NORMAL LABOR AND DELIVERY

FETAL LIE The lie is the relationship of the long axis of the fetus to that of the mother Longitudinal 99% Transverse - multiparity, placenta previa, hydramnios, uterine anomalies Oblique - unstable FETAL PRESENTATION The presenting part is the portion of the body that is foremost within the birth canal or in close proximity to it CEPHALIC PRESENTATION Vertex or occiput presentation occipital fontanel Face presentation Sinciput presentation anterior fontanel Brow presentation Why does the term fetus usually presents with the vertex? The uterus is piriform shaped. Breech and its flexed extremities is bulkier and more mobile than the cephalic pole FETAL PRESENTATION BREECH PRESENTATION Incidence: 3-4% at term 14% between 29 and 32 weeks gestation Types: Frank breech Complete breech Incomplete breech FETAL ATTITUDE or POSTURE or HABITUS The fetus becomes folded or bent upon itself in such a manner that the back becomes markedly convex , the head is sharply flexed so that the chin is in contact with chest, the thighs are flexed over the abdomen, the legs are bent at the knees, and the arches of the feet rest upon the anterior surfaces of the legs. The arms are usually crossed over the thorax. FETAL POSITION Relationship of an arbitrarily chosen portion of the feral presenting part to the right or left side of the maternal birth canal Fetal occiput, mentum, sacrum are the determining points OA ROA LOA ROT LOT ROP LOP OP LEOPOLDS MANEUVER FIRST MANEUVER what occupies the uterine fundus SECOND MANEUVER palms placed on either side of the maternal abdomen THIRD MANEUVER if presenting part not engaged FOURTH MANEUVER if presenting part deeply engaged LEOPOLDS MANEUVER PRESENTATION CEPHALIC

smallest possible cross section passing through the birth canal. 12. ENGAGEMENT The mechanism by which the biparietal diameter, the greatest transverse diameter of the fetal head in occiput presentations, passes through the pelvic inlet Fetal head usually enters the pelvic inlet either transversely or obliquely ASYNCLITISM The sagittal suture of the fetal head may not lie exactly midway between the symphysis and the sacral promontory. Lateral deflection of the fetal head to a more anterior or posterior position in the pelvis ANTERIOR ASYNCLITISM when the sagittal suture approaches the sacral promontory so that more of the anterior parietal bone presents itself to the examining finger POSTERIOR ASYNCLITISM the sagittal suture lies close to the symphysis and more of the posterior parietal bone will present ASYNCLITISM DESCENT The first requisite for birth of the newborn. Usually begins with engagement Brought about by the ff. forces: 1. pressure of the amnionic fluid 2. direct pressure of the fundus upon the breech with contractions 3. bearing down efforts of maternal abdominal muscles 4. extension and straightening of the fetal body OCCIPUT POSTERIOR POSITION With effective contractions, adequate flexion of the head, and a fetus of average size, the great majority of posteriorly positioned occiput rotates promptly as soon as they reach the pelvic floor Factors that predispose to incomplete rotation: poor contractions faulty flexion of the fetal head epidural analgesia PERSISTENT OCCIPUT POSTERIOR - if no rotation towards the symphysis takes place and the occiput remains in direct occiput posterior position CHANGES IN THE SHAPE OF THE FETAL HEAD CAPUT SUCCEDANEUM swelling at the portion of the fetal scalp immediately over the cervical os seen in prolonged labors before complete cervical dilatation MOLDING change in fetal head shape from external compressive forces results in shortened suboccipitobregmatic diameter and a lengthened mentovertical diameter When does labor start? Presence of painful uterine contractions accompanied by any of the following: 1. ruptured membranes 2. bloody show 3. complete cervical effacement

CARDINAL MOVEMENTS OF LABOR ENGAGEMENT DESCENT FLEXION INTERNAL ROTATION EXTENSION EXTERNAL ROTATION EXPULSION The fetal ovoid is transformed into a cylinder, with the

