Normal labor

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By Dr. Suhas Otiv

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Normal labor

  1. 1. Normal labor Dr. S. R. OtivConsultant, KEM Hospital, Pune
  2. 2. 10
  3. 3. 11
  4. 4. 12
  5. 5. Flexed vertex Deflexed vertex Brow Face13
  6. 6. 14
  7. 7. Fetal skull15
  8. 8. Diameters of the fetal skull16
  9. 9. Fetal head - pelvis relationship17
  10. 10. 18
  11. 11. Mechanism of labor QuickTime™ and a decompressor are needed to see this picture.19
  12. 12. Cardinal movements in labor• Engagement• Descent• Flexion• Internal rotation• Extension• External rotation• Expulsion
  13. 13. Flexion21
  14. 14. Mechanism of labor video save-video2.mp423
  15. 15. 24
  16. 16. 25
  17. 17. 26
  18. 18. 28 28
  19. 19. Course of labor with OP• Engagement • Engagement • Engagement• Descent • Descent • Descent• Flexion • Flexion • Deflexion• Long IR 135o • Short IR 45o • DTA or POP• Extension • Flexion• Restitution • Extension• Ext rotn • Restitution• Lat flexion • Ext rotn 29 • Lat flexion
  20. 20. OP: Failure of cardinal movementsEngagement • Engagement occurs late after onset ofDescent laborFlexion • Descent is slowInternal rotationExtension • Flexion is inadequate or absentExternal rotation • Long internal rotation does not occurExpulsion 30 30
  21. 21. Why does the fetal head remain high after onset of labor?Engagement • Extension of fetal spineDescentFlexion – misdirection of fetal axis – deflexion of fetal headInternal rotationExtension • Deflexion of fetal head largerExternal rotation diameter of presenting partExpulsion 31
  22. 22. Why does slow descent occur in OP labor?Engagement • Deflexion leads to oblong presenting diameter that does not dilate the cervixDescent properly. The resulting weak Ferguson reflex leads to inadequate uterineFlexion contractionsInternal rotation • Misdirected uterine force: verticallyExtension down rather than inclined posteriorly into the brimExternal rotationExpulsion 32
  23. 23. Why does flexion fail?Engagement • Fetal spine lies against convexity of maternal spine.Descent Extension of fetal spine --> deflexionFlexion • Tight maternal abdomen in primi exaggerates deflexionInternal rotationExtension • Weak uterine forceExternal rotation • Other - brachycephaly, steep angle of inclinationExpulsion 33 33
  24. 24. Failure of internal rotationEngagement • Deflexed head - sinciput reaches pelvicDescent floor and is rotated anteriorly, occiput posteriorlyFlexion • Inadequate uterine contractionsInternalrotation • Shoulder caught against maternal spineExtension • Shallow or flat sacrum in android pelvisExternal rotation 34Expulsion 34
  25. 25. Management of labor• Initial assessment• Monitoring• Pain relief• Emotional support• Nursing care• Intervention
  26. 26. Initial assessment• Assess baseline status to determine progress• Medical or obstetric conditions that need to be addressed – prenatal record• Development of new disorders• Evaluate fetal status
  27. 27. Examination• General: P, BP, temp, wt• Systemic – CVS , RS,• P/A – scars, presentation, position, anterior shoulder, head level, FHR location, contraction freq / duration / baseline tone• CTG trace
  28. 28. Internal examination• Lesions of genital herpes• Cervix – dilatation, effacement, consistency, direction, how well applied to pp• Presenting part - ?, station, moulding, position, caput, asynclitism, descent during contraction• Bag of fore water – intact / absent, size• AF – clear / colored• Pelvis
  29. 29. Lab tests• Check reports – Hb, HCT, blood group, HIV HbsAg, GBS screen• Urine albumin, HIV, HbsAg,
  30. 30. 40
  31. 31. Prenatal record• History• E• Serology• USG – IUGR, dates,
  32. 32. Deep transverse arrestArrest of fetal head at the ischial spines aftermore than 1 hour of full cervical dilatationin spite of adequate contractions.Causes – epidural analgesia – narrow outlet43 43
  33. 33. Management of DTA• Digital rotation• Manual rotation• Forceps rotation – Smellie Scanzoni maneuver with Simpson forceps – Kjelland forceps• Vacuum extraction• C-section44
  34. 34. Manual Rotation of head • Adequate amniotic fluid • Normal fetal heart • Head should be on pelvic floor45 • Dis-impact head before rotation
  35. 35. 46
  36. 36. Simpson Forceps47
  37. 37. 48
  38. 38. Prevention•Maternal positions (upright, non supine and hands/knees)in labor•Augmentation of labor reduces likelihood of persistent OPP•Manual rotation of the fetal head to occiput anterior after7cm to full dilatation improves the rate of occiput anteriordeliver•Epidural analgesia does not facilitate rotation49
  39. 39. Thank you !50

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