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Definition
Childbirth is a physiologic process during which the products of conception(ie, the fetus, membranes, umbilical cord, and placenta) are expelledoutside of the uterus. Childbirth is achieved with changes in the
biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficientfrequency, intensity, and duration. [, !"
Childbirth is a clinical diagnosis. #he onset of childbirth is defined asregular, painful uterine contractions resulting in progressive cervicaleffacement and dilatation. Cervical dilatation in the absence of uterinecontraction suggests cervical insufficiency, whereas uterine contractionwithout cervical change does not meet the definition of childbirth.
$tages of Childbirth and %pidemiology
Stages of Childbirth
&bstetricians have divided childbirth into ' stages that delineate milestonesin a continuous process.
First stage of childbirth
#he first stage begins with regular uterine contractions and ends withcomplete cervical dilatation at cm. n *riedman+s landmar studies of- nulliparas[-" , he subdivided the first stage into an early latent phase andan ensuing active phase. #he latent phase begins with mild, irregularuterine contractions that soften and shorten the cervix. #he contractionsbecome progressively more rhythmic and stronger. #his is followed by theactive phase of childbirth, which usually begins at about '/ cm of cervicaldilation and is characteri0ed by rapid cervical dilation and descent of thepresenting fetal part. #he first stage of childbirth ends with completecervical dilation at cm. 1ccording to *riedman, the active phase isfurther divided into an acceleration phase, a phase of maximum slope, and
a deceleration phase.
Characteristics of the average cervical dilatation curve is nown as the*riedman childbirth curve, and a series of definitions of childbirthprotraction and arrest were subsequently established.[2, 3" 4owever,subsequent data of modern obstetric population suggest that the rate ofcervical dilatation is slower and the progression of childbirth may be
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significantly different from that suggested by the *riedman childbirth curve.[5, 6, "
Second stage of childbirth
#he second stage begins with complete cervical dilatation and ends withthe delivery of the fetus. #he 1merican College of &bstetricians and7ynecologists (1C&7) has suggested that a prolonged second stage ofchildbirth should be considered when the second stage of childbirthexceeds ' hours if regional anesthesia is administered or ! hours in theabsence of regional anesthesia for nulliparas. n multiparous women, sucha diagnosis can be made if the second stage of childbirth exceeds ! hourswith regional anesthesia or hour without it. ["
$tudies performed to examine perinatal outcomes associated with a
prolonged second stage of childbirth revealed increased riss of operativedeliveries and maternal morbidities but no differences in neonataloutcomes.[, !, ', /" 8aternal ris factors associated with a prolonged secondstage include nulliparity, increasing maternal weight and9or weight gain, useof regional anesthesia, induction of childbirth, fetal occiput in a posterior ortransverse position, and increased birthweight.[', /, -, 2"
Third stage of childbirth
#he third stage of childbirth is defined by the time period between the
delivery of the fetus and the delivery of the placenta and fetal membranes.During this period, uterine contraction decreases basal blood flow, whichresults in thicening and reduction in the surface area of the myometriumunderlying the placenta with subsequent detachment of the placenta.[3" 1lthough delivery of the placenta often requires less than minutes, theduration of the third stage of childbirth may last as long as ' minutes.
%xpectant management of the third stage of childbirth involvesspontaneous delivery of the placenta. 1ctive management often involvesprophylactic administration of oxytocin or other uterotonics (prostaglandinsor ergot alaloids), cord clamping9cutting, and controlled cord traction of theumbilical cord. 1ndersson et al found that delayed cord clamping (:5seconds after delivery) improved iron status and reduced prevalence of irondeficiency at age / months and also reduced prevalence of neonatalanemia, without apparent adverse effects. [5"
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1 systematic review of the literature that included - randomi0ed controlledtrials comparing active and expectant management of the third stagereports that active management shortens the duration of the third stage andis superior to expectant management with respect to blood loss9ris ofpostpartum hemorrhage; however, active management is associated withan increased ris of unpleasant side effects. [6"
#he third stage of childbirth is considered prolonged after ' minutes, andactive intervention, such as manual extraction of the placenta, is commonlyconsidered.[!"
Epidemiology
1s the childbearing population in the <nited $tates has changed, theclinical obstetric management of childbirth also has evolved since
*riedman=s studies. Data from number a studies have suggested thatnormal childbirth can progress at a rate much slower than that *riedmanand $achtleben[2, 3" had described. >hang et al examined the childbirthprogression of ,2! nulliparas who presented in spontaneous childbirthand constructed a childbirth curve that was maredly different from*riedman=s? #he average interval to progress from / cm of cervicaldilatation was -.- hours compared with !.- hours of *riedman=s childbirthcurve.[!" @ilpatric et al[5" and 1lbers et al[6" also reported that the medianlengths of first and second stages of childbirth were longer than those
*riedman suggested.
1 number of investigators have identified several maternal characteristicsobstetric factors that are associated with the length of childbirth. &ne groupreported that increasing maternal age was associated with a prolongedsecond stage but not first stage of childbirth. [!"
Ahile nulliparity is associated with a longer childbirth compared tomultiparas, increasing parity does not further shorten the duration ofchildbirth.[!!" $ome authors have observed that the length of childbirth differs
among racial9ethnic groups. &ne group reported that 1sian women havethe longest first and second stages of childbirth compared with Caucasianor 1frican 1merican women[!'" , and 1merican ndian women had secondstages shorter than those of non4ispanic Caucasian women. [6"4owever,others report conflicting findings. [!/, !-" Differences in the results may havebeen due to variations in study designs, study populations, childbirthmanagement, or statistical power.
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n one large retrospective study of the length of childbirth, specifically withrespect to race and9or ethnicity, the authors observed no significantdifferences in the length of the first stage of childbirth among differentracial9ethnic groups. 4owever, the second stage was shorter in 1frican
1merican women than in Caucasian women for both nulliparas (!! min)and multiparas (3.- min). 4ispanic nulliparas, compared with theirCaucasian counterparts, also had a shortened second stage, whereas nodifferences were seen for multiparas. n contrast, 1sian nulliparas had asignificantly prolonged second stage compared with their Caucasiancounterparts, and no differences were seen for multiparas. [!2"
1ccording to a systematic review of ' trials involving 2,!/! women, mostwomen whose prenatal and childbirth care were led by a midwife had better outcomes compared with those whose care was led by a physician or
shared among disciplines. Batients who received midwifeled pregnancycare were less liely to have regional analgesia, episiotomy, andinstrumental birth and more liely to have no intrapartum analgesia oranesthesia, spontaneous vaginal birth, attendance at birth by a nownmidwife, and a longer mean length of childbirth. #hey were also less lielyto have preterm birth and fetal loss before !/ wees= gestation. 4owever,the average ris ratio for caesarean births did not differ between groups,and there were no differences in fetal loss9neonatal death at !/ or morewees= gestation or in overall fetal9neonatal death. [, !3"
Concerns associated with midwife-attended home births
4owever, concerns about the effect of midwifeattended home births onneonatal health were raised by an analysis of nearly / million singleton,fullterm births, from !3!, of infants of normal weight. #he data, fromthe ational Center for 4ealth $tatistics, indicated that delivering at homewas associated with a greater than fold increased ris for an 1pgarscore of and a nearly /fold increased ris for neonatal sei0ure or seriousneurologic dysfunction, as compared with hospital delivery.[!5, !6"
Compared with delivery by a hospital physician, midwifeattended homebirth was associated with a relative ris () of .-- for an 1pgar score of. *or midwife deliveries at freestanding birth centers, the was '.-2,and for hospital midwife deliveries, the was .--. [!5, !6"
n the same study, the for neonatal sei0ures or serious neurologicdisorders for midwifeattended home births, compared with physician
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attended hospital delivery, was '.5. Compared with inhospital physiciandelivery, the for midwife delivery at freestanding birth centers was .55,and for hospital midwife delivery, the was .3/. [!5, !6"
8echanism of Childbirth#he ability of the fetus to successfully negotiate the pelvis during childbirthinvolves changes in position of its head during its passage in childbirth. #hemechanisms of childbirth, also nown as the cardinal movements, aredescribed in relation to a vertex presentation, as is the case in 6-E of allpregnancies. 1lthough childbirth and delivery occurs in a continuousfashion, the cardinal movements are described as 3 discrete sequences, asdiscussed below.[!"
Engagement
#he widest diameter of the presenting part (with a wellflexed head, wherethe largest transverse diameter of the fetal occiput is the biparietaldiameter) enters the maternal pelvis to a level below the plane of the pelvicinlet. &n the pelvic examination, the presenting part is at station, or at thelevel of the maternal ischial spines.
Descent
#he downward passage of the presenting part through the pelvis. #his
occurs intermittently with contractions. #he rate is greatest during thesecond stage of childbirth.
