Labor dystocia

Mechanisms andMechanisms and
Management of LaborManagement of Labor
Nancy Goodwine Wozniak, MDNancy Goodwine Wozniak, MD

Definition of LaborDefinition of Labor
 Labor is the physiologic process by which the fetus isLabor is the physiologic process by which the fetus is
expelled from the uterus to the outside worldexpelled from the uterus to the outside world
 Could also be described as the transition fromCould also be described as the transition from
“contractures” to “contractions”“contractures” to “contractions”
 Bottom line defination: Contractions with cervicalBottom line defination: Contractions with cervical
change. The diagnosis is a clinical one.change. The diagnosis is a clinical one.
Gabbe: Obstetrics Normal and Problem pregnancies 4Gabbe: Obstetrics Normal and Problem pregnancies 4thth
editionedition

Full term pregnancy is 280 days (40 weeks)Full term pregnancy is 280 days (40 weeks)
or 36 completed weeks.or 36 completed weeks.
Post term pregnancy is beyond 42 weeksPost term pregnancy is beyond 42 weeks
SROM is seen in about 8% of patientsSROM is seen in about 8% of patients

Labor PhysiologyLabor Physiology
Labor is contractions with cervical changeLabor is contractions with cervical change
The fetus is in control of the timing of laborThe fetus is in control of the timing of labor
The factors responsible for initiating labor are not well-defined…likely anThe factors responsible for initiating labor are not well-defined…likely an
autocrine and/or paracrine event.autocrine and/or paracrine event.
We do know there is some endocrine maternal/fetal cross talk (eg horses andWe do know there is some endocrine maternal/fetal cross talk (eg horses and
donkeys indicate that fetal genotype is a factor—365 vs 340 days)donkeys indicate that fetal genotype is a factor—365 vs 340 days)
editionedition

No matter what seems to initiate labor it involves regular uterineNo matter what seems to initiate labor it involves regular uterine
contractions, mediated through ATP-dependent binding of myosin tocontractions, mediated through ATP-dependent binding of myosin to
actin. Unlike vascular smooth muscle, myometrium has sparseactin. Unlike vascular smooth muscle, myometrium has sparse
innervation, thus regulation of contractions is hormonal.innervation, thus regulation of contractions is hormonal.
There is thought to be a parturition cascade. Ultimately, human laborThere is thought to be a parturition cascade. Ultimately, human labor
is a multifactorial physiologic process involving an integrated set ofis a multifactorial physiologic process involving an integrated set of
changes that occur gradually over days to weeks. Changes includechanges that occur gradually over days to weeks. Changes include
prostaglandin synthesis and release within the uterus, an increaseprostaglandin synthesis and release within the uterus, an increase
in myometrial gap junction formation, and up-regulation ofin myometrial gap junction formation, and up-regulation of
myometrial oxytocin receptors. At some point labor begins with themyometrial oxytocin receptors. At some point labor begins with the
activation of the fetal-hypothalamic-pituitary adrenal axis in a wayactivation of the fetal-hypothalamic-pituitary adrenal axis in a way
likely common to all species.likely common to all species.
editionedition

The regulation of uterine activity can be divided into 4The regulation of uterine activity can be divided into 4
physiologic phasesphysiologic phases
Phase 0: uterus is quiet due to progesterone, relaxin,Phase 0: uterus is quiet due to progesterone, relaxin,
prostacyclin Iprostacyclin I22 (PGI(PGI22), parathyroid hormone), parathyroid hormone
Phase 1: before termPhase 1: before term “activation” phase- uterus is more“activation” phase- uterus is more
responsive to estrogen and more receptors for oxytocin andresponsive to estrogen and more receptors for oxytocin and
prostaglandinsprostaglandins
Phase 2: uterus more stimulated because of increase in gapPhase 2: uterus more stimulated because of increase in gap
junctions so that it can be stimulated by oxytocins andjunctions so that it can be stimulated by oxytocins and
prostaglandins (PGEprostaglandins (PGE22 and PGFand PGF2 alpha2 alpha))
Phase 3: involution of the uterus (mediated by oxytocin)Phase 3: involution of the uterus (mediated by oxytocin)
editionedition

Labor MechanicsLabor Mechanics
For a successful vaginal delivery, the fetusFor a successful vaginal delivery, the fetus
must negotiate the maternal pelvis.must negotiate the maternal pelvis.
Three factors: the power, the passage, andThree factors: the power, the passage, and
the passenger.the passenger.

