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What is Labor ? (: work)

What is Labor ? (: work). Regular painful uterine contractions accompanied by progressive effacement and dilatation of the cervix. Timing of Labor. 40 weeks 8% deliver on E.D.C. 7% premature < 37 weeks 10% post-mature > 42 weeks.

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What is Labor ? (: work)

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  1. What is Labor ?(: work) Regular painful uterine contractions accompanied by progressive effacement and dilatation of the cervix

  2. Timing of Labor • 40 weeks • 8% deliver on E.D.C. • 7% premature < 37 weeks • 10% post-mature > 42 weeks

  3. Signs of Onset of Labour “Show”Rupture of membranes Contractions

  4. Detection of ruptured membranes Nitrazine Test - alkaline pH of fluidturns blue Ferning - high Na+ content causes“ferning” on air dried slide

  5. Stages of Labor 1st stage - Onset to ‘full dilatation Latent active 2nd stage - Full dilatation to delivery of baby 3rd stage - Delivery of placenta 4th stage - Bonding

  6. DR. DR.

  7. Table 30-1. Characteristics of Labor Nulliparas and Multiparas* Nulliparas Multiparas Characteristic All patients Ideal Labor All patients Ideal labor Duration of first stage (hr) Latent phase 6.4(±5.1) 6.1 (±4.0) 4.8 (±4.9) 4.5 (±4.2) Active phase 4.6(±3.6) 3.4(±1.5) 2.4(±2.2) 2.1 (±2.0) Total 11.0(±8.7) 9.5(±5.5) 7.2(±7.1) 6.6(±6.2) Maximum rate of descent (cm/hr) 3.3(±2.3) 3.6(±1.9) 6.6(±4.0) 7.0(±3.2) Duration of second stage (hr) 1.1(±0.8) 0.76(±0.5) 0.39(±0.3) 0.32(±0.3) * All values given are ± SD. (Data from Friedman EA: Labor: Clinical Evaluation and Management. 2nd ed. New York, Appleton-Century-Crofts, 1978).

  8. Cesarean Section Indications Failure to progress Repeat (Failed VBAC) Fetal Distress Breech Presentation Placenta Previa Cord prolapse Abruption Diabetes Social...

  9. DYSTOCIA

  10. DYSTOCIA DIAGNOSIS • Abnormal progression of labour in the ACTIVE Phase • Cervical dilatation of <0.5 cm/hr over a 4 hr period • arrest of progress in the ACTIVE phase either in the first or second stage of labour This includes a failure in the descent of the presenting part

  11. OUTCOME OF PROLONGED LATENT PHASE • NCPP 1965  Apgar  perinatal death and poor outcomewhere latent phase greater than 15 hours • Chelmow are 1993 -  for labour intervention and low apgars where latent phase greater than 12 hours in nullip and 6 hours in multips • Piezner 1985 found that length of latent phase related to cervical dilatation on admission • Roemer 1996 found lower I.Q.’s in siblings with dystocia greater than 12 hours.

  12. CAUSES OF DYSTOCIA Power Incoordinate uterine action Dysfunctional Labour Passenger CPD Relative disproportion Passages Diameters

  13. DYSTOCIA • A 4 cm cut off separates latent from active labour • Abnormal progress never diagnosed before 4cm dilatation • Women not in active labour ‘triaged’ from the labour floor

  14. CESAREAN SECTION FOR DYSTOCIA • Timing of procedure Rate • Latent phase 41% • Active phase 38% • Second stage 21% • Source: Stewart CMAJ 1990:142; 459-463

  15. DYSFUNCTIONAL LABOUR - FACTORS OF INTEREST • Age • Parity • Infection • Epidural • Position in labour • Cervix • Induction • Macrosomia

  16. INITIAL MEASURE TO TREAT DYSTOCIA • Comfort • wellbeing • hydration A. Attention to B. Amniotomy C. Oxytocin if A+B fail D. Wait long enough to see a response

  17. OXYTOCIN USAGE Initial dose: 1 to 2 mlu/min Rate increased by 1 to 2 mlu/min every 30 min Until contractions are considered adequate and cervical dilatation achieved Clinical response usually seen at dose levels of 8 - 10 mlu/min

  18. REDUCTION OF RISK OF DYSTOCIAFactors to avoid • Induction for large fetal weight • Oxytocin use with unfavourable cervix • No admission to Labour and Delivery at <4cm dilatation • Discontinuation of epidural at full dilatation • Immediate pushing after full dilatation

  19. SUPPORTIVE STRATEGIES • Cervical evaluation for ripening prior to booking induction • Obstetrical triage • Continuous professional support in active labour • Mobilisation of women in active labour • Minimisation of motor blockage with epidural • Use of amniotomy and oxytocin prior to C/S for dystocia

  20. APPROPRIATE MANAGEMENT FOR SLOW LABOUR ASSOCIATED WITH AN OCCIPITO POSTERIOR DURING THE FIRST STAGE OF LABOUR WOULD INCLUDE: a) immediate cesarean section b) forceps c) augmentation with oxytocin d) external cephalic version e) fetal blood sampling

  21. NS NS -------------------------------------------- C C C C C C C

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