NORMAL LABOR

GENERAL DATA

• SG
• 23 y/o
• 11/19/1994
• Single
• Filipino
• Catholic
• Mapulang Lupa, Valenzuela City
• Jan. 23 2018
CHIEF COMPLAINT
• Labor Pains
HISTORY OF PRESENT PREGNANCY
• Onset of labor pains
• Intermittent contractions every 10 minutes
Few Hours • No bloody or watery vaginal discharge
PTA • Persistence prompted consult

Admission
LMP: April 20, 2017
PMP: March 18, 2017
AOG: 39 weeks and 5 days
OB score: G1P0
EDC: January 25, 2018
 PRENATAL CHECK UP
1ST TRIMESTER
PNCU: 3X Paso de Blas Health center
Cessation of menses: May 2017
Pregnancy test: (+) with urine
Signs and symptoms: (+) nauea,
vomiting in the morning
Labs: CBC, Urinalysis
Medications: Ferrous sulfate
Teratogens: no exposure
2ND TRIMESTER
PNCU: 3x Paso de Blas 1x VMC
Quickening felt at 5th month
Signs and symptoms: none
Labs: hepa, HIV, cbc, ultrasound, 75g
OGTT
Medications: FeSO4, OBMV, Ca,
Ascorbic Acid
Teratogens: no exposure
3RD TRIMESTER
PNCU: VMC 5x
Signs and symptoms: none
Labs: placental Doppler UTZ
Medications: FeSO4, OBMV, Ca,
Ascorbic Acid
Teratogens: no exposure
PAST MEDICAL HISTORY
(-)HPN
(-)DM
(-)ASTHMA
(-)HEART PROBLEMS
(+)UTI – JUNE 2017 -Amoxicillin 500mg TID x 7days
FAMILY MEDICAL HISTORY
(+) HPN (both maternal and paternal side)
(-)DM
(-)CANCER
(-)ASTHMA
PERSONAL AND SOCIAL HISTORY

unemployed
(-) smoker
(-) alcoholic beverage drinker
(-) illicit drug use
MENSTRUAL HISTORY
• Menarche: 14y/o
• Interval: 28 – 30 days
• Duration: 3 days
• Amount: 5 pads/day, moderately soaked
• Symptoms: (+) dysmenorrhea
GYNECOLOGICAL HISTORY
First sexual contact: 21y/o
Number of sexual partner: 1
No post coital bleeding
Denies STD/STI
Contraceptive use: none
OBSTETRICAL HISTORY
• G1P0
• G1 – Present Pregnancy
Review of sysytems
General: (-) weight loss

Cutaneous: (-) rash, pruritus, skin pigmentation

Head: (-) blurring of vision, epistaxis, facial numbness

Cardiovascular: (-) cyanosis, easy fatigability, palpitation

Respiratory: (-) shortness of breath, cough/colds

Genitourinary: (-) difficulty in voiding, dysuria, hematuria

(-) loss of consciousness, tremors, convulsions,
Nervous:
weakness
Muskuloskeletal: (-) joint/muscle pain, swelling
Physical Examination
BP= 110/80 mmHgPR: 98 bpm RR: 19 cpr Temp: 36.80C
Awake, alert, coherent, not in cardio-respiratory distress,
ambulatory
• Head and Neck: Anicteric Sclera, Pink Palpebral
conjuncitiva, (-) NAD/CLAD, (-) TPC
• Heart: Adynamic Precordium, Normal rate and Regular
Rhythm, (-) murmur
• Lungs: Symmetric Chest expansion, (-)retractions, (-)
lagging, Clear breath sounds
• Extremities: Grossly normal extremities, no edema, no
cyanosis
• ABDOMEN:
• Globular, with striae gravidarum, normoactive bowelsound
• L1: breech L2: back-Right L3: not engaged L4: N/A
• FH: 28cms FHT: 130s/min EFW: 2480g
• INTERNAL EXAM
• At the ER, initial IE is: cervix is soft in consistency, located
midposterior, dilated at 2 cm, 40% effaced, cephalic, station -
2, with intact bag of water
• The cervix is soft in consistency located mid posterior, fully
dilated, fully Effaced, cephalic in presentation at Station 0 with
intact bag of water.
• CLINICAL PELVIMETRY:
Diagonal Conjugate: >11.5cms
Ischial Spine: Not Prominent
Interspinous Diameter: >10cms
Sacrosciatic Notch: wide
Sacral Cavity: Average
Pelvic Walls: Parallel
Pubic Arch: Wide
Intertuberous Diameter: >8cms
• Evaluation: Adequate pelvic capacity
• Assessment: normal
IMPRESSION

G1 P 0 Pregnancy Uterine 39 weeks and 5 days Age of

Gestation, Cephalic in Labor
Normal Labor
Labor
• Defined as the process that leads to childbirth

• Uterine contractions that bring about demonstrable effacement and

dilatation of the cervix

• Begins with the onset of regular uterine contraction and ends with
the delivery of the newborn and expulsion of placenta.
Mechanisms of Labor
• Fetal Lie

