Normal Labor and Delivery
Dr. H. R. Siswosudarmo
Faculty of Medicine, UGM
Yogyakarta
Terminologies
Contraction: uterine contraction leading to
cervical dilatation
Effacement: shortening or thinning of the
cervix
Dilatation: dilatation of the external os
Station or plane: arbitrary level or plane in
the birth canal
Descent: level of the presenting part in the
birth canal
Presenting part: the lowermost part of the
fetus
Terminologies
Lies: relation between fetal long axis against
maternal long axis
Longitudinal
Transverse
Oblique (transient)
Presentation: portion of the fetus that lies in the
most caudal (inferior) part of the mother
Vertex or cephalic
Breech
Shoulder (transverse lie)
Face (maximally deflexed in vertex presentation)
Terminologies
Position: relation of the arbitrarily point of the
presenting part (denominator) against plane of the
birth canal
In vertex presentation (occiput): LOT, ROT or LOA, RCA,
and less common, LOP and ROP
In breech presentation (sacrum): LST, RST, LSA and LSP
In face presentation, chin is the denominator
Attitude: relation between fetal longitudinal axis of
the head against fetal longitudinal axis of the body
Flexion Denominator: occiput
Mild deflexion Sinsiput
Moderate deflexion Brow
Maximal deflexion Chin
Labor or Persalinan: definition:
Labor: All processes from the onset of contraction
to the end of the forth stage (2 hours after delivery
of he placenta)
Four stages of labor:
First: Dilatation of the cervix (1-10 cm)
Second: Expulsion of the fetus, or delivery
Third: Expulsion of the placenta
Fourth: Hemostasis period, 2 hours after expulsion of
the placenta
Delivery or Kelahiran
Definition: Expulsion of the fetus (second stage)
Delivery is included in labor.
Types:
Spontaneous delivery vs. Assisted delivery
Kelahiran spontan vs kelahiran berbantu
Operative delivery
vaginal (vacuum or forceps, embryotomy)
Abdominla (C section)
Vaginal vs. Abdominal (Cesarean section)
Kelahiran vaginal vs kelahiran abdominal
Normal labor and delivery,
definition
Spontaneous initiation
Pregnancy age: 37-42 weeks
Longitudinal lie, occiput presentation
Duration of the first stage: 4-18 hours
Spontaneous and vaginal expulsion
Amount of bleeding: < 500 ml
Pregnancy outcome: good
Leopold maneuver
Pelvic or Bimanual examination
Clinical pelvimetry
Cervix during labor,
Unripe: Ripe:
Closed Dilated
Stiff Soft
No effacement Effaced
Posterior Mid or anterior position
position
Cervical dilatation
Effacement, dilatation and retraction ring
Engagemnt & descent
First stage
PARTOGRAPH
Uterine contraction: frequency, duration, intensity
Fetal heart rate: every 30 ‘ (uncomplicated) and 15 ‘ for high
risk fetus or electronic fetal monitoring
Descent (external and internal)
Maternal vital signs: BP, T, PR every 4 hours
First vaginal ex: dilatation, thickness, and consistency of the
cervix, presentation, position, station, membrane, and
cephalopelvic balance (clinical pelvimetry)
Next vaginal ex: 2-4 hours dilatation, internal rotation and
descent)
Oral intake: avoid dehydration especially for prolonged labor
Intravenous fluid: indicated for potential bleeders
Analgesia: indicated in certain condition
First stage
Dilatation and descent of fetal head
Station
Longitudinal lies, cephalic presentation
Different attitudes, different presentation
Position of the Occiput
Position of the Occiput
Vertex presentation, different position
Position of the Occiput
Deflexed head, face presentation
Longitudinal lie, breech position
Transverse lie, position of the acromion
Cardinal mouvement
Engagement
Cardinal mouvement
Further decent and Internal rotation
Cardinal mouvement
Extensoin and external rotation
Cardinal mouvement
Delivery of the anterior and posterior shouldes
Synclitism and asynclitism
Lever action
Flexed head, shorter diameter is
suboccipito bregmatica
Second stage, Episiotomy
Delivery of the head
Suction of the nose
Umbilical cord rounds the neck
Third stage, delivery of placenta
Prevensi: MAKT
J Obstet Gynaecol Can 2003;25(11):952–3.
