generally defined as the period between 3 cm to 4 cm to complete cervical dilatation, in the presence of regular uterine contractions

According to Zhang, active labor is probably closer to 5 cm.

-Can't be identified by objective means

-Don't begin labor with identical cervical anatomy

-Cervical exams vary

-Recognition of onset of active phase and second stage is variable

-Interventions 

-Maternal characteristics

-Limited to hospital birth

Increased vaginal deliveries

Decreased anesthesia, negative feelings about birth, labor length (1 hour), instrumental birth, c-section

-Sleeping: Best to lie on side, great idea to rest if a woman can.

-All fours, supported by a ball, pillows, partner, etc.

- in shower or tub - hydrotherapy can be fantastic for pain management and can help labor progress.  it can slow labor, too, so need to work with each woman individually.

• women in labor require 50-100kcal.hr to maintain adequate muscle function

• research firmly supports use of oral intake - both fluid and solids

• most women will take what they need, but some may need to be reminded

• prolonged labor may be both a cause and effect of dehydration and insufficient caloric intake - therefore focus on prevention

• non-acidic, easy to digest carb snacks and drinks (broth, electrolyte drinks, fruit, honey, toast

  
  

• Urine: laboring woman should void Q2hrs, light in color,

• Ketonuria: metabolizing stored fat - may indicate maternal compromise, but this is controversial

• Temp: slight rise is normal, but 0.5C or 1F and labor is prolonged it may indicate dehydration. Sig increase in temp >38C or 100.4F especially with ROM may signal infection

• Emesis: vomiting in labor is common, may increase risk of dehydration if fluid cannot be replaced

• Fluid loss through perspiration: if room is hot or in warm water - may need additional, may need to be reminded more to drink.  Offering - no pushing - fluids between contractions is better than asking her if she wants something to drink

• Maternal distress: IV may be necessary

Simpkin book says that a woman should void at least every 2 hours. The urine should be a clear straw color. Dark, concentrated urine is a sign of poor hydration status.

> or = to 30 mL/hr is standard

1. Obstructed Labor - The overdistended bladder can impede the progress of labor by preventing fetal descent.

1. Do the aniotomy btw contractions so that

a.The force behind the rupture is reduced

b.The membranes are not stretched tightly against the fetal head (which leaves too little room in which to safely grasp the membranes in order to tear them)

2. Use an instrument that will be effective quickly and easily.

To perform AROM (artificial rupture of membranes) put on a sterile glove. Place sterile gel over your two examining fingers. Gently place your fingers into the vagina and locate the cervix and the bag of water. Holding the amniohook in the hand opposite from the vaginal hand, slide the amniohook along your vaginal hand until it reaches the bag of water. Lift up with the end of the amniohook and pull the tip towards you to tear the membranes. Remove the amniohook gently as you cover the tip with your finger so as not to scratch the walls of the vagina.

3. After rupturing the membranes, leave your fingers in the vagina through the next contraction in order to

a. evaluate the effect of the amniotomy on the cervix(dilation) and on the fetus(descent

and rotation).

b. assure that there was no prolapse of the umbilical cord

1. Labor is in progress, as indicated by the presence of regular uterine contractions and observed changes in the cervix.

2. The cervix is at least 3cm dilated and effaced.

3. The head is fixed in the pelvis and applied to the cervix

4. The patient does not have active genital herpes simplex virus infection or have a high HIV viral load.

1. atypical or abnormal fetal heart rate

2. To detect the presence of meconium

3. To facilitate the use of an internal scalp electrode or an internal intrauterine pressure catheter.

4. To induce or augment labor

5. enables the condition of the amniotic fluid to be observed, especially detection of meconium.

1.

The reduction in amniotic fluid may increase compression of the cord and result in transient reduced blood flow to the fetus and abnormal FHR patterns.

2. Maybe slight increase in the risk of cesarean section

3. Maybe a risk of cord prolapse if performed when the presenting part is not well applied against the cervix or in cases of unstable lie of the fetus. Incidence 1 in 200-300 pregnancies.

4. uneven head compression with more extensive molding and caput succedaneum may increase the risk of intravascular hemorrhage, especially if membranes are ruptured early in labor.( First 4 are from Varney, 778)

5.Potential intrauterine infection if prolonged rupture of membranes results•

6.Rupture of vasa previa, previa•

7.Accidental cervical trauma•

8.Maternal discomfort

1. known vasa previa,

2.active genital Herpes Simplex

3.untreated HIV infection.

