Labor dystocia

Mechanisms and Mechanisms and Management of Labor Management of Labor

Nancy Goodwine Wozniak, MDNancy Goodwine Wozniak, MD

Definition of LaborDefinition of Labor

Labor is the physiologic process by which the Labor is the physiologic process by which the fetus is expelled from the uterus to the outside fetus is expelled from the uterus to the outside worldworld

Could also be described as the transition from Could also be described as the transition from ““contracturescontractures”” to to ““contractionscontractions””

Bottom line defination: Contractions with cervical Bottom line defination: Contractions with cervical change. The diagnosis is a clinical one.change. The diagnosis is a clinical one.

Gabbe: Obstetrics Normal and Problem pregnancies 4Gabbe: Obstetrics Normal and Problem pregnancies 4thth edition edition

Full term pregnancy is 280 days (40 Full term pregnancy is 280 days (40 weeks) or 36 completed weeks.weeks) or 36 completed weeks.

Post term pregnancy is beyond 42 Post term pregnancy is beyond 42 weeksweeks

SROM is seen in about 8% of patientsSROM is seen in about 8% of patients

Labor PhysiologyLabor Physiology

Labor is contractions with cervical changeLabor is contractions with cervical change

The fetus is in control of the timing of laborThe fetus is in control of the timing of labor

The factors responsible for initiating labor are not well-defined…The factors responsible for initiating labor are not well-defined…likely an autocrine and/or paracrine event.likely an autocrine and/or paracrine event.

We do know there is some endocrine maternal/fetal cross talk (eg We do know there is some endocrine maternal/fetal cross talk (eg horses and donkeys indicate that fetal genotype is a factor—365 horses and donkeys indicate that fetal genotype is a factor—365 vs 340 days)vs 340 days)

Gabbe: Obstetrics Normal and Problem pregnancies 4Gabbe: Obstetrics Normal and Problem pregnancies 4 thth edition edition


No matter what seems to initiate labor it involves regular uterine No matter what seems to initiate labor it involves regular uterine contractions, mediated through ATP-dependent binding of myosin contractions, mediated through ATP-dependent binding of myosin to actin. Unlike vascular smooth muscle, myometrium has sparse to actin. Unlike vascular smooth muscle, myometrium has sparse innervation, thus regulation of contractions is hormonal.innervation, thus regulation of contractions is hormonal.

There is thought to be a parturition cascade. Ultimately, human There is thought to be a parturition cascade. Ultimately, human labor is a multifactorial physiologic process involving an labor is a multifactorial physiologic process involving an integrated set of changes that occur gradually over days to integrated set of changes that occur gradually over days to weeks. Changes include prostaglandin synthesis and release weeks. Changes include prostaglandin synthesis and release within the uterus, an increase in myometrial gap junction within the uterus, an increase in myometrial gap junction formation, and up-regulation of myometrial oxytocin receptors. At formation, and up-regulation of myometrial oxytocin receptors. At some point labor begins with the activation of the fetal-some point labor begins with the activation of the fetal-hypothalamic-pituitary adrenal axis in a way likely common to all hypothalamic-pituitary adrenal axis in a way likely common to all species.species.

Gabbe: Obstetrics Normal and Problem pregnancies 4Gabbe: Obstetrics Normal and Problem pregnancies 4thth edition edition


The regulation of uterine activity can be divided into The regulation of uterine activity can be divided into 4 physiologic phases4 physiologic phases

Phase 0: uterus is quiet due to progesterone, relaxin, Phase 0: uterus is quiet due to progesterone, relaxin, prostacyclin Iprostacyclin I2 2 (PGI(PGI22), parathyroid hormone), parathyroid hormonePhase 1: before term Phase 1: before term ““activationactivation”” phase- uterus is more phase- uterus is more responsive to estrogen and more receptors for oxytocin and responsive to estrogen and more receptors for oxytocin and prostaglandinsprostaglandinsPhase 2: uterus more stimulated because of increase in Phase 2: uterus more stimulated because of increase in gap junctions so that it can be stimulated by oxytocins and gap junctions so that it can be stimulated by oxytocins and prostaglandins (PGEprostaglandins (PGE22 and PGF and PGF2 alpha2 alpha))Phase 3: involution of the uterus (mediated by oxytocin)Phase 3: involution of the uterus (mediated by oxytocin)

Gabbe: Obstetrics Normal and Problem pregnancies Gabbe: Obstetrics Normal and Problem pregnancies 44thth edition edition

Labor MechanicsLabor Mechanics

For a successful vaginal delivery, the For a successful vaginal delivery, the fetus must negotiate the maternal fetus must negotiate the maternal pelvis.pelvis.

Three factors: the power, the passage, Three factors: the power, the passage, and the passenger.and the passenger.


