CPG on Normal Labor and Delivery
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Transcript of CPG on Normal Labor and Delivery
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CPG on Normal Labor
and Dellivery
Prepared by: Jaramillo, Neptune S.
MSU COM, CLASS 2012
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In Latin, the word labormeans a troublesome effortor suffering. Another term for labor isparturition
which comes from the Latin word Parturireto beready to bear young and is related topartustoproduce. To labor in this sense is to produce.
a physiologic process that begins with the onset of
rhythmic contractions which bring about changes inthe biochemical connective tissue resulting gradualeffacement and dilatation of the cervix and ends withthe expulsion of the product of conception
DEFINITION OF LABOR
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a clinical diagnosis
criteria for the diagnosis of labor include: Uterine contractions (at least 1 in 10 minutes or 4 in 20
minutes) by direct observation or electronically usinga cardiotocogram
Documented progressive changes in cervical dilatationand effacement
Cervical effacement of > 70-80%
Cervical dilatation > 3 cm
DEFINITION OF LABOR
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goal of intrapartum fetalsurveillance to detect potentialfetal decompensation and to
allow timely and effectiveintervention
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aims to identify hypoxia before it is
sufficient to lead to long term poorneurological outcome for babies
done at regular intervals using a handheld Doppler device
MONITORING OF FETAL WELL-BEING DURING NORMAL LABOR
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intermittent auscultation be undertaken every15-30 minutes in the 1ststage of labor and
every 5 minutes in the 2ndstage of labor at least30 seconds after each contraction
cardiotocography (CTG) is not recommended
for healthy women at term in labor in theabsence of risk factors for adverse perinataloutcome
Recommendations:
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Continuous EFM should be recommendedwhen either risk factors for fetal compromisehave been identified antenatally, at the onsetor during labor
Recommendations:
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defined as an intervention
designed to artificially initiateuterine contractions leading toprogressive dilatation and
effacement of the cervix and birthof the baby.
INDUCTION OF LABOR
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Assessment with documentation prior tostarting the induction should include:
Confirmation of parityPresentationBishops scoreConfirmation of gestational ageUterine activityNonstress test
Recommendations:
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Confirmation of gestational age
Confirmation of Term Gestation
American College of Obstetrics and Gynecology (ACOG)
Practice Bulletin #230, November 1996
Fetal heart tones have been documented for 20 weeks by
nonelectronic fetoscope or for 30 weeks by Doppler
The passage of 36 weeks since a serum or urine humn chorionic
gonadotropin (HCG) pregnancy test was found to be positive Ultrasound measurement of the crown-rump length at 6-11 weeks
gestational age (GA) that support a current GA equal =/> 39 weeks
Ultrasound measurements at 13-20 weeks GA supports a clinically
determined GA equal =/> 39 weeks.
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Induction of labor should be
administered only in a hospital setting,particularly in a labor room under theresponsibility of an obstetrician
Assess cervical ripening with the use ofBishops preinduction score system
Recommendations:
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FACTOR SCORE
0 1 2 3
CervicalDilatation
(in cm)
Closed 1-2 3-4 5
Cervical
Effacement
(%)
0-30 40-50 60-70 >80
Station -3 -2 -1 +1,+2Cervical
ConsistencyFirm Medium Soft
Cervical Position
Posterior Midposition Anterior
Bishops Preinduction
Cervical Score System
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Gestational hypertension
Preeclampsia, eclampsiaPrelabor rupture of membranes
Maternal medical conditions (e.g.,
diabetes mellitus, renal disease, chronichypertension)
Gestation 41 1/7 weeks
Induction is indicated when the continuance ofpregnancy may no longer be advisable in the
following clinical circumstances:
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Malpresentation (e.g., transverse,
breech)Absolute cephalopelvic disproportion
Placenta previa
Previous major uterine surgery orclassical cesarean section
Contraindications for
Labor Induction
