Labor and Delivery

1. Labor and Delivery

2. زایمان طبیعی • فيزيولوژي: • سير زايمان طبيعي و وضع حمل با هماهنگي بين انقباضات رحمي و گشاد شدن سرويكس نزول جنين و زمان سپري شده بستگي دارد • شروع زايمان 280 روزه يا 40 هفته بعد از LMP • كاهش غلظت پروژسترون سرم مادر و افزايش استروژن • پروستاگاندين ها

3. مراحل زایمان : سه مرحله • شروع انقباضات رحمي منظم همراه با تغييرات دهانه رحم شامل مرحله نهفته و فعال • مرحله دوم بين گشادي كامل گردن رحم و وضع حمل نوزاد • مرحله سوم بين وضع حمل نوزاد و خروج جفت

4. مکانیسم زایمان • افزايش اندازه مغز • تغييرات شكل لگن

5. اندازه گيري ابعاد لگن : ورودي لگن، قسمت مياني لگن، خروجي لگن، • نمايش جنين، قرار جنين، موقعيت، مانورهاي لئوپولد

6. حرکات اصلی زایمان • آنگاژمان • فلكسيون سر جنين • نزول • چرخش داخلي • اكستانسيون • چرخش خارجي

7. ارزيابي اوليه مادر و پذيرش بيمارستاني • پارگي احتمالي پرده ها • انقباضات منظم و دردناك رحمي • خونريزي واژينال قابل توجه • درد بيش از حد انتظار در پشت لگن، شكم و لگن • شرح حال دقيق و معاينه فيزيكي • دقت به آزمايشات بارداري

8. رويكرد به زايمان • مرحله اول زايمان (تشخيص مرحله فعال، موقعیت مادر، علائم حياتي، هيدراته كردن مادر، ارزيابي آزمايشگاهي، مراقبت دائمي،پايش ضربان قلب جنين، معاينه سرويكس، آمنيوتومي) • مرحله دوم زايمان: (مدت، بيحسي منطقه اي، مانورهاي مربوطه) • مرحله سوم : خروج جفت(مدت بررسي جفت ) • اپي زيوتومي و ترميم پارگيهاي زايمان

9. مراقبت بعد از زايمان علائم حياتي، بررسي رحم، بررسي محل اپي زيوتومي، رژيم غذائي، شيردادن، تعيين Rh مادر، طول دوره بستري)

10. دوران نفاس: تعريف، لوشيا، عوارض شامل خونريزي، عفونت و افسردگي بعد از زايمان، توصيه هاي قبل از ترخيص، كنتراسپتیو، ويزيت بعد از زايمان)

11. مراقبت از نوزاد تازه متولد شده • ارزيابي و احياي فوري • مكونيوم • امتياز آپگار • شيردهي (فوايد، موارد ممنوعيت)

12. Labor • Regular, frequent, leading to progressive cervical effacement and dilatation • Braxton-Hicks contractions • May be painful and regular, but usually are not • Do not lead to cervical change • Labor diagnosis usually made in retrospect. • Cause of labor is unknown

13. Latent Phase Labor • <4 cm dilated • Contractions may or may not be painful • Dilate very slowly • Can talk or laugh through contractions • May last days or longer • May be treated with sedation, hydration, ambulation, rest, or pitocin

14. Active Phase Labor • At least 4 cm dilated • Regular, frequent, usually painful contractions • Dilate at least 1.2-1.5 cm/hr • Are not comfortable with talking or laughing during their contractions

15. Progress of Labor • Lasts about 12-14 hours (first baby) • Lasts about 6-8 hours (subsequent babies) • Considerable variation. • Effacement (thinning) • Dilatation (opening) • Descent (progress through the birth canal)

16. Descent • Fetal head descends through the birth canal • Defined relative to the ischial spines • 0 station = top of head at the spines (fully engaged) • +2 station = 2 cm past (below) the ischial spines

17. Cardinal Movements of Labor Engagement (0 Station) Descent Flexion (fetal head flexed against the chest) Internal rotation (fetal head rotates from transverse to anterior Extension (head extends with crowning) External rotation (head returns to its’ transverse orientation) Expulsion (shoulders and torso of the baby are delivered)

