IMLE Preparatory Course
Lecture 53
Obstetrics and Gynecology
Normal Labor and Delivery
Critical factors in labor & birth
The passage
The fetus
The relationship between the passage
and the fetus
The forces of labor
The psychosocial consideration
Obstetric Examination
Leopold’s
maneuvers are used
to determine fetal
lie (longitudinal or
trans-verse) and, if
possible, fetal
presentation (breech
or cephalic).
Obstetric Examination
Cervical examination:
Dilation
Effacement
Station
Cervical position
Cervical consistency
Bishop score
Evaluates the favorability of delivery and the
probability of succeeding with an induction
Bishop Score
Scoring is interpreted as follows:
0–4: Indicates a 45–50% chance of failure. Give
prostaglandins for induction.
5–9: Points to a 10% chance of failure. Give
pitocin for induction.
10–13: Associated with a very high probability of
success. There is no need for intervention for
induction.
Obstetric Examination
Confirm or determine fetal presentation.
Determine fetal position through palpation
of the fetal sutures and fontanelles.
Conduct a sterile speculum exam if rupture
of membranes (ROM) is suspected
The Birth Passage
The true pelvis is divided into 3 sections:
The inlet, the pelvic cavity (midpelvis), and the
outlet
The four classic types of pelvis are:
Gynecoid, android, anthropoid and platypelloid.
The gynecoid, or female, pelvis is most common
Pelvic Types
The Fetus
Fetal head (size and presence of molding)
Fetal attitude
Fetal lie
Fetal presentation
Placenta (implantation site)
Fetal head
The fetal skull or cranium consists of the face, the base of
the skull and the vault of the cranium or roof.
The bones of the face and cranial base are well fused and
essentially fixed
Molding refers to the cranial bones overlapping under
pressure during labor
Sutures of the fetal skull are membranous spaces
between the cranial bones.
Fontanelles are the intersections of the cranial sutures.
These sutures allow for molding of the fetal head.
Fontanelles
The anterior fontanelle is
diamond shaped and measures
about 2-3cm. It permits growth of
the brain by remaining unossified
for as long as 18 months.
The posterior fontanelle is much
smaller and closes within 8-12
weeks after birth
Fetal Lie
Refers to the relationship of the cephalocaudal
(spinal column) axis of the fetus to the cephalocaudal
axis of the woman.
A longitudinal lie occurs when the cephalocaudal
axis of the fetus is parallel to the woman’s spine.
A transverse lie occurs when the cephalocaudal axis
of the fetus is at a right angle to the woman’s spine
Which of the following serve as landmarks when
assessing descent of the fetal head?
A. Ischial spines
B. Symphysis pubis
C. Ischial tuberosities
D. Sacral promonotory
Which of the following serve as landmarks when
assessing descent of the fetal head?
A. Ischial spines
B. Symphysis pubis
C. Ischial tuberosities
D. Sacral promonotory
Fetal Lie
Fetal Presentation
Is determined by fetal lie and by the body part of
the fetus that enters the pelvic passage first, the
presenting part
May be cephalic (most common), breech, or
shoulder
Breech and shoulder presentations are referred to
as malpresentations as they are associated with
difficulties during labor
Examples of presentations
Cephalic Presentation
97% of births
Fetal head presents itself to the passage
“Subcategories” of cephalic presentation includes:
Vertex presentation: Occiput is the presenting part –
most common type
Military presentation: The fetal head is neither flexed
nor extended
Brow Presentation: The fetal head is partially
extended
Face presentation: The fetal head is hyperextended
The relationship of which fetal part to the mother's pelvis
determines the cephalic presentation?
A.mentum
B.sacrum
C.acromion
D.occiput
E.sinciput
The relationship of which fetal part to the mother's pelvis
determines the cephalic presentation?
