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8/20/2019 Swiatkowski Labor & Delivery[1]
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Normal and AbnormalNormal and Abnormal
Labor and DeliveryLabor and Delivery
Valerie Swiatkowski, MDValerie Swiatkowski, MD
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ObjectivesObjectives
At the end of this lecture, you will be able At the end of this lecture, you will be able
to:to: – – Diagnose labor and define the stagesDiagnose labor and define the stages
– – Assess a laboring patient Assess a laboring patient – – Diagnose abnormal labor Diagnose abnormal labor
– – Understand the cardinal movements of labor Understand the cardinal movements of labor
– – Deliver a babyDeliver a baby
– – Understand complications of labor Understand complications of labor
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What is Labor?What is Labor?
Progressive dilation of theProgressive dilation of the
uterine cervix in associationuterine cervix in associationwith repetitive contractionswith repetitive contractions
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What is Labor like?What is Labor like?
Subjectively:Subjectively:
– – Regular contractions getting stronger, longer,Regular contractions getting stronger, longer,closer together closer together
– – Bloody show presentBloody show present
– – Sedation does not stop true labor Sedation does not stop true labor
Objectively:Objectively:
– – Cervical change occursCervical change occurs
– – Descent of the presenting partDescent of the presenting part
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What is cervical change?What is cervical change?
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Dilation/ Effacement/StationDilation/ Effacement/Station
www.who.int/.../impac/Images_C/normal2.gif
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Bishops ScoreBishops Score
0 1 2 3
Dilation (cm) 0 1-2 3-4 5+
Effacement (%) 0-30 40-50 60-70 80+
Station -3 -2 -1
Consistency firm med soft
Position post mid ant
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False Labor is different!False Labor is different!
Irregular contractionsIrregular contractions
No bloody showNo bloody showNo cervical changeNo cervical change
Head may be ballotableHead may be ballotableSedation stops false labor Sedation stops false labor
Cervical insufficiency (incompetence):Cervical insufficiency (incompetence):dilation without contractionsdilation without contractions
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Taking a Labor HistoryTaking a Labor History
and Physicaland PhysicalHistoryHistory ::
Know 4 factsKnow 4 facts (at least)(at least):: – – Onset of contractions?Onset of contractions?
– – Did the water breakDid the water break
(ROM)?(ROM)? – – Vaginal bleeding?Vaginal bleeding?
– – Fetal movement (FM)?Fetal movement (FM)?
PMH/ Meds?PMH/ Meds?
Last PO intake?Last PO intake?
PhysicalPhysical ::
VitalsVitalsCV/CV/Pulm/AbdPulm/Abd
FHTFHT (fetal heart tracing)(fetal heart tracing)
Tocometer Tocometer ((ctxctx tracing)tracing)
EFW byEFW by LeopoldsLeopolds
Pelvic examPelvic examFetal position andFetal position andpresentationpresentation
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Assessing labor Assessing labor
What is normal labor?What is normal labor?
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Stages of Labor Stages of Labor
FirstStage:
labor onset tocomplete dilation
latent
active
SecondStage:
complete dilation todelivery of infant
ThirdStage:
delivery of infant todelivery of placenta
FourthStage: After delivery of theplacenta…
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Friedman Curve 1978
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Assessing labor Assessing labor
The importance of PThe importance of P’’ssPower Power
PassagePassage
Passenger Passenger
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POWER!POWER!
