2. Labor Labor is the physiologic process by which a fetus is expelled from the uterus to the outside world. It involves the sequential integrated changes in the uterine decidua, and myometrium. Changes in the uterine cervix tend to precede uterine contractions Dilatation: the enlarging of the cervix to 10 centimeters. Effacement: the thinning of the cervix. cervix starts out being two inches long, and 50% effaced would be a 1 inch cervix.

3. Cervical effacement and dilation

4. Labor - Mechanics  Uterine contractions have two major goals: 1. To dilate cervix 2. To push the fetus through the birth canal  Success will depend on the three P’s:  Powers  Passenger  Passage

5. Power Uterine contractions Power refers to the force generated by the contraction of the uterine myometrium Activity can be assessed by the simple observation by the mother, palpation of the fundus, or external tocodynamometry. Contraction force can also be measured by direct measurement of intrauterine pressure using internal manometry.

6. Power Generally 3-5 contractions in a 10 minute period is considered adequate labor

7. Passenger Passenger =fetus Fetal variables that can affect labor: Fetal Lie – the relationship of the long axis of the fetus to the long axis of the mother: longitudinal, transverse or oblique

8. Fetal size 40 weeks20.16 inches7.63 pounds51.2 cm3462 grams 41 weeks20.35 inches7.93 pounds51.7 cm3597 grams 42 weeks20.28 inches8.12 pounds51.5 cm3685 grams

9. Fetal presentation the part of the fetus that lies closest to or has entered the true pelvis. Cephalic presentations are vertex, brow, face, and chin. Breech presentations include frank breech, complete breech, incomplete breech, and single or double footling breech. Shoulder presentations are rare and require cesarean section or turning before vaginal birth. Compound presentation involves the entry of more than one part in the true pelvis,

10. Attitude – degree of flexion or extension of the fetal head A--Complete flexion. B-- Moderate flexion. C--Poor flexion. D--Hyperextension

11. Position - the relationship of the part of the fetus that presents in the pelvis to the four quadrants of the maternal pelvis, identified by initial L (left), R (right), A (anterior), and P (posterior). The presenting part is also identified by initial O (occiput), M (mentum), and S (sacrum) Number of fetuses Presence of fetal anomalies – hydrocephalus, sacrococcygeal teratoma

12. The Fetal Skull

13. Fetal Positions for Labor and Birth Left Occiput Anterior (LOA)

14. Left Occiput Transverse (LOT)

15. Left Occiput Posterior (LOP)

16. Right Occiput Anterior (ROA)

17. Right Occiput Transverse (ROT)

18. Right Occiput Posterior (ROP)

19. Leopold's Maneuvers

21. Station Station – degree of descent of the presenting part of the fetus, measured in centimeters from the ischial spines in negative and positive numbers. -5 is a floating baby, 0 station is said to be engaged in the pelvis, and +5 is crowning.

22. Passage Passage = Pelvis Consists of the bony pelvis and soft tissues of the birth canal (cervix, pelvic floor musculature) Small pelvic outlet can result in cephalopelvic disproportion Bony pelvis can be measured by pelvimetry but it not accurate and thus has been replaced by a clinical trial of labor

23. Passage

24. The Stages of Labor First Stage Interval between the onset of labor and full cervical dilation Two phases: Latent phase – onset of labor with slow cervical dilation to ~4 cm and variable duration Active phase – faster rate of cervical change, 1-1.2 cm /hour, regular uterine contractions

25. The Labor Curve First stage - A: latent phase; B + C + D: active phase; B: acceleration; C: maximum slope of dilation; D: deceleration; E: second stage.

26. Labor Freidman’s curve is a good guideline for expected progression in labor and therefore helpful to note abnormal labor patterns. LaborNulliGMultiG 1 st Stage Activephase Duration 6-18 h2-10 h Dilation ~1 cm/h~1.5 cm/h 2 nd Stage 0.5-3 h5-30 min 3 rd Stage 0-30 min

27. Fig 1: An idealized labor pattern. The normal patterns of cervical dilation (solid line) and descent (broken line) as they are traced against elapsed time in labor. The distinctive phases of the first stage are shown. The active phase comprises the interval from the onset of the acceleration phase to the beginning of the second stage.

