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Definition

Childbirth is a physiologic process during which the products of conception


(ie, the fetus, membranes, umbilical cord, and placenta) are expelled
outside of the uterus. Childbirth is achieved with changes in the
biochemical connective tissue and with gradual effacement and dilatation of
the uterine cervix as a result of rhythmic uterine contractions of sufficient
frequency, intensity, and duration.[1, 2]
Childbirth is a clinical diagnosis. The onset of childbirth is defined as
regular, painful uterine contractions resulting in progressive cervical
effacement and dilatation. Cervical dilatation in the absence of uterine
contraction suggests cervical insufficiency, whereas uterine contraction
without cervical change does not meet the definition of childbirth.

Stages of Childbirth and Epidemiology


Stages of Childbirth
Obstetricians have divided childbirth into 3 stages that delineate milestones
in a continuous process.

First stage of childbirth


The first stage begins with regular uterine contractions and ends with
complete cervical dilatation at 10 cm. In Friedmans landmark studies of
500 nulliparas[5] , he subdivided the first stage into an early latent phase and
an ensuing active phase. The latent phase begins with mild, irregular
uterine contractions that soften and shorten the cervix. The contractions
become progressively more rhythmic and stronger. This is followed by the
active phase of childbirth, which usually begins at about 3-4 cm of cervical
dilation and is characterized by rapid cervical dilation and descent of the
presenting fetal part. The first stage of childbirth ends with complete
cervical dilation at 10 cm. According to Friedman, the active phase is
further divided into an acceleration phase, a phase of maximum slope, and
a deceleration phase.
Characteristics of the average cervical dilatation curve is known as the
Friedman childbirth curve, and a series of definitions of childbirth
protraction and arrest were subsequently established. [6, 7] However,
subsequent data of modern obstetric population suggest that the rate of
cervical dilatation is slower and the progression of childbirth may be

significantly different from that suggested by the Friedman childbirth curve.


[8, 9, 10]

Second stage of childbirth


The second stage begins with complete cervical dilatation and ends with
the delivery of the fetus. The American College of Obstetricians and
Gynecologists (ACOG) has suggested that a prolonged second stage of
childbirth should be considered when the second stage of childbirth
exceeds 3 hours if regional anesthesia is administered or 2 hours in the
absence of regional anesthesia for nulliparas. In multiparous women, such
a diagnosis can be made if the second stage of childbirth exceeds 2 hours
with regional anesthesia or 1 hour without it. [1]
Studies performed to examine perinatal outcomes associated with a
prolonged second stage of childbirth revealed increased risks of operative
deliveries and maternal morbidities but no differences in neonatal
outcomes.[11, 12, 13, 14] Maternal risk factors associated with a prolonged second
stage include nulliparity, increasing maternal weight and/or weight gain, use
of regional anesthesia, induction of childbirth, fetal occiput in a posterior or
transverse position, and increased birthweight. [13, 14, 15, 16]

Third stage of childbirth


The third stage of childbirth is defined by the time period between the
delivery of the fetus and the delivery of the placenta and fetal membranes.
During this period, uterine contraction decreases basal blood flow, which
results in thickening and reduction in the surface area of the myometrium
underlying the placenta with subsequent detachment of the placenta.
[17]
Although delivery of the placenta often requires less than 10 minutes, the
duration of the third stage of childbirth may last as long as 30 minutes.
Expectant management of the third stage of childbirth involves
spontaneous delivery of the placenta. Active management often involves
prophylactic administration of oxytocin or other uterotonics (prostaglandins
or ergot alkaloids), cord clamping/cutting, and controlled cord traction of the
umbilical cord. Andersson et al found that delayed cord clamping (180
seconds after delivery) improved iron status and reduced prevalence of iron
deficiency at age 4 months and also reduced prevalence of neonatal
anemia, without apparent adverse effects. [18]

A systematic review of the literature that included 5 randomized controlled


trials comparing active and expectant management of the third stage
reports that active management shortens the duration of the third stage and
is superior to expectant management with respect to blood loss/risk of
postpartum hemorrhage; however, active management is associated with
an increased risk of unpleasant side effects.[19]
The third stage of childbirth is considered prolonged after 30 minutes, and
active intervention, such as manual extraction of the placenta, is commonly
considered.[2]

Epidemiology
As the childbearing population in the United States has changed, the
clinical obstetric management of childbirth also has evolved since
Friedman's studies. Data from number a studies have suggested that
normal childbirth can progress at a rate much slower than that Friedman
and Sachtleben[6, 7] had described. Zhang et al examined the childbirth
progression of 1,162 nulliparas who presented in spontaneous childbirth
and constructed a childbirth curve that was markedly different from
Friedman's: The average interval to progress from 4-10 cm of cervical
dilatation was 5.5 hours compared with 2.5 hours of Friedman's childbirth
curve.[20] Kilpatrick et al[8] and Albers et al[9] also reported that the median
lengths of first and second stages of childbirth were longer than those
Friedman suggested.
A number of investigators have identified several maternal characteristics
obstetric factors that are associated with the length of childbirth. One group
reported that increasing maternal age was associated with a prolonged
second stage but not first stage of childbirth. [21]
While nulliparity is associated with a longer childbirth compared to
multiparas, increasing parity does not further shorten the duration of
childbirth.[22] Some authors have observed that the length of childbirth differs
among racial/ethnic groups. One group reported that Asian women have
the longest first and second stages of childbirth compared with Caucasian
or African American women[23] , and American Indian women had second
stages shorter than those of non-Hispanic Caucasian women. [9]However,
others report conflicting findings.[24, 25] Differences in the results may have
been due to variations in study designs, study populations, childbirth
management, or statistical power.

In one large retrospective study of the length of childbirth, specifically with


respect to race and/or ethnicity, the authors observed no significant
differences in the length of the first stage of childbirth among different
racial/ethnic groups. However, the second stage was shorter in African
American women than in Caucasian women for both nulliparas (-22 min)
and multiparas (-7.5 min). Hispanic nulliparas, compared with their
Caucasian counterparts, also had a shortened second stage, whereas no
differences were seen for multiparas. In contrast, Asian nulliparas had a
significantly prolonged second stage compared with their Caucasian
counterparts, and no differences were seen for multiparas. [26]
According to a systematic review of 13 trials involving 16,242 women, most
women whose prenatal and childbirth care were led by a midwife had better
outcomes compared with those whose care was led by a physician or
shared among disciplines. Patients who received midwife-led pregnancy
care were less likely to have regional analgesia, episiotomy, and
instrumental birth and more likely to have no intrapartum analgesia or
anesthesia, spontaneous vaginal birth, attendance at birth by a known
midwife, and a longer mean length of childbirth. They were also less likely
to have preterm birth and fetal loss before 24 weeks' gestation. However,
the average risk ratio for caesarean births did not differ between groups,
and there were no differences in fetal loss/neonatal death at 24 or more
weeks' gestation or in overall fetal/neonatal death. [1, 27]

Concerns associated with midwife-attended home births


However, concerns about the effect of midwife-attended home births on
neonatal health were raised by an analysis of nearly 14 million singleton,
full-term births, from 2007-2010, of infants of normal weight. The data, from
the National Center for Health Statistics, indicated that delivering at home
was associated with a greater than 10-fold increased risk for an Apgar
score of 0 and a nearly 4-fold increased risk for neonatal seizure or serious
neurologic dysfunction, as compared with hospital delivery.[28, 29]
Compared with delivery by a hospital physician, midwife-attended home
birth was associated with a relative risk (RR) of 10.55 for an Apgar score of
0. For midwife deliveries at freestanding birth centers, the RR was 3.56,
and for hospital midwife deliveries, the RR was 0.55. [28, 29]
In the same study, the RR for neonatal seizures or serious neurologic
disorders for midwife-attended home births, compared with physician-

attended hospital delivery, was 3.80. Compared with in-hospital physician


delivery, the RR for midwife delivery at freestanding birth centers was 1.88,
and for hospital midwife delivery, the RR was 0.74. [28, 29]

Mechanism of Childbirth
The ability of the fetus to successfully negotiate the pelvis during childbirth
involves changes in position of its head during its passage in childbirth. The
mechanisms of childbirth, also known as the cardinal movements, are
described in relation to a vertex presentation, as is the case in 95% of all
pregnancies. Although childbirth and delivery occurs in a continuous
fashion, the cardinal movements are described as 7 discrete sequences, as
discussed below.[2]

Engagement
The widest diameter of the presenting part (with a well-flexed head, where
the largest transverse diameter of the fetal occiput is the biparietal
diameter) enters the maternal pelvis to a level below the plane of the pelvic
inlet. On the pelvic examination, the presenting part is at 0 station, or at the
level of the maternal ischial spines.

Descent
The downward passage of the presenting part through the pelvis. This
occurs intermittently with contractions. The rate is greatest during the
second stage of childbirth.

Flexion
As the fetal vertex descents, it encounters resistance from the bony pelvis
or the soft tissues of the pelvic floor, resulting in passive flexion of the fetal
occiput. The chin is brought into contact with the fetal thorax, and the
presenting diameter changes from occipitofrontal (11.0 cm) to
suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis.

