THREE STAGES OF LABOR
Latent phase: beginning of labor until about 4cm dilated
Active phase: 4cm dilation to 10cm, this dilation happens fast = rapid dilation
Some Complications Slow progress, evaluate for:
Adequacy of uterine contractions: is the uterus contracting enough, should oxytocin be given?
External monitor or an intrauterine monitor
Oxytocin: will increase contraction of the uterus
Fetal malposition: a sterile vaginal exam can sometimes determine the position of the baby. Typically the baby's occiput (back of head) should be facing the mothers pubic bone (anterior), but sometimes the baby will be turned and looking in a difficult direction which can complicate delivery.
Often, the physician can rotate the baby's head to the correct position, other times the baby will rotate on its own, but sometimes the baby never rotates correctly and is delivered in whatever position it is in. Which as you can imagine, causes some difficulty during the second stage of labor.
Cephalopelvic disproportion: This is a fascinating concept to me: the mother's pelvic inlet is too small for the size of the baby's head =cephalo. There is a mismatch in size (disproportion) that restricts the baby from successfully coming down the birth canal. In this case, she would need a C-section. Here is the fascinating part to me... there is no way to accurately tell if this is the case and needs to be under the judgment of the physician.
Second stage: Baby is delivered! = Fetal expulsion.
Starts when the cervix is fully dilated and ends... with a baby!
Shoulder dystocia: posterior shoulder delivers first. This can cause fetal distress or nerve damage if not delivered quickly enough. Time is crucial during this event.
Suprapubic pressure: pressure above pubic bone to deliver anterior shoulder
McRoberts maneuver: flexing the thighs up close to the mother's abdomen to flatten the sacrum
Instruments: if the baby is in distress/descending slowly but still able to be delivered vaginally, an instrument is used to manipulate the baby into the second stage of labor.
Forceps: Need to know the head position for the forceps to be applied (to the parietal bones, for the least amount of harm). Some facial and head markings may be present after use but should resolve over a few days. Forceps are more decisive and preferred by the physician I am working with.
Vacuum: My preceptor said that the vacuum has a safety mechanism that releases under too much pressure making it difficult to deliver the baby sometimes. It should not be applied over the fontanelles (or it will cause serious damage).
Third stage: Placenta is delivered = placental separation
The mother should feel the urge to push on another contraction when she is ready to deliver the placenta. Some signs that the placenta is separated and ready to come out:
1. Gush of blood from vagina (fairly noticeable)
2. Umbilical cord begins to lengthen (this is the one I think is most noticeable)
3. Uterus becomes firm and rises up in the abdomen
Some Complications: If the placenta is not removed in 30 min, it will need to be manually removed to prevent prolonged placental retention
In the meantime, it is typically physician preference when to perform episiotomies and even when to repair them. Sometimes the doctor will simply let the mother "tear" if he knows she will deliver without difficulty. This is generally the most concerning part for some mothers during healthy deliveries.
After the baby is delivered the physician then repairs the tears with vicryl and/or monocryl sutures. The damage from the perineal tears are classified as the following:
1st degree tear: Fourchette, perineal skin and vaginal mucosa
2nd degree tear: 1st + fascial and muscle involvement of the perineal body
3rd degree tear: 2nd + involving anal sphincter
4th degree tear: 3rd + through rectal mucosa to expose lumen
Need to repair carefully to prevent fecal incontinence or rectovaginal fistula