Normal Labor and

Delivery
 OBJECTIVES
• Describe the maternal factors in birth
• List the various fetal positions and
presentations
• Review the 7 Cardinal Movements
• Define the 4 stages of labor
• Describe a normal fetal heart rate pattern
• Discuss the factors affecting the US C/S
rate and VBAC rate.
NORMAL LABOR & DELIVERY
Definitions
• Labor: progressive dilatation of the cervix
in association with uterine contractions
• Term : > 37 weeks gestation
• Preterm: < 37 weeks gestation
 Obstetrical Pelvic Exam
• Dilation (dilatation): patency of the internal
cervical os
– 0 = “closed”
– 10 cm = “complete”
• Effacement: shortening of the cervical
length
– 0% = “thick”
– 100% = “fully effaced”
 Obstetrical Pelvic Exam
• Station: level of presenting part
(bony portion) in relation to the
maternal ischial spines
– Ischial spines = O station
– Above spines: -5 to -1
– Below spines: +1 to +5
 Obstetrical Pelvic Exam
• Presentation: fetal part closet to pelvic inlet
– vertex
– brow
– face
– breech
– shoulder
• Position: relationship of particular point on the
presenting part of the fetus and the vertical and
horizontal planes of the maternal pelvis
– Vertex: occiput for orientation
– Breech: sacrum
– Face: mentum
Vertex Parietal Brow Face
 Obstetrical Pelvic Exam
• Lie: relationship between the long axis
of the fetus and the mother
– Longitudinal
– Transverse
• Asynclitism: anterior or posterior
parietal bone precedes the sagittal
suture
– Anterior
– Posterior
 Cardinal Movements of Labor

1. Engagement: descent of biparietal diameter

to the level of the ischial spines (0 station)
– Often occurs before onset of labor in nulliparous
patients
2. Descent
3. Flexion: presenting diameters of fetal head
presenting to maternal pelvis are optimized
 Cardinal Movements of Labor
4. Internal rotation: fetal occiput rotates
from transverse to AP
5. Extension: head rotates under
symphysis pubis
6. External rotation (restitution): occiput
and spine assume same position
7. Expulsion: fetal body delivers
NORMAL LABOR & DELIVERY
Stages of Labor
• First stage: Onset of labor to full
dilation (10m cm)
• Second stage: Full cervical
dilation to delivery of infant
• Third stage: Delivery of infant to
delivery of placenta
• Fourth stage: First hour after birth
Ritgen Maneuver

Erb’s palsey
NORMAL LABOR & DELIVERY
Phases of Labor
• Latent phase: onset of contractions
until active phase
• Active phase: 3 cm dilation in
nulliparas; 4 cm dilation in
multiparas to deceleration phase
• Deceleration phase: 8 – 9 cm dilation
to complete dilation
Abnormal Latent Phase of
Labor
• > 20 hours in nulliparas
• > 14 hours in multiparas
• Treatment
– Therapeutic rest
• Morphine (10- 20 mg)
• Hypnotic (Ambien)
– 85% proceed into active phase of labor
– 10% - no contractions
– 5% - may need oxytocin
 Primary Dysfunctional Labor

Slow rate of dilation in the active

phase of labor
– < 1.2 cm/hr in nulliparas
– < 1.5 cm/hr in multiparas
 Disorders of the Active Phase
• Secondary Arrest: cessation of
previously normal rate of dilation for
two hours
• Combined Disorder: cessation of
dilation when patient has previously
exhibited a primary dysfunctional labor
Disorders of the Second Stage
• Protracted Descent:
– < 1 cm/hr in nulliparas
– < 2 cm/hr in multiparas
• Prolonged:
– Nulliparas
• With epidural – 3 hours
• No epidural – 2 hours
– Multiparas
• With epidural – 2 hours
• No epidural – 1 hour
Abnormalities of Labor
THE 5 “P”

• Passageway: maternal pelvis

• Powers: uterine contractions
• Passenger: fetus
• Placenta: profusion
• Psyche: mother’s readiness
 Uterine Contractions
• External tocodynamometry
– Less accurate
– 3-5 contractions/10 minutes
• Internal tocodynamometry
– Measures mm Hg
– 180 – 220 Montevido units/10
minutes
 INDUCTION OF LABOR
Oxytocin
• Peptide from posterior pituitary
• Usually given IV; can be given IM
• IV bolus = hypotension
• 10 units/ml; dilute in 1000 cc LR
• Routine dose: Start at 2mu/min,
 2 mu/min every 15-30 minutes to 36 IU/min
• Active management of labor: start at 6 mu/min, by
6 mu/min every 15 minutes to 36 mu/min
• High doses – ADH effect = water intoxication
 INDUCTION OF LABOR
Bishop Score
0 1 2 3

