Pregnancy,

Labor, and Delivery

Calla Holmgren, MD
Department of Obstetrics & Gynecology
University of Washington
 Objectives
• Review normal physiologic changes in
pregnancy
• Discuss historical context of labor and
delivery
• Review normal and abnormal labor
• Evaluate interventions for abnormal labor
 Cardiovascular Changes
• Major hemodynamic changes induced by
pregnancy include
– Increase in cardiac output
– Sodium and water retention leading to blood
volume expansion
• Increase until 34 weeks gestation
– Reductions in systemic vascular resistance and
systemic blood pressure
 Cardiovascular Changes
• These changes begin early in pregnancy
• Reach their peak during the second
trimester, and then remain relatively
constant until delivery
• They contribute to optimal growth and
development of the fetus
• Help to protect the mother from the risks of
delivery, such as hemorrhage
Hemodynamic changes in normal
pregnancy
 Pulmonary Changes
• Marked changes in respiratory system during
pregnancy
• These can be measured using direct spirometry
– Vital Capacity- increased by 100-200 mL
– Inspiratory Capacity- increased by 300 mL
– Expiratory Reserve Volume- decreases
– Residual Volume- Decreases
– Functional Residual Capacity- reduced
– Tidal Volume- increases from 500 to 700 mL
– Minute Ventilation- increases 40%
 Pulmonary Changes
• The total of these changes is increased
ventilation
• Due to deeper but not more frequent
breathing
• Most likely used to help supply increased
basal oxygen consumption
 Gastrointestinal Changes
• Pregnancy has little, if any, effect on
gastrointestinal secretion or absorption
• But it has a major effect on gastrointestinal
motility
– Hormones
– Enlarging uterus
 Endocrine Changes
• Endocrine adaptations to the pregnant state
begin just after conception and evolve
through delivery
• They almost completely revert back to the
nonpregnant state over a period of weeks
• Virtually all endocrine glands are affected
 Endocrine Changes
• Maternal endocrine
adaptations to pregnancy
– Hypothalamus
– Pituitary
– Parathyroid
– Thyroid
– Adrenal glands
– Ovary
 Musculoskeletal Changes
• Anatomic and physiologic changes
occurring during pregnancy have the
potential to affect the musculoskeletal
system at rest and during exercise
– Weight gain
– Shift in center of gravity
– Increased ligamentous laxity
 Musculoskeletal Changes
• Weight gain
– Typically 11.5 to 16 kg
– May double the forces across joints compared to
nonpregnant forces
• Shift in center of gravity
– Shifted forward
– A posture of increased lumbar lordosis
– Back pain
– Loss of balance; increased fall risk
• Increased ligamentous laxity
– Related to the effects of estrogen and relaxin
 Prenatal Care
• The major goal of prenatal care is to ensure the
birth of a healthy baby with minimal risk for the
mother
– Early, accurate estimation of gestational age
– Identification of the patient at risk for complications
– Ongoing evaluation of the health status of both mother
and fetus
– Anticipation of problems and intervention, if possible,
to prevent or minimize morbidity
– Patient education and communication
 Prenatal Care
• History and physical
• Laboratory tests
• Ultrasound examination
• Patient education
• Preparation for labor and delivery
 History and Physical
• History
– Personal and demographic information
– Past obstetrical history
– Personal and family medical history
– Past surgical history
– Genetic history
– Menstrual and gynecological history
– Current pregnancy history
– Psychosocial information
• Physical
– Special attention to uterine size and shape and evaluation of the adnexa
– Fetal heart tones
• Doppler: 9 to 12 weeks of gestation
• Transvaginal ultrasound 5.5 to 6.0 weeks
 Laboratory Assessment
• Hematocrit or hemoglobin to detect anemia
• Cervical cytology
• Blood type and screen
• Rubella immunity testing
• Urinary infection testing
• Syphilis testing
• Hepatitis B antigen testing
• Gonorrhea and Chlamydia testing
• HIV testing
• Thyroid disorders?
• Heritable disorders
• Genetic screening
 Ultrasound Examination
• First trimester
– Accurately dates pregnancy
– Assessment of fetal well being
• 18-20 weeks
– Anatomic survey
• Late second/third trimester
– Growth
– Fetal well being
 Patient Education
• Seat belts
• Vitamins, nutrition, and weight gain
• Substance use
• Infection precautions
• Work
• Exercise
• Birth defects and genetic issues
• Use of medications
• Airline travel
 The History of Childbirth
• Historically,
pregnancy has been
managed by women
(family, friends,
midwife) with delivery
in the home
• In the 14th-18th
Centuries medicine
was dominated by
men and the Church
 History of Childbirth
• Industrialization of
America brought
mothers from their
homes to hospitals
(“lying-in”) for birth
• Obstetrics was then
performed by surgeons
(not midwives)
 Why do we need to know about
labor?
