Mindanao State University - College of Medicine

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

Case Presentation
Yousef Hassan Basman Bazar
Senior Clerk
 Case Presentation
OBJECTIVES
General Objective:
 To discuss and understand normal labor and vaginal
delivery

Specific Objectives:
 To present a case of a 33 y/o G4P3 pregnancy uterine
381/7 wks AOG by LMP cephalic presentation, in labor
 To discuss the definition, stages, mechanisms and
management of labor.
 Case Presentation
DISCUSSION OUTLINE

• Definition of Labor
• Stages of Labor
• Mechanisms of Labor
• Management of Labor
 Case Presentation
IDENTIFYING DATA

• A. N.
 33 y/o
 G4P3(3003)
 married
 Muslim
 housewife
 from Ambolong, Marawi City
 Case Presentation
INFORMANT AND PERCENT RELIABILITY
• Patient herself, 99%
 Case Presentation
CHIEF COMPLAINTS
• Hypogastric pain
 Case Presentation
PAST MEDICAL HISTORY
 No history of previous blood transfusion
 No previous surgeries
 No known chronic diseases
i.e. hypertension, DM, bronchial asthma
 No known allergy to food or drugs
 Case Presentation
MENSTRUAL HISTORY
 Patient had her menarche at the age of 12. She
initially had irregular cycles (every 3-4 months)
which later became regular (~30 days) after her first
delivery. Her menstruation usually lasts for 7 days
and uses up 12 pads of napkin per day. She
experiences dysmenorrhea on the 1st to 3rd day. Of
her period
 Case Presentation
OBSTETRIC HISTORY
PMP:
LMP: Nov 22, 2018, 7 days duration
EDC: Aug 2, 2019
AOG: 38 1/7 weeks by LMP
 Case Presentation
OBSTETRIC HISTORY
G4P3 (3003)

Year AOG Manner Place Gender Status

G1 2011 Term NSD Hospital Female Alive

G2 2013 Term NSD Hospital Female Alive

Lying-in
G3 2016 Term NSD Clinic Female Alive

G4 Present Pregnancy
 Case Presentation
PNCU HISTORY
 Had prenatal check-up at a local hospital in
Cavite (2x) and APMC OPD (2x)
 Started at 3 months AOG
 Had completed her Tetanus Toxoid doses.
 Prescribed with Ferrous Sulfate and Calcium
Carbonate once a day
 Case Presentation
CONTRACEPTIVE/SEXUAL HISTORY
 No current nor past contraceptive methods
used
 Coitarche at age of 23 years old
 Had two sexual partner, all monogamous
sexual partner
 Case Presentation
GYNECOLOGIC HISTORY
 No history of breast diseases (i.e. lumps,
dimpling, pigmentation)
 Not doing self-breast examination
 Practice breastfeeding to her children (1st 6
months)
 Case Presentation
GYNECOLOGIC HISTORY
 Did not have previous gyneclogic surgical
operations
 No history of difficulty conceiving in the past

 No symptoms of STD (i.e. vaginal itching,

discharges or lesions)
 Did not have any cervical nor vaginal
cytologic examinations
 Case Presentation
FAMILY HISTORY
 No known heredofamilial diseases (i.e.
hypertension, DM, asthma, malignancies, etc.) were
noted.
 Case Presentation
PERSONAL SOCIAL HISTORY
 Finished College Level
 A stay at home mom
 Daily activities include doing household chores
 Rest/Sleep: duration of 6-8 hrs/day
 Usual diet consisting of rice, vegetables and fish
 No regular physical exercise
 Nonsmoker,Non-alcoholic beverage drinker
 Case Presentation
REVIEW OF SYSTEMS
General: (-) for body weakness, fever; (-) for loss of
consciousness, and anorexia;
Skin: (-) for dryness, discoloration and rashes
HEENT: (-) for dizziness; (-) for visual disturbances,
yellowing of eyes, eye/ear pain, and ear/nasal discharges
Neck: (-) for mass and stiffness
Respiratory: (-) for cough; (-) for shortness of breath,
and difficulty breathing
Cardiovascular: (-) for palpitations and chest pain
 Case Presentation
REVIEW OF SYSTEMS
Gastrointestinal: (+) for abdominal pain, (-) nausea, vomiting;
(-) for changes in bowel habits, hematochezia, and melena
Genitourinary: (-) for dysuria, hematuria, urgency and
frequency
Peripheral Vascular: (-) for leg cramps and edema
Musculoskeletal: (-) for joint and bone pain
Neurologic: (-) for memory loss and loss of consciousness
Hematologic: (-) for easy bruising and history of bleeding
Endocrine: (-) for excessive sweating, heat or cold intolerance
Psychiatric: (-) for depression and nervousness
 Case Presentation
PHYSICAL EXAMINATION
HEAD/EYES/EARS/NOSE/THROAT
H: normocephalic
E: anicteric sclerae, pupils equally reactive to light, pale palpebral
conjunctivae
E: well developed pinnae, no aural discharges
N: septum midline, no nasal discharges
T: no tonsillopharyngeal congestion

