S1ACLS Cl LA8C8 and uLLlvL8?

Lvery womans labor ls unlque even from one pregnancy Lo Lhe nexL ln some cases labor ls over ln a maLLer of
hours or less ln oLher cases labor LesLs a moLhers physlcal and emoLlonal sLamlna ?ou wonL know how your
labor wlll unfold unLll lL happens ?ou can prepare however by undersLandlng Lhe Lyplcal sequence of evenLs
Stage 1 Lar|y |abor and act|ve |abor
1he flrsL sLage of labor occurs when Lhe cervlx opens (dllaLes) and Lhlns ouL (effaces) Lo allow Lhe baby Lo move
lnLo Lhe blrLh canal 1hls ls Lhe longesL of Lhe Lhree sLages of labor lLs acLually dlvlded lnLo Lwo phases of lLs own
early labor and acLlve labor
Lar|y |abor
uurlng early labor your cervlx wlll begln Lo dllaLe ?oull feel mlld Lo moderaLely sLrong conLracLlons durlng early
labor 1hey may lasL 30 Lo 90 seconds and come aL regular lnLervals As your cervlx beglns Lo open you mlghL
noLlce a Lhlck sLrlngy bloodLlnged dlscharge from your vaglna 1hls ls known as bloody show
now |ong |t |asts Larly labor ls unpredlcLable lL can lasL for hours or even days especlally for flrsLLlme moms lLs
ofLen much shorLer for subsequenL dellverles
What you can do unLll your conLracLlons lncrease ln frequency and lnLenslLy lLs up Lo you lor many women
early labor lsnL parLlcularly uncomforLable ?ou mlghL feel llke dolng household chores Laklng a walk or waLchlng
a movle or you mlghL slmply conLlnue your dally acLlvlLles
1o promoLe comforL durlng early labor
O 1ake a shower or baLh
O LlsLen Lo relaxlng muslc
O ave a genLle massage
O 1ry slow deep breaLhlng
O hange poslLlons
O urlnk waLer [ulce or oLher clear llqulds
O LaL llghL healLhy snacks
O Apply lce packs or heaL Lo your lower back
ct|ve |abor
now lLs Llme for Lhe real work Lo begln uurlng acLlve labor your cervlx wlll dllaLe Lo 10 cenLlmeLers ?our
conLracLlons wlll geL sLronger lasL longer and come closer LogeLher near Lhe end of acLlve labor lL mlghL feel as
Lhough Lhe conLracLlons never compleLely dlsappear ?ou mlghL feel lncreaslng pressure ln your back as well lf you
havenL headed Lo your labor and dellvery faclllLy yeL nows Lhe Llme
uonL be surprlsed lf your lnlLlal exclLemenL wanes as your labor progresses and Lhe paln lnLenslfles uonL feel LhaL
youre glvlng up lf you ask for paln medlcaLlon or anesLhesla ?our healLh care Leam wlll help you make Lhe besL
cholce for you and your baby 8emember youre Lhe only one who can [udge your need for paln rellef
now |ong |t |asts AcLlve labor ofLen lasLs up Lo elghL hours lor some women acLlve labor lasLs hours longer lor
oLhers especlally Lhose whove had a prevlous vaglnal dellvery acLlve labor ls much shorLer
What you can do Look Lo your labor coach and healLh care Leam for encouragemenL and supporL 1ry breaLhlng
and relaxaLlon Lechnlques Lo combaL your growlng dlscomforL use whaL you learned ln chlldblrLh class or ask your
healLh care Leam for suggesLlons
1o promoLe comforL durlng acLlve labor
O hange poslLlons
O 8ock ln a rocklng chalr
O 8oll on a blrLhlng ball
O 1ake a warm shower or baLh
O 9lace a cool damp cloLh on your forehead
O 1ake a walk sLopplng Lo breaLhe Lhrough conLracLlons
O ave a genLle massage beLween conLracLlons
1he lasL parL of acLlve labor ofLen referred Lo as LranslLlon can be parLlcularly lnLense lf you feel Lhe urge Lo
push buL youre noL fully dllaLed your healLh care provlder mlghL ask you Lo hold back 9ushlng Loo soon could
cause your cervlx Lo Lear or swell whlch mlghL delay dellvery or cause Lroublesome bleedlng 9anL or blow your
way Lhrough Lhe conLracLlons
Stage 2 1he b|rth of your baby
lLs Llme! ?oull dellver your baby durlng Lhe second sLage of labor
now |ong |t |asts lL can Lake from a few mlnuLes up Lo several hours or more Lo push your baby lnLo Lhe world lL
ofLen Lakes longer for flrsLLlme moms and women whove had an epldural
What you can do 9ush! ?ou mlghL be encouraged Lo push wlLh each conLracLlon Lo speed Lhe process Cr you
mlghL Lake lL more slowly leLLlng naLure do Lhe work unLll you feel Lhe urge Lo push
When you push donL hold Lenslon ln your face 8ear down and concenLraLe on pushlng where lL counLs
LxperlmenL wlLh dlfferenL poslLlons unLll you flnd one LhaL feels besL ?ou can push whlle squaLLlng slLLlng
kneellng even on your hands and knees
AL some polnL you mlghL be asked Lo push more genLly or noL aL all Slowlng down glves your vaglnal Llssues
Llme Lo sLreLch raLher Lhan Lear 1o sLay moLlvaLed you mlghL ask Lo feel Lhe babys head beLween your legs or see
lL ln a mlrror
AfLer your babys head ls dellvered hls or her alrway wlll be cleared and your healLh care provlder wlll make sure
Lhe umblllcal cord ls free 1he resL of your babys body wlll follow shorLly
Stage 3 De||very of the p|acenta
AfLer your baby ls born youll llkely feel a greaL sense of rellef ?ou mlghL hold Lhe baby ln your arms or on your
abdomen herlsh Lhe momenL 8uL a loL ls sLlll happenlng uurlng Lhe Lhlrd sLage of labor your healLh care
provlder wlll dellver Lhe placenLa and make sure your bleedlng ls under conLrol
now |ong |t |asts 1he placenLa ls Lyplcally dellvered ln abouL flve Lo 10 mlnuLes ln some cases lL may Lake up Lo
30 mlnuLes
What you can do 8elax! 8y now your focus has llkely shlfLed Lo your baby ?ou mlghL be obllvlous Lo whaLs golng
on around you lf youd llke Lry breasLfeedlng your baby
?oull conLlnue Lo have mlld conLracLlons ?our healLh care provlder mlghL massage your lower abdomen Lo
encourage your uLerus Lo conLracL and expel Lhe placenLa ?ou mlghL be asked Lo push one more Llme Lo dellver
Lhe placenLa whlch usually comes ouL wlLh a small gush of blood
?our healLh care provlder wlll examlne Lhe placenLa Lo make sure lLs lnLacL Any remalnlng fragmenLs musL be
removed from Lhe uLerus Lo prevenL bleedlng and lnfecLlon lf youre lnLeresLed ask Lo see Lhe placenLa
?our healLh care provlder wlll also deLermlne wheLher you need sLlLches or oLher repalr work lf you do youll
recelve an ln[ecLlon of local anesLheLlc ln Lhe area Lo be sLlLched lf lLs noL numb already ?ou mlghL also be glven
medlcaLlon Lo encourage uLerlne conLracLlons and mlnlmlze bleedlng
MLAnlSMS Cl LA8C8