Internal rotation
As the head descends, the presenting part, usually in the transverse
position, is rotated about 45 to anteroposterior (AP) position under the
symphysis. Internal rotation brings the AP diameter of the head in line with
the AP diameter of the pelvic outlet.

Extension
With further descent and full flexion of the head, the base of the occiput
comes in contact with the inferior margin of the pubic symphysis. Upward
resistance from the pelvic floor and the downward forces from the uterine
contractions cause the occiput to extend and rotate around the symphysis.
This is followed by the delivery of the fetus' head.

Restitution and external rotation


When the fetus' head is free of resistance, it untwists about 45 left or right,
returning to its original anatomic position in relation to the body.

Expulsion
After the fetus' head is delivered, further descent brings the anterior
shoulder to the level of the pubic symphysis. The anterior shoulder is then
rotated under the symphysis, followed by the posterior shoulder and the
rest of the fetus.

Clinical History and Physical Examination


History
The initial assessment of childbirth should include a review of the patient's
prenatal care, including confirmation of the estimated date of delivery.
Focused history taking should be conducted to include information, such as
the frequency and time of onset of contractions, the status of the amniotic
membranes (whether spontaneous rupture of the membranes has
occurred, and if so, whether the amniotic fluid is clear or meconium
stained), the fetus' movements, and the presence or absence of vaginal
bleeding.
Braxton-Hicks contractions, which are often irregular and do not increase in
frequency with increasing intensity, must be differentiated from true
contractions. Braxton-Hicks contractions often resolve with ambulation or a
change in activity. However, contractions that lead to childbirth tend to last
longer and are more intense, leading to cervical change. True childbirth is
defined as uterine contractions leading to cervical changes. If contractions
occur without cervical changes, it is not childbirth. Other causes for the
cramping should be diagnosed. Gestational age is not a part of the
definition of childbirth.

In addition, Braxton-Hicks contractions occur occasionally, usually no more


than 1-2 per hour, and they often occur just a few times per day. Childbirth
contractions are persistent, they may start as infrequently as every 10-15
minutes, but they usually accelerate over time, increasing to contractions
that occur every 2-3 minutes.
Patients may also describe what has been called lightening, ie, physical
changes felt because the fetus' head is advancing into the pelvis. The
mother may feel that her baby has become light. As the presenting fetal
part starts to drop, the shape of the mother's abdomen may change to
reflect descent of the fetus. Her breathing may be relieved because tension
on the diaphragm is reduced, whereas urination may become more
frequent due to the added pressure on the urinary bladder.

Physical examination
Physical examination should include documentation of the patient's vital
signs, the fetus' presentation, and assessment of the fetal well-being. The
frequency, duration, and intensity of uterine contractions should be
assessed, particularly the abdominal and pelvic examinations in patients
who present in possible childbirth.
Abdominal examination begins with the Leopold maneuvers described
below[2] :

The initial maneuver involves the examiner placing both of his or her
hands on each upper quadrant of the patient's abdomen and gently
palpating the fundus with the tips of the fingers to define which fetal pole
is present in the fundus. If it is the fetus' head, it should feel hard and
round. In a breech presentation, a large, nodular body is felt.

The second maneuver involves palpation in the paraumbilical regions


with both hands by applying gentle but deep pressure. The purpose is to
differentiate the fetal spine (a hard, resistant structure) from its limbs
(irregular, mobile small parts) to determinate the fetus' position.

The third maneuver is suprapubic palpation by using the thumb and


fingers of the dominant hand. As with the first maneuver, the examiner
ascertains the fetus' presentation and estimates its station. If the
presenting part is not engaged, a movable body (usually the fetal occiput)
can be felt. This maneuver also allows for an assessment of the fetal
weight and of the volume of amniotic fluid.

The fourth maneuver involves palpation of bilateral lower quadrants


with the aim of determining if the presenting part of the fetus is engaged
in the mother's pelvis. The examiner stands facing the mother's feet. With
the tips of the first 3 fingers of both hands, the examiner exerts deep
pressure in the direction of the axis of the pelvic inlet. In a cephalic
presentation, the fetus' head is considered engaged if the examiner's
hands diverge as they trace the fetus' head into the pelvis.
Pelvic examination is often performed using sterile gloves to decrease the
risk of infection. If membrane rupture is suspected, examination with a
sterile speculum is performed to visually confirm pooling of amniotic fluid in
the posterior fornix. The examiner also looks for fern on a dried sample of
the vaginal fluid under a microscope and checks the pH of the fluid by
using a nitrazine stick or litmus paper, which turns blue if the amniotic fluid
is alkalotic. If frank bleeding is present, pelvic examination should be
deferred until placenta previa is excluded with ultrasonography.
Furthermore, the pattern of contraction and the patient's presenting history
may provide clues about placental abruption.
Digital examination of the vagina allows the clinician to determine the
following: (1) the degree of cervical dilatation, which ranges from 0 cm
(closed or fingertip) to 10 cm (complete or fully dilated), (2) the effacement
(assessment of the cervical length, which is can be reported as a
percentage of the normal 3- to 4-cm-long cervix or described as the actual
cervical length); actual reporting of cervical length may decrease potential
ambiguity in percent-effacement reporting, (3) the position, ie, anterior or
posterior, and (4) the consistency, ie, soft or firm. Palpation of the
presenting part of the fetus allows the examiner to establish its station, by
quantifying the distance of the body (-5 to +5 cm) that is presenting relative
to the maternal ischial spines, where 0 station is in line with the plane of the
maternal ischial spines).[2]
The pelvis can also be assessed either by clinical examination (clinical
pelvimetry) or radiographically (CT or MRI). The pelvic planes include the
following:

Pelvic inlet: The obstetrical conjugate is the distance between the


sacral promontory and the inner pubic arch; it should measure 11.5 cm or
more. The diagonal conjugate is the distance from the undersurface of
the pubic arch to sacral promontory; it is 2 cm longer than the obstetrical
conjugate. The transverse diameter of the pelvic inlet measures 13.5 cm.

Midpelvis: The midpelvis is the distance between the bony points of


ischial spines, and it typically exceeds 12 cm.

Pelvic outlet: The pelvic outlet is the distance between the ischial
tuberosities and the pubic arch. It usually exceeds 10 cm.
The shape of the mother's pelvis can also be assessed and classified into 4
broad categories based on the descriptions of Caldwell and Moloy:
gynecoid, anthropoid, android, and platypelloid. [30] Although the gynecoid
and anthropoid pelvic shapes are thought to be most favorable for vaginal
delivery, many women can be classified into 1 or more pelvic types, and
such distinctions can be arbitrary.[2]

Workup
High-risk pregnancies can account for up to 80% of all perinatal morbidity
and mortality. The remaining perinatal complications arise in pregnancies
without identifiable risk factors for adverse outcomes. [31] Therefore, all
pregnancies require a thorough evaluation of risks and close surveillance.
As soon as the mother arrives at the Childbirth and Delivery suite, external
tocometric monitoring for the onset and duration of uterine contractions and
use of a Doppler device to detect fetal heart tones and rate should be
started.
In the presence of childbirth progression, monitoring of uterine contractions
by external tocodynamometry is often adequate. However, if a childbirthing
mother is confirmed to have rupture of the membranes and if the
intensity/duration of the contractions cannot be adequately assessed, an
intrauterine pressure catheter can be inserted into the uterine cavity past
the fetus to determine the onset, duration, and intensity of the contractions.
Because the external tocometer records only the timing of contractions, an
intrauterine pressure catheter can be used to measure the intrauterine
pressure generated during uterine contractions if their strength is a
concern. While it is considered safe, placental abruption has been reported
as a rare complication of an intrauterine pressure catheter placed
extramembraneously.[32]
Bedside ultrasonography may be used to assess the risk of gastric content
aspiration in pregnant women during childbirth, by measuring the antral
cross-sectional area (CSA), according to a study by Bataille et al. [33, 34] In the
report, which involved 60 women in childbirth who were under epidural
analgesia, the investigators found that at epidural insertion, half of the

women had an antral CSA of over 320 mm2, indicating that they were at
increased risk of gastric content aspiration while under anesthesia. [33, 34]
It was also found that the antral CSA was reduced during childbirth, falling
from a median of 319 mm2 at epidural insertion to 203 mm2 at full cervical
dilatation, with only 13% of the women at that time still considered at risk of
aspiration.[33, 34] This change, according to the investigators, suggested that
even under epidural anesthesia, gastric motility is preserved.
Often, fetal monitoring is achieved using cardiotography, or electronic fetal
monitoring. Cardiotography as a form of fetal assessment in childbirth was
reviewed using randomized and quasirandomized controlled trials involving
a comparison of continuous cardiotocography with no monitoring,
intermittent auscultation, or intermittent cardiotocography. This review
concluded that continuous cardiotocography during childbirth is associated
with a reduction in neonatal seizures but not cerebral palsy or infant
mortality; however, continuous monitoring is associated with increased
cesarean and operative vaginal deliveries.[35]
If nonreassuring fetal heart rate tracings by cardiotography (eg, late
decelerations) are noted, a fetal scalp electrode may be applied to
generate sensitive readings of beat-to-beat variability. However, a fetal
scalp electrode should be avoided if the mother has HIV, hepatitis B or
hepatitis C infections, or if fetal thrombocytopenia is suspected. Recently, a
framework has been suggested to classify and standardize the
interpretation of a fetal heart rate monitoring pattern according to the risk of
fetal acidemia with the intention of minimizing neonatal acidemia without
excessive obstetric intervention.[36]
The question of whether fetal pulse oximetry may be useful for fetal
surveillance in childbirth was examined in a review of 5 published trials
comparing fetal pulse oximetry and cardiotography with cardiotography
alone. It concluded that existing data provide limited support for the use of
fetal pulse oximetry when used in the presence of a nonreassuring fetal
heart rate tracing to reduce caesarean delivery for nonreassuring fetal
status. The addition of fetal pulse oximetry does not reduce overall
caesarean deliveries.[37]
Further evaluation of a fetus at risk for childbirth intolerance or distress can
be accomplished with blood sampling from fetal scalp capillaries. This
procedure allows for a direct assessment of fetal oxygenation and blood

pH. A pH of < 7.20 warrants further investigation for the fetus' well-being
and for possible resuscitation or surgical intervention.
Routine childbirthatory studies of the parturient, such as complete blood
cell (CBC) count, blood typing and screening, and urinalysis, are usually
performed. Intravenous (IV) access is established.

