Ivano-Frankivsk National Medical University Obstetrics and Gynecological Department

NORMAL LABOR AND DELIVERY. OBSTETRIC ANALGESIA AND

ANESTESIA.

The most common signs that may occur two to four weeks prior to labor include:
The fetal head engages into the pelvis, which is called lightening. The abdomen usually appears lower and more protruding. The pregnant may feel a greater ease in breathing. The lower position of the baby, can lead to increased backache and increased frequency of urination. Increased "practice" contractions that prepare the uterus for labor and may cause softening, some effacement and dilation (thinning and opening) of the cervix, and expansion of the lower uterine segment. These contractions do not ordinarily cause pain, are not strong and regular. This is false labor or prodromal labor which may occur few hours prior to labor. Possible the release of slightly brown, pink or blood-tinged mucus from effacement and dilation of the cervix. A loss off in weight as a result of hormonal shifts.

Labor is defined as uterine contractions that cause cervical change in either effacement and dilation. Labor is divided into 3 stages.
First Stage of Labor begins with regular uterine contractions that cause cervical effacement and dilatation and ends when the cervix is completely dilated to 10 centimeters. This stage is named the stage of cervical effacement and dilatation. Average length ranges for a first-time mother is from 10 to 14 hours and shorter for subsequent births.

 Second Stage of Labor begins when the cervix is completely dilated and ends with delivery of the infant. This stage is named the stage of expulsion of the fetus. Average length for a first-time mother ranges from to 2 hours and several-time to 1 hour.

Third Stage of Labor begins with delivery of

the infant and ends with the delivery of the placenta and fetal membranes. This stage is named the stage of separation and expulsion of the placenta. Average length for all vaginal deliveries ranges from 5 to 30 minutes.

THE FIRST STAGE is divided into the latent and active phases. The latent phase generally ranges from the onset of labor until 3 or 4 cm of dilation and is characterized by slow cervical change. The active phase follows the latent phase and expends until than 9 cm of dilation and is defined by fast cervical change, at least 1,0 cm/h. After the rupture of membranes the contractions will strengthen and accelerate in frequency. In the transition phase from 8 cm10 cm of dilation, the contractions often come every 2 minutes and typically last 7090 seconds, and the cervix completes dilation.

In labor the uterine contractions are characterized by frequency, duration and intensity. The duration of each contraction increases from 20 to 60 seconds, the interval between contractions diminishes gradually from about 10 minutes at the onset to 2-3 minutes or less in the end of the first stage. During the second stage of labor, the uterus continues to contract about every 1-2 minutes and each contraction lasts 45 to 90 seconds. The contractions are usually strong and forceful and may be accompanied by efforts to push.

With labor, the uterus differentiates into two distinct parts: the actively contracting upper segment, and the lower portion, comprising the lower segment of the uterus and cervix. The lower segment is analogous to a isthmus of the uterus of nonpregnant woman, and develops gradually as pregnancy progresses and than thins during labor. By abdominal palpation the two segments can be differentiated during a contraction.

The upper segment is quite firm, it contracts, retracts, and expels the fetus. The lower uterine segment is much less firm, it dilates and with the cervix forms a muscular tube which the fetus can pass. The boundary between the two uterine parts is marked by a ridge on the uterine surface and is named physiologic retraction ring. Due to retraction ring the examiner can define the degree of cervical dilatation.

During normal labor there is a gradient of

diminishing physiologic activity from the fundus to the cervix. When the labor is progressing, the

intensity of each contraction is greater in the fundal

zone than in the midzone, and greater in the midzone than lower down. Occasionally, when the labor is not progressing, this gradient is absent, and both the intensity and the duration of the contractions may be the same in all three zones. It does not result in cervical effacement and dilatation, and than in expulsion of the fetus.

The mechanism of cervical effacement is the shortening of the cervical canal from 2 cm in length to 1 in which the canal is replaced by a circular with almost paper-thin edges. In the nulliparous patient this process occurs as the muscular fibers of the internal os are taken up into the lower segment, while the condition of the external os remains unchanged. When the cervix is completely effaced, the exernal os is dilating. The uterine contractions act to cause pressure on the membranes, and the hydrostatic action of the amniotic sac dilates the cervical canal. In the multiparous patient the cervical effacement and dilatation take place together. The cervical canal must dilate to a diameter of about 10 cm, it is named completely dilated or fully dilated.

