Labor and Delivery

Joserizal Serudji
Bag/SMF OBGIN FK Unand/RS.
M.Djamil Padang
!BOR

"#ild$ir%# is %#e &eriod 'rom %#e onse% o'

regular u%erine (on%ra(%ions un%il e)&ulsion
o' %#e &la(en%a. *#e &ro(ess $+ ,#i(# %#is
normall+ o((urs is (alled labor

,omen ,i%# single%on (e&#ali(

&resen%a%ions a% %erm #ad a s&on%aneous
la$or and deli-er+
CHARACTERISTICS OF NORMAL LABOR
*#e s%ri(% de.ni%ion o' la$or/ 0 uterine contractions that
bring about demonstrable efacement and dilatation of the
cervix, - does not easily aid the clinician in de%ermining
,#en la$or #as a(%uall+ $egun/ $e(ause %#is diagnosis is
(on.rmed onl+ re%ros&e(%i-el+.
Se-eral me%#ods ma+ $e used %o de.ne i%s s%ar%. One
1uan%i.es onse% as %#e (lo(2 %ime ,#en &ain'ul
(on%ra(%ions $e(ome regular.
! se(ond me%#od de.nes %#e onse% o' la$or as $eginning
a% %#e %ime o' admission %o %#e la$or uni%. *#ese (ri%eria a%
%erm re1uire &ain'ul u%erine (on%ra(%ions a((om&anied $+
an+ one o' %#e 'ollo,ing3
45 ru&%ured mem$ranes/
65 $lood+ 7s#o,/7
85 (om&le%e (er-i(al e9a(emen%.
True Labor

"on%ra(%ions o((ur a% regular

in%er-als.

In%er-als graduall+ s#or%en.

In%ensi%+ graduall+ in(reases.

Dis(om'or% is in %#e $a(2 and

a$domen.

"er-i) dila%es.

Dis(om'or% is no% s%o&&ed $+

seda%ion.
S%ages o' la$or3

Firs% s%age3 Dila%a%ion

Se(ond s%age3 Deli-er+

*#ird s%age3 Pla(en%al

FIRST STAGE OF LABOR
Latent Phase.

The onset of latent labor, as defned by Friedman

(197!, is the "oint at #hich the mother "erceives
regular (on%ra(%ions.

*#e la%en% &#ase 'or mos% ,omen ends a%

$e%,een 8 and : (m o' dila%a%ion.

*#is %#res#old ma+ $e (lini(all+ use'ul/ 'or i%

de.nes (er-i(al dila%a%ion limi%s $e+ond ,#i(#
a(%i-e la$or (an $e e)&e(%ed.

latent "hase as being greater than $ hours in

the nulli"ara and 1% #ours in %#e mul%i&ara
Active Labor.

The "rogress of labor in nulli"arous #omen has

"articular signifcance because these (ur-es all
re-eal a ra&id (#ange in %#e slo&e o' (er-i(al
dila%a%ion ra%es $e%,een 8 and : (m.

*#us/ (er-i(al dila%a%ion o' 8 %o : (m or more/ in

%#e &resen(e o' u%erine (on%ra(%ions/ (an $e
%a2en %o relia$l+ re&resen% %#e %#res#old 'or a(%i-e
la$or. Similarl+/ %#ese (ur-es &ro-ide use'ul
guide&os%s 'or la$or managemen%.
"om&osi%e o' %#e a-erage
dila%a%ion (ur-e 'or
nulli&arous la$or.
*#e .rs% s%age is di-ided
in%o a rela%i-el+ &at latent
"hase and a ra&idl+
"rogressive active "hase.
In %#e a(%i-e &#ase/ %#ere
are %#ree iden%i.a$le
(om&onen% &ar%s %#a%
in(lude an acceleration
&#ase/ a linear &#ase o'
maximum slo"e/ and a
deceleration
&#ase.
a$or (ourse di-ided 'un(%ionall+
on %#e $asis o' dila%a%ion and
des(en% (ur-es in%o
;45 a &re&ara%or+ di-ision/
in(luding la%en% and
a((elera%ion &#ases<
;65 a dila%a%ional di-ision/
o((u&+ing %#e &#ase o'
ma)imum slo&e o' dila%a%ion<
and
;85 a &el-i( di-ision/
en(om&assing $o%#
de(elera%ion &#ase and
se(ond s%age (on(urren% ,i%#
%#e &#ase o' ma)imum slo&e
o' des(en%.
SECOND STAGE OF LABOR.