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Invasive carcinoma of the cervix
Cord presentationActive genital herpes
Gynecological, obstetrical, or medical
conditions that preclude vaginal birthObstetricians convenience
Contraindications for
Labor Induction
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OXYTOCIN
MEMBRANE SWEEPING /STRIPPING
AMNIOTOMY
Methods of Induction of Labor
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seeks to provide adequate hydration andnutrition while maintaining safety for themother and the baby
Many obstetricians restrict oral food andfluid intake during active labor because of
the possible riskincidence of aspiration of gastric contents has
always been low and therefore plays a verysmall role as a cause of maternal death
INTRAPARTUM NUTRITION
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thought to decrease the risk puerperal
and neonatal infections
Recommendation:
There is no evidence to support the routineuse of enemas during labor
ENEMA DURING LABOR
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Friedmans Curve
MONITORING THE
PROGRESS OF LABOR
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1. Latent phase: up to 3-4 cm dilatation (approximately 8 hrs
long)
2. Active Phase
a. Acceleration phase-not always present
b. Phase of Maximum Slope
- Occurs at approximately 9 cm. dilatation
- Fetus is considered fully descended as it falls one station
below the ischial spine (+1)
c. Deceleration- always present
DILATATION CURVE
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ends at 3-4 cm dilatation
( approx. 8 hrs long)
Extends from the onset of labor,
time from the onset of the regularuterine contractions, to thebeginning of the active phase.
Latent phase
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The point when the curve becoming more steeplyinclined.
ends at full cervical dilatation when the cervix is nolonger palpable.
The active phase may be further subdivided in tothree distinctive phase:
Acceleration phase Phase of maximum slope
Deceleration phase
Active Phase
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1. Latent phase- no fetal descent occurs
- Extends beyond dilatational phase of descent curve
1. Active Phase- come much later
a. Acceleration
b. Phase of maximum descent
- Occurs at around 9 cm dilatation
- Corresponds to the deceleration of dilatation
- Fetus fully descended at +1 (station below level of ischial
spines)
Fetal Descent
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o The pattern of descent follows a hyperbolic curve, it too
has its phases as follows:
1. The Latent Phase - corresponds to the latent and
acceleration phase of cervical dilatation (the preparatory
division of labor). At this time, little if at all, fetal head
descent takes place.
2. The Accelaration Phase - corresponds to the phase of
maximum slope (the dilatation division of labor) of
cervical dilatation. This is time that fetal head descent
ensues.
Fetal Descent
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1. The Place of Maximum Slope corresponds to
the deceleration phase and second stage of labor
in cervical dilatation (pelvic division of labor).
Increased rates of descent begins during this
phase and progresses to a maximum until the
presenting part reaches the perennial floor.As this
event occurs, the cervix is expected to be at an
advanced stage of dilatation (8-9 cm)
Fetal Descent
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The WHO
PARTOGRAM
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If graph is located on the right side of
the ALERT LINE: one should monitorthe patient closely
If graph reaches the ACTION LINE:should do cesarean section orforceps/vacuum delivery.
WHO PARTOGRAPH
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There is evidence that walking and uprightposition in the first stage of labor reduce the
length of labor and do not seem associatedwith increase intervention or negative effectson mothers and babies well-being.
Women should be encouraged to take upwhatever position they find mostcomfortable in the first stage of labor.
MATERNAL POSITION DURINGTHE FIRST STAGE OF LABOR
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When not contraindicated (e.g. hypovolemia,coagulopathy), neuraxial analgesia (spinal or
epidural) using local anesthetic with or withoutneuraxial opioids provides the most effective painrelief for labor.
This techniques should be administered by a trainedand skilled anesthesiologist in an appropriatemedical fascility with appropriate resources for thetreatment of complications should be available.
