OBGYN - Normal and Abnormal Labor

From Iusmicm

(Difference between revisions)
(Created page with '=Labor: Normal, Abnormal, and Points Between= ==Definitions== *Labor: regular / rhythmic contractions, cervical dilation and effacement. **Labor is considered "preterm" if it co…')
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**Positive = >50% UC’s with late decelerations
**Positive = >50% UC’s with late decelerations
**Equivocal = intermittent or late decelerations or significant variable decelerations
**Equivocal = intermittent or late decelerations or significant variable decelerations
-
 
=====Decelerations=====
=====Decelerations=====
*Early declerations: occur with cntx
*Early declerations: occur with cntx
 +
**'''Non worrisome'''
**Head compression leads to vagal stimulation
**Head compression leads to vagal stimulation
**Recall that vagus carries parasympathetics to the heart
**Recall that vagus carries parasympathetics to the heart
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*Variable Decelerations: mild, moderate, and severe.
*Variable Decelerations: mild, moderate, and severe.
 +
**Lower the blood pressure the more severe.
 +
**Longer the duration the more severe.
 +
**'''Severity of variable decelerations are a function of blood pressure and duration'''
====Sinusoidal====
====Sinusoidal====
-
*Fetal Lie, Presentation, Attitude, and Position
+
 
 +
===Fetal Lie, Presentation, Attitude, and Position===
*Clinical: abd palpation, auscultation of fht’s, vaginal exam
*Clinical: abd palpation, auscultation of fht’s, vaginal exam
*Studies: u/s, x-ray, MRI
*Studies: u/s, x-ray, MRI
-
===Definitions===
+
====Definitions====
-
*Lie: relation of long axis of fetus to long axis of mother
+
*'''Lie: relation of long axis of fetus to long axis of mother'''
**Longitudinal
**Longitudinal
**Transverse
**Transverse
Line 89: Line 93:
-
*Presentation: part foremost in the pelvis
+
*'''Presentation: part foremost in the pelvis'''
**Cephalic
**Cephalic
**Breech
**Breech
**Shoulder
**Shoulder
-
 
+
**'''Compound:'''
-
 
+
-
*Other Presentations:
+
-
**Compound
+
***Head / hand -> watch
***Head / hand -> watch
***Head / foot-> c-section
***Head / foot-> c-section
-
 
-
 
*Cord prolapse (funic presentation): an '''emergency'''.
*Cord prolapse (funic presentation): an '''emergency'''.
-
*Attitude: folded on itself w/ flexed head
+
*'''Attitude: folded on itself w/ flexed head'''
-
**extension of head
+
**extension of head?
-
*Position: relation of presenting part to maternal pelvis
+
*'''Position: relation of presenting part to maternal pelvis'''
**Cephalic -> occiput
**Cephalic -> occiput
**Face -> mentum
**Face -> mentum
Line 116: Line 115:
====Fetal Attitude====
====Fetal Attitude====
*There are a variety of ways the fetus can present at the os; these are called attitudes:
*There are a variety of ways the fetus can present at the os; these are called attitudes:
-
**Full flexion
+
**Full flexion (A)
-
**Military attitude
+
**Military attitude (B)
-
**brow presentation
+
**Brow presentation (C)
-
**face presentation
+
**Face presentation (D)
 +
http://www.glowm.com/resources/glowm/graphics/figures/v2/0760/001f.gif
-
*Leopold’s Maneuver can be used to reposition the fetus into another attitude.
+
*Leopold’s Maneuver can be used to determine the attitude of the fetus.
 +
http://www.sciencephoto.com/image/288555/350wm/M8000133-Leopold_s_Maneuver-SPL.jpg
====Vaginal Exam====
====Vaginal Exam====
-
 
