OB 1 – CONDUCT OF NORMAL LABOR AND DELIVERY LALALA-LALAϋ

LABOR WHAT DO YOU DO IN THE 1ST STAGE?
- A clinical diagnosis 1. Get px history (Gen data)
- Onset of labor characterized as: regular, painful o Chief complaint
uterine contractions -> progressive cervical  Vaginal bleeding
effacement and dilatation  Watery vaginal discharge
- Cervical dilatation in the absence of uterine  Hypogastric pain
contractions = incompetent cervix  Ask how many hours,
- Uterine contractions W/O cervical changes = NOT intervals, if accompanied
true labor by watery/bloody
discharge (VERY IMPT
Admission criteria: TO KNOW THE HOURS
Uterine contractions plus any of the ff: she has been experiencing
1. Ruptured membranes them because the longer
2. Bloody show the bag of water has
3. Complete cervical effacement and dilatation ruptured, the higher the
risk for infection =
chorioamnionitis ->
increased maternal and
STAGES OF LABOR infant mortality and
morbidity)
FIRST STAGE o Menstrual hx (important for determining
Stage of cervical effacement and dilatation AOG)
o Obstetrical hx
- Involves widely spaced uterine contractions (intervals
diminishes from 10 mins at onset of stage 1 to 1 min  Ask for the ff: manner of delivery in
or less in stage 2) past pregnancies, complications,
duration of labor, hx of difficult
- Period of relaxation in between is important for fetal
labor, weight of babies (may
welfare
indicate a problem in descent or an
o Unremitting contractions may result to fetal
arrest in cervical dilatation)
hypoxemia 
2. Do PE
- 3 parameters to assess in uterine contractions:
o Interval o Get vital signs (monitor hourly)
o Duration  Temperature: important in
chorioamnionitis
o Intensity
 BP is taken more frequently during
- Has 2 phases: latent phase & active phase
active phase (usually timed after
o Latent phase: period between the onset of
contraction) – a rise in BP is usually
labor and when rate of cervical dilatation
seen during contraction
changes most rapidly (0-4cm dilatation)
- Abdominal exam
 Contractions are still not too close
to each other (8-10 mins interval) o Fundic height: important for estimating fetal
weight and lightening (if FH is 35-36: this
 Normal duration:
may be a big baby)
 8 ½ hrs in nulliparas
o Leopold’s maneuver: LM3 allows
 5 hrs in multiparas
determination of presentation
 Abnormal:
o Uterine contractions (normal must be
 >20 hrs in nulliparas
alternating contract and relax)
 > 12 hrs in multiparas
o Uterine tenderness
o Active phase: period of increased rapidity of
cervical dilatation o Tenderness over scar may indicate
 Contractions w/ 2-3mins interval dehiscence or possible uterine rupture
(abruption placenta)
(ideal), lasting 40-60 secs
o Check for fetal heart tones
 Ends with full cervical dilatation at
10cm (also marks the end of the
- Pelvic exam
first stage of labor)
o Cervical dilatation, effacement, station,
 Also coincides with descent of PP
presentation, position, consistency of cervix
into pelvis
 Normal duration and rate of o Clinical pelvimetry for primigravidas
o Check for intact bag of water and
dilatation:
membranes
 5-7 hrs in nulliparas (1-
2cm/hr) o pH and nutracine test
o Litmus paper test and Comb (?) test – used
 2-4 hrs in multiparas
to confirm whether bag of water has ruptured
(1.5cm/hr)
 Pelvic exams done every o Speculum exam: important in cases where
bag of water has ruptured -> cause pooling
2-3 hrs to evaluate labor
of amniotic fluid in posterior fornix
progress (lack of progress
 There are 2 indications for a
in dilatation/descent may
indicate dystocia) speculum exam:
 Watery vaginal discharge
 Bleeding

Pain management/Analgesia during contractions o Give only during active phase o Fetoscope/stethoscope for auscultation OR a. Cord Prolapse may occur when the patient is ambulatory after the BOW has ruptured OB 1 – CONDUCT OF NORMAL LABOR AND DELIVERY LALALA-LALAϋ 3. ask patient to assume left o Due to progesterone effect of delayed gastric lateral decubitus as it increases blood flow to emptying fetus o Regurgitated food can cause aspiration especially after giving anesthesia 9. Anesthesia: pudendal. sedated  If you have decelerations while baby is in utero. you expect that it will be worse during labor 8.Primigravida Aminotomy . Monitoring Progress of Labor o Cleanse GI tract o Check for cervical dilatation . Do a Labor Admission Test o Fleet enema o 20 min EFM strip done on admission  Do early because if you do it at 7 o Get heartbeat and acceleration and cm dilatation. shock. Check urinary bladder function  May also reduce intensity of o Head descent may cause pressure on contractions -> interferes with urinary bladder -> voiding becomes difficult progress of labor o Palpate suprapubic area to check if bladder o Upright position: speed contractions in early is full labor  Mother is asked to void and empty o Exceptions to allowing pregnant woman to bladder take desired/comfortable positions:  If bladder is distended but voiding a) Membranes have ruptured in does not occur spontaneously – do the presence of a NON- straight catheterization engaged fetal head b) Sedated patients 5. the baby might come deceleration in relation to uterine out before she empties the GI tract contractions o Woman in lithotomy position w/ cleansing of  Purpose: to find out whether the vulva and perineal scrubbing downward and fetus in utero can undergo the away from introitus stress of labor o C/I: ruptured membranes. Enema and Vulvar & Perineal Preparation o Prevent contamination of newborn with feces 10. Augmenting labor may also be achieved by giving OXYTOCIN. high risk labor . spinal.the bag of water usually spontaneously ruptures during the first stage of labor.multigravid downwards.2 cm / Hr . Non-medicated measures  If manual ausculatation.How often should you monitor ? 