NECK
supple, trachea at midline, no jugular vein distention
no lymphadenopathies, thyroid not enlarged
 Case Presentation
PHYSICAL EXAMINATION
HEART
I: PMI at 4th ICS LMCL
P: no thrills, no heaves
A: normal rate, regular rhythm, no murmur

CHEST AND LUNGS

I: equal chest expansion, no intercostal, subcostal and
supraclavicular retractions
P: equal tactile fremitus
P: equally resonant lung fields
A: vesicular breath sounds, no crackles, no wheezes
 Case Presentation
PHYSICAL EXAMINATION
ABDOMEN
I: gravid, prominent linea alba,no scars, no dilated veins, fundal height
of 31cm
A: FHT of 147 bpm
P: no abnormal area of dullness nor tympany
P: soft in between contraction and rigid on contraction, no mass
palpated
L1: large, nodular mass
L2: convex, bony edge, fetal back on right maternal side; nodular fetal
extremities on left maternal side
L3: round, hard mass above pelvic inlet
L4: engaged
 Case Presentation
PHYSICAL EXAMINATION
BACK
no gross bony deformities
no costovertebral angle tenderness

EXTREMITIES
equally palpable, strong peripheral pulses
pink nailbeds, no clubbing, no edema
CRT <2 seconds
 Case Presentation
PHYSICAL EXAMINATION
PELVIC EXAM
 normal female external genitalia
 the vagina is smooth and parous
 cervix smooth, 9cm dilated, 90% effaced,
cephalic in presentation, station +1, intact bag
of water
 uterus enlarged to a 38 week AOG, nontender
 no adnexal masses nor tenderness
 Case Presentation
PRIMARY IMPRESSION/ ADMITTING DX

G4P3 (3003) Pregnancy Uterine 38 1/7

weeks AOG by LMP, cephalic in
presentation, in labor
 Case Presentation
AT THE EMERGENCY ROOM
HD 0
8:30 am
ADMITTING ORDERS:
 Please admit patient under OB service
 Secure consent to care
 NPO
 IVF: PLR 1L at 30gtts/min
 Labs:
 CBC with platelet
 Urinalysis
 Blood Type
 HbsAg
 Monitor vital sign every 30 minutes
 Monitor the progress of labor, fetal heart tone, and uterine contraction every 15 minutes
 Case Presentation
AT THE DELIVERY ROOM
HD 0
10:28 am

 Patient underwent normal spontaneous Outcome:

delivery Baby boy

Apgar score: 8, 9
 No episiotomy done, no perineal
Birth weight: 3.8kg
lacerations
Birth length: 55 cm
 The placenta was delivered spontaneously and
Head circumference: 35 cm
is grossly normal, with complete cotyledons
Chest circumfeence: 36 cm
and a three-vessel umbilical cord.
Abdominal circumference: 36
cm
Ballard's score: 41 weeks AOG
Appropriate with gestational
age
Thinly Meconium Stained AF
 Case Presentation
COURSE IN THE WARD
HD 1,
6:30 PM

