Mindanao State University - College of Medicine

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

NORMAL
LABOR CASE PRESENTATION

Llupar, Roann Faye

Saga, June Marie
Satar, Shalman
Solatorio, Nilfred Christian
 01 Objectives

02 Case Presentation

OUTLINE 03 Mechanism of Labor

04 Normal Labor Characteristics

05 Management of Normal Labor

 OBJECTIVES
1. To discuss the case about Normal
Labor
2. To discuss the mechanism of
General:
To discuss and
Normal Labor
present Normal
3. To discuss the different
Labor.
stages of Normal Labor
4. To discuss the management on
Normal Labor
IDENTIFYING DATA

Name: NB
Age: 27 years old, Primigravid/nulliparous
Sex: Female
AOG: 38 weeks 2/7 days by LMP
Status: Married
Religion: Islam
Chief complaint: Hypogastric Pain
HISTORY OF PRESENT ILLNESS

24 hrs PTA 5 hrs PTA ON ADMISSION

Hypogastric pain that Pain every 3 to 4 minutes for 1

radiates to the back minute

Vaginal Discharge
(Sticky with small
amount of blood)
MENSTRUAL HISTORY

LMP January 1, 2020

AOG 38 weeks 2/7 days

Menarche 13 years old

Menstruation Regular, every 28 days for 7 days, heaviest on 3rd and

4th day, 3-4 pads/day, (+) dysmenorrhea relieved with
mefenamic acid
PRENATAL CHECK-UP HISTORY
● Private physician
● 6 sessions
● Blood type: O+
● Ultrasound: 3 weeks ago
● Vaccines: TT (2 doses), Flu vaccine
● Supplements: Obimin plus; Calcium
PAST MEDICAL HISTORY

● No previous hospitalization and surgeries

● No known diseases such as asthma, hypertension,
diabetes mellitus
● No known allergies to food and/or medications
FAMILY HISTORY

● No previous hospitalization and surgeries

● No known diseases such as asthma, hypertension,
diabetes mellitus
● No known allergies to food and/or medications
OBSTETRIC HISTORY
Gravida 1 Para 0 (0000)

GYNECOLOGIC HISTORY
● No history of breast diseases
● No previous gynecologic surgical
operation
● No history of infertility
PERSONAL AND SOCIAL HISTORY

● Married to BB, 30 years old, works at a grocery

store
● Non-smoker, non-alcoholic beverage drinker
● Currently a housewife
 REVIEW OF SYSTEMS

(+) fatigue, (-) fever (+) hypogastric pain, (-) nausea, (-)
vomiting

(-) rashes, (-) itching, (-) skin

discoloration (+) vaginal discharge, (-) dysuria

(-) headache, (-) dizziness,

(-) blurred vision, (-) earaches, (-) nasal (+) backache, (-) muscle or joint
congestion, (-) sore throat pains

(-) changes in mood, (-) changes in

(-) lumps, (-) pain orientation, (-) seizures

(-) cough, (-) difficulty breathing

(-) easy bruising, (-) bleeding

(-) chest pain, (-) palpitations

PHYSICAL EXAMINATION
General Survey:
Conscious, coherent, oriented to time and
place; not in respiratory distress but in pain

Vital Signs:
BP - 100/80, RR - 88bpm, RR - 21cpm,
Temperature - 37.2; Weight - 48kg, Height -
154cm
PHYSICAL EXAMINATION

HEENT:
Normocephalic, PERLA, Dry lips and
moist buccal mucosa

Chest and Lungs:

Equal chest expansion, no retractions;
equal tactile fremitus; Resonant lung
fields, Normal breath sounds
PHYSICAL EXAMINATION

Heart:
PMI at 6th ICS, LMCL; no heaves nor
thrills, CAD not enlarged; Normal rate,
regular rhythm; no murmurs
PHYSICAL EXAMINATION
Abdomen: Globularly enlarged, prominent linea nigra
Fundic height: 31cm
LEOPOLD’S MANEUVER
○ L1: Large nodular mass
○ L2: Convex fetal back, right maternal side;
Nodular fetal extremities, left maternal side
○ L3: Round hard Mass above the pelvic inlet
○ L4: Cephalic prominence, maternal left
○ FHT: 136 of the lower quadrant
PHYSICAL EXAMINATION