Intrapartum Management of Childbirth


First stage of childbirth
Cervical change occurs at a slow, gradual pace during the latent phase of
the first stage of childbirth. Latent phase of childbirth is complex and not
well-studied since determination of onset is subjective and may be
challenging as women present for assessment at different time duration
and cervical dilation during childbirth. In a cohort of women undergoing
induction of childbirth, the median duration of latent childbirth was 384min
with an interquartile range of 240-604 min. The authors report that cervical
status at admission for childbirth induction, but not other risk factors
typically associated with cesarean delivery, is associated with length of the
latent phase.[38]
Most women experience onset of childbirth without premature rupture of
the membranes (PROM); however, approximately 8% of term pregnancies
is complicated by PROM. Spontaneous onset of childbirth usually follows
PROM such that 50% of women with PROM who were expectantly
managed delivered within 5 hours, and 95% gave birth within 28 hours of
PROM.[39] Currently, the American College of Obstetricians and
Gynecologists (ACOG) recommends that fetal heart rate monitoring should
be used to assess fetal status and dating criteria reviewed, and group B
streptococcal prophylaxis be given based on prior culture results or risk
factors of cultures not available. Additionally, randomized controlled trials to
date suggest that for women with PROM at term, childbirth induction,
usually with oxytocininfusion, at time of presentation can reduce the risk of
chorioamnionitis.[40]
According to Friedman and colleagues,[6] the rate of cervical dilation should
be at least 1 cm/h in a nulliparous woman and 1.2 cm/h in a multiparous
woman during the active phase of childbirth. However, childbirth
management has changed substantially during the last quarter century.
Particularly, obstetric interventions such as induction of childbirth,

augmentation of childbirth with oxytocin administration, use of regional


anesthesia for pain control, and continuous fetal heart rate monitoring are
increasingly common practice in the management of childbirth in todays
obstetric population.[41, 42, 20] Vaginal breech and mid- or high-forceps
deliveries are now rarely performed.[43, 44, 45] Therefore, subsequent authors
have suggested normal childbirth may precede at a rate less rapid than
those previously described.[8, 9, 20]
Data collected from the Consortium on Safe Childbirth suggests that
allowing childbirth to continue longer before 6-cm dilation may reduce the
rate of intrapartum and subsequent cesarean deliveries in the United
States.[46] In the study, the authors noted that the 95 th percentile for
advancing from 4-cm dilation to 5-cm dilation was longer than 6 hours; and
the 95th percentile for advancing from 5-cm dilation to 6-cm dilation was
longer than 3 hours, regardless of the patients parity.
On admission to the Childbirth and Delivery suite, a woman having normal
childbirth should be encouraged to assume the position that she finds most
comfortable. Possibilities including walking, lying supine, sitting, or resting
in a left lateral decubitus position. Of note, ambulating during childbirth did
not change the progression of childbirth in a large randomized controlled
study of >1000 women in active childbirth.[47]
The patient and her family or support team should be consulted regarding
the risks and benefits of various interventions, such as the augmentation of
childbirth using oxytocin, artificial rupture of the membranes, methods and
pharmacologic agents for pain control, and operative vaginal delivery
(including forceps or vacuum-assisted vaginal deliveries) or cesarean
delivery. They should be actively involved, and their preferences should be
considered in the management decisions made during childbirth and
delivery.[2]
The frequency and strength of uterine contractions and changes in cervix
and in the fetus' station and position should be assessed periodically to
evaluate the progression of childbirth. Although progression must be
monitored, vaginal examinations should be performed only when necessary
to minimize the risk of chorioamnionitis, particularly in women whose
amniotic membrane has ruptured. During the first stage of childbirth, fetal
well-being can be assessed by monitoring the fetal heart rate at least every
15 minutes, particularly during and immediately after uterine contractions.

In most childbirth and delivery units, the fetal heart rate is assessed
continuously.[3]
Two methods of augmenting childbirth have been established. The
traditional method involves the use of low doses of oxytocin with long
intervals between dose increments. For example, low-dose infusion of
oxytocin is started at 1 mili IU/min and increased by 1-2 mili IU/min every
20-30 minutes until adequate uterine contraction is obtained. [2]
The second method, or active management of childbirth, involves a
protocol of clinical management that aims to optimize uterine contractions
and shorten childbirth. This protocol includes strict criteria for admission to
the childbirth and delivery unit, early amniotomy, hourly cervical
examinations, early diagnosis of inefficient uterine activity (if the cervical
dilation rate is < 1.0 cm/h), and high-dose oxytocin infusion if uterine
activity is inefficient. Oxytocin infusion starts at 4 mili IU/min (or even 6 mili
IU/min) and increases by 4 mili IU/min (or 6 mili IU/min) every 15 minutes
until a rate of 7 contractions per 15 minutes is achieved or until the
maximum infusion rate of 36 mili IU/min is reached. [48, 2]
Although active management of childbirth was originally intended to
shorten the length of childbirth in nulliparous women, its application at the
National Maternity Hospital in Dublin produced a primary cesarean delivery
rate of 5-6% in nulliparas.[49] Data from randomized controlled trials
confirmed that active management of childbirth shortens the first stage of
childbirth and reduces the likelihood of maternal febrile morbidity, but it
does not consistently decrease the probability of cesarean delivery.[50, 51, 52]
Although the active management protocol likely leads to early diagnosis
and interventions for childbirth dystocia, a number of risk factors are
associated with a failure of childbirth to progress during the first stage.
These risk factors include premature rupture of the membranes (PROM),
nulliparity, induction of childbirth, increasing maternal age, and or other
complications (eg, previous perinatal death, pregestational or gestational
diabetes mellitus, hypertension, infertility treatment). [53, 54]
While the ACOG defines childbirth dystocia as abnormal childbirth that
results form abnormalities of the power (uterine contractions or maternal
expulsive forces), the passenger (position, size, or presentation of the
fetus), or the passage (pelvis or soft tissues), childbirth dystocia can rarely
be diagnosed with certainty.[1] Often, a "failure to progress" in the first stage

is diagnosed if uterine contraction pattern exceeds 200 Montevideo units


for 2 hours without cervical change during the active phase of childbirth is
encountered.[1] Thus, the traditional criteria to diagnose active-phase arrest
are cervical dilatation of at least 4 cm, cervical changes of < 1 cm in 2
hours, and a uterine contraction pattern of >200 Montevideo units. These
findings are also a common indication for cesarean delivery.
Proceeding to cesarean delivery in this setting, or the "2-hour rule," was
challenged in a clinical trial of 542 women with active phase arrest. [55] In this
cohort of women diagnosed with active phase arrest, oxytocin was started,
and cesarean delivery was not performed for childbirth arrest until
adequate uterine contraction lasted at least 4 hours (>200 Montevideo
units) or until oxytocin augmentation was given for 6 hours if this
contraction pattern could not be achieved. This protocol achieved vaginal
delivery rates of 56-61% in nulliparas and 88% in multiparas without severe
adverse maternal or neonatal outcomes. Therefore, extending the criteria
for active-phase childbirth arrest from 2 to at least 4 hours appears to be
effective in achieving vaginal birth.[55, 1]