 -BM, +flatus, decreased lochia, freely voiding, -fever, -abdominal bleeding,

S -dizziness
 GS: awake, conscious, not in respiratory distress, ambulatory
 VS: BP=110/70 mmHg, PR=90bpm, RR=20cpm, T=36.5C, O2 Sat=97%
O  HEENT: anicteric sclerae, pink conjunctivae, moist lips and buccal mucosa
 C/L: equal lung expansion, tactile fremitus, vesicular breath sounds

A  Abdomen: contacted uterus, nontender

 Extremities: equal palpable peripheral pulses
 Postpartum Day 1

P  Continue present management

 Refer accordingly
 Case Presentation
COURSE IN THE WARD
HD 2,
9:30 AM

 +BM, +flatus, minimal lochia, freely voiding, -fever, -abdominal bleeding,

S -dizziness

 GS: awake, conscious, not in respiratory distress, ambulatory

O  VS: BP=120/70 mmHg, PR=87bpm, RR=20cpm, T=36.8C, O2 Sat=98%

 HEENT: anicteric sclerae, pink conjunctivae, moist lips and buccal mucosa
 C/L: equal lung expansion, tactile fremitus, vesicular breath sounds
 Abdomen: well contracted uterus, nontender
 Extremities: equal palpable peripheral pulses

P
 Case Presentation
COURSE IN THE WARD
HD 2,
9:30 AM

S
 Postpartum Day 2

O  May go home today

 Home meds:
 Cefuroxime 500mg tab, i tab BID PO for 5 days

A  Metronidazole 500mg tag TID for 5 days

 Mefenamic Acid 500 mg tab, i tab TID PRN for pain
 Mutlivit + Iron 500 mg cap OD PO for 2 weeks

PP  Ascorbic Acid 500mg tab, i tab OD PO for 2 weeks

 Perineal care BID
 To f ollowup at OPD after 1 week
 Case Presentation
FINAL DIAGNOSIS

G4P4 (4004) Pregnancy Uterine

delivered term, cephalic, to a live baby
boy, appropriate for gestational age (BW
3800 g)
NORMAL LABOR

CASE
DISCUSSION
 Case Presentation
DEFINITION OF LABOR

“Uterine contractions that bring

about demonstrable effacement and
dilation of the cervix”
 Case Presentation
STAGES OF LABOR
• First stage:
Starts with the onset of true labor contractions
Ends when the cervix is fully dilated (10cm)
Longest stage of labor
• Second stage:
Begins with the complete dilatation of the cervix
Ends with the birth of the baby
Duration is between 30 and 90 minutes
 Case Presentation
STAGES OF LABOR
Third stage of labor:
Separation and expulsion of placenta and
membranes
Duration is between 5 and 30 minutes
Shortest stage of labor
Fourth stage of labor:
After the expulsion of placenta
Duration is 2 hours
Increased risk for bleeding
 Case Presentation
FRIEDMAN’S CURVE
 Case Presentation
FIRST STAGE OF LABOR

Stronger and
Increasing in
stronger
frequency (↑)
contractions

Longer and
Regular
longer
contractions
contractions
Cervical
Dilation and
Effacement
 Case Presentation
FIRST STAGE OF LABOR

