Normal labor-and-delivery by Dr syed khawar

2. Syed Khawar Shah
08-191

3.  Definitions
 Scenario
 Stages
 Mechanics
 Cardinal movements
 Delivery
 Management

4.  Labor – Uterine contractions that result in
effacement and dilatation of the cervix.
 Braxton-Hicks – Uterine contractions NOT
associated with cervical change.
 Shorter in duration
 Less intense
 Over lower abdomen and groin
 Resolve with ambulation
 Lightening – Descent of the fetal head into the
pelvis

5.  Preterm labor – Prior to 37 weeks
 Term – 37 to 42 weeks
 Post term – After 42 weeks
 Post dates – After 40 weeks

6.  22yo G2P1 at 39 wks comes complaining of RUC’s q5
minutes x 2 hours.Bring the patient up to the monitor
and patient’s chart to you to further evaluate the
patient.

7.  Talk with the patient
 HISTORY
 Frequency,duration and strength of ctx’s
 Colour & amount of amniotic fluid lost
 Abnormal veginal discharge or bleeding
 Fetal movements
 Examine patient
Abdominal examination
Veginal examination

8.  Admit patient to Labor and Delivery
 Complete Hx of ctx
 Consents signed for delivery and potential blood
transfusion
 Clear diet
 IVF’s
 T&S/CBC
 Continuous EFM vs. intermittent
 Intermittent = FHTs q 30 min to include a ctx and immediately after
 Membranes intact and well-engaged
 Continuous
poorly engaged, augmented labor, epidural?

9.  1st
Stage
 Interval between onset of labor and full cervical
dilatation
 2 phases:
 Latent – period between onset of labor and point at
which a change in slope of rate of cervical dilatation is
noted.
 Active – Greater rate of cervical dilatation and usually
begins around 2-3cm

10.  2nd
stage
 Interval between full cervical dilatation and delivery
 Duration
 Nulliparous – 3 hrs w/ epidural; 2 hrs w/o epidural
 Multiparous – 2 hrs w/ epidural; 1 hr w/o epidural
 3rd
stage
 Delivery of the placenta and membranes
 Duration – maximum of 30 minutes

11.  The Powers
 Forces generated by uterine musculature
 Frequency, amplitude, and duration of ctx’s
 Observation, manual palpation, tocodynamometry,
intrauterine pressure catheter (IUPC)

12.  Passenger
 Fetal size
 Abdominal palpation or Ultrasound
 Macrosomia (>4500g) associated w/ failure to
progress
 Lie
 Longitudinal axis of fetus relative to longitudinal
axis of uterus
 Longitudinal*, transverse or oblique
 Presentation
 Fetal part that directly overlies pelvic inlet
 Cephalic, breech, or shoulder
 Compound – presence of >1 fetal part overlying
the pelvic inlet
 Funic – umbilical cord presenting at pelvic inlet
 Malpresentation – any presentation that is not
cephalic with occiput leading

13.  Attitude
 Position of head with regard to fetal spine (ie: degree of
flexion or extension)
 Flexion allows smallest diameter of fetal head to
present at pelvic inlet
 Position
 Relationship of a nominated site of presenting part to
denominating location on internal pelvis
 Example: cephalic presentation

15.  Station
 Measure of descent of presenting
part of the fetus through the birth
canal.
 Multifetal Pregnancy
 Increase probability of abnormal lie
and malpresentation in labor

16.  Leopold’s maneuvers
 #1 – Correct dextrorotation of the uterus with the back of one
hand and delineate the fundus with the other to determine
gestational age and/or appropriate size.
 #2 – Run hands down maternal abdomen on either side of
fetus to determine fetal lie, identifying small parts and fetal
spine
 #3 – Firmly grasp upper and lower poles of fetus by placing
fingers at uterine fundus and above symphysis to determine
presentation and fetal size.
 #4 – Move hands in bilaterally from anterior superior iliac
crests to determine whether or not the presenting part of the
fetus is engaged in maternal pelvis.
 Head regarded as unengaged if examiner’s hands are see to
converge below fetal head.

17.  Passage
 Bony pelvis + soft tissues
 4 types of the female bony pelvis

18.  Engagement
 Passage of widest diameter of presenting part to level below
the plane of the pelvic inlet
 0 station
 Occurs earlier in nulliparous women (36 wks)
 Descent
 Downward passage of presenting part through the pelvis.
 Flexion
 Occurs passively as the head descends due to the shape of the
bony pelvis and resistance of pelvic floor soft tissues
 Allows smallest diameter of fetal head to pass through the
pelvis.

19.  Internal Rotation
 Rotation of presenting part from original position (transverse)
to anteroposterior position
 Extension
 Occurs once fetus has descended to the level of the introitus
 Base of occiput in contact with inferior margin of symphysis
pubis
 External Rotation
 Return of fetal head to correct anatomic position in relation to
the fetal torso
 Expulsion
 Delivery of rest of fetus
 Anterior shoulder delivered first with rotation under the
symphysis pubis

21.  Prepare for the delivery taking into account parity, progression of
labor, presentation of fetus, complications of labor
 When head crowns and delivery is eminent, protect the perineum
+ downward pressure to keep head flexed
 Ritgen’s maneuver my help if delay in delivery of the fetal head
 Sterile towel used to palpate fetal chin through the rectum to apply upward
pressure to facilitate extension of fetal head
 After delivery of head
 Allow for external rotation (restitution).
 Reduce nuchal cord
 Suction fetal mouth and nares
 After clearing fetal airway
 Place a hand on each parietal eminence to apply downward traction to
deliver anterior shoulder
 Followed by upward traction to deliver posterior shoulder

22.  Inspect the placenta
 Abnormalities of lobulation
 Site of insertion of umbilical cord into the placenta
 Marginal insertion –inserts into edge of placenta
 Membranous insertion – vessels course through the membranes
prior to attaching to placental disk
 Length (50-60cm)
 2 arteries and 1 vein
 Single umbilical artery associated with 20% risk of other structural
anomalies.

23.  Maternal vital signs
-temperature, pulse, blood pressure
: at least every 4 hours
(if membrane rupture or high temperature: hourly)
-prolonged membrane rupture (>18 hrs)
:antibiotics (preventtion of group B streptococcus)

24.  Oral intake
- food should be withheld during active labor
and delivery
- in labor & analgesics are administered
:gastric emptying time is prolonged
:not absorbed ,vomited, and aspiration
-sips of clear liquids, occasional ice chips, and
lip moisturizers are permitted

25.  Intravenous fluids
-there is seldom any real need for such in the
normally pregnant at least until analgesia
is administered
-advantage: oxitocin prophylactically (atony persist)
administration of glucose, Na, water
(prevent dehydration & acidosis)

26.  Subsequent vaginal examination
-the status of the cervix
the station & position of the presenting part
-at 2- to 3-hour intervals
-sterile, water-soluble lubricants
avoid povidone-iodine and hexachlorophene
-if membrane rupture before engage
:fetal heart rate should be checked
vaginal exam-umbilical cord compression

27.  Analgesia
-depend on the needs and desires of the women
-the timing, method of the administration, and
size of initial and subsequent doses are based
to a considerable degree on the anticipated
interval of the time until delivery
-a repeat vaginal exam before administering analgesia

28.  Urinary bladder function
-bladder distention should be avoided
: obstructed labor
subsequent bladder hypotonia and infection
-ambulation: self voiding
if not, intermittent catheterization