Intrapartum Care and Abnormal Labor

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Introductory lecture for M3 Clerkship in Obstetrics & Gynecology. Addresses APGO Educational Objectives, 8th Edition, Educational Topics 11 and 22.

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  • Intrapartum Care and Abnormal Labor

    1. 1. Intrapartum Care & Abnormal Labor Francis S. Nuthalapaty, MD Medical Student Lecture Series Department of Obstetrics & Gynecology Greenville Hospital System University Medical Center Greenville, South Carolina
    2. 2. Learning Objectives <ul><li>APGO ET-11: Intrapartum Care </li></ul><ul><li>Understanding the process of normal labor and delivery allows optimal care and reassurance for the parturient and timely recognition of abnormal events. </li></ul>APGO Medical Student Educational Objectives 8 th Ed. 2004
    3. 3. Learning Objectives ET-11 APGO Medical Student Educational Objectives 8 th Ed. 2004 KH Describe the evaluation of common puerperal complications KH Describe the different methods of delivery with the indications and contraindications of each SH Describe the steps of a vaginal delivery KH Describe the three stages of labor and recognize common abnormalities KH List the signs and symptoms of labor Level of Competence Objective
    4. 4. Learning Objectives <ul><li>APGO Educational Topic 22: Abnormal Labor </li></ul><ul><li>Labor is expected to progress in an orderly and predictable manner. Careful observation of the mother and fetus during labor will allow early detection of abnormalities so that management can be directed to optimize outcome. </li></ul>APGO Medical Student Educational Objectives 8 th Ed. 2004
    5. 5. Learning Objectives ET-22 APGO Medical Student Educational Objectives 8 th Ed. 2004 K List indications and contraindications for oxytocin administration K Discuss fetal and maternal complications of abnormal labor K Describe methods of fetal surveillance K List abnormal labor patterns Level of Competence Objective
    6. 6. Learning Objectives ET-22 APGO Medical Student Educational Objectives 8 th Ed. 2004 K Discuss strategies for emergency management of breech, shoulder dystocia and cord prolapse K List indications for VBAC Level of Competence Objective
    7. 7. Terminology <ul><li>Gravidity </li></ul><ul><ul><li>#of current and completed pregnancies of any kind </li></ul></ul><ul><li>Parity </li></ul><ul><ul><li># of completed pregnancies ≥ 20 weeks </li></ul></ul><ul><ul><li>not delivered infants (e.g. twins) </li></ul></ul>
    8. 8. Terminology <ul><li>Nullipara </li></ul><ul><li>Primipara </li></ul><ul><li>Multipara </li></ul><ul><li>Grand Multipara </li></ul>
    9. 9. Terminology <ul><li>TPAL Nomenclature: T = Term deliveries ≥ 37 wks P = Preterm deliveries < 37 wks A = Abortions (< 20 wks) L = Living children </li></ul>
    10. 10. <ul><li>G3/P1-0-1-1: </li></ul>Terminology
    11. 11. <ul><li>G3/P1-0-1-1: </li></ul><ul><ul><li>3rd Pregnancy </li></ul></ul><ul><ul><li>1 Term delivery </li></ul></ul><ul><ul><li>0 Preterm deliveries </li></ul></ul><ul><ul><li>1 Abortion </li></ul></ul><ul><ul><li>1 Living child </li></ul></ul>Terminology
    12. 12. <ul><li>G5/P2-1-1-0: </li></ul>Terminology
    13. 13. <ul><li>G5/P2-1-1-0: </li></ul><ul><ul><li>5th Pregnancy </li></ul></ul><ul><ul><li>2 Term deliveries </li></ul></ul><ul><ul><li>1 Preterm delivery </li></ul></ul><ul><ul><li>1 Abortion </li></ul></ul><ul><ul><li>0 Living children </li></ul></ul>Terminology
    14. 14. <ul><li>G2/P0-2-0-3: </li></ul>Terminology
    15. 15. <ul><li>G2/P0203: </li></ul><ul><ul><li>2nd Pregnancy </li></ul></ul><ul><ul><li>0 Term deliveries </li></ul></ul><ul><ul><li>2 Preterm deliveries </li></ul></ul><ul><ul><li>0 Abortions </li></ul></ul><ul><ul><li>3 Living children </li></ul></ul>Terminology
    16. 16. <ul><li>Fetal Presentation </li></ul><ul><li>Attitude </li></ul><ul><li>Fetal Lie </li></ul><ul><li>Fetal Position </li></ul><ul><li>Fetal Station </li></ul>Terminology
    17. 17. <ul><li>Designates the fetal part over the pelvic inlet </li></ul>Fetal Presentation
    18. 18. Fetal Presentation Presentation % Incidence Cephalic 96.8 --- Breech 2.7 1:36 Transverse 0.3 1:335 Compound 0.1 1:1000 Face 0.05 1:2000 Brow 0.01 1:10,000 Williams Obstetrics, 21 st Ed. 452.
