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APGO educational topic number eleven
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intrapartum care meet la florida live
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which she is a gravida one pair zero at
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39 weeks estimated gestational age and
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we are going to follow her through the
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process of a normal labor and delivery
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the learning objectives are to
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differentiate between the signs and
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symptoms of true and false labor perform
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the initial assessment of a laboring
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patient describe the four stages of
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labor and recognize common abnormalities
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explain pain management approaches
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during labor describe methods for
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monitoring the mother and fetus describe
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the steps of a vaginal delivery list
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indications for operative delivery and
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finally identify maternal risks specific
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to delivery in developing countries
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labora is at home feeling contractions
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and she’s not sure if she’s in true or
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false labor what is the definition of
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labor let’s check our smart device the
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definition of labor requires that two
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things need to occur number one painful
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uterine contractions and number two
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cervical dilation at term many women
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will feel spontaneous contractions which
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they describe as tightening of the
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uterus if they are not causing cervical
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dilation then they are referred to as
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Braxton Hicks contractions labora is on
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the phone with her OB provider and she’s
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trying to decide whether she should come
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in to be evaluated on labor and delivery
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what does the OB provider recommend come
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in if you have leakage of fluid bleeding
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painful contractions every five minutes
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for one hour or decrease in fetal
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movements laborious contractions are
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every five minutes and they happen for
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one hour so she and her partner head to
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labor and delivery
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in triage laborious prenatal records
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will be reviewed and a focused history
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will be performed let’s review the
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assessments unique to pregnancy and
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labor and delivery we need to assess
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both maternal and fetal status fetal
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heart tones are usually assessed with a
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fetal heart monitor we also need to know
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fetal presentation whether the fetuses
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vertex or breech assess with either an
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abdominal ultrasound or by exam since we
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need to assess whether labora is in
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labor we need to perform a sterile
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vaginal examination we described three
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components from this exam we assess the
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cervical dilation the effacement and the
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fetal station will first discuss
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cervical dilation and effacement here is
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the uterus and the cervix with the
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internal
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and the external loss the cervix will
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dilate and this refers to the opening of
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the internal loss complete dilation is
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10 centimeters the cervix will also
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undergo a Faceman which means that it
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will thin out or the distance between
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the internal and the external
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awesome marked by the screen error will
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become zero a non effaced cervix is
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about four centimeters this green dotted
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line shows a cervix that is about 50%
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thinned out or will be about two
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centimeters and this pink dotted line
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shows a completely effaced cervix that
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is zero centimeters thick moving on to
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fetal station station describes the
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fetal presenting part usually the vertex
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in relation to the issue of spines which
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are palpable vaginally when the
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presenting parts at the level of the
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ischial spines it is zero station as the
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vertex descends down the pelvis the
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station passes plus one plus two all the
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way to plus five these divisions
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represent centimeters below the ischial
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spines on the other hand a minus one
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station would meet the vertex was still
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one centimeter above the ischial spine
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minus 2 station would be 2 centimeters
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above etc labora is found to be 5
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centimeters dilated 80% effaced and 0
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station so she is now admitted to labor
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and delivery we described four stages of
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labor the first stage of labor is from
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the onset of labor to full cervical
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dilation stage one is further divided
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into the latent phase and the active
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phase labora is already passed the
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latent phase which includes from
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cervical dilation to about 4 centimeters
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and can be variable in length the active
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phase starts at about 4 centimeters
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dilated and there should be more rapid
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and predictable cervical dilation the
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latent phase can last for days whereas
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the cervix should dilate at
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approximately 1.2 to 1.5 centimeters per
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hour in the active phase stage 2 is from
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complete dilation to delivery of the
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infant stage 3 is from delivery of the
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infant to delivery of the placenta stage
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4 is the immediate postpartum period of
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approximately two hours after delivery
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of the placenta labora is in the active
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phase of stage 1 of labor walking is
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generally more comfortable than laying
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supplying there is decreased GI
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peristalsis so patients should limit
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their solid food intake for this can
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lead to nausea and vomiting fetal
