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101 Cards in this Set
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Labor and delivery length |
Primiparous women ( giving birth for first time ) 8-14 hours Multiparous women ( have had child previously) 4-9 hours. Length can be up to 24 hours or even longer and be considered within normal limits. |
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Labor and delivery stages |
Stage 1 of labor : cervical effacement and cervical dilation with fetus in uterus. Stage 2 of labor : fetus head leaves uterus and passes through cervix into vagina. Delivery of the fetus Stage 3 of labor : delivery of placenta |
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Stage 1 of labor |
Effacement may occur before dilation Effacement and dilation may occur together |
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Cervical effacement in stage 1 |
Cervical effacment : thinning of the normally thick walls of the cervix and retraction of the cervix upward Purpose to soften and thin out cervix intensity of uterine contraction are usually mild Length of contraction : 30-60 seconds Interval of contraction : 5-20 mintues Duration of effacement : vairable depending on purpose |
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Progression of cervical effacement and spontanous dislogement of cervical mucus plug and breakage of aminiotic sac |
With the progression of effacement , a cervical mucus plug may become dislodged along with a small amount of blood which is refereed to as bloody show As effacement progresses , an enzyme weakens the amniotic sac and the sac may break releasing the amniotic fluid. |
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Progression of labor |
When contraction intervals become five mintues of less , women are instructed to come into the hospital unless they are planning to have a home birth. |
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Cervical dilation in stage 1 |
Pre labor cervical os is 0.3 cm Purpose : dilate os to increase cervical opening Intensity : strong and more painful contraction compared to effacement alone Length of contraction <60 seconds Interval of contraction 1-3 mintues As dilation increases , contractions tend to be progressively more painful |
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Final phase of stage 1 labor : transition phase to complete dilation |
Purpose: complete opening of cervix from 7 cm to 10 cm Intensity : progressively stronger and more painful contraction Length of contraction : 60-90 seconds Interval between contraction :1 mintue Duration : relatively short. |
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Cervical dilation in stage 1 |
Fully dilated cervix can be 10 m in diameter just before going into the 2nd stage of labor. Duration of dilation : 5-9 hours ( primiparious ) 2-5 hours ( muliparious ) |
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Labor and delivery stages |
Stage 1 : effacement Stage 1 : early dilation Stage 1 : transitional dilation Stage 2 : moves through cervix into vagina Delivery Stage 3 : explusion of the placenta |
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Stage 2 of labor |
Full cervical dilation to 10 cm and full effacement Fetus head passes through cervix into vagina uterine contraction move fetus through birth canal. |
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Stage 2 : movment of fetus out of uterus through cervix and vagina |
Purpose : move fetus head out of uterus through cervix and into vagina Intensity : less strong contractions than cervical dilation transition phase Length of contractions : around 60 seconds Interval of contractions : 1-3 mintues Duration : 30 min to 2 hours ( longer with first baby) |
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Regulation of fetal growth and maternal constraints |
Maternal constraint in pregnancy includes the limitations to the capacity of how much the utero-placental unit can supply nutrients to the fetus. Hence , fetal growth is not solely controlled by genetics but rather a combination of fetal genetics and the intra-uterine environment |
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Birth weights , parents and relatives |
An examination between brith weights of ifrst degree relatives demonstrates a higher inter pair correlation between half sibilings who share the same mother compared to half siblings who share the same father. Thus paternal factors tend to play little direct role in directing fetal and newborn size and it is estimated that genetic factors may only contribute around 40% to fetal size However adult body in highly correlated with maternal and paternal size and hence is from a blend of maternal and paternal genetic contributions. |
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Regulation of fetal growth |
Fetal growth is directly regulated by supply of nutrients across the placenta , which influences the levels of insulin and insulin-like growth factor 1. Fetal growth is a balanced link between fetal genetics and maternal placental nutrients avalibitly which is incfluenced by maternal size. Thus, size at birth in humans correlates much more with maternal stature and maternal birth weight than with paternal stature or birth weight. |
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Regulation of fetal growth |
Thus size in humans correlates much more with maternal stature and maternal birth weight and than with paternal stature or birth weight. From an evolutionary standpoint considering the difficulties humans already have with the size of pelvic outlet , this makes labor and delivery of a fetus with a taller father and a short mother safer and more feasible. |