Measuring contractions:Measuring contractions:
Palpation: duration, frequency, intensityPalpation: duration, frequency, intensity – – work intensivework intensive
ExternalExternal Tocometer Tocometer : graphic display: graphic display – – no info on strength of contractionsno info on strength of contractions
Intrauterine pressure catheter (IUPC):Intrauterine pressure catheter (IUPC): – – accurate feedback in Montevideo unitsaccurate feedback in Montevideo units
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IUPCIUPC
Adequate contractions are
>200 MVU in 10 minutes
http://images.google.com/imgres?imgurl=http://z.about.com/d/pregnancy/1/5/y/Z/3/internalmonitor.jpg&imgrefurl=http://pregnancy.about.com/od/laborbasics/ss/interventions_6.htm&h=248&w=400&sz=143&hl=en&start=1&um=1&tbnid=TRuIqIKd9W-zQM:&tbnh=77&tbnw=124&prev=/images%3Fq%3Dintrauterine%2Bpressure%2Bcatheter%26um%3D1%26hl%3Den
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The Pelvis = PassageThe Pelvis = Passage
U to date. com
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Clinical PelvimetryClinical Pelvimetry
Obstetrical conjugateObstetrical conjugate
– – anterioranterior – – symphysissymphysis pubispubis – – posteriorposterior – – sacral promontorysacral promontory
– – laterallateral – – linealinea terminalisterminalis
Diagonal conjugate (clinical)Diagonal conjugate (clinical)
– – inferior border of s.pubis to s.promontoryinferior border of s.pubis to s.promontory
InterspinousInterspinous/ Bi/ Bi--ischialischial diameter diameter
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Bi-ischial Diameter
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Calwell-Moloy Classification
Pelvic Types
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Gynecoid Pelvis
Pelvic brim is a transverse ellipse
(nearly a circle)
Most favorable for delivery
50 percent of patients
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Android Pelvis
Pelvic brim is triangularConvergent Side Walls (widest posteriorly)
Prominent ischial spinesNarrow subpubic arch
More common in white women
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Anthropoid Pelvis
Pelvic brim is an anteroposterior elipseGynecoid pelvis turned 90 degrees
Narrow ischial spinesMuch more common in black women
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Platypelloid Pelvis
Pelvic brim is transverse kidney shape
Flattened gynecoid shape
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DonDon’’t forget about thet forget about thePassenger!Passenger!
http://images.google.com/imgres?imgurl=http://www.health-in-action.org/library/pdf/Shaken%2520Baby/Images/sm%2520shake%2520baby%2520with%2520bkgd.jpg&imgrefurl=http://www.health-in-action.org/node/311&h=1200&w=1350&sz=131&hl=en&start=16&tbnid=9Z42gBPsTsefNM:&tbnh=133&tbnw=150&prev=/images%3Fq%3Dbaby%26gbv%3D2%26hl%3Den
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LeopoldsLeopoldsmaneuversmaneuvers
4 maneuvers4 maneuvers
to identifyto identify
fetal landmarksfetal landmarksandand
reviewreview
fetofeto--maternalmaternal
relationshipsrelationships
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DefinitionsDefinitions
PresentationPresentation -- the part that lies closestthe part that lies closest
to the pelvic inletto the pelvic inlet
Attitude Attitude -- relationship of fetal parts torelationship of fetal parts to
each other (flexion/extension)each other (flexion/extension)
LieLie -- relationship between long axis ofrelationship between long axis offetus to mother fetus to mother
PositionPosition -- relationship between fetalrelationship between fetaldenominator and the vertical (a/p) anddenominator and the vertical (a/p) and
horizontal (r/l) planes of the birth canalhorizontal (r/l) planes of the birth canal
SynclitismSynclitism
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Williams 2001
vertex brow facesinciput
Cephalic Presentation and Attitude
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Williams 2001
Breech Presentation
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Williams 2001
A. Longitudinal: 99% of lie
B. Transverse: Associated with multiparity,
placentae previa, polyhydraminos, uterine
anomaly
C. Oblique: Unstable
Lie
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PositionPosition
Anterior Fontanelle Posterior Fontanelle
http://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/AnteriorFontanel.jpg
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Determining PositionDetermining Position
OP OT
OA
http://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/LOT.jpghttp://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/OP.jpghttp://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/LOT.jpg
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Williams 2001
A. Anterior asynclitism
B. Posterior asynclitism
SynclitismSynclitism
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Caput and moldingCaput and molding
www.fammed.washington.edu/.../Newbornexam.htm
http://www.fammed.washington.edu/network/sfm/NewbornExam/Newbornexam.htmhttp://www.fammed.washington.edu/network/sfm/NewbornExam/Newbornexam.htm
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Abnormal Labor Abnormal Labor
Prolonged latent phaseProlonged latent phase
– – Treatment: therapeutic restTreatment: therapeutic rest – – 85% active, 10% false labor 85% active, 10% false labor
Protraction disorder (primary dysfunctionalProtraction disorder (primary dysfunctional
labor)labor) – – dilation/descent occur at a slower ratedilation/descent occur at a slower rate
Secondary arrestSecondary arrest – – cessation of a previous normal dilation for 2cessation of a previous normal dilation for 2
hourshours
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Maximum Dilation: 10!Maximum Dilation: 10!
Finally the Second stage ofFinally the Second stage of
labor!labor!