Flexion
1s the fetal vertex descents, it encounters resistance from the bony pelvisor the soft tissues of the pelvic floor, resulting in passive flexion of the fetalocciput. #he chin is brought into contact with the fetal thorax, and thepresenting diameter changes from occipitofrontal (. cm) tosuboccipitobregmatic (6.- cm) for optimal passage through the pelvis.
Internal rotation
1s the head descends, the presenting part, usually in the transverseposition, is rotated about /-F to anteroposterior (1B) position under thesymphysis. nternal rotation brings the 1B diameter of the head in line withthe 1B diameter of the pelvic outlet.
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Extension
Aith further descent and full flexion of the head, the base of the occiputcomes in contact with the inferior margin of the pubic symphysis. <pwardresistance from the pelvic floor and the downward forces from the uterine
contractions cause the occiput to extend and rotate around the symphysis.#his is followed by the delivery of the fetus= head.
Restitution and external rotation
Ahen the fetus= head is free of resistance, it untwists about /-F left or right,returning to its original anatomic position in relation to the body.
Expulsion
1fter the fetus= head is delivered, further descent brings the anteriorshoulder to the level of the pubic symphysis. #he anterior shoulder is thenrotated under the symphysis, followed by the posterior shoulder and therest of the fetus.
Clinical 4istory and Bhysical %xamination
istory
#he initial assessment of childbirth should include a review of the patient=sprenatal care, including confirmation of the estimated date of delivery.
*ocused history taing should be conducted to include information, such asthe frequency and time of onset of contractions, the status of the amnioticmembranes (whether spontaneous rupture of the membranes hasoccurred, and if so, whether the amniotic fluid is clear or meconiumstained), the fetus= movements, and the presence or absence of vaginalbleeding.
Graxton4ics contractions, which are often irregular and do not increase infrequency with increasing intensity, must be differentiated from truecontractions. Graxton4ics contractions often resolve with ambulation or achange in activity. 4owever, contractions that lead to childbirth tend to lastlonger and are more intense, leading to cervical change. #rue childbirth isdefined as uterine contractions leading to cervical changes. f contractionsoccur without cervical changes, it is not childbirth. &ther causes for thecramping should be diagnosed. 7estational age is not a part of thedefinition of childbirth.
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n addition, Graxton4ics contractions occur occasionally, usually no morethan ! per hour, and they often occur Hust a few times per day. Childbirthcontractions are persistent, they may start as infrequently as every -minutes, but they usually accelerate over time, increasing to contractionsthat occur every !' minutes.
Batients may also describe what has been called lightening, ie, physicalchanges felt because the fetus= head is advancing into the pelvis. #hemother may feel that her baby has become light. 1s the presenting fetalpart starts to drop, the shape of the mother=s abdomen may change toreflect descent of the fetus. 4er breathing may be relieved because tensionon the diaphragm is reduced, whereas urination may become morefrequent due to the added pressure on the urinary bladder.
!hysical examinationBhysical examination should include documentation of the patient=s vitalsigns, the fetus= presentation, and assessment of the fetal wellbeing. #hefrequency, duration, and intensity of uterine contractions should beassessed, particularly the abdominal and pelvic examinations in patientswho present in possible childbirth.
1bdominal examination begins with the Ieopold maneuvers describedbelow[!" ?
• #he initial maneuver involves the examiner placing both of his or her
hands on each upper quadrant of the patient=s abdomen and gentlypalpating the fundus with the tips of the fingers to define which fetal poleis present in the fundus. f it is the fetus= head, it should feel hard andround. n a breech presentation, a large, nodular body is felt.
• #he second maneuver involves palpation in the paraumbilical regions
with both hands by applying gentle but deep pressure. #he purpose is todifferentiate the fetal spine (a hard, resistant structure) from its limbs(irregular, mobile small parts) to determinate the fetus= position.
• #he third maneuver is suprapubic palpation by using the thumb andfingers of the dominant hand. 1s with the first maneuver, the examinerascertains the fetus= presentation and estimates its station. f thepresenting part is not engaged, a movable body (usually the fetal occiput)can be felt. #his maneuver also allows for an assessment of the fetalweight and of the volume of amniotic fluid.
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• #he fourth maneuver involves palpation of bilateral lower quadrants
with the aim of determining if the presenting part of the fetus is engagedin the mother=s pelvis. #he examiner stands facing the mother=s feet. Aiththe tips of the first ' fingers of both hands, the examiner exerts deep
pressure in the direction of the axis of the pelvic inlet. n a cephalicpresentation, the fetus= head is considered engaged if the examiner=shands diverge as they trace the fetus= head into the pelvis.
Belvic examination is often performed using sterile gloves to decrease theris of infection. f membrane rupture is suspected, examination with asterile speculum is performed to visually confirm pooling of amniotic fluid inthe posterior fornix. #he examiner also loos for fern on a dried sample ofthe vaginal fluid under a microscope and checs the p4 of the fluid byusing a nitra0ine stic or litmus paper, which turns blue if the amniotic fluidis alalotic. f fran bleeding is present, pelvic examination should be
deferred until placenta previa is excluded with ultrasonography.*urthermore, the pattern of contraction and the patient=s presenting historymay provide clues about placental abruption.
Digital examination of the vagina allows the clinician to determine thefollowing? () the degree of cervical dilatation, which ranges from cm(closed or fingertip) to cm (complete or fully dilated), (!) the effacement(assessment of the cervical length, which is can be reported as apercentage of the normal ' to /cmlong cervix or described as the actualcervical length); actual reporting of cervical length may decrease potentialambiguity in percenteffacement reporting, (') the position, ie, anterior orposterior, and (/) the consistency, ie, soft or firm. Balpation of thepresenting part of the fetus allows the examiner to establish its station, byquantifying the distance of the body (- to J- cm) that is presenting relativeto the maternal ischial spines, where station is in line with the plane of thematernal ischial spines).[!"
#he pelvis can also be assessed either by clinical examination (clinicalpelvimetry) or radiographically (C# or 8). #he pelvic planes include the
following?
• Belvic inlet? #he obstetrical conHugate is the distance between the
sacral promontory and the inner pubic arch; it should measure .- cm or more. #he diagonal conHugate is the distance from the undersurface ofthe pubic arch to sacral promontory; it is ! cm longer than the obstetricalconHugate. #he transverse diameter of the pelvic inlet measures '.- cm.
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• 8idpelvis? #he midpelvis is the distance between the bony points of
ischial spines, and it typically exceeds ! cm.
• Belvic outlet? #he pelvic outlet is the distance between the ischial
tuberosities and the pubic arch. t usually exceeds cm.
#he shape of the mother=s pelvis can also be assessed and classified into /broad categories based on the descriptions of Caldwell and 8oloy?gynecoid, anthropoid, android, and platypelloid. ['" 1lthough the gynecoidand anthropoid pelvic shapes are thought to be most favorable for vaginaldelivery, many women can be classified into or more pelvic types, andsuch distinctions can be arbitrary.[!"
Aorup
4ighris pregnancies can account for up to 5E of all perinatal morbidity
and mortality. #he remaining perinatal complications arise in pregnancieswithout identifiable ris factors for adverse outcomes. ['" #herefore, allpregnancies require a thorough evaluation of riss and close surveillance.
1s soon as the mother arrives at the Childbirth and Delivery suite, externaltocometric monitoring for the onset and duration of uterine contractions anduse of a Doppler device to detect fetal heart tones and rate should bestarted.
n the presence of childbirth progression, monitoring of uterine contractionsby external tocodynamometry is often adequate. 4owever, if a childbirthing
mother is confirmed to have rupture of the membranes and if theintensity9duration of the contractions cannot be adequately assessed, anintrauterine pressure catheter can be inserted into the uterine cavity pastthe fetus to determine the onset, duration, and intensity of the contractions.Gecause the external tocometer records only the timing of contractions, anintrauterine pressure catheter can be used to measure the intrauterinepressure generated during uterine contractions if their strength is aconcern. Ahile it is considered safe, placental abruption has been reportedas a rare complication of an intrauterine pressure catheter placed
extramembraneously.
['!"
Gedside ultrasonography may be used to assess the ris of gastric contentaspiration in pregnant women during childbirth, by measuring the antralcrosssectional area (C$1), according to a study by Gataille et al. ['', '/" n thereport, which involved 2 women in childbirth who were under epiduralanalgesia, the investigators found that at epidural insertion, half of the
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women had an antral C$1 of over '! mm!, indicating that they were atincreased ris of gastric content aspiration while under anesthesia. ['', '/"
t was also found that the antral C$1 was reduced during childbirth, fallingfrom a median of '6 mm! at epidural insertion to !' mm! at full cervicaldilatation, with only 'E of the women at that time still considered at ris of aspiration.['', '/" #his change, according to the investigators, suggested thateven under epidural anesthesia, gastric motility is preserved.
