1. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 1 Labor and Delivery CAPT Mike Hughey, MC, USNR

2. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 2 Labor Regular, frequent, leading to progressive cervical effacement and dilatation Braxton-Hicks contractions –May be painful and regular, but usually are not –Do not lead to cervical change Labor diagnosis usually made in retrospect. Cause of labor is unknown

3. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 3 Latent Phase Labor <4 cm dilated Contractions may or may not be painful Dilate very slowly Can talk or laugh through contractions May last days or longer May be treated with sedation, hydration, ambulation, rest, or pitocin

4. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 4 Active Phase Labor At least 4 cm dilated Regular, frequent, usually painful contractions Dilate at least 1.2-1.5 cm/hr Are not comfortable with talking or laughing during their contractions

5. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 5 Progress of Labor Lasts about 12-14 hours (first baby) Lasts about 6-8 hours (subsequent babies) Considerable variation. Effacement (thinning) Dilatation (opening) Descent (progress through the birth canal)

6. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 6 Descent Fetal head descends through the birth canal Defined relative to the ischial spines 0 station = top of head at the spines (fully engaged) +2 station = 2 cm past (below) the ischial spines

7. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 7 Cardinal Movements of Labor Engagement (0 Station) Descent Flexion (fetal head flexed against the chest) Internal rotation (fetal head rotates from transverse to anterior Extension (head extends with crowning) External rotation (head returns to its’ transverse orientation) Expulsion (shoulders and torso of the baby are delivered)

8. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 8 Watch a Delivery

9. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 9 Placental Separation Signs of separation: –Increased bleeding –Lengthening of the cord –Uterus rises, becoming globular instead of discoid –Uterus enlarges, approaching the umbilicus Normally separates within a few minutes after delivery

10. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 10 Initial Labor Management Risk assessment Contractions: frequency, duration, onset Membranes: Ruptured, intact Status of cervix: dilatation, effacement, station Position of the fetus: vertex, transverse lie, breech Fetal status: fetal heart rate, EFM

11. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 11 Cervix Dilatation: How far has the cervix opened (in cm) Effacement: How thin is the cervix (in cm or %)

12. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 12 Status of Membranes Nitrazine paper turns blue in the presence of alkaline amniotic fluid (“nitrazine positive”) Vaginal secretions are nitrazine negative (yellow) because of their acidity Pooling of amniotic fluid in the vaginal vault is a reliable sign

13. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 13 Orientation of Fetus Vertex, breech or transverse lie Palpate vaginally Leopold’s Maneuvers

14. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 14 Management of Early Labor Ambulation OK with intact membranes If in bed, lie on one side or the other…not flat on her back Check vital signs every 4 hours NPO except ice chips or small sips of water

15. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 15 Monitor the Fetal Heart During early labor, for low risk patients, note the fetal heart rate every 1-2 hours. During active labor, evaluate the fetal heart every 30 minutes Normal FHR is 120-160 BPM Persistent tachycardia (>160) or bradycardia (<120, particularly <100) is of concern

16. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 16 Electronic Fetal Monitors Continuously records the instantaneous fetal heart rate and uterine contractions Patterns are of clinical significance. Use in high-risk patients. Use in low-risk patients optional

17. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 17 Normal Patterns Normal rate Short term variability (3-5 BPM) Long term variability (15 BPM above baseline, lasting 10-20 seconds or longer) Contractions every 2-3 minutes, lasting about 60 seconds

18. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 18 Tachycardia >160 BPM Most are not suggestive of fetal jeopardy Associated with: –Fever, Chorioamnionitis –Maternal hypothyroidism –Drugs (tocolytics, etc.) –Fetal hypoxia –Fetal anemia –Fetal arrythmia

19. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 19 Bradycardia Sustained <120 BPM Most are caused by increased in vagal tone Mild bradycardia (80-90) with retention of variability is common during 2nd stage of labor <80 BPM with loss of BTBV may indicate fetal distress

20. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 20 Late Decelerations Repetive, non- remediable slowings of the fetal heartbeat toward the end of the contraction cycle Reflect utero-placental insufficiency

21. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 21 Early Decelerations Periodic slowing of the FHR, synchronized with contractions Rarely more than 20- 30 BPM below the baseline Innocent Associated with fetal head compression

22. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 22 Variable Decelerations Variable in onset, duration and depth May occur with contractions or between them Sudden onset/recovery Increased vagal tone, usually due to some degree of cord compression

23. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 23 Severe Variable Decelerations Below 60 BPM for at least 60 seconds If persistent, can be threatening to fetal well-being, with progressive acidosis

24. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 24 Prolonged Decelerations Last > 60 seconds Occur in isolation Associated with: –Maternal hypotension –Epidural –Paracervical block –Tetanic contractions –Umbilical cord prolapse

25. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 25 Pain Relief Narcotics Continuous Lumbar Epidural Paracervical Block 50/50 nitrous/oxygen Psychoprophylaxis (Lamaze breathing) Hypnosis

26. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 26 Anesthesia During Delivery Local Pudendal Block Epidural Caudal Spinal 50/50 nitrous/oxygen

27. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 27 Episiotomy Avoids lacerations Provides more room for obstetrical maneuvers Shortens the 2nd Stage Labor Midline associated with greater risk of rectal lacerations, but heals faster Many women don’t need them.

28. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 28 Clamp and Cut the Cord Clamp about an inch from the baby’s abdomen Use any available instruments or usable material Check the cord for 3-vessels, 2 small arteries and one larger vein

29. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 29 Inspect the Placenta Make sure it is complete Look for missing pieces Look for malformations Look for areas of adherent blood clot

30. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 30