Obstetrics and Gynecology
NORMAL LABOR
DEFINITION OF TERMS:
 Labor
o uterine contractions that bring about demonstrable
effacement and dilatation of the cervix
 Fetal lie
o The relation of the fetal long axis to that of the
mother
 Presenting Part
o is that portion of the fetal body that is either foremost
within the birth canal or in closest proximity to it.
 Fetal Attitude
o characteristic posture in later pregnancy (fetal
position)
o results from the mode of fetal growth and its
accommodation to the uterine cavity.
 Fetal Position
o refers to the relationship of an arbitrarily chosen
portion of the fetal presenting part to the right or left
side of the birth canal.
DIAGNOSIS OF FETAL PRESENTATION AND POSITION:
 Leopold Maneuvers:
o LM1: identiication of which fetal pole—that is,
cephalic or podalic—occupies the uterine fundus
o LM2: is accomplished as the palms are placed on
either side of the maternal abdomen, and gentle but
deep pressure is exerted. To identify fetal back.
o LM3: is performed by grasping with the thumb and
fingers of one hand the lower portion of the maternal
abdomen just above the symphysis pubis. If the
presenting part is not engaged or not.
o LM4: the examiner faces the mother’s feet and, with
the tips of the irst three ingers of each hand, exerts
deep pressure in the direction of the axis of the
pelvic inlet.
 Vaginal Examination (IE to, alam niyo na to friends )
 Sonography and Radiography
CARDINAL MOVEMENTS OF LABOR:
 Engagement
o The mechanism by which the biparietal diameter—
the greatest transverse diameter in an occiput
presentation—passes through the pelvic inlet.
 Descent
o This movement is the first requisite for birth of the
newborn.
o Descent is brought about by one or more of four
forces: (1) pressure of the amniotic fluid, (2) direct
pressure of the fundus upon the breech with
contractions,(3) bearing-down efforts of maternal
abdominal muscles, and (4) extension and
straightening of the fetal body.
 Flexion
o As soon as the descending head meets resistance,
whether from the cervix, pelvic walls, or pelvic loor, it
normally lexes.
o shorter sub-occipitobregmatic diameter is
substituted for the longer occipitofrontal diameter
 Internal Rotation
o This movement consists of a turning of the head in
such a manner that the occiput gradually moves
toward the symphysispubis anteriorly from its original
position or, less commonly, posteriorly toward the
hollow of the sacrum
 Extension
o the sharply flexed head reaches the vulva and
undergoes extension
 External Rotation
Magnanimite 2016
o The delivered head next undergoes restitution
o If the occiput was originally directed toward the left, it
rotates toward the left ischial tuberosity. If it was
originally directed toward the right, the occiput
rotates to the right.
 Expulsion
o the anterior shoulder appears under the symphysis
pubis, and the perineum soon becomes distended by
the posterior shoulder. After delivery of the
shoulders, the rest of the body quickly passes.
FETAL HEAD SHAPE CHANGES:
 Caput Succedaneum
o In prolonged labors before complete cervical
dilatation, the portion of the fetal scalp immediately
over the cervical os becomes edematous
 Molding
o the bony fetal head shape is also altered by external
compressive forces
CHARACTERISTICS OF NORMAL LABOR:
Parturition:
 Encompasses all physiologic processes involved in birthing.
o Phase 0: Prelude to Parturition
o Phase 1: Preparation for Labor
o Phase 2: Process of Labor
o Phase 3: Parturition Recovery
PHASE 0: Uterine QUIESCENCE
• Uterine smooth muscles tranquility with maintenance of
cervical structural integrity
• Unresponsive to natural stimuli, contractile paralysis
• Myometrium : quiescent state
• Cervix : firm unyielding
• Successful anatomical structural integrity :essential for
successful parturition
• Some myometrial contractions occur but do not cause cervix
dilation = Braxton-Hicks contraction / false labor
PHASE 1: PREPARATION FOR LABOR
• Uterine awakening or activation
• Progression of change in uterus during last 6-8 weeks of
pregnancy
– Cervical change
– Myometrial change
PHASE 2: PROCESS OF LABOR
TRUE LABOR:
 Presence of regular uterine contractions (duration 30-60
seconds, every 2-5 minutes) that lead to progressive cervical
effacement and dilatation
 Labor pain: fundal to lower back
 (+/-) bloody show
 (+/-) rupture of membranes
 IE: cervix is 4cm dilated, fully effaced (in active labor)
Page 1 of 3
 STAGE 3:
STAGE 1 and 2:  Goals: delivery of an intact placenta and avoidance of uterine
inversion or post-partum hemorrhage
 Signs of placental separation:

