Labor and Delivery Options and Best Practices

Kenzie CookKenzie Cook
Sci-Tech ProjectSci-Tech Project
Sci-Tech ProjectSci-Tech Project
Best Practices and Medical OptionsBest Practices and Medical Options
in Labor and Deliveryin Labor and Delivery
withwith
Innovative Spinal Block PatchInnovative Spinal Block Patch

Disclaimer to the ClassDisclaimer to the Class
Due to the medical nature of Labor
and Delivery, this Key Note
Presentation is rated PG-13.
I carefully chose slides that were not
too graphic in nature, but found a
wide array of eye-popping images
during my research.

General Facts and StatisticsGeneral Facts and Statistics
about U.S. Labor and Delivery:about U.S. Labor and Delivery:
about U.S. Labor and Delivery:about U.S. Labor and Delivery:
In 2011 most pregnant women in the U.S. (about
99%) gave birth in hospitals with the help of a
physician (91.3%).
Of the 1% of births that took place outside of
hospitals, 66% were in homes and 28% were in
birthing centers.
In 2011, there were 4.2 million maternal childbirth-
related hospitalizations (down from 4.5 million in
2010) totaling $16.1 billion in hospital costs.

Evidence-Based Maternity Care:Evidence-Based Maternity Care:
Effective Care with Least HarmEffective Care with Least Harm
Effective Care with Least HarmEffective Care with Least Harm
“Evidence-based maternity care” uses the best available research on the safety
and effectiveness of specific practices to help guide maternity care decisions and
facilitate optimal outcomes in mothers and newborns. Various paths that might
be pursued in a given situation often have very different benefit/harm profiles.
Evidence-based maternity care gives priority to care paths and practices that are
effective and least invasive, with limited or no known harms whenever possible.
Practices with established or plausible adverse effects should be avoided when
best available research identifies no clear anticipated benefit to justify their use.
An evidence-based framework also questions the wisdom of using interventions
with a marginal expected benefit that is overshadowed by greater risk of
established harm.
To help guide maternity care decisions, decision makers need access to the
highest quality of evidence about the safety and effectiveness of specific
procedures, medications, and other interventions.

Best Medical Practices Are Based OnBest Medical Practices Are Based On
Confounding Variables and Personal ChoicesConfounding Variables and Personal Choices
Facilities
Care Providers
Pain Management
Birthing Positions
Birthing Techniques
Monitoring
Labor Augmentation/Induction
Financial Costs and Insurance Coverage
Innovation There is no One Best
Way.

OptionsOptions
forfor
Facilities:Facilities:
Home Births
Hospitals
Birthing Centers
Water Births

Birthing CentersBirthing Centers

Water BirthsWater Births
There haven't been many high-quality
studies done on water births. Of those
that have been done, the results are
mixed. Some studies found rare but
serious risks for baby. Other research
shows that water births are just as safe
as (if not safer than) bed births.
Some of the risks include:
• Brain injury from lack of oxygen
underwater
• Electrolyte problems from the baby
swallowing water
• Serious infection from contaminated
water
Research on the benefits of water birth is also
unclear. Some studies have shown certain
benefits for moms while others show no real
benefit. However, some people believe a water
birth offers moms a natural, soothing
environment for delivery.
Here are some reasons why new moms may
choose a water delivery:
• Some moms believe a water birth is a more
natural and less stressful experience for them
and their new baby.
• A water birth may give a woman a sense of
control over her delivery.
• Water provides natural buoyancy, which makes
the mother feel lighter.
• Water relaxes the mother, allowing her to
concentrate on the birth.
• Water relaxes the mother's muscles and
improves blood flow.
• Water may reduce vaginal tearing, thus helping
the mother avoid an episiotomy or stitches.
• A water birth may shorten the first stage of labor
and reduce the need for anesthesia.

Options forOptions for
CareCare
Providers:Providers:
Ob/Gyn Doctor
Family Physician
Nurse/Midwife
Traditional or Lay Midwife
Maternal-Fetal Medicine
Specialist (perinatologist)
Doula

Family PhysicianFamily Physician

Nurse/MidwifeNurse/Midwife
National U.S. Midwifery credentials: Certified Nurse-Midwife, Certified Midwife,
and Certified Professional Midwife
The accrediting body of the National Organization for Competency Assurance
accredits three midwife credentials in the U.S. Certified nurse-midwives (CNMs)
are well-established maternity professionals in the United States. Educated in the
two disciplines of nursing and midwifery, they provide prenatal, childbirth,
postpartum, and well-woman care. CNMs are licensed to practice in all states
and covered by a wide variety of insurance programs. Certified Midwives (CMs)
are equivalent in training and practice to CNMs but do not have a nursing
credential. This newer path to the midwifery profession is recognized in several
states. CNMs and CMs practice in all settings and primarily attend hospital
births (American College of Nurse-Midwives 2005). Another newer credential,
the certified professional midwife (CPM), indicates a midwife who is educated to
provide pregnancy, birth, and postpartum care for women who give birth in out-
of-hospital birth centers or at home. the number of CPMs has grown rapidly in
recent years. Nearly one-half of state license CPMs and efforts are under way to
extend licensure to all states.

