Swiatkowski Labor & Delivery[1]

8/20/2019 Swiatkowski Labor & Delivery[1]

1/59

Normal and AbnormalNormal and Abnormal

Labor and DeliveryLabor and Delivery

Valerie Swiatkowski, MDValerie Swiatkowski, MD


2/59

ObjectivesObjectives

At the end of this lecture, you will be able At the end of this lecture, you will be able

to:to: – – Diagnose labor and define the stagesDiagnose labor and define the stages

– – Assess a laboring patient Assess a laboring patient – – Diagnose abnormal labor Diagnose abnormal labor

– – Understand the cardinal movements of labor Understand the cardinal movements of labor

– – Deliver a babyDeliver a baby

– – Understand complications of labor Understand complications of labor


3/59

What is Labor?What is Labor?

Progressive dilation of theProgressive dilation of the

uterine cervix in associationuterine cervix in associationwith repetitive contractionswith repetitive contractions


4/59

What is Labor like?What is Labor like?

Subjectively:Subjectively:

– – Regular contractions getting stronger, longer,Regular contractions getting stronger, longer,closer together closer together

– – Bloody show presentBloody show present

– – Sedation does not stop true labor Sedation does not stop true labor

Objectively:Objectively:

– – Cervical change occursCervical change occurs

– – Descent of the presenting partDescent of the presenting part


5/59

What is cervical change?What is cervical change?


6/59

Dilation/ Effacement/StationDilation/ Effacement/Station

www.who.int/.../impac/Images_C/normal2.gif


7/59


8/59

Bishops ScoreBishops Score

0 1 2 3

Dilation (cm) 0 1-2 3-4 5+

Effacement (%) 0-30 40-50 60-70 80+

Station -3 -2 -1

Consistency firm med soft

Position post mid ant


9/59

False Labor is different!False Labor is different!

Irregular contractionsIrregular contractions

No bloody showNo bloody showNo cervical changeNo cervical change

Head may be ballotableHead may be ballotableSedation stops false labor Sedation stops false labor

Cervical insufficiency (incompetence):Cervical insufficiency (incompetence):dilation without contractionsdilation without contractions


10/59

Taking a Labor HistoryTaking a Labor History

and Physicaland PhysicalHistoryHistory ::

Know 4 factsKnow 4 facts (at least)(at least):: – – Onset of contractions?Onset of contractions?

– – Did the water breakDid the water break

(ROM)?(ROM)? – – Vaginal bleeding?Vaginal bleeding?

– – Fetal movement (FM)?Fetal movement (FM)?

PMH/ Meds?PMH/ Meds?

Last PO intake?Last PO intake?

PhysicalPhysical ::

VitalsVitalsCV/CV/Pulm/AbdPulm/Abd

FHTFHT (fetal heart tracing)(fetal heart tracing)

Tocometer Tocometer ((ctxctx tracing)tracing)

EFW byEFW by LeopoldsLeopolds

Pelvic examPelvic examFetal position andFetal position andpresentationpresentation


11/59

Assessing labor Assessing labor

What is normal labor?What is normal labor?


12/59

Stages of Labor Stages of Labor

FirstStage:

labor onset tocomplete dilation

latent

active

SecondStage:

complete dilation todelivery of infant

ThirdStage:

delivery of infant todelivery of placenta

FourthStage: After delivery of theplacenta…


13/59

Friedman Curve 1978


14/59http://www.emedicine.com/med/TOPIC3488.HTM


15/59


16/59

Assessing labor Assessing labor

The importance of PThe importance of P’’ssPower Power

PassagePassage

Passenger Passenger


17/59

POWER!POWER!

Measuring contractions:Measuring contractions:

Palpation: duration, frequency, intensityPalpation: duration, frequency, intensity – – work intensivework intensive

ExternalExternal Tocometer Tocometer : graphic display: graphic display – – no info on strength of contractionsno info on strength of contractions

Intrauterine pressure catheter (IUPC):Intrauterine pressure catheter (IUPC): – – accurate feedback in Montevideo unitsaccurate feedback in Montevideo units


18/59

IUPCIUPC

Adequate contractions are

>200 MVU in 10 minutes

http://images.google.com/imgres?imgurl=http://z.about.com/d/pregnancy/1/5/y/Z/3/internalmonitor.jpg&imgrefurl=http://pregnancy.about.com/od/laborbasics/ss/interventions_6.htm&h=248&w=400&sz=143&hl=en&start=1&um=1&tbnid=TRuIqIKd9W-zQM:&tbnh=77&tbnw=124&prev=/images%3Fq%3Dintrauterine%2Bpressure%2Bcatheter%26um%3D1%26hl%3Den


