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NORMAL LABOR AND

DELIVERY

MECHANISM OF LABOR
LIE
Relation of the long axis of the fetus to that
of the mother
Longitudinal or transverse
Oblique

MECHANISM OF LABOR
PRESENTATION
Portion of the fetal body that is either
foremost within the birth canal or in closest
proximity to it.
Longitudinal lie
Cephalic or breech

Transverse lie
shoulder
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MECHANISM OF LABOR
Cephalic presentation
Vertex/occiput
Face presentation
Sinciput
brow

MECHANISM OF LABOR
WHY DOES TERM FETUSES
PRESENTS WITH THE VERTEX?
BECAUSE THE UTERUS IS PYRIFORM
SHAPED

MECHANISM OF LABOR
FETAL ATTITUDE OR POSTURE
Back is markedly convex
Head is sharply flexed
Thighs are flexed over the abdomen
Legs are bent at the knees
Arches of the feet rests upon the ant
surface of the legs
Arms are crossed over the thorax or
parallel to the sides
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MECHANISM OF LABOR
FETAL POSITION
Relationship of an arbitrarily chosen
position of the fetal presenting part to the
right or left side of the maternal birth canal
2/3 of all vertex presentation are in Left
occiput position and 1/3 in the right
Shoulder presentation
Scapula(acromion)
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MECHANISM OF LABOR
OA
ROA

LOA
LOT

ROT
ROP

LOP

OP

MECHANISM OF LABOR
LABOR WITH OCCIPUT PRESENTATIONS
LOT position(40%)
ROT position(20%)
Occiput posterior(20%), ROP >LOP

MECHANISM OF LABOR
CARDINAL MOVEMENTS
engagement
descent
flexion
internal rotation
extension
external rotation
expulsion
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MECHANISM OF LABOR
Occiput Posterior Position
Occiput has to internally rotate to the
symphysis pubis through 135 degrees
In 5-10%, rotation may be incomplete or
may not take place

Direct occiput posterior /persistent


occiput posterior
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MECHANISM OF LABOR
CHARACTERISTIC OF NORMAL LABOR
The greatest impediment in understanding
normal labor is recognizing its start
Labor is defined as uterine contractions that
bring about demostrable effacement and
dilatation of the cervix

MECHANISM OF LABOR
FIRST STAGE OF LABOR
3 FUNCTIONAL DIVISIONS:
Preparatory
Dilatational
Pelvic

MECHANISM OF LABOR
2 phases of cervical dilatation:
Latent Phase = preparatory division
Active Phase = dilatational division

MECHANISM OF LABOR
Latent Phase
Ends at between 3 and 5 cm of dilatation
Prolonged latent phase
> 20 hrs in nullipara
>14 hrs in multipara
Factors: excessive sedation, unfavorable cervix

MECHANISM OF LABOR
Active Phase
Cervical dilatation of >3 to 5 cm or more in
the presence of uterine contractions
Friedman subdivided active phase
problems into protraction and arrest
disorders
Protraction = slow rate of cervical
dilatation or descent
Arrest = complete cessation of
dilatation or descent

MECHANISM OF LABOR
According to ACOG 1989, before the
diagnosis of arrest during the first stage
of labor is made the ff criteria should be
met:
1. the latent phase should be completed
2. a uterine contraction pattern of 200
Montevideo units or more in a 10 min
period has been present for 2 hrs without
cervical change

MECHANISM OF LABOR
Criteria for Diagnosis of Abnormal Labor
Due to Arrest or Protraction Disorders:
Labor Pattern
Nullipara
Multipara
Protraction Disorder
Dilatation
<1.2 cm/hr
<1.5cm/hr
Descent
<1 cm/hr
< 2 cm/hr
Arrest Disorder
No dilatation
>2 hr
> 2 hr
No descent
> 1 hr
> 1 hr
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MECHANISM OF LABOR

Abnormal Labor Patterns, Diagnostic Criteria, and Methods of Treatment

Preferred
Exceptonal
Labor Pattern
Nullipara
Multipara
Treatment
Prolonged Latent
>20 hr >14 hr
Phase
Protraction DO
1.Protracted Active
<1.2cm/hr <1.5cm/hr
CPD
Phase
2.Protracted Descent
<1 cm/hr <2cm/hr
Arrest DO
1.Prolonged Decceleration >3hr >1 hr
2.Arrest of Descent
>2hr
>2hr
3.Failure of Descent >1hr
>1hr

Treatment
Bedrest
Expectant

Oxy w/o CPD


CS with CPD

oxy or CS
CS for

Rest
CS

MECHANISM OF LABOR
MANAGEMENT OF THE FIRST STAGE OF LABOR:
Monitoring Fetal Well Being during Labor
Uterine Contractions
Maternal vital signs
Subsequent vaginal examinations
Oral intake
Intravenous fluids
Maternal position during labor
Analgesia
Amniotomy
Urinary bladder function
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MECHANISM OF LABOR
MANAGEMENT OF NORMAL LABOR AND DELIVERY
TRUE LABOR
FALSE LABOR
Contractions occur at regular irregular
intervals
Intervals shorten
long
Intensity increases
unchanged
Discomfort at the back
lower abdomen
and abdomen
Cx dilates
does not dilate
Discomfort not stopped
relieve by sedation
by sedation

