Block VI Module I Case 2

The Storm and the Aftermath

1. Describe the management of the second stage of labor

1.1 Identify definitions and descriptions of the second stage of labor
Definition: Stage from full cervical dilatation until complete delivery of the baby
Delivery and descent of the baby is aided by maternal abdominal efforts
Duration: maximum of 2 hours

1.2 Identify definitions of descent & station of the presenting part

Descent is the first requisite of birth brought about by any one or more of the following forces
Pressure of the amniotic fluid
Direct pressure of the uterine fundus upon the breech with contractions
Bearing down efforts with the abdominal muscles
Extensions and straightening of the fetal body

It ultimately results to downward progress of the fetal presenting part until it reaches the pelvic floor.

Station is the level of the fetal presenting part in the birth canal in relation to the ischial spines which are halfway between
the pelvic inlet and outlet. When the lowermost portion is located at the level of the ischial spines, it is designated as station
0.

1.3 Give the average duration in a primipara & multipara

Primi: 50 minutes
Multi: 20 minutes

1.4 Cite factors influencing the 2nd stage

Fetal factors: Malpresentation, Malrotation, FPD
Maternal factors: Expulsive efforts, Contraction characteristics, conduction analgesia, CPD

1.5 Describe fetal monitoring in the 2nd stage of labor

Frequency of monitoring: after every contraction
FH Rate: 110-160 bpm

2. Describe maternal expulsive efforts at delivery

Position: Dorsal lithotomy, this position is said to cause and upward mobility of the sacroiliac joint, thereby promoting an
increase in diameter of the outlet by 1.5 to 2 cm(p. 55, Williams); the use of birthing chair does not offer any advantage
(p.435 Williams)
Breathing: Encourage mother to take and hold a deep breath prior to bearing down

3. Identify the cardinal movement of labor in occiput presentation

Engagement, descent, flexion, internal rotation, Extension, External rotation, Expulsion ( EDFIEE)
Describe the preparation for delivery
a. Place patient in dorsal lithotomy position
b. Asepsis and antisepsis with draping
c. Let mother bear down together with each uterine contraction and check FHT after each bearing down
d. When fetal is 2-3 cm visible in the introitus, episiotomy is done when indicated

4. Describe the management of spontaneous delivery:

4.1 Delivery of the head
The perineum is supported using one hand with a towel and the other hand tries to keep the head flexed to control
the delivery of the baby (Ritgens Maneuver)
Eternally rotate the fetal head to the transverse position

4.2 Delivery of the shoulders

Delivered in the AP diameter of the pelvis. Anterior shoulder delivered by gentle downward traction followed by
upward traction to deliver the posterior shoulder. The rest of the baby follows.

4.3 Clearing the nasopharynx: suctioning the secretions using a suction bulb

4.4 Management of the Nuchal cord

If loose, gently slide it along the fetal body
If light, Doubly clamp it then cut

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 4.5 Clamping of the cord: Done after delivery of the baby and clearing the airways; cord is doubly clamped, cut between
clamps

4.6 Determination of the APGAR score (p387 Williams)

Apgar scores are useful in assessing the condition of the infant at birth
Scoring:
Time: Parameters are scored at birth, 5 minutes, 10 minutes
Scores per parameter: rated as 0, 1, 2
Score of 7-10 Normal
Interpretation
Apgar score at 5 minutes is a useful index of the effectiveness of resuscitation efforts( Particularly the change in
score at 1&5 minutes
Low scores do not indicate the severity of problems nor correlate with neurological outcome
Should not be considered evidence of or consequence of substantial asphyxia

Parameter 0 1 2
Appearance (color) Blue, Pale Body pink, Extremities Blue Completely Pink
Pulse (HEART) RATE Absent Below 100 Above 100
Grimace (reflex, irritability) No response Grimace Vigorous response
Activity (Muscle Tone) Flaccid Some flexion of extremities Active Recoil
Respiratory effort Absent Slow Irregular Good crying

4.7 Discuss Episiotomy

4.7.1 State the purpose of episiotomy, cite advantage/disadvantage of its use (p. 326)
Incision done over the perineum to facilitate delivery of the head
Reduces anterior perineal trauma
Data shows that there is increased incidence of anal sphincter fecal and flatus incontinence in women who had
episiotomy vs those without

4.7.2 Identify the timing of episiotomy

When the fetal scalp is 2-3 cm visible in the introitus without bearing down
If done too early increase in blood loss, if done too late will not prevent lacerations

4.7.3 Identify the 2 types of episiotomy cite advantages/ disadvantages (p.326)

Median: easier to repair, less dyspareunia, less pain, less, blood loss, better anatomical results more 3 rd & 4th
degree extension
Mediolateral (right or Left) begins in the midline but is directed away from the rectum, more difficult to repair,
more pain, more blood loss, more faulty anatomical results, less extensions

