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MANAGEMENT OF LABOR

JEHAD AL-HARMI
DEPARTMENT OF OBS & GYN
FACULTY OF MEDICINE/KUWAIT UNIVERSITY
You should know-1
• Obstetrical history & examination
• Definition of labor
• Mechanism of labor initiation
• Anatomical considerations:
– The female pelvis
– The fetal skull
• The stages of labor
You should know-2
• The mechanism of labor (vertex, OA)
• Management of normal labor
• Pain relief during labor
• Drugs commonly used during labor
• Induction of labor (IOL)
• Abnormalities of labor
• Malpresentations (breech, brow, face & shoulder presentations)
You should know-3
• Labor in multifetal gestation
• Preterm labor
• Vaginal birth after cesarean section (VBAC)
• Shoulder dystocia
• Complications of the third stage:
– Retained placenta
– Uterine inversion
Obstetrical History-1
• Biodata:
– Name, age, nationality, occupation
• Marital status:
– Duration of marital life, previous marriages & if any
resulted in offspring, consanguinity
• Gravidity = pregnancy
– Nulligarvida
– Primigravida
– Multigravida
Obstetrical History-2
• Parity = delivery of an infant (alive or dead)
weighing 500 g or more which is approximately
20/52
• Nullipara, primipara, multipara, grandmultipara (5
or more)
• G P (T + P + A + L)
• Remember:
– Multiple pregnancy
– Ectopic pregnancy
Obstetrical History-3
Current pregnancy:
– LNMP:
• Accuracy
• Regularity & length of menstrual cycle
• Confounding factors: OCP, lactation, spotting,
Hartman’s sign
– Nigel’s rule:
• To calculate EDD from LMP. Assuming:
– Duration of pregnancy = 266 days from conception
– Ovulation occurs 14 days prior to onset of menstruation
Obstetrical History-4
• Nigel’s rule:
– Add 7 days & subtract 3 months
– 40% deliver within 5/7; 67% within 10/7
– What if cycle length 21 days? Or 35 days?
• Calculate & report gestational age (GA) in
weeks not months
• Exceptions: IVF. 2 dates (EC & ET)
• Obstetrical calculator or calendar
Obstetrical calculator or
calendar
• Two concentric circles
• Outer circle EXAMPLE
represents days &
months of the year – LMP 06/04/2008
• Inner circles – EDD 13/01/2009
represents weeks of
gestation – Today 06/10/2008
– GA 26 weeks
• Arrows indicate
current status
Obstetrical History-5
Other methods to determine GA:
– Date of first positive pregnancy test
• Urine 4-5/52 after LMP
• Serum 8-10/7 after conception
– Uterine size during first half of pregnancy Caution!
– Time of quickening (16-20/52)
– Time of detection of fetal heart beats (FHB)
• Doptone 10-12/52
• Pinard 18-20/52
Obstetrical History-6

Other methods of determining GA:


– U/S:
• CRL during T1 Error of 7/7
• BPD, FL, AC up to 22/52 Error of 10/7
• Endovaginal U/S can detect an IUGS at 5/52
gestation and βHCG=1000-1500 mIU/ml
(discriminatory zone)
• Transabdominal U/S can detect an IUGS one week
later when βHCG=6500 mIU/ml
Obstetrical History-7
Past obstetrical history:
– Date
– Onset of labor & indication of IOL
– Mode of delivery
– Sex, BW, AS of baby
– Complications: antepartum, intrapartum,
postpartum, &/or puerperal
– Breastfeeding
Obstetrical Examination-1
Abdomen:
– Striae gravidarum (red or white)
– Linea nigra
– Organomegaly (HSM, hydronephrosis)
Obstetrical Examination-2

Uterine fundus:
– Just above symphysis
pubis: 12/52
– At umbilicus: 20-22/52
– At xiphisternum: 36/52
– What happens after
36/52?
– Lightening
Obstetrical Examination-3