CONTRACTIONS OF CONTRACTIONS OF TRUE LABOR FALSE LABOR Regular intervals Intervals gradually shortens Intensity gradually increases Discomfort is in the back and abdomen Cervix dilates Discomfort is not stopped by sedation Irregular intervals Intervals remain long Intensity remains unchanged Discomfort in the lower abdomen Cervix does not dilate Discomfort is usually relieved by sedation FUNCTIONAL DIVISIONS OF LABOR FRIEDMAN LABOR CURVE LATENT PHASE The onset of latent labor is the point when the mother perceives uterine contractions and ends at between 3 and 5 cm of dilatation PROLONGED LATENT PHASE greater than 20 hours in nullipara and 14 hours in multipara Affected by excessive sedation or epidural analgesia, unfavorable cervical dilatation and false labor ACTIVE PHASE Cervical dilatation of 3 to 5 cm or more + uterine contractions represent he threshold of active labor Mean duration in nulliparas was 4.9 hours Descent begins at about 7-8 cm in nulliparas Protracted active phase slow rate of cervical dilatation or descent , which for nulliparas < 1.2 cm dilatation/hour or < 1 cm descent/hour and for multiparas < 1.5 cm/hour or < 2 cm descent/hour Arrest of dilatation 2 hours with no cervical change Arrest of descent 1 hour without fetal descent ACTIVE PHASE Factors contributing to protraction and arrest disorders: excessive sedation, vaginal analgesia, fetal malposition Treatment for protraction disorders: expectant management Treatment for arrest disorders: oxytocin in absence of CPD Epidural anesthesia lengthened the active phase by 1 hour SECOND STAGE OF LABOR Begins when cervical dilatation is complete and ends with fetal delivery Mean duration : 50 minutes for nulliparas 20 minutes for multiparas DURATION OF LABOR Mean length of 1 st and 2 nd stage of labor 9 hours in nulliparas 6 hours in multiparas MANAGEMENT OF NORMAL LABOR AND DELIVERY VAGINAL EXAMINATION Detection of ruptured membranes pH of vagina = 4.5-5.5 pH of amnionic fluid = 7.0-7.5 Nitrazine paper Cervical effacement Cervical dilatation Position of the cervix Station

SPONTANEOUS DELIVERY The encirclement of the largest head diameter by the vulvar ring is known as crowning. RITGEN MANEUVER * gloved hand is used to exert pressure on the chin of the fetus through the perineum just in front of the coccyx * allows controlled delivery of the fetal head * favors extension of the fetal head RITGEN MANEUVER SIGNS OF PLACENTAL SEPARATION The uterus becomes globular and firmer There is sudden gush of blood The uterus rises in the abdomen The umbilical cord protrudes These signs appear usually within 5 minutes after delivery of the newborn DELIVERY OF THE PLACENTA Traction on the umbilical cord must not be used to pull the placenta out of the uterus Inversion of the uterus is a complication FOURTH STAGE OF LABOR The hour immediately following delivery Postpartum hemorrhage as a result of atony may occur OXYTOCIN Half life of I.V. oxytocin is 3 minutes I.V. bolus of 10 units can cause transient but marked fall in arterial BP followed by an abrupt increase in cardiac output Antidiuretic action can cause water intoxication ERGONOVINE AND METHYLERGONOVINE May result in a tetanic contraction I.V. route initiates transient but severe hypertension PROSTAGLANDINS Misoprostol Prostglandin F2a LACERATIONS OF THE BIRTH CANAL FIRST DEGREE LACERATIONS involve the fourchette, perineal skin, and vaginal mucosa SECOND DEGREE LACERATIONS involve the skin, mucuc membrane, fascia and muscles of the perineal body THIRD DEGREE LACERATIONS involve the skin, mucus membrane, perineal body and anal sphincter FOURTH DEGREE LACERATIONS extends to the rectal mucosa to expose the lumen of the rectum, tears of the region of the urethra EPISIOTOMY AND REPAIR Purposes of episiotomy: Substitution of a straight surgical incision, which was easier to repair, for the ragged laceration Prevention of pelvic relaxation Increased incidence of anal sphincter and rectal tear Increased fecal and flatus incontinence Restricted use of episiotomy lower rates of posterior perineal trauma, surgical repair, and healing complications

