Labor consists of a series of rhythmic, involuntary or medically induced contractions of the uterus that result in effacement (thinning and shortening) and dilation of the uterine cervix. The World Health Organization (WHO) defines normal birth as follows: Show
The stimulus for labor is unknown, but digitally manipulating or mechanically stretching the cervix during examination enhances uterine contractile activity, most likely by stimulating release of oxytocin by the posterior pituitary gland. Normal labor usually begins within 2 weeks (before or after) the estimated delivery date. In a first pregnancy, labor usually lasts 12 to 18 hours on average; subsequent labors are often shorter, averaging 6 to 8 hours. Rupture of the chorioamniotic membranes or bloody show is diagnostic for onset of labor. Bloody show (a small amount of blood with mucous discharge from the cervix) may precede onset of labor by as much as 72 hours. Bloody show can be differentiated from abnormal 3rd-trimester vaginal bleeding Vaginal Bleeding During Late Pregnancy Bleeding during late pregnancy (≥ 20 weeks gestation, but before birth) occurs in 3 to 4% of pregnancies. Some disorders can cause substantial blood loss, occasionally enough to cause hemorrhagic... read more because the amount is small, bloody show is typically mixed with mucus, and the pain due to abruptio placentae Placental Abruption (Abruptio Placentae) Placental abruption (abruptio placentae) is premature separation of the placenta from the uterus, usually after 20 weeks gestation. It can be an obstetric emergency. Manifestations may include... read more (premature separation) is absent. In most pregnant women, previous routine ultrasonography has been done and ruled out placenta previa Placenta Previa Placenta previa is implantation of the placenta over or near the internal os of the cervix. It typically manifests as painless vaginal bleeding after 20 weeks gestation; the source of bleeding... read more . However, if ultrasonography has not ruled out placenta previa and vaginal bleeding occurs, placenta previa is assumed to be present until it is ruled out. In such cases, digital vaginal examination is contraindicated, and ultrasonography is done as soon as possible to determine the location of the placenta and rule out abruptio placentae. Labor begins with irregular uterine contractions of varying intensity; they apparently soften (ripen) the cervix, which begins to efface and dilate. As labor progresses, contractions increase in duration, intensity, and frequency. There are 3 stages of labor. The 1st stage—from onset of labor to full dilation of the cervix (about 10 cm)—has 2 phases, latent and active. During the latent phase, irregular contractions become progressively coordinated, discomfort is minimal, and the cervix effaces and dilates to 4 cm. The latent phase is difficult to time precisely, and duration varies, averaging 8 hours in nulliparas and 5 hours in multiparas; duration is considered abnormal if it lasts > 20 hours in nulliparas or > 12 hours in multiparas. If the membranes have not spontaneously ruptured, some clinicians use amniotomy (artificial rupture of membranes) routinely during the active phase. As a result, labor may progress more rapidly, and meconium-stained amniotic fluid may be detected earlier. Amniotomy during this stage may be necessary for specific indications, such as facilitating internal fetal monitoring to confirm fetal well-being. Amniotomy should be avoided in women with HIV infection or hepatitis B or C, so that the fetus is not exposed to these organisms. The 2nd stage is the time from full cervical dilation to delivery of the fetus. On average, it lasts 2 hours in nulliparas (median 50 minutes) and 1 hour in multiparas (median 20 minutes). It may last another hour or more if conduction (epidural) analgesia or intense opioid sedation is used. For spontaneous delivery, women must supplement uterine contractions by expulsively bearing down. In the 2nd stage, women should be attended constantly, and fetal heart sounds should be checked continuously or after every contraction. Contractions may be monitored by palpation or electronically. The 3rd stage of labor begins after delivery of the infant and ends with delivery of the placenta. This stage usually lasts only a few minutes but may last up to 30 minutes.