+
*Nullip versus Multip
-
*Nullip Multip
+
-
�
+
-
Vaginal
+
-
Exam
+
-
stations fetal head.jpg 000138B4 Macintosh HD BB8E171A:
+
-
Station
+
-
�
+
-
Vaginal Exam (Position)
+
-
bones fetal head.jpg 000138B4 Macintosh HD BB8E171A:
+
-
fetal position.jpg 000138B4 Macintosh HD BB8E171A:
+
-
�
+
-
Vaginal Exam (Pelvimetry)
+
-
pelvic inlet.jpg 000138B4 Macintosh HD BB8E171A:
+
-
transverse diameter.jpg 000138B4 Macintosh HD BB8E171A:
+
-
Diagonal Conjugate
+
-
Ischial Spines
+
-
�
+
-
Vaginal Exam – Pelvic Inlet
+
-
. Diagonal conjugate
+
-
>11.5 cm = adequate
+
-
. Diagonal conjugate – 1.5
+
-
to 2.0 cm = True
+
-
Obstetric conjugate
+
-
 
+
-
 
+
-
 
+
-
DiagonalConjugate
+
-
�
+
-
Vaginal Exam - Midpelvis
+
-
. Ischial spines – blunt vs.
+
-
prominent
+
-
. Pelvic sidewalls
+
-
. Parallel = OK
+
-
. Divergent = good
+
-
. Convergent = bad
+
-
 
+
-
 
+
-
 
+
-
. Sacrum – hallow vs.
+
-
shallow (flat)
+
-
 
+
-
 
+
-
 
+
-
ProminenceoftheSpines
+
-
�
+
-
Vaginal Exam – Pelvic Outlet
+
-
. Bituberous diameter >6-
+
-
8 cm
+
-
. Pubic arch >90 degrees
+
-
 
+
-
 
+
-
 
+
-
TransverseOutlet
+
-
�
+
-
Stages of Labor
+
-
. 1st- beginning of cervical dilation to
+
-
complete dilation
+
-
. 2nd- complete dilation to delivery of
+
-
fetus
+
-
. 3rd- delivery of placenta (up to 30 min.)
+
-
. 4th- first hour after delivery of placenta
+
-
 
+
-
 
+
-
 
+
-
�
+
-
Cardinal Movements
+
-
of Labor
+
-
. Engagement
+
-
. Flexion
+
-
. Descent
+
-
. Internal rotation
+
-
. Extension
+
-
. External rotation
+
-
. Expulsion
+
-
 
+
-
 
+
-
+
-
cardinal.jpg 000138B4 Macintosh HD BB8E171A:
+
-
�
+
-
Labor Curve
+
-
scan1.jpg 000138B4 Macintosh HD BB8E171A:
+
-
�
+
-
Prolonged/Arrested Labor
+
-
. Power- uterine contractions
+
-
. Pelvis- ?adequate
+
-
. Passenger- EFW, position/attitude
+
-
 
+
-
 
+
-
 
+
-
�
+
-
Dysfunctional Labor
+
-
Pattern
+
-
 
+
-
Nullip
+
-
 
+
-
Multip
+
-
 
+
-
Rx
+
-
 
+
-
Prolonged
+
-
latent phase
+
-
 
+
-
>20 hr
+
-
 
+
-
>14 hr
+
-
 
+
-
Rest, AROM,
+
-
Pit
+
-
 
+
-
Protracted
+
-
dilation
+
-
 
+
-
<1.2 cm/hr
+
-
 
+
-
<1.5 cm/hr
+
-
 
+
-
AROM, Pit
+
-
 
+
-
Protracted
+
-
descent
+
-
 
+
-
<1 cm/hr
+
-
 
+
-
<2 cm/hr
+
-
 
+
-
Pit
+
-
 
+
-
Arrest of
+
-
dilation
+
-
 
+
-
>2 hr
+
-
 
+
-
>2 hr
+
-
 
+
-
AROM, Pit, C/S
+
-
 
+
-
Arrest of
+
-
descent
+
-
 
+
-
>2 hr
+
-
 
+
-
>1 hr
+
-
 
+
-
Vacuum,
+
-
forceps, C/S
+
-
 
+
-
 
+
-
 
+
-
�
+
-
Cesarean Section
+
-
. History
+
-
. Caedere->caesura = to cut; seco = to cut
+
-
. Francois Rousset (1581)
+
-
. Max Sanger (1882)- Leipzig
+
-
 