The passengerThe passengerEstimating fetal size: ultrasound, leopolds, what Estimating fetal size: ultrasound, leopolds, what does does mom think?mom think?

How big is too big? Definition of macrosomia is How big is too big? Definition of macrosomia is

diabetics: 4500g non-diabetics: 5000gdiabetics: 4500g non-diabetics: 5000g


PowerPowerAssessing amplitude, duration, and intensity of ctxAssessing amplitude, duration, and intensity of ctx

internal IUPC vs external tocointernal IUPC vs external toco

WhatWhat’’s adequate contractions? (ultimately it is a clinical dx)s adequate contractions? (ultimately it is a clinical dx)3-5 ctx in 10 min3-5 ctx in 10 min7 ctx in 15 min7 ctx in 15 min250 MVU250 MVU’’s – the average strength of ctx in mm Hg s – the average strength of ctx in mm Hg multiplied by the number of contractions in 10 minutes. multiplied by the number of contractions in 10 minutes. No real data support an absolute number of ctx or MVUNo real data support an absolute number of ctx or MVU’’s s to be adequate…adequacy is still a clinical determination.to be adequate…adequacy is still a clinical determination.

If ctx are adequate either the cervix will dilate or the caput If ctx are adequate either the cervix will dilate or the caput will become worse.will become worse.


The most precise way of determining The most precise way of determining uterine contractions are adequate is with uterine contractions are adequate is with internal monitoring by IUPCinternal monitoring by IUPC

External monitoring measures the change External monitoring measures the change in shape of the abdominal wall relative to in shape of the abdominal wall relative to contractions thus is qualitative rather than contractions thus is qualitative rather than quantitative. Does allow for accurate quantitative. Does allow for accurate correlation between fetal heart rate and correlation between fetal heart rate and contraction pattern .contraction pattern .


The PassengerThe Passenger The passenger is the fetus. Fetal size can The passenger is the fetus. Fetal size can

influence laborinfluence labor

Can be assessed by LeopoldCan be assessed by Leopold’’s, US or both. s, US or both. ( Mom( Mom’’s opinion counts, too!)s opinion counts, too!)

ACOG definition of Macrosomia is defined as >4500 ACOG definition of Macrosomia is defined as >4500 gg


The passengerThe passenger

Fetal lie: Fetal position relative to the maternal spine. Fetal lie: Fetal position relative to the maternal spine. longitudinal, oblique, longitudinal, oblique, transversetransverse

Presentation: refers to the fetal part that is above the pelvic inlet. (eg a fetus can have Presentation: refers to the fetal part that is above the pelvic inlet. (eg a fetus can have a logitudinal lie but be breech or cephalic)a logitudinal lie but be breech or cephalic)

Attitude: refers to position of fetal head relative to the fetal spineAttitude: refers to position of fetal head relative to the fetal spine

Position: referes to the relationship of a nominated site of the presenting part to a Position: referes to the relationship of a nominated site of the presenting part to a denomintating location in the internal pelvis. Eg. Occiput/sacrum ROA, RSAdenomintating location in the internal pelvis. Eg. Occiput/sacrum ROA, RSA

Station: a measure of descent of the presenting part.Station: a measure of descent of the presenting part.

Abnormalilty of any of these variables can influence whether or not to proceed with a Abnormalilty of any of these variables can influence whether or not to proceed with a vaginal delivery.vaginal delivery.

Fetal presentation: Fetal part directly over the Fetal presentation: Fetal part directly over the pelvic pelvic inlet; eg breech, cephalic, compound, inlet; eg breech, cephalic, compound,

funicfunic


The passengerThe passengerMalpresentation is any presentation Malpresentation is any presentation that is not cephalic with occiput that is not cephalic with occiput leading. (about 5%) Multifetal leading. (about 5%) Multifetal pregnancies increase the risk of pregnancies increase the risk of malpresetnationmalpresetnation

The cephalic presentation can be classified The cephalic presentation can be classified by boney landmarks of the skull; eg occiput , by boney landmarks of the skull; eg occiput ,

mentum, browmentum, brow

passengerpassengerpasengerpasenger

A: Right occiput anterior (ROA); B: Left occiput anterior (LOA); C: Occiput anterior (OA).* Posterior fontanel. This is the smaller of the two fontanels and is at the intersection of the three sutures: the sagittal suture and two lambdoid sutures.** Anterior fontanel. This large fontanel is at the intersection of four sutures: the sagittal, frontal, and two coronal sutures. From