A.mentum
B.sacrum
C.acromion
D.occiput
E.sinciput
Breech Presentation
3% of births
Sacrum is the landmark to be noted
Frank Breech: the fetal hips are flexed and the knees are
extended. The buttocks of the fetus present to the
maternal pelvis
Complete Breech: the fetal knees and hips are both
flexed; the thighs are on the abdomen and the calves are
on the posterior aspect of the thighs
Footling Breech: the fetal hips and legs are extended, and
the feet of the fetus present to the maternal pelvis (single
or double footling)
Breech Presentation
A 27 year old woman, gravida 2, para 1 at 30 week of gestation
presents to clinic for a routine prenatal visit. She has known to
suffer from "serosal fibroids". Her fundus measures 37cm from
the pubis. In discussing possible complications of a fibroid
uterus during pregnancy you mention that she is at highest risk
for:
A. preterm premature rupture of membranes (PPROM)
B. Placental previa
C. Pregnancy induced hypertension (PIH)
D. Breech presentation
E. placental abruption
A 27 year old woman, gravida 2, para 1 at 30 week of gestation
presents to clinic for a routine prenatal visit. She has known to
suffer from "serosal fibroids". Her fundus measures 37cm from
the pubis. In discussing possible complications of a fibroid
uterus during pregnancy you mention that she is at highest risk
for:
A. preterm premature rupture of membranes (PPROM)
B. Placental previa
C. Pregnancy induced hypertension (PIH)
D. Breech presentation
E. placental abruption
The Stages of Labor
The Stages of Labor
Engagement
Flexion
Internal Rotation
Extension
External Rotation
Delivery of Anterior and Posterior Shoulders
Phases of the first stage labor:
Latent phase of labor begins with the onset of regular
uterine contractions and extends to the start of the
active phase of cervical dilatation (0-3 cm).
Cervical effacement from 0-40%
Dilate very slowly
Nullipara lasting up to 9 hours, multipara lasting up to 5
to 6 hours.
Prolonged latent phase: defined as greater than 20 hours
in a nullipara and greater than 14 hours in a parous
woman
Phases of the first stage labor:
Active phase of labor: lasts from 4 to 7 cm dilation,
moderate contractions.
Regular, frequent, usually painful contractions
Cervical dilation rate of 1.2 cm/hr for nulliparas and 1.5
cm/hr for parous women
Cervical effacement 40 to 80%
Nullipara lasting lasting up to 6 hours, multipara lasting
up to 4 hours.
Contraction frequency every 2 to 5 min.
Contraction duration 45 to 60 seconds.
Phases of the first stage labor:
Transition phase: is from 8 to 10cm dilation,
strong uterine contraction.
Cervical effacement from 80 to 100%
Nullipara lasting up to 1 hour, multi Para lasting
up to 30 minutes.
Contraction duration 60 to 90 seconds
Contraction intensity hard by palpation.
The second stage of labor
Begins when the cervix becomes fully dilated and
ends with the complete birth of the infant.
Normally lasts up to 1 hour.
Safety for the fetus may be assured by thoughtful
monitoring.
The second stage of labor
Pelvic phase: period of fetal descend
Perineal phase: period of active pushing
Nullipara lasts up to 1 hour, multipara lasts up to
30 minutes.
Contraction frequency every 2 to 3 minutes
Contraction duration 60 to 90 seconds.
Strong urge to push in perineal phase.
The third and fourth stages of labor
Third stage, called also placental stage of labor.
Is the period from birth of the infant to 1 h after
delivery of the placenta.
The rapidity of separation and means of recovery
of the placenta determine the duration of the
third stage
Fourth stage of labor: is 1 to 4 hours after birth,
time of maternal physiologic adjustment.
Which of the following placental implantation most
like predisposed to inverted uterine in 3rd stage of
labor?
a. Fundal
b. Anterior
c. Posterior
d. Lateral
e. Lumbar stage of labor
Which of the following placental implantation most
like predisposed to inverted uterine in 3rd stage of
labor?
a. Fundal
b. Anterior
c. Posterior
d. Lateral
e. Lumbar stage of labor
Fetal Heart Rate Monitoring
Tachycardia
Bradycardia
Variability: LTV versus STV
Accelerations
Decelerations: Early, Late & Variable
Fetal Heart Rate Monitoring
Baseline rate:
Refers to the average FHR observed
during a 10-minute period of monitoring.