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Regulation of fetal growth in horses and ponies |
Maternal size constraint is demonstrated in research on crosses between large shire horses and small shetland ponies When a small shetland father was crossed with a large shire mother the fetuses grew much larger compared to the fetuses resulting from a cross between small shetland mother was crossed with large shire father., |
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Delivery |
Largest diameter of newborn body is head ( a verage circumference is 13 inches ) Crowning : top of head appears just before delivery. Usually the head is delivered face down ( dorsal) and then the infant head and trunk rotates to faciliate shoulder and arm delivery. Shoulders and arms are then delivered and baby slides out and takes first breath. With first breath , the ductus arteriosus and foramen ovale close so that infant blood from right side of heart is pushed trhough the lungs to be oxygenated. |
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Fetal circulation |
Ductus arteriosus L: shunt connecting the pulmonary trunk artery to the aortic arch to bypass fetal fluid filled lungs. Foramen ovale : allows blood to enter the left atrium from the right atrium to bypass the fetal fluid filled lungs. Ductus venosus : shunts blood around fetal liver. |
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Two fetal cardiac shunts which allow blood in right side of fetal heart |
Ductus arteriosus Foramen ovale |
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Ductus arteriosus |
In the developing fetus , the dutus arteriosus (DA) is a shunt connecting the pulmonary artery to the aortic arch. It allow blood from the right ventricle to bypass the fetal fluid filled lungs. Upon delivery and inhalation of oxygen by the newborn , the ductus arteriosus typically closes and pulmonary artery vascular resistane falls which allows blood from right ventricle to flow into the lungs for oxygen. |
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Foramen ovale |
In the fetal heart , the foramen ovale allows blood to enter the left atrium from the right atrium thus bypassing the fetal fluid filled lungs. The foramen ovale typically closes at birth |
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Ductus venosus |
In the fetus , the ductus venosus shunts a significant majority 80% of the blood flow of the umbilical vein directly to the inferior vena cava. Thus it allows oxygenated blood from the placenta to bypass the liver. In conjunction with the other fetal shunts , the foramen ovale and ductus arteriosus , it plays a critical role in preferentially shunting oxygenated blood to the fetal brain. |
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New born circulation |
With the firstt breath of oxygenated air , the ductus arteriosus closes , the pulmonary artery vascular resistance falls and the fetal circulation immediately shift to the newborn circulation which enables blood from the right side of the heart to be pumped through the newborn lungs for oxygenation. The foramen ovale and the ductus venosus also close in reponse to the newborn taking their first bbreath of oxygen. |
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Post delivery |
Umbilical cord is cut and clamped Placenta is delivered ( stage 3 of labor ) Antibacterial drops are put into infants eyes to prevent infection with chlamydia or gonorrhea. Vitamin K injection because some newborns have low levels of vitamin K dependent clotting factors. Hepatitis B vaccination in first 24 hours Circumcision may be done in first 48 hours of life on males. |
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Stage 3 labor : delivery of the placenta |
15 to 30 mintues after delivery of the infant , the placenta is delivered. Hematopoietic multipotent stem cells can be harvested from cord blood from placenta Uterine bleeding typically occurs immediately after delivery of placenta but then subsides. Breast feeding/ nippling stimulates release of oxytocin which can decrease the post delivery uterine bleeding. |
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Typical fetal position |
Cephalic posterior presentation with the head facing down in the pelvic cavity is the most typical and easy position for the fetus in labor and delivery. |
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Forceps delivery and vacuum extraction |
Used when infant is not progressing in the second stage of labor due to abnormal fetal position or other reasons. Forcepts delivery : two curved steel lades are placed around the infants head and are carefully rotated and pulled to facilitate delivery. Vacuum delivery : suction cup is attached to fetus head and fetus is pulled out. |
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Benefits of vaginal delivery |
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Immediate benefits of vaginal delivery to help infant adjust to breathing post delivery |
Fluid squeezed out of infant lungs Stimulation of infant triggers increased production of epinephrine that stimulates the cardiovascular system. |
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Benefit of vaginal delivery to infant |
As fetus passes through the vaginal canal they are inoculated with the beneficial maternal microbiome. |
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Maternal vaginal microbiome |
NIH human microbiome project research finding on vaginal microbiome. During pregnancy a woman's vaginal microbiome changes to produce a higher precentage of Latobacillus speices. When baby is born and passes through the vaginal tract , their cut will be colonized by mom's vaginal microtiota |
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Benefits of lactobacillus |
