CPG on Normal Labor

and Dellivery
Prepared by: Jaramillo, Neptune S.
MSU COM, CLASS 2012

In Latin, the word labor means a troublesome effort
or suffering. Another term for labor is parturition
which comes from the Latin word Parturire to be
ready to bear young and is related to partus to
produce. To labor in this sense is to produce.
a physiologic process that begins with the onset of
rhythmic contractions which bring about changes in
the biochemical connective tissue resulting gradual
effacement and dilatation of the cervix and ends with
the expulsion of the product of conception
DEFINITION OF LABOR

a clinical diagnosis

criteria for the diagnosis of labor include:
Uterine contractions (at least 1 in 10 minutes or 4 in 20
minutes) by direct observation or electronically using
a cardiotocogram
Documented progressive changes in cervical dilatation
and effacement
Cervical effacement of > 70-80%
Cervical dilatation > 3 cm

DEFINITION OF LABOR
goal of intrapartum fetal
surveillance to detect potential
fetal decompensation and to
allow timely and effective
intervention

aims to identify hypoxia before it is
sufficient to lead to long term poor
neurological outcome for babies

done at regular intervals using a hand
held Doppler device

MONITORING OF FETAL WELL-
BEING DURING NORMAL LABOR

intermittent auscultation be undertaken every
15-30 minutes in the 1
st
stage of labor and
every 5 minutes in the 2
nd
stage of labor at least
30 seconds after each contraction

cardiotocography (CTG) is not recommended
for healthy women at term in labor in the
absence of risk factors for adverse perinatal
outcome
Recommendations:

Continuous EFM should be recommended
when either risk factors for fetal compromise
have been identified antenatally, at the onset
or during labor

Recommendations:

defined as an intervention
designed to artificially initiate
uterine contractions leading to
progressive dilatation and
effacement of the cervix and birth
of the baby.
INDUCTION OF LABOR

Assessment with documentation prior to
starting the induction should include:

Confirmation of parity
Presentation
Bishops score
Confirmation of gestational age
Uterine activity
Nonstress test


Recommendations:


Confirmation of gestational age

Confirmation of Term Gestation
American College of Obstetrics and Gynecology (ACOG)
Practice Bulletin #230, November 1996

Fetal heart tones have been documented for 20 weeks by
nonelectronic fetoscope or for 30 weeks by Doppler
The passage of 36 weeks since a serum or urine humn chorionic
gonadotropin (HCG) pregnancy test was found to be positive
Ultrasound measurement of the crown-rump length at 6-11 weeks
gestational age (GA) that support a current GA equal =/> 39 weeks
Ultrasound measurements at 13-20 weeks GA supports a clinically
determined GA equal =/> 39 weeks.

Induction of labor should be
administered only in a hospital setting,
particularly in a labor room under the
responsibility of an obstetrician

Assess cervical ripening with the use of
Bishops preinduction score system
Recommendations:

FACTOR SCORE
0 1 2 3
Cervical
Dilatation
(in cm)
Closed 1-2 3-4 5
Cervical
Effacement
(%)
0-30 40-50 60-70 >80
Station
-3 -2 -1 +1,+2
Cervical
Consistency
Firm Medium Soft
Cervical Position
Posterior Midposition Anterior
Bishops Preinduction
Cervical Score System

Gestational hypertension
Preeclampsia, eclampsia
Prelabor rupture of membranes
Maternal medical conditions (e.g.,
diabetes mellitus, renal disease, chronic
hypertension)
Gestation 41 1/7 weeks
Induction is indicated when the continuance of
pregnancy may no longer be advisable in the
following clinical circumstances:

Evidence of fetal compromise (e.g.,
severe fetal growth restriction,
isoimmunization)
Intraamnionic infection
Fetal demise
Logistic factors for term pregnancy
(e.g., history of rapid labor, distance
from hospital, psychosocial indications)
Induction is indicated when the continuance of
pregnancy may no longer be advisable in the
following clinical circumstances:

Malpresentation (e.g., transverse,
breech)
Absolute cephalopelvic disproportion
Placenta previa
Previous major uterine surgery or
classical cesarean section
Contraindications for
Labor Induction

Invasive carcinoma of the cervix
Cord presentation
Active genital herpes
Gynecological, obstetrical, or medical
conditions that preclude vaginal birth
Obstetricians convenience
Contraindications for
Labor Induction

OXYTOCIN

MEMBRANE SWEEPING /
STRIPPING

AMNIOTOMY
Methods of Induction of Labor

seeks to provide adequate hydration and
nutrition while maintaining safety for the
mother and the baby
Many obstetricians restrict oral food and
fluid intake during active labor because of
the possible risk
incidence of aspiration of gastric contents has
always been low and therefore plays a very
small role as a cause of maternal death
INTRAPARTUM NUTRITION

thought to decrease the risk puerperal
and neonatal infections

Recommendation:
There is no evidence to support the routine
use of enemas during labor
ENEMA DURING LABOR

Friedmans Curve
MONITORING THE
PROGRESS OF LABOR

1. Latent phase: up to 3-4 cm dilatation (approximately 8 hrs
long)
2. Active Phase
a. Acceleration phase-not always present
b. Phase of Maximum Slope
- Occurs at approximately 9 cm. dilatation
- Fetus is considered fully descended as it falls one station
below the ischial spine (+1)
c. Deceleration- always present
DILATATION CURVE

ends at 3-4 cm dilatation
( approx. 8 hrs long)

Extends from the onset of labor,
time from the onset of the regular
uterine contractions, to the
beginning of the active phase.
Latent phase

The point when the curve becoming more steeply
inclined.
ends at full cervical dilatation when the cervix is no
longer palpable.
The active phase may be further subdivided in to
three distinctive phase:
Acceleration phase
Phase of maximum slope
Deceleration phase
Active Phase

1. Latent phase- no fetal descent occurs
- Extends beyond dilatational phase of descent curve

1. Active Phase- come much later
a. Acceleration
b. Phase of maximum descent
- Occurs at around 9 cm dilatation
- Corresponds to the deceleration of dilatation
- Fetus fully descended at +1 (station below level of ischial
spines)
Fetal Descent

o The pattern of descent follows a hyperbolic curve, it too
has its phases as follows:
1. The Latent Phase - corresponds to the latent and
acceleration phase of cervical dilatation (the preparatory
division of labor). At this time, little if at all, fetal head
descent takes place.
2. The Accelaration Phase - corresponds to the phase of
maximum slope (the dilatation division of labor) of
cervical dilatation. This is time that fetal head descent
ensues.
Fetal Descent

1. The Place of Maximum Slope corresponds to
the deceleration phase and second stage of labor
in cervical dilatation (pelvic division of labor).
Increased rates of descent begins during this
phase and progresses to a maximum until the
presenting part reaches the perennial floor.As this
event occurs, the cervix is expected to be at an
advanced stage of dilatation (8-9 cm)
Fetal Descent

The WHO
PARTOGRAM

If graph is located on the right side of
the ALERT LINE: one should monitor
the patient closely

If graph reaches the ACTION LINE:
should do cesarean section or
forceps/vacuum delivery.
WHO PARTOGRAPH


There is evidence that walking and upright
position in the first stage of labor reduce the
length of labor and do not seem associated
with increase intervention or negative effects
on mothers and babies well-being.

Women should be encouraged to take up
whatever position they find most
comfortable in the first stage of labor.
MATERNAL POSITION DURING
THE FIRST STAGE OF LABOR


When not contraindicated (e.g. hypovolemia,
coagulopathy), neuraxial analgesia (spinal or
epidural) using local anesthetic with or without
neuraxial opioids provides the most effective pain
relief for labor.