TYPES OF EPISIOTOMY: MIDLINE MEDIOLATERAL Surgical repair Easy More difficult Faulty healing Rare More common Postoperative pain Minimal Common Anatomical results Excellent Occ. faulty Blood loss Less More Dyspareunia Rare Occasional Extensions Common Uncommon 40. DYSTOCIA ABNORMAL LABOR Abnormalities of the expulsive forces, either uterine forces insufficiently strong or inappropriately coordinated to efface or dilate the cervix uterine dysfunction or inadequate voluntary muscle effort during the 2 nd stage of labor Abnormalities of presentation, position or development of the fetus Abnormalities of the maternal bony pelvis that is, pelvic contraction Abnormalities of soft tissues of the reproductive tract that form an obstacle to fetal descent CATEGORIES OF DYSTOCIA Abnormalities of the powers uterine contractility and maternal expulsive effort Abnormalities involving the passenger the fetus Abnormalities of the passage the pelvis COMMON CLINICAL FINDINGS IN WOMEN WITH INEFFECTIVE LABOR Inadequate cervical dilatation or fetal descent Protracted labor slow progress Arrested labor no progress Inadequate expulsive effort ineffective pushing Fetopelvic disproportion Excessive fetal size Inadequate pelvic capacity Malpresentation or position of fetus Ruptured membranes without labor MECHANISM OF DYSTOCIA Uterine contractions, cervical resistance, and the forward pressure exerted by the leading fetal head are the factors influencing the progress of the 1 st stage of labor Uterine muscle malfunction can result from uterine overdistension or obstructed labor TYPES OF UTERINE DYSFUNCTION HYPOTONIC UTERINE DYSFUNCTION There is no basal hypertonus and uterine contractions have a normal gradient, but the slight rise in pressure during a contraction is insufficient to dilate the cervix HYPERTONIC UTERINE DYSFUNCTION or INCOORDINATE UTERINE DYSFUNCTION Either basal tone is elevated or the pressure gradient is distorted ACTIVE PHASE DISORDERS Inadequate uterine contractions defined as less than 180 Montevideo units were diagnosed in 80% of women with active phase disorders Protraction is defined as less than 1 cm /hr cervical

dilatation for a minimum of 4 hours Criteria for dx of arrest during the 1 st stage of labor: 1. The latent phase has been completed, with the cervix dilated 4 cm or more 2. A uterine contraction pattern of 200 MVU or more in a 10 minute period has been present for 2 hours without cervical change

47. 48. SECOND STAGE DISORDERS The 2 nd stage in nulliparas was limited to 2 hours and extended to 3 hours when regional analgesia was used For multiparas, 1 hour was the limit, extended to 2 hours with regional analgesia CAUSES OF UTERINE DYSFUNCTION Epidural analgesia Chorioamnionitis Maternal position during labor Ambulation in labor is not harmful and mobility may increase in greater comfort Birthing position in the 2 nd stage of labor RUPTURED MEMBRANES WITHOUT LABOR Stimulation of contractions when labor did not begin after 6 to 12 hours Labor is induced when ruptured membranes is diagnosed at term PRECIPITOUS LABOR AND DELIVERY Precipitous labor terminates in expulsion of the fetus in less than 3 hours Short labors, defined as a rate of cervical dilatation of 5 cm/hr or faster for nulliparas and 10 cm/hr for multiparas , were associated with abruption, meconium, postpartum hemorrhage, cocainre abuse and low Apgar scores May lead to uterine rupture, or extensive lacerations of the cervix, vagina , vulva, perineum The uterus that contracts vigorously before delivery is likely to be hypotonic after delivery Increased perinatal mortality and morbiditry CLINICALLY ADEQUATE PELVIS The diagonal conjugate is normal The pelvic sidewalls are nearly parallel. The ischial spines are not prominent. The sacrum is not flat. The subpubic angle is not narrow. The occiput is known to be the presenting part. The fetal head is engaged or descends through the pelvic inlet with pressure. FETOPELVIC DISPROPORTION CONTRACTED PELVIC INLET AP diameter < 10 cm Greatest transverse diameter < 12 cm Diagonal conjugate < 11.5 cm Face and shoulder presentation and cord prolapse occurs more frequently

