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*All in red are taught by Dr. Villaflor and Dr. Nematian.

Stations:
I. KNOT TYING: one hand, two hand, instrumental
II. INSTRUMENTS: identification, those usually available in the CD
III. PELVIS: asynclitism, station 0 vs engagement, cardinal movements of labor
IV. EFM: interpretation and Diagnosis
V. PARTOGRAPH: Diagnosis (What is happening between point A to point B? = normal labor, arrest, failure, etc)
VI. FORCEPS or MANEUVERS of DELIVERY: breech, sometimes pudendal block, sometimes active or traditional
(passive); 3rd stage of labor
VII. ANATOMY of the UTERUS + LIGAMENTS – ureters (trick question)
VIII. CASE: UTI, HPN, Vaginal discharge with prescription writing
IX. REST STATION

Management of Third Stage of Labor


A. Traditional
I will wait for the signs of placental separation.
1. Sudden gush of blood
2. Cord lengthening
3. Uterus rises in the abdomen as the detached placenta drops
4. Calkin’s sign – uterus becomes globular and firmer
As soon as the fetus is delivered, and I am certain that there won’t be another baby coming out, I will clamp
the cord and coil it around the clamp while applying gentle traction. At the same time I will place my other hand at the
suprapubic area and apply gentle counter-traction. Once the placenta is at the introitus, I will gently rotate the placenta
360 degrees until it is fully extracted. I will remove the clamp from the cord and pull out remaining membranes that may
be left behind. From there I will inspect the placenta for completeness of the cotyledons and membranes. Massage the
uterus to help it contract.

B. Active
I will not wait for the signs of placental separation.
As soon as the fetus is delivered, and I am certain that there won’t be another baby coming out, I will
administer oxytocin (10 units, 30gtts/min) via IV to the patient. I will clamp the cord and coil it around the clamp while
applying gentle traction. At the same time I will place my other hand at the suprapubic area and apply gentle counter-
traction. Once the placenta is at the introitus, I will gently rotate the placenta 360 degrees until it is fully extracted. I will
remove the clamp from the cord and pull out the remaining membranes that may be left behind. From there I will
inspect the completeness of the cotyledons and membranes. Massage the uterus to help it contract.

What to do when there is resistance upon cord traction


I will stop applying gentle traction on the cord. I will wait for the oxytocin to take effect. I will also wait for the
next uterine contraction. At the height of the uterine contraction, I will resume my gentle traction. If there is still
resistance, I will stop and continue to wait until there is successful traction.

Pudendal Block
I will prepare the 10ml of 2% Lidocaine, 5mL per side that will be used on the patient.
Upon the insertion of my fingers within the introitus, I will feel for the ischial spine. I will take the Iowa trumpet and use
my hand as a guide for its insertion. It would be directed approximately 1cm below and medial to the ischial spine. The needle of
my syringe will then be inserted, and once I feel the “give” (the indication that the needle has penetrated the pelvic
tissue/muscle), I will aspirate first and check if there is a back-flow. If I did not hit a vessel, I will proceed to administer the drug. I
will then remove the needle and syringe. The Iowa trumpet will be removed afterwards. (There is an option to simultaneously
remove Iowa trumpet and your hand, but never remove needle and trumpet simultaneously.) Simulate the perineum on that
particular side to see if drug as taken effect.
Repeat procedure on opposite side.