Traditional or Lay MidwifeTraditional or Lay Midwife
“Midwives are an appealing option for
women who want a more
individualized, less routine approach to
childbirth than many traditional
obstetricians tend to provide, and
particularly for those who want to give
birth at home. Midwives focus on
helping you learn about the physical
and emotional changes you go through
during pregnancy, teach you how to
maintain good health habits, and
consider you an active participant in all
aspects of your care. They see every
pregnancy as a unique event and
encourage you to consider your options
for labor and delivery and to
personalize your own birth plan.”

Maternal-Fetal SpecialistMaternal-Fetal Specialist
PerinatologistPerinatologist
PerinatologistPerinatologist
Perinatology:
A subspecialty of obstetrics concerned with the care of the fetus
and complicated, high-risk pregnancies. Perinatology is also
known as maternal-fetal medicine.
In addition to four years of residency training in obstetrics and
gynecology the maternal-fetal medicine subspecialist has
received two to three years of education in the diagnosis and
treatment of disorders of the mother and fetus. The maternal-
fetal medicine specialist typically works in consultation with the
obstetrician.
Some of the services provided by the maternal-fetal specialist
include diabetes care, management of multiple gestations, level
II ultrasound of the fetus, chorionic villus sampling, genetic
amniocentesis, and in some centers fetal surgery or treatment.

DoulaDoula
A Doula is a trained non-
medical woman who assists a
woman before, during and
after childbirth. Continuous
support during labor has
proven to result in healthier
outcomes for both mother
and child.

PainPain
Management:Management:
Natural Pain Management Options
Drug Induced Pain Management
Options

Natural Pain ManagementNatural Pain Management
Breathing and
Relaxation/Distraction
Techniques

Acupressure
Massage

Supplemental Oxygen
When the mother has a long or hard
labor, she tends to sweat a lot and is
more likely to be dehydrated. The
mother may have been nauseated
earlier or the baby may be
experiencing failure to progress.
Oxygen is given to lower the mothers
blood pressure and give her the
energy to continue to push the baby
out. The baby may be in distress or
the heart beat is a little low, so the
extra oxygen helps the baby as well.
Sometimes the extra oxygen is simply
a comfort measure that helps the
mother to focus on her breathing.

Music &
Lighting
Effects

Mental Imaging
Self-Hypnosis

Enema
Not so long ago, giving a laboring mother an
enema wasn’t a matter of choice but rather a
standard, routinely administered in early labor
as part of the hospital admission procedure.
The theory behind giving an enema in early
labor is that emptying the bowels before delivery
eliminates the possibility of waste matter in the
rectum hindering the baby's descent through the
birth canal and prevents contamination of the
sterile birthing field.
Today, the choice to receive an enema is usually
that of the expectant mothers. It's recognized
that as long as the mother has had a bowel
movement in the past 24 hours, the
compression or tightness of the birth canal isn't
likely to be a problem. Today all the supplies
used under the mother's bottom half are usually
disposable.

Warm Bath

Hot/Cold Therapy

Drug Induced Pain ManagementDrug Induced Pain Management
Epidural
• Advantages
• Better pain relief than other pain medication
• Fewer babies needing naloxone to counter opiate
use by the mother
• Disadvantages
• More use of instruments to assist with the birth
• Increased risk of Caesarean section for fetal
distress
• Longer delivery (second stage of labour)
• Increased need of oxytocin to stimulate
uterine contractions
• Increased risk of experiencing very low blood
pressure
• Increased risk of muscular weakness for a period
of time after the birth
• Increased risk of fluid retention
• Increased risk of fever

Spinal
Block
An epidural block takes about 10 to 20 minutes to
work, and because a catheter is inserted into the
epidural space, the effects can last as long as
needed due to the ability to inject more medication. A
spinal block begins working immediately, but its
effects last only about 2 ½ hours. It is possible to
have a combination of spinal and epidural
anesthesia.

Pudendal Block
Paracervical Block
Pudendal block
To relieve pain associated with the second (pushing) stage of labor, an injection called a pudendal block can be
given through the vaginal wall and into the pudendal nerve in the pelvis, numbing the area between the vagina and
anus (perineum). Pudendal blocks do not relieve the pain of contractions.
A pudendal block works quickly, is easily administered, and does not affect the baby. It is given shortly before
delivery. But it cannot be used if the baby's head is too far down in the birth canal (vagina).
Paracervical block
An injection of pain medicine into the tissues around the cervix is called a paracervical block. A paracervical block
is another form of local anesthesia. It reduces the pain caused by contractions and stretching of the cervix. A
paracervical block lasts about 1 to 2 hours.
Sometimes the baby's heartbeat can slow down after a paracervical block is done. Paracervical blocks are rarely
done today, because epidural anesthesia is more effective.

