LABOR AND DELIVERY II

Labor

is defined as a physiologic process during which the products of conception (fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus.

biochemical changes

It is achieved with ______ _______ in the connective tissue of the cervix promoting its gradual effacement and dilatation.

labor

One of the most critical diagnoses in obstetrics is the diagnosis of ____.

• First Stage of Labor (Regular uterine contraction/true labor - full dilatation)

• Second Stage of Labor (full dilatation - delivery of fetus)

• Third Stage of Labor (delivery of fetus - delivery of placenta)

• Fourth Stage of Labor (delivery of placenta - recovery)

4 STAGES OF LABOR

First Stage of Labor

begins with regular uterine contractions and ends with full cervical dilatation at 10 cms.

• Latent phase

• Active phase

2 PHASES OF FIRST STAGE OF LABOR

Latent phase

describes the period between the onset of labor and when the rate of cervical dilatation changes most rapidly, usually at about 3-4 cm of cervical dilatation.

Latent phase

This phase is difficult to time precisely, and duration varies, averaging  8 ½ hrs in nulliparas and 5 hrs in multiparas.

>20, >12

Duration of the latent phase is considered abnormal if it lasts hrs in nulliparas or __ hrs in multiparas.

Active phase

marks a period of increased rapidity of cervical dilatation and ends with complete cervical dilatation of 10 cms.

Active phase

This is also the period where the presenting part descends well into the pelvis.

5-7, 2-4

active phase lasts ___ hrs in nulliparas and __ hrs in multiparas.

1.2, 1.5

The cervix should dilate cm/h in nulliparas and ___ cm/h in multiparas.

Pelvic examinations

are done every 2 to 4 hrs to evaluate labor progress.

dystocia, difficult labor.

Lack of progress in dilatation and descent of the presenting part may indicate ______ or ______

Second Stage of Labor

 starts with full cervical dilatation and ends with the delivery of the fetus

2, 1

second stage of labor lasts __ hours in nulliparas (median 50 min) and _ h may ours in multiparas (median 20 min).

Third Stage of Labor

 begins with the delivery of the fetus until the delivery of the placenta.

Delivery of the Placenta

may require less than 10 minutes, but duration of the third stage of labor may last as long as 30 minutes before active intervention is considered.

• Admit the patient is she is true labor

• Diet & Do

• Monitor maternal vital signs

• Intravenous fluids & Investigate

• Therapeutic measures

FSL - MANAGEMENT

• fundic height

• lie & presentation (leopold’s maneuver_

• fetal heart tone

• frequency, duration, and intensity of uterine contractions

 Assess the following 4 on abdominal exam

15-30

Monitor character of uterine contractions and fetal heart tones every ___ minutes.

Intravenous fluids

______ may be started if the mother has had nothing per orem for 5-8 hours and if sedation and amniotomy has been done.

Therapeutic measures

_______ are given for management of pain (sedation)

partograph

is a tool that can be used to assess the progress of labor and to identify when intervention is necessary.

partograph

It is a graphical record of cervical dilatation in centimeters against duration of labor in hours

WHO Partograph

has been designed to identify problems in the course of labor.

WHO Partograph

It has been modified to make it simpler and easier to use.

WHO Partograph

The latent phase has been removed and plotting on the partograph begins in the active phase when the cervix is 4 cms dilated.

Patient information

name, gravida, para, hospital number, date and time of admission and time of ruptured membranes

Fetal heart rate

 record every 30 minutes

Amniotic fluid

record the color of amniotic fluid at every vaginal exam

I

 membranes intact

C

membranes ruptured, clear fluid

M

Meconium-stained fluid

B

Blood-stained fluid

• 1

• 2

• 3

Moulding

1

sutures apposed

2

 sutures overlapped but reducible

3

sutures overlapped and not reducible

Cervical dilatation

assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 4 cms.

Alert line

a line starts at 4 cms. of cervical dilatation to the point of expected full dilatation at the rate of 1cm per hour.

Action line

Parallel line and 4 hours to the right of the alert line.

Descent assessed by abdominal palpation

refers to the part of the head (divided into 5 parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal examination. 

Contractions

chart every half-hour; palpate the number of contractions in 10 minutes and their duration in seconds

Oxytocin

record the amount of oxytocin per volume IV fluid in drops per minute every 30 minutes when used

Vital signs

 record every 4 hours (BP, Pulse, Temperature)

Protein, acetone and volume (urine)

record every time urine is passed

Second Stage of Labor

from full cervical dilatation to expulsion of the fetus.

This stage is usually called the “pushing” stage or the “bearing down” stage.

 It is characterized by uterine contractions which are stronger, longer (60-90 seconds) and more frequent (every 1-2 minutes).

  is relatively shorter than the first stage

20, 50

it may take 20 minutes for multiparas and __minutes for the nulliparas.

after

Check fetal heart tone ___each bearing down effort.

episiotomy

Once the fetal head reaches the perineum and the scalp is seen with a diameter of 2-3 cms, an ____ is done, if the attendant feels a need to do so.

Ritgen’s Maneuver

Whether or not an episiotomy is done, the perineum is supported with one hand using a hand towel and the other hand tries to keep the head flexed to control delivery of the head.

nuchal cord

Once the head is delivered, and _____ is noted, slip the cord over the shoulders if loose or cut between 2 clamps if tight. Clear the baby’s nose and mouth with a bulb syringe.

anterior-posterior

Await external rotation or assist by bringing shoulders into _______ position.

Third Stage of Labor

 starts from the delivery of the fetus up to the delivery of the placenta.

Delivery of the placenta

usually happens within 5-10 minutes after delivery of the fetus but may last up to 30 minutes.

 Active management of the third stage of labor (AMTSL)

involves the administration of a prophylactic uterotonic, usually oxytocin, (at or after delivery of the baby), early cord clamping and cutting, controlled cord traction (CCT) to deliver the placenta, and uterine massage.

• Calkin’s sign

• Sudden gush of blood

• Lengthening of the cord

• Uterus rises in the abdomen as the placenta descends to the lower uterine segment and displaces the uterus upwards. 

4 signs of placenta separation

Calkin’s sign

change in the shape of the uterus from discoid to globular as it contracts

placenta

After the ____ is delivered, the labor and delivery period are complete.

Uterine Atony

Ongoing blood loss and a soft, boggy uterus

Fourth Stage of Labor

  The first four hours immediately following delivery is a crucial period and has been called the

Postpartum hemorrhage

 is more likely during fourth stage of labor

Maternal vital signs

are monitored immediately after delivery and every 15 minutes for the first hour.