Increased rates of descent begins during this

phase and progresses to a maximum until the

presenting part reaches the perennial floor.As this

event occurs, the cervix is expected to be at an

advanced stage of dilatation (8-9 cm)

Fetal Descent


27/59

The WHO

PARTOGRAM


28/59

If graph is located on the right side of

the ALERT LINE: one should monitorthe patient closely

If graph reaches the ACTION LINE:should do cesarean section orforceps/vacuum delivery.

WHO PARTOGRAPH


29/59

There is evidence that walking and uprightposition in the first stage of labor reduce the

length of labor and do not seem associatedwith increase intervention or negative effectson mothers and babies well-being.

Women should be encouraged to take upwhatever position they find mostcomfortable in the first stage of labor.

MATERNAL POSITION DURINGTHE FIRST STAGE OF LABOR


30/59

When not contraindicated (e.g. hypovolemia,coagulopathy), neuraxial analgesia (spinal or

epidural) using local anesthetic with or withoutneuraxial opioids provides the most effective painrelief for labor.

This techniques should be administered by a trainedand skilled anesthesiologist in an appropriatemedical fascility with appropriate resources for thetreatment of complications should be available.

ANALGESIA AND ANESTHESIADURING LABOR


31/59

For imminent delivery, the following may be used:

Pudendal block may offer analgesia for

episiorraphy and repair if needed

Single shot spinal (saddle block)

Intravenous thiopental, propofol, ketamine maybe administered parenterally by a skilledanesthesiologist. (Level 3, Grade C)



32/59

The use of low concentrations of

volatile anesthesia for labor analgesia isno longer accepted as a standard of carefor labor and vaginal delivery. Generalanesthesia obtunds the patients

airway, reflexes and increases the riskfor airway aspiration and itssubsequent sequelae. (Level 3, Grade C)



33/59

Amniotomy is the artificial rupture ofmembranes.

Artificial rupture of the amniotic

membranes during labor is one of themost commonly performedprocedures in modern obstetrics.

AMNIOTOMY


34/59

Timing

There is still no conclusive evidence to supportthat early amniotomy has a clear advantage overexpectant management (Level 1, Grade C).

Supporting Statements:

Early amniotomy appears to lead to an averagereduction of labor.

Routine amniotomy does not significantly reducethe duration of first-stage labor in eitherprimiparous or multiparous women (Grade A).

It slightly shortens second-stage labor inprimiparous women only (Grade A).

Recommendations:


35/59

Use

The primary aim is to speed upcontractions and shorten the lengthof labor.

also to assess the status of the fetus

It is clinically indicated to observethe color and amount of amnioticfluid

Recommendations:


36/59

Complicationsincreases the risk of chorioamnionitis.Possible complications includeumbilical cord prolapse, cord

compression and fetal heart ratedecelerations, increase ascending

infection rate, bleeding from fetal orplacental vessels and discomfort fromthe actual procedure.

Recommendations:


37/59

Elements of Support:

Emotional support (continuous presence,

reassurance and praise)

Physical measures of comfort(massages,

comforting touches, acupressure)

Advocacy like helping the woman to express her

wishes and needs to others

CONTINUOUS SUPPORT

DURING LABOR


38/59

Continuous support by a lay woman during

labor and delivery:

Facilitates birth

Enhances the mothersmemory of the experience

Strengthens mother-infant bonding; increases

breastfeeding success

Significantly reduces many forms of medical

intervention, including cesarean delivery, the use

of analgesia, anesthesia, and vacuum extraction.

CONTINUOUS SUPPORT

DURING LABOR


39/59

Duration of support:

Continuous

IntermittentTypes of Provider:

Untrained lay women

Trained lay women (doulas) Female relatives

Nurses

Monitrices (lay midwives acting solely as labor

su ort ersons

CONTINUOUS SUPPORT

DURING LABOR


40/59

Outcomes assessed:

Use of any analgesiaNeed for oxytocin augmentation

Need for forceps or vacuum

Need for cesarean section

Duration of labor

CONTINUOUS SUPPORT

DURING LABOR


41/59

ROUTINE PERINEAL SHAVING


42/59

o There is insufficient evidence to recommend

routine perineal shaving for women on admission

in labor. (Level 1, Grade E)

Late side effects attributable to shaving occur

later such as:

1. Irritation

2. Redness

3. Multiple superficial scratches from the razor

4. Burning and itching of the vulva

ROUTINE PERINEAL SHAVING

BEFORE DELIVERY


43/59

Recommendations

The upright positionin the second stage of labor isassociated in women without epidural anesthesiawith a 4-minute shorter interval to delivery, lesspain, lower indices of abnormal fetal heart pattern

and of operative vaginal delivery, as well as higherrates blood loss of > 50 ml compared with otherpositions in 20 trials including 6135 women.

