Four ’s of Labor

Passenger Power Passageway Psyche

Passenger Lie – Relationship of the longitudinal

axis of the baby to the longitudinal axis of the mother

Longitudinal Transverse Which do you think was intended?

Passenger Issues with Transverse Lie

1)

2)

Passenger – Station Relationship of the presenting part

to the ischial spines Engagement – Station 0 or below Minus stations – Above the spines Positive stations – Below the spines

Back to Premonitory Signs

Passenger – Presentation Part of the passenger that

enters the pelvis first Vertex presentation – 95% Breech presentation – 4% Brow, face, shoulder - 1%

Passenger – Breech Presentation Footling breech– double or single Frank breech Complete breech

Passenger – Risks of Breech Presentation

Prolapsed cord CPD Asphyxia C/S

Prolapsed Umbilical Cord

Passenger – External Breech Version

Decision Choosing a

Candidate Safety Measures The Version Follow-up

Increased risks:Preterm labor and birthCesarean DeliveryPostpartum Hemorrhage

Passenger – Multiple Passengers

Passenger – Position Three letters denoting relationship of a

landmark on the baby to the mother’s pelvis

Landmark = Occiput/vertex

Sacrum/breech Ex. LOA = Left occiput anterior (The occiput of the baby is pointing toward

the left front of the mother’s pelvis.)

Passenger – Mechanisms of Labor

Movements of the baby through the pelvis during labor/birth. Each is essential to an easy, safe passage.

Engagement/ descent Flexion Internal rotation Extension External rotation/restitution

Passenger – Mechanisms of Labor

Power! Power during labor comes

from strong contraction of the upper uterine segment

2nd stage – adds power of abdominal muscles

Use of DRUGS to augment (“to add to”) or induce (“to begin”) labor, or ripen(“soften and efface”) the cervix

Action: Stimulate uterine contractions Prostaglandins

Prepidil gel

Cervidil vaginal insert

Cytotec vaginal tablet Oxytocin

Power!

Cervical Ripening Agents

ProstaglandinsEvening Primrose OilMechanical dilation using balloon cath.“Stripping” the membranesCastor Oil Sexual Intercourse

Most common reasons for induction:

1)

2) Other reasons: Who would not be a candidate

for induction?

Power!

Power! – Safe Use of Oxytocin Know the Standard of Care! Follow protocols exactly Start slowly and evaluate before

advancing Watch patient, vital signs and fetal

monitor Know side effects When to hold? When to fold?

Collaborate!

Power! – Risks of Oxytocin in a Pregnant Patient

Hyperstimulation Fetal distress Uterine rupture Hypertension

Passageway – Pelvic types

types -

gynecoid

android

anthropoid

platypelloid

Passageway – Pelvic Characteristics

If you were a baby shopping for a great pelvis to be born from, which would you choose? Why?

1)

2)

3)

4)

Passageway – Pelvic Measurements

Diagonal Conjugate – usually about 12.5cm measured vaginally from the symphysis to the sacral promontory

True Conjugate – measurement from the top of the symphysis to the sacral promontory estimated by subtracting 1.5cm from the diagonal conjugate

Passageway – Episiotomies & Lacerations

Midline/Median episiotomies are the most common

Cut right before the delivery of the head to minimize blood loss

Midline = Skin and perineal muscle May extend into the anal

sphincter/rectal mucosa if lacerations occur

Passageway – Lacerations1st degree = tearing of perineal skin2nd degree = skin & perineal muscle3rd degree = skin, muscle & anal

sphincter4th degree = skin, muscle, sphincter

& rectal mucosa

Passageway – Life After Lacerations?

Yes! These usually heal quickly and well facilitated by:

1)

2)

3)

4)

5)

Possible Indications for C/S

Cephalopelvic disproportionActive genital herpesNonreassuring fetal heart rate patternsProlapsed umbilical cordFetal malpresentations (breech, transverse lie)Certain prior uterine surgeries (classical

cesarean incision, etc.)Certain maternal diseases where labor not

advisable

Skin Incisions for Cesarean Birth

Uterine Incisionsfor Cesarean Birth

Nursing Care Preparing for C/S

Pre-op teaching (if possible)Touch, eye contact, info. to decrease anxietyNeeds IV line, Foley, shave prep lower abd.Keep NPO- may give antacid like “Bicitra”Notifies pediatrician – Prepare baby itemsPositioning on OR table - displace uterusMonitor FHR until procedure-check one more

time prior to surgery

VBACVaginal Birth After CesareanSuccess rate 70-80%Candidates for VBAC (ACOG): - 1 prior low-transverse C/S

- clinically adequate pelvis

- no other uterine scars or prior uterine rupture

- MD immediately available to perform emerg. C/S

Risks of VBAC: - uterine rupture

- fetal/maternal death

- hysterectomy

Anesthesia - Local Local infiltration of the Perineum Pudendal Block –

infiltration of the pudendal nerves transvaginally

provides effective perineal anesthesia

performed using an Iowa trumpet late in 2nd stage

very low risk/few side effects

Anesthesia – Regional

Continuous Lumbar Epidural (CLE) - provides relief from contraction pain

during labor/C/S usually given once active labor

established ( but may be given earlier/later depending on situation)

no penetration of dura, so no risk of headache

give fluid bolus to decrease hypotension risk

Anesthesia – RegionalSpinal Block

• Used for cesarean birth, or BTL

• Not used for vaginal delivery

• Penetration of dura may cause post spinal HA

• Hypotension risk also tx. with fluid bolus

Blood Patch for Relief of Spinal Headache

Anesthesia – RegionalRisks for CLE and Spinal

Hypotension Urinary catheterization Infection Ascending anesthesia

*Need to have informed consent for regional anesthetic!