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Labor
-
Parturition or childbirth
Begins with onset of regular uterine
contraction
and ends with delivery of newborn and
expulsion of placenta
Characterized
by
functional
and
mechanical changes of the cervix as well
as the uterus to prepare for the labor
process
3. Uterine Phase 2 ( stimulation)
Active labor, incorporate the 3 stages of labor
from the onset of labor to the delivery of the
fetus
4. Uterine Phase 3 ( involution)
Events of puerperium
Uterine involution
Breast feeding is encouraged
Restoration period
-
4.
-
Prostaglandin
is a uterotonin and uterotropin
element
causes smooth muscle contraction
Oxytocin theory
Phases of parturition
1. Uterine phase 0 (uterine quiescence )
Prior to conception until the initiation
of parturition
Prelude to parturition
Characterized by:
o Uterine contractility
o Unresponsiveness
o Cervix is unyielding and still firm
2. Uterine Phase 1 (activation)
Time of uterine awakening
Prepare patient before labor
UTERINE PHASE 0
Prelude to parturition
Period of myometrial quiescenc
or unresponsiveness
Occurs before implantation until about 3538 weeks AOG
UTERINE PHASE 1
Uterine awakening
Initiation of parturition / preparation
childbirth
Suspension of uterine tranquility
Uterine modification:
Increase myometrial oxytocin receptors
Increase gap junctions
for
Uterine irritability
Responsiveness to uterotonins
Transition from occasional painless to
more frequent contraction
Formation of LUS (counterpart in non
pregnant patient: ISTHMUS)
Cervical softening and ripening
Cervical changes:
Cervix softens, yields and easily dilatable
Cervical ripening (PGE2a, PGF2a, relaxin)
Collagen breakdown
collagen fibers
rearrangement of
Decreased intracellular Ca
relaxation
o Increase
cGMP
intracellular
cAMP
and
uterine relaxation
UTERINE PHASE 3
Events of puerperium
Maternal recovery from childbirth
o
3rd
stage
4th
stage
PLACENTAL STAGE
an hour after the delivery of the placneta
UTERINE PHASE 2
Process of labor
3 stages of labor
Prodromes labor
Bloody show: extrusion of mucus plug
Lightening: 2-4 weeks before labor
Braxton-Hickscontractions
Weight loss: 1.3 lbs
Urinary frequency
Increased vaginal secretions
Increased backache and sacroiliac pain
Uterine changes
Pain
o Causes:
generation
o Increased intracellular Ca
contraction
Hypoxia
Formation of the:
o Upper uterine segment (UUS): ACTIVE
o Lower uterine segment (LUS): INACTIVE
Uterine
Uterine
activity
Contraction
Thickness
Fibers
Function
activity
UUS(fundus)
Active
Thicker
Shorter
Contracts
Retracts to expel
fetus
LUS
(isthmus)
Passive
Thinner
Longer
Dilates,
expands, thins
out for fetal
expulsion
UTERUS
Contracts
dilates
upper segment
becomes thicker
(actively
contracing)
Shape
o Elongation of uterus (ovoid)
CERVIX
as contraction
occurs , the
hydrostatic
action of
amniotic sac or
the pressure of
lower segment
the presenting
becomes thinned
out (passive
acontraction)
cervical dilatation
NORMAL LABOR
Uterine contraction (UC)
o Check for duration, intensity ,
frequency
o 10
mmhg:
palpation
perception threshold
o 15 mmhg
o
Picture: elongation of the shape of the uterus from
non-pregnant to uterus in labor
Last 2 pictures: formation of physiologic
Bandls ring between UUS and LUS
If exaggerated
pathologic Bandls ring
( deceleration phase)
o
Indicative of obstructed labor
o Present as hourglass appearance of
uterus/ figure of 8
o Corrected by operative delivery (CS) to
prevent uterine rupture
60 mmhg
Normal spontaneous
contractions
period
Equal to average intensity (mmhg) of
UC x number of contraction in a 10
minutes
period
o Good UC: at least 200 Montevideo units
o Measured by a cardiotocogram
o
Molding
Overlap of flat bones of vault of skull due
to compression of head during labor
leading to alteration in its shape
Results in a shortened
suboccipitophregmatic diameter and a
lengthened mentovertical diameter
Usually resolve within a week following delivery
Cephalhematoma
More pathologic fetal shape change
Subperiosteal
hemorrhage
due
accumulation of blood
to
CONDUCT OF LABOR
Identification of labor
Criteri
a
Contracttions
a. Frequency
b. Interval
c.
