Labor Review

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Labor Review

• Petrenko N., MD,PhD

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Critical Factors in Labor

• 5 critical factors
• Birth passage
• Fetus
• Relationship of Maternal Pelvis and Presenting
  Part
• Physiologic forces of labor
• Psychosocial considerations

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1 Birth Passage

• Four different types of pelvises, but frequently
  mixed types

anthrapoid
android
gynaecoid
platypelloid
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2 Fetus

• Sutures
• Frontal
• Sagittal
• Coronal
• Lambdoidal

Lambdoidal suture
Sagittal suture
Coronal suture
Frontal suture
Note sutures are actually membranous spaces that
meet at fontanels
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Fetus

• ?Fontanelles intersection of sutures, allows for
  molding, helps identify position of head
• Anterior (bregma)
• Diamond shaped
• Approx 2-3 cm
• Ossifies in 12-18 months
• Posterior
• Triangle shaped
• Smaller
• Closes in 8-12 weeks

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Fetus

• Other landmarks on the fetal head
• Mentum
• Sinciput
• Vertex
• occiput

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Fetus

• Fetal attitude
• Relation of fetal parts to one another
• Normal mod flexion of head, flexion of arms onto
  chest, flexion of legs onto abdomen
• Changes in attitude can contribute to longer,
  more difficult labor or Cesarean Section

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Fetus

• Fetal lie
• Relationship of the spine (cephalocaudal axis) of
  the fetus to the spine of the mom
• Longitudinal parallel
• Transverse right angle
• Oblique acute abgle

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Fetus Fetal lie
Longitudinal
Transverse
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Fetus

• Fetal presentation
• Body part entering the pelvis (presenting part)
• Cephalic
• Breech
• Shoulder

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Fetus Fetal lie
Cephalic
Breech
Shoulder
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Fetus

• Fetal presentation Cephalic
• ?Vertex presentation
• Most common
• Head completely flexed on chest
• Suboccipitobregmatic (Smallest diameter)
• Occiput in presenting part

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Fetus

• Fetal presentation Cephalic
• Military presentation
• Fetal head neither flexed nor extended
• Occipitofrontal diameter presents
• Top of the head is presenting part

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Fetus

• Fetal presentation Cephalic
• Brow presentation
• Fetal head partially extended
• Occipitomental diameter presents
• Sinciput is presenting part

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Fetus

• Fetal presentation Cephalic
• Face presentation
• Head hyperextended
• Submentobregmatic diameter presents
• Face is presenting part

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Fetal presentations
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Fetus

• Fetal presentation Breech
• Sacrum is the landmark
• Complete breech
• Knees and hips are flexed, thighs on abdomen
  (fetal position)
• Buttocks and feet are presenting parts

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Fetus

• Fetal presentation Breech
• Sacrum is the landmark
• Frank breech
• Hips flexed, knees extended
• Buttocks is presenting part

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Fetus

• Fetal presentation Breech
• Sacrum is the landmark
• Footling breech
• Hips and legs extended
• Feet are presenting parts (single vs double)

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Fetus

• Fetal presentation Shoulder
• Acromion process of shoulder is presenting part

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Station
??In Gynaecoid Android pelvis distance between
ischial spine to brim is 5 cm. ??In Anthropoid
pelvis distance is 7 cm ??In Platypelloid pelvis
distance is 3 cm
Station of the head in relation to ischial spines
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Relationship of maternal pelvis and presenting
part
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Relationship of maternal pelvis and presenting
part

• OA most common, easiest to deliver
• Other positions are considered malpositions
• Position influences labor and birth
• Largest diameter in posterior position back
  pain, longer 2nd stage
• Can tell position by palpation of abdomen and
  Vaginal Examination

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2 Fetus

• Sutures
• Frontal
• Sagittal
• Coronal
• Lambdoidal

Lambdoidal suture
Sagittal suture
Coronal suture
Frontal suture
Note sutures are actually membranous spaces that
meet at fontanels
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Fetus

• ?Fontanelles intersection of sutures, allows for
  molding, helps identify position of head
• Anterior (bregma)
• Diamond shaped
• Approx 2-3 cm
• Ossifies in 12-18 months
• Posterior
• Triangle shaped
• Smaller
• Closes in 8-12 weeks

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Fetus

• Other landmarks on the fetal head
• Mentum
• Sinciput
• Vertex
• occiput

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Fetus

• Fetal attitude
• Relation of fetal parts to one another
• Normal mod flexion of head, flexion of arms onto
  chest, flexion of legs onto abdomen
• Changes in attitude can contribute to longer,
  more difficult labor or Cesarean Section