    19. 20. Cephalic Presenting Diameters FACE SINCIPUT MILITARY BROW VERTEX FLEXED Figure 9-2 Lateral view of the fetal skull showing the prominent landmarks and the anteroposterior diameters.
    20. 21. <ul><li>The degree of flexion a fetus assumes during labor or the relation of the fetal parts to each other </li></ul>Fetal Attitude
    21. 22. Variations in Fetal Attitude SINCIPUT, MILITARY BROW FACE VERTEX, FLEXED
    22. 23. Fetal Lie <ul><li>Refers to the relation of the long axis of fetus (back) to the long axis of the mother: </li></ul>------ Transverse ------ -------------- Longitudinal ----------------
    23. 24. Diagnosis of Fetal Presentation <ul><li>Abdominal Palpation </li></ul><ul><ul><li>- Leopold’s Maneuvers </li></ul></ul>
    24. 26. Diagnosis of Fetal Presentation <ul><li>Abdominal Palpation </li></ul><ul><ul><li>- Leopold’s Maneuvers </li></ul></ul><ul><li>Vaginal Examination </li></ul><ul><li>Auscultation </li></ul><ul><li>Sonography </li></ul>
    25. 27. Fetal Position <ul><li>Refers to the relation of an arbitrarily chosen portion of the fetal presenting part to the right or left side of the maternal birth canal </li></ul><ul><li>Reference points (denominators) are: </li></ul><ul><ul><ul><ul><li>Fetal occiput </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fetal chin (mentum) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fetal sacrum </li></ul></ul></ul></ul>
    26. 28. Fetal Head: Landmarks Figure 9-1 Superior view of the fetal skull showing the sutures, fontanelles, and transverse diameters.
    27. 29. Occiput Presentation
    28. 30. Fetal Position OP LOT OA ROT LOP ROP LOA ROA <ul><li>LOT: 40% </li></ul><ul><li>ROT: 20% </li></ul><ul><li>OP: 20% </li></ul>
    29. 31. Fetal Position ?????
    30. 32. Fetal Position Left Occiput Anterior
    31. 33. Fetal Position ?????
    32. 34. Fetal Position Right Occiput Posterior
    33. 35. Fetal Position ?????