*#is s%age $egins ,#en (er-i(al dila%a%ion is

(om&le%e and ends ,i%# 'e%al deli-er+.

*#e median dura%ion is a$ou% := minu%es 'or

nulli&aras and a$ou% 6= minu%es 'or mul%i&aras/ $u% i%
(an $e #ig#l+ -aria$le .

In a ,oman o' #ig#er &ari%+ ,i%# a &re-iousl+ dila%ed

-agina and &erineum/ %,o or %#ree e)&ulsi-e e9or%s
a'%er 'ull (er-i(al dila%a%ion ma+ su>(e %o (om&le%e
deli-er+.

"on-ersel+/ in a ,oman ,i%# a (on%ra(%ed &el-is or a

large 'e%us or ,i%# im&aired e)&ulsi-e e9or%s 'rom
(ondu(%ion analgesia or seda%ion/ %#e se(ond s%age
ma+ $e(ome a$normall+ long
SUMMARY OF NORMAL LABOR.

a$or is (#ara(%erized $+ $re-i%+ and (onsidera$le

$iologi(al -aria%ion.
!(%i-e la$or (an $e relia$l+ diagnosed ,#en (er-i(al
dila%a%ion is 8 (m or more in %#e &resen(e o' u%erine
(on%ra(%ions. On(e %#is (er-i(al dila%a%ion %#res#old is
rea(#ed/ normal &rogress %o deli-er+ (an $e e)&e(%ed/
de&ending on &ari%+/ in %#e ensuing ? %o @ #ours.
!n%i(i&a%ed &rogress during a 40 %o 60#our se(ond s%age
is moni%ored %o ensure 'e%al sa'e%+.

Finall+/ mos% ,omen in s&on%aneous la$or/ regardless o'

&ari%+ and i' le'% unaided/ ,ill deli-er ,i%#in
a&&ro)ima%el+ 4= #ours a'%er admission 'or
s&on%aneous la$or.
MA"B!NISM OF !BOUR

!% %#e onse% o' la$or/ %#e &osi%ion o'

%#e 'e%us ,i%# res&e(% %o %#e $ir%#
(anal is (ri%i(al %o %#e rou%e o'
deli-er+. I% is %#us o' &aramoun%
im&or%an(e %o 2no, %#e 'e%al &osi%ion
,i%#in %#e u%erine (a-i%+ a% %#e onse%
o' la$or.
LIE, PRESENTATION, ATTITUDE, AND POSITION.
Fe%al orien%a%ion rela%i-e %o %#e ma%ernal &el-is is des(ri$ed in
%erms o' 'e%al lie/ &resen%a%ion/ a%%i%ude/ and &osi%ion.
Fetal Lie. The lie is the relation of the long axis of the fetus
to that of the mother, and is either longitudinal or transverse'
Fetal Presentation' The "resenting "art is that "ortion of
the fetal body that is either foremost #ithin the birth canal or
in (loses% &ro)imi%+ %o i%. I% (an $e 'el% %#roug# %#e (er-i) on
-aginal e)amina%ion.
!((ordingl+/ in longi%udinal lies/ %#e &resen%ing &ar% is ei%#er
%#e 'e%al #ead or $ree(#/ (rea%ing ce"halic and breech
"resentations, res"ectively'
(hen the fetus lies #ith the long a)is %rans-ersel+/ %#e
shoulder is the "resenting "art and is felt through the cervix
on vaginal examination'

Fetal Attitude or Posture. )n the later months of

"regnancy the fetus assumes a characteristic
"osture described as attitude or #a$i%us

Fetal Position. *osition refers to the relationshi"

of an arbitrarily chosen "ortion of the fetal
"resenting "art to the right or left side o' %#e
ma%ernal $ir%# (anal.

!((ordingl+/ ,i%# ea(# &resen%a%ion %#ere ma+ $e

%,o &osi%ions/ rig#% or le'%.