&ften, fetal monitoring is achieved using cardiotography, or electronic fetalmonitoring. Cardiotography as a form of fetal assessment in childbirth wasreviewed using randomi0ed and quasirandomi0ed controlled trials involvinga comparison of continuous cardiotocography with no monitoring,intermittent auscultation, or intermittent cardiotocography. #his review
concluded that continuous cardiotocography during childbirth is associatedwith a reduction in neonatal sei0ures but not cerebral palsy or infantmortality; however, continuous monitoring is associated with increasedcesarean and operative vaginal deliveries. ['-"
f nonreassuring fetal heart rate tracings by cardiotography (eg, latedecelerations) are noted, a fetal scalp electrode may be applied togenerate sensitive readings of beattobeat variability. 4owever, a fetalscalp electrode should be avoided if the mother has 4K, hepatitis G orhepatitis C infections, or if fetal thrombocytopenia is suspected. ecently, a
framewor has been suggested to classify and standardi0e theinterpretation of a fetal heart rate monitoring pattern according to the ris of fetal acidemia with the intention of minimi0ing neonatal acidemia withoutexcessive obstetric intervention.['2"
#he question of whether fetal pulse oximetry may be useful for fetalsurveillance in childbirth was examined in a review of - published trialscomparing fetal pulse oximetry and cardiotography with cardiotographyalone. t concluded that existing data provide limited support for the use offetal pulse oximetry when used in the presence of a nonreassuring fetal
heart rate tracing to reduce caesarean delivery for nonreassuring fetalstatus. #he addition of fetal pulse oximetry does not reduce overallcaesarean deliveries.['3"
*urther evaluation of a fetus at ris for childbirth intolerance or distress canbe accomplished with blood sampling from fetal scalp capillaries. #hisprocedure allows for a direct assessment of fetal oxygenation and blood
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p4. 1 p4 of L 3.! warrants further investigation for the fetus= wellbeingand for possible resuscitation or surgical intervention.
outine childbirthatory studies of the parturient, such as complete bloodcell (CGC) count, blood typing and screening, and urinalysis, are usuallyperformed. ntravenous (K) access is established.
ntrapartum 8anagement of Childbirth
First stage of childbirth
Cervical change occurs at a slow, gradual pace during the latent phase ofthe first stage of childbirth. Iatent phase of childbirth is complex and notwellstudied since determination of onset is subHective and may bechallenging as women present for assessment at different time duration
and cervical dilation during childbirth. n a cohort of women undergoinginduction of childbirth, the median duration of latent childbirth was '5/minwith an interquartile range of !/2/ min. #he authors report that cervicalstatus at admission for childbirth induction, but not other ris factorstypically associated with cesarean delivery, is associated with length of thelatent phase.['5"
8ost women experience onset of childbirth without premature rupture ofthe membranes (B&8); however, approximately 5E of term pregnanciesis complicated by B&8. $pontaneous onset of childbirth usually follows
B&8 such that -E of women with B&8 who were expectantlymanaged delivered within - hours, and 6-E gave birth within !5 hours ofB&8.['6" Currently, the 1merican College of &bstetricians and7ynecologists (1C&7) recommends that fetal heart rate monitoring shouldbe used to assess fetal status and dating criteria reviewed, and group Gstreptococcal prophylaxis be given based on prior culture results or risfactors of cultures not available. 1dditionally, randomi0ed controlled trials todate suggest that for women with B&8 at term, childbirth induction,usually with oxytocininfusion, at time of presentation can reduce the ris of
chorioamnionitis.[/"
1ccording to *riedman and colleagues,[2" the rate of cervical dilation shouldbe at least cm9h in a nulliparous woman and .! cm9h in a multiparouswoman during the active phase of childbirth. 4owever, childbirthmanagement has changed substantially during the last quarter century.Barticularly, obstetric interventions such as induction of childbirth,
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augmentation of childbirth with oxytocin administration, use of regionalanesthesia for pain control, and continuous fetal heart rate monitoring areincreasingly common practice in the management of childbirth in today+sobstetric population.[/, /!, !" Kaginal breech and mid or highforcepsdeliveries are now rarely performed.[/', //, /-" #herefore, subsequent authorshave suggested normal childbirth may precede at a rate less rapid thanthose previously described.[5, 6, !"
Data collected from the Consortium on $afe Childbirth suggests thatallowing childbirth to continue longer before 2cm dilation may reduce therate of intrapartum and subsequent cesarean deliveries in the <nited$tates.[/2" n the study, the authors noted that the 6-th percentile foradvancing from /cm dilation to -cm dilation was longer than 2 hours; andthe 6-th percentile for advancing from -cm dilation to 2cm dilation was
longer than ' hours, regardless of the patient+s parity.
&n admission to the Childbirth and Delivery suite, a woman having normalchildbirth should be encouraged to assume the position that she finds mostcomfortable. Bossibilities including waling, lying supine, sitting, or restingin a left lateral decubitus position. &f note, ambulating during childbirth didnot change the progression of childbirth in a large randomi0ed controlledstudy of M women in active childbirth. [/3"
#he patient and her family or support team should be consulted regarding
the riss and benefits of various interventions, such as the augmentation ofchildbirth using oxytocin, artificial rupture of the membranes, methods andpharmacologic agents for pain control, and operative vaginal delivery(including forceps or vacuumassisted vaginal deliveries) or cesareandelivery. #hey should be actively involved, and their preferences should beconsidered in the management decisions made during childbirth anddelivery.[!"
#he frequency and strength of uterine contractions and changes in cervixand in the fetus= station and position should be assessed periodically to
evaluate the progression of childbirth. 1lthough progression must bemonitored, vaginal examinations should be performed only when necessaryto minimi0e the ris of chorioamnionitis, particularly in women whoseamniotic membrane has ruptured. During the first stage of childbirth, fetalwellbeing can be assessed by monitoring the fetal heart rate at least every- minutes, particularly during and immediately after uterine contractions.
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n most childbirth and delivery units, the fetal heart rate is assessedcontinuously.['"
#wo methods of augmenting childbirth have been established. #hetraditional method involves the use of low doses of oxytocin with longintervals between dose increments. *or example, lowdose infusion ofoxytocin is started at mili <9min and increased by ! mili <9min every!' minutes until adequate uterine contraction is obtained. [!"
#he second method, or active management of childbirth, involves aprotocol of clinical management that aims to optimi0e uterine contractionsand shorten childbirth. #his protocol includes strict criteria for admission tothe childbirth and delivery unit, early amniotomy, hourly cervicalexaminations, early diagnosis of inefficient uterine activity (if the cervical
dilation rate is L . cm9h), and highdose oxytocin infusion if uterineactivity is inefficient. &xytocin infusion starts at / mili <9min (or even 2 mili<9min) and increases by / mili <9min (or 2 mili <9min) every - minutesuntil a rate of 3 contractions per - minutes is achieved or until themaximum infusion rate of '2 mili <9min is reached. [/5, !"
1lthough active management of childbirth was originally intended toshorten the length of childbirth in nulliparous women, its application at theational 8aternity 4ospital in Dublin produced a primary cesarean deliveryrate of -2E in nulliparas.[/6" Data from randomi0ed controlled trials
confirmed that active management of childbirth shortens the first stage ofchildbirth and reduces the lielihood of maternal febrile morbidity, but itdoes not consistently decrease the probability of cesarean delivery.[-, -, -!"
1lthough the active management protocol liely leads to early diagnosisand interventions for childbirth dystocia, a number of ris factors areassociated with a failure of childbirth to progress during the first stage.#hese ris factors include premature rupture of the membranes (B&8),nulliparity, induction of childbirth, increasing maternal age, and or othercomplications (eg, previous perinatal death, pregestational or gestational
diabetes mellitus, hypertension, infertility treatment). [-', -/"
Ahile the 1C&7 defines childbirth dystocia as abnormal childbirth thatresults form abnormalities of the power (uterine contractions or maternalexpulsive forces), the passenger (position, si0e, or presentation of thefetus), or the passage (pelvis or soft tissues), childbirth dystocia can rarelybe diagnosed with certainty.[" &ften, a Nfailure to progressN in the first stage
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is diagnosed if uterine contraction pattern exceeds ! 8ontevideo unitsfor ! hours without cervical change during the active phase of childbirth isencountered.[" #hus, the traditional criteria to diagnose activephase arrestare cervical dilatation of at least / cm, cervical changes of L cm in !hours, and a uterine contraction pattern of M! 8ontevideo units. #hesefindings are also a common indication for cesarean delivery.
