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Labor

Labor consists of a series of rhythmic, progressive involuntary contractions of the


uterus that produce effacement (thinning and shortening) and dilation of the cervix.
The stimulus to the onset of labor is unknown, but the digital handling or
mechanical stretching the neck during examination increase uterine contractile
activity, probably by stimulating the release of oxytocin in the posterior pituitary
gland.

The normal labor begins within 2 weeks before (before or after) the estimated due
date. In the first pregnancy, labor usually lasts 12 to 18 hours on average;
Subsequent work shorten labor, and averaged 6 to 8 h.

The management of complications during labor requires additional steps (p. G.,
Induction of labor, forceps or vacuum extractor, cesarean).

Start of labor

Prepartum loss (small amounts of blood with mucus through the cervix) may
precede the labor up to 72 h. Antepartum losses can be distinguished from the
different types of vaginal bleeding in the third quarter because the amount of blood
is small, losses generally are mixed with mucus and lack the characteristic pain of
premature detachment of placenta. In most pregnant women it has been performed
prior ultrasound to rule out placenta previa. However, if the ultrasound was unable
to exclude placenta previa and vaginal bleeding occurs, it should be taken for
granted the presence of placenta previa until you can dismiss it. Digital vaginal
examination is contraindicated, and should an ultrasound done as quickly as
possible.

Labor begins with irregular uterine contractions of varying intensity; apparently


softened his neck and begin to erase it and expand it. As labor progresses, the
contractions increase its duration, intensity and frequency.

Stages or periods of labor


Labor has 3 periods or stages.

Stage 1 (From start to full dilatation of the neck, about 10 cm) has two phases:
latent and active.

During the latent phase, irregular contractions become progressively more


coordinated, discomfort is minimal and neck is cleared and about 4 cm dilated. The
time of the latent phase is difficult to determine and duration varies on average 8 h
in nulliparous and 5 h in multiparous; the duration is considered abnormal if it
persists> 20 h in nulliparous or> 12 h in multiparous.

During the active phase, the neck is fully dilated and the presentation descends to
the average pelvis. On average, the active phase lasts 5 to 7 h in nulliparous and 2
to 4 h in multiparous. In the traditional approach, it was expected that dilate the
cervix about 1.2 cm / h in nulliparous and 1.5 cm / h in multiparous. However,
recent data suggests that the slower progression of cervical dilation of 4 to 6 cm
may be normal (1). Pelvic examinations are carried out every 2 to 3 h to evaluate
the progression of labor. The lack of progress in dilation and descent of the
presentation may indicate a dystocia (fetopelviana disproportion).

If the membranes are not broken spontaneously, some physicians use amniotomy
(artificial rupture of membranes) routinely during the active phase. As a result,
labor can progress quickly, and amniotic fluid rapidly dyeable meconium.
Amniotomy during this stage may be required in specific indications, such as
facilitating internal fetal monitoring to confirm fetal well-being. Amniotomy should
be avoided in HIV positive women or hepatitis B or C to not expose the fetus to
these microorganisms.

During the first stage of labor, the heart rate and maternal blood pressure and fetal
heart rate must be continuously monitored by electronic or intermittently monitoring
by auscultation, generally with a portable Doppler ultrasound (see Fetal
monitoring). Women may begin to feel urge to push as the presentation goes down
to the pelvis. However, it should be prevented from bidding until the neck is fully
dilated cervix to not tear and energy is spent.
Stage 2 is the time from complete cervical dilation until delivery. On average, it
takes about 2 h in nulliparous (median 50 min) and 1 h in multiparous (median 20
min). It can last for another hour or more if driving analgesia (epidural) or strong
opioid anesthesia is used. In spontaneous birth, women should supplement uterine
contractions exclusively with pujos. In stage 2, the woman must be constantly
attended, and should be monitored continuously after each contraction or fetal
heart sounds. Contractions can be controlled by touch or by electronic means.

The stadium 3 labor begins after delivery, when the baby is out and delivery, or
delivery of the placenta is expected. This step typically lasts a few minutes, but can
take up to 30 minutes.

