NORMAL

LABOR AND
DELIVERY OBSTETRICS AND
GYNECOLOGY

DR WISAM ASSAF
CARMEL MEDICAL CENTER
 CRITICAL FACTORS IN LABOR & BIRTH

• The passage
• The fetus
• The relationship between the passage and
the fetus
• The forces of labor
• The psychosocial consideration
 OBSTETRIC EXAMINATION

• Leopold’s
maneuvers are used
to determine fetal
lie (longitudinal or
trans-verse) and, if
possible, fetal
presentation
(breech or cephalic).
 OBSTETRIC
EXAMINATION

Cervical examination:
• Dilation
• Effacement
• Station
• Cervical position
• Cervical consistency
 BISHOP SCORE

Evaluates the favorability of delivery and the

probability of succeeding with an induction
 BISHOP SCORE
Scoring is interpreted as follows:
• 0–4: Indicates a 45–50% chance of failure.
Give prostaglandins for induction.
• 5–9: Points to a 10% chance of failure. Give
pitocin for induction.
• 10–13: Associated with a very high
probability of success. There is no need for
intervention for induction.
 OBSTETRIC EXAMINATION

• Confirm or determine fetal presentation.

• Determine fetal position through palpation of the

fetal sutures and fontanelles.

• Conduct a sterile speculum exam if rupture of

membranes (ROM) is suspected
 THE BIRTH PASSAGE

• The true pelvis is divided into 3 sections:

• The inlet, the pelvic cavity (midpelvis), and the
outlet
• The four classic types of pelvis are:
• Gynecoid, android, anthropoid and platypelloid.
• The gynecoid, or female, pelvis is most common
PELVIC TYPES
 THE FETUS
• Fetal head (size and presence of molding)
• Fetal attitude
• Fetal lie
• Fetal presentation
• Placenta (implantation site)
 FETAL LIE

• Refers to the relationship of the cephalocaudal (spinal

column) axis of the fetus to the cephalocaudal axis of
the woman.
• A longitudinal lie occurs when the cephalocaudal axis
of the fetus is parallel to the woman’s spine.
• A transverse lie occurs when the cephalocaudal axis of
the fetus is at a right angle to the woman’s spine.
FETAL LIE
• What percentage of term labors present with a
longitudinal lie?
A. 20.
B. 50
C. 70
D. 99
• What percentage of term labors present with a
longitudinal lie?
A. 20.
B. 50
C. 70
D. 99
Which of the following serve as landmarks when
assessing descent of the fetal head?

A. Ischial spines
B. Symphysis pubis
C. Ischial tuberosities
D. Sacral promonotory
Which of the following serve as landmarks when
assessing descent of the fetal head?

A. Ischial spines
B. Symphysis pubis
C. Ischial tuberosities
D. Sacral promonotory
 FETAL PRESENTATION

• Is determined by fetal lie and by the body part of

the fetus that enters the pelvic passage first, the
presenting part.
• May be cephalic (most common), breech, or
shoulder.
• Breech and shoulder presentations are referred
to as malpresentations as they are associated
with difficulties during labor.
EXAMPLES OF PRESENTATIONS
 CEPHALIC PRESENTATION
• 97% of births
• Fetal head presents itself to the passage
• “Subcategories” of cephalic presentation includes:
• Vertex presentation: Occiput is the presenting part –
most common type
• Brow Presentation: The fetal head is partially
extended.
• Face presentation: The fetal head is hyperextended.
The relationship of which fetal part to the mother's
pelvis determines the cephalic presentation?

A.mentum
B.sacrum
C.acromion
D.occiput
E.sinciput
The relationship of which fetal part to the mother's
pelvis determines the cephalic presentation?