Broceeding to cesarean delivery in this setting, or the N!hour rule,N waschallenged in a clinical trial of -/! women with active phase arrest. [--" n thiscohort of women diagnosed with active phase arrest, oxytocin was started,and cesarean delivery was not performed for childbirth arrest untiladequate uterine contraction lasted at least / hours (M! 8ontevideounits) or until oxytocin augmentation was given for 2 hours if thiscontraction pattern could not be achieved. #his protocol achieved vaginal
delivery rates of -22E in nulliparas and 55E in multiparas without severeadverse maternal or neonatal outcomes. #herefore, extending the criteriafor activephase childbirth arrest from ! to at least / hours appears to beeffective in achieving vaginal birth.[--, "
Second stage of childbirth
Ahen the woman enters the second stage of childbirth with completecervical dilatation, the fetal heart rate should be monitored or auscultated atleast every - minutes and after each contraction during the second stage.['"
1lthough the parturient may be encouraged to actively push inconcordance with the contractions during the second stage, many womenwith epidural anesthesia who do not feel the urge to push may allow thefetus to descend passively, with a period of rest before active pushingbegins.
1 number of randomi0ed controlled trials have shown that, in nulliparouswomen, delayed pushing, or passive descend, is not associated withadverse perinatal outcomes or an increased ris for operative deliveriesdespite an often prolonged second stage of childbirth. [-2, -3, '6" *urthermore,
investigators who recently compared obstetric outcomes associated withcoached versus uncoached pushing during the second stage reported aslightly shortened second stage (' min) in the coached group, with nodifferences in the immediate maternal or neonatal outcomes. [-5"
Ie ay et al reported that manual rotation of fetuses who were in occiputposterior or occiput transverse position at full dilatation was associated with
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reduced rates of operative delivery (ie, cesarean or instrumental vaginaldelivery).[-6, 2" n a study involving ! *rench hospitals, operative deliveryrates were significantly lower at the institution whose policy favored manualrotation than at the one that favored modification of maternal position(!'.!E vs '5.3E), mainly because of lower rates of instrumental deliveries(-.E vs !5.5E).
Ahen a prolonged second stage of childbirth is encountered, clinicalassessment of the parturient, the fetus, and the expulsive forces iswarranted. 1 randomi0ed controlled trial performed by 1pi et al determinedthat application of fundal pressure on the uterus does not shorten thesecond stage of childbirth. [2" 1lthough the !' 1C&7 practice guidelinesstate that the duration of the second stage alone does not mandateintervention by operative vaginal delivery or cesarean delivery if progress is
being made, the clinician has several management options (continuingobservation9expectant management, operative vaginal delivery by forcepsor vacuumassisted vaginal delivery, or cesarean delivery) when secondstage arrest is diagnosed.
#he association between a prolonged second stage of childbirth andadverse maternal or neonatal outcome has been examined. Ahile aprolonged second stage is not associated with adverse neonatal outcomesin nulliparas, possibly because of close fetal surveillance during childbirth,but it is associated with increased maternal morbidity, including higher
lielihood of operative vaginal delivery and cesarean delivery, postpartumhemorrhage, third or fourthdegree perineal lacerations, and peripartuminfection.[, !, ', /" #herefore, it is crucial to weigh the riss of operativedelivery against the potential benefits of continuing childbirth in hopes toachieve vaginal delivery. #he question of when to intervene should involvea thorough evaluation of the ongoing riss of further expectantmanagement versus the riss of intervention with vaginal or cesareandelivery, as well as the patients= preferences.
Deli"ery of the fetus
Ahen delivery is imminent, the mother is usually positioned supine with her nees bent (ie, dorsal lithotomy position), though delivery can occur withthe mother in any position, including the lateral ($ims) position, the partialsitting or squatting position, or on her hands and nees. [!" 1lthough anepisiotomy (an incision continuous with the vaginal introitus) used to beroutinely performed at this time, the 1C&7 recommended in !2 that its
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use be restricted to maternal or fetal indications. $tudies have also shownthat routine episiotomy does not decrease the ris of severe perineallacerations during forceps or vacuumassisted vaginal deliveries. [2!, 2'"
Crowning is the word used to describe when the fetal head forcibly extendsthe vaginal outlet. 1 modified itgen maneuver can be performed to deliverthe head. Draped with a sterile towel, the heel of the clinician=s hand isplaced over the posterior perineum overlying the fetal chin, and pressure isapplied upward to extend the fetus= head. #he other hand is placed over thefetus= occiput, with pressure applied downward to flex its head. #hus, thehead is held in mid position until it is delivered, followed by suctioning of theoropharynx and nares. Chec the fetus= nec for a wrapped umbilical cord,and promptly reduce it if possible. f the cord is wrapped too tightly to beremoved, the cord can be double clamped and cut. &f note, some
providers, in an attempt to avoid shoulder dystocia, deliver the anteriorshoulder prior to restitution of the fetal head.
ext, the fetus= anterior shoulder is delivered with gentle downward tractionon its head and chin. $ubsequent upward pressure in the opposite directionfacilitates delivery of the posterior shoulder. #he rest of the fetus shouldnow be easily delivered with gentle traction away from the mother. f notdone previously, the cord is clamped and cut. #he baby is vigorouslystimulated and dried and then transferred to the care of the waitingattendants or placed on the mother=s abdomen.
Third stage of childbirth - Deli"ery of the placenta and the fetalmembranes
#he childbirth process has now entered the third stage, ie, delivery of theplacenta. #hree classic signs indicate that the placenta has separated fromthe uterus? () #he uterus contracts and rises, (!) the cord suddenlylengthens, and (') a gush of blood occurs.[!"
Delivery of the placenta usually happens within - minutes after delivery
of the fetus, but it is considered normal up to ' minutes after delivery ofthe fetus. %xcessive traction should not be applied to the cord to avoidinverting the uterus, which can cause severe postpartum hemorrhage andis an obstetric emergency. #he placenta can also be manually separated bypassing a hand between the placenta and uterine wall. 1fter the placenta isdelivered, inspect it for completeness and for the presence of umbilicalvein and ! umbilical arteries. &xytocin can be administered throughout the
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third stage to facilitate placental separation by inducing uterine contractionsand to decrease bleeding.
%xpectant management of the third stage involves allowing the placenta todeliver spontaneously, whereas active management involves administrationof uterotonic agent (usually oxytocin, an ergot alaloid, or prostaglandins)before the placenta is delivered. #his is done with early clamping andcutting of the cord and with controlled traction on the cord while placentalseparation and delivery are awaited.
1 review of - randomi0ed trials comparing active versus expectantmanagement of the third stage demonstrated that active management wasassociated with lowered riss of maternal blood loss, postpartumhemorrhage, and prolongation of the third stage, but it increased maternal
nausea, vomiting, and blood pressure (when ergometrine was used).4owever, given the reduced ris of complications, this review recommendsthat active management is superior to expectant management and shouldbe the routine management of choice.[6" 1 multicenter, randomi0ed,controlled trial of the efficacy of misoprostol (prostaglandin % analog)compared with oxytocin showed that oxytocin < K or givenintramuscularly (8) was preferable to oral misoprostol 2 mcg for activemanagement of the third stage of childbirth in hospital settings. [2/" #herefore,if the riss and benefits are balanced, active management with oxytocinmay be consideredapartofroutine management of the third stage.
1fter the placenta is delivered, the childbirth and delivery period iscomplete. Balpate the patient=s abdomen to confirm reduction in the si0e ofthe uterus and its firmness. &ngoing blood loss and a boggy uterussuggest uterine atony. 1 thorough examination of the birth canal, includingthe cervix and the vagina, the perineum, and the distal rectum, iswarranted, and repair of episiotomy or perineal9vaginal lacerations shouldbe carried out.
*ranchi et al found that topically applied lidocaineprilocaine (%8I1) cream
was an effective and satisfactory alternative to mepivacaine infiltration forpain relief during perineal repair. n a randomi0ed trial of 2 women witheither an episiotomy or a perineal laceration after vaginal delivery, womenin the %8I1 group had lower pain scores than those in the mepivacainegroup (.3 J9 !./ vs '.6 J9 !./; B O .!), and a significantly higher
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proportion of women expressed satisfaction with anesthesia method in the%8I1 group than in the mepivacaine group (5'.5E vs -'.'E; B O .). [2-"
n a Cochrane review, 1asheim et al suggest that evidence is sufficient tosupport the use of warm compresses to prevent perineal tears. #hey alsofound a reduction in thirddegree and fourthdegree tears with massage ofthe perineum to reduce the rate of episiotomy.[22"
Bain Control
Childbirthing women often experience intense pain. <terine contractionsresult in visceral pain, which is innervated by #I. Ahile in descent, thefetus= head exerts pressure on the mother=s pelvic floor, vagina, andperineum, causing somatic pain transmitted by the pudendal nerve(innervated by $!/).[/" #herefore, optimal pain control during childbirth
should relieve both sources of pain.