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Fetus

• Fetal lie
• Relationship of the spine (cephalocaudal axis) of
  the fetus to the spine of the mom
• Longitudinal parallel
• Transverse right angle
• Oblique acute abgle

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Fetus Fetal lie
Longitudinal
Transverse
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Fetus

• Fetal presentation
• Body part entering the pelvis (presenting part)
• Cephalic
• Breech
• Shoulder

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Fetus Fetal lie
Cephalic
Breech
Shoulder
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Fetus

• Fetal presentation Cephalic
• ?Vertex presentation
• Most common
• Head completely flexed on chest
• Suboccipitobregmatic (Smallest diameter)
• Occiput in presenting part

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Fetus

• Fetal presentation Cephalic
• Military presentation
• Fetal head neither flexed nor extended
• Occipitofrontal diameter presents
• Top of the head is presenting part

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Fetus

• Fetal presentation Cephalic
• Brow presentation
• Fetal head partially extended
• Occipitomental diameter presents
• Sinciput is presenting part

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Fetus

• Fetal presentation Cephalic
• Face presentation
• Head hyperextended
• Submentobregmatic diameter presents
• Face is presenting part

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Fetal presentations
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Fetus

• Fetal presentation Breech
• Sacrum is the landmark
• Complete breech
• Knees and hips are flexed, thighs on abdomen
  (fetal position)
• Buttocks and feet are presenting parts

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Fetus

• Fetal presentation Breech
• Sacrum is the landmark
• Frank breech
• Hips flexed, knees extended
• Buttocks is presenting part

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Fetus

• Fetal presentation Breech
• Sacrum is the landmark
• Footling breech
• Hips and legs extended
• Feet are presenting parts (single vs double)

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Fetus

• Fetal presentation Shoulder
• Acromion process of shoulder is presenting part

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Station
??In Gynaecoid Android pelvis distance between
ischial spine to brim is 5 cm. ??In Anthropoid
pelvis distance is 7 cm ??In Platypelloid pelvis
distance is 3 cm
Station of the head in relation to ischial spines
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Relationship of maternal pelvis and presenting
part
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Relationship of maternal pelvis and presenting
part

• OA most common, easiest to deliver
• Other positions are considered malpositions
• Position influences labor and birth
• Largest diameter in posterior position back
  pain, longer 2nd stage
• Can tell position by palpation of abdomen and
  Vaginal Examination

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Physiologic forces of labor

• Primary uterine muscles (causes dilation and
  effacement)
• Secondary abdominal muscles (for 2nd stage)

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Physiologic forces of labor

• Phases of contractions
• Increment
• Acme
• Decrement
• Relaxation
• Uterine muscle rest
• Rest for mom
• Restores oxygenation to baby

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Physiologic forces of labor

• Frequency
• Duration
• Intensity

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Physiologic forces of labor

• Intensity
• indirect (subjective) palpation mild,
  moderate, strong,
• direct (objective) mmHg pressure with IUPC
  (intauterine)

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Physiologic forces of labor

• Early labor mild, short duration, irregular
• As labor progresses stronger, longer, more
  regular, closer together

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Physiologic forces of labor

• Bearing down (Pushing)
• must be 10cm dilated (complete)
• involuntary and voluntary muscles

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Stages of Labor ?

• Stage 1
• Onset of regular contractions to complete
  dilatation
• Stage 2
• Complete dilatation to birth
• Stage 3
• Birth of infant to birth of placenta
• Stage 4
• Birth of placenta to 1-4 hrs recovery

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Stages of Labor ?

• Stage 1 divided into 3 phases
• 1 Latent phase 0-3 cm
• Primip 8.6 hrs
• Multip 5.3 hrs
• May have irregular contractions, short, mild
  moderate
• Excited, talkative, smiling
• 2 Active phase 4-7 cm
• Primip 4.6 hrs dilation at least 1.2 cm/hr
• Multip 2.4 dilation at least 1.5 cm/hr
• Uterus contraction through 2-5 min, by 40-60 sec,
  mod strong
• ? anxiety, sense of hopelessness, fear of loss of
  control

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Stages of Labor ?