UpToDate.com

Occiput posteriorOcciput posterior

From UpToDate.com

Occiput transverseOcciput transverse

From From UpToDate.comUpToDate.com


The passengerThe passengerStation: measure of descent of the presenting part Station: measure of descent of the presenting part

through the birth canal relative to ischial spinesthrough the birth canal relative to ischial spines this is the relationship between the leading bony part of fetal this is the relationship between the leading bony part of fetal

presenting part ( skull bone NOT scalp) and the maternal ischial presenting part ( skull bone NOT scalp) and the maternal ischial spines. Must take into account molding and caput succedaneum spines. Must take into account molding and caput succedaneum (not doing so is a common error)(not doing so is a common error)

Often described as -3 to + 3Often described as -3 to + 3

Newer scale is -5 to +5Newer scale is -5 to +5

Nucleus medical art.Nucleus medical art.Nucleusinc.comNucleusinc.com

http://catalog.nucleusinc.com/enlargeexhibit.php?ID=8741


The PassageThe Passage

The passage consists of the bony pelvis (sacrum, ilium, ischium, The passage consists of the bony pelvis (sacrum, ilium, ischium, pubis) and the resistance provided by the soft tissues.pubis) and the resistance provided by the soft tissues.

Bony pelvis is divided into the greater (false) and lesser(true) Bony pelvis is divided into the greater (false) and lesser(true) pelvis by the pelvic brim which is demarcated by the sacral pelvis by the pelvic brim which is demarcated by the sacral promontory.promontory.

The diagonal conjugate is the distance from the sacral The diagonal conjugate is the distance from the sacral promontory to the inferior margin of the symphysis pubis as promontory to the inferior margin of the symphysis pubis as assessed on examination ( see next slide )assessed on examination ( see next slide )

Clinical pelvimetry is the only way to assess the dimensions of the Clinical pelvimetry is the only way to assess the dimensions of the pelvis in labor.pelvis in labor.

To figure out the true conjugate, measure the To figure out the true conjugate, measure the diagonal conjugate and subtract 1.5 – 2cm. The diagonal conjugate and subtract 1.5 – 2cm. The limiting factor is the interspinous diameter.limiting factor is the interspinous diameter.

Bony pelvis—most favorable is gynecoid and Bony pelvis—most favorable is gynecoid and antropoidantropoid

From UpToDate.com

A little bit about cervical ripening…A little bit about cervical ripening…

When induction is attempted against an unripe cervix the When induction is attempted against an unripe cervix the likelihood of succcess is reduced.likelihood of succcess is reduced.

Bishops score: dilatation, effacement, position, Bishops score: dilatation, effacement, position, consistency, station. Total score is up to 13.consistency, station. Total score is up to 13.

BishopBishop’’s = 8 chances of successful induction are s = 8 chances of successful induction are the same as spontaneous laborthe same as spontaneous labor

BishopBishop’’s = 6 s = 6 ““favorable cervixfavorable cervix””

(A) Cervix is uneffaced and minimally dilated. (B) Cervix is almost (A) Cervix is uneffaced and minimally dilated. (B) Cervix is almost completely effaced and dilated. completely effaced and dilated. From UpToDate.comFrom UpToDate.com

Methods of cervical ripeningMethods of cervical ripening

Non Pharmacologic methods:Non Pharmacologic methods:membrane stripping – digital separation of chorionic and amniotic membrane stripping – digital separation of chorionic and amniotic membranes from the cervix. Releases endogenous prostaglandins from membranes from the cervix. Releases endogenous prostaglandins from the decidua and adjacent membranes.the decidua and adjacent membranes.

May also cause May also cause ““Ferguson reflexFerguson reflex”” stimulating release of oxytocin from the stimulating release of oxytocin from the pituitary.pituitary.

Foley bulbFoley bulb

Amniotomy – needs favorable cervix, but if cervix is favorable amniotomy Amniotomy – needs favorable cervix, but if cervix is favorable amniotomy by itself can get labor started (better still when combined with Pitocin)by itself can get labor started (better still when combined with Pitocin)

risks: risks: cord prolapse, prolonged ROM, fetal injury, rupture cord prolapse, prolonged ROM, fetal injury, rupture of vasa previa with fetal hemorrhage, fetal malposition and of vasa previa with fetal hemorrhage, fetal malposition and asynclitismasynclitism

Benefits: FSE placement, can determine if MSF or blood, high Benefits: FSE placement, can determine if MSF or blood, high success success in inducing laborin inducing labor

Methods of cervical ripeningMethods of cervical ripening

Pharmacologic methodsPharmacologic methods

Dinoprostone (Prepadil and Cervadil) PGEDinoprostone (Prepadil and Cervadil) PGE22 , , oxytocin, oxytocin, misoprostyl (cytotec) PGEmisoprostyl (cytotec) PGE11

The uterus has precursors of the prostaglandin of The uterus has precursors of the prostaglandin of the 2 series. the 2 series. PGEPGE2 2 : important for cervical : important for cervical maturationmaturation PGF PGF 22 alpha. : causes alpha. : causes myometrial myometrial contractions contractions