1he ,echan|sms of Labor occur Lo Lhe feLus durlng dellvery knowledge of Lhese mechanlsms enables Lhe nurse Lo
proceed wlLh normal dellvery and deLecL lf any abnormallLles are occurrlng durlng dellvery LhaL can enable Lhe
healLh care Leam Lo perform measures LhaL could prevenL posslble compllcaLlons ?ou can be gulded by Lhe
acronym LDIILkLkL
L Lngagement
lL ls Lhe mechanlsm whereln Lhe feLus 'engages' Lo Lhe pelvls lL ls also called llghLenlng or dropplng
D Descent
uescenL ls Lhe mechanlsm where Lhe feLal head beglns lLs [ourney Lhrough Lhe pelvls AssessmenL measuremenL ls
Lermed as sLaLlon
I I|ex|on
ls Lhe mechanlsm where Lhe feLal head ls noddlng or flexlng forward Loward lLs chesL
Ik Interna| kotat|on
1hls occurs from Lhe occlpuL Lransverse poslLlon Lo Lhe occlpuL anLerlor poslLlon whlle descendlng
L Lxtens|on
1hls enables Lhe head Lo emerge when Lhe feLus ls ln cephallc poslLlon 1hls beglns when Lhe head ls crownlng
k kest|tut|on
lL ls Lhe reallgnmenL of Lhe head of Lhe feLus wlLh Lhe body as Lhe feLus' head emerges
Lk Lxterna| kotat|on
1hls mechanlsm ls where Lhe shoulders roLaLe exLernally once Lhe head emerges and resLlLuLlon occurs so LhaL Lhe
shoulders would be ln Lhe anLeroposLerlor dlameLer of Lhe moLher's pelvls
L Lxpu|s|on
lL ls Lhe blrLh of Lhe enLlre body of Lhe feLus
CLher 1ermlnologles and 9rocedures
Crown|ng 1he feLal head dlsLends Lhe lablal and perlneal Llssue and Lhe anus ls sLreLched wlde
k|tgen ,aneuver 9ressure ls applled Lo Lhe feLal chln Lhrough Lhe perlneum aL Lhe same Llme pressure ls applled
Lo Lhe occlpuL 1hls alds Lhe mechanlsm of exLenslon as Lhe feLal head comes under Lhe symphysls

