13. Normal L&D, Apgar, Puerperium

Parturition (define)

L&D processed

Cervical effacement (define)

- Shortening/thinning of cervix in preparation for delivery

- Estimated from 0-100%

- Use average uneffaced cervical length of 3.5-4cm as guide

Cervical ripening (define)

Physical & chemical changes in cervix to prep for stretching

Station (define)

Relationship of presenting part to level of ischial spine

Engaged (at ischial spine) — 0

Minus (above ischial spines) — -1 to -4cm

Plus (below ischial spines) — +1 to +4cm

At what plus station is the presenting part at the perineum & can be seen?

+3 and +4

What scoring system is used to determine degree of cervical ripening?

Bishop score

Components of Bishop score

Dilation, effacement, station, cervical position, cervical consistency

Bishop score determines...

- Risk for preterm labor

- Prediction of response to induction to labor

- C of timing of L&D

Lie (define)

Relationship of long axis of fetus to mother (longitudinal, oblique, transverse)

Position (define)

Relationship of presenting part to maternal pelvis

Presentation (define)

Described part of fetus at cervical opening (breech, vertex, shoulder)

What occurs 2-4 weeks prior to onset of labor? S/S?

"Lightening" — Fetal head settles into pelvic brim → Easier to breathe, increased urinary frequency/urgency

Biochemical changes to cervix during labor

- Mucus plug released from cervical canal

- Blood-tinged mucus passes — "bloody show"

Fetal movement is dependent on...

Power — Force generated by uterine contractions & bearing down

Passenger — Fetal factors (size, lie, presentation, position, station)

Passage — Bony pelvic & soft tissues of birth canal

MC presentation of labor

Vertex presentation

Vertex presentation sequence

Engagement, flexion, descent, internal rotation, extension, external rotation, expulsion

Cardinal movements of labor: Engagement

- Presenting part at pelvic inlet

- Primigravida → Commonly occurs in last 2 weeks of pregnancy in

- Multiparous → Occurs at onset of labor

Cardinal movements of labor: Descent

Presenting part passes gradually through pelvis

Cardinal movements of labor: Flexion

Passive flexion of fetal head to navigate through smallest diameter through pelvis

**Essential for engagement & descent

Cardinal movements of labor: Internal rotation

Head from original position moving anteriorly towards symphysis

Cardinal movements of labor: Extension

- Fetal descent to introitus & then de-flexes

- Spontaneous delivery is imminent

**AKA "Ring of fire"

Cardinal movements of labor: External rotation

Passive rotation of fetal head back to anatomical position of fetal body; Anterior shoulder rotates under symphysis pubic

**AKA Restitution

Summary of cardinal movements of labor

1. Engagement and flexion

2. Flexion and descent

3. Descent and internal rotation

4. Extension

4. External rotation

Every (Engagement) Delivery (Descent) Follows (Flexion) Internal (Internal rotation) Effort (Extension) Rest (external Rotation) Exit (Expulsion)

3 Stages of labor

1: Onset of labor through full cervical dilation (divided into latent & active); Up to 6 cm

2: Full cervical dilation through delivery of infant; 10 cm

3: After delivery through delivery of placenta

Signs of onset of labor

- Mucus plug

- Rupture of membranes

- Regular uterine contractions

Sign of onset of labor: Mucus plug

- Discharge of mucus & small amount of blood (bloody show) when plug blocking opening of uterus is pushed out

- Can occur days prior or right before labor

**NOT everyone passes

Signs of onset of labor: Rupture of membranes

- Amniotic sac ruptures (water breaks)

- Shortly before, beginning of, or during labor

- Can be done manually

Risks of prolonged rupture of membranes

Once rupture, baby at risk of infection (chorioamionitis) → Assess need to induce labor if does not begin within safe period (>24h)

Signs of onset of labor: Regular uterine contractions

- Similar to menstrual cramps but stronger

- Associated w/ changes to cervical length & dilation between serial exams

When are pregnant patients soon to give birth advised to go to the hospital?

