Intrapartum stages

• Intrapartum refers to the period of childbirth from the onset of labor to the delivery of the placenta
• It involves a series of continuous, progressive contractions of the uterus resulting in expulsion of the fetus and placenta
• The process is divided into stages, each with specific events and management considerations

Stages of Labor

• First Stage: Onset of labor to complete cervical dilatation (10 cm)
  • Latent Phase: Cervical effacement and early dilation (0-6 cm), contractions are irregular and mild to moderate in intensity
  • Active Phase: More rapid cervical dilation (6-10 cm), contractions become more regular, stronger, and longer in duration
• Second Stage: Complete cervical dilation to delivery of the baby.
  • Passive Phase: From complete dilation until the woman has the urge to push
  • Active Phase: From the urge to push until the baby is delivered
• Third Stage: Delivery of the baby to delivery of the placenta
• Fourth Stage: 1-4 hours after delivery, critical time for maternal physiological adjustment and observation

Mechanisms of Labor

• Engagement: Fetal head passes into the pelvic inlet
• Descent: Progression of the fetal head into the pelvis
• Flexion: Fetal chin touching the chest to present the smallest diameter
• Internal Rotation: Rotation of the fetal head to align with the long axis of the pelvis
• Extension: Fetal head pivots beneath the pubic symphysis
• External Rotation (Restitution): Fetal head rotates externally to align with the shoulders
• Expulsion: Delivery of the anterior shoulder, followed by the posterior shoulder and the rest of the body

Monitoring During Labor

• Fetal Heart Rate: Assessed via intermittent auscultation or continuous electronic fetal monitoring to evaluate fetal well-being
• Contractions: Frequency, duration, and intensity are monitored to assess labor progress
• Maternal Vital Signs: Monitored regularly to detect any deviations from normal
• Cervical Dilation and Effacement: Assessed via vaginal examination to determine the progress of labor
• Fetal Position and Presentation: Determined by Leopold's maneuvers and vaginal examination

Pain Management

• Non-Pharmacological Methods: Breathing techniques, massage, hydrotherapy, position changes, and continuous support
• Pharmacological Methods:
  • Analgesia: Systemic opioids, epidural analgesia, and local anesthesia
  • Anesthesia: Spinal anesthesia, general anesthesia (reserved for emergencies)

Post-Term Labor (Postdates Pregnancy)

• Definition: Pregnancy that extends beyond 42 weeks (294 days) from the first day of the last menstrual period
• Incidence: Occurs in approximately 3-14% of pregnancies
• Etiology: Often unknown, but factors may include inaccurate dating, previous post-term pregnancy, genetic predisposition, and fetal anomalies
• Risks:
  • Fetal: Macrosomia, shoulder dystocia, oligohydramnios, meconium aspiration, dysmaturity syndrome, and increased risk of stillbirth
  • Maternal: Increased risk of cesarean delivery, perineal trauma, postpartum hemorrhage, and infection
• Diagnosis: Based on accurate pregnancy dating using early ultrasound
• Management:
  • Antepartum surveillance to assess fetal well-being
  • Induction of labor: considered if the cervix is favorable or if fetal or maternal risks are present
  • Cesarean delivery: may be necessary if induction fails or in the presence of fetal distress or other complications

Management of Post-Term Pregnancy

• Confirmation of Gestational Age: Accurate dating via early ultrasound is crucial to confirm post-term status
• Fetal Surveillance:
  • Non-Stress Test (NST): Assesses fetal heart rate response to movement
  • Amniotic Fluid Index (AFI): Measures the volume of amniotic fluid surrounding the fetus
  • Biophysical Profile (BPP): Combines NST with ultrasound assessment of fetal breathing, movement, tone, and amniotic fluid volume
• Cervical Assessment:
  • Bishop Score: Evaluates cervical readiness for labor, considering dilation, effacement, station, consistency, and position
• Induction of Labor:
  • Indications: Unfavorable fetal surveillance results, oligohydramnios, maternal medical conditions, or patient preference
  • Methods:
    • Prostaglandins: Cervical ripening agents (e.g., misoprostol, dinoprostone) to soften and dilate the cervix
    • Oxytocin: Synthetic hormone to stimulate uterine contractions
    • Mechanical Methods: Foley catheter insertion to promote cervical dilation
• Amniotomy: Artificial rupture of membranes to augment labor
• Cesarean Delivery:
  • Indications: Non-reassuring fetal status, failed induction, malpresentation, or other obstetric complications

Delivery

• Vaginal Delivery: Normal delivery of a fetus through the vaginal canal
• Cesarean Section: Surgical delivery of a fetus through an incision in the mother's abdomen and uterus
  • Indications: Fetal distress, malpresentation, placental abruption, placenta previa, uterine rupture, failed induction, and certain maternal medical conditions

Episiotomy and Perineal Tears

• Episiotomy: Surgical incision of the perineum to enlarge the vaginal opening
  • Types: Midline and mediolateral
  • Indications: Fetal distress, shoulder dystocia, need for operative vaginal delivery
  • Risks: Pain, infection, bleeding, dyspareunia
• Perineal Tears: Lacerations of the perineum during childbirth
  • Classification:
    • First Degree: Involves the perineal skin and vaginal mucosa
    • Second Degree: Extends into the perineal muscles
    • Third Degree: Extends into the anal sphincter
    • Fourth Degree: Extends through the anal sphincter and rectal mucosa
  • Management: Repair with sutures, pain management, and stool softeners

Third Stage of Labor: Placental Delivery

• Active Management: Administration of oxytocin, controlled cord traction, and uterine massage to expedite placental delivery and reduce the risk of postpartum hemorrhage
• Signs of Placental Separation:
  • Gush of blood
  • Lengthening of the umbilical cord
  • Uterine fundus becomes firm and globular
• Manual Removal: May be necessary if the placenta does not spontaneously separate within 30 minutes

Postpartum Care

• Monitoring: Vital signs, uterine tone, lochia, perineal healing, and signs of infection
• Uterine Involution: Contraction of the uterus to its pre-pregnancy size
• Lochia: Vaginal discharge after childbirth
  • Rubra: Red, lasts for 3-4 days
  • Serosa: Pink or brown, lasts for 4-10 days
  • Alba: White or yellow, lasts for 10-28 days
• Breastfeeding: Encouraged to promote maternal-infant bonding and provide nutritional benefits to the newborn
• Pain Management: Analgesics for perineal pain, uterine cramping
• Emotional Support: Addressing postpartum blues and screening for postpartum depression

Potential Complications During Labor and Delivery

• Shoulder Dystocia: Difficulty delivering the fetal shoulders after the head has been delivered
  • Risk Factors: Macrosomia, gestational diabetes, previous shoulder dystocia
  • Management: McRoberts maneuver, suprapubic pressure, internal rotation maneuvers
• Umbilical Cord Prolapse: Umbilical cord precedes the fetal presenting part
  • Management: Elevate presenting part, administer oxygen, and prepare for immediate cesarean delivery
• Uterine Rupture: Tearing of the uterine wall
  • Risk Factors: Previous cesarean delivery, uterine surgery, high parity
  • Management: Immediate laparotomy and delivery of the fetus
• Postpartum Hemorrhage: Excessive bleeding after delivery
  • Causes: Uterine atony, retained placental fragments, lacerations, coagulopathies
  • Management: Uterine massage, administration of oxytocin, misoprostol, tranexamic acid, and in severe cases, surgical intervention
• Amniotic Fluid Embolism: Amniotic fluid enters the maternal circulation, causing a severe allergic-like reaction
  • Management: Supportive care, including oxygenation, hemodynamic stabilization, and correction of coagulopathy