Extremities:
equally strong palpable peripheral
pulses, CRT <2 seconds; no bipedal
edema
PHYSICAL EXAMINATION
Pelvic Examination (speculum/internal examination)
○ External genitalia: normal; no lesions,
masses and pigmentations
○ Vagina: pink, no apparent masses or
discharge; smooth and parous
○ Uterus: enlarged to 38 weeks AOG
○ Cervix: 7 cm dilated, fully effaced, engaged
at station +1; soft, anterior position
○ Bag of Water: intact
○ No adnexal masses or tenderness
PHYSICAL EXAMINATION
Rectovaginal Examination
Good sphincter tone. Intact rectal vault. No
intraluminal mass. Rectovaginal septum is intact.
Parametria is soft , thin, smooth, pliable, with no
masses.

Clinical Pelvimetry: Adequate

○ Inlet (Diagonal conjugate ⥸11.5cm)
○ Midpelvis (bi-ischial diameter ⥸10.5cm)
○ Outlet (bi-tuberous diameter ⥸ 11cm)
 PRIMARY IMPRESSION

Gravida 1, Para 0,
Pregnancy uterine, 38
2/7 weeks AOG by LMP,
Cephalic, in active phase
of Labor
MECHANISM OF LABOR
 LABOR
- Process that leads to
childbirth

- Begins with the onset of

regular uterine
contractions and ends with
delivery
 FETAL LIE
- Relation of the fetal long axis to that of the
mother
SAMPLE PPT
PRESENTATION back-up back-down
LOREM IPSUM DOLOR SIT AMET
 FETAL PRESENTATION
- portion of the fetal body that either foremost within the birth canal

SAMPLE PPT
CEPHALIC BREECH
PRESENTATION
Vertex or occiput Frank breech Complete breech
Face presentation
presentation LOREM IPSUM DOLOR SIT AMET presentation presentation

Incomplete breech Footling breech

Sinciput presentation Brow presentation
presentation presentation
FETAL PRESENTATION

CEPHALIC
SAMPLE PPT
PRESENTATION
LOREM IPSUM DOLOR SIT AMET
FETAL PRESENTATION
CEPHALIC

SAMPLE PPT
PRESENTATION
OCCIPITAL FONTANELE is
the presenting part
LOREM IPSUM DOLOR SIT AMET

Vertex or occiput presentation

FETAL PRESENTATION
CEPHALIC

SAMPLE PPT
Neck is only flexed,
PRESENTATION
ANTERIOR FONTANEL
LOREM IPSUM DOLOR SIT AMET may present

Face presentation
FETAL PRESENTATION
CEPHALIC

SAMPLE PPT
Neck is only partially
PRESENTATION
extended.
LOREM IPSUM DOLOR SIT AMET BROW may emerge

Brow presentation
FETAL PRESENTATION
CEPHALIC
Fetal neck may be sharply
SAMPLE PPT extended so that the
PRESENTATIONocciput and back come in
contact,
LOREM IPSUM DOLOR SIT AMET
FACE is foremost in birth
canal
Vertex or occiput presentation
 FETAL PRESENTATION
BREECH

SAMPLE PPT
PRESENTATION
LOREM IPSUM DOLOR SIT AMET
FETAL PRESENTATION
BREECH
Lower extremities are
SAMPLE PPT
flexed at the hips and
PRESENTATION
extended at the knees and
LOREM IPSUM DOLOR SIT AMET thus the feet lie in close

proximity to the head

Frank breech presentation
FETAL PRESENTATION
BREECH

SAMPLE PPT
PRESENTATION one or both knees are
flexed
LOREM IPSUM DOLOR SIT AMET

Complete breech presentation

FETAL PRESENTATION
BREECH

SAMPLE PPT one or both hip are not

flexed, and one or both feet or
PRESENTATION
knee lie below the breech,
LOREM IPSUM DOLOR SIT AMET
such that a foot or knee is
lowermost in birth canal

Incomplete breech presentation

FETAL PRESENTATION
BREECH
incomplete breech with one
SAMPLE PPT or both feet below the breech
PRESENTATION
STARGAZER FETUS
- extreme hyperextension
LOREM IPSUM DOLOR SIT AMET - 5%
- vaginal delivery may result in injury to the
cervical spinal cord
- an indication for cesarean delivery

