WH: L19 normal/abnormal labor and delivery

Braxton Hicks Contractions

- irregular, generally painless contractions

- can occur throughout 3rd trimester

- no dilation of cervix

- relieved with ambulation and hydration

Lightening

- lighter sensation from fetal head descending further into pelvis

- baby "drops"

- typically in last 2-4 weeks of pregnancy

Passage of mucus plug

- mucus forms in cervical canal during pregnancy that acts as a barrier against infection

- cervix softens and thins in days/weeks prior to labor and plug passes

- may be blood tinged "bloody show"

How many stages of labor are there?

Three

First Stage of Labor

- interval between onset of labor and complete cervical dilation

- latent/early and active phases

First Stage of Labor: Latent/Early phase

- onset of labor

- longest stage of labor: lasts several hours

- contractions more mild, less frequent, and can be irregular

- cervix gradually softens, opens and gets thinner

First Stage of Labor: Active phase

- once cervix is ~6cm

- more rapid cervical change to get to 10cm (~3-5hr)

- contractions more frequent, painful, and regular

Second Stage of Labor

interval between complete cervical dilation and delivery of baby

Third Stage of Labor

interval between delivery of baby and delivery of the placenta

When should you go to the hospital

When contractions are 3-5min apart for >1hr and last longer than 45-60sec each

What should be done at the hospital? (6)

- review prenatal records to confirm gestational age

- determine any development of new issues

- check pt vitals

- check fetal HR and assess frequency, qualify, and duration of contractions

- perform exam to determine fetal lie, presentation, and position

When should you perform a digital vaginal exam once at the hopsital?

After placenta previa and prelabor rupture of membranes excluded

What do you confirm with digital vaginal exam?

Cervical dilation/effacement and fetal station

Placenta Previa

placenta extends over the internal cervical os, can cause bleeding

Rupture of membrane

- "my water broke"

- may report leaking/gushing of fluid

- can increase infection risk if contractions haven't begun

When should you admit a patient into the hospital for labor?

Those in active labor

Active Labor 3 Criteria

- regular contractions that require patient's focus and attention

- significant cervical effacement (>80%)

- dilation between 4-6cm

3 P's of Successful Labor and Delivery

- power

- passenger

- passage

Power

Force generated by uterine contractions

Passenger

Characteristics of the fetus including size, weight, lie, presentation, and position

Passenger: Lie

- relation of fetal long axis to the maternal axis

- longitudinal mc

Passenger: Presentation

- part of fetus that presents itself lowest in birth canal

- mc cephalic

Passenger: position

fetal presenting part either to the right or left side of the pelvis

Passage

- Bony pelvic and soft tissue of the birth canal

- different pelvic types can make delivery easier or more challenging

Passage: Dilation

- cervix opens

- need to be at 10cm for delivery

Passage: Effacement

- thinning and shortening of the cervix

- must be 100% effaced for delivery

Passage: Station

- position of baby's head in relation to the ischial spines (in cm)

- from -5 to +5; 0 being at the spines

hospital admission Check list (5)

- CBC, STI (high risk)

- restrict PO intake

- IV access

- In GBS + patient: IV PCN G

- perform vaginal exams at 2-4hr intervals, prior to analgesia, or with FHR abnormalities

1st stage of labor: pain

- all visceral

- uterine contractions and cervical dilation

2nd stage of labor: pain

- visceral and somatic

- contractions and vaginal/perineal tissue distention

- more severe than 1st stage

Nonpharm Pain Management Options (7)

- massage

- movement

- applying heat or cold

- breathing techniques

- taking a shower

- TENS unit

- Aromatherapy

Pharm Pain Management Options (3)

- opioids

- nitrous oxide

- neuracial analgesia

When should opioids be avoided

If birth is imminent

Nitrous oxide monitor

monitor for Respiratory depression

What's the most effective pain management option?

Neuraxial analgesion (epidural or spinal)

when can Neuraxial analgesion be initiated

At any point during labor

Neuraxial analgesion: mc techniques

Epidural and combined spinal-epidural (CSE)

Neuraxial analgesion should be considered in what patients?

Those at high risk for C section

Neuraxial analgesion ADE (5)

- hypotension

- pruritus

- fever

- risk of postpartum puncture HA

- doesn't work

Neuraxial analgesion C/I (4)

- coagulopathy

- thrombocytopenia

- infection of lower back

- increased intracranial pressure

Neuraxial analgesion most effective form

Epidural

Epidural Neuraxial analgesion, where is it places, and what remains intact

- catheter present for continuous analgesia through labor

- placed below L2 to L3 lumbar space

- sense of touch and motor ability is intact

Combined Spinal Epidural (CSE) Neuraxial analgesion

- faster onset of analgesia

- catheter present for continuous analgesia

- reduced need for rescue analgesia

Alternative Neuraxial analgesion

Pudendal Nerve Block

Pudendal Nerve Block ID

- alleviating vaginal and perineal pain during 2nd stage

- supplement with an epidural

mc Obstetric procedure for Fetal Monitoring during labor

Intrapartum electronic FHR monitoring

Intrapartum electronic FHR determine

if fetus is well-oxygenated

Intrapartum electronic FHR type of monitoring

intermittent or continuous

Intermittent Intrapartum electronic FHR

- low-risk pts

- not as practical

Intrapartum electronic FHR Continuous

- more common

- high-risk pts

How often should Intrapartum electronic FHR tracings be reviewed?