MECHANISM OF LABOR
SECOND STAGE OF LABOR
Complete cervical dilatation and ends with
fetal delivery
Nulliparas: 50 mins
Multiparas: 20 mins

MECHANISM OF LABOR
MANAGEMENT OF THE SECOND STAGE OF LABOR:
Maternal expulsive efforts
Preparation for delivery
Delivery of the head
Ritgens maneuver favors extension, head is delivered to
its smallest diameters passing thru the introitus

Delivery of the shoulders


Clearing the nasopharynx
Nuchal cord
Clamping the cord
4-5 cm from the fetal abdomen

MECHANISM OF LABOR
MANAGEMENT OF THE THIRD STAGE OF LABOR:
Signs of placental separation:

Uterus becomes globular


Sudden gush of blood
Uterus rises in the abdomen
Umbilical cord protrudes farther out of the vagina

Delivery of the placenta


Traction on the umbilical cord should not be used to pull the
placenta out of the uterus

MECHANISM OF LABOR
Active management of the third stage of labor:
Oxytocin

Syntocinon and pitocin


Half life is 3 mins
Cardiovascular effects:IV bolus of 10u cause a
transient but marked fall in arterial blood
pressure followed by an abrupt increase in
cardiac output
Water intoxication:antidiuretic action
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MECHANISM OF LABOR
Ergonovine and methylergonovine
Oral, IV, IM
Causes transient but severe hypertension

Prostaglandins

DYSTOCIA:
Abnormal Labor

DYSTOCIA
Abnormalities of the expulsive efforts
Abnormalities of presentation,position
or development of the fetus
Abnormalities of the maternal bony
pelvis
Abnormalities of soft tissues of the
reproductive tract
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DYSTOCIA
Abnormalities of the powers
Abnormalities of the passenger
Abnormalities of the pasage

ABNORMALITIES OF THE EXPULSIVE FORCES


Types of Uterine Dysfunction:
Hypotonic : no basal hypertonus and uterine contractions
have a normal gradient pattern but the slight rise in pressure
during a contraction is insufficient to dilate the cervix
Hypertonic or Incoordinate : either basal tone is elevated
appreciably or the pressure gradient is distorted
causes:
Epidural Anesthesia
Chorioamnionitis

ABNORMALITIES OF THE EXPULSIVE FORCES

Precipitous Labor and Delivery:


Definition: according to Hughes 1972,
Precipitous labor terminates in expulsion of
the fetus in <3hrs
- Short labors: nulliparas 5 cm/hr or faster
multiparas 10 cm/hr
- Associated with
abruptio(20%),meconium, post partum
hge, cocaine abuse and low apgar
scores
- 93% were multiparas with uterine
contractions at intervals < 2 mins
#

FETOPELVIC DISPROPORTION
Arises from diminished pelvic cavity,
excessive fetal size,or combination
Contractions of the pelvic inlet, midpelvis,
outlet or combination

FETOPELVIC DISPROPORTION
Pelvic Inlet
Bounded posteriorly by the promontory and
alae of the sacrum and laterally by the linea
terminalis and anteriorly by the horizontal
pubic rami and symphysis pubis
4 diameters:
1. Anteroposterior:
Diagonal conjugate
Measured clinically
Distance from the sacral promontory to the
lower margin of the symphysis pubis
12 cm
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FETOPELVIC DISPROPORTION
Obstetrical conjugate
Diagonal conjugate 1.5 to 2 cm
10 cm
2. transverse diameter
- greatest distance between the linea
terminalis on either sides
- contraction of the inlet can be measured
only by imaging pelvimetry
- normal = 13 cms
3. Two oblique diameter

FETOPELVIC DISPROPORTION
Midpelvis
Contraction is more common
Causes transverse arrest of the fetal head
Inferior margin of the symphysis pubis
through the ischial spines and touches the
sacrum near the junction of the 4th or 5th
vertebrae.
clinical estimation by any direct form of
measurement is not possible
Ischial spines are prominent, sidewalls
convergent, and concavity of the sacrum is
very shallow
#

FETOPELVIC DISPROPORTION
average midpelvis measurements:
Transverse/interspinous = 10.5 cm
Anteropostrerio r (lower border of the sym
pubis up to jxn of S4 and S5) = 11.5 cm
Post sagittal (midpoint of the interspinous line
up to the same pt on the sacrum) = 5 cm

FETOPELVIC DISPROPORTION
Pelvic Outlet
important dimension of the pelvic outlet that
is accesible for clinical measurement is the
diameter between the ischial tuberosities
(biischial diameter, intertuberous diameter,
and transverse diameter of the outlet)
Normal > 8cms
Can be estimated by placing a closed fist
againts the perineum between the ischial
tuberosities
Outlet contraction without concomittant
midplane contraction is very rare
#