Footling breech presentation

FETAL ATTITUDE/POSTURE

CONVEX CONCAVE

Flexed Extended
 FETAL POSITION

DETERMINING POINTS
Fetal occiput Vertex

Chin (mentum) Face

Sacrum Breech

Shoulder presentation Acromion/ scapula

FETAL POSITION

Refers to the relationship of an arbitrarily chosen

portion of the fetal presenting part to the right or left
side of the birth canal .
DIAGNOSIS
LEOPOLD’S MANEUVER

FETAL HEAD Firm, round, smooth

Usual at upper fetal pole

BUTTOCKS Firm but irregular, less
globular than the head

TRANSVERSE Neither part is palpated

FUNDAL GRIP
LEOPOLD’S MANEUVER

Smooth, firm surface

BACK (32 weeks gestation)

ARMS/LEGS Irregular bump

UMBILICAL GRIP
LEOPOLD’S MANEUVER

- If the presenting part is not

engaged, a movable mass will be
felt, usually the head

FIRST PELVIC GRIP

LEOPOLD’S MANEUVER
If the cephalic prominence juts
EXTENDED
out along the line of the fetal
HEAD anterior side

If the cephalic prominence juts

FLEXED HEAD out along the line of the fetal
anterior side

Determines the degree of descent

SECOND PELVIC
GRIP
CARDINAL MOVEMENTS OF LABOR

ENGAGEMENT
DESCENT
FLEXION
LOT LOA
INTERNAL ROTATION
EXTENSION
ROT ROA
EXTERNAL ROTATION
EXPULSION
CARDINAL MOVEMENTS OF LABOR
ENGAGEMENT
DESCENT
FLEXION
INTERNAL ROTATION
EXTENSION
EXTERNAL ROTATION
EXPULSION

LOT LOA
ROT ROA
CARDINAL MOVEMENTS OF LABOR

ENGAGEMENT
DESCENT

FLEXION

INTERNAL ROTATION

EXTENSION

EXTERNAL ROTATION

EXPULSION

LOT LOA
ROT ROA
CARDINAL MOVEMENTS OF LABOR

ENGAGEMENT
DESCENT

FLEXION

INTERNAL ROTATION

EXTENSION

EXTERNAL ROTATION

EXPULSION

LOT LOA
ROT ROA
ASYNCLITISI Lateral deflection of the sagittal suture either posteriorly toward the promontory
of anteriorly toward the symphysis pubis
M

ANTERIOR
ASYNCLITISM
ASYNCLITISI Lateral deflection of the sagittal suture either posteriorly toward the promontory
of anteriorly toward the symphysis pubis
M

POSTERIOR
ASYNCLITISM
CARDINAL MOVEMENTS OF LABOR
ENGAGEMENT

DESCENT
FLEXION

INTERNAL ROTATION

EXTENSION

EXTERNAL ROTATION

EXPULSION

LOT LOA
ROT ROA
CARDINAL MOVEMENTS OF LABOR
ENGAGEMENT

DESCENT

FLEXION
INTERNAL ROTATION

EXTENSION

EXTERNAL ROTATION

EXPULSION

LOT LOA
ROT ROA
CARDINAL MOVEMENTS OF LABOR
ENGAGEMENT

DESCENT

FLEXION

INTERNAL ROTATION
EXTENSION

EXTERNAL ROTATION

EXPULSION

LOT LOA
ROT ROA
CARDINAL MOVEMENTS OF LABOR
ENGAGEMENT

DESCENT

FLEXION

INTERNAL ROTATION

EXTENSION
EXTERNAL ROTATION

EXPULSION

LOT LOA
ROT ROA
CARDINAL MOVEMENTS OF LABOR
ENGAGEMENT

DESCENT

FLEXION

INTERNAL ROTATION

EXTENSION

EXTERNAL ROTATION
EXPULSION

LOT LOA
ROT ROA
CARDINAL MOVEMENTS OF LABOR
ENGAGEMENT

DESCENT

FLEXION

INTERNAL ROTATION

EXTENSION

EXTERNAL ROTATION

EXPULSION
LOT LOA
ROT ROA
CARDINAL MOVEMENTS OF LABOR

ROP LOP
Right Occiput Posterior

- associated with narrow pelvis

- Anterior placentation
VAGINAL EXAMINATION

ROP LOP
Right Occiput Posterior

- associated with narrow pelvis

- Anterior placentation
 - effective contractions
OCCIPUT
POSTERIOR
- Adequate head flexion
- Average fetal size
ROTATION

