{"id":109,"date":"2020-08-12T20:01:12","date_gmt":"2020-08-12T20:01:12","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=109"},"modified":"2023-09-30T10:02:44","modified_gmt":"2023-09-30T10:02:44","slug":"11-intrapartum-care","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/basic_obgyn\/overview\/11-intrapartum-care\/","title":{"rendered":"11. Intrapartum Care"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/p-T0nibAY74\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><span data-mce-type=\"bookmark\" style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" class=\"mce_SELRES_start\">\ufeff<\/span><\/iframe><\/p>\n<p>Duration = 8:28<\/p>\n<input type='hidden' bg_collapse_expand='69e9dc203d8e51030785274' value='69e9dc203d8e51030785274'><input type='hidden' id='bg-show-more-text-69e9dc203d8e51030785274' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9dc203d8e51030785274' value='Hide Transcript'><button id='bg-showmore-action-69e9dc203d8e51030785274' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9dc203d8e51030785274' ><\/p>\n<p>00:00<br \/>\nAPGO educational topic number eleven<br \/>\n00:02<br \/>\nintrapartum care meet la florida live<br \/>\n00:05<br \/>\nwhich she is a gravida one pair zero at<br \/>\n00:07<br \/>\n39 weeks estimated gestational age and<br \/>\n00:10<br \/>\nwe are going to follow her through the<br \/>\n00:11<br \/>\nprocess of a normal labor and delivery<br \/>\n00:13<br \/>\nthe learning objectives are to<br \/>\n00:15<br \/>\ndifferentiate between the signs and<br \/>\n00:17<br \/>\nsymptoms of true and false labor perform<br \/>\n00:19<br \/>\nthe initial assessment of a laboring<br \/>\n00:21<br \/>\npatient describe the four stages of<br \/>\n00:23<br \/>\nlabor and recognize common abnormalities<br \/>\n00:25<br \/>\nexplain pain management approaches<br \/>\n00:27<br \/>\nduring labor describe methods for<br \/>\n00:29<br \/>\nmonitoring the mother and fetus describe<br \/>\n00:32<br \/>\nthe steps of a vaginal delivery list<br \/>\n00:34<br \/>\nindications for operative delivery and<br \/>\n00:36<br \/>\nfinally identify maternal risks specific<br \/>\n00:39<br \/>\nto delivery in developing countries<br \/>\n00:41<br \/>\nlabora is at home feeling contractions<br \/>\n00:44<br \/>\nand she&#8217;s not sure if she&#8217;s in true or<br \/>\n00:45<br \/>\nfalse labor what is the definition of<br \/>\n00:47<br \/>\nlabor let&#8217;s check our smart device the<br \/>\n00:50<br \/>\ndefinition of labor requires that two<br \/>\n00:52<br \/>\nthings need to occur number one painful<br \/>\n00:55<br \/>\nuterine contractions and number two<br \/>\n00:56<br \/>\ncervical dilation at term many women<br \/>\n01:00<br \/>\nwill feel spontaneous contractions which<br \/>\n01:01<br \/>\nthey describe as tightening of the<br \/>\n01:03<br \/>\nuterus if they are not causing cervical<br \/>\n01:05<br \/>\ndilation then they are referred to as<br \/>\n01:06<br \/>\nBraxton Hicks contractions labora is on<br \/>\n01:09<br \/>\nthe phone with her OB provider and she&#8217;s<br \/>\n01:11<br \/>\ntrying to decide whether she should come<br \/>\n01:12<br \/>\nin to be evaluated on labor and delivery<br \/>\n01:14<br \/>\nwhat does the OB provider recommend come<br \/>\n01:17<br \/>\nin if you have leakage of fluid bleeding<br \/>\n01:19<br \/>\npainful contractions every five minutes<br \/>\n01:22<br \/>\nfor one hour or decrease in fetal<br \/>\n01:24<br \/>\nmovements laborious contractions are<br \/>\n01:27<br \/>\nevery five minutes and they happen for<br \/>\n01:29<br \/>\none hour so she and her partner head to<br \/>\n01:31<br \/>\nlabor and delivery<br \/>\n01:31<br \/>\nin triage laborious prenatal records<br \/>\n01:34<br \/>\nwill be reviewed and a focused history<br \/>\n01:36<br \/>\nwill be performed let&#8217;s review the<br \/>\n01:39<br \/>\nassessments unique to pregnancy and<br \/>\n01:41<br \/>\nlabor and delivery we need to assess<br \/>\n01:43<br \/>\nboth maternal and fetal status fetal<br \/>\n01:46<br \/>\nheart tones are usually assessed with a<br \/>\n01:47<br \/>\nfetal heart monitor we also need to know<br \/>\n01:50<br \/>\nfetal presentation whether the fetuses<br \/>\n01:52<br \/>\nvertex or breech assess with either an<br \/>\n01:54<br \/>\nabdominal ultrasound or by exam since we<br \/>\n01:56<br \/>\nneed to assess whether labora is in<br \/>\n01:58<br \/>\nlabor we need to perform a sterile<br \/>\n01:59<br \/>\nvaginal examination we described three<br \/>\n02:01<br \/>\ncomponents from this exam we assess the<br \/>\n02:03<br \/>\ncervical dilation the effacement and the<br \/>\n02:05<br \/>\nfetal station will first discuss<br \/>\n02:08<br \/>\ncervical dilation and effacement here is<br \/>\n02:11<br \/>\nthe uterus and the cervix with the<br \/>\n02:13<br \/>\ninternal<br \/>\n02:13<br \/>\nand the external loss the cervix will<br \/>\n02:15<br \/>\ndilate and this refers to the opening of<br \/>\n02:17<br \/>\nthe internal loss complete dilation is<br \/>\n02:19<br \/>\n10 centimeters the cervix will also<br \/>\n02:22<br \/>\nundergo a Faceman which means that it<br \/>\n02:23<br \/>\nwill thin out or the distance between<br \/>\n02:25<br \/>\nthe internal and the external<br \/>\n02:27<br \/>\nawesome marked by the screen error will<br \/>\n02:29<br \/>\nbecome zero a non effaced cervix is<br \/>\n02:31<br \/>\nabout four centimeters this green dotted<br \/>\n02:34<br \/>\nline shows a cervix that is about 50%<br \/>\n02:36<br \/>\nthinned out or will be about two<br \/>\n02:38<br \/>\ncentimeters and this pink dotted line<br \/>\n02:41<br \/>\nshows a completely effaced cervix that<br \/>\n02:43<br \/>\nis zero centimeters thick moving on to<br \/>\n02:45<br \/>\nfetal station station describes the<br \/>\n02:48<br \/>\nfetal presenting part usually the vertex<br \/>\n02:50<br \/>\nin relation to the issue of spines which<br \/>\n02:51<br \/>\nare palpable vaginally when the<br \/>\n02:53<br \/>\npresenting parts at the level of the<br \/>\n02:54<br \/>\nischial spines it is zero station as the<br \/>\n02:57<br \/>\nvertex descends down the pelvis the<br \/>\n02:59<br \/>\nstation passes plus one plus two all the<br \/>\n03:01<br \/>\nway to plus five these divisions<br \/>\n03:02<br \/>\nrepresent centimeters below the ischial<br \/>\n03:04<br \/>\nspines on the other hand a minus one<br \/>\n03:07<br \/>\nstation would meet the vertex was still<br \/>\n03:08<br \/>\none centimeter above the ischial spine<br \/>\n03:10<br \/>\nminus 2 station would be 2 centimeters<br \/>\n03:12<br \/>\nabove etc labora is found to be 5<br \/>\n03:15<br \/>\ncentimeters dilated 80% effaced and 0<br \/>\n03:18<br \/>\nstation so she is now admitted to labor<br \/>\n03:20<br \/>\nand delivery we described four stages of<br \/>\n03:22<br \/>\nlabor the first stage of labor is from<br \/>\n03:25<br \/>\nthe onset of labor to full cervical<br \/>\n03:27<br \/>\ndilation stage one is further divided<br \/>\n03:29<br \/>\ninto the latent phase and the active<br \/>\n03:31<br \/>\nphase labora is already passed the<br \/>\n03:33<br \/>\nlatent phase which includes from<br \/>\n03:34<br \/>\ncervical dilation to about 4 centimeters<br \/>\n03:37<br \/>\nand can be variable in length the active<br \/>\n03:39<br \/>\nphase starts at about 4 centimeters<br \/>\n03:41<br \/>\ndilated and there should be more rapid<br \/>\n03:43<br \/>\nand predictable cervical dilation the<br \/>\n03:45<br \/>\nlatent phase can last for days whereas<br \/>\n03:47<br \/>\nthe cervix should dilate at<br \/>\n03:49<br \/>\napproximately 1.2 to 1.5 centimeters per<br \/>\n03:52<br \/>\nhour in the active phase stage 2 is from<br \/>\n03:54<br \/>\ncomplete dilation to delivery of the<br \/>\n03:56<br \/>\ninfant stage 3 is from delivery of the<br \/>\n03:59<br \/>\ninfant to delivery of the placenta stage<br \/>\n04:02<br \/>\n4 is the immediate postpartum period of<br \/>\n04:04<br \/>\napproximately two hours after delivery<br \/>\n04:05<br \/>\nof the placenta labora is in the active<br \/>\n04:08<br \/>\nphase of stage 1 of labor walking is<br \/>\n04:10<br \/>\ngenerally more comfortable than laying<br \/>\n04:12<br \/>\nsupplying there is decreased GI<br \/>\n04:14<br \/>\nperistalsis so patients should limit<br \/>\n04:15<br \/>\ntheir solid food intake for this can<br \/>\n04:17<br \/>\nlead to nausea and vomiting fetal<br \/>\n04:20<br \/>\nwell-being is monitored during labor by<br \/>\n04:22<br \/>\nmeasurement of the fetal heart tones<br \/>\n04:23<br \/>\nwhich can be done by either electronic<br \/>\n04:25<br \/>\nfetal monitoring or intermittent oskol<br \/>\n04:27<br \/>\nan external toka motor is used to assess<br \/>\n04:29<br \/>\nuterine activity labor would like for us<br \/>\n04:32<br \/>\nto start discussing pain management<br \/>\n04:33<br \/>\noptions during labor labor results<br \/>\n04:35<br \/>\nsevere pain for most women during stage<br \/>\n04:38<br \/>\n1 of labor pain results from the<br \/>\n04:40<br \/>\ncontractions of the uterus and dilation<br \/>\n04:42<br \/>\nof the cervix resulting in visceral pain<br \/>\n04:44<br \/>\nat the levels of T 10 to l1 as labor<br \/>\n04:47<br \/>\nprogresses the fetal head distance the<br \/>\n04:49<br \/>\nlower birth canal and perineum resulting<br \/>\n04:51<br \/>\nin somatic pain transmitted through s2<br \/>\n04:53<br \/>\nto s4 some patients tolerate the pain of<br \/>\n04:56<br \/>\nlabor and delivery without any need for<br \/>\n04:58<br \/>\nmedications for women who opt for pain<br \/>\n05:00<br \/>\nrelief during labor we have many safe<br \/>\n05:02<br \/>\neffective methods the epidural block is<br \/>\n05:04<br \/>\nthe most effective form of intrapartum<br \/>\n05:06<br \/>\npain relief in the United States local<br \/>\n05:08<br \/>\nanesthetic or narcotics are infused<br \/>\n05:10<br \/>\nthrough a catheter into the epidural<br \/>\n05:12<br \/>\nspace this lasts during labor and<br \/>\n05:14<br \/>\ndelivery and can be individually<br \/>\n05:15<br \/>\ntitrated IV opioids and opioid agonist<br \/>\n05:19<br \/>\nand antagonist can also be used however<br \/>\n05:21<br \/>\nsince they are systemically administered<br \/>\n05:23<br \/>\nthe primary mechanism of pain relief is<br \/>\n05:25<br \/>\nvia a sedation labora is now completely<br \/>\n05:28<br \/>\ndilated at 10 centimeters and is now in<br \/>\n05:30<br \/>\nstage 2 of Labor<br \/>\n05:31<br \/>\nhow long do women push once they are<br \/>\n05:34<br \/>\ncompletely dilated for women who have<br \/>\n05:36<br \/>\nnot had a vaginal delivery pushing<br \/>\n05:38<br \/>\nusually takes about two to three hours<br \/>\n05:39<br \/>\nthe length is shorter if the woman has<br \/>\n05:41<br \/>\nnot received an epidural if a woman has<br \/>\n05:44<br \/>\nalready had one vaginal delivery the<br \/>\n05:46<br \/>\nsecond stage may be very short and she<br \/>\n05:48<br \/>\nmay not need to push for very long since<br \/>\n05:51<br \/>\nthis is laborious first delivery she<br \/>\n05:52<br \/>\nwill likely need to push for 2 to 3<br \/>\n05:54<br \/>\nhours as a student you may stay in the<br \/>\n05:56<br \/>\nroom to help with this pushing part of<br \/>\n05:58<br \/>\nstage 2 delivery of the fetus is<br \/>\n06:00<br \/>\nimminent when a half dollar size amount<br \/>\n06:02<br \/>\nof the fetal vertex