A.mentum
B.sacrum
C.acromion
D.occiput
E.sinciput
 BREECH PRESENTATION
• 3% of births
• Frank Breech: the fetal hips are flexed and the knees are
extended.
• Complete Breech: the fetal knees and hips are both
flexed; the thighs are on the abdomen and the calves are
on the posterior aspect of the thighs.
• Footling Breech: the fetal hips and legs are extended, and
the feet of the fetus present to the maternal pelvis
(single or double footling).
BREECH PRESENTATION
A 27 year old woman, gravida 2, para 1 at 30 week of
gestation presents to clinic for a routine prenatal visit.
She has known to suffer from "serosal fibroids". Her
fundus measures 37cm from the pubis. In discussing
possible complications of a fibroid uterus during
pregnancy you mention that she is at highest risk for:
A. preterm premature rupture of membranes (PPROM)
B. Placental previa
C. Pregnancy induced hypertension (PIH)
D. Breech presentation
E. placental abruption
A 27 year old woman, gravida 2, para 1 at 30 week of
gestation presents to clinic for a routine prenatal visit.
She has known to suffer from "serosal fibroids". Her
fundus measures 37cm from the pubis. In discussing
possible complications of a fibroid uterus during
pregnancy you mention that she is at highest risk for:
A. preterm premature rupture of membranes (PPROM)
B. Placental previa
C. Pregnancy induced hypertension (PIH)
D. Breech presentation
E. placental abruption
THE STAGES OF LABOR
THE STAGES OF LABOR
Engagement
Flexion
Internal Rotation
Extension
External Rotation
Delivery of Anterior and Posterior Shoulders
During labor, what is the order of the cardinal
movements of the fetus in the birth canal?
Internal rotation,
engagement, flexion,
descent, extension, external
rotation, expulsion. (wrong
answer)
Which of the following placental
implantation most like predisposed to
inverted uterine in 3rd stage of labor?

a. Fundal
b. Anterior
c. Posterior
d. Lateral
e. Lumbar stage of labor
Which of the following placental
implantation most like predisposed to
inverted uterine in 3rd stage of labor?

a. Fundal
b. Anterior
c. Posterior
d. Lateral
e. Lumbar stage of labor
 FETAL HEART RATE MONITORING

• Tachycardia
• Bradycardia
• Variability
• Accelerations
• Decelerations: Early, Late & Variable
 FETAL HEART RATE
MONITORING
• Baseline rate:
• Refers to the average FHR observed
during a 10-minute period of
monitoring.
• Normal range is 110-160 BPM
• >160 BPM = tachycardia
• <110 BPM = bradycardia
FETAL BRADYCARDIA
 CAUSES OF FETAL TACHYCARDIA
• Early fetal hypoxia - Compensation for reduced blood flow
• Maternal fever - Accelerates the metabolism of the fetus
• Maternal dehydration
• Beta-sympathomimetic drugs (Atropine, terbutaline and
other drugs with cardiac stimulant effect).
• Amnionitis - Fetal tachycardia may be first sign of intrauterine
infection.
• Maternal hyperthyroidism - TSH may cross the placenta and
stimulate fetal heart rate.
• Fetal anemia - Heart rate is compensating to improve tissue
perfusion.
 CAUSES OF FETAL BRADYCARDIA

• Late (profound) fetal hypoxia

• Maternal hypotension - Results in decreased
blood flow to the fetus.
• Prolonged umbilical cord compression
• Fatal arrhythmia
 VARIABILITY

• Baseline variability is a measure of the interplay (the push-

pull effect) between the sympathetic and parasympathetic
nervous systems (adequate oxygenation promotes normal
function of the autonomic nervous system and helps the
fetus adapt to the stress of labor).

• Variability - The FETUS is RESPONDING to multiple

factors which constantly speed and slow the heart rate;
adapting to the stress of labor- A GOOD THING!!!
CAUSES OF DECREASED VARIABILITY

• Hypoxia and acidosis - Decreased blood flow

to the fetus.
• Administration of certain drugs -Demerol,
Valium or other CNS depressants
• Fetal sleep cycle - During fetal sleep, LTV is
decreased.
• Fetus of less than 32 weeks gestation
 CAUSES OF INCREASED VARIABILITY

• Early mild hypoxia – compensatory

mechanism.
• Fetal stimulation – stimulation of autonomic
nervous system, i.e. palpation, vaginal
examination etc.
 ACCELERATION

• Transient increases in the FHR (>15 bpm above

the baseline, lasting >15 seconds), normally
caused by fetal movement (think about the NST).

• It often accompany uterine contractions, usually

due to the fetal movement in response to the
pressure of the contraction.
FHR ACCELERATIONS
 DECELERATION

• Periodic decrease in FHR from the normal baseline.