1?9LS Cl 9LALn1A (98LvlA and A8L1A)

|acenta accreta ls a severe obsLeLrlc compllcaLlon lnvolvlng an abnormally deep aLLachmenL of Lhe placenLa
Lhrough Lhe endomeLrlum and lnLo Lhe myomeLrlum (Lhe mlddle layer of Lhe uLerlne wall) 1here are Lhree forms
of placenLa accreLa dlsLlngulshable by Lhe depLh of peneLraLlon
1he placenLa usually deLaches from Lhe uLerlne wall relaLlvely easlly buL women who encounLer placenLa accreLa
durlng chlldblrLh are aL greaL rlsk of haemorrhagedurlng lLs removal 1hls commonly requlres surgery Lo sLem Lhe
bleedlng and fully remove Lhe placenLa and ln severe forms can ofLen lead Lo a hysLerecLomy or be faLal
9lacenLa accreLa affecLs approxlmaLely 1 ln 2300 pregnancles
varlanLs
1here are mulLlple varlanLs deflned by Lhe depLh of Lhelr aLLachmenL Lo uLerlne wall
1ype Descr|pt|on ercent
placenLa
accreLa
An lnvaslon of Lhe myomeLrlum whlch does noL peneLraLe Lhe enLlre Lhlckness of Lhe muscle
1hls form of Lhe condlLlon accounLs for around 73 of all cases
7378
placenLa
lncreLa
Cccurs when Lhe placenLa furLher exLends lnLo Lhe myomeLrlum 17
placenLa
percreLa
1he worsL form of Lhe condlLlon ls when Lhe placenLa peneLraLes Lhe enLlre myomeLrlum Lo
Lhe uLerlne serosa (lnvades Lhrough enLlre uLerlne wall) 1hls varlanL can lead Lo Lhe placenLa
aLLachlng Lo oLher organs such as Lhe recLum or bladder
1

37
ulagnosls
9lacenLa accreLa ls very rarely recognlsed before blrLh and ls very dlfflculL Lo dlagnose A uoppler ulLrasound can
lead Lo Lhe dlagnosls of a suspecLed accreLa and an M8l wlll glve more deLall leadlng Lo furLher susplclon of such an
abnormal placenLa owever boLh Lhe ulLrasound and Lhe M8l rarely conflrm an accreLa wlLh cerLalnLy Whlle lL
can lead Lo some vaglnal bleedlng durlng Lhe Lhlrd LrlmesLer Lhls ls more commonly assoclaLed wlLh Lhe facLors
leadlng Lo Lhe condlLlon ln some cases Lhe second LrlmesLer can see elevaLed maLernal serum alpha
feLoproLeln levels Lhough Lhls ls also an lndlcaLor of many oLher condlLlons
2

uurlng blrLh placenLa accreLa ls suspecLed lf Lhe placenLa has noL been dellvered wlLhln 30 mlnuLes of Lhe blrLh
usually ln Lhls case manual blunL dlssecLlon or placenLa LracLlon ls aLLempLed buL can cause haemorrhage ln
accreLa
8lsk facLors
1he condlLlon affecLs around 10 of cases of placenLa praevla and ls lncreased ln lncldence by Lhe presence
of scar Llssue le Ashermans syndrome usually from pasL uLerlne surgery especlally from a pasL ullaLlon and
cureLLage
3
(whlch ls used for many lndlcaLlons lncludlng mlscarrlage LermlnaLlon and posLparLum
hemorrhaglng) myomecLomy
4
or caesarean secLlon A Lhln decldua can also be a conLrlbuLlng facLor Lo
such LrophoblasLlc lnvaslon Some sLudles suggesL LhaL Lhe raLe of lncldence ls hlgher when Lhe feLus ls female
3

1reaLmenL
1he safesL LreaLmenL ls a planned caesarlan secLlon and abdomlnal hysLerecLomy lf placenLa accreLa ls dlagnosed
before blrLh
67