is visible in<br \/>\n06:04<br \/>\nbetween pushes as the fetus crowns it is<br \/>\n06:07<br \/>\nhelpful to support the perineum and<br \/>\n06:09<br \/>\nfacilitate extension of the head after<br \/>\n06:11<br \/>\ndelivery of the head there is<br \/>\n06:13<br \/>\nrestitution then there is delivery of<br \/>\n06:16<br \/>\nthe anterior shoulder then the delivery<br \/>\n06:19<br \/>\nof the posterior shoulder the optimum<br \/>\n06:21<br \/>\nplace for baby after delivery is skin to<br \/>\n06:23<br \/>\nskin on the maternal chest next we&#8217;ll<br \/>\n06:25<br \/>\nmove on to stage 3 active management of<br \/>\n06:28<br \/>\nthe third stage of labor it decreases<br \/>\n06:30<br \/>\nthe risk of postpartum hemorrhage this<br \/>\n06:32<br \/>\ninvolves bundle massage gentle core<br \/>\n06:34<br \/>\ntraction and administration of IV or I<br \/>\n06:36<br \/>\nam oxytocin the placenta can take up to<br \/>\n06:39<br \/>\n30 minutes to do<br \/>\n06:41<br \/>\nthere are two classic signs that the<br \/>\n06:42<br \/>\nplacenta is separating from the uterus<br \/>\n06:44<br \/>\none a gush of blood and two lengthening<br \/>\n06:47<br \/>\nof the umbilical cord after the placenta<br \/>\n06:50<br \/>\ndelivers the uterus should be palpated<br \/>\n06:51<br \/>\nto ensure that it is firm and has<br \/>\n06:53<br \/>\ncontracted and the placenta should be<br \/>\n06:55<br \/>\nvisually examined to make sure it has<br \/>\n06:57<br \/>\nbeen completely removed moving now to<br \/>\n06:59<br \/>\noperative deliveries operative<br \/>\n07:01<br \/>\ndeliveries are accomplished by applying<br \/>\n07:03<br \/>\ndirect traction to the fetal skull with<br \/>\n07:05<br \/>\nforceps or by applying traction to the<br \/>\n07:07<br \/>\nfetal scalp with a vacuum extractor the<br \/>\n07:10<br \/>\nincidence of operative vaginal delivery<br \/>\n07:12<br \/>\nin the United States is estimated to be<br \/>\n07:13<br \/>\napproximately 3.5% the general<br \/>\n07:16<br \/>\nindications are one prolonged or<br \/>\n07:18<br \/>\narrested second stage number two<br \/>\n07:20<br \/>\nsuspicion of immediate or potential<br \/>\n07:22<br \/>\nfetal compromise and number three<br \/>\n07:24<br \/>\nshortening of the second stage for<br \/>\n07:26<br \/>\nmaternal benefit our journey on to labor<br \/>\n07:28<br \/>\nand delivery with our patient labora has<br \/>\n07:30<br \/>\nassumed that we are in a high resource<br \/>\n07:32<br \/>\nsetting in low resource settings there<br \/>\n07:34<br \/>\nare a multitude of risks of labor and<br \/>\n07:36<br \/>\ndelivery and 99% of maternal deaths<br \/>\n07:38<br \/>\noccur in developing countries every day<br \/>\n07:41<br \/>\n800 women die from preventable causes<br \/>\n07:43<br \/>\nrelated to pregnancy and childbirth this<br \/>\n07:45<br \/>\nis the equivalent of two jumbo jets<br \/>\n07:47<br \/>\ndaily more than half of these deaths<br \/>\n07:49<br \/>\noccur in sub-saharan Africa and another<br \/>\n07:51<br \/>\none-third occur in Southeast Asia the<br \/>\n07:54<br \/>\nhighest risk is for adolescent girls the<br \/>\n07:56<br \/>\nmajor complications that account for 75%<br \/>\n07:58<br \/>\nof maternal deaths are bleeding<br \/>\n08:00<br \/>\ninfection high blood pressure<br \/>\n08:02<br \/>\ncomplications from delivery and unsafe<br \/>\n08:04<br \/>\nabortion this concludes the aapko video<br \/>\n08:06<br \/>\non intrapartum care we reviewed normal<br \/>\n08:08<br \/>\nlabor and delivery operative deliveries<br \/>\n08:10<br \/>\nand maternal risks specific to<br \/>\n08:12<br \/>\ndeveloping countries<br \/>\n08:19<br \/>\n[Music]<\/p>\n<p><\/div>\n<p>&nbsp;<\/p>\n<input type='hidden' bg_collapse_expand='69e9dc203e3ae8022298580' value='69e9dc203e3ae8022298580'><input type='hidden' id='bg-show-more-text-69e9dc203e3ae8022298580' value='Ischial Spines Comment'><input type='hidden' id='bg-show-less-text-69e9dc203e3ae8022298580' value='Close'><button id='bg-showmore-action-69e9dc203e3ae8022298580' class='bg-showmore-plg-button bg-red-button bg-arrow '   style=\" color:#fafafa;\">Ischial Spines Comment<\/button><div id='bg-showmore-hidden-69e9dc203e3ae8022298580' ><\/p>\n<p>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.