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Syed Khawar Shah08-191
Definitions Scenario Stages Mechanics Cardinal movements Delivery Management
Labor – Uterine contractions that result in effacement and dilatation of the cervix.
Braxton-Hicks – Uterine contractions NOT associated with cervical change. Shorter in duration Less intense Over lower abdomen and groin Resolve with ambulation
Lightening – Descent of the fetal head into the pelvis
Preterm labor – Prior to 37 weeks Term – 37 to 42 weeks Post term – After 42 weeks Post dates – After 40 weeks
22yo G2P1 at 39 wks comes complaining of RUC’s q5 minutes x 2 hours.Bring the patient up to the monitor and patient’s chart to you to further evaluate the patient.
Talk with the patient HISTORY Frequency,duration and strength of ctx’s Colour & amount of amniotic fluid lost Abnormal veginal discharge or bleeding Fetal movements
Examine patient Abdominal examination Veginal examination
Admit patient to Labor and Delivery Complete Hx of ctx Consents signed for delivery and potential blood
transfusion
Clear diet IVF’s T&S/CBC Continuous EFM vs. intermittent
Intermittent = FHTs q 30 min to include a ctx and immediately after Membranes intact and well-engaged
Continuous poorly engaged, augmented labor, epidural?
1st Stage Interval between onset of labor and full cervical
dilatation 2 phases:
Latent – period between onset of labor and point at which a change in slope of rate of cervical dilatation is noted.
Active – Greater rate of cervical dilatation and usually begins around 2-3cm
2nd stage Interval between full cervical dilatation and delivery Duration
Nulliparous – 3 hrs w/ epidural; 2 hrs w/o epidural Multiparous – 2 hrs w/ epidural; 1 hr w/o epidural
3rd stage Delivery of the placenta and membranes Duration – maximum of 30 minutes
The Powers Forces generated by uterine musculature Frequency, amplitude, and duration of ctx’s Observation, manual palpation, tocodynamometry,
intrauterine pressure catheter (IUPC)
Passenger Fetal size
Abdominal palpation or Ultrasound Macrosomia (>4500g) associated w/ failure to
progress Lie
Longitudinal axis of fetus relative to longitudinal axis of uterus
Longitudinal*, transverse or oblique Presentation
Fetal part that directly overlies pelvic inlet Cephalic, breech, or shoulder Compound – presence of >1 fetal part overlying
the pelvic inlet Funic – umbilical cord presenting at pelvic inlet Malpresentation – any presentation that is not
cephalic with occiput leading
Attitude Position of head with regard to fetal spine (ie: degree of
flexion or extension) Flexion allows smallest diameter of fetal head to
present at pelvic inlet Position
Relationship of a nominated site of presenting part to denominating location on internal pelvis Example: cephalic presentation
Station Measure of descent of presenting
part of the fetus through the birth canal.
Multifetal Pregnancy Increase probability of abnormal lie
and malpresentation in labor
Leopold’s maneuvers #1 – Correct dextrorotation of the uterus with the back of one
hand and delineate the fundus with the other to determine gestational age and/or appropriate size.
#2 – Run hands down maternal abdomen on either side of fetus to determine fetal lie, identifying small parts and fetal spine
#3 – Firmly grasp upper and lower poles of fetus by placing fingers at uterine fundus and above symphysis to determine presentation and fetal size.
#4 – Move hands in bilaterally from anterior superior iliac crests to determine whether or not the presenting part of the fetus is engaged in maternal pelvis. Head regarded as unengaged if examiner’s hands are see to
converge below fetal head.
Passage Bony pelvis + soft tissues 4 types of the female bony pelvis
Engagement Passage of widest diameter of presenting part to level below
the plane of the pelvic inlet 0 station Occurs earlier in nulliparous women (36 wks)
Descent Downward passage of presenting part through the pelvis.
Flexion Occurs passively as the head descends due to the shape of the
bony pelvis and resistance of pelvic floor soft tissues Allows smallest diameter of fetal head to pass through the
pelvis.
Internal Rotation Rotation of presenting part from original position (transverse)
to anteroposterior position Extension
Occurs once fetus has descended to the level of the introitus Base of occiput in contact with inferior margin of symphysis
pubis External Rotation
Return of fetal head to correct anatomic position in relation to the fetal torso
Expulsion Delivery of rest of fetus Anterior shoulder delivered first with rotation under the
symphysis pubis
Prepare for the delivery taking into account parity, progression of labor, presentation of fetus, complications of labor
When head crowns and delivery is eminent, protect the perineum + downward pressure to keep head flexed Ritgen’s maneuver my help if delay in delivery of the fetal head
Sterile towel used to palpate fetal chin through the rectum to apply upward pressure to facilitate extension of fetal head
After delivery of head Allow for external rotation (restitution). Reduce nuchal cord Suction fetal mouth and nares
After clearing fetal airway Place a hand on each parietal eminence to apply downward traction to
deliver anterior shoulder Followed by upward traction to deliver posterior shoulder
Inspect the placenta Abnormalities of lobulation Site of insertion of umbilical cord into the placenta
Marginal insertion –inserts into edge of placenta Membranous insertion – vessels course through the membranes
prior to attaching to placental disk Length (50-60cm) 2 arteries and 1 vein
Single umbilical artery associated with 20% risk of other structural anomalies.
Maternal vital signs -temperature, pulse, blood pressure : at least every 4 hours (if membrane rupture or high temperature: hourly)
-prolonged membrane rupture (>18 hrs) :antibiotics (preventtion of group B streptococcus)
Oral intake - food should be withheld during active labor and delivery - in labor & analgesics are administered :gastric emptying time is prolonged :not absorbed ,vomited, and aspiration -sips of clear liquids, occasional ice chips, and lip moisturizers are permitted
Intravenous fluids -there is seldom any real need for such in the normally pregnant at least until analgesia is administered
-advantage: oxitocin prophylactically (atony persist) administration of glucose, Na, water (prevent dehydration & acidosis)
Subsequent vaginal examination -the status of the cervix the station & position of the presenting part -at 2- to 3-hour intervals -sterile, water-soluble lubricants avoid povidone-iodine and hexachlorophene
-if membrane rupture before engage :fetal heart rate should be checked vaginal exam-umbilical cord compression
Analgesia -depend on the needs and desires of the women
-the timing, method of the administration, and size of initial and subsequent doses are based to a considerable degree on the anticipated interval of the time until delivery
-a repeat vaginal exam before administering analgesia
Urinary bladder function -bladder distention should be avoided : obstructed labor subsequent bladder hypotonia and infection
-ambulation: self voiding if not, intermittent catheterization