Mechanical
pressure by the
membrane

Contraction and
retraction of Descent of
uterine presenting part
musculature

Cervical
Dilation and
Effacement
 Case Presentation
PHASES OF CERVICAL DILATION
Latent phase:
• the first 5 cm of dilatation, it is a slow process
- 20 hours at nulliparous, 14 hours at multiparous
Active phase:
• faster dilatation, from 6 cm to fully dilatation
(10cm)
– Normal rate is 1 cm / hour
 Case Presentation
FIRST STAGE OF LABOR
Latent phase
• Onset –regular
contractions
• Ends –6 cm of dilatation
• Prolonged latent phase-
>20 hours in the
nullipara, >14 hours in
the multipara –95th
percentiles
 Case Presentation
FIRST STAGE OF LABOR
Active phase
• Onset –cervical
dilatation of 6 cm
• Protraction –slow
rate of cervical
dilatation
• Arrest –complete
cessation of
dilatation or descent
 Case Presentation
SECOND STAGE OF LABOR
Begins with full dilatation of the cervix and
ends with the delivery of the baby
• It have TWO phases:
Propulsive phase:
From full dilatation until presenting part
has descended to the pelvic floor
Expulsive phase:
Ends with the delivery of the fetus
 Case Presentation
SECOND STAGE OF LABOR
• Begins when cervical dilatation is complete
and ends with fetal delivery.
• Median duration 50 min for nulliparas and 20
min for multiparas.
• Contractions
– Interval: 2 to 3 minutes
– Duration: 50 to 100 seconds
 Case Presentation
THIRD STAGE OF LABOR
Begins after delivery of the baby and ends with
the delivery of the placenta and membranes
It contains two phases
A. Separation
B. Expulsion
Duration: 5-20minutes
(if actively managed)
Blood loss: 150-250 ml
(average)
 Case Presentation
MECHANISM OF LABOR
- at the onset of labor, the position of the fetus
with respect to the birth canal is critical and
thus should be determined in early labor.
 Case Presentation
MECHANISM OF LABOR
Important relationships include:
Fetal Lie
Fetal Presentation
Fetal Attitude
Fetal Position
 Case Presentation
MECHANISM OF LABOR
Important relationships include:
Fetal Lie
Fetal Presentation
Fetal Attitude
Fetal Position
 Case Presentation
MECHANISM OF LABOR
The relation of the long axis of the fetus to that
of the mother

• Longitudinal lie (~99%)

• Transverse lie (<1%)
• Oblique lie
 Case Presentation
MECHANISM OF LABOR
Important relationships include:
Fetal Lie
presenting
The Fetal Presentation
part is that portion of the fetal
body that is either foremost within the birth
Fetal
canalAttitude
or in closest proximity to it.
Fetal Position
 Case Presentation
MECHANISM OF LABOR
LONGITUDINAL LIE

• Cephalic Presentations • Breech Presentation

 Vertex/Occiput  Frank
 Sinciput  Complete
 Brow  Incomplete
 Face  Footling
 Case Presentation
CEPHALIC PRESENTATIONS
 Case Presentation
BREECH PRESENTATIONS
 Case Presentation
SHOULDER PRESENTATIONS
 Case Presentation
MECHANISM OF LABOR
Important relationships include:
The
Fetal Lie
fetus becomes folded upon itself:
Fetal
- the backPresentation
becomes markedly convex,
- the head is sharply flexed,
 Fetal
- the thighsAttitude
are flexed over the abdomen,
Fetal - thePosition
legs are bent at the knees,
 Case Presentation
MECHANISM OF LABOR
Important relationships include:
Fetal Lie
Fetal Presentation
Fetal Attitude
Fetal Position
 Case Presentation
FETAL POSITION

Varieties of the
fetal positions
 Case Presentation
DIAGNOSIS OF FETAL PRESENTATION AND POSITION

• Abdominal palpation –Leopold

maneuvers (4)
• Vaginal examination
• Ultrasonography and radiography
 Case Presentation
DIAGNOSIS OF FETAL PRESENTATION AND POSITION

LEOPOLD’S MANEUVER
 Case Presentation
DIAGNOSIS OF FETAL PRESENTATION AND POSITION
VAGINAL EXAMINATION
• Before labor vaginal examination is often
inconclusive
• With the onset of labor, after cervical
dilatation, vertex presentation and their
positions are recognized by palpation of the
various sutures and fontanels.
• Face and breech presentation can be identified
by palpation.
 Case Presentation
VAGINAL EXAMINATION
 Case Presentation
SONOGRAPHY AND RADIOGRAPHY

• Ultrasonographic techniques can aid

identification of fetal position, especially in
obese women or in women with rigid
abdominal walls.
• In some clinical situations, the value of
information obtained radiographically far
exceeds the minimal risk from a single x-ray
exposure.
 Case Presentation
CARDINAL MOVEMENTS OF LABOR
 Engagement
 Descent
 Flexion
 Internal rotation
 Extention
 External rotation
 Expulsion
 Case Presentation
ESSENTIAL FACTORS OF LABOR

