Presentation on theme: "Mechanisms and Management of Labor"— Presentation transcript:
1 Mechanisms and Management of Labor Nancy Goodwine Wozniak, MD
2 Definition of LaborLabor is the physiologic process by which the fetus is expelled from the uterus to the outside worldCould also be described as the transition from “contractures” to “contractions”Bottom line defination: Contractions with cervical change. The diagnosis is a clinical one.Gabbe: Obstetrics Normal and Problem pregnancies 4th edition
3 Full term pregnancy is 280 days (40 weeks) or 36 completed weeks. Post term pregnancy is beyond 42 weeksSROM is seen in about 8% of patients
4 Labor PhysiologyLabor is contractions with cervical changeThe fetus is in control of the timing of laborThe factors responsible for initiating labor are not well-defined…likely an autocrine and/or paracrine event.We do know there is some endocrine maternal/fetal cross talk (eg horses and donkeys indicate that fetal genotype is a factor—365 vs 340 days)Gabbe: Obstetrics Normal and Problem pregnancies 4th edition
5 Labor PhysiologyNo matter what seems to initiate labor it involves regular uterine contractions, mediated through ATP-dependent binding of myosin to actin. Unlike vascular smooth muscle, myometrium has sparse innervation, thus regulation of contractions is hormonal.There is thought to be a parturition cascade. Ultimately, human labor is a multifactorial physiologic process involving an integrated set of changes that occur gradually over days to weeks. Changes include prostaglandin synthesis and release within the uterus, an increase in myometrial gap junction formation, and up-regulation of myometrial oxytocin receptors. At some point labor begins with the activation of the fetal-hypothalamic-pituitary adrenal axis in a way likely common to all species.Gabbe: Obstetrics Normal and Problem pregnancies 4th edition
6 Labor PhysiologyThe regulation of uterine activity can be divided into 4 physiologic phasesPhase 0: uterus is quiet due to progesterone, relaxin, prostacyclin I2 (PGI2), parathyroid hormonePhase 1: before term “activation” phase- uterus is more responsive to estrogen and more receptors for oxytocin and prostaglandinsPhase 2: uterus more stimulated because of increase in gap junctions so that it can be stimulated by oxytocins and prostaglandins (PGE2 and PGF2 alpha)Phase 3: involution of the uterus (mediated by oxytocin)Gabbe: Obstetrics Normal and Problem pregnancies 4th edition
7 Labor MechanicsFor a successful vaginal delivery, the fetus must negotiate the maternal pelvis.Three factors: the power, the passage, and the passenger.
8 Labor Mechanics The passenger Estimating fetal size: ultrasound, leopolds, what does mom think?How big is too big? Definition of macrosomia isdiabetics: 4500g non-diabetics: 5000g
9 Labor MechanicsPowerAssessing amplitude, duration, and intensity of ctxinternal IUPC vs external tocoWhat’s adequate contractions? (ultimately it is a clinical dx)3-5 ctx in 10 min7 ctx in 15 min250 MVU’s – the average strength of ctx in mm Hg multiplied by the number of contractions in 10 minutes. No real data support an absolute number of ctx or MVU’s to be adequate…adequacy is still a clinical determination.If ctx are adequate either the cervix will dilate or the caput will become worse.
11 Labor MechanicsThe most precise way of determining uterine contractions are adequate is with internal monitoring by IUPCExternal monitoring measures the change in shape of the abdominal wall relative to contractions thus is qualitative rather than quantitative. Does allow for accurate correlation between fetal heart rate and contraction pattern .
12 Labor Mechanics The Passenger The passenger is the fetus. Fetal size can influence laborCan be assessed by Leopold’s, US or both. ( Mom’s opinion counts, too!)ACOG definition of Macrosomia is defined as >4500 g
13 Labor Mechanics The passenger Fetal lie: Fetal position relative to the maternal spine. longitudinal, oblique, transversePresentation: refers to the fetal part that is above the pelvic inlet. (eg a fetus can have a logitudinal lie but be breech or cephalic)Attitude: refers to position of fetal head relative to the fetal spinePosition: referes to the relationship of a nominated site of the presenting part to a denomintating location in the internal pelvis. Eg. Occiput/sacrum ROA, RSAStation: a measure of descent of the presenting part.Abnormalilty of any of these variables can influence whether or not to proceed with a vaginal delivery.
