This document summarizes the normal labor and delivery process. It defines labor as beginning with regular uterine contractions and ending with childbirth. Labor involves three stages - first stage is cervical dilation from 0-10cm, second stage is birth of the baby, and third is delivery of the placenta. Key aspects of managing normal labor are admitting women in early labor, monitoring the fetus, allowing freedom of movement, and active management including amniotomy and oxytocin to shorten stages of labor. The goal is a safe birth for both mother and child with minimal medical intervention.
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Normal labor and delivery
1. Normal Labor and Delivery
Resident Lecturer: A. Polintan, MD
Moderator: V. Espallardo, MD, FPOGS
2. Outline:
• Definition of Labor
• Mechanism of Labor
• Stages of Labor
• Management of Normal Labor
3. Definition ofLabor:
• The process that leads to childbirth
• Begins with the onset of regular
uterine contractions
• Ends with delivery of the newborn
and expulsion of the placenta
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
4. Outline:
• Definition of Labor
• Mechanism of Labor
• Stages of Labor
• Management of Normal Labor
5. Mechanism of Labor
• Important relationship to be
considered:
• Fetal lie
• Fetal presentation
• Fetal attitude or posture
• Fetal position
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
6. Mechanismof Labor:
Fetal Lie
• Definition: The relation of the fetal
long axis to that of the mother.
• Longitudinal
• Transverse
• Oblique
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
7. Mechanismof Labor:
Fetal Presentation
• Definition: The presenting part is that
portion of the fetal body that is either
foremost within the birth canal or in
closest proximity to it.
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
11. Mechanismof Labor:
Fetal Attitude or Posture
• Definition: A characteristic posture
that the fetus assumes in the later
months of pregnancy
• Usually convex
• May rarely be concave
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
12. Mechanismof Labor:
Fetal Position
• Definition: Refers to the relationship
of an arbitrary chosen portion of the
fetal presenting part to the right or left
side of the birth canal.
• May be directed anteriorly,
transversely or posteriorly
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
14. Mechanismof Labor:
Abdominal Palpation – Leopolds
Maneuver
• LM 1: Identifies which fetal
pole occupies the fundus
• LM 2: Performed to
determine the fetal lie
• LM3: Determined if the
presenting part is engaged
• LM4: Readily differentiates
the anterior shoulder
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
15. Mechanism of Labor:
Cardinal Movements of
Labor
• Engagement – the
mechanism by
which the biparietal
diameter passes
through the pelvic
inlet
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
16. Mechanism of Labor:
Cardinal Movements of
Labor
• Descent - The first
requisite for birth
• 4 Forces:
– Pressure of AF
– Direct pressure of the
fundus upon the breech
with contractions
– Bearing-down efforts of
maternal abdominal
muscles
– Extension and
straightening of the fetal
body
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
17. Mechanism of Labor:
Cardinal Movements of
Labor
• Flexion – as soon as
the descending head
meets resistance
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
18. Mechanism of Labor:
Cardinal Movements of
Labor
• Internal Rotation -
consist of a turning of
the head in such a
manner that the
occiput gradually
moves toward the
symphysis pubis
anteriorly, or less
commonly posteriorly
towards the hollow of
the sacrum.
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
19. Mechanism of Labor:
Cardinal Movements of
Labor
• Extension – takes
place when the head
reaches the vulva
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
20. Mechanism of Labor:
Cardinal Movements of
Labor
• External Rotation
(Restitution) –
Corresponds to the
rotation of the fetal
body and serves to
bring its bisacromial
diameter into the
relation with the AP
diameter of the pelvic
outlet
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
21. Mechanism of Labor:
Cardinal Movements of
Labor
• Expulsion
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
22. Outline:
• Definition of Labor
• Mechanism of Labor
• Stages of Labor
• Management of Normal Labor
23. Stages of Labor
• Strict definition of labor – uterine
contractions that bring about
demonstrable effacement and
dilatation of the cervix
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
24. Stages of Labor
First Stage
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
25. Stages of Labor
First Stage
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
26. Stages of Labor
Second Stage
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
• Begins with complete cervical dilatation
• Ends with fetal delivery
27. Outline:
• Definition of Labor
• Mechanism of Labor
• Stages of Labor
• Management of Normal Labor
28. Management of NormalLabor:
• 1. Birthing should be recognized as a
normal physiological process that
most women experience without
complications
• 2. Intrapartum complications, often
arising quickly and unexpectedly,
should be anticipated.
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
30. Managementof NormalLabor:
Identification of Labor
• Uterine contractions 5 minutes apart
for 1 hour
• Cervical dilatation ≥4cm
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
31. Managementof NormalLabor:
Electronic Fetal Monitoring
• Routine for high risk pregnancies
from admission
• May be used for low-risk pregnancies
as admission test, then followed by
intermittent assessment for the
remainder of labor
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
35. Managementof NormalLabor:
First Stage of Labor
• Intrapartum Fetal Monitoring
– OB Normal
• FHT monitoring at least every 30 minutes during
the 1st stage
• FHT monitoing at least every 15 minutes during
the 2nd stage
– FHT
• Immediately after a contraction at least every 30
minutes and then every 15 minutes during the 2nd
stage
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
36. Managementof NormalLabor:
First Stage of Labor
• Intrapartum Fetal Monitoring
– High Risk Pregnancy
• FHT monitoring every 15 minutes and every 5
minutes during the 2nd stage of labor
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
37. Managementof NormalLabor:
First Stage of Labor
• Cervical Examination
– 2-3 hours intervals during the 1st stage of
labor
• Oral Intake
– Food should be witheld during active labor
and delivery
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
38. Managementof NormalLabor:
First Stage of Labor
• Intravenous Fluid
– No actual need unless analgesia has been
given
– 60 -120mL/hour
• Maternal Position
– Let the woman assume the position most
comfortable to her
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
39. Managementof NormalLabor:
Second Stage of Labor
• Bearing-down efforts
• Active Management of Labor
– Amniotomy
– Oxytocin
Chapter 22: Normal Labor. William’s Obstetrics 24th Edition.