FETOPELVIC DISPROPORTION CONTRACTED MIDPELVIS More common than inlet contraction Frequently causes transverse arrest of the fetal head Sum of ischial spine and posterior sagittal diameters of the midpelvis ( normal , 10.5 + 5 cm, or 15.5 cm) falls 13.5 and below Clinical pelvimetry: spines are prominent, pelvic sidewalls converge, sacrosciatic notch is narrow FETOPELVIC DISPROPORTION CONTRACTED PELVIC OUTLET Interischial tuberous diameter of 8 cm or less Outlet contraction without concomitant midplane contraction is rare FETAL DIMENSIONS IN FETOPELVIC DISPROPORTION Excessive fetal size was considered to be 4500 g Malposition of the fetal head MUELLER-HILLIS MANEUVER Fundal pressure followed by vaginal examination BREECH PRESENTATION Frank breech presentation Complete breech presentation Incomplete breech presentation 59. 60. LEOPOLDS MANEUVER PRESENTATION BREECH

67. PINARD MANEUVER- A method for delivering a

fetus in breech position in which one leg is bent and passed along the thigh of the other leg as the foot of the bent leg is brought down and out.

MAURICEU MANEUVER A method of delivering the head in an ass isted breech delivery inwhich the infant's body is supported by the right forearm w hiletraction is made upon the shoulders b y the left hand.

VAGINAL EXAMINATION IN A BREECH PRESENTATION Ischial tuberosities and anus are in a straight line while the mouth and malar prominences form a trianguLar shape VAGINAL BREECH DELIVERY ACOG has concluded that, except in cases of advanced labor and imminent delivery, women with persistent singleton breech presentation should undergo a planned cesarean delivery RECOMMENDATIONS FOR CESAREAN DELIVERY Large fetus Any degree of contraction or unfavorable shape of the pelvis A hyperextended head When delivery is indicated in the absence of spontaneous labor Uterine dysfunction Incomplete or footling breech An apparently healthy and viable preterm fetus with the mother in labor or in whom delivery is indicated Several growth restriction Previous perinatal death A request for sterilization Lack of an experienced operator METHODS OF VAGINAL DELIVERY IN BREECH PRESENTATION Spontaneous breech delivery Partial breech extraction Total breech extraction 66. EXTERNAL CEPHALIC VERSION PRAGUE MANEUVER

Prague maneuver (prg)

n. A method for delivering a fetus in breech position in which the infant's shoulders are grasped from below by one hand while the other hand supports the legs.

