Latent phase – Cervical effacement and early dilatation
Active phase – Rapid cervical dilatation
Protraction disorder of the active phase (dilatation)
SECOND STAGE (pushing) Primip – 30min – 3 hr, multip – 5 –30 min Mechanisms of Labor
Descent – uterine contractions, maternal pushing, gravity
Internal Rotation – Fetal head from transverse/oblique to occiput anterior
Extension – Vaginal outlet is upward and forward
Crowning – largest diameter of fetal head encircled by vulvar ring
External Rotation – delivered head returns to original position to align with back and shoulders
Expulsion – anterior shoulder delivers under symphysis
THIRD STAGE
Delivery of the placenta – avg 2 –10min
Signs of placental seperation 1) Fresh show of blood 2) Umbilical cord lengthens 3) Fundus of uterus rises up 4) Uterus becomes firm and globular
First degree –vaginal epithelium or perineal skin Second degree – extends into subepithelial tissues or perineum with or without involvement of muscles of the perineal body
Third degree – involvement of the anal sphincter
Fourth degree – involvement of the rectal mucosa
FOURTH STAGE
Follow vitals and any signs of postpartum hemorrhage
INDUCTION OF LABOR – labor initiated by artificial means AUGMENTATION OF LABOR – stimulation of labor after it has begun spontaneously Indications – Maternal or Fetoplacental Bishop Score– Cervix
High score 9-13 High likelihood of vaginal delivery Low score <5 decreased likelihood of success (65-80%) Cervical Ripening – mechanical +/- pharmacological
Intracervical dilators – Foley catheter, Laminaria
Prostaglandin E gel or vaginal insert, new – misoprostol (Cytotec)
Oxytocin – Identical to natural pituitary peptide Amniotomy ACTIVE MANAGEMENT OF LABOR
1) Nulliparous – spontaneous labor, singleton pregnancy, cephalic 2) Prenatal education classes 3) Constant attendance in labor with labor nurse specialist/midwife 4) Peer review of all c-sections 5) Not admitted without clear diagnosis of labor
Regular/painful contractions with one of the following: complete cervical effacement, rupture of membranes, bloody show
6) Amniotomy upon admission 7) Regular exams for progress 8) Oxytocin if <1cm/hr or no descent for an hour
DELIVERY
Position, prep and drape Crowning – decide if needs episiotomy SUPPORT THE PERINEUM!
Ritgen maneuver- increases extension of head
Understand the force / counterforce – you apply counterforce to control the delivery Head delivered – check for cord Suction airway Deliver anterior shoulder – downward traction Deliver posterior shoulder –upward Deliver body Clamp cord/suction airway – hand off baby Check vagina/perineum Prepare to delivery placenta – mild traction on cord with counterforce on uterus SHOULDER DYSTOCIA “the scariest event in obstetrics”
Anterior Shoulder is impacted behind symphysis pubis
DON’T APPLY MORE TRACTION – need to disengage anterior shoulder!
McRoberts maneuver – Flex maternal thighs
Wood’s screw – try to rotate posterior shoulder upward
Zavanelli maneuver – manually push head into vagina/uterus followed by stat c/section
Complication – fractures of humerus, clavicle, Erb’s palsy – brachial plexus injury RETAINED PLACENTA
IDENTIFICATION DATA: A 78-year-old male. REASON FOR CONSULTATION: The patient is scheduled for total hip replacement, who has hypertension, hypercholesterolemia, possible peripheral vascular disease, previous smoker. He is a patient of Dr. John B. Luster. Surgery is scheduled for August 1, 2006. HISTORY OF PRESENT ILLNESS : I saw the patient today, who is scheduled for total hip re