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well-being is monitored during labor by
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measurement of the fetal heart tones
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which can be done by either electronic
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fetal monitoring or intermittent oskol
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an external toka motor is used to assess
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uterine activity labor would like for us
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to start discussing pain management
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options during labor labor results
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severe pain for most women during stage
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1 of labor pain results from the
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contractions of the uterus and dilation
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of the cervix resulting in visceral pain
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at the levels of T 10 to l1 as labor
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progresses the fetal head distance the
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lower birth canal and perineum resulting
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in somatic pain transmitted through s2
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to s4 some patients tolerate the pain of
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labor and delivery without any need for
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medications for women who opt for pain
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relief during labor we have many safe
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effective methods the epidural block is
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the most effective form of intrapartum
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pain relief in the United States local
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anesthetic or narcotics are infused
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through a catheter into the epidural
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space this lasts during labor and
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delivery and can be individually
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titrated IV opioids and opioid agonist
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and antagonist can also be used however
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since they are systemically administered
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the primary mechanism of pain relief is
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via a sedation labora is now completely
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dilated at 10 centimeters and is now in
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stage 2 of Labor
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how long do women push once they are
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completely dilated for women who have
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not had a vaginal delivery pushing
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usually takes about two to three hours
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the length is shorter if the woman has
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not received an epidural if a woman has
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already had one vaginal delivery the
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second stage may be very short and she
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may not need to push for very long since
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this is laborious first delivery she
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will likely need to push for 2 to 3
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hours as a student you may stay in the
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room to help with this pushing part of
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stage 2 delivery of the fetus is
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imminent when a half dollar size amount
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of the fetal vertex is visible in
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between pushes as the fetus crowns it is
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helpful to support the perineum and
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facilitate extension of the head after
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delivery of the head there is
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restitution then there is delivery of
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the anterior shoulder then the delivery
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of the posterior shoulder the optimum
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place for baby after delivery is skin to
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skin on the maternal chest next we’ll
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move on to stage 3 active management of
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the third stage of labor it decreases
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the risk of postpartum hemorrhage this
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involves bundle massage gentle core
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traction and administration of IV or I
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am oxytocin the placenta can take up to
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30 minutes to do
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there are two classic signs that the
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placenta is separating from the uterus
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one a gush of blood and two lengthening
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of the umbilical cord after the placenta
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delivers the uterus should be palpated
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to ensure that it is firm and has
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contracted and the placenta should be
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visually examined to make sure it has
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been completely removed moving now to
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operative deliveries operative
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deliveries are accomplished by applying
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direct traction to the fetal skull with
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forceps or by applying traction to the
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fetal scalp with a vacuum extractor the
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incidence of operative vaginal delivery
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in the United States is estimated to be
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approximately 3.5% the general
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indications are one prolonged or
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arrested second stage number two
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suspicion of immediate or potential
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fetal compromise and number three
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shortening of the second stage for
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maternal benefit our journey on to labor
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and delivery with our patient labora has
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assumed that we are in a high resource
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setting in low resource settings there
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are a multitude of risks of labor and
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delivery and 99% of maternal deaths
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occur in developing countries every day
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800 women die from preventable causes
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related to pregnancy and childbirth this
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is the equivalent of two jumbo jets
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daily more than half of these deaths
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occur in sub-saharan Africa and another
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one-third occur in Southeast Asia the
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highest risk is for adolescent girls the
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major complications that account for 75%
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of maternal deaths are bleeding
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infection high blood pressure
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complications from delivery and unsafe
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abortion this concludes the aapko video
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on intrapartum care we reviewed normal
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labor and delivery operative deliveries
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and maternal risks specific to
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developing countries
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[Music]

I believe the video is a little unclear about the exact location of the ischial spines. Here are a couple of images that I hope will clarify their location and clinical use.

– Dr. Hughey

Definitions of the latent and active phases of the first stage of labor have changed over time.

This came about after a workshop was convened with ACOG, Society of Maternal Fetal Medicine (SMFM) and the NIH to address the high Cesarean delivery rates in the U.S. resulting in the publication of “Safe Prevention of the Primary Cesarean Delivery.”

The active phase of labor more likely begins at approximately 6 cm dilation (previously 4 cm). The active phase of labor and the 2nd stage of labor (pushing) can take longer than previously believed. 4-6 hrs in the active phase of labor with no change in the cervix is often allowed before diagnosing arrest of dilation and can wait up to 4 hr in the second stage of labor before diagnosing arrest of descent. These changes should give patients more time to deliver vaginally without compromising safety.

– Dr. Hughey