normal labor & delivery - scs.msu.edu labor and delivery.pdf · 6/10/2019 1 normal labor &...

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Normal Labor & DeliveryJulianne Scott, DO-PGY 2

Henry Ford Wyandotte Hospital

June, 2019

Normal Labor & Delivery - Outline

1. True vs. False labor2. Assessment of laborers

• Cervical exams• Internal monitors

3. First stage of Labor4. Second stage of Labor5. Third Stage of Labor6. Recovery

Normal Labor & Delivery – True vs. False

• Definition: Uterine contractions that cause progressive cervical change (dilation and effacement)

• Regular uterine contractions every 3 to 5 minutes for 1 hour

True Labor:

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• Braxton Hicks contractions• “practice contractions”• Contractions w/o cervical change• Night-time fluctuations of Oxytocin• May be pacified with intervening maneuvers

False Labor:


Other easily confused “labor” pains:Lower back strainGas / Constipation

Hip instabilityRound ligament pain

Ovarian cystsUTI / pyelonephritis

Uterine rupture

Any history of cesarean sections?

• Electronic fetal monitoring- Assessment of Uterine Activity- Assessment of Fetal Heart Tones- Known problems during pregnancy- Fetal movement

Normal Labor & Delivery – Assessment Status of Fetus:

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• Baseline • Variability • Accelerations • Decelerations

• Baseline (110-160 bpm)• Variability (moderate: 5-25 bpm)• Accelerations (10-15 bpm over 10-15 sec)• Decelerations (15 bpm over 15 sec)• Contractions


Practice Bulletin # 106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles

Practice Bulletin # 116: Management of Fetal Heart Rate Tracings


• Baseline (110-160 bpm)• Variability (moderate: 5-25 bpm)• Accelerations (10-15 bpm over 10-15 sec)• Decelerations (15 bpm over 15 sec)

• Decelerations


Decelerations

Early

Head compressionGradual decrease in FHR

corresponding with contraction

Late

Uteroplacentalinsufficiency

Gradual decrease in FHR;nadir at end of contraction

Variable

Cord compressionAbrupt decrease in FHR;

any point during contractions

Prolonged 15 bpm below baseline > 2 min but < 10 min

Baseline shift > 10 min

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Normal Labor & Delivery – Assessment

• Decelerations – interventions/considerations~ cervical check (check for cord, rapid change)~ reposition~ oxygen~ placement of internal monitors ~ bolus with fluids ~ turn off pitocin~ tocolytics- Amnioinfusion (variables)

• D5 IV fluids (caution in diabetics)• Scalp / Vibroacoustic stimulation

Status of Fetus:



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• Frequency• Duration • Intensity• Adequate contractions: Every 2-3 minutes

approximately 60s in duration

Status of Contractions:

• Montevideo unit (aka: MVU): Pressure of contractions over a 10 minute period~ 200 MVU




• ROM, SROM, PROM, PPROM, AROM• Pooling• Fluid produced with valsava• Nitrazine testing• Ferning• AFI / MVP• ROM+

Normal Labor & Delivery – Assessment Status of Membranes:

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• Dilation• Effacement• Stage • Consistency• Position

Status of Cervix:


• Dilation

Presentation vs. Position?


The “presenting” part

Orientation of he “presenting” part

• Cephalic~ Vertex (occiput)~ Sinciput~ Brow~ Face (mental)

• Breech~ Frank~ Complete~ Incomplete~ Footling

Cephalic presentation:


Vertex(Occiput)

Sinciput Brow Face(Mental)

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Breech presentation:


Hips: Flexed Flexed FlexedKnees: B/L Flexed Flex/Ext B/L extended

Position:


Anterior fontanelle

Posterior fontanelle

Metopic suture

Coronal suture

Sagittal suture

Lambdoid suture

Position:


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Normal Labor & Delivery – Stages of Labor

• Latent phase: begins with maternal perception of regular contractions until 4-6 cm

• Prolonged latent phase:

– Nullip: >20 hours

– Multip: >14 hours


Active phase: Begins at 4-6 cm and lasts until complete dilation

Multips are often faster than nullips in the active phase

(Consortium on Safe Labor 2010)

0.5-0.7 cm/hr nullip

0.5-1.3 cm/hr multip


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• Second stage: • Second stage: Expulsion of the fetus

Stage Duration Begins Ends

Stage II -Expulsion

of fetus

Nulliparous w/ regional anesthesia < 3Hrs

w/o regional anesthesia < 2 Hrs

Multiparousw/ regional anesthesia < 2 Hrsw/o regional anesthesia < 1 Hr

Full dilation (10 cm)

Delivery of neonate

• Second stage: Expulsion of the fetus


Non - Operative delivery

Vacuum Forceps

Operative delivery

~ Bell~ Mushroom

~ Perineal support• “Laboring down”• Perineal massage• Warm compress


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• Second stage: Expulsion of the fetus

~ Episiotomy: no longer routine

• Midline vs. Mediolateral

• NRFHT / Create room to perform dystocia maneuvers or operative delivery


1) Support of perineum

2) Restitution

3) Check for nuchal cord

4) Thumbs to nose

5) Anterior shoulder > Posterior shoulder > rest of baby

6) Suctioning? No evidence it is beneficial in healthy term newborns unless obvious obstruction with secretions

7) Cord clamping (delayed 30-60sec) > cut > cord gases? > cord blood

Anterior shoulder

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Posterior shoulder


Stage III - Placental separation and expulsion

Less than 30 minutes

Delivery of neonate

Delivery of placenta and fetal

membranes

• Third stage: • Third stage: Placental separation & expulsion

Signs of placental separation:• Gush of blood• Cord elongation• Globular and firming uterus• Rising of uterus

Signs of placental separation:

Normal Labor &Delivery – Stages of Labor

Third stage

Active management: prophylactic administration of uterotonic agent prior to placenta and controlled cord traction +/- uterine massage

Often oxytocin is used

Brandt-Andrews maneuver


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Stage IV - Recovery2 hours post

deliveryDelivery of placenta

2 hours post partum

• “Fourth stage”: • “Fourth stage”: Recovery

Observe for possible complicationsPost-partum hemorrhageHematomas


Inspect vaginal area for lacerations ~ Labial~ Vaginal~ Periurethral~ Clitoral~ Perineal (1o, 2o, 3o, 4o)

Inspect placenta~ Number of vessels~ Cord insertion~ All membranes/cotyledons

Read these!



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Normal Labor & Delivery – References

1. Cunnigham, et. Al. “Williams Obstetrics. Chpt. 22 and 23.2. Tikkanen, et. Al. “Placenta percreta left in situ – management by delayed hysterectomy:

a case report.” J. of Med. Case Reports. 2011. 5:4183. www.doctorsintraining.com – Solid series Obgyn – videos: Normal labor parts 1, 2, &

3; Abnormal Labor parts 1 & 2.4. www.pennstatehershey.adam.com – Pregnancy Central – Labor and Delivery.

Retrived June 20155. Chao TT, et. Al. “The diagnosis and natural history of false preterm labor.” Obstet

Gynecol 118(6):1301, 2011.6. Practice Bulletin # 106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature,

Interpretation, and General Management Principles7. Practice Bulletin # 116: Management of Fetal Heart Rate Tracings

Thank you, and best of luck!

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• First stage: Cervical effacement and dilation

- Active Phase Abnormalities• More common in nulliparous


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