OBgyn Week 10 Labor & Delivery. Birth Practitioners Who can deliver the baby? Obstetrician-Gynecologists Maternal-Fetal Med Specialists Family Practice.

OBgyn Week 10Labor & Delivery

Birth PractitionersWho can deliver the baby?

• Obstetrician-Gynecologists

• Maternal-Fetal Med Specialists

• Family Practice Physicians

• Midwives

Phases of Labor

– Stage 1 (early labor and active labor)– Stage 2 (birth of baby)– Stage 3 (birth of placenta)– (Stage 4 (uterine recovery))– Post-partum

Stages of Labor

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Early Labor

• What initiates labor onset?Labor initiation theories:– Baby-initiated

Fetal pituitary signals fetal adrenals

Adrenals secrete cortisol-type hormone

Released into amniotic fluid via fetal urination

Absorbed into maternal blood stream

Stimulates maternal pituitary release of oxitocin

Enters maternal blood stream, stimulates uterine contractions

Labor initiation theories

Mom-initiated– Uterus reaches specific size that causes contractions

due to stretching of muscle fibers (& oxytocin release)– ANS signal that stimulates contractions– Drop in progesterone right before labor removes block

to uterine contractionsWeather-initiated– More babies born when barometric pressure drops

suddenly (eg during snow or rain storm)

Most likely a combination of factors.

(Physiology of Labor Onset)• Physiology of cervical ripening and initiation of

UC (uterine contractions)– Oxytocin produced and released by pituitary into

maternal bloodstream throughout pregnancy• Large # oxytocin receptors in uterus - # of receptors grows

as pregnancy progresses.

– Late PG increase in oxytocin 500% due to uterine stretching and increase in E:P

• Estrogen increases relative to progesterone in 2nd trimester• E increases concentration of oxytocin receptors in uterus• Affects cytokine and prostaglandin production that causes

cervical ripening (soften, thin out, and dilate)

Labor Onset: S/Sx

– Pre-labor = regular uterine contractions without cervical change

– True labor = regular contractions that cause cervical change and continue until baby is born

– Stalled labor = strong regular contractions with cervical change followed by halt in cervical change and descent of baby

Rupture of Membranes

• Membrane rupture aka “water breaking”– Can occur before, during or even after

baby is born

• Concern for infection rises the longer it is between membrane rupture and labor– Consider prophylactic antibiotics, esp. if

mom is beta-strep positive

Labor Onset: S/Sx

• SROM= spontaneous rupture of membranes– Mom can feel fluid leak either as a gush or trickle– May be confused with urine incontinence or vaginal

fluids– Fluid should be clear and smell slightly of seawater– Watch for presence of meconium in amniotic fluid:

starts as dark brown/black and goes pale green over time (may indicate fetal distress)

– Maintain hygiene carefully after rupture: nothing inserted into vagina, clean well after urination & bowel movements

Meconium• Thick, dark green, very sticky, tar-like

substance that lines fetal intestines. – Not usu released until after birth– If released before birth, mixes with amniotic fluid– More chance of release if post-term – Degree of release (color of amniotic fluid) helps

determine action - from monitoring only to amnioinfusion and neonatal airway suction

• Aspiration of meconium can --> pnemonia

Meconium• Baby will normally

pass meconium in first few BMs after birth

• Oiling baby’s bottom beforehand can help to remove this very sticky substance

More S/Sx of Labor Onset

– “Bloody show”: pink-tinged mucus (from a bit of blood), caused by cervical effacement and/or dilation; capillaries break and mix with mucus

– Mucous plug: inner os filled with plug during PG; is usually yellowish-brown. May lose this before or during labor and is a sign that the cervix is changing

– Diarrhea / loose stools as body prepares for labor– Low back and butt pain, urge to poop that is

nagging and won’t go away

Abnormal SX to watch for

• Important for mom to monitor for:– Cessation of fetal movement for > 12 hours– Any vaginal bleeding (more than Bloody

Show)– Marked edema or h/a– Dizziness– Visual changes

Contractions During Early Labor

• Pre-labor contractions vs Braxton-Hicks• B-H: usu felt in lower abd, cervix or back