• Determination of fundal level using the ulnar


side of the left hand
• Symphysial-fundal height = SFH
– SFH in cm correspond to GA in weeks after 24/52
– Can detect SFD babies in 75% of cases with
maximal accuracy at 32-34/52
– Causes of SFD & LFD
– Confirmation
Obstetrical Examination-4

Leopold maneuvers:
• Clockwise from upper
left corner
– Determination of
fundal level
– Fundal grip
– Lateral grips
– First pelvic grip
Obstetrical Examination-5

Leopold maneuvers:
– Second pelvic grip
• Determine:
– SFH & EFW
– Lie
– Presentation
– Position
– Station
– FHR
Obstetrical Examination-6
• Palpation of fetal parts after
28/52
• Description of relationship
of fetus to maternal trunk
and pelvis:
– Lie: relationship of long axis
of fetus to long axis of uterus
• Longitudinal
• Oblique
• Transverse
Obstetrical Examination-7

• Fetal poles: head, breech


– Head: hard, round, discreet, ballotable
– Breech: soft, more diffuse

• Ascertain position of fetal back and


limbs. Why?
Obstetrical Examination-8

• Attitude: relationship
of various fetal body
parts to one another
– Flexion
– Extension
Obstetrical Examination-9
Presentation:
– The presenting part of the fetus is that part
which is in or over the pelvic brim
– Cephalic:
• Well-flexed head vertex
• Completely extended face
• Deflexed brow
Obstetrical Examination-10
Presentation:
– Breech:
• Flexed hips, extended knees frank
• Flexed hips & knees complete
• Extended hips & knees footling
– Shoulder
– Cord
Obstetrical Examination-11
• Position: relationship of a denominator
(bony point) on the presenting part to the
right or left side of the maternal pelvis
– Vertex occiput
– Face mentum/chin
– Breech sacrum
• 8 positions for each presentation
Obstetrical Examination-12
Obstetrical Examination-13
• Station:
– The relationship between the presenting part & the
pelvis

• Engagement:
– When the widest diameter of the fetal head has passed
through the pelvic brim
Obstetrical Examination-14
• P/A the station is
described in fifths above
the pelvic brim
– 5/5 floating
– 2/5 engaged
• P/V the station is
described in cm above or
below the ischial spines
– Engaged = 0 station
Obstetrical Examination-15
Auscultation:
– FHS:
• Doptone 10-12/52
• Pinard 24/52
• Location: anterior shoulder
– Uterine and funic souffle
Definition of Labor

• The process whereby the products of


conception are expelled from the uterus after
20 weeks of gestation
• It begins when uterine contractions of
sufficient intensity, frequency & duration are
attained to bring about progressive
effacement & dilatation of the cervix as well
as descent of the presenting part
Mechanism of Labor Initiation-1

• Braxton-Hicks contractions

• Myometrial unresponsiveness  transitional phase


 labor initiation: the phases of parturition
Mechanism of Labor Initiation-2

• These mechanisms are not well defined in


humans
• In most mammalian species studied,
progesterone withdrawal precedes the
initiation of labor
– This is not true in primates including humans
– Progesterone levels decline only after delivery of
the placenta
Mechanism of Labor Initiation-3

Retreat from pregnancy maintenance theory:


– No substantial evidence of:
• Increased progesterone metabolism
• Progesterone compartmentalization or sequestration
• Increased protein-binding (decreased free, active
hormone)
• Reduced number of receptors
Mechanism of Labor Initiation-4
The role of the placenta:
– Human pregnancy is a hyperestrogenic state
• The placenta is virtually the sole site of estrogen
production during pregnancy
• In the placenta, estrogen is NOT synthesized de
novo from acetate or cholesterol
Mechanism of Labor Initiation-5
The role of the placenta:
– Human pregnancy is a hyperestrogenic state
• Fetal adrenal gland produces DHEA which is
hydroxylated in the fetal liver (16 OH-DHEA) &
then converted in the placenta to estriol (E3) by
aromatization
• Placental sulfatase deficiency may be associated
with prolonged gestation because it is associated
with decreased placental estrogen production
Mechanism of Labor Initiation-6