Oral Pain Killers
Oral pain killers are infrequently used but are less
invasive than other medical procedures. They are a
good choice for a more natural birthing option.
Pros:Narcotics decrease the perception of pain for
two to six hours and promote rest.
Cons: Narcotics don't eliminate pain. They might
cause sleepiness and nausea, and temporarily
depress breathing for mother or the baby.

IV or IM Pain
Medicine/
Narcotics
Demerol, Nubaine, Staydol,
Morphine (pain medications)
May reduce sensation of, or caring
about, pain. May allow mom to rest
and relax.
Causes extreme drowsiness. Mom
may not realize she has given
birth. May cause disorientation,
hallucinations, nausea and
vomiting. May cause respiratory
distress in mom and newborn.
Slows labor. Lowers blood
pressure. Baby’s heart rate is less
reactive. May alter baby behavior.
May interfere with breastfeeding.
IV Fluids (Needle inserted in vein, taped and hooked to
IV stand for fluid intake.)
Provides hydration. Maintains blood pressure when
anesthesia is used. Allows immediate access to vein.
Restricts movement. May cause swelling. May cause
distended bladder. Many hospitals require and IV in
VBAC moms and you may wish to decline or switch birth
locations to avoid this..

Episiotomy
Episiotomy (A cut made on the
perineum usually at the time of
delivery.)
Provides more space for forceps or
vacuum. Enlarges perineal area.
Pain – while being cut, while being
sewn up and possibly for months
while healing. Does not enlarge birth
canal just perineal tissue area. Can
cause pain with intercourse,
urination, and/or bowel movements
for months and even years after
delivery. Can be traumatic and cause
problems with self-image.

Drug Inducted Pain ManagementDrug Inducted Pain Management
Combine spinal/epidural
block also known as a
walking epidural
Combined spinal and epidural
anaesthesia (CSE) is a regional anaesthetic
technique, which combines the benefits of both
spinal anaesthesia and epidural anaesthesia and
analgesia. The spinal component gives a rapid
onset of a predictable block. The indwelling
catheter gives the ability to provide long lasting
analgesia and to titrate the dose given to the
desired effect.

BirthingBirthing
Positions:Positions:
Stage I: Early and Active Labor
Stage II: Pushing
Stage III: The Placenta Delivery

Stage I: Early and Active LaborStage I: Early and Active Labor
Standing or Walking
Early labor
During early labor, the cervix will begin to dilate. The woman may
feel mild contractions during early labor. They will typically last 30
to 90 seconds and come at regular intervals. Near the end of early
labor, your contractions will likely be less than five minutes apart.
As the cervix begins to open, the woman might notice a brown or
blood-tinged discharge from your vagina. This is likely the mucus
plug that blocks the cervical opening, also known as bloody show.
How long it lasts: Early labor is unpredictable. For first-time
moms, the average length of early labor is six to 12 hours. It's
often much shorter for subsequent deliveries.

Sitting Upright/Sitting
backward
Active labor
During active labor, the cervix will dilate to 10 centimeters (cm).
The contractions will become stronger, longer, closer together
and regular. The woman’s legs might cramp, and she might feel
nauseous. The woman might feel her water break — if it hasn't
already. She might feel increasing pressure in her back as well. If
she hasn’t headed to the labor and delivery facility yet, now's the
time.

Rocking
How long Early and Active Labor lasts:
Active labor often lasts up to eight hours. For
some women, active labor lasts hours longer. For
others — especially those who've had a previous
vaginal delivery — active labor is much shorter.
The 1st part of active labor — often referred to as
transition — can be particularly intense. If the
woman feels the urge to push but is not fully
dilated, the health care provider might ask her to
hold back. Pushing too soon could cause the
cervix to swell, which might delay delivery. Pant
or blow through the contractions instead.

Hands and Knees
Method
Don't be surprised if her initial
excitement wanes as her labor
progresses and the pain intensifies.
Moms shouldn’t feel that they are
giving up if they ask for pain
medication or anesthesia.
Remember, the patient is the only
one who can judge her need for pain
relief.

Using an exercise ball

Lying Down on
Side

Squatting Bar

Stage II: Pushing PositionsStage II: Pushing Positions
Unrestricted
Positioning
Non-Supine
Position
Delivery on bed in supine position (Pushing and delivery of baby is often
on a hospital bed with mom laying on her back.)
Allows care provider to see perineal area. Can slow 2nd stage/pushing stage.
If done, Mom should always have one butt cheek raised with a folded towel.
Doesn’t use gravity. Can cause compromised blood flow in mom and baby.
Can slow 2nd stage/pushing stage. Higher incident of broken tail bone. Mom
often feels far away from what’s happening between her legs.
Stage 2: The birth of the
baby
It's time! The mom delivers her baby
during the second stage of labor.
How long it lasts: It can take
from a few minutes up to a few
hours or more to push the baby into
the world. It often takes longer for
first-time moms and women who've
had an epidural.

