Normal and Abnormal Normal and Abnormal Labor and DeliveryLabor and Delivery

Valerie Swiatkowski, MDValerie Swiatkowski, MD

ObjectivesObjectives

At the end of this lecture, you will be able At the end of this lecture, you will be able to:to: Diagnose labor and define the stagesDiagnose labor and define the stages Assess a laboring patientAssess a laboring patient Diagnose abnormal laborDiagnose abnormal labor Understand the cardinal movements of laborUnderstand the cardinal movements of labor Deliver a babyDeliver a baby Understand complications of laborUnderstand complications of labor

What is Labor?What is Labor?

Progressive dilation of the Progressive dilation of the uterine cervix in association uterine cervix in association with repetitive contractionswith repetitive contractions

What is Labor like?What is Labor like?

Subjectively:Subjectively: Regular contractions getting stronger, longer, Regular contractions getting stronger, longer,

closer togethercloser together Bloody show presentBloody show present Sedation does not stop true laborSedation does not stop true laborObjectively: Objectively: Cervical change occursCervical change occurs Descent of the presenting partDescent of the presenting part

What is cervical change?What is cervical change?

Dilation/ Effacement/StationDilation/ Effacement/Station

www.who.int/.../impac/Images_C/normal2.gif

Williams 2001

Fetal Station

Bishops ScoreBishops Score

0 1 2 3 Dilation (cm) 0 1-2 3-4 5+ Effacement (%) 0-30 40-50 60-70 80+ Station -3 -2 -1 Consistency firm med soft Position post mid ant

False Labor is different!False Labor is different!

Irregular contractionsIrregular contractionsNo bloody showNo bloody showNo cervical changeNo cervical changeHead may be ballotableHead may be ballotableSedation stops false laborSedation stops false labor

Cervical insufficiency (incompetence): Cervical insufficiency (incompetence): dilation without contractionsdilation without contractions

Taking a Labor History Taking a Labor History and Physicaland Physical

HistoryHistory::Know 4 facts Know 4 facts (at least)(at least):: Onset of contractions?Onset of contractions? Did the water break Did the water break

(ROM)?(ROM)? Vaginal bleeding?Vaginal bleeding? Fetal movement (FM)?Fetal movement (FM)?

PMH/ Meds?PMH/ Meds?Last PO intake?Last PO intake?

PhysicalPhysical::Vitals Vitals CV/CV/Pulm/AbdPulm/AbdFHT FHT (fetal heart tracing)(fetal heart tracing)TocometerTocometer ((ctxctx tracing)tracing)EFW by EFW by LeopoldsLeopoldsPelvic examPelvic examFetal position and Fetal position and presentationpresentation

Assessing laborAssessing labor

What is normal labor?What is normal labor?

Stages of LaborStages of Labor

First Stage:

labor onset to complete dilation

latent

active

Second Stage:

complete dilation to delivery of infant

Third Stage:

delivery of infant to delivery of placenta

Fourth Stage:

After delivery of the placenta

Friedman Curve 1978

http://www.emedicine.com/med/TOPIC3488.HTM

Assessing laborAssessing labor

The importance of PThe importance of PssPowerPower

PassagePassagePassengerPassenger

POWER! POWER!

Measuring contractions:Measuring contractions:Palpation: duration, frequency, intensityPalpation: duration, frequency, intensity work intensivework intensiveExternal External TocometerTocometer: graphic display: graphic display no info on strength of contractionsno info on strength of contractionsIntrauterine pressure catheter (IUPC): Intrauterine pressure catheter (IUPC): accurate feedback in Montevideo unitsaccurate feedback in Montevideo units

IUPCIUPC

Adequate contractions are>200 MVU in 10 minutes

http://images.google.com/imgres?imgurl=http://z.about.com/d/pregnancy/1/5/y/Z/3/internalmonitor.jpg&imgrefurl=http://pregnancy.about.com/od/laborbasics/ss/interventions_6.htm&h=248&w=400&sz=143&hl=en&start=1&um=1&tbnid=TRuIqIKd9W-zQM:&tbnh=77&tbnw=124&prev=/images%3Fq%3Dintrauterine%2Bpressure%2Bcatheter%26um%3D1%26hl%3Den

The Pelvis = PassageThe Pelvis = Passage

Up to date. com

Clinical PelvimetryClinical PelvimetryObstetrical conjugateObstetrical conjugate anterior anterior symphysissymphysis pubispubis posterior posterior sacral promontorysacral promontory lateral lateral linealinea terminalisterminalisDiagonal conjugate (clinical)Diagonal conjugate (clinical) inferior border of s.pubis to s.promontoryinferior border of s.pubis to s.promontoryInterspinousInterspinous/ Bi/ Bi--ischialischial diameterdiameter