    34. 36. Fetal Position Left Occiput Transverse
    35. 37. <ul><li>The relationship of the fetal presenting part to the level of the ischial spines </li></ul>Fetal Station
    36. 38. Fetal Station World Health Organization: Managing Complications in Pregnancy and Childbirth www.who.int/reproductivehealth/impac/Clinical_Principles/Normal_labour_C57_C76.html
    37. 39. Clinical Correlation <ul><li>Correct identification of fetal position relative to the birth canal is critical! </li></ul><ul><li>Document the following: </li></ul><ul><ul><li>Fetal Lie </li></ul></ul><ul><ul><li>Fetal Presentation </li></ul></ul><ul><ul><li>Fetal Position </li></ul></ul><ul><ul><li>Fetal Station </li></ul></ul>
    38. 40. Labor
    39. 41. Terminology <ul><li>False Labor (Braxton-Hicks ctx) </li></ul><ul><ul><li>May be present from first trimester </li></ul></ul><ul><ul><li>Irregular, nonrhythmic </li></ul></ul><ul><li>True Labor </li></ul><ul><ul><li>Rhythmic contractions with cervical change </li></ul></ul>
    40. 42. Essential Factors of Labor (The 3 P’s) <ul><li>Passage </li></ul><ul><li>Powers </li></ul><ul><li>Passenger </li></ul>
    41. 43. The 3 P’s of Labor Passage
    42. 44. Passage <ul><li>Bony Pelvis </li></ul><ul><ul><li>inlet </li></ul></ul><ul><ul><li>midpelvis </li></ul></ul><ul><ul><li>outlet </li></ul></ul><ul><li>Soft Tissue </li></ul>
    43. 45. Caldwell-Moloy Classification A P Gynecoid A P Android P A Platypelloid P A Anthropoid
    44. 46. Caldwell-Moloy Classification <ul><li>Gynecoid = 40 – 50% (10-15% AA) </li></ul><ul><li>Android = 30% </li></ul><ul><li>Anthropoid = 20% (40% in AA) </li></ul><ul><li>Platypelloid = 2- 5% </li></ul>
    45. 47. Gynecoid Pelvis <ul><li>Round at the inlet, with the widest transverse diameter only slightly greater than the anteroposterior diameter </li></ul><ul><li>Side walls straight </li></ul><ul><li>Ischial spines of average prominence </li></ul><ul><li>Well-rounded sacrosciatic notch </li></ul><ul><li>Well-curved sacrum </li></ul><ul><li>Spacious subpubic arch, with an angle of approximately 90 degrees </li></ul>
    46. 48. Android Pelvis <ul><li>Triangular inlet with a flat posterior segment and the widest transverse diameter closer to the sacrum than in the gynecoid type </li></ul><ul><li>Convergent side walls with prominent spines </li></ul><ul><li>Shallow sacral curve </li></ul><ul><li>Long and narrow sacrosciatic notch </li></ul><ul><li>Narrow subpubic arch </li></ul>
    47. 49. Anthropoid Pelvis <ul><li>A much larger AP than transverse diameter, creating a long narrow oval at the inlet </li></ul><ul><li>Side walls that do not converge </li></ul><ul><li>Ischial spines that are not prominent but are close, owing to the overall shape </li></ul><ul><li>Variable, but usually posterior, inclination of the sacrum </li></ul><ul><li>Large sacrosciatic notch </li></ul><ul><li>Narrow, outwardly shaped subpubic arch </li></ul>
    48. 50. Pelvic Landmarks - Inlet <ul><li>Sacral promontory </li></ul><ul><li>Illiopectineal line </li></ul><ul><li>Symphysis pubis </li></ul>
    49. 51. <ul><li>mywebpages.comcast.net/wnor/pelvis.htm --Wesley Norman, PhD, DSc Georgetown University </li></ul>Pelvic Landmarks - Inlet
    50. 52. Pelvic Landmarks - Inlet
    51. 53. Vaginal Examination to Determine the Diagonal Conjugate
    52. 54. Pelvic Landmarks - Mid <ul><li>Ischial spines </li></ul><ul><li>Sacrum </li></ul><ul><li>Sacrosciatic notch </li></ul>
    53. 55. <ul><li>mywebpages.comcast.net/wnor/pelvis.htm --Wesley Norman, PhD, DSc Georgetown University </li></ul>Pelvic Landmarks - Mid
    54. 56. Assessment of Mid-pelvis
    55. 57. Pelvic Landmarks - Outlet <ul><li>Pubic arch </li></ul><ul><li>Ischial tuberosities </li></ul><ul><li>Sacrococcygeal joint </li></ul>
    56. 58. Pelvic Landmarks - Outlet Figure 9-4 Pelvic outlet and its diameters.