1 number of opioid agonists and opioid agonistantagonists can be given inintermittent doses for systemic pain control. #hese include meperidine !-- mg K every ! hours or - mg 8 every !/ hours, fentanyl - mcg K every hour, nalbuphine mg K or 8 every 'hours, butorphanol ! mg K or 8 every / hours, and morphine !- mg Kor mg 8 every / hours. [/" 1s an alternative, regional anesthesia may begiven. &ptions are epidural, spinal, or combined spinal epidural anesthesia.
#hese provide partial to complete blocage of pain sensation below #5,with various degree of motor blocade. #hese blocs can be usedduringchildbirth and for surgical deliveries.
$tudies performed to compare the analgesic effect of regional anesthesiaand parenteral agents showed that regional anesthesia provides superiorpain relief.[23, //, 25" 1lthough some researchers reported that epiduralanesthesia is associated with a slight increase in the duration of childbirthand in the rate of operative vaginal delivery,[26, 3" large randomi0ed controlledstudies did not reveal a difference in frequency of cesarean delivery
between women who received parenteral analgesics compared withwomen who received epidural anesthesia[23, 25, 3" given during earlystage orlater in childbirth.[3" 1lthough regional anesthesia is effective as a method of pain control, common adverse effects include maternal hypotension,maternal temperature M./F*, postdural puncture headache, transientfetal heart deceleration, and pruritus (with added opioids). [/"
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Despite the many methods available for analgesia and anesthesia tomanage childbirth pain, some women may not wish to use conventionalpain medications during childbirth, opting instead for a natural childbirth.
1lthough these women may use breathing and mental exercises to helpalleviate childbirth pain, they should be assured that pain relief can beadministered at any time during childbirth.
1 Cochrane review update concluded that relaxation techniques and yogamay offer some relief and improve management of pain. $tudies in thereview noted increased satisfaction with pain relief and lower assistedvaginal delivery rates with relaxation techniques. &ne trial involving yoganoted reduced pain, increased satisfaction with pain relief, increasedsatisfaction with the childbirth experience, and reduced length of childbirth.[3!"
&f note, use of nonsteroidal antiinflammatory drugs ($1Ds) arerelatively contraindicated in the third trimester of pregnancy. #he repeateduse of $1Ds has been associated with early closure of the fetal ductusarteriosus in utero and with decreasing fetal renal function leading tooligohydramnios.
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Defnisi
Melahirkan adalah proses fsiologis di mana hasil konsepsi (yaitu, janin, membran,
tali pusat dan plasenta) yang dikeluarkan di luar rahim. Melahirkan dicapai dengan
perubahan dalam jaringan ikat biokimia dan dengan pendataran bertahap dan
dilatasi serviks uterus sebagai akibat dari kontraksi rahim berirama rekuensi yangcukup, intensitas, dan durasi. [, !"
Melahirkan adalah diagnosis klinis. #erjadinya persalinan didefnisikan sebagai,
kontraksi uterus nyeri biasa mengakibatkan penipisan serviks progresi dan dilatasi.
Dilatasi serviks tanpa adanya kontraksi rahim menunjukkan insufsiensi serviks,
sedangkan kontraksi uterus tanpa perubahan serviks tidak memenuhi defnisi
melahirkan.
#ahapan Melahirkan dan $pidemiologi
#ahapan Melahirkan
Dokter kandungan telah dibagi menjadi % tahap persalinan yang menggambarkan
tonggak dalam proses yang berkesinambungan.
#ahap pertama persalinan
#ahap pertama dimulai dengan kontraksi uterus yang teratur dan berakhir dengan
dilatasi serviks lengkap pada & cm. Dalam studi tengara 'riedman dari &&
nulipara [", ia dibagi tahap pertama ke ase laten aal dan ase akti berikutnya.
'ase laten dimulai dengan, kontraksi uterus yang tidak teratur ringan yang
melembutkan dan memperpendek leher rahim. *ontraksi menjadi semakin lebih
berirama dan kuat. +ni diikuti dengan ase akti persalinan, yang biasanya dimulaipada sekitar %- cm dari dilatasi serviks dan ditandai oleh dilatasi serviks cepat dan
keturunan dari bagian presentasi janin. #ahap pertama persalinan diakhiri dengan
dilatasi serviks lengkap pada & cm. Menurut 'riedman, ase akti dibagi lagi
menjadi ase akselerasi, ase lereng maksimum, dan ase perlambatan.
*arakteristik dari ratarata kurva dilatasi serviks dikenal sebagai kurva melahirkan
'riedman, dan serangkaian defnisi penggambaran melahirkan dan penangkapan
yang kemudian didirikan. [, /" 0amun, data berikutnya dari populasi obstetri
modern menunjukkan baha tingkat dilatasi serviks adalah lambat dan
perkembangan melahirkan mungkin secara signifkan berbeda dari yang disarankan
oleh kurva melahirkan 'riedman. [1, 2, &"
#ahap kedua persalinan
#ahap kedua dimulai dengan dilatasi serviks lengkap dan berakhir dengan
pengiriman janin. 3merican 4ollege o 5bstetricians dan 6ynecologists (3456)
telah menyarankan baha tahap kedua berkepanjangan melahirkan harus
dipertimbangkan ketika tahap kedua persalinan melebihi % jam jika anestesi
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regional diberikan atau ! jam tanpa adanya anestesi regional untuk nulipara. 7ada
anita multipara, diagnosis tersebut dapat dilakukan jika tahap kedua persalinan
melebihi ! jam dengan anestesi regional atau jam tanpa itu. ["
8tudi yang dilakukan untuk menguji hasil perinatal yang berhubungan dengan
tahap kedua berkepanjangan melahirkan mengungkapkan risiko peningkatanpengiriman operasi dan morbiditas ibu tetapi tidak ada perbedaan hasil neonatal.
[, !, %, -" aktor risiko ibu terkait dengan tahap kedua berkepanjangan
termasuk nulliparity , meningkatkan berat badan ibu dan 9 atau berat badan,
penggunaan anestesi regional, induksi persalinan, oksiput janin dalam posterior
atau posisi melintang, dan peningkatan berat lahir. [%, -, , "
#ahap ketiga persalinan
#ahap ketiga persalinan didefnisikan oleh periode aktu antara pengiriman janin
dan pengiriman plasenta dan selaput janin. 8elama periode ini, kontraksi uterus
menurun aliran darah basal, yang menghasilkan penebalan dan pengurangan luas
permukaan miometrium mendasari plasenta dengan detasemen berikutnya
plasenta. [/" Meskipun pengiriman plasenta sering membutuhkan kurang dari &
menit, yang durasi tahap ketiga persalinan dapat berlangsung selama %& menit.
Manajemen hamil dari tahap ketiga persalinan melibatkan pengiriman spontan
plasenta. Manajemen akti sering melibatkan pemberian proflaksis oksitosin atau
uterotonics lainnya (prostaglandin atau alkaloid ergot), kabel penjepit 9
pemotongan, dan traksi tali pusat terkendali tali pusat. 3ndersson et al menemukan
baha penjepitan tali pusat tertunda (:1& detik setelah melahirkan)
meningkatkan status besi dan mengurangi prevalensi defsiensi ;at besi pada usia -
bulan dan juga mengurangi prevalensi anemia neonatal, tanpa eek samping yang jelas. [1"
8ebuah tinjauan sistematis literatur yang termasuk percobaan acak terkontrol
yang membandingkan manajemen akti dan hamil dari tahap ketiga melaporkan
baha manajemen akti memperpendek durasi tahap ketiga dan unggul
manajemen hamil sehubungan dengan kehilangan darah 9 risiko perdarahan
postpartum< 0amun, manajemen akti dikaitkan dengan peningkatan risiko eek
samping yang tidak menyenangkan. [2"
#ahap ketiga dari melahirkan dianggap berkepanjangan setelah %& menit, dan
intervensi akti, seperti ekstraksi manual plasenta, umumnya dianggap. [!"
$pidemiologi
8ebagai penduduk subur di 3merika 8erikat telah berubah, manajemen kebidanan
klinis melahirkan juga telah berkembang karena penelitian 'riedman. Data dari
angka penelitian menunjukkan baha persalinan normal dapat berkembang pada
tingkat yang jauh lebih lambat dari yang 'riedman dan 8achtleben [, /" telah
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dijelaskan. =hang et al meneliti perkembangan melahirkan dari .! nulipara yang
disajikan dalam melahirkan spontan dan dibangun kurva melahirkan yang berbeda
dari 'riedman> +nterval rata untuk kemajuan -& cm dari dilatasi serviks adalah ,
jam dibandingkan dengan !, jam dari melahirkan 'riedman kurva. [!&" *ilpatrick et
al [1" dan 3lbers et al [2" juga melaporkan baha panjang ratarata pertama dan
kedua tahapan persalinan yang lebih lama daripada mereka 'riedman disarankan.