Stage III: The Placenta DeliveryStage III: The Placenta Delivery
Unrestricted
Positioning
Non-Supine
Position
Cord Traction
Moves 3rd stage of birth process along. Light traction may help a
“sticky” part of the uterus. If placenta is off the wall of the uterus
and lying against the cervix, traction will allow placenta to descend
the canal and be expelled.
Can pull umbilical cord off placenta requiring a manual removal.
Can cause inverted uterus. Can cause placental hemorrhaging.

BirthingBirthing
TechniquesTechniques
McMoyler
Lamaze
Bradley
HypnoBirthing

McMoyler Birthing Technique:McMoyler Birthing Technique:
McMoyler Method Childbirth Education
The McMoyler Method Course includes four topics:
Childbirth Preparation, Infant CPR, Breastfeeding
and Newborn Care.
The course is available in a 'Two Evening Format'
midweek or 'One Day Format' on the weekend.
McMoyler Method is a new way of educating parents-to-be that focuses on parent
involvement and support. In 1993, McMoyler designed a course that recognizes the
need for insightful, sensitive, and relevant prenatal and postnatal education with
expectant mothers and their partners. McMoyler Method: Preparing for Birth in
the 21st Century is an innovation in childbirth education, created especially for
today's educated, informed, and busy parents-to-be. The fast-paced, interactive
courses are based on current medical science and practice.
McMoyler blogs for a number of sites, including The Best Birth and Cafe Mom. She
has a dedicated following on Facebook.

Lamaze Birthing Technique:Lamaze Birthing Technique:
Lamaze La·maze (l -mäz'),ə Ferdinand .
1891-1957.
French obstetrician who in the 1950's
developed a method of childbirth
preparation using behavioral training to
reduce pain and anxiety in labor.
Lamaze method of childbirth
a method of childbirth that
prepares a mother for natural
childbirth; the pregnant woman
(in classes and at home)
practices (usually with the help
of a coach) and learns about
the physiology of childbirth and
techniques of relaxation,
concentration, and breathing.

Bradley Birthing Technique:Bradley Birthing Technique:
This birthing technique helps women and their partners to a
safe and natural childbirth.
The Bradley Method teaches how to:
•Build better, deeper, and more trusting communication skills
with your partner in preparation for a drug-free childbirth
•Learn the physical, emotional, and mental relaxation
techniques essential to a natural childbirth
•Discover how you and your doctor can work together toward
your natural delivery
•Monitor your weight, nutrition, and your overall well-being
during pregnancy
•Use natural prevention methods for the most common
pregnancy problems
•Get the most out of the bonding experience you will share
with your baby and your partner
The Bradley Method is an essential guide for anyone
considering childbirth without unnecessary medications or
medical intervention and to share fully in your child’s arrival
into the world.

HypnoBirthing Technique:HypnoBirthing Technique:
Hypnobirthing techniques can help a mom cope with labour and reduce the need
for other forms of pain relief. If a mom is in a lot of pain, is worried or feels
scared during labour, her body is likely to go into fight-or-flight mode. Stress
hormones, the main one being adrenaline, will flood her body.
Adrenaline reduces the blood flow to the uterus (womb) and digestive system.
Instead, the blood flows more readily to the large muscles in your limbs so that
you're ready to fight or run away.
As a result, the muscles of her uterus will work less well, because they are
deprived of blood and oxygen. This can make labour harder and longer. The
baby will be getting less oxygen too.
Plus, just when she most needs it, the hormone that eases labour, oxytocin, is
less likely to be released. Stress hormones stop her body producing oxytocin.
She'll also produce fewer of the natural hormones (endorphins) which numb the
pain and help her feel good.
Controlling her feelings through self-hypnosis can help her to prevent these
stress responses from kicking in. Hypnobirthing is thought to:
•Help keep higher levels of oxygen in the body because of the deep breathing
techniques.
•Reduce the need for pain-relieving drugs, such as pethidine or an epidural.
•Increase the chance of having a straightforward vaginal birth.
•Reduce the need for drugs to speed up labour.

VaginalVaginal
BirthsBirths
Natural expulsion
Forceps
Vacuum extraction

ForcepsForceps
Forceps (Metal tongs placed on
either side of baby’s head to help pull
baby out.)
Can be used to rotate baby to
anterior position. Allows for more
rapid delivery of baby. Assists in
delivering baby when mom can’t feel
the push sensation due to
anesthesia.
Usually requires an episiotomy.
Usually requires regional anesthesia.
May badly bruise baby’s head and
face. May bruise or tear vaginal
tissue. May cause permanent birth
injuries.

Vacuum ExtractionVacuum Extraction
Vaccuum (Small suction cup placed on
top of baby’s head to help pull baby
out.)
Requires less space than forceps. Helps
with descent of baby’s head.
May cause bruising or swelling of baby’s
head. Not helpful in rotating baby. May
bruise or tear vaginal tissues. May cause
birth injuries.

