The Labor and Delivery Process

• Labor is a physiologic process concluding in childbirth
  • Begins with consistent uterine contractions
  • Ends upon placental delivery

Definition of Terms

• Nulligravida: A woman who has never been pregnant
• Gravida: A woman who is currently pregnant or has been in the past, irrespective of the pregnancy outcome
• Nullipara: A woman who has never completed a pregnancy beyond 20 weeks
• Primipara: A woman who has been delivered only once of a fetus/fetuses born alive or dead with a gestational duration of 20+ weeks
• Multipara: A woman who has completed two or more pregnancies with gestational ages after at least 20 weeks

Start of Actual Labor

• Clinical diagnosis during labor relies on patient's report of commencement
• The labor start depends on hospital criteria like lying-in-clinics
• Contractions are defined as regular and painful
• If cervix dilates upon admission, that is also considered true labor
• Accurately identifying the onset of labor is important for plotting the partograph

True vs. False Labor

• It is important to be able to differentiate true from false labor so as to not waste time or energy
• Do not admit if categorized as false labor
• True labor can take a while, so observe and confirm the consistency of the contractions

True Labor Signs

• Contractions occur 3x in 20 minutes
  • Admission occurs if patient feels contractions every 5-7 minutes
• Intensity: mild, moderate, or strong
  • There is usually an increase in pain, but pain levels differ from patient to patient
• Cervical changes are the main identifier
  • Even with regular contractions, the patient is likely not in true labor if the cervical dilation is at 2cm

Duration of Labor

• Nullipara: 9 to 18.5 hours on average
• Multipara: 6 to 13.5 hours on average
• The more deliveries, the shorter the labor duration
• 95% of women deliver within 10 hours
• Patients usually have more than enough time to reach the delivery room once labor starts

Partogram Components

• The partogram plots the progress of labor for each patient
• Components to note
  • Patient information
  • Admitting impressions
  • Internal examination findings
    • Cervical dilation, effacement, and characteristic
    • Consistency and position of cervix
    • Fetal station

Axes of a Partogram

• X-axis (time)
  • Records hours of labor
  • The first plot connects to "hour 0" with a dotted line
• Y-axes (dilation and fetal station)
  • Records cervical dilation (left Y-axis) from 0-10 cm

Three Stages of Labor

• Stage 1: Start of labor to full cervical dilation (10 cm)
• Stage 2: Full cervical dilation to the baby's delivery
• Stage 3: Delivery of baby to placental delivery

First Stage of Labor

• Start of labor until 10cm dilation
• Full cervical dilation is 10cm
  • Assess using fingerbreadths into the vaginal canal
• Friedman's curve in 1954 summarizes this stage using labor curves
  • It divides the first stage and functional divisions
  • Interventions can be provided immediately as needed for augmentation,sedation, or Cesarean section

Functional Divisions of Labor

• Functional divisions of labor include preparatory, dilatation, and pelvic

Preparatory Division

• Cervical changes with less dilation
• Softening of cervix
• From 3-3.5cm, the cervix becomes fully effaced
• Both the latent phase and acceleration phase are included
• It is the longest division

Dilatation Division

• Cervical dilation at its maximum
• Averaged when the patient is either a nullipara or multipara

Pelvic Division

• Cardinal movements are starting to be observed
• Towards the labor end, the fetus descends and delivers through the pelvis

Phases of Labor

• The active labor phases include latent, acceleration, maximum slope, and deceleration

Latent Phase

• Cervix changes texture and becomes effaced
• Maximum duration for nullipara is 20 hours
• Maximum duration for multipara is 14 hours
• Patients are not admitted immediately in this phase
• Factors like excessive sedation and epidural anesthesia can affect the this phase

Active Phase

• Threshold cervical dilation
  • Friedman: 3-6 cm average
  • POGS: 5cm
  • ACOG: 6cm
• Cervical dilation rate:
  • Nullipara: 1.2cm/hr
  • Multipara: 1.5cm/hr
• Further divided into
  • Acceleration phase
    • Slight increase in cervical dilation and not as fast as phase of maximum slope
  • Phase of maximum slope
    • Fastest increase in cervical dilation
  • Deceleration phase
    • Begins at Friedman 7-8 cm
    • POGS 9 cm
    • Cardinal movements begin to occur
    • Rate of fetal descent Nullipara 1cm/hr
    • multipara 2cm/hr

Labor Curve Interpretation

• To identify labor phases it is important to know the baseline values
  • Active phase at 5 cm
  • Deceleration phase at 9cm
• Note the slope of the curve

How First Stage of Labor Occurs

• Engagement
• Descent
• Flexion
• Internal Rotation
• Extension
• External Rotation
• Expulsion

