Normal Labor ,Delivery and the Puerperium

Four major factors determined labor and delivery

The

power The pelvis The fetus Psychological factors

The power: The characteristics of

myometrial muscle are unique which compared with skeletal muscle

The degree of shortening of smooth muscle cells with contractions may be greater Forces can be exerted in smooth muscles in any direction Smooth muscle is organized in different manners Multidirectional force generation permits versatility in expulsive force directionality

An important ancillary force in expulsion of the fetus is that produced by increased maternal intraabdominal pressure.

Pelvic Planes

The pelvis is divided into 3 planes: The plane of the pelvic inlet: The fetal head enters the pelvis through this plane in the transverse position. The midplane: is the most important. Because most instances of arrest of descent occur at this level. The plane of the pelvic outlet: is formed by two triangular planes with a commom base at the level of the ischial tuberosities.This plane is the site of a low pelvic arrest.

Main pelvic diameters

Pelvic

inlet: anteroposterior; transvers;left and right oblique Midplane: bispinous diameter Pelvic outlet: bituberous diameter; posterior sagittle diameter; subpubic angle

Cervical Effacement
Prior

to the onset of parturition Become soft and thin frequently Take up into the lower uterine segment Mucous plug released Bloody show

Psychological factors :recent research has shown that it act an important role in labor.because of fearing labor pain,a considerable number of women suffered dystocia.

Labor
Is

a physiologic process that permits a series of extensive physiologic changes in the mother. Allow for the delivery of the fetus through the birth canal. It is defined as progressive cervical effacement and dilatation, resulting from the regular uterine contractions.

What is the regular contraction?

The

regular contraction: Occurs at

least every 5 minutes and last 30 to 60 seconds,with greater intensity.

The

contractions appear to arise in the upper coronal regions of the uterus, then near the fundus,spread to the lower pole progressively.

Preparation for labor

Lightening:

two or more weeks before labor,fetal head in most primigravid women settles into the brim of the pelvis. False labor: during last 4~8 weeks of pregnancy,the uterus undergoes irregular contractions. Cervical effacement. These are not associated with progressive cervical dilatation.

Engagement
Engagement

occurs when the widest diameter of the fetal presenting part has passed through the pelvic inlet. (in cephalic presentations, the widest diameter is occipitofrontal diameter) When the fetal head has engaged, that means the bony presenting part is at the level of the ischial spine.

 The

station of the presenting part in the pelvic canal is defined as its level above or below the plane of the ischial spine. The level of the ischial spines assigned as zero(S-0), each centimeter above or below this level is given a minus or plus designation(S-1; S+2 ).

 When

the presenting is out of the pelvis, it is freely movable, it is considered to be floating. When it has passed through the plane of the inlet ,but is not yet engaged, it is considered to be dipping.

Labor is divided into three stages

First

stage : From the onset of regular contraction of uterine to complete dilation of the cervix.(10cm) It consists of two phases: The latent phase: onset of true labor to cervical effacement and early dilation.(3cm); The active phase: the cervical dilation is more rapid occurs.(4cm~10cm). Second stage : From complete dilation of the cervix to the birth of the baby.

Third stage :is from the birth of the baby to the delivery of placenta and membrances.

Length of stages
primipara
Duration of the first stage Rate of cervical dilatation during active phase

multipara 6~8 hours 1.5cm/hour

11~12 hours 1.2cm/hour

Duration of second stage Duration of third stage

1~2hours 5~15min

5~30min 5~15min

Management of first stage

Drawing picture of stages of labor(partogram). Record maternal pulse rate,BP,respiratory rate,temperature ,urine output every 1~2 hours; descent of the fetal head. Auscultate the fetal heart rate(FHR) every 30 minutes Monitor the uterine contraction every 30 minutes for frequency,duration,intensity Do vaginal examination every 2 hours to determine the progress of labor. Amniotomy: amniotic fluid; meconium? augment uterine contractility

Second stage of labor----Descent of the fetal head The mechanism of the labor : six-movements of the baby enable it to adapt to the maternal pelvis. They are:
Descent

Flexion
Internal

rotation Extension External rotation Expulsion

Descent
:

Is brought by The force of the uterine contractions Maternal bearing down(Valsalva) efforts Gravity if the patient is upright

Flexion
Partial

flexion exists before labor. Further flexion is caused by: (1)resistance from the cervix (2)walls of the pelvis (3)pelvic floor It can change the presenting diameter from the occipitofrontal to the smaller suboccipitobregmatic.

