43 - M ANAGEM ENT OF S ECOND- STAGE LABOR LABOR Th e on s e...

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Unformatted text preview: M ANAGEM ENT OF S ECOND- STAGE LABOR LABOR Th e on s e t : f ul l di l a t a t i on of t h e c e r vi x b e a r down de s c e n t of t h e p r e s e n t i n g p a r t de t h e ur ge of de f e c a t e ut e r i n e c on t r a c t i on & e xp ul s e f or c e M ANAGEM ENT OF S ECOND- STAGE LABOR LABOR Dur a t i on - 50 mi n i n n ul l i p a r ous 20 mi n i n mul t i p a r ous 20 - b e c ome a b n or ma l l y l on g : a c on t r a c t e d p e l vi s a l a r ge f e t us i mp a i r e d e xp ul s i ve e f f or t f r om c on duc t i on a n a l ge s i a or i n t e n s e s e da t i on or M ANAGEM ENT OF S ECOND- STAGE LABOR LABOR Fe t a l h e a r t r a t e - l ow r i s k: 15 mi n h i gh r i s k: 5 mi n - s l owi n g of t h e FHR : due t o f e t a l h e a d c omp r e s s i on d ue : r e duc e p l a c e n t a l p e r f us i on : r e c ove r y a f t e r t h e c on t r a c t i on a n d e xp ul s i ve e f f or t c e a s e - de s c e n t of t h e f e t us : ob s t r uc t umb i l i c a l c or d b l ood f l ow ( t i gh t e n l oop or c or d n e c k) - >un i n t e r r up t e d ma t e r n a l e xp ul s i ve e f f or t c a n b e da n ge r ous t o t h e f e t us - ma t e r n a l t a c h yc a r di a i n s e c on d s t a ge : c ommon , mus t n ot b e mi s t a ke n f or a n or ma l FHR M ANAGEM ENT OF S ECOND- STAGE LABOR LABOR M t e r n a l e xp ul s i ve e f f or t s a - b e a r i n g down : r e f l e x a n d s p on t a n e ous b ut , doe s n ot e mp l oy e xp ul s i ve f or c e a n d c oa c h i n g i s de s i r a b l e - l e g: h a l f - f l e xe d de e p b r e a t h & b r e a t h h e l d de e xe r t down wa r d p r e s s ur e - Sh e s h oul d n ot b e e n c our a ge d t o “ p us h ” - Ga r dos i ( 1989) : s qua t t i n g or s e mi s qua t t i n g us i ng a s p e c i a l i z e d p i l l ow - > s h or t e n s s e c on d l a b or - i n i n c r e a s i n g b ul gi n g of t h e p e r i n e um : e n c our a ge me n t i s ve r y i mp or t a n t - > FHR i s l i ke l y t o b e s l ow - f e c e s i s f r e que n t l y e xp e l l e d p e r i n e um b e gi n s t o b ul ge , t e n s e a n d M ANAGEM ENT OF S ECOND- STAGE LABOR LABOR Pr e p a r a t i on f or de l i ve r y - t h e dor s a l l i t h ot omy p os i yi on : i n c r e a s e t h e di a me t e r of t h e p e l vi c out l e t : us i n g l e g h ol de r a n d s t i r r up us - >r e s ul t i n s p on t a n e ous t e a r or f our t h de gr e e - n ot s t r a p p e d i n t o t h e s t i r r up : a l l owi n g qui c k f l e xi on of t h e t h i gh s b a c k on t o SPONTANEOUS DELI VERY S PONTANEOUS De l i ve r y of t h e h e a d - ” c r own i n g: : e n c i r c l e me n t of t h e l a r ge s t h e a d d i a me t e r b y t h e vul va r r i n g v ul - un l e s s e p i s i ot omy ; s p on t a n e ous l a c e r a t i on - I t i s n ow c l e a r t h a t a n e p i s i ot omy wi l l i n c r e a s e t h e wi r i s k of a t e a r i n t o t h e e xt e r n a l a na l s phi nc t e r a nd