• Stage 1 divided into 3 phases cont
• 3 Transition phase 8-10 cm
• Primip 3.6 hrs
• Multip variable
• Uterus contraction through 1 ½ - 2 min 60-90
  sec, mod strong
• Acutely aware of intensity of uterus contraction,
  significant anxiety, restless, cant get
  comfortable, fears being alone, yet may not want
  anyone to touch her, hot-cold, apprehensive
• As dilation progresses, ? bloody show, ROM. As
  gets to closer to complete, ? rectal pressure,
  splitting feeling, urge to push

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Stages of Labor ?

• 2nd stage
• Usually lt2 hrs (less in multips)
• Affected by epidural, maternal pushing, position
  of presenting part, size of pelvis
• As head approaches perineum, labia separate, may
  see presenting part with pushing, then recede.
  Rectum bulges and flattens
• Crowning

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Stages of Labor
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Stages of Labor ?

• 3rd stage
• Usually will induced 5 mins. May be up to 30
  mins. Retained after 30 mins.
• Signs of separation
• Globular shaped uterus
• Rise in fundus
• Sudden gush or heavy trickle of blood
• Lengthening of cord from vagina
• Shiny schultze
• Dirty duncan

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Stages of Labor ?

• 4th stage
• Blood loss normal up to 500mL (vag del)
• Hemodynamic changes ? ? BP, ? pulse pressure,
  tachycardia
• Uterus contracted and midline 1/2 way between
  symphysis and umbilicus. Within 1st hour about
  level with umbilicus
• Shaking, hunger, thirst
• Bladder is hypotonic

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Post-term Pregnancy

• gt 42 completed weeks
• Cause of true post-term is unknown often
  incorrect dates
• Maternal Risks
• Large baby and associations
• Psychologic ills
• Fetal-Neonatal Risks
• Placental changes ? insufficiencies
• Oligohydramnios
• macrosomia? birth trauma, glucose maintenance
  problems
• Meconmium stained fluid (aspiration)
• As pregnancy approached term, fetal well-being
  studies done

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Fetal Malposition

• OP position
• Fetus must rotate 135 or occasionally born in OP
  position
• If born OP, increased risk of 3rd or 4th degree
  laceration, broken symphysis
• May use forceps or manual rotation
• Positioning knee chest, pelvic rocking

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Fetal Malpresentation

• Brow
• Usually C/S recommended
• Perinatal morbidity and mortality
• Trauma cerebral and neck compression damage to
  trachea and larynx
• Tx pelvimetry, oxytocin?, C/S
• Face
• Perinatal morbidity and mortality
• Risk of prolonged labor, fetal edema, swelling of
  neck and internal structures, petechiae,
  ecchymosis
• Tx C/S in no progress

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Fetal Malpresentation

• Breech
• Most common malpresentation
• Frank breech most common
• Risk of cord prolapse fetal anomolies 3x higher
• If vag del head trauma, fetal entrapment
• Tx external version (50-60 success), if vag
  del epidural, double set-up

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Fetal Malpresentation

• Shoulder
• Version may be attempted
• C/S
• Compound presentation

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Macrosomia

• gt4500 g
• Obese 3-4x more likely to have macrosomic baby
• ?risk of perineal lacerations, infection
• Most significant problem is shoulder dystocia
• OB emergency? permanent injury of brachial
  plexus, fx clavicle, asphyxia, neurologic damage
• Tx
• Assessment of adequacy of pelvis
• Suprapubic pressure
• Intentional breaking of clavicle
• ?C/S

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Prolapsed Cord

• Umbilical cord precedes presenting part
• May be visible or occult
• More common with
• Abnormal lie
• Low birth weight
• gt previous births
• Amniotomy
• Long cord

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Prolapsed Cord

• Key interventions
• Relieve pressure on cord
• Trendelberg or knee chest position
• Oxygen to increase maternal oxygen saturation
• Pressure on the presenting part
• Call for help, but do not leave mother
• Expedite delivery

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Prolapsed Cord

• Maternal Risk
• No direct risk
• Fetal-Neonatal Risk
• Cord compression ? ?O2 ? possible death or
  neurologic compromise
• Tx
• Prevention!
• If palpated, keep pressure off cord
• ?When ROM occurs, listen to FHTs for full minute
  if decel heard, do vag exam to r/o cord prolapse

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Intrauterine Fetal Demise (IUFD)

• May be found prior to coming to hosp or at time
  of admission
• May be unexplained or r/t materanal disease
  process or fetal insult
• May be induced right away or wait for spontaneous
  labor. C/S not automatically done
• Pain med give freely

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Intrauterine Fetal Demise (IUFD)

• Provide privacy for families
• Listen
• Avoid inappropriate consolations
• Give accurate info
• Obtain mementos
• Allow opportunity to see and hold
• Provide information re burial options
• Provide support information

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Premature Rupture of Membrane(PROM)

• Spontaneous break in the amniotic sac before
  onset of regular contractions
• Mother at risk for chorioamnionitis, especially
  if the time between Rupture of Membranes (ROM)
  and birth is longer than 24 hours
• Risk of fetal infection, sepsis and perinatal
  mortality increase with prolonged ROM.
• Vaginal examinations or other invasive procedure
  increase risk of infection for mother and fetus.