 The passengerThe passenger
Estimating fetal size: ultrasound, leopolds, what doesEstimating fetal size: ultrasound, leopolds, what does
mom think?mom think?
How big is too big? Definition of macrosomia isHow big is too big? Definition of macrosomia is
diabetics: 4500g non-diabetics: 5000gdiabetics: 4500g non-diabetics: 5000g

 PowerPower
Assessing amplitude, duration, and intensity of ctxAssessing amplitude, duration, and intensity of ctx
internal IUPC vs external tocointernal IUPC vs external toco
WhatWhat’s adequate contractions? (ultimately it is a clinical dx)’s adequate contractions? (ultimately it is a clinical dx)
3-5 ctx in 10 min3-5 ctx in 10 min
7 ctx in 15 min7 ctx in 15 min
250 MVU250 MVU’s – the average strength of ctx in mm Hg multiplied by’s – the average strength of ctx in mm Hg multiplied by
the number of contractions in 10 minutes. No real data supportthe number of contractions in 10 minutes. No real data support
an absolute number of ctx or MVU’s to be adequate…adequacyan absolute number of ctx or MVU’s to be adequate…adequacy
is still a clinical determination.is still a clinical determination.
If ctx are adequate either the cervix will dilate or the caput willIf ctx are adequate either the cervix will dilate or the caput will
become worse.become worse.

 The most precise way of determining uterineThe most precise way of determining uterine
contractions are adequate is with internalcontractions are adequate is with internal
monitoring by IUPCmonitoring by IUPC
 External monitoring measures the change inExternal monitoring measures the change in
shape of the abdominal wall relative toshape of the abdominal wall relative to
contractions thus is qualitative rather thancontractions thus is qualitative rather than
quantitative. Does allow for accurate correlationquantitative. Does allow for accurate correlation
between fetal heart rate and contraction pattern .between fetal heart rate and contraction pattern .

The PassengerThe Passenger
The passenger is the fetus. Fetal size can influence laborThe passenger is the fetus. Fetal size can influence labor
Can be assessed by LeopoldCan be assessed by Leopold’s, US or both. ( Mom’s’s, US or both. ( Mom’s
opinion counts, too!)opinion counts, too!)
ACOG definition of Macrosomia is defined as >4500 gACOG definition of Macrosomia is defined as >4500 g

Fetal lie: Fetal position relative to the maternal spine.Fetal lie: Fetal position relative to the maternal spine. longitudinal, oblique, transverselongitudinal, oblique, transverse
Presentation: refers to the fetal part that is above the pelvic inlet. (eg a fetus can have a logitudinalPresentation: refers to the fetal part that is above the pelvic inlet. (eg a fetus can have a logitudinal
lie but be breech or cephalic)lie but be breech or cephalic)
Attitude: refers to position of fetal head relative to the fetal spineAttitude: refers to position of fetal head relative to the fetal spine
Position: referes to the relationship of a nominated site of the presenting part to a denomintatingPosition: referes to the relationship of a nominated site of the presenting part to a denomintating
location in the internal pelvis. Eg. Occiput/sacrum ROA, RSAlocation in the internal pelvis. Eg. Occiput/sacrum ROA, RSA
Station: a measure of descent of the presenting part.Station: a measure of descent of the presenting part.
Abnormalilty of any of these variables can influence whether or not to proceed with a vaginal delivery.Abnormalilty of any of these variables can influence whether or not to proceed with a vaginal delivery.

Fetal presentation: Fetal part directly over the pelvicFetal presentation: Fetal part directly over the pelvic inlet;inlet;
eg breech, cephalic, compound, funiceg breech, cephalic, compound, funic

Malpresentation is any presentation that isMalpresentation is any presentation that is
not cephalic with occiput leading. (aboutnot cephalic with occiput leading. (about
5%) Multifetal pregnancies increase the5%) Multifetal pregnancies increase the
risk of malpresetnationrisk of malpresetnation

The cephalic presentation can be classified byThe cephalic presentation can be classified by
boney landmarks of the skull; eg occiput , mentum,boney landmarks of the skull; eg occiput , mentum,
browbrow
passengerpassengerpasengerpasenger

A: Right occiput anterior (ROA); B: Left occiput anterior (LOA); C: Occiput anterior
(OA).
* Posterior fontanel. This is the smaller of the two fontanels and is at the
intersection of the three sutures: the sagittal suture and two lambdoid sutures.
** Anterior fontanel. This large fontanel is at the intersection of four sutures: the
sagittal, frontal, and two coronal sutures.
From UpToDate.com

 Occiput posteriorOcciput posterior
From UpToDate.com

Occiput transverseOcciput transverse
From UpToDate.comFrom UpToDate.com

Station: measure of descent of the presenting partStation: measure of descent of the presenting part
through the birth canal relative to ischial spinesthrough the birth canal relative to ischial spines
this is the relationship between the leading bony part of fetalthis is the relationship between the leading bony part of fetal
presenting part ( skull bone NOT scalp) and the maternal ischial spines.presenting part ( skull bone NOT scalp) and the maternal ischial spines.
Must take into account molding and caput succedaneum (not doing soMust take into account molding and caput succedaneum (not doing so
is a common error)is a common error)
Often described as -3 to + 3Often described as -3 to + 3
Newer scale is -5 to +5Newer scale is -5 to +5