Internal Rotation
Transverse

or oblique diameter rotates so that the occiput turns anteriorly toward the symphysis pubis. It occurs as the fetal head meets the muscular sling of the pelvic floor. The presenting part reach the lever of the ischial spines.

Extension

The vaginal outlet is directed upward and forward Bulge of the perinium Crowning: the largest diameter of the fetal head is encircled by the vulvar ring. Episiotomy: mediolateral and midline episiotomy. To reduce perineal resistance and avoid tearing and stretching of perineal tissues.

External Rotation
The

delivered head returns to its origional position at the time of engagement(restitution) Shoulders undergo an internal rotation to anteroposterior position within the pelvis

Expulsion
Anterior

shoulder delivers, followed by the posterior shoulder and body of the child

Clinical management of second stage

To encourage the patient to hold her breath and to bearing down with each contractions. Monitor the fetal heart rate every 5 minutes. Vaginal examination every 30 minutes. After delivery, the cord is clamped and cut within 15~20 seconds. Delayed cord clamping can result in hyperbilirubinemia as additional blood is transferred to the newborn infant.

Clinical management of third stage

After the babys delivery,to inspect the cervix and vagina for laceration and surginal repair performed if necessary. To add 20 units of oxytocin to the intravenous infusion to enforce the contractions to reduce uterine bleeding. Separation of the placenta occurs within 2~10minutes

Signs of placental separation

A

fresh show of blood from the vagina. The umbilical cord lengthens outside the vagina natually. The fundus of the uterus rises up. The uterus becomes firm and globular.

Perineal laceration classified as:

First degree: a laceration involving the vaginal epithelium or perineal-skin. Second degree: a laceration extending into the subepithelial tissues of the vagina or perineum with or without involvement of the muscles of the perineal. Third degree: a laceration involving the anal sphincter. Fourth degree: a laceration involving the rectal mucosa.

Puerperium

The puerperium : after delivery of the baby and placenta to approximately 6 weeks postpartum.During the puerperium ,the reproductive organs and maternal physiology return to the prepregnancy state. In women who do not nurse, menstrual flow will return by 6~8 weeks. Ovulation may not occur for several months.

lochia
First

few days after delivery, the uterine discharge is red.----lochia rubra After 3~4 days, the lochia becomes paler.---lochia serosa By tenth day, it becomes a white or yellow-white color.---- lochia alba. Complete involution of the uterus(about 42 days).

Lactation

Two events are instrumental in initiating lactation: (1) the drop in placental hormones (particularly estrogen)allows lactation to occur, (2)Sucking stimulate the release of prolactin and oxytocin. Sucking is thought important for milk production and the ejection. The second day after delivery, colostrum is secreted. After about 3~6 days, the colostrum is replaced by mature milk.

Induction and Augmentation of labor

The indications and contraindications for induction and augmentation of labor . (text book P162). Bishop Score (cervix position, consistency, effacement, dilatation,fetal head station) to assess likelihood of successful induction of labor . If the score >6,the induction may be successful.

Several principles about oxytocin used should be note:

Oxytocin must be given intravenously. A dilute infusion must be used. 5%Glucose 500ml + oxytocin 2.5U iv. The drug is best infused with calibrated infusion pump. The induction of labor should not exceed 72 hours. If adequented labor is estabilished, the infusion rate and the concentration may be reduced.

Complications of induction
Hyperstimulation:

case fetal distress

from ischemia Rupture of the uterus. Antidiuretic effect: coma. Uterine muscle fatigue,postdelivery uterine atony : to increase the risk of postpartum hemorrhage.