- Poor contractions
- Faulty head flexion INCOMPLETE
- Epidural analgesia
- Large fetus ROTATION
LOREM IPSUM DOLOR SIT AMET

PERSISTENT DYSTOCIA
-No rotation toward the
OCCIPUT symphysis pubs CESAREAN
POSTERIOR
DELIVERY
NORMAL LABOR
CRITERIA
Williams CPG on NORMAL LABOR
Uterine contractions that bring about at least 1 in 10 minutes (or 4 in 20 minutes)
demonstrable effacement and dilatation of by direct observation or cardiotocogram
cervix

Uterine Contractions In active phase labor, the duration of each

contraction ranges from 30-90 sec, averaging
about 1 minute. There is appreciable
variability in contraction intensity during
normal labor.

Cervical dilatation 3-4cm or greater >3cm

Cervical effacement >70-80%

The criteria at term require painful uterine Documented progressive change in cervical
contractions accompanied by any of the dilatation and effacement as observed by one
following; observer.
Other requierements ● ruptured membranes,
● bloody “show”, or
● complete cervical effacement
PREPARATORY DILATATIONAL
PELVIC DIVISION
DIVISION DIVISION

LA B O R
● Contraction, effacement, dilation
(3-4 cm or greater)

LATENT ACTIVE
PHASE LABOR
ACTIVE PHASE ABNORMALITIES
NULLIPARAS MULTIPARAS
<1.2 cm <1.5 cm
dilatation /hour dilatation /hour

PROTRACTION Or Or

<1 cm descent per <2 cm descent per

hour hour

ARREST Defined as 2 hours

DILATATION with no cervical
change

1 hour without fetal

DESCENT descent
 LABOR Contraction, effacement, dilatation (3-4 cm or greater)

DILATATION
(sweeping the examining
finger from the margin of the
cervical opening on one side
to that of the opposite side) 10 cm fully dilated

CERVICAL
EFFACEMENT
(length of the cervical canal
compared with that of an
uneffaced cervix)
When the length of the
cervix is reduced by half,
it is 50% effaced

CERVICAL ASSESMENT
 LABOR Contraction, effacement, dilatation (3-4 cm or greater)

POSITION OF THE CERVIX ANTERIOR

(relationship of the cervical os to the MID-POSTERIOR
fetal head) POSTERIOR

Soft, intermediate,
CONSISTENCY OF THE CERVIX
firm

FETAL STATION
(level of the presenting fetal part in the
birth canal in relation to the ischial spine)
CERVICAL ASSESMENT
LABOR BISHOP SCORING SYSTEM

CERVICAL ASSESMENT
MANAGEMENT OF LABOR
MANAGEMENT OF FIRST STAGE OF LABOR

Intrapartum Monitoring, Maternal Monitoring, Oral

Intake, IV fluids, Maternal Position, Rupture of
Membranes

MANAGEMENT OF SECOND STAGE OF LABOR

Maternal Expulsive Efforts, Spontaneous

Delivery

MANAGEMENT OF THIRDS STAGE OF LABOR

Oxytocin, Placenta Delivery, Uterine

massage
ADMISSION PROCEDURES

IDENTIFICATION OF LABOR
TRUE FALSE
Increases Intensity Does not change
Increases Duration Does not change
Regular Interval Irregular
Increases Frequency Does not change
Present even with sedation Pain Disappears with sedation
Progressive effacement and
Cervix None
dilatation
ADMISSION PROCEDURES

❏ Recording the medical and obstetric history

❏ General examination
❏ Vital signs
❏ Blood pressure, respiratory rate, pulse rate, temperature
❏ Urine analysis
❏ CBC, blood typing and antibody screening
MONITORING PROGRESS
OF LABOR
MANAGEMENT OF FIRST
STAGE OF LABOR

FIRST STAGE OF LABOR SECOND STAGE OF LABOR

Normal Pregnancies at Normal Pregnancies at

pregnancy risk pregnancy risk

Fetal heart
Every 30 mins Every 15 mins Every 15 mins Every 5 mins
rate

Continuous
electronic Every 30 mins Every 15 mins Every 15 mins Every 5 mins
monitoring
MANAGEMENT OF FIRST
STAGE OF LABOR

