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OBGYN: Normal labor and delivery
normal labor and delivery OBGYN
65
Anatomy
Graduate
09/08/2011

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Term
The first stage of labor is divided into the __ phase and the ___ phase. Define each of these:
Definition
- Latent phase: onset of regular contraction until dilated 3-5 cm, may last 14-20 hours
- Active phase: from 3-5 cm until 10 cm or pushing, contractions are closer together, cervical changes are more rapid
Term
So the first stage is until:
Definition
cervix is diated to 10 cm

latent phase first stage: dilation up to 3-5 cm
active phase first stage: dilation from 3-5 cm to 10 cm
Term
Characteristics of true labor:
Definition
Regular intervals
Intervals gradually shorten
Intensity gradually increases
Pain is in back and abdomen
Cervix dilates
Pain not stopped by sedation
Term
Characteristics of false labor:
Definition
Occur at irregular intervals
Intervals remain long
Intensity remains unchanged
Pain is mainly in lower abdomen
Cervix does not dilate
Pain is usually relieved by sedation
Term
Braxton Hix contractions: false labor contractions, abdomen hardens and gets tense but not real
Definition
Term
hallmark of true labor:
Definition
cervical changes
Term
During the active phase of the first stage of labor nulliparous women dialte ___ cm/hour so the active phase lasts about __ hours. The baby usually descends __cm/hour during this stage in nulliparous women.
Definition
- 1.2cm/hour
- 11.7 hours
- 1cm/hour
Term
In multiparas women during the active phase of labor their cervix usually dilates __cm/hour and the baby descends _cm/hour.
Definition
1.5 cm/hour
2 cm/hour
Term
3 main parts of vaginal exam during delivery:
Definition
- Dilation: of cervix
- Effacement: thinning of cervix
- Station: where baby is at
Term
Other factors of vaginal exam during labor:
Definition
Ruptured membranes
Bloody show
Fetal position / presenting part
Pelvimetry
Term
Station is the presenting part related to __ __. It is divided into fifths or thirds above and below. Engagement is at the __ __.
Definition
- ischial spines
- "0" station
Term
At the end of pregnancy, the pubic symphsysis and sacroiliac joints have increased in diameter.
Definition
Term
When doing vaginal exams during labor, use __ ___ __ lubricant. Avoid __ and ___ ___.
Definition
- sterile water soluble lubricant
- iodine and hexachlorophene antiseptics
Term
If ROM intentionally or not, check __ immediately and during next contraction to detect __ __ __.
Definition
- FHR
- occult cord compression

Vaginal exams are typically done every 2 hours when in labor
Term
If there is a question of ROM, insert a __ __ and observe for fluid in the __ __ __.
Definition
- sterile speculum
- posterior vaginal fornix
Term
Fetal lie is the relation of the __ __ of the fetus to that of the mother. Lie can be __, __, or ___. Oblique lie is unstable and usually becomes transverse or longitudinal during course of labor.
Definition
- long axis of the fetus to that of the mother
- longitudinal, transverse, or oblique
Term
Presenting part should be determined by __ or __. Longitudinal lie can have the head as the presenting part (__) or the legs or butt (__).
Definition
- physcal or ultrasound
- cephalic
- breech
Term
Incidence of presentations at term:
96% Cephalic
3.5% Breech (Preterm higher -14%)
0.3% Face
can deliver vaginal if mentum anterior (MA)
0.4% Shoulder
Definition
Term
Face vaginal deliveries can occur if ___ __.
Definition
mentum anterior (chin is up)
Term
Incidence of presentations at term:
96% Cephalic
3.5% Breech (Preterm higher -14%)
0.3% Face
can deliver vaginal if mentum anterior (MA)
0.4% Shoulder
Definition
Term
V-back= vaginal birth after a C-section. Vaginal birth after C-section carries a 1-2% chance of uterine rupture.
Definition
Term
Cephalic presentations:
Definition
- Vertex
- Sinciput
- Brow aka Military
- Face
Term
Different Breech presentations:
Definition
- Complete breech(Indian Style)
- Incomplete breech aka Footling
- Frank Breech: flexed at thighs, extended at knees
Term
Position is the relation of an arbitrarily chosen portion of the fetal __ __ to the __ or __ side of the __ __ __ .
Definition
- presenting part to the right or left side of the maternal birth canal
Term
look at slides 23-26 of normal labor powerpoint to see picture examples of position
Definition
Term
occiput posterior is much harder labor
Definition
Term
Leopold’s maneurver: hand maneuvers on belly to feel position of baby and about how much it weighs

With posterior positition can feel lots of lumps and bumps b/c face and elbows up. Also harder to find heart beats when baby is in posteior position.
Definition
Term
It is just as accurate to estimate fetal weight with leopolds as a sonogram is
Definition
Term
7 cardinal movements of labor, these occur in sequential order:
Definition
1. Head floating before enagagement
2. Engagement, flexion and descent
3. Further descent, internal rotation
4. Complete rotation, beginning extension
5. Complete extension
6. Restitution (external rotation)
7. Delivery of anterior shoulder
8. Delivery of posterior shoulder
Term
3 methods to monitor fetal heart rate:
Definition
- doppler
- continuous external fetal monitoring
- scalp electrode
Term
Doppler measures it intermittently.
Continuous fetal monitioring: has increased C-section rate but has not improved fetal outcomes, so you have just restricted the woman to the bed
ACOG monitors doppler every 30 minutes and then lets lady walk around instead of being on bed. Then monitor it every 15 minutes during 2nd stage.

