Lesson 2: Intrapartal Care

Signs of Impending Birth

• Lightening

• Bloody Show

• Rupture of membranes

• Regular contractions

False Labor vs True Labor?

False Labor

• Braxton Hicks contraction

True Labor

• 4 stages of labor

4 Stages of Labor?

• Cervical effacement and dilation

• Fetal descent

• Delivery of placenta and membranes

• Recovery and Stabilization

2 Phases of Cervical Effacement

• Latent Phase

• Active Phase

Duration and cervical dilation of latent phase?

Duration:

Nulliparas = more than 20 hours

Multipara = more than 14 hours

Cervical Dilation: 4-6 cm

Measurement of cervical dilation during the active phase?

Nullipara: 1.2 cm

Multipara: 1.5 cm

What are the two main types of maternal assessment?

1. Initial interview

2. Physical Examination

Give examples of maternal initial interview.

• Current Pregnancy History

• Past Pregnancy History

• Past Health History

• Family Medical History

Give examples of maternal physical examinations.

• Abdominal and lower leg assessment

• Leopolds maneuver

• Vaginal Examination

• Sonography

What are the two types of fetal assessment (electronic fetal monitoring: cardiotocography)?

• Indirect or External

• Direct or Internal

What are the components of writing a CTG report?

1. Baseline FHR

2. Variability

3. Acceleration

4. Deceleration

5. Uterine Contractions

6. Category

How to read the graph of CTG report (vertically and horizontally)?

Vertical

• Represents fetal heart rate

• Each square is equivalent to 10

Horizontally

• Represent the time

• Two boxes are equivalent to 1 minute

Ranges of Baseline FHR?

Normal: 110-160

Tachycardia: >160

Bradycardia: <110

What does tachycardia FHR indicates?

• Maternal fever

• Fetal compromise

• Cardiac arrhythmias

• Atropine and terbutaline are administered.

What does Bradycardia in FHR indicates?

• Head compression

• Congenital Heart Block

Types of Variability?

• Absent variability = 0

• Minimal variability = less than or equal to 5 bpm

• Moderate variability = 6-25 bpm

• Marked variability = more than 25

State the expected rate of acceleration.

• For Babies at 32 Weeks or older: the "15 by 15" rule under 2 minutes.

• For Premature Babies under 32 Weeks: the “10 by 10” rule under 2 minutes.

• Prolonged Acceleration: if it lasts 2 minutes or more, but less than 10 minutes total.

Types of deceleration:

• Early Decelerations

• Late Decelerations

• Variable Decelerations

• Prolonged Decelerations

• Sinusoidal Pattern

Gradual dip (≥30 sec to the bottom). Matches the contraction peak perfectly. Caused by head compression during active labor. Normal and safe.

Early Deceleration

Gradual dip (≥30 sec to bottom). Bottoms out after the contraction peak. Caused by placenta/oxygen shortage (e.g., epidural drop, too much oxytocin). Concerning.

Late Deceleration

Sharp, sudden "V" or "W" shape (<30 sec to bottom). Drops ≥15 bpm, lasts 15 sec to 2 min. Caused by cord compression. Common; requires position change.

Variable Deceleration

Any drop of ≥15 bpm lasting 2 to 10 minutes. Caused by long-lasting oxygen loss (e.g., cord prolapse, seizures, quick drop in mom's blood pressure). Urgent.

Prolonged Deceleration

Smooth, repeating wave pattern instead of normal ups and downs. Caused by severe baby anemia, brain bleeding, or extreme distress. Critical emergency; requires immediate C-section.

Sinusoidal Pattern

What are the ranges of intensities of uterine contractions?

Mild to Moderate: 0-40 mvu

Average: 40-80 mvu

Strong: 80-100 mvu

Components of Uterine Contraction

• Number

• Duration

• Interval

What are the 3 categories in CTG?

1. Category 1

2. Category 2

3. Category 3

• Baseline FHR: 110-160 bpm

• Moderate Variability

• (+/-) Acceleration

• (+/-) Early Deceleration

• (-) Late/Variable Deceleration

—> NO action required

Category 1

·         Baseline FHR: >160 bpm

·         <110 bpm without absent variability

·         Minimal/Marked variability

·         Absent variability without recurrent decelerations

·         Absent induced acceleration

·         Variable deceleration with slow return to baseline, overshoot

·         Recurrent variable deceleration with moderate variability

·         Prolonged deceleration.

—> Do resuscitative measures. Continued surveillance and re-evaluation.

Category 2

How do we do resuscitation if category 2?

1. O₂ support at 10 liters per minute using a face mask.

2. Left lateral decubitus position

3. 300 mL fast drip of saline solution.

• <110 bpm + absent variability

• Absent baseline variability with ANY of the following: bradycardia, Recurrent late decelerations, and recurrent variable decelerations

• Decrease variability >50 min

• Increase variability >30 min

• Sinusoidal patterns

—> Discontinue labor stimulation

—> Treat maternal hypotension

—> Change maternal position

—> Treat tachysystole

—> DELIVER

Category 3

7 Cardinal Movements

1. Engagement

2. Descent

3. Flexion

4. Internal Rotation

5. Extension

6. External Rotation

7. Expulsion

Cardinal movement wherein the BPD of the fetal head passes through the pelvic inlet.

Engagement

• First requisite for the birth of a newborn

• Most important component of labor

Descent

How many cm descent start in nulliparas?

8 cm

4 forces of Descent

• Pressure of the amniotic fluid

• Direct pressure of the fundus

• Bearing-down efforts of maternal abdominal muscles.

• Extension and straightening of the fetal body.

• Occurs as the descending head meets resistance, whether from the cervix, pelvic walls, or pelvic floor.

• Allows the narrowest AP diameter to present to the birth canal.

Flexion

• The occiput gradually moves toward the symphysis pubis anteriorly from its original position.

• Allows the widest diameter to present to the widest diameter of the mid-pelvis.

Internal Rotation

• Base of the occiput is in direct contact with the inferior margin of the symphysis pubis.

• Directs the axis of the fetal head upward to the pelvic outlet.

Extension

2 forces of extension

• Force exerted by the uterus

• Force exerted by the resistant pelvic floor and the symphysis

What are the signs of placental seperation.

CRLS

• Calkin’s sign (Uterus becomes globular and firmer)

• Rise of the uterus into the abdomen

• Lengthening of the umbilical cord

• Sudden gush of blood

What are the two mechanisms of placental expulsion?

• Schultze Mechanism or Shiny Schultze

• Duncan Mechanism or Dirty Duncan