Uncomplicated Labor and Delivery

First Stage of Labor

time between onset of labor and full cervical dilation (10 cm)

Latent phase of First Stage of Labor

effacement and early dilation (<6 cm)

Active phase of First Stage of Labor

RAPID dilation (6-10 cm)

Second Stage of Labor

time between full cervical dilation and delivery of infant

Third Stage of Labor

time between delivery of infant to delivery of placenta (~30 min)

Fourth Stage of Labor

2 hours following delivery of placenta

Average rate of dilation during labor

Roughly 1-2 cm per hour

1st stage of labor: Initial exam

Review prenatal record, determine whether new disorders have developed, eval maternal and fetal status, and confirm pt is in labor

Physical exam during 1st stage of labor

Status of membranes: intact or ruptured

Presence and amount of vaginal bleeding

Cervical dilation and effacement — DO NOT perform digital exam before placenta previa and prenatal rupture of membranes have been excluded

Fetal lie, presentation, position, station

Fetal size and pelvic capacity

Fetal wellbeing

Maternal wellbeing

Fetal Station

The number of centimeters of the leading bondy edge of the presenting part

• measurement of engagement

Measures in distance from ischial spines

Patient Prep — First stage of labor

• oral intake / IV fluids if NPO (heparin lock)

• Medication mgmt (routine meds, PCN G for GB strep)

• Pain mgmt (pt specific)

• Movement (encourage walking)

• Position (pt preference)

• Amniotomy (risk of cord prolapse)

• Monitoring (FHR, contraction, cervical)

Managing — 2nd stage of labor

• Monitoring (FHR, vaginal exams)

• Pushing (once fully dilated, open glottis) — normal duration is < 3 hrs and < 2 hrs (multiparous)

• Perineal protection intrapartum (warm compress, massage, ritgan)

Cardinal Movements

movement of baby through the birth canal

1. head floating, before engagement

2. engagement; descent and flexion

3. further descent, internal rotation

4. complete extension

5. restitution, external rotation

6. delivery of anterior shoulder

7. expulsion of baby

Most common incision for an episiotomy

Mediolateral incision — preferred because it doesn’t increase risk of anal sphincter laceration

Managing — 3rd stage of labor

• Cord severance (delayed cord clamping)

• Placental separation precedes expulsion

• Active mgmt of expulsion (reduces risk of severe postpartum blood loss and blood transfusion; oxytocin)

• Assess uterine contraction post-placental delivery to ensure uterus is contracted (hemorrhage, typical blood loss is <500 mL)

• Inspection (placenta, cord, and fetal membranes; should be 3 cord vessels)

Lacerations

1. Degree — injury to the perineal skin and vaginal epithelium ONLY

2. Degree — fascia + muscles of perineum

3. Degree — fascia + muscles + involvement of anal sphincter

4. Degree — perineal fascia + muscles + external and internal anal sphincters + anal epithelium

Managing — 4th stage of labor

• Immediate skin-to-skin contact with mother and initiation of breastfeeding w/in first hour

• Maternal monitoring (hourly x 2 hrs, then q4 hours x 24 hours; routine vital signs, fundal checks, perineal checks)

Labor Induction

Initiate labor when benefits of delivery outweigh risks. Elective induction permitted after 39 weeks

Cervical Ripening

Labor Induction — typically started at night so pt can sleep throughout the night.

• Misoprostol inserted vaginally prior to induction.

• Cervical ripening balloon

Amniotomy

Labor Induction — if cervix is favorable, more effective in conjunction with oxytocin

Oxytocin

Labor Induction — IV oxytocin titrated to induce/augment contractions

Stripping or sweeping of membranes

Labor Induction — inserting finger beyond the internal cervical os and then rotating finger circumferentially along the lower uterine segment to detach the fetal membranes from the decidua

Cesarean Delivery

• Operative delivery using abdominal incision to deliver fetus

• May be scheduled or following trial of labor/unscheduled

Trial of Labor after Cesarean / Vaginal birth after cesarean

• attempt of vaginal birth after prior c-section

Risks of vaginal birth after c-section

• uterine rupture

• peripartum hysterectomy

• increased infection if convert VBAC to c-section

• higher perinatal mortality

Benefits of vaginal birth after c-section

• potentially avoid surgical risk

• quicker recovery

• potentially larger family size (repeat c-section increases risk placenta previa)

• desire to experienc evaginal birth