Second stage of childbirth


When the woman enters the second stage of childbirth with complete
cervical dilatation, the fetal heart rate should be monitored or auscultated at
least every 5 minutes and after each contraction during the second stage.
[3]
Although the parturient may be encouraged to actively push in
concordance with the contractions during the second stage, many women
with epidural anesthesia who do not feel the urge to push may allow the
fetus to descend passively, with a period of rest before active pushing
begins.
A number of randomized controlled trials have shown that, in nulliparous
women, delayed pushing, or passive descend, is not associated with
adverse perinatal outcomes or an increased risk for operative deliveries
despite an often prolonged second stage of childbirth. [56, 57, 39] Furthermore,
investigators who recently compared obstetric outcomes associated with
coached versus uncoached pushing during the second stage reported a
slightly shortened second stage (13 min) in the coached group, with no
differences in the immediate maternal or neonatal outcomes. [58]
Le Ray et al reported that manual rotation of fetuses who were in occiput
posterior or occiput transverse position at full dilatation was associated with

reduced rates of operative delivery (ie, cesarean or instrumental vaginal


delivery).[59, 60] In a study involving 2 French hospitals, operative delivery
rates were significantly lower at the institution whose policy favored manual
rotation than at the one that favored modification of maternal position
(23.2% vs 38.7%), mainly because of lower rates of instrumental deliveries
(15.0% vs 28.8%).
When a prolonged second stage of childbirth is encountered, clinical
assessment of the parturient, the fetus, and the expulsive forces is
warranted. A randomized controlled trial performed by Api et al determined
that application of fundal pressure on the uterus does not shorten the
second stage of childbirth.[61] Although the 2003 ACOG practice guidelines
state that the duration of the second stage alone does not mandate
intervention by operative vaginal delivery or cesarean delivery if progress is
being made, the clinician has several management options (continuing
observation/expectant management, operative vaginal delivery by forceps
or vacuum-assisted vaginal delivery, or cesarean delivery) when secondstage arrest is diagnosed.
The association between a prolonged second stage of childbirth and
adverse maternal or neonatal outcome has been examined. While a
prolonged second stage is not associated with adverse neonatal outcomes
in nulliparas, possibly because of close fetal surveillance during childbirth,
but it is associated with increased maternal morbidity, including higher
likelihood of operative vaginal delivery and cesarean delivery, postpartum
hemorrhage, third- or fourth-degree perineal lacerations, and peripartum
infection.[11, 12, 13, 14] Therefore, it is crucial to weigh the risks of operative
delivery against the potential benefits of continuing childbirth in hopes to
achieve vaginal delivery. The question of when to intervene should involve
a thorough evaluation of the ongoing risks of further expectant
management versus the risks of intervention with vaginal or cesarean
delivery, as well as the patients' preferences.

Delivery of the fetus


When delivery is imminent, the mother is usually positioned supine with her
knees bent (ie, dorsal lithotomy position), though delivery can occur with
the mother in any position, including the lateral (Sims) position, the partial
sitting or squatting position, or on her hands and knees. [2] Although an
episiotomy (an incision continuous with the vaginal introitus) used to be
routinely performed at this time, the ACOG recommended in 2006 that its

use be restricted to maternal or fetal indications. Studies have also shown


that routine episiotomy does not decrease the risk of severe perineal
lacerations during forceps or vacuum-assisted vaginal deliveries. [62, 63]
Crowning is the word used to describe when the fetal head forcibly extends
the vaginal outlet. A modified Ritgen maneuver can be performed to deliver
the head. Draped with a sterile towel, the heel of the clinician's hand is
placed over the posterior perineum overlying the fetal chin, and pressure is
applied upward to extend the fetus' head. The other hand is placed over the
fetus' occiput, with pressure applied downward to flex its head. Thus, the
head is held in mid position until it is delivered, followed by suctioning of the
oropharynx and nares. Check the fetus' neck for a wrapped umbilical cord,
and promptly reduce it if possible. If the cord is wrapped too tightly to be
removed, the cord can be double clamped and cut. Of note, some
providers, in an attempt to avoid shoulder dystocia, deliver the anterior
shoulder prior to restitution of the fetal head.
Next, the fetus' anterior shoulder is delivered with gentle downward traction
on its head and chin. Subsequent upward pressure in the opposite direction
facilitates delivery of the posterior shoulder. The rest of the fetus should
now be easily delivered with gentle traction away from the mother. If not
done previously, the cord is clamped and cut. The baby is vigorously
stimulated and dried and then transferred to the care of the waiting
attendants or placed on the mother's abdomen.

Third stage of childbirth - Delivery of the placenta and the fetal


membranes
The childbirth process has now entered the third stage, ie, delivery of the
placenta. Three classic signs indicate that the placenta has separated from
the uterus: (1) The uterus contracts and rises, (2) the cord suddenly
lengthens, and (3) a gush of blood occurs.[2]
Delivery of the placenta usually happens within 5-10 minutes after delivery
of the fetus, but it is considered normal up to 30 minutes after delivery of
the fetus. Excessive traction should not be applied to the cord to avoid
inverting the uterus, which can cause severe postpartum hemorrhage and
is an obstetric emergency. The placenta can also be manually separated by
passing a hand between the placenta and uterine wall. After the placenta is
delivered, inspect it for completeness and for the presence of 1 umbilical
vein and 2 umbilical arteries. Oxytocin can be administered throughout the

third stage to facilitate placental separation by inducing uterine contractions


and to decrease bleeding.
Expectant management of the third stage involves allowing the placenta to
deliver spontaneously, whereas active management involves administration
of uterotonic agent (usually oxytocin, an ergot alkaloid, or prostaglandins)
before the placenta is delivered. This is done with early clamping and
cutting of the cord and with controlled traction on the cord while placental
separation and delivery are awaited.
A review of 5 randomized trials comparing active versus expectant
management of the third stage demonstrated that active management was
associated with lowered risks of maternal blood loss, postpartum
hemorrhage, and prolongation of the third stage, but it increased maternal
nausea, vomiting, and blood pressure (when ergometrine was used).
However, given the reduced risk of complications, this review recommends
that active management is superior to expectant management and should
be the routine management of choice.[19] A multicenter, randomized,
controlled trial of the efficacy of misoprostol (prostaglandin E1 analog)
compared with oxytocin showed that oxytocin 10 IU IV or given
intramuscularly (IM) was preferable to oral misoprostol 600 mcg for active
management of the third stage of childbirth in hospital settings. [64] Therefore,
if the risks and benefits are balanced, active management with oxytocin
may be consideredapartofroutine management of the third stage.
After the placenta is delivered, the childbirth and delivery period is
complete. Palpate the patient's abdomen to confirm reduction in the size of
the uterus and its firmness. Ongoing blood loss and a boggy uterus
suggest uterine atony. A thorough examination of the birth canal, including
the cervix and the vagina, the perineum, and the distal rectum, is
warranted, and repair of episiotomy or perineal/vaginal lacerations should
be carried out.
Franchi et al found that topically applied lidocaine-prilocaine (EMLA) cream
was an effective and satisfactory alternative to mepivacaine infiltration for
pain relief during perineal repair. In a randomized trial of 61 women with
either an episiotomy or a perineal laceration after vaginal delivery, women
in the EMLA group had lower pain scores than those in the mepivacaine
group (1.7 +/- 2.4 vs 3.9 +/- 2.4; P = .0002), and a significantly higher

proportion of women expressed satisfaction with anesthesia method in the


EMLA group than in the mepivacaine group (83.8% vs 53.3%; P = .01). [65]
In a Cochrane review, Aasheim et al suggest that evidence is sufficient to
support the use of warm compresses to prevent perineal tears. They also
found a reduction in third-degree and fourth-degree tears with massage of
the perineum to reduce the rate of episiotomy.[66]

Pain Control
Childbirthing women often experience intense pain. Uterine contractions
result in visceral pain, which is innervated by T10-L1. While in descent, the
fetus' head exerts pressure on the mother's pelvic floor, vagina, and
perineum, causing somatic pain transmitted by the pudendal nerve
(innervated by S2-4).[4] Therefore, optimal pain control during childbirth
should relieve both sources of pain.
A number of opioid agonists and opioid agonist-antagonists can be given in
intermittent doses for systemic pain control. These include meperidine 2550 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours, fentanyl 50100 mcg IV every hour, nalbuphine 10 mg IV or IM every 3
hours, butorphanol 1-2 mg IV or IM every 4 hours, and morphine 2-5 mg IV
or 10 mg IM every 4 hours.[4] As an alternative, regional anesthesia may be
given. Options are epidural, spinal, or combined spinal epidural anesthesia.
These provide partial to complete blockage of pain sensation below T8-10,
with various degree of motor blockade. These blocks can be used
duringchildbirth and for surgical deliveries.
Studies performed to compare the analgesic effect of regional anesthesia
and parenteral agents showed that regional anesthesia provides superior
pain relief.[67, 44, 68] Although some researchers reported that epidural
anesthesia is associated with a slight increase in the duration of childbirth
and in the rate of operative vaginal delivery,[69, 70] large randomized controlled
studies did not reveal a difference in frequency of cesarean delivery
between women who received parenteral analgesics compared with
women who received epidural anesthesia[67, 68, 70] given during early-stage or
later in childbirth.[71] Although regional anesthesia is effective as a method of
pain control, common adverse effects include maternal hypotension,
maternal temperature >100.4F, postdural puncture headache, transient
fetal heart deceleration, and pruritus (with added opioids). [4]

Despite the many methods available for analgesia and anesthesia to


manage childbirth pain, some women may not wish to use conventional
pain medications during childbirth, opting instead for a natural childbirth.
Although these women may use breathing and mental exercises to help
alleviate childbirth pain, they should be assured that pain relief can be
administered at any time during childbirth.
A Cochrane review update concluded that relaxation techniques and yoga
may offer some relief and improve management of pain. Studies in the
review noted increased satisfaction with pain relief and lower assisted
vaginal delivery rates with relaxation techniques. One trial involving yoga
noted reduced pain, increased satisfaction with pain relief, increased
satisfaction with the childbirth experience, and reduced length of childbirth.
[72]

Of note, use of nonsteroidal anti-inflammatory drugs (NSAIDs) are


relatively contraindicated in the third trimester of pregnancy. The repeated
use of NSAIDs has been associated with early closure of the fetal ductus
arteriosus in utero and with decreasing fetal renal function leading to
oligohydramnios.