The relation of the fetal long axis to that of the mother

either longitudinal or transverse

Longitudinal lie is present in more than 99 percent of labors at term

Mechanisms of Labor
• Fetal Presentation

The portion of the fetal body that is either foremost within the birth canal or in
closest proximity to it
 Cephalic Presentation
• vertex or occiput presentation - the head is flexed sharply so that the chin is in
contact with the thorax, occipital fontanel is the presenting part

• face presentation - fetal neck may be sharply extended so that the occiput and back
come in contact, and the face is foremost in the birth canal

• sinciput presentation - the anterior (large) fontanel, or bregma is the presenting part

• brow presentation – fetal head is partially extended

Breech Presentation
• result from circumstances that prevent normal version
e.g.
septum that protrudes into the uterine cavity
extension of the vertebral column of the fetus
placenta is implanted in the lower uterine segment

• Three general configurations

Frank
Complete
Footling
ABDOMINAL EXAM – LEOPOLD MANEUVERS

• L1 – FUNDAL GRIP
• L2 – UMBILICAL GRIP
• L3 – PAWLIK’S GRIP
• L4 – PELVIC GRIP
Mechanisms of Labor
• Fetal Attitude or Posture
the fetus assumes a characteristic posture described as attitude or habitus

the fetus forms an ovoid mass that corresponds roughly to the shape of the
uterine cavity
Mechanisms of Labor
• Fetal Position

refers to the relationship of the fetal presenting part to the right or left side of
the birth canal.
 Cardinal Movements of Labor
• Engagement - The mechanism by which the biparietal diameter passes through the pelvic inlet.

• Descent - brought about by one or more of four 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

• Flexion – when the descending head meets resistance, whether from the cervix, pelvic walls,
or pelvic floor

• Internal rotation - consists of a turning of the head in such a manner that the occiput gradually
moves toward the symphysis pubis anteriorly from its original position or, less commonly,
posteriorly toward the hollow of the sacrum
• Extension – When the head presses on the pelvic floor, two forces come
into play. The first force, exerted by the uterus, acts more posteriorly, and
the second, supplied by the resistant pelvic floor and the symphysis, acts
more anteriorly. The resultant vector is in the direction of the vulvar
opening, thereby causing head extension.

• External rotation - The delivered head next undergoes restitution, This

movement corresponds to rotation of the fetal body and serves to bring
its bisacromial diameter into relation with the anteroposterior diameter
of the pelvic outlet.

• Expulsion – occurs almost immediately after external rotation

Characteristic of Normal Labor – First Stage of Labor
• Functional Division of Labor
• Preparatory division – minimal cervical dilatation. Sedation and
conduction analgesia are capable of arresting this division.

• Dilatation division - dilatation proceeds at its most rapid rate, is

unaffected by sedation.

• Pelvic division – commences with the deceleration phase of cervical

dilatation, cardinal fetal movements of the cephalic presentation take
place principally during this division.
• Phases of cervical dilatation
• Latent Phase - Point at which the mother perceives regular
contractions and ends once dilatation of 3 to 5 cm is achieved.

• Active Phase – subdivided into acceleration phase, the phase of

maximum slope, and the deceleration phase
Characteristic of Normal Labor – Second Stage of Labor
• Begins with complete cervical dilatation and ends with fetal delivery

• The median duration is approximately 50 minutes for nulliparas and

about 20 minutes for multiparas,
Management
Stages of Labor
Management of the First Stage of Labor
• Monitoring Fetal Well-Being during Labor
• Uterine Contractions
• Maternal Vital Signs
• Oral Intake
• Intravenous Fluids
• Maternal Position
• Analgesia
• Amniotomy
• Urinary Bladder Function
Management Of The Second Stage Of Labor
• Full cervical dilatation—onset of the second stage
• Median duration of the second stage is 50 minutes in nulliparas and 20
minutes in multiparas
• Expulsive Efforts
• Preparation for Delivery
• Spontaneous Delivery
• Delivery of the Shoulders
• Clearing the nasopharynx
• Clamping the cord
Management Of The Third Stage Of Labor
• After delivery of the newborn
• Watchful waiting until the placenta separates is the usual practice
• Fundus is frequently palpated to make certain that it does not become atonic and
filled with blood from placental separation
• Signs of placental separation (1 to 5 minutes after delivery of the newborn )
• Physiological management of the third stage
• Uterus is contracted firmly, pressure is exerted with the hand on the fundus to propel the
detached placenta into the vagina
• Expression of the placenta: not forced or use traction before placental separation lest the
uterus becomes inverted.
• Uterine inversion is one of the grave complications associated with delivery, and it constitutes an
emergency requiring immediate attention
• Uterus is then lifted cephalad with the abdominal hand
• Repeated until the placenta reaches the introitus.
Active Management of the Third Stage