In labor the membranes serve a role in dilating the cervix. Spontaneous rupture of them most often occurs in the end of the first stage, while cervix is fully dilated, it is named

timely rupture of membranes In 10 % of pregnancies the membranes rupture prior to the onset of labor

premature rupture of membranes

Less frequently, the uterine contractions may begin with a "breaking of the water"

early rupture of membranes Diagnosis of rupture of membranes is defined with a history of a gush or leaking of fluid from the vagina and can be confirmed by the special tests.

Vaginal examination should be done rarely to decrease the risk of an intrauterine infection. The cervical examination allows the obstetrician to determine whether a patient is in labor, the phase of labor, how labor is progressing, a fetus presentation, amniotic fluid, pelvic architecture, and diagonal conjugate.

The five components of the cervical examination -

Bishop score:
1. cervical dilation (cm), 2. cervical effacement (%) the cervix is 2 cm in length, it is 50% effaced, 3. fetal station - relationship of the fetal head to the ischial spines of the female pelvis; if at the level of the spines it is at 0(zero) station, above the spines - it is 1 or -2; if it passed them by 2 cm it is at +2 station, 4. cervical position may be posterior, mid or anterior in relation to the leader line of the female pelvis, 5. consistency of the cervix may be firm, medium, soft. A Bishop score greater than 8 is considered that a cervix is ready to the spontaneous labor.

In labor the mothers temperature, blood pressure, and pulse are determined every 1 to 2 hours. Determination of fetal heart rate can be done by auscultation with a stethoscope. The normal range for the fetal heart rate is 110 170 beats per minute. The fetal heart rate should be auscultated every 15 minutes in the first stage and after each uterine contraction in the second stage of the labor. In patients with obstetric risk factors electronic fetal monitoring is using during the all time of labor.

Free position the patient in the first stage of labor

In THE SECOND STAGE OF LABOR, the baby is pushed through the birth canal by both the uterine contractions and by the additional maternal efforts of "pushing". Most women feel increased pressure in their perineum, and rectum. This stage begins when the cervix is fully dilated that can be determined by performing a vaginal exam.

LABOR IN OCCIPUT ANTERIOR PRESENTATION

The cardinal movements of a labor in occiput anterior
presentation are: 1- flexion 2 - internal rotation of the fetal head 3 - extension of the fetal head

4 - internal rotation of the fetal head and external

rotation of the fetal body. Then the anterior shoulder and posterior shoulders is delivered.

On the beginning of delivery, on vaginal examination, the sagittal suture of the fetal head occupies the transverse diameter of the pelvic inlet more or less midway between the sacral promontory and the symphysis. It is called normal synclitism. Such lateral deflection of the head to a more anterior or posterior position in the pelvis is called asynclitism. If the sagittal suture approaches the sacral promontory, and more of the anterior parietal bone can be examining by fingers, this condition is called anterior asynclitism. If the sagittal suture lies close to the symphysis, and more of the posterior parietal bone presents, this condition is called posterior asynclitism.

The first step for the birth of the infant is descent. Descent is occur due to one or four forces: pressure of the amniotic fluid, direct pressure of the fundus upon the breech,

contraction of the abdominal muscles,

extension and straightening of the fetal body.

1. Flexion. As soon as the descending head meets resistance, whether from the cervix, the walls of the pelvis, or the pelvic floor, flexion of the head normally results. In this movement, the chin is brought into more intimate contact with the fetal thorax, and the shorter suboccipitobregmatic diameter (9.5 cm) is substituted for the longer occipitofrontal (12 cm). The leader point is the small posterior fontanel.

2. Internal rotation. The rotation begins when the fetal head descends from the plane of greatest pelvic dimensions to the least pelvic dimensions (midpelvis). The rotation is completed when the head reaches the pelvic floor, the sagittal suture is in the anteroposterior diameter of the pelvic outlet and the small fontanel is under the symphysis.

Internal rotation

3. Extension. After internal rotation, the sharply flexed head reaches the pelvic floor, two forces come into play. The first, exerted by the uterus, and the second, supplied by the resistant pelvic

floor. The resultant force is in the direction of the

vulvar opening, thereby causing extension. Extension begins when the fixing point (fossa

suboccipitalis) is under the inferior margin of the

symphysis pubis. The head is born by further extension as the occiput, bregma, forehead, nose, mouth, and chin pass over the anterior margin of the perineum.

