Low Risk Obstetrics
Session 2
Birthing Suite & Puerperium
Dr. Kristine Whitehead
2015
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Objectives
• Able to diagnosis and manage early labour
• Able to practice active management of
labour, including augmentation
• Prepare for expected procedures: ARM,
fetal scalp electrode, SVD
• Able to provide early postpartum care
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Spontaneous vaginal delivery
• video
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Management of Labour
• Your main responsibility on this rotation
• Respect labour, do not fear labour
• Active management is practiced at TOH
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Definition of Labour
• Regular, Frequent Contractions
PLUS
• Cervical Change
(Dilatation and Effacement)
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Definition of Labour
• Must diagnose labour correctly
• Otherwise can not diagnose labour
dystocia
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Stages of Labour
First Stage
A. Latent phase
- up to 3-4 cm in primip, 4-5 cm in multip
B. Active phase
- more rapid cervical dilatation
- follows latent phase
- ends with full cervical dilatation
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Second Stage
• A. Early period is from full dilatation to +2 or
urge to push
• B. Second component is marked by maternal
expulsive effort
• lasts until delivery of fetus
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Third Stage
• Delivery of placenta
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Normal Labour - Friedman
Historical data were collected before the widespread use of
epidural analgesia
Second stage values must be modified to reflect this
Nulliparous Multiparous
Latent Phase
Mean (time)
Longest normal
6.4h
20.1h
4.8h
13.6h
Active Phase
Mean (rate)
Slowest normal
3.0cm/h
1.2cm/h
5.7cm/h
1.5cm/h
Second Stage
Mean (time)
Longest normal
1.1h
2.9h
0.4h
1.1h
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1969 O’Driscoll
• Active management of labour
• To prevent primips from labouring >24 hrs
• Objective to decrease C/S rate
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O’Driscoll’s methods
• Only admit in true active labour
• ARM on admission
• Midwife to “monitor the labour and
encourage the mother”
• 1 cm/hr or oxytocin titrated to achieve 5-7
contractions q15mins
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Results
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C/S rate increased from 4% to 9%
40% women required oxytocin
12X increase in epidural analgesia
Cochrane review: only continuous
psychological support in labour lowered the
C/S rate
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• Labor seems to progress more slowly now
than in the 1950s
• Mean duration active labor 4.6 hrs. in 195060’s
• Mean duration active labor 8 hrs. in 198090s
• WHY?
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What’s different?
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Mean body mass higher (BMI)
Increased fetal size
Increased maternal age
Obstetric management eg. Induction,
oxytocin, epidural, continuous monitoring
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Normal Labour
• 90% women who have successful vaginal
birth progress >1cm/hr after 5cm cervical
dilatation
Peisner DB, Rosen MG: Transition from latent to active labor. Obstet Gynecol 68:448, 1986.
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Normal Labour - Partogram
• Used routinely in caseroom
• Nurse starts plotting when (and only when)
in labour
• to follow progress of labour and descent of
presenting part
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Labour Dystocia
• Definition
>4 hrs of <0.5 cm/hr dilatation
(< 2 cm dilatation in 4 hrs.)
or
>1 hr of no descent during active
pushing
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Labour Dystocia - Diagnosis
Most common reasons for non-elective csection (LSCS):
1)
2)
3)
4)
labour dystocia/failure to progress – 30%
non-reassuring FHR tracing – 22%
Malposition/malpresentation – 12%
Breech – 9%
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Labour Dystocia - Diagnosis
Therefore…
Must diagnose dystocia correctly to reduce
number of inappropriate C/S
WHAT CAN GO WRONG?