In the gut , a number of lactobacillus bacteria are beneficial , because they outcompete the growth of harmful bacteria. An infant with a gut microbiota rich in lactobacillus bacteria is less likely to develop diarrhea. |
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C section birth and commensals |
Compared to infants born vaginally , infatns born by C- section have diminisehd exposure to their mother's biota and are more likley to be colonized from the surronding environment including the nursing staff , other support staff and other infants. |
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Gut flora of infants born by C - section compared to vaginal birth |
vaginally born infants take up to one month for their intestinal microflora to be well established. The primary gut flora in infants born by C-delivery may take for up to 6 months after birth to become well established |
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Microbiome in infants vaginal delivery vs C-section |
Compared to infants born by vaginal delivery, infants born by C- section have a particulary low bacterial richness and diversity. |
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Low diversithy of gut microtbiota in infants and atopic eczema |
Association of low diversity of gut microbiota in infatnas and atopic eczema |
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Gut microtiota and risk of obescity |
Certain gut microbiota environment in infants are associated with risk of obesity as children. |
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C- section increaes risk of asthma , obesity and diabetes |
Studies have demonstrated that children delived by C- section have a higher risk of asthma , obesity and diabetes. It has been suggested that part of these heightened risk may be due to the types of microbiota colonizing these babies guts |
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C- section associating with breast feeding |
Infants delivered by C - section are less likely to breast feed |
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Microbiota of breast fed versus bottle fed babies |
Breast fed infants have a different gut microbiota than formula fed babies. |
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Microbiota of human breast milk |
Women's milk contains many speices of beneficial microbes as well as sugars called olisaccharides that nourish beneficial gut bacteria. The more the good bacteria thrive , the harder it is for harmful species to gain foothold. As the child grows and the microbiome becomes more ecologically complex , it also strengthens the immune system. |
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Breast milk compared to cow's milk formula results in lower levels of the following disease |
Respiratory infections Intestinal disease eg diahrrhea Allergies and autoimmune disease eg eczema and asthma Obescity Type 1 and type 2 diabetes mellitus Certain type of cancer. |
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Breast milk compared to cow's milk formula |
Breast fed infants have an higher IQ and better brain development compared to cow's milk formula fed infants |
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Cesarean section |
C section rate was 5% in USA in 1970. C setion rate is 30% in USA today. C- section rate is over 90% in some hospital in Brazil and China. C- setion rate at dublin maternity hospital in ireland is 2-3% where all delivereis are by midwives |
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Reasons for high C- section rate |
Lawsuit risks create low medical threshold for doing C- section Use of pain drugs during labor which inhibit labor . Use of continuous fetal heart monitoring Stressful; hospital environment inhibit labor Delivering on back Increased average weight of mothers . Some women choose to have C- section becasue they do not want to go through vaginal delivery however , recovery time and potential morbidity is much higher for C- section delivereis than vaginal deliveries . Some C- section are necessay (2-3% of birth) and save both the mom's and infant's life. |
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Biological reasons for Cesarean section |
Fetal distress that poses risk to fetal health. Maternal distress that poses risk to health of mother or fetus. Difficulty with vaginal delivery suh as arrested 1st stage of labor or arrested 2nd stage of labor Breech or other abnormal position |
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Difficult fetal positions |
Breech : fetus has head up and feet buttocks or knees extending downward Transverse: fetus is positioned sideways or transversely in pelvis |
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Increase in C - section rate between 1970- today in USA |
The biggest driver for the high C - section rate in the USA is to avoid being sued if a child is delivered vaginally who has some brain problem; ,hence , even slight indication of fetal stress triggers a C setion even though slight fetal stress has NOT been demonstrated to increase risk for cerebral palsy or other brain injuries. When comparing 1970 and today in the USA , the rate of newborns with cerebral palsy and other brain injuries is unchanged despite a 600% increase in C- section rate. |
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C- section |
Before C-section mother recieves spinal anesthesia or general anesthesia. C - section is major surgery with an abdominal incision made below the naval in the midline and the incision continues through the uterine wall and the infant is removed. Recovery time for mother is much longer than after a vaginal delivery. |
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Cesarean section |