+
-
 
+
-
 
+
-
. Most common surgical procedure
+
-
. 1965 <5%, 1996 - 20.7%, 2004 - 29.1%
+
-
. No change in cerebral palsy rate
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
-National Center for Health Studies
+
-
�
+
-
C-section - Techniques
+
-
uterine incision.jpg 000138B4 Macintosh HD BB8E171A:
+
-
�
+
-
C-section - Indications
+
-
. Fetal
+
-
. Distress/intolerance of labor
+
-
. Malpresentation (breech, transverse)
+
-
. Twins, multiples
+
-
. Vtx/Vtx = allow to labor
+
-
 
+
-
 
+
-
 
+
-
. Some congenital anomalies
+
-
. NTD
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
�
+
-
C-sections – Indications
+
-
(cont.)
+
-
. Maternal-Fetal
+
-
. Arrest of active labor
+
-
. Failed induction of labor (?)
+
-
. Placenta previa, vasa previa
+
-
. Active HSV outbreak
+
-
. HIV+ (viral load >1000/ml)
+
-
. EFW >4500 - 5000 gms (increasing risk of
+
-
shoulder dystocia)
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
�
+
-
C-section – Indications (cont.)
+
-
. Maternal
+
-
. Obstructive tumors (some leiomyomas)
+
-
. Severe condylomata acuminata
+
-
 
+
-
 
+
-
 
+
-
. Cervical cancer
+
-
. Abdominal cerclage
+
-
. Prior c-section
+
-
. Prior vaginal colporrhaphy
+
-
. Vaginal delivery contraindicated medically
+
-
. Pregnant ???
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
�
+
-
C-section - Risks
+
-
. At time of surgery/Immediate post-op
+
-
. Infection- endometritis, wound infection,
+
-
Septic pelvic thrombophlebitis (SPT)
+
-
. Bleeding- transfusion, hysterectomy
+
-
. Damage to fetus
+
-
. Damage to adjacent organs
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
�
+
-
C-section – Risks (cont.)
+
-
. Subsequent pregnancy
+
-
. Uterine rupture
+
-
. Placenta previa->accreta
+
-
. 0 –> 5%
+
-
. 1 –> 24%
+
-
. 2 –> 48%
+
-
. 3 –> 67%
+
-
 
+
-
 
+
-
 
+
-
. Adhesions
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
�
+
-
Operative Vaginal
+
-
Delivery
+
-
. Forceps
+
-
and
+
-
vacuum
+
-
 
+
-
 
+
-
+
-
forceps.jpg 000138B4 Macintosh HD BB8E171A:
+
-
�
+
-
Classification of Delivery
+
-
. Outlet- scalp visible at introitus w/out
+
-
separating labia. No rotation
+
-
. Low- leading point of skull at or below
+
-
+2 cm station
+
-
. Rotate < 45°
+
-
. Rotate > 45°
+
-
 
+
-
 
+
-
 
+
-
. Mid- above +2 cm station but engaged
+
-
 
+
-
 
+
-
 
+
-
�
+
-
Indications for Operative Vaginal
+
-
Delivery
+
-
. Nonreassuring FHT’s
+
-
. Prolonged 2nd stage of labor
+
-
. Shortened 2nd stage if pushing/Valsalva
+
-
not indicated
+
-
. Maternal exhaustion
+
-
 