Intensity
Discomfort
Cervix
Sedation
1.
2.
3.
4.
5.
6.
7.
True labor
False labor
Regular
Gradually
Shortening
Gradually
Increasing
Back,
abdomen
Dilates
Doesnt stop
discomfort
Irregular
Remains long
Unchanged
Lower
abdomen
Doesn/t dilae
Relieves
discomfort
History and PE
o Vital signs: BP, PR, RR,
temperature o FH, FHT
o Leopoldd maneuver
o Uterine
contarctions:
frequency, intensity, duration
o IE
IE/ Vaginal exam
o Cervical effacement and dilatation
o Cervical position in the vaginal canal
o Descent position of presenting fetal pole
o
o
o
presenting part
Pelvic adequacy by pelvic
pelvimetry and probably assess
pelvic type
Statis of BOW
Station
Level to which the
presenting part has
descended into maternal
pelvis (BPD)
ischial
spine
Effacement affects
dilatation because a
thinned out cervix dilate
faster than uneffaced cervix
Fetal monitoring
Auscultation (Doppler
or fetal stethoscope)
Electronic fetal
st
1 stage
nd
2 stage
-
monitoring
provides precise
information about
FHT behavior in
relation to uterine
contractions
FHR checked
immediately after
a contraction
Low risk
High risk
Every 30 mins
Every 15 mins
Every 15 mins
Every 5 mins
Landmark:
(station 0)
before
INTRAPARTUM NUTRITION
Oral food and fluid withheld during active
labor and delivery
Delayed gastric emptying time may cause
gastric contents to be vomited out and
aspirated during course of labor especially
when sedated
Diet of easy-to digest foods and fluids
during labor
IVF to treat or prevent dehydration,
ketosis, electrolyte imbalance
Mendelsons syndrome
o Aspiration of stomach contents into
the lungs during anesthesia
secondary to delayed gastric
emptying in labor
MATERNAL POSITION DURING FIRST SATGE OF
LABOR
- Walking and upright positions o
Reduce length of labor
o Do not seem to be associated with
increased intervention or negative
effects on mothers and babies
well being
Take up whatever comfortable position
o Left lateral decubitus position
the baby
Restriction of activity for those with
ROM to prevent cord prolapse or when
sedation is administered
o Bladder hypotonia
o Urinary stasis with subsequent
infection
AMNIOTOMY
- Artificial rupture of membrane
Acceleration phase
Predictive
outcome of labor
3-4 cm to 5 cm
Maximum slope
of
Overall efficiency
of machine
Rapid rate of dilatation
Deceleration
Feto-pelvic relationship
Cervix: 9cm to
full dilatation
Phase where descent
problems are
diagnosed
Latent phase
starts from onset
of uterine
contraction 0.6
cm/hr
Active phase
starts at 3-4 cm
cervical
dilatation
mulliparas: 20 hrs
not responsive to
sedation
multipara: 14 hrs
nullipara: 1.2
cm/hr
multipara: 1.5
cm/hr
Dilatational
Division
Cervix actively dilated
Pelvis division
Pelvis negotiated; mechanism of
labor; fetal descent; delivery
Primipara
1.8 cm
20 hrs
1.2 cm/hr
Multipara
2.2 cm
14 hrs
1.5 cm/hr
2hrs
3 hrs
1cm/hr
1hr
2hrs
2cm/hr
Bishops score
FACTORS
Scor
e
0
1
2
3
Dilatatio
n
(cm)
Closed
1-2
3-4
5-6
Effacement
(%)
0-30
40-50
60-70
80
Station
-3
-2
-1, 0
+1, +2
Cervical
consistency
Firm
Medium
soft
WHO PAROGRAM
Simplified partograph (2003)
Divided into 3 color (green, yellow and red)
Position of
cervix
Posterior
Mid
Anterior
ASSESSMENT OF STATION
Important
Alert line
In the active phase of labor, plotting of cervical
dilatation will normally remain on, or to the lest