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Labour Dystocia - 3 “P’s”
• POWER
- hypotonic contractions
- uncoordinated contractions
- weak maternal expulsive
effort
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Labour Dystocia - 3 “P’s”
• PASSENGER
fetal position
fetal attitude
fetal size
fetal abnormalities
(e.g. hydrocephalus)
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Labour Dystocia - 3 “P’s”
• PASSAGE
bony pelvis
soft tissue
(full bladder/rectum)
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Labour Dystocia - 3 “P’s” +
• Person - the woman (her beliefs, preparation, knowledge &
"capacity" for doing the work of labour & birth
• Partner - her support & his/her knowledge, beliefs & preparation
• People – the others involved
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Labour Dystocia - 3 “P’s” +
• Pain – impact of experience of pain & socio-cultural
beliefs/environment on capacity for coping
• Professionals – how the health care team supports, informs &
collaborates in care & share info with the woman & her partner
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Labour Dystocia - 3 “P’s” +
• Patience – difficult to be passive
• Peripherals - reasonable privacy, quiet, adequate accessories
for labour and delivery (functioning birthing beds, lights, birthing
balls, hot water, mirrors, linens)
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How can we prevent dystocia?
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Accurate diagnosis of labour
Management of latent labour
Prepared childbirth (e.g. classes)
Birthing companion (e.g. doula) &
consistent nursing
• Ambulation (?) – Cochrane review 2009
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Continuous Intrapartum Support
(RN, family/friend, doula)
• Greatest benefit for vulnerable populations
• Compared to limited support as control
• Benefits: shortened duration of labour, increased
SVD, fewer epidurals, less oxytocin, fewer
AVD/C-sections, greater patient satisfaction
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Continuous labour support from labor attendant for primiparous women: a
meta-analysis. Zhang et al, Obstet Gynecol 1996
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How do we manage dystocia?
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ARM
Oxytocin augmentation
Therapeutic rest with analgesia
Repositioning of patient
Empty bladder
If dystocia persists, then consider Dx CPD and
proceed to delivery
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ARM
• Routine ROM does not accelerate spontaneous
labour – Cochrane 2007, reviewed 14 RCTs
• Insignificant shortening of first and second stage,
both primips and multips
• Does reduce need for oxytocin
• Does not increase maternal infection or epidurals
• Cochrane 2009, review 12 RCTs, shortened labor
by 1.11 hrs if ARM + pitocin in prolonged labor
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ARM
• Amniotomy for shortening spontaneous labour. Smyth
RM, Markham C, Dowswell T. Cochrane Database Syst
Rev. 2013 June;6:CD006167
• ? More FHR tracing abnormalities
afterwards
• Intervention for dystocia, not for prevention
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Indications for ARM
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Assess for meconium
Application of fetal scalp electrode
Insertion of IUPC
Prior to initiation of oxytocin, to augment labor
• Consider presentation first (ensure cephalic)
• Commits you to delivery
• Ensure explicit consent
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Technique ( ↓ risk of cord prolapse):
1. Avoid dislodging fetal head
2. Fundal pressure/suprapubic pressure
3. ARM during contraction
4. Head is preferably engaged (station = 0)
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Photos - amnihook
• practice
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Contraindications to ARM
• Unengaged presenting part - absolute
• Relative - Polyhydramnios
• Relative - Hepatitis B/C or HIV, GBS not
on ABs
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Augmentation of labor
• Low dose vs. high dose protocol
• Risks and benefits: must have informed
consent
• Properties of pitocin
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Oxytocin/pitocin
• Receptors in myoepithelial cells of breast, myometrium,
decidua
• Causes rhythmic contractions of myometrial smooth
muscle at low dose
• 8-10 mU/min infusion gives same clinical response found
in spontaneous labour
• Hypotension possible with bolus iv admin
• Antidiuretic activity – water intoxication possible with
high-dose (> 40mU/min)
• Half-life appx 5 mins
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Oxytocin/Pitocin
• Low dose protocol – less hyperstim, smaller
overall dose
• High dose protocol – more hyperstim but no
increased maternal/neonatal morbidity, may