Nucleus medical art.Nucleus medical art.
Nucleusinc.comNucleusinc.com

 The PassageThe Passage
The passage consists of the bony pelvis (sacrum, ilium, ischium, pubis)The passage consists of the bony pelvis (sacrum, ilium, ischium, pubis)
and the resistance provided by the soft tissues.and the resistance provided by the soft tissues.
Bony pelvis is divided into the greater (false) and lesser(true) pelvis byBony pelvis is divided into the greater (false) and lesser(true) pelvis by
the pelvic brim which is demarcated by the sacral promontory.the pelvic brim which is demarcated by the sacral promontory.
The diagonal conjugate is the distance from the sacral promontory toThe diagonal conjugate is the distance from the sacral promontory to
the inferior margin of the symphysis pubis as assessed onthe inferior margin of the symphysis pubis as assessed on
examination ( see next slide )examination ( see next slide )
Clinical pelvimetry is the only way to assess the dimensions of theClinical pelvimetry is the only way to assess the dimensions of the
pelvis in labor.pelvis in labor.

To figure out the true conjugate, measure the diagonalTo figure out the true conjugate, measure the diagonal
conjugate and subtract 1.5 – 2cm. The limiting factor is theconjugate and subtract 1.5 – 2cm. The limiting factor is the
interspinous diameter.interspinous diameter.

Bony pelvis—most favorable is gynecoid and antropoidBony pelvis—most favorable is gynecoid and antropoid

A little bit about cervical ripening…A little bit about cervical ripening…
 When induction is attempted against an unripe cervix the likelihoodWhen induction is attempted against an unripe cervix the likelihood
of succcess is reduced.of succcess is reduced.
Bishops score: dilatation, effacement, position, consistency, station.Bishops score: dilatation, effacement, position, consistency, station.
Total score is up to 13.Total score is up to 13.
BishopBishop’s = 8 chances of successful induction are the same as’s = 8 chances of successful induction are the same as
spontaneous laborspontaneous labor
BishopBishop’s = 6 “favorable cervix”’s = 6 “favorable cervix”

(A) Cervix is uneffaced and minimally dilated. (B) Cervix is almost completely(A) Cervix is uneffaced and minimally dilated. (B) Cervix is almost completely
effaced and dilated.effaced and dilated. From UpToDate.comFrom UpToDate.com

Methods of cervical ripeningMethods of cervical ripening
Non Pharmacologic methods:Non Pharmacologic methods:
membrane stripping – digital separation of chorionic and amniotic membranes frommembrane stripping – digital separation of chorionic and amniotic membranes from
the cervix. Releases endogenous prostaglandins from the decidua and adjacentthe cervix. Releases endogenous prostaglandins from the decidua and adjacent
membranes.membranes.
May also causeMay also cause “Ferguson reflex” stimulating release of oxytocin from the pituitary.“Ferguson reflex” stimulating release of oxytocin from the pituitary.
Foley bulbFoley bulb
Amniotomy – needs favorable cervix, but if cervix is favorable amniotomy by itself canAmniotomy – needs favorable cervix, but if cervix is favorable amniotomy by itself can
get labor started (better still when combined with Pitocin)get labor started (better still when combined with Pitocin)
risks:risks: cord prolapse, prolonged ROM, fetal injury, rupturecord prolapse, prolonged ROM, fetal injury, rupture
of vasa previa with fetal hemorrhage, fetal malposition andof vasa previa with fetal hemorrhage, fetal malposition and
asynclitismasynclitism
Benefits: FSE placement, can determine if MSF or blood, high successBenefits: FSE placement, can determine if MSF or blood, high success
in inducing laborin inducing labor

Methods of cervical ripeningMethods of cervical ripening
 Pharmacologic methodsPharmacologic methods
Dinoprostone (Prepadil and Cervadil) PGEDinoprostone (Prepadil and Cervadil) PGE22 , oxytocin,, oxytocin,
misoprostyl (cytotec) PGEmisoprostyl (cytotec) PGE11
The uterus has precursors of the prostaglandin of the 2The uterus has precursors of the prostaglandin of the 2
series.series. PGEPGE22 : important for cervical maturation: important for cervical maturation
PGFPGF 22 alpha. : causes myometrialalpha. : causes myometrial
contractionscontractions