The role of the fetus:


– The fetus has been implicated as the source of the
initial signal for the commencement of labor
– Little direct experimental support in humans
– Some fetal anomalies are associated with prolonged
pregnancy:
• Anencephaly
• Congenital adrenal hypoplasia
Mechanism of Labor Initiation-7

The role of the fetus:


– These are associated with reduction in the supply of
precursors for estrogen
– Other fetal anomalies that prevent or severely reduce the
entry of fetal urine (renal agenesis) or lung secretions
(pulmonary hypoplasia) into amniotic fluid do not cause
prolongation of pregnancy
– This implies that a fetal role in initiation of labor by a
paracrine mechanism is unlikely
The Female Pelvis

• True vs. false pelvis


• True pelvis:
– Pelvic brim
– Pelvic cavity
– Pelvic outlet
The Pelvic Inlet

• Shape:
– Oval & in one plane
• Boundaries:
– Anteriorly: SP
– Laterally: upper margin of pubic bone & iliopectineal line
– Posteriorly: sacral promontory
• Dimensions:
– AP = 11 cm Transverse = 13.5 cm
The Pelvic Cavity

• Shape:
–Imaginary plane between inlet & outlet
• Boundaries:
–Anteriorly: middle of SP
–Laterally: pubic bone, obturator fascia & inner aspect of
ischial bone. Ischial spine!
–Posteriorly: junction between S2 & 3
• Dimensions:
–AP = transverse = 12 cm
The Pelvic Outlet

• Shape:
– Diamond shaped in 2 planes
• Boundaries:
– Anteriorly: lower margin of SP
– Laterally: descending ramus of pubic bone, ischial
tuberosity & sacrotuberous ligament
– Posteriorly: last piece of sacrum (not coccyx)
• Dimensions:
– AP = 13.5 cm Transverse = 11 cm
Clinical Pelvimetry

• Pelvic inlet:
– Sacral promontory
• True conjugate (TC)= AP of inlet
• Diagonal conjugate (DC) measured clinically
• TC = DC − 1.5 cm
• Pelvic cavity:
– Anterior surface of sacrum & ischial spine
• Pelvic outlet:
– Subpubic arch & intertuberous diameter
Types of Female Pelvis-1

Gynecoid:
– Rounded brim with
widest transverse
diameter slightly
behind its center
– Rounded subpubic
arch
Types of Female Pelvis-2

Platypelloid:
– Flat pelvis
– Elliptical brim with a
wide transverse
diameter
– Wide subpubic arch
Types of Female Pelvis-3
Android:
– Heart-shaped brim
– Convergent side walls
– Prominent ischial spines
– Straight sacrum
– Narrow subpubic arch
– Both AP & transverse
diameters of outlet reduced
– Funnel-shaped cavity
Types of Female Pelvis-4

Anthropoid:
– AP diameter of pelvis
> transverse diameter
– Deep pelvis; sacrum
often has 6 segments
– Narrow subpubic arch
but wide sacrosciatic
notches
– Large AP diameter of
outlet
Fetal Skull-1
• Vault
• Face
• Base
Fetal Skull-2

Vault:
– Parietal & parts of occipital, frontal & temporal bones
– Bones not well ossified by birth
– Joined by membranes at the sutures
– Moulding: alteration of the shape of the skull by
overriding of the cranial bones with reduction of some
of its diameters
– Caput & chignon
Fetal Skull-3
Sutures:
– Sagittal: between the superior borders of
parietal bones
– Frontal: the forward continuation of the
sagittal suture; between the two parts of the
frontal bone
– Coronal: between the parietal & frontal bones
Fetal Skull-4