+
-
 
+
-
 
+
-
�
+
-
Prerequisites for Operative
+
-
Vaginal Delivery
+
-
. Cervix completely dilated
+
-
. Ruptured membranes
+
-
. Fetal skull engaged in pelvis
+
-
. Empty bladder
+
-
. Position! Position! Position!
+
-
. Adequate pelvis
+
-
. Adequate anesthesia
+
-
 
+
-
 
+
-
 
+
-
�
+
-
Forceps Assisted Vaginal Delivery
+
-
hrphysioL08
+
-
�
+
-
Risks of Operative Vaginal
+
-
Delivery
+
-
. Maternal
+
-
. Vaginal/perineal trauma, damage to rectal
+
-
sphincter
+
-
 
+
-
 
+
-
 
+
-
. Fetal
+
-
. Cephalohematoma
+
-
. Subgaleal hemorrhage
+
-
. Bony facial trauma
+
-
. Facial nerve injury
+
-
. Intraventricular hemorrhage
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
 
+
-
�
+
-
Birth Trauma
+
-
. Caput succedaneum
+
-
. Very common
+
-
. Crosses midline
+
 +
*Station:
-
. Subgaleal
 
-
hemorrhage
 
-
. Rare
 
-
. Hypovolemia and
 
-
DIC
 
 +
*Position:
 +
*Pelvimetry:
 +
**Diagonal Conjugate
 +
**Ischial Spines
 +
=====Pelvic Inlet=====
 +
*Diagonal conjugate: >11.5 cm is adequate
 +
*True obstetric conjugate = diagonal conjugate – 1.5 to 2.0 cm
 +
=====Midpelvis=====
 +
*Ischial spines – blunt vs. prominent
 +
*Pelvic sidewalls
 +
**Parallel = OK
 +
**Divergent = good
 +
**Convergent = bad
 +
*Sacrum – hallow vs. shallow (flat)
-
2925
+
=====Pelvic Outlet=====
-
vacuum-fig1
+
*Bituberous diameter > 6-8 cm
-
�
+
*Pubic arch > 90 degrees
-
Common Post Partum
+
-
Problems
+
-
. PP Hemorrhage- >500cc (>1000cc for
+
-
c/s)
+
-
. Atony
+
-
. Lacerations (cervix, vagina, perineum)
+
-
. Retained placenta
+
-
. Uterine rupture
+
-
. Uterine inversion
+
-
. Amniotic fluid embolism
+
 +
===Stages of Labor===
 +
*1st Stage: beginning of cervical dilation to complete dilation
 +
*2nd Stage: complete dilation to delivery of fetus
 +
*3rd Stage: delivery of placenta (up to 30 minutes)
 +
*4th Stage: first hour after delivery of placenta
 +
===Cardinal Movements of Labor====*Engagement
 +
*Flexion
 +
*Descent
 +
*Internal rotation
 +
*Extension
 +
*External rotation
 +
*Expulsion
 +
===Labor Curve===
 +
Interpret chart
 +
===Prolonged / Arrested Labor===
 +
*'''P'''ower: uterine contractions
 +
*'''P'''elvis: adequate?
 +
*'''P'''assenger: EFW, position / attitude
 +
===Dysfunctional Labor===
 +
{|border=1
 +
!Pattern
 +
!Nullip
 +
!Multip
 +
!Rx
 +
|-
 +
!Prolonged latent phase
 +
|>20 hr
 +
|>14 hr
 +
|Rest, AROM, Pit
 +
|-
 +
!Protracted dilation
 +
|<1.2 cm/hr
 +
|<1.5 cm/hr
 +
|AROM, Pit
 +
|-
 +
!Protracted descent
 +
|<1 cm/hr
 +
|<2 cm/hr
 +
|Pit
 +
!Arrest of dilation
 +
|>2 hr
 +
|>2 hr
 +
|AROM, Pit, C/S
 +
|-
 +
!Arrest of descent
 +
|>2 hr
 +
|>1 hr
 +
|Vacuum, forceps, C/S
 +
|}
-
�
+
===Cesarean Section===
-
PP Problems (cont.)
+
*History
-
. Endometritis- Fundal tenderness w/
+
**''Caedere -> caesura'': to cut; ''seco'': to cut.
-
T>38°C x 2 or >38.5°C
+
**Francois Rousset (1581)
-
. Polymicrobial infection
+
**Max Sanger (1882)- Leipzig
-
. More common after c/s
+
*Most common surgical procedure
-
. Prolonged ruptured membranes
+
**1965 <5%, 1996 - 20.7%, 2004 - 29.1%
-
. chorioamnionitis
+
**No change in cerebral palsy rate
 +
====C-section - Techniques====
 +
*Uterine Incisions:
 +
**Low transverse
 +
**Low verticle
 +
**Classical
 +
**Kerr
 +
====C-section - Indications====
 +
