Labor and Delivery

CAPT Mike Hughey, MC, USNR

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 1

Labor
Regular, frequent, leading to progressive cervical effacement and dilatation Braxton-Hicks contractions
May be painful and regular, but usually are not Do not lead to cervical change

Labor diagnosis usually made in retrospect. Cause of labor is unknown

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000 Slide 2

Latent Phase Labor

<4 cm dilated Contractions may or may not be painful Dilate very slowly Can talk or laugh through contractions May last days or longer May be treated with sedation, hydration, ambulation, rest, or pitocin
Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000 Slide 3

Active Phase Labor

At least 4 cm dilated Regular, frequent, usually painful contractions Dilate at least 1.2-1.5 cm/hr Are not comfortable with talking or laughing during their contractions

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 4

Progress of Labor
Lasts about 12-14 hours (first baby) Lasts about 6-8 hours (subsequent babies) Considerable variation. Effacement (thinning) Dilatation (opening) Descent (progress through the birth canal)
Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000 Slide 5

Descent
Fetal head descends through the birth canal Defined relative to the ischial spines 0 station = top of head at the spines (fully engaged) +2 station = 2 cm past (below) the ischial spines

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

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Cardinal Movements of Labor

Engagement (0 Station) Descent Flexion (fetal head flexed against the chest) Internal rotation (fetal head rotates from transverse to anterior Extension (head extends with crowning) External rotation (head returns to its transverse orientation) Expulsion (shoulders and torso of the baby are delivered)

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 7

Watch a Delivery

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 8

Placental Separation
Signs of separation:
Increased bleeding Lengthening of the cord Uterus rises, becoming globular instead of discoid Uterus enlarges, approaching the umbilicus

Normally separates within a few minutes after delivery

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

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Initial Labor Management

Risk assessment Contractions: frequency, duration, onset Membranes: Ruptured, intact Status of cervix: dilatation, effacement, station Position of the fetus: vertex, transverse lie, breech Fetal status: fetal heart rate, EFM

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 10

Cervix
Dilatation: How far has the cervix opened (in cm) Effacement: How thin is the cervix (in cm or %)

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

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Status of Membranes
Nitrazine paper turns blue in the presence of alkaline amniotic fluid (nitrazine positive) Vaginal secretions are nitrazine negative (yellow) because of their acidity Pooling of amniotic fluid in the vaginal vault is a reliable sign
Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000 Slide 12

Orientation of Fetus
Vertex, breech or transverse lie Palpate vaginally Leopolds Maneuvers

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 13

Management of Early Labor

Ambulation OK with intact membranes If in bed, lie on one side or the othernot flat on her back Check vital signs every 4 hours NPO except ice chips or small sips of water

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 14

Monitor the Fetal Heart

During early labor, for low risk patients, note the fetal heart rate every 1-2 hours. During active labor, evaluate the fetal heart every 30 minutes Normal FHR is 120-160 BPM Persistent tachycardia (>160) or bradycardia (<120, particularly <100) is of concern

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 15

Electronic Fetal Monitors

Continuously records the instantaneous fetal heart rate and uterine contractions Patterns are of clinical significance. Use in high-risk patients. Use in low-risk patients optional
Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000 Slide 16

Normal Patterns
Normal rate Short term variability (3-5 BPM) Long term variability (15 BPM above baseline, lasting 10-20 seconds or longer) Contractions every 2-3 minutes, lasting about 60 seconds
Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000 Slide 17

Tachycardia

>160 BPM Most are not suggestive of fetal jeopardy Associated with:
Fever, Chorioamnionitis Maternal hypothyroidism Drugs (tocolytics, etc.) Fetal hypoxia Fetal anemia Fetal arrythmia
Slide 18

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Bradycardia
Sustained <120 BPM Most are caused by increased in vagal tone Mild bradycardia (80-90) with retention of variability is common during 2nd stage of labor <80 BPM with loss of BTBV may indicate fetal distress
Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000 Slide 19

Late Decelerations
Repetive, nonremediable slowings of the fetal heartbeat toward the end of the contraction cycle Reflect utero-placental insufficiency

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 20

Early Decelerations
Periodic slowing of the FHR, synchronized with contractions Rarely more than 20-30 BPM below the baseline Innocent Associated with fetal head compression

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 21

Variable Decelerations
Variable in onset, duration and depth May occur with contractions or between them Sudden onset/recovery Increased vagal tone, usually due to some degree of cord compression
Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000 Slide 22

Severe Variable Decelerations

Below 60 BPM for at least 60 seconds If persistent, can be threatening to fetal well-being, with progressive acidosis

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 23

Prolonged Decelerations
Last > 60 seconds Occur in isolation Associated with:
Maternal hypotension Epidural Paracervical block Tetanic contractions Umbilical cord prolapse

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

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Pain Relief
Narcotics Continuous Lumbar Epidural Paracervical Block 50/50 nitrous/oxygen Psychoprophylaxis (Lamaze breathing) Hypnosis

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

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Anesthesia During Delivery

Local Pudendal Block Epidural Caudal Spinal 50/50 nitrous/oxygen

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

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Episiotomy
Avoids lacerations Provides more room for obstetrical maneuvers Shortens the 2nd Stage Labor Midline associated with greater risk of rectal lacerations, but heals faster Many women dont need them.
Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000 Slide 27

Clamp and Cut the Cord

Clamp about an inch from the babys abdomen Use any available instruments or usable material Check the cord for 3-vessels, 2 small arteries and one larger vein

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

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Inspect the Placenta

Make sure it is complete Look for missing pieces Look for malformations Look for areas of adherent blood clot

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

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Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

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