Definisi
Melahirkan adalah proses fisiologis di mana hasil konsepsi (yaitu, janin, membran,
tali pusat dan plasenta) yang dikeluarkan di luar rahim. Melahirkan dicapai dengan
perubahan dalam jaringan ikat biokimia dan dengan pendataran bertahap dan
dilatasi serviks uterus sebagai akibat dari kontraksi rahim berirama frekuensi yang
cukup, intensitas, dan durasi. [1, 2]
Melahirkan adalah diagnosis klinis. Terjadinya persalinan didefinisikan sebagai,
kontraksi uterus nyeri biasa mengakibatkan penipisan serviks progresif dan dilatasi.
Dilatasi serviks tanpa adanya kontraksi rahim menunjukkan insufisiensi serviks,
sedangkan kontraksi uterus tanpa perubahan serviks tidak memenuhi definisi
melahirkan.
Tahapan Melahirkan dan Epidemiologi
Tahapan Melahirkan
Dokter kandungan telah dibagi menjadi 3 tahap persalinan yang menggambarkan
tonggak dalam proses yang berkesinambungan.
Tahap pertama persalinan
Tahap pertama dimulai dengan kontraksi uterus yang teratur dan berakhir dengan
dilatasi serviks lengkap pada 10 cm. Dalam studi tengara Friedman dari 500
nulipara [5], ia dibagi tahap pertama ke fase laten awal dan fase aktif berikutnya.
Fase laten dimulai dengan, kontraksi uterus yang tidak teratur ringan yang
melembutkan dan memperpendek leher rahim. Kontraksi menjadi semakin lebih
berirama dan kuat. Ini diikuti dengan fase aktif persalinan, yang biasanya dimulai
pada sekitar 3-4 cm dari dilatasi serviks dan ditandai oleh dilatasi serviks cepat dan
keturunan dari bagian presentasi janin. Tahap pertama persalinan diakhiri dengan
dilatasi serviks lengkap pada 10 cm. Menurut Friedman, fase aktif dibagi lagi
menjadi fase akselerasi, fase lereng maksimum, dan fase perlambatan.
Karakteristik dari rata-rata kurva dilatasi serviks dikenal sebagai kurva melahirkan
Friedman, dan serangkaian definisi penggambaran melahirkan dan penangkapan
yang kemudian didirikan. [6, 7] Namun, data berikutnya dari populasi obstetri
modern menunjukkan bahwa tingkat dilatasi serviks adalah lambat dan
perkembangan melahirkan mungkin secara signifikan berbeda dari yang disarankan
oleh kurva melahirkan Friedman. [8, 9, 10]
Tahap kedua persalinan
Tahap kedua dimulai dengan dilatasi serviks lengkap dan berakhir dengan
pengiriman janin. American College of Obstetricians dan Gynecologists (ACOG)
telah menyarankan bahwa tahap kedua berkepanjangan melahirkan harus
dipertimbangkan ketika tahap kedua persalinan melebihi 3 jam jika anestesi

regional diberikan atau 2 jam tanpa adanya anestesi regional untuk nulipara. Pada
wanita multipara, diagnosis tersebut dapat dilakukan jika tahap kedua persalinan
melebihi 2 jam dengan anestesi regional atau 1 jam tanpa itu. [1]
Studi yang dilakukan untuk menguji hasil perinatal yang berhubungan dengan
tahap kedua berkepanjangan melahirkan mengungkapkan risiko peningkatan
pengiriman operasi dan morbiditas ibu tetapi tidak ada perbedaan hasil neonatal.
[11, 12, 13, 14] faktor risiko ibu terkait dengan tahap kedua berkepanjangan
termasuk nulliparity , meningkatkan berat badan ibu dan / atau berat badan,
penggunaan anestesi regional, induksi persalinan, oksiput janin dalam posterior
atau posisi melintang, dan peningkatan berat lahir. [13, 14, 15, 16]
Tahap ketiga persalinan
Tahap ketiga persalinan didefinisikan oleh periode waktu antara pengiriman janin
dan pengiriman plasenta dan selaput janin. Selama periode ini, kontraksi uterus
menurun aliran darah basal, yang menghasilkan penebalan dan pengurangan luas
permukaan miometrium mendasari plasenta dengan detasemen berikutnya
plasenta. [17] Meskipun pengiriman plasenta sering membutuhkan kurang dari 10
menit, yang durasi tahap ketiga persalinan dapat berlangsung selama 30 menit.
Manajemen hamil dari tahap ketiga persalinan melibatkan pengiriman spontan
plasenta. Manajemen aktif sering melibatkan pemberian profilaksis oksitosin atau
uterotonics lainnya (prostaglandin atau alkaloid ergot), kabel penjepit /
pemotongan, dan traksi tali pusat terkendali tali pusat. Andersson et al menemukan
bahwa penjepitan tali pusat tertunda (180 detik setelah melahirkan)
meningkatkan status besi dan mengurangi prevalensi defisiensi zat besi pada usia 4
bulan dan juga mengurangi prevalensi anemia neonatal, tanpa efek samping yang
jelas. [18]
Sebuah tinjauan sistematis literatur yang termasuk 5 percobaan acak terkontrol
yang membandingkan manajemen aktif dan hamil dari tahap ketiga melaporkan
bahwa manajemen aktif memperpendek durasi tahap ketiga dan unggul
manajemen hamil sehubungan dengan kehilangan darah / risiko perdarahan
postpartum; Namun, manajemen aktif dikaitkan dengan peningkatan risiko efek
samping yang tidak menyenangkan. [19]
Tahap ketiga dari melahirkan dianggap berkepanjangan setelah 30 menit, dan
intervensi aktif, seperti ekstraksi manual plasenta, umumnya dianggap. [2]
Epidemiologi
Sebagai penduduk subur di Amerika Serikat telah berubah, manajemen kebidanan
klinis melahirkan juga telah berkembang karena penelitian Friedman. Data dari
angka penelitian menunjukkan bahwa persalinan normal dapat berkembang pada
tingkat yang jauh lebih lambat dari yang Friedman dan Sachtleben [6, 7] telah

dijelaskan. Zhang et al meneliti perkembangan melahirkan dari 1.162 nulipara yang


disajikan dalam melahirkan spontan dan dibangun kurva melahirkan yang berbeda
dari Friedman: Interval rata untuk kemajuan 4-10 cm dari dilatasi serviks adalah 5,5
jam dibandingkan dengan 2,5 jam dari melahirkan Friedman kurva. [20] Kilpatrick et
al [8] dan Albers et al [9] juga melaporkan bahwa panjang rata-rata pertama dan
kedua tahapan persalinan yang lebih lama daripada mereka Friedman disarankan.
Sejumlah peneliti telah mengidentifikasi beberapa faktor obstetri karakteristik ibu
yang berkaitan dengan panjang melahirkan. Satu kelompok melaporkan bahwa
peningkatan usia ibu dikaitkan dengan tahap kedua lama tapi tidak tahap pertama
persalinan. [21]
Sementara nulliparity dikaitkan dengan persalinan lebih lama dibandingkan dengan
multipara, peningkatan paritas tidak lebih mempersingkat durasi persalinan. [22]
Beberapa penulis telah mengamati bahwa panjang melahirkan berbeda antara
kelompok ras / etnis. Satu kelompok melaporkan bahwa wanita Asia memiliki
terpanjang pertama dan kedua tahapan melahirkan dibandingkan dengan wanita
Kaukasia atau Afrika Amerika [23], dan perempuan India Amerika memiliki tahap
kedua lebih pendek dibandingkan wanita Kaukasia non-Hispanik. [9] Namun, orang
lain melaporkan temuan yang bertentangan. [24, 25] Perbedaan dalam hasil
mungkin karena variasi dalam desain penelitian, populasi penelitian, manajemen
persalinan, atau kekuatan statistik.
Dalam satu studi retrospektif besar panjang melahirkan, khususnya sehubungan
dengan ras dan / atau etnis, penulis mengamati ada perbedaan yang signifikan
dalam panjang tahap pertama persalinan antara kelompok ras / etnis yang berbeda.
Namun, tahap kedua lebih pendek pada wanita Afrika Amerika dibandingkan pada
wanita Kaukasia untuk kedua nulipara (-22 menit) dan multipara (-7,5 min). Nulipara
Hispanik, dibandingkan dengan rekan-rekan Kaukasia mereka, juga memiliki tahap
kedua dipersingkat, sedangkan tidak ada perbedaan yang terlihat untuk multipara.
Sebaliknya, nulipara Asia memiliki tahap kedua secara signifikan lama dibandingkan
dengan rekan-rekan Kaukasia mereka, dan tidak ada perbedaan yang terlihat untuk
multipara. [26]
Menurut tinjauan sistematis dari 13 percobaan yang melibatkan 16.242 wanita,
kebanyakan wanita yang prenatal dan melahirkan perawatan dipimpin oleh bidan
memiliki hasil yang lebih baik dibandingkan dengan mereka yang peduli dipimpin
oleh dokter atau dibagi di antara disiplin ilmu. Pasien yang menerima perawatan
kehamilan bidan yang dipimpin kurang mungkin untuk memiliki analgesia regional,
episiotomi, dan kelahiran instrumental dan lebih mungkin untuk memiliki analgesia
intrapartum atau anestesi, kelahiran vagina spontan, kehadiran saat lahir oleh bidan
dikenal, dan lagi berarti panjang melahirkan. Mereka juga cenderung memiliki
kelahiran prematur dan kematian janin sebelum usia kehamilan 24 minggu. Namun,
rasio risiko rata-rata untuk kelahiran caesar tidak berbeda antara kelompok, dan
tidak ada perbedaan dalam penurunan janin / kematian neonatal pada usia