SPONTANEOUS DELI VERY S PONTANEOUS Ri t ge n ma n e uve r - By t h e t i me t h e h e a d di s t e n ds t h e vul va a n d v ul p e r i n e um e n ough t o op e n t h e va gi n a l i n t r oi t us t o a di a ma t e r of 5 c m or mor e di - o n e h a n d: a t owe l - dr a p e d, gl ove d h a n d ma y b e ma e xe r t f or wa r d p r e s s ur e on t h e c h i n of t h e f e t us t h r ough t h e p e r i n e um j us t SPONTANEOUS DELI VERY S PONTANEOUS De l i ve r y of s h oul de r - t h e oc c i p ut : t ur n s t owa r d on e of t h e ma t e r n a l t h i gh ma f e t a l h e a d: t r a n s ve r s e p os i t i on e xt e r n a l r ot a t i on : b i s a c r omi a l di a me t e r h a d r ot a t e d i nt o t he a n t e r i op os t e r i or di me t e r of t h e p e l vi s of - s uc ki n g t h e n a s op h a r i n x or c h e c ki n g f or a c or d - t h e r e s t of t h e b ody a l mos t a l wa ys f ol l ows t h e s h oul de r wi t h out di f f i c ul t y - p r ol on ge d de l a y : mor e t r a c t on p r e s s ur e on t h e f un dus on - t r a c t i on s h oul d b e e xe r t e d on l y i n t h e di r e c t i on of t h e l on g a xi s of t h e i n f a n t , f or i f a p p l i e d ob l i que l y SPONTANEOUS DELI VERY S PONTANEOUS Cl e a r i n g t h e n a s op h a r yn x - p r e ve n t of a s p i r a t i on of a mn i on i c f l ui d, de b r i s , b l ood de - t h e f a c e : qui c kl y wi p e d n a r e s a n d mout h : a s p i r a t e d Nuc h a l c or d - a f t e r h e a d di l e ve r e d, a s c e r t a i n t h e umb i l i c a l c or d u mb - oc c ur 25% or di n a r i l y do n o h a r m , - dr a wn down or c ut ( t oo t i gh t l y) SPONTANEOUS DELI VERY S PONTANEOUS Cl a mp i n g t h e c or d - b e t we e n t wo c l a ms : 4 or 5c m a n d l a t e r 2 or 3 c m or f r om t h e f e t a l a b dome n - t i mi n g of c or d c l ma p i n g : a f t e r de l i ve r y, t h e i n f a n t i s p l a c e d a t t h e l e ve l o f va gi n a f or 3 mi n , t h e f e t op l a c e n t a l c i r c ul a t i on i s n ot oc c l ude d : 80 ml of b l ood – s h i f t t o t h e f e t us ( 50 mg of Fe ) M ANAGEM ENT OF THE THI RD STAGE THI - a f t e r de l i ve r y of t h e i n f a n t , t h e h e i gh t of f un dus a n d i t s c on s i s t e n c y a r e a s c e r t a i n e d - No ma s s a ge i s p r a c t i c e d - t h e h a n d i s s i mp l y r e s t e d on t h e f udus f r e que n c y : b e c ome a t on y a n d f i l l e d wi t h b l ood M ANAGEM ENT OF THE THI RD STAGE THI Si gn s of t h e p l a c e n t a l s e p a r a t i on 1. ut e r us : gl ob ul a r , f i r me r 1. t h e e a r l i e s t s i gn 2. a s udde n gus h of b l ood 2. 