Premature rupture of membranes

Occasionally, membranes (amniotic sac and chorionic) rupture before labor starts,
and amniotic fluid is filtered through the cervix and vagina. The rupture of the
membranes at any stage before the onset of labor is called premature rupture of
membranes (PROM). Some women with RPM feel a jet of liquid out of the vagina,
followed by a steady loss.

More confirmation is not required if, during the examination, is fluid leaking through
the cervix. Confirmation subtler cases may require some study. For example, pH
can be measured with the vaginal fluid nitrazine paper, which becomes dark blue at
pH> 6.5 (the pH of amniotic fluid is between 7.0 and 7.6); may occur if false
positive vaginal fluid contains blood or semen, or with certain infections. You can
take a sample of secretions from the bottom of posterior vaginal sac or neck,
placed on a slide, let it air dry and observed under a microscope for fern
formations. Generally arborization fern (crystallization of sodium chloride as this
pattern) confirms membrane rupture.

If the rupture is not yet confirmed, ultrasound showing oligohydramnios (small


amount of amniotic fluid) provides evidence suggests a break. Rarely,
amniocentesis with instillation of dye is needed to confirm the break; if the dye is
detected in the Vagia or a buffer, break is confirmed.
When the membranes rupture, the woman should contact your doctor immediately.
Between 80 and 90% of women with term RPM and 50% with preterm RPM they
reach the labor spontaneously within 24 h; > 90% of those with RPM go into labor
within 2 weeks. The earlier membrane rupture before 37 weeks, the longer the time
between membrane rupture and the onset of labor. If the membranes rupture in the
period of the term but labor does not start within a few hours, usually it must be
induced labor to lower the risk of maternal and fetal infection.

Delivery options

Most women prefer to have their birth in a hospital, and most health workers
recommend that unexplained maternal or fetal complications can occur during
labor and delivery or postpartum, even in women without risk factors. About 30% of
hospital births involve an obstetric complication (p. Eg., Lacerations, postpartum
hemorrhage). Other complications include placental abruption, abnormal fetal heart
rate patterns, shoulder dystocia, need an emergency Caesarean and neonatal
depression or anomalies.

However, many women want a more homely environment for childbirth; In


response, some hospitals provide facilities for delivery with fewer formalities and
rigid rules but with emergency equipment and personnel available. Maternal and
child health centers can be independent or be located within hospitals; attention on
these sites is similar or identical to that of hospital maternity wards. In some
hospitals, registered nurses and midwives provide much of the care for low-risk
pregnancies. Midwives work with a doctor who is always available for consultation
and the need of an instrumental delivery or operation (p. Eg., Forceps, vacuum or
need vacuum extractor or cesarean).

For many women, the presence of your partner or another support person during
labor is useful and should be encouraged. Moral support, constant encouragement
and expressions of affection can reduce anxiety and make labor less scary and
unpleasant. Childbirth classes pain can prepare parents for labor and normal or
uncomplicated delivery. Share stress of labor and see and hear your child helps
create strong bonds between parents and between parents and child. Parents
should be well informed about any possible complications.

Admission

Often, pregnant women are advised to go to hospital if they believe their


membranes have ruptured or if they have contractions lasting at least 30 seconds
and appear regularly at intervals of about 6 minutes or less. Within the hour after
the presentation at the hospital, it can be determined if a woman started her labor
as the appearance of the following elements:

Occurrence of painful uterine contractions regular and sustained

 antepartum bleeding
 Membrane rupture
 complete cervical effacement

If these criteria are not met, you can tentatively diagnosed a false labor, and
women should be observed for a while and if labor does not begin within a few
hours, sent to the house.

When pregnant woman is internal, blood pressure, heart rate and respiratory rate,
temperature and weight, and the presence or absence of edema must register. a
urine sample is collected to analyze the presence of protein and glucose, and
blood is sent to the laboratory for a complete blood count and compatibility. a
physical examination. In examining the abdomen, the physician must estimate the
size, position and presentation of the fetus using Leopold maneuvers (see Figure
Maneuver Leopold). The doctor records the presence and frequency of fetal heart
sounds, and the location of auscultation. the preliminary estimate of the strength,
frequency and duration of contractions is also recorded.

