1. Joint Special Operations Medical Training Center NORMAL LABOR AND DELIVERY SFC WARD

2. Joint Special Operations Medical Training Center Terminology Gravida - number of pregnancies Para - number of pregnancies carried to viability and delivered Primigravida - pregnant for first time Multigravida - pregnant more than once Viability - able to survive outside the womb (24+ weeks gestation) Nulliparous - never carried a pregnancy to viability Multiparous - has had two or more deliveries that were carried to viability

3. Joint Special Operations Medical Training Center Duration of Pregnancy Average 280 days or 40 weeks (9 lunar months) Estimated Date of Confinement (EDC) –Nagele’s rule –Date of first day of LMP –Subtract 3 months –Add 7 days Accurate to plus or minus 2.5 weeks

4. Joint Special Operations Medical Training Center First Stage of Labor Begins with onset of coordinated contractions leading to dilation of cervical os and ends with complete dilation (10 cm) of the cervical os. False Labor (Braxton Hicks contractions) –Cervix fails to dilate greater than 2 cm Duration of first stage - –Primigravida: 12 hours –Multiparous: 7 hours or less

5. Joint Special Operations Medical Training Center First Stage of Labor Contractions Interval –10 to 20 minutes between contractions: early labor –3 to 5 minutes between contractions: late labor Duration –20 second long contraction: early labor –40 to 80 second long contraction: late labor Quality –Uterus can be dented (poor quality): early labor –Uterus is hard (good quality): late labor

6. Joint Special Operations Medical Training Center First Stage of Labor Management Take VS between contractions Fetal Heart Rate should be between 120 - 160 BPM Mother should be coached to relax and conserve energy between contractions

7. Joint Special Operations Medical Training Center Assessing Progress of Labor Vaginal Exam Cervix –Soft or Hard –Effaced or Thick –Dilatation Presentation –Part (cephalic, breech, shoulder) –Flexion, Extension –Station

8. Joint Special Operations Medical Training Center Second Stage of Labor Begins with complete dilation of the cervix and ends with delivery of fetus Duration of Second Stage - –Primigravida: 50 minutes –Multiparous: 20 minutes or less Contractions –Interval: 2 to 3 minutes –Duration: 50 to 100 seconds

9. Joint Special Operations Medical Training Center Second Stage of Labor Management –Mother may feel urge to push, coach to push only during a contraction once the cervix has been determined to be fully dilated Episiotomy –Perform to avoid unecessary tearing when head is crowning –Controlled delivery avoids need for episiotomy in most cases

10. Joint Special Operations Medical Training Center Second Stage of Labor Episiotomy –Anesthetize with pudendal block –Put two fingers into the vagina along the posterior wall –Place one blade of scissors between fingers inside vagina, other blade outside vagina toward anus –Cut to approximately 1 inch away from anus during a contraction

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13. Second Stage of Labor Delivery of head - CONTROL head to prevent explosive delivery and subsequent tearing Check for presence of cord around neck Aspirate oral and nasal cavities with bulb syringe Deliver anterior shoulder with downward pressure Complete delivery and HANG ON TO BABY!

14. Joint Special Operations Medical Training Center Second Stage of Labor Clear airway, Assess respirations, Resuscitate if necessary Clamp cord when pulsations cease Leave 3 - 6 inches of cord on baby Obtain blood for fetal labs from the placental stub of cord

15. Joint Special Operations Medical Training Center Third Stage of Labor Begins after delivery of baby and ends with delivery of the placenta Average duration: 8 minutes Signs of separation –Uterus rises to become globular –Increase (gush) of blood from vagina –Lengthening of cord Do not PULL cord. Apply gentle traction Check Placenta for completeness

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17. Third Stage of Labor Recover missing pieces of placenta as necessary Massage uterus to aid in hemostasis IV Oxytocin can be given if available to aid uterine contractions and aid in hemostasis

18. Joint Special Operations Medical Training Center Neonatal Care Reassess Airway and Respirations Keep warm and dry Eye drops (1% silver nitrate or Neosporin) Allow for maternal bonding Stimulation of nipples during attempts at breastfeeding will aid in release of oxytocin by posterior pituitary gland resulting in uterine contraction and hemorrhage control

19. Joint Special Operations Medical Training Center APGAR Taken at 1 minute and 5 minutes after delivery Score of zero to two is given for each category The higher the score, the more vigorous and “healthy” the child is considered to be

20. Joint Special Operations Medical Training Center APGAR APPEARANCE: –2: Completely Pink –1: Hands and Feet are blue –0: Paleness and blue color over entire body PULSE: (most important sign) –2: Greater than 100 BPM –1: Detectable rate below 100 BPM –0: No heart rate detected

21. Joint Special Operations Medical Training Center APGAR GRIMACE: (flexing and muscle tone of limbs and resistance to straightening) –2: Normal muscle tone –1: Limp to normal muscle tone –0: No resistance to straightening ACTIVITY: (response to flicking of foot) –2: Infant cries in response to flick –1: Weak cry or head movement in response –0: No response

22. Joint Special Operations Medical Training Center APGAR RESPIRATORY: (Second most important) –2: Regular respirations and vigorous cry –1: Weak cry –0: No respiratory response Scoring: –7 to 10 provide supportive care –4 to 6 indicates moderate depression –< 4 requires aggressive resuscitation

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25. Emergency Birth Video

26. Joint Special Operations Medical Training Center SUMMARY First Stage of Labor Second Stage of Labor Third Stage of Labor APGAR

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