=====Fetal C-section Indications=====
 +
*Distress / intolerance of labor
 +
*Malpresentation (breech, transverse)
 +
*Twins, multiples
 +
**Vtx / Vtx = allow to labor
 +
*Some congenital anomalies
 +
**NTD
 +
=====Maternal-Fetal C-section Indications=====
 +
*Arrest of active labor
 +
*Failed induction of labor (?)
 +
*Placenta previa, vasa previa
 +
*Active HSV outbreak
 +
*HIV+ (viral load >1000/ml)
 +
*EFW > 4500 - 5000 gms (increasing risk of shoulder dystocia)
 +
=====Maternal C-section Indications=====
 +
*Obstructive tumors (some leiomyomas)
 +
*Severe condylomata acuminata
 +
*Cervical cancer
 +
*Abdominal cerclage
 +
*Prior c-section
 +
*Prior vaginal colporrhaphy
 +
*Vaginal delivery contraindicated medically
 +
*Pregnant???
 +
====C-section - Risks====
 +
*At time of surgery / Immediate post-op
 +
*Infection: endometritis, wound infection, septic pelvic thrombophlebitis (SPT)
 +
*Bleeding: transfusion, hysterectomy
 +
*Damage to fetus
 +
*Damage to adjacent organs
 +
*Subsequent pregnancy
 +
**Uterine rupture
 +
**Placenta previa -> accreta
 +
***0 –> 5%
 +
***1 –> 24%
 +
***2 –> 48%
 +
***3 –> 67%
 +
**Adhesions
 +
===Operative Vaginal Delivery===
 +
*Forceps and vacuum
 +
====Operative Vaginal Delivery - Classification====
 +
*Outlet: scalp visible at introitus w/out separating labia; no rotation
 +
*Low: leading point of skull at or below +2 cm station
 +
**Rotate < 45°
 +
**Rotate > 45°
 +
*Mid: above +2 cm station but engaged
-
�
+
====Operative Vaginal Delivery - Indications====
-
PP/Post-Op Fever
+
*Nonreassuring FHT’s
-
. Wind
+
*Prolonged 2nd stage of labor
-
. Wound
+
*Shortened 2nd stage if pushing / Valsalva not indicated
-
. Water
+
*Maternal exhaustion
-
. Walk
+
-
. Wonder drug
+
-
. Womb
+
-
. Wean
+
 +
====Operative Vaginal Delivery - Prerequisites====
 +
*Cervix completely dilated
 +
*Ruptured membranes
 +
*Fetal skull engaged in pelvis
 +
*Empty bladder
 +
*Position! Position! Position!
 +
*Adequate pelvis
 +
*Adequate anesthesia
 +
====Operative Vaginal Delivery - Forceps Assisted====
-
. Atelectasis, pneu
+
====Operative Vaginal Delivery - Risks====
-
. Seroma, nec. Fasc.
+
*Maternal:
-
. UTI
+
**Vaginal / perineal trauma, damage to rectal sphincter
-
. Thrombophlebitis
+
*Fetal:
-
. Drug rxn
+
**Cephalohematoma
-
. Endometritis
+
**Subgaleal hemorrhage
-
. Mastitis,
+
**Bony facial trauma
-
engorgement
+
**Facial nerve injury
 +
**Intraventricular hemorrhage
 +
===Birth Trauma===
 +
*Caput succedaneum:
 +
**Very common
 +
**Crosses midline
 +
*Subgaleal hemorrhage:
 +
**Rare
 +
**Hypovolemia and DIC
 +
===Common Post Partum Problems===
 +
*PP Hemorrhage: >500cc (>1000cc for c/s):
 +
**Atony
 +
**Lacerations (cervix, vagina, perineum)
 +
**Retained placenta
 +
**Uterine rupture
 +
**Uterine inversion
 +
**Amniotic fluid embolism
 +
*Endometritis:
 +
**Fundal tenderness w/ temperature >38°C x 2 or >38.5°C
 +
**Polymicrobial infection
 +
**More common after c/s
 +
***Prolonged ruptured membranes
 +
***Chorioamnionitis
-
�
+
====PP / Post-Op Fever====
 +
*Causes and symptoms
 +
**Wind (atelectasis, pneumonia)
 +
**Wound (seroma, necrotizing fasciitis)
 +
**Water (UTI)
 +
**Walk (thrmobophlebitis)
 +
**Wonder drug (drug reaction)
 +
**Womb (endometriosis)
 +
**Wean (mastitis, engorgement)