lf lL ls lmporLanL Lo save Lhe womans uLerus (for fuLure pregnancles) Lhen resecLlon around Lhe placenLa may be
successful
onservaLlve LreaLmenL can also be uLerus sparlng buL may noL be as successful and has a hlgher rlsk of
compllcaLlons
7
1echnlques lnclude
leavlng Lhe placenLa ln Lhe uLerus
lnLeruLerlne balloon caLheLerlsaLlon Lo compress Lo blood vessels
embollsaLlon of pelvlc vessels
lf Lhe woman decldes Lo proceed wlLh a vaglnal dellvery blood producLs for Lransfuslon should be prepared
1he placenLa normally aLLaches Lo Lhe uLerlne wall however Lhere ls a condlLlon LhaL occurs where Lhe placenLa
aLLaches lLself Loo deeply lnLo Lhe wall of Lhe uLerus 1hls condlLlon ls known as placenLa accreLa placenLa lncreLa
or placenLa percreLa dependlng on Lhe severlLy and deepness of Lhe placenLa aLLachmenL ApproxlmaLely 1 ln
2300 pregnancles experlence placenLa accreLa lncreLa or percreLa
WhaL ls Lhe dlfference beLween accreLa lncreLa or percreLa?
1he dlfference beLween placenLa accreLa lncreLa or percreLa ls deLermlned by Lhe severlLy of Lhe aLLachmenL of
Lhe placenLa Lo Lhe uLerlne wall
|acenta ccreta occurs when Lhe placenLa aLLaches Loo deep ln Lhe uLerlne wall buL lL does noL peneLraLe Lhe
uLerlne muscle 9lacenLa accreLa ls Lhe mosL common accounLlng for approxlmaLely 73 of all cases
|acenta Increta occurs when Lhe placenLa aLLaches even deeper lnLo Lhe uLerlne wall and does peneLraLe lnLo Lhe
uLerlne muscle 9lacenLa lncreLa accounLs for approxlmaLely 13 of all cases
|acenta ercreta occurs when Lhe placenLa peneLraLes Lhrough Lhe enLlre uLerlne wall and aLLaches Lo anoLher
organ such as Lhe bladder 9lacenLa percreLa ls Lhe leasL common of Lhe Lhree condlLlons accounLlng for
approxlmaLely 3 of all cases
WhaL causes placenLa accreLa?
1he speclflc cause of placenLa accreLa ls unknown buL lL can be relaLed LoplacenLa prevla and prevlous cesarean
dellverles 9lacenLa accreLa ls presenL ln 3 Lo 10 of women wlLh placenLa prevla
A cesarean dellvery lncreases Lhe posslblllLy of a fuLure placenLa accreLa and Lhe more cesareans Lhe greaLer Lhe
lncrease MulLlple cesareans were presenL ln over 60 of placenLa accreLa cases
WhaL are Lhe rlsks of placenLa accreLa Lo Lhe baby?
9remaLure dellvery and subsequenL compllcaLlons are Lhe prlmary concerns for Lhe baby 8leedlng durlng Lhe Lhlrd
LrlmesLer may be a warnlng slgn LhaL placenLa accreLa exlsLs and when placenLa accreLa occurs lL commonly
resulLs ln a premaLure dellvery ?our healLhcare provlder wlll examlne your condlLlon and use medlcaLlon bed resL
and whaLever else necessary Lo help conLlnue Lhe pregnancy Lowards full Lerm
WhaL are Lhe rlsks of placenLa accreLa Lo Lhe moLher?
1he placenLa usually has dlfflculLy separaLlng from Lhe uLerlne wall 1he prlmary concern for Lhe moLher ls
hemorrhaglng durlng manual aLLempLs Lo deLach Lhe placenLa Severe hemorrhaglng can be llfe LhreaLenlng CLher
