FACTORS THAT AFFECT LABOR

JUAN CARLOS LUNA

Power - Refers to the Uterine Contractions - Stages of Labor o First Stage of Labor (from onset of regular uterine contractions to full cervical dilatation): Phase of Cervical Effacement and Dilatation  Power: Uterine Contractions  Divided into Phases based on Cervical Dilatation: y Latent Phase cervical dilatation < 4cm y Active Phase cervical dilatation >/= 4 cm o Acceleration Phase considered predictive of outcome of labor  Initial increase in cervical dilatation, from a very gradual increase to rapid acceleration o Phase of Maximum Slope cervix dilates at a very rapid rate  Cervical Dilatation: 4 cm 8 cm  Measures the efficiency of the Machine (Uterus) y Generation of sufficient uterine pressure to push the baby out o Deceleration Phase reflective of Feto-Pelvic Relationship  Mother enters this phase as soon as the cervix is dilated 8 cm or more  In actuality there is no deceleration of the rate of cervical dilatation; lecturer is not certain of the reason for the delineation

o Second Stage of Labor (from full cervical dilatation to expulsion of the fetus): Phase of Fetal Expulsion  Powers: Uterine contractions + Intra-abdominal pressure (Valsalva Maneuver: mother s bearing down effort)  Outcomes: successful vaginal delivery or decision to do a caesarean section o Third Stage of Labor (Expulsion of the Fetus to Expulsion of the Placenta) Phase of Placental Separation and Expulsion o Fourth Stage of Labor first 2-3 hours postpartum Functional Divisions of Labor o For ease in establishing correct diagnosis o In each division there is a predominating activity taking place; this activity is what is monitored o Divisions:  Preparatory y Composed of the Latent and Acceleration Phases y Predominant Activity: Cervical Ripening o Softening of the Cervix Goodell s Sign  Commencement of biochemical changes that allow the ground substance of the cervix to be softer and easily dilatable o Shortening of the Cervical Canal Effacement  Normal length 2-3 cm  Effacement degree of obliteration of the cervical canal; expressed in % o Change in its position: Posterior to Anterior  Early in labor: cervix is directed downward toward the posterior vaginal wall

As labor progresses the cervix begins to shift its position, moving anteriorly y Minimal cervical dilatation 1-4 cm y Most notable change: change in cervical consistency, effacement and position y Fetal descent: minimal to absent y Sedation is usually given during this time with the side effect of prolongation of labor  Dilatational y Most notable change: Cervical Dilatation y Rate of cervical dilatation: o Primigravida: 1.2 cm/hr o Multigravida: 1.5 cm/hr y Fetal descent is minimal y Sedation doesn t affect rate of cervical dilatation y Corresponds to the Phase of Maximum Slope  Pelvic y Encompasses the Deceleration Phase and the 2nd Stage of Labor y Cervical Dilatation: 8 cm onwards y Most notable change: Fetal Descent o Rate:  1 cm/hr nulligravida  2 cm/hr - multigravida o Fetus proceeds through the Cardinal Movements of Labor  Engagement presenting part already at the level of the maternal ischial spines  Descent further movement of the fetal presenting part beyond the maternal ischial spines  Flexion  Internal Rotation  Extension  External Rotation  Expulsion *Mnemonic: Even Daisy Fails In Easy English Exam  Unaffected by sedation Functional divisions of the Uterus: o Corpus Uteri during labor this is further subdivided onto:  Upper Uterine Segment Active segment y Increases in thickness as labor progresses (due to recruitment of muscles from the lower segment)  Lower Uterine Segment Passive segment 

y y

Some of the muscles are pulled upward to become part of the upper uterine segment o Necessary for the generation of adequate force of contraction Decreases in thickness as labor progresses (due to recruitment of muscle to the upper segment) If muscles from this segment are insufficient for adequate contraction to take place, muscles from the cervical stroma will be pulled up as well

o Cervix Uteri * Isthmus arbitrarily divides the uterus into these two segments * Gravid uterus assumes a configuration where: - Upper segment is thickened - Lower segment is thinner compared to upper segment - Cervical canal is obliterated  Uterus has now assumed a configuration that will allow sufficient generation of intrauterine pressure that will permit expulsion of fetus Measures of Quantifying Uterine Activity o Palpation record uterinc contractions in three parameters: severity, duration, interval o External Tocodynamometry o Internal Uterine Pressure Sensors  Used to monitor minute changes in intrauterine pressure that may be important in salvaging the life of the fetus Physiology of uterine contractions o Fundal dominance  Onset, intensity and duration  Corneal area of the Fundus pacemaker of the uterus; muscle fibers of the uterus have four, interlacing, orientations; pacemaker is necessary for proper, coordinated contractions of appropriate segments in order to squeeze out uterine contents  Greatest and longest activity at the fundus enough to push the baby out  Force of contractions: diminishing towards the cervix o Triple Descending Gradient  Gradient of contractions diminishes from upper to lower segment  Upper uterine segment retracts about the fetus as the fetus descends through birth canal  Analogy: person trying to squeeze out catsup from a bottle starting from the bottom  Uterus generates three pressures: Upper third > Middle third > Lower third

   