– Doesn’t tend to include fundus or upper abdomen– Tend to be irregular, but can get regular– Do not lead to dilation, effacement, or descent– Generally are not painful

Labor Progression Terminology

– Dilation: distance from one side of inner os to the other side; 0-10 cm

– Effacement: depth of cervix (0-100%)– Station: degree of descent; how far baby’s head is

into vaginal canal (ischial spine as landmark)• Range is from -5 (above spines) to +5 (below spines:

crowning)• Measured at the farthest point you can touch on either

side of baby’s head (biparietal diameter)

Fetal Descent Stations

First Stage of Labor pt 1

Early phase: 0-4/ 5 cm dilation; effacement varies– Contractions at regular intervals causing dilation

(interval measured from beginning of one contraction to beginning of next)

– Contractions often 5-10 minutes apart, lasting 30-45 seconds; gradually getting closer and longer

– Baby’s head may be descending– Woman can often talk through these, esp. early on

• Mom should rest if she can to help save her energy for later• If at home, can continue to eat and drink• Good time to walk / climb stairs / do lunges / slow dance (with

assistance/support)

First Stage of Labor pt 2

• Active phase – Starts at 4/5 cm to complete dilation– Intervals usually less than 4 minutes, duration

more than 45 seconds. – Contractions much stronger, closer together– Baby should be starting to descend– Bag should be bulging with the strength of uterine

contractions– Whole uterus involved in contraction in

coordinated effort to push baby out.

Active Labor

• Transition is the part of the active phase when cervix dilates from 7-10cm – Usually more painful contractions, more intense,

much closer together, little rest in between– Mom may get chilly, spacey, flushed, emotional,

want to be alone or have someone there for every contraction, n/v

– Coaching support extremely important at this stage

Symptoms during Transition

• Factors causing these symptoms:– Hormones: oxytocin release– Pressure on nerves– Dilation of birth canal from baby’s head– Pain medications (epidural)– Signs of 2nd stage being near: start hearing

bearing-down efforts, desire to push, feel as if about to have BM (b/c pudendal nerve gets pressure which gives the urge to push)

Length of Labor

• Labor stage length averages1st stage 2nd stage 3rd stage

Primip 11-14 h 45-80 mins 15 mins

Multip 7.5 h 20-30mins 5-15 mins

Amt of time labor takes all together depends upon whether she’s a first time mom or not.

Stage 1• Practitioner’s activities in First stage:

– Determine if labor has begun: internal vaginal exam checks for dilation, station, effacement, membranes (intact or not)

– Vitals and FHT (fetal heart tones)– Enema for mom if she desires/if necessary– Baths can help relax muscles but not a good idea

before 5 cm dilation because it can stall labor– Pressure or massage to back, feet, shoulders– Encouragement

• In many hospital settings a L&D nurse responsible for most of these activities

Stage 1

• Fluids/ food – During a hospital birth, will have IV fluids/ lactated

ringer’s solution (electrolytes) and ice chips– During a home birth, woman allowed to eat

(simple, bland foods best) and drink water or electrolyte drink

• Encourage frequent urination• If in hospital mom will have catheter• Toilet a good place to have contractions

(sense of letting go, she’s used to letting go there)

Stage 1 - Positions• Positions

– Home birth/Birth Center: allows for ambulation; help mom find comfortable positions: walking, leaning, use pillows, as long as FHT respond well to positions

– Hospital: change from side to side, but confined to bed because is hooked up to IV and monitors

Stage 1 - Breathing

• Breathing – Not very formalized anymore– Have mom breath comfortably– Lamaze breathing helps give mom/dad something to

concentrate on– Make sure mom not hyperventilating or holding her

breath– Premature urge to push may require coaching mom

to pant to prevent pushing on the undilated cervix

Stage 1

• Monitor: – PE: progression of dilation, effacement, station– Duration and interval of uterine contractions– FHT: baseline is 120-160bpm, which usually

change during contractions• Late deceleration: gradual decrease of FHT during

contractions; drop is after peak of contraction; degree of severity is associated with the length of return to baseline

• Sign that baby is not tolerating stress of contractions well

Stage 2

Commonly called the “pushing” stage• Two parts of 2nd stage:

– Phase one: passive fetal descent• Complete dilation of cervix before pushing• Part of baby that is presenting is rotating to best possible

position for delivery • Urge to bear down becomes reflexive when baby

descends into pelvis

– Phase two: expulsive phase• Pushing or bearing down until infant is delivered• Begins after fetus has descended and rotated into proper

position

Stage 2 - positions

• Positions: anything ok as long as it makes mom comfortable and FHT remain normal

• Birth chair: advantage of gravity and can move legs• Squatting: with support under arms (1 person on either

side), good for end pushes• Semi-reclined: least advantageous, good if labor is too

quick as it helps slow it down• Hands and knees: helpful if pelvis small, great for shoulder

dystocia• Side lying: common with epidural, slows deliver, helps

prevent tearing

Stage 2 - positions

– Advantage of upright v supine positions: upright preferred by mother, shorter 2nd stage, reduction in episiotomies, fewer FHT abnormalities

– Disadvantage of upright: increase in 2nd degree lacerations

– Advantages of being mobile: increased placental perfusion, optimize fetal alignment and descent, shorter 2nd stage, fewer episiotomies, lacerations and FHT abnormalities, less severe pain, squatting increases pelvic space and avoids compression of vena cava

Stage 2 - positions

• Lateral delivery: fewer lacerations, good placental perfusion

• Birthing chairs disadvantages: increased perineal edema, lacerations, and blood loss

Stage 2 - pushing

– Premature urge to push is sometimes felt by women before complete dilation

– Common with occiput posterior (OP – faced the wrong way) babies because occiput presses on rectum

• Prolonged pushing can cause cervical edema, cervical laceration, and exhaustion of the mom

• If baby in other positions and if dilated to 8-9 cm let woman push as her body guides her

Stage 2 - Fetal Heart Tones• Normal FHT patterns

– FHT increases with contractions – they get a little stressed here.

– Variable decelerations: FHT not matching contractions usually due to cord compression. Ok as long as baby recovers to baseline each time.

• Monitor closely if– Decelerations down to 80-100 while pushing;

should come back to baseline after mom stops pushing when contraction done

– Abnormal FHT: change position, if no improvement, delivery necessary (or transport if at home)

Stage 2 - breathing

• 2nd stage breathing – Have mom do what feels right– Coached pushing: Valsalva technique

• Push as if having a BM• Hold breath while pushing after taking in a deep breath• Aim is for 3 pushes per contraction; longer pushes with

quick breath in between are more effective than short pushes

• If making noise during push, not doing it correctly• Rest in between contractions• Only push during contractions• Offer mirror for “self-directed” pushing

Stage 2 - support

• 2nd stage coaching – Emotional support:

• Encourage the mother, tell her she can do it• Decreases catecholamines due to stress, fear• Prevents decreased uterine contractions due to

catecholamine release• Decreases need for pain meds• Shorter labor• Decreased need for instrumental or cesarean

delivery• Supports woman’s bodily functions

Stage 2 - support

• 2nd stage coaching techniques – Encourage woman to delay pushing until her body

directs her to (difficult if epidural), usually at +1 or +2 station

– Direct mother’s pushing efforts when necessary (when don’t appear to be effective)

– Help her into positions of her choice, encourage changes every 20-30 minutes

– Reassure her intensity of sensations are normal– Make her aware of her progress (provide

feedback) b/c she can’t see what she’s doing and what’s going on.

Stage 2 - Labor Dystocia

• Labor Dystocia or Failure to Progress– Ferguson Reflex (bearing down during

contraction) may be delayed or premature• Delayed: usually contractions further apart

– Let mom rest if no urge to push– Can stimulate urge by squatting, pressing on

posterior vaginal wall, other techniques

Failure to Progress

• Premature Ferguson reflexAvoid pushing if cervix not fully dilated!

