(Clinical Practice Guidelines) NORMAL LABOR AND DELIVERY

Almamyr D. Bautista, M.D.

Dr. Rubio Moderator

July 2012

 Definition:

Physiologic process Diagnosis: Based on clinical findings Internal Examination (persistent uterine contractions)

LABOR

Phases of Parturition

Uterine Contractions
Progressive Changes in cervical Dilatation and Effacement
Cervical Effacement (>70-80%)

Cervical Dilatation >3cms.

CRITERIA FOR THE DIAGNOSIS OF LABOR

Stages of Labor

Functional Divisions of Labor

Monitoring of Fetal Well-Being During Normal Labor B. Induction of Labor 1. Oxytocin 2. Membrane Sweeping (Stripping) 3. Amniotomy
A.

*Failed Induction

FIRST STAGE OF LABOR

Hypoxia

FHR Monitoring

Long-term poor neurological outcome

Labor Induction

Monitoring of the Fetal Heart Rate in Labor

1st Stage of Labor q15-30mins

2nd Stage of Labor q5mins

at least 30 secs after each contractions

Intermittent Auscultation

Electronic Fetal Heart Rate Monitoring

 Not recommended for healthy women at term No risk factors

No evident benefit

Admission CTG

Assessment with documentation prior to starting the induction Induction of labor is a major intervention = only with valid indication (documented)
Assess cervical ripening with the use of Bishops preinduction score system Only in the hospital setting

General Recommendations

Assessment with documentation prior to induction

Confirmation

Presentation

Parity
Gest. Age

Transverse Breech

Bishops Score

Others

Cephalic

Uterine Activity

Nonstress Test

Induction of Labor

Bishops Score

OXYTOCIN AUGMENTATION
2nd IV line, piggy-backed to the main IV line (close to venipuncture site)

Starting dose: 1-2 mU/min increased at intervals of >30 mins

AIM: 3-4 contractions every 10 mins Adequate contractions @ 12mU/min Max dose > 32mU/min

1ml/hr = 1mU/min

Oxytocin

Abnormal FHR or tetanic contractions

Infusion stopped Intrauterine resuscitation Re-evaluated * Restarting Oxytocin lower dose and lengthened interval between subsequent increases.

Oxytocin Administration

Uterine Tachysystole
5 contractions in 10mins

Uterine Hypertonus
Single contraction lasting >2mins

NRFS

Hyperstimulation

 Stop!
Reposition Continue

(or Initiate EFM) Give O2 mask at 10L/min Notify responsible physician Administer a tocolytic agent Prepare for possible cesaren delivery if fetal pattern remains abnormal Intrauterine Resuscitation Measures

C. Intrapartum Nutrition D. Enema During Labor E. Monitoring the Progress of Labor F. Maternal Position During the First Stage of Labor G. Analgesia and Anesthesia During Labor H. Amniotomy I. Continuous Support During Labor

FIRST STAGE OF LABOR

Alert line monitor the patient closely Action line should do CS or forceps/vacuum delivery
The principles of the partograph include the following:
1. Active phase 3cms 2. Latent phase <8hrs 3. Active phase rate of CD >1cm/hr 4. Lagtime of 4 hrs 5. Vaginal examination (once/4hrs is recommended)

WHO Partograph

 Walking

and upright positions reduced length of labor they find most comfortable

Position

Maternal Position During the 1st Stage of Labor

Most ideal reduce pain in the 2nd stage of labor

Should not interfere with the progress of labor Devoid of unwanted side effect
Participate readily in the birthing process None or very minimal effect on the baby

Analgesia and Anesthesia

Systemic opioids are the most common medications used for labor pain relief
Usually given intramuscularly They allow the parturient to better tolerate the pain of labor Dose-dependent increase in unwanted effects (drowsiness, nausea and vomiting) However, these drugs readily cross the placenta, thus they are associated with risks of respiratory depression and neurobehavioral changes in the newborn

ANALGESIA AND ANESTHESIA DURING LABOR

Of all the methods of labor pain relief available in clinical practice, neuraxial analgesia are the most effective methods of intrapartum relief.
This technique offers the highest patient satisfaction and the LEAST depressant effects on the newborn compared with parenteral opioids

ANALGESIA AND ANESTHESIA DURING LABOR

 Primary Goal: Adequate analgesia Minimal motor block

Neuraxial anesthesia + local anesthetics

Local anesthesia At low concentrations + opioids

Effect on the duration of 1st and 2nd stage labor Epidural increases the risk of CS.

