Introductory lecture for M3 Clerkship in Obstetrics & Gynecology. Addresses APGO Educational Objectives, 8th Edition, Educational Topics 11 and 22.

1. Intrapartum Care & Abnormal Labor Francis S. Nuthalapaty, MD Medical Student Lecture Series Department of Obstetrics & Gynecology Greenville Hospital System University Medical Center Greenville, South Carolina

3. Learning Objectives ET-11 APGO Medical Student Educational Objectives 8 th Ed. 2004 KH Describe the evaluation of common puerperal complications KH Describe the different methods of delivery with the indications and contraindications of each SH Describe the steps of a vaginal delivery KH Describe the three stages of labor and recognize common abnormalities KH List the signs and symptoms of labor Level of Competence Objective

5. Learning Objectives ET-22 APGO Medical Student Educational Objectives 8 th Ed. 2004 K List indications and contraindications for oxytocin administration K Discuss fetal and maternal complications of abnormal labor K Describe methods of fetal surveillance K List abnormal labor patterns Level of Competence Objective

6. Learning Objectives ET-22 APGO Medical Student Educational Objectives 8 th Ed. 2004 K Discuss strategies for emergency management of breech, shoulder dystocia and cord prolapse K List indications for VBAC Level of Competence Objective

18. Fetal Presentation Presentation % Incidence Cephalic 96.8 --- Breech 2.7 1:36 Transverse 0.3 1:335 Compound 0.1 1:1000 Face 0.05 1:2000 Brow 0.01 1:10,000 Williams Obstetrics, 21 st Ed. 452.

20. Cephalic Presenting Diameters FACE SINCIPUT MILITARY BROW VERTEX FLEXED Figure 9-2 Lateral view of the fetal skull showing the prominent landmarks and the anteroposterior diameters.

22. Variations in Fetal Attitude SINCIPUT, MILITARY BROW FACE VERTEX, FLEXED

28. Fetal Head: Landmarks Figure 9-1 Superior view of the fetal skull showing the sutures, fontanelles, and transverse diameters.

29. Occiput Presentation

31. Fetal Position ?????

32. Fetal Position Left Occiput Anterior

33. Fetal Position ?????

34. Fetal Position Right Occiput Posterior

35. Fetal Position ?????

36. Fetal Position Left Occiput Transverse

38. Fetal Station World Health Organization: Managing Complications in Pregnancy and Childbirth www.who.int/reproductivehealth/impac/Clinical_Principles/Normal_labour_C57_C76.html

40. Labor

43. The 3 P’s of Labor Passage

45. Caldwell-Moloy Classification A P Gynecoid A P Android P A Platypelloid P A Anthropoid

52. Pelvic Landmarks - Inlet

53. Vaginal Examination to Determine the Diagonal Conjugate

56. Assessment of Mid-pelvis

58. Pelvic Landmarks - Outlet Figure 9-4 Pelvic outlet and its diameters.

59. Assessment of Pelvic Outlet

60. Minimum Pelvimetrics * Average measurement, no minimum defined 8 Bituberous Outlet 10.5* Bispinous Midplane 11.5 Diagonal conjugate Inlet Length (cm) Diameter Pelvic Plane

61. The 3 P’s of Labor Powers

63. The 3 P’s of Labor Passenger

66. Molding

69. COURSE OF NORMAL LABOR

72. First Stage of Labor

74. First Stage of Labor

81. INTRAPARTUM MANAGEMENT

88. Intrapartum Monitors

102. Fetal Heart Rate Tracing

103. Fetal Monitoring Guidelines

104. Normal Labor Parameters Source: Modified from Friedman EA. Labor: Clinical Evaluation and Management, 2 nd ed. New York. Appletion-Century-Cronz 1370.43 2.5 h 57 min Second Stage 1.2 cm/h 3.0 cm/h Maximum Slope 3.3 h 54 min Deceleration 11.5 h 4.9 h Active 20.6 h 8.6 h Latent Lower Limit (95%) Mean Nulliparous Labor

105. Normal Labor Parameters Source: Modified from Friedman EA. Labor: Clinical Evaluation and Management, 2 nd ed. New York. Appletion-Century-Cronz 1370.43 50 min 14 min Second Stage 1.5 cm/h 5.7 cm / h Maximum Slope 53 min 14 min Deceleration 5.2 h 2.2 h Active 13.6 h 5.3 h Latent Lower Limit (95%) Mean Multiparous Labor

108. MVUs = ????

109. MVUs = 270 “Adequate Labor”