18. Watch a Delivery

19. Placental Separation • Signs of separation: • Increased bleeding • Lengthening of the cord • Uterus rises, becoming globular instead of discoid • Uterus enlarges, approaching the umbilicus • Normally separates within a few minutes after delivery

20. Initial Labor Management • Risk assessment • Contractions: frequency, duration, onset • Membranes: Ruptured, intact • Status of cervix: dilatation, effacement, station • Position of the fetus: vertex, transverse lie, breech • Fetal status: fetal heart rate, EFM

21. Cervix • Dilatation: How far has the cervix opened (in cm) • Effacement: How thin is the cervix (in cm or %)

22. Status of Membranes • Nitrazine paper turns blue in the presence of alkaline amniotic fluid (“nitrazine positive”) • Vaginal secretions are nitrazine negative (yellow) because of their acidity • Pooling of amniotic fluid in the vaginal vault is a reliable sign

23. Orientation of Fetus • Vertex, breech or transverse lie • Palpate vaginally • Leopold’s Maneuvers

24. Management of Early Labor • Ambulation OK with intact membranes • If in bed, lie on one side or the other…not flat on her back • Check vital signs every 4 hours • NPO except ice chips or small sips of water

25. Monitor the Fetal Heart • During early labor, for low risk patients, note the fetal heart rate every 1-2 hours. • During active labor, evaluate the fetal heart every 30 minutes • Normal FHR is 120-160 BPM • Persistent tachycardia (>160) or bradycardia (<120, particularly <100) is of concern

26. Electronic Fetal Monitors • Continuously records the instantaneous fetal heart rate and uterine contractions • Patterns are of clinical significance. • Use in high-risk patients. • Use in low-risk patients optional

27. Normal Patterns • Normal rate • Short term variability (3-5 BPM) • Long term variability (15 BPM above baseline, lasting 10-20 seconds or longer) • Contractions every 2-3 minutes, lasting about 60 seconds

28. Tachycardia • >160 BPM • Most are not suggestive of fetal jeopardy • Associated with: • Fever, Chorioamnionitis • Maternal hypothyroidism • Drugs (tocolytics, etc.) • Fetal hypoxia • Fetal anemia • Fetal arrythmia

29. Bradycardia • Sustained <120 BPM • Most are caused by increased in vagal tone • Mild bradycardia (80-90) with retention of variability is common during 2nd stage of labor • <80 BPM with loss of BTBV may indicate fetal distress

30. Late Decelerations • Repetive, non-remediable slowings of the fetal heartbeat toward the end of the contraction cycle • Reflect utero-placental insufficiency

31. Early Decelerations • Periodic slowing of the FHR, synchronized with contractions • Rarely more than 20-30 BPM below the baseline • Innocent • Associated with fetal head compression

32. Variable Decelerations • Variable in onset, duration and depth • May occur with contractions or between them • Sudden onset/recovery • Increased vagal tone, usually due to some degree of cord compression

33. Severe Variable Decelerations • Below 60 BPM for at least 60 seconds • If persistent, can be threatening to fetal well-being, with progressive acidosis

34. Prolonged Decelerations • Last > 60 seconds • Occur in isolation • Associated with: • Maternal hypotension • Epidural • Paracervical block • Tetanic contractions • Umbilical cord prolapse

35. Pain Relief • Narcotics • Continuous Lumbar Epidural • Paracervical Block • 50/50 nitrous/oxygen • Psychoprophylaxis (Lamaze breathing) • Hypnosis

36. Anesthesia During Delivery • Local • Pudendal Block • Epidural • Caudal • Spinal • 50/50 nitrous/oxygen

37. Episiotomy • Avoids lacerations • Provides more room for obstetrical maneuvers • Shortens the 2nd Stage Labor • Midline associated with greater risk of rectal lacerations, but heals faster • Many women don’t need them.

38. Clamp and Cut the Cord • Clamp about an inch from the baby’s abdomen • Use any available instruments or usable material • Check the cord for 3-vessels, 2 small arteries and one larger vein

39. Inspect the Placenta • Make sure it is complete • Look for missing pieces • Look for malformations • Look for areas of adherent blood clot

40. دکتر گیتی رحیمی با تشکر