Normal range is 120-160 BPM
>160 BPM = tachycardia
<120 BPM = bradycardia
Fetal Tachycardia
Fetal Bradycardia
Causes of fetal tachycardia
Early fetal hypoxia
Compensation for reduced blood flow
Maternal fever
Accelerates the metabolism of the fetus
Maternal dehydration
Beta-sympathomimetic drugs
Atropine, terbutaline and other drugs with cardiac stimulant effect
Amnionitis
Fetal tachycardia may be first sign of intrauterine infection
Maternal hyperthyroidism
TSH may cross the placenta and stimulate fetal heart rate
Fetal anemia
Heart rate is compensating to improve tissue perfusion
Causes of Fetal Bradycardia
Late (profound) fetal hypoxia
Maternal hypotension
Results in decreased blood flow to the fetus
Prolonged umbilical cord compression
Fatal arrhythmia
Variability
Baseline variability is a measure of the interplay (the
push-pull effect) between the sympathetic and
parasympathetic nervous systems (adequate oxygenation
promotes normal function of the autonomic nervous
system and helps the fetus adapt to the stress of labor).
Variability - The FETUS is RESPONDING to multiple
factors which constantly speed and slow the heart rate;
adapting to the stress of labor- A GOOD THING!!!
There are two types of variability:
Short-term variability (STV)- the beat-to-beat
change in FHR. It represents fluctuations of the baseline.
STV can only be measured via internal (scalp electrode)
means and is classified as either present or absent.
Long-term variability (LTV)- the waviness or
rhythmic fluctuations (called cycles) of the FHR tracing
which occurs 3-5 times/minute. LTV can be classified as
absent, decreased, average, increased, or marked.
Causes of decreased variability
Hypoxia and acidosis
Decreased blood flow to the fetus
Administration of certain drugs
Demerol, Valium or other CNS depressants
Fetal sleep cycle
During fetal sleep, LTV is decreased
Fetus of less than 32 weeks gestation
Causes of increased variability
Early mild hypoxia – compensatory
mechanism
Fetal stimulation – stimulation of autonomic
nervous system, i.e. palpation, vaginal
examination etc.
Acceleration
Transient increases in the FHR (>15 bpm above
the baseline, lasting >15 seconds), normally
caused by fetal movement (think about the NST)
It often accompany uterine contractions, usually
due to the fetal movement in response to the
pressure of the contraction
FHR Accelerations
Deceleration
Periodic decrease in FHR from the normal baseline.
They are categorized as early, late, and variable according
to the time of their occurrence in the contraction cycle
and their waveform.
Early deceleration- when the fetal head is compressed,
cerebral flood flow is decreased which leads to central
vagal stimulation. The onset of early deceleration occurs
before the onset of the uterine contraction. Usually
benign.
Early decelerations
Late Decelerations
Caused by uteroplacental insufficiency resulting
from decreased blood flow and oxygen transfer to
the fetus through the intervillous spaces during
uterine contraction.
Occurs after the onset of a uterine contraction.
Non-reassuring sign.
Late decelerations
A gradual, smooth deceleration of the fetal heart rate
that follows the peak of a contraction describes
which of the following deceleration types?
A. Late
B. Early
C. Variable
D. Prolonged
A gradual, smooth deceleration of the fetal heart rate
that follows the peak of a contraction describes
which of the following deceleration types?
A. Late
B. Early
C. Variable
D. Prolonged
Variable Decelerations
Occur if the umbilical cord becomes compressed,
this reducing blood flow between the placenta
and fetus.
The peripheral resistance in the fetal circulation
increases, causing fetal hypertension.
Non-reassuring sign. Further assessment of this
pattern is necessary.