• Four million births per year in the United
States alone
• In underdeveloped nations – lack of skilled
attendants
• Natural process with modernization
 Maternal Mortality Ratio
(WHO, 2002)
Maternal deaths per Lifetime risk of
100,000 live births maternal death 1/
United States 17 2500
UK 13 3800
Australia 8 5800
Lao 650 25
Ethiopia 850 14
Rwanda 1400 10
Niger 1600 7
Afghanistan 1900 6
 Maternal Mortality
(Grady Memorial Hospital, GA)
 Maternal Mortality
(GMH, 1949-2000)
Causes of Death 1949-1971 (n=165) 1972-2000 (n=125)
Direct 101 (61) 44(35)
Pre-eclampsia 21(13) 16(13)
Infection 36(22) 7(6)
Hemorrhage 21(13) 8(6)
Vascular/AFE 15(9) 9(7)
Indirect 31(19) 32(26)
Unrelated Medical 29(17) 45(39)
Infection 3(2) 10(8)
Homicide 3(2) 15(12)
Accident 7(4) 8(6)
 What is labor?
• Labor = the act of uterine contractions
combined with cervical change
• Fetus is gradually pushed through the birth
canal (consisting of the cervix, vagina and
perineum)
• Placenta is extruded and uterus involutes
What is labor?
What is labor?
 What starts labor?
• An intricate and baffling association
between fetus and mother exist
• Several components are known, but many
are not – extrapolated from animals
• Involves hormonal communications
between mother and fetus
• In other words – we can speculate but we’re
not quite sure!
 Induction of Labor
• Need to have a reason!
– Maternal indications
– Fetal indications
• Need to have a plan!
– Favorable cervix?
• No? Cervical ripening
• Yes? Pitocin
 Bishop Score

Parameter\Score 0 1 2 3
Position Posterior Intermediate Anterior -
Consistency Firm Intermediate Soft -
Effacement 0-30% 40-50% 60-70% 80%
Dilation <1 cm 1-2 cm 2-4 cm >4 cm
Fetal station -3 -2 -1, 0 +1, +2
 Cervical Ripening
• Mechanical
– Stripping (or sweeping) of the fetal membranes
– Placement of hygroscopic dilators within the
endocervical canal
– Insertion of a balloon catheter above the
internal cervical os (with or without infusion of
extra-amniotic saline)
• Pharmacologic
– Prostaglandins
• Prostaglandin E2-cervidil
• Prostaglandin E1-misoprostil
 After the initiation of labor…
• Factors responsible for the ongoing labor
process include:
– Oxytocin
– Prostaglandins (PGF2-alpha, thromboxane,
PGE1,E3)
– Endothelin (by receptor-PLC coupling via
nifedipine sensitive channels)
– Epidermal Growth Factor
 How does the uterus contract?
• The uterus is made from a weave of smooth
muscle (myometrium) covered by a smooth
cellular surface (serosa) – all formed by the
joining of the two original mullerian horns
• The cavity is hollow and lined by
vascular/stromal bed that is responsive to
hormonal stimulation (i.e. menstrual cycle)
Structure of the uterus
What does the myometrium need
to contract?
• CALCIUM!
• Calcium channels allow influx which
through a cascade of events activates
myosin
• Smaller calcium supply comes from other
organelles (i.e.. Sarcoplasmic reticulum)
• These all play a part in how we can
manipulate labor!
The Cardinal Movements of Labor
 Stages of Labor
• First stage – Latent and active labor
• Second stage – Descent with pushing to
delivery of baby
• Third stage – Delivery of placenta
• Fourth stage – involution of the uterus
Stages of Labor
 Stages of Labor
• Stage 1 (Latent Phase)
– Uterus and cervix prepare for active labor
– Dilatation up to 4 cm
– Variable length of time
 Stages of Labor
• Stage 1
– The “Active” Phase – rapid cervical dilatation
from 4 centimeters to 10 centimeters (or
complete dilatation). Varies for nulliparous vs.
multiparous patients
• Nulliparous – 1.2 cm/hr
• Multiparous – 1.5 cm/hr
 Stages of Labor
• Stage 2 “Pushing”
– Starts from complete dilatation to delivery of
the fetus
– Variable depending on parity maternal forces
– Fetus has to make it’s way through the curves
of the pelvis
 Third Stage of Labor
• Stage 3
– From delivery of the fetus to delivery of the
placenta
– Variable amounts of time for placental
extrusion but generally within the first 20-30
minutes
– Medications can be used to augment placenta
delivery and post-partum bleeding
 Fourth Stage of Labor
• Stage 4
– Immediate period after placental delivery
– Uterus contracts to close off venous sinuses
and slow bleeding
– Watch for signs of post-partum hemorrhage
When is labor not progressing?
 Fetal causes of dystocia
• Breech – presenting parts not optimal
• Macrosomia – too big!
• Occiput posterior – fetus is facing “sunnyside up”
(face up)
• Malpresentation – fetal head is not perfectly
flexed
• Compound presentation – two parts presenting
• Congenital abnormalities obstructed in the birth
canal
 Breech Presentation
• Non-vertex presenting
part – Buttocks!
