Labor and Delivery

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Labor and Delivery
CAPT Mike Hughey, MC, USNR
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Labor

• Regular, frequent, leading to progressive
  cervical effacement and dilatation
• Braxton-Hicks contractions
• May be painful and regular, but usually are not
• Do not lead to cervical change
• Labor diagnosis usually made in retrospect.
• Cause of labor is unknown

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Latent Phase Labor

• lt4 cm dilated
• Contractions may or may not be painful
• Dilate very slowly
• Can talk or laugh through contractions
• May last days or longer
• May be treated with sedation, hydration,
  ambulation, rest, or pitocin

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Active Phase Labor

• At least 4 cm dilated
• Regular, frequent, usually painful contractions
• Dilate at least 1.2-1.5 cm/hr
• Are not comfortable with talking or laughing
  during their contractions

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Progress of Labor

• Lasts about 12-14 hours (first baby)
• Lasts about 6-8 hours (subsequent babies)
• Considerable variation.
• Effacement (thinning)
• Dilatation (opening)
• Descent (progress through the birth canal)

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Descent

• Fetal head descends through the birth canal
• Defined relative to the ischial spines
• 0 station top of head at the spines (fully
  engaged)
• 2 station 2 cm past (below) the ischial spines

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Cardinal Movements of Labor

• Engagement (0 Station)
• Descent
• Flexion (fetal head flexed against the chest)
• Internal rotation (fetal head rotates from
  transverse to anterior
• Extension (head extends with crowning)
• External rotation (head returns to its
  transverse orientation)
• Expulsion (shoulders and torso of the baby are
  delivered)

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Watch a Delivery
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Placental Separation

• Signs of separation
• Increased bleeding
• Lengthening of the cord
• Uterus rises, becoming globular instead of
  discoid
• Uterus enlarges, approaching the umbilicus
• Normally separates within a few minutes after
  delivery

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Initial Labor Management

• Risk assessment
• Contractions frequency, duration, onset
• Membranes Ruptured, intact
• Status of cervix dilatation, effacement, station
• Position of the fetus vertex, transverse lie,
  breech
• Fetal status fetal heart rate, EFM

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Cervix

• Dilatation How far has the cervix opened (in cm)
• Effacement How thin is the cervix (in cm or )

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Status of Membranes

• Nitrazine paper turns blue in the presence of
  alkaline amniotic fluid (nitrazine positive)
• Vaginal secretions are nitrazine negative
  (yellow) because of their acidity
• Pooling of amniotic fluid in the vaginal vault is
  a reliable sign

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Orientation of Fetus

• Vertex, breech or transverse lie
• Palpate vaginally
• Leopolds Maneuvers

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Management of Early Labor

• Ambulation OK with intact membranes
• If in bed, lie on one side or the othernot flat
  on her back
• Check vital signs every 4 hours
• NPO except ice chips or small sips of water

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Monitor the Fetal Heart

• During early labor, for low risk patients, note
  the fetal heart rate every 1-2 hours.
• During active labor, evaluate the fetal heart
  every 30 minutes
• Normal FHR is 120-160 BPM
• Persistent tachycardia (gt160) or bradycardia
  (lt120, particularly lt100) is of concern

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Electronic Fetal Monitors

• Continuously records the instantaneous fetal
  heart rate and uterine contractions
• Patterns are of clinical significance.
• Use in high-risk patients.
• Use in low-risk patients optional

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Normal Patterns

• Normal rate
• Short term variability (3-5 BPM)
• Long term variability (15 BPM above baseline,
  lasting 10-20 seconds or longer)
• Contractions every 2-3 minutes, lasting about 60
  seconds

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Tachycardia

• gt160 BPM
• Most are not suggestive of fetal jeopardy
• Associated with
• Fever, Chorioamnionitis
• Maternal hypothyroidism
• Drugs (tocolytics, etc.)
• Fetal hypoxia
• Fetal anemia
• Fetal arrythmia

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Bradycardia

• Sustained lt120 BPM
• Most are caused by increased in vagal tone
• Mild bradycardia (80-90) with retention of
  variability is common during 2nd stage of labor
• lt80 BPM with loss of BTBV may indicate fetal
  distress

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Late Decelerations

• Repetive, non-remediable slowings of the fetal
  heartbeat toward the end of the contraction cycle
• Reflect utero-placental insufficiency

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Early Decelerations

• Periodic slowing of the FHR, synchronized with
  contractions
• Rarely more than 20-30 BPM below the baseline
• Innocent
• Associated with fetal head compression

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Variable Decelerations

• Variable in onset, duration and depth
• May occur with contractions or between them
• Sudden onset/recovery
• Increased vagal tone, usually due to some degree
  of cord compression

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Severe Variable Decelerations

• Below 60 BPM for at least 60 seconds
• If persistent, can be threatening to fetal
  well-being, with progressive acidosis

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Prolonged Decelerations

• Last gt 60 seconds
• Occur in isolation
• Associated with
• Maternal hypotension
• Epidural
• Paracervical block
• Tetanic contractions
• Umbilical cord prolapse

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Pain Relief

• Narcotics
• Continuous Lumbar Epidural
• Paracervical Block
• 50/50 nitrous/oxygen
• Psychoprophylaxis (Lamaze breathing)
• Hypnosis

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Anesthesia During Delivery

• Local
• Pudendal Block
• Epidural
• Caudal
• Spinal
• 50/50 nitrous/oxygen

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Episiotomy

• Avoids lacerations
• Provides more room for obstetrical maneuvers
• Shortens the 2nd Stage Labor
• Midline associated with greater risk of rectal
  lacerations, but heals faster
• Many women dont need them.

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Clamp and Cut the Cord

• Clamp about an inch from the babys abdomen
• Use any available instruments or usable material
• Check the cord for 3-vessels, 2 small arteries
  and one larger vein

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Inspect the Placenta

• Make sure it is complete
• Look for missing pieces
• Look for malformations
• Look for areas of adherent blood clot

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