Neuraxial catheter techniques

Controversy

Epidural Anesthesia COMBINED SPINAL EPIDURAL ANESTHESIA (CSE) the patients obstetric Can be tailored to meet
needs

Spinal component Should not beonsetas a single entity faster taken Epidural - subsequent labor analgesia

Epidural Anesthesia

 Other

techniques:

Pudendal block Nitrous oxide Subanesthetic concentrations of inhalational gases

ANALGESIA AND ANESTHESIA DURING LABOR

During labor. A parturients request for pain is a sufficient indication for its use Although meperidine is the most common parenteral opioid used
When not contraindicated, neuraxial analgesia provides the most effective pain relief for labor

RECOMMENDATIONS

1. Epidural analgesia using intermittent boluses or continuous infusion

2. CSE may be used to rapid and effective onset of analgesia for labor 3. Patient controlled epidural analgesia (PCEA) may be used to provide an effective and flexible approach for the maintenance of labor analgesia

RECOMMENDATIONS

Single shot spinal injection spinal opioids with or without local anesthetics may be used to provide less expensive but effective, although time-limited analgesia for labor when VSD is anticipated
Patients in early labor should be given the option of neuraxial analgesia when this service is available

RECOMMENDATIONS

 For

imminent delivery the ff may be used:

Pudendal block Single shot spinal IV thiopental, propofol, or ketamine

RECOMMENDATIONS

The use of low concentrations of volatile anesthesia for labor analgesia is no longer accepted standard of care of labor and vaginal delivery

RECOMMENDATIONS

Amniotomy
Artificial rupture of membranes

Recommendations
Timing Use
Speed up contractions Shorten the length of labor Assumption that shortening the length of labor is beneficial, with little apparent regard for any potential associated adverse effects Clinically indicated to observe the color and amount of amniotic fluid

Increases labor contractions improves progress of labor (prolonged labor)

 Complications
Umbilical cord prolapse

Cord compression Amniotomy may

enhance progress in the Fetal heart rate decelerations active phase and negate the need for oxytocin Increased ascending infection it may augmentation, but rate increase the risk of Bleeding from fetal or placental vessels chorioamnionitis
Discomfort from the actual procedure

More likely to deliver without anesthesia

Shorter duration of labor Most likely to deliver spontaneously

Less likely to be dissatisfied with their childbirth experience

Continuous Support During Labor

Emotional Support

Physical Measures of Comfort

Advocacy like helping the woman to express her wishes and needs to others

Elements of Support

Facilitates birth
Enhances the mothers memory of the experience Strengthens mother-infant bonding; increases breastfeeding success Significantly reduces many forms of medical intervention

Continuous support by a lay woman during labor and delivery

Untrained lay women

Trained lay women (Doulas) Female relatives Nurses Monitrices (lay midwives acting solely as labor support persons)

Types of Provider

Use of any analgesia

Need for oxytocin augmentation Need for forceps or vacuum Need for cesarean section Duration of labor

Outcomes assessed

26% less likely to give birth by cesarean section 41% less likely to give birth with vacuum extraction or forceps 28% less likely to use any pain medications 33% less likely to be dissatisfied with or negatively rate their birth experience

Continuous Labor Support

Beginning earlier rather than later in labor

In settings that do not allow them to bring companions of choice In settings where epidural analgesia is not routine

Benefits of continuous labor support appear to be greater

A.
B.

C.
D. E.

Routine Perineal Shaving Before Delivery Maternal Position During the Second Stage of Labor Alternative Methods of Bearing Down Perineal Support (Hands Poised Versus Hands On) Instrumental Vaginal Delivery
A. Forceps Delivery B. Vacuum Delivery

SECOND STAGE OF LABOR

There is insufficient evidence to recommend perineal shaving for women on admission in labor The aim is to minimize infection risk if there is tearing or cutting of the area between the vagina and anus during birth process Late side effects

Irritation Redness Multiple superficial scratches from the razor Burning and itching of the vulva

ROUTINE PERINEAL SHAVING

Recommendations:
Upright position
Has 4 min shorter interval to delivery Less pain Lower incidence of abnormal fetal heart rate pattern Include sitting, semi-recumbent, kneeling squatting, squatting aided with cushions Benefits: less aortovagal compression, improved fetal alignment, larger anterior, posterior and transverse pelvic outlets

MATERNAL POSITION DURING SECOND STAGE OF LABOR

No evidence that the rate of adverse perineal outcomes is affected by different types of bearing down during the 2nd stage of labor.
1. Holding (Valsalva) 2. Spontaneous exhalatory methods of pushing

Alternative Methods of Bearing Down

Hands On: touch the perineum

Hands poised/Hands off: do not touch the perineum Did not affect the frequency or severity of perineal trauma in women undergoing childbirth for the first time

PERINEAL SUPPORT: HANDS POISED VS HANDS ON

Perineal trauma is associated with other factors: Supporting Statement: 1. position during delivery The hands oxytocinmethod increased 2. use of poised short maternal expulsive and increased 3. term perineal pain efforts the manual removal of the placenta, 4. presence of suport person however it found no evidence of an effect on the perineal trauma or 3rd/4th degree tears.

