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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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