30 mins for 2h. because by rupturing it. Position and Movement During Labor  Allows you to detect high o Encouraged to assume position she is most risk/compromised fetuses and comfortable in allows for early intervention o Supine position affects blood flow in uterus o Studies show greater benefit in using LAT for  Pregnant uterus can compress high risk patients only aortocaval system -> reduce blood flow to fetus -> fetal compromise 4.5 cm / HR . the head will proceed 1.15 minutes Left lateral decubitus position . NPO for 8 hours usually o In these cases. follow one  Natural childbirth px to one attendant ratio  Support person/doula – provide  Normal pregnancies: get FHR coaching during delivery after each contraction every 30  Soaking tubs (temp kept at 98.  Abnormal EFM findings are general (epidural is still the best!) confirmed via fetal pulse oximetry (help det if C/S is needed) 7. epidural. Fetal Monitoring o IV fluids are given when px has nothing per o Main parameters: FHR and FHR variability orem for 6-8 hrs to prevent dehydration  Usually based on recordings while (provide glucose and water) px is hooked to electronic fetal  Always keep an IV line open for monitor emergencies which require  Normal baseline HR: 110-160bpm immediate infusion of medication (varies by 6-25 beats ruing o However caution must also be exercised movement or contractions) because full NPO may cause  Accelerates appropriately hypoglycaemia.most comfortable position. mins during 1st stage of labor and o nd 100 F to prevent fever in mother every 15 mins during 2 stage and baby)  High risk pregnancies: get FHR st every 15 mins during 1 stage and nd b.most accurate o Minimizes infection in episiotomy wound measure of labor progress 1-1. Analgesics you can give: 3-5 mins during 2 stage  Benzodiazepine  Always listen for heart tones  Nalbuphine Hcl AFTER contractions because  Meperedine Hcl contractions may cause a slowing (give in smallest possible dose to prevent of HR adverse effects in fetus) o EFM: standard of care for high risk pregnancies and is now used for ALL pregnancies c. when you want to shorten the first stage of labor by doing Amniotomy. seizures for gest age  Does not decelerate 6. .

When do we ask mothers to push?  Hours – time since onset of labor  Time – actual time a. Starts with full cervical dilatation of 10cm and ends  Highly effective in reducing with delivery of the fetus complications from Duration: prolonged labor Nulliparas (postpartum hemorrhage. Increased birthweight C: membranes ruptured. o Normal: 50 mins sepsis. clear fluid M: meconium-stained WHAT DO YOU DO IN THE 2ND STAGE? B: blood-stained 1. they may need per volume IV fluids coaching  Drugs given  Pulse (every 30 mins)  Temperature (every 2 hrs) 3. 2nd stage of labor  Contractions – chart every half hour b. >1 hr w/o  Progress of labor anesthesia  Maternal condition o Content of the partograph: (not sure if this is impt. There is no strict guideline when to transfer the woman to the dorsal lithotomy position. Preparations for Delivery  Protein. At full dilatation (10cm) contractions in 10 minutes and their duration o Pushing is usually spontaneous and reflex  Oxytocin – record amt of oxytocin given  In nulliparas. Monitoring of Fetus and Mother  Moulding o Low risk pregnancies: 1: sutures apposed 2: sutures overlap but reducible  FHR every 15 mins after each 3: sutures overlap but not reducible contraction  Cervical dilatation (begin plot at 4cm)  Fetal heart tones best heard after  Alert line: line starts at 4cm to the point contraction or 1-2 mins before peak of expected full dilatation at a rate of of contraction 1cm/hr) o High risk pregnancies:  You go beyond this IF  FHR checked every 5 minutes dilatation is less than 1cm/hr o Slowing of FHR during this stage may be  Action line: parallel and 4 hrs to the right of alert line due to compression of head during descent  You go beyond this if there is (but not all) delay in progress (>4hrs)  Other reasons: cord compression or  Descent assessed by abdominal tightening of nuchal cord. Strict asepsis and antisepsis (sterile gown. Assume a dorsal lithotomy position .OB 1 – CONDUCT OF NORMAL LABOR AND DELIVERY LALALA-LALAϋ  Partograph (sigmoid curve) – used  If patient comes to you with to assess progress of labor and ruptured membranes already. uterine rupture) o Abnormal: > 2 hrs w/o anesthesia.legs each time urine is passed) flexed  Asked to breathe normally until start o Check for uterine contractions every 30 of contraction when they are asked minutes to strain down  If patient is high risk. do every 15  Push sustained as long as possible mins  Ideal position because it increases o IE or vaginal exam is done as needed the diameter of pelvic outlet  Done every 4 hours in latent phase and after rupture of membranes b. >3 hrs w/  Plotting begins in the anesthesia active phase when cervix is 4cm dilated Multiparas o 3 components of partograph: o Normal: 20 mins  Fetal condition o Abnormal: >2 hrs w/ anesthesia. Nulliparity  