MECHANISMS OF NORMAL LABOR
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
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 examination
Determines the presentation
longitudinal lie creating
cephalic and
breech
presentation
In
In
transverse lie
presentation
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
The fetal head
partially flexed
.
Anterior/large
frontal is the
presenting part
Labor
progresse
s
Vertex
presentation
presentation
Brow
presentation
Partially
extended
Brow is the
presenting part
Labor
progress
es
Face
Transient
Breech presentation
There are three general
configuration :
Frank breech
presentation :
The thighs are
flexed
The legs
extended over
the anterior
surfaces of the
body
Complete
breech
presentation :
Incomplete;
footling breech
presentation :
One or both
The thighs are
feet/knees are
flexed on the
lowermost
abdomen &
the legs upon
the thighs
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
Fetal position
The relation of an arbitrarily chosen
portion of the fetal presenting part
to the right or left side of the
maternal birth canal
Each presentation there maybe two
position, right or left
The determining part of :
vertex
occiput
face
chin (mentum)
Varieties of presentation and
position
OA
ROA
LOA
ROT
ROP
LOT
Diagnosis of fetal presentation and
position
A. Abdominal
palpation Leopold
maneuvers
Conducted
systematic
ally
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
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
of all labors the fetus is in the
occiput or vertex presentation
95%
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
In
Cardinal movement of labor
Irregular
shape of the pelvic canal
The
relatively large dimensions of
the mature fetal head
process of adaptation or
accomodation of suitable portion
of the head to the various
segments of the pelvis is required
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
simultaneously
For example :
Engagement :
The greatest transverse diameter
(BPD) in occiput presentation, passes
through the pelvis inlet
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
Asyinclitism
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 symphysis
Such lateral deflection of the head to
a more anterior or posterior position
Descent
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
Flexion
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 diameter
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 floor
A fourth internal rotation is
completed very shortly after the
head reaches the pelvic floor
5 percent internal rotation does
not take place
Extension
Extension
brings the base of the
occiput into direct contact with the
interior margin of the symphysis pubis
Causes
The
of extension :
vulva outlet is directed upward
and forward
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 extension
External Rotation
The delivered head next undergoes
restitution
If the occiput was originally directed
toward the left it rotates toward
the left ischial tuberosity
Expulsion
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
The swelling :
Diffuse
Boggy
Not limited by the suture line
Disappears spontaneously within
24 hours after birth
Occurs after rupture of the
membranes
Importance
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
Moulding
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
Grading
Grade 1 : The bones touching but not
overlapping
Grade 2 : Overlapping but easily
separated
Grade 3 : Fixed overlapping
Importance
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
Cephalhematoma
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
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