4. External rotation of the fetal head and internal rotation of the fetal body. During the head extension the fetal body is in the pelvic cavity. The biacromial diameter turns from the oblique to the antenoposterior diameter of the pelvic outlet. Fetal head rotates as a result of the body rotation. In the I position fetal face turns towards the right ischial tuberosity, in the II position - towards the left.

The anterior shoulder appears under the symphysis pubis, fixes, the fetal body flexes and posterior arm is born first. Then the anterior arm is born. After delivery of the shoulders, the rest of the body of the child is quickly extruded.

LABOR IN OCCIPUT ANTERIOR PRESENTATION

LABOR IN OCCIPUT POSTERIOR PRESENTATION In the majority of labors in the occiput posterior presentations, the mechanism of labor is identical in the anterior varieties, except that the occiput has to rotate to the symphysis pubis through 135 degrees. In 5 to 10 % of causes with poor contractions or faulty flexion of the head, the rotation may be incomplete or may not take place at all, especially if the fetus is large.

The cardinal movements of labor in posterior occiput presentation are: 1. Flexion. 2. Internal rotation. 3. Additional flexion. After internal rotation the head reaches the pelvic floor. Fetal head fixes with the area of the border of the hair part of head (the first fixing point) under symphysis pubis and flexes. This process leads to delivery of the vertex. 4. Extension. Extension begins when the second fixing point (fossa suboccipitalis) become under the tip of the sacrum. The head is born by further extension. 5. External rotation of the fetal head and internal rotation of the fetal body.

In vertex presentations, the changes of shape of the fetal head is occurred as a result of the pressures to which it is subjected during labor. The portion of the fetal scalp becomes edematous, forming a swelling known as a caput succedaneum.

Caput succedaneum

The THIRD STAGE begins after the infant has been delivered. Placental separation usually occurs within 5 to 10 minutes, however, up to 30 minutes is considered normal limits. The placenta is mechanically separated from the wall with contractions.

 Central type of placental separation (is known as the mechanism of Schltze) - the retroplacental hematoma is believed to push the placenta toward the uterine cavity, first the central portion and than the rest. The placenta, thus inverted and weighted with the hematoma, than descents. The glistening fetal surface of the placenta appears first at the vulva. The retroplacental hematoma either follows the placenta or is found within the interverted sac, and blood not escaping externally untill after extrusion of the placenta.

Mechanisms of placental extrusion:

 Duncan mechanism in which separation of the placenta occurs first at the periphery, with the result that blood collects between the membranes and the uterine wall and escapes from the vagina. The placenta descents to the vagina sideways, and the maternal surface appears first at the vulva. During the third stage oxytocin can be used to strengthen uterine contractions to decrease both placental delivery time and blood loss.

The main signs of placental separation :

The uterus rises up and to the right in the abdomen because the placenta passes down into the lower uterine segment (Shreder`s sign). The umbilical cord protrudes farther out of the vagina, indicating that the placenta has descended (Alfeld`s sign). The uterus becomes globular and firm. While pressure by the rib of palm above symphysis pubis the umbilical cord goes down out of the vagina (Chukalov`s sign).

The method of choise of the separation of the placenta is the active method. Oxytocin should be used after the delivery of the baby to strengthen uterine contractions to decrease both placental delivery time and blood loss. The placenta is delivered by gentle traction on the cord and contrtraction on the uterus. After delivery the placenta should be examined carefully to ensure that it was delivered whole.

In labor the woman normally loses 0.5% of body's weight.

OBSTETRIC ANALGESIA AND ANESTESIA

Non-medical pain control: psychological preparation education massage hypnosis water therapy in a bathroom family delivery meditation and mind medicine techniques

Medical pain control:

inhaled nitrous oxide gas opioids may be used early in labor, but there is a risk of respiratory depression in the infant regional epidural anesthesia spinal anesthesia local infiltration with an anesthetic (episiotomy) general anesthesia (cesarean section, particularly in the emergent setting) - but there are the risk of maternal aspiration and the risk of hypoxia to the mother and fetus during induction.

Thank you for attention