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Hidayat Wijayanegara
I. Lie, presentation, attitude and position

 Fetal orientation can be established

clinically :
 abdominal palpation
 vaginal examination
 auscultation
 sonography
 X-Ray
Fetal lie

 Is the relation of the long axis of the fetus to that

of mother
 Longitudinal - transverse - oblique
 Longitudinal lies are present in over 99 percent
of labor at term
 Predisposing factors for transverse lie :
 multi parity
 placenta previa
 hydramnios
 uterine anomalies
Fetal presentation

 The presenting part :

 portion of the body of the fetus is either
foremost within the birth canal or in
proximity to it
 Can be felt through the cervix on vaginal
 Determines the presentation
 In longitudinal lie  creating cephalic and
breech presentation

 In transverse lie  the shoulder

Cephalic presentation

1. The head is flexed sharply

The chin is contact with the thorax

The occipital fontanel is the presenting part

Vertex or occiput presentation
Cephalic presentation

2. Face presentation :
Fetal neck  extended

Occiput & back come in contact

The face is foremost in the birth canal

Face presentation
Vertex presentation --- Face presentation

Sinciput presentation Brow presentation

 The fetal head  Partially extended
partially flexed  Brow is the
 Anterior/large presenting part
frontal is the
presenting part
Labor Labor
progresses progresses

Vertex Face
presentation Transient presentation
Fetal attitude or posture

 The head is sharply flexed

 The chin is almost contact with the chest
 The thighs are flexed over the abdomen
 The legs are bent at the knees
 The arms usually crossed over the thorax

Accomodation to the uterine cavity
Diagnosis of fetal presentation and position

A. Abdominal
palpation -
 Conducted
B. Vaginal examination

Comprised of three maneuvers :

1. Two fingers of either gloved hand are
introduced into the vagina and carried up
to the presenting part
The differentiation :
 vertex
 face
 breech
2. If the vertex is presenting :
 Sagittal suture (?)
 Small & large fontanels
3. The station  is established
C. Auscultation

Does not provide reliable information

concerning fetal presentation & position

D. Sonography
Fetal head & body can be located
Labor with occiput presentation

 95% of all labors  the fetus is in the occiput

or vertex presentation
 In the majority of cases  the vertex enters
the pelvis with the sagital suture in the
transverse pelvic diameter
 Left occiput transverse (LOT) : 40% of labors
 Right occiput transverse (ROT) : 20% of labors
 Occiput posterior : 20% of labors
Cardinal movement of labor

 Irregular shape of the pelvic canal

 The
relatively large dimensions of the
mature fetal head

A process of adaptation or accomodation of

suitable portion of the head to the various
segments of the pelvis is required for
vaginal delivery
The cardinal movements of labor :
- engagement - extension
- descent - external rotation
- flexion - expulsion
- internal rotation
For purposes of instruction, the various
movement often are described as though they
occurred separately and independently  in
reality the mechanism of labor consists of a
combination of movements that are ongoing
For example :
- as part of the process of engagement 
there is both flexion and descent of the head
Engagement :

 The greatest transverse diameter (BPD) in

occiput presentation, passes through the pelvis
 In many primigravida this phenomena may
takes place during the last weeks of pregnancy
 In many multiparous and some nulliparous
 the fetal head is still freely movable above
the pelvic inlet (floating)

 The sagital suture, entering the pelvic inlet may

not lie exactly midway between the symphysis
and sacral promontory
 The sagital suture deflected either posteriorly
toward the promontory or anteriorly toward the
 Such lateral deflection of the head to a more
anterior or posterior position is called
asynclitism  anterior & posterior asynclitism

 The first requisite for birth of the infant

 In nulliparas, engagement may take place before
the onset of labor  and further descent takes
place at the second stage
 Four forces :
a. pressure of amniotic fluid
b. direct pressure of the fundus upon the breech
with contraction
c. bearing down effort
d. extension and straightening of the fetal body

 Resistance from the cervix, wall of the pelvis,

pelvic floor  flexion of the head
 The chin more contact with the fetal thorax
 Suboccipito bregmatic diameter is
substituted for the longer occipito frontal
Internal rotation

 The occiput gradually moves anteriorly

toward the symphysis pubis or less
commonly, posteriorly toward the hollow of
the sacrum
 Is always associated with descent
 Is not accomplished until the head has
reached the level of the spine and thereafter
is engaged
Calkins (1939)

 Concluded :
 Two thirds  internal rotation is completed
by the time the head reaches the pelvic
 A fourth  internal rotation is completed
very shortly after the head reaches the
pelvic floor
 5 percent  internal rotation does not take

 Extension brings the base of the occiput into

direct contact with the interior margin of the
symphysis pubis
 Causes of extension :
 The vulva outlet is directed upward and
 Two forces come into play :
a. Exerted by the uterus  act more posteriorly
b. Resistant pelvic floor and the symphysis acts
more anteriorly  the resultant vector is in
the direction of the vulva opening  causing
External Rotation

 The delivered head next undergoes restitution

 If the occiput was originally directed toward

the left  it rotates toward the left ischial

 After delivery of the shoulders, the rest

of the left body is quickly extruded
Changes in shape of the fetal head

1. Caput Succedaneum
 The formation of swelling due to stagnation
of fluid in the layers of the scalp beneath the
girdle of contact
 The girdle of contact is either :
 Bony
 Dilating cervix
 Vulval ring
 The swelling :
 Diffuse
 Boggy
 Not limited by the suture line
 Disappears spontaneously within 24 hours
after birth
 Occurs after rupture of the membranes
 It signifies static position of the head for a long
period of time
 Location of the caput  gives an idea about the
position of the head occupied in the pelvis and the
degree of flexion achieved :
 in left position  caput in right parietal bone
 in right position  on left parietal bone
 With the increasing flexion  the caput is placed
more posteriorly
 The alteration of the shape of the forecoming head
while passing through the risistant birth passage
during labor
 Mechanism :
 There is compression of the engaging diameter
of the head with corresponding elongation of
the diameter at right angle to it
 Moulding disappears within few hours after birth

 Grade 1 : The bones touching but not overlapping

 Grade 2 : Overlapping but easily separated
 Grade 3 : Fixed overlapping

 Slight molding is irritable and beneficial  the

head to pass more easily through the birth canal
 Extreme molding (CPD)  may produce severe
intracranial disturbance in the form of tearing of
tentorium serebelli or subdural haemorrhage
 Shape of the molding  give an information about
the position of the head occupied in the pelvis

 A collection of blood in between the

pericranium in the flat bone of the skull
 Unilateral
 Over a parietal bone
 Due to rupture of a small emissary vein from
the skull and may be associated with fracture
of the skull bone
 Causes : - following normal delivery
- forceps delivery
 The swelling is limited by the suture lines
 It is circumscribed, soft, fluctuant, incompressible

 Prognosis is good  the blood is absorbed in

cause of time (6-8 weeks) leaving an entirely
normal skull.