labor and delivery : physiology, normal, abnormal, and preterm labor william goodnight, md, mscr...
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Labor and DeliveryLabor and Delivery::Physiology, Normal, Abnormal, Physiology, Normal, Abnormal,
andandPreterm LaborPreterm Labor
William Goodnight, MD, MSCR
Division of Maternal-Fetal Medicine
Images: googleimage.com; gabbeobstetrics.com
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ObjectivesObjectives• Describe physiology of
initiation of labor• Define normal and abnormal
labor• Review the mechanics of labor• Describe diagnosis and
management of abnormal labor
• Discuss diagnosis, etiologies and management of preterm labor
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ParturitionParturition• Normal Pregnancy
» Uterine quiescence
» Immature fetus
» Closed cervix
• Parturition» Coordinated uterine activity
» Maturation of the fetus
» Maternal lactation
» Progressive cervical dilation
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Uterine Activity During PregnancyUterine Activity During Pregnancy
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Inhibitors•Progesterone•Prostacycline•Relaxin•Nitric Oxide•Parathyroid hormone-related peptide
•CRH•HPL
Quiescence
UterotoninsProstaglandinsOxytocin
Stimulation
UterotrophinsEstrogen•Progesterone•Prostaglandins•CRH
Activation
InvolutionOxytocin•Thrombin
Involution
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Initiation of LaborInitiation of Labor
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• Fetus» Sheep
• Fetal ACTH and cortisol» Placental 17 α hydroxylase
» Estradiol
» Progesterone
» Placental production of oxytocin, PGF2 α
» Humans• Fetal increased DHEA
» Placental conversion to estradiol
» Increased decidual PGF2 and gap junctions
» Increased oxytocin and PG receptors
» Decreased progesterone receptors
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Initiation of laborInitiation of labor• Oxytocin
» Peptide hormone
» Hypothalamus-posterior pituitary
» Fetal production• Maternal serum increase in second stage of labor
» Oxytocin receptors• Fundal location• 100-200 x during pregnancy
» Actions• Stimulate uterine contractions• Stimulate PG production from amnion/decidua
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Calcium channel
Ca store+ Oxytocin
+ Prostaglandin
Ca+MLCK
Extracellular
Intracellular
Uterine contractions
cAMP
Oxytocin receptor
Phospholipase C
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LaborLabor
Regular uterine contractions (duration 30-60 seconds, every 5 minutes)
and
Progressive cervical dilatation
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Management of laborManagement of labor
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• Requirements» Continued progress
• Station and dilatation
» Continued reassuring fetal status
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LABOR PROGRESSLABOR PROGRESS
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Mechanisms of laborMechanisms of labor• Effacement• Dilatation• Three “P’s”
» Powers• Uterine activity
» Passage
» Passenger
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PowersPowers• Uterine contractions
» Normal labor» Duration 30-60 seconds» Q 2-5 minutes
• 3-5 contractions / 10 minutes
» Montevedeo units (intrauterine catheter)• Baseline to peak, sum of contractions in 10 minutes• Adequate: >200-250 MVU
• Interventions» Induction» Augmentation
• Oxytocin
• AROM04/19/23 12
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PassagePassage
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PassengerPassenger• Size
» 4500gram = macrosomia
• Lie• Presentation
» 5% not vertex
• Attitude• Position• Station
» Engagement• Widest diameter
passes inlet• ‘0’ station, vertex
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Cardinal Movements of LaborCardinal Movements of Labor
• Descent• Flexion• Internal rotation• Extension• External rotation• Expulsion
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Labor stagesLabor stages• First stage – onset of labor to complete dilatation
» Latent phase
» Active phase
• Second stage• Third stage
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PartogramPartogram
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Labor stagesLabor stages
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Labor stagesLabor stages
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Labor stagesLabor stages
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INTRAPARTUM FETAL ASSESSMENT:INTRAPARTUM FETAL ASSESSMENT:ENSURE REASSURING FETAL STATUSENSURE REASSURING FETAL STATUS
