MANAGEMENT OF LABOR

JEHAD AL-HARMI DEPARTMENT OF OBS & GYN FACULTY OF MEDICINE/KUWAIT UNIVERSITY

You should know-1
• • • • Obstetrical history & examination Definition of labor Mechanism of labor initiation Anatomical considerations:
– The female pelvis – The fetal skull

• The stages of labor

You should know-2
• • • • • • • The mechanism of labor (vertex, OA) Management of normal labor Pain relief during labor Drugs commonly used during labor Induction of labor (IOL) Abnormalities of labor Malpresentations (breech, brow, face & shoulder presentations)

You should know-3
• • • • • Labor in multifetal gestation Preterm labor Vaginal birth after cesarean section (VBAC) Shoulder dystocia Complications of the third stage:
– Retained placenta – Uterine inversion

Obstetrical History-1
• Biodata:
– Name, age, nationality, occupation

• Marital status:
– Duration of marital life, previous marriages & if any resulted in offspring, consanguinity

• Gravidity = pregnancy
– Nulligarvida – Primigravida – Multigravida

Obstetrical History-2
• Parity = delivery of an infant (alive or dead) weighing 500 g or more which is approximately 20/52 • Nullipara, primipara, multipara, grandmultipara (5 or more) • G P (T + P + A + L) • Remember:
– Multiple pregnancy – Ectopic pregnancy

Obstetrical History-3
Current pregnancy:
– LNMP:
• Accuracy • Regularity & length of menstrual cycle • Confounding factors: OCP, lactation, spotting, Hartman’s sign

– Nigel’s rule:
• To calculate EDD from LMP. Assuming:
– Duration of pregnancy = 266 days from conception – Ovulation occurs 14 days prior to onset of menstruation

Obstetrical History-4
• Nigel’s rule:
– Add 7 days & subtract 3 months – 40% deliver within 5/7; 67% within 10/7 – What if cycle length 21 days? Or 35 days?

• Calculate & report gestational age (GA) in weeks not months • Exceptions: IVF. 2 dates (EC & ET) • Obstetrical calculator or calendar

Obstetrical calculator or calendar
• Two concentric circles • Outer circle represents days & months of the year • Inner circles represents weeks of gestation • Arrows indicate current status
EXAMPLE
– LMP – EDD 06/04/2008 13/01/2009

– Today 06/10/2008 – GA 26 weeks

Obstetrical History-5
Other methods to determine GA:
– Date of first positive pregnancy test
• Urine • Serum 4-5/52 after LMP 8-10/7 after conception

– Uterine size during first half of pregnancy Caution! – Time of quickening (16-20/52) – Time of detection of fetal heart beats (FHB)
• Doptone • Pinard 10-12/52 18-20/52

Obstetrical History-6
Other methods of determining GA:
– U/S:
• CRL during T1 Error of 7/7 • BPD, FL, AC up to 22/52 Error of 10/7 • Endovaginal U/S can detect an IUGS at 5/52 gestation and βHCG=1000-1500 mIU/ml (discriminatory zone) • Transabdominal U/S can detect an IUGS one week later when βHCG=6500 mIU/ml

Obstetrical History-7
Past obstetrical history:
– Date – Onset of labor & indication of IOL – Mode of delivery – Sex, BW, AS of baby – Complications: antepartum, intrapartum, postpartum, &/or puerperal – Breastfeeding

Obstetrical Examination-1
Abdomen:
– Striae gravidarum (red or white) – Linea nigra – Organomegaly (HSM, hydronephrosis)

Obstetrical Examination-2
Uterine fundus:
– Just above symphysis pubis: 12/52 – At umbilicus: 20-22/52 – At xiphisternum: 36/52 – What happens after 36/52? – Lightening

Obstetrical Examination-3
• Determination of fundal level using the ulnar side of the left hand • Symphysial-fundal height = SFH
– SFH in cm correspond to GA in weeks after 24/52 – Can detect SFD babies in 75% of cases with maximal accuracy at 32-34/52 – Causes of SFD & LFD – Confirmation

Obstetrical Examination-4
Leopold maneuvers: • Clockwise from upper left corner
– Determination of fundal level – Fundal grip – Lateral grips – First pelvic grip

Obstetrical Examination-5
Leopold maneuvers:
– Second pelvic grip

• Determine:
– – – – – – SFH & EFW Lie Presentation Position Station FHR

Obstetrical Examination-6
• Palpation of fetal parts after 28/52 • Description of relationship of fetus to maternal trunk and pelvis:
– Lie: relationship of long axis of fetus to long axis of uterus
• Longitudinal • Oblique • Transverse

Obstetrical Examination-7
• Fetal poles: head, breech
– Head: hard, round, discreet, ballotable – Breech: soft, more diffuse

• Ascertain position of fetal back and limbs. Why?