3 Planes of the Bony pelvis

Passageway - Pelvic Inlet
•- Midpelvis
Uterine contraction
Power •- Pelvic Outlet actions of the
Hydrostatic
amniotic membrane
• Vertex
Passenger Action of
•• Brow
Expulsive
the fetal head
Presentation
power or
Presentarion
• bearing down of mother
Sinciput Presentation
• Face Presentation
 Case Presentation
MANAGEMENT OF NORMAL LABOR
Admission procedures
• Identification of labor
True labor
• Contractions occur at regular intervals
• Intervals gradually shorten
• Intensity gradually increase
• Discomfort is in the back and abdomen
• Cervix dilates
• Discomfort is not stopped by sedation
 Case Presentation
MANAGEMENT OF NORMAL LABOR
False labor
• Contractions occur at irregular intervals
• Intervals remain long
• Intensity remains unchanged
• Discomfort is chiefly in the lower abdomen
• Cervix does not dilate
• Discomfort is usually is relieved by sedation
 Case Presentation
MANAGEMENT OF LABOR
Abdominal examination
(Leopold, fetal heart-auscultation, uterine contractions)
Vaginal examination:
• Detection of ruptured membranes
– Possibility of cord prolapse
– Labor is likely to begin soon if the pregnancy at term
– If the delivery is delayed for 24 hours or more, intrauterine
infection is more likely
• Cervical effacement
• Cervical dilatation
• Presenting part, attitude, position
• Position of the cervix
 Case Presentation
MANAGEMENT OF LABOR
Admission procedures:
Station
- The level of the presenting part in the birth
canal is described in relationship to the ischial
spines, which are halfway between the pelvic
inlet and pelvic outlet.
 Case Presentation
STATION
 Case Presentation
MANAGEMENT OF THE FIRST STAGE OF LABOR
• Monitoring of the fetal well-being (CTG, amnioscopy)
- Uterine contractions (by hand and/or by CTG)
- Evaluate the frequency, duration, and intensity
• Maternal vital signs
• Subsequent vaginal examinations
• Intravenous fluids (not necessary in all cases)
• Maternal position during labor (lying, walking, sitting, use of
ball)
• Analgesia (intramuscular and/or epidural)
• Amniotomy
• Urinary bladder function
 Case Presentation
MANAGEMENT OF THE SECOND STAGE OF LABOR
Spontaneous delivery
• Delivery of the head
– Crowning –encirclement of the largest head diameter by the vulvar ring.
– Episiotomy
– Ritgen maneuver
• Delivery of the shoulders
– External rotation – bisacromial diameter has rotated into the
anteroposterior diameter of the pelvis
– Gentle downward traction of the head
• Clearing the nasopharynx**
• Nuchal cord
• Clamping the cord
 Case Presentation
MANAGEMENT OF THE SECOND STAGE OF LABOR
• Episiotomy
– Anesthetize with pudendal block
– Put two fingers into the vagina along the
posterior wall
– Place one blade of scissors between fingers
inside vagina, other blade outside vagina
toward anus
– Cut to approximately 1 inch away from anus
during a contraction
 Case Presentation
MANAGEMENT OF THE SECOND STAGE OF LABOR
 Case Presentation
MANAGEMENT OF THE THIRD STAGE OF LABOR
Signs of placental separation
1. The uterus becomes globular and firmer
2. There is often a sudden gush of blood
3. The placenta passing down into the lower
uterine segment, where its bulk pushes the
uterus upward
4. The umbilical cord protrudes further out
of the vagina
 Case Presentation
MANAGEMENT OF THE THIRD STAGE OF LABOR
Delivery of the placenta
• Traction on the umbilical cord must not be
used to pull the placenta out of the uterus
• Manual removal of the placenta
Active management of the third stage
• Oxytocin
• Controlled cord traction
 Case Presentation
MANAGEMENT OF THE THIRD STAGE OF LABOR

• The cervix and vagina should be immediately

inspected for lacerations and surgical repair
performed if necessary!
• Duration: 0 –30 min
 Case Presentation

THANK YOU!
Case Presentation