14 Fetal presentation: Fetal part directly over the pelvic Fetal presentation: Fetal part directly over the pelvic inlet; eg breech, cephalic, compound, funic
15 Labor Mechanics The passenger Malpresentation is any presentation that is not cephalic with occiput leading. (about 5%) Multifetal pregnancies increase the risk of malpresetnation
17 The cephalic presentation can be classified by boney landmarks of the skull; eg occiput , mentum, browpasengerpassenger
18 A: Right occiput anterior (ROA); B: Left occiput anterior (LOA); C: Occiput anterior (OA). * Posterior fontanel. This is the smaller of the two fontanels and is at the intersection of the three sutures: the sagittal suture and two lambdoid sutures. ** Anterior fontanel. This large fontanel is at the intersection of four sutures: the sagittal, frontal, and two coronal sutures From UpToDate.com
21 Labor Mechanics The passenger Station: measure of descent of the presenting part through the birth canal relative to ischial spinesthis is the relationship between the leading bony part of fetal presenting part ( skull bone NOT scalp) and the maternal ischial spines. Must take into account molding and caput succedaneum (not doing so is a common error)Often described as -3 to + 3Newer scale is -5 to +5
23 Labor Mechanics The Passage The passage consists of the bony pelvis (sacrum, ilium, ischium, pubis) and the resistance provided by the soft tissues.Bony pelvis is divided into the greater (false) and lesser(true) pelvis by the pelvic brim which is demarcated by the sacral promontory.The diagonal conjugate is the distance from the sacral promontory to the inferior margin of the symphysis pubis as assessed on examination ( see next slide )Clinical pelvimetry is the only way to assess the dimensions of the pelvis in labor.
24 To figure out the true conjugate, measure the diagonal conjugate and subtract 1.5 – 2cm. The limiting factor is the interspinous diameter.
28 A little bit about cervical ripening… When induction is attempted against an unripe cervix the likelihood of succcess is reduced.Bishops score: dilatation, effacement, position, consistency, station. Total score is up to 13.Bishop’s = 8 chances of successful induction are the same as spontaneous laborBishop’s = 6 “favorable cervix”
29 (A) Cervix is uneffaced and minimally dilated (A) Cervix is uneffaced and minimally dilated. (B) Cervix is almost completely effaced and dilated From UpToDate.com
30 Methods of cervical ripening Non Pharmacologic methods:membrane stripping – digital separation of chorionic and amniotic membranes from the cervix. Releases endogenous prostaglandins from the decidua and adjacent membranes.May also cause “Ferguson reflex” stimulating release of oxytocin from the pituitary.Foley bulbAmniotomy – needs favorable cervix, but if cervix is favorable amniotomy by itself can get labor started (better still when combined with Pitocin)risks: cord prolapse, prolonged ROM, fetal injury, rupture of vasa previa with fetal hemorrhage, fetal malposition and asynclitismBenefits: FSE placement, can determine if MSF or blood, high success in inducing labor
31 Methods of cervical ripening Pharmacologic methodsDinoprostone (Prepadil and Cervadil) PGE2 , oxytocin, misoprostyl (cytotec) PGE1The uterus has precursors of the prostaglandin of the 2 series. PGE2 : important for cervical maturation PGF 2 alpha. : causes myometrial contractions
32 Stages of Labor First stage: Onset of labor to full dilatation latent phase- onset of labor until cervix starts to make change.active phase-greater rate of cervical change1.2 cm/h for nulliparous1.5 cm/h for multiparousSecond stage: full dilation to deliveryLength of Pushing: nullip: 2h without epidural, 3 h with epiduralmultip: 1 h without epidural,2 h with epiduralThird stage: delivery of placenta-can take up to 30 minutes
33 Cardinal movements of labor Engagement: passage of the widest diameter of the presenting part to a level below the plane of the pelvic inlet. In cephalic fetus, the largest diameter is the biparietal diameter (9.5 cm); in a breech fetus the widest diameter is the bitrochanteric diameter. The presenting part is engaged if you can feel presenting part both abdominally and vaginally.Descent: downward passage of the presenting partFlexion: occurs passively d/t boney maternal pelvisInternal rotation: refers to rotation of presenting part from its original position (usually transverse) to the AP positionExtension: Occurs once the fetus has descended to the introitusExternal rotation (aka restitution) return of the fetal head to the correct anatomic position in relation to the fetal torso.Expulsion: delivery of the rest of the fetus.
35 Management of Normal Labor and Delivery All women need adequate surveillance throughout labor and delivery.Okay to let women walk (doesn’t shorten course of labor, the need for augmentation, the use of analgesia, or the rate of C/S)Record FHT’s q 30 minutes (minimum)During second stage, FHT’s should be recorded q 15 and after each contraction
36 Augmentation of Labor at Term Abnormalities of the first stage of labor may be either protraction or arrest disorders and can occur during active or latent phases of labor.--Administer Pitocin as long as no malpresentation.Goal is ctx q 2-3 min lasting seconds. Resting tone should be mm Hg if IUPC is used.--Takes 30 to 40 minutes to see full effect of Pitocin dose--A slow rate of pitocin increase is as effective as a fast rate.--Whether to add pitocin to a patient who is already adequately contracting is controversial, but 80% of patients will respond to pitocin
37 Augmentation of Labor at Term Advantages:Oxytocin is cheap, and well known to usShort t1/2Complications:uterine hyperstimulation (tachysystole)increased uterine tone (hypertonia)water intoxication (at doses of miu since it’s a vasopressin analogue)hypotension (usually if pitocin is given as a bolus)uterine rupture (associated with “excessive oxytocin”)
38 Abnormal patterns of labor “Latent phase arrest”—means labor never began“prolonged latent phase”—greater than 20h in nullip---greater than 14h in multipProlongation of latent phase is variable; doesn’t mean the fetus will have a bad outcome or that the patient needs a c/s. Can be managed expectantly (presuming mom and baby other wise look good)Can administer analgesics (eg morphine mg for therapeutic rest)Augmentation (Pitocin)Defer amniotomy!
39 Pitocin regimen Regimen Starting dose Incremental increase Dosage change interval in minutesLow dosemu1 mu30-40 minutesAlternative low dose1-2 mu215 minutesHigh dose6 muMax 40 muAlternative high dose4 muMax 32 mu
40 Abnormal patterns of labor Abnormalities of second stage“Failure to Progress” “Arrest of dilatation”generally patient is falling off Friedman’s curve, or no cervical change in 2 hoursConsider augmentation, placement of IUPC
41 Abnormal patterns of labor “Protraction of descent”Descent of < 1 cm/h in nullipsDescent of < 2 cm/h in multipsDeliveries complicated by prolonged second stage put the fetus at risk of acidosis, thus, ACOG recommends intervention after 2 h without epidural, 3 h with epidural.In reality, can consider expectant management if mother and fetus are otherwise reassuring, descent is progressive, and delivery is imminent.
42 Abnormal patterns of labor “Arrest of Descent”This requires an assessment of contractions, maternal fetal well being, and CPDRe-evaluate clinical pelvimetry, fetal station, caput.The decision to proceed with assisted vaginal delivery or C/S should be individualized
43 Do you really want to do that episiotomy?? Episiotomy– the incision in the perineal body during the second stage of labor.Indicated in 1) cases of arrested or protracted descent2) expedite delivery in NRFHT’sMedian: performed when the fetal head is on the perineum. Associated with occasional extensions to 3rd or 4th degreeMediolateral: 45 degree angle from the hymenal ring. Does not increase risk of 3rd or 4th degree extension. Procedure of choice in patients with inflammatory bowel disease. More pain post partum.
45 EpisiotomyFewer episiotomies are being performed…most repairs after a vaginal delivery are a result of tears.Episiotomies (and lacerations) are graded on a scale of 1 to 4
46 Episiotomy/Lacerations 1st degree lacerations: involve the forchette, perineal skin, and vaginal mucosa2nd degree lacerations: above plus extend to the fascia and muscles of the perineal body but not to the anal sphincter3rd degree lacerations: skin, mucosa, perineal body and anal sphincter4th degree: exposed lumen of the rectum
51 Vaccuum Deliveries Vaccuums have been around since 1953 By 1970’s popular in Northern EuropeDidn’t exceed number of forceps deliveries in the U.S. until 1992
52 Fetal contraindications to a Vaccuum 1) < 34 weeks increases risk of intraventricular hemorhage 2) Fetal bleeding diathesis e.g., ITP, hemophilia 3) Multiple FSE attempts 4) CPD
53 Vaccuum types Take a look at what we have! Optimum type…who knows Can use any of them if no contraindicationIn general…soft cups, more likely to fail but less fetal scalp injury; rigid cups probably better for OP
54 A Vaccuum does not require less clinical knowledge than forceps! Must know fetal position, station, and take into account moldingMust know contraindicationsPlacement of cup now becomes flexion point.Unlike forceps which can be used to correct asynclitism, a vaccuum will impede delivery if cup not placed over flexion point.
55 Check list prior to instrumental delivery Empty bladderDorsal lithotomy positionAdequate anesthesia ( a MUST for forceps!)Fetal position, station, EFW
56 Putting on the VacDetermine flexion point: basically flexion point is the point where pulling is going to best allow flexion at the neck keeping the fetus OA.Midline, over sagital suture, 6 cm from Anterior fontanelle, 3 cm from posterior fontanelle.Anterior fontanelle has to be your reference point.360 degree inspectionGreen zone to 450
57 The instrumental delivery itself Pull along pelvic curve (down, then up)Let handle passively turn as fetus rotates with deliveryDescent should occur with each pullNo routine episiotomy
58 How long is too long?No one knows maximal amount of time and maximal amount of pop-offs that is acceptableIdeally less than 15 minutes, certainly less than 30Usually less than 3 pop-offs, less than 5 pulls
59 Documentation Indications Were prerequisites met (full dilatation, empty bladder, no contraindications, gest. Age, station (+2/3 or +2/5??)Fetal status (station, position, FHT’sVerbal consentDetailed description of procedureType of vaccuum, total time, reduced between contractions, # pulls, # ctx, # pop-offs, progress with each pull, epis or not
60 Reasons instrumental deliveries fail CPD Bad technique (eg pulling without contractions, upward pull before crowning: deflexed, paramedian application Large Caput
61 Remember…No one thanks you for a vaginal delivery unless its perfect.
64 If the anterior and posterior shoulders descend together instead of sequentially, the anterior shoulder can become impacted behind the symphysis pubis (or the posterior shoulders on the sacral promontory)
65 If descent of the fetal head continues while the shoulders remain impacted, stretching of the nerves of the brachial plexus can occur.Most brachial plexus injuries resolve on their own, but permanent injury is a often a medicolegal issue.
66 Risks for shoulder dystocia maternal obesity, diabetes, post dates, macrosomic infant, operative deliveryOther risks associated with shoulder dystocia: fetal hypoxia and neurologic injury; fractured clavical or humerus, fetal death.
67 Management of Shoulder dystocia Call for help!Suprapubic pressureMcRoberts ManeuverEpisiotomyWoods screw/ Ruben’s manueversDeliver posterior armFracture claviclesZavenelli maneuverMom should not push during maneuvers!!
71 After difficult delivery… Careful documentationExplain to patient the events, explanation of problem, steps taken to correct the problem, and what the anticipated sequelae are
72 Interpretation of the Electronic Fetal Heart Rate During Labor Fetal MonitoringThe following examples of fetal monitoring strips are from…Interpretation of the Electronic Fetal Heart Rate During LaborAMIR SWEHA, M.D., and TREVOR W. HACKER, M.D.Mercy Healthcare SacramentoSacramento, CaliforniaNUOVO, M.D.University of California, Davis, School of MedicineDavis, CaliforniaUsed with permission from The American Family Physician
73 Figure 1 Interpreting fetal monitiring Strips; American Academy of Family Physicians May, 1999
74 Figure 1 Interpretation of Electronic Fetal Heart rate During Labor American Family Physician, May 1999
75 Figure 1Reassuring pattern. Baseline fetal heart rate is 130 to 140 beats per minute (bpm), preserved beat-to-beat and long-term variability. Accelerations last for 15 or more seconds above baseline and peak at 15 or more bpm. (Small square=10 seconds; large square=one minute
76 Figure 2Interpretation of Electronic Fetal Heart rate During LaborAmerican Family Physician, May 1999
77 FIGURE 2. Saltatory pattern with wide variability FIGURE 2. Saltatory pattern with wide variability. The oscillations of the fetal heart rate above and below the baseline exceed 25 bpm.
79 Fetal tachycardia with possible onset of decreased variability (right) during the second stage of labor. Fetal heart rate is 170 to 180 bpm. Mild variable decelerations are present.
80 Figure 3Interpretation of Electronic Fetal Heart rate During LaborAmerican Family Physician, May 1999
81 Figure 3Fetal tachycardia that is due to fetal tachyarrhythmia associated with congenital anomalies, in this case, ventricular septal defect. Fetal heart rate is 180 bpm. Notice the "spike" pattern of the fetal heart rate.
82 Figure 4Interpretation of Electronic Fetal Heart rate During LaborAmerican Family Physician, May 1999
83 Figure 4Early deceleration in a patient with an unremarkable course of labor. Notice that the onset and the return of the deceleration coincide with the start and the end of the contraction, giving the characteristic mirror image.
85 Figure 5Nonreassuring pattern of late decelerations with preserved beat-to-beat variability. Note the onset at the peak of the uterine contractions and the return to baseline after the contraction has ended. The second uterine contraction is associated with a shallow and subtle late deceleration
87 FIGURE 6. Nonreassuring pattern of late decelerations with preserved beat-to-beat variability. Note the onset at the peak of the uterine contractions and the return to baseline after the contraction has ended. The second uterine contraction is associated with a shallow and subtle late deceleration
95 Figure 10FIGURE 10. Late deceleration related to bigeminal contractions. Beat-to-beat variability is preserved. Note the prolonged contraction pattern with elevated uterine tone between the peaks of the contractions, causing hyperstimulation and uteroplacental insufficiency. Management should include treatment of the uterine hyperstimulation. This deceleration pattern also may be interpreted as a variable deceleration with late return to the baseline based on the early onset of the deceleration in relation to the uterine contraction, the presence of an acceleration before the deceleration (the "shoulder") and the relatively sharp descent of the deceleration. However, late decelerations and variable decelerations with late return have the same clinical significance and represent nonreassuring patterns. This tracing probably represents cord compression and uteroplacental insufficiency.