28. Labor – Second Stage Interval between full cervical dilation to delivery of the infant. Characterized by descent of the presenting part through the maternal pelvis and expulsion of the fetus. Indications of second stage: 1. Increased maternal show 2. Pelvic/rectal pressure 3. Mother has active role of pushing to aid in fetal descent.

29. Labor – Second Stage Molding is the alteration of the fetal cranial bones to each other as a result of compressive forces of the maternal bony pelvis. Examining the fetal head during the second stage may become difficult due to molding Caput is the localized edematous area on the fetal scalp caused by pressure on the scalp by the cervix. PrimiG – 0.5-3 h; mulitG 0- 30min

30. Cardinal Movements of Labor This refers to the movements made by the fetus during the first and second stage of labor. As the force of the uterine contractions stimulates effacement and dilatation of the cervix, the fetus moves toward the cervix. When the presenting part reaches the pelvic bones, it must make adjustments to pass through the pelvis and down the birth canal

31. Seven distinct movements: 1. Engagement 2. Descent 3. Flexion 4. Internal rotation 5. Extension 6. External rotation/restitut ion 7. Expulsion

32. Descent: As the fetal head engages and descends, it assumes an occiput transverse position because that is the widest pelvic diameter available for the widest part of the fetal head.

33. Flexion: While descending through the pelvis, the fetal head flexes so that the fetal chin is touching the fetal chest. This functionally creates a smaller structure to pass through the maternal pelvis. When flexion occurs, the occipital (posterior) fontanel slides into the center of the birth canal and the anterior fontanel becomes more remote and difficult to feel. The fetal position remains occiput transverse.

34. Internal Rotation: With further descent, the occiput rotates anteriorly and the fetal head assumes an oblique orientation. In some cases, the head may rotate completely to the occiput anterior position

35. Extension: The curve of the hollow of the sacrum favors extension of the fetal head as further descent occurs. This means that the fetal chin is no longer touching the fetal chest.

36. External Rotation: The shoulders rotate into an oblique or frankly anterior-posterior orientation with further descent. This encourages the fetal head to return to its transverse position. This is also known as restitution.

37. Expulsion Delivery of the fetus After delivery of the fetal head, descent and intraabdominal pressure by mother brings shoulder to the level of the symphysis Downward traction allows release of the shoulder and the fetus is delivered.

38. Suctioning the nasopharynx Clamp the umbilical cord Cut between the clamps

39. Labor – Third Stage Placental separation and delivery. The time from fetal delivery to delivery of the placenta Signs of placental separation: a. The uterus becomes globular in shape and firmer. b. The uterus rises in the abdomen. c. The umbilical cord descends three (3) inches or more further out of the vagina. d. Sudden gush of blood.

40. Labor – Third Stage Placenta is delivered using one hand on umbilical cord with gentle downward traction. Other hand on abdomen supporting the uterine fundus. Risk factor for aggressive traction is uterine inversion. Obstetrical emergency!! Normal duration between 0-30 min for both PrimiG and MultiG

41. Inspect the placenta for completeness

43. Labor – Fourth Stage Refers to the time from delivery of the placenta to 1 hour immediately postpartum Blood pressure, uterine blood loss and pulse rate must be monitor closely ~ 15 minutes High risk for postpartum hemorrhage from: Uterine atony, retained placental fragments, unrepaired lacerations of vagina, cervix or perineum. Occult bleeding may occur – vaginal hematoma Be suspicious with increased heart rate, pelvic pain or decreased BP!!!!!!

44. Analgesia in labor Discomfort during Labor and Birth Pain and discomfort experienced during labor have two neurologic origins: visceral and somatic Neurologic origins Visceral pain: from cervical changes, distention of lower uterine segment, and uterine ischemia Located over the lower portion of abdomen Referred pain: originates in uterus, radiates to abdominal wall, lumbosacral area of back, iliac crests, gluteal area, and down the thighs Somatic pain : pain described as intense, sharp, burning, and well localized Stretching and distention of perineal tissues and pelvic floor to allow passage of fetus, from distention and traction on peritoneum and uterocervical supports during contractions, and from lacerations of soft tissue

45. Expression of pain Pain results in physiologic effects and sensory and emotional (affective) responses Emotional expressions of suffering often seen Increasing anxiety Writhing, crying, groaning, gesturing (hand clenching and wringing), and excessive muscular excitability Cultural expression of pain varies

46. Factors influencing pain response Physiologic factors Culture Anxiety Previous experience Childbirth preparation Comfort and support Environment

47. Distribution of labor pain A. Distribution of labor pain during first stage B. Distribution of labor pain during later phase of first stage and early phase of second stage C. Distribution of labor pain during later phase of second stage and during birth (Gray shading indicates areas of mild discomfort; light-colored shading indicates areas of moderate discomfort; dark-colored shading indicates areas of intense discomfort.)

