1. “Womb To Grow” Normal Labor & Delivery (ch 10) Malpresentation (ch 21)
Complications of Labor & Delivery (ch 25)
Obstetric Anesthesia (ch 26)
Operative Delivery (ch 27)

2. Birth Experience

3. Presentation
Vertex (cephalic)
Breech
Transverse

4. Leopolds Maneuvers

5. Cephalic Presentation
Relationship of occiput to maternal pelvis
Anterior fontanelle (frontal bones/parietal bones) larger & diamond shape
Posterior fontanelle (parietal bones & occipital bone) smaller & triangle shaped
Sagittal suture is midline
Asynclitism = sagittal suture not midline

7. Preparations for Labor
Lightening – fetal head settles into pelvis
Increased pelvic pressure
Braxton Hicks
Cervical effacement (thinning)
Bloody show
Mucous plug
Nausea/diarrhea

8. Let’s Talk Cervix Dilation (closed to 10 cm) Effacement (thinning)
Station (biparietal diameter in relation to ischial spines)

9. Subjective measurement
Effacement
Typical cervix 3-5 cm
Subjective measurement

10. Station

11. Labor
Contractions that cause cervical change (either effacement or dilation)

12. Contractions True Labor Regular intervals Increased intensity
Discomfort lower abdomen/back
Does not stop with walking/shower
Cervical change
False Labor
Irregular intervals
Intensity same
Discomfort lower abdomen
Relieved with walking/shower
No cervical change

14. Pain of Labor Thinning & dilation of the cervix
Lactic acid build up as the uterus contracts
Compression of the bladder/rectum
Stretching of the vagina & perineum
Personal beliefs & cultural conditioning in response to pain

15. Normal Labor – Stage 1 Onset of labor until completely dilated (10 cm)
Nulliparous: average hours
6-20 still considered normal
Multiparous: average 6-8 hours
2 to 12 still considered normal

16. Stage 1 – Latent Phase Onset of labor until 3-4 cm dilation
Characterized by slow cervical dilation

17. Stage 1 – Active Phase Nulliparous: expect 1 cm/hour 
Multiparous: expect 1.2 cm/hour 

18. Cervical Exams

19. Rupture of Membranes SROM = spontaneous rupture of membranes
PROM = premature ROM
AROM = artificial ROM
PPROM = preterm premature ROM

20. Stage 2
Begins when the cervix is completely dilated to delivery of the infant
Nulliparous: average 50 minutes
Multiparous: average 20 minutes

21. Cardinal Movements of Labor

22. Episiotomy Previously commonplace Sometimes needed to hasten delivery
Relief from impending or ongoing shoulder dystocia
Rate of 3rd & 4th degree lacerations increased with routine use

23. Stage 3
Begins with delivery of the infant until delivery of the placenta
Up to 30 minutes still considered normal

24. Difficult labor or childbirth
Dystocia
Difficult labor or childbirth
Power
Passenger
Pelvis

25. Abnormal Labor Patterns
Arrest Disorders
Arrest of dilatation – no cervical change for > 2 hours with adequate contractions
Arrest of descent – no fetal descent with adequate maternal effort
50% patients with arrest disorders demonstrate fetopelvic disproportion

26. Precipitous Labor Primipara >5 cm/hour dilatation
Multipara >10 cm in one hour! (Ouch!)

27. Abnormalities of the Passenger
5% of all labors
Vertex malpositions
Occiput posterior
Malrotation during active phase (66% time)
Contracted pelvis (android/anthropoid)
Insufficient uterine action

28. Transverse (back up/down)
Passenger
Other malpositions
Occiput transverse
Brow presentation
Face presentation
Transverse (back up/down)

30. Breech Presentation

31. Breech Presentation At term 3-4% 32 weeks = 7% < 28 weeks = 25%
ACOG’s formal position is that planned vaginal delivery of breech presentation no longer appropriate
External cephalic version
Planned cesarean section

32. External Cephalic Version

33. Fetal Macrosomia Implies fetal growth 4000-4500 g 5% deliveries
Risk Factors
Maternal diabetes
Maternal obesity (>90 kg)
Excessive weight gain (>20 kg)
Post-date pregnancy
Previous macrosomic delivery
Male infant
Advanced maternal age
40% macrosomic infants born to patients without identifiable risk factors

34. Shoulder Dystocia
Difficult delivery of the shoulders after delivery of the fetal head
Obstetric emergency
High risk of brachial plexus injury, hypoxia, asphyxia
Fracture of clavicle/humerus

36. Spinal Cord Injuries

37. Brachial Plexus Injuries
Erb’s Palsy
Injury to C5-C6 nerve roots
Upper limb internally rotated/flexed wrist (Waiter’s tip)
Klumpke’s Palsy
Less common
Injury to C7-C8 nerve roots
Paralysis of intrinsic muscles of the hand, wrist weakness

39. Fractures Clavicle most frequently fractured bone during delivery
Infant doesn’t move affected arm as freely
Crepitus or bony irregularity
Immobilization
Remarkable callous formation within 1 week
Excellent prognosis

41. Cranial Molding
Over-riding of parietal bones allows passage of vertex into pelvis
Results in caput succedaneum
Disappears within first few days of life
Diffuse, edematous swelling of soft tissues of scalp
Crosses suture lines

42. Cephalohematoma Subperiosteal hematoma Usually over one parietal bone
Usually results from difficult vacuum or forceps delivery
Develops hours after birth
Occasionally associated with skull fracture
Usually resolves spontaneously

44. Operative Vaginal Delivery
Prolonged second stage
Maternal exhaustion
Maternal medical conditions that preclude pushing
Need to hasten delivery (fetal indications)
Vaginal operative delivery rate 10-12%
Forceps vs. Vacuum
Cesarean section

45. Forceps Traction +/- rotation Cervix must be fully dilated
Membranes ruptured
Head at “0” station or below
Empty bladder
Exact position known
No significant cephalopelvic disproportion
Adequate anesthesia
Experienced operator

46. Forceps Application

47. Vacuum Extractor Introduced in 1954 Same indications/contraindications
Only traction – no rotation
3 pop offs indicates need to move toward c-section
Higher incidence of cephalohematoma

49. Cesarean Section Maternal mortality 0.01%
Nothing to do with Julius Caesar!
First documented c-section on a living patient 1610 (died 25 days later)
First successful C/S in the US 1794
Maternal mortality 0.01%
Past 20 years rate has risen from 5% to >20%
Avoidance of mid-forceps/vaginal breech delivery
Fetal heart rate monitoring in labor
Previous c-sections

50. Reasons for C-section Previous c-section (most common)
Failure to progress in labor
Breech, shoulder, or compound presentation
Placenta previa
Placental abruption
Fetal distress
Cord prolapse
Failed operative delivery
Active herpes

51. Uterine not skin incision is what counts
Types of C-section
Uterine not skin incision is what counts

52. Classical “Simplest” Greatest blood loss
Highest risk for rupture in subsequent pregnancies (4-9%)
Vertical incision on the uterus
Placenta previa
Transverse lie
Premature delivery

53. Low Transverse/Low Cervical
Much more common
Incision made transversely in low uterine segment
Risk of rupture %

54. Goals for Healthy People 2010
Reduce primary C/S rate among low risk women to 15.5%
Increase VBAC among low risk women to 37/100 deliveries (baseline 30/100 in 1996)

55. Labor Pain First Stage Second Stage T10-L1 segments
Ischemia of the uterus during contractions
Dilation & effacement
Second Stage
Distention of the vagina & perineum
Pudendal nerve

56. Subarachnoid (spinal) block
Regional Anesthesia
Lumbar epidural block
Subarachnoid (spinal) block
Pudendal block

57. Have a good week off! Don’t forget your Take Home Exam