4.7.4 Describe the timing & technique of repair

Repaired in layers with hemostasis and anatomical restoration without excessive suturing
Timing after delivery of the placenta

4.7.5 Identify the muscles involve in episiotomy, the blood supply & nerve supply
Superficial transverse perineal muscles
Levator ani muscles
Blood supply internal pudendal artery and its branches
Innervation: pudendal nerve and its branches (S2-S4)

5. Identify definitions of describe precipitate labor and delivery. Give its effect and treatment
Definition: Expulsion of baby from onset of labor to delivery less than 3 hours
Maternal Effects: Genital and cervical lacerations, uterine hypotonia or atony, amniotic fluid embolism
Fetal Effect: higher perinatal morbidity and mortality due to fetal hypoxia
Treatment of precipitate labor discontinue oxytocin immediately if being used

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 TRIGGER 2
1. Describe the management of the third stage of labor
1.1 Define 3rd stage of labor
Time from delivery of the baby to the delivery of the placenta
Duration average: 6 minutes

1.2 Cite 4 signs of placental separation

Uterus becomes globular
Sudden gushing of blood
Uterus rises in the abdomen
Cord lengthens

1.3 Describe delivery of the placenta

If signs of placental separation have appeared expression of the placenta should be attempted by manual
fundal pressure, umbilical cord is kept taut. Uterus is lifted cephalad, maneuver repeated until placenta appears
at introitus whereupon it is then gently lifted away; care is taken that the membranes are not torn off and left
behind
Danger traction on the umbilical cord to pull out the placenta may lead to uterine inversion
Duncan: dirty side appears first( Maternal Side); blood from placenta usually escapes immediately into vagina
Schultze; Shiny side presents first ( Fetal Side), blood from placenta usually concealed until placenta is delivered

1.4 Describe & Demonstrate manual removal of the placenta

There should be adequate anesthesia or analgesia
Aseptic surgical technique
After grasping the uterine fundus through the abdominal wall with one hand, the other hand is introduced into
the vagina and passed into the uterus, along the umbilical cord. The margin of the placenta is located, then the
ulnar border of the hand is insinuated between the placental margin and the uterine wall; placenta is peeled off
its uterine attachment by a motion similar to that employed in separating the leaves of a book. After its complete
separation, the placenta is grasped with the entire hand, then gradually withdrawn. Membranes are removed
at the same time
After delivery of the placenta, fundal massage is done; if the uterus is not well contracted, uterotonics may be
given

1.5 Describe active management of the third stage

Administration of uterotonics during the third stage of labor to promote uterine contraction and aid in placental
separation; this results in reduction of duration of 3rd stage

2. Identify definitions of & describe the management of the fourth stage of labor
2.1 Definition of the 4th stage
The hour immediately following the delivery of the placenta
Significance: monitoring of vital signs, amount of bleeding, to detect any hemorrhage from the uterus or vagina

2.1.1 Normal blood loss in delivery:

o Vaginal: 500 cc
o CS: 1000 cc

2.2 State the complications of the 4th stage

2.2.1 Immediate postpartum hemorrhage
i. Placental retention
ii. Uterine atony: failure of the uterus to contract following delivery
Incidence increased with: overdistended uterus (large babies, multiple fetuses), high parity, oxytocin
stimulation, prolonged labor
iii. Vulvar hematomas
iv. Uterine inversion
v. Lacerations of birth canal
Inspection of cervix, vagina, perineum for tears
Suture lacerations, ligate bleeders

3. Identify descriptions of types / degrees of lacerations

First degree laceration of the vaginal mucosa only
Second degree laceration of the vaginal mucosa, perineal muscles and fascia
Third degree Second degree plus rectal sphincter
Fourth degree third degree with rectal mucosal extension

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 3.1 Cite long-term sequelae of birth canal trauma
Fistula
Incontinence (urinary and fecal)
Prolapse
Dyspareunia

4. Identify the various uterotonic agents that may be used to diminish postpartum bleeding; cite
pharmacokinetics & pharmacodynamics
4.1 OXYTOCIN (Williams p. 475; Goodman & Gillman p.1558)
Endogenous source: hypothalamus
Onset of action: 3-5 minutes
Half-life: 5 minutes
Renal clearance
Administration: incorporated with IV fluid / IM
Action:
- Stimulates both force and frequency of uterine contractions in the last half of pregnancy,
- Also plays a role in milk ejection by causing contraction of myoepithelial cells surrounding areolar channels
in the mammary gland, forcing milk in alveolar channels into large collecting sinuses
Toxicity:
- Structurally similar to vasopressin, also has antidiuretic effect in high doses may lead to water intoxication if
infused with large volume of aqueous fluids, leading to convulsions, coma, death
- IV bolus may cause cardiac arrhythmias or hypotension