Uterine activity Montevideo units (MvU) o MvU = intensity x frequency / 10 minutes  Intensity (intrauterine pressure) = peak contraction minus baseline contraction  200 MvU = adequate uterine contractions y <200 MvU uterine contractions are insufficient to cause expulsion o Increase force of contraction by giving uterotonic agents  A single contraction to be considered sufficient should generate 30 MvU parameter  latent phase  active phase frequency/interval  3-5 mins  2-3 mins duration  30-40 sec  40-60 secs intensity  mild to moderate  Moderate to strong  With every contraction blood supply to the fetus is somewhat diminished. If uterine contractions are in excess of these normal parameters, decrease tone of contractions: y Sedate patient y Reduce administered uterotonic agents  Intensity of uterine contractions should match the phase of labor Mechanical forces of labor o Factors responsible for progression and completion of each stage  First stage: y Uterine power o Cervical resistance this allows the active segment of the uterus to form; diminished towards the end as the cervix opens up y Forward pressure of the fetal head head exerts a dilating force  Second stage: y Mechanical relationship between fetal head and pelvic capacity y Period in which the mother gets the urge to bear down combining intra-abdominal contraction force with uterine contraction force y Delivery may be hindered by size of the baby s head or size of the mother s pelvis  Cervical effacement degree of obliteration of the endocervical canal y Normally the endocervical canal is about 2-3 cm long

Passenger

Fetal Attitude, Presentation, Position Ability to adapt through passage Fetal Lie o Relationship of the long axis of fetus (crown-rump length) with the long axis of mother o Longitudinal, Transverse or Oblique o Clinical implication: baby in longitudinal lie will be delivered easier. When the uterus, having a fetus in transverse lie, continues to contract the lower segment will continue to thin out and eventually will rupture. o Longitudinal Lie  The long axis of the fetus parallels the longitudinal axis of the uterus  Lie assumed by the fetus in the majority of cases o Transverse Lie  Long axis of the mother is perpendicular to the long axis of the fetus  Shoulder / fetal small parts are overlying the maternal pelvis, depending on where the fetus is facing o Oblique Lie  The long axis of the fetus forms an angle with the longitudinal axis of the uterus  This is an unstable / transient lie  It may become longitudinal or transverse during the course of labor  External Cephalic Version external manipulation of the position of the fetus, from transverse or oblique to longitudinal Fetal Presentation o Fetal body part  Within the birth canal or in closest proximity to it  Felt through the cervix on IE o The presenting fetal body part determines the presentation o May be: Cephalic, Breech, Shoulder, or Compound Presentation o Normal & most common presentation: Vertex / Cephalic  IE feel the Fetal Head Fetal attitude (Posture / Habitus) relationship between one fetal part to another fetal part (e.g. fetal head and body); o Determines varieties in fetal presentations o Relationship of one fetal part to one another o Characteristic Posture in the Later Months of Pregnancy o Posturing Maneuvers that fetus undergoes to accommodate inside the uterus:  Fetus folds upon itself  Back markedly convex  Head and neck sharply flexed  Thighs flexed over abdomen 6

 Legs flexed at knee  Arches of feel rest upon anterior surface of legs o Can help determine if the delivery will be normal o Types (Vertex Presentation):  Occiput = completely flexed; posterior fontanel is readily palpable y Most common y Attitude head sharply flexed o Chin touches chest y Presenting fixed reference point: o Occipital or posterior fontanel o Triangle shaped y Presenting AP diameter o Suboccipitobregmatic 9.5 cm; narrowest AP diameter of the fetal head  Sinciput = partially flexed; anterior and posterior fontanels palpable y Attitude head only partially flexed, almost in line with fetal body o Military attitude y Presenting fixed reference point: o Bregma or anterior fontanel o Diamond-shaped y Presenting AP diameter o Occipitofrontal 12.5 cm  Brow = partially extended; anterior fontanel readily palpable y Rarest presentation y Presenting AP diameter o Occipitomental 13.5 cm  Face = completely extended; no fontanel palpable y IE: soft tissue and bony prominences y Attitude neck hyperextended y Presenting fixed reference point: o Mentum y Presenting AP diameter o Submentooccipital (Sumpaico: Sumoccipitobregmatic) / Trachelobregmatic 9.5 cm y Vaginal delivery possible provided that presenting part is Mentum Anterior y Difficulty may arise in the differentiation between face presentation and breech presentation as both contain soft tissues:

o o

o Face: Malar prominences form a triangle with the fetal mouth o Breech: Ischial tuberosities form a straight line with the anal opening  Etiology of deflection attitudes factors that favor extension or prevent head flexion: y Neck masses y Cord coils y Anencephaly y Large babies y Contracted pelvis y Pendulous abdomen o Types (Breech Presentation):  Frank y Thighs are flexed, legs extended  Incomplete (Footling) y When one or both thighs are extended so that the feet and legs are below the level of the buttocks. When one leg is completely extended and the other leg is flexed, it is a single footling; when both legs are extended below the level of the buttocks, it is double footling (definition from Sumpaico; lecturer s definition is misleading)  Complete y Thighs and legs are flexed o Shoulder Presentation:  Appreciated when the fetus is in Transverse Lie:  Landmark: Acromion process  No chance of vaginal delivery, except when fetus is dead y Neglected Transverse Lie: Transverse lie not diagnosed. Leads to death of fetus and/or mother (secondary to uterine rupture) o Compound Presentation:  One fetal presenting part combined with another fetal presenting part  Delays labor o Malpresentations:  Brow  Face  Breech  Shoulder / Transverse Lie Fetal position o Relationship of an arbitrary chosen point of the presenting part to one of the four quadrants of the maternal birth canal Presenting Part o Arbitrary chosen point Vertex o Occiput

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Face o Chin / Mentum Breech o Sacrum Transverse o Acromion o Varieties of the 3 presentations:  Anterior  Posterior  Left Transverse  Right Transverse  Left Anterior  Right Anterior  Left Posterior  Right Posterior o In determining the variety take into consideration:  Laterality (i.e. left or right)  Polarity (i.e. anterior or posterior)

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