Further confirmation is not needed if during examination, fluid is seen leaking from the cervix. Confirmation of more subtle cases may require testing. For example, the pH of vaginal fluid may be tested with Nitrazine paper, which turns deep blue at a pH > 6.5 (pH of amniotic fluid: 7.0 to 7.6); false-positive results can occur if vaginal fluid contains blood or semen or if certain infections are present. A sample of the secretions from the posterior vaginal fornix or cervix may be obtained, placed on a slide, air dried, and viewed microscopically for ferning. Ferning (crystallization of sodium chloride in a palm leaf pattern in amniotic fluid) usually confirms rupture of membranes. If rupture is still unconfirmed, ultrasonography showing oligohydramnios (deficient amniotic fluid) provides further evidence suggesting rupture. Rarely, amniocentesis with instillation of dye is done to confirm rupture; dye detected in the vagina or on a tampon confirms rupture. When a woman’s membranes rupture, she should contact her physician immediately. About 80 to 90% of women with PROM at term ( ≥ 37 weeks) and about 50% of women with preterm PROM (< 37 weeks) go into labor spontaneously within 24 hours; > 90% of women with PROM go into labor within 2 weeks. The earlier the membranes rupture before 37 weeks, the longer the delay between rupture and labor onset. If membranes rupture at term but labor does not start within several hours, labor is typically induced to lower risk of maternal and fetal infection. Most women prefer hospital delivery, and most health care practitioners recommend it because unexpected maternal and fetal complications may occur during labor and delivery or postpartum, even in women without risk factors. About 30% of hospital deliveries involve an obstetric complication Introduction to Abnormalities and Complications of Labor and Delivery Abnormalities and complications of labor and delivery should be diagnosed and managed as early as possible. Most of the following complications are evident before onset of labor: Multifetal... read more (eg, laceration, postpartum hemorrhage Postpartum Hemorrhage Postpartum hemorrhage is blood loss of > 1000 mL or blood loss accompanied by symptoms or signs of hypovolemia within 24 hours of birth. Diagnosis is clinical. Treatment depends on etiology... read more ). Other complications include abruptio placentae Placental Abruption (Abruptio Placentae) Placental abruption (abruptio placentae) is premature separation of the placenta from the uterus, usually after 20 weeks gestation. It can be an obstetric emergency. Manifestations may include... read more , abnormal fetal heart rate pattern, shoulder dystocia Fetal Dystocia Fetal dystocia is abnormal fetal size or position resulting in difficult delivery. Diagnosis is by examination, ultrasonography, or response to augmentation of labor. Treatment is with physical... read more , need for emergency cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. Up to 30% of deliveries in the US are cesarean. The rate of cesarean delivery fluctuates. It has recently increased, partly... read more , and neonatal depression or abnormality. Nonetheless, many women want a more homelike environment for delivery; in response, some hospitals provide birthing facilities with fewer formalities and rigid regulations but with emergency equipment and personnel available. Birthing centers may be freestanding or located in hospitals; care at either site is similar or identical. In some hospitals, certified nurse-midwives provide much of the care for low-risk pregnancies. Midwives work with a physician, who is continuously available for consultation and operative deliveries (eg, by forceps, vacuum extractor, or cesarean). All birthing options should be discussed. For many women, presence of the their partner or another support person during labor is helpful and should be encouraged. Moral support, encouragement, and expressions of affection decrease anxiety and make labor less frightening and unpleasant. Childbirth education classes can prepare parents for a normal or complicated labor and delivery. Sharing the stresses of labor and the sight and sound of their own child tends to create strong bonds between the parents and between parents and child. The parents should be fully informed of any complications. Typically, pregnant women are advised to go to the hospital if they believe their membranes have ruptured or if they are experiencing contractions lasting at least 30 seconds and occurring regularly at intervals of about 6 minutes or less. Within an hour after presentation at a hospital, whether a woman is in labor can usually be determined based on the following:
If these criteria are not met, false labor may be tentatively diagnosed, and the pregnant woman is typically observed for a time and, if labor does not begin within several hours, is sent home. When pregnant women are admitted, their blood pressure, heart and respiratory rates, temperature, and weight are recorded, and presence or absence of edema is noted. A urine specimen is collected for protein and glucose analysis, and blood is drawn for a complete blood count (CBC), blood typing, and antibody screening. If routine laboratory tests were not done during prenatal visits, they should be done; these tests include screening for HIV, hepatitis B, syphilis, and group B streptococcal infection. A physical examination is done. While examining the abdomen, the clinician estimates size, position, and presentation of the fetus, using the Leopold maneuver (see figure
Leopold maneuver
Leopold maneuver A helpful mnemonic device for evaluation is the 3 Ps:
Leopold maneuver(A) The uterine fundus is palpated to determine which fetal part occupies the fundus. (B) Each side of the maternal abdomen is palpated to determine which side is fetal spine and which is the extremities. (C) The area above the symphysis pubis is palpated to locate the fetal presenting part and thus determine how far the fetus has descended and whether the fetus is engaged. (D) One hand applies pressure on the fundus while the index finger and thumb of the other hand palpate the presenting part to confirm presentation and engagement. If labor is active and the pregnancy is at term, a clinician examines the vagina with 2 fingers of a gloved hand to evaluate progress of labor. If bleeding (particularly if heavy) is present, the examination is delayed until placental location is confirmed by ultrasonography. If bleeding results from placenta previa, vaginal examination can initiate severe hemorrhage. If labor is not active but membranes are ruptured, a speculum examination is done initially to document cervical dilation and effacement and to estimate station (location of the presenting part); however, digital examinations are delayed until the active phase of labor or problems (eg, decreased fetal heart sounds) occur. If the membranes have ruptured, any fetal meconium (producing greenish-brown discoloration) should be noted because it may be a sign of fetal stress. If labor is preterm (< 37 weeks) or has not begun, only a sterile speculum examination should be done, and a culture should be taken for gonococci, chlamydiae, and group B streptococci. Cervical dilation is recorded in centimeters as the diameter of a circle; 10 cm is considered complete. Effacement is estimated in percentages, from zero to 100%. Because effacement involves cervical shortening as well as thinning, it may be recorded in centimeters using the normal, uneffaced average cervical length of 3.5 to 4.0 cm as a guide. Station is expressed in centimeters above or below the level of the maternal ischial spines. Level with the ischial spines corresponds to 0 station; levels above (+) or below (−) the spines are recorded in cm increments. Fetal lie, position, and presentation are noted.