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PROMSigns of Infection

• Maternal fever
• Fetal tachycardia
• Foul-smelling vaginal discharge

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PROM Detecting Amniotic Fluid

• Nitrazine
• Ferning Place a smear of fluid on a slide and
  allow to dry. Check results. If fluid takes on a
  fernlike pattern, it is amniotic fluid.
• Speculum exam

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fernlike pattern
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PROM Treatment

• Depends on fetal age and risk of infection
• In a near-term pregnancy, induction within 12-24
  hours of membrane rupture
• In a preterm pregnancy (28 -34 weeks), the woman
  is hospitalized and observed for signs of
  infection. If an infection is detected, labor is
  induced and an antibiotic is administered

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PROMNursing Interventions

• Explain all diagnostic tests
• Assist with examination and specimen collection
• Administer IV Fluids
• Observe for initiation of labor
• Offer emotional support
• Teach the patient with a history of PROM how to
  recognize it and to report it immediately

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Signs of Preterm Labor

• Rhythmic uterine contraction producing cervical
  changes before fetal maturity
• Onset of labor 20 37 weeks gestation.
• Increases risk of neonatal morbidity or mortality
  from excessive maturational deficiencies.
• There is no known prevention except for treatment
  of conditions that might lead to preterm labor.

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Treatment of Preterm Labor

• Used if tests show premature fetal lung
  development, cervical dilation is less than 4 cm,
  there are no that contraindications to
  continuation of pregnancy.
• Bed rest, drug therapy (if indicated) with a
  tocolytic

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Preterm Labor Pharmacotherapies

• Terbutaline (Brethine), a beta-adrenergic
  blocker, is the most commonly used tocolytic
• Side effects maternal fetal tachycardia,
  maternal pulmonary edema, tremors, hyperglycemia
  or chest pain, and hypoglycemia in the infant
  after birth
• Ritodrine (Yutopar) is less commonly used.

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Preterm Labor Pharmacotherapies

• Magnesium Sulfate
• Acts as a smooth muscle relaxant and leads to
  decreased blood pressure
• Many side effects including flushing, nausea,
  vomiting and respiratory depression
• Should not be used in women with cardiac or renal
  impairment
• Excreted by the kidneys

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Perterm Labor Pharmacotherapies

• Corticosteroids
• Help mature fetal lungs
• Betamethasone or dexamethasone
• Most effective if 24 hours has elapsed before
  delivery

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Nursing Interventions with Preterm Labor

• Nursing Intervention in Premature labor
• Observe for signs of fetal or maternal distress
• Administer medications as ordered
• Monitor the status of contractions, and notify
  the physician if they occur more than 4 times per
  hour.

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Nursing Interventions with Preterm Labor

• Nursing Intervention in Premature labor
• Encourage patient to lie on her side
• Bed rest encouraged but not proven effective
• Provide guidance about hospital stay, potential
  for delivery of premature infant and possible
  need for neonatal intensive care

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Nursing Interventions with Preterm Labor

• Discharge teaching for home care
• Avoid sex in any form
• Take medications on time
• Teach to recognize the signs of preterm labor and
  what to do

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Birth Related Procedures
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Procedures

• Version
• External
• Internal
• Cervical Ripening
• Cervidil
• Cytotec
• Amnioinfusion
• 250-500 mL warmed saline or LR is infused into
  uterus via IUPC over 20-30 min
• Used to correct variables, dilute mec stained
  fluid

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Labor Induction

• Stimulation of U/C before spontaneous onset of
  labor
• Prior to starting induction
• Verification of gestation age
• Confirmation of fetal presentation
• Assessment of risk factors
• Well-being assessment of mom and baby
• Cervical Assessment

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Labor Induction

• Cervical Assessment (Bishops Score)
• Higher the score, more successful the induction
  will be
• Favorable cervix is most important criteria for
  successful induction

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Bishops Score)
Cervical dilatation 1-2 3-4 5-6
Cervical effacement 0-40 40-80 80
Position of cervix posterior medial Anterior
Consistency of cervix Firm Medium soft
Station of presenting part -2 -1/0 1/2
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Labor Induction