Stages of LaborStages of Labor
 First stage: Onset of labor to full dilatationFirst stage: Onset of labor to full dilatation
latent phase- onset of labor until cervix starts to makelatent phase- onset of labor until cervix starts to make
change.change.
active phase-greater rate of cervical changeactive phase-greater rate of cervical change
1.2 cm/h for nulliparous1.2 cm/h for nulliparous
1.5 cm/h for multiparous1.5 cm/h for multiparous
Second stage: full dilation to deliverySecond stage: full dilation to delivery
Length of Pushing: nullip: 2h without epidural, 3 hLength of Pushing: nullip: 2h without epidural, 3 h
with epiduralwith epidural
multip: 1 h without epidural,multip: 1 h without epidural,
2 h with epidural2 h with epidural
Third stage: delivery of placenta-can take up to 30 minutesThird stage: delivery of placenta-can take up to 30 minutes

Cardinal movements of laborCardinal movements of labor
Engagement:Engagement: passage of the widest diameter of the presenting part topassage of the widest diameter of the presenting part to
a level below the plane of the pelvic inlet. In cephalic fetus, thea level below the plane of the pelvic inlet. In cephalic fetus, the
largest diameter is the biparietal diameter (9.5 cm); in a breech fetuslargest diameter is the biparietal diameter (9.5 cm); in a breech fetus
the widest diameter is the bitrochanteric diameter. The presentingthe widest diameter is the bitrochanteric diameter. The presenting
part is engaged if you can feel presenting part both abdominally andpart is engaged if you can feel presenting part both abdominally and
vaginally.vaginally.
Descent:Descent: downward passage of the presenting partdownward passage of the presenting part
Flexion:Flexion: occurs passively d/t boney maternal pelvisoccurs passively d/t boney maternal pelvis
Internal rotation: refers to rotation of presenting part from its originalInternal rotation: refers to rotation of presenting part from its original
position (usually transverse) to the AP positionposition (usually transverse) to the AP position
Extension:Extension: Occurs once the fetus has descended to the introitusOccurs once the fetus has descended to the introitus
External rotationExternal rotation (aka restitution) return of the fetal head to the correct(aka restitution) return of the fetal head to the correct
anatomic position in relation to the fetal torso.anatomic position in relation to the fetal torso.
Expulsion:Expulsion: delivery of the rest of the fetus.delivery of the rest of the fetus.

Management of Normal Labor and DeliveryManagement of Normal Labor and Delivery
 All women need adequate surveillance throughout laborAll women need adequate surveillance throughout labor
and delivery.and delivery.
 Okay to let women walk (doesnOkay to let women walk (doesn’t shorten course of labor, the’t shorten course of labor, the
need for augmentation, the use of analgesia, or the rate of C/S)need for augmentation, the use of analgesia, or the rate of C/S)
 Record FHTRecord FHT’s q 30 minutes (minimum)’s q 30 minutes (minimum)
 During second stage, FHTDuring second stage, FHT’s should be recorded q 15 and after’s should be recorded q 15 and after
each contractioneach contraction

Augmentation of Labor at TermAugmentation of Labor at Term
Abnormalities of the first stage of labor may be either protraction or arrestAbnormalities of the first stage of labor may be either protraction or arrest
disorders and can occur during active or latent phases of labor.disorders and can occur during active or latent phases of labor.
--Administer Pitocin as long as no malpresentation.--Administer Pitocin as long as no malpresentation.
Goal is ctx q 2-3 min lasting 60-90 seconds. Resting tone should beGoal is ctx q 2-3 min lasting 60-90 seconds. Resting tone should be
10-15 mm Hg if IUPC is used.10-15 mm Hg if IUPC is used.
--Takes 30 to 40 minutes to see full effect of Pitocin dose--Takes 30 to 40 minutes to see full effect of Pitocin dose
--A slow rate of pitocin increase is as effective as a fast rate.--A slow rate of pitocin increase is as effective as a fast rate.
--Whether to add pitocin to a patient who is already adequately contracting--Whether to add pitocin to a patient who is already adequately contracting
is controversial, but 80% of patients will respond to pitocinis controversial, but 80% of patients will respond to pitocin

Augmentation of Labor at TermAugmentation of Labor at Term
 Advantages:Advantages:
Oxytocin is cheap, and well known to usOxytocin is cheap, and well known to us
Short tShort t1/21/2
Complications:Complications:
uterine hyperstimulation (tachysystole)uterine hyperstimulation (tachysystole)
increased uterine tone (hypertonia)increased uterine tone (hypertonia)
water intoxication (at doses of 30-40 miu since itwater intoxication (at doses of 30-40 miu since it’s a vasopressin’s a vasopressin
analogue)analogue)
hypotension (usually if pitocin is given as a bolus)hypotension (usually if pitocin is given as a bolus)
uterine rupture (associated withuterine rupture (associated with “excessive oxytocin”)“excessive oxytocin”)