Stages of LaborStages of Labor

First stage: Onset of labor to full dilatationFirst stage: Onset of labor to full dilatationlatent phase- onset of labor until cervix starts to make latent phase- onset of labor until cervix starts to make

change.change.active phase-greater rate of cervical changeactive phase-greater rate of cervical change

1.2 cm/h for nulliparous1.2 cm/h for nulliparous 1.5 cm/h for multiparous1.5 cm/h for multiparous

Second stage: full dilation to deliverySecond stage: full dilation to deliveryLength of Pushing: nullip: 2h without epidural, 3 h Length of Pushing: nullip: 2h without epidural, 3 h

with epiduralwith epiduralmultip: 1 h without epidural,multip: 1 h without epidural,

2 h with epidural2 h with epiduralThird stage: delivery of placenta-can take up to 30 minutesThird stage: delivery of placenta-can take up to 30 minutes

Cardinal movements of laborCardinal movements of labor

Engagement:Engagement: passage of the widest diameter of the presenting passage of the widest diameter of the presenting part to a level below the plane of the pelvic inlet. In cephalic part to a level below the plane of the pelvic inlet. In cephalic fetus, the largest diameter is the biparietal diameter (9.5 fetus, the largest diameter is the biparietal diameter (9.5 cm); in a breech fetus the widest diameter is the cm); in a breech fetus the widest diameter is the bitrochanteric diameter. The presenting part is engaged if bitrochanteric diameter. The presenting part is engaged if you can feel presenting part both abdominally and vaginally.you can feel presenting part both abdominally and vaginally.

Descent:Descent: downward passage of the presenting part downward passage of the presenting partFlexion:Flexion: occurs passively d/t boney maternal pelvis occurs passively d/t boney maternal pelvisInternal rotation: refers to rotation of presenting part from its Internal rotation: refers to rotation of presenting part from its

original position (usually transverse) to the AP positionoriginal position (usually transverse) to the AP positionExtension:Extension: Occurs once the fetus has descended to the introitus Occurs once the fetus has descended to the introitusExternal rotationExternal rotation (aka restitution) return of the fetal head to the (aka restitution) return of the fetal head to the

correct anatomic position in relation to the fetal torso.correct anatomic position in relation to the fetal torso.Expulsion:Expulsion: delivery of the rest of the fetus. delivery of the rest of the fetus.

Management of Normal Labor and DeliveryManagement of Normal Labor and Delivery

All women need adequate surveillance All women need adequate surveillance throughout labor and delivery.throughout labor and delivery. Okay to let women walk (doesnOkay to let women walk (doesn’’t shorten course of labor, t shorten course of labor,

the need for augmentation, the use of analgesia, or the the need for augmentation, the use of analgesia, or the rate of C/S)rate of C/S)

Record FHTRecord FHT’’s q 30 minutes (minimum)s q 30 minutes (minimum)

During second stage, FHTDuring second stage, FHT’’s should be recorded q 15 and s should be recorded q 15 and after each contractionafter each contraction

Augmentation of Labor at TermAugmentation of Labor at Term

Abnormalities of the first stage of labor may be either protraction or Abnormalities of the first stage of labor may be either protraction or arrest disorders and can occur during active or latent phases of labor.arrest disorders and can occur during active or latent phases of labor.

--Administer Pitocin as long as no malpresentation.--Administer Pitocin as long as no malpresentation.Goal is ctx q 2-3 min lasting 60-90 seconds. Resting tone Goal is ctx q 2-3 min lasting 60-90 seconds. Resting tone

should be should be 10-15 mm Hg if IUPC is used.10-15 mm Hg if IUPC is used.

--Takes 30 to 40 minutes to see full effect of Pitocin dose--Takes 30 to 40 minutes to see full effect of Pitocin dose

--A slow rate of pitocin increase is as effective as a fast rate.--A slow rate of pitocin increase is as effective as a fast rate.

--Whether to add pitocin to a patient who is already adequately --Whether to add pitocin to a patient who is already adequately contracting contracting is controversial, but 80% of patients will respond to is controversial, but 80% of patients will respond to pitocinpitocin

Augmentation of Labor at TermAugmentation of Labor at Term

Advantages: Advantages: Oxytocin is cheap, and well known to usOxytocin is cheap, and well known to us

Short tShort t1/21/2

Complications:Complications:uterine hyperstimulation (tachysystole)uterine hyperstimulation (tachysystole)

increased uterine tone (hypertonia)increased uterine tone (hypertonia)

water intoxication (at doses of 30-40 miu since itwater intoxication (at doses of 30-40 miu since it’’s a s a vasopressin analogue)vasopressin analogue)

hypotension (usually if pitocin is given as a bolus)hypotension (usually if pitocin is given as a bolus)

uterine rupture (associated with uterine rupture (associated with ““excessive oxytocinexcessive oxytocin””))