• Fontanelles:
– Anterior (bregma): kite-shaped; where the sagittal,
frontal & coronal sutures meet
– Posterior: triangular; where the two parietal & coronal
bones meet
• Vertex:
– Area bounded by the two parietal eminences & the two
fontanelles
Fetal Skull-5
Presentation Diameter Value (cm)
Transverse Biparietal 9.5
Vx, well-flexed Suboccipitobregmatic 9.5
Vx, deflexed Suboccipitofrontal 10
Persistent OP Occipitofrontal 11
Brow Mentovertical 13.5
Face Submentobregmatic 9.5
Symptoms & Signs of Labor

• Contractions
• “Show”
• ROM
• Abdominal examination
• Pelvic examination:
– Manual or digital
– Speculum
• CTG
Stages of Labor

• First stage: average 4-7 hours


– Latent phase
– Active phase: at 3-5 cm dilatation
• Second stage:
– Phase A
– Phase B (active pushing)
• Third stage
• Fourth stage
Mechanism of Labor-1
Mechanism of Labor-2

Vertex presentation, OA position:


– The cardinal movements of labor:
• Occur simultaneously
• Descent & engagement: in the transverse position
• Flexion: occurs as the head reaches the pelvic floor to
present the smallest possible diameter
• Internal rotation: from OT position towards SP to OA position
or towards sacrum to OP position
Mechanism of Labor-3

Vertex presentation, OA position:


– The cardinal movements of labor:
• Extension: occurs as the base of the occiput comes into contact
with the subpubic arch “Crowning”
• Restitution
• External rotation: shoulders rotate into AP diameter as they reach
the pelvic floor, head follows
• Delivery of the shoulders & trunk with next 1-2 contractions
Management of Normal Labor-1
• Health education during ANC
• History taking & physical examination
• Preparation:
– Shaving the pubic hair
– Enema
Management of Normal Labor-2

First stage of labor:


– Observation:
– Partogram:
• Visual representation of
events during labor
against time
• Maternal VS
• Cervical dilatation
• Station of presenting part,
moulding & caput
formation
Management of Normal Labor-3

First stage of labor:


– Observation:
– CTG:
• FHR: baseline rate,
variability & periodic
events (accelerations or
decelerations)
• Uterine activity
– Other methods of
intrapartum fetal
surveillance?
Management of Normal Labor-4
First stage of labor:
– Pain relief & emotional support
– Hydration
Management of Normal Labor-5

Second stage of labor:


– Position
– Preparation
– Maternal pushing &
perineal support
– Ritgen’s maneuver
– Episiotomy
– Cleaning the upper
airways
– Clamping the cord
Management of Normal Labor-6
Third stage of labor:
– Normal duration: < 30
minutes
– Signs of separation of the
placenta
– Delivery of the placenta:
• Spontaneous
• Maternal effort
• Controlled cord traction or
Brandt-Andrews technique
– Repair perineal tears
Drugs Commonly Used
During Labor
• Phosphate enema
• Syntocinon, oxytocin or pitocin
• PGE2, prostin E2 or dinoprostone
• Methergine or methylergotamine maleate
• Pethidine (HCl)
• Naloxone HCl or narcan
• Phenergan or promethazine HCl
• Entonox
IOL-1

• Definition:
– Induction vs. augmentation
• Indications:
– Maternal
– Fetal
• Contraindications:
– Absolute
– Relative
IOL-2

• Methods:
– Stripping or sweeping the membranes
– ARM or amniotomy
– Mechanical dilatation: 24-Fr Foley or laminaria
– PGE2
– Pitocin, oxytocin or syntocinon
• Patient preparation including informed consent
IOL-3

• Bishop’s score:
– Total = 0 – 13; favorable ≥ 7

cm % Station Consistency Position

0 Closed 0-30 −3 Firm Post


1 1-2 40-50 −2 Medium Central
2 3-4 60-70 -1 or 0 Soft Ant
3 ≥5 80≤ +1 or +2 --- ---
Abnormalities of Labor-1

Prolonged latent phase:


– Definition:
• > 20 hours in primipara
• > 14 hours in multipara
– Treatment:
• Maternal sedation (therapeutic morphine test)
• Oxytocin stimulation
– Outcome of sedation:
• 85% progress into the active phase
• 5% wake up without contractions
Abnormalities of Labor-2

Protracted active phase:


– Definition:
• Dilatation < 1.2 cm/h in primipara
• Dilatation < 1.5 cm/h in multipara
– Causes
– Management:
• Observation
• Augmentation
Abnormalities of Labor-3
Arrest of active phase:
– Definition:
• Cessation of previously normal dilatation after uterine contractions of
200 montevideo units has been present for ≥ 2 hours
– Causes:
• CPD
• Malpresentation or malposition
– Management:
• Augmentation
• CS
Abnormalities of Labor-4

• Protraction of descent:
– Definition:
• Descent < 1 cm/h in primipara
• Descent < 2 cm/h in multipara
– Causes & management
• Arrest of descent:
– Definition: no descent for 2 hours
– Causes & management:
• Operative vaginal delivery
• CS
Malpresentations-1

Breech:
– Incidence: 2-3% at term
– Risk factors: fetal, maternal & placental
– Options for delivery:
• External cephalic version (ECV)
• Elective CS
• Trial of vaginal delivery, assisted breech delivery (ABD)
Malpresentations-2

ABD:
– Pre-requisites:
• Not footling
• No neck flexion (star-gazing)
• EFW < 3800 grams
• No previous scar
• Experienced operator & assistant
• No other medical complications
Malpresentations-3
ABD:
– Maneuvers:
• Allow spontaneous delivery until umbilicus
• Abduct thighs to deliver legs
• Rotate back anteriorly
• Gently pull until scapulae are visible
• Rotate trunk to deliver arms
• Maintain held flexion:
– “Mauriceau-Smellie-Veit maneuver
– “Piper forceps”
– Assistant
Malpresentations-4
Face:
– Incidence:
• Approximately 1 in 2000 at term
– Management:
• Expectant in early labor
• Mento-anterior  allow trial of vaginal delivery
• Mento-posterior  CS
Malpresentations-5
• Brow:
– No mechanism of labor

• Shoulder:
– Transverse lie
– Delivery by CS
VBAC-1
• Incidence: CS rate ~ 20%
• Indications for CS
• Types of uterine incisions
• Pre-operative preparation for CS
• Complications of CS:
– Intra-operative
– Post-operative:
• Short-term
• Long-term
VBAC-2

• VBAC or trial of labor


• Management:
– Elective repeat CS
– Trial of vaginal delivery
• Complications:
– Uterine rupture vs. dehiscence
• Prior transverse incision 1%
• Prior low vertical incision 1-7%
• Prior classic or inverted T incision 4-7%
VBAC-3
• Counseling:
– Chances for success 60-70%
– Risks
– Pre-requisites
Shoulder Dystocia-1

• Definition:
– Impaction of fetal shoulders against maternal
pelvis (usually: anterior shoulder above or
behind SP)
• Incidence:
– In general 0.6 – 1.4%
– 4000-45000 grams 3 – 5%
– > 4500 grams 8 – 20%
Shoulder Dystocia-2

• Risk factors:
– Macrosomia
– Diabetes
– Dysfunctional labor
– Operative vaginal delivery
• Complications:
– Maternal
– Fetal: asphyxia & trauma
Shoulder Dystocia-3

• Management:
– HELP!!! HELP!!! HELP!!!
– Episiotomy
– McRobert’s maneuver:
• Sharp flexion of maternal legs upon abdomen
– Suprapubic pressure
– Woods corkscrew maneuver:
• Rotating posterior shoulder 180º
– Delivery of the posterior shoulder
Shoulder Dystocia-4

• Management:
– Rubin maneuver:
• Displacing anterior shoulder towards chest
– Deliberate fracture of the clavicle(s)
– Zavanelli maneuver:
• Flexion of fetal head & replacement into uterus followed
by CS
– Symphysiotomy or deliberate fracture of SP
THE END