Obstetrical Examination-8

• Attitude: relationship of various fetal body parts to one another
– Flexion – Extension

Obstetrical Examination-9
Presentation:
– The presenting part of the fetus is that part which is in or over the pelvic brim – Cephalic:
• Well-flexed head • Completely extended • Deflexed vertex face brow

Obstetrical Examination-10
Presentation:
– Breech:
• Flexed hips, extended knees • Flexed hips & knees • Extended hips & knees frank complete footling

– Shoulder – Cord

Obstetrical Examination-11
• Position: relationship of a denominator (bony point) on the presenting part to the right or left side of the maternal pelvis
– Vertex – Face – Breech occiput mentum/chin sacrum

• 8 positions for each presentation

Obstetrical Examination-12

Obstetrical Examination-13
• Station:
– The relationship between the presenting part & the pelvis

• Engagement:
– When the widest diameter of the fetal head has passed through the pelvic brim

Obstetrical Examination-14
• P/A the station is described in fifths above the pelvic brim
– 5/5 – 2/5 floating engaged

• P/V the station is described in cm above or below the ischial spines
– Engaged = 0 station

Obstetrical Examination-15
Auscultation:
– FHS:
• Doptone 10-12/52 • Pinard 24/52 • Location: anterior shoulder

– Uterine and funic souffle

Definition of Labor
• The process whereby the products of conception are expelled from the uterus after 20 weeks of gestation • It begins when uterine contractions of sufficient intensity, frequency & duration are attained to bring about progressive effacement & dilatation of the cervix as well as descent of the presenting part

Mechanism of Labor Initiation-1
• Braxton-Hicks contractions • Myometrial unresponsiveness  transitional phase  labor

initiation: the phases of parturition

Mechanism of Labor Initiation-2
• These mechanisms are not well defined in humans • In most mammalian species studied, progesterone withdrawal precedes the initiation of labor
– This is not true in primates including humans – Progesterone levels decline only after delivery of the placenta

Mechanism of Labor Initiation-3
Retreat from pregnancy maintenance theory:
– No substantial evidence of:
• Increased progesterone metabolism • Progesterone compartmentalization or sequestration • Increased protein-binding (decreased free, active hormone) • Reduced number of receptors

Mechanism of Labor Initiation-4
The role of the placenta:
– Human pregnancy is a hyperestrogenic state
• The placenta is virtually the sole site of estrogen production during pregnancy • In the placenta, estrogen is NOT synthesized de novo from acetate or cholesterol

Mechanism of Labor Initiation-5
The role of the placenta:
– Human pregnancy is a hyperestrogenic state
• Fetal adrenal gland produces DHEA which is hydroxylated in the fetal liver (16 OH-DHEA) & then converted in the placenta to estriol (E3) by aromatization • Placental sulfatase deficiency may be associated with prolonged gestation because it is associated with decreased placental estrogen production

Mechanism of Labor Initiation-6
The role of the fetus:
– The fetus has been implicated as the source of the initial signal for the commencement of labor – Little direct experimental support in humans – Some fetal anomalies are associated with prolonged pregnancy:
• Anencephaly • Congenital adrenal hypoplasia

Mechanism of Labor Initiation-7
The role of the fetus:
– These are associated with reduction in the supply of precursors for estrogen – Other fetal anomalies that prevent or severely reduce the entry of fetal urine (renal agenesis) or lung secretions (pulmonary hypoplasia) into amniotic fluid do not cause prolongation of pregnancy – This implies that a fetal role in initiation of labor by a paracrine mechanism is unlikely

The Female Pelvis

• True vs. false pelvis • True pelvis:
– Pelvic brim – Pelvic cavity – Pelvic outlet

The Pelvic Inlet
• Shape:
– Oval & in one plane – Anteriorly: SP – Laterally: upper margin of pubic bone & iliopectineal line – Posteriorly: sacral promontory – AP = 11 cm Transverse = 13.5 cm

• Boundaries:

• Dimensions:

The Pelvic Cavity
• Shape:
–Imaginary plane between inlet & outlet

• Boundaries:
–Anteriorly: middle of SP –Laterally: pubic bone, obturator fascia & inner aspect of ischial bone. Ischial spine! –Posteriorly: junction between S2 & 3

• Dimensions:
–AP = transverse = 12 cm

The Pelvic Outlet
• Shape:
– Diamond shaped in 2 planes

• Boundaries:
– Anteriorly: lower margin of SP – Laterally: descending ramus of pubic bone, ischial tuberosity & sacrotuberous ligament – Posteriorly: last piece of sacrum (not coccyx)

