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Transcript of Normal Labor & Delivery - scs.msu.edu Labor and Delivery.pdf · 6/10/2019 1 Normal Labor & Delivery...
6/10/2019
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Normal Labor & DeliveryJulianne Scott, DO-PGY 2
Henry Ford Wyandotte Hospital
June, 2019
Normal Labor & Delivery - Outline
1. True vs. False labor2. Assessment of laborers
• Cervical exams• Internal monitors
3. First stage of Labor4. Second stage of Labor5. Third Stage of Labor6. Recovery
Normal Labor & Delivery – True vs. False
• Definition: Uterine contractions that cause progressive cervical change (dilation and effacement)
• Regular uterine contractions every 3 to 5 minutes for 1 hour
True Labor:
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Normal Labor & Delivery – True vs. False
• Braxton Hicks contractions• “practice contractions”• Contractions w/o cervical change• Night-time fluctuations of Oxytocin• May be pacified with intervening maneuvers
False Labor:
Normal Labor & Delivery – True vs. False
Other easily confused “labor” pains:Lower back strainGas / Constipation
Hip instabilityRound ligament pain
Ovarian cystsUTI / pyelonephritis
Uterine rupture
Any history of cesarean sections?
• Electronic fetal monitoring- Assessment of Uterine Activity- Assessment of Fetal Heart Tones- Known problems during pregnancy- Fetal movement
Normal Labor & Delivery – Assessment Status of Fetus:
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• Baseline • Variability • Accelerations • Decelerations
• Baseline (110-160 bpm)• Variability (moderate: 5-25 bpm)• Accelerations (10-15 bpm over 10-15 sec)• Decelerations (15 bpm over 15 sec)• Contractions
Normal Labor & Delivery – Assessment Status of Fetus:
Practice Bulletin # 106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles
Practice Bulletin # 116: Management of Fetal Heart Rate Tracings
Normal Labor & Delivery – Assessment Status of Fetus:
• Baseline (110-160 bpm)• Variability (moderate: 5-25 bpm)• Accelerations (10-15 bpm over 10-15 sec)• Decelerations (15 bpm over 15 sec)
• Decelerations
Normal Labor & Delivery – Assessment Status of Fetus:
Decelerations
Early
Head compressionGradual decrease in FHR
corresponding with contraction
Late
Uteroplacentalinsufficiency
Gradual decrease in FHR;nadir at end of contraction
Variable
Cord compressionAbrupt decrease in FHR;
any point during contractions
Prolonged 15 bpm below baseline > 2 min but < 10 min
Baseline shift > 10 min
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Normal Labor & Delivery – Assessment
• Decelerations – interventions/considerations~ cervical check (check for cord, rapid change)~ reposition~ oxygen~ placement of internal monitors ~ bolus with fluids ~ turn off pitocin~ tocolytics- Amnioinfusion (variables)
• D5 IV fluids (caution in diabetics)• Scalp / Vibroacoustic stimulation
Status of Fetus:
Normal Labor & Delivery – Assessment
Normal Labor & Delivery – Assessment
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Normal Labor & Delivery – Assessment
• Frequency• Duration • Intensity• Adequate contractions: Every 2-3 minutes
approximately 60s in duration
Status of Contractions:
• Montevideo unit (aka: MVU): Pressure of contractions over a 10 minute period~ 200 MVU
Normal Labor & Delivery – Assessment Status of Fetus:
Practice Bulletin # 106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles
Practice Bulletin # 116: Management of Fetal Heart Rate Tracings
• ROM, SROM, PROM, PPROM, AROM• Pooling• Fluid produced with valsava• Nitrazine testing• Ferning• AFI / MVP• ROM+
Normal Labor & Delivery – Assessment Status of Membranes:
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• Dilation• Effacement• Stage • Consistency• Position
Status of Cervix:
Normal Labor & Delivery – Assessment
• Dilation
Presentation vs. Position?