Engagement

• Biparietal diameter goes through the pelvic inlet
• Top of baby’s head is at the level of the ischial spines (STATION 0)
  • Nullipara: occurs before labor
  • Multipara: occurs during labor
• Feel between the 4-5 o’clock and 7-8 o’clock to feel for ischial spines
• Internal examination is difficult if bag of water is ruptured
• Note the head position
  • Laterality of the posterior fontanelle/occiput
    • The baby’s occiput is oriented towards the mother’s left side and anterior plane

Asynclitism

• Lateral deflection of the sagittal suture to a more anterior or more posterior position
• The normal process turns abnormal when the baby gets stuck and fails to descend
• Types:
  • Anterior Baby’s sagittal suture approaches the sacral promontory Anterior parietal bone presents itself
  • Posterior Baby’s sagittal suture approaches the symphysis pubis Posterior parietal bone presents itself

Decent

• Overlaps with engagement
• 1st prerequisite for vaginal brith
• Factors that affect descent
  • Amniotic fluid pressure
  • Direct pressure of the fundus upon the breech during the contraction
    • Bearing down efforts of the maternal abdominal muscles

Flexion

• Head flexion occurs as it meets resistance from
  • Cervix
  • Pelvic floor
  • Pelvic wall
• Chin to chest when baby is in proper position
• The smallest head diameter is required for the mother's bispinous diameter

Internal Rotation

• The occiput rotates anteriorly toward the symphysis pubis

Extension

• Head needs to extend during delivery
• Pushing down or the direction towards the anus is dangerous
• Use the uterus as a posterior force
• Use pelvic floor as an anterior force

External Rotation

• Head turns to restore shoulder alignment
• Check if the baby is turning in the right direction
• Fetal position turns occiput transverse in the end

Expulsion

• Anterior shoulder appears under the symphysis pubis
• Perineum becomes distended by the posterior shoulder

Fetal Head Changes

• Labor forces head shape
• Caput succedaneum
  • Soft-tissue edema of the scalp
    • The localized swelling resolves in a day
  • pressure on head during labor
  • Soft, fluctuant mass
  • No intervention needed
• Molding
  • Important for people with contracted pelvis or asynclitism
  • Bony Fetal Head Alteration with the same symptoms as Caput

Initial Evaluation

• Begin with the patient’s chief complaint
• Ideally, vitals are taken during history taking
• Obtain maternal vital signs
• Systematic examination is done with emphasis on:
  • Leopold’s maneuvers
  • Fetal heart rates
• Internal/Vaginal Examination
  • Contraindications: - Bleeding Patients -HypertensivePatient-RiskOfPreeclampsia
  • Cervical dilation, Effacement, Contractions, Fetal Station
  • Record Bishop’s Score
  • Fetal Station

Ruptured Membranes Test

• Asking the patient if she had any watery vaginal discharge
• Present if there is still a film-like consistency on top of the presenting part (head) with water in between
  • Amniotic fluid leakage
• Uses amniotic fluid is a key factor Actim PROM or ferning tests are some key tests
• Positive test will most likely indicate rupture

Laboratory Tests

• Done for OB normal patient
  • Hemoglobin,Hematocrit,Blood type,Antibody screen
• Urine RatioCreatinine is done for Hypertensive woman

Fetal Heart Rate Monitoring

• Toco Monitor Machine is placed on the Abdomen
• High Risk is recommended for patients with medical or obstetric conditions
• Low Risk is sufficient enough To check
  • Fetal Admissions
  • cardio Tocogram results
  • Every 15Min

Management During the First Stage of Labor

• Fetal Admissions
  • Monitoring every 15min
• Uterine Contractions
• Monitor every contraction. If contractions not regular patient still will deliver To get regular contractions will need Medicine

Bladder Function

• Asses bladder , Check patient every 4 hours -Encourage the the body with fluids

Amniotomy

• Some perform Amniotomy @Phase with persumes

Patients Preparation (2nd stage)

• Bring patient to the room when fully dilated
• Check if bladder id fulled
• Shaving or clippers
• Sterile drapes

Crowning

• 3-4 cm of head is showing out but contractions occurs

Delivery of Occiput Anterior

• Preform Retgens Maneuver when
• After a long rest , help deliver the anterior, and posterior, shoulder

episiotomy

• Types of Incisions or pudendum
• Shoulder dystocia Breech delivery Fetal macrosomia
• Types -Median- Episiotomy Mediolateral Episiotomy -Posterior reflects malrotation the fontanelle is closer to anus Inverted delivery is coming out spine: higher blood loss

The first step: Intervene

• Internal/Exam every 2 to 3 hrs
• Perform after delivery Mandatory

Active Management

• To fasten the labor
• Rupture Induction (if its not ruptured)

Delivery Performance (AfterFetalDeliveryPerformEINC)

• Initial contact -non separation from baby
• Non separation from mother