Perineal Support

Vaginal delivery

Recommendations

Indications for operative vaginal delivery are not absolute When the fetal head is engaged and the cervix fully dilated, the following indications apply 1. Prolonged 2nd stage Nulliparous women:

Multiparous women:

> 3hrs w/ regional anesthesia > 2hrs w/o regional anesthesia

2. Suspicion of immediate or potential fetal compromise 3. Shortening of the 2nd stage for maternal benefit

> 2 hrs w/ regional anesthesia > 1 hr without regional anesthesia

INSTRUMENTAL VAGINAL DELIVERY

Should be done when the criteria for outlet forceps have been met Criteria

Outlet forceps
Scalp is visible at introitus without separating the labia Fetal skull has reached the pelvic floor Sagittal suture is in AP diameter or ROA/LOA or ROP/LOP Fetal head is at or on perineum Rotation does not exceed 45 degrees

Forceps Delivery

Low forceps
Leading point of fetal skull is at station > 2 cm and not on the pelvic floor Rotation is less 45 or less

Rotation is greater than 45

Midforceps
Station is above +2 cm but head is engaged

High Forceps
Not included in classification

Mid/High forceps are not currently recommended

If satisfactory application of forceps cannot be achieved, then the procedure is abandoned and delivery accomplished by use of either vacuum extraction or caesarian section
If application has been achieved but gentle downward pulls do not result in descent, the procedure is abandoned

Recommendations

A successful vacuum extraction is most likely if there is:

Accurate cup application at the flexion point Appropriate traction technique A favorable flexed fetal cranial position Low station at the time of application

Only attempt a vacuum assisted delivery when a specific obstetric indication is present The use of soft, bell-shaped vacuum extractor is recommended for uncomplicated, OA deliveries

Vacuum Delivery

Limit vacuum assisted procedures to 2-3 pop-offs. And a total time of 15-30 minutes Failure of an attempted vacuum assisted delivery increases the likelihood of neonatal morbidity; the subsequent use of sequential forceps in this setting should be undertaken with extreme caution Prompt CS delivery is advised after an unsuccessful vacuum assisted procedure.

A.
B. C.

Use of Episiotomy and Repair

Suture Materials for Episiorraphy Management of Third Stage of Labor

D.

Drugs in the Third Stage of Labor

THIRD STAGE OF LABOR

Recommendations
fetal well-being to avoid lacerations

Restricted use of episiotomy preferable to routine use.

Restricted Avoided unless indicated

Routine routinely conducted or usual care

Use to preempt a tear

Median Episiotomy increased rate of injury to anal sphincter and rectum. Mediolateral episotomy preferable to median episiotomy Routine Episiotomy does not prevent pelvic floor damage leading to incontinence.

Use of Episiotomy and Repair

Repair
Polyglycolic acid derivative suture
With minimal reaction to prevent wound inflammation

Median and mediolateral = 2-layered closure vs. 3-layered closure

Improve post-partum pain and healing complications

Episiotomy and Repair

Facilitate 2nd stage of labor to improve maternal and neonatal outcome.

Maternal Benefit
Decreased risk of perineal trauma Subsequent pelvic floor dysfunction Urinary incontinence Sexual dysfunction Fetal Benefit Shortened 2nd stage of labor

Purpose

1.
2.

Expedite delivery in the 2nd stage of labor

When spontaneous laceration is likely

3.
4.

Maternal or fetal distress

Breech position

5.
6. 7.

Assisted forceps deliver

Large baby

Maternal exhaustion

Indications

Fast-absorption polyglactin 910

Obviates need for suture removal up to 3 month

Recommendations: Less dyspareunia @ 6weeks Rapid absorption polyglactin most Similar wound breakdown profile as chromic appropriate rarely requires late removal Catgut withdrawn from Earlier UK since 2002 resumption of sexual intercourse Suture Materials for Episiorraphy

Recommendations:
Active Management
1Prophylactic uterotonin within 1 min after the delivery of the baby prior to the delivery of the placenta 2. early cord clamping and cutting 3. Controlled cord traction to deliver the placenta

Management of the 3rd stage of labor

Giving Uterotonics

Increase uterine contractions /retraction

Total detachment and expulsion of the placenta

Prevent PPH

Optimal occlusion of the myometrial vessels

Physiologic Basis of Active Management

A. Early Breastfeeding

FOURTH STAGE OF LABOR