Day II Normal Labor PDF

Lela Tandashvili Obstetrician and Gynecologist  Day II Normal labor, stages of labor, cardinal movement of labor Intrapartum period Breech presentation  Normal birth Spontaneous in onset, low-risk at the start of labor and remaining so throughout lab...

Lela Tandashvili Obstetrician and Gynecologist  Day II Normal labor, stages of labor, cardinal movement of labor Intrapartum period Breech presentation  Normal birth Spontaneous in onset, low-risk at the start of labor and remaining so throughout labor and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth, mother and infant are in good condition World Health Organization  Stages of labor First stage -Begins from the uterine contractions until mother’s cervix is fully dilated (10cm) Second stage -Begins when the mother’s cervix is fully dilated until the baby is delivered Third stage -Begins when the baby is delivered until placenta is delivered  First stage Latent Phase –when the cervix is dilated about 4 cm Active Phase- when the cervix is dilated from 4 cm about 10cm  https://www.nichd.nih.gov/health/topics/labor- delivery/topicinfo/stages Opening of the Cervix  How the fetus is located in the uterus Fetal lie Presentation Attitude Position  Fetal Lie Fetal lie describes the relationship of the fetal long axis to that of the mother. In more than 99% of labors at term, the fetal lie is longitudinal A transverse lie is less frequent Occasionally, the fetal and maternal axes may cross at a 45- degree angle, forming an oblique lie  Presentation and Position https://www.youtube.com/watc h?v=jITAO8AcLz0 The occiput as the reference point to determine the position The left occiput anterior (LOA) position is the most common in labor. In this position, the baby's head is slightly off center in the pelvis with the back of the head toward the mother's left thigh.  Attitude The relation of the various parts of the fetus to each other. In the normal attitude, the fetus is in universal flexion  Fetal descent through the birth canal Engagement: The vertex is engaged when the biparietal diameter is at the level of the pelvic inlet or lower. In clinical practice, this translates into an occiput palpable at 0 station. Descent: This cardinal movement will usually happen concomitant with engagement, and is typically documented late in the active phase of the first stage of labor. Flexion: As the vertex descends into the maternal pelvis, it will encounter resistance from the maternal pelvic floor muscles. This will cause the flexion of the fetal head onto the thorax. Internal rotation: At the moment of engagement and descent of the vertex into the pelvis, the fetus will be in a transverse position. Because of the anatomic configuration of the pubococcygeus and iliococcygeus muscles, the occiput will be forced to rotate to the symphysis pubis. This is the widest area of the pelvic floor that will allow the passage of the fetus. Extension: At the moment of the delivery of the fetal head, the combined effects of the uterine contractions and the pelvic floor result in this cardinal movement. External rotation: This movement occurs as a consequence of the alignment of the head of the fetus with its spine as the pressure from the maternal pelvis and muscles on the fetal head is alleviated. Expulsion: After delivery of the head, the anterior shoulder will descend under the pubic bone. As it is delivered, it will follow the external rotation of the head of the fetus. Fetal descent through the birth canal https://www.youtube.com/watch?v=2kM35XMMiPk  Observations that are recorded Maternal well-being: record pulse rate every 30 minutes, blood pressure and temperature 4-hourly, urine output and lipstick testing for protein, ketones (if available) and glucose after voiding, and record all fluids and drugs administered Fetal well-being: record fetal heart rate for 1 minute every 15–30 minutes after a contraction in the first stage, and every 5 minutes in the second stage Liquor: clear, meconium stained (thick or thin), bloody or absent. Thick meconium suggests fetal distress, and closer monitoring of the fetus is indicated. Check every 30 minutes. Frequency, duration and strength of uterine contractions (assessed by palpation): record every 30 minutes Abdominal examination: to assess descent of the fetal head Vaginal examination: in every 4 hours to assess cervical dilatation, descent of the fetal head, and moulding of skull bones. More frequent examination is only undertaken if indicated Partogram during labor progress pathologies The partogram is a graphic record of the progress of labor and relevant details of the mother and fetus Partogram begins only in the active phase of labor, when the cervix is 4 cm or more dilated Partogram is effective in preventing prolonged labor, in reducing operative intervention, and in improving the neonatal outcome  Delivery of the Head With each contraction, the vulvovaginal opening is dilated by the fetal head to gradually form an ovoid and finally, an almost circular opening This encirclement of the largest head diameter by the vulvar ring is termed crowning Perineum thins and especially in nulliparous women, may undergo spontaneous laceration The anus becomes greatly stretched, and the anterior wall of the rectum may be easily seen through it.  