of, the alert line
Moving to the right of the alert line is a
warning that labor may be prolonged. The
woman may have to be transferred to a
tertiary facility
Action line
The action line is 4 hours to the right of the
alert line
If the labor reaches this line, woman lust be
carefully reassessed to determine the possible
reason for lack of progress and a decision
made on further management
Plot cervical dilatation (X) fetal head descent (0)
Normal partograph
Median
Easy
Rare
Minimal
Excellent
Mediolateral
More difficult
More common
Common
Occasionally faulty
Less
Rare
More
Occasional
Common
common
descent of
Duration
o
Nullipara: 50 min
o Multipara: 20 min
Preparation for delivery
o Dorsal lithotomy
o Vulvar and perineal cleansing
o Sterile draping
o Scrubbing gowning, gloving
Management
Identify: full cervical dilatation
Patient begins to bear down
presenting part
Perineual trauma
Fetal benefit
nd
o Shortened 2 stage of labor
Surgical repair
Faulty
Post-op pain
Anatomical
result
Blood loss
Dyspareunia
Rectal
extension
and
Delivery of Head
With each contraction:
o Perineal opening becomes ovoid
to
circular
with
progressive
dilatation
o Perineum stretched to almost paperthin
o Rectal opening stretches
Crowning
o Stage where fetal head is encircled
by vulvar ring and failure to perform
episiotomy invites perineal
laceration
Ritgens maneuver
o When
vulvar
opening
reaches
diameter of 5 cm, a towel-draped hand
is used to exert forward pressure on
the chin of the fetus thru the perineum
o Other hand exerts pressure on
the pcciput
Delivery of shoulders
Occurs
spontaneously
when
transverse
diameter of thorax moves into the AP position
If delay in delivery occurs, head is grasped
with the hands placed over the ears and
hooked on the mandible
Gentle downward traction is done until the
anterior shoulder is delivered then upward
movement is done to deliver posterior
shoulder, then the rest of the body follows.
Brandt- Andrews
Modified Credes
Manual removal
Active management of third stage
o Oxytocin
+
ergometrine
controlled cord traction
Brandt-Andrews maneuver
Traction is extended on the cord as the
uterus is elevated gently
Pressure exerted between the symphysis
and uterine fundus, forcing the uterus
upward and placenta outward, as traction
on the cord is continued
by reabsorption of water
water intoxication
Ergot derivatives:
o Ex:
methylergonovine,
methylergometrine
o
o
o
SUMMARY
Obstetric care is unique, it concerns 2
individual the mother and her unborn child
Timely intervention based on sound
judgment and application of honed skills
may spell the difference between a
successful birth and catastrophe
The obligation of the obstetrician is clearthe responsibility great and the rewards of
success immeasurable.
1 hour PTA
moderate pains, 5-6 minutes
interval, 30 -40 second duration
Admission
IE: cx 4cm, 80%, soft, midline, vertex,
LOT, station 0, BOW (+)
Labor progress
1 hour after
cervix 5cm, 80%, soft,
anterior, vertex, station 0, BOW (+)
2 hours after
cervix 7 cm, 90%, soft,
anterior, vertex, station 0, BOW (+)
3 hours after
cervix 9 cm, 100%, soft,
anterior, vertex, station 0, BOW (+)
1 hour after
BOW ruptures spontaneously:
cervix fully dilated and effaced, vertex
30 mins later
5 mins later
placental delivery, with
membranes presenting