Normal labour and delivery
From IDWiki
Definition
- Uterine contractions leading to progressive dilation of the cervix
- Preterm before 37 weeks
- Post-term after 42 weeks
Physiology
- Estrogen-progesterone changes lead to coordinated uterine contractions
- Contractions soften the cervix, which dilates and thins
Clinical Manifestations
- Increased pelvic pressure
- Regular contractions
- Cramping
- Lower back ache
- Clear fluid leakage from vagina
- Increased urinary frequency
Assessment
- Leopold's maneuvers
- First: palpate fundus with both hands to determine presenting part
- Second: move down to identify the back and front to determine lie
- Third: one-handed assessment of pelvis to determine engagement
- Fourth: both hands to determine flexion of fetal neck (brow?)
- Contractions
- Frequency
- Duration
- Intensity
- Cervix
- Effacement
- Dilation
- Position
- Posterior
- Midposition
- Anterior
- Membrane: vaginal exam
- Intact or ruptured
- Fetus
- Heart rate
- Presenting part: Leopold's maneuvers and vaginal exam
- Position: feel the sutures
- Occiput posterior (OP)
- Occiput anterior (OA), etc
- Lie: Leopold's maneuvers
- Longitudinal: normal
- Oblique
- Transverse
- Back down: requires a classical vertical Caesarian section
- Back up: can have a horizontal uterine incision
- Engagement: fetal head descended into pelvis
- Station: relationship between presenting part and pelvis
- Ranges from -5 to +5 cm in relation to 0 station
- 0 station is the ischial spine
- Poor inter-rater reliability
- Bishop score
- Predicts the success of induction of labour
- Components: NEEDS CORRECTION
- Cervical dilatation: closed, 1-2, 3-4, >4
- Cervical effacement: 0-30%, 40-50%, 60-70%, 80+%
- Cervical consistency: firm, medium, soft
- Cervical position: posterior, midposition, anterior
- Fetal station: -3, -2, -1, +1 or +2
- Each component scored from 0 to 2 or 3, to a maximum of 13
- Add one point for each of
- Preeclampsia
- Each previous vaginal delivery
- Subtract one point for each of
- Post dates
- Preterm
Stages of Labour
- Stage I: cervical dilatation
- Latent
- Starts with any contractions leading to cervical dilatation
- Ends around 4-5 cm dilatation
- Active
- Starts when cervical dilatation reaches 4-5 cm
- Ends at complete dilatation of the cervix
- Latent
- Stage II: delivery of the fetus
- Cardinal movements
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
- Lasts up to 1h in primiparous, 1/2h in multiparous
- Cardinal movements
- Stage III: delivery of the placenta
- Lasts up to 1/2h
- Stage IV: recovery
Management
- Management depends on stage
- Ask patient to come to hospital when contractions occur every five minutes, lasting at least one minute, ongoing for at least one hour
- Stage I
- Regularly monitor cervical dilatation, fetal station, fetal heart rate, and frequency of contractions
- Increase frequency of monitoring as labour progresses
- Fetal heart rate monitoring q1-2h during latent and q30min during active phase
- Ambulation, lying on side
- Vitals q4h or q1h if concerns exist
- If risk of operative delivery: maintain NPO when active labour
- If GBS positive: GBS prophylaxis
- Stage II
- Position
- Pushing
- Control expulsion
- Clamp cord (delayed)
- Stage III
- Position fingers below uterus to prevent uterine inversion
- Gentle cord traction
- Watch for signs of placental detachment
- Apparent cord lengthening
- Gush of blood
- Uterus firming and balling
- If no progress, can attempt fundal massage or oxytocin
- Oxytocin 10 IU IV or misoprostol 600mcg po once, to decrease risk of postpartum hemorrhage
- Stage IV
- Monitor for hemorrhage