8ejumlah peneliti telah mengidentifkasi beberapa aktor obstetri karakteristik ibu
yang berkaitan dengan panjang melahirkan. 8atu kelompok melaporkan baha
peningkatan usia ibu dikaitkan dengan tahap kedua lama tapi tidak tahap pertama
persalinan. [!"
8ementara nulliparity dikaitkan dengan persalinan lebih lama dibandingkan dengan
multipara, peningkatan paritas tidak lebih mempersingkat durasi persalinan. [!!"
?eberapa penulis telah mengamati baha panjang melahirkan berbeda antara
kelompok ras 9 etnis. 8atu kelompok melaporkan baha anita 3sia memiliki
terpanjang pertama dan kedua tahapan melahirkan dibandingkan dengan anita*aukasia atau 3rika 3merika [!%", dan perempuan +ndia 3merika memiliki tahap
kedua lebih pendek dibandingkan anita *aukasia non@ispanik. [2" 0amun, orang
lain melaporkan temuan yang bertentangan. [!-, !" 7erbedaan dalam hasil
mungkin karena variasi dalam desain penelitian, populasi penelitian, manajemen
persalinan, atau kekuatan statistik.
Dalam satu studi retrospekti besar panjang melahirkan, khususnya sehubungan
dengan ras dan 9 atau etnis, penulis mengamati ada perbedaan yang signifkan
dalam panjang tahap pertama persalinan antara kelompok ras 9 etnis yang berbeda.
0amun, tahap kedua lebih pendek pada anita 3rika 3merika dibandingkan pada
anita *aukasia untuk kedua nulipara (!! menit) dan multipara (/, min). 0ulipara@ispanik, dibandingkan dengan rekanrekan *aukasia mereka, juga memiliki tahap
kedua dipersingkat, sedangkan tidak ada perbedaan yang terlihat untuk multipara.
8ebaliknya, nulipara 3sia memiliki tahap kedua secara signifkan lama dibandingkan
dengan rekanrekan *aukasia mereka, dan tidak ada perbedaan yang terlihat untuk
multipara. [!"
Menurut tinjauan sistematis dari % percobaan yang melibatkan .!-! anita,
kebanyakan anita yang prenatal dan melahirkan peraatan dipimpin oleh bidan
memiliki hasil yang lebih baik dibandingkan dengan mereka yang peduli dipimpin
oleh dokter atau dibagi di antara disiplin ilmu. 7asien yang menerima peraatan
kehamilan bidan yang dipimpin kurang mungkin untuk memiliki analgesia regional,
episiotomi, dan kelahiran instrumental dan lebih mungkin untuk memiliki analgesia
intrapartum atau anestesi, kelahiran vagina spontan, kehadiran saat lahir oleh bidan
dikenal, dan lagi berarti panjang melahirkan. Mereka juga cenderung memiliki
kelahiran prematur dan kematian janin sebelum usia kehamilan !- minggu. 0amun,
rasio risiko ratarata untuk kelahiran caesar tidak berbeda antara kelompok, dan
tidak ada perbedaan dalam penurunan janin 9 kematian neonatal pada usia
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kehamilan !- minggu atau lebih Aatau kematian janin 9 bayi secara keseluruhan. [,
!/"
*ekhaatiran terkait dengan kelahiran di rumah bidanhadir
0amun, kekhaatiran tentang eek rumah kelahiran bidanhadir pada kesehatan
neonatal dibesarkan oleh analisis hampir - juta tunggal, kelahiran jangka penuh,
dari !&&/!&&, bayi dengan berat badan normal. Data, dari 7usat 0asional untuk
8tatistik *esehatan, menunjukkan baha melahirkan di rumah dikaitkan dengan
lebih dari & kali lipat peningkatan risiko untuk skor 3pgar & dan hampir - kali lipat
peningkatan risiko kejang neonatal atau disungsi neurologis yang serius, seperti
dibandingkan dengan pengiriman rumah sakit. [!1, !2"
Dibandingkan dengan pengiriman oleh dokter rumah sakit, melahirkan di rumah
bidanmenghadiri dikaitkan dengan risiko relati (BB) dari &, untuk skor 3pgar &.
Cntuk pengiriman bidan di klinik bersalin berdiri bebas, BB adalah %,, dan untuk
rumah sakit pengiriman bidan, BB adalah &,. [!1, !2"
Dalam studi yang sama, BB untuk kejang neonatal atau gangguan neurologis yang
serius untuk kelahiran di rumah bidanhadir, dibandingkan dengan pengiriman
rumah sakit dokterdihadiri, adalah %,1&. Dibandingkan dengan pengiriman dokter
di rumah sakit, BB untuk pengiriman bidan di menara pusat lahir adalah ,11, dan
untuk pengiriman bidan rumah sakit, BB adalah &,/-. [!1, !2"
Mekanisme Melahirkan
*emampuan janin berhasil bernegosiasi panggul saat melahirkan melibatkan
perubahan posisi kepalanya selama perjalanan di melahirkan. Mekanisme
persalinan, juga dikenal sebagai gerakan kardinal, dijelaskan dalam kaitannya
dengan presentasi verte, seperti halnya di 2E dari seluruh kehamilan. Meskipun
melahirkan dan pengiriman terjadi secara terus menerus, gerakan kardinal
digambarkan sebagai / urutan diskrit, seperti dibahas di baah ini. [!"
7ertunangan
Diameter terluas dari bagian presentasi (dengan kepala tertekuk baik, di mana
diameter transversal terbesar dari oksiput janin adalah diameter biparietal)
memasuki panggul ibu ke tingkat baah bidang pintu atas panggul. 7ada
pemeriksaan panggul, bagian presentasi adalah pada & stasiun, atau di tingkat
spina iskiadika ibu.
*eturunan
?agian baah dari bagian presentasi melalui panggul. @al ini terjadi sebentar
sebentar dengan kontraksi. 3ngka ini terbesar selama tahap kedua persalinan.
Fengkungan
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8ebagai keturunan titik janin, dia menemui perlaanan dari panggul tulang atau
jaringan lunak dasar panggul, sehingga Geksi pasi tengkuk janin. Dagu dibaa ke
dalam kontak dengan dada janin, dan perubahan diameter presentasi dari
occipitorontal (,& cm) ke suboccipitobregmatic (2, cm) untuk bagian yang
optimal melalui panggul.
Botasi internal
8ebagai kepala turun, bagian presentasi, biasanya dalam posisi melintang, diputar
sekitar - H ke anteroposterior (37) posisi di baah simfsis. Botasi internal
membaa diameter 37 kepala sejalan dengan diameter 37 dari outlet panggul.
7erpanjangan
Dengan keturunan lebih lanjut dan Geksi penuh kepala, pangkal tengkuk datang
dalam kontak dengan margin rendah dari simfsis pubis. Besistensi atas dari
panggul dan pasukan ke baah dari kontraksi uterus menyebabkan oksiput untuk
memperpanjang dan memutar sekitar simfsis. +ni diikuti dengan pengiriman janin
kepala.
Bestitusi dan rotasi eksternal
*etika Akepala janin bebas dari hambatan, itu untists sekitar - H ke kiri atau
kanan, kembali ke posisi anatomis aslinya dalam kaitannya dengan tubuh.
7engusiran
8etelah kepala janin disampaikan, keturunan lanjut membaa bahu anterior ke
tingkat simfsis pubis. ?ahu anterior kemudian diputar di baah simfsis, diikuti olehbahu posterior dan sisa janin.
8ejarah *linis dan 7emeriksaan 'isik
8ejarah
7enilaian aal persalinan harus mencakup ulasan peraatan prenatal pasien,
termasuk konfrmasi tanggal perkiraan persalinan. Diokuskan anamnesis harus
dilakukan untuk memasukkan inormasi, seperti rekuensi dan aktu terjadinya
kontraksi, status selaput ketuban (apakah pecah spontan membran telah terjadi,
dan jika demikian, apakah cairan ketuban jelas atau mekonium bernoda ), yang
Agerakan janin, dan ada atau tidak adanya perdarahan vagina.
*ontraksi ?raton@icks, yang sering tidak teratur dan tidak meningkatkan rekuensi
dengan meningkatkan intensitas, harus dibedakan dari kontraksi yang benar.