Delivery of the Head When the head distends the vulva and perineum enough to open the vaginal introitus to a diameter of 5 cm or more, a gloved hand may be used to support the perineum The other hand is used to guide and control the fetal head to avoid expulsive delivery Slow delivery of the head may decrease lacerations  Delivery of the Head Following its delivery, the fetal head falls posteriorly, bringing the face almost into contact with the maternal anus The occiput promptly turns toward one of the maternal thighs, and the head assumes a transverse position This external rotation indicates that the bisacromial diameter, which is the transverse diameter of the thorax, has rotated into the anteroposterior diameter of the pelvis  Delivery The sides of the head are grasped with two hands, and gentle downward traction is applied until the anterior shoulder appears under the pubic arch Next, by an upward movement, the posterior shoulder is delivered Shoulder dystocia Shoulder dystocia refers to a situation where, after delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder becomes impacted on the sacral promontory It is an obstetric emergency, with an incidence of approximately 0.2-3% in all deliveries  Clinical Features of Shoulder dystocia Difficulty in delivery of the fetal head or chin Failure of restitution – the fetal remains in the occipital-anterior position after delivery by extension and therefore does not ‘turn to look to the side’ ‘Turtle Neck‘ sign – the fetal head retracts slightly back into the pelvis, so that the neck is no longer visible, akin to a turtle retreated into its shell Shoulder dystocia  Brachial plexus injury During delivery, abrupt or powerful force is avoided to avert brachial plexus injury  Brachial plexus injury https://www.ypo.education/orthopaedics/pediatric/obstetrical- brachial-plexus-injury-t427/video/ Shoulder dystocia  Shoulder dystocia REMEMBER – If managed appropriately the risk of permanent brachial plexus injury can be almost eliminated The immediate steps in the management of shoulder dystocia Call for help – shoulder dystocia is an obstetric emergency (will need senior obstetrician, senior midwife and paediatrician in attendance) Advise the mother to stop pushing – this can worsen the impaction Avoid downwards traction on the fetal head (increases risk of brachial plexus injury) – only use“routine” axial traction (i.e. keep the head in line with the baby’s spine), and do not apply fundal pressure (increases the risk of uterine rupture) Consider episiotomy – this will not relieve obstruction but can make access for manoeuvres easier  Shoulder dystocia The maneuver consists of removing the legs from the stirrups and sharply flexing the thighs up onto the abdomen The assistant is also providing suprapubic pressure simultaneously (arrow)  Suprapubic pressure Moderate suprapubic pressure can be applied by an assistant, while downward traction is applied to the fetal head Pressure is applied with the heel of the hand to the anterior shoulder wedged above and behind the symphysis The anterior shoulder is thus either depressed or rotated, or both, so the shoulders occupy the oblique plane of the pelvis and the anterior shoulder can be freed  Delivery of the posterior shoulder Another maneuver, delivery of the posterior shoulder, consists of carefully sweeping the posterior arm of the fetus across its chest, followed by delivery of the arm The shoulder girdle is then rotated into one of the oblique diameters of the pelvis with subsequent delivery of the anterior shoulder  Fracture of the anterior clavicle Deliberate fracture of the anterior clavicle by using the thumb to press it toward and against the pubic ramus can be attempted to free the shoulder impaction In practice, however, deliberate fracture of a large neonate clavicle is difficult. If successful, the fracture will heal rapidly and is usually trivial compared with brachial nerve injury, asphyxia, or death Third Stage of Labour-Delivery of the Placenta Third-stage labor begins immediately after fetal birth and ends with placental delivery Goals include: delivery of an intact placenta avoidance of uterine inversion Avoidance of postpartum hemorrhage  Management of placenta period Active Management Expectant Management  Active management of placenta period 1. Giving a drug (uterotonic) to help contract the uterus 2. Clamping the cord early (usually before, alongside, or immediately after giving the uterotonic) 3. Traction is applied to the cord with counter-pressure on the uterus to deliver the placenta (controlled cord traction) Expectant management of the third stage of labour No prophylactic administration of a uterotonic The umbilical cord is neither clamped nor cut until the placenta has been delivered or until cord pulsation has ceased The placenta is delivered spontaneously with the aid of gravity and sometimes by maternal effort Active management lowers the risk of hemorrhage (NICE) Extraction of the fetus in case of breech presentation  Breech Presentation Complete breech: The buttocks are pointing downward with the legs folded at the knees and feet near the buttocks Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body  Delivery with breech presentation Vaginal breech birth should take place in a hospital with facilities for emergency caesarean section Caesarean section should be considered if there is delay in the descent of the breech at any stage in the second stage of labour Women should be advised that, as most experience with vaginal breech birth is in the dorsal or lithotomy position, that this position is advised Episiotomy should be performed when indicated to facilitate delivery not routinely Breech extraction should not be used routinely Factors regarded as unfavorable for vaginal breech birth include the following: Other contraindications to vaginal birth (e.g. placenta praevia, compromised fetal condition) Clinically inadequate pelvis Footling or kneeling breech presentation Large baby (usually defined as larger than 3800 g) Growth-restricted baby (usually defined as smaller than 2000 g) Hyperextended fetal neck in labor (diagnosed with ultrasound or X-ray where ultrasound is not available) Lack of presence of a clinician trained in vaginal breech delivery Previous caesarean section  Homework Fetal skull Fetal descent through the birth canal