CesareanCesarean
SectionSection
Births:Births:
Scheduled Cesarean
Emergency Cesarean

Scheduled CesareanScheduled Cesarean
Breech position (bottom first) is present in 3 to 4% of term pregnancies. Breech positioning is
more common prior to term—25% are breech before 28 weeks, but by 32 weeks only 7% of
babies are breech. The vast majority of breech babies in the U.S. are now born by planned C-
section. The use of a safe procedure to help turn babies into a head-down position (aka
cephalic position), may help reduce the C-section rate (Lannie and Seeds 2012).

Emergency CesareanEmergency Cesarean
In 2008, 33 percent of childbirths were by C-
section, up from 21 percent in 1997. In fact, C-
sections were, overall, the most commonly
performed operating room procedures in U.S.
hospitals.

FetalFetal
Monitoring:Monitoring:
Handheld Doppler
Fetoscope
Continuous electronic fetal monitoring
Intermittent auscultation
Internal Probe
External fetal monitoring

Handheld DopplerHandheld Doppler
Doppler (Machine used to listen to a
baby’s heart rate.)
Allows care provider to listen to baby
while mom is in any position. More
sensitive than fetoscope. Allows others
in the room to hear the baby.
Does not provide continuous record.
Exposes baby to ultrasound. Not
proven safe for mom or baby.

FetoscopeFetoscope
A fetoscope, one of the tools used for fetal monitoring, is similar
to a stethoscope. It works by amplifying the sound of the baby's
heartbeat. It can be used at any time during labour. It is a non-
invasive method of monitoring, meaning that it carries no side
effects, risks, and does not require the use of extra interventions.
The main benefits of choosing fetoscopic monitoring are that it is
the least-invasive form of monitoring. It carries the lowest rate of
false alarms of fetal distress, has no adverse effects for the baby,
does not restrict the mother from freely moving or using water
during labor, and can be done on an intermittent monitoring
schedule. There are also no risks of increased interventions when
this type of monitoring is selected. The only drawback of this
method is that is cannot be used when continuous monitoring is
truly medically indicated.

Continuous Electronic FetalContinuous Electronic Fetal
MonitoringMonitoring
Continuous External Fetal Monitor/EFM
(A paddle monitor placed around mom’s belly
to measure baby’s heart tones)
Allows care provider to hear baby’s heart beat
continuously and assess baby’s well being.
Provides a continuous record of heart tones.
Not always accurate and significantly
increases risk of cesarean birth. This is
standard in nearly every hospital, particularly
in the second stage of birthing. If misread,
can lead to more extreme interventions.
Restricts movement. Requires adjustment.
Exposes fetus to ultrasound. Has not been
associated with a better outcome of mom and
baby (in fact it is associated with worse
outcome). Care provider and others may pay
more attention to monitor than mom.

Intermittent auscultationIntermittent auscultation
FHR tracing should be reviewed every 30 minutes in the first stage of labor and every 15 minutes in the
second stage. The intervals should be shortened in patients with complications.
When the FHR tracing includes recurrent variable decelerations, consider amnioinfusion to relieve
umbilical cord compression.
Compared with intermittent manual auscultation, electronic
fetal monitoring was associated with increased rates of
cesarean delivery, with cesarean delivery for abnormal FHR,
acidosis, or both, and with operative vaginal delivery. Only
3% of women in the U.S. receive intermittent auscultation
care. The other 91% receive electronic fetal monitoring.

Internal probeInternal probe
Internal Fetal Monitor/IFM (Probe screwed
into baby’s head during labor and taped to
mom’s leg to measure heart tones and
contractions.)
Allows for assessment of fetal well being.
More accurate than an external fetal monitor,
but should never be routine. Provides a
continuous record of heart tones.
Requires AROM. Restricts movement. Requires
adjustments. May cause infection of uterus or
fetal scalp. Interpretation of results varies per
practitioner. Has not been associated with
better outcome of mom and baby. Care
provider and others may be more attention to
monitor than mom. May be painful for baby.

Intra Uterine Pressure CatheterIntra Uterine Pressure Catheter
Intra Uterine Pressure Catheter
(Small diameter hollow plastic tube with
a flexible probe is inserted vaginally,
through the cervix and rests next to
baby to measure intensity of
contractions)
Provides information on frequency and
intensity of contractions.
Requires AROM. Restricts movement.
Can be painful as it passes through the
cervix. May cause infection of uterus.
May scrape or injure baby. Interpretation
of results is only for one “pocket” of
space and results may not be accurate.
Care provider may pay more attention to
monitor than mom.

LaborLabor
Augmentation/IAugmentation/I
nduction:nduction:
Free Progession
IV Oxytocin (Pitocin)
PGE2 Gel
Artificial Rupture of
Membranes
(AROM)
External Version

Manually Assisted ExtractionManually Assisted Extraction
Manually assisted extraction
Some light downward traction may help
“sticky shoulders”.
Does not allow baby to follow normal
movements of restitution and external
rotation. Can injure baby’s vocal cords,
neck muscles and potentially cause
paralysis. Can cause perineal tearing.