• Occurs in about 3-5%
of term deliveries
• Forms of breech
presentation include
complete, footling, and
frank breech
 Breech presentation
• Look for possible causes (large baby, no
fluid, birth defects, uterine anomalies)
• Risks of labor from breech presentations
include fetal injury, cord prolapse,
entrapment, maternal injury
• Delivery options include vaginal breech
delivery, external cephalic version (ECV),
elective cesarean section
 Occiput posterior (OP) presentation
• Approximately 10% of
deliveries
• Face is looking up
towards the ceiling
versus the floor
• Fetus must perform
opposite
flexion/extension
maneuvers to navigate
the birth canal
 OP Presentations
• What can we do about OP presentations?
– Leave it alone – babies can deliver from OP,
ROP and LOP presentations (back labor!)
– Rotate the fetal head – manually or with forceps
– Change labor positions for the mother such as
knee-chest
– Offer regional anesthesia – allows for pelvic
muscle relaxation
– If labor arrests - cesarean
 Malpresentation
• Occurs when the bony parietal bones of the
fetus are not the presenting. These include:
– Face presentation 0.1-0.2% of all deliveries
(head is hyper-extended)
• Let nature work its magic – they usually deliver
vaginally
• Do not try to correct
• Babies can have edematous faces, they resolve
 Malpresentation
• Brow presentation –
area between orbital
ridge and anterior
fontanel
• Press on but if labor
arrests - cesarean
 Malpresentation
• Shoulder presentation
– Also called transverse or oblique lie
– About 0.3% of all deliveries
– Reasons include grandmultiparity (5 or more
births), prematurity, placenta previa and small
pelvis
– What you can do: ECV to vertex presentation
or cesarean
 Malpresentation
• Compound presentation
– Extremity + presenting part enter the pelvis
(most commonly hand + head)
– Very common in extremely premature infants
– Majority of the time not a problem – babies can
deliver with or without hand on head. Many
times they retract spontaneously.
 Fetal macrosomia
• Fetus is too large for the pelvis
– >4500 grams in a non-diabetic patient
– >4000 grams in a diabetic patient
– >95%-ile for gestational age
– Can estimated by experienced hands on
Leopold's maneuver or by ultrasound and
sometimes even by the mother!
Types of Maternal Pelves
 What can we do when labor is
not progressing?
• Natural methods
– Rupture of membranes
– Walking
– Nipple stimulation
– Position change
– Herbs (used as abortifacients)
Medical treatments for protracted
labor
• Augmentation of contractions with Pitocin
• Anesthesia
• Repositioning of fetal head
• Assistance with vacuum or forceps
 Other options for delivery…

• Vaginal assistance
with forceps (18th
Century)
• Vaginal assistance
with vacuum
• C/S
 Considerations for Operative
Vaginal Delivery
• Maternal Criteria
– Adequate analgesia
– Lithotomy position
– Bladder empty
– Clinical pelvimetry must be adequate in
dimension and size
– Consent
 Considerations
• Fetal criteria
– Vertex presentation
– Fetal head engaged in the pelvis
– Position of fetal head must be known
– ? Presence of caput or molding
 Considerations
• Other criteria
– Cervix fully dilated
– Membranes ruptured
– No placenta previa
– Experienced operator
– Capability to perform an emergent cesarean
delivery if needed
 Operative Vaginal Delivery
• Assisted
• Two methods used
– Forceps
– Vacuum
• Randomized studies comparing the two have
not shown a significant difference in success
rate
• Choice of use dependent largely on clinician
preference and experience
 Cesarean Section
• Named after Julius
Caesar?
• Evidence goes back as
far as ancient times
• Originally performed
to save fetus from
dying/deceased mother
(particularly males)
 History of the C-section
• Latin term “caedare”
means to cut
• “Caesones” = infants
born by post-mortem
operations
• Was not meant to save
mother’s life until the
18th Century
 How far we’ve come…
• Addition of
anesthesia, antisepsis
and sterile technique
• Closure of uterine
incisions vs.
hysterectomy
• Significant reduction
in mortality after
1940’s –Why?
 Cesarean section
• In the US, 20% of all deliveries
• Popularity is growing for elective c-sections
(as high as 90% of deliveries in Brazil)
• In underdeveloped nations – significant
birth trauma to mother/baby, even death due
to inability to perform (skilled attendants)
• Surgery is not without risks
 Indications for C-section
• Failure to progress
• Fetal distress without imminent delivery
• Fetal anomaly
• Breech or macrosomia
• Maternal pelvis
• Maternal illness
How do we perform a C-section?
• A “smile” incision is
made on mother’s
lower abdomen
• Incision is made to
open the uterus
• “Bag of waters” is
broken (amniotomy)
 C-section procedure
• Surgeon reaches into
uterus and obtains
presenting part
• Assistant compresses
the uterus at the
fundus to push baby
out the incision
• Placenta delivered,
uterus and incision
closed
 Risks of C-section
• Bleeding
• Infection
• Injury to surrounding organs (which ones?)
• Subsequent scarring for future surgery
• Anesthesia risks
Risks of previous c-sections
Risks of previous c- section
Why do we do all this?