MATERNAL VITAL SIGNS

o Temperature
o Pulse Rate are evaluated at least
o Respiratory Rate every 4 hours
o Blood pressure

o Prolonged rupture
of membranes
o Borderline checked hourly
temperature
elevation
MANAGEMENT OF FIRST
STAGE OF LABOR

UTERINE CONTRACTIONS

Contractions can be
both quantitatively and
qualitatively evaluated
manually
MANAGEMENT OF FIRST
STAGE OF LABOR

CERVICAL EXAMINATIONS

 When the membranes rupture, an

examination to exclude cord prolapse is
performed
 FHR is also checked

2-3 hours interval: pelvic examination

MANAGEMENT OF FIRST
STAGE OF LABOR

ORAL INTAKE

• Intake of moderate amounts of clear liquids for

uncomplicated labor
• Water, clear tea, black coffee, carbonated beverages in
modest amount
• Those risk for CS, liquid halted 2 hours before OR
sched, solids stopped 6-8 hrs prior
MANAGEMENT OF FIRST
STAGE OF LABOR

IV FLUIDS

• Should be institutes until analgesia is administered in

normal pregnant women
• With longer labors, administered glucose, sodium and
water at a rate of 60-120 ml/hr to prevent dehydration
and acidosis
• Shorter labor in nulliparas delivering vaginally with IV
normal saline with dextrose solution compared with
those given saline only
MANAGEMENT OF FIRST
STAGE OF LABOR

MATERNAL POSITION

 LATERAL
RECUMBENCY
POSITION

 Supine is avoided
MANAGEMENT OF FIRST
STAGE OF LABOR

AMNIOTOMY

BENEFITS:
o more rapid labor
o earlier detection of meconium stained
amniotic fluid
o opportunity to apply an electrode to the fetus
or insert pressure catheter into the uterine
cavity for monitoring
MANAGEMENT OF FIRST
STAGE OF LABOR

AMNIOTOMY

Fetal head must be well applied to the cervix

and not be dislodged from the pelvis during
the procedure to avoid umbilical cord
prolapse
MANAGEMENT OF FIRST
STAGE OF LABOR

URINARY BLADDER FUNCTION

• Woman should be encouraged to void to prevent bladder

distention and subsequent bladder hypotonia and
infection

• Bladder distention hinder descent of the fetal presenting

part
MANAGEMENT OF SECOND
STAGE OF LABOR

MATERNAL EXPULSIVE FORCES

• Taking a deep breath as soon as the next uterine

contraction begins, and with her breath held, to exert
downward pressure exactly as though she were straining
at stool.
• The fetal heart rate is likely to be slow, but should
recover to normal range before the next expulsive effort.
MANAGEMENT OF SECOND
STAGE OF LABOR

SPONTANEOUS DELIVERY

● Delivery of the head

○ Crowning –encirclement of the largest head diameter
by the vulvar ring.
○ Episiotomy
○ Ritgen maneuver
■ Controlled delivery of the head
MANAGEMENT OF SECOND
STAGE OF LABOR

SPONTANEOUS DELIVERY

● Delivery of the shoulders

○ External rotation – bisacromial diameter has rotated
into the anteroposterior diameter of the pelvis
○ Gentle downward traction of the head
○ The rest of the body almost always follows the
shoulders
● Clamping the cord
MANAGEMENT OF SECOND
STAGE OF LABOR

From the birth of the baby to the delivery of the placenta

The cervix and vagina should be immediately inspected

for lacerations and surgical repair performed if necessary!

Duration: 0 – 30 min
MANAGEMENT OF SECOND
STAGE OF LABOR

PLACENTAL SEPERATION

• Sudden gush of blood

• Globular and firmer fundus
• Lengthening of the umbilical cord as the placenta
descends into the vagina
• Rise of the uterus into the abdomen
MANAGEMENT OF SECOND
STAGE OF LABOR

Physiologic or expectant
Active management
management

Waiting for placental separation

Early cord clamping
signs

Allowing the placenta to deliver

Controlled cord traction during
either spontaneously or aided by
placental delivery
nipple stimulation

Immediate administration of
prophylactic uterotonics.
 References
Williams Obstetrics 25th edition (2018)

POGS, Inc., Clinical Practice Guidelines on Normal Labor and

Delivery 2nd ed., November 2009
Mindanao State University - College of Medicine
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

THANK YOU

Llupar, Roann Faye

Saga, June Marie
Satar, Shalman
Solatorio, Nilfred Christian