IV Oxytocin (Pitocin)IV Oxytocin (Pitocin)
Pitocin induction (Synthetic
hormone added to IV to start uterus
contracting.)
May cause contractions. May speed
up a slowed or resting labor.
Increases intensity and frequency of
contractions. Requires constant
EFM. Often requires narcotic pain
medication due to increased
intensity of contractions. Increases
incidence of newborn jaundice. May
substantially increase risk of cesrean
birth if Mom and/or baby are not
ready for birthing (and some moms
and babies aren't ready until well
past their "due date".

PGE2 GelPGE2 Gel
Prostaglandin Gel (Horse sperm gel
inserted to cervix to start dilation.)
May cause ripening of cervix. May start
uterine contractions.
May not work. Higher risk of infection.
May have intense contractions. May
increase risk of further intervention and
care provider will usually follow this with
pitocin.

Bishop ScoreBishop Score
For the purpose of inducing labor
with medicine, the Bishop score
helps a health professional assess
a woman's physical readiness to
progress through vaginal delivery.
The Bishop score is a rating of
how soft, open, and thinned the
cervix is (dilation and effacement),
as well as how low in the pelvis the
cervix and baby are positioned.
Bishop scores range from 0 to 10.
The higher the number, the more
likely a vaginal delivery will be
successful.

Artificial Rupture of MembranesArtificial Rupture of Membranes
known as AROMknown as AROM
Stripping the Membranes (Care provider manually pulls cervix
away from bag of waters.)
May cause labor to begin.
May not work or may cause labor before baby is actually ready to be
born. May rupture membranes, potentially before your body is ready
to give birth. Bloody discharge possible. May be painful.
Artificial Rupture of Membranes (AROM) (Small hook inserted
vaginally and used to break bag of waters.)
Many providers believe it may start or speed up labor but there have been
no studies to prove it does when performed before 8-9 cm. Care provider
is able to check color of amniotic fluid.
May not be successful in starting or speeding labor, which can lead to
other interventions. Higher risk of infection, which leads to other
interventions. Reduces cushion of baby’s head on cervix, which may result
in stronger contractions. Higher possibility of cord prolapse and cesarean.
You may wish to decline this or swich birth locations if this is routine.

External VersionExternal Version

Labor and DeliveryLabor and Delivery
Financial Considerations:Financial Considerations:
Financial Considerations:Financial Considerations:2008 Stats:
On average, hospital deliveries cost
$3,800 per stay, but the mean cost
per stay varied depending on the
mode of delivery. C-sections
tended to be more costly than
vaginal deliveries ($4,700 versus
$2,900 without complications, and
$6,500 versus $3,800 with
complications, respectively). While
uncommon, vaginal delivery with
an operating room procedure (such
as operative forceps or vacuum
delivery) had the highest average
cost ($8,100)—more than double
the cost per stay for all types of
delivery ($3,800). In total, vaginal
deliveries accounted for 54 percent
of annual hospital delivery costs
($8.7 billion), and C-sections
accounted for the remaining 46
percent ($7.3 billion).

Innovation Statement:Innovation Statement:
To create a prototype topical spinal
nerve block patch that works in
conjunction with I.V. medications to
reduce the frequency of epidural
procedures used in the birthing process.

Innovation Goals:Innovation Goals:
To lower the anxiety and reduce the stress levels that laboring
mothers often experience when anticipating the labor and delivery
process.
To increase the satisfaction rate and overall experience of giving
birth.
To decrease the number of “highly invasive” procedures that
hospitals perform each year, reducing the risk for litigation
procedures and high legal costs.
To reduce the over-all financial cost of labor and delivery by
reducing insurance costs for the hospital and for the individual.
Reduce medical professionals costs by eliminating the high skill
and education necessary to perform these procedures.

What medications would be used?What medications would be used?
The same class of drugs that are used in epidural anesthesia would be used for
the prototype spinal patch.
Epidural anesthesia is regional anesthesia that blocks pain in a particular region
of the body. The goal of an epidural is to provide analgesia, or pain relief, rather
than anesthesia which leads to total lack of feeling. Epidurals block the nerve
impulses from the lower spinal segments. This results in decreased sensation in
the lower half of the body. Epidural medications fall into a class of drugs called
local anesthetics, such as bupivacaine, chloroprocaine, or lidocaine. They are
often delivered in combination with opioids or narcotics such as fentanyl and
sufentanil in order to decrease the required dose of local anesthetic. This
produces pain relief with minimal effects. These medications may be used in
combination with epinephrine, fentanyl, morphine, or clonidine to prolong the
epidural’s effect or to stabilize the mother’s blood pressure.

