Surgery and Healing in the Developing World - Dartmouth-Hitchcock

15
128 Surgery and Healing in the Developing World
Protraction of Descent
Descent at a rate below the minimum indicated in Table 1 may be treated with
an oxytocin drip. More than one hour without change of station is evidence of
protraction of descent. This may be due to CPD, uterine dysfunction, or fetal malposition.
It may be useful to palpate for descent of the presenting part while you
assistant provides fundal pressure with a contraction. If good descent is possible
with external help, CPD is less likely as an etiology of the protraction.
Arrest of Dilatation
If dilatation has plateaued for 2 hours or more, and is unresponsive to AROM
and pitocin with no cervical change after 3-4 hours, the patient should be readied
for Cesarean section.
Arrest of Descent
If descent has halted for an hour (multipara) or two (primipara) and is unresponsive
to pitocin, operative delivery is indicated. If vacuum-assisted delivery is
inappropriate (the head is too high), plan to do a cesearean or symphysiotomy.
(Perform symphysiotomy in limited cases of CPD, as described below.)
Note: Protraction and arrest are identified in the face of adequate uterine contractions.
In the absence of an intrauterine pressure catheter, you will have to rely on
your own judgment and that of your midwives to determine that contractions are
indeed adequate.
Prolonged Second Stage
After two hours of full dilatation, even if intrapartum fetal assessment is reassuring,
you will need to assist the delivery. As discussed below, forceps deliveries are
dangerous without experience, and vacuum-assist may be the most appropriate. Sym-
Table 1. The stages and phases of labor
STAGE I: From onset of true labor to full dilatation
10 hours average, 25 hours maximum for primiparas
8 hours average, 19 hours maximum for multiparas
Latent phase (contractions with slow cervical change)
6 hrs/20 hrs primipara,
5 hrs/14 hrs multipara.
Active phase (begins at 3-4 cm dilatation)
Phase of maximal dilatation
3 cm/hr average, 1.2 cm/hr minimum (primips)
6 cm/hr average, 1.5 cm/hr minimum (multips)
Deceleration phase (also phase of maximal descent rate)
STAGE II: From full dilatation to delivery
30 min average, 120 min maximum (primips)
10 min average, 45 min maximum (multips)
STAGE III: From delivery of the infant to delivery of the placenta
5-30 minutes for all patients
Beyond 30 minutes is considered “retained placenta”
STAGE IV: Stabilization of the mother