see also: [[postpartum haemorrhage]], [[pre-term labour|premature labour]] see: - [rosen labor and delivery](x-devonthink-item://BC43844F-7576-42FE-9ACA-DC63AF1A5A08) - [Dunn Normal labour](x-devonthink-item://2DC31C7A-B061-45D0-99EE-858E0A4D44BF) # Labor - assessed through cervical exam > *dilation* of os up to 10 cm > *effacement* softening and thinking of cervix > *station* location of presenting part relative to ischial spines > ![[Pasted image 20231205095148.png]] # Delivery steps 1. IV access, monitoring, pelvic exam 2. wash perineum wiht mild soap /iodine if time allows, drape patient + sterile covering 3. *six movements of fetal descent* (see below) 1. engagement 2. flexion 3. descent 4. internal rotation 5. extension 6. external rotation 4. clamp the cord → do not clamp in preterm infants for 1-3 minutes (increases neonatal iron sores) 1. double clamp umbilical cord 3cm distal to its insertion at the umbilicus and transect with sterile scissors 5. dry the infant and give infant to mum or place in warming unit 6. delivery placenta ![[Pasted image 20231206123723.png]] The movements of normal delivery for a vertex presentation. - A. Engagement, flexion, and descent with vertex anterior. - B. Internal rotation with occiput becoming anterior. - C. Extension and delivery of the head. As the infant’s head emerges from the introitus, support the perineum by placing a sterile towel along the inferior part of the perineum with one hand, and support the fetal head with the other hand. Ask the mother to breathe through contractions (rather than bear down) in order to deter rapid expulsion of the baby. Provide mild counterpressure for controlled extension of the fetal head. As the infant’s head presents, use the inferior hand to control the fetal chin and keep the superior hand on the crown of the head, supporting the delivery. - D. External rotation, bringing the thorax into the anteroposterior diameter of the pelvis. As the head delivers, palpate the infant’s neck to assess for the presence of a nuchal cord. Nuchal cord is noted in approximately 25% to 35% of all term deliveries. If the cord is loose, move it over the infant’s head, and allow delivery to proceed as usual. If the cord is wound tightly around the neck, however, apply two close clamps in the most accessible area, and then cut the cord. - E. Delivery of the anterior shoulder. Once the head is delivered, it will turn to one side or the other. Grasp the sides of the head with both hands, and apply gentle downward traction (go with gravity) until the anterior shoulder is delivered. Jerky or aggressive traction may injure the brachial plexus. If you have not checked for a nuchal cord, do so now. As the head rotates, place the hands on either side of the head, providing gentle downward traction. This maneuver allows for the delivery of the anterior shoulder. - F. Delivery of the posterior shoulder. Use an upward movement to deliver the upward shoulder. Do not apply traction. If meconium is present or the newborn is limp or poorly responsive, stimulate the baby and be prepared to begin the steps of neonatal resuscitation with ventilation and oxygenation ## delivery in the ED - analgesia - usually too late for epidural/opiate, etc - delivering bub is a decent anagesic - +/- entonox (and reduces uterine contractility/impair communication with mum) - prep - IV access - no need for O2 - delivery pack - neonatal resus trolley - involve maternal support person if available - monitor - fetal heart rate - strength an dduration of contractions - CTG if thought ot be complicated or FHR is low - position - supine or lateral - hips abducted and flexed - vaginal exam if nead not crowning - determine - presenting part (if breech or face get urgetn obstetric help) - cervical dilation (1-10cm) and effacement (thins to 1mm) - level of descent of presenting part below ischial spines in CM - delivery - position usually left occipito-transverse initially - lateral flexion of head - internal rotation of head 90 deg - extensio of head around pubic symphysis - preserve perineum if possible - deliver head - maintain flexion as this has a smaller diameter - when head delivered, free cord from around neck - clamp and cut cord if cannot get off neck - suction nose and mouth - external