Laudelino Lopes MD, MSc, PhD, MBA, FRCSC

Department of Obstetrics & Gynaecology Maternal Fetal Medicine, Division Head

MFM Program Director Perinatal Ultrasound Unit, Co-Director

Associate Professor Associate Scientist – LHRI

Scientist - CHRI

Labour Management

University of Western Ontario The Department of Obstetrics and Gynecology

Maternal Fetal Medicine Division

�Understand normal and abnormal progress of labour for nulliparous and multiparous women including the assessment of labour, cervical dilation, fetal position.

�Define the terms position, presentation,

station, effacement and dilation. �State the definition of labour and the stages

of normal labour and delivery.

tand ormano al anand

Labour Management

• Describe the normal labour curve for nulliparous and multiparous and techniques to evaluate the progress of labour.

• Review methods of induction, including cervical ripening, and augmentation of labour.

• Describe 3 options for managing failure to

progress in labour.

bbebbe htheehhehth ormano alormaalonon lalaaboua uraboaabouruubo r

Labour Management

�Learn the criteria for ensuring intrapartum fetal wellbeing:

��Fetal heart rate monitoring:

� Intermittent � Continuous

Labour Management

� Describe the methods of intermittent and continuous intrapartum fetal heart

monitoring LIST: � 5 criteria used to describe fetal heart rate

tracings. �The indications for electronic fetal monitoring

in labour �3 types of decelerations and the implications

of each

e the methods of inntermnterm

Labour Management

Uterine Activity • amplitude • frequency • duration

• Braxton Hicks contraction • painless tightening, no cx change, start ~ 28 wks

• Cervical effacement • softening, thinning

• Engagement • ~2 weeks prior to labour in primip • Fetal head fixed in pelvis

John Braxton Hicks, the man who 140 years ago described fake contractions.

• Definition: • Onset of labour ��full dilatation

• Latent phase: 0-4 cm • Active phase: 4-10 cm

• True Labour: regular uterine contractions causing progressive cervical dilation

Definitionn:

�Baseline • Normal 120-160 beats per minute (bpm) • Tachycardia >160 bpm • Bradycardia <120 bpm

�Accelerations • > 10 bpm from baseline

�Decelerations • > 10 bpm from baseline

�Type of decelerations • Early, late, variable or mixed-pattern decelerations

�Baseline variability • + or – 5 bpm

Baseline fetal heart is 120-160, preserved beat-to-beat and long term variabilitiy. Accelerations last for 15 or more seconds above baseline and peak to 15 or more bpm.

�INTERMITTENT: • q 15 min 1st stage / q 5 min 2nd stage

�CONTINUOUS: • Meconium staining of amniotic fluid • High risk – Preeclampsia, bleeding, abn FHR • Induction / Augmentation – Syntocinon • VBAC (Vaginal Birth After Caesarian)

• Baseline • Accelerations • Decelerations • Type of

decelerations • Baseline

variability

• Contractions • Frequency • Amplitude • Duration • Baseline tone

�Contractions • yes/no

�Frequency of contractions • Optimally every 2-3 min

�Amplitude • 40-60 mmHg

�Duration • 60-90 seconds

�Baseline tone • <15 mmHg

�CONTRACTIONS: • By palpation – q 30 min early • Tocometer – in high risk or slow progress

�CERVICAL CHANGE: • Q 2 hours in early labour • Sooner based on patient symptoms, FHR • Assess dilation, effacement, station

Normal curves of progress of labour Not strict rules, but guideline

�FIRST STAGE • 6 - 18 hrs primip / active phase 1.2 cm/hr • 2 – 10 hrs multip / active phase 1.5 cm/hr

• Most common cited reason for C/S

1. PASSAGE – Abnormal pelvis

2. PASSENGER – LGA fetus

3. POWERS �� poor contraction pattern � poor pushing

�DEFINITION: • Full dilatation �� Delivery of fetus

• Friedman: 30 min � 3 hrs primip 5 min � 30 min multips ________________________________________ • Progress monitored by station

• 0 = ischial spines • 1-5 cm (or thirds) of total distance

��DEFINITIOND N:

Occiput Lambdoid suture

Posterior fontanelle Sagittal suture Anterior fontanelle Coronal suture Frontal suture