Women are admitted to the labor suite for frequent observation until delivery. If labor is active, they should receive little or nothing by mouth to prevent possible vomiting and aspiration during delivery or in case emergency delivery with general anesthesia is necessary. Shaving or clipping of vulvar and pubic hair is not indicated, and it increases the risk of wound infections. An IV infusion of Ringer's lactate may be started, preferably using a large-bore indwelling catheter inserted into a vein in the hand or forearm. During a normal labor of 6 to 10 hours, women should be given 500 to 1000 mL of this solution. The infusion prevents dehydration during labor and subsequent hemoconcentration and maintains an adequate circulating blood volume. The catheter also provides immediate access for drugs or blood if needed. Fluid preloading is valuable if epidural or spinal anesthesia is planned. If instrumental or cesarean delivery seems unlikely, women may drink clear liquids. Analgesics may be given during labor as needed, but only the minimum amount required for maternal comfort should be given because analgesics cross the placenta and may depress the neonate’s breathing. Neonatal toxicity can occur because after the umbilical cord is cut, the neonate, whose metabolic and excretory processes are immature, clears the transferred drug much more slowly by liver metabolism or by urinary excretion. Preparation for and education about childbirth lessen anxiety. If epidural injection is inadequate or if IV administration is preferred, fentanyl (100 mcg) or morphine sulfate (up to 10 mg) given IV every 60 to 90 minutes is commonly used. These opioids provide good analgesia with only a small total dose. If neonatal toxicity results, respiration is supported, and naloxone 0.01 mg/kg can be given IM, IV, subcutaneously, or endotracheally to the neonate as a specific antagonist. Naloxone may be repeated in 1 to 2 minutes as needed based on the neonate’s response. Clinicians should check the neonate 1 to 2 hours after the initial dosing with naloxone because the effects of the earlier dose abate. If fentanyl or morphine provides insufficient analgesia, an additional dose of the opioid or another analgesic method should be used rather than the so-called synergistic drugs (eg, promethazine), which have no antidote. (These drugs are actually additive, not synergistic.) Synergistic drugs are still sometimes used because they lessen nausea due to the opioid; doses should be small.
Fetal status must
be monitored during labor. The main parameters are baseline fetal heart rate (HR) and fetal HR variability, particularly how they change in response to uterine contractions and fetal movement. Because interpretation of fetal HR can be subjective, certain parameters have been defined (see table
Fetal Monitoring Definitions
Fetal Monitoring Definitions 
A normal pattern strongly predicts normal fetal acid-base status at the time of observation. This pattern has all of the following characteristics:
Early decelerations and age-appropriate accelerations may be present or absent in a normal pattern. An indeterminate pattern is any pattern not clearly categorized as normal or abnormal. Many patterns qualify as indeterminate. Whether the fetus is acidotic cannot be determined from the pattern. Indeterminate patterns require close fetal monitoring so that any deterioration can be recognized as soon as possible. An abnormal pattern usually indicates fetal metabolic acidosis at the time of observation. This pattern is characterized by one of the following:
Abnormal patterns require prompt actions to correct them (eg, supplemental oxygen, repositioning, treatment of maternal hypotension, discontinuation of oxytocin) or preparation for an expedited delivery. Patterns reflect fetal status at a particular point in time; patterns can and do change. Monitoring can be manual and intermittent, using a fetoscope for auscultation of fetal HR. However, in the US, electronic fetal HR monitoring (external or internal) has become standard of care for high-risk pregnancies, and many clinicians use it for all pregnancies. The value of routine use of electronic monitoring in low-risk deliveries is often debated. Electronic fetal monitoring has not been shown to reduce overall mortality rates in large clinical trials and has been shown to increase rate of cesarean delivery, probably because many apparent abnormalities are false positives. Thus, the rate of cesarean delivery is higher among women monitored electronically than among those monitored by auscultation. Fetal pulse oximetry has been studied as a way to confirm abnormal or equivocal results of electronic monitoring; status of fetal oxygenation may help determine whether cesarean delivery is needed. Fetal ST-segment and T-wave analysis in labor (STAN) can be used to check the fetal ECG for ST-segment elevation or depression; either finding presumably indicates fetal hypoxemia and has a high sensitivity and specificity for fetal acidosis. For STAN, an electrode must be attached to the fetal scalp; then changes in the T wave and ST segment of the fetal ECG are automatically identified and analyzed. If manual auscultation of fetal HR is used, it must be done throughout labor according to specific guidelines, and one-on-one nursing care is needed.