Amniotic fluid – record color every . Use of conduction/regional anesthesia vaginal exam . Since the 2nd stage of labor may be fatiguing due to this position. acetone and volume (record a. During contraction  Palpate number of c. sinciput is at the level You may perform the Valsalva maneuver at this point of symphysis pubis 2. mask) If the woman is a Primigravida. limit identify when intervention is needed IEs to prevent infection  Graphical record of cervical dilatation in cm SECOND STAGE against duration of labor in Stage of Fetal Expulsion hrs . Fetal occiput in posterior position I: membranes intact . cap. palpation premature separation of placenta  Refers to part of head o Monitor FHR after contraction palpable above symphysis  Determines the response of FHR to pubis temporary loss of oxygenation  At zero. . Risk factors for prolonged 2nd stage: We dint discuss it read nalang ) . Maternal weight/weight gain  Px info  Fetal HR (every half hour) .

Purpose: prevent tears of perineal muscles o Suction nares and throat to prevent aspiration of amniotic fluid Maternal benefits Fetal benefits o Check fetus neck for wrapped umbilical cord Reduced risk of: nd Shortened 2 stage of labor  If loose. Modified Ritgen maneuver with the descent of the fetal presenting part o When vulvar ring is at 5cm. skin to skin contact. Extension o Very small preterm to prevent cranial truma turning a page of a book) 2. late clamping of the umbilical cord . Mother w/ certain medical conditions that make her  Apply antiseptic first before sterile vaginal tissues susceptible to damage drapes are applied . May require less than 10 mins but may last as long as Harder to repair 30 mins (coaptation has to o If beyond this. Uterus rises in abdomen as placenta descends to baby’s head downwards) lower uterine segment or vagina -> displaces uterus . Usually begins 5-10 mins after delivery of the fetus . Do only if indicated! extension so that smallest diameter passes . there is active management  immediately . Begins after delivery of fetus until delivery of the Less dyspareunia you cut through a muscle placenta Transect rectum w/c is highly vascular . ER . Maternal exhaustion 4. – Do Mc Robert’s position 3. Gush of blood from vagina but the problem will be the shoulder. Surgical incision of the mother’s perineum performed through introitus as the baby’s head emerges from vaginal canal . If this does not work. Now. you may now perform epi o Change in the shape of the uterus from discoid to globular as it contracts ** If a big baby was not anticipated. uterine inversion Does not return to normal and placental entrapment = more dyspareunia Away from the rectum rd th (no 3 degree or 4 Signs of Placental Separation degree lacerations) 1. Do gentle and downward traction on the cord 3. consider active intervention. cut through the baby’s clavicle upwards because if you don’t do this. Fetus in definite distress and needs to be delivered out. Deliver anterior shoulder by gentle downward traction -> upward traction to delivery upward shoulder o Slide one hand at back of baby and prepare to grasp both feet Midline Episiotomy Mediolateral episiotomy . Delivery of the Head and Episiotomy Delivery of Fetal Head o Perineal opening becomes ovoid to circular . Get anesthesia to relax the uterus -> do gloving and sterile gowning -> insert finger inside (similar to EINC / STEPS Size of baby - 1. Calkin’s sign (earliest sign) Know adv. bearing down with an assistant pushing the 4. OB 1 – CONDUCT OF NORMAL LABOR AND DELIVERY LALALA-LALAϋ  Perineal area scrubbed w/ o Very large babies to prevent dystocia antiseptic solution . heel of clinician’s o Perineum is stretched to almost paper thin hand that is draped with a sterile towel is o Crowning – event wherein fetal head is placed over posterior perineum overlying encircled by the vulvar ring fetal chin  Sign that episiotomy can be done o Pressure applied upwards to extend fetus head Episiotomy o Allows control of delivery of head with . Before. the head will pass through 2. they used to just wait for the placenta to go . the baby will die  Active Management of 3rd stage Indications for Episiotomy . After delivery of head: during birth o Wipe face of fetus . Expulsion. simulate that of normal o Interference in the absence of hemorrhage skin repair) may cause: hemorrhage. Lengthening of the cord (foot on stirrups. Clamp 1 in cord halfway between mother and fetus Easier to repair Indicated if perineum is o Clamp 2 at 5cm from baby’s umbilicus Heals better very short or if more o Cut between clamps Less postop pain room is needed because Excellent anatomical results of an anticipated large Less blood loss because you baby THIRD STAGE cut throught a muscle Stage of Placental Separation and Expulsion insertion More blood loss because . Await external rotation or assist by bringing shoulders Sexual dysfunction Fewer complications from into anterior-posterior position shoulder dystocia . slip over baby’s head More rapid spontaneous  If cannot be reduced but not too Perineal trauma delivery tight – slip over shoulder as it is Pelvic floor dysfunction Reduced perinatal asphyxia born and prolapse and fetal distress  If very tight – double clamp cord Urinary incontinence Higher APGAR scores and cut BEFORE delivery Fecal incontinence Less fetal acidosis . upon seeing a 3cm crowning. New concept in the management of labor: Dry the baby.