In the past midwives have performed amniotomy at 4-5cm to “speed up labor” for no reason other than to shorten the whole process for mother and attendants but now have moved away from this practice and only perform amniotomy late in labor and only if there is an indication

1. the pattern of contractions (duration and frequency)

2. the quality of contractions (through abdominal palpation)

3. the intensity of contractions (by assessing mother’s ability to cope)

4. changing location of fetal heart tones

1. On admission

2) before deciding on the kind, amount and route of any medication

3) to verify complete dilation in order to encourage or discourage pushing

4) after SROM if prolapsed cord is suspected or possible

5) to check for prolapsed cord when fetal heart rate decelerates and not improve

1. do a vag exam, and place fingers on the anterior lip where it touches the fetal head

2. during a contration, run your fingers back and for the the distance fo the junction of the anterior lip with the fetal head and push the lip backwards until it slips over the fetal head and above the inferior border of the SP

3. hold the lip in this position while waiting for the next contraction

4. continue to hold it in position and ask the woman to push down during the next contraction

5. allow your fingers, but not the cx, to be pushed downwards and out as the fetal head fills the space and presses against the inferior border of the SP

6. do not remove your fingers from the vagina until you are sure that the lip will remain in its new position during and between contractions.  Make sure to examine the cx for lacs after delivery of placenta.

• Sometimes prior to complete dilatation we see an uncontrollable urge to push when the fetal head is low in the pelvis or when the baby is in an OP position. Pushing against a cervix that is not fully dilated may lead to cervical edema and delayed progress, and/or cervical laceration.

• Try forward leaning positions. Forward leaning positions often help relieve some of the posterior pressure which is resulting in the urge to push. Examples of forward leaning positions: hands and knees, standing while leaning forward on the bed, kneeling at the foot of the bed, exaggerated Sims. See Simkin's book (p121) for pictures of these positions.

• Help Heather to focus on breathing with her contractions. It is difficult to breathe and push at the same time. How can you do this?

• If a position change doesn't work, try another one.

• If women are unable to stop pushing with breathing and position change and they have a ways to go in their labor (eg. progress has slowed, the cervix is edematous) consider IV narcotics or epidural.

• If women are unable to stop pushing with breathing and position change and the cervix is soft and stretchy, not swollen, and she is +1 station or greater, try gentle, short, pushes at the peak of contractions, just to relieve the urge. Check the cervix after a short while of doing this to make sure that the cervix is not swelling. Continue to encourage breathing and position change to assist with deferring pushing.

• Sometimes multiparas who are having a fast descent will begin involuntarily pushing at 8-9 cms. If the cervix is soft and stretchy, it often quickly retracts with the pressure of the push and the cervix changes quickly to complete. Again, just check the cervix and see how it's responding to the premature pushing

Engagement

Descent

Flexion

Internal rotation

Extension

Restitution

External rotation 

Expulsion

Gynecoid pelvis

-inlet

-mid pelvis

outlet

-prognosis for NSVD

-inlet: adequate

mid pelvis: adequate

-outlet: long

prognosis good

Android pelvis

-inlet

-mid pelvis

outlet

-prognosis for NSVD

-inlet: adequate

-mid pelvis: reduced

outlet: short

-prognosis for NSVD: poor

Anthropoid pelvis

-inlet

-mid pelvis

outlet

-prognosis for NSVD

-inlet: long

-mid pelvis: adequate

outlet: long

-prognosis for NSVD: good

platypelloid pelvis

-inlet

-mid pelvis

outlet

-prognosis for NSVD

-inlet: short 

-mid pelvis: shortened

outlet: short

-prognosis for NSVD: poor

Paired internal illiac arteries

Paired ovarian arteries

Medial sacral artery

Superior rectal artery

• 2 Frontal bones ( in the front)

• 2 Parietal bones ( on either side)

• 1 occipital bone ( in the back)

Frontal suture is located between the 2 frontal bones

Sagittal suture is between the 2 parietal bones

2 Coronal sutures are between teh front and parietal bones

2 lamboidal sutures are between the pareital and occipital bone

Formed by frontal, sagital, and coronal sutures.  

Dimond shaped

Bigger 

Bregma

Formed by sagital and lamboidal sutures

Triangle shaped

Smaller

suboccipitobregmatic diameter(9.5cm) from bregma  to occiput.

submentobregmatic diameter(9.5cm) from chin to anterior fontanel(bregma)

occipitomental diameter(aka verticomental)(12.5cm) from chin to posterior fontanel.

occipitofrontal(aka suboccipitofrontal) diameter(11.5cm) from brow to occiput.

Coming out crooked: 

Posterior Aceynctilism:

usual/normal

more common than synclitism and anterior

As head approaches the pelvis, the posterior parietal bone is lower than the anterior parietal bone, the sagittal suture is closer to the symphysis pubis than to the promontory of the scarum, and the biparietal diameter of the head is in an oblique relationship to the plane of the inlet.  

Anterior Asynctilism:

When woman’s abdominal muscles are lax and the abdomen is pendulous so that the uterus and baby fall forward or when the pelvis is abnormal and prevents the more common posterior asynctilism, the head enters the pelvis by anterior asynctilism. In this mechanism the anterior parietal bone descends first, the anterior parietal boss passes by the pubic symphysis into the pelvis, and the sagittal suture lies closer to the sacral promontory than to the pubic symphysis.  

arbitrarily chosen point on the presenting part of the fetus used in describing position.

occiput (with the vertex presentation)

frontum (brow presentation)

mentum (face presentation)

sacrum (breech presentation)

scapula or acromion (shoulder presentation).  