Abnormal patterns of laborAbnormal patterns of labor
 ““Latent phase arrest”—means labor never beganLatent phase arrest”—means labor never began
 ““prolonged latent phase”—greater than 20h in nullipprolonged latent phase”—greater than 20h in nullip
---greater than 14h in multip---greater than 14h in multip
 Prolongation of latent phase is variable; doesnProlongation of latent phase is variable; doesn’t mean the fetus will’t mean the fetus will
have a bad outcome or that the patient needs a c/s. Can behave a bad outcome or that the patient needs a c/s. Can be
managed expectantly (presuming mom and baby other wise lookmanaged expectantly (presuming mom and baby other wise look
good)good)
Can administer analgesics (eg morphine 15-20 mg forCan administer analgesics (eg morphine 15-20 mg for
therapeutic rest)therapeutic rest)
Augmentation (Pitocin)Augmentation (Pitocin)
Defer amniotomy!Defer amniotomy!

Pitocin regimenPitocin regimen
RegimenRegimen Starting doseStarting dose IncrementalIncremental
increaseincrease
Dosage changeDosage change
interval ininterval in
minutesminutes
Low doseLow dose 0.5-1.0 mu0.5-1.0 mu 1 mu1 mu 30-40 minutes30-40 minutes
Alternative lowAlternative low
dosedose
1-2 mu1-2 mu 22 15 minutes15 minutes
High doseHigh dose 6 mu6 mu 6 mu6 mu
Max 40 muMax 40 mu
15 minutes15 minutes
Alternative highAlternative high
dosedose
4 mu4 mu 4 mu4 mu
Max 32 muMax 32 mu
15 minutes15 minutes

 Abnormalities of second stageAbnormalities of second stage
““Failure to Progress” “Arrest of dilatation”Failure to Progress” “Arrest of dilatation”
generally patient is falling off Friedmangenerally patient is falling off Friedman’s curve, or’s curve, or
no cervical change in 2 hoursno cervical change in 2 hours
Consider augmentation, placement of IUPCConsider augmentation, placement of IUPC

““Protraction of descent”Protraction of descent”
Descent of < 1 cm/h in nullipsDescent of < 1 cm/h in nullips
Descent of < 2 cm/h in multipsDescent of < 2 cm/h in multips
Deliveries complicated by prolonged second stage put the fetus atDeliveries complicated by prolonged second stage put the fetus at
risk of acidosis, thus, ACOG recommends intervention after 2 hrisk of acidosis, thus, ACOG recommends intervention after 2 h
without epidural, 3 h with epidural.without epidural, 3 h with epidural.
In reality, can consider expectant management if mother and fetusIn reality, can consider expectant management if mother and fetus
are otherwise reassuring, descent is progressive, and delivery isare otherwise reassuring, descent is progressive, and delivery is
imminent.imminent.

 ““Arrest of Descent”Arrest of Descent”
This requires an assessment of contractions,This requires an assessment of contractions,
maternal fetal well being, and CPDmaternal fetal well being, and CPD
Re-evaluate clinical pelvimetry, fetal station, caput.Re-evaluate clinical pelvimetry, fetal station, caput.
The decision to proceed with assisted vaginal delivery orThe decision to proceed with assisted vaginal delivery or
C/S should be individualizedC/S should be individualized

Do you really want to do that episiotomy??Do you really want to do that episiotomy??
 Episiotomy– the incision in the perineal body during the secondEpisiotomy– the incision in the perineal body during the second
stage of labor.stage of labor.
Indicated in 1) cases of arrested or protracted descentIndicated in 1) cases of arrested or protracted descent
2) expedite delivery in NRFHT2) expedite delivery in NRFHT’s’s
Median: performed when the fetal head is on the perineum.Median: performed when the fetal head is on the perineum.
Associated with occasional extensions to 3Associated with occasional extensions to 3rdrd
or 4or 4thth
degreedegree
Mediolateral: 45 degree angle from the hymenal ring. Does notMediolateral: 45 degree angle from the hymenal ring. Does not
increase risk of 3increase risk of 3rdrd
or 4or 4thth
degree extension. Procedure of choice indegree extension. Procedure of choice in
patients with inflammatory bowel disease. More pain post partum.patients with inflammatory bowel disease. More pain post partum.