• Dimensions:
– AP = 13.5 cm Transverse = 11 cm

Clinical Pelvimetry
• Pelvic inlet:
– Sacral promontory
• True conjugate (TC)= AP of inlet • Diagonal conjugate (DC) measured clinically • TC = DC − 1.5 cm

• Pelvic cavity:
– Anterior surface of sacrum & ischial spine

• Pelvic outlet:
– Subpubic arch & intertuberous diameter

Types of Female Pelvis-1
Gynecoid:
– Rounded brim with widest transverse diameter slightly behind its center – Rounded subpubic arch

Types of Female Pelvis-2
Platypelloid:
– Flat pelvis – Elliptical brim with a wide transverse diameter – Wide subpubic arch

Types of Female Pelvis-3
Android:
Heart-shaped brim Convergent side walls Prominent ischial spines Straight sacrum Narrow subpubic arch Both AP & transverse diameters of outlet reduced – Funnel-shaped cavity – – – – – –

Types of Female Pelvis-4
Anthropoid:
– AP diameter of pelvis > transverse diameter – Deep pelvis; sacrum often has 6 segments – Narrow subpubic arch but wide sacrosciatic notches – Large AP diameter of outlet

Fetal Skull-1
• Vault • Face • Base

Fetal Skull-2
Vault:
– Parietal & parts of occipital, frontal & temporal bones – Bones not well ossified by birth – Joined by membranes at the sutures – Moulding: alteration of the shape of the skull by overriding of the cranial bones with reduction of some of its diameters – Caput & chignon

Fetal Skull-3
Sutures:
– Sagittal: between the superior borders of parietal bones – Frontal: the forward continuation of the sagittal suture; between the two parts of the frontal bone – Coronal: between the parietal & frontal bones

Fetal Skull-4
• Fontanelles:
– Anterior (bregma): kite-shaped; where the sagittal, frontal & coronal sutures meet – Posterior: triangular; where the two parietal & coronal bones meet

• Vertex:
– Area bounded by the two parietal eminences & the two fontanelles

Fetal Skull-5
Presentation Transverse Vx, deflexed Persistent OP Brow Face Diameter Biparietal Suboccipitofrontal Occipitofrontal Mentovertical Submentobregmatic Value (cm) 9.5 9.5 10 11 13.5 9.5

Vx, well-flexed Suboccipitobregmatic

Symptoms & Signs of Labor
• • • • • Contractions “Show” ROM Abdominal examination Pelvic examination:
– Manual or digital – Speculum

• CTG

Stages of Labor
• First stage: average 4-7 hours
– Latent phase – Active phase: at 3-5 cm dilatation

• Second stage:
– Phase A – Phase B (active pushing)

• Third stage • Fourth stage

Mechanism of Labor-1

Mechanism of Labor-2
Vertex presentation, OA position:
– The cardinal movements of labor:
• Occur simultaneously • Descent & engagement: in the transverse position • Flexion: occurs as the head reaches the pelvic floor to present the smallest possible diameter • Internal rotation: from OT position towards SP to OA position or towards sacrum to OP position

Mechanism of Labor-3
Vertex presentation, OA position:
– The cardinal movements of labor:
• Extension: occurs as the base of the occiput comes into contact with the subpubic arch “Crowning” • Restitution • External rotation: shoulders rotate into AP diameter as they reach the pelvic floor, head follows • Delivery of the shoulders & trunk with next 1-2 contractions

Management of Normal Labor-1
• Health education during ANC • History taking & physical examination • Preparation:
– Shaving the pubic hair – Enema

Management of Normal Labor-2
First stage of labor:
– Observation: – Partogram:
• Visual representation of events during labor against time • Maternal VS • Cervical dilatation • Station of presenting part, moulding & caput formation

Management of Normal Labor-3
First stage of labor:
– Observation: – CTG:
• FHR: baseline rate, variability & periodic events (accelerations or decelerations) Uterine activity

– Other methods of intrapartum fetal surveillance?

Management of Normal Labor-4
First stage of labor:
– Pain relief & emotional support – Hydration

Management of Normal Labor-5
Second stage of labor:
– Position – Preparation – Maternal pushing & perineal support – Ritgen’s maneuver – Episiotomy – Cleaning the upper airways – Clamping the cord

Management of Normal Labor-6
Third stage of labor:
– Normal duration: < 30 minutes – Signs of separation of the placenta – Delivery of the placenta:
• Spontaneous • Maternal effort • Controlled cord traction or Brandt-Andrews technique

– Repair perineal tears

Drugs Commonly Used During Labor
• • • • • • • • Phosphate enema Syntocinon, oxytocin or pitocin PGE2, prostin E2 or dinoprostone Methergine or methylergotamine maleate Pethidine (HCl) Naloxone HCl or narcan Phenergan or promethazine HCl Entonox

