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Published on November 19, 2017

Author: Elfeonomenon


Normal and Abnormal Labor: Normal and Abnormal Labor Elton Fayiah Gbollie, BSc, MD Department of Obstetrics and Gynecology Ganta United Methodist Hospital, Liberia November 16, 2017 TABLE OF CONTENTS: TABLE OF CONTENTS Physiology of labor Normal labor and delivery Abnormal labor Review References PHYSIOLOGY OF LABOUR: PHYSIOLOGY OF LABOUR Uterine smooth muscle cells growth occurs by hypertrophy and hyperplasia Hypertrophy of cells increase 20-30 times the size Non pregnant uterus weighs 60g while the gravid uterus weighs 1000g Uterus changes in labor 2 segments Upper segment : thickens (contractile) Lower segment : thins (non contractile) Slide6: For most of the pregnancy, the uterus and cervix have a containment function Most of the cervix is collagen, not smooth muscle Internal os 75% External os 95% Cervical softening and effacement occurs due to prostaglandin effect on the disulfide collagen links. NORMAL LABOR AND DELIVERY: NORMAL LABOR AND DELIVERY To understand normal labor, we must discuss the ff: Fetal orientation Lie Presentation Position Attitude S tation Maternal changes Cervical dilation Cervical effacement Stages of labor FETAL LIE: FETAL LIE Longitudinal lie -fetal and maternal vertical axis are parallel Transverse lie - fetal and maternal vertical axis are perpendicular Oblique lie - between longitudinal and transverse FETAL PRESENTATION: FETAL PRESENTATION Cephalic presentation- Head presents first Facial presentation- face present first Breech presentation- legs or buttocks present first Complete breech : breech w/ thighs and legs flexed Frank breech : breech w/ thighs flexed and legs extended Feet in the Face with Frank breech Footling breech : breech and thighs and legs extended Compound presentation Shoulder presentation FETAL POSITION : FETAL POSITION Position of the presenting part relative to the maternal pelvis Side + presenting part + ant/post/trans Occiput anterior (OA): the occiput is directed anteriorly Left occiput anterior (LOA): the occiput is directed anteriorly but slanted towards the maternal left Right occiput transverse (ROT): the occiput is directed towards the maternal right To determine the position, feel for the three-sided posterior fontanelle . This is the back of the head( occiput ). FETAL ATTITUDE: FETAL ATTITUDE Degree of flexion/extension of the fetal head Vertical attitude: maximal flexion (ideal) Military attitude: some flexion Brow attitude: some extension Facial attitude: maximal extension Cervical effacement: Cervical effacement Thickness of the cervix, expressed as a percentage 2cm is 0% effacement, 1cm is 50%; etc. At 100% effacement, the cervix is simply a thin membrane Effacement coincides with increasing levels of prostaglandins and oxytocin Cervical ripening agents Misoprostol Laminaria STAGES OF LABOR: STAGES OF LABOR Labor : regular contractions( every 5mins lasting approximately 30secs) accompanied by cervical change Stage one : closed to full dilation (10cm) Latent phase : closed to 3-4 cm dilated Active phase : 3-4cm to full dilation (dilation accelerates) Cardinal movements begin to occur Stage two : full dilation to delivery of fetus Stage three : delivery of fetus to delivery of placenta Stage four : the two hours following delivery Friedman’s curve: Friedman’s curve EXPECTED VALUES: EXPECTED VALUES Primipara Multipara Latent stage one <20hrs <14hrs Active stage one <5-6hrs <4-5hrs Rate of cervical dilation 1.0-1.2cm/hr 1.2-1.5cm/hr Stage two <2hours <1hour Stage three 30mins 30mins CARDINAL MOVEMENTS OF LABOR: CARDINAL MOVEMENTS OF LABOR Changes in the head of the fetus as it rotates internally, externally, flexes and extends Pelvic inlet: Anterior Posterior diameter: narrowest Transverse diameter: widest so the head enter the pelvis transversely Mid pelvis AP dimension: widest so fetus has to go through internal rotation to pass through mid pelvis Transverse dimension: narrowest CARDINAL MOVEMENTS OF DELIVERY: CARDINAL MOVEMENTS OF DELIVERY At the onset of