*#e 'e%al o((i&u%/ (#in ;men%um5/ and sa(rum are

%#e de%ermining &oin%s in -er%e)/ 'a(e/ and $ree(#
&resen%a%ions/ res&e(%i-el+
ongi%udinal lie.
"e&#ali( &resen%a%ion.
Di9eren(es in a%%i%ude
o' %#e'e%al $od+ in (A)
vertex, (B) si!i"#t,
(C) $r%&, '( (D)
)'!e "reset'ti%s.
N%te* (#anges in
'e%al a%%i%ude in
rela%ion %o 'e%al -er%e)
as %#e 'e%al #ead
$e(omes less Ce)ed
ongi%udinal lie.
Der%e) &resen%a%ion.
A. Le)t %!!i"#t
'teri%r (LOA).
B. Le)t %!!i"#t
"%steri%r (LOP)
ongi%udinal lie.
Der%e) &resen%a%ion.
A. Ri+,t %!!i"#t
"%steri%r (ROP).
B. Ri+,t %!!i"#t
tr'sverse (ROT)
ongi%udinal lie.
Der%e) &resen%a%ion.
Rig#% o((i&u% an%erior
;RO!5
Abdominal Palpation: Leopold Maneuvers.

Se-eral me%#ods (an $e used %o diagnose 'e%al

&resen%a%ion and &osi%ion. *#ese in(lude
a$dominal &al&a%ion/ -aginal e)amina%ion/
aus(ul%a%ion/ and/ in (er%ain dou$%'ul (ases/
imaging s%udies su(# as ul%rasonogra&#+/
(om&u%ed %omogra&#+/ or magne%i( resonan(e
imaging.

!$dominal e)amina%ion (an $e (ondu(%ed

s+s%ema%i(all+ em&lo+ing %#e 'our maneu-ers
des(ri$ed $+ eo&old and S&orlin in 4EF?
eo&old
maneu-ers
Auscultation.

+lthough auscultation alone #ith an aural

fetosco"e does not "rovide reliable information
concerning fetal &resen%a%ion and &osi%ion/
aus(ul%a%or+ .ndings some%imes rein'or(e resul%s
o$%ained $+ &al&a%ion.

*#e region o' %#e ma%ernal a$domen in ,#i(#

'e%al #ear% sounds are mos% (learl+ #eard -aries
a((ording %o %#e &resen%a%ion and %#e e)%en% %o
,#i(# %#e &resen%ing &ar% #as des(ended.
Ultrasonography and Radiography.

,ltrasonogra"hic techni-ues can aid identifcation

of fetal "osition, es"ecially in obese ,omen or in
,omen ,i%# rigid a$dominal ,alls.

In some (lini(al si%ua%ions/ %#e -alue o'

in'orma%ion o$%ained radiogra&#i(all+ 'ar e)(eeds
%#e minimal ris2 'rom a single )0ra+ e)&osure
Vaginal !amination.

Be'ore la$or/ %#e diagnosis o' 'e%al &resen%a%ion

and &osi%ion $+ -aginal e)amina%ion is o'%en
in(on(lusi-e/ $e(ause %#e &resen%ing &ar% mus%
$e &al&a%ed %#roug# a (losed (er-i) and lo,er
u%erine segmen%.

Gi%# %#e onse% o' la$or and a'%er (er-i(al

dila%a%ion/ -er%e) &resen%a%ions and %#eir
&osi%ions are re(ognized $+ &al&a%ion o' %#e
-arious su%ures and 'on%anels. Fa(e and $ree(#
&resen%a%ions are iden%i.ed $+ &al&a%ion o' %#e
'a(ial 'ea%ures and %#e 'e%al sa(rum/ res&e(%i-el+.
LABOR -ITH OCCIPUT PRESENTATIONS.

In %#e majori%+ o' (ases/ %#e -er%e) en%ers %#e

&el-is ,i%# %#e sagi%%al su%ure l+ing in %#e
%rans-erse &el-i( diame%er.

*#e &osi%ional (#anges in %#e &resen%ing &ar%

re1uired %o na-iga%e %#e &el-i( (anal (ons%i%u%e
%#e mechanisms of labor

The cardinal movements of labor are

engagement, descent, &exion, internal rotation,
extension, e)%ernal ro%a%ion/ and e)&ulsion

During la$or/ %#ese mo-emen%s are se1uen%ial

$u% also s#o, grea% %em&oral o-erla&.
ENGAGEMENT.

