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