kehamilan 24 minggu atau lebih 'atau kematian janin / bayi secara keseluruhan. [1,
27]
Kekhawatiran terkait dengan kelahiran di rumah bidan-hadir
Namun, kekhawatiran tentang efek rumah kelahiran bidan-hadir pada kesehatan
neonatal dibesarkan oleh analisis hampir 14 juta tunggal, kelahiran jangka penuh,
dari 2007-2010, bayi dengan berat badan normal. Data, dari Pusat Nasional untuk
Statistik Kesehatan, menunjukkan bahwa melahirkan di rumah dikaitkan dengan
lebih dari 10 kali lipat peningkatan risiko untuk skor Apgar 0 dan hampir 4 kali lipat
peningkatan risiko kejang neonatal atau disfungsi neurologis yang serius, seperti
dibandingkan dengan pengiriman rumah sakit. [28, 29]
Dibandingkan dengan pengiriman oleh dokter rumah sakit, melahirkan di rumah
bidan-menghadiri dikaitkan dengan risiko relatif (RR) dari 10,55 untuk skor Apgar 0.
Untuk pengiriman bidan di klinik bersalin berdiri bebas, RR adalah 3,56, dan untuk
rumah sakit pengiriman bidan, RR adalah 0,55. [28, 29]
Dalam studi yang sama, RR untuk kejang neonatal atau gangguan neurologis yang
serius untuk kelahiran di rumah bidan-hadir, dibandingkan dengan pengiriman
rumah sakit dokter-dihadiri, adalah 3,80. Dibandingkan dengan pengiriman dokter
di rumah sakit, RR untuk pengiriman bidan di menara pusat lahir adalah 1,88, dan
untuk pengiriman bidan rumah sakit, RR adalah 0,74. [28, 29]
Mekanisme Melahirkan
Kemampuan janin berhasil bernegosiasi panggul saat melahirkan melibatkan
perubahan posisi kepalanya selama perjalanan di melahirkan. Mekanisme
persalinan, juga dikenal sebagai gerakan kardinal, dijelaskan dalam kaitannya
dengan presentasi vertex, seperti halnya di 95% dari seluruh kehamilan. Meskipun
melahirkan dan pengiriman terjadi secara terus menerus, gerakan kardinal
digambarkan sebagai 7 urutan diskrit, seperti dibahas di bawah ini. [2]
Pertunangan
Diameter terluas dari bagian presentasi (dengan kepala tertekuk baik, di mana
diameter transversal terbesar dari oksiput janin adalah diameter biparietal)
memasuki panggul ibu ke tingkat bawah bidang pintu atas panggul. Pada
pemeriksaan panggul, bagian presentasi adalah pada 0 stasiun, atau di tingkat
spina iskiadika ibu.
Keturunan
Bagian bawah dari bagian presentasi melalui panggul. Hal ini terjadi sebentarsebentar dengan kontraksi. Angka ini terbesar selama tahap kedua persalinan.
Lengkungan

Sebagai keturunan titik janin, dia menemui perlawanan dari panggul tulang atau
jaringan lunak dasar panggul, sehingga fleksi pasif tengkuk janin. Dagu dibawa ke
dalam kontak dengan dada janin, dan perubahan diameter presentasi dari
occipitofrontal (11,0 cm) ke suboccipitobregmatic (9,5 cm) untuk bagian yang
optimal melalui panggul.
Rotasi internal
Sebagai kepala turun, bagian presentasi, biasanya dalam posisi melintang, diputar
sekitar 45 ke anteroposterior (AP) posisi di bawah simfisis. Rotasi internal
membawa diameter AP kepala sejalan dengan diameter AP dari outlet panggul.
Perpanjangan
Dengan keturunan lebih lanjut dan fleksi penuh kepala, pangkal tengkuk datang
dalam kontak dengan margin rendah dari simfisis pubis. Resistensi atas dari
panggul dan pasukan ke bawah dari kontraksi uterus menyebabkan oksiput untuk
memperpanjang dan memutar sekitar simfisis. Ini diikuti dengan pengiriman janin
kepala.
Restitusi dan rotasi eksternal
Ketika 'kepala janin bebas dari hambatan, itu untwists sekitar 45 ke kiri atau
kanan, kembali ke posisi anatomis aslinya dalam kaitannya dengan tubuh.
Pengusiran
Setelah kepala janin disampaikan, keturunan lanjut membawa bahu anterior ke
tingkat simfisis pubis. Bahu anterior kemudian diputar di bawah simfisis, diikuti oleh
bahu posterior dan sisa janin.
Sejarah Klinis dan Pemeriksaan Fisik
Sejarah
Penilaian awal persalinan harus mencakup ulasan perawatan prenatal pasien,
termasuk konfirmasi tanggal perkiraan persalinan. Difokuskan anamnesis harus
dilakukan untuk memasukkan informasi, seperti frekuensi dan waktu terjadinya
kontraksi, status selaput ketuban (apakah pecah spontan membran telah terjadi,
dan jika demikian, apakah cairan ketuban jelas atau mekonium bernoda ), yang
'gerakan janin, dan ada atau tidak adanya perdarahan vagina.
Kontraksi Braxton-Hicks, yang sering tidak teratur dan tidak meningkatkan frekuensi
dengan meningkatkan intensitas, harus dibedakan dari kontraksi yang benar.
Kontraksi Braxton-Hicks sering menyelesaikan dengan ambulasi atau perubahan
aktivitas. Namun, kontraksi yang menyebabkan persalinan cenderung bertahan
lebih lama dan lebih intens, menyebabkan perubahan serviks. Benar melahirkan
didefinisikan sebagai kontraksi uterus yang menyebabkan perubahan serviks. Jika

kontraksi terjadi tanpa perubahan serviks, tidak melahirkan. Penyebab lain untuk
kram harus didiagnosis. Usia kehamilan bukan merupakan bagian dari definisi
melahirkan.
Selain itu, kontraksi Braxton-Hicks terjadi sesekali, biasanya tidak lebih dari 1-2 per
jam, dan mereka sering terjadi hanya beberapa kali per hari. Kontraksi persalinan
gigih, mereka mungkin mulai jarang karena setiap 10-15 menit, tetapi mereka
biasanya mempercepat dari waktu ke waktu, meningkatkan kontraksi yang terjadi
setiap 2-3 menit.
Pasien juga dapat menggambarkan apa yang disebut keringanan, yaitu, perubahan
fisik merasa karena kepala janin maju ke dalam panggul. Ibu mungkin merasa
bahwa bayinya telah menjadi cahaya. Sebagai bagian presentasi janin mulai turun,
bentuk perut ibu dapat berubah untuk mencerminkan turunnya janin. Napasnya
dapat lega karena ketegangan pada diafragma berkurang, sedangkan buang air
kecil bisa menjadi lebih sering karena tekanan ditambahkan pada kandung kemih.
Pemeriksaan fisik
Pemeriksaan fisik harus mencakup dokumentasi tanda-tanda vital pasien,
presentasi janin, dan penilaian kesejahteraan janin. Frekuensi, durasi, dan intensitas
kontraksi uterus harus dinilai, khususnya pemeriksaan perut dan panggul pada
pasien yang hadir dalam mungkin melahirkan.
Pemeriksaan abdomen dimulai dengan manuver Leopold dijelaskan di bawah [2]:
Manuver awal melibatkan pemeriksa menempatkan kedua tangan nya pada setiap
kuadran atas perut pasien dan lembut meraba fundus dengan ujung jari untuk
menentukan yang tiang janin hadir dalam fundus. Jika itu adalah 'kepala janin,
harus terasa keras dan bulat. Dalam presentasi sungsang,, tubuh nodular besar
dirasakan.
Manuver kedua melibatkan palpasi di daerah paraumbilical dengan kedua tangan
dengan menerapkan tekanan lembut tapi dalam. Tujuannya adalah untuk
membedakan tulang belakang janin (hard, struktur tahan) dari anggota tubuhnya
(tidak teratur, bagian-bagian kecil mobile) untuk determinate posisi janin.
Manuver ketiga adalah suprapubik palpasi dengan menggunakan ibu jari dan jarijari tangan yang dominan. Seperti dengan manuver pertama, pemeriksa
mengetengahkan janin presentasi dan memperkirakan stasiun nya. Jika bagian
presentasi tidak terlibat, tubuh bergerak (biasanya tengkuk janin) dapat dirasakan.
Manuver ini juga memungkinkan untuk penilaian dari berat janin dan volume cairan
ketuban.
Manuver keempat melibatkan palpasi kuadran bawah bilateral dengan tujuan
menentukan apakah bagian presentasi janin bergerak dalam panggul ibu.
Pemeriksa berdiri menghadap kaki ibu. Dengan tips dari 3 jari pertama dari kedua

