Ch 13.

CONDUCT OF NORMAL LABOR AND DELIVERY

R1

 The ideal conduct of labor and delivery

- Birthing is recognized as a normal physiological process that most women experience without complication - Intrapartum complications can arise very quickly and unexpectedly

ADMISSION PROCEDURES
Identification of labor -One of the most critical diagnoses in obstetrics is the accurate diagnosis of labor -Hx, PEx, V/S (BP, PR, BT) -Uterine contraction (duration, frequency, intensity) -fetus (presentation, heart rate, size) -fetal membrane, vaginal bleeding & leakage ->The fetal heart rate should be checked, especially at the end of a contraction and immediately, thereafter, to identify pathological slowing of the heart rate

ADMISSION PROCEDURES
True labor -regular interval -gradually shorten -intensity: increase -discomfort back & abdomen -cervix: dialte -discomfort: not stopped by sedation False labor -irregular interval -remian long -intensity: unchanged -discomfort low abdomen -cervix: not dilate -discomfort: usually relieved by sedation

ADMISSION PROCEDURES
Federal requirements for inter-hospital transfer of laboring women -all Medicare-participating hospitals with emergency services must provide an appropriate medical screening examination for any pregnant women
-LABOR: the precess of childbirth beginning with the latent phase of labor continuing through delivery of the placenta

-penalty; $50,000

ADMISSION PROCEDURES
Electronic admission testing -NST (nonsterss test) :an assessment of fetal heart rate accelerations or lack of the same with fetal movement -CST (contraction stress test) : an assessment of fetal heart rate before, during, and following a uterine contraction if the patient is in labor
-fetal heart rate: variability and variable deceleration with fetal acoustic stimulation

ADMISSION PROCEDURES
Vaginal examination -aseptic conditions 1) amnionic fluid: membrane rupture posterior vaginal fornix (vernix or meconium) , swab
2) cervix: softness, effacement, dilatation, location presentation , presence of membrane 3) presenting part

4)station: the degree of descent high level- fundal pressure

5)pelvic architecture: diagonal conjugate ischial spine, pelvic sidewall sacrum

ADMISSION PROCEDURES
Cervical effacement - the length of the cervical canal compared to that of an uneffaced cervix -reduced by one half: 50 % effaced completely: 100 % effaced
Cervical dilatation -the average diameter of the cervical opening -dilated fully: 10cm

ADMISSION PROCEDURES
Position of the cervix -the relationship of the cervacal os to the fetal head -posterior, modposition, or anterior (ex. preterm labor: posterior) Station -the presenting part in the birth canal in relationship to the ischial spine -ischial spine: halfway between the pelvic inlet and the pelvic outlet

-the lowermost portion of the fetal presenting part is at the level of the ischial spine: ZERO (0) engagement -divided into third ->ACOG (1988) divided into fifth (-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5) -If the head is unusually molded, of if there is an extensive caput formation, or both, engagement might not have taken place even through the head appears to be at 0 station

ADMISSION PROCEDURES
Detection of ruptured membranes -Ruptere of membrane
1) if not fixed in the pelvis, prolapse & cmpression of umbilical cord is greatly increased 2) if the pregnancy is at or near term, labor is likely to occur soon 3) if delivery is delayed for 24 hours or more after membranes rupture, serious intrauterine infection

-diagnosis of rupture of the membrane : pooling in the posterior fornix or passing from the cervical canal of the amnionic fluid : testing of pH normal (4.5~5.5) amnionic fluid (7.0~7.5) Nirazine test false-positive: blood, semen bacterial vaginosis false-negative: minimal fluid #Nitrazine test: insert sterile cotton tip->touching it to a strip-> comparering the color -arborization, ferning pattern or AFP of amnionic fluid

ADMISSION PROCEDURES
Vital signs and review of the pregnancy record Preparation of vulva and perineum -cleansing and scrubbing -clipping or mini-shaving or hair (But. not routinely) Vaginal examination -sterile gloves -avoid the anal region -the number of vaginal exam: infectious morbidity especially rupture

ADMISSION PROCEDURES
Enema -to minimize subesquent contaminaton by feces during the second stage -not routinely at Parkland hospital Larboratory -Hb, Hct: recheck -blood type, UA (pretein, glucose) -syphilis, hepatitis B, HIV (ex. Routine in TEXAS)

MANAGEMENT OF FIRST STAGE OF LABOR

The average duration of the first stage -nulliparous: 7 hours -parous: 4 hours ->individual variations
#The physician can best reach a conclusion about the normalicy of the pregnancy when all examinations ,including record and laboratory review, are completed

MANAGEMENT OF FIRST STAGE OF LABOR

Monitoring fetal well-being during labor
-The frequency, intensity, and duration of uterine contraction, and the response of the fetal heart rate to the contracton, are of considerable concern.

# Fetal heart rate -change in the fetal heart rate that most likely are ominous almost always are detectable immediately after a uterine contraction
- To avoid confusing maternal and fetal heart rates. the maternal pulse should be counted as the fetal heart rate is counted - fetal jeopardy, compromise, or distress ; FHR below 110 bpm after a contracton

-fetal jeopardy very likely exists if the rate is heard to be less than 100 per minute, even though there is recovery to a rate in the 110 to 160 bpm range before the next contraction
-any abnormalities: every 30 minute in the 1st stage every 15 minite in the 2nd stage at risk: every 15 minutes in the 1st stage every 5 minitus in the 2nd stage

# Uterine contraction
-with the palm of the hand lightly on the uterus, the examiner determines the time of onset of the contraction -It is best to quantify the contractions as regards

the degree of firmness or resistance to indentation

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

Maternal vital signs -temperature, pulse, blood pressure : at least every 4 hours (if membrane rupture or high temperature: hourly)
-prolonged membrane rupture (>18 hrs) :antibiotics (preventtion of group B streptococcus)

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

Subsequent vaginal examination -the status of the cervix the station & position of the presenting part -at 2- to 3-hour intervals -sterile, water-soluble lubricants avoid povidone-iodine and hexachlorophene -if membrane rupture before engage :fetal heart rate should be checked vaginal exam-umbilical cord compression

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

Oral intake - food should be withheld during active labor and delivery - in labor & analgesics are administered :gastric emptying time is prolonged :not absorbed ,vomited, and aspiration -sips of clear liquids, occasional ice chips, and lip moisturizers are permitted

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

Intravenous fluids -there is seldom any real need for such in the normally pregnant at least until analgesia is administered
-advantage: oxitocin prophylactically (atony persist) administration of glucose, Na, water (prevent dehydration & acidosis)

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

Maternal position during labor
-need not be confined to bed early in labor -a comfortable chair may be beneficial -lateral recumbency must not be restricted to lying supine

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

Analgesia -depend on the needs and desires of the women
-the timing, method of the administration, and size of initial and subsequent doses are based to a considerable degree on the anticipated interval of the time until delivery -a repeat vaginal exam before administering analgesia

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

Amniotomy -aseptic technique -the fetal head must not be dislodged from the pelvis: prevents umbilical cord prolapse
-more rapid labor early detection of meconeum staining the opportunity to apply an electrode to the fetus insert a pressure catheter

MATERNAL MONITORING AND MANAGEMENT DURING LABOR

Urinary bladder function -bladder distention should be avoided : obstructed labor subsequent bladder hypotonia and infection
-ambulation: self voiding if not, intermittent catheterization