This techniques should be administered by a trained
and skilled anesthesiologist in an appropriate
medical fascility with appropriate resources for the
treatment of complications should be available.
ANALGESIA AND ANESTHESIA
DURING LABOR

For imminent delivery, the following may be used:
Pudendal block may offer analgesia for
episiorraphy and repair if needed

Single shot spinal (saddle block)

Intravenous thiopental, propofol, ketamine may
be administered parenterally by a skilled
anesthesiologist. (Level 3, Grade C)
ANALGESIA AND ANESTHESIA
DURING LABOR

The use of low concentrations of
volatile anesthesia for labor analgesia is
no longer accepted as a standard of care
for labor and vaginal delivery. General
anesthesia obtunds the patients
airway, reflexes and increases the risk
for airway aspiration and its
subsequent sequelae. (Level 3, Grade C)
ANALGESIA AND ANESTHESIA
DURING LABOR

Amniotomy is the artificial rupture of
membranes.

Artificial rupture of the amniotic
membranes during labor is one of the
most commonly performed
procedures in modern obstetrics.
AMNIOTOMY

Timing
There is still no conclusive evidence to support
that early amniotomy has a clear advantage over
expectant management (Level 1, Grade C).
Supporting Statements:
Early amniotomy appears to lead to an average
reduction of labor.
Routine amniotomy does not significantly reduce
the duration of first-stage labor in either
primiparous or multiparous women (Grade A).
It slightly shortens second-stage labor in
primiparous women only (Grade A).
Recommendations:

Use
The primary aim is to speed up
contractions and shorten the length
of labor.
also to assess the status of the fetus
It is clinically indicated to observe
the color and amount of amniotic
fluid
Recommendations:

Complications
increases the risk of chorioamnionitis.
Possible complications include
umbilical cord prolapse, cord
compression and fetal heart rate
decelerations, increase ascending
infection rate, bleeding from fetal or
placental vessels and discomfort from
the actual procedure.
Recommendations:

Elements of Support:

Emotional support (continuous presence,
reassurance and praise)
Physical measures of comfort(massages,
comforting touches, acupressure)
Advocacy like helping the woman to express her
wishes and needs to others
CONTINUOUS SUPPORT
DURING LABOR

Continuous support by a lay woman during
labor and delivery:
Facilitates birth
Enhances the mothers memory of the experience
Strengthens mother-infant bonding; increases
breastfeeding success
Significantly reduces many forms of medical
intervention, including cesarean delivery, the use
of analgesia, anesthesia, and vacuum extraction.
CONTINUOUS SUPPORT
DURING LABOR

Duration of support:
Continuous
Intermittent
Types of Provider:
Untrained lay women
Trained lay women (doulas)
Female relatives
Nurses
Monitrices (lay midwives acting solely as labor
support persons)

CONTINUOUS SUPPORT
DURING LABOR

Outcomes assessed:
Use of any analgesia
Need for oxytocin augmentation
Need for forceps or vacuum
Need for cesarean section
Duration of labor
CONTINUOUS SUPPORT
DURING LABOR

o There is insufficient evidence to recommend
routine perineal shaving for women on admission
in labor. (Level 1, Grade E)
Late side effects attributable to shaving occur
later such as:
1. Irritation
2. Redness
3. Multiple superficial scratches from the razor
4. Burning and itching of the vulva
ROUTINE PERINEAL SHAVING
BEFORE DELIVERY


Recommendations

The upright position in the second stage of labor is
associated in women without epidural anesthesia
with a 4-minute shorter interval to delivery, less
pain, lower indices of abnormal fetal heart pattern
and of operative vaginal delivery, as well as higher
rates blood loss of > 50 ml compared with other
positions in 20 trials including 6135 women.
MATERNAL POSITION DURING
THE SECOND STAGE OF LABOR

Recommendations

The upright positions studies include sitting
(obstetric chair/stool), semi-recumbent
(trunk tilted backwards 30
o
to the vertical),
kneeling squatting (unaided or using
squatting bars), and squatting aided with
birth cushion.
MATERNAL POSITION DURING
THE SECOND STAGE OF LABOR

There is no evidence that the rate of adverse
perineal outcomes is affected by different types of
bearing down during the second stage of labor
(Level 1, Grade C)