Cardinal Movements of Labor


• This mechanism is described in relation to the most common presentation (95% of all pregnancies) – vertex
1. Engagement
a. Passage of the widest diameter (biparietal diameter) of the presenting part to a level below the plan of the
pelvic inlet
b. Clinically, if the lowest portion of the fetal skull is at or below the level of the maternal ischial spines (station
0), engagement has usually taken place.
c. Primigravidas – occurs by 38 weeks AOG; Multigravidas – at the onset of labor
d. At the level of the pelvic inlet, the maternal bony pelvis is sufficiently large to allow descent of the fetal head
e. At station 0, the fetal head is at the bony ischial spines and fills the maternal sacrum
2. Descent
a. Downward passage of the presenting part through the pelvis
b. This occurs intermittently with contractions
c. Factors facilitating Descent:
i. Fundus upon the breech
ii. Contraction of the abdominal muscles and extension
iii. Straightening of the fetal body
iv. Thinning of the lower uterine segment
d. *pelvic configuration, size and position of the presenting part may also play a part
e. The rate is greatest during the deceleration phase of the first stage and during the second stage of labor
3. Flexion
a. The chin is brought into contact with the fetal thorax and the presenting diameter changes from
occipitofrontal to suboccipitobregmatic for optimal passage through pelvis
b. This is due to the resistance encountered from the bony pelvis or the soft tissues of the pelvic floor as the
fetal vertex descends
4. Internal Rotation
a. Rotary movement of the fetal head from the transverse to the antero-posterior position
b. Starts at about the level of the ischial spines and is generally completed as the head reaches the pelvic floor
c. As the head descends, the fetal occiput rotates from its original position (usually in transverse) toward the
symphysis pubis (occiput anterior) or less commonly, toward the hollow of the sacrum
d. PRE-REQUISITES FOR ANTERIOR ROTATION OF THE HEAD:
i. Well-flexed head
ii. Efficient uterine contractions
iii. Favorable mid-pelvic plane
iv. Tone of the levator ani muscles
e. Pressure from the spine and the levator sling of the pelvic floor diaphragm accomplishes internal rotation
5. Extension
a. Upon contact of the base of the occiput with the symphysis pubis, there is upward resistance from the pelvic
floor and downward forces from the uterine contractions that causes the occiput to extend and rotate around
the symphysis
b. The occiput serves as a hinge allowing the extension of the fetal head
c. This allows the occiput enough room to slip under the symphysis with complete extrusion of the fetal head
6. External Rotation (Restitution)
a. Return of the fetal head to the correct anatomic position in relation to the fetal torso
b. When the fetal head is free of resistance, it untwists 45 degrees left or right, returning to its original anatomic
position
c. This is a passive movement
d. Fetus resumes its face forward position, with the occiput and spine lying in the same plane
7. Expulsion
a. Delivery of the rest of the fetus
b. Further descent brings the anterior shoulder to the level of the symphysis pubis. The anterior shoulder is
delivered in much the same manner as the head, with rotation of the shoulder under the symphysis pubis
c. According to Dr Mariano: It is important to note that the reason why we initiate with the anterior shoulder is
because the symphysis pubis presents with marked bony resistance anteriorly as opposed to the muscles
and soft tissues of the pelvic floor

Synclitism/Asynclitism
• Relationship of the sagittal suture to the symphysis pubis and sacrum
SYNCLITISM
! The sagittal suture is midway between the symphysis pubis and the sacral promontory
ASYNCLITISM
! Describes the fetal head that is deirected anteriorly towards the symphysis pubis or posteriorly towards the sacral
promontory
! NAEGELE’S OBLIQUITY: anterior parietal bone presents and the sagittal suture is more posterior aka ANTERIOR
asynclitism
! LITZMANN’s OBLIQUITY: the posterior parietal bone presents and the sagittal suture is more anterior aka
POSTERIOR asynclitism

MANEUVERS
1. Ritgen
Delivery of a child's head by pressure on the perineum while controlling the speed of delivery by pressure with the other
hand on the head.
2. Mueller-Hillis – also used in pelvimetry, to measure the adequacy of the midpelvis
Manual pressure on the term fundus while a finger in the vagina determines the descent of the head into the pelvis.
3. Pinard
In management of a frank breech presentation, pressure on the popliteal space is made by the index finger while the other
three fingers flex the leg while sliding it along the other thigh as the foot of the flexed leg is brought down and out.
4. Mauriceu
A method of delivering the head in an assisted breech delivery in which the infant's body is supported by the right forearm
while traction is made upon the shoulders by the left hand.
5. Prague
A method for delivering a fetus in breech position in which the infant's shoulders are grasped from below by one hand while
the other hand supports the legs.
6. External Cephalic Version
Process by which a breech baby can sometimes be turned from buttocks or foot first to head first. It is usually performed
after about 37 weeks. It is often reserved for late pregnancy because breech presentation greatly decreases with every week.It
can be contrasted with "internal cephalic version", which involves the hand inserted through the cervix
--(for shoulder dystocia)--
7. McRoberts
It is employed in case of shoulder dystocia during childbirth and involves hyperflexing the mother's legs tightly to her
abdomen. It is effective due to the increased mobility at the sacroiliac joint during pregnancy, allowing rotation of the pelvis and
facilitating the release of the foetal shoulder. If this maneuver does not succeed, an assistant applies pressure on the lower
abdomen (suprapubic pressure), and the delivered head is also gently pulled.
8. Wood’s Corkscrew
The attendant tries to turn the shoulder of the baby by placing fingers behind the shoulder and pushing in 180 degrees.
9. Rubin
Like the Woods maneuver, two fingers are placed behind the baby's shoulder, this time they are pushing in the directions of the
baby's eyes, to line up the shoulders.
10. Zavanelli
Pushing the baby's head back inside the vagina and doing a cesarean. This is the mostly frequently asked about method, but
also one of the most dangerous.
11. Gaskin
Get the woman into a hands and knees position. This will also change the diameters of her pelvis, though is not always possible
with epidural anesthesia.
12. Suprapubic Pressure
This pressure is at the pubic bone, not at the top of the uterus. This might allow the shoulder enough room to move under the
pubis symphysis.