- Belief that membranes ruptured

- Contractions lasting at least 30 seconds & occurring regularly at intervals of 6 mins or fewer

Indications for hospital admission of pregnant patient with signs of labor

- Regular & sustained painful uterine contractions

- Bloody show

- Membrane rupture

- Complete cervical effacement

Workup upon hospital admission of pregnant patient with signs of labor

- UA for protein & glucose

- CBC — Baseline Hb

- T&S

- Leopold maneuvers

- Rate of fetal heart sounds & location

- Preliminary estimates of strength, frequency, duration of contractions

Preparation for delivery of pregnant patient with active signs of labor

- NPO to prevent aspiration during delivery

- IV placement (large bore if possible)

- IV lactated ringers — Rehydration & prevention of volume depletion (especially if epidural or spinal anesthesia is planned)

First stage of labor: Latent phase

- Contractions progressively better coordinate & regular

- Cervical effacement & dilation to 5-6 cm

- Varies — 8h nulliparas; 5h multiparas

First stage of labor: Active phase

- Contractions more strong/painful & frequent

- Full defacement at cervix, descent well into midpelvis & full dilation

- Generally does not go beyond 12h primiparas; 10h multiparas

Monitoring during 1st stage of labor with any RF for complications

Continuous monitoring (otherwise intermittent is acceptable)

How frequent to assess fetal wellbeing / fetal HR auscultation?

- Every 30 mins in active phase of stage 1

- Every 15 mins in 2nd stage

Assessment of uterine contractions during 1st stage of labor

- Via palpation, tocodynamometer, internal pressure catheter

- Every 30 mins

How frequent to assess / exam cervix during 1st phase of labor?

Latent → Sparingly

Active → q2 hours (dilation, effacement, position, consistency of cervix)

What to assess if significantly fetal HR deceleration?

Cord prolapse +/- stimulate fetal scalp

2nd stage of labor: Delivery process

- Crowning → Imminent delivery

- When episiotomy would be done

- Once head delivered → Restitution (ext rotation) occurs spontaneously

- Eval neck for nuchal cord; Reduce if possible

- Anterior shoulder → Gentle downward traction on head

- Posterior shoulder → Gentle upward traction on head (caution risk of brachial plexus injury)

What occurs immediately after delivery?

- Baby under introitus to facilitate blood from placenta to baby w/ delayed cord clamping (30-60 secs)

- Skin to skin — Place baby on abd

- Cord clamped / cut

3rd stage of labor

- Examine cervix, vagina, perineum for trauma/lacerations & repair

- Delivery of placenta — Within 30 mins

- Examine placenta to ensure completeness

Signs of placental separation

- Fresh blood appearing from vagina

- Lengthening of umbilical cord outside vagina

- Uterus firm and globular

How to prevent excessive bleeding with delivery of placenta?

Uterine massage & oxytocin infusion enhances contractions → Decreases bleeding

Induction (define)

Process of initiating labor by artificial means

Augmentation (define)

Artificial stimulation of labor that has started spontaneously

Bishop score required for elective induction

≥9

Through what GA is induction contraindicated?

Before 39 weeks

Specific indications for induction <39 weeks GA

- Maternal comorbidities — Gestational HTN, gestational DM, intrauterine growth restrictions

- Late/postterm pregnancy

- Fetal complications — Oligohydramnios, premature rupture

Absolute contraindications to induction

- Pelvic anomalies

- Placenta previa (baby would need to go through placenta)

- Myomectomy / previous classical C-section

- Transverse lie

Increased risk of complications with induction

- Breech

- Previous c-section with low transverse scar

- Multiple gestation

- Macrosomia

Complication of induction for mother

- Failure of induction → Risk of C-section

- Uterine inertia & prolonged labor

- Tumultuous labor → Premature placental separation, uterine rupture, cervical laceration

- Post-partum hemorrhage

- Intrauterine infection

Complication of induction for fetus

- Prematurity (incorrect estimated due date)

- Cord prolapse

- Fetal HR abnormalities

Methods of induction: Cervical ripening

- Prostaglandins: Misoprostol (PGE 1) OR dinoprostone (PGE 2) given vaginally — Increases change of vaginal delivery

- Oxytocin can be started 4h after miso; 12h after dino

- Endocervical balloon catheter — Foley into endocervix, inflated, withdrawn into internal cervical os

Contraindications to dinoprostone (PGE 2)

Asthma, MI, glaucoma

Methods of induction: Oxytocin

- IV Pitocin — Starting dose and PRN q15 mins

- Can also be used for augmentation of labor

- Must monitor contractions & FHR

Methods of induction: Amniotomy

- Artificial rupture of membranes via amniohook → Shortens bundles of myometrium to increase strength and duration of contractions

- Indicated if internal fetal / uterine monitoring is required

**Monitor FHR before & after rupture

What is the most effective medical means of inducing labor?