A systematic review of controlled trails has found
no evidence of a difference. Holding (Valsalva) or
spontaneous exhalatory methods of pushing are
used during the second stage of labor.
ALTERNATIVE METHODS
OF BEARING DOWN

Definition:
o Hands on = touch the perineum
o Hands poised / Hands off = do not touch the perineum

Recommendations:
o Hands off and Hands on techniques did not affect the
frequency or severity of perineal trauma in women
undergoing childbirth for the first time. (Level 1, grade C)
PERINEAL SUPPORT: HANDS
POSED VERSUS HANDS ON

Recommendations:
Restricted use of episiotomny preferable to routine
use. (Level 1, Grade A)
Median episiotomy is associated with higher rates of
injury to the anal sphincter and rectum. (level 1,
Grade A)
Mediolateral episiotomy may be preferable to
median episiotomy in selected cases. (Level 1, Grade
B)
Routine episiotomy does not prevent pelvic floor
damage leading to incontinence. (Level 1, Grade B)
USE OF EPISIOTOMY
AND REPAIR


Repair

o In either median or medioolateral episiotomy, 2-layered
closure can improve postpartum pain and healing
complications vs a 3-layered closure.
o Polyglycolic acid derivative suture, with minimal reaction,
is recommended to reduce wound inflammation. (Level 1,
Grade A)
USE OF EPISIOTOMY
AND REPAIR


Episiotomy
Purpose: facilitate second stage of labor to improve
maternal and neonatal outcome

Maternal benefit
Reduced risk of perineal trauma, subsequent pelvic floor
dysfunction and prolapse, urinary incontinence, fecal
incontinence and sexual dysfunction
Fetal benefit
Shortened second stage of labor
USE OF EPISIOTOMY
AND REPAIR


o There is good evidence to support the use of fast-
absorption polyglactin 910 as material of choice for
perineal closure. (Level 1, Grade A)
Fast-absorbing Polyglactin 910
- Obviates need for suture removal up to 3 months
postpartum for 1 in 10 women sutured
- Less dyspareunia at 6 weeks
- Similar wound breakdown profile as chromic rarely
requires late removal
- Earlier resumption of sexual intercourse
SUTURE MATERIALS FOR
EPISIORRAPHY

Recommendations:
Active management includes a group of
interventions such as
1. Administration of prophylactic uterotonin within
one minute after the delivery of the baby and prior
to the delivery of the placenta
2. Early cord clamping and cutting
3. Controlled cord traction to deliver the placenta
MANAGEMENT OF THIRD
STAGE OF LABOR

Recommendations:
o Oxytocin is effective as first line prophylactic
uterotonic during the 3
rd
stage of labor in the
prevention of PPH and is safe to use in all
patients. (level 1)
o Use of ergot alkaloid and ergometrine-oxytocin
are valid alternatives in the absence of oxytocin.
Their use have to be weighed against maternal
adverse effects. (Level 1)
DRUGS IN THE THIRD
STAGE OF LABOR


The American Academy of Physicians,
American College of Obstetricians and
Gynecologists, American Academy of
Breastfeeding Medicine, World Health
Organization, United Nations
Childrens Fund, and many other
health organizations recommend
exclusive breastfeeding for the first 6
months of life.
EARLY BREASTFEEDING

Breastfeeding should be continued for
at least te first year of life and beyonf
for as long as mutually desired by
mother and child.
EARLY BREASTFEEDING

oManeuvers that maintain milk
production:
1.Maternal anatomic abnormalities of the
breast
2.Neonatal anatomic abnormalities
3.Neonatal depression
EARLY BREASTFEEDING

o Breastfeeding is contraindicated in mothers with
the following conditions:
Use of street drugs or alcohol
Infant with galactosemia
Maternal infection (HIV, active PTB, varicella,
herpes simplex)
Use of neoplastic, thyroid, immunosuppresants
Undergoing treatment of breast cancer
EARLY BREASTFEEDING