• Uterine massage following placental delivery to prevent

postpartum hemorrhage
• Oxytocin, ergonovine, and methylergonovine
"Fourth Stage" of Labor

• Hour immediately following delivery is critical

• Postpartum hemorrhage as the result of uterine atony
• Uterus and perineum should be frequently evaluated
• Maternal blood pressure and pulse be recorded immediately after delivery
and every 15 minutes for the first hour
•
• Episiotomy
• Incision of the pudenda
• Episiotomy often is used synonymously with perineotomy
• Incision
• Purposes of Episiotomy
• Timing of Episiotomy
 Midline versus Mediolateral Episiotomy
Characteristic Midline Mediolateral
Surgical repair Easy More difficult
Faulty healing Rare More common
Postoperative pain Minimal Common
Anatomical results Excellent Occasionally faulty
Blood loss Less More
Dyspareunia Rare Occasional
Extensions Common Uncommon
• Pain after Episiotomy
• Pudendal block analgesia
• Relieve perineal pain postoperatively
• Application of ice packs  reduce swelling and allay discomfort
• Codeine
• Pain is severe or persistent
• May be a signal of a large vulvar, paravaginal, or ischiorectal
hematoma or perineal cellulitis
The Routine Use of Prophylactic
Oxytocin in the Third Stage of
Labor to Reduce Maternal Blood
Loss
Kuzume, et al., 2017
Department of Obstetrics and Gynecology, NHO Nagasaki Medical
Center, Omura, Japan
Study Objective
To demonstrate whether or not the routine use of prophylactic
oxytocin (RUPO) reduces the blood loss and incidence of postpartum
hemorrhaging (PPH).
Method
• Used a prospective cohort and a historical control in a tertiary
perinatal care center in Japan. In the prospective cohort, introduced
RUPO in April 2012 by infusing 10 units of oxytocin per 500 mL of
normal saline into a venous line after anterior shoulder delivery
(RUPO group). In the historical control, oxytocin was administered via
a case-selective approach (historical control group).
• Included were completed singleton vaginal deliveries and compared
were the volume of blood loss and the incidence of PPH between the
groups.
Results
Significantly lower volume of blood loss (520 ± 327 versus 641 ±
375 mL, p < 0.001) and a lower incidence of PPH (6.1% versus 14.0%, p
< 0.001) in the RUPO group (n = 392) than in the control group (n =
407). Although the oxytocin dose was significantly higher in the RUPO
group (12.8 ± 6.7 versus 10.1 ± 8.0 IU, p < 0.001), no adverse outcomes
were observed to be associated with RUPO.
Citation
Kuzume, A., Sugimi, S., Suga, S., Yamashita, H., & Yasuhi, I. (2017). The
Routine Use of Prophylactic Oxytocin in the Third Stage of Labor to
Reduce Maternal Blood Loss. Journal of Pregnancy, 2017, 3274901.
http://doi.org/10.1155/2017/3274901
 Intravenous fluid rate for reduction of
cesarean delivery rate in nulliparous women:
a systematic review and meta-analysis

Ehsanipoor, et al., 2017

Objective
Aim of study was to determine whether an intravenous fluid rate of
250 vs. 125 mL/h is associated with a difference in cesarean delivery
rate.
Methods
Included all randomized controlled trials comparing intravenous fluid
rates of 250 vs. 125 mL/h
Spontaneous labor
Singleton
≥36 weeks
Regardless of type of IVF
Excluded: Multiparous, induced labor
Primary outcome: incidence of cesarean delivery.
 Results
Women who received intravenous fluids at 250 mL/h had a
significantly lower incidence of cesarean delivery for any indication
(12.5 vs. 18.1%; RR 0.70, 95% CI 0.53–0.92; seven studies, 1215
participants; I2 = 0%) and for dystocia (4.9 vs. 7.7%; RR 0.60, 95% CI
0.38–0.97; five studies, 1093 participants; I2 = 18%), a significantly
shorter mean duration of labor of about one hour (mean difference
−64.38 min, 95% CI −121.88 to −6.88; six studies, 1155 participants;
I2 = 83%) and a significantly shorter mean length of second stage of
labor (mean difference −2.80 min, 95% CI −4.49 to −1.10; 899
participants; I2 = 22%) compared with those who received
intravenous fluid at 125 mL/h.
Conclusion
Duration of labor in low-risk nulliparous women may be shortened by a
policy of intravenous fluids at a rate of 250 mL/h rather than 125 mL/h.
A rate of 250 mL/h seems to be associated with a reduction in the
incidence of cesarean delivery compared to 125 mL/h. The number
needed to treat to prevent one cesarean delivery is 18 women.
Citation
Ehsanipoor RM, Saccone G, Seligman NS, Pierce-Williams RAM, Ciardulli
A, Berghella V. Intravenous fluid rate for reduction of cesarean delivery
rate in nulliparous women: a systematic review and meta-analysis. Acta
Obstet Gynecol Scand 2017; 96:804–811.