A useful mnemonic device for evaluation is the 3 P:

 Power (force of contraction, frequency and duration)


 Passage (pelvic measurements)
 Passenger (p. G., Fetal size, position, heart rate pattern)

If labor is active and the pregnancy term, the doctor examines the vagina with 2
fingers of a gloved hand to assess progression. If bleeding occurs (especially if
abundant), the test is postponed until determining the location of the placenta by
ultrasound. If bleeding due to placenta previa, vaginal examination can trigger
serious bleeding.

If the labor has not started but the membranes are broken, an initial test is
performed to document speculum cervical dilation and effacement, and estimate
the presentation; however, the digital test may be delayed until there is an active
phase of labor or appear problems (p. g., changes in the fetal heart rate). If the
membranes have ruptured, the presence or absence of meconium (greenish brown
discoloration) should be set because it can be a sign of fetal distress. If labor is
preterm (<37 weeks) or has not started, only one examination should be performed
with a sterile speculum and culture taken to gonococcus, chlamydia and group B
streptococcus

cervical dilation in centimeters of diameter of a circle is recorded; 10 cm is


considered complete dilatation.

effacement is estimated percentages from zero to 100%. As effacement and


cervical shortening involves refining, you can be recorded in centimeters using
average normal cervical length not deleted from 3.5 to 4 cm as a guide.

The station is expressed in feet above or below the level of maternal ischial spines.
The level of the ischial spines corresponds to Station 0; levels above (+) or below
(-) of the spines is recorded in centimeters increments. fetal position and
presentation are recorded.

The presentation describes the ratio of the major axis of the fetus to the mother
(longitudinal, oblique, transverse).

The position describes the relationship of the part of the presentation to maternal
pelvis (p. G., Previous occipito left cephalic posterior sacral right buttocks).
The presentation describes the part of the fetus relative to the cervical opening (p.
G., Buttocks, apex, shoulder).

Childbirth preparation

Women are admitted to the labor room for frequent observation until the time of
delivery. If labor is active, they must remain fasting to avoid vomiting and aspiration
during delivery or, in an emergency, general anesthesia if necessary. shaving or
trimming pubic hair or vulva is indicated; It increases the risk of wound infection.

You can start an IV infusion of Ringer lactate, preferably using an indwelling


catheter placed in a vein thickness of the hand or forearm. For a normal labor 6 to
10 h, administered 500 to 1000 mL of this solution. Infusion prevents dehydration
during labor and subsequent hemoconcentration and maintains adequate
circulating blood volume. The catheter also provides immediate access to drugs or
blood if necessary. Preload liquid is valuable if planned use a spinal or epidural
anesthesia.

Analgesia

During labor there may be analgesic if necessary, but should be administered only
the minimum amount required for maternal comfort because analgesics cross the
placenta and can depress respiration neonate. There may be neonatal toxicity
because once the umbilical cord is cut, the neonate, whose metabolic processes
and excretory are immature, debugged agents transferred more slowly by hepatic
metabolism or excretion. Preparation and childbirth education reduce anxiety.

Doctors increasingly offer epidural injection (providing regional anesthesia) as the


first analgesic option during labor. Typically, a local anesthetic (p. Eg., Ropivacaine
0.2%, 0.125%) was infused continuously, often with opioids (p. G., Fentanyl,
sufentanil), in lumbar epidural space. In principle, the anesthetic is given slowly to
avoid masking the sensation of pressure that helps stimulate pujos and to avoid
motor blockade. Women should be sure that epidural analgesia does not increase
the risk of cesarean delivery (2).
If the epidural injection is inadequate or IV administration is preferred, it can be
used fentanyl (100 mcg) or morphine sulfate (to 10 mg) intravenously every 60 to
90 min. These opioids provide good analgesia with a small dose. If toxicity occurs,
it should instarurarse ventilation and administered naloxone 0.01 mg / kg IM, IV,
SC or endotracheal neonate as specific antagonist. Naloxone can be repeated
every 1 to 2 min as needed based on the response of the neonate. Clinicians must
control the neonate 1 to 2 h after the initial dose naloxone because the effects of
the first dose disappear.

If the fentanyl or morphine provide insufficient analgesia, should an additional dose


of the opioid analgesic or other method instead called synergistic drugs (p. G.,
Promethazine), which have no antidote. (These drugs are actually additives, no
synergistic). Synergists still sometimes used because they reduce nausea due to
opioids; doses should be small.

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