NORMAL

LABOR
JI ANIES AND CALAGUI
 Table of contents
01 02 03
WORKING
PATIENT’ S ROS AND PE IMPRESSION
PROFILE

04 05
COURSE IN THE CASE
WARD DISCUSSION
PATIENT’S PROFILE

N.S.

38
ELDERLY
PRIMIGRAVID

LABOR PAINS
HPI
PERTINENT HISTORY
 ROS AND PE

REVIEW OF SYSTEMS PHYSICAL EXAM FINDINGS

WORKING IMPRESSION
 COURSE IN THE WARD
DAY 1

SUBJECTIVE

OBJECTIVE
 COURSE IN THE WARD
DAY 1

ASSESSMENT

PLAN
 COURSE IN THE WARD
DAY 2

SUBJECTIVE

OBJECTIVE
 COURSE IN THE WARD
DAY 2

ASSESSMENT

PLAN
Labor
✅begins with the onset of regular uterine
contractions resulting in cervical dilatation
✅ends with delivery of the newborn and
expulsion of the placenta.
 01
FETAL
ORIENTATION
✅FETAL LIE
- describes the relationship
of the fetal long axis to that
of the mother
- Longitudinal, Transverse
and oblique
✅ FETAL PRESENTATION
- portion of the fetal body either
within or in closest proximity to
the birth canal
● Cephalic
○ Vertex (occipital fontanel)
○ Face
○ Sinciput (anterior fontanel)
○ Brow
● Breech
○ Frank
○ Complete
○ footling
FETAL ATTITUDE (HABITUS)
- characteristic posture the fetus assumes
✅ FETAL POSITION
- refers to the relationship of a defined portion of the fetal presenting
part to either the right or left side o the birth canal.

Occiput ANTERIOR positions

● the convex back is felt

Occiput POSTERIOR
positions
● nodular extremity parts are
appreciated
02
MECHANISM
OF LABOR
  Positional changes of the presenting
part are needed or the fetus to navigate
through the pelvic canal.
 Engagement
 Descent- 1st requisite of vaginal delivery
 Flexion
 Internal rotation- essential for the
completion of labor
 Extension
 External Rotation
 Expulsion
OCCIPUT POSTERIOR
POSITION (20%)
● more often associated with a
narrow pelvis
● If rotation is incomplete, a
transverse arrest may result.
● If no rotation toward the
symphysis proceeds, the
occiput may remain in the
direct OP position, a condition
known as persistent occiput
posterior.
*** Both can lead to dystocia
and cesarean delivery
 FETAL HEAD CHANGES
• portion of the fetal scalp immediately over
the cervical os becomes edematous
• More commonly formed when the head is
in the lower portion of the birth canal and
frequently only alter the resistance of a
rigid vaginal outlet is encountered
• develops over the most dependent area of
the head
CAPUT SUCCEDANEUM
• may form far from the sagittal midline
(marked asynclitism and dystocia)
 FETAL HEAD CHANGES

• changes in the bony fetal head shape as a

result of external compressive forces
• related to Braxton Hicks contractions
• yields a shortened suboccipitobregmatic
diameter.
• Of greatest importance in women with
MOLDING contracted pelves or asynclitism
• Most resolves within the week following
delivery
 FETAL HEAD CHANGES

• small pool of blood develops into a mass

just underneath the baby's scalp outside
the skull
• caused when the pressure on a baby's
head during vaginal childbirth damages or
ruptures very small blood vessels in scalp.
CEPHALHEMATOMA
 03
CHARACTERISTIC
S OF NORMAL
LABOR
WHEN TO KNOW THAT LABOR
HAS COMMENCE?
● when painful contractions
become regular resulting in
cervical dilatation
● beginning at the time of
admission to a labor unit
FIRST STAGE OF LABOR
• Onset of labor to cervical dilation
✅PREPARATORY DIVISION
● Sedation and conduction
analgesia are capable of arresting
this labor division
✅DILATATIONAL DIVISION
● dilation proceeds at its most rapid
rate, and is unaffected by
sedation
✅PELVIC DIVISION
● cardinal movements of labor take
place
● commences with the deceleration
phase of cervical dilation
FIRST STAGE OF LABOR
 2 PHASES:

✅LATENT PHASE
● Corresponds to the preparatory
division
● Prolonged latent phase
 Nullipara : >20 hours
 Multipara : >14 hours
✅ACTIVE PHASE
● Corresponds to the dilatational
division
 Acceleration phase
 Phase of maximum slope
 Deceleration phase
FIRST STAGE OF LABOR
 2 PHASES:

✅LATENT PHASE
● Corresponds to the preparatory
division
● FACTORS AFFECTING LATENT
PHASE DURATION:
1. excessive sedation or epidural
analgesia
2. unfavorable cervical condition (thick,
uneffaced, or undilated)
3. false labor
FIRST STAGE OF LABOR
 2 PHASES:

✅ACTIVE PHASE
● Corresponds to the Dilatational
division
● 3-6 cm Cervical dilatation
threshold of active labor
 1.2-6.8 cm/hr minimum
rate of cervical dilation
 1.5 cm/hr- multipara
 1.2 cm/hr nullipara
FIRST STAGE OF LABOR
 2 PHASES:
✅ACTIVE PHASE
Acceleration phase
 the rapid increase in cervical
dilatation
Phase of maximum slope
 The peak of cervical dilatation
Deceleration phase
 the most important- it
determines if vaginal delivery is
favorable or possible
SECOND STAGE OF LABOR
• begins with complete cervical
dilation and ends with fetal
delivery
 nulliparas 50 mins
Multiparas 20 minutes
 04
MANAGEMENT OF
NORMAL LABOR
Identification of Labor
• Early admittance
 important during antepartum care, the
woman, her fetus, or both are found to carry risks
for intrapartum complications.
• For women without antepartum risks and
with reassuring materno-fetal status
 expectant care during latent labor is
reasonable (American College of Obstetricians and
Gynecologists, 2019a).
INITIAL EVALUATION
• PREGNANT
 Blood pressure, temperature, pulse, and
respiratory rate are recorded for the gravida presenting
with labor symptoms.
 Fetal heart rate is evaluated using a portable
Doppler device, sonography, or fetoscope.

• A vaginal examination is performed unless there is a

known placenta previa or vasa previa.
 The gloved index and second fingers are
introduced into the vagina while avoiding the anal
region.
 INITIAL EVALUATION
• Ruptured membranes
- diagnosed if amnionic fluid pools in the posterior fornix or clear fluid
flows from the cervical canal
o pH determination of vaginal fluid (Nitrazine test)
- A pH above 6.5 is consistent with ruptured membranes. False-
positive test results may stem from blood, semen, or bacterial vaginosis, which
raise pH. Scant fluid can yield a false-negative test result.
o AFP measurement
o AmniSure, Actim PROM,ROM PLUS
o Microscopic evaluation- Arborization or a fern pattern suggests
amnionic rather than cervical fluid
 INITIAL EVALUATION
• CERVICAL ASSESSMENT
o Cervical dilation
o Cervical effacement
 When the lowermost portion of
the presenting fetal part reaches
the spines, it is designated as
being at zero (0) station.
o Cervical position reflects the
relationship of the cervical os to
the center point of the presenting
part.
o Bishop’s Scoring  cervical dilation,
effacement, consistency, position, and fetal
station—are assessed when tabulating the
Bishop score.
INITIAL EVALUATION
 05
MANAGEMENT OF
1st STAGE OF
LABOR
INTRAPARTUM ASSESSMENT
o in the absence of any abnormalities, the fetal heart rate
should be checked immediately after a contraction at least
every 30 minutes and then every 15 minutes during
second-stage labor.
 If continuous electronic monitoring is used, the
tracing is evaluated at least every 30 minutes during the
first stage and at least every 15 minutes during the
second stage.
INTRAPARTUM ASSESSMENT
o For women with pregnancies at risk, fetal heart auscultation
is performed at least every 15 minutes during first-stage
labor and every 5 minutes during the second stage.
o Continuous electronic monitoring may be used with evaluation
of the tracing every 15 minutes during the first stage of labor,
and every 5 minutes during the second stage.
MATERNAL MONITORING
o Temperature, pulse, and blood pressure are evaluated at
least every 4 hours.
 If membranes have been ruptured for many hours or
if there is a borderline temperature elevation,
 the temperature is checked hourly
 When the membranes rupture, an examination to
exclude cord prolapse is performed expeditiously if
the fetal head was not definitely engaged at the
previous examination.
 The fetal heart rate is also checked immediately and
during the next uterine contraction to help detect occult
umbilical cord compression
PAIN MANAGEMENT
Pharmacologic options:

 epidural analgesia
 intermittent intravenous (IV)
 intramuscular (IM) opioids
 meperidine
 nitrous oxide
 ORAL INTAKE
• Food and liquids with particulate matter should be withheld during
active labor and delivery.
• Gastric emptying time is remarkably prolonged once labor is
established and analgesics are administered.
• As a consequence, ingested food and most medications remain in the
stomach and are poorly absorbed.
• They may be vomited and aspirated
• oral intake of moderate amounts of clear liquids is reasonable for
women with uncomplicated labor
• with planned cesarean delivery, liquids are halted 2 hours before and
solids are stopped 6 to 8 hours prior to surgery
 IVF
• In the immediate puerperium, a dilute oxytocin
solution can be given prophylactically to prevent
uterine atony and at times therapeutically to treat it
• with longer labors, the administration o  glucose,
sodium, and water to the otherwise asting
woman at the rate o 60 to 120 mL/hr prevents
dehydration and acidosis
 RUPTURED MEMBRANES
• If the membranes are intact, temptation is great, even during normal
labor, to perform amniotomy.
• Benefits are earlier detection of meconium-stained amnionic fluid and
the opportunity to apply an electrode to the fetus or insert a pressure
catheter into the uterine cavity for monitoring
• With prolonged membrane rupture and unknown group B streptococcal
(GBS) status, antimicrobial administration for prevention of GBS
infections is recommended for intrapartum
 rupture of membranes greater than 18 hours or intrapartum
temperature >38.0°C or >100.4°F
URINARY BLADDER FUNCTION
 Catheterization is indicated if the bladder is distended
and voiding is not possible.
 Regional analgesia
 both have comparable rates of puerperal urinary
tract infection and urinary retention
 06
MANAGEMENT OF
2nd STAGE OF
LABOR
 SEVERAL POSITIONS THAT AUGMENTS PUSHING
EFFORT
• Upright positions (standing, sitting out of bed, kneeling,
or squatting)
• lateral recumbent position required the head of the bed
to have an incline ≤30 degrees
• To help avoid femoral or lumbosacral nerve injury for
lithotomy positions, hips are not overly flexed, abducted,
or externally rotated for extended periods
To improve spontaneous birth rates, delayed pushing for 60
minutes once the second stage is reached has been suggested to
permit passive fetal descent to increase pushing efficiency and
minimize maternal exhaustion.
 06
PROTOCOL OF
LABOR
MANAGEMENT
ACTIVE MANAGEMENT
• Oxytocin strengthens and increases frequency of
uterine contractions

• Amniotomy artificial rupture of membranes (AROM)

Pelvic examination is performed each hour for the next

3 hours, and thereafter at 2-hour intervals
ACTIVE MANAGEMENT
• Oxytocin
• amniotomy

Pelvic examination is performed each hour for the next 3 hours,

and thereafter at 2-hour intervals

When dilation has not increased by at least 1 cm/hr, amniotomy is

performed.
Progress is again assessed at 2 hours, and high-dose oxytocin
infusion, is started unless dilation of at least 1 cm/hr is attained.
If membranes rupture before admission, oxytocin is begun or no
progress at the 1-hour mark.
ACTIVE MANAGEMENT
Pelvic examination is performed each hour for the next 3 hours,
and thereafter at 2-hour intervals

When dilation has not increased by at least 1 cm/hr, amniotomy is

performed.
Progress is again assessed at 2 hours, and high-dose oxytocin
infusion, is started unless dilation of at least 1 cm/hr is attained.

If membranes rupture before admission, oxytocin is begun or no

progress at the 1-hour mark.
 The goal is the uterine activity of 200
ACTIVE MANAGEMENT to 250 Montevideo units for 4 hours
before dystocia is diagnosed

Ineffective labor is suspected when the cervix does not dilate within
approximately 2 hours of admission. Amniotomy is then performed,
and labor progress is determined at the next 2-hour evaluation.

In women whose labors do not progress, an intrauterine pressure

catheter is placed to assess uterine function.

Hypotonic contractions and no cervical dilation after an additional 2 to

3 hours result in stimulation of labor using the high-dose oxytocin
regimen.
ACTIVE MANAGEMENT
Dilation rates of 1 to 2 cm/hr are accepted as evidence of progress
after satisfactory uterine activity has been established with oxytocin.
This can require up to 8 hours or more before cesarean delivery is
performed for dystocia

In cases in which hypotonic contractions are strongly suspected,

internal monitors may be placed with amniotomy, and again cervical
change and contraction pattern are assessed in 2 hours.
Reference: William’s Obstetrics 26th Edition