Dilation Closed 1-2 3–4 >5

Effacement 0 – 30 40 – 50 60 – 70 > 80

Station -3 -2 -1 +1, +2

Consistency Firm Medium Soft

Position Posterior Mid Anterior

 INDUCTION OF LABOR
Misoprostol (Cytotec®)
• PO tablet FDA approved to prevent gastric
ulceration in patients taking NSAID’s
• PGE1
• 25 mcg (1/4 of 100mcg tablet) in vagina Q 4
hours X 4 doses
• Wait 6 hours after last dose to start oxytocin
• Contraindicated with uterine eschar
 NORMAL LABOR & DELIVERY
Foley Bulb
• Place special foley through cervix and inflate
balloon to 30 cc
• Tape to thigh – remove by 12 hours
• Used when Cytotec contraindicated – uterine
eschar
• Mechanism: mechanical/local release of
prostaglandins
• Frequently used with pitocin
NORMAL LABOR & DELIVERY
Anesthesia
• Cesarean section
– Spinal
– Epidural
– General (more risky in obstetrics)
• Vaginal delivery
– Local
– Pudendal
– Epidural
– Combined spinal/epidural
Pudendal Block
NORMAL LABOR & DELIVERY
Lacerations
• Cervical (use clock to describe location)
• Vaginal (left or right)
• Periurethrael
• Clitoral
• Perineal
– 1st degree: skin only involved
– 2nd degree: skin and subcutaneous tissue
– 3rd degree: external rectal sphincter
– 4th degree: rectal mucosa not intact
NORMAL LABOR & DELIVERY
Episiotomy
• Types
– Midline
– Mediolateral
– Proctoepisiotomy

• Originally thought to protect perineum

• Now thought to result in more 3rd and
4th degree extensions
• More perineal pain
 First degree

External sphincter

Second degree External sphincter

Third degree
NORMAL LABOR & DELIVERY
Cesarean Delivery
• Skin incisions
– Vertical
– Pfannensteil

• Uterine incisions
– Low cervical transverse (Kerr)
– Low vertical or “T” shaped
– Classical
 BREECH

Frank breech Complete breech

Incomplete breech
 NORMAL LABOR & DELIVERY
Breech Presentation
• 37 weeks gestation – external cephalic
version (50% success)
– Ultrasound
– Non-stress test
– IV/subcut terbutaline for tocolysis
– Ultrasound monitoring
– Repeat non-stress test/

• Cesarean section vs vaginal birth

 Multiple Gestation
• Twins
– Vertex/vertex – vaginal delivery
– Vertex/breech or transverse lie – breech extraction
of 2nd twin
– Breech/other – C-section (locked twins)
• Triplets or higher order gestation
– Cesarean delivery indicated
NORMAL LABOR & DELIVERY
Estimated Fetal Weight
• Leopold’s maneuvers (palpation of
the maternal abdomen)
• Ultrasound estimate of fetal weight
(error of 10 – 15%)
• Maternal estimate of fetal weight
(best)
 Forceps Assisted Vaginal
Delivery
• Outlet forceps:
– Scalp visible at the introitus w/o parting the labia
– Sagittal suture < 45 degrees
• Low forceps:
– Leading point of skull at +2 or below
• < 45 degrees
• > 45 degrees
• Mid-forceps:
– Head is engaged but presenting part is above +2 station
– Rarely done
NORMAL LABOR & DELIVERY
Vacuum vs Forceps
• Forceps
– More maternal trauma
– Minimal fetal trauma (bruising)
• Vacuum
– Less maternal trauma
– Potential for increased fetal trauma
(subgaleal bleeding)
Mitivac vacuum
 Understanding
Fetal Monitoring (Parameters)
• Baseline rate
• Variability
• Presence of accelerations
• Presence of decelerations
• Changes or trends of FHR patterns
over time
 Fetal Heart Rate Baseline

• 10 minute window
• Duration: at least 2 minutes
• Bradycardia: < 110 bpm
• Tachycardia: > 170 bpm
 Fetal Monitoring (Variability)
• Concept of long-term variability
dropped
• Absent: undetectable
• Minimal: undetectable - < 5 bpm
• Moderate: 6 - 25 bpm
• Marked: > 25 bpm
 Fetal Monitoring
(Accelerations)

• Onset to peak: < 30 seconds

• > 32 weeks: >15 bpm X >15 secs
• < 32 weeks: > 10 bpm X > 10 secs
• > 2 minutes in duration: prolonged
• > 10 minutes in duration: change in
baseline
 DECELERATIONS
Fetal Monitoring (Variables)
• Onset to nadir < 30 secs
• > 15 bpm below baseline
• Duration: > 15 seconds
• < 2 minutes from onset to return
to baseline
 DECELERATIONS
Fetal Monitoring (Variables)
Treatment
• Pelvic exam (rule out prolapsed cord)
• Maternal oxygen
• Change maternal position
• Stop pushing
• Amnioinfusion
 Fetal Monitoring
(Late Decelerations)
• Onset to nadir > 30 secs
• Delayed in timing
• Nadir occurring after the peak of
the contraction
• Reoccuring can be ominous
 Fetal Monitoring
(Late Decelerations)
Treatment
• Correct hypotension or other maternal
conditions
• Maternal oxygen
• Scalp stimulation
• Cesarean delivery if repetitive
NORMAL LABOR & DELIVERY
Cord Blood Gases
Umbilical artery (No labor)
• Acidemia: pH < 7.15
• Metabolic: base excess > -11 mmol/L and
pCO2 < 65 mm
• Respiratory: base excess < 11 mmol/L and
pCO2 > 65 mm
• Mixed: base excess > -11 mmol/L and
pCO2 > 65 mm
NORMAL LABOR & DELIVERY
Cord Blood Gases

Umbilical artery (No labor)

Clinically significant acidemia is
probably represented by an
umbilical arterial pH of < 7.0