    57. 59. Assessment of Pelvic Outlet
    58. 60. Minimum Pelvimetrics * Average measurement, no minimum defined 8 Bituberous Outlet 10.5* Bispinous Midplane 11.5 Diagonal conjugate   Inlet Length (cm) Diameter Pelvic Plane
    59. 61. The 3 P’s of Labor Powers
    60. 62. Powers <ul><li>50 mm Hg or more </li></ul><ul><li>Contractions occur q 2-3 minutes </li></ul><ul><li>Upper uterus more active with pacemakers at cornual </li></ul>
    61. 63. The 3 P’s of Labor Passenger
    62. 64. Passenger <ul><li>Head is typically the largest structure </li></ul><ul><li>Molding </li></ul><ul><li>Smallest diameter of head: </li></ul><ul><ul><li>suboccipitobregmatic </li></ul></ul><ul><li>Abnormal lie or size or presentation can cause problems </li></ul>
    63. 65. Passenger: Fetal Head Considerations <ul><li>Bones in face fused but cranial vault has movable bones </li></ul><ul><li>Molding is when bones overlap under pressure </li></ul><ul><li>Sutures are membranous spaces between bones </li></ul><ul><li>Fontanelles or “soft spots” are the intersections between sutures </li></ul>
    64. 66. Molding
    65. 67. Passage and Passenger Relationship <ul><li>Engagement –the fetal head is thru the pelvic inlet when fetal BPD reaches the ischial spines </li></ul>
    66. 68. Passage and Passenger Relationship <ul><li>Station - descent of the fetal BPD, relative to the level of the ischial spines. </li></ul>
    67. 69. COURSE OF NORMAL LABOR
    68. 70. Labor Definition <ul><li>The physiologic process by which the gravid uterus evacuates its contents at or near term by a mechanism involving coordinated sequence of periodic contractions of the myometrium effecting progressive cervical dilatation and fetal descent through the birth canal. </li></ul><ul><li>- Emanuel A. Friedmin </li></ul>
    69. 71. First Stage of Labor <ul><li>Onset of true labor until cervix fully dilated: Latent Phase Active Phase </li></ul>
    70. 72. First Stage of Labor
    71. 74. First Stage of Labor
    72. 75. Second Stage of Labor <ul><li>Complete dilatation to delivery of the infant </li></ul>
    73. 76. Cardinal Movements of Labor <ul><li>Engagement, descent, flexion </li></ul><ul><li>Internal rotation </li></ul><ul><li>Complete rotation with beginning of extension </li></ul><ul><li>Complete extension </li></ul>
    74. 77. <ul><li>External Rotation (Restitution) </li></ul><ul><li>External rotation with delivery of Anterior shoulder </li></ul><ul><li>Expulsion with delivery of Posterior shoulder </li></ul>
    75. 78. Third Stage of Labor <ul><li>Delivery of the infant to delivery of the placenta </li></ul>
    76. 79. Third Stage of Labor <ul><li>Placental separation: </li></ul><ul><ul><li>Uterus becomes firmer </li></ul></ul><ul><ul><li>Gush of blood </li></ul></ul><ul><ul><li>Uterus rises in abdomen as placenta passes into lower segment </li></ul></ul><ul><ul><li>Lengthening of umbilical cord </li></ul></ul>
    77. 80. Power: Forces of Labor <ul><li>First Stage of Labor </li></ul><ul><ul><li>Primary Forces = Uterine ctx to dilate cervix to 10 cm </li></ul></ul><ul><li>Second Stage of Labor </li></ul><ul><ul><li>Secondary Forces = Abdominal muscles to push fetus out after cervix is fully dilated </li></ul></ul><ul><li>Third Stage of Labor </li></ul><ul><ul><li>- Primary Forces = Uterine ctx to deliver placenta </li></ul></ul>