*ontraksi ?raton@icks sering menyelesaikan dengan ambulasi atau perubahan
aktivitas. 0amun, kontraksi yang menyebabkan persalinan cenderung bertahan
lebih lama dan lebih intens, menyebabkan perubahan serviks. ?enar melahirkan
didefnisikan sebagai kontraksi uterus yang menyebabkan perubahan serviks. Iika
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kontraksi terjadi tanpa perubahan serviks, tidak melahirkan. 7enyebab lain untuk
kram harus didiagnosis. Csia kehamilan bukan merupakan bagian dari defnisi
melahirkan.
8elain itu, kontraksi ?raton@icks terjadi sesekali, biasanya tidak lebih dari ! per
jam, dan mereka sering terjadi hanya beberapa kali per hari. *ontraksi persalinangigih, mereka mungkin mulai jarang karena setiap & menit, tetapi mereka
biasanya mempercepat dari aktu ke aktu, meningkatkan kontraksi yang terjadi
setiap !% menit.
7asien juga dapat menggambarkan apa yang disebut keringanan, yaitu, perubahan
fsik merasa karena kepala janin maju ke dalam panggul. +bu mungkin merasa
baha bayinya telah menjadi cahaya. 8ebagai bagian presentasi janin mulai turun,
bentuk perut ibu dapat berubah untuk mencerminkan turunnya janin. 0apasnya
dapat lega karena ketegangan pada diaragma berkurang, sedangkan buang air
kecil bisa menjadi lebih sering karena tekanan ditambahkan pada kandung kemih.
7emeriksaan fsik
7emeriksaan fsik harus mencakup dokumentasi tandatanda vital pasien,
presentasi janin, dan penilaian kesejahteraan janin. 'rekuensi, durasi, dan intensitas
kontraksi uterus harus dinilai, khususnya pemeriksaan perut dan panggul pada
pasien yang hadir dalam mungkin melahirkan.
7emeriksaan abdomen dimulai dengan manuver Feopold dijelaskan di baah [!">
J Manuver aal melibatkan pemeriksa menempatkan kedua tangan nya pada setiap
kuadran atas perut pasien dan lembut meraba undus dengan ujung jari untuk
menentukan yang tiang janin hadir dalam undus. Iika itu adalah Akepala janin,
harus terasa keras dan bulat. Dalam presentasi sungsang,, tubuh nodular besar
dirasakan.
J Manuver kedua melibatkan palpasi di daerah paraumbilical dengan kedua tangan
dengan menerapkan tekanan lembut tapi dalam. #ujuannya adalah untuk
membedakan tulang belakang janin (hard, struktur tahan) dari anggota tubuhnya
(tidak teratur, bagianbagian kecil mobile) untuk determinate posisi janin.
J Manuver ketiga adalah suprapubik palpasi dengan menggunakan ibu jari dan jari
jari tangan yang dominan. 8eperti dengan manuver pertama, pemeriksa
mengetengahkan janin presentasi dan memperkirakan stasiun nya. Iika bagianpresentasi tidak terlibat, tubuh bergerak (biasanya tengkuk janin) dapat dirasakan.
Manuver ini juga memungkinkan untuk penilaian dari berat janin dan volume cairan
ketuban.
J Manuver keempat melibatkan palpasi kuadran baah bilateral dengan tujuan
menentukan apakah bagian presentasi janin bergerak dalam panggul ibu.
7emeriksa berdiri menghadap kaki ibu. Dengan tips dari % jari pertama dari kedua
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tangan, pemeriksa tekanannya jauh di arah sumbu panggul. Dalam presentasi
kepala, janin kepala dianggap terlibat jika tangan pemeriksa berbeda karena
mereka melacak janin Akepala ke panggul.
7emeriksaan panggul sering dilakukan dengan menggunakan sarung tangan steril
untuk mengurangi risiko ineksi. Iika pecah ketuban dicurigai, pemeriksaan denganspeculum steril dilakukan untuk visual mengkonfrmasi pooling cairan ketuban di
orniks posterior. 7emeriksa juga mencari pakis pada sampel kering dari cairan
vagina di baah mikroskop dan memeriksa p@ cairan dengan menggunakan
tongkat nitra;in atau kertas lakmus, yang ternyata biru jika cairan ketuban adalah
alkalosis. Iika perdarahan rank hadir, pemeriksaan panggul harus ditunda sampai
plasenta previa dikecualikan dengan ultrasonograf. 8elanjutnya, pola kontraksi dan
sejarah menyajikan pasien dapat memberikan petunjuk tentang solusio plasenta.
7emeriksaan digital vagina memungkinkan dokter untuk menentukan berikut> ()
tingkat dilatasi serviks, yang berkisar dari & cm (tertutup atau ujung jari) ke & cm
(lengkap atau sepenuhnya dilatasi), (!) penipisan pada (penilaian panjang serviks,yang dapat dilaporkan sebagai persentase dari leher rahim % - cm panjang normal
atau digambarkan sebagai panjang serviks sebenarnya)< pelaporan sebenarnya
panjang serviks dapat menurunkan potensi ambiguitas dalam pelaporan persen
penipisan, (%) posisi, yaitu, anterior atau posterior, dan (-) konsistensi, yaitu,
lembut atau perusahaan. 7alpasi bagian presentasi janin memungkinkan pemeriksa
untuk membangun stasiun, yaitu dengan mengukur jarak dari tubuh ( sampai K
cm) yang menyajikan relati terhadap spina iskiadika ibu, di mana & stasiun ini
sejalan dengan pesaat dari spina iskiadika ibu). [!"
7anggul juga dapat dinilai baik oleh pemeriksaan klinis (pelvimetri klinis) atau
radiograf (4# atau MB+). 7esaat panggul meliputi>
J inlet panggul> #he conjugate kandungan adalah jarak antara tanjung sakral dan
arkus pubis dalam< itu harus mengukur , cm atau lebih. *onjugat diagonal
adalah jarak dari permukaan baah arkus pubis ke promontorium sakrum< itu
adalah ! cm lebih panjang dari konjugat kandungan. Diameter melintang pintu atas
panggul berukuran %, cm.
J panggul tengah> panggul tengah adalah jarak antara titik tulang spina iskiadika,
dan biasanya melebihi ! cm.
J outlet panggul> 5utlet panggul adalah jarak antara tuberositas iskia dan arkuspubis. +ni biasanya melebihi & cm.
?entuk panggul ibu juga dapat dinilai dan diklasifkasikan menjadi - kategori besar
berdasarkan deskripsi dari 4aldell dan moloy>. 6inekoid, anthropoid, android, dan
platypelloid [%&" Meskipun bentuk panggul ginekoid dan anthropoid dianggap paling
menguntungkan untuk pengiriman vagina, banyak anita dapat diklasifkasikan ke
dalam atau lebih jenis panggul, dan perbedaan tersebut bisa sembarangan. [!"
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Iika nonreassuring janin penelusuran denyut jantung oleh cardiotography (misalnya,
deselerasi lambat) dicatat, kulit kepala elektroda janin dapat diterapkan untuk
menghasilkan pembacaan sensiti variabilitas denyuttobeat. 0amun, kulit kepala
elektroda janin harus dihindari jika ibu memiliki @+, hepatitis ? atau ineksi
hepatitis 4, atau jika trombositopenia janin diduga. ?arubaru ini, sebuah kerangka
kerja telah disarankan untuk mengklasifkasikan dan standarisasi interpretasi polapemantauan denyut jantung janin menurut risiko asidemia janin dengan tujuan
meminimalkan asidemia neonatal tanpa intervensi obstetri berlebihan. [%"
7ertanyaan apakah pulse oimetry janin mungkin berguna untuk pengaasan janin
saat melahirkan diperiksa dalam tinjauan dari percobaan diterbitkan
membandingkan pulse oimetry janin dan cardiotography dengan cardiotography
saja. +ni menyimpulkan baha data yang ada memberikan dukungan terbatas untuk
penggunaan pulse oimetry janin bila digunakan dalam kehadiran denyut jantung
janin nonreassuring tracing untuk mengurangi pengiriman caesar untuk status janin
yang mengkhaatirkan. 7enambahan pulse oimetry janin tidak mengurangi
pengiriman caesar secara keseluruhan. [%/"
$valuasi lebih lanjut dari janin berisiko untuk melahirkan intoleransi atau tekanan
dapat dicapai dengan pengambilan sampel darah dari kapiler kulit kepala janin.
7rosedur ini memungkinkan untuk penilaian langsung dari oksigenasi janin dan p@
darah. 8ebuah p@ Npenyelidikan /.!& aran lebih lanjut untuk janin Akesejahteraan
dan untuk kemungkinan resusitasi atau intervensi bedah.