EpisiotomyEpisiotomy
Fewer episiotomies are being performed…mostFewer episiotomies are being performed…most
repairs after a vaginal delivery are a result ofrepairs after a vaginal delivery are a result of
tears.tears.
Episiotomies (and lacerations) are graded on aEpisiotomies (and lacerations) are graded on a
scale of 1 to 4scale of 1 to 4

Episiotomy/LacerationsEpisiotomy/Lacerations
11stst
degree lacerations: involve the forchette, perineal skin,degree lacerations: involve the forchette, perineal skin,
and vaginal mucosaand vaginal mucosa
22ndnd
degree lacerations: above plus extend to the fascia anddegree lacerations: above plus extend to the fascia and
muscles of the perineal body but not to the analmuscles of the perineal body but not to the anal
sphinctersphincter
33rdrd
degree lacerations: skin, mucosa, perineal body anddegree lacerations: skin, mucosa, perineal body and
anal sphincteranal sphincter
44thth
degree: exposed lumen of the rectumdegree: exposed lumen of the rectum

Vaccuum DeliveriesVaccuum Deliveries

Vaccuum DeliveriesVaccuum Deliveries
 Vaccuums have been around since 1953Vaccuums have been around since 1953
 By 1970By 1970’s popular in Northern Europe’s popular in Northern Europe
 DidnDidn’t exceed number of forceps’t exceed number of forceps
deliveries in the U.S. until 1992deliveries in the U.S. until 1992

Fetal contraindications to a VaccuumFetal contraindications to a Vaccuum
1) < 34 weeks1) < 34 weeks
increases risk of intraventricular hemorhageincreases risk of intraventricular hemorhage
2) Fetal bleeding diathesis e.g., ITP,2) Fetal bleeding diathesis e.g., ITP,
hemophiliahemophilia
3) Multiple FSE attempts3) Multiple FSE attempts
4) CPD4) CPD

Vaccuum typesVaccuum types
Take a look at what we have!Take a look at what we have!
 Optimum type…who knowsOptimum type…who knows
 Can use any of them if noCan use any of them if no
contraindicationcontraindication
 In general…soft cups, more likely to fail but lessIn general…soft cups, more likely to fail but less
fetal scalp injury; rigid cups probably better forfetal scalp injury; rigid cups probably better for
OPOP

A Vaccuum does not require less clinicalA Vaccuum does not require less clinical
knowledge than forceps!knowledge than forceps!
 Must know fetal position, station, and takeMust know fetal position, station, and take
into account moldinginto account molding
 Must know contraindicationsMust know contraindications
Placement of cup now becomes flexion point.Placement of cup now becomes flexion point.
Unlike forceps which can be used to correct asynclitism, aUnlike forceps which can be used to correct asynclitism, a
vaccuum will impede delivery if cup not placed overvaccuum will impede delivery if cup not placed over
flexion point.flexion point.

Check list prior to instrumental deliveryCheck list prior to instrumental delivery
 Empty bladderEmpty bladder
 Dorsal lithotomy positionDorsal lithotomy position
 Adequate anesthesia ( a MUST forAdequate anesthesia ( a MUST for
forceps!)forceps!)
 Fetal position, station, EFWFetal position, station, EFW

Putting on the VacPutting on the Vac
Determine flexion point:Determine flexion point: basically flexion point isbasically flexion point is
the point where pulling is going to best allow flexion atthe point where pulling is going to best allow flexion at
the neck keeping the fetus OA.the neck keeping the fetus OA.
 Midline, over sagital suture, 6 cm from AnteriorMidline, over sagital suture, 6 cm from Anterior
fontanelle, 3 cm from posterior fontanelle.fontanelle, 3 cm from posterior fontanelle.
 Anterior fontanelle has to be your reference point.Anterior fontanelle has to be your reference point.
360 degree inspection360 degree inspection
Green zone to 450Green zone to 450

The instrumental delivery itselfThe instrumental delivery itself
 Pull along pelvic curve (down, then up)Pull along pelvic curve (down, then up)
 Let handle passively turn as fetus rotatesLet handle passively turn as fetus rotates
with deliverywith delivery
 Descent should occur with each pullDescent should occur with each pull
 No routine episiotomyNo routine episiotomy

How long is too long?How long is too long?
 No one knows maximal amount of timeNo one knows maximal amount of time
and maximal amount of pop-offs that isand maximal amount of pop-offs that is
acceptableacceptable
 Ideally less than 15 minutes, certainly less than 30Ideally less than 15 minutes, certainly less than 30
 Usually less than 3 pop-offs, less than 5 pullsUsually less than 3 pop-offs, less than 5 pulls

DocumentationDocumentation
IndicationsIndications
Were prerequisites metWere prerequisites met (full dilatation, empty(full dilatation, empty
bladder, no contraindications, gest. Age, station (+2/3 orbladder, no contraindications, gest. Age, station (+2/3 or
+2/5??)+2/5??)
Fetal status (station, position, FHTFetal status (station, position, FHT’s’s
Verbal consentVerbal consent
Detailed description of procedureDetailed description of procedure
Type of vaccuum, total time, reduced betweenType of vaccuum, total time, reduced between
contractions, # pulls, # ctx, # pop-offs, progress withcontractions, # pulls, # ctx, # pop-offs, progress with
each pull, epis or noteach pull, epis or not

Reasons instrumental deliveries failReasons instrumental deliveries fail
CPDCPD
Bad techniqueBad technique (eg pulling without contractions,(eg pulling without contractions,
upward pull before crowning: deflexed, paramedianupward pull before crowning: deflexed, paramedian
applicationapplication
Large CaputLarge Caput

Remember…No one thanks you for aRemember…No one thanks you for a
vaginal delivery unless its perfectvaginal delivery unless its perfect..

