B6 M1 Case 1 TG

• Typical progression of labor

  1. First Stage

  2. Latent Phase

  3. Active Phase

  4. Second Stage
• Latent Phase


  • Begins with regular uterine contractions, typically ending around 3-5 cm dilation
  • Duration: Up to 14 hours in multiparas, and 20 hours in primiparas. Beyond this is considered prolonged
  • Influencing Factors: Excessive sedation, epidural analgesia, and unfavorable cervix conditions
• Active Phase


  • Starts when cervical dilation reaches 3-5 cm or more, marked by rapid cervical changes
  • Duration: Typically 4.9 hours in nulliparas, with a maximum of 11.7 hours. Multiparas progress at a minimum rate of 1.5 cm/hr
  • Descent of the fetal head begins around 7-8 cm in nulliparas
• Second Stage


  • Begins at full dilation and ends with fetal delivery
  • Duration: Maximum of 2 hours for both nulliparas and multiparas
  • Median duration: 50 minutes for nulliparas; 20 minutes for multiparas
• Dystocia


  Difficult labor characterized by abnormally slow progress, often due to a disproportion between the fetus and the birth canal
• Failure to progress


  Lack of cervical dilation or fetal descent in either spontaneous or stimulated labors

  
• ACOG recommends diagnosing dystocia only after the cervix has dilated to 4 cm, indicating entry into the active phase of labor
• Causes of Dystocia


  • Abnormalities of Powers
  • Abnormalities of Passenger (Fetus)
• Abnormalities of Powers - Uterine Contractility

  • Inadequate uterine contractions hinder cervical effacement and dilation
  • Causes: Uterine muscle dysfunction due to factors like overdistention or obstructed labor, Epidural analgesia and chorioamnionitis might also impact uterine activity
  • Management: Strengthen contractions using oxytocin or amniotomy, If ineffective, consider operative delivery
• Abnormalities of Powers - Inadequate Maternal Expulsive Effort


  • Insufficient maternal pushing during the second stage of labor
  • Influences: Sedation or analgesia may diminish the urge to push
  • Intervention: Allow effects to dissipate or assist with forceps or vacuum extraction
• Abnormalities of Passenger (Fetus) - Fetopelvic Disproportion

  • Mismatch between fetal size and pelvic capacity
  • Factors: Excessive fetal size or malposition obstructing birth canal passage, Head Size Estimation: Clinical predictions often unreliable
  • Malpresentations: Various fetal presentations impacting labor progress

  
• Abnormalities of Passenger (Fetus) - Specific Presentations


  • Face Presentation: Occurs due to factors favoring head extension, Successful delivery usually occurs without pelvic contraction
  • Brow Presentation: Rare, hindering engagement and delivery
  • Transverse Lie: Diagnosis straightforward, often requiring cesarean delivery, Factors include abdominal wall laxity and abnormal uterine anatomy, Early attempts at version may be considered, but cesarean delivery is often necessary

  
• Shoulder Dystocia


  Delivery complication where the fetal shoulders cannot pass through the birth canal after the head is delivered
• Shoulder Dystocia


  • Proposed criteria: Head-to-body delivery time >60 seconds
  • Neonates have disproportions in shoulder-to-head and chest-to-head ratios
  • Incidence: 0.6-1.4%
  • Maternal Consequences: Postpartum hemorrhage, often from uterine atony, Vaginal and cervical tears
  • Fetal Consequences: Injuries: 25% cases associated with fetal injuries, Common injuries include brachial plexus injuries, clavicular and humeral fractures, Risk of transient or persistent brachial plexopathy
  • Risk Factors: Increased birth weight, maternal obesity, diabetes, multiparity, post-term fetus, History of prior shoulder dystocia increases risk
  • ACOG Guidelines: Prediction and prevention are difficult, Elective induction or Cesarean section not recommended for all suspected cases, Cesarean delivery may be considered for non-diabetic women with estimated fetal weight >5000g or diabetic women with estimated fetal weight >4500g
  • Management: Goals: Reduce head-to-body delivery time while avoiding fetal and maternal injury, Initial gentle traction with maternal effort, Adequate analgesia, Consider episiotomy for room, Maneuvers: Suprapubic pressure, McRoberts Maneuver, Woods corkscrew maneuver, delivery of posterior shoulder, Rubin maneuvers, clavicle fracture, Zavanelli maneuver, Terbutaline for uterine relaxation, Cesarean delivery if maneuvers fail
  • Shoulder Dystocia Drill: Call for help, gentle traction, episiotomy, suprapubic pressure, McRoberts Maneuver, Repeat maneuvers if necessary
• Fetal Abnormalities