Up to date. com

Bi-ischial Diameter

Calwell-Moloy Classification Pelvic Types

Gynecoid Pelvis

Pelvic brim is a transverse ellipse (nearly a circle) Most favorable for delivery50 percent of patients

Android Pelvis

Pelvic brim is triangular Convergent Side Walls (widest posteriorly) Prominent ischial spines Narrow subpubic arch More common in white women

Anthropoid Pelvis

Pelvic brim is an anteroposterior elipseGynecoid pelvis turned 90 degrees Narrow ischial spines Much more common in black women

Platypelloid Pelvis

Pelvic brim is transverse kidney shape Flattened gynecoid shape

DonDont forget about the t forget about the Passenger!Passenger!

http://images.google.com/imgres?imgurl=http://www.health-in-action.org/library/pdf/Shaken%2520Baby/Images/sm%2520shake%2520baby%2520with%2520bkgd.jpg&imgrefurl=http://www.health-in-action.org/node/311&h=1200&w=1350&sz=131&hl=en&start=16&tbnid=9Z42gBPsTsefNM:&tbnh=133&tbnw=150&prev=/images%3Fq%3Dbaby%26gbv%3D2%26hl%3Den

LeopoldsLeopolds maneuversmaneuvers

4 maneuvers 4 maneuvers to identifyto identify

fetal landmarks fetal landmarks and and

review review fetofeto--maternal maternal relationshipsrelationships

DefinitionsDefinitionsPresentation Presentation -- the part that lies closest the part that lies closest to the pelvic inletto the pelvic inletAttitude Attitude -- relationship of fetal parts to relationship of fetal parts to each other (flexion/extension)each other (flexion/extension)Lie Lie -- relationship between long axis of relationship between long axis of fetus to motherfetus to motherPosition Position -- relationship between fetal relationship between fetal denominator and the vertical (a/p) and denominator and the vertical (a/p) and horizontal (r/l) planes of the birth canalhorizontal (r/l) planes of the birth canalSynclitismSynclitism

Williams 2001

vertex brow facesinciput

Cephalic Presentation and Attitude

Williams 2001

Breech Presentation

Williams 2001

A. Longitudinal: 99% of lie

B. Transverse: Associated with multiparity, placentae previa, polyhydraminos, uterine anomaly

C. Oblique: Unstable

Lie

Presentation at Term

3.5% breech

0.3% face

Position at Term

33% ROA or ROP66% LOA or LOP

96% vertex

PositionPosition

Anterior Fontanelle Posterior Fontanelle

http://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/AnteriorFontanel.jpg

Determining PositionDetermining Position

OP OT

OA

http://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/LOT.jpghttp://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/OP.jpg

Williams 2001

A. Anterior asynclitism

B. Posterior asynclitism

SynclitismSynclitism

Caput and moldingCaput and molding

www.fammed.washington.edu/.../Newbornexam.htm

http://www.fammed.washington.edu/network/sfm/NewbornExam/Newbornexam.htm

Abnormal LaborAbnormal Labor

Prolonged latent phase Prolonged latent phase Treatment: therapeutic restTreatment: therapeutic rest 85% active, 10% false labor85% active, 10% false laborProtraction disorder (primary dysfunctional Protraction disorder (primary dysfunctional labor) labor) dilation/descent occur at a slower ratedilation/descent occur at a slower rateSecondary arrest Secondary arrest cessation of a previous normal dilation for 2 cessation of a previous normal dilation for 2

hourshours

Maximum Dilation: 10!Maximum Dilation: 10!

Finally the Second stage of Finally the Second stage of labor!labor!

Cardinal Movement of LaborCardinal Movement of Labor

EngagementEngagementDescent Descent FlexionFlexionInternal rotation Internal rotation Extension Extension External rotation (restitution)External rotation (restitution)Expulsion Expulsion

EngagementEngagement

descent of BPD to a level below the plane of the pelvic inletdescent of BPD to a level below the plane of the pelvic inletoften occurs before true labor, especially in often occurs before true labor, especially in nulliparousnulliparous

Flexion during descentFlexion during descent

9.5cm for 9.5cm for vtxvtx / 13.5 cm for brow/ 13.5 cm for brow

Williams 2001

Stage 2Stage 1

Our job in the delivery roomOur job in the delivery room

Control extension of the headControl extension of the headProtect the perineumProtect the perineumCheck for Check for NuchalNuchal cordcordSuction mouth and noseSuction mouth and noseAvoid stimulation if Avoid stimulation if meconiummeconiumCatch the baby!Catch the baby!Clamp the cordClamp the cord

Delivery ComplicationsDelivery ComplicationsArrest of descentArrest of descent

NuchalNuchal cordcord

Fetal distressFetal distress

PerinealPerineal lacerationlaceration

Shoulder Shoulder dystociadystocia

PerinealPerineal LacerationsLacerations

First degree First degree -- may involve the vaginal may involve the vaginal mucosa, mucosa, perinealperineal skinskinSecond degree Second degree -- perinealperineal musclesmusclesThird degree Third degree -- external anal sphincterexternal anal sphincterFourth degree Fourth degree -- anterior rectal wallanterior rectal wall

Episiotomy?Episiotomy?