C- section increae illness and mortality amoung both mother and their babies. C- section is painful and uncomfortable for the mother, requires weeks for the mother to fully recover and may interfere with her ability to breast feed and bond with her baby. |
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History of birthing |
In the 1800s in europe and the USA , male physician started taking over the job of delivering babies as women midwives became more and more marginalized. |
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History of birthing |
The increase in the importance of medical licensing in the USA and europe in the 1800s also contributed to the reduction of the midwife activies. Midwife training at the time was a decentralized system of female mentors and students. Students recieved comprehensive training from their mentor midwife , however the midwives did not have a system of formal licensing. |
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History of birthing |
Literature was disseminated by the male - dominated medical establishement that portrayed midwives as unscientific and untrained , even though during these times studies showed that mothers and infatns had a higher morbidity and mortality rate when they were delivered in hospitals by male physicians compared to at home by female midwives |
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Location of delivery |
Pre 1900 in USA less than 5% of babies were delivered in hospitals. studies conducted from the 1890s to the present showed that birth in hospitals attended by physiians were NO safer than births at home by mid-wife. Studies in the early 1900s showed that there was an increase in maternal and infant death rate in hospital births compared to home birth by midwives ; part of the reason was infectious disease in hospitals passed from patient to patient. |
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Location of delivery |
In the USA , hospital delivers steadily have increased ; pre 1900 5% of babies deliverd in hospitals by 1936 75% of babies delivered in hospitals by 1970 99% of babies delivered in hospitals Attempt to create home environment in hospital :1970 family centered care in delivery room 1980s rooming in of infants with mom in hospital; |
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Anesthetics in labor and delivery |
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Medical intervention for a painless delivery |
In 1800s in germany , chloroform or ether were used to put laboring women asleep so they would not feel the pain of childbirth |
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Medical intervention for a painless delivery |
Around 1900 in gemany the twilight sleep system was developed to replace the use of chloroform or ether with injection of morphine and scopolamine that enabled women to deliver without pain or without memory of pain. - morphine injection for pain in labor - scopolamine for an amesiac effect to allow mother to dissassociate from the labor and birth pain |
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Medical intervention for a painless delivery |
In the 1800s , male obstetricians in europe develop the method for women to deliver on their Because women were anesthetized on chloroform either or morohine and scopolamine , the women would often thrash and move around even though they were unconcious. |
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Medical intervention for a painless delivery |
Along with anesthesia , the horizonal position for women to lay on their back was adopted so men's arm could be more easily restrained and tied down and their legs could be strapped to the stirrups. THis also gave the male physician control over the laboring mother In standard obsterical practice today ,women often go through late stage labor and delivery on their backs |
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Location of infant after birth |
From late 1800s up through 1950s mother often recieved anesthesia and were unconcious or semi concious at delivery. Newborn baby were taken away into a nursery with other newborns and it would often several hours after delivery before the mom and newborn would see each other. |
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Forceps and episiotomy |
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Development of Forceps delivery and episiotomy |
Mothers who received anesthesia were unconcious at delivery and were not able to push the baby out so the use of forceps delivery was very common. To facilitate inserting forceops into vagina and around the babies head , the practice of episiotomy was developed . |
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Development of forceps delivery and episiotomy |
An episiotomy is a scissors cut of perineum, the space in between the vulva and anus. Episiotomy cut gave more room for the forceps to be inserted into the vagina around the babies head. After delivery the episiotomy cut needs to be closed with suture. |
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Episiotomy |
First development to facilitate forcep delivery. Later became routine for NSVD ( normal spontaneous vaginal delivereis ) in europe and the USA the rationale was that a vaginal delivery may genertae a spontanoues tear and if you already cut a small tear in the perineum before delivery it will reduce the size of the delivery induced tear. |
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Research has shown that episiotomies |
Promote more extensive, large tears in the vaginal opening where the episiotomy was placed. Take a longer time to heal than the small tears that can occur with a vaginal delivery. Associated with prolonged discomfort and can be disabling for several weeks after delivery and inteferes with the mothers ability to bond with and care for her newborn baby. |