Right or left describes which side of the maternal pelvis the denominator is in.  Anterior, posterior , or transverse describe where the denominator is in relation to the front, back or side of the pelvis.

station

-5 = inlet

0 = isheal spines

+3 = crowning

engagement

When the biparietal diameter has passed through the pelvic inlet.The head enters the pelvis and engages with the sagittal suture in the oblique or transverse position and with the occiput right, left, anterior, posterior or transverse.

lie

the relationship of the long axis of the fetus to the long axis of the mother.  Longitudinal (parallel), transverse (perpendicular), oblique (this doesn’t last long, usually converts to longitudinal or transverse after a bit of labor.

presentation

- first part of the fetus to enter the pelvis.  cephalic, breech, shoulder (all transverse lies)

attitude

The relationship of fetal parts to each other and the effect this has on the vertebral column. The basic attitudes are flexion and extension.

• Flexion – The baby’s chin is near its chest. The posterior part of the vertex is the presenting part.

• Military – The head is neither flexed nor extended.

• Partial extension – The forehead (frontum) is the presenting part.

• Complete extension – The face is the presenting part.

(135 degrees): (aka Anterior rotation):

ROP to ROT to ROA to OA.  

Occurs in 90 percent of OP positions.  Baby is born OA.

• Vertex - The vertex presents when the fetal head is fully flexed; the chin is in contact with the thorax.

• Sincipital –The bregma (anterior fontanelle) presents when the fetal head is partially flexed. This is usually a transient presentation. Oxorn refers to this presentation as the median vertex presentation. Oxorn’s term is not commonly used.

• Brow – The brow presents when the fetal head is partially extended. This is usually a transient presentation.

• Face – The face presents when the head is fully extended; the occiput and back come in contact with each other and the face presents in the birth canal.

1. OA

2. LOA

3. LOT

4. LOP

5. OP

6. ROP

7. ROT

8. ROA

1. The examiner inserts two fingers into the vagina and the presenting part is found. Differentiation of vertex, face, and breech is then accomplished readily

2. If the vertex is presenting, the fingers are directed posteriorly and then swept forward over the fetal head toward the maternal symphysis (Fig. 17-9). During this movement, the fingers necessarily cross the sagittal suture and its course is delineated

3. The positions of the two fontanels then are ascertained. The fingers are passed to the most anterior extension of the sagittal suture, and the fontanel encountered there is examined and identified. Then, with a sweeping motion, the fingers pass along the suture to the other end of the head until the other fontanel is felt and differentiated (Fig. 17-10)

4. The station, or extent to which the presenting part has descended into the pelvis, can also be established at this time (seeCervical Examination). Using these maneuvers, the various sutures and fontanels are located readily (see Fig. 4-9).

   
   

False labor

Contractions do not increase in frequency, duration and intensity; they are irregular and of short duration; they are rarely intensified and may be relieved by walking; and they are usually felt in the lower abdomen and groin

True Labor

Contractions may start as irregular and of short duration but the become regular with increased frequency, duration, and intensity; they ARE intensified by walking,and they are usually felt as radiating across the uterus and lower back.

Once fetal well-being is assured and labor is ruled out, send the woman home with some suggested comfort measures. Soak in water, drink a hot drink and sleep. Involve family members in care with back rubs and assistance getting in and out of tub.

Who do we admit in labor?

• How do we define onset of labor:

• Regular uterine contractions that result in cervical change

• Cervical dilation

• Fetal well-being

• 20 minute strip w/2 accels with no decels (reactive strip), if not reactive in 20 minutes can go to 40 min

• Category 1 to send her home

• Maternal well-being

• VS

• Psychosocial (distress, ability to leave and come back, coping)

• Risk profile: comorbidities and complications

• Intact BOW

• GBS status (if positive should be admitted)

• Heb B antigen positive should be admitted and not sent home if ruptured

• Patient desire

• Parity

• History of precipitous birth

• Position of baby

  
  

Norms according to Friedman for latent phase

• 20 hours for nulips

• 14 hours for multips

• 1.2cm/hour for nul. (usually rounded to 1 cm/hour)

• 1.5 cm/hour for multips

• Usually not until later in labor

• Nulips descend at end of first stage

• Multips descend in 2nd stage

• Epidural

• GDM

• Dehydration

• Fetal tachycardia

• Maternal tachycardia

• Concern w/fetal heart rate

• Fever

• GBS

• Chorio

• Ketosis +2 or more ketones (diluted apple juice or 180 cc/hour of D5)

• Low platelets (under 50 thousand) - risk of general

• Worried about baby

• Epidural is NPO (ice chips--can sometimes get an order to override to clear liquids)

• Palpate above SP

• Pain in lower abdominal area

• Slowed descent

• Leaking urine with pushing

• Amount

• Color:

• Port wine red: abruption

• Fetal heart tones

• Note time

• Double check GBS status

• Inform nurse to chart

• Desire to push

• FHE, IUP

• Baseline

• Period of time w/o progress (after 3 hours)

• After an intervention (to see if it worked)

• Pooping desire

• Non reassuring FHT