Occiput

• Engagement

• Descent

• Flexion

• Internal rotation

• Extension

• External rotation

• Expulsion • Engagement • Descent

• Flexion • Internal rotation

• Extension • External rotation

• Expulsion

Pelvic architecture issues: � Best outcomes with gynecoid & android � Cardinal movements may be inhibited by

narrow or flat pelvis ___________________________________

Trial of labour is only true test of pelvic adequacy

Delivery of fetus �� Expulsion of placenta

Timeline� 2 – 30 minutes

______________________________________ Active management – WHO / SOGC

�Uterotonic agents (Syntocinon / Misoprostol ) �GENTLE traction on cord �Fundal massage

� Signs of separation � New onset bright bleed � Lengthening of cord � “balling up” of fundus

� Uterine involution – oxytocin mediated � Inspection and repair of lacerations

• Natural supported labour

• Narcotics

• Nitrous/Oxygen inhalation

• Regional analgesia (Epidural)

• Post dates • Preeclampsia • Diabetes Mellitus • Maternal disease (cardiac) • PROM / IUGR

�Balloon / Foley

�Prostaglandins

�Cervidil

� Prostin gel,

�Misoprostol

HERBAL SUPPLEMENTS

CASTOR OIL, HOT BATHS, AND ENEMAS

SEXUAL INTERCOURSE

BREAST STIMULATION

ACUPUNCTURE/TRANSCUTANEOUS NERVE STIMULATION

� no evidence supports the use of these modalities

The Cochrane reviewers concluded that stripping of the membranes alone does not seem to produce clinically important benefits, but when used as an adjunct does seem to be associated with a lower mean dose of oxytocin needed and an increased rate of normal vaginal deliveries.[Evidence level A]

�Prostaglandins (PGE1) analog

– Cervidil (Dinoprostone), Prostin gel,

Misoprostol

�Syntocinon – synthetic oxytocin

�ARM – artificial rupture of membranes,

may be enough to initiate labour

Oxytocin infusion

GOAL • Good contraction pattern and cervical

change

Failure to progress

Intrauterine pressure catheter (IUPC)

o Congenital Heart Disease – short 2nd stage

o Pulmonary compromise

o Exhaustion

o Prolonged second stage

o Not �� advocated unless extreme protraction

o Nonreassuring FHR

o Abruption

o Malpresentation – OT/OP

FORCEPS

VACUUM EXTRACTOR

lateral view Elliot (left) and Simpson (right) (superior view)

Axis of pelvis

1. Passage � Abnormal pelvis 2. Passenger� LGA fetus 3. Powers � poor contraction pattern � poor pushing

1. Failure to progress 2. Non-reassuring FHR status 3. Previous caesarian section 4. Fetal malpresentation – breech, transverse

t

1. Abnormal placentation – previa, vasa previa 2. Mechanical obstruction – fibroid, teratoma 3. Maternal Infection – HSV, HIV 4. Multiple gestations 5. Cervical cancer 6. Fetal congenital anomalies

Ab l l t til i

�VERTICAL o Faster, less blood loss o Emergency, previous scar, obese

patient, abn bleeding

�PFANNENSTEIL o Low transverse, more cosmetic, less

stress? o Standard for most C/S

�VERTICAL

�STANDARD o Lower uterine segment o Transverse o Low risk of rupture in subsequent labour (0.5%)

�VERTICAL (CLASSICAL) or � “T” INCISION

o High risk of rupture in subsequent labour (5%)

�Understand normal and abnormal progress of labour for nulliparous and multiparous women including the assessment of labour, cervical dilation, fetal position.

�Define the terms position, presentation,

station, effacement and dilation. �State the definition of labour and the stages

of normal labour and delivery.

tand ormano al anand

Labour Management

• Describe the normal labour curve for nulliparous and multiparous and techniques to evaluate the progress of labour.

• Review methods of induction, including cervical ripening, and augmentation of labour.

• Describe 3 options for managing failure to

progress in labour.

bbebbe htheehehth ormano alormaalonon lalaaboua uraboaabouruubo r

Labour Management

�Learn the criteria for ensuring intrapartum fetal wellbeing:

��Fetal heart rate monitoring:

� Intermittent � Continuous

Labour Management

� Describe the methods of intermittent and continuous intrapartum fetal heart

monitoring LIST: � 5 criteria used to describe fetal heart rate

tracings. �The indications for electronic fetal monitoring

in labour �3 types of decelerations and the implications

of each

e the methods of inntermnterm

Labour Management

Laudelino Lopes