tangan, pemeriksa tekanannya jauh di arah sumbu panggul. Dalam presentasi


kepala, janin kepala dianggap terlibat jika tangan pemeriksa berbeda karena
mereka melacak janin 'kepala ke panggul.
Pemeriksaan panggul sering dilakukan dengan menggunakan sarung tangan steril
untuk mengurangi risiko infeksi. Jika pecah ketuban dicurigai, pemeriksaan dengan
speculum steril dilakukan untuk visual mengkonfirmasi pooling cairan ketuban di
forniks posterior. Pemeriksa juga mencari pakis pada sampel kering dari cairan
vagina di bawah mikroskop dan memeriksa pH cairan dengan menggunakan
tongkat nitrazin atau kertas lakmus, yang ternyata biru jika cairan ketuban adalah
alkalosis. Jika perdarahan frank hadir, pemeriksaan panggul harus ditunda sampai
plasenta previa dikecualikan dengan ultrasonografi. Selanjutnya, pola kontraksi dan
sejarah menyajikan pasien dapat memberikan petunjuk tentang solusio plasenta.
Pemeriksaan digital vagina memungkinkan dokter untuk menentukan berikut: (1)
tingkat dilatasi serviks, yang berkisar dari 0 cm (tertutup atau ujung jari) ke 10 cm
(lengkap atau sepenuhnya dilatasi), (2) penipisan pada (penilaian panjang serviks,
yang dapat dilaporkan sebagai persentase dari leher rahim 3- 4 cm panjang normal
atau digambarkan sebagai panjang serviks sebenarnya); pelaporan sebenarnya
panjang serviks dapat menurunkan potensi ambiguitas dalam pelaporan persenpenipisan, (3) posisi, yaitu, anterior atau posterior, dan (4) konsistensi, yaitu,
lembut atau perusahaan. Palpasi bagian presentasi janin memungkinkan pemeriksa
untuk membangun stasiun, yaitu dengan mengukur jarak dari tubuh (-5 sampai +5
cm) yang menyajikan relatif terhadap spina iskiadika ibu, di mana 0 stasiun ini
sejalan dengan pesawat dari spina iskiadika ibu). [2]
Panggul juga dapat dinilai baik oleh pemeriksaan klinis (pelvimetri klinis) atau
radiografi (CT atau MRI). Pesawat panggul meliputi:
inlet panggul: The conjugate kandungan adalah jarak antara tanjung sakral dan
arkus pubis dalam; itu harus mengukur 11,5 cm atau lebih. Konjugat diagonal
adalah jarak dari permukaan bawah arkus pubis ke promontorium sakrum; itu
adalah 2 cm lebih panjang dari konjugat kandungan. Diameter melintang pintu atas
panggul berukuran 13,5 cm.
panggul tengah: panggul tengah adalah jarak antara titik tulang spina iskiadika,
dan biasanya melebihi 12 cm.
outlet panggul: Outlet panggul adalah jarak antara tuberositas iskia dan arkus
pubis. Ini biasanya melebihi 10 cm.
Bentuk panggul ibu juga dapat dinilai dan diklasifikasikan menjadi 4 kategori besar
berdasarkan deskripsi dari Caldwell dan moloy:. Ginekoid, anthropoid, android, dan
platypelloid [30] Meskipun bentuk panggul ginekoid dan anthropoid dianggap paling
menguntungkan untuk pengiriman vagina, banyak wanita dapat diklasifikasikan ke
dalam 1 atau lebih jenis panggul, dan perbedaan tersebut bisa sembarangan. [2]

Bekerja
Kehamilan berisiko tinggi dapat menjelaskan hingga 80% dari semua morbiditas
dan mortalitas perinatal. Sisanya komplikasi perinatal muncul pada kehamilan tanpa
faktor risiko diidentifikasi untuk hasil yang merugikan. [31] Oleh karena itu, semua
kehamilan memerlukan evaluasi menyeluruh dari risiko dan pengawasan yang
ketat. Begitu ibu tiba di Melahirkan dan Pengiriman suite, pemantauan tocometric
eksternal untuk onset dan durasi kontraksi uterus dan penggunaan perangkat
Doppler untuk mendeteksi nada jantung janin dan tingkat harus dimulai.
Di hadapan kemajuan persalinan, pemantauan kontraksi uterus oleh
tocodynamometry eksternal sering memadai. Namun, jika seorang ibu childbirthing
dikonfirmasi untuk memiliki pecahnya membran dan jika intensitas / durasi
kontraksi tidak dapat dinilai cukup, kateter tekanan intrauterine dapat dimasukkan
ke dalam rongga rahim masa janin untuk menentukan onset, durasi, dan intensitas
kontraksi. Karena catatan tocometer eksternal hanya waktu kontraksi, kateter
tekanan intrauterine dapat digunakan untuk mengukur tekanan intrauterin yang
dihasilkan selama kontraksi rahim jika kekuatan mereka adalah kekhawatiran.
Meskipun dianggap aman, placental abruption telah dilaporkan sebagai komplikasi
langka kateter tekanan intrauterus ditempatkan extramembraneously. [32]
Bedside ultrasonografi dapat digunakan untuk menilai risiko aspirasi konten
lambung pada wanita hamil saat melahirkan, dengan mengukur luas penampang
antral (CSA), menurut sebuah studi oleh Bataille et al. [33, 34] Dalam laporan yang
melibatkan 60 wanita melahirkan yang berada di bawah analgesia epidural, para
peneliti menemukan bahwa pada penyisipan epidural, setengah dari wanita
memiliki CSA antral dari lebih dari 320 mm2, menunjukkan bahwa mereka berada
pada peningkatan risiko lambung aspirasi konten sementara di bawah anestesi. [33,
34]
Hal itu juga menemukan bahwa CSA antral berkurang saat melahirkan, jatuh dari
rata-rata 319 mm2 di penyisipan epidural untuk 203 mm2 di dilatasi serviks penuh,
dengan hanya 13% dari wanita pada waktu itu masih dianggap berisiko aspirasi. [33
, 34] Perubahan ini, menurut para peneliti, menunjukkan bahwa bahkan di bawah
anestesi epidural, motilitas lambung yang diawetkan.
Seringkali, pemantauan janin dicapai menggunakan cardiotography, atau
pemantauan janin elektronik. Cardiotography sebagai bentuk penilaian janin saat
melahirkan ditinjau menggunakan acak dan quasirandomized percobaan terkontrol
yang melibatkan perbandingan cardiotocography terus menerus tanpa
pemantauan, auskultasi intermiten, atau cardiotocography intermiten. Ulasan ini
menyimpulkan bahwa cardiotocography terus menerus selama persalinan dikaitkan
dengan penurunan kejang neonatal tetapi tidak cerebral palsy atau kematian bayi;
Namun, pemantauan terus menerus dikaitkan dengan peningkatan sesar dan
pengiriman vagina operatif. [35]

Jika nonreassuring janin penelusuran denyut jantung oleh cardiotography (misalnya,