 Start repair 1cm from the apex of If you have tachycardia. gently o Breast and nipple stimulation grasp with both hands and pull while twisting o Uterotonic agents: oxytocin. Massage fundus until contraction is felt Oxytocin o Palpate abdomen to confirm reduction in . C/I: hypertensive px anal sphincter Third degree Vaginal mucosa. FOURTH STAGE Hour immediately following delivery .BOLUS OF UTEROTONICS . Ligate bleeding vessels d. Powerful agent to contract uterus mucosa (sparing . uterus is contracted and bleeding is the mucosal defect so that any apparent. Giving this may also stimulate ADH and will cause o Ongoing blood loss and soft boggy uterus urinary retention suggests uterine atony o This is significant because if you do not o If uterus is firm but with ongoing blood loss = monitor bladder distention. the lower consider cervical or vaginal lacerations segment of the uterus may not contract . retracted blood vessels will be ligated If uterus is relaxed and there isn't any bleeding. b. Otherwise if it is bleeding check if there are What to do: unrepaired lacerations that extend up to the vaginal canal. Maternal and vital signs monitored immediately after delivery and every 15 mins for the first hour . hemostasis is achieved by vasoconstriction at placental site produced by a well contracted endometrium . Suture and repair the bleeder and ligatures 1. 2. Effective for prevention and control of postpartum muscle) hemorrhage but may be deleterious to mother and Second degree Fascia and muscles of baby prior to delivery perineal body but not . prostaglandin analogues membranes . repair the rectal mucosa FIRST before the vaginal mucosa. Analog of the hormone size of uterus and firmness . Start oxytocin drip or give ergot derivatives (do not because bladder distention impedes give if px is hypertensive) effective uterine contractions -> may result to bleeding REMEMBER THIS! 4 Degrees of Laceration (Dra. Incision is closed by layers using absorbable suture. Know the types of Lacerations that can cause the bleeding. After delivery of fetus and placenta. Order of repair: a. One hand is placed on abdomen and uterus is o You may do gentle uterine massages to pushed cephalad until placenta reaches introitus stimulate contraction o When majority of placenta is out. o Catheterize if px is on anesthesia Rivera asked us to know this) First degree lacerations Involve fourchette. Time to observe for postpartum hemorrhage especially when labor was prolonged . ergot the placenta allowing separation of the fetal derivatives. Subcutaneous and fascial layers (interrupted suture)  Do not leave any dead space – potential hematoma formation c. Skin (interrupted or subcuticular sutures) th Remember that if you are dealing with 4 degree lacerations. Give Oxytocin. Methylergonovine malate perineal skin. Oxytocin and ergot derivatives more effective sphincter but not rectal If the vital signs should be checked mucosa Fourth degree Extension up to rectal ATONY and CERVICAL and VAGINAL LACERATIONS mucosa The uterus should be contracted by this time (says it does not have ATONY). perineal Misoprostol skin and fascia up to anal . Vaginal mucosa (interlocking suture) First thing to be affected is the CARDIAC RATE. Effect may last for hours underlying fascia and .MOST IMPORTANT ALLOWING THE UTERUS TO CONTRACT developed due to the incidences that may lead to hemorrhage OB 1 – CONDUCT OF NORMAL LABOR AND DELIVERY LALALA-LALAϋ . vaginal . Cut sphincter muscles (interrupted suture)  Prevent fecal incontinence e.