rotation of head back to LOT - deliver trunk, anterior shoulder first - rest of body should follow easily - post delivery - check for undx twin - administer **oxyocin 10u** IV or IM (carbetocin 100 mcg IM alternative) - clamp and cut cord 10cm from bub - immediatly if neonate needs resus - if no urgency then delay clamping for 2-3 min or until cord no longer pulses significantly - deliver placenta with controlled cord raction - inspect placenta for completness - check for evidence of birth truama - monitor ongoing vaginal blood loss - average loss is 500-600mL - postnatal care - repar episiotomy or lacs - neonatal resus as required - keep warm - suciton - stimulation - +/- BCM or intubation - anti-D admin (625 IU) within 72 h of delivery if indicated # Stages of Labour **Stage 1 -- contractions to full cervical dilation** - may be preceded by bloody show - from regular contractions to full cervical dilation - 6-20 hours for first bub; 2-14 hours for multi bubs **Stage 2 -- dilation to delivery of infant** - 30 min-3 hours (5 min-60 min for multi bub) **Stage 3 -- delivery to placenta out** - 0-30 min # True labour vs false labour false labour aka braxton hicks - normal contracitons of uterus that prepare uterus for labour and enhance placental blood flow - not a sign of commencement of labour - start at about 7 weeks, often become symptomatic around 16 weeks - pain similar to menstrual cramps, not usually severe - last for 30-60 seconds, irregular interval btwn contractions - no more than twice per hour, a few times per day - stop with change in position or activity - no specific mgmt required | feature of contractions | true labour | false labour | | ----------------------- | --------------------------------------------------------------------------------- | ------------------------------------------------ | | frequency | regular intervals becoming more frequent w/ time (eg q10 min → 8 min → 5 min, etc | occur *sporadically* without predictable pattern | | duration | 15-30 sec at onset, progressively *longer* | vary in length and intensity | | location | start high in abdomen, radiate across abdo and lower back | central abdomen or in groin | | change with movement | unchanged | may stop or slow with change of position | # complications of delivery ## dystocia - abnormal labour -- cervix not dilated, fetus not descending - can ber anatomically - real distocia is full dilation and cannot deliver ## shoulder dystocia - anterior shoulder is not coming out Suspect when: - head turtling in and out - difficulty w/ birth of face and chin - the anterior shoulder does not birth with normal downward traction **Emergency manouvres** for managing shoulder dystocia are designed to do one of three things: 1. increase the functional size of the bony pelvis 2. decrease the bisacromial diameter of the fetus 3. change the relationship of the bisacromial diameter within the bony pelvis by rotating the fetus into the wider oblique diameter **safety tips:** 1. rotate pressure on scapula or clavicle, never rotate head 2. avoid excessive traction at all times 3. avoid fundal pressure → risk of brachial plexus injury, uterine rupture, haemorrhage **Technique / manoeuvres:** 1. ==McRobert's manoeuvre== → ==flex legs== 1. increase AP diameter of pelvic inlet by reducing lumbosacral lordosis 2. ==suprapubic pressure== → ==Rubins I== 1. gentle downwards traction to the baby's head 3. reposition mother on all fours (*rare*) 4. if attempting internal manoeuvres, then cut or extend episiotomy 1. ==Rubins II==: apply pressure w/ fingers to posterior aspect of anterior shoulder of foetus pushing it towards the chest of the baby rotating shoulder forward 2. ==Wood's screw==: apply pressure w/ fingers to posterior aspect of anterior shoulder and to anterior aspect of posterior shoulder, rotating foetus 180 deg 3. ==delivery of posterior arm== : identify posterior arm, bend it at the elbow and sweep it across the chest and face delivering the limb > **HELPER** mnemonic for shoulder dystocia > Help - Ob, neonatology > Episiotomy > Legs flexed (mcRoberts' maneouver) > Pressure - suprapubic pressure, shoulder pressure > Enter vagina (rubin's maneuver) > Remove posterior arm ![[Pasted image 20231205110720.png]] ![[Pasted image 20231205111709.png]] ![[Pasted