OB CHAPTER 22 NORMAL LABOR

Labor is the process that leads to childbirth.

o Begins with = onset of regular uterine contractions
o Ends with = delivery of the newborn and expulsion of the placenta

MECHANISMS OF LABOR
o Fetal lie
The relation of the fetal long axis to that of the mother is termed fetal
lie
Three types:
Longitudinal = more than 99 percent of labors at term
Transverse = Predisposing factors include:
o multiparity,
o placenta previa,
o hydramnios, and
o uterine anomalies
Oblique (Ocassional; fetal and the maternal axes cross at a 45-
degree angle. This is unstable and converts to the first two
during labor)
o Fetal Presentation
Presenting part = portion of the fetal body that is either foremost
within the birth canal or in closest proximity to it. It can be felt through
the cervix on vaginal examination.
Cephalic and Breech presentations = Seen in Longitudinal lie
Shoulder presentation = seen in transverse lie
Most common presentation: (Cephalic, breech, Transverse lie,
Compound, face, Brow)

Cephalic presentation
Vertex/Occiput
o head is flexed sharply so that the chin is in contact with
the thorax.
o occipital fontanel is the presenting part
Face
o fetal neck may be sharply extended so that the occiput
and back come in contact
o face is foremost in the birth canal
Sinciput
o Partially flexed in some cases, with the anterior (large)
fontanel, or bregma, presenting (Transient)
Brow
o Partially extended (Transient)
Failure of Sinciput and Brow to convert can lead to dystocia
Reasons why Vertex is the most common:
o uterus is piriform or pear shaped
o Podalic pole is bulkier and more mobile than the cephalic
pole

Breech Presentation
Frank = thighs flexed, legs extended
Complete = thighs and legs flexed
Footling = thighs and knees extended
 Breech results from:
o Circumstances that prevent normal version from taking
place. (eg: septum that protrudes into the uterine cavity)
o Peculiarity of fetal attitude, (extension of the vertebral
column)
o Placenta is implanted in the lower uterine segment
The incidence of breech presentation decreases with gestational
age
There is high incidence of breech presentation in hydrocephalic
fetuses because the larger fetal cephalic pole requires more
room than its podalic pole

o Fetal attitude/Posture
Check subtypes of cephalic presentation (theyre the same)
Normal attitudes:
back becomes markedly convex
head is sharply flexed so that the chin is almost in contact with
the chest
thighs are flexed over the abdomen
legs are bent at the knees
In all cephalic presentations, the arms are usually crossed over
the thorax or become parallel to the sides
o Fetal position
refers to the relationship of an arbitrarily chosen portion of the fetal
presenting part to the right or left side of the birth canal
Rules:
With each presentation there may be two positionsright or left
The fetal occiput, chin (mentum), and sacrum are the
determining points in vertex, face, and breech presentations,
respectively
Six possible positions: left and right occipital, left and right
mental, and left and right sacral presentations
For still more accurate orientation, the relationship of a given
portion of the presenting part to the anterior, transverse, or
posterior portion of the maternal pelvis is considered.
Approximately two thirds of all vertex presentations are in the left
occiput position, and one third in the right.
In shoulder presentations, the acromion (scapula) is the portion of the
fetus arbitrarily chosen for orientation with the maternal pelvis
(example below). It is customary to refer to all transverse lies simply as
shoulder presentations. Another term used is transverse lie, with back
up or back down, which is clinically important when deciding incision
type for cesarean delivery
o Diagnosis of fetal presentation and position
Abdominal Palpation (Leopold maneuvers)
First maneuver = to identify which pole occupies the fundus
(Fundal grip)
o If breech = gives the sensation of a large, nodular mass
o If head = feels hard and round and is more mobile and
ballottable.
Second maneuver = Determine the fetal back (umbilical grip)
o accomplished as the palms are placed on either side of
the maternal abdomen, and gentle but deep pressure is
exerted
o The back = felt as a hard, resistant structure
o The extremities = felt as numerous small, irregular,
mobile parts
Third Maneuver = determine what fetal part is lying above the
inlet (1st pelvic grip)
o Performed by grasping with the thumb and fingers of
one hand the lower portion of the maternal abdomen
just above the symphysis pubis
o If the presenting part is not engaged, a movable mass
will be felt, usually the head. (The differentiation
between head and breech is made as in the first
maneuver)
o If the presenting part is deeply engaged, however, the
findings from this maneuver are simply indicative that
the lower fetal pole is in the pelvis, and details are then
defined by the fourth maneuver.
Fourth maneuver = to locate the fetus' brow (2nd pelvic grip)
o the examiner faces the mothers feet and, with the tips
of the first three fingers of each hand, exerts deep
pressure in the direction of the axis of the pelvic inlet
o The side where there is resistance to the descent of the
fingers toward the pubis is greatest is where the brow is
located
o If the head of the fetus is well-flexed, it should be on the
opposite side from the fetal back. If the fetal head is
extended though, the occiput is instead felt and is
located on the same side as the back.
Notes:
o The mother lies supine and comfortably positioned with
her abdomen bared
 o These maneuvers may be difficult if not impossible to
perform and interpret if (1) the patient is obese, (2) if
there is excessive amnionic fluid, or if the (3) placenta is
anteriorly implanted.
Vaginal Examination
More effective during labor than before labor
Face and breech presentations are identified by palpation of
facial features and fetal sacrum, respectively.
In attempting to determine presentation and position by vaginal
examination, it is advisable to pursue a definite routine,
comprising four movements:
o First, the examiner inserts two fingers into the vagina
and the presenting part is found. (differentiation of
vertex, face, breech)
o Second, if the vertex is presenting, the fingers are
directed posteriorly and then swept forward over the
fetal head toward the maternal symphysis (delineation of
the sagittal suture)
o Next, the positions of the two fontanels are ascertained.
For this, fingers are passed to the most anterior
extension of the sagittal suture, and the fontanel
encountered there is examined and identified. Then, with
a sweeping motion, the fingers pass along the suture to
the other end of the head until the other fontanel is felt
and differentiated
o Last, the station, or extent to which the presenting part
has descended into the pelvis, can also be established at
this time