FACE PRESENTATION Flexion of the head and vaginal delivery are typical with mento anterior presentation . Vaginal delivery is impossible with mento posterior presentation unless the chin rotates anteriorly Causes: Marked enlargement of the neck or cord coils around the neck may prevent extension Anencephalic fetuses Inlet contractions Pendulous abdomen High parity BROW PRESENTATION Rarest Unstable TRANSVERSE LIE 0.3 % incidence Shoulder presentation Causes: Abdominal wall relaxation Preterm fetus Placenta previa Abnormal uterine anatomy Excessive amnionic fluid Contracted pelvis Neglected transverse lie Conduplicato corpore LEOPOLDS MANEUVER TRANSVERSE LIE COMPOUND PRESENTATION Extremity prolapses alongside the presenting part Causes: conditions that prevent complete occlusion of the pelvic inlet by the fetal head, including preterm birth COMPOUND PRESENTATION PERSISTENT OCCIPUT POSTERIOR POSITION Reasons for failure of spontaneous rotation: Transverse narrowing of the midpelvis Malrotation of occiput anterior during labor Possibilities for vaginal delivery: Spontaneous delivery Forceps delivery with occiput directly posterior Manual rotation to anterior position Forceps rotation to anterior position SHOULDER DYSTOCIA 0.6% - 1.4% incidence Head to body delivery time exceeding 60 seconds Mean head to body delivery time in normal births was 24 seconds compared with 79 seconds in shoulder dystocia Risk factors: Obesity, Multiparity Gestational diabetes Postterm pregnancy SHOULDER DYSTOCIA Most cases of shoulder dystocia cannot be accurately predicted or prevented Elective induction of labor or elective cesarean delivery for all women suspected of carrying a macrosomic fetus is not appropriate Planned cesarean delivery may be considered for the non-diabetic woman carrying a fetus with an estimated fetal weight exceeding 5000 g or the diabetic woman whose fetus is estimated to weigh more than 4500 g MANAGEMENT OF SHOULDER DYSTOCIA Suprapubic pressure McRoberts maneuver Woods corkscrew maneuver Delivery for the posterior shoulder Rubin maneuver Fracture of

the clavicle Strong fundal pressure Zavanelli maneuver Cleidotomy Symphysiotomy McROBERTS MANEUVER- The McRoberts maneuver is employed in case of shoulder dystocia during childbirth and involves hyperflexing the mother's legs tightly to her abdomen. This widens the pelvis, and flattens the spine in the lower back (lumbar spine). If this maneuver does not succeed, an assistant applies pressure on the lower abdomen (suprapubic pressure), and the delivered head is also gently pulled. The technique is effective [1] in about 42% of cases. WOODS CORKCREW MANEUVER OTHER CAUSES OF DYSTOCIA Hydrocephalus Enlargement of the fetal abdomen Soft tissue dystocia SOFT TISSUE DYSTOCIA MATERNAL EFFECTS OF DYSTOCIA Intrapartum infection Uterine rupture Pathological retraction ring Fistula formation Pelvic floor injury Postpartum lower extremity nerve injury FETAL EFFECTS OF DYSTOCIA Caput succedaneum Fetal head molding Skull fractures

Bracht's maneuver a method of extraction of the aftercoming head in breech presentation. Brandt-Andrews maneuver a method of expressing the placenta from the uterus. forward-bending maneuver a method of detecting retraction signs in neoplastic changes in the mammae; the patient bends forward from the waist with chin held up and arms extended toward the examiner. If retraction is present, an asymmetry in the breast is seen. Heimlich maneuver a method of dislodging food or other material from the throat of a choking victim: wrap one's arms around the victim, allowing their upper torso to hang forward; with both hands against the victim's abdomen (slightly above the navel and below the rib cage), make a fist with one hand, grasp it with the other, and forcefully press into the abdomen with a quick upward thrust. Repeat several times if necessary.

Heimlich maneuver.

Pajot's maneuver a method of forceps delivery with traction along the axis of the superior pelvic aperture. Pinard's maneuver a method of bringing down the foot in breech extraction. Prague maneuver a method of extracting the aftercoming head in breech presentation. Scanzoni maneuver double application of forceps blades for delivery of a fetus in the occiput posterior position. Toynbee maneuver pinching the nostrils and swallowing; if the auditory tube is patent, the tympanic membrane will retract medially. Valsalva maneuver 1. increase in intrathoracic pressure by forcible exhalation effort against the closed glottis. 2. increase in the pressure in the eustachian tube and middle ear by forcible exhalation effort against occluded nostrils and closed mouth.