shorten labour and lower C/S rate (2010 metaanalysis of RCTs)
• Potential risk of fetal compromise with hyperstim
• Tiny risk of uterine rupture, water intox
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Persistent dystocia
• True CPD (craniopelvic disproportion)
management = c-section
• Most CPD is relative so try other maneuvers
first
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Second Stage Management
• Debate exists re. setting time limit in the
absence of fetal compromise
• Woman should not be encouraged to push
unless she feels the urge
• Non-directed pushing in NCB
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Second Stage Management
• Generally, prolonged 2nd stage occurs at :
Primip
3 hr with epidural
2 hr without epidural
Multip
2 hr with epidural
1 hr without
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Second Stage Management
• Ottawa Hospital uses In-House Clinical Practice
Guidelines (CPG’s), see myHospital
• Categorized
= Primip with and without regional anesthesia
= Multip with and without regional anesthesia
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Third Stage Management
• Active management of the third stage should be
offered, since it reduces incidence of PPH due to
uterine atony
• This includes: oxytocin, controlled cord traction,
uterine massage after delivery of placenta
• Active management of the third stage of labour: prevention and
treatment of postpartum hemorrhage – SOGC Oct. 2009
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Active Management of the
Third Stage
• Signs of Separation
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Gush of blood
Lengthening of umbilical cord
Anterior-cephalad movement of fundus
Firm, globular fundus
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Active Management of the
Third Stage
• Active Management
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Early cord clamping (no longer recommended)
Controlled cord traction
Uterotonic agent: oxytocin vs. duratocin
Know dose and route, order prior to delivery
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Delayed Cord Clamping
• Benefits: elevated hematocrit/ferritin up to 6
months, less anemia at 3-6 months
• Increased asymptomatic polycythemia
• ? Increased neonatal jaundice requiring
phototherapy
• See myHospital for policy and procedure
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Late vs. early clamping of the umbilical cord in full-term neonates: systematic review
and meta-analysis of controlled trials: Hutton, EK et al, JAMA 2007 Mar 21
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Management of Labour - Case
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Phillipa 28 y.o. G1P0 EGA = 39+5 weeks
Presents at 1700 to triage
Contraction q 7-10 min since last night
More frequent this afternoon x 1.5 hours
Very uncomfortable
• What do you need to know?
• V/E BUILDING A HEALTHY COMMUNITY
1 cm dil, 2 cm long, stn – 2
FHR = 155 bpm, + accels, no decels on IA
Your assessment?
What is your management?
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• She goes home with nubain 20 mg IM
• Rest/sleep, returns at 0200 - contractions
now q3-4min
• Uncomfortable - wants to “go natural”
• What do you need to know?
• V/E -
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4 cm dil., thin (1/4 cm), cephalic, intact
FHR normal, 140-145 bpm, + accels, no
decels
Your assessment?
What now?
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• Uses shower/tub
• V/E 4 hrs later (0600)
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• Cx = 5 cm, station -1
• FHR normal
Assessment?
Management?
She has many questions about the epidural
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Epidural
• See info sheet in each room
• Informed consent – from anesthesia
• Risks – sytemic toxicity, high spinal,
hypotension, inadequate or failed block,
pruritis, N and V, resp depression, spinal
HA, backache, infxn, PP neuropathy
• ? Prolonged labour, increased AVD/CS
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• Epidural inserted 0700
Now what?
Do you need continuous EFM?
When to reassess?
Next exam BUILDING A HEALTHY COMMUNITY
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V/E at 0900: 8 cm, station -1
Bulging membranes, head well applied
FH shows frequent variable decelerations
FHR - baseline 145 bpm, acceleration with
scalp stim
• Comfortable but contractions spacing out to
q4-5 mins
• T = 37.7 C
Assessment? Management?
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• Successful ARM for abundant clear liquor
• Over 30 mins. contractions increase to q2-3
mins.
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• V/E at 1100 hr: Fully / station 0
• FH - occasional uncomplicated variable
decels
• Uncomfortable with contractions, especially
in her back
What do you do?