every 15-30min

Intrapartum electronic FHR What is shows (4)

- Variability

- Baseline rate

- acceleration/Deceleration

- Sinusoidal pattern

Intrapartum electronic FHR: Variability

- fluctuations that are irregular in amplitude and frequency

- 10min window

Intrapartum electronic FHR Reassuring variability

amplitude of 6-25 bpm

Intrapartum electronic FHR Baseline normal

110-160bpm

Baseline Bradycardia FHR

-

Baseline Tachycardia FHR

- >160 bpm

- >200 bpm usually due to fetal tachyarrhythmia

Intrapartum electronic FHR: Acceleration

- abrupt increase in FHR for ≥15sec and ≥15bpm above baseline

- associated with reassuring fetal status and absence of hypoxia

- can occur with fetal movement or contractions

Intrapartum electronic FHR: Deceleration benign

- early

- gradual decrease in FHR and return to baseline during a contraction

Intrapartum electronic FHR: Deceleration needs prompt attention

- late

- gradual decrease in FHR and return to baseline after a contraction

- concern for transient hypoxemia during contraction

Intrapartum electronic FHR: Deceleration Variable

- abrupt decrease in FHR ≥ 15bpm below baseline and lasting

Intrapartum electronic FHR: Prolonged

decrease in FHR ≥15bpm below baseline lasting at least 2min

Intrapartum electronic FHR: Sinosoidal pattern

- rare but ominous

- high rate of fetal morbidity and mortality

- smooth sine wave that occurs 2-5 cycles per minute

- amplitude of 5-15bpm

- indicates severe fetal anemia

Intrapartum electronic FHR Category 1

normal tracing

Intrapartum electronic FHR: Normal Tracing

- baseline normal range

- moderate variability

- no late or variable decelerations

- early decelerations or accelerations may be absent or present

Intrapartum electronic FHR Normal Tracing management

- intermittent or continuous monitoring

- review q30min in 1st stage

- review q15min in 2nd stage

Intrapartum electronic FHR Category 2

Indeterminate tracings

Intrapartum electronic FHR: Indeterminate tracings

Tracings don't meet criteria for category 3 or 1

Intrapartum electronic FHRL Indeterminate Management

- address underlying issue

- delivery indicated if tracing doesn't improve

Intrapartum electronic FHR Category 3

Abnormal

Intrapartum electronic FHR: Abnormal

absent baseline FHR variability + recurrent late decelerations, recurrent variable decelerations, bradycardia, or sinusoidal pattern

Intrapartum electronic FHR: Abnormal management

- prepare for delivery

- reposition patient

- IV fluid bolus

- fetal scalp stimulation

- if no improvement after conservative: then delivery is advised (cesarean or operative vaginal delivery)

Uterine Contraction Monitoring

External tocodynamometry

Uterine Contraction Monitoring: Normal

- regular and painful

- cause progressive dilation and effacement of the cervix

- cause descent and eventual expulsion of the fetus

Abnormal Uterine Contractions: Hypocontractile

- contractions not sufficiently frequent and/or strong or aren't coordinated to dilate the cervix

- mc risk factor for protraction or arrest disorders

- mc reason for intrapartum cesareans

Abnormal Uterine Contractions: Tachysystole

- more than 5 contractions over 10min averaged over 30min

- associated with oxytocin administration and lead to FHR abnormalities

- uterine rupture rare complication

Abnormal Uterine Contractions: protraction disorders

Labor is slow to progress

protraction disorders: prolonged latent phase

exceeds 20hr (nullparous) or 14hr (multiparous)

protraction disorders: prolonged latent phase management

observe, rest, +/- oxytocin

protraction disorders: prolonged active phase

rate of cervical dilation is

protraction disorders: prolonged active phase tx

administer oxytocin or perform amniotomy (artificial rupture of membranes)

protraction disorders: prolonged second stage

exceeds 2hr if no regional anesthesia or 3hr with regional anesthesia

protraction disorders: prolonged second stage tx

give oxytocin, possible indication for cesarean or operative vaginal delivery

Abnormal Uterine Contractions: arrest disorders

labor ceases to progress

arrest disorders: active phase

no cervical change for ≥4hr or ≥6hr if oxytocin administered

arrest disorders: active phase tx

cesarean delivery

arrest disorders: second phase

no fetal descent after 1hr of pushing

arrest disorders: second phase tx

- coaching

- oxytocin administration

- operative delivery

When does the active phase of 1st stage of labor end?

- Once cervix is fully dilated

- time to push

Labor progression: 2nd stage

- interval between complete cervical dilation and delivery of baby

- can last less than an hour or 2-3hr

Labor progression: 3rd stage

interval between delivery of baby and delivery of placenta

Hallmarks of placenta-uterus separation (3)

- gush of blood at vagina

- lengthening of the umbilical cord

- globular shaped uterine fundus on palpation

When does expulsion of placenta usually occur?

Within 30min

Expulsion of placenta takes longer increases the risk of what; indicated what

- Postpartum hemorrhage

- indication for manual removal

Labor progression: 4th stage

first 1-2hr after placental expuslion

- monitor for abnormal postpartum bleeding

- assess for perineal lacerations and repair