Abnormal patterns of laborAbnormal patterns of labor

““Latent phase arrestLatent phase arrest””—means labor never began—means labor never began ““prolonged latent phaseprolonged latent phase””—greater than 20h in nullip—greater than 20h in nullip

---greater than 14h in multip---greater than 14h in multip Prolongation of latent phase is variable; doesnProlongation of latent phase is variable; doesn’’t mean the t mean the

fetus will have a bad outcome or that the patient needs a fetus will have a bad outcome or that the patient needs a c/s. Can be managed expectantly (presuming mom and c/s. Can be managed expectantly (presuming mom and baby other wise look good)baby other wise look good)

Can administer analgesics (eg morphine 15-20 mg Can administer analgesics (eg morphine 15-20 mg for for therapeutic rest)therapeutic rest)

Augmentation (Pitocin)Augmentation (Pitocin)

Defer amniotomy!Defer amniotomy!

Pitocin regimenPitocin regimen

RegimenRegimen Starting doseStarting dose Incremental Incremental increaseincrease

Dosage change Dosage change interval in interval in minutesminutes

Low doseLow dose 0.5-1.0 mu0.5-1.0 mu 1 mu1 mu 30-40 minutes30-40 minutes

Alternative low Alternative low dosedose

1-2 mu1-2 mu 22 15 minutes15 minutes

High dose High dose 6 mu6 mu 6 mu6 mu

Max 40 muMax 40 mu

15 minutes15 minutes

Alternative high Alternative high dosedose

4 mu4 mu 4 mu4 mu

Max 32 muMax 32 mu

15 minutes15 minutes


Abnormalities of second stageAbnormalities of second stage

““Failure to ProgressFailure to Progress”” ““Arrest of dilatationArrest of dilatation””generally patient is falling off Friedmangenerally patient is falling off Friedman’’s s

curve, or curve, or no cervical change in 2 hoursno cervical change in 2 hours

Consider augmentation, placement of IUPCConsider augmentation, placement of IUPC


““Protraction of descentProtraction of descent””

Descent of < 1 cm/h in nullipsDescent of < 1 cm/h in nullips

Descent of < 2 cm/h in multipsDescent of < 2 cm/h in multips

Deliveries complicated by prolonged second stage put the Deliveries complicated by prolonged second stage put the fetus at risk of acidosis, thus, ACOG recommends fetus at risk of acidosis, thus, ACOG recommends intervention after 2 h without epidural, 3 h with epidural.intervention after 2 h without epidural, 3 h with epidural.

In reality, can consider expectant management if mother In reality, can consider expectant management if mother and fetus are otherwise reassuring, descent is progressive, and fetus are otherwise reassuring, descent is progressive, and delivery is imminent.and delivery is imminent.


““Arrest of DescentArrest of Descent””This requires an assessment of This requires an assessment of

contractions, maternal fetal well being, and CPDcontractions, maternal fetal well being, and CPD

Re-evaluate clinical pelvimetry, fetal station, caput. Re-evaluate clinical pelvimetry, fetal station, caput.

The decision to proceed with assisted vaginal The decision to proceed with assisted vaginal delivery or C/S should be individualizeddelivery or C/S should be individualized

Do you really want to do that episiotomy??Do you really want to do that episiotomy??

Episiotomy– the incision in the perineal body during the Episiotomy– the incision in the perineal body during the second stage of labor.second stage of labor.

Indicated in 1) cases of arrested or protracted descentIndicated in 1) cases of arrested or protracted descent2) expedite delivery in NRFHT2) expedite delivery in NRFHT’’ss

Median: performed when the fetal head is on the perineum. Median: performed when the fetal head is on the perineum. Associated with occasional extensions to 3Associated with occasional extensions to 3rdrd or 4 or 4thth degree degree

Mediolateral: 45 degree angle from the hymenal ring. Does Mediolateral: 45 degree angle from the hymenal ring. Does not increase risk of 3not increase risk of 3rdrd or 4 or 4thth degree extension. Procedure degree extension. Procedure of choice in patients with inflammatory bowel disease. of choice in patients with inflammatory bowel disease. More pain post partum.More pain post partum.

Uptodate.comUptodate.com

EpisiotomyEpisiotomy

Fewer episiotomies are being performed…most Fewer episiotomies are being performed…most repairs after a vaginal delivery are a result of repairs after a vaginal delivery are a result of tears.tears.