19/59

The Pelvis = PassageThe Pelvis = Passage

U to date. com


20/59

Clinical PelvimetryClinical Pelvimetry

Obstetrical conjugateObstetrical conjugate

– – anterioranterior – – symphysissymphysis pubispubis – – posteriorposterior – – sacral promontorysacral promontory

– – laterallateral – – linealinea terminalisterminalis

Diagonal conjugate (clinical)Diagonal conjugate (clinical)

– – inferior border of s.pubis to s.promontoryinferior border of s.pubis to s.promontory

InterspinousInterspinous/ Bi/ Bi--ischialischial diameter diameter


21/59U to date. com


22/59

Bi-ischial Diameter


23/59

Calwell-Moloy Classification

Pelvic Types


24/59

Gynecoid Pelvis

Pelvic brim is a transverse ellipse

(nearly a circle)

Most favorable for delivery

50 percent of patients


25/59

Android Pelvis

Pelvic brim is triangularConvergent Side Walls (widest posteriorly)

Prominent ischial spinesNarrow subpubic arch

More common in white women


26/59

Anthropoid Pelvis

Pelvic brim is an anteroposterior elipseGynecoid pelvis turned 90 degrees

Narrow ischial spinesMuch more common in black women


27/59

Platypelloid Pelvis

Pelvic brim is transverse kidney shape

Flattened gynecoid shape


28/59

DonDon’’t forget about thet forget about thePassenger!Passenger!

http://images.google.com/imgres?imgurl=http://www.health-in-action.org/library/pdf/Shaken%2520Baby/Images/sm%2520shake%2520baby%2520with%2520bkgd.jpg&imgrefurl=http://www.health-in-action.org/node/311&h=1200&w=1350&sz=131&hl=en&start=16&tbnid=9Z42gBPsTsefNM:&tbnh=133&tbnw=150&prev=/images%3Fq%3Dbaby%26gbv%3D2%26hl%3Den


29/59

LeopoldsLeopoldsmaneuversmaneuvers

4 maneuvers4 maneuvers

to identifyto identify

fetal landmarksfetal landmarksandand

reviewreview

fetofeto--maternalmaternal

relationshipsrelationships


30/59

DefinitionsDefinitions

PresentationPresentation -- the part that lies closestthe part that lies closest

to the pelvic inletto the pelvic inlet

Attitude Attitude -- relationship of fetal parts torelationship of fetal parts to

each other (flexion/extension)each other (flexion/extension)

LieLie -- relationship between long axis ofrelationship between long axis offetus to mother fetus to mother

PositionPosition -- relationship between fetalrelationship between fetaldenominator and the vertical (a/p) anddenominator and the vertical (a/p) and

horizontal (r/l) planes of the birth canalhorizontal (r/l) planes of the birth canal

SynclitismSynclitism


31/59

Williams 2001

vertex brow facesinciput

Cephalic Presentation and Attitude


32/59

Williams 2001

Breech Presentation


33/59

Williams 2001

A. Longitudinal: 99% of lie

B. Transverse: Associated with multiparity,

placentae previa, polyhydraminos, uterine

anomaly

C. Oblique: Unstable

Lie


34/59


35/59

PositionPosition

Anterior Fontanelle Posterior Fontanelle

http://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/AnteriorFontanel.jpg


36/59

Determining PositionDetermining Position

OP OT

OA

http://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/LOT.jpghttp://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/OP.jpghttp://www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/AbnormalLD/LOT.jpg


37/59

Williams 2001

A. Anterior asynclitism

B. Posterior asynclitism

SynclitismSynclitism


38/59

Caput and moldingCaput and molding

www.fammed.washington.edu/.../Newbornexam.htm

http://www.fammed.washington.edu/network/sfm/NewbornExam/Newbornexam.htmhttp://www.fammed.washington.edu/network/sfm/NewbornExam/Newbornexam.htm


39/59

Abnormal Labor Abnormal Labor

Prolonged latent phaseProlonged latent phase

– – Treatment: therapeutic restTreatment: therapeutic rest – – 85% active, 10% false labor 85% active, 10% false labor

Protraction disorder (primary dysfunctionalProtraction disorder (primary dysfunctional

labor)labor) – – dilation/descent occur at a slower ratedilation/descent occur at a slower rate

Secondary arrestSecondary arrest – – cessation of a previous normal dilation for 2cessation of a previous normal dilation for 2

hourshours


40/59

Maximum Dilation: 10!Maximum Dilation: 10!

Finally the Second stage ofFinally the Second stage of

labor!labor!