• Causes cervix to swell and decrease dilation• Causes intrauterine pressure to rise,

decreasing fetal oxygenation• Can overstretch ligaments supporting fetus• If urge is uncontrollable, let her uterus push

without using abdominal walls and diaphragm

Stage 2 - ease• Factors affecting length and degree of ease

of 2nd stage – Strength and coordination of contractions– Strength and ability of mom’s pushing effort

• Weak abdominal muscles, unwillingness to push hard, mom exhausted

– Resistance of lower birth canal: outlet contraction or rigid perineum

• Higher in primips• Athletes/dancers have well-toned mm which don’t relax

easily• Full bladder or rectum• Malpresentations

Induction of Labor

• 5% of primips do not have natural cervical ripening and may require induction

• Several methods to do so:– Herbs, acupuncture, homeopathy (Gelsemium)– Breast stimulation, foley catheter, prostaglandin gel on cervix,

stripping of membranes, amniotomy (artificial rupture of membranes)

– IV pitocin

Induction of Labor

– Over 60% of labors in US are induced – C-section rate in hospital for failed inductions

around 60%– Indications:

• Post dates• PROM• PIH• Fetal distress• Significant antepartum hemorrhage• Macrosomia (very large baby)• Patient or doctor convenience – weird western

convenience thing.

Contraindications to Induction of Labor

– True CPD (cephalopelvic disproportion – rare – head “too large” to exit cervix. Measure pelvic spines to determine.)

– Abnormal presentation which prevents vaginal delivery

– High station– Fetal distress– Placenta previa – placenta across cervical

opening– Cord presentation– Invasive carcinoma of the cervix– Gestational age <37 weeks or >42/43 weeks

(primip/multip)

Stage 2 - Delivery

– Progress checked with sterile glove– Perineal stretching with mineral or olive oil:

massage from internal introitus with two fingers

• Also good to do prenatally in last 6 weeks of pregnancy, 5 min daily

• Minimizes tearing at delivery

– Also hot compresses (add betadine to hot water) hold on perineum and intoritus during or between contractions

Delivery - perineal stretch

• Delivery of the head should be slow to give the perineum time to stretch

• Counter pressure with flexion of baby’s head toward perineum and away from urethra and clitoris

• Have mom moan during contraction (instead of holding breath) to help slow down delivery

Delivery - cord check

• Check for cord after delivery of the head– Nuchal cord is when the umbilical cord is

over head and around neck– If enough slack, can be lifted around head– Special maneuvers to deliver through cord– Cord can be clamped and cut early if

necessary• Baby needs to be delivered quickly if cord

around neck

Delivery of Head

Delivery - body

• After head is delivered, ideally the rest of the baby should be out on the next contraction if possible

• Restitution: baby usually rotates on its own so that shoulders can be delivered

Delivery - care of infant

• Immediate baby care– Skin-to-skin contact with mom will help with

temperature regulation, bonding, and vitality– Have ready: bulb syringe, blanket, cord clamp kit– Drying off baby can stimulate breathing, circulation– Suction baby’s nose and mouth– Baby wrapped in clean blanket, hat put on (cannot

regulate body temp well first few days of life)– Less focus these days on removing vernix (coating

around the baby – very moisturizing)

Neonate

Neonatal Assessment

• APGAR scores assessed at 1 and 5 minutes• Baby given a 0-2 points in 5 categories,

added together– Appearance– Pulse – Grimace– Activity– Respirations

– 7-10 is good; anything under 7 requires emergency efforts

Umbilical Cord

• When to clamp / cut cord– Wait until cord stops beating, unless baby needs

to be moved quickly– Especially if baby premature or has been in any

type of distress– Blood ends up in baby instead of in placenta– Proponents claim it prevents a variety of birth

injuries, from autism, hypoxia, cerebral palsy, mental retardation

Umbilical Cord

• Cord clamping – First clamp is placed about 1 inch from baby’s

umbilicus second clamp is about three inches from baby

– Cord cut in between both clamps– Cord clamp stays on for 24 hours, then cut off,

leaving stump– If need blood sample, can get it from the end of cord – Cord stump dries and falls off in 7-10 days; baby

should not be submerged in water (bath) until this has occurred

Stage 3

• Third stage of labor = delivery of placenta– Usually within 5-15 minutes after baby is delivered

• Placental shearing: uterus becomes firmer as muscles contract– If uterus is still boggy, means muscles are not

contracting, either due to uterine inertia or atony

• Sudden blood gush: blood vessels are open during birth and close off suddenly after placental delivery