Episiotomies (and lacerations) are graded on a Episiotomies (and lacerations) are graded on a scale of 1 to 4 scale of 1 to 4

Episiotomy/LacerationsEpisiotomy/Lacerations

11stst degree lacerations: involve the forchette, degree lacerations: involve the forchette, perineal skin, and vaginal mucosaperineal skin, and vaginal mucosa

22ndnd degree lacerations: above plus extend to the degree lacerations: above plus extend to the fascia and muscles of the perineal body but not to fascia and muscles of the perineal body but not to the anal sphincterthe anal sphincter

33rdrd degree lacerations: skin, mucosa, perineal body degree lacerations: skin, mucosa, perineal body and anal sphincterand anal sphincter

44thth degree: exposed lumen of the rectum degree: exposed lumen of the rectum

Vaccuum DeliveriesVaccuum Deliveries

Vaccuum DeliveriesVaccuum Deliveries

Vaccuums have been around since Vaccuums have been around since 19531953

By 1970By 1970’’s popular in Northern Europe s popular in Northern Europe DidnDidn’’t exceed number of forceps t exceed number of forceps

deliveries in the U.S. until 1992deliveries in the U.S. until 1992

Fetal contraindications to a VaccuumFetal contraindications to a Vaccuum

1) < 34 weeks1) < 34 weeks

increases risk of intraventricular increases risk of intraventricular hemorhagehemorhage

2) Fetal bleeding diathesis e.g., ITP, 2) Fetal bleeding diathesis e.g., ITP, hemophiliahemophilia

3) Multiple FSE attempts 3) Multiple FSE attempts

4) CPD4) CPD

Vaccuum typesVaccuum types

Take a look at what we have!Take a look at what we have!

Optimum type…who knowsOptimum type…who knows Can use any of them if no Can use any of them if no

contraindicationcontraindication In general…soft cups, more likely to fail In general…soft cups, more likely to fail

but less fetal scalp injury; rigid cups but less fetal scalp injury; rigid cups probably better for OPprobably better for OP

A Vaccuum does not require less A Vaccuum does not require less clinical knowledge than forceps!clinical knowledge than forceps!

Must know fetal position, station, and Must know fetal position, station, and take into account moldingtake into account molding

Must know contraindicationsMust know contraindicationsPlacement of cup now becomes flexion point.Placement of cup now becomes flexion point.

Unlike forceps which can be used to correct Unlike forceps which can be used to correct asynclitism, a vaccuum will impede delivery if cup asynclitism, a vaccuum will impede delivery if cup not placed over flexion point.not placed over flexion point.

Check list prior to instrumental Check list prior to instrumental deliverydelivery

Empty bladderEmpty bladder Dorsal lithotomy positionDorsal lithotomy position Adequate anesthesia ( a MUST for Adequate anesthesia ( a MUST for

forceps!)forceps!) Fetal position, station, EFWFetal position, station, EFW

Putting on the VacPutting on the Vac

Determine flexion point: Determine flexion point: basically flexion basically flexion point is the point where pulling is going to best point is the point where pulling is going to best allow flexion at the neck keeping the fetus OA.allow flexion at the neck keeping the fetus OA.

Midline, over sagital suture, 6 cm from Midline, over sagital suture, 6 cm from Anterior fontanelle, 3 cm from posterior Anterior fontanelle, 3 cm from posterior fontanelle.fontanelle.

Anterior fontanelle has to be your reference point.Anterior fontanelle has to be your reference point.

360 degree inspection360 degree inspection

Green zone to 450Green zone to 450

The instrumental delivery itselfThe instrumental delivery itself

Pull along pelvic curve (down, then Pull along pelvic curve (down, then up)up)

Let handle passively turn as fetus Let handle passively turn as fetus rotates with deliveryrotates with delivery

Descent should occur with each pullDescent should occur with each pull No routine episiotomyNo routine episiotomy

How long is too long?How long is too long?

No one knows maximal amount of No one knows maximal amount of time and maximal amount of pop-offs time and maximal amount of pop-offs that is acceptablethat is acceptable

Ideally less than 15 minutes, certainly less than Ideally less than 15 minutes, certainly less than 3030

Usually less than 3 pop-offs, less than 5 pullsUsually less than 3 pop-offs, less than 5 pulls

DocumentationDocumentation

IndicationsIndicationsWere prerequisites met Were prerequisites met (full dilatation, empty (full dilatation, empty

bladder, no contraindications, gest. Age, station (+2/3 or bladder, no contraindications, gest. Age, station (+2/3 or +2/5??)+2/5??)

