Intrapartum Care

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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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