ANALGESIA AND ANESTHESIADURING LABOR
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For imminent delivery, the following may be used:
Pudendal block may offer analgesia for
episiorraphy and repair if needed
Single shot spinal (saddle block)
Intravenous thiopental, propofol, ketamine maybe administered parenterally by a skilledanesthesiologist. (Level 3, Grade C)
ANALGESIA AND ANESTHESIADURING LABOR
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The use of low concentrations of
volatile anesthesia for labor analgesia isno longer accepted as a standard of carefor labor and vaginal delivery. Generalanesthesia obtunds the patients
airway, reflexes and increases the riskfor airway aspiration and itssubsequent sequelae. (Level 3, Grade C)
ANALGESIA AND ANESTHESIADURING LABOR
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Amniotomy is the artificial rupture ofmembranes.
Artificial rupture of the amniotic
membranes during labor is one of themost commonly performedprocedures in modern obstetrics.
AMNIOTOMY
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Timing
There is still no conclusive evidence to supportthat early amniotomy has a clear advantage overexpectant management (Level 1, Grade C).
Supporting Statements:
Early amniotomy appears to lead to an averagereduction of labor.
Routine amniotomy does not significantly reducethe duration of first-stage labor in eitherprimiparous or multiparous women (Grade A).
It slightly shortens second-stage labor inprimiparous women only (Grade A).
Recommendations:
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Use
The primary aim is to speed upcontractions and shorten the lengthof labor.
also to assess the status of the fetus
It is clinically indicated to observethe color and amount of amnioticfluid
Recommendations:
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Complicationsincreases the risk of chorioamnionitis.Possible complications includeumbilical cord prolapse, cord
compression and fetal heart ratedecelerations, increase ascending
infection rate, bleeding from fetal orplacental vessels and discomfort fromthe actual procedure.
Recommendations:
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Elements of Support:
Emotional support (continuous presence,
reassurance and praise)
Physical measures of comfort(massages,
comforting touches, acupressure)
Advocacy like helping the woman to express her
wishes and needs to others
CONTINUOUS SUPPORT
DURING LABOR
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Continuous support by a lay woman during
labor and delivery:
Facilitates birth
Enhances the mothersmemory of the experience
Strengthens mother-infant bonding; increases
breastfeeding success
Significantly reduces many forms of medical
intervention, including cesarean delivery, the use
of analgesia, anesthesia, and vacuum extraction.
CONTINUOUS SUPPORT
DURING LABOR
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Duration of support:
Continuous
IntermittentTypes of Provider:
Untrained lay women
Trained lay women (doulas) Female relatives
Nurses
Monitrices (lay midwives acting solely as labor
su ort ersons
CONTINUOUS SUPPORT
DURING LABOR
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Outcomes assessed:
Use of any analgesiaNeed for oxytocin augmentation
Need for forceps or vacuum
Need for cesarean section
Duration of labor
CONTINUOUS SUPPORT
DURING LABOR
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ROUTINE PERINEAL SHAVING
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o There is insufficient evidence to recommend
routine perineal shaving for women on admission
in labor. (Level 1, Grade E)
Late side effects attributable to shaving occur
later such as:
1. Irritation
2. Redness
3. Multiple superficial scratches from the razor
4. Burning and itching of the vulva
ROUTINE PERINEAL SHAVING
BEFORE DELIVERY
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Recommendations
The upright positionin the second stage of labor isassociated in women without epidural anesthesiawith a 4-minute shorter interval to delivery, lesspain, lower indices of abnormal fetal heart pattern
and of operative vaginal delivery, as well as higherrates blood loss of > 50 ml compared with otherpositions in 20 trials including 6135 women.
MATERNAL POSITION DURINGTHE SECOND STAGE OF LABOR
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Recommendations
The upright positions studies include sitting(obstetric chair/stool), semi-recumbent(trunk tilted backwards 30oto the vertical),
kneeling squatting (unaided or usingsquatting bars), and squatting aided withbirth cushion.
MATERNAL POSITION DURINGTHE SECOND STAGE OF LABOR
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There is no evidence that the rate of adverseperineal outcomes is affected by different types of
bearing down during the second stage of labor(Level 1, Grade C)
A systematic review of controlled trails has foundno evidence of a difference. Holding (Valsalva) orspontaneous exhalatory methods of pushing areused during the second stage of labor.