*#e me(#anism $+ ,#i(# %#e $i&arie%al diame%er/ %#e

grea%es% %rans-erse diame%er o' %#e 'e%al #ead in
o((i&u% &resen%a%ions/ &asses %#roug# %#e &el-i( inle% is
designa%ed engagement'

The fetal head may engage during the last fe# #ee.s
o' &regnan(+ or no% un%il a'%er %#e (ommen(emen% o'
la$or. In man+ mul%i&arous and some nulli&arous
,omen/ %#e 'e%al #ead is 'reel+ mo-a$le a$o-e %#e
&el-i( inle% a% %#e onse% o' la$or. In %#is (ir(ums%an(e/
%#e #ead is some%imes re'erred %o as 7Coa%ing.7
! normal0sized #ead usuall+ does no% engage ,i%# i%s
sagi%%al su%ure dire(%ed an%ero&os%eriorl+. Ins%ead/ %#e
'e%al #ead usuall+ en%ers %#e &el-i( inle% ei%#er
%rans-ersel+ or o$li1uel+.
ASYNCLITISM.
!l%#oug# %#e 'e%al #ead %ends %o a((ommoda%e %o %#e
%rans-erse a)is o' %#e &el-i( inle%/ %#e sagi%%al su%ure/ ,#ile
remaining &arallel %o %#a% a)is/ ma+ no% lie e)a(%l+ mid,a+
$e%,een %#e s+m&#+sis and %#e sa(ral &romon%or+.
*#e sagi%%al su%ure 're1uen%l+ is deCe(%ed ei%#er &os%eriorl+
%o,ard %#e &romon%or+ or an%eriorl+ %o,ard %#e s+m&#+sis .
Su(# la%eral deCe(%ion o' %#e #ead %o a more an%erior or
&os%erior &osi%ion in %#e &el-is is (alled asynclitism'
)f the sagittal su%ure a&&roa(#es %#e sa(ral &romon%or+/ more
o' %#e an%erior &arie%al $one &resen%s i%sel' %o %#e e)amining
.ngers/ and %#e (ondi%ion is (alled anterior asynclitism'
)f, ho#ever, the sagittal suture lies close to the sym"hysis,
more of the "osterior &arie%al $one ,ill &resen%/ and %#e
(ondi%ion is (alled "osterior asynclitism'
(ith extreme "osterior asynclitism, the "osterior ear ma+ $e
easil+ &al&a%ed.
DESCENT.
*#is mo-emen% is %#e .rs% re1uisi%e 'or $ir%# o' %#e
ne,$orn.

In nulli&aras/ engagemen% ma+ %a2e &la(e $e'ore %#e

onse% o' la$or/ and 'ur%#er des(en% ma+ no% 'ollo, un%il
%#e onse% o' %#e se(ond s%age.
In mul%i&arous ,omen/ des(en% usuall+ $egins ,i%#
engagemen%.

Des(en% is $roug#% a$ou% $+ one or more o' 'our 'or(es3

45 &ressure o' %#e amnioni( Cuid/
65 dire(% &ressure o' %#e 'undus u&on %#e $ree(# ,i%#
(on%ra(%ions/
85 $earing do,n e9or%s o' ma%ernal a$dominal mus(les/ and
?5 e)%ension and s%raig#%ening o' %#e 'e%al $od+.
FLE.ION.

!s soon as %#e des(ending #ead mee%s

resis%an(e/ ,#e%#er 'rom %#e (er-i)/ ,alls o' %#e
&el-is/ or &el-i( Coor/ Ce)ion o' %#e #ead normall+
resul%s.