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Episiotomy |
Large multi decade study following 1000s of women shows that episiotomy increases the rate of urinary incontinence in women later in life. When these study results came out , sweden reduced the rate of episiotomies from 90% to 5% in a short period of time. Today in USA and europe the rate of epiostomy is very low. |
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Position of mother during labor and delivery |
In anthropological studeies of over 70 cultures around the world , there are NO examples where women deliver on their backs , rather they deliver while awake in an upright position. In all these cultures , women midwives deliver babies and in the majority if the cultures men are not present at the deliveries. |
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Advantages of labor and deliver in an upright crounched position |
Utilizes the benefit of gravity to increase strength of uterine contraction and -> lower length of labor -> lower likelihood of C-section. increreases surface area of pelvic opening/birth canal by 33-38% decrease pressure on mother aorta ( largest artery) which increases blood supply to the fetus -> lower likelihood of fetal stress |
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Mothers who labor / delivery on backs compared to upright position |
Less comfortable for mothers. lower benefit of gravity for labor -> decrease strength of uterine contraction -> increase length of labor -> increase likelihood of C- section Lower benefit of gravity for labor -> lower opening of cavity / birth canal increase pressure on mothers aorta ( Largest artery) which may reduce blood supply to fetus -> increase likelihood of fetal stress -> increase likelihood of C- section |
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Rupture of amniotic membrane and its influence labor and delivery |
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Intentional rupter of membrane to progress labor |
The membrane may be intentionally ruptured by physician or midwife |
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Intentional rupture of membranes to progress labor |
Advantage : decrease total length of labor by 40-120 min |
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Disadvantage of intentional ruptrue of membranes to progress labor |
24 hour time clock starts because bacteria can invade and infect uterus and fetus , so if delivery does not occur within 24 hours of rupture of membranes , a C- section must be done. Intact membranes which contain amniotic fluid function as a barriet that provides a cushion during labor as the baby descend through birth canal. Ruptured membranes lack protective barrier and increase chance that a baby will have a cephalohematoma ( hemmorrhage between scalp and bones of skull ) |
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Disadvantage of intentional rupture of membranes to progress labor |
Mother's report that after membrane are ruptered they feel like they loose control If labor progresses too quickly -> severe pain -> epidural for pain -> decrease uterine contraction -> labor does not progress - > C- section If labor does not progress -> pitocin ( oxytocin) is given -> if labor does not progress -> C- section. |
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Continuous monitoring of fetal heart rate |
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Continuous monitoring of fetal heart rate |
Continuous heart monitoring of infant is achieved by screwing a small monitor into the fetal scalp which requires the intentional rupture of the amniotic membrane. Nine seperate studies throughout world have not shown any improvement in outcome for the baby with continuous fetal heart monitoring in healthy women. |
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Continuous monitoring of fetal heart rate |
Prevents mom from walking during labor decrease beneficial effects of gravity on labor increase length of labor increase rate of C - section 2X |
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Continuous monitoring of fetal heart rate |
When continuous fetal monitoring was instituded in USA: doubled the C- section rate , Resulted in NO reduction in incidence of cerebral palsy. |
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Continuous monitoring of fetal heart rate |
Most expoerts recommended that continuous monitoring offers no advantage to healthy pregnant women with no pregnancy complication and with normal growth and development of fetus. However, in spite of this data , the policy continues to be the common use of fetal monitoring throughout the USA to reduce the threat of lawsuit in case there is any problem with the baby. |
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Flexible monitoring of fetal heart rate |
Check fetal heart rate on mom's abdomen with stethoscope every 10-15 mintues Short monitor strip applied over mom's abdomen given every 30 min. |
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Medication given during labor today |
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Medication during labor |
Intravenous pitoin ( exogenous oxytocin ) given to induce or augment uterine contraction. Intravenous tranquilizers , anxiolytics and oral analgesics. Pudental block : analgesic is injected around the pudendal nerve on each side of vagina Epidural block injection : pain medicine ( typically an opiate) is injeted into outside membranes outside the dura of the spinal cord Epidural injections numb sensation in the body below the site of injection. |