ALTERNATIVE METHODS
OF BEARING DOWN
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Definition:
o Hands on = touch the perineum
o Hands poised / Hands off = do not touch theperineum
Recommendations:
o Hands off and Hands on techniques did not affect thefrequency or severity of perineal trauma in women
undergoing childbirth for the first time. (Level 1, grade C)
PERINEAL SUPPORT: HANDS
POSED VERSUS HANDS ON
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USE OF EPISIOTOMY
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Recommendations:
Restricted use of episiotomny preferable to routine
use. (Level 1, Grade A)Median episiotomy is associated with higher rates of
injury to the anal sphincter and rectum. (level 1,Grade A)
Mediolateral episiotomy may be preferable tomedian episiotomy in selected cases. (Level 1, GradeB)
Routine episiotomy does not prevent pelvic floor
damage leading to incontinence. (Level 1, Grade B)
USE OF EPISIOTOMYAND REPAIR
USE OF EPISIOTOMY
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Repair
o In either median or medioolateral episiotomy, 2-layered
closure can improve postpartum pain and healing
complications vs a 3-layered closure.
o Polyglycolic acid derivative suture, with minimal reaction,
is recommended to reduce wound inflammation. (Level 1,
Grade A)
USE OF EPISIOTOMYAND REPAIR
USE OF EPISIOTOMY
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Episiotomy
Purpose: facilitate second stage of labor to improve
maternal and neonatal outcome
Maternal benefit
Reduced risk of perineal trauma, subsequent pelvic floor
dysfunction and prolapse, urinary incontinence, fecal
incontinence and sexual dysfunction
Fetal benefit
Shortened second stage of labor
USE OF EPISIOTOMYAND REPAIR
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o There is good evidence to support the use of fast-
absorption polyglactin 910 as material of choice for
perineal closure. (Level 1, Grade A)
Fast-absorbing Polyglactin 910
- Obviates need for suture removal up to 3 months
postpartum for 1 in 10 women sutured
- Less dyspareunia at 6 weeks
- Similar wound breakdown profile as chromic rarely
requires late removal
- Earlier resumption of sexual intercourse
SUTURE MATERIALS FOR
EPISIORRAPHY
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Recommendations:
Active management includes a group of
interventions such as
1. Administration of prophylactic uterotonin within
one minute after the delivery of the baby and prior
to the delivery of the placenta
2. Early cord clamping and cutting
3. Controlled cord traction to deliver the placenta
MANAGEMENT OF THIRDSTAGE OF LABOR
DRUGS IN THE THIRD
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Recommendations:
o Oxytocin is effective as first line prophylactic
uterotonic during the 3rd stage of labor in the
prevention of PPH and is safe to use in all
patients. (level 1)
o Use of ergot alkaloid and ergometrine-oxytocin
are valid alternatives in the absence of oxytocin.
Their use have to be weighed against maternal
adverse effects. (Level 1)
DRUGS IN THE THIRD
STAGE OF LABOR
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The American Academy of Physicians,American College of Obstetricians andGynecologists, American Academy ofBreastfeeding Medicine, World HealthOrganization, United Nations
Childrens Fund, and many otherhealth organizations recommendexclusive breastfeeding for the first 6
months of life.
EARLY BREASTFEEDING
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Breastfeeding should be continued forat least te first year of life and beyonffor as long as mutually desired bymother and child.
EARLY BREASTFEEDING
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oManeuvers that maintain milk
production:1.Maternal anatomic abnormalities of the
breast
2.Neonatal anatomic abnormalities
3.Neonatal depression
EARLY BREASTFEEDING
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o Breastfeeding is contraindicated in mothers with
the following conditions:
Use of street drugs or alcohol
Infant with galactosemia
Maternal infection (HIV, active PTB, varicella,
herpes simplex)
Use of neoplastic, thyroid, immunosuppresants
Undergoing treatment of breast cancer
EARLY BREASTFEEDING
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