3 . ut e r us : r i s e i n t h e a b dome n b e c a us e t he p l a c e n t a p a s s e s down 4 . t h e umb i l i c a l c or d p r ot r ude d out of t h e va gi n a . i n di c a t i n g t h a t t h e p l a c e n t a h a s de s c e n de d de - wh e n p l a c e n t a h a s s e p a r a t e d, a s c e r t a i n ut e r us ut f i r ml y - >mot h e r : b e a r down , i n c e a s e a b domi n a l p r e s s ur e i f f a i l or i mp os s i b l e : p r e s s ur e on t h e f un dus p r op e l t h e de t a c h e d p l a c e n t a M ANAGEM ENT OF THE THI RD STAGE THI De l i ve r y of t h e p l a c e n t a - t r a c t i on i n t h e umb i l i c a l c or d mus t n ot b e us e d t o p ul l t h e p l a c e n t a out of t h e ut e r us ut - t h e ut e r us i s l i f t e d c e p h a l a d wi t h t h e a b domi n a l h a n d. Th i s ma n e uve r wa s s t op p e d a s t he pl a c e nt a p a s s e s t h r ough t h e i n t r oi t us M ANAGEM ENT OF THE THI RD STAGE THI M n ua l r e mova l of p l a c e n t a a - t h e p l a c e n t a wi l l n ot s e p a r a t e p r omp t l y ( p r e t e r m) - t h e r e i s b r i s k b l e e di n g a n d t h e p l a c e n t a c a n n ot b e de l i ve r e d - > ma n ua l r e mova l de - p r oof of t h i s p r a c t i c e h a s n ot b e e n e s t a bl i s he d a n d mos t ob s t e t r i c i a n s a wa i t s p on t a n e ous p l a c e n t a l s e p a r a t i on un l e s s b l e e di n g i s e xc e s s i ve M ANAGEM ENT OF THE THI RD STAGE THI “ Four t h s t a ge ” of l a b or - t h e h our i mme di a t e l y f ol l owi n g de l i ve r y i s c r i t i c a l de a n d i t h a s b e e n de s i gn a t e d b y s ome a s t he “ f our t h s t a ge of l a b or ” - p os t p a r t um h e mor r h a ge ut e r i n e a t on y ut o b s e r va t i on of va gi n a l e xc e s s i ve b l e e di n g OXYTOCI N AGENT OXYTOCI - a f t e r p l a c e n t a de l i ve r y, t h e p r i ma r y me c h a n i s m me b y wh i c h h e mos t a s i s i s va s oc on s t r i c t i on p r oduc e d va b y a we l l - c on t r a c t e d myome t r i um - oxyt oc i n ( Pi t oc i n , Syn t oc i n on ) e r gon ovi n e ma l e a t e ( Er got r a t e ) me t h yl e r gon ovi n e ma l e a t e ( M t h e r gi n e ) e me OXYTOCI N AGENT OXYTOCI Oxyt oc i n - t h e s yn t h e t i c f or m of t h e oc t a p e p t i de oxyt oc i n o xyt - n ot e f f e c t i ve b y mout h - h a l f - t i me of I V : 3 mi n ut e s - b e f or e de l i ve r y : t h e ut e r us i s s e n s i t i ve t o oxyt oc i n - >s o vi ol e n t l y a s t o ki l l t h e f e t us r up t ue d i t s el f a f t e r de l i ve r y t h e s e da n ge r s n o OXYTOCI N AGENT OXYTOCI Ca r di ova s c ul a r e f f e c t s - de l e t e r i ous e f f e c t : I V i n j e t i on of a b ol us de c r e a s e d ma t e r n a l BP ( 5 un i t ) ma de c r e a s e d a r t e r i a l BP - >i n c r e a s e d c a r di a c out p ut - n ot b e gi ve n I V a s a l a r ge b ol us d i l ut e s ol ut i on b y c on t i n uous I V i n f us i on OXYTOCI N AGENT OXYTOCI An t i di ur e s i s - wa t e r i n t oxi c a t i on : ma t e r n a l c on vul s i on - c on t i n uous I V i n j ( 20 un i t ) : de c r e a s e d ur i n e f l ow de - n ot i n e l e c t r ol yt e - f r e e a que ous de xt r os e s ol ut i on de : n or ma l s a l i n e or l a c t a t e d Ri n ge r s ol ut i on - n e e d f or h i gh dos e of oxyt oc i n : c on c e n t r a t i on s h oul d b e i n c r e a s e d OXYTOCI N AGENT OXYTOCI Er gon ovi n e a n d me t h yl e r gon ovi n e - a n a l ka l oi d f r om l ys e r gi c a c i d - ef f ect s : us e I V, I M , PO : p owe r f ul myome t r i a l c on t r a c t i on : p e r s i s t f or h our s : s e n s i t i vi t y of ut e r us i s ve r y gr e a t : t h e r e s p on s e i s s us t a i n e d wi t h l i t t l e t e n de n c y t owa r d r e l a xa t i on - But , s ome t i me s i n duc e s e v e r e hy pe r t e ns i on hy : a l s o c ol vul s i on or c a di a c a r r e s t ( Br own i n g( 1974) ) - b e c a us e of t h e f r e que n c y of h yp e r t e n s i on , do n ot us e t h e s e a l ka l oi ds r out i n e l y do OXYTOCI N AGENT OXYTOCI Oxyt oc i c s a f t e r de l i ve r y - s t a n da r d p r a c t i c e : 20 un i t of oxyt oc i n p e r l i t e r : a r a t e of 10 ml / mi n a f t e r de l i ve r y of p l a c e n t a of f or a f e w mi n ut e s un t i l t h e ut e r us r e ma i n s f i r ml y c on t r a c t e d a n d b l e e di n g i s c on t r ol l e d : t r a n s f e r t o p os t p a r t um un i t LACERATI ONS OF THE LACERATI BI RTH CANAL BI F i r s t - de gr e e : f our c h e t t e , p e r i n e a l s ki n , Fi v a gi n a l moc a s a l me mb r a n e S e c on d- de gr e e : f a s c i a a n d mus c l e of t h e Se pe r i ne a l b ody u s ua l l u e xt e n d up wa r d on on e or up b ot h s i de s of t h e va gi n a Th i r d- de gr e e : i n vol ve t h e a n a l s p h i n c t e r Four t h - de gr e e : r e c t a l moc os a EPI SI OTOM AND REPAI R Y EPI Pur p os e s of e p i s i ot omy - e a s i e r t o r e pa i r p os t op e r a t i ve p a i n i s l e s s h e a l i n g i mp r ove d - p r e ve n t e d p e l vi c r e l a xa t i on ( c ys t oc e l e , r e c t oc e l e ur i n a r y i n c on t i n e n c e ) ur - b ut , i n c r e a s e d i n c i de n c e of a n a l s phi nc t e r a nd r ect al t ear s EPI SI OTOM AND REPAI R Y EPI Ti mi n g of - ear l y : l at e : e p i s i ot omy b l e e di n g l a c e r a t i on - wh e n t h e h e a d i s vi s i b l e dur i n g a c on t r a c t i on t o a di a me t e r of 3 t o 4 c m di EPI SI OTOM AND REPAI R Y EPI M dl i n e ve r s us me di ol a t e r a l e p i s i ot omy i EPI SI OTOM AND REPAI R Y EPI Ti mi n g of t h e r e p a i r of e p i s i ot omy - a f t e r t h e p l a c e n t a h a s b e e n de l i ve r e d Te c h n i que - h e mos t a s i s a n d a n a t omi c a l r e s t or a t i on wi t h out wi e xc e s s i ve s ut ur i n g a r e e s s e n t i a l - s ut ur e ma t e r i a l : 3 - 0 c h r omi c c a t gut EPI SI OTOM AND REPAI R Y EPI F o u r t h - de g r e e Fo l a c e r a t i on - a ppr o xi ma t e t h e t o r n e dg e s o f t h e r e c t a l mu c o s a wi t h wi mu s c u l a r i s s u t u r e s pl a c e d pl a p pr o xi ma t e l y 0. 5 c m a pa r t - t h i s mu s c u l a r l a ye r t he n i s c o ve r e d wi t h a l a ye r EPI SI OTOM AND REPAI R Y EPI Pa i n a f t e r e p i s i ot omy - i c e pa c k a e r os ol s p r a ys c on t a i n i n g a l oc a l a ne s t he s i a - I f p a i n i s s e ve r e or p e r s i s t e n t : vul va r , p a r a va gi n a l or i s c h i or a c t a l h e ma t oma or p e r i n e a l h e ma t oma ...
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