  • Include hydrocephalus, distended bladder, ascites, enlarged organs, Mode of delivery depends on severity, often vaginal delivery for severe multiple anomalies
• Contracted Pelvic Inlet


  • Characterized by a short front-to-back diameter (<10 cm) and a narrow side-to-side diameter (<12 cm), Labor may stall as the baby's head gets stuck at the inlet, increasing the likelihood of early membrane rupture, Slow or ineffective dilation may follow membrane rupture due to reduced pressure on the cervix, Associated with abnormal fetal presentations, such as face or shoulder first, increasing the risk of cord prolapse
• Contracted Midpelvis


  • More common than inlet contraction, Can cause the baby's head to be trapped sideways, making midforceps delivery or cesarean section necessary, Suspected if the space between the pelvic bones is less than 10.5 cm, and diagnosed if less than 8 cm, although measurements are imprecise, Signs include prominent pelvic bones, converging sidewalls, and a narrow sacrosciatic notch

  
• Contracted Outlet


  • Defined as a narrow space between the bony protrusions at the bottom of the pelvis (<8 cm), Usually occurs in conjunction with midpelvis contraction, Narrowing of the pelvic arch may force the baby's head to descend further down the birth canal, increasing the risk of perineal tearing

  
• Maternal Effects of Prolonged Obstructed Labor

  • Infection Risk
  • Uterine Rupture
  • Pathologic Retraction Ring
  • Fistula Formation
  • Pelvic Floor Injury
  • Postpartum Nerve Injury
• Fetal Effects of Prolonged Obstructed Labor

  • Infection Risk
  • Caput Succedaneum
  • Fetal Head Molding

  
• Augmentation of Labor with Oxytocin


  • Careful assessment of labor progression and fetal positioning is crucial before initiating oxytocin, Close monitoring of uterine activity and fetal heart rate is essential to avoid complications, Oxytocin infusion should be administered intravenously, with attention to dosage and discontinuation criteria, Risks and benefits of oxytocin use should be weighed, with cesarean delivery considered if progress is not satisfactory within a reasonable timeframe
• Indications for Cesarean Section

  • Previous cesarean delivery (most common)
  • Dystocia
  • Fetal distress (linked to electronic fetal monitoring)
  • Malpresentation (especially for breech births)
• Complications of Cesarean Section

  • Anesthetic complications (aspiration, hypotension)
  • Hemorrhage
  • Post-op issues (infections, urinary problems)
  • Future risks (repeat surgeries, uterine rupture)
• Forceps


  • Indications: Maternal (exhaustion, health conditions), Fetal (umbilical cord prolapse, fetal distress)
  • Precautions: Proper fetal position and dilation, Awareness of fetal head position, No suspected fetopelvic disproportion

  
• Close monitoring of uterine activity and fetal heart rate

  • Essential to avoid complications such as hypertonic contractions or uterine rupture
• Oxytocin infusion


  1. Administered intravenously

  2. Attention to dosage and discontinuation criteria
• Risks and benefits of oxytocin use


  Cesarean delivery considered if progress is not satisfactory within a reasonable timeframe
• Cesarean Section


  Operative delivery procedure
• Indications for Cesarean Section

  • Previous cesarean delivery (most common)
  • Dystocia
  • Fetal distress (linked to electronic fetal monitoring)
  • Malpresentation (especially for breech births)
• Complications of Cesarean Section

  • Anesthetic complications (aspiration, hypotension)
  • Hemorrhage
  • Post-op issues (infections, urinary problems)
  • Future risks (repeat surgeries, uterine rupture)
• Forceps


  Operative delivery procedure
• Indications for Forceps


  • Maternal (exhaustion, health conditions)
  • Fetal (umbilical cord prolapse, fetal distress)
• Precautions for Forceps


  • Proper fetal position and dilation
  • Awareness of fetal head position
  • No suspected pelvic disproportion

  
• Complications of Forceps


  • Fetal injuries (if improperly applied)
  • Vaginal and cervical injuries
  • Bladder and rectal injuries
• Vacuum Extraction


  Operative delivery procedure
• Indications for Vacuum Extraction

  • Similar to forceps extraction
• Precautions for Vacuum Extraction


  • Similar to forceps; often for fetuses 34 weeks or more
• Complications of Vacuum Extraction

  • Similar to forceps applications
• Risk Factors for Macrosomia

  • Maternal diabetes
  • Maternal obesity
  • Multiparity
  • Prolonged gestation
  • Advanced maternal age
  • Male fetus
  • Previous large infant
  • Race and ethnicity

  
• Gestational DM


  Diagnosed during pregnancy