Normal Labor & Delivery – Assessment
The “presenting” part
Orientation of he “presenting” part
• Cephalic~ Vertex (occiput)~ Sinciput~ Brow~ Face (mental)
• Breech~ Frank~ Complete~ Incomplete~ Footling
Cephalic presentation:
Normal Labor & Delivery – Assessment
Vertex(Occiput)
Sinciput Brow Face(Mental)
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Breech presentation:
Normal Labor & Delivery – Assessment
Hips: Flexed Flexed FlexedKnees: B/L Flexed Flex/Ext B/L extended
Position:
Normal Labor & Delivery – Assessment
Anterior fontanelle
Posterior fontanelle
Metopic suture
Coronal suture
Sagittal suture
Lambdoid suture
Position:
Normal Labor & Delivery – Assessment
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Normal Labor & Delivery – Stages of Labor
• Latent phase: begins with maternal perception of regular contractions until 4-6 cm
• Prolonged latent phase:
– Nullip: >20 hours
– Multip: >14 hours
Normal Labor & Delivery – Stages of Labor
Active phase: Begins at 4-6 cm and lasts until complete dilation
Multips are often faster than nullips in the active phase
(Consortium on Safe Labor 2010)
0.5-0.7 cm/hr nullip
0.5-1.3 cm/hr multip
Normal Labor & Delivery – Stages of Labor
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Normal Labor & Delivery – Stages of Labor
• Second stage: • Second stage: Expulsion of the fetus
Stage Duration Begins Ends
Stage II -Expulsion
of fetus
Nulliparous w/ regional anesthesia < 3Hrs
w/o regional anesthesia < 2 Hrs
Multiparousw/ regional anesthesia < 2 Hrsw/o regional anesthesia < 1 Hr
Full dilation (10 cm)
Delivery of neonate
• Second stage: Expulsion of the fetus
Normal Labor & Delivery – Stages of Labor
Non - Operative delivery
Vacuum Forceps
Operative delivery
~ Bell~ Mushroom
~ Perineal support• “Laboring down”• Perineal massage• Warm compress
Normal Labor & Delivery – Stages of Labor
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Normal Labor & Delivery – Stages of Labor
• Second stage: Expulsion of the fetus
~ Episiotomy: no longer routine
• Midline vs. Mediolateral
• NRFHT / Create room to perform dystocia maneuvers or operative delivery
Normal Labor & Delivery – Stages of Labor
1) Support of perineum
2) Restitution
3) Check for nuchal cord
4) Thumbs to nose
5) Anterior shoulder > Posterior shoulder > rest of baby
6) Suctioning? No evidence it is beneficial in healthy term newborns unless obvious obstruction with secretions
7) Cord clamping (delayed 30-60sec) > cut > cord gases? > cord blood
Anterior shoulder
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Posterior shoulder
Stage Duration Begins Ends
Stage III - Placental separation and expulsion
Less than 30 minutes
Delivery of neonate
Delivery of placenta and fetal
membranes
• Third stage: • Third stage: Placental separation & expulsion
Signs of placental separation:• Gush of blood• Cord elongation• Globular and firming uterus• Rising of uterus
Signs of placental separation:
Normal Labor &Delivery – Stages of Labor
Third stage
Active management: prophylactic administration of uterotonic agent prior to placenta and controlled cord traction +/- uterine massage
Often oxytocin is used
Brandt-Andrews maneuver
Normal Labor & Delivery – Stages of Labor
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Normal Labor & Delivery – Stages of Labor
Stage Duration Begins Ends
Stage IV - Recovery2 hours post
deliveryDelivery of placenta
2 hours post partum
• “Fourth stage”: • “Fourth stage”: Recovery
Observe for possible complicationsPost-partum hemorrhageHematomas
Normal Labor & Delivery – Stages of Labor
Inspect vaginal area for lacerations ~ Labial~ Vaginal~ Periurethral~ Clitoral~ Perineal (1o, 2o, 3o, 4o)
Inspect placenta~ Number of vessels~ Cord insertion~ All membranes/cotyledons
Read these!
Practice Bulletin # 106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles
Practice Bulletin # 116: Management of Fetal Heart Rate Tracings
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Normal Labor & Delivery – References
1. Cunnigham, et. Al. “Williams Obstetrics. Chpt. 22 and 23.2. Tikkanen, et. Al. “Placenta percreta left in situ – management by delayed hysterectomy:
a case report.” J. of Med. Case Reports. 2011. 5:4183. www.doctorsintraining.com – Solid series Obgyn – videos: Normal labor parts 1, 2, &
3; Abnormal Labor parts 1 & 2.4. www.pennstatehershey.adam.com – Pregnancy Central – Labor and Delivery.
Retrived June 20155. Chao TT, et. Al. “The diagnosis and natural history of false preterm labor.” Obstet
Gynecol 118(6):1301, 2011.6. Practice Bulletin # 106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature,
Interpretation, and General Management Principles7. Practice Bulletin # 116: Management of Fetal Heart Rate Tracings
Thank you, and best of luck!
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Normal Labor & Delivery – Stages of Labor
• First stage: Cervical effacement and dilation
- Active Phase Abnormalities• More common in nulliparous
Normal Labor & Delivery – Stages of Labor