Mechanisms of Placental Extrusion:

Duration of Labor Stages: STAGE 4:

 when the tone of the uterus is reestablished after delivery as
the uterus contracts again, expelling any remaining contents.
 These contractions are hastened by breastfeeding, which
stimulates production of the hormone oxytocin.
• Postpartum hemorrhage as the result of uterine atony is more
likely at this time.
• During this time, lacerations are repaired
• ACOG recommendation:
– Maternal blood pressure and pulse be recorded
immediately after delivery and q 15 minutes for the
first 2 hours.

• A patient is a primigravid at 4cm cervical dilation. How BIRTH CANAL LACERATION:

long until she delivers the baby? • 1st degree
– Stage 1: 6cm/1.2cm = 5hr – fourchette, perineal skin, vaginal mucous membrane
• Patient needs 6cm to get to 10cm (full but not the underlying fascia and muscle
dilatation)
– Stage 2: 2hrs
– Answer = Stage 1 + Stage 2 = 7hrs • 2nd degree
Labor Course: – Skin and mucous membrane, fascia and muscle of
• divided fuctionally on basis of expected evolution of dilatation & the perineal body but not the anal sphincter
descent curves into 3 divisions: • 3rd degree
– PREPARATORY DIVISION – Skin, mucous membrane, perineal body and anal
• latent & acceleration phases sphincter
– DILATATIONAL DIVISION • 4th degree
• phase of maximum slope of cervical – Extends through the rectal mucosa to expose the
dilatation lumen of the rectum
• most rapid rate of dilatation occur
– PELVIC DIVISION
• deceleration phase & second stage while
concurrent with phase of maximum slope
of fetal descent

PHASE 3: THE PUERPERIUM

• The period of 6 weeks following delivery of the fetus and
placenta
– Immediate: first 24hrs
– Early: first week

Magnanimite 2016 Page 2 of 3

 – Late: 2nd to 6th week
• The period taken for the uterus and other body systems return
to the pre-pregnant condition.
• Lactation is initiated during this period.
Management of the First Stage of Labor:
 Intrapartum Fetal Monitoring
 Maternal Vital Signs
 Subsequent Cervical Examinations
o at 2- to 3-hour intervals to evaluate labor progress
 Oral Intake
o Food should be withheld during active labor and
delivery.
o Gastric emptying time is remarkably prolonged once
labor is established and analgesics are administered.
o May be vomited and aspirated
o sips of clear liquids, occasional ice chips,and lip
moisturizers are permitted.
 Intravenous Fluids
o there is seldom any real need for this in the normal
pregnant woman
 Maternal Position
o In bed, the laboring woman should be allowed to
assume the position she finds most comfortable—
this will be lateral recumbency most of the time
o She must not be restricted to lying supine because of
resultant aortocaval compression and its potential to
lower uterine perfusion
 Analgesia
o In general, pain relief should depend on the needs
and desires of the woman.
 Amniotomy
o Importantly, the fetal head must be well applied to
the cervix and not be dislodged from the pelvis
during the procedure to avert umbilical cord
prolapse.
 Urinary Bladder Function
o Distention of the bladder should be avoided because
it can hinder descent of the fetal presenting part and
lead to subsequent bladder hypotonia and infection

Management of the Second Stage of Labor:

 Expulsive Efforts
o Occasionally, a woman may not employ her
expulsive forces to good advantage and coaching is
desirable.

Magnanimite 2016 Page 3 of 3