    78. 81. INTRAPARTUM MANAGEMENT
    79. 82. Fetal Heart Rate Monitoring <ul><li>External: Indirect - Doppler ultrasound </li></ul><ul><li>Internal: Direct – Scalp electrode </li></ul>
    80. 83. Fetal Heart Rate Monitoring <ul><li>External: </li></ul><ul><ul><li>Assessment of: </li></ul></ul><ul><ul><ul><li>baseline, variability, accelerations, decelerations </li></ul></ul></ul><ul><ul><li>Limitations: </li></ul></ul><ul><ul><ul><li>Maternal Body Habitus </li></ul></ul></ul><ul><ul><ul><li>Maternal/Fetal Movement Artifact </li></ul></ul></ul>
    81. 84. Fetal Heart Rate Monitoring <ul><li>Internal: </li></ul><ul><ul><li>Assessment of: </li></ul></ul><ul><ul><ul><li>baseline, variability, accelerations, decelerations </li></ul></ul></ul><ul><ul><li>Limitations: </li></ul></ul><ul><ul><ul><li>Membranes must be ruptured </li></ul></ul></ul><ul><ul><ul><li>Minimally invasive </li></ul></ul></ul><ul><ul><ul><li>Increase risks of Hep B/HIV if mother + </li></ul></ul></ul><ul><ul><ul><li>Maternal HR detected if FHR absent </li></ul></ul></ul>
    82. 85. Contraction Monitoring <ul><li>External: </li></ul><ul><ul><li>Indirect: Abdominal pressure electrode </li></ul></ul><ul><li>Internal: </li></ul><ul><ul><li>Direct: IUPC with pressure sensor </li></ul></ul>
    83. 86. Contraction Monitoring <ul><li>External: - Can detect presence and interval of ctx, but not strength - Limitations: Maternal Body Habitus Maternal/Fetal Movement Artifact Factitious contractions </li></ul>
    84. 87. Contraction Monitoring <ul><li>Internal: - Assessment of BOTH frequency and intensity of contractions - Limitations: Membranes must be ruptured Minimally invasive </li></ul>
    85. 88. Intrapartum Monitors
    86. 89. Fetal Heart Rate Interpretation Assessment <ul><li>Quality of tracing </li></ul><ul><li>Baseline fetal heart rate </li></ul><ul><li>Describe overall variability </li></ul><ul><li>Presence of accelerations? </li></ul><ul><li>Presence of decelerations? </li></ul><ul><li>Contraction frequency/intensity </li></ul>
    87. 102. Fetal Heart Rate Tracing
    88. 103. Fetal Monitoring Guidelines
    89. 104. Normal Labor Parameters Source: Modified from Friedman EA. Labor: Clinical Evaluation and Management, 2 nd ed. New York. Appletion-Century-Cronz 1370.43 2.5 h 57 min Second Stage 1.2 cm/h 3.0 cm/h Maximum Slope 3.3 h 54 min Deceleration 11.5 h 4.9 h Active 20.6 h 8.6 h Latent Lower Limit (95%) Mean Nulliparous Labor
    90. 105. Normal Labor Parameters Source: Modified from Friedman EA. Labor: Clinical Evaluation and Management, 2 nd ed. New York. Appletion-Century-Cronz 1370.43 50 min 14 min Second Stage 1.5 cm/h 5.7 cm / h Maximum Slope 53 min 14 min Deceleration 5.2 h 2.2 h Active 13.6 h 5.3 h Latent Lower Limit (95%) Mean Multiparous Labor
    91. 106. Abnormal Labor Assessment <ul><li>Clinical Caveat </li></ul><ul><li>Labor dystocia requires a close assessment of the 3-P’s to determine the etiology and implement appropriate management changes to address the problem identified. </li></ul>
    92. 107. Adequate Labor <ul><li>Defined as > 200 Montevideo units (MVU) as measured by IUPC </li></ul><ul><li>MVU = Sum of contraction strength for each contraction occurring over 10 minutes </li></ul>
    93. 108. MVUs = ????