MATERNAL POSITION DURINGTHE SECOND STAGE OF LABOR


44/59

Recommendations

The upright positions studies include sitting(obstetric chair/stool), semi-recumbent(trunk tilted backwards 30oto the vertical),

kneeling squatting (unaided or usingsquatting bars), and squatting aided withbirth cushion.

MATERNAL POSITION DURINGTHE SECOND STAGE OF LABOR


45/59

There is no evidence that the rate of adverseperineal outcomes is affected by different types of

bearing down during the second stage of labor(Level 1, Grade C)

A systematic review of controlled trails has foundno evidence of a difference. Holding (Valsalva) orspontaneous exhalatory methods of pushing areused during the second stage of labor.

ALTERNATIVE METHODS

OF BEARING DOWN


46/59

Definition:

o Hands on = touch the perineum

o Hands poised / Hands off = do not touch theperineum

Recommendations:

o Hands off and Hands on techniques did not affect thefrequency or severity of perineal trauma in women

undergoing childbirth for the first time. (Level 1, grade C)

PERINEAL SUPPORT: HANDS

POSED VERSUS HANDS ON


47/59

USE OF EPISIOTOMY


48/59

Recommendations:

Restricted use of episiotomny preferable to routine

use. (Level 1, Grade A)Median episiotomy is associated with higher rates of

injury to the anal sphincter and rectum. (level 1,Grade A)

Mediolateral episiotomy may be preferable tomedian episiotomy in selected cases. (Level 1, GradeB)

Routine episiotomy does not prevent pelvic floor

damage leading to incontinence. (Level 1, Grade B)

USE OF EPISIOTOMYAND REPAIR

USE OF EPISIOTOMY


49/59

Repair

o In either median or medioolateral episiotomy, 2-layered

closure can improve postpartum pain and healing

complications vs a 3-layered closure.

o Polyglycolic acid derivative suture, with minimal reaction,

is recommended to reduce wound inflammation. (Level 1,

Grade A)


USE OF EPISIOTOMY


50/59

Episiotomy

Purpose: facilitate second stage of labor to improve

maternal and neonatal outcome

Maternal benefit

Reduced risk of perineal trauma, subsequent pelvic floor

dysfunction and prolapse, urinary incontinence, fecal

incontinence and sexual dysfunction

Fetal benefit

Shortened second stage of labor



51/59

o There is good evidence to support the use of fast-

absorption polyglactin 910 as material of choice for

perineal closure. (Level 1, Grade A)

Fast-absorbing Polyglactin 910

- Obviates need for suture removal up to 3 months

postpartum for 1 in 10 women sutured

- Less dyspareunia at 6 weeks

- Similar wound breakdown profile as chromic rarely

requires late removal

- Earlier resumption of sexual intercourse

SUTURE MATERIALS FOR

EPISIORRAPHY


52/59

Recommendations:

Active management includes a group of

interventions such as

1. Administration of prophylactic uterotonin within

one minute after the delivery of the baby and prior

to the delivery of the placenta

2. Early cord clamping and cutting

3. Controlled cord traction to deliver the placenta

MANAGEMENT OF THIRDSTAGE OF LABOR

DRUGS IN THE THIRD


53/59

Recommendations:

o Oxytocin is effective as first line prophylactic

uterotonic during the 3rd stage of labor in the

prevention of PPH and is safe to use in all

patients. (level 1)

o Use of ergot alkaloid and ergometrine-oxytocin

are valid alternatives in the absence of oxytocin.

Their use have to be weighed against maternal

adverse effects. (Level 1)

DRUGS IN THE THIRD

STAGE OF LABOR


54/59


55/59

The American Academy of Physicians,American College of Obstetricians andGynecologists, American Academy ofBreastfeeding Medicine, World HealthOrganization, United Nations

Childrens Fund, and many otherhealth organizations recommendexclusive breastfeeding for the first 6

months of life.

EARLY BREASTFEEDING


56/59

Breastfeeding should be continued forat least te first year of life and beyonffor as long as mutually desired bymother and child.

EARLY BREASTFEEDING


57/59

oManeuvers that maintain milk

production:1.Maternal anatomic abnormalities of the

breast

2.Neonatal anatomic abnormalities

3.Neonatal depression

EARLY BREASTFEEDING


58/59

o Breastfeeding is contraindicated in mothers with

the following conditions:

Use of street drugs or alcohol

Infant with galactosemia

Maternal infection (HIV, active PTB, varicella,

herpes simplex)

Use of neoplastic, thyroid, immunosuppresants

Undergoing treatment of breast cancer

EARLY BREASTFEEDING


59/59

cpg on normal labor and delivery

Documents