How would it work?How would it work?
the Prototype Spinal Block Patch would work similarly to a Pudendal Block or
Paracervical Block but would eliminate invasive injections into the spinal cord.
The patch would be a gel combination of the drugs bupivacaine, chloroprocaine,
and lidocaine. Combined with opioids or narcotics such as fentanyl and
sufentanil. IV Morphine Sulfate would be given in addition via PCA pump.
The descent of the fetus during the second stage of labor causes the primary
focus of pain to shift from the uterus to the lower vagina, perineum, and vulva.
These areas obtain most of their sensory and motor innervation from sacral
nerve roots 2, 3, and 4 via the pudendal nerve. The spinal patch would include
a dose of a local anesthetic around the trunk of the pudendal nerve at the level
of the ischial spine resulting in pain relief for these areas

Frequently Asked Questions:Frequently Asked Questions:
Would it block out all of the contraction pain? No. You would still feel the contractions but it would reduce
the level of the pain associated with them.
Would I be able to walk around? No. Just like an epidural, your lower abdomen and legs would be
practically numb.
Does the patch go on the abdomen or on the back? The spinal block would be placed along the lumbar,
sacrum and coccygeal vertebrae of the spinal area in the back and not on top of the uterus.
Would there be side effects for the baby? Much like the risks of an epidural the mother may experience
sudden drops in blood pressure and it may slow the second stage of labor. Other common side effects
include pruritus, inability to urinate, and hypotension. The baby may experience difficulty latching on
during breast feeding and a lower respiratory rate.
Would constant monitoring be necessary? Yes the mother would have intermittent 15 minute vital sign
checks and the baby would be on a continuous fetal monitor.

Continued FAQ’sContinued FAQ’s
How long would it last? The spinal block patch could be made available in different dosages to
work the with woman’s age, height, weight and other health factors and history. The goal would
be to last for 4-6 hours. An additional patch could be added if the analgesia started to wear off
and if the mother was not showing signs of slowing labor.
How long would it take to work? Anywhere between 30 minutes and 45 minutes depending on
the woman. It would take much longer for the medicine to reach a therapeutic level than with an
epidural.
What if too much medicine is given or if it is given too late? If given too late in labor or if too
much medicine is used, it might be hard to push when the time comes. There would be an
increased risk of assisted vaginal delivery with forceps or vacuum extraction.
The Spinal patch would not be used for home births, birthing centers or water births, but would
be appropriate for use in hospitals only.
This would not be the strongest or the fastest method of pain relief, but it would be less invasive
and cost less to administer than an epidural.

Drug calculations for different analgesics andDrug calculations for different analgesics and
routesroutes
Relative Potencies
Oral 1/3 of IV dose
Epidural 10x greater than IV dose
Intracathether 100x greater than IV dose
Dilaudid 5x greater than morphine
Fentanyl 100x greater than morphine
Sufentanil 1000x greater than morphine
Fentanyl patch Same as IV fentanyl

How I would figure out the dosageHow I would figure out the dosage
1. Start from the epidural dose
2. Downscale for spinal dose
3. Calculate the LA dose in relation to the
potency from epidural dose
4. Adapt the does for the specific patient
5. Calculate the mL. needed

1. A generally accepted guideline for dosing epidural anesthesia in adults is 1-2 mL per segment
to be
blocked.
Adjust the
guideline
for shorter
patents
(<5ft 2 in.
=157.48
cm) or
taller
patients
(>6 ft. 2 in.
= 187.96
cm) *
according
to Admir
Hadzic,
Textbook
of regional
anesthesia
and pain
managem
ent, pg.
245
2. Downscale for Spinal dose: 25 mg: 10 = 2.5 mg
3. Calcuate the equipotent dose
Marcaine is 4 times stronger than Lidocaine mg/segment 0.625= 4 : 2.5

Example Drug CalculationExample Drug Calculation
Height (cm) Millilleters Milligrams
150-155 1.5-1.55 7.5-7.75
155-160 1.6-1.65 8-8.25
165-170 1.65-1.7 8.25-8.5
170-175 1.7-1.75 8.5-8.75
175-180 1.75-1.8 8.75-9

Morphine Sulfate extended-release (liposomal) by IV Administration
Administer by direct IV injection or IV infusion. Also administered IV via a controlled-delivery device for patient-controlled analgesia (PCA).
For IV injection, morphine sulfate should be injected slowly with the patient in the recumbent position.b
Rapid IV injection may result in an increased frequency
of opiate-induced adverse effects; severe respiratory depression, apnea, hypotension, peripheral circulatory collapse, chest wall rigidity, cardiac arrest, and
anaphylactoid reactions have occurred following rapid IV injection.
Dilution
For continuous IV infusion, morphine sulfate has been diluted to a concentration of 0.1–1 mg/mL in 5% dextrose and administered via a controlled-infusion
device; more concentrated solutions have been used in patients whose fluid intake was restricted and/or dosage requirements were high.
Morphine sulfate injections containing 25 or 50 mg/mL are intended for preparation of IV infusion solutions and should not be administered IV without prior
dilution.
Rate of Administration
The rate of continuous IV infusion of the drug must be individualized according to the response and tolerance of the patient.
Highly concentrated, preservative-free morphine sulfate solutions for epidural or intrathecal use (e.g., Infumorph 10 or 25 mg/mL)
are intended for use via continuous, controlled-microinfusion devices. Such injections should not be used for individual-dose
epidural or intrathecal injection since less-concentrated, preservative-free injections can be employed more reliably for the small
doses required.b
Morphine sulfate extended-release liposomal injection (DepoDur) is administered epidurally.
IV Morphine Sulfate as additional
pain relief measure to the patch

