Normal labor

Dr. S. R. Otiv Consultant, KEM Hospital, Pune

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Flexed vertex

Deflexed vertex

Brow

Face

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Fetal skull

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Diameters of the fetal skull

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Fetal head - pelvis relationship

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Mechanism of labor

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Cardinal movements in labor

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Flexion

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Mechanism of labor video

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Course of labor with OP Engagement Descent Flexion Long IR 135o Extension Restitution Ext rotn Lat flexion
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Engagement Descent Flexion Short IR 45o Flexion Extension Restitution Ext rotn Lat flexion

Engagement Descent Deflexion DTA or POP

OP: Failure of cardinal movements

Engagement

Descent

Engagement occurs late after onset of labor Descent is slow Flexion is inadequate or absent Long internal rotation does not occur
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Flexion

Internal rotation

Extension

External rotation

Expulsion
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Why does the fetal head remain high after onset of labor?
Engagement
Descent

Extension of fetal spine

misdirection of fetal axis deflexion of fetal head

Flexion

Internal rotation

Extension

Deflexion of fetal head larger diameter of presenting part

External rotation

Expulsion 31

Why does slow descent occur in OP labor?

Engagement

Descent
Flexion

Deflexion leads to oblong presenting diameter that does not dilate the cervix properly. The resulting weak Ferguson reflex leads to inadequate uterine contractions Misdirected uterine force: vertically down rather than inclined posteriorly into the brim

Internal rotation

Extension

External rotation

Expulsion 32

Why does flexion fail?

Engagement Descent

Fetal spine lies against convexity of maternal spine. Extension of fetal spine --> deflexion Tight maternal abdomen in primi exaggerates deflexion Weak uterine force Other - brachycephaly, steep angle of inclination
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Flexion
Internal rotation

Extension

External rotation

Expulsion 33

Failure of internal rotation

Engagement

Descent

Deflexed head - sinciput reaches pelvic floor and is rotated anteriorly, occiput posteriorly Inadequate uterine contractions

Flexion

Internal rotation
Extension

Shoulder caught against maternal spine Shallow or flat sacrum in android pelvis

External rotation

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Management of labor
Initial assessment Monitoring Pain relief Emotional support Nursing care Intervention

Initial assessment
Assess baseline status to determine progress Medical or obstetric conditions that need to be addressed prenatal record Development of new disorders Evaluate fetal status

Examination
General: P, BP, temp, wt Systemic CVS , RS,

P/A scars, presentation, position, anterior shoulder, head level, FHR location, contraction freq / duration / baseline tone
CTG trace

Internal examination
Lesions of genital herpes Cervix dilatation, effacement, consistency, direction, how well applied to pp Presenting part - ?, station, moulding, position, caput, asynclitism, descent during contraction Bag of fore water intact / absent, size AF clear / colored Pelvis

Lab tests
Check reports Hb, HCT, blood group, HIV HbsAg, GBS screen Urine albumin, HIV, HbsAg,

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Prenatal record
History E Serology USG IUGR, dates,

Deep transverse arrest

Arrest of fetal head at the ischial spines after more than 1 hour of full cervical dilatation in spite of adequate contractions. Causes epidural analgesia narrow outlet

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Management of DTA
Digital rotation Manual rotation Forceps rotation
Smellie Scanzoni maneuver with Simpson forceps Kjelland forceps

Vacuum extraction C-section

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Manual Rotation of head

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Adequate amniotic fluid Normal fetal heart Head should be on pelvic floor Dis-impact head before rotation

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Simpson Forceps

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Prevention
Maternal positions (upright, non supine and hands/knees) in labor Augmentation of labor reduces likelihood of persistent OPP

Manual rotation of the fetal head to occiput anterior after 7cm to full dilatation improves the rate of occiput anterior deliver Epidural analgesia does not facilitate rotation

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Thank you !

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