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Oxytocin : reason for giving oxytocin ( = pitocin ) |
Women is post term and labor is not spontaneously progressing. Need to deliver a baby before term because of possible risks to fetus and or mother Pitocin ( exogenous oxytocin) can be given to women already in labor , but whose labor is not progressing fast enough. |
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Induction of labor |
Labor can be induced by administration of exogenous oxytocin ( pitocin) and or prostaglandins. Pitocin is given intraveneously. Prostaglandins can be given intravenously , orally , or as vaginal suppository. |
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Oxytocin ( pitocin ) |
Oxytocin is natural hormone that increase strength and increase frequency of uterine contraction When exogenous oxytocin is given -> increase pain of contractions -> increase likelihood of taking pain medication Pain may be so bad from pitocin that the pitocin needs to be discontinued and in some cases a counteracting medicine is given. |
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Epidural analgesia |
Opiates are frequently given by epidural injection to numb pain of uterine contraction during delivery which results in the following: decrease mothers own endogenous production of endorphins decrease mother ability to feel the natural urge to push in labor decrease mother sense of control over labor decrease mother production of oxytocin , decrease mother ability to push , increase c- setion rate. decrease mothers production of oxytocin -> may decrease the mothers feeling of attachment to newborn baby. |
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Epidural analgesia |
1/3rd of mothers who recieved epidural early in labor develop a fever as high as 103-104: at delivery many of their infants also have fever and since it is not known whether the fever is from epidural or infection the infant must recieve a septic work up which involves blood culture , spinal tap and 3 days of intravenous antibiotics waiting for the culture results. inteferes with the maternal- infant bonding in the early hours and days of life. |
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Breech presentation |
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Breech presentation |
Standard approach in western obstetrics is to schedule a C - setion for fetus in breech position. However , methods can be applied to turn the fetus around into the head down ( cephalic ) postion: - external cephalic version applied by midwives - internal cephalic version applied by midwives - moxibustion with stimulation of acupoint BL 67 is on the outside corner of the fifth toe. |
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Stress / anxiety effects on labor and C- section rate |
Anxiety / fear / stress : increase production of stress hormones/ increase sympathetic nervous system decrease parasymphatethic nervous system -> decrease uterine contraction -> decrease progression of labor -> increase likelihood of C- section. |
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Doula support |
Doula : female labor / delivery support person Doula is labor support person who is with the mother from when labor begins and stays with the mother until after the baby is delivered. Doula does not delivery baby Doula supports mom and works with midwife or obstetrician Doula works with mom , dad , midwife or obstetrician to develop a birth plan. |
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Doula support |
In labor and delivery women are in a dependent and psychologically open state. Benefit from a nutring female caregiver with experience in childbirth. Calm , nutruing , accepting , holding , loving : mothering the mother Provides quite reassurance and support the mothers natural ability to proceed with labor Mother is validated as a person , mother and future care give. |
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Doula support |
Provides emotional and physical support without interruption throughout labor/ delivery Feeling of security with and support from another woman enhances the mother's ability to develop and explore her own capabilities as a mother in a way that empowers her as a mother and allows her to adapt and respond to the power of the birthing process. Enables mother to be in control of her own labor and deliver |
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Doula supported delivered ( based on seven randomized trials ) |
decrease length of labor by 25% decrease exogenous oxytocin use by 40$ decrease pain medication by 60% decrease forceps use by 40% decrease C section rate by 50% |
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Psycho- physiological state of women in pregnancy and peri natal period |
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Females experiences with Birth and child 0 rearing |
- parents/family practices - Friends practices Cultural practices Western hospital based obstetrical practices have had the dominant influences in USA over the past century |
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Psycho - physicological state of women in pregnancy and peri natal period |
inward focus of mother is one of the most universal psychiological change in pregnancy psychologically open physiologically open |
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To reduce anxiety in labor and delivery it is important that women feel |
in control respected supported |
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Stress/ anxiety reduction techniques that may facilitate labor and lower C- section rate |
excercise hatha yoga tai chi massage / acupressure relaxation techniques to release tension Breathing Visualization mediatation self - hypnosis |