Pitocin

Analgesia vs. Anesthesia

Analgesia: Loss or modulation of pain sensation

Anesthesia: Total loss of sensory perception

Methods of analgesia in childbirth

- Psychophysical methods

- Regional anesthesia

- Systemic analgesia

General principles of analgesia in childbirth

- Psych prep & education → Requires less medication

- ALL analgesics cross the placenta

- Potential ADRs — CNS depression and respiratory suppression in neonates

Analgesia in childbirth: Psychophysical methods

"Natural birth" — Focus on relaxation techniques, positioning/movement, concentration, breathing

Analgesia in childbirth: Regional anesthesia

- Epidural block — Local anesthetic + narcotic

- Admin as initial injection, followed by continuous infusion to maintain block

What is the 1st choice of analgesia during labor?

Epidural block

What is the 1st choice of analgesia during C-section?

Spinal anesthesia (more strong & rapid than epidural)

Analgesia in childbirth: Systemic anesthesia

- IM codeine or meperidine — Sometimes used in 1st stage of labor (analgesia & mood elevation effects)

- Remiferntanil — Does NOT accumulate in fetus

- Butorphanol & Nalbuphine — Mixed agonist/antagonist opioids (less risk of respiratory depression)

**With ALL systemic → Monitor FHR & neonatal exam closely

After the cord is cut...

Place baby skin-to-skin OR radiant warmer → Dried with prewired towels → Suctioning of mouth & nares (ensures latency of airway)

Benefits of skin-to-skin contact between mother & baby

- Increases likelihood & duration of breastfeeding

- Decreases infant crying

- Facilitates bonding

Initial evaluation of newborn assessment

- Respiratory effort, HR, color, activity → Determine if intervention is required

- APGAR at 1 and 5 mins

Interventions if abnormal newborn assessment

- Drying/suctioning does NOT stimulate sufficient breathing → Flick soles of feet / rub back

- Meconium in amniotic fluid / on skin & distress → Intubation & suction of trachea before stimulation baby

- Gasping, apnea, HR <100 → PPV

If meconium is present but the infant is well-appearing...

NO need for intubation & tracheal suction

Correlations / Interpretations of APGAR scores at 1 and 5 mins

- Change between scores is meaningful measure of effectiveness of resuscitation efforts

- 5 min score of 0-3 → Increased mortality

Puerperium AKA

4th stage of labor — Postpartum / postnatal period

Puerperium period

After delivery of baby & placenta through 1st 6 weeks post-delivery

What occurs during the puerperium period?

Body / hormones & uterus size return to non-pregnancy state & newborn adjust to external life

What is monitored during the 1st hour after delivery?

- Maternal BP, HR, uterine blood loss

- Maternal bonding

- Initiation of breastfeeding

**Most postpartum hemorrhages occur during this time

Early initiation of breastfeeding is associated with...

- Maximized benefits and increased likelihood of continuation LT

- Lactation consultants maximize likelihood of success

Maternal benefits of breastfeeding

- Accelerates involution of uterus, reducing blood loss

- Decreases risk of breast & ovarian CA, HTN, T2DM

Infant benefits of breastfeeding

- Maternal antibodies → Passive immunity

- IgA plentiful → Protects infant gut by preventing attachment of pathogens to gut mucosa

- Deal nutritional source — Adapts to changes to baby's needs

WHO & postnatal period

MOST critical & neglected phase of mothers & babies — MOST deaths occur during postnatal period

MC postpartum issues

- Postpartum hemorrhage — Generally during while still in hospital

- Infections — Endometritis, UTI, C-section wound infection, episiotomy wound infection, mastitis (Immediately report fever in mom)

- Postpartum depression

Postpartum depression (define)

Begins 1st 12 months after delivery with S/S present daily for 2 weeks

Risk factors to postpartum depression

- Major life event

- Hormonal alterations

- Genetic susceptbility

**Greatest factor is ANY history of depression

S/S of postpartum depression

- Change in sleep pattern, energy, appetite, weight, libido**

- Irritability, anger, anxiety, depressed mood, guilt, inadequacy, overwhelmed**

- Inability to bond emotionally w/ baby

**Very common & normal in postnatal period if TRANSIENT

Screening tool for postpartum depression

Edinburgh Postnatal Depression Scale

Complications of postpartum depression

Poor bonding → Impact on child development

Depression w/ psychosis → Increased risk of suicide & infanticide

Management of postpartum depression

Psychosocial therapy, medications (pending breastfeeding compatibilty)