48. Nonpharmacologic Management of Discomfort Nonpharmacologic measures often simple, safe, and inexpensive Provide sense of control over childbirth and measures best for woman Methods require practice for best results Try variety of methods and seek alternatives, including pharmacologic methods, if measure used is not effective

49. Nonpharmacologic Management of Discomfort Childbirth education Dick-Read method( recommended the need for education and his teaching method included lectures, exercise, and a focus on breathing and relaxation techniques. Lamaze method Bradley method Relaxing and breathing techniques Relaxation Imagery and visualization Music Touch and massage Breathing techniques Effleurage and counterpressure Water therapy (hydrotherapy) Transcutaneous electrical nerve stimulation

50. Pharmacologic Management of Discomfort Nerve block analgesia and anesthesia Local perineal infiltration anesthesia Prudendal nerve block Spinal anesthesia (block) Disadvantages Medication reactions (allergy) Hypotension Ineffective breathing Headache Autologous epidural blood patch Sedatives Analgesia and anesthesia Anesthesia Systemic analgesia Opioid agonist analgesics Opioid (narcotic) agonist– antagonist analgesics Co-drugs Ataractics Opioid (narcotic) antagonists

51. Pain Pathways and Sites of Pharmacologic Nerve Blocks A. Pudendal block; suitable during second and third stages of labor and for repair of episiotomy B. Epidural block; suitable during all stages of labor and for repair of episiotomy

52. Membranes and spaces of spinal cord and levels of sacral, lumbar, and thoracic nerves Membranes and spaces of spinal cord and levels of sacral, lumbar, and thoracic nerves Cross section of vertebra and spinal cord

55. Levels of Anesthesia Necessary for Cesarean and Vaginal Births Cesarean birth Vaginal birth

56. Administration of medication Intravenous route Intramuscular route Spinal nerve block Maternal fluid balance is essential during spinal and epidural nerve blocks Maternal analgesia or anesthesia potentially affects neonatal neurobehavioral response Use of opioid agonist-antagonist analgesics in women with preexisting opioid dependence may cause symptoms of abstinence syndrome (opioid withdrawal) General anesthesia rarely used for vaginal birth May be used for cesarean birth or when needed in emergency childbirth situation

57. Expected outcome of preparation for childbirth and parenting is “education for choice” Nonpharmacologic pain and stress management strategies are valuable for managing labor discomfort alone or in combination with pharmacologic methods Gate-control theory of pain and stress response are bases for many of the nonpharmacologic methods of pain relief Type of analgesic or anesthetic used is determined in part by stage of labor and method of birth

58. Regarding Labour: the latent phase may last for more than four hours the active phase should be associated with cervical dilatation at a rate of at least 1 cm. per hour the active phase starts when the cervix is effaced and 2 cm. dilated involves artificial rupture of the membranes is best charted using a partogram epidural anaesthesia has an adverse effect on the rate of progress in the 1st. stage of labour

59. the latent phase may last for more than four hours the active phase should be associated with cervical dilatation at a rate of at least 1 cm. per hour the active phase starts when the cervix is effaced and 2 cm. dilated involves artificial rupture of the membranes is best charted using a partogram epidural anaesthesia has an adverse effect on the rate of progress in the 1st. stage of labour TTFFTFTTFFTF

60. During delivery, what comes next after Engagement, Descent, and Flexion? 1. Internal Rotation. 2. Extension. 3. External Rotation. 4. Expulsion.

61. During delivery, what comes next after Engagement, Descent, and Flexion? 1. Internal Rotation. 2. Extension. 3. External Rotation. 4. Expulsion.

62. In Summary Know the different stages of labor Know the labor curve Know the cardinal movements of labor Know the causes of postpartum hemorrhage MD must understand medications, expected effects, potential adverse reactions, and methods of administration

63. Thank you for your attention!