concerns lnvolve damage Lo Lhe uLerus or oLher organs (percreLa) durlng removal of Lhe placenLa ysLerecLomy ls
a common LherapeuLlc lnLervenLlon buL Lhe resulLs lnvolve Lhe loss of Lhe uLerus and Lhe ablllLy Lo concelve
WhaL ls Lhe LreaLmenL for placenLa accreLa?
1here ls noLhlng a woman can do Lo prevenL placenLa accreLa and Lhere ls llLLle LhaL can be done for LreaLmenL
once placenLa accreLa has been dlagnosed lf you have been dlagnosed wlLh placenLa accreLa your healLhcare
provlder wlll monlLor your pregnancy wlLh Lhe lnLenL of schedullng a dellvery and uslng a surgery LhaL may spare
Lhe uLerus lL ls parLlcularly lmporLanL Lo dlscuss Lhls surgery wlLh your docLor lf you deslre Lo have addlLlonal
chlldren
unforLunaLely placenLa accreLa may be severe enough LhaL a hysLerecLomy may be needed Agaln lL ls lmporLanL
Lo dlscuss surglcal opLlons wlLh your healLhcare provlder
|acenta praev|a (p|acenta prev|a AL) ls an obsLeLrlc compllcaLlon ln whlch Lhe placenLa ls aLLached Lo Lhe uLerlne
wall close Lo or coverlng Lhe cervlx
1
lL can someLlmes occur ln Lhe laLer parL of Lhe flrsL LrlmesLer buL usually
durlng Lhe second or Lhlrd lL ls a leadlng cause of anLeparLum haemorrhage (vaglnal bleedlng) lL affecLs
approxlmaLely 03 of all labours
lL ls hypoLheslzed
wbo?
Lo be relaLed Lo abnormal vascularlsaLlon of Lhe endomeLrlum caused by scarrlng
or aLrophy from prevlous Lrauma surgery or lnfecLlon
ln Lhe lasL LrlmesLer of pregnancy Lhe lsLhmus of Lhe uLerus unfolds and forms Lhe lower segmenL ln a normal
pregnancy Lhe placenLa does noL overlle lL so Lhere ls no bleedlng lf Lhe placenLa does overlle Lhe lower segmenL
lL may shear off and a small secLlon may bleed
Women wlLh placenLa prevla ofLen presenL wlLh palnless brlghL red vaglnal bleedlng 1hls bleedlng ofLen sLarLs
mlldly and may lncrease as Lhe area of placenLal separaLlon lncreases 9raevla should be suspecLed lf Lhere ls
bleedlng afLer 24 weeks of gesLaLlon Abdomlnal examlnaLlon usually flnds Lhe uLerus nonLender and
relaxed Leopolds Maneuvers may flnd Lhe feLus ln an obllque or breech poslLlon or lylng Lransverse as a resulL of
Lhe abnormal poslLlon of Lhe placenLa 9raevla can be conflrmed wlLh an ulLrasound
2
ln parLs of Lhe world where
ulLrasound ls unavallable lL ls noL uncommon Lo conflrm Lhe dlagnosls wlLh an examlnaLlon ln Lhe surglcal LheaLre
1he proper Llmlng of an examlnaLlon ln LheaLre ls lmporLanL lf Lhe woman ls noL bleedlng severely she can be
managed nonoperaLlvely unLll Lhe 36Lh week 8y Lhls Llme Lhe babys chance of survlval ls as good as aL full Lerm
9lacenLa prevla ls classlfled accordlng Lo Lhe placemenL of Lhe placenLa
1ype I or low lylng 1he placenLa encroaches Lhe lower segmenL of Lhe uLerus buL does noL lnfrlnge on Lhe
cervlcal os
1ype II or marglnal 1he placenLa Louches buL does noL cover Lhe Lop of Lhe cervlx
1ype III or parLlal 1he placenLa parLlally covers Lhe Lop of Lhe cervlx
1ype IV or compleLe 1he placenLa compleLely covers Lhe Lop of Lhe cervlx