Shoulder dystociaShoulder dystocia

 www.shoulderdystociaattorney.comwww.shoulderdystociaattorney.com

If the anterior and posterior shoulders descend together instead of sequentially, theIf the anterior and posterior shoulders descend together instead of sequentially, the
anterior shoulder can become impacted behind the symphysis pubis (or the posterioranterior shoulder can become impacted behind the symphysis pubis (or the posterior
shoulders on the sacral promontory)shoulders on the sacral promontory)

 If descent of the fetal head continues whileIf descent of the fetal head continues while
the shoulders remain impacted, stretchingthe shoulders remain impacted, stretching
of the nerves of the brachial plexus canof the nerves of the brachial plexus can
occur.occur.
 Most brachial plexus injuries resolve onMost brachial plexus injuries resolve on
their own, but permanent injury is a often atheir own, but permanent injury is a often a
medicolegal issue.medicolegal issue.

Risks for shoulder dystociaRisks for shoulder dystocia
maternal obesity, diabetes, post dates,maternal obesity, diabetes, post dates,
macrosomic infant, operative deliverymacrosomic infant, operative delivery
Other risks associated with shoulderOther risks associated with shoulder
dystocia: fetal hypoxia and neurologicdystocia: fetal hypoxia and neurologic
injury; fractured clavical or humerus, fetalinjury; fractured clavical or humerus, fetal
death.death.

Management of Shoulder dystociaManagement of Shoulder dystocia
 Call for help!Call for help!
 Suprapubic pressureSuprapubic pressure
 McRoberts ManeuverMcRoberts Maneuver
 EpisiotomyEpisiotomy
 Woods screw/ RubenWoods screw/ Ruben’s manuevers’s manuevers
 Deliver posterior armDeliver posterior arm
 Fracture claviclesFracture clavicles
 Zavenelli maneuverZavenelli maneuver
 Mom should not push during maneuvers!!Mom should not push during maneuvers!!

Henry Lerner, MDHenry Lerner, MD
Graphics Susan Seif, medical graphicsGraphics Susan Seif, medical graphics

After difficult delivery…After difficult delivery…
Careful documentationCareful documentation
Explain to patient the events, explanation ofExplain to patient the events, explanation of
problem, steps taken to correct the problem,problem, steps taken to correct the problem,
and what the anticipated sequelae areand what the anticipated sequelae are

Fetal MonitoringFetal Monitoring
The following examples of fetal monitoring strips are from…The following examples of fetal monitoring strips are from…
Interpretation of the Electronic Fetal Heart RateInterpretation of the Electronic Fetal Heart Rate
During LaborDuring Labor
AMIR SWEHA, M.D., and TREVOR W. HACKER, M.D.AMIR SWEHA, M.D., and TREVOR W. HACKER, M.D.
Mercy Healthcare SacramentoMercy Healthcare Sacramento
Sacramento, CaliforniaSacramento, California
NUOVO, M.D.NUOVO, M.D.
University of California, Davis, School of MedicineUniversity of California, Davis, School of Medicine
Davis, CaliforniaDavis, California
Used with permission fromUsed with permission from The American Family PhysicianThe American Family Physician

 Figure 1 Interpreting fetal monitiring Strips; American Academy of FamilyFigure 1 Interpreting fetal monitiring Strips; American Academy of Family
Physicians May, 1999Physicians May, 1999

Figure 1Figure 1
 Interpretation of Electronic Fetal Heart rate During LaborInterpretation of Electronic Fetal Heart rate During Labor
American Family Physician, May 1999American Family Physician, May 1999

Figure 1Figure 1
 Reassuring pattern. Baseline fetal heartReassuring pattern. Baseline fetal heart
rate is 130 to 140 beats per minute (bpm),rate is 130 to 140 beats per minute (bpm),
preserved beat-to-beat and long-termpreserved beat-to-beat and long-term
variability. Accelerations last for 15 orvariability. Accelerations last for 15 or
more seconds above baseline and peak atmore seconds above baseline and peak at
15 or more bpm. (Small square=1015 or more bpm. (Small square=10
seconds; large square=one minuteseconds; large square=one minute

Figure 2Figure 2

 FIGURE 2.FIGURE 2. Saltatory pattern with wideSaltatory pattern with wide
variability. The oscillations of the fetalvariability. The oscillations of the fetal
heart rate above and below the baselineheart rate above and below the baseline
exceed 25 bpm.exceed 25 bpm.