1. Tujuan
a. meningkatkan kontraksi uterus
b. mempercepat lahirnya plasenta
c. menurunkan kejadian perdarahan
pascasalin karena atoni uteri
2. Tiga komponen utama yakni:
(a) pemberian uterotonika,
(b) tarikan tali pusat terkendali dan
(c) masase uterus setelah plasenta lahir.
Manajemen Aktif Kala III
Risanto Siswosudarmo, Bagian OBGIN FK UGM
(J Obstet Gynaecol Can 2003;25(11):952–3)
Suntik 10 unit oksitosin (1 ampul) segera setelah janin lahir.
Tunggu uterus kontraksi
Ibu merasa mules, Uterus berbentuk globuler, Uterus terasa
keras
Lakukan tarikan terkendali pada talipusat kearah ventro kaudal,
sambil melakukan counter-pressure kearah dorsokranial untuk
menghindari inversi uterus, sambil ibu diminta mengejan.
Lakukan masase fundus uterus
segera setelah plasenta lahir sampai uterus berkontraksi
kuat
ulangi masase tiap 15 menit dan yakinkan uterus tidak lembek
setelah masase berhenti.
Observasi di kamar bersalin sampai 2 jam pascasalin
Degree of perineal rupture
Repair of perineum (perineorraphy)
Repair of perineum (perineorraphy)
Delivery room
Handheld Doppler fetal heart
rate monitor
Cardiotocography
Reactive Non-Stress Test (CTG)
Normal Contraction Stress Test
(CTG)
Abnormal Contraction Stress Test
(CTG)
Late deceleration
Second stage
Signs and symptoms:
Bearing down sensation
Dilated anus
Vomiting
Ruptured membrane
Bimanual (Vaginal) examination
Check for dilatation and descent
Determine: station, position of denominator
Check for cord prolapsed
Preparation
Dorsal lithotomy with leg holder
Supine with flexed, semi-abducted hip and flexed knee
Catheterization, if bladder is disturbing
Delivery the head (1)
Engagement: Sagital suture fits the transverse
diameter of the inlet (occiput in 3 or 9 o’clock)
Flexion
Descent
Internal rotation (occiput moves to 12 o’clock, to fits
the mid pelvis)
More descent
Crowning (distension of the head on the vaginal
opening as wide as 3-4 cm diameter)
Delivery the head (2)
Episiotomy (if necessary)
Extension of the head
External rotation
Delivery of the anterior followed by posterior
shoulders
Delivery of the rest of the body
Clamp the cord on two points, cut
Deliver the newborn to baby nurse
Third stage
Delivery of the placenta, active management
Oxytocin 10 IU soon after delivery of the fetus
Or, 3 tablets of 200 mg misoprostol orally or rectally
Catheterization in case of full bladder
Examine signs of separation of the placenta
Controlled cord traction and counter pressure on the
suprasymphisis dorsocranially to avoid inverted
uterus
Examine maternal surface to detect missing
cotyledon
Methylergonovin maleat 0.3 mg i. m. only if indicated
(bleeding or weak contraction)
Massage on the fundus
Forth stage
Monitor vital sign
Every 15 minutes: the first hour
Every 30 minutes: the second hour
Monitor uterine contraction
Repair episiotomy
Monitor bleeding especially for potential
bleeders
Synclitism and asynclitism
Engagement, descent to delivery of the head
Delivery of the placenta
Repair of episiotomy or perineal rupture
Transverse lie with subseptate
uterus & low lying placenta
Deflection of the head