9lacenLa prevla ls lLself a rlsk facLor of placenLa accreLa
8lsk facLors
1he followlng have been ldenLlfled as rlsk facLors
nfoo oeeJeJ
for placenLa praevla
9revlous placenLa prevla caesarean dellvery
3
or u eg used for lncompleLe or
mlssed mlscarrlage aborLlon Lo LreaL or lnvesLlgaLe heavy bleedlng or oLher dlagnosLlc purposes
Women who have had prevlous pregnancles especlally a large number of closely spaced pregnancles are aL
hlgher rlsk
Women who are younger Lhan 20 are aL hlgher rlsk and women older Lhan 30 are aL lncreaslng rlsk as Lhey geL
older
Women wlLh a large placenLae from Lwlns or eryLhroblasLosls are aL hlgher rlsk
8ace ls a conLroverslal rlsk facLor wlLh some sLudles flndlng LhaL people from Asla and Afrlca are aL hlgher rlsk
and oLhers flndlng no dlfference
lnLervenLlon
An lnlLlal assessmenL Lo deLermlne Lhe sLaLus of Lhe moLher and feLus ls requlred AlLhough moLhers used Lo be
LreaLed ln Lhe hosplLal from Lhe flrsL bleedlng eplsode unLll blrLh lL ls now consldered safe Lo LreaL placenLa
praevla on an ouLpaLlenL basls lf Lhe feLus ls aL less Lhan 30 weeks of gesLaLlon and nelLher Lhe moLher nor Lhe
feLus are ln dlsLress
lmmedlaLe dellvery of Lhe feLus may be lndlcaLed lf Lhe feLus ls maLure or lf Lhe feLus or moLher are ln dlsLress
8lood volume replacemenL (Lo malnLaln blood pressure) and blood plasma replacemenL (Lo malnLaln flbrlnogen
levels) may be necessary
lL ls conLroverslal lf vaglnal dellvery or a aesarean secLlon ls Lhe safesL meLhod of dellvery ln cases of feLal
dlsLress a aesarean secLlon ls lndlcaLed aesarlan secLlon ls conLralndlcaLed ln cases of dlssemlnaLed
lnLravascular coagulaLlon
A problem exlsLs ln places where a aesarean secLlon cannoL be performed due Lo Lhe lack of a surgeon or
equlpmenL ln Lhese cases Lhe lnfanL can be dellvered vaglnally 1here are Lwo ways of dolng Lhls wlLh a placenLa
praevla
1he babys head can be broughL down Lo Lhe placenLal slLe (lf necessary wlLh WllleLs forceps or a vulsellum)
and a welghL aLLached Lo hls scalp
A leg can be broughL down and Lhe babys buLLocks used Lo compress Lhe placenLal slLe
1he goal of Lhls Lype of dellvery ls Lo save Lhe moLher and boLh meLhods wlll ofLen klll Lhe baby 1hese meLhods
were used for many years before aesarean secLlon and saved Lhe llves of boLh moLhers and bables wlLh Lhls
condlLlon
1he maln rlsk wlLh a vaglnal dellvery wlLh a praevla ls LhaL as you are Lrylng Lo brlng down Lhe head or a leg you
mlghL separaLe more of Lhe placenLa and lncrease Lhe bleedlng
9lacenLa praevla lncreases Lhe rlsk of puerperal sepsls and posLparLum haemorrhage because Lhe lower segmenL
Lo whlch Lhe placenLa was aLLached conLracLs less well posLdellvery
9lacenLa 9revla ls a condlLlon where Lhe placenLa lles low ln Lhe uLerus and parLlally or compleLely covers Lhe
cervlx 1he placenLa may separaLe from Lhe uLerlne wall as Lhe cervlx beglns Lo dllaLe (open) durlng labor
ow common ls placenLa prevla?
9lacenLa prevla affecLs abouL 1 ln 200 pregnanL women ln Lhe Lhlrd LrlmesLer of pregnancy
9lacenLa prevla ls more common ln women who have had one or more of Lhe followlng
O More Lhan one chlld
O A cesarean blrLh
O Surgery on Lhe uLerus
O 1wlns or LrlpleLs
WhaL are Lhe dlfferenL Lypes of placenLa prevla?
O Comp|ete prev|a Lhe cervlcal openlng ls compleLely covered
O art|a| prev|a a porLlon of Lhe cervlx ls covered by Lhe placenLa
O ,arg|na| prev|a exLends [usL Lo Lhe edge of Lhe cervlx
WhaL are Lhe sympLoms of placenLa prevla?
Slgns and sympLoms of placenLa prevla vary buL Lhe mosL common sympLom ls palnless bleedlng durlng Lhe Lhlrd
LrlmesLer CLher reasons Lo suspecL placenLa prevla would be
O 9remaLure conLracLlons
O 8aby ls breech or ln Lransverse poslLlon
O uLerus measures larger Lhan lL should accordlng Lo gesLaLlonal age
WhaL ls Lhe LreaLmenL for placenLa prevla?
Cnce dlagnosed placenLa prevla wlll usually requlre bed resL for Lhe moLher and frequenL hosplLal vlslLs
uependlng on Lhe gesLaLlonal age sLerold shoLs may be glven Lo help maLure Lhe babys lungs lf Lhe bleedlng
cannoL be conLrolled an lmmedlaLe cesarean dellvery ls usually done regardless of Lhe lengLh of Lhe pregnancy
Some fof pevf can be dellvered vaglnally alLhough nopee or pff pevf would requlre a cesarean
dellvery
MosL physlclans recommend women who are experlenclng placenLa prevla Lo
O Avold lnLercourse
O LlmlL Lravellng
O Avold pelvlc exams
WhaL causes placenLa prevla?
1he exacL cause of placenLa prevla ls unknown owever Lhe followlng can lncrease your rlsk
O lf over Lhe age of 33
O ad more Lhan four pregnancles
O ave a hlsLory of uLerlne surgery (regardless of lnclslon Lype)
ow do l cope wlLh placenLa prevla?
WlLh all Lhe exclLemenL and anLlclpaLlon of a healLhy dellvery recelvlng Lhe dlagnosls of placenLa prevla can be a
very shocklng and frusLraLlng experlence 1here are supporL groups for bed resL moLhers and even some for
moLhers wlLh placenLa prevla 1hey are avallable Lo help you Lhrough Lhls dlfflculL Llme ?our docLor mldwlfe or
doula should be able Lo asslsL you wlLh flndlng supporL groups or oLher women who have also had placenLa prevla