Revision as of 20:52, 14 December 2011

Contents

Labor: Normal, Abnormal, and Points Between

Definitions

  • Labor: regular / rhythmic contractions, cervical dilation and effacement.
    • Labor is considered "preterm" if it commences before 37 weeks EGA (estimated gestational age)
    • 10-12% of pregnancies include preterm labor.
    • Labor is considered "postdates" if it commences after 42 weeks EGA.
  • Braxton Hicks contractions are contractions of a weak or irregular nature.

Physiology of Labor

  • There are many factors that play a role in the coordinated contraction of all the uterine smooth muscle for labor.
  • Progesterone and Relaxin are key regulating factors in animals.
    • 17alpha-hydroxyprogesterone caproate
  • Gap juctions of the uterine smooth muscle are increased near term.
    • Presumably to augment myofiber-myofiber communication for a well sequenced contraction.
  • Oxytocin, surprisingly, shows no change in blood levels.
    • Oxytocin receptors, however are elevated. 
**Furthermore, there is elevated decidual production.
  • Several prostaglandins are elevated for labor: PGE1, PGE2, PGF2alpha
  • Mother becomes more sensitive to changes in Ca at term.
    • This is presumably because the uterine muscle is storing up more and more Ca to augment contraction.
  • Like prostaglandins, many cytokines are elevated: IL-1, IL-6, IL-8, TNF-alpha.

Labor and Delivery Admission

  • The workup for a L&D admission includes:
    • H&P
    • Fetal monitoring
    • Leopold’s maneuver
    • Vaginal exam
      • R/o (rule out) placenta previa and ROM first
      • Cervical dilation / effacement / station and fetal position

Fetal Monitoring

  • There are several technical methods for fetal monitoring.
  • With fetal monitoring we are concerned with the baby's heart rate and the uterine pressure.


  • For baby's heart rate, the baseline should be around 120-160 bpm.
  • We are looking for: variability, accelerations / decelerations


  • For uterine pressure (contractions) we are looking for: frequency, duration, uterine tone.

