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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
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.
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.
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.
*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