Physiology andManagement of Labor(An Overview)

Dr.dr.J.M.Seno Adjie SpOG(K)Departemen Obstetri dan GinekologiFakultas Kedokteran Universitas Indonesia

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Objectives Definition and diagnosis of labor Definition and diagnosis of dystocia Causes of dystocia Prevention and management of dystocia Appropriate use of oxytocin

*Fetal Distress really does exist but it must be very precisely definedAsphyxia must be documented biochemicallyThe implication of decompensation of physiologic responses is that there are such responses and these will be examined

First Stage Latent Phase Active Phase

Second Stage Passive Active

Third StageFourth Stage

*Most of what is called fetal distress is in fact a false positive, so true fetal distress is usually not presentA consequences of calling something fetal distress when it isnt is to invite the assumption of improper care, and so just send money

Laboris regular frequent uterine contractionsandcervical change (dilatation and effacement)

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Philpotts Partogram06420108246810Cervical dilatation (cm)Time (hours)Alert lineAction line

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Source: WHO/UNFPA/UNICEF/WORLD BANK. IMPAC-Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO 2000 (WHO/RHR/ 00.7)

Etiology of Dystocia Power Passenger Passage

Adequate Powers Contractions that last 60 seconds reach 50 - 60 mm Hg of pressure occur every 2 - 3 minutes

or result in good progress

Preventing Dystocia Accurate diagnosis of labor Management of prolonged latent phase Labor preparation Birth companion

Preventing Dystocia (cont.) Ambulation Analgesia Amniotomy (ARM) Fetal size

Management of Dystocia Arrest without CPD

- amniotomy- consider oxytocin augmentation if contractions are inadequate Arrest with true CPD

- C-Section

Active Management of Labor Rigorous diagnosis of labor Close surveillance of progress of labor by partogram Continuous support in labor

Active Management of Labor (cont.) Early intervention to correct inadequate progress of labor

- ARM- Oxytocin

Augmentation of Labor Initial dose of oxytocin 1 - 2 mU / min Increase interval every 30 min. Dosage increment 1 - 2 mU Usual dose for good labor 8 - 10 mU / min.

Contraction Strength with OxytocinDepends on:the dose of oxytocinandthe uterine sensitivity to oxytocin

Adverse Effects of OxytocinAdverse EffectMechanismPreventionFetal compromiseHyperstimulationCorrect doseUterine ruptureHyperstimulationCorrect doseWater intoxicationADH effectLimit free waterHypotensionVasodilatationLow dose

Summary - Prevention of Dystocia Avoid unnecessary induction Admit women in active labor Encourage ambulation / upright posture Encourage the use of prenatal education Continuous support of laboring women Use of appropriate analgesia

Summary - Management of DystociaAppropriate assessment of adequate progress in labor Appropriate intervention when necessary

- Amniotomy- Ambulation- Analgesia- Augmentation- Rest- C-sections

Obstructed Labor

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Definition and IncidenceFailure of descent of the fetus in the birth canal for mechanical reasons in spite of good uterine contractions. (Philpott, 1982)

Incidence: 1-3%

Risks Associated with neglected obstructed labor

Fetal:

Asphyxia, sepsis, death

Maternal:

Sepsis, uterine rupture, hemorrhage, fistula, death

Etiology of Obstructed LaborFetal: Pelvic disproportion:Malpresentations, malposition, malformations

Maternal: Small pelvis, soft tissue tumors of the pelvis

Clinical Presentation of a Patient with Obstructed Labor

DehydrationOliguriaKeto-acidosisSepsis

Clinical Presentation of a Patient with Obstructed LaborState of the Uterus:Ruptured Uterus

State of the Bladder:Vaginal FindingsCervical Findings

Complications of Obstructed LaborMaternal:

Ruptured uterusVsico-Vaginal FistulaeRecto-vaginal FistulaePueperal Sepsis

Fetal:

Asphyxia/ cerebral palsyNeonatal sepsisDeath

TreatmentPrevention- Good nutrition in childhood- Promotion of antenatal care- Use of partogram in the health unit- Development of appropriate and timely referral systems

Cesarean section

Prolonged or neglected obstructed labor

Ruptured Uterus

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*Fetal Distress really does exist but it must be very precisely definedAsphyxia must be documented biochemicallyThe implication of decompensation of physiologic responses is that there are such responses and these will be examined

*Most of what is called fetal distress is in fact a false positive, so true fetal distress is usually not presentA consequences of calling something fetal distress when it isnt is to invite the assumption of improper care, and so just send money

*This slide could easily be omitted*This slide could easily be omitted*