IOL-1
• Definition:
– Induction vs. augmentation

• Indications:
– Maternal – Fetal

• Contraindications:
– Absolute – Relative

IOL-2
• Methods:
– Stripping or sweeping the membranes – ARM or amniotomy – Mechanical dilatation: 24-Fr Foley or laminaria – PGE2 – Pitocin, oxytocin or syntocinon

• Patient preparation including informed consent

IOL-3
• Bishop’s score:
– Total = 0 – 13; favorable ≥ 7

cm 0 1 2 3 Closed 1-2 3-4 ≥5

% 0-30 40-50 60-70 80≤

Station −3 −2 -1 or 0 +1 or +2

Consistency Position Firm Medium Soft --Post Central Ant ---

Abnormalities of Labor-1
Prolonged latent phase:
– Definition:
• > 20 hours in primipara • > 14 hours in multipara

– Treatment:
• Maternal sedation (therapeutic morphine test) • Oxytocin stimulation

– Outcome of sedation:
• 85% progress into the active phase • 5% wake up without contractions

Abnormalities of Labor-2
Protracted active phase:
– Definition:
• Dilatation < 1.2 cm/h in primipara • Dilatation < 1.5 cm/h in multipara

– Causes – Management:
• Observation • Augmentation

Abnormalities of Labor-3
Arrest of active phase:
– Definition:
• Cessation of previously normal dilatation after uterine contractions of 200 montevideo units has been present for ≥ 2 hours

– Causes:
• CPD • Malpresentation or malposition

– Management:
• Augmentation • CS

Abnormalities of Labor-4
• Protraction of descent:
– Definition:
• Descent < 1 cm/h in primipara • Descent < 2 cm/h in multipara

– Causes & management

• Arrest of descent:
– Definition: no descent for 2 hours – Causes & management:
• Operative vaginal delivery • CS

Malpresentations-1
Breech:
– Incidence: 2-3% at term – Risk factors: fetal, maternal & placental – Options for delivery:
• External cephalic version (ECV) • Elective CS • Trial of vaginal delivery, assisted breech delivery (ABD)

Malpresentations-2
ABD:
– Pre-requisites:
• • • • • • Not footling No neck flexion (star-gazing) EFW < 3800 grams No previous scar Experienced operator & assistant No other medical complications

Malpresentations-3
ABD:
– Maneuvers:
• • • • • • Allow spontaneous delivery until umbilicus Abduct thighs to deliver legs Rotate back anteriorly Gently pull until scapulae are visible Rotate trunk to deliver arms Maintain held flexion:
– “Mauriceau-Smellie-Veit maneuver – “Piper forceps” – Assistant

Malpresentations-4
Face:
– Incidence:
• Approximately 1 in 2000 at term

– Management:
• Expectant in early labor • Mento-anterior  allow trial of vaginal delivery • Mento-posterior  CS

Malpresentations-5
• Brow:
– No mechanism of labor

• Shoulder:
– Transverse lie – Delivery by CS

VBAC-1
• • • • • Incidence: CS rate ~ 20% Indications for CS Types of uterine incisions Pre-operative preparation for CS Complications of CS:
– Intra-operative – Post-operative:
• Short-term • Long-term

VBAC-2
• VBAC or trial of labor • Management:
– Elective repeat CS – Trial of vaginal delivery

• Complications:
– Uterine rupture vs. dehiscence
1% • Prior transverse incision 1-7% • Prior low vertical incision 4-7% • Prior classic or inverted T incision

VBAC-3
• Counseling:
– Chances for success – Risks – Pre-requisites 60-70%

Shoulder Dystocia-1
• Definition:
– Impaction of fetal shoulders against maternal pelvis (usually: anterior shoulder above or behind SP)

• Incidence:
– In general 0.6 – 1.4% – 4000-45000 grams 3 – 5% – > 4500 grams 8 – 20%

Shoulder Dystocia-2
• Risk factors:
– Macrosomia – Diabetes – Dysfunctional labor – Operative vaginal delivery

• Complications:
– Maternal – Fetal: asphyxia & trauma

Shoulder Dystocia-3
• Management: – HELP!!! HELP!!! HELP!!!
– Episiotomy – McRobert’s maneuver:
• Sharp flexion of maternal legs upon abdomen

– Suprapubic pressure – Woods corkscrew maneuver:
• Rotating posterior shoulder 180º

– Delivery of the posterior shoulder

Shoulder Dystocia-4
• Management:
– Rubin maneuver:
• Displacing anterior shoulder towards chest

– Deliberate fracture of the clavicle(s) – Zavanelli maneuver:
• Flexion of fetal head & replacement into uterus followed by CS – Symphysiotomy or deliberate fracture of SP

THE END

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