*Pelvimetry
1. Measure the adequacy of the inlet through the assessment of the true conjugate (using the diagonal conjugate) by reaching
for the sacral promontory with your tallest finger. You should know the length of your tallest finger. If you can’t reach for the
sacral promontory, the diagonal conjugate is probably >11.5 and adequate.
2. Measure the adequacy of the midpelvis by assessing the transverse diameter using the Meuller Hillis technique. Apply manual
pressure on the term fundus while a finger in the vagina determines the descent of the head into the pelvis. If this can be done,
the midpelvis is adequate. Then describe the ischial spines, sacrum, and the side walls accordingly: “Ischial spine not
prominent. Sacrum is curved. Side walls should not be convergent.”
3. Adequacy of the outlet is measured at the suprapubic arch. Supapubic arch should be wide to be adequate.

EFM (Electronic Fetal Monitor)

Electronic Fetal Heart Rate: Basic Patterns


1. Baseline FHR
a. Approximate mean fetal heart rate over a 10 minute segment excluding decelerations, accelerations and
periods of marked variability.
b. Normal value: 110 – 160 bpms
2. Variability
a. Fluctuations above and below the FHR baseline
b. Four Categories:
i. Absent fluctuations
ii. Minimal (detectable fluctuations to 5 bpm)
iii. Moderate (6bpm – 25bpm)
iv. Marked – Saltatory (>25bpm)
3. Acceleration
a. A peak in the FHR above baseline at least 15 bpm lasting 15 seconds but less than 2 minutes
b. Before 32 weeks, accelerations increase only 10 bpm lasting 10 seconds
4. Deceleration
a. A decrease in FHR with reference to uterine contractions
b. Three Categories:
i. Early deceleration (Head compression)
1. A gradual decrease in FHR associated with a uterine contraction, with return to baseline
by the end of the contraction
ii. Variable deceleration (Cord Compression)
1. Abrupt decrease in FHR below baseline varies in shape, duration, depth and timing, can
occur with or without contractions. Shapes can presenas U, V or W. Classified as mild,
moderate, severe.
a. Mild – duration of less an 30 seconds, regardless of level or a deceleration
below 70 – 80bpm, regardless of duration
b. Moderate – have a level less than 80bpm regardless of duration
c. Severe – less than 70 bpm for greater than 60 seconds
iii. Late Deceleration (Utero-placental Insufficiency)
1. Similar to early deceleration but the timing is delayed, 30 seconds or more after the onset
of the contraction. The nadir occurs after the contraction peak and return to baseline
when the contraction is over.
c. Prolonged Deceleration
i. A decrease in FHR that lasts > 2 minutes but < 10 minutes
ii. A decrease > 10 minutes is considered a change in baseline FHR

*Intensity of Uterine Contractions:


60-80 MV units = Strong
40-60 = Moderate
20-40 = Mild
Measured in a 10 min strip (3 strips), add all the uterine contractions (from baseline).
Total should be equal to 200 MV units to be adequate.

*Partograph:
FAQ:
1. From point A to Ponit B, is it normal or retracted?
2. Diagnosis?
3. What is the cause? Answer: CPD (absolute), macrosomia from GDM, etc.

STAGES OF LABOR
First Stage
! Onset of regular contractions to complete dilatation. Are three phases:
1. Latent Phase
a. 0 – 3 cms
b. Primipara 20 hours
c. Multipara 14 hours
d. May have irregular contractions, short, mild – moderate
2. Active Phase
a. 4 – 7 cms
b. Primipara 5 hours; dilatation at least 1.2cm/hour
c. Multipara 4 hours; dilatation at least 1.5cm/hour
d. Uterine contractions q 2-5 minutes, 40 – 60 seconds, moderate to strong
3. Transition Phase
a. 8 – 10 cms
b. Primipara 3.6 hours
c. Multipara variable
d. Uterine contractions every 1½ - 2 minutes; 60 – 90 second, moderate to strong
Second Stage
! Complete dilatation (10cm) to delivery of the fetus
o Primipara: 60 minutes
o Multipara: 30 minutes
o Affected by epidural anesthesia, maternal pushing, position of presenting part, size of the pelvis
Third Stage
! Delivery of fetus to delivery of placenta
o Usually within 5 minutes after delivery of fetus (may be upto 30 minutes)
o RETAINED – if after 30 minutes

References:
APMC
G&A
http://www.slideshare.net/crisbertc/normal-labor-and-delivery