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Snapshot
  • A 32-year-old G2P1 at 39 weeks of gestation presents to the labor and delivery ward. She states that she has been having contractions for the past 4 hours. Currently, she believes the contractions are about 5 minutes apart. She is placed in a room, and the resident comes to take a history and do an exam. On pelvic exam, the resident notes that the patient's cervix is 2 cm dilated and 20% effaced, and she is having regular contractions, consistent with latent labor.
Introduction
 
Stage Timing Description Notes
Stage 1
Latent
  • Starts with regular uterine contractions

 

  • ≤ 20 hours if nulliparous
  • ≤14 hours if multiparous

 

  • Highly variable duration
  • Cervix effaces and slowly dilates
  • Continous FHR monitoring
    • doppler
    • fetal scalp electrode (FSE)
  • Monitor uterine activity
    • tocodynamometer
    • contractions should be 200 mV/10 min
    • internal uterine pressure catheter
  • Analgesic
    • epidural
    • meperidine
  • Cervix dilates from 0 cm to 6 cm
Active
  • Cervix dilates from 6 cm to 10 cm

 

  • 2-3.5 hours
  • Dilation rate accelerates from latent stage

 

  • Regular and intense contractions
  • Cervix effaces and dilates quickly
  • Fetal head progressively descends into the pelvis
  • Ends at full cervix dilation of 10 cm
Stage 2
  • Starts at complete cervical dilation of 10 cm

 

  • ≤3 hours if nulliparous
  • ≤2 hours if multiparous

 

 

  • Baby undergoes all stages of cardinal movements - descent, flexion,internal rotation, extension, and external rotation 

 

  • Maternal effort accelerates delivery
  • Pressure on perineum for control
  • Once head delivered
    • evaluate nuchal cord
  • Deliver shoulders
  • Gentle downward pressure on head
    • deliver anterior shoulder
    • easy upward force
    • deliver posterior shoulder
  • Deliver body
  • Warm, dry, stimulate baby
  • Clamp and cut cord
  • Send umbilical cord blood for
    • ABO & Rh testing
    • blood gases
  • Ends at delivery of baby
Stage 3
  • Starts after baby is delivered
  • ≤30 minutes
  • Placenta separates and uterus contracts to establish hemostasis
  • Wait for signs of placental separation
    • uterus firms/rises in abdomen
    • gush of blood
    • lengthening of cord
  • Apply gentle / constant traction
    • may take 30 minutes
    • placenta in clumps may indicate abnormal placentation
  • If >30 minutes
    • uterine massage
    • oxytocin
    • manual extraction with hand
  • Ends at delivery of placenta
Stage 4
  • Starts immediately postpartum
  • 2 hours
  • Period with significant physiologic changes
  • Systematic evaluation of
    • cervix
    • vagina
    • vulva
    • perineum
    • periurethra
  • Monitor for postpartum complications
  • Ends 2 hours postpartum
 
  • Cervical changes during labor
    • softening/ripening
    • effacement
      • thinning/shortening of cervix
    • dilation
      • widening of cervix
    • pathophysiology
      • breakage of disulfide bonds
      • engagement of fetal head with cervix
  • Fetal station
    • describes position of fetal head relative to maternal ischial spines
    • scale
      • -5, -4, -3, -2, -1, 0, +1, +2, +3, +4, +5
        • -5 = initial position prior to labor
        • 0 = at level of narrowest point of ischial spines
        • +5 = at vaginal opening
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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