Possible ContraindicationsPossible Contraindications
Patient refusal
Lack of resuscitation equipment available
Allergy to analgesic medication
Skin infection at patch site
History of heart or breathing problems

Potential problems:Potential problems:
It might take longer for the medication to take
effect, thus leaving the mother in pain longer if
she is in the advanced stages of labor
progression.
Since the same medications would be used as in
an epidural, the patient and the baby would have
many of the same risks associated with these
drugs. Continuous monitoring would still be
necessary for both the mother and baby.

Method How it can help Some disadvantages
Opioids – also called narcotics, are
medicines given through a tube inserted in a
vein or by injecting the medicine into a
muscle. Sometimes, opioids also are given
with epidural or spinal blocks.
Opioids can make the pain bearable,
and don't affect your ability to push. After
getting this kind of pain relief, you can still
get an epidural or spinal block later.
• Opioids don't get rid of all the pain, and
they are short-acting.
• They can make
you feel sleepy and
drowsy.
• They can cause
nausea and vomiting.
• They can make
you feel very itchy.
• Opioids cannot
be given right before
delivery because they
may slow the baby's
Comparison of Medical methods of pain relief

HistoryHistory
The paracervical block was a method commonly used in the 1940s and
1950s; however, its use has decreased with the increasing availability of
epidurals. A paracervical block involved the injection of local anesthetics
into either side of the cervix. A major disadvantage seen with
paracervical blocks was fetal bradycardia. When this procedure was first
implemented, fetal bradycardia was reported to occur 70% of the time.
However, this incidence has dropped to a rate of 15% with present
methods.
The prototype spinal block would change the combination of route and
dosage of drugs but would probably still have a 15% possibility of fetal
bradycardia.

A large jump in lawsuits has been seen in the health care industry,
where doctors have been paying significantly higher liability
premiums to defend against potential litigation. While some say
the increase in health care lawsuits may provide a safer
environment for patients, opponents believe they are keeping
patients from receiving the best care. Some interesting facts:
• 79 percent of doctors report that they've ordered more tests
than they would based only on professional judgment due to
litigation fears, according to a Harris Interactive Poll.
• The American Medical Association lists 21 states as being in a
"medical liability crisis."
• 71,000 drug lawsuits have been filed in federal courts since
2001 -- and have outnumbered asbestos, tobacco and auto safety
lawsuits since 2002.
• 45 percent of U.S. hospitals reported that the liability crisis
has caused a loss of physicians and/or reduced coverage in
emergency departments.

Reduce potential side-effectsReduce potential side-effects
EpiduralsEpidurals
EpiduralsEpidurals
• Epidurals may cause the patient’s blood pressure to suddenly drop. For this reason their blood pressure will be routinely checked to
help ensure an adequate blood flow to the baby. If there is a sudden drop in blood pressure, they may need to be treated with IV fluids,
medications, and oxygen.
• They may experience a severe headache caused by leakage of spinal fluid. Less than 1% of women experience this side effect. If
symptoms persist, a procedure called a “blood patch”, which is an injection of their blood into the epidural space, can be performed to relieve the
headache.
• After the epidural is placed, the patient will need to alternate sides while lying in bed and have continuous monitoring for changes in
fetal heart rate. Lying in one position can sometimes cause labor to slow down or stop.
• They might experience the following side effects: shivering, ringing of the ears, backache, soreness where the needle is inserted,
nausea, or difficulty urinating.
• They might find that the epidural makes pushing more difficult and additional interventions such as Pitocin, forceps, vacuum
extraction or cesarean might become necessary.
• For a few hours after the birth the lower half of their body may feel numb. Numbness will require them to walk with assistance.
• In rare instances, permanent nerve damage may result in the area where the catheter was inserted.
• Though research is somewhat ambiguous, most studies suggest that some babies will have trouble “latching on” causing
breastfeeding difficulties. Other studies suggest that a baby might experience respiratory depression, fetal malpositioning, and an increase in
fetal heart rate variability, thus increasing the need for forceps, vacuum, cesarean deliveries and episiotomies.

Reducing the use of Epidurals could also mean:
Less sympathetic block
Less swings (drops) in blood pressure
Less interventions needed from the anesthetist (fluids, ephedrine etc.)
Less useless motor block in the lower limbs
Faster recovery from the motor block and the mother is up on her feet sooner
Less concern for the patient that she doesn’t feel the legs
More comfort for both the patient and the personnel.

The EndThe End
Thank you for your time!Thank you for your time!

Labor and Delivery Options and Best Practices

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