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Top-up the epidural
Frequent postion change
RN empties her bladder
Re-assess in 1 hour as per protocol
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• V/E at 1200: fully dilated, stn 0, prominent
anterior lip
• RN wonders re. OP?, wants OB resident to
check
• Contr q3-4min X 45 sec
• FHR normal
• Comfortable with epidural
Management plan?
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OBS Resident advises you to call your staff
Staff confirms position is LOA
Oxytocin started
Repositioned to knee-chest
Staff returns briefly to office, near by
RN wants scalp electrode
What now?
When to recheck?
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Fetal scalp electrode
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Technique: see instructions with packaging
Risks – superficial scalp trauma, infxn
Benefits – accuracy, consistency of FHR
Must have informed consent
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• V/E at 1300 (one hour later): spines +3
• Urge to push
Plan?
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• Start pushing!!
• Call staff back
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• FH shows prolonged deceleration to 60 bpm
x 3 minutes at 1400
• Presenting part can be seen easily with
pushing
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• OB staff present, supervises your vacuum
delivery (FM staff coming up the elevator)
• Baby boy 4050 g delivered over 2 pulls, no popoffs
• Neonates in attendance
• Apgars 9,9
What are the important issues here?
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Summary - Management of
Dystocia
• ARM
• Oxytocin augmentation
• Therapeutic rest with analgesia
• Repositioning
• Empty bladder
• Always assess maternal and fetal wellbeing
If dystocia persists, consider CPD/FTP and proceed
to operative delivery
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• Break
• Practice simulation: ARM, scalp electrode
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Delivery Room
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PPH prophylaxis
Neonatal resuscitation prn
Delayed cord clamping
Possible cord blood collection
Skin-to-skin benefits
– Temperature, HR, respirations
– Glucose
– Breastfeeding
• Epidural removed, catheter prn, vitals, iv
• Shower, teaching by RN
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A4/8E
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PP orders
Vitals, care map assessment
Breastfeeding on demand, rooming in
LC, SW, DPH prn
Vaccination (MMR, influenza), Rhogam
prn
• Discharge planning
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Early Maternal Issues
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After pains
Engorgement: milk, edema
Urinary retention: protocol, pudendal nerve injury
Hemorrhoids
Musculoskeletal pain
Headache
DVT: 21-84 times more common for 2/52 PP
Anemia
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Case #1
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23 year old G2P2, healthy
SVD, healthy girl, epidural
Second degree perineal tear
PPD # 1 - slightly tender uterine fundus,
some breastfeeding trouble
• PPD # 2 – T = 38.0 deg C
• What do you do?
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Postpartum Endometritis
Presentation
• Fever +/- chills
• Tenderness, pain - uterus
• Lochia may be foul, heavier bleeding
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Postpartum Endometritis
• Polymicrobial: anaerobes and aerobes
• Potentially lethal: esp GAS, clostridium
• Both cause toxic shock syndrome
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Postpartum Endometritis
Treatment
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Clindamycin and Gentamicin iv
Clindamycin po
Doxycycline and Metronidazole
Clavulin
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• Breastfeeding problem ie. Pain, weight loss,
hungry baby
• Risk of dehydration, xs wt loss >10%
• ? Risk of pacifier
• ? Risk of formula
• ? Risk of PPD
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Case #2
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37 year old G1P1
C-section, healthy boy, epidural
Day 2 : tender nipples, 8% weight loss, fussy baby
Tearful Mom, mother-in-law rocking baby with a
pacifier
• Is this all normal?
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Management
• Support/encourage/teach +++
• LC consult
• Start hand expression, pumping
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Case #3
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30 year old G2P2
SVD, healthy girl
First degree tear
Increasing perineal pain on day 2
• Is this normal?
• What should you do?
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Case #4
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32 year old G4P4
Day 2 : exhausted, lethargic, new Canadian
History of depression
Limited supports
• Is there anything you can do to help?
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• Assess supports
• SW consult
• PHD referral/HBHC – request early visit
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QUESTIONS/COMMENTS
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