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Fetal assessment in laborFetal assessment in labor
• External monitoring• Internal monitoring
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Patterns of fetal heart rate monitoringPatterns of fetal heart rate monitoring
• Baseline• Variability• Periodic changes
» Accelerations» Decelerations
• Variable• Early • Late
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Patterns of fetal heart rate monitoringPatterns of fetal heart rate monitoring
• Normal» 120-160
• Tachycardia» >160
• Bradycardia» <120
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Patterns of fetal heart rate monitoringPatterns of fetal heart rate monitoring• Absent
» undectable
• Minimal» < 5bpm
• Moderate» 5-25bpm
• Marked» >25bpm
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Patterns of fetal heart rate monitoringPatterns of fetal heart rate monitoring
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<32 weeks 10bpm over baseline>32 weeks 15bpm over baseline
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Patterns of fetal heart rate monitoringPatterns of fetal heart rate monitoring
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Patterns of fetal heart rate monitoringPatterns of fetal heart rate monitoring• Variable decelerations
» Umbilical cord compression
» Variable in appearance
» Processes• UV compression
» Decreased cardiac return
» Fetal hypotension
» Fetal increased HR
• UA compression» Increased SVR
» Decreased fetal heart rate
• protective
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Patterns of fetal heart rate monitoringPatterns of fetal heart rate monitoring
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•5-10% of labors•Vagal reflex
•cervical compression on fetal head
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Patterns of fetal heart rate monitoringPatterns of fetal heart rate monitoring
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•Uteroplacental insufficiency - hypoxia•Reflex late
• low O2 in CNS, increased sympathetic tone, increased BP, baroreceptor medicated bradycardia
•Myocardial depression
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Management of abnormal fetal heart rate Management of abnormal fetal heart rate patternspatterns
• Remove potential etiologies» Hypotension
• Maternal position – left lateral recumbent• IVF hydration, ephedrine
» Maternal O2 administration
» Cessation of contractions• Discontinue oxytocin• Uterine relaxants – terbutaline
» Amnioinfusion
» Expedite delivery
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Pain control in laborPain control in labor• Uterine pain
» T10-T12• Delivery pain
» S2-4• Cesarean
» T4• Management
» Psychoprophylaxis• TENS
• Acupuncture
• Prenatal education
» Systemic opioid» Regional
analgesia/anesthesia04/19/23 32
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Pain control in laborPain control in labor• Systemic opioids
» Analgesia» Sedation
• Bolus/PCA» Meperidine» Nalbuphine» Butorphanol
• Risks» Neonatal depression» Delayed gastric emptying
04/19/23 33Bucklin BA. Anesthesiology 103:645, 2005
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Pain control in laborPain control in labor
• Regional analgesia/anesthesia» Epidural
• L2-5• Local anesthetic
» Bupivicaine (0.25%)
» Spinal• CSE
» Intrathecal opioid
» Local anesthetic
» Local/pudendal
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Abnormal laborAbnormal labor
• Prolonged descent• Prolonged dilatation
• Assess/correct “3 P’s”
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Abnormal labor - interventionsAbnormal labor - interventions
• Augmentation» Oxytocin
• Achieve adequate uterine contractions• Requires reassuring fetal status
» AROM
• Therapeutic rest• Operative vaginal delivery• Cesarean delivery
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Operative vaginal deliveryOperative vaginal delivery
• Indications» Prolonged second
stage» Fetal compromise» Aftercoming fetal
head/breech» Maternal indications
• Cardiac disease• CNS disease
• Requirements» Consent» Completely dilated» Ruptured membranes» Adequate anesthesia» Empty bladder» Known fetal position
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Operative vaginal deliveryOperative vaginal delivery
• Vacuum» Suction cup » Sagital suture» Maintain flexion
• Lower success rate• Lower maternal
trauma• Increased fetal
trauma
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www.aafp.org
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Operative vaginal deliveryOperative vaginal delivery