    94. 109. MVUs = 270 “Adequate Labor”
    95. 110. 7 Labor Dysfunctions <ul><li>Prolonged Latent Phase </li></ul><ul><ul><li>Definition: </li></ul></ul><ul><ul><ul><li>> 20 hours nullipara </li></ul></ul></ul><ul><ul><ul><li>> 14 hours multipara </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>“ Therapeutic rest” = sedatives </li></ul></ul></ul><ul><ul><ul><ul><li>85% awaken in 6-10 hours and progress to active phase </li></ul></ul></ul></ul><ul><ul><ul><ul><li>10% have stopped contracting </li></ul></ul></ul></ul><ul><ul><ul><ul><li>5% continue to contract without progression, requiring uterine stimulation. </li></ul></ul></ul></ul><ul><ul><ul><li>Oxytocin </li></ul></ul></ul>
    96. 111. 7 Labor Dysfunctions <ul><li>Protracted Active Phase </li></ul><ul><ul><li>Definition: </li></ul></ul><ul><ul><ul><li>Cervical dilation < 1.2 cm/h nullipara </li></ul></ul></ul><ul><ul><ul><li>Cervical dilation < 1.4 cm/h multipara </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Evaluate passenger, passageway, power </li></ul></ul></ul><ul><ul><ul><li>IUPC to calculate MVU (goal > 200) </li></ul></ul></ul><ul><ul><ul><li>Oxytocin augmentation </li></ul></ul></ul>
    97. 112. 7 Labor Dysfunctions <ul><li>Protracted Deceleration Phase </li></ul><ul><ul><li>Definition: </li></ul></ul><ul><ul><ul><li>> 3 hours nullipara </li></ul></ul></ul><ul><ul><ul><li>> 1 hour multipara </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Same as for protracted active phase </li></ul></ul></ul><ul><ul><ul><li>Evaluate passenger, passageway, power </li></ul></ul></ul><ul><ul><ul><li>IUPC to calculate MVU (goal > 200) </li></ul></ul></ul><ul><ul><ul><li>Oxytocin augmentation </li></ul></ul></ul>
    98. 113. 7 Labor Dysfunctions <ul><li>Secondary Arrest of Dilatation in Active phase </li></ul><ul><ul><li>Definition: </li></ul></ul><ul><ul><ul><li>Absence of cervical change over 2 hours* </li></ul></ul></ul><ul><ul><ul><li>MVU > 200 </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Cesarean delivery </li></ul></ul></ul><ul><li>* Extension to 4 hours results in higher rate of vaginal delivery (92%) and is also acceptable </li></ul>
    99. 114. 7 Labor Dysfunctions <ul><li>Protracted Descent </li></ul><ul><ul><li>Definition: </li></ul></ul><ul><ul><ul><li>< 1 cm/h nullipara </li></ul></ul></ul><ul><ul><ul><li>< 2 cm/h multipara </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Same as for protracted active phase </li></ul></ul></ul><ul><ul><ul><li>Evaluate passenger, passageway, power </li></ul></ul></ul><ul><ul><ul><li>IUPC to calculate MVU (goal > 200) </li></ul></ul></ul><ul><ul><ul><li>Oxytocin augmentation </li></ul></ul></ul>
    100. 115. 7 Labor Dysfunctions <ul><li>Arrest of Descent in Second Stage </li></ul><ul><ul><li>Definition: </li></ul></ul><ul><ul><ul><li>No descent of presenting part in: </li></ul></ul></ul><ul><ul><ul><li>> 2 hours (or > 3 hours with CLE) nullipara </li></ul></ul></ul><ul><ul><ul><li>> 1 hour (or > 2 hours with CLE) multipara </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Continued observation </li></ul></ul></ul><ul><ul><ul><li>Operative vaginal delivery </li></ul></ul></ul><ul><ul><ul><li>Cesarean delivery </li></ul></ul></ul>
    101. 116. 7 Labor Dysfunctions <ul><li>Failure of Descent </li></ul><ul><ul><li>Definition: </li></ul></ul><ul><ul><ul><li>No descent in > 1 hour nullipara </li></ul></ul></ul><ul><ul><ul><li>No descent in > 30 min multipara </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Same as for protracted active phase </li></ul></ul></ul><ul><ul><ul><li>Evaluate passenger, passageway, power </li></ul></ul></ul><ul><ul><ul><li>IUPC to calculate MVU (goal > 200) </li></ul></ul></ul><ul><ul><ul><li>Oxytocin augmentation </li></ul></ul></ul>