Variable Decelerations
Antepartum Fetal Surveillance
Is used in pregnancies in which the risk of
antepartum fetal demise is ↑.
Testing is initiated in most at-risk patients at 32–
34 weeks (or 26–28 weeks if there are multiple
worrisome risk factors present.
Fetal movement assessment
Assessed by the mother as the number of fetal
movements over one hour.
The average time to obtain 10 movements is 20
minutes.
Maternal reports of ↓ fetal movements should be
evaluated by means of the tests described below.
Nonstress test (NST)
Performed with the mother resting in the lateral
tilt position (to prevent supine hypotension).
FHR is monitored externally by Doppler along
with a tocodynamometer to detect uterine
contractions.
Acoustic stimulation may be used.
Reactive and Nonreactive Responses
Reactive: (normal response): Two accelerations of ≥ 15
bpm above baseline lasting for at least 15 seconds over a
20-minute period.
Nonreactive: Fewer than two accelerations over a 20-
minute period.
Perform further tests (e.g., a biophysical profile).
Lack of FHR accelerations may occur with any of the
following: GA < 32 weeks, fetal sleeping, fetal CNS
anomalies, and maternal sedative or narcotic
administration.
Definition of reactive non stress test:
A. 1 acceleration in 20 min
B. 2 acceleration in 20 min
C. 8 acceleration in 20 min
D. 15 acceleration in 20 min
Definition of reactive non stress test:
A. 1 acceleration in 20 min
B. 2 acceleration in 20 min
C. 8 acceleration in 20 min
D. 15 acceleration in 20 min
Contraction stress test (CST)
Performed in the lateral recumbent position.
FHR is monitored during spontaneous or induced (via
nipple stimulation or oxytn) contractions.
Reactivity is determined from fetal heart monitoring, as
with the NST.
The procedure is contraindicated in women with
preterm membrane rupture or known placenta previa;
women with a history of uterine surgery; and women
who are at high risk for preterm labor.
CST Analysis
“Positive” CST: Defined by late decelerations following 50% or
more of contractions in a 10-minute window; raises concerns
about fetal compromise. Delivery is usually warranted.
“Negative” CST: Defined as no late or significant variable
decelerations within 10 minutes and at least three contractions.
Highly predictive of fetal well-being in conjunction with a normal
NST.
“Equivocal” CST: Defined by intermittent late decelerations or
significant variable decelerations.
Biophysical profile (BPP)
Uses real-time ultrasound to assign a score of 2 (normal)
or 0 (abnormal) to five parameters: fetal tone, breathing,
movement, amniotic fluid volume, and NST.
Scoring is as follows:
8–10: Reassuring for fetal well-being.
6: Considered equivocal. Term pregnancies are usually
delivered with this profile.
0–4: Extremely worrisome for fetal asphyxia; strong
consideration should be given to immediate delivery if
no other explanation is found.
Modified biophysical profile (mBPP):
Combines the NST with the amniotic fl uid index
(AFI, or the sum of the measurements of the
deepest cord-free amniotic fluid measured in
each of the abdominal quadrants).
The test is considered normal with a reactive
NST and an AFI > 5 cm
Umbilical artery Doppler velocimetry
With IUGR, there is reduction and even reversal
of umbilical artery diastolic flow. The test is of
benefit only when IUGR is suspected.
Oligohydramnios (AFI < 5 cm) always warrants
further workup.
Admission Procedure
One of the most critical diagnoses in obstetrics is
the accurate diagnosis of labor:
History
Physical examination
Fundal height measurement
Uterine contraction (duration, frequency, intensity)
Fetus (presentation, heart rate, size)
Fetal membrane, vaginal bleeding & leakage
The fetal heart rate should be checked, especially at the
end of a contraction and immediately, thereafter, to
identify pathological slowing of the heart rate
Pain level
Laboratory studies upon admission:
CBC
Blood type and RH
UA (pretein, glucose)
Syphilis, hepatitis B, HIV