deselerasi lambat) dicatat, kulit kepala elektroda janin dapat diterapkan untuk
menghasilkan pembacaan sensitif variabilitas denyut-to-beat. Namun, kulit kepala
elektroda janin harus dihindari jika ibu memiliki HIV, hepatitis B atau infeksi
hepatitis C, atau jika trombositopenia janin diduga. Baru-baru ini, sebuah kerangka
kerja telah disarankan untuk mengklasifikasikan dan standarisasi interpretasi pola
pemantauan denyut jantung janin menurut risiko asidemia janin dengan tujuan
meminimalkan asidemia neonatal tanpa intervensi obstetri berlebihan. [36]
Pertanyaan apakah pulse oximetry janin mungkin berguna untuk pengawasan janin
saat melahirkan diperiksa dalam tinjauan dari 5 percobaan diterbitkan
membandingkan pulse oximetry janin dan cardiotography dengan cardiotography
saja. Ini menyimpulkan bahwa data yang ada memberikan dukungan terbatas untuk
penggunaan pulse oximetry janin bila digunakan dalam kehadiran denyut jantung
janin nonreassuring tracing untuk mengurangi pengiriman caesar untuk status janin
yang mengkhawatirkan. Penambahan pulse oximetry janin tidak mengurangi
pengiriman caesar secara keseluruhan. [37]
Evaluasi lebih lanjut dari janin berisiko untuk melahirkan intoleransi atau tekanan
dapat dicapai dengan pengambilan sampel darah dari kapiler kulit kepala janin.
Prosedur ini memungkinkan untuk penilaian langsung dari oksigenasi janin dan pH
darah. Sebuah pH <penyelidikan 7.20 waran lebih lanjut untuk janin 'kesejahteraan
dan untuk kemungkinan resusitasi atau intervensi bedah.
Studi childbirthatory rutin ibu melahirkan, seperti sel darah lengkap (CBC) count,
mengetik darah dan skrining, dan urine, biasanya dilakukan. Intravena (IV) Akses
didirikan.
Intrapartum Pengelolaan Melahirkan
Tahap pertama persalinan
Perubahan serviks terjadi pada lambat, laju bertahap selama fase laten tahap
pertama persalinan. Fase laten persalinan adalah kompleks dan tidak dipelajari
dengan baik karena penentuan awal adalah subjektif dan mungkin menantang
sebagai perempuan hadir untuk penilaian pada durasi waktu yang berbeda dan
dilatasi serviks saat persalinan. Dalam kohort wanita yang menjalani induksi
persalinan, durasi rata-rata melahirkan laten itu 384min dengan berbagai
interkuartil dari 240-604 menit. Para penulis melaporkan bahwa status serviks saat
masuk untuk induksi persalinan, tetapi faktor risiko tidak lain biasanya terkait
dengan kelahiran sesar, terkait dengan panjang fase laten. [38]
Kebanyakan wanita mengalami onset persalinan tanpa pecah prematur membran
(PROM); Namun, sekitar 8% dari kehamilan jangka rumit oleh PROM. Onset spontan
persalinan biasanya mengikuti PROM seperti bahwa 50% dari wanita dengan PROM
yang penuh harap dikelola disampaikan dalam waktu 5 jam, dan 95% melahirkan

dalam waktu 28 jam dari PROM. [39] Saat ini, American College of Obstetricians dan
Gynecologists (ACOG) merekomendasikan bahwa pemantauan denyut jantung janin
harus digunakan untuk menilai status dan kencan kriteria janin Ulasan, dan
kelompok B streptokokus profilaksis diberikan berdasarkan hasil kultur sebelumnya
atau faktor risiko budaya tidak tersedia. Selain itu, percobaan terkontrol acak
sampai saat ini menunjukkan bahwa untuk wanita dengan PROM di jangka, induksi
persalinan, biasanya dengan oxytocininfusion, pada saat presentasi dapat
mengurangi risiko korioamnionitis. [40]
Menurut Friedman dan rekan, [6] tingkat dilatasi serviks harus minimal 1 cm / jam
pada wanita nulipara dan 1,2 cm / jam pada wanita multipara selama fase aktif
persalinan. Namun, manajemen melahirkan telah berubah secara substansial
selama seperempat abad terakhir. Terutama, intervensi obstetri seperti induksi
persalinan, augmentasi persalinan dengan pemberian oksitosin, penggunaan
anestesi regional untuk mengontrol rasa sakit, dan pemantauan denyut jantung
janin terus menerus adalah praktek semakin umum dalam pengelolaan melahirkan
dalam populasi obstetri saat ini. [41, 42, 20] vagina sungsang dan pertengahan
atau pengiriman tinggi forsep sekarang jarang dilakukan. [43, 44, 45] [8, 9, 20 Oleh
karena itu, penulis selanjutnya telah menyarankan persalinan normal bisa
mendahului pada tingkat kurang cepat dari yang telah dijelaskan sebelumnya. ]
Data yang dikumpulkan dari Konsorsium Aman Melahirkan menunjukkan bahwa
memungkinkan melahirkan untuk melanjutkan lagi sebelum 6-cm pelebaran dapat
mengurangi tingkat intrapartum dan sesar berikutnya di Amerika Serikat. [46]
Dalam studi tersebut, para penulis mencatat bahwa 95 persen untuk maju dari 4 cm
dilatasi untuk 5-cm pelebaran itu lebih dari 6 jam; dan 95 persen untuk maju dari 5
cm pelebaran 6-cm pelebaran itu lebih lama dari 3 jam, tanpa paritas pasien.
Pada masuk ke Melahirkan dan Pengiriman suite, wanita memiliki persalinan normal
harus didorong untuk mengambil posisi yang dia menemukan paling nyaman.
Kemungkinan termasuk berjalan, berbaring telentang, duduk, atau beristirahat
dalam posisi dekubitus lateral kiri. Dari catatan, ambulating saat melahirkan tidak
mengubah perkembangan melahirkan dalam studi acak terkontrol besar> 1000
wanita melahirkan aktif. [47]
Pasien dan tim keluarga atau dukungan nya harus dikonsultasikan mengenai risiko
dan manfaat dari berbagai intervensi, seperti augmentasi persalinan menggunakan
oksitosin, pecah buatan dari membran, metode dan agen farmakologis untuk
mengontrol rasa sakit, dan pengiriman vagina operasi (termasuk tang atau
pengiriman vagina-vakum dibantu) atau sesar. Mereka harus terlibat aktif, dan
preferensi mereka harus dipertimbangkan dalam keputusan manajemen dibuat
selama persalinan dan melahirkan. [2]
Frekuensi dan kekuatan kontraksi uterus dan perubahan serviks dan dalam 'stasiun
janin dan posisi harus dinilai secara berkala untuk mengevaluasi perkembangan

melahirkan. Meskipun kemajuan harus dimonitor, pemeriksaan vagina harus


dilakukan hanya bila diperlukan untuk meminimalkan risiko korioamnionitis,
terutama pada wanita yang membran amnion telah pecah. Selama tahap pertama
persalinan, kesejahteraan janin dapat dinilai dengan memantau denyut jantung
janin setidaknya setiap 15 menit, terutama selama dan segera setelah kontraksi
uterus. Dalam kebanyakan melahirkan dan pengiriman unit, denyut jantung janin
dinilai terus menerus. [3]
Dua metode menambah melahirkan telah ditetapkan. Metode tradisional melibatkan
penggunaan dosis rendah oksitosin dengan interval panjang antara kenaikan dosis.
Misalnya, infus dosis rendah oksitosin dimulai pada 1 mili IU / menit dan meningkat
1-2 mili IU / menit setiap 20-30 menit sampai kontraksi uterus yang memadai
diperoleh. [2]
Metode kedua, atau manajemen aktif persalinan, melibatkan protokol manajemen
klinis yang bertujuan untuk mengoptimalkan kontraksi rahim dan memperpendek
persalinan. Protokol ini mencakup kriteria yang ketat untuk masuk ke persalinan dan
pengiriman Unit, amniotomi dini, pemeriksaan serviks per jam, diagnosis dini
aktivitas uterus yang tidak efisien (jika tingkat dilatasi serviks adalah <1,0 cm /
jam), dan dosis tinggi oksitosin infus jika aktivitas uterus tidak efisien. Infus
oksitosin dimulai pada 4 mili IU / menit (atau bahkan 6 mili IU / min) dan meningkat
4 mili IU / menit (atau 6 mili IU / menit) setiap 15 menit sampai tingkat 7 kontraksi
per 15 menit dicapai atau sampai laju infus maksimum 36 mili IU / min tercapai.
[48, 2]
Meskipun manajemen aktif persalinan pada awalnya ditujukan untuk
memperpendek panjang melahirkan pada wanita nulipara, penerapannya di Rumah
Sakit Bersalin Nasional di Dublin menghasilkan tingkat kelahiran sesar utama 5-6%
pada nulipara. [49] Data dari percobaan terkontrol acak dikonfirmasi bahwa
manajemen aktif persalinan lebih pendek tahap pertama persalinan dan
mengurangi kemungkinan morbiditas demam ibu, tetapi tidak konsisten
mengurangi kemungkinan kelahiran sesar. [50, 51, 52]
Meskipun protokol manajemen aktif cenderung mengarah ke diagnosis dini dan
intervensi untuk distosia persalinan, sejumlah faktor risiko yang terkait dengan
kegagalan melahirkan untuk kemajuan selama tahap pertama. Faktor risiko ini
termasuk pecah prematur membran (PROM), nulliparity, induksi persalinan,
meningkatkan usia ibu, dan atau komplikasi lain (misalnya, kematian perinatal
sebelumnya, diabetes mellitus pragestasional atau kehamilan, hipertensi,
pengobatan infertilitas). [53, 54 ]
Sementara ACOG mendefinisikan distosia persalinan sebagai melahirkan normal
yang menghasilkan bentuk kelainan daya (kontraksi rahim atau kekuatan ekspulsif
ibu), penumpang (posisi, ukuran, atau presentasi janin), atau bagian itu (pelvis atau
jaringan lunak), melahirkan distosia jarang dapat didiagnosis dengan pasti. [1]

Seringkali, "kegagalan untuk kemajuan" dalam tahap pertama didiagnosis jika pola
kontraksi uterus melebihi 200 unit Montevideo selama 2 jam tanpa perubahan
serviks selama fase aktif persalinan ditemui. [1 ] Dengan demikian, kriteria
tradisional untuk mendiagnosis penangkapan aktif-fase yang dilatasi serviks
minimal 4 cm, perubahan serviks dari <1 cm dalam 2 jam, dan pola kontraksi
uterus dari> 200 unit Montevideo. Temuan ini juga merupakan indikasi umum untuk
sesar.