Variability and Accelerations / Decelerations

  • Variability:
    • Absent: 0-2 bpm
    • Minimal: 3-5 bpm
    • Moderate: 6-25 bpm
    • Marked: saltatory, >25 bpm


  • Fetal Monitoring:
    • Accelerations- “15 x 15”


  • Reactive fetal heart tracing (nonstress test)
    • 2 accelerations in 20 minutes or less


  • Contraction stress test (Oxytocin challenge test)
    • 3 UC’s x 40 sec in 10 mins
    • Negative = no decelerations
    • Positive = >50% UC’s with late decelerations
    • Equivocal = intermittent or late decelerations or significant variable decelerations
Decelerations
  • Early declerations: occur with cntx
    • Non worrisome
    • Head compression leads to vagal stimulation
    • Recall that vagus carries parasympathetics to the heart
  • Late decelerations: begin at peak of cntx or after
    • Fetal hypoxia is usually the culprit of late decelerations.
  • Variable: can occur at any time
    • Variable decelerations should raise one's suspicion for cord compression


  • Variable Decelerations: mild, moderate, and severe.
    • Lower the blood pressure the more severe.
    • Longer the duration the more severe.
    • Severity of variable decelerations are a function of blood pressure and duration

Sinusoidal

Fetal Lie, Presentation, Attitude, and Position

  • Clinical: abd palpation, auscultation of fht’s, vaginal exam
  • Studies: u/s, x-ray, MRI

Definitions

  • Lie: relation of long axis of fetus to long axis of mother
    • Longitudinal
    • Transverse
    • Oblique


  • Presentation: part foremost in the pelvis
    • Cephalic
    • Breech
    • Shoulder
    • Compound:
      • Head / hand -> watch
      • Head / foot-> c-section
  • Cord prolapse (funic presentation): an emergency.


  • Attitude: folded on itself w/ flexed head
    • extension of head?


  • Position: relation of presenting part to maternal pelvis
    • Cephalic -> occiput
    • Face -> mentum
    • Breech -> sacrum
    • Transverse -> acromion process

Fetal Attitude

  • There are a variety of ways the fetus can present at the os; these are called attitudes:
    • Full flexion (A)
    • Military attitude (B)
    • Brow presentation (C)
    • Face presentation (D)

001f.gif


  • Leopold’s Maneuver can be used to determine the attitude of the fetus.

M8000133-Leopold_s_Maneuver-SPL.jpg

Vaginal Exam

  • Nullip versus Multip


  • Station:


  • Position:


  • Pelvimetry:
    • Diagonal Conjugate
    • Ischial Spines
Pelvic Inlet
  • Diagonal conjugate: >11.5 cm is adequate
  • True obstetric conjugate = diagonal conjugate – 1.5 to 2.0 cm
Midpelvis
  • Ischial spines – blunt vs. prominent
  • Pelvic sidewalls
    • Parallel = OK
    • Divergent = good
    • Convergent = bad
  • Sacrum – hallow vs. shallow (flat)
Pelvic Outlet
  • Bituberous diameter > 6-8 cm
  • Pubic arch > 90 degrees

Stages of Labor

  • 1st Stage: beginning of cervical dilation to complete dilation
  • 2nd Stage: complete dilation to delivery of fetus
  • 3rd Stage: delivery of placenta (up to 30 minutes)
  • 4th Stage: first hour after delivery of placenta

===Cardinal Movements of Labor====*Engagement

  • Flexion
  • Descent
  • Internal rotation
  • Extension
  • External rotation
  • Expulsion

Labor Curve

Interpret chart

Prolonged / Arrested Labor

  • Power: uterine contractions
  • Pelvis: adequate?
  • Passenger: EFW, position / attitude

Dysfunctional Labor

Pattern Nullip Multip Rx
Prolonged latent phase >20 hr >14 hr Rest, AROM, Pit
Protracted dilation <1.2 cm/hr <1.5 cm/hr AROM, Pit
Protracted descent <1 cm/hr <2 cm/hr Pit Arrest of dilation >2 hr >2 hr AROM, Pit, C/S
Arrest of descent >2 hr >1 hr Vacuum, forceps, C/S