SlCnS Cl 9LALn1AL SL9A8A1lCn

1 uLerus becomes flrm and globular
2 sudden gush of blood from Lhe vaglna
3 umblllcal cord lengLhens ouLslde vulva
4 uLerlne fundus rlses ln Lhe abdomen


lL1AL 9CSl1lCnS
leLal poslLlon reflecLs Lhe orlenLaLlon of Lhe feLal head or buLL wlLhln Lhe blrLh canal
nter|or Iontane|
1he bones of Lhe feLal scalp are sofL and meeL aL suLure llnes
Cver Lhe forehead where Lhe bones meeL ls a gap called Lhe anLerlor fonLanel or sofL spoL 1hls wlll close as
Lhe baby grows durlng Lhe 1sL year of llfe buL aL blrLh lL ls open
1he anLerlor fonLanel ls an obsLeLrlcal landmark because of lLs dlsLlncLlve dlamond shape leellng Lhls fonLanel on
pelvlc exam Lells you LhaL Lhe forehead ls [usL beneaLh your flngers
Larly ln labor lL ls usually dlfflculL (lf noL lmposslble) Lo feel Lhe anLerlor fonLanel AfLer Lhe paLlenL ls nearly
compleLely dllaLed lL becomes easler Lo feel Lhe fonLanel
When aLLachlng a feLal scalp elecLrode lL ls beLLer Lo noL aLLach lL Lo Lhe area of Lhe fonLanel
oster|or Iontane|
1he occlpuL of Lhe baby has a slmllar obsLeLrlc landmark Lhe posLerlor fonLanel
1hls [uncLlon of suLure llnes ln a ? shape LhaL ls very dlfferenL from Lhe anLerlor fonLanel
ln cases of feLal scalp swelllng or slgnlflcanL moldlng Lhese landmarks may
Ccc|put nter|or (C%
CcclpuL anLerlor ls usually Lhe easlesL poslLlon for Lhe feLal head Lo Lraverse Lhe maLernal pelvls
Shown here ls Lhe dlrecL CA poslLlon Whlle some feLuses dellver ln Lhls poslLlon oLhers dellver sllghLly roLaLed
clockwlse (LCA) or counLerclockwlse (8CA) LlLher way Lhe feLus ls sLlll consldered Lo be an an anLerlor poslLlon
Left Ccc|put nter|or (LC%
1he feLal poslLlon ls ofLen descrlbed uslng Lhree leLLers
1hls ls an example of LCA meanlng
O LefL
O CcclpuL
O AnLerlor
ln oLher words Lhe feLal occlpuL ls dlrecLed Lowards Lhe moLhers lefL anLerlor slde
k|ght Ccc|put nter|or (kC%
1hls ls an example of 8CA meanlng
O 8lghL
O CcclpuL
O AnLerlor
1hese anLerlor presenLaLlons (8CA and LCA) are normal and usually are Lhe easlesL way for Lhe feLus Lo Lraverse
Lhe blrLh canal
1ransverse os|t|on
1hls LC1 (LefL CcclpuL 1ransverse) poslLlon and lLs mlrror lmage 8C1 are common ln early labor
As labor progresses and Lhe feLal head descends Lhe occlpuL usually roLaLes anLerlorly converLlng Lhls LC1 Lo an
LCA or CA as Lhe head dellvers
lf Lhe head falls Lo roLaLe desplLe sLeady descenL Lhls ls called a deep Lransverse arresL and ls common among
O 8ables who are Loo blg Lo come Lhrough and
O MoLhers wlLh flaL pelvlses LhaL favor a Lransverse dellvery
Women wlLh Lhls condlLlon who fall Lo dellver sponLaneously are LreaLed wlLh cesarean secLlon forceps or
vacuum exLracLlon dependlng on Lhe cllnlcal clrcumsLances avallable resources and experlence of Lhe operaLor
Ccc|put oster|or
CcclpuL posLerlor poslLlons lncludlng dlrecL C9 LC9 (LefL CcclpuL 9osLerlor) and 8C9 (8lghL CcclpuL 9osLerlor) are
poslLlons favored by cerLaln lnLernal pelvlc shapes 1hls poslLlon has some obsLeLrlcal slgnlflcance
O normally lf Lhe head ls aL 0 SLaLlon Lhe blparleLal dlameLer ls aL Lhe pelvlc lnleL and Lhe head ls fully
engaged ln posLerlor poslLlons aL 0 SLaLlon Lhe blparleLal dlameLer ls sLlll a couple cenLlmeLers above Lhe
pelvlc lnleL meanlng LhaL Lhe head ls noL fully engaged
O 8ables can dellver ln Lhe posLerlor poslLlon buL Lhe pelvls needs Lo be large enough and lL usually Lakes
longer
O lorceps are ofLen used Lo dellver bables ln Lhls poslLlon buL Lhere ls conLroversy wheLher Lhe feLus should
be dellvered ln Lhe posLerlor poslLlon or roLaLed wlLh Lhe forceps Lo Lhe anLerlor poslLlon Much depends
on Lhe cllnlcal clrcumsLances and Lhe experlence of Lhe operaLor
reech os|t|ons
1he Lerms used for breech poslLlons are Lhe same as for cephallc poslLlons excepL Lhe sacrum of Lhe feLus ls used
as Lhe ldenLlfylng landmark lnsLead of Lhe occlpuL
O Sacrum AnLerlor (SA) means Lhe feLal sacrum ls closesL Lo Lhe moLhers symphysls
O LefL Sacrum AnLerlor (LSA) means Lhe feLal sacrum ls closesL Lo Lhe moLhers symphysls and roLaLed
sllghLly Lo Lhe moLhers lefL (clockwlse from dlrecL SA)
O 8lghL Sacrum AnLerlor (8SA) means Lhe feLal sacrum ls closesL Lo Lhe moLhers symphysls and roLaLed
sllghLly Lo Lhe moLhers rlghL (counLerclockwlse from dlrecL SA)
O 8lghL Sacrum 1ransverse (8S1)
O LefL Sacrum 1ransverse (LS1)
O 8lghL Sacrum 9osLerlor (8S9)
O LefL Sacrum 9osLerlor (LS9)
O Sacrum 9osLerlor (S9)