• Obstetrics forceps» Higher success rate» Increased maternal
trauma» Allow rotational
maneuvers
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Cesarean DeliveryCesarean Delivery
• 2006 cesarean rate (US)» 31.1% 2005
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Cesarean deliveryCesarean delivery
• Indications» Maternal
• CNS/cardiac disease
» Fetal• NR fetal status• Malpresentation• HSV
» Maternal-fetal• Arrest of labor• Abruption• Placenta previa
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Vaginal Birth Following CesareanVaginal Birth Following Cesarean
• Success rates» 60-80%» Higher success
• Prior vaginal birth• Prior malpresentation• Spontaneous labor
• Risks» Uterine rupture
• LTCS: 0.5-1.0%• LVCS: 0.8-1.1%• Classical: 4-9%
• Candidates» ACOG
• One prior LTCS• No prior rupture/ut scars• Immediate cesarean
available
» Others possible
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PRETERM LABOR, PRETERM LABOR, PRETERM PREMATURE PRETERM PREMATURE RUPTURE OF MEMBRANESRUPTURE OF MEMBRANES
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Preterm labor/birthPreterm labor/birth• Labor/delivery < 37 weeks
EGA• 10-12% of US births with
PTB» 50-70% of neonatal
morbidity and mortality
• Risk factors» Prior PTB
» Multiple gestations
» SES
» Uterine anomalies
» Fetal anomalies
» First trimester bleeding
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Preterm Labor - interventionsPreterm Labor - interventions
• Primary prevention» Risk factor scoring
» Early identification
• Secondary prevention» Tocolysis
• Tertiary prevention» Improve neonatal outcome
• Antenatal corticosteroids• Surfactant
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Evaluation of PTLEvaluation of PTL• Admission to labor and delivery• Fetal status and contraction monitoring• Make diagnosis
» Regular uterine contractions» Examination
• Evaluation for etiologies» Cervical/vaginal infection» PPROM» Intra-amniotic infection
• Interventions» ACS» Transfer» Tocolytics
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Diagnosis of preterm laborDiagnosis of preterm labor
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Iams JD et al: AJOG 173:141, 1995; *Crane JM et al: Ob Gyn 90:357, 1997; **Peaceman AM et al: 177:13, 1997; Gomez, AJOG 192:350, 2005
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TocolysisTocolysis
• Goals» Prolong pregnancy,
prevent PTB» Delay preterm delivery
• Allow administration of ACS
• Allow maternal transfer
• Agents» Magnesium sulfate» ß mimetics
• terbutaline
» Nifedipine» Indomethacin» Oxytocin receptor
antagonists
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Calcium channel
NifedipineMagnesium sulfate
Ca storeCa store+ Oxytocin
+ Prostaglandin
Ca+MLCK
Extracellular
Intracellular Oxytocin receptor
antagonists
IndomethacinUterine contractions
cAMP
ß-mimetics
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• Betamethasone (12mg IM q 24 hours x 2 doses)
• Dexamethasone (6mg IM q 12 hours x 4 doses)
» Reduction (% reduction)• RDS (65%)• IVH (52%)• NEC (65%)• Neonatal death (40%)
04/19/23 50
Am J Obstet Gynecol 1995;173:322-35
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• Weekly 17-P (16-36 weeks) in women with prior PTB» Reduction PTB RR 0.66 (0.54-0.81)
» Reduction in IVH, BW<2500gram, need for supplemental O2
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PPROMPPROM• Definition
» Preterm premature ROM» Premature ROM
• Diagnosis» Vaginal pooling» ‘Nitrazine’ positive» ‘Ferning’
• Complications» PTB» IAI» IUFD/cord accident
• Management» Admission» ACS» Delivery at 34 weeks EGA
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Antibiotics for PPROMAntibiotics for PPROM
• PPROM» Antibiotics (ampicillin + erythromycin, IV x 48 hours + po x 5
days)• Reduction:
» Odds of delivery in 7 days: 0.56 (0.41,0.76)
» Infant sepsis: OR 0.53 (0.3,0.93)
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Preterm birth effective strategiesPreterm birth effective strategies
• Antibiotics for PPROM» Increase latency
» Reduction in neonatal morbidity
• 17-P for prevention of recurrent PTB• Antenatal corticosteroids• GBS antimicrobial prophylaxis
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SummarySummary• Initiation of labor
» Maternal-fetal-placental interactions
• Optimal maternal-fetal outcome » Normal labor progress
» Reassuring fetal testing
• Preterm labor/PPROM» 10-12% incidence/ 50-70% perinatal morbidity
• TVCL and FFN best predictors of absence or PTB
» Effective strategies • Antenatal corticosteroids• PPROM abx• 17P in prior PTB
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