Listening for at least 1 to 2 minutes beginning at a contraction’s peak is recommended to check for late deceleration. Periodic auscultation has a lower false-positive rate for abnormalities and incidence of intervention than continuous electronic monitoring, and it provides opportunities for more personal contact with women during labor. However, following the standard guidelines for auscultation is often difficult and may not be cost-effective. Also, unless done accurately, auscultation may not detect abnormalities. Electronic fetal HR monitoring may be
Usually, external and internal monitoring are similarly reliable. External devices are used for women in normal labor; internal methods are used when external monitoring does not supply enough information about fetal well-being or uterine contraction intensity (eg, if the external device is not functioning correctly). A nonstress test records fetal heart rate and uterine contractions using external electronic monitors and correlates the HR with fetal movements (reported by the mother); it is called nonstress because no stressors are applied to the fetus during the test, although sounds (eg, bell, acoustic stimulator) may be used to wake the fetus. HR is expected to increase when the fetus is moving and at other intervals. The nonstress test is typically done for 20 minutes (occasionally for 40 minutes). Results are considered reactive (reassuring) if there are 2 accelerations of 15 beats/minute over 20 minutes. Absence of accelerations is considered nonreactive (nonreassuring). Presence of late decelerations suggests hypoxemia, potential for fetal acidosis, and the need for intervention. A biophysical profile is usually done after a nonreassuring nonstress test. The biophysical profile adds ultrasonographic assessment of amniotic fluid volume and sometimes assessment of fetal movement, tone, breathing, and HR, to the nonstress test. A nonstress test and biophysical profile are frequently used to monitor complicated or high-risk pregnancies Overview of High-Risk Pregnancy In a high-risk pregnancy, the mother, fetus, or neonate is at increased risk of morbidity or mortality before, during, or after delivery. Risk assessment is part of routine prenatal care. Family... read more (eg, complicated by maternal diabetes or hypertension or by stillbirth or fetal growth restriction in a previous pregnancy). Contraction stress testing (oxytocin challenge test) is now rarely done. In this test, fetal movements and HR are monitored (typically externally) during contractions induced by oxytocin. When done, contraction stress testing must be done in a hospital. If a problem (eg, fetal HR decelerations, lack of normal HR variability) is detected during labor, intrauterine fetal resuscitation is tried; women may be given oxygen by a tight nonrebreather face mask or rapid IV fluid infusion or may be positioned laterally. If fetal heart pattern does not improve in a reasonable period and delivery is not imminent, urgent delivery by cesarean is needed.
What are the factors that may influence the beginning of labor?Factors Affecting Labor. At least five factors affect the process of labor and birth. These are easily remembered as the five Ps: passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response.
What happens in stage 1 of labor?During the 1st stage of labour, contractions make your cervix gradually open (dilate). This is usually the longest stage of labour. At the start of labour, your cervix starts to soften so it can open. This is called the latent phase and you may feel irregular contractions.
What are the 3 parts of the first stage of labor?There are 3 phases to the first stage: Phase 1: Early (latent) labour. Phase 2: Active labour. Phase 3: Transition.
What are the first 4 stages of labour?Stages of labour. The first stage of labour is the slow opening of your cervix.. The second stage is the birth of your baby.. The third stage is separation and birth of the placenta.. The fourth stage is the first two hours after birth.. |
Which of the following are the factors that can affect the first stage of labor?
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