Stage 3

• Signs of placental shearing – Uterus rises in abdomen as placenta is no longer

holding it down– Cord lengthens as placenta starting to descend

and separate– If placenta shears from uterus only partially,

greatest risk for hemorrhage as uterus can not fully contract vessels

• As long as mom not hemorrhaging, wait until placenta delivers naturally

Stage 3

• If placenta not delivering and there is no hemorrhage– Acupuncture, homeopathy, herbs– Have mom squat and push for a couple of

minutes– Nipple stimulation (baby to breast)– Milk the cord to squeeze out blood– After 60 minutes intervention may be

necessary

Placenta

• Placenta examination– Make sure no pieces are retained– Ensure proper cord implantation– Vessels: check for 2 arteries and one vein;

if not, may be a sign of congenital abnormalities (e.g. renal agenesis)

– Size, smell, color, calcifications, weight all may be associated with specific conditions

Checking the Placenta

Placenta

• (Placental abnormalities)– Placenta succenturiata: one or more small

accessory lobes which may be retained in uterus– Placenta membranacea: a large, thin,

membranous placenta that surrounds the fetal membranes. Associated with retention and hemorrhage

– Circumvallate placenta: doubling of amnion and chorion; possibly associated with undiagnosed amnionitis, PROM

• Bottom line: placenta should be inspected for abnormalities

Placenta

• (Placental abnormalities)– Placenta accreta: placenta implants deeply in

uterine wall; little or no bleeding after birth of baby• Increta: more deeply inserted into uterine wall• Percreta: insertion though the entire uterus

• If interventions to remove placenta, increased risk of hemorrhage; also higher risk for infection and DIC.

• May require hysterectomy

Hemorrhage

• Blood loss during delivery– Normal: 250-500ml– Over 500ml is considered a hemorrhage– If mom asymptomatic and bleeding stops, not

worrisome– Monitor for shock: pallor, dizziness, chilliness,

eyes rolling back, shaking

Stage 4 / post partum

• After normal delivery of placenta– Uterus is checked periodically to make sure it is

firm (prevent hemorrhage)– 1 cup of fluids every hour she’s awake– Stay in bed 2 days minimum, getting up only to

use bathroom– May shower 12 hours post delivery– Watch bleeding: slight dripping ok, steady stream

or gush sign of hemorrhage = emergency

Post Term Pregnancy

• Post Term or Post Dates = 42 weeks or more– Increases risk to the mother and baby

• Risk: neonatal mortality and stillbirth rates are 3x higher with post term pregnancy due to placental failure

• Incidence: about 6-12% deliver at 42 weeks or after

Post term pregnancy

• Inadequate placental function may lead to: – Asphyxia – Diminished amniotic fluid level– Dry and peeling skin (baby) b/c vernix washes off– Absence of subcutaneous fat on infant– Increased risk of umbilical cord entanglement– Low blood sugar and low clotting factors in baby– Increase risk for cesarean birth

Post term pregnancy

• Etiology – Most common: failure of cervix to soften (ripen)– High doses of aspirin or other prostaglandin

inhibitors prohibit cervical ripening– Lack of stimulatory factors such as oxytocin and

prostaglandin– Abnormal fetus– Psychological factors– Stress and fear can also inhibit labor

Post term pregnancy

• Management– Induction of labor (usually with pitocin)– Some doctors will induce as early as 41

weeks– If any complications, even if mild, need to

induce

Malpresentations

• Breech: sacrum presenting first– Frank: flexed thighs and extended legs

(butt downward, feet up)– Complete: flexed thighs and legs – sitting

“Indian” style– Footling: extended thighs and legs

One of most dangerous presentations – foot comes out first, baby will not fit through the opening.