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Cardinal Movement of Labor Cardinal Movement of Labor
EngagementEngagement
DescentDescentFlexionFlexion
Internal rotationInternal rotationExtensionExtension
External rotation (restitution)External rotation (restitution)ExpulsionExpulsion
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EngagementEngagement
descent of BPD to a level below the plane of the pelvic inletdescent of BPD to a level below the plane of the pelvic inletoften occurs before true labor, especially inoften occurs before true labor, especially in nulliparousnulliparous
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Flexion during descentFlexion during descent
9.5cm for9.5cm for vtxvtx / 13.5 cm for brow/ 13.5 cm for brow
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Williams 2001
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Stage 2Stage 1
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Our job in the delivery roomOur job in the delivery room
Control extension of the headControl extension of the head
Protect the perineumProtect the perineumCheck forCheck for NuchalNuchal cordcord
Suction mouth and noseSuction mouth and nose Avoid stimulation if Avoid stimulation if meconiummeconium
Catch the baby!Catch the baby!Clamp the cordClamp the cord
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Delivery ComplicationsDelivery Complications
Arrest of descent Arrest of descent
NuchalNuchal cordcord
Fetal distressFetal distress
PerinealPerineal lacerationlaceration
ShoulderShoulder dystociadystocia
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PerinealPerineal LacerationsLacerations
First degreeFirst degree -- may involve the vaginalmay involve the vaginal
mucosa,mucosa, perinealperineal skinskinSecond degreeSecond degree -- perinealperineal musclesmuscles
Third degreeThird degree -- external anal sphincter external anal sphincter Fourth degreeFourth degree -- anterior rectal wallanterior rectal wall
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Episiotomy?Episiotomy?
Easier to repair Easier to repair
Decrease length ofDecrease length ofsecond stagesecond stage
Decreased trauma toDecreased trauma to
the perineumthe perineum
Increased blood lossIncreased blood loss
Increased traumaIncreased trauma
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ShoulderShoulder DystociaDystocia
Incidence 0.2Incidence 0.2--2% of deliveries2% of deliveries (Acker 1986)(Acker 1986)
Impingement of biImpingement of bi--acromialacromial diameter ofdiameter ofthe fetus against the s.pubis and thethe fetus against the s.pubis and the
s.promontorys.promontory
4040--50% occur with birth weight
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ShoulderShoulder DystociaDystocia
Maternal morbidityMaternal morbidity -- postpartumpostpartum
hemorrhage, 4th degree lacerationshemorrhage, 4th degree lacerations
Neonatal morbidityNeonatal morbidity -- asphyxia, brachialasphyxia, brachialplexus (plexus (ErbErb palsy, 10palsy, 10--20%, 8020%, 80--90%90%
recover completely), fracture ofrecover completely), fracture of
humerushumerus/clavicle/clavicle
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ShoulderShoulder DystociaDystocia ManeuversManeuvers
Look for turtle signLook for turtle sign
Avoid excessive traction on shoulders Avoid excessive traction on shouldersMcRobertsMcRoberts: flattens the: flattens the lumbosacrallumbosacral curvecurve
SuprapubicSuprapubic pressurepressure
Ruben/Wood ScrewRuben/Wood Screw -- rotate shoulders to obliquerotate shoulders to oblique
position and pushing posterior shoulder towardposition and pushing posterior shoulder toward
fetal backfetal backDeliver posterior armDeliver posterior arm
ZavanelliZavanelli
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BabyBaby’’s out!s out!
Now What?Now What?
Stage 3: PlacentaStage 3: Placenta
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Delivery of the PlacentaDelivery of the Placenta
Signs of placenta separationSigns of placenta separation
– – rise in therise in the fundusfundus – – firm, globular uterusfirm, globular uterus
– – sudden gush of bloodsudden gush of blood
– – umbilical cord lengtheningumbilical cord lengthening
Examine the placentaExamine the placenta
Delivers within 5Delivers within 5--30 minutes30 minutes
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Placenta deliveryPlacenta delivery
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Care of the NeonateCare of the Neonate
Apgar Scoring System
0 1 2
AppearancePale Blue Pink
Pulse Absent 100Grimace Absent Grimace Cry Active
Activity Limp Some tone Active
Respiration Absent Irregular Reg & Cry
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ConclusionsConclusions
You will be able to:You will be able to:
– – Diagnose labor and define the stagesDiagnose labor and define the stages – – Assess a laboring patient Assess a laboring patient
– – Diagnose abnormal labor Diagnose abnormal labor
– – Understand the cardinal movements of labor Understand the cardinal movements of labor
– – Deliver a babyDeliver a baby
– – Understand complications of labor Understand complications of labor
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Thank you!Thank you!
Any questions? Any questions?