Intro: At the onset of labor, the position of the fetus with respect to the birth canal is critical to the route of delivery and thus should be determined in early labor.
Intro: At the onset of labor, the position of the fetus with respect to the birth canal is critical to the route of delivery and thus should be determined in early labor.
It may either be any of the 3:
Longitudinal lie is seen in 99% of pregnancies
Predisposition to transverse lie include multiparity, placenta previa, hydamios and uterine animalies
Oblique lie is when the fetal and maternal axes may cross at a 45degree angle, it is unstable and becomes either longitudinal or transverse during labor
The cephalic presentation is classified according to the relationship between the head and body of the fetus.
Vertex or Occiput Presentation – Head is flexed sharply so that the chin is in contact with the thorax. The posterior (occipital) fontanel is the presenting part.
Face Presentation- Fetal neck is sharply extended to that the occiput and back come in contact.
Sinciput (Military) Presentation- midway between vertex and face, the anterior (bregma) fontanel is the presenting part.
Brow Presentation – the head is partially extended.
If the fetus is breech in presentation, the fetus often changes polarity to make us of the roomier fundus for its bulkier and more mobile podalic pole (breech).
Incidence of breech presentation decreases with gestational age:
25% at 28weeks
17% at 30weeks
11% at 32 weeks
3% at term
Complete Breech – the lower extremities are flexed at the hip, and wither one of both knees are flexed
Frank Breech – the lower extremities are flexed at the hips and extended at the knees
Footling Presentation – a presentation wherein one of both feet are below the breech
Convex meaning the fetus is folded or bent on itself, in such that the shin is touching the chest and the thighs are flexed over the abdomen, and the umbilical cord lies in the space between them.
Concave occurs as the fetal head becomes progressively more extended from the vertex to the face presentation.
The fetal occiput, chin, and sacrum are the determining points in vertex, face and breech presentations.
LO, RO, LM, RM, LS and RS
A, T, P
Approximately 2/3 of vertex presentation are in the left occiput position, an done third in the right.
In shoulder presentation, the acromion is the portion of the fetus arbitrary chosen for orientation with the maternal pelvis. The acromion may be directed anteriorly or posteriorly and superiorly or inferiorly.
It is impossible to differentiate exactly the several varieties of shoulder presentation by clinical examination and serves no practical purpose.
More practically it may be written as transverse lie or shoulder presentation with back up or back down which is clinically important when deciding the incision type for cesarean delivery.
LM1:
Breech – sensation of a large, nodular mass
Head – hard and round, mobile and ballotable
LM2:
Hard resistant structure
Numerous small, irregular, mobile parts
LM3:
Not engaged – movable mass
Engaged
Asynclitism – lateral deflection to a more anterior or posterior position in the pelvis
Anterior asynclitism – the sagittal suture approaches the sacral promotory, more of the anterior parietal bone presents itself to the examining fingers.
Posterior asynclitism – the sagittal suture lies close to the symphysis, more of the posterior parietal bone will present
If severe, the condition, is a common reason for CPD even with an otherwise normal sized pelvis.
Nulliparas- engagement may take place before the onset of labor, and further descent may not follow until the onset of the 2nd stage
Multiparas – descent usually begins with engagement
Functional Labor Division:
Preparatory Division
cervix dilates littles, connective tissue components change considerably
Sedation and conduction of analgesia are capable of arresting this labor division
Dilatation Division
dilatation proceeds at its most rapid rate
Unaffected by sedation
Pelvic Division
a. Commence with the deceleration phase of cervical dilatation
Two phases of cervical dilatation:
Latent Phase – corresponds to the preparatory division
Point at which the mother perceives regular contractions
3-5cm dilatation
Active Phase – subdivided into:
Acceleration Phase
Phase of Maximum Slope
Decceleration Phase
Median duration is 50 minutes for nulliparas and 20 minutes for multiparas
Rupture of Membranes is significant for 3 reasons:
If the presenting part is not fixed in the pelvis, the possibility of umbilical cord prolapse and compression is greatly increased
Labor is likely to begin soon if the pregnancy is at or near term
If delivery is delayed after membrane rupture, intrauterine infection is more likely as the time interval increases
Cervical Assessment includes:
Degree of cervical effacement – expressed in terms of the length of the cervical canal compared to that of an uneffaced cervix
Cervical dilatation – determined by estimating the average diameter of the cervical opening by sweeping the examining finger from the margin of the cervical opening.
Position – detremined by the relationship of the cervical os to the fetal head (posterior, mid-posterior or anterior)
Consistency is detremined to be soft, firm or intermediate
Level or Station – described in relationship to the ischial spine, and is designated to be station 0, negative stations above station 0 and plus stations below station 0 at an increment of 1cm
Wome with no prior prenatal consultations should be considered to be high risk for syphilis, hepatits and HIV
Women with no prior prenatal consultations should be considered to be high risk for syphilis, hepatits and HIV
Women with no prior prenatal consultations should be considered to be high risk for syphilis, hepatits and HIV