FETOPELVIC DISPROPORTION
Fetal Dimensions in FPD:
1.Face presentation
- head is hyperextended, occiput is in
contact with the fetal back and chin is
presenting
- mentum anterior or posterior
- mentum posterior = labor progression
is impeded because the fetal brow is
pressed againts the maternal symphysis
pubis
- mentum anterior = vaginal delivery is
typical
#

FETOPELVIC DISPROPORTION
Possible to mistake a breech for a face
presentation
etiology:
Marked enlargement of the neck
Cord coil
Anencephalic fetuses
Pendulous abdomen
High parity
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FETOPELVIC DISPROPORTION
In a series of 141 face presentations by
Hellman and co-workers(1950), the
incidence of inlety contraction was 40%

FETOPELVIC DISPROPORTION
Management:
In the absence of contracted pelvis, and
with effective labor, successful vaginal
delivery will follow

FETOPELVIC DISPROPORTION
2. Brow presentation
- rarest
- portion of the fetal head between
the orbital ridge and the anterior
fontanel presents at the pelvic inlet
-Management:
- if brow persists, prognosis is poor
- for vaginal delivery
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FETOPELVIC DISPROPORTION
3. Transverse Lie
- long axis of the fetus is perpendicular to that
of the mother
- oblique lie usually transient
- shoulder at the pelvic inlet with the head
lying in one iliac fossa and the breech in the
other
- Diagnosis:
-abdomen is wide
- fundus extends slightly over the
umbilicus
- no fetal pole in the fundus
- ballotable head is in one iliac fossa and
the
breech in the other
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FETOPELVIC DISPROPORTION
Etiology;
Abdominal wall relaxation
Preterm fetuses
Placenta previa
Uterine anomaly
Excessive amniotic fluid
Contracted pelvis

Management:
Cesarean delivery
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FETOPELVIC DISPROPORTION
4.Compound presentation
An extremity prolapses alongside the presenting part
with both presenting in the pelvis simultaneously
Cause: preterm birth
Perinatal loss is increased as a result of
concomittant preterm delivery , prolapsed cord and
traumatic obstetrical procedures
In most cases, the prolapsed part is left alone
If it appears to prevent the descent o0f thje head, the
prolapsed arm should be pushed gently upward and
the head simultaneously downward by fundal
pressure
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FETOPELVIC DISPROPORTION
5. Persistent Occiput Posterior Position
Most often undergo spontaneous anterior
rotation
Failure of spontaneous rotation is
unknown, however transverse narrowing of
midpelvis is a factor

FETOPELVIC DISPROPORTION
6. Shoulder Dystocia
incidence is increased from 1960 to 1980
(Hopwood, 1982)
Postpartum hemorrhage is the major
maternal risk
Maybe associated with significant fetal
morbidity and even mortality
Most common fetal injury: Transient Erb or
Duchenne brachial plexus palsy(45%),
clavicular fractures(38%),
Humeral fractures(17%)
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FETOPELVIC DISPROPORTION
Risk Factors:
Obesity
Multiparity
Diabetes
Postterm fetuses
Fetal macrosomia

FETOPELVIC DISPROPORTION
The American College of Obstetrician and
Gynecologists (2002) review studies classified
according to evidence based methods
outlined by the US Preventive Services Task
Force.
Conclusion:
1. Most cases of shoulder dystocia cannot be
accurately predicted or prevented
2. Elective induction of labor or elective CS delivery
for all women suspected of carrying a macrosomic
fetus is not appropriate
3. Planned CS delivery may be considered for the
non-diabetic women carrying a fetus with an
estimated exceeding 5000g or the the diabetic
women whose weight exceeding to wt > 4500 g
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FETOPELVIC DISPROPORTION

1.
2.
3.

Management:
Suprapubic pressure
Mc Roberts maneuver
Woods maneuver
- rotating the posterior shoulder 180
degrees in a corkscrew fashion
- the impacted ant shoulder could be
released
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FETOPELVIC DISPROPORTION
4. Rubin (2 maneuvers)
- first the fetal shoulders are rocked
from side to side by applying force to
the maternal abdomen. If not succesful,
the pelvic hand reaches the most easily
accesible fetal shoulders which is then
pushed towards the anterior surface of
the chest
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FETOPELVIC DISPROPORTION
5. Fracture of the clavicle
6. Hibbard(1982) reccomended tat pressure be
applied on the fatal jaw and and neck in the
direction of the maternal rectumwith strong
fundal pressure applied by the assistant
7. Zavanelli maneuver
- cephalic replacement into the pelvis and
then CS
8. Cleidotomy
- cutting the clavicle with scissors
- used for dead fetuses

FETOPELVIC DISPROPORTION
9. Symphysiotomy
- increased maternal morbidities

FETOPELVIC DISPROPORTION
The American College of Obstetricians
and Gynecologists(2002) concluded
that there is no evidence that any one
maneuver is superior to another in
releasing the impactedshoulder or
reducing the chance of injury.
Performing the Mc Roberts
Maneuver , however, was deemed a
reasonable initial approach.
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