Normal Intrapartum

5 P’s of labor

Power, passage, psyche, position, passenger

Powers

Involuntary UCs (primary), voluntary expulsive efforts (secondary)

Passage

Bony pelvis, soft tissue, pelvic floor, vagina, introitus

Position

Frequent changes during labor enhance maternal comfort and promote optimal fetal positioning

Passenger

Fetal skull, posture, lie, presentation

Psyche

Culturally sensitive patient-centered care, gender-affirming care, prior birth experiences or abuse/SA history, childbirth preparation/education, plans for adoption, adolescents, support system or lack of, pain perception, tolerance, and ability to cope

Effects of “fight or flight” on labor

Decreased blood flow to uterus/placenta, decreased contractions, decreased O2 to fetus, increased catecholamines (decreases fetal conservation of O2), increased negative perception by patient

Fetal positioning

Lie, presentation, presenting part, positioning

Lie

Longitudinal or transverse

Presentation

Cephalic, breech, or shoulder

Presenting part

Head, buttocks, feet, shoulder, or compounding (i.e. hand up with head)

Positioning

Three letter abbreviation; presenting part to left or right of patient’s pelvis, specific fetal part presenting (O – occiput, M – mentum, S – sacrum, A – shoulder), relationship of presenting part to patient’s pelvis (A – anterior, P – posterior, T – transverse)

Types of breech

Complete, single footing, frank

Mechanisms of labor (cardinal movements)

Engagement, descent, flexion, internal rotation, extension, external rotation and restitution

Labor progression

Cervix moves forward, ripens/softens, effaces, dilates; fetal head rotates, flexes, molds, descends

Dilation

Measured in cm, closed to 10cm

Effacement

Measured in percentage, thick to 100%

Station

Fetal presenting part in relation to ischial spines, 0 = engaged/at ischial spines, negative numbers are “up” inside the patient, positive numbers are “down” or toward exit

First stage

Regular contractions to full dilatation (10 cm)

Second stage

Full dilation to delivery of infant (pushing)

Third stage

Delivery of infant to delivery of placenta

Fourth stage

Delivery of placenta to 1-4 hours after delivery (controlled bleeding)

Latent phase (0-5cm dilation)

Contractions may be more spread out, over time become stronger and more regular, effacement <80%, may have bloody show, may experience ROM, fetal station likely 0 for nullipara, 0 to -2 for primipara, patient receptive to education, praise, support, remains mobile, talks between contractions

Active phase (6-10cm dilation)

Contractions regular, every 2-5 minutes, no more than 5 in a 10-min period, effacement likely >80%, may have bloody show, may have ROM, fetal station likely 0 or +, closer to complete the patient gets, the more likely they experience n/v, become introspective exhaustion, trembling, diaphoresis, strong urge to bear down or push, become more vocal

Latent (laboring down) phase

Only really possible if patient has epidural anesthesia, pushing positions, direction for pushing with epidural, rest between contractions, avoid breath holding (encourage vocal)

Active (pushing) phase

If no epidural, patient will likely feel urge to push when complete or almost complete, “cannot stop”, very important to check for full dilation/effacement prior to pushing

APGAR scoring

1 and 5 minutes always, 10 minutes if poor; 7 or greater is good, reassess with 4-6, resuscitation likely with 0-3

APGAR

Activity/muscle tone, pulse/HR, grimace/reflex response, appearance/skin color, respiration/breathing effort

Activity/muscle tone

Flaccid, some flexion, active motion

Pulse/heart rate

Absent, <100, over 100

Grimace/Reflex irritability

No response, weak cry/grimace, vigorous

Respiratory rate

Absent, slow/irregular, good/crying

Third stage

Placenta delivery

Signs of placenta separation

Uterus becomes globular, rises in abdomen, sudden gush or trickle of blood, further protrusion of umbilical cord out of the vagina

Fourth stage

Assess fundus for firmness, pitocin (Oxytocin) infusion based on policy/provider, other uterotonics as necessary per order, complete counts, pain medications as needed, ice to perineum as appropriate, monitor for bladder distension, offer congratulations, reassurance, support

Common reasons for cesarean delivery

Previous c/s delivery, maternal or fetal health conditions, malpresentation of fetus, maternal request (CDMR)

Emergent cesarean delivery

Immediate need to deliver fetus, usually within minutes (less than 30)

Emergent cesarean delivery reasons

Umbilical cord prolapse, uterine rupture, vasa previa rupture, category III FHR pattern

Urgent cesarean section

Need for rapid delivery of fetus, but patient and fetus stable, within hour- couple hours

Urgent cesarean section reasons

Malpresentation diagnosed after labor has begun/ROM, placenta previa with mild bleeding but category I FHR pattern

Non urgent cesarean section

Need for delivery related to complications during labor, that shift/day

Non urgent cesarean section reasons

Failure to progress, failure to descend, category I FHR pattern throughout

Types of cesarean delivery methods

Lower transverse uterine incision, classical uterine incision or t-incision

Classical uterine incision or t-incision implications

Mother will only be allowed to give birth via c-section from now on due to risk for uterine rupture

TOLAC

Trial of labor after cesarean

VBAC

Vaginal birth after cesarean

TOLAC/VBAC candidates

2 or less previous c/s (1 is better) with lower transverse uterine incision, reason for previous c/s not related to factors present again, extensive risk vs. benefit counseling from HCP

TOLAC/VBAC requirements

HCP and OR team immediately available (on site at all times) to perform emergent c/s if necessary

Physiological reasons for pain in labor

Contractions, leading to muscle hypoxia, lactic acid accumulation, cervical and lower uterine segment stretching, traction of surrounding organs, muscles, ligaments, pressure on pelvic bones, nerves, sacrum, perineal stretching

Nonpharmacologic advantages

Does not slow labor, no side effects or risk of allergy, some pharmacologic methods may not eliminate labor pain, may be the only realistic option in advanced, rapid labor

Nonpharmacologic limitations

Desired level of pain control not always achieved, even a well-prepared and highly motivated woman may have a difficult labor and need analgesia or anesthesia

Parenteral analgesic medications used in labor

Nubain, stadol, demerol, fentanyl, morphine

Parenteral analgesic medications side effects

Drowsiness, dizziness, fainting, hypotension, nausea/vomiting, urinary retention, respiratory depression

Local (infiltration) anesthesia

Anesthetic injected into perineum, utilized most often immediately before delivery or for repair of laceration/episiotomy after delivery, risks for infection & hematoma

Pudendal block

Anesthetic injected into pudendal nerve, utilized in second stage of labor prior to delivery, risks of infection and hematoma

Epidural anesthesia

Injected into the epidural space, most commonly used for vaginal deliveries, hypotension is the most common side effect, other side effects include n/v, pruritus; preload with IVF, check lab values, consent, monitor UO/may need catheterization

Spinal anesthesia

Injected into the subarachnoid space, most commonly used for c/s, hypotension is most common complication, other side effects include n/v, pruritis, spinal headache; preload with IVF, check lab values, consent, will need catheterization

General anesthesia

IV injection or inhalation of anesthetic agents that render unconsciousness, used mainly for emergency c/s, need for additional team members, risk for fetal depression, uterine relaxation, maternal vomiting/aspiration