Easier to repairEasier to repairDecrease length of Decrease length of second stagesecond stageDecreased trauma to Decreased trauma to the perineumthe perineum

Increased blood lossIncreased blood lossIncreased traumaIncreased trauma

Shoulder Shoulder DystociaDystociaIncidence 0.2Incidence 0.2--2% of deliveries 2% of deliveries (Acker 1986)(Acker 1986)Impingement of biImpingement of bi--acromialacromial diameter of diameter of the fetus against the s.pubis and the the fetus against the s.pubis and the s.promontorys.promontory4040--50% occur with birth weight

Shoulder Shoulder DystociaDystocia

Maternal morbidity Maternal morbidity -- postpartum postpartum hemorrhage, 4th degree lacerationshemorrhage, 4th degree lacerations

Neonatal morbidity Neonatal morbidity -- asphyxia, brachial asphyxia, brachial plexus (plexus (ErbErb palsy, 10palsy, 10--20%, 8020%, 80--90% 90% recover completely), fracture of recover completely), fracture of humerushumerus/clavicle/clavicle

Shoulder Shoulder DystociaDystocia ManeuversManeuvers

Look for turtle signLook for turtle signAvoid excessive traction on shoulders Avoid excessive traction on shoulders McRobertsMcRoberts: flattens the : flattens the lumbosacrallumbosacral curvecurveSuprapubicSuprapubic pressurepressureRuben/Wood Screw Ruben/Wood Screw -- rotate shoulders to oblique rotate shoulders to oblique position and pushing posterior shoulder toward position and pushing posterior shoulder toward fetal backfetal backDeliver posterior armDeliver posterior armZavanelliZavanelli

BabyBabys out!s out!

Now What?Now What?Stage 3: PlacentaStage 3: Placenta

Delivery of the PlacentaDelivery of the Placenta

Signs of placenta separationSigns of placenta separation rise in the rise in the fundusfundus firm, globular uterusfirm, globular uterus sudden gush of bloodsudden gush of blood umbilical cord lengtheningumbilical cord lengthening

Examine the placentaExamine the placentaDelivers within 5Delivers within 5--30 minutes30 minutes

Placenta deliveryPlacenta delivery

Care of the NeonateCare of the Neonate

Apgar Scoring System

0 1 2

AppearancePale Blue Pink

Pulse Absent 100

Grimace Absent Grimace Cry Active

Activity Limp Some tone Active

Respiration Absent Irregular Reg & Cry

ConclusionsConclusions

You will be able to:You will be able to: Diagnose labor and define the stagesDiagnose labor and define the stages Assess a laboring patientAssess a laboring patient Diagnose abnormal laborDiagnose abnormal labor Understand the cardinal movements of laborUnderstand the cardinal movements of labor Deliver a babyDeliver a baby Understand complications of laborUnderstand complications of labor

Thank you!Thank you!

Any questions?Any questions?

Normal and Abnormal Labor and DeliveryObjectivesWhat is Labor?What is Labor like?What is cervical change?Dilation/ Effacement/StationFetal StationBishops ScoreFalse Labor is different!Taking a Labor History and PhysicalAssessing laborStages of LaborFriedman Curve 1978Slide Number 14Slide Number 15Assessing laborPOWER! IUPCThe Pelvis = PassageClinical PelvimetrySlide Number 21Bi-ischial DiameterCalwell-Moloy Classification Pelvic TypesGynecoid PelvisAndroid PelvisAnthropoid PelvisPlatypelloid PelvisDont forget about the Passenger!Leopolds maneuversDefinitionsCephalic Presentation and AttitudeBreech PresentationLieSlide Number 34PositionDetermining PositionSynclitismCaput and moldingAbnormal LaborMaximum Dilation: 10!Cardinal Movement of LaborEngagementFlexion during descentSlide Number 44Slide Number 45Our job in the delivery roomDelivery ComplicationsPerineal LacerationsEpisiotomy?Shoulder DystociaShoulder DystociaShoulder Dystocia ManeuversSlide Number 53Babys out!Delivery of the PlacentaPlacenta deliveryCare of the NeonateConclusionsThank you!