Continuous monitoring can be external or internal (in baby’s scalp)
Definition
Term
ACOG recommends during 1st stage of labor, in absence of any abnormalities, FHR may be checked:
Definition
- at the end and immediately after contraction at least every 30 minutes
- every 15 minutes during the second stage of labor
Term
Whats the difference b/w internal and external monitoring?
Definition
- external just measures frequency of contraction, NOT intensity
- internal measures frequency and intensity
Term
If risk factors are present, what type of fetal monitoring should be done?
Definition
continuous electronic fetal monitoring
Term
what maternal things should you evaluate during active labor
Definition
maternal temperature and pulse
Term
Ruptured membranes
Definition
If presenting part is not fixed in pelvis, risk of cord prolapse
Labor is likely to occur soon if pregnancy is at or near term appx 90% at 24 hours
If delivery is significantly delayed, increasing likelihood of intrauterine infection
Term
Like to keep water intct until about 4 cm, b/c risk of prolapsed cord. Membranes rupture too early> cord falls down> head puts pressure on cord (so have to put hand up there and keep babies head off cord).

Don’t like water to be broken too long> increased risk of infections.
Definition
Term
Amniotomy is when you intentionally break a pregnant woman's water. The technique involves perforation of ___ membranes (AROM).
Definition
choriamniotic
Term
advantages of AROM:
Definition
- high success rate for stimulating labor
- assess amniotic fluid for blood or meconium
- access for internal monitoring
Term
If baby has meconium fluid in sac have NICU in there to suck out meconium. You don’t want baby to aspirate meconium> pulmonary hypertension.
Definition
Term
Amniotomy:
Definition
Vertex should be well applied
Vaginal exam to evaluate dilitation and station
Amnihook is passed through cervical canal across examining hand between fingers and a gentle hooking motion
Membranes retracted over vertex by blunt dissection with examining finger
Term
If they get an epidural> have to be in bed and continuously monitored. But still can get on heads and knees with epidural in bed. Hands and knees can help the baby get into right position.
Definition
Term
Pain relief during labor:
Definition
Non-pharmacological
IV sedation
Meperidine
Butorphanol
Anesthesia
Pudendal
Spinal
Epidural
Term
Person at your bedside can be as effective as 50 mg pain demural.
Definition
Term
Used to wait 4 cm until epidural, but sense then studies have been done saying epidural can be given at 1 cm and its fine. Spinal doesn’t last as long epidural.
Definition
Term
Bladder distention in labor:
Definition
Can lead to obstructed labor
Consider bladder distention if patient not progressing, station remains high, no relief from pain meds
Always allow patient to attempt to void on her own

May have to have a folley cath to empty bladder
Term
Management of second stage:
Definition
Complete dilation of cervix
Woman will have urge to push if no anesthesia
Contractions may last 1 ½ minutes and recur after resting phase of no more than 1 minute
Term
Side to push: optimal for baby’s heart beat b/c not as much stress on baby, decreases amount of vaginal tearing also.
Definition
Term
Duration of second stage:
Definition
Nulliparas is 50 minutes
Multiparas is 20 minutes
Nulliparas with epidural are given 3 hours/without epidural 2 hours
Multips with epidural 2 hours/ without epidural 1 hour
May vary from patient to patient
Term
Bearing down is reflex and spontaneous
Squatting position has been associated with shortened second stage
In preparation for delivery, take care not to separate legs too widely or place one leg higher than other
Definition
Term
Ferguson's reflex:
Definition
without the epidural> bearing down to get baby out
Term
Crowning is when the largest diameter of fetal head reaches the the __ __.
Definition
vulvar ring
Term
Episiotomy

Should not be used routinely but selectively for fetal indications such as:
Fetal distress to facilitate delivery
Breech
Forceps, vacuum
Shoulder dystocia
Has been reported to increase risk of anal sphincter lacerations
Definition
Term
Ritgen maneuver:
Definition
foward pressure to fetal chin through perineum superiorly against coccyx while other hand supports fetal head at symphysis
Term
Most often shoulders appear at vulva- grasp both sides of head and apply gentle downward pressure
Definition
Term
After delivery of anterior shoulder, check for cord
Nuchal cord: Occurs in about 25% of deliveries
If unable to reduce, can be clamped and cut but deliver quickly after
Definition
Term
Delayed cord clamping:
Definition
Increased ferritin levels in neonate up to 6 months
Antibody transfer
Stem Cell Transfer
Hyperbilirubinemia
phototherapy
Term
Management of Third stage of labor:

Signs of placental separation:
Definition
- uterus rises in the abdomen
- sudden gush of blood
- umbilical cord protrudes from the vagina
Term
Third stage of labor is:
Definition
delivery of placenta
Term
What is the highest risk stage of labor?
Definition
3rd stage
THIS IS THE STAGE THE HEMORRHAGE OCCURS.

If the mom is bleeding a lot, have to get placenta out.
DON'T FORCE THE PLACENTA OUT> CAN INVERT THE UTERUS
Term
Third stage continued :
Definition
Placental expression should never be forced
Excessive traction on umbilical cord can result in uterine inversion which is an obstetrical emergency
Apply gentle pressure to abdomen while keeping cord taut
In the absence of excessive bleeding, there is no absolute time manual removal
Term
After placenta is delivered have to do a uterine massage to make uterus contract down. Most common time for uterine atony is right after delivery of placenta.
Definition
Term
when does uterine atony usually occur?
Definition
third stage, right after delivery of placenta
Term
Apply firm uterine massage FIRST!
Examine placenta for completeness and anomalies
“Fourth Stage” is the critical hour immediately following delivery. Most common time for uterine atony.
Vasoconstriction by contracted myometrium is primary mechanism of placental site hemostasis
Definition
Term
Oxytocin for third stage:
Definition
Given diluted in IV fluid
Half-life 3 min
Hypotension is side effect of IV bolus. May give IM if no IV access
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