image 20231206123026.png| Suprapubic pressure (Rubin 1)]] ## nuchal cord - cord *wrapped around the neck* - Tx: - prevent compression of cord - gently reduce manually if loose - if cord is tight, can clamp and cut but need to then have rapid delivery ## Cord prolapse - high fetal morbidity/mortality - need to elevate presenting part to prevent compression of cord - need *immediate C section* - put mum in knee-chest position to get pressure off cord ![[Pasted image 20231205110232.png]] 1. administer O2 and immediate assessment (dilation, fetal wellbeing/CTG) 2. knee-to-chest position or exaggerated simms position (left lateral supported with 2 pillows) 3. prevent cord compression -- presenting part should be pushed out of the pelvis upwards by fingers in the vagina to relieve pressure on the cord by the presenting part, until delivery 4. discontinue oxytocics 5. +/- urinary bladder filled with fluid to help elevate the presenting part off the compressed cord 6. deep trendenburg position (head-down bed position) 7. consider tocolysis (terbutaline) if delay to C section 8. immediate delivery ![[Pasted image 20240317160808.png]] ## Breach presentation - shoulder, foot, etc - call for help! ![[Pasted image 20231206124513.png]] ## caesarean section - see description in [[Resuscitative Hysterotomy]] # monitoring - *late decelerations* are bad -- signs of uteroplacental insufficiency (see [[CTG monitoring]]) # APGAR - measure at 1 and 5 min - if <7 at 5 min, continue Q5min until >7 - 1 min ∝ acidosis and survival - 5 min ∝ neuro outcome > \> 8 → no resus needed > 4-7 → IPPV, intubate if no improvement at 30 sec > < 4 → intubate ![[Pasted image 20241230172212.png]] # Related Questions ## delivery - [ ] 5Q: [Delivery](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=9) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=12) ## labour - [ ] 10Q: [Shoulder dystocia](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=8) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=8) - [ ] 11Q: [Delivery in the Emergency Department](x-devonthink-item://EE8AC47E-BE40-4377-885E-FA9C91C8C262?page=7) -- [Answer]() - [x] DUPLICATE Q: [Delivery](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=9) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=12) - [ ] 12Q: [Precipitous labour](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=28) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=16) ## post partum haemorrhage - [ ] 14Q: [Post partum haemorrhage](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=80) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=81) - [x] DUPLICATE Q: [Delivery in the Emergency Department](x-devonthink-item://EE8AC47E-BE40-4377-885E-FA9C91C8C262?page=7) -- [Answer]() - [ ] 15Q: [Post partum haemorrhage](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=10) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=4) - [x] 16Q: [Delivery in an Ambulance](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=20) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=9) - [x] 17Q: [Post partum haemorrhage](x-devonthink-item://EF003416-CCE0-4A7D-AE59-F054D2880322?page=14) -- [Answer](x-devonthink-item://30A6ADA2-CC99-445A-B901-7117A6AEB2CC?page=16) - [ ] 18Q: [Post Partum Haemorrhage](x-devonthink-item://335900F2-D054-4D3D-983F-04A22741BF68?page=5) -- [Answer](x-devonthink-item://E3D816B5-653D-4DC6-A389-8C69022A6062?page=19) ## resuscitative hysterotomy - [ ] 20Q: [Resuscitative Hysterotomy](x-devonthink-item://7E9EF652-F67B-42C5-A536-2EE85BA1954F?page=3) -- [Answer](x-devonthink-item://2DE5FACA-6D8F-41A2-8EAA-8DFE1E76FA61?page=1) ## shoulder dystocia - [ ] 21Q: [Shoulder dystocia](x-devonthink-item://71171BE8-7F92-40FA-99D2-0FF4C482F766?page=1) -- [Answer](x-devonthink-item://A0D348CE-FCD4-4ECD-BE21-6CA73F6DE8CD?page=16) - [x] DUPLICATE Q: [Shoulder dystocia](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=8) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=8) - [x] DUPLICATE Q: [Delivery](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=9) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=12) ## third trimester bleeding - [ ] 22Q: [Third trimester bleeding](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=53) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=58)