Normal Labor

Fetal Lie

Relationship of the fetal

long axis to that of the
mother
 Fetal Presentation

Presenting part – portion of the fetal body that is

either foremost within the birth canal or in closest
proximity to it
 Cephalic Presentation

Vertex/Occiput Sinciput Brow Face

Flexed Extended
Fully Vertex/occiput Face
Partially Sinciput Brow
Breech Presentation

Incidence: 3% at term
Shoulder Presentation
 Fetal Attitude or Habitus

● Ovoid mass
● Fetus foiled upon itself to create convex back
● Head sharply flexed
● Chin in contact with chest
● Thighs flexed over abdomen
● Legs bent at the knees
 Fetal Position
● Relationship of an arbitrary chosen portion of the fetal presenting part to the right or
left side of the birth canal
● Occiput, chin (mentum) and sacrum – determining points
● 2/3 of all vertex presentation are LO
 Leopold’s Maneuver

Assess fundus Back- hard, resistant

Breech- large, nodular mass Extremities – numerous small,
Head – hard, round, more mobile irregular, mobile parts

Obese, polyhydramnios, placenta anteriorly implanted

 Leopold’s Maneuver

If not engaged, movable mass felt Degree of descent

is usually the head
Vaginal Examination
● Presenting part
● Position of the two
fontanels
● Differentiate OA & OP
● Station
 Sonography and Radiography

● Obese women or in those with muscular abdominal walls

● More accurate in determining fetal head position during
second stage of labor
Cardinal Movements
1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External Rotation
(Restitution)
7. Expulsion
 Engagement
● Biparietal diameter – greatest transverse diameter in occiput position -
passes through the pelvic inlet
 Last few weeks of pregnancy or after labor commencement

● Lateral deflection of sagittal suture to more anterior or posterior position

in pelvis – ASYNCLITISM
 Descent

● First requisite for birth

● Due to 4 forces:
1. Pressure of amniotic fluid
2. Direct pressure of the fundus upon the
breech with contractions
3. Maternal bearing down efforts
4. Extension and straightening of the fetal
body
 Flexion

● Occurs when descending head meets

resistance
● Chin brought to more intimate contact
with thorax – shorter
suboccipitobregmatic diameter
substituted for longer occipitofrontal
diameter

● AP diameter reduced from 12 to 9.5cm

 Internal Rotation

● Occiput turns gradually away from transverse

axis
● Rotates anteriorly to symphysis pubis or
posteriorly toward the sacrum
 Extension

● Sharply flexed head extends upon reaching the

vulva
● Due to 2 opposing forces with resultant vector in
direction of vulvar opening -> head extension

1. Force exerted by the uterus acting more posteriorly

2. Force supplied by resistance of pelvic floor and
symphysis acting anteriorly
 External Rotation

● Restitution of head to oblique position

followed by external rotation completion to
reach a transverse position
● Brings the bisacromial diameter into relation
with the AP diameter of pelvic outlet
 Expulsion

● Anterior shoulder appears under symphysis pubis,

deliver
● Perineum soon becomes extended by posterior
shoulder, deliver
● Rest of the body
 Fetal Head Changes

Caput succedaneum
● Prolonged labor before complete cervical dilation
● Part of scalp over cervical os becomes edematous

Molding
● Changes in bony fetal head shape due to external
compressive forces
● Shortened SOB diameter and lengtened mentovertical
diameter
● Resolve within weeks following delivery
 Labor
Uterine contractions that bring
about demonstrable effacement
and dilation of the cervix
 First Stage of Labor (Functional Divisions)

Preparatory
● Cervix dilate little, connective tissue
change considerably
● Sedation and conduction analgesia
can arrest

Dilation
● Dilation at most rapid rate
● Unaffected by sedation

Pelvic division
● Cardinal movements
 First Stage of Labor (Phases of cervical dilation)

Latent phase = Preparatory division

Active phase = Dilation division

 Latent Phase

● Onset : point at which mother perceives regular contractions

● Ends: 3 cm to 5 cm dilation (Friedman)
● Prolonged latent phase:

 Nullipara: 20 hours

 Multipara: 14 hours
 Active Phase

● Cervical dilation of 3 to 6 cm or more in the presence of uterine contractions

● Cervical dilation of 6cm not 4cm is now the recommended threshold (Obstetrical Care Consensus
Committee 2016)

● Mean duration of active phase labor (Friedman)

 Nulliparas: 1.2 to 6.8cm/hr
 Multiparas: minimum 1.5cm/hr

• Descent commences at 7 to 8 cm in nulliparas; most rapid at 8cm

 Second Stage of Labor

● Complete cervical dilation to fetal delivery

● 50 minutes in nulliparas, 20 minutes in multiparas
Management of Normal Labor
 Identification of Labor

● In the absence of ruptured membranes or bleeding, uterine contractions 5 minutes apart for 1 hour
(12 contractions or more in 1 hour)

● Uncomplicated pregnancies with intact membranes and cervical dilation <4cm -> continous external
fetal monitoring for up to 2 hrs

● With cervical change or persistent contractions = ADMIT

 Initial Evaluation

● Maternal blood pressure

● Temperature
● Pulse
● Respiratory rate
● Fetal heart rate

● Cervical examination unless there is bleeding or excess bloody show

 Ruptured Membranes

1. Presenting part not fixed -> cord prolapse and compression

2. Labor is likely to commence
3. Intrauterine and neonatal infection if delivery is delayed

● Speculum exam
 pooling of amniotic fluid in the posterior fornix or clear fluid flows
from cervical canal

• pH determination
 Amniotic fluid >7.0, vaginal secretion 4.5 to 5.5

• Nitrazine test
 pH above 6.5

• Arborization or ferning of amniotic fluid

 Ruptured Membranes

● AmniSure – placental alpha microglobulin-1

● ROM Plus– IGF binding protein-1 plus alpha-feto protein
 Cervical Assessment

Cervical Effacement
● Reflect length of cervical canal compared with that of an uneffaced cervix
● 100% - as thin as LUS

Cervical Dilation
● Estimating diameter of cervical opening

Position
● Relationship of cervical to fetal head

Consistency

Station
● Level of presenting part in birth canal in relation to ischial spines
 Laboratory Studies

● Hematocrit, Hemoglobin
● Blood type
● Syphilis, HIV serology
● Urinalysis
 Intrapartum Fetal Monitoring

1st stage 2nd stage

Low risk 30 min 15 min

High risk 15 min 5 min

 Maternal Monitoring

● Temperature, pulse, BP – Q4H

● Ruptured membrane – temperature Qhourly
● Uterine contractions – frequency, duration, intensity
● Vaginal examinations
 Oral Intake

● Withhold food and liquids with particulate matter during active labor

● Oral intake of moderate amount of clear liquids in uncomplicated cases (ACOG, 2017)

● CS – stop liquids 2 hours and solids 6-8 hours prior to surgery

 Intravenous Fluids

● Venous access for oxytocin during immediate puerperium or if with uterine atony

● In long labor, glucose, sodium and water to fasting woman at rate of 60 to 120 mL/hr to prevent
dehydration and acidosis
 Maternal Position

● Lateral recumbency to avoid aortocaval compression

● Walking – shorten labor, lower rate of oxytocin augmentation, diminished need for analgesia
 Rupture of Membranes

● Amniotomy
 More rapid labor
 Detection of meconium stained AF
 Internal monitoring

• Prolonged membrane rupture > 18 hrs = antibiotic for group B streptococcal infections
 Urinary Bladder Function

● Distention hinders descent and can lead to bladder hypotonia & infection

● Palpate suprapubic region for distention

● If voiding not possible - catheterization

 Management of Second Stage Labor

● Urge to defecate with descent of presenting part

● Contractions and expulsive effect may now last 1 minute and recur no longer than 90 seconds

● Legs should be half flexed to push against mattress

● Not encouraged to push beyond completion of each contraction -> rest and recover
● Monitor FHR

● Head descends to pelvis – perineum bulge – skin stretched – scalp visible – DELIVERY