labor the fetus is usually in OT position Engagement - fetal part enters the pelvis(OT) Descent – fetal part descends in pelvis (OT) Flexion – fetal head flexes to allow smallest diameter of the head to present (OT) Internal rotation- fetal head rotates, from a transverse to a more anterior/ posterior oriented position (OT to OA) Extension : fetal head extends to facilitate delivery of the head External rotation : fetal body rotates such that the head is in a transverse position and the shoulders are along the anterior maternal axis, facilitating delivery of the shoulders Expulsion MANAGEMENT OF THE PARTURIENT: MANAGEMENT OF THE PARTURIENT Admit when the cervix is dilated to 3cm or ROM Orders IV access Clear liquid diet Notify anesthesia Continuous EFM Nursing : keep patient in left lateral decubitus postion Begin pushing at full dilation in coordination w/ contractions Administer IV oxytocin immediately after delivery to reduce the risk of uterine atony and hemorrhage Monitor for at least two hours after delivery(controversial) ABNORMAL LABOR AND DELIVERY: ABNORMAL LABOR AND DELIVERY Occurs when there is prolongation of any stage or phase of labor. Latent stage 1 Prolonged latent phase Active stage 1 Prolonged active phase Arrested active phase Stage 2 Prolonged second stage Stage 3 Prolonged third stage : THE MONTEVIDEO UNIT: THE MONTEVIDEO UNIT Montevideo units= peak pressure per contraction (mmHg)- resting tone of uterus (mmHg) multiplied by frequency (contractions in 10minutes. Example: pt has 5 contractions in 10minutes, each with a peak pressure of 70mmHg. Resting tone is 13mmHg. (70mmHg-13mmHg) *5= 285 MVU It is generally accepted that 200MVU is needed for labor to progress properly. Lower than 200 MVU suggests prolongation or arrest of labor PROLONGED LATENT PHASE: PROLONGED LATENT PHASE Pt in labor and remains <3cm dilated for >20 hrs (primp)or >14hrs ( multip ) Causes : Anesthesia administered too early Irregular contractions Hypotonic : infrequent, weak contractions Hypertonic : strong, short contractions Ddx : False labor Management: rest and IV morphine sedation False labor (10%): contractions stop after administration of sedative True labor (90%): cervical change will have occurred by the time sedative wears off PROLONGED ACTIVE PHASE: PROLONGED ACTIVE PHASE Pt in labor and has cervical change of <1.2cm/hr ( primip ) or <1.5cm/hr ( multip ) Causes Passenger : increase fetal size; abnormal orientation in utero Pelvis : Inadequate bony pelvis anatomy History can be important. Compare current fetal size to fetal size of previous pregnancies. If CPD with similar or smaller babies, then it is probably the case here. If no CPD with larger babies, CPD is unlikely. Power : inadequate contractions Management depends on the tonicity of contractions Hypotonic: IV oxytocin Hypertonic: Morphine sedation Eutonic : Emergent caesarean Slide37: DILATION ARRESTED ACTIVE PHASE: ARRESTED ACTIVE PHASE Patient is in labor but has no cervical change for 2-3hrs. Causes: 3Ps Management the same as prolonged active phase PROLONGED SECOND STAGE: PROLONGED SECOND STAGE Pt is 10cm dilated and fails to deliver infant in <2hrs ( primip ) or <1hr ( multip ) Add one hour if pt has received spinal anesthesia Causes: 3Ps Passenger: increased fetal size; persistent OT position; abnormal presentation; asynclitism (head wedge in pelvis) Power: inadequate contraction and dysfunctional contraction Management : Assess Contractions Inadequate : IV oxytocin Adequate: assess engagement of fetal head Engaged : consider forceps or vacuum delivery attempt Not engaged: emergent caesarean section PROLONGED THIRD STAGE: PROLONGED THIRD STAGE Failure to deliver placenta in <30mins Causes Inadequate contractions Abnormal placentation ( accreta , increta , percreta ) Management: Assess Contractions Inadequate: IV oxytocin Adequate: attempt manual removal; rarely hysterectomy COMPLICATIONS OF PROLONGED THIRD STAGE: COMPLICATIONS OF PROLONGED THIRD STAGE Review: Review Phases of Abnormal Labor: Phases of Abnormal Labor

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