Cesarean Section

  • History
    • Caedere -> caesura: to cut; seco: to cut.
    • Francois Rousset (1581)
    • Max Sanger (1882)- Leipzig
  • Most common surgical procedure
    • 1965 <5%, 1996 - 20.7%, 2004 - 29.1%
    • No change in cerebral palsy rate

C-section - Techniques

  • Uterine Incisions:
    • Low transverse
    • Low verticle
    • Classical
    • Kerr

C-section - Indications

Fetal C-section Indications
  • Distress / intolerance of labor
  • Malpresentation (breech, transverse)
  • Twins, multiples
    • Vtx / Vtx = allow to labor
  • Some congenital anomalies
    • NTD
Maternal-Fetal C-section Indications
  • Arrest of active labor
  • Failed induction of labor (?)
  • Placenta previa, vasa previa
  • Active HSV outbreak
  • HIV+ (viral load >1000/ml)
  • EFW > 4500 - 5000 gms (increasing risk of shoulder dystocia)
Maternal C-section Indications
  • Obstructive tumors (some leiomyomas)
  • Severe condylomata acuminata
  • Cervical cancer
  • Abdominal cerclage
  • Prior c-section
  • Prior vaginal colporrhaphy
  • Vaginal delivery contraindicated medically
  • Pregnant???

C-section - Risks

  • At time of surgery / Immediate post-op
  • Infection: endometritis, wound infection, septic pelvic thrombophlebitis (SPT)
  • Bleeding: transfusion, hysterectomy
  • Damage to fetus
  • Damage to adjacent organs
  • Subsequent pregnancy
    • Uterine rupture
    • Placenta previa -> accreta
      • 0 –> 5%
      • 1 –> 24%
      • 2 –> 48%
      • 3 –> 67%
    • Adhesions

Operative Vaginal Delivery

  • Forceps and vacuum

Operative Vaginal Delivery - Classification

  • Outlet: scalp visible at introitus w/out separating labia; no rotation
  • Low: leading point of skull at or below +2 cm station
    • Rotate < 45°
    • Rotate > 45°
  • Mid: above +2 cm station but engaged

Operative Vaginal Delivery - Indications

  • Nonreassuring FHT’s
  • Prolonged 2nd stage of labor
  • Shortened 2nd stage if pushing / Valsalva not indicated
  • Maternal exhaustion

Operative Vaginal Delivery - Prerequisites

  • Cervix completely dilated
  • Ruptured membranes
  • Fetal skull engaged in pelvis
  • Empty bladder
  • Position! Position! Position!
  • Adequate pelvis
  • Adequate anesthesia

Operative Vaginal Delivery - Forceps Assisted

Operative Vaginal Delivery - Risks

  • Maternal:
    • Vaginal / perineal trauma, damage to rectal sphincter
  • Fetal:
    • Cephalohematoma
    • Subgaleal hemorrhage
    • Bony facial trauma
    • Facial nerve injury
    • Intraventricular hemorrhage

Birth Trauma

  • Caput succedaneum:
    • Very common
    • Crosses midline
  • Subgaleal hemorrhage:
    • Rare
    • Hypovolemia and DIC

Common Post Partum Problems

  • PP Hemorrhage: >500cc (>1000cc for c/s):
    • Atony
    • Lacerations (cervix, vagina, perineum)
    • Retained placenta
    • Uterine rupture
    • Uterine inversion
    • Amniotic fluid embolism
  • Endometritis:
    • Fundal tenderness w/ temperature >38°C x 2 or >38.5°C
    • Polymicrobial infection
    • More common after c/s
      • Prolonged ruptured membranes
      • Chorioamnionitis

PP / Post-Op Fever

  • Causes and symptoms
    • Wind (atelectasis, pneumonia)
    • Wound (seroma, necrotizing fasciitis)
    • Water (UTI)
    • Walk (thrmobophlebitis)
    • Wonder drug (drug reaction)
    • Womb (endometriosis)
    • Wean (mastitis, engorgement)
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