Breech Presentations

Malpresentations

• Etiology:– Less room in the pelvis– Large fetal head– Prematurity– Polyhydramnios– Placenta previa– Low uterine fibroids– Twins

Malpresentations

• Diagnosis– Before labor usually by week 34 ultrasound– During labor during speculum exam

• Risks– Fetal mortality- up to 25%– Delivery trauma

• Nervous system, abdominal injury, cord prolapse, congenital abnormalities, prematurity

Malpresentations

• Cesarean delivery indicated– Prematurity– Pelvic contracture– Hyperextension of fetal spine or head– Footling breech– Dysfunctional labor– Previous prenatal death

– Frank breech vaginal delivery still possible

Malpresentations

• Face presentation

Malpresentations

• Brow presentation (partially extended head)

Malpresentations

• Shoulder presentation:– Transverse lie

Malpresentation

• Compound presentation

Malpresentation - OP

• Occiput posterior (OP): vertex presentation with the fetal occiput facing maternal spine– Occurs in 6-10% of labors– Etiologies

• Poorly flexed head• Flat sacrum• Ineffective uterine contractions• Epidural– decreased pelvic floor muscle tone

Malpresentations - OP

Malpresentation

• Characteristics of OP labor– Slow progress in dilation and descent– Mild to severe back pain– Uncoordinated contractions– Urge to push before second stage– Bulge in sacral area

Malpresentation

• Management of malpresentations– Many techniques to assist rotation– Prevention before labor: pelvic rocks,

hands and knees, avoidance of supine position, lying in different positions; ambulation

– May require interventions: forceps, vacuum extraction, C-section

Forceps

• Prerequisites for forceps delivery:– Proper presentation, position and station– Fully dilated cervix– Head position is known– Minimal CPD (cephalopelvic disproportion)– Membranes ruptured– Adequate anesthesia and facilities– Competent operator

Forceps

• Benefits of forceps delivery – Assists difficult labor– No increase in fetal morbidity

• Risks– Maternal lacerations, bleeding, perineal tear/ need for

episiotomy, fecal incontinence (damage to rectal sphincter)

– Neonatal: forceps marks on face, facial nerve injuries, intracranial bleeding, cerebral palsy

– Statistics complicated because done only in cases of difficult, prolonged labor

Vacuum Extraction

• Prerequisites for vacuum extractors– Term infant– Vertex presentation– Engagement of fetal head to 2+ station– Ruptured membranes– Full cervical dilation– Minimal CPD

Vacuum Extraction

• Indications– persistent occiput posterior, malposition of fetal

head, exhausted mother, fetal distress• Use discontinued if disengagement of vacuum cup,

failure to deliver head within 10 minutes of accrued use or 30 min total use (no suction in between contractions)

• Complications – Maternal: vaginal lacerations from improper use– Fetal/ neonatal: scalp abrasions, bruising,

cephalohematoma, hemorrhage, jaundice if excessive bruising

Assisted Birth

Epidural• Epidural Anesthesia blocks labor pains

without causing fetal respiratory distress– Does not always block pain– Does not allow natural maternal endorphin release– Often stalls labor– Requires need for constant fetal monitoring thus

limiting maternal mobility during labor– Requires urinary catheterization, risk for UTI– Can suppress contractions --> need for pitocin– Can cause fetal malposition into OP position– Increases need for C-section– Mother can’t feel what an effective push during a

contraction feels like

Pitocin

• Pitocin is synthetic OxytocinOxytocin:• Stimulates labor contractions and milk let-down• “Love hormone”, promotes bonding• Suppressed by adrenalin• Release supported by dim light, privacy,

supportive talk

Pitocin

• Pitocin adverse effects – More painful uterine contractions– Does not cross BBB, no effect on bonding– Given as continuous drip (oxytocin

naturally released in pulsatile manner); needs a higher dose to achieve effect

– May cause fetal distress

Problems during Labor

• Premature labor is onset < 37 weeks gest with contractions that lead to dilation

• Etiology– Incompetent cervix: won’t stay firmly

closed– Over distention of the uterus– Infection– Psychological stress

• Etiology of premature labor continued– Stimulation (nipple stim or bowel irritation) – Very poor nutrition– Fetal malformation– Antepartum hemorrhage– Congenital malformations of the uterus– Artificial induction

• Premature labor – Need to ddx from Braxton-Hicks– Any event that can have induced labor?