In %#is mo-emen%/ %#e (#in is $roug#% in%o more

in%ima%e (on%a(% ,i%# %#e 'e%al %#ora)/ and %#e
a&&re(ia$l+ s#or%er su$o((i&i%o$regma%i(
diame%er is su$s%i%u%ed 'or %#e longer
o((i&i%o'ron%al diame%er
INTERNAL ROTATION.
*#is mo-emen% (onsis%s o' a %urning o' %#e #ead in su(# a
manner %#a% %#e o((i&u% graduall+ mo-es %o,ard %#e
s+m&#+sis &u$is an%eriorl+ 'rom i%s original &osi%ion or/ less
(ommonl+/ &os%eriorl+ %o,ard %#e #ollo, o' %#e sa(rum.
In%ernal ro%a%ion is essen%ial 'or %#e (om&le%ion o' la$or/
e)(e&% ,#en %#e 'e%us is unusuall+ small.
in a&&ro)ima%el+ %,o %#irds/ in%ernal ro%a%ion is (om&le%ed
$+ %#e %ime %#e #ead rea(#es %#e &el-i( Coor< in a$ou% one
'our%#/ in%ernal ro%a%ion is (om&le%ed -er+ s#or%l+ a'%er %#e
#ead rea(#es %#e &el-i( Coor< and in a$ou% : &er(en%/
an%erior ro%a%ion does no% %a2e &la(e.
G#en %#e #ead 'ails %o %urn un%il rea(#ing %#e &el-i( Coor/ i%
%+&i(all+ ro%a%es during %#e ne)% one or %,o (on%ra(%ions in
mul%i&aras. In nulli&aras/ ro%a%ion usuall+ o((urs during %#e
ne)% %#ree %o .-e (on%ra(%ions.
E.TENSION.
!'%er in%ernal ro%a%ion/ %#e s#ar&l+ Ce)ed #ead rea(#es %#e
-ul-a and undergoes e)%ension. I' %#e s#ar&l+ Ce)ed #ead/
0on rea(#ing %#e &el-i( Coor/ did no% e)%end $u% ,as dri-en
'ar%#er do,n,ard/ i% ,ould im&inge on %#e &os%erior &or%ion
o' %#e &erineum and ,ould e-en%uall+ $e 'or(ed %#roug# %#e
%issues o' %#e &erineum.
G#en %#e #ead &resses u&on %#e &el-i( Coor/ #o,e-er/ %,o
'or(es (ome in%o &la+. *#e .rs%/ e)er%ed $+ %#e u%erus/ a(%s
more &os%eriorl+/ and %#e se(ond/ su&&lied $+ %#e resis%an%
&el-i( Coor and %#e s+m&#+sis/ a(%s more an%eriorl+.
*#e resul%an% -e(%or is in %#e dire(%ion o' %#e -ul-ar o&ening/
%#ere$+ (ausing #ead e)%ension. *#is $rings %#e $ase o' %#e
o((i&u% in%o dire(% (on%a(% ,i%# %#e in'erior margin o' %#e
s+m&#+sis &u$is

Gi%# &rogressi-e dis%en%ion o' %#e &erineum and

-aginal o&ening/ an in(reasingl+ larger &or%ion o'
%#e o((i&u% graduall+ a&&ears.

*#e #ead is $orn as %#e o((i&u%/ $regma/

'ore#ead/ nose/ mou%#/ and .nall+ %#e (#in &ass
su((essi-el+ o-er %#e an%erior margin o' %#e
&erineum.

Immedia%el+ a'%er i%s deli-er+/ %#e #ead dro&s

do,n,ard so %#a% %#e (#in lies o-er %#e ma%ernal
anal region.
E.TERNAL ROTATION.
*#e deli-ered #ead ne)% undergoes restitution' )f the occi"ut
#as originally directed to#ard the left, it ro%a%es %o,ard %#e
le'% is(#ial %u$erosi%+< i' i% ,as originall+ dire(%ed %o,ard %#e
rig#%/ %#e o((i&u% ro%a%es %o %#e rig#%.
Res%i%u%ion o' %#e #ead %o %#e o$li1ue &osi%ion is 'ollo,ed $+
(om&le%ion o' e)%ernal ro%a%ion %o %#e %rans-erse &osi%ion/
mo-emen% %#a% (orres&onds %o ro%a%ion o' %#e 'e%al $od+/
ser-ing %o $ring i%s $isa(romial diame%er in%o rela%ion ,i%#
%#e an%ero&os%erior diame%er o' %#e &el-i( ou%le%.
*#us/ one s#oulder is an%erior $e#ind %#e s+m&#+sis and %#e
o%#er is &os%erior.
*#is mo-emen% a&&aren%l+ is $roug#% a$ou% $+ %#e same
&el-i( 'a(%ors %#a% &rodu(ed in%ernal ro%a%ion o' %#e #ead.
E.PULSION.

!lmos% immedia%el+ a'%er e)%ernal ro%a%ion/ %#e

an%erior s#oulder a&&ears under %#e s+m&#+sis
&u$is/ and %#e &erineum soon $e(omes dis%ended
$+ %#e &os%erior s#oulder.

!'%er deli-er+ o' %#e s#oulders/ %#e res% o' %#e

$od+ 1ui(2l+ &asses.
Than"#s