Discuss the Mechanism of Labor (vertex presentation)

Key stages of labour

● Descent
● Engagement
● Neck flexion
● Internal rotation
● Crowning
● Extension of the presenting part
● Restitution
● Internal rotation
● Lateral flexion

1. DESCENT
● The fetus descends into the pelvis.
● In the primigravida this is likely to occur from 38 weeks gestation onwards, in a
multigravida woman, this may not occur until labour is established.
● Descent is encouraged by:
▪ Increased abdominal muscle tone
▪ Braxton hicks in the late stages of pregnancy
▪ Fundal dominance of the uterine contractions during labour
▪ Increased frequency and strength of contractions during labour
● As the head descends, it moves towards the