CONDUCT OF NORMAL SPONTANEOUS LABOR
A 20-year-old primigravida comes to the maternity unit at 39 weeks’ gestation complaining of regular uterine contractions every 3 min for the past 6 h. The contractions are becoming more frequent. She denies any vaginal fluid leakage. Vital signs are blood pressure is 125/75 mm Hg, pulse 80 beats/min, respirations 17 breaths/min. On pelvic examination the fetus is cephalic presentation at –1 station. Her cervix is 5 cm dilated, 90% effaced, and soft and anterior in position. On the electronic fetal monitor (EFM) the fetal heart rate baseline is 135 beats/min with moderate variability, frequent accelerations, and no decelerations. How will you manage this patient?
Preadmission
The parturient is not admitted to the maternity unit until cervical dilation is at least 3 cm, unless premature membrane rupture has occurred. Fetal presentation is confirmed to be cephalic.
Admission
On admission intravenous access is established, and oral clear liquid may be ingested. The patient is allowed whatever position is comfortable; however, the lateral recumbent position is encouraged as it optimizes uteroplacental blood flow.
First Stage
The fetal heart rate is assessed, usually with continuous electronic monitoring. Cervical dila-tion and fetal head descent are followed through appropriately spaced vaginal examinations. Amniotomy is performed in the active phase when the fetal head is well applied to the cervix. Obstetric analgesia is administered at patient request.
Second and Third Stages
Maternal pushing efforts augment uterine contractions in the second stage of labor. An episi-otomy is not routine, but is performed as indicated. After delivery of the fetus, the placenta is allowed to spontaneously separate, after which IV oxytocin is administered to prevent uterine atony and bleeding.
Recovery Period
For the first 2 hours postpartum, the parturient is observed closely for excessive bleeding and development of preeclampsia.
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| S2 OB-GYN.indb 118 | 7/8/13 6:35 PM | |||
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Chapter 14 l Normal and Abnormal Labor
ABNORMAL LABOR
Prolonged Latent Phase
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A 20-year-old primigravida at 39 weeks’ gestation is being observed in the maternity unit. She states she has been having irregular uterine contractions for 24 h but cervical dilation remains at 1–2 cm. Her vital signs are stable. EFM tracing is reassuring regarding fetal status.
Diagnosis. Cervical dilation is<4 cm, and the acceleration phase of dilation has not beenreached. Duration has extended to >20 h in a primipara or to >14 h in a multipara.
Cause. Latent-phase abnormalities are most commonly caused by injudicious analgesia. Othercauses are contractions, which are hypotonic (inadequate frequency, duration, or intensity) or hypertonic (high intensity but inadequate duration or frequency).
Management. This involves therapeutic rest and sedation.
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