• Methods
• Stripping membranes
• Oxytocin
• ?Always given via IV pump (may be given IM after
  del)
• Site closest to insertion
• Continuous EFM
• Risks
• Hyperstimulation
• Uterine rupture
• Water intoxication
• Fetal risks associated with maternal problems,
  hyperbilirubinemia, trauma from rapid birth

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Episiotomy

• Decline over the years
• May make it more likely will have deep tears
• Lacerations heal more quickly in absence of epis
• 3rd or 4th degree lacerations more likely with
  epis

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Episiotomy

• Midline
• from vag orifice to fibers of rectal sphincter
• Less blood loss, easier to repair, heals with
  less discomfort
• Mediolateral
• From midline of posterier forchette to 45 angle
  to right or left
• Provides more room but has gt blood loss, longer
  healing time and more discomfort
• Tx
• Pain relief measures
• Ice
• Inspect!

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Operative Assisted Deliveries

• Forceps
• Maternal complications
• Trauma
• Increased pain in pp period
• Weakening of the pelvic floor
• Fetal-neonatal complications
• Caput
• Caphalohematoma
• Transient facial paralysis
• trauma

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Operative Assisted Deliveries

• Vacuum Extractor
• Longer duration of suction, more likely scalp
  injury
• Maternal complications
• Perineal trauma
• Edema
• Genital tract and anal sphincter probs (lt than
  with forceps)
• Neonatal complications
• Scalp lacerations
• Bruising/subdural hematoma
• Cephalohematoma
• Jaundice
• Fx clavicle
• Retinal hemorrhage
• death

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Cesarean Birth

• 1970 - 5
• 1988 24.7
• 2001 21
• 2005 - ? But higher
• Indications
• Failure to progress/descend
• Previa/abruption/prolapse cord
• Non-reassuring fetal status
• Malpresentation
• Previous C/S
• Maternal morbidity and mortality is gt than vag
  delivery

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Cesarean Birth

• Technique
• NOTE Skin incision NOT indicative of uterine
  incision
• Transverse (Pfannenstiel)-lower uterine segment
• Adv below pubic hair line, less bleeding, better
  healing
• Disadv difficult to extend if needed, requires
  more time, if adipose fold difficult to keep
  clean and dry
• Vertical-between naval and symphysis
• Adv quicker, more room
• Disadv scar obvious, longer

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Cesarean Birth
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Cesarean Birth
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Cesarean Birth

• Technique
• Uterine incision (type depends on need for C/S)
• Transverse-lower uterine segment
• Adv thinnest ? less blood loss, only mod
  dissection of bladder, easier to repair, site
  less likely to rupture during subsequent
  pregnancies, less chance of adherence of bowel or
  omentum to incision line
• Disadv takes longer, limited in size due to
  major blood vessels, greater tendency to extend
  into uterine vessels

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Cesarean Birth

• Technique
• Lower Uterine Segment Vertical Incision
• Preferred for multiple gestation, abnormal
  presentation, previa, preterm, macrosomia
• Adv more room
• Disadv may extend into cx, more extensive
  dissection of the bladder is necessary, if
  extends upward hemostasis and closure more
  difficult, higher risk of rupture in subsequent
  pregnancies

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Cesarean Birth

• Technique
• Classic incision
• Upper uterine segment
• Adv more room, quicker to do
• Disadv more blood loss, difficult to repair,
  higher risk of rupture in subsequent pregnancies

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Cesarean Birth

• Prep for C/S (time dependent)
• Permits NPO
• IV Oral/IV antacids, H2 inhibitors
• Foley Teaching
• Shave
• Immediate PP care
• Freq vs (q 5-10 min) Lungs
• Check dressing IO
• Lochia and uterus Anesthetic level

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VBAC (vaginal birth after cesarean)

• That was then, this is now
• Specific criteria
• Must sign consent
• Contraindications
• Classic incision or previous fundal uterine
  surgery
• Most common risk is hemorrhage and uterine rupture

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Placental accreta

•  occurs when the placenta attaches too deep in
  the uterine wall but it does not penetrate the
  uterine muscle. Placenta accreta is the most
  common accounting for approximately 75 of all
  cases.
•  Approximately 1 in 2,500 pregnancies experience
  placenta accreta, increta or percreta.
• There are two further variants of the condition
  that are known by specific names and are defined
  by the depth of their attachment to uterine wall.