(overexertion, excessive GI stimulation)– Needs careful monitoring: bleeding, infection– May require drugs given in hospital to stop

contractions– Natural treatment: bed rest, herbs to relax uterus,

warm baths, water, remove underlying cause, homeopathy, acupuncture

• Dystocia = difficult or abnormal labor– Shoulder dystocia: impaction of baby’s shoulders

in maternal pelvis after head delivery; lodges above pelvic bone

– Is an emergency: 6-8 minutes before brain damage

– Incidence: 1/100 births, 1.7% babies > 8.5#– Etiology: CPD, failure to rotate, baby’s hand

behind his back, broadening the shoulders

Shoulder Dystocia

• Diagnosis of shoulder dystocia: – Prenatally: diabetic moms, small mom and large

dad, ultrasound, history of large babies, hx of shoulder dystocia

– Interpartum: long, hard labor despite good quality contractions, long slow pushing despite good effort

– Warning signs at birth: head delivers slowly, can’t find neck

– Management involves different maternal positions

Umbilical Cord Problems

• Prolapse– Occult: cord lies beside the presenting

body part– Frank: cord below presenting part with the

membranes ruptured; may or may not be preceded by cord presentation (cord below presenting part with intact membranes)

– Incidence: <1%

Cord Prolapse

• Risk factors– Fetal malpresentations– Multiple pregnancies– Malformations– Prematurity– Polyhydramnios– Placenta previa– Uterine fibroids, congenital malformations, laxity– Iatrogenic: intrauterine manipulation

Cord Prolapse

• Diagnosis– Palpation– Abnormal fetal heart tones (variable decels with

cord prolapse)– Passage of meconium

– Best to prevent by not rupturing membranes before presenting part engaged

– May require C-section

• Cord entanglement– Incidence around neck common: 30%

• Incidence of multiple loops very low

– Etiology: long cord, excess fluid, combination; related to freedom of fetal movement

– Common in monoamniotic twins (2 cords, one sac)– Complications: compromise to umbilical blood

flow, failure of descent of head, low APGAR

• Short cord – Absolute: < 30cm– Relative- due to looping around fetus– Complications: fetal distress, fetal death,

placental abruption, breech presentation, delayed onset of labor, occasional cord rupture

• Cord knotting– Incidence: 0.5% with occurrence as early as 1st

trimester– Etiology: similar to entaglement, occurs

accidentally dt fetal activity, more common in male fetuses

– Usually does not tighten until descent of the presenting part of labor

– Complications: fetal distress 15%, lower APGAR, perinatal death rate increased 5x

Problems during Labor• Meconium aspiration

– Asphyxia stimulates the vagus nerve (supplies intestines), producing peristalsis, relaxation of anal sphincter, release of meconium

– If in baby’s mouth / nasal passages, can enter lungs on first inhalation

– Very sticky - interferes with lung inflation and can lead to infection, pneumonia

– Suction airways to reduce risk of aspiration– Requires O2 administrationMeconium release usu stress reaction

• Hypoxia (cord accident or other reason)• Incidence: 10-15%

Other topics - VBAC

• VBAC: Vaginal Birth after Cesarean – 60-80% of women can have VBAC– ACOG recommendation: based on clinical

circumstances and the patient’s choice after appropriate counseling of potential risks

– Types of incisions:• Low transverse: horizontal cut made across the lower,

thinner part of uterus – better for VBAC?• Low vertical: vertical cut made on the lower part of uterus• High vertical/ classical: vertical cut upper uterus; highest

risk of rupture

Other topics - VBAC

• Benefits of VBAC– Less morbidity– Fewer blood transfusions– Fewer post partum infections– Shorter hospital stay– No increase in perinatal morbidity– Emotional advantages from achieving

vaginal birth

Other topics - VBAC

• VBAC contraindications:– Prior classical incision or T scar– Transfundal uterine surgery– Contracted pelvis– Other medical complications or

contraindications for vaginal delivery

Other topics - VBAC

• VBAC relative contraindications – Multiple low transverse incisions from previous C-

sections– Unknown uterine scar– Breech presentation– Twin gestation– Post term pregnancy– Suspected macrosomia

– Prostaglandin use for induction is associated with high risk of uterine rupture in VBAC patients

OBgyn Week 10 Labor & Delivery. Birth Practitioners Who can deliver the baby? Obstetrician-Gynecologists Maternal-Fetal Med Specialists Family Practice.

stages of labor slide

labor delivery slide

early labor

stalled labor

phases of labor stage

active labor stage

cervical change true

ssx prelabor

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