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Laudelino Lopes MD, MSc, PhD, MBA, FRCSC
Department of Obstetrics & Gynaecology Maternal Fetal Medicine, Division Head
MFM Program Director Perinatal Ultrasound Unit, Co-Director
Associate Professor Associate Scientist – LHRI
Scientist - CHRI
Labour Management
University of Western Ontario The Department of Obstetrics and Gynecology
Maternal Fetal Medicine Division
�Understand normal and abnormal progress of labour for nulliparous and multiparous women including the assessment of labour, cervical dilation, fetal position.
�Define the terms position, presentation,
station, effacement and dilation. �State the definition of labour and the stages
of normal labour and delivery.
tand ormano al anand
Labour Management
• Describe the normal labour curve for nulliparous and multiparous and techniques to evaluate the progress of labour.
• Review methods of induction, including cervical ripening, and augmentation of labour.
• Describe 3 options for managing failure to
progress in labour.
bbebbe htheehhehth ormano alormaalonon lalaaboua uraboaabouruubo r
Labour Management
�Learn the criteria for ensuring intrapartum fetal wellbeing:
��Fetal heart rate monitoring:
� Intermittent � Continuous
Labour Management
� Describe the methods of intermittent and continuous intrapartum fetal heart
monitoring LIST: � 5 criteria used to describe fetal heart rate
tracings. �The indications for electronic fetal monitoring
in labour �3 types of decelerations and the implications
of each
e the methods of inntermnterm
Labour Management
Uterine Activity • amplitude • frequency • duration
• Braxton Hicks contraction • painless tightening, no cx change, start ~ 28 wks
• Cervical effacement • softening, thinning
• Engagement • ~2 weeks prior to labour in primip • Fetal head fixed in pelvis
John Braxton Hicks, the man who 140 years ago described fake contractions.
• Definition: • Onset of labour ��full dilatation
• Latent phase: 0-4 cm • Active phase: 4-10 cm
• True Labour: regular uterine contractions causing progressive cervical dilation
Definitionn:
�Baseline • Normal 120-160 beats per minute (bpm) • Tachycardia >160 bpm • Bradycardia <120 bpm
�Accelerations • > 10 bpm from baseline
�Decelerations • > 10 bpm from baseline
�Type of decelerations • Early, late, variable or mixed-pattern decelerations
�Baseline variability • + or – 5 bpm
Baseline fetal heart is 120-160, preserved beat-to-beat and long term variabilitiy. Accelerations last for 15 or more seconds above baseline and peak to 15 or more bpm.
�INTERMITTENT: • q 15 min 1st stage / q 5 min 2nd stage
�CONTINUOUS: • Meconium staining of amniotic fluid • High risk – Preeclampsia, bleeding, abn FHR • Induction / Augmentation – Syntocinon • VBAC (Vaginal Birth After Caesarian)
• Baseline • Accelerations • Decelerations • Type of
decelerations • Baseline
variability
• Contractions • Frequency • Amplitude • Duration • Baseline tone
�Contractions • yes/no
�Frequency of contractions • Optimally every 2-3 min
�Amplitude • 40-60 mmHg
�Duration • 60-90 seconds
�Baseline tone • <15 mmHg
�CONTRACTIONS: • By palpation – q 30 min early • Tocometer – in high risk or slow progress
�CERVICAL CHANGE: • Q 2 hours in early labour • Sooner based on patient symptoms, FHR • Assess dilation, effacement, station
Normal curves of progress of labour Not strict rules, but guideline
�FIRST STAGE • 6 - 18 hrs primip / active phase 1.2 cm/hr • 2 – 10 hrs multip / active phase 1.5 cm/hr
• Most common cited reason for C/S
1. PASSAGE – Abnormal pelvis
2. PASSENGER – LGA fetus
3. POWERS �� poor contraction pattern � poor pushing
�DEFINITION: • Full dilatation �� Delivery of fetus
• Friedman: 30 min � 3 hrs primip 5 min � 30 min multips ________________________________________ • Progress monitored by station
• 0 = ischial spines • 1-5 cm (or thirds) of total distance
��DEFINITIOND N:
Occiput Lambdoid suture
Posterior fontanelle Sagittal suture Anterior fontanelle Coronal suture Frontal suture
Occiput
• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• External rotation
• Expulsion • Engagement • Descent
• Flexion • Internal rotation
• Extension • External rotation
• Expulsion
Pelvic architecture issues: � Best outcomes with gynecoid & android � Cardinal movements may be inhibited by
narrow or flat pelvis ___________________________________
Trial of labour is only true test of pelvic adequacy
Delivery of fetus �� Expulsion of placenta
Timeline� 2 – 30 minutes
______________________________________ Active management – WHO / SOGC
�Uterotonic agents (Syntocinon / Misoprostol ) �GENTLE traction on cord �Fundal massage
� Signs of separation � New onset bright bleed � Lengthening of cord � “balling up” of fundus
� Uterine involution – oxytocin mediated � Inspection and repair of lacerations
• Natural supported labour
• Narcotics
• Nitrous/Oxygen inhalation
• Regional analgesia (Epidural)
• Post dates • Preeclampsia • Diabetes Mellitus • Maternal disease (cardiac) • PROM / IUGR
�Balloon / Foley
�Prostaglandins
�Cervidil
� Prostin gel,
�Misoprostol
HERBAL SUPPLEMENTS
CASTOR OIL, HOT BATHS, AND ENEMAS
SEXUAL INTERCOURSE
BREAST STIMULATION
ACUPUNCTURE/TRANSCUTANEOUS NERVE STIMULATION
� no evidence supports the use of these modalities
The Cochrane reviewers concluded that stripping of the membranes alone does not seem to produce clinically important benefits, but when used as an adjunct does seem to be associated with a lower mean dose of oxytocin needed and an increased rate of normal vaginal deliveries.[Evidence level A]
�Prostaglandins (PGE1) analog
– Cervidil (Dinoprostone), Prostin gel,
Misoprostol
�Syntocinon – synthetic oxytocin
�ARM – artificial rupture of membranes,
may be enough to initiate labour
Oxytocin infusion
GOAL • Good contraction pattern and cervical
change
Failure to progress
Intrauterine pressure catheter (IUPC)
o Congenital Heart Disease – short 2nd stage
o Pulmonary compromise
o Exhaustion
o Prolonged second stage
o Not �� advocated unless extreme protraction
o Nonreassuring FHR
o Abruption
o Malpresentation – OT/OP
Axis of pelvis
1. Passage � Abnormal pelvis 2. Passenger� LGA fetus 3. Powers � poor contraction pattern � poor pushing
1. Failure to progress 2. Non-reassuring FHR status 3. Previous caesarian section 4. Fetal malpresentation – breech, transverse
t
1. Abnormal placentation – previa, vasa previa 2. Mechanical obstruction – fibroid, teratoma 3. Maternal Infection – HSV, HIV 4. Multiple gestations 5. Cervical cancer 6. Fetal congenital anomalies
Ab l l t til i
�VERTICAL o Faster, less blood loss o Emergency, previous scar, obese
patient, abn bleeding
�PFANNENSTEIL o Low transverse, more cosmetic, less
stress? o Standard for most C/S
�VERTICAL
�STANDARD o Lower uterine segment o Transverse o Low risk of rupture in subsequent labour (0.5%)
�VERTICAL (CLASSICAL) or � “T” INCISION
o High risk of rupture in subsequent labour (5%)
�Understand normal and abnormal progress of labour for nulliparous and multiparous women including the assessment of labour, cervical dilation, fetal position.
�Define the terms position, presentation,
station, effacement and dilation. �State the definition of labour and the stages
of normal labour and delivery.
tand ormano al anand
Labour Management
• Describe the normal labour curve for nulliparous and multiparous and techniques to evaluate the progress of labour.
• Review methods of induction, including cervical ripening, and augmentation of labour.
• Describe 3 options for managing failure to
progress in labour.
bbebbe htheehehth ormano alormaalonon lalaaboua uraboaabouruubo r
Labour Management
�Learn the criteria for ensuring intrapartum fetal wellbeing:
��Fetal heart rate monitoring:
� Intermittent � Continuous
Labour Management
� Describe the methods of intermittent and continuous intrapartum fetal heart
monitoring LIST: � 5 criteria used to describe fetal heart rate
tracings. �The indications for electronic fetal monitoring
in labour �3 types of decelerations and the implications
of each
e the methods of inntermnterm
Labour Management
Laudelino Lopes