<\/p>\n<p>&#8211; Dr. Hughey<\/p>\n<p><figure id=\"attachment_111\" aria-describedby=\"caption-attachment-111\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-111 size-medium\" src=\"https:\/\/brooksidepress.org\/basic_obgyn\/wp-content\/uploads\/2020\/08\/Ischial-Spine-300x212.jpg\" alt=\"\" width=\"300\" height=\"212\" srcset=\"https:\/\/brooksidepress.org\/basic_obgyn\/wp-content\/uploads\/2020\/08\/Ischial-Spine-300x212.jpg 300w, https:\/\/brooksidepress.org\/basic_obgyn\/wp-content\/uploads\/2020\/08\/Ischial-Spine.jpg 596w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><figcaption id=\"caption-attachment-111\" class=\"wp-caption-text\">The ischial spines and their attachment to the spine by the sacrospinous ligament.<\/figcaption><\/figure><\/p>\n<p><figure id=\"attachment_114\" aria-describedby=\"caption-attachment-114\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-114 size-medium\" src=\"https:\/\/brooksidepress.org\/basic_obgyn\/wp-content\/uploads\/2020\/08\/1-Station-1024x746-1-300x219.jpg\" alt=\"\" width=\"300\" height=\"219\" srcset=\"https:\/\/brooksidepress.org\/basic_obgyn\/wp-content\/uploads\/2020\/08\/1-Station-1024x746-1-300x219.jpg 300w, https:\/\/brooksidepress.org\/basic_obgyn\/wp-content\/uploads\/2020\/08\/1-Station-1024x746-1-768x560.jpg 768w, https:\/\/brooksidepress.org\/basic_obgyn\/wp-content\/uploads\/2020\/08\/1-Station-1024x746-1.jpg 1024w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><figcaption id=\"caption-attachment-114\" class=\"wp-caption-text\">When the presenting part is one centimeter below a line drawn between the two ischial spines (in red), it is said to be at \u201cplus one station.&#8217;<\/figcaption><\/figure><\/p>\n<p><\/div>\n<p>&nbsp;<\/p>\n<input type='hidden' bg_collapse_expand='69e9dc203e5fe9084244124' value='69e9dc203e5fe9084244124'><input type='hidden' id='bg-show-more-text-69e9dc203e5fe9084244124' value='Active Phase Labor Comment'><input type='hidden' id='bg-show-less-text-69e9dc203e5fe9084244124' value='Close'><button id='bg-showmore-action-69e9dc203e5fe9084244124' class='bg-showmore-plg-button bg-red-button bg-arrow '   style=\" color:#fcfafa;\">Active Phase Labor Comment<\/button><div id='bg-showmore-hidden-69e9dc203e5fe9084244124' ><\/p>\n<p>Definitions of the latent and active phases of the first stage of labor have changed over time.<\/p>\n<p>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 \u201cSafe Prevention of the Primary Cesarean Delivery.\u201d<\/p>\n<p>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.<\/p>\n<p>&#8211; Dr. Hughey<\/p>\n<p><\/div>\n","protected":false},"excerpt":{"rendered":"<p>\ufeff Duration = 8:28 &nbsp; &nbsp;<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":46,"menu_order":11,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-109","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/109","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/comments?post=109"}],"version-history":[{"count":6,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/109\/revisions"}],"predecessor-version":[{"id":1266,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/109\/revisions\/1266"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/46"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/media?parent=109"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}