    102. 117. Labor Assessment Case 1 <ul><li>32 yo G1P0 36 weeks presented with contractions. Looks uncomfortable, and is contracting every 3 minutes but cervix is 2 cm and 50% effaced. Was seen the previous day with similar complaints and findings. </li></ul><ul><li>Diagnosis: </li></ul><ul><li>Management: </li></ul>
    103. 118. Labor Assessment Case 1 <ul><li>32 yo G1P0 36 weeks presented with contractions. Looks uncomfortable, and is contracting every 3 minutes but cervix is 2 cm and 50% effaced. Was seen the previous day with similar complaints and findings. </li></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>Prolonged latent phase </li></ul></ul><ul><li>Management: </li></ul><ul><ul><li>“ Therapeutic Rest” </li></ul></ul>
    104. 119. Labor Assessment Case 2 <ul><li>24 yo P1001 39 weeks presented in labor. Contracting every 3 minutes but looks comfortable. Progressed from 4 to 6 centimeters in 6 hours. Membranes intact. Estimated fetal weight – 3000 grams. Pelvis adequate on examination. Vertex presentation. </li></ul><ul><li>Diagnosis: </li></ul><ul><li>Management: </li></ul>
    105. 120. Labor Assessment Case 2 <ul><li>24 yo P1001 39 weeks presented in labor. Contracting every 3 minutes but looks comfortable. Progressed from 4 to 6 centimeters in 6 hours. Membranes intact. Estimated fetal weight – 3000 grams. Pelvis adequate on examination. Vertex presentation. </li></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>Protracted active phase likely secondary to inadequate labor (insufficient power) </li></ul></ul><ul><li>Management: </li></ul><ul><ul><li>Amniotomy, Oxytocin augmentation +/- IUPC </li></ul></ul>
    106. 121. Labor Assessment Case 3 <ul><li>32 yo P0000 Class C diabetic at 40 weeks undergoing labor induction. Contracting every 2-3 minutes. 7 cm dilation x 4 hours. Confirmed adequate labor with intrauterine pressure catheter. Membranes ruptured, Estimated fetal weight – 4200 grams. Pelvis adequate on examination. Vertex presentation. </li></ul><ul><li>Diagnosis: </li></ul><ul><li>Management: </li></ul>
    107. 122. Labor Assessment Case 3 <ul><li>32 yo P0000 Class C diabetic at 40 weeks undergoing labor induction. Contracting every 2-3 minutes. 7 cm dilation x 4 hours. Confirmed adequate labor with intrauterine pressure catheter. Membranes ruptured, Estimated fetal weight – 4200 grams. Pelvis adequate on examination. Vertex presentation. </li></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>Arrest of dilatation likely secondary to cephalopelvic disproportion/fetal macrosomia (Passenger too big for pelvis) </li></ul></ul><ul><li>Management: Cesarean Delivery </li></ul>
    108. 123. Labor Assessment Case 4 <ul><li>28 yo P0101 at 42 weeks presented in labor. History of previous MVA with pelvic fracture. Contracting every 2-3 minutes. 6 cm dilation x 4 hours. Confirmed adequate labor with intrauterine pressure catheter. Membranes ruptured, Estimated fetal weight – 3200 grams. Constricted pelvic inlet with non-engaged fetal head. Vertex presentation. </li></ul><ul><li>Diagnosis: </li></ul><ul><li>Management: </li></ul>
    109. 124. Labor Assessment Case 4 <ul><li>28 yo P0101 at 42 weeks presented in labor. History of previous MVA with pelvic fracture. Contracting every 2-3 minutes. 6 cm dilation x 4 hours. Confirmed adequate labor with intrauterine pressure catheter. Membranes ruptured, Estimated fetal weight – 3200 grams. Constricted pelvic inlet with non-engaged fetal head. Vertex presentation. </li></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>Arrest of dilatation likely secondary to cephalopelvic disproportion/abnormal pelvis (Pelvis too small for pelvis) </li></ul></ul><ul><li>Management: Cesarean Delivery </li></ul>

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