4.2 ERGONOVINE / METHYLERGONOVINE

Source: product of fungus that grows on rye & other grains
Absorption, fate, excretion:
- Metabolized by liver, excreted in bile
- Rapidly absorbed orally
- Onset of action: uterotonic effects seen within 10 minutes after oral administration
Action: increases motor activity of uterus; in high doses, contractions are sustained forceful
- Used primarily postpartum to prevent hemorrhage and not for induction of labor
Duration of action: Half-life 0.5 to 2 hours, peak concentration in 60-90 minutes
Administration: IV, IM, PO
Toxicity: hypertension due to vasoconstriction, fetal distress, miscarriage (if given to pregnant women)

4.3 PROSTAGLANDINS: PGF2a , PGE2
Action: dose dependent increase in uterine tone as well as frequency & intensity of rhythmic uterine contraction
- Used to induce labor at midtrimester (for molar pregnancies, missed abortion; facilitates labor at term by
promoting ripening and dilatation of the cervix
Onset of action: immediate
Duration of action: 90 minutes
Half-life: 15 minutes
Administration: IM (PGF2a) oral, rectal (PGE2)
Toxicity: diarrhea, hypertension, vomiting, fever, tachycardia;
- Adverse effect: abortifacient

5. Define & describe the puerperium.

Period extending from after delivery of the placenta until about 6 weeks after. During this period, maternal adaptations of
pregnancy are reversed and maternal status returns to its normal, non-pregnant state.

5.1 Describe the puerperium as to:

5.1.1. Uterine changes: normal & abnormal
Regeneration and involution of placental site and return of uterine size to normal. Regeneration of the
endometrium from the remaining deciduas.

5.1.2. Breast changes:

Anatomic changes in pregnancy & lactation
Breasts hypertrophy due to milk production
Physiology of lactation
Hormones involved in milk production/ejection
Oxytocin, prolactin
Describe the milk ejection reflex
Repetitive infant suckling produces a stimulus which curtails the release of a prolactin-inhibiting
factor from the hypothalamus
So there is a transient increase in the secretion of prolactin from the pituitary. Suckling also
stimulates the neurohypophysis to liberate oxytocin ejection of milk from the milk ducts.

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 Review: components of colostrums
High protein and mineral content, less sugar, larger fat globules, rich in IgA antibodies, which
protect against enteric bacteria like E. coli (the breast-fed infant is less susceptible to enteric
infections than bottle-fed infants). Colostrum is gradually converted to mature milk.

5.1.3. Menstruation and ovulation

If the woman does not nurse her child, menses usually return after 6 8 weeks (55-60 days). For the woman
who nurses her child, ovulation is greatly varied. Usually it depends on the duration and frequency of breast
feeding.

5.2 Define and describe puerperal abnormalities & state management

Puerperal morbidity / fever. a temperature of 38 degrees or higher on any two of the first ten days postpartum,
exclusive of the first 24 hours and to be taken by mouth by standard technique, at least 4x a day.
Causes:

5.2.1 Infections
Mastitis
- Definition: Parenchymatous infection of the mammary glands
- Sns/sx: Breast pain, swelling, tenderness and redness. Predominant organism is Staph. aureus.
- Treatment: antibiotics vs. GM (+) cocci, analgesics

Urinary tract infection

- Dysuria, urinary frequency, bacteriuria, pyuria. Predominant organism is E.coli

Pelvic infections
- Endometritis, metritis, Endomyometritis, parametritis, salpingitis, oophoritis.
- Sns/sx: Pelvic pain, fever, bleeding
- Predominant organisms are a mixture of aerobic and anaerobic bacteria of the vagina and rectum

5.2.2 Bleeding
Late post-partum bleeding / hemorrhage = Increased vaginal bleeding after the first 24 hours of delivery.
Causes:
a. Subinvolution of placental site
- Definition: Failure of the placental implantation site to involute; arrest of process by which
uterus returns to prepregnant state
- Sns/sx: Prolongation of lochial discharge, occ. hemorrhage may occur;
- Pelvic exam: uterus larger and softer than normal for particular period in the puerperium.
- May be due to: retained placental fragment , infection (metritis)
- Management: Antibiotics, uterotonics, curettage

b. Retained placental fragments

- Failure of complete expulsion or separation of the placenta
- Management: Antibiotics, uterotonics, curettage

c. Endometritis
- Infection of the endometrium
- Management: Antibiotics (broad spectrum), uterotonics

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