1. Obstetrics and Gynecology Clerkship Case Based Seminar Series
Intrapartum Care
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series

2. Objectives Review the signs and symptoms of true and false labor
Review the assessment of laboring patient
Describe stages of labor
Review pain management strategies
Review methods for monitoring mother and fetus
Review indications for operative delivery

3. Labor
Labor: progressive change of the cervix in the setting of uterine contractions
Term Labor: > 37 weeks gestation, but < 42 weeks
Preterm Labor: < 37 weeks gestation
Leading direct cause of neonatal death
The risk of mortality decreases with gestational age, but relationship is non-linear
12% of all US births in 2011
The majority late preterm

4. Signs and Symptoms of Labor
Frequent, painful contractions
“bloody show” – cervical effacement with extrusion of mucus from endocervical glands and small amount of bleeding
Leakage of vaginal fluid – rupture of membranes

5. False Labor Braxton Hicks Contractions Management
Not associated with dilation of cervix
Shorter in duration that true labor contractions
Less intense that true labor contractions
Common late in pregnancy
Management
Ambulation
Hydration
Analgesia

6. Stages of Labor
1st stage – onset of labor until full cervical dilitation
2nd stage – from full dilitation to birth of infant
3rd stage – from birth of infant until delivery of placenta
4th stage – 2 hours after the delivery of placenta

7. Latent phase: onset of contractions until active phase
Stages of Labor
Latent phase: onset of contractions until active phase
Active phase: 3 cm dilation in nulliparas; 4 cm dilation in multiparas to deceleration phase
Deceleration phase: 8 – 9 cm dilation to complete dilation

9. Exam of the laboring woman and her Fetus
Review of prenatal records and labs
Physical exam
1. Vitals and routine physical exam
2. Abdominal Exam
Palpation of contractions
Leopold’s maneuvers
3. Pelvic Exam
Membranes
Cervical status
4. Fetal heart rate monitoring

10. Review of Prenatal Records
Past medical, surgical, obstetrical, gynecologic, social and family histories
Medications
Allergies
Routine prenatal lab work
GBS status
Complications of current or past pregnancies

11. Abdominal Exam Leopold maneuvers
To assess estimated fetal weight, fetal lie, presentation and position, attitude, and (a)synclitism

12. Estimating Fetal Weight
Leopold’s maneuvers
Ultrasound
Estimate of fetal weight (error of 10 – 15%)
Maternal estimate of fetal weight (best)

13. Fetal Lie
Lie: relationship between the long axis of the fetus and the mother
Longitudinal
Transverse
Oblique

14. Fetal presentation Presentation: fetal part closet to pelvic inlet
cephalic
breech
shoulder

15. Fetal Position
Position: relationship of fetal presenting part to the maternal pelvis
Occiput
Brow
Mentum
Breech
Shoulder

16. Fetal Attitude
The relationship of the fetal parts to one another (i.e. flexion  extension of head relative to body).

17. (A)synclitism
Synclitism is when the biparietal diameter of the fetal head is parallel to the planes of the maternal pelvis.

18. Pelvic Exam
Pelvic Exam = sterile vaginal exam +/- sterile speculum exam
Assessing for:
Dilation
Effacement
Station
Position of cervix

19. Obstetrical Pelvic Exam
Dilation (dilatation): patency of the internal cervical os
0 = “closed”
10 cm = “complete”
Effacement: shortening of the cervical length
0% = “thick”
100% = “fully effaced”

20. Obstetrical Pelvic Exam
Station: level of presenting part (bony portion) in relation to the maternal ischial spines
Ischial spines = O station
Above spines: -5 to -1
Below spines: +1 to +5

23. What’s going on in there?
The cardinal movements of labor are the mechanism by which the fetus moves progressively through the birth canal.

24. Cardinal Movements of Labor
Engagement: descent of biparietal diameter to the level of the ischial spines (0 station)
Often occurs before onset of labor in nulliparous patients
Descent
Flexion: presenting diameters of fetal head presenting to maternal pelvis are optimized

25. Cardinal Movements of Labor
Internal rotation: fetal occiput rotates from transverse to AP
Extension: head rotates under symphysis pubis
External rotation (restitution): occiput and spine assume same position
Expulsion: fetal body delivers

29. 3rd and 4th stages
Delivery of placenta
Bonding, etc

30. Anesthesia/Analgesia
Cesarean section
Spinal
Epidural
General (more risky in obstetrics)
Vaginal delivery
IV pain meds
Local
Pudendal
Combined spinal/epidural

31. Pudendal Block

32. Lacerations Cervical (use clock to describe location)
Vaginal (left or right)
Periurethral
Clitoral
Perineal
1st degree: skin only involved
2nd degree: skin and subcutaneous tissue
3rd degree: external rectal sphincter
4th degree: rectal mucosa not intact 32

33. First degree
Second degree
Third degree
External sphincter
External sphincter

34. Indications for Operative Vaginal Delivery
Prolonged second stage of labor
Non-reassuring fetal status
Maternal cardiac or neurologic disease
Valsalva maneuver is contraindicated or cant be performed well in some conditions
Abnormal labor covers in more detail

35. Indications for Cesarean Delivery
Hemorrhage from placenta previa
Placental abruption
Prolapse of umbilical cord
Uterine rupture
Breech (though vaginal delivery also a possibility)

36. Multiple Gestation The approach to delivery depends on: Twins Multiple
Gestational age/estimated fetal weight
Presentation
Experience of attending physician
Twins
Vertex/vertex – vaginal delivery
40% of all twin pairs enter labor this way
Vertex/breech or transverse lie – external cephalic version, breech extraction of 2nd twin, or cesarean
Breech/other – C-section (locked twins)
Multiple
Cesarean delivery indicated

38. Bottom Line Concepts
False labor is characterized by irregular uterine contractions that do not lead to cervical change
Labor management includes good communication, providing comfort and regular assessment of both maternal and fetal status.
Leopold’s maneuvers and cervical examination provide information about fetal lie, presentation and station
After delivery of the placenta, it should be examined to make sure it is intact