Fetal status (station, position, FHTFetal status (station, position, FHT’’ss

Verbal consentVerbal consent

Detailed description of procedureDetailed description of procedureType of vaccuum, total time, reduced between contractions, Type of vaccuum, total time, reduced between contractions,

# pulls, # ctx, # pop-offs, progress with each pull, epis or # pulls, # ctx, # pop-offs, progress with each pull, epis or notnot

Reasons instrumental deliveries failReasons instrumental deliveries fail

CPDCPDBad techniqueBad technique (eg pulling without (eg pulling without

contractions, upward pull before crowning: contractions, upward pull before crowning: deflexed, paramedian applicationdeflexed, paramedian application

Large CaputLarge Caput

Remember…No one thanks you for a Remember…No one thanks you for a vaginal delivery unless its perfectvaginal delivery unless its perfect..

Shoulder dystociaShoulder dystocia

www.shoulderdystociaattorney.comwww.shoulderdystociaattorney.com

If the anterior and posterior shoulders descend together instead of If the anterior and posterior shoulders descend together instead of sequentially, the anterior shoulder can become impacted behind the sequentially, the anterior shoulder can become impacted behind the

symphysis pubis (or the posterior shoulders on the sacral promontory)symphysis pubis (or the posterior shoulders on the sacral promontory)

http://www.shoulderdystociainfo.com/images/baby_uterus_nerves.htm

If descent of the fetal head continues If descent of the fetal head continues while the shoulders remain impacted, while the shoulders remain impacted, stretching of the nerves of the stretching of the nerves of the brachial plexus can occur.brachial plexus can occur.

Most brachial plexus injuries resolve Most brachial plexus injuries resolve on their own, but permanent injury is on their own, but permanent injury is a often a medicolegal issue.a often a medicolegal issue.

Risks for shoulder dystociaRisks for shoulder dystociamaternal obesity, diabetes, post maternal obesity, diabetes, post dates, macrosomic infant, operative dates, macrosomic infant, operative deliverydelivery

Other risks associated with shoulder Other risks associated with shoulder dystocia: fetal hypoxia and neurologic dystocia: fetal hypoxia and neurologic injury; fractured clavical or humerus, injury; fractured clavical or humerus, fetal death.fetal death.

Management of Shoulder dystociaManagement of Shoulder dystocia

Call for help!Call for help! Suprapubic pressureSuprapubic pressure McRoberts ManeuverMcRoberts Maneuver EpisiotomyEpisiotomy Woods screw/ RubenWoods screw/ Ruben’’s manueverss manuevers Deliver posterior armDeliver posterior arm Fracture claviclesFracture clavicles Zavenelli maneuverZavenelli maneuver Mom should not push during maneuvers!!Mom should not push during maneuvers!!

http://www.shoulderdystociainfo.com/images/delivery.htm

Henry Lerner, MDHenry Lerner, MDGraphics Susan Seif, medical graphicsGraphics Susan Seif, medical graphics

After difficult delivery…After difficult delivery…

Careful documentationCareful documentation

Explain to patient the events, explanation of Explain to patient the events, explanation of problem, steps taken to correct the problem, problem, steps taken to correct the problem, and what the anticipated sequelae areand what the anticipated sequelae are

Fetal MonitoringFetal Monitoring

The following examples of fetal monitoring strips are from… The following examples of fetal monitoring strips are from…

Interpretation of the Electronic Fetal Heart Interpretation of the Electronic Fetal Heart Rate During Labor Rate During Labor

AMIR SWEHA, M.D., and TREVOR W. HACKER, M.D. AMIR SWEHA, M.D., and TREVOR W. HACKER, M.D. Mercy Healthcare Sacramento Mercy Healthcare Sacramento Sacramento, California Sacramento, California

NUOVO, M.D. NUOVO, M.D. University of California, Davis, School of Medicine University of California, Davis, School of Medicine Davis, CaliforniaDavis, California

Used with permission from Used with permission from The American Family PhysicianThe American Family Physician

Figure 1 Interpreting fetal monitiring Strips; American Academy of Family Figure 1 Interpreting fetal monitiring Strips; American Academy of Family Physicians May, 1999Physicians May, 1999

Figure 1Figure 1

Interpretation of Electronic Fetal Heart rate During LaborInterpretation of Electronic Fetal Heart rate During Labor

American Family Physician, May 1999American Family Physician, May 1999

Figure 1Figure 1

Reassuring pattern. Baseline fetal Reassuring pattern. Baseline fetal heart rate is 130 to 140 beats per heart rate is 130 to 140 beats per minute (bpm), preserved beat-to-minute (bpm), preserved beat-to-beat and long-term variability. beat and long-term variability. Accelerations last for 15 or more Accelerations last for 15 or more seconds above baseline and peak at seconds above baseline and peak at 15 or more bpm. (Small square=10 15 or more bpm. (Small square=10 seconds; large square=one minute seconds; large square=one minute

Figure 2Figure 2



FIGURE 2.FIGURE 2. Saltatory pattern with Saltatory pattern with wide variability. The oscillations of wide variability. The oscillations of the fetal heart rate above and below the fetal heart rate above and below the baseline exceed 25 bpm. the baseline exceed 25 bpm.