• They are categorized as early, late, and variable according
to the time of their occurrence in the contraction cycle
and their waveform.
• Early deceleration- when the fetal head is compressed,
cerebral flood flow is decreased which leads to central
vagal stimulation. The onset of early deceleration occurs
with the onset of the uterine contraction. Usually benign.
EARLY DECELERATIONS
 LATE DECELERATIONS

• Caused by uteroplacental insufficiency

resulting from decreased blood flow and
oxygen transfer to the fetus through the
intervillous spaces during uterine contraction.
• Occurs after the onset of a uterine
contraction. Non-reassuring sign.
LATE DECELERATIONS
A gradual, smooth deceleration of the fetal heart rate
that follows the peak of a contraction describes which
of the following deceleration types?

A. Late
B. Early
C.Variable
D. Prolonged
A gradual, smooth deceleration of the fetal heart rate
that follows the peak of a contraction describes which
of the following deceleration types?

A. Late
B. Early
C.Variable
D. Prolonged
 VARIABLE DECELERATIONS

• Occur if the umbilical cord becomes

compressed, this reducing blood flow between
the placenta and fetus.
• The peripheral resistance in the fetal circulation
increases, causing fetal hypertension.
• Non-reassuring sign. Further assessment of this
pattern is necessary.
VARIABLE DECELERATIONS
INTRAUTERINE RESUSCITATION

• Oxytocin off.
• Position- left lateral.
• Tocolysis.
• Oxygen.
• Fluids.
 NONSTRESS TEST (NST)

• Performed with the mother resting in the

lateral tilt position (to prevent supine
hypotension).
• FHR is monitored externally by Doppler along
with a tocodynamometer to detect uterine
contractions.
• Acoustic stimulation may be used.
 • Reactive: (normal response): Two
accelerations of ≥ 15 bpm above baseline
lasting for at least 15 seconds over a 20-
minute period.

REACTIVE AND • Nonreactive: Fewer than two

accelerations over a 20-minute period.
NONREACTIVE • Perform further tests (e.g., a biophysical
RESPONSES profile).
• Lack of FHR accelerations may occur with
any of the following: GA < 32 weeks, fetal
sleeping, fetal CNS anomalies, and maternal
sedative or narcotic administration.
Definition of reactive non stress test:

A. 1 acceleration in 20 min
B. 2 acceleration in 20 min
C. 8 acceleration in 20 min
D. 15 acceleration in 20 min
Definition of reactive non stress test:

A. 1 acceleration in 20 min
B. 2 acceleration in 20 min
C. 8 acceleration in 20 min
D. 15 acceleration in 20 min
 • Performed in the lateral recumbent position.
• FHR is monitored during spontaneous or
induced (via nipple stimulation or oxytocin)
contractions.
CONTRACTION • Reactivity is determined from fetal heart
STRESS TEST monitoring, as with the NST.
(CST) • The procedure is contraindicated in women
with preterm membrane rupture or known
placenta previa; women with a history of
uterine surgery; and women who are at high
risk for preterm labor.
 • “Positive” CST: Defined by late decelerations
following 50% or more of contractions in a 10-
minute window; raises concerns about fetal
compromise. Delivery is usually warranted.

• “Negative” CST: Defined as no late or

significant variable decelerations within 10 minutes
CST ANALYSIS and at least three contractions. Highly predictive
of fetal well-being in conjunction with a normal
NST.

• “Equivocal” CST: Defined by intermittent late

decelerations or significant variable decelerations.
 • Uses real-time ultrasound to assign a score of 2
(normal) or 0 (abnormal) to five parameters: fetal
tone, breathing, movement, amniotic fluid volume,
and NST.

BIOPHYSICAL • Scoring is as follows:

PROFILE (BPP) • 8–10: Reassuring for fetal well-being.

• 6: Considered equivocal. Term pregnancies are

usually delivered with this profile.

• 0–4: Extremely worrisome for fetal asphyxia;

strong consideration should be given to immediate
delivery if no other explanation is found.
UMBILICAL ARTERY DOPPLER VELOCIMETRY

• With IUGR, there is reduction and even

reversal of umbilical artery diastolic flow.
The test is of benefit only when IUGR is
suspected.