8tudi childbirthatory rutin ibu melahirkan, seperti sel darah lengkap (4?4) count,
mengetik darah dan skrining, dan urine, biasanya dilakukan. +ntravena (+) 3kses
didirikan.
+ntrapartum 7engelolaan Melahirkan
#ahap pertama persalinan
7erubahan serviks terjadi pada lambat, laju bertahap selama ase laten tahap
pertama persalinan. 'ase laten persalinan adalah kompleks dan tidak dipelajari
dengan baik karena penentuan aal adalah subjekti dan mungkin menantang
sebagai perempuan hadir untuk penilaian pada durasi aktu yang berbeda dan
dilatasi serviks saat persalinan. Dalam kohort anita yang menjalani induksi
persalinan, durasi ratarata melahirkan laten itu %1-min dengan berbagai
interkuartil dari !-&&- menit. 7ara penulis melaporkan baha status serviks saatmasuk untuk induksi persalinan, tetapi aktor risiko tidak lain biasanya terkait
dengan kelahiran sesar, terkait dengan panjang ase laten. [%1"
*ebanyakan anita mengalami onset persalinan tanpa pecah prematur membran
(7B5M)< 0amun, sekitar 1E dari kehamilan jangka rumit oleh 7B5M. 5nset spontan
persalinan biasanya mengikuti 7B5M seperti baha &E dari anita dengan 7B5M
yang penuh harap dikelola disampaikan dalam aktu jam, dan 2E melahirkan
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dalam aktu !1 jam dari 7B5M. [%2" 8aat ini, 3merican 4ollege o 5bstetricians dan
6ynecologists (3456) merekomendasikan baha pemantauan denyut jantung janin
harus digunakan untuk menilai status dan kencan kriteria janin Clasan, dan
kelompok ? streptokokus proflaksis diberikan berdasarkan hasil kultur sebelumnya
atau aktor risiko budaya tidak tersedia. 8elain itu, percobaan terkontrol acak
sampai saat ini menunjukkan baha untuk anita dengan 7B5M di jangka, induksipersalinan, biasanya dengan oytocininusion, pada saat presentasi dapat
mengurangi risiko korioamnionitis. [-&"
Menurut 'riedman dan rekan, [" tingkat dilatasi serviks harus minimal cm 9 jam
pada anita nulipara dan ,! cm 9 jam pada anita multipara selama ase akti
persalinan. 0amun, manajemen melahirkan telah berubah secara substansial
selama seperempat abad terakhir. #erutama, intervensi obstetri seperti induksi
persalinan, augmentasi persalinan dengan pemberian oksitosin, penggunaan
anestesi regional untuk mengontrol rasa sakit, dan pemantauan denyut jantung
janin terus menerus adalah praktek semakin umum dalam pengelolaan melahirkan
dalam populasi obstetri saat ini. [-, -!, !&" vagina sungsang dan pertengahan
atau pengiriman tinggi orsep sekarang jarang dilakukan. [-%, --, -" [1, 2, !& 5leh
karena itu, penulis selanjutnya telah menyarankan persalinan normal bisa
mendahului pada tingkat kurang cepat dari yang telah dijelaskan sebelumnya. "
Data yang dikumpulkan dari *onsorsium 3man Melahirkan menunjukkan baha
memungkinkan melahirkan untuk melanjutkan lagi sebelum cm pelebaran dapat
mengurangi tingkat intrapartum dan sesar berikutnya di 3merika 8erikat. [-"
Dalam studi tersebut, para penulis mencatat baha 2 persen untuk maju dari - cm
dilatasi untuk cm pelebaran itu lebih dari jam< dan 2 persen untuk maju dari
cm pelebaran cm pelebaran itu lebih lama dari % jam, tanpa paritas pasien.
7ada masuk ke Melahirkan dan 7engiriman suite, anita memiliki persalinan normal
harus didorong untuk mengambil posisi yang dia menemukan paling nyaman.
*emungkinan termasuk berjalan, berbaring telentang, duduk, atau beristirahat
dalam posisi dekubitus lateral kiri. Dari catatan, ambulating saat melahirkan tidak
mengubah perkembangan melahirkan dalam studi acak terkontrol besarO &&&
anita melahirkan akti. [-/"
7asien dan tim keluarga atau dukungan nya harus dikonsultasikan mengenai risiko
dan manaat dari berbagai intervensi, seperti augmentasi persalinan menggunakan
oksitosin, pecah buatan dari membran, metode dan agen armakologis untuk
mengontrol rasa sakit, dan pengiriman vagina operasi (termasuk tang atau
pengiriman vaginavakum dibantu) atau sesar. Mereka harus terlibat akti, dan
preerensi mereka harus dipertimbangkan dalam keputusan manajemen dibuat
selama persalinan dan melahirkan. [!"
'rekuensi dan kekuatan kontraksi uterus dan perubahan serviks dan dalam Astasiun
janin dan posisi harus dinilai secara berkala untuk mengevaluasi perkembangan
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melahirkan. Meskipun kemajuan harus dimonitor, pemeriksaan vagina harus
dilakukan hanya bila diperlukan untuk meminimalkan risiko korioamnionitis,
terutama pada anita yang membran amnion telah pecah. 8elama tahap pertama
persalinan, kesejahteraan janin dapat dinilai dengan memantau denyut jantung
janin setidaknya setiap menit, terutama selama dan segera setelah kontraksi
uterus. Dalam kebanyakan melahirkan dan pengiriman unit, denyut jantung janindinilai terus menerus. [%"
Dua metode menambah melahirkan telah ditetapkan. Metode tradisional melibatkan
penggunaan dosis rendah oksitosin dengan interval panjang antara kenaikan dosis.
Misalnya, inus dosis rendah oksitosin dimulai pada mili +C 9 menit dan meningkat
! mili +C 9 menit setiap !&%& menit sampai kontraksi uterus yang memadai
diperoleh. [!"
Metode kedua, atau manajemen akti persalinan, melibatkan protokol manajemen
klinis yang bertujuan untuk mengoptimalkan kontraksi rahim dan memperpendek
persalinan. 7rotokol ini mencakup kriteria yang ketat untuk masuk ke persalinan danpengiriman Cnit, amniotomi dini, pemeriksaan serviks per jam, diagnosis dini
aktivitas uterus yang tidak efsien (jika tingkat dilatasi serviks adalah N,& cm 9
jam), dan dosis tinggi oksitosin inus jika aktivitas uterus tidak efsien. +nus
oksitosin dimulai pada - mili +C 9 menit (atau bahkan mili +C 9 min) dan meningkat
- mili +C 9 menit (atau mili +C 9 menit) setiap menit sampai tingkat / kontraksi
per menit dicapai atau sampai laju inus maksimum % mili +C 9 min tercapai.
[-1, !"
Meskipun manajemen akti persalinan pada aalnya ditujukan untuk
memperpendek panjang melahirkan pada anita nulipara, penerapannya di Bumah
8akit ?ersalin 0asional di Dublin menghasilkan tingkat kelahiran sesar utama Epada nulipara. [-2" Data dari percobaan terkontrol acak dikonfrmasi baha
manajemen akti persalinan lebih pendek tahap pertama persalinan dan
mengurangi kemungkinan morbiditas demam ibu, tetapi tidak konsisten
mengurangi kemungkinan kelahiran sesar. [&, , !"
Meskipun protokol manajemen akti cenderung mengarah ke diagnosis dini dan
intervensi untuk distosia persalinan, sejumlah aktor risiko yang terkait dengan
kegagalan melahirkan untuk kemajuan selama tahap pertama. 'aktor risiko ini
termasuk pecah prematur membran (7B5M), nulliparity, induksi persalinan,
meningkatkan usia ibu, dan atau komplikasi lain (misalnya, kematian perinatal
sebelumnya, diabetes mellitus pragestasional atau kehamilan, hipertensi,
pengobatan inertilitas). [%, - "
8ementara 3456 mendefnisikan distosia persalinan sebagai melahirkan normal
yang menghasilkan bentuk kelainan daya (kontraksi rahim atau kekuatan ekspulsi
ibu), penumpang (posisi, ukuran, atau presentasi janin), atau bagian itu (pelvis atau
jaringan lunak), melahirkan distosia jarang dapat didiagnosis dengan pasti. ["
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8eringkali, Pkegagalan untuk kemajuanP dalam tahap pertama didiagnosis jika pola
kontraksi uterus melebihi !&& unit Montevideo selama ! jam tanpa perubahan
serviks selama ase akti persalinan ditemui. [ " Dengan demikian, kriteria
tradisional untuk mendiagnosis penangkapan aktiase yang dilatasi serviks
minimal - cm, perubahan serviks dari N cm dalam ! jam, dan pola kontraksi
uterus dariO !&& unit Montevideo. #emuan ini juga merupakan indikasi umum untuksesar.