Fetal tachycardia with possible onset Fetal tachycardia with possible onset of decreased variability of decreased variability (right)(right) during during the second stage of labor. Fetal heart the second stage of labor. Fetal heart rate is 170 to 180 bpm. Mild variable rate is 170 to 180 bpm. Mild variable decelerations are present. decelerations are present.

Figure 3Figure 3



Figure 3Figure 3

Fetal tachycardia that is due to fetal Fetal tachycardia that is due to fetal tachyarrhythmia associated with tachyarrhythmia associated with congenital anomalies, in this case, congenital anomalies, in this case, ventricular septal defect. Fetal heart ventricular septal defect. Fetal heart rate is 180 bpm. Notice the "spike" rate is 180 bpm. Notice the "spike" pattern of the fetal heart rate. pattern of the fetal heart rate.

Figure 4Figure 4



Figure 4Figure 4

Early deceleration in a patient with Early deceleration in a patient with an unremarkable course of labor. an unremarkable course of labor. Notice that the onset and the return Notice that the onset and the return of the deceleration coincide with the of the deceleration coincide with the start and the end of the contraction, start and the end of the contraction, giving the characteristic mirror giving the characteristic mirror image. image.

Figure 5Figure 5

Figure 5Figure 5

Nonreassuring pattern of late Nonreassuring pattern of late decelerations with preserved beat-to-decelerations with preserved beat-to-beat variability. Note the onset at the beat variability. Note the onset at the peak of the uterine contractions and peak of the uterine contractions and the return to baseline after the the return to baseline after the contraction has ended. The second contraction has ended. The second uterine contraction is associated with uterine contraction is associated with a shallow and subtle late deceleration a shallow and subtle late deceleration

Figure 6Figure 6

FIGURE 6.FIGURE 6. Nonreassuring pattern of late Nonreassuring pattern of late decelerations with preserved beat-to-beat decelerations with preserved beat-to-beat variability. Note the onset at the peak of the variability. Note the onset at the peak of the uterine contractions and the return to baseline uterine contractions and the return to baseline after the contraction has ended. The second after the contraction has ended. The second uterine contraction is associated with a shallow uterine contraction is associated with a shallow and subtle late deceleration and subtle late deceleration

Figure 7Figure 7

Figure 7Figure 7

. Late deceleration with loss of variability. This is an ominous pattern, and immediate delivery is indicated

Figure 8Figure 8

.

FIGURE 8. Variable deceleration with pre- and post-accelerations ("shoulders"). Fetal heart rate is 150 to 160 beats per minute, and beat-to-beat variability is preserved.

Figure 9Figure 9

Figure 9Figure 9

Severe variable deceleration with Severe variable deceleration with overshoot. However, variability is overshoot. However, variability is preserved. preserved.

Figure 10Figure 10

Figure 10Figure 10

FIGURE 10.FIGURE 10. Late deceleration related to bigeminal Late deceleration related to bigeminal contractions. Beat-to-beat variability is preserved. Note the contractions. Beat-to-beat variability is preserved. Note the prolonged contraction pattern with elevated uterine tone prolonged contraction pattern with elevated uterine tone between the peaks of the contractions, causing between the peaks of the contractions, causing hyperstimulation and uteroplacental insufficiency. hyperstimulation and uteroplacental insufficiency. Management should include treatment of the uterine Management should include treatment of the uterine hyperstimulation. This deceleration pattern also may be hyperstimulation. This deceleration pattern also may be interpreted as a variable deceleration with late return to the interpreted as a variable deceleration with late return to the baseline based on the early onset of the deceleration in baseline based on the early onset of the deceleration in relation to the uterine contraction, the presence of an relation to the uterine contraction, the presence of an acceleration before the deceleration (the "shoulder") and acceleration before the deceleration (the "shoulder") and the relatively sharp descent of the deceleration. However, the relatively sharp descent of the deceleration. However, late decelerations and variable decelerations with late late decelerations and variable decelerations with late return have the same clinical significance and represent return have the same clinical significance and represent nonreassuring patterns. This tracing probably represents nonreassuring patterns. This tracing probably represents cord compression and uteroplacental insufficiency. cord compression and uteroplacental insufficiency.

Figure 11Figure 11

FIGURE 11.FIGURE 11. (A)(A) Pseudosinusoidal pattern. Note Pseudosinusoidal pattern. Note the decreased regularity and the preserved beat-the decreased regularity and the preserved beat-to-beat variability, compared with a true to-beat variability, compared with a true sinusoidal pattern sinusoidal pattern (B).(B).

When all else fails….When all else fails….

Enough already!!!Enough already!!!

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