 Fetal tachycardia with possible onset ofFetal tachycardia with possible onset of
decreased variabilitydecreased variability (right)(right) during theduring the
second stage of labor. Fetal heart rate issecond stage of labor. Fetal heart rate is
170 to 180 bpm. Mild variable170 to 180 bpm. Mild variable
decelerations are present.decelerations are present.

Figure 3Figure 3

Figure 3Figure 3
 Fetal tachycardia that is due to fetalFetal tachycardia that is due to fetal
tachyarrhythmia associated withtachyarrhythmia associated with
congenital anomalies, in this case,congenital anomalies, in this case,
ventricular septal defect. Fetal heart rate isventricular septal defect. Fetal heart rate is
180 bpm. Notice the "spike" pattern of the180 bpm. Notice the "spike" pattern of the
fetal heart rate.fetal heart rate.

Figure 4Figure 4

Figure 4Figure 4
 Early deceleration in a patient with anEarly deceleration in a patient with an
unremarkable course of labor. Notice thatunremarkable course of labor. Notice that
the onset and the return of thethe onset and the return of the
deceleration coincide with the start anddeceleration coincide with the start and
the end of the contraction, giving thethe end of the contraction, giving the
characteristic mirror image.characteristic mirror image.

Figure 5Figure 5
 Nonreassuring pattern of lateNonreassuring pattern of late
decelerations with preserved beat-to-beatdecelerations with preserved beat-to-beat
variability. Note the onset at the peak ofvariability. Note the onset at the peak of
the uterine contractions and the return tothe uterine contractions and the return to
baseline after the contraction has ended.baseline after the contraction has ended.
The second uterine contraction isThe second uterine contraction is
associated with a shallow and subtle lateassociated with a shallow and subtle late
decelerationdeceleration

 FIGURE 6.FIGURE 6. Nonreassuring pattern of late decelerationsNonreassuring pattern of late decelerations
with preserved beat-to-beat variability. Note the onset atwith preserved beat-to-beat variability. Note the onset at
the peak of the uterine contractions and the return tothe peak of the uterine contractions and the return to
baseline after the contraction has ended. The secondbaseline after the contraction has ended. The second
uterine contraction is associated with a shallow anduterine contraction is associated with a shallow and
subtle late decelerationsubtle late deceleration

 Figure 7Figure 7
. Late deceleration with loss of variability. This is an ominous pattern, and immediate delivery is indicated

FIGURE 8. Variable deceleration with pre- and post-accelerations ("shoulders").
Fetal heart rate is 150 to 160 beats per minute,
and beat-to-beat variability is preserved.

Figure 9Figure 9
 Severe variable deceleration withSevere variable deceleration with
overshoot. However, variability isovershoot. However, variability is
preserved.preserved.

Figure 10Figure 10
 FIGURE 10.FIGURE 10. Late deceleration related to bigeminal contractions.Late deceleration related to bigeminal contractions.
Beat-to-beat variability is preserved. Note the prolonged contractionBeat-to-beat variability is preserved. Note the prolonged contraction
pattern with elevated uterine tone between the peaks of thepattern with elevated uterine tone between the peaks of the
contractions, causing hyperstimulation and uteroplacentalcontractions, causing hyperstimulation and uteroplacental
insufficiency. Management should include treatment of the uterineinsufficiency. Management should include treatment of the uterine
hyperstimulation. This deceleration pattern also may be interpretedhyperstimulation. This deceleration pattern also may be interpreted
as a variable deceleration with late return to the baseline based onas a variable deceleration with late return to the baseline based on
the early onset of the deceleration in relation to the uterinethe early onset of the deceleration in relation to the uterine
contraction, the presence of an acceleration before the decelerationcontraction, the presence of an acceleration before the deceleration
(the "shoulder") and the relatively sharp descent of the deceleration.(the "shoulder") and the relatively sharp descent of the deceleration.
However, late decelerations and variable decelerations with lateHowever, late decelerations and variable decelerations with late
return have the same clinical significance and representreturn have the same clinical significance and represent
nonreassuring patterns. This tracing probably represents cordnonreassuring patterns. This tracing probably represents cord
compression and uteroplacental insufficiency.compression and uteroplacental insufficiency.

Figure 11Figure 11
 FIGURE 11.FIGURE 11. (A)(A) Pseudosinusoidal pattern. Note thePseudosinusoidal pattern. Note the
decreased regularity and the preserved beat-to-beatdecreased regularity and the preserved beat-to-beat
variability, compared with a true sinusoidal patternvariability, compared with a true sinusoidal pattern (B).(B).

When all else fails….When all else fails….

Enough already!!!Enough already!!!

Labor dystocia

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