ln1L8nAL LxAMlnA1lCn
WIen u womun's cervIx LIIns durIng Iubour IL Is reIerred Lo us eIIucIng. WIen Ier cervIx Is openIng IL Is cuIIed dIIuLIng.

TIese cervIcuI cIunges cun be meusured by LIe curegIver doIng un InLernuI vugInuI exumInuLIon wILI LIeIr gIoved IIngers durIng Iubour, oILen
reIerred Lo us u VE or vugInuI exumInuLIon, or perIups un 'InLernuI'. DurIng Iubour, vugInuI exumInuLIons ure usuuIIy currIed ouL uILer u
conLrucLIon IInIsIes und wIen LIe womun suys sIe Is reudy.

An InLernuI exumInuLIon procedure InvoIves LIe curegIver puLLIng on u sLerIIe gIove und oILen usIng un unLIsepLIc creum, uppIIed Lo LIe IIrsL
und second IIngerLIps.TIeIr z IIngers ure LIen genLIy InserLed InLo LIe womun's vugInu, so LIe curegIver cun exumIne Ier cervIx. TIe womun's
cervIx Is cIecked Ior LIe IoIIowIng:

O DIIuLIon - or Iow open LIe cervIx Is. TIIs Is meusured Irom 1 Lo 1o cenLImeLres (1o cm beIng IuIIy open or IuIIy dIIuLed).
O TIe consIsLency oI LIe cervIx. s IL soIL, sLreLcIy und yIeIdIng - oILen reIerred Lo us rIpe or IuvourubIe. Or Is IL IIrm und LIgIL rImmed
oILen cuIIed unrIpe durIng IuLe pregnuncy.
O TIe posILIon oI LIe cervIx. DurIng pregnuncy LIe cervIx Ieuns Lowurds LIe buck (or posLerIor) beIInd LIe buby's Ieud. TIIs oILen
mukes IL dIIIIcuIL Ior LIe curegIver Lo reucI. As LIe cervIx rIpens (und durIng Iubour) IL moves Iorwurd Lowurds LIe IronL, mukIng IL
more uccessIbIe Ior LIe curegIver und IndIcuLIng progress Is beIng mude.
O TIe esLImuLIon oI Iow Iur LIe buby's Ieud Ius come down InLo LIe peIvIs. TIIs Is cuIIed LIe sLuLIon und Is meusured Irom mInus (-
), meunIng LIe buby's Ieud Is IIgI und noL enguged, Lo pIus (+), wIere LIe buby's Ieud cun be seen uL bIrLI. MosL bubIes' Ieuds
ure uL mInus z uL LIe begInnIng oI Iubour und o Lo +1 wIen LIe pusIIng sLurLs.
O TIe eIIucemenL. TIIs Is Iow LIIn LIe cervIx IeeIs und Is meusured In percenLuges Irom o% Lo 1oo%. o % Is wIen LIe cervIx Is Iong
und LIIck, 1oo % Is wIen LIe cervIx Is puper LIIn, wIen mosL oI IL Ius been puIIed up und ubsorbed InLo LIe Iower segmenL oI LIe
uLerIne wuII.
O ow weII LIe buby's Ieud Is sILLIng on LIe cervIx. TIe purL oI LIe buby 'IeudIng LIe wuy' durIng Iubour Is cuIIed LIe 'presenLIng purL',
wIIcI muy be LIeIr boLLom II In u breecI posILIon. TIe curegIver LrIes Lo esLImuLe Iow 'weII uppIIed' LIe buby's Ieud or presenLIng
purL Is Lo LIe cervIx. A weII uppIIed Ieud Is regurded us beIng more eIIIcIenL uL dIIuLIng LIe cervIx durIng Iubour.
O TIe posILIon LIe buby Is IyIng In (I.e. posLerIor or unLerIor). TIIs cun be IeIL II LIe cervIx Is more LIun q cms dIIuLed buL cun
someLImes be dIIIIcuIL Lo uccuruLeIy deLermIne.