41/59

Cardinal Movement of Labor Cardinal Movement of Labor

EngagementEngagement

DescentDescentFlexionFlexion

Internal rotationInternal rotationExtensionExtension

External rotation (restitution)External rotation (restitution)ExpulsionExpulsion


42/59

EngagementEngagement

descent of BPD to a level below the plane of the pelvic inletdescent of BPD to a level below the plane of the pelvic inletoften occurs before true labor, especially inoften occurs before true labor, especially in nulliparousnulliparous


43/59

Flexion during descentFlexion during descent

9.5cm for9.5cm for vtxvtx / 13.5 cm for brow/ 13.5 cm for brow


44/59

Williams 2001


45/59

Stage 2Stage 1


46/59

Our job in the delivery roomOur job in the delivery room

Control extension of the headControl extension of the head

Protect the perineumProtect the perineumCheck forCheck for NuchalNuchal cordcord

Suction mouth and noseSuction mouth and nose Avoid stimulation if Avoid stimulation if meconiummeconium

Catch the baby!Catch the baby!Clamp the cordClamp the cord


47/59

Delivery ComplicationsDelivery Complications

Arrest of descent Arrest of descent

NuchalNuchal cordcord

Fetal distressFetal distress

PerinealPerineal lacerationlaceration

ShoulderShoulder dystociadystocia


48/59

PerinealPerineal LacerationsLacerations

First degreeFirst degree -- may involve the vaginalmay involve the vaginal

mucosa,mucosa, perinealperineal skinskinSecond degreeSecond degree -- perinealperineal musclesmuscles

Third degreeThird degree -- external anal sphincter external anal sphincter Fourth degreeFourth degree -- anterior rectal wallanterior rectal wall


49/59

Episiotomy?Episiotomy?

Easier to repair Easier to repair

Decrease length ofDecrease length ofsecond stagesecond stage

Decreased trauma toDecreased trauma to

the perineumthe perineum

Increased blood lossIncreased blood loss

Increased traumaIncreased trauma


50/59

ShoulderShoulder DystociaDystocia

Incidence 0.2Incidence 0.2--2% of deliveries2% of deliveries (Acker 1986)(Acker 1986)

Impingement of biImpingement of bi--acromialacromial diameter ofdiameter ofthe fetus against the s.pubis and thethe fetus against the s.pubis and the

s.promontorys.promontory

4040--50% occur with birth weight


51/59

ShoulderShoulder DystociaDystocia

Maternal morbidityMaternal morbidity -- postpartumpostpartum

hemorrhage, 4th degree lacerationshemorrhage, 4th degree lacerations

Neonatal morbidityNeonatal morbidity -- asphyxia, brachialasphyxia, brachialplexus (plexus (ErbErb palsy, 10palsy, 10--20%, 8020%, 80--90%90%

recover completely), fracture ofrecover completely), fracture of

humerushumerus/clavicle/clavicle


52/59

ShoulderShoulder DystociaDystocia ManeuversManeuvers

Look for turtle signLook for turtle sign

Avoid excessive traction on shoulders Avoid excessive traction on shouldersMcRobertsMcRoberts: flattens the: flattens the lumbosacrallumbosacral curvecurve

SuprapubicSuprapubic pressurepressure

Ruben/Wood ScrewRuben/Wood Screw -- rotate shoulders to obliquerotate shoulders to oblique

position and pushing posterior shoulder towardposition and pushing posterior shoulder toward

fetal backfetal backDeliver posterior armDeliver posterior arm

ZavanelliZavanelli


53/59


54/59

BabyBaby’’s out!s out!

Now What?Now What?

Stage 3: PlacentaStage 3: Placenta


55/59

Delivery of the PlacentaDelivery of the Placenta

Signs of placenta separationSigns of placenta separation

– – rise in therise in the fundusfundus – – firm, globular uterusfirm, globular uterus

– – sudden gush of bloodsudden gush of blood

– – umbilical cord lengtheningumbilical cord lengthening

Examine the placentaExamine the placenta

Delivers within 5Delivers within 5--30 minutes30 minutes


56/59

Placenta deliveryPlacenta delivery


57/59

Care of the NeonateCare of the Neonate

Apgar Scoring System

0 1 2

AppearancePale Blue Pink

Pulse Absent 100Grimace Absent Grimace Cry Active

Activity Limp Some tone Active

Respiration Absent Irregular Reg & Cry


58/59

ConclusionsConclusions

You will be able to:You will be able to:

– – Diagnose labor and define the stagesDiagnose labor and define the stages – – Assess a laboring patient Assess a laboring patient

– – Diagnose abnormal labor Diagnose abnormal labor

– – Understand the cardinal movements of labor Understand the cardinal movements of labor

– – Deliver a babyDeliver a baby

– – Understand complications of labor Understand complications of labor


59/59

Thank you!Thank you!

Any questions? Any questions?