1. Normal Labor and Delivery Valerie Robinson D.O.

2. Definition of Labor Contractions Become regular Increase in strength and frequency Cervical change: Dilation and Effacement Normal is >1.2cm/hour in P0, >1.5cm/hour in P>0 0% effacement is 3-4cm thick ROM may be spontaneous or assisted 3 factors affecting successful labor and delivery are the Power, Passenger, and Passage

3. 3 Stages #1: Onset to full Dilation #2: full Dilation to Delivery Mom wants to bear down May feel rectal pressure May have N/V #3: Delivery to Placental expulsion

4. 4 Phases Latent – Onset of labor and slow cervical dilation Active – Rapid cervical dilation. Usu begins at 2-4 cm After Involution – Empty uterus contracts to become smaller and hard. Stops bleeding.

5. Power Tocodynamometer (TOCO) measures length and strength of contractions May also use IUPC after ROM Adequate contractions for labor are 3-5 per 10 minutes

6. Passenger Size Presentation: breech, vertex, transverse Position: LOA, etc Movements FHR How many babies are there?

8. 7 cardinal movements Engagement – widest diameter is below pelvic inlet Descent Flexion Internal Rotation – rotation into the AP dimension Extension – occiput contacts the pubic symphysis External Rotation – head rotates to correct anatomy Expulsion

9. Fetal heart monitor Baseline – average FHR over 10 minutes. 110-160 Variability – Fluctuations in FHR amplitude Absent Minimal - <5 BPM Moderate - 6-25 BPM Marked - >25 BPM Accelerations – increase from baseline Normal is a 15 BPM increase lasting at least 15 seconds, <2 minutes If it lasts >10 minutes, it is a baseline change Decelerations – decrease in FHR with return to baseline Early Late Variable Prolonged - >2 minutes

10. Passage Is the pelvic outlet large enough? Infections such as GBS, herpes, hepatitis

11. Initial Assessment Check cervical D/E/S Dilation: 0-10 cm Effacement: 0-100% Station: – 5-+5cm above-below ischial spines Check presentation and position Check for ROM; color and quantity Check vitals Apply TOCO and Doppler transducer Review prenatal chart

12. L&D Care IV fluids are not necessary IV access should be gained for emergency, labor augmentation, antibiotics Restriction of drink is not necessary, but food may be restricted due to risk of aspiration pneumonitis Pain control Encouragement and reassurance An anterior cervical lip lasting >30 minutes may be normal or may indicate a malposition

13. Delivery Nurse or doctor will check labor progression by monitoring TOCO and checking Dilation/Effacement/ Station Allowing passive descent instead of pushing at 10cm increased chance of SVD, decreased chance of instrument assistance, decreased pushing time Pushing: Reflexive, or Valsalva. 10x3 in contraction May use hands to support the perineum or fetal head and reduce risk of tearing. May do a manual reduction of an anterior cervical lip Episiotomy is only used when there is a risk of severe perineal laceration Watch for and reduce a nuchal cord

14. Delivery cont. Deliver anterior shoulder, use downward traction on the head in concert with contractions Then upward traction to deliver posterior shoulder Suctioning may be performed but has not been shown to have any benefit except in babies with obvious secretory obstruction or who will be on a ventilator Cord clamping can take place immediately, but there is some benefit to delaying it so the placenta can deliver more blood to the baby. 75% of available blood is transfused in the first minute following delivery. Cord blood can be collected for diagnostic purposes Cord blood pH is measured by needle aspiration of artery

15. Stage 3 Uterus contracts, placenta separates, cord lengthens WHO suggests that placenta is retained after 1 hour Retained placenta increases risk of hemorrhage More commonly retained in preterm delivery Active management includes: Prophylactic oxytocin, Cord traction, and Uterine massage When providing cord traction, support the fundus to prevent inversion Slowly rotate the placenta as it is delivered, so you can get the attached membranes out intact.

16. Repair lacerations

17. Post-Partum Check incision if C/S Birth control Screen for depression Breast-feeding?

18. References Costanzo, Linda S. Physiology. 3 rd Ed. Saunders/Elsevier: Philadelphia, PA. 2007. pp. 456-460 Gordon, John David MD, Et al. Obstetrics, Gynecology, and Infertility: Handbook for Clinicians. 6 th Ed. Scrub Hill Press: Arlington, VA. 2007. pp 87-88. http://www.gynaeonline.com/perineal_tear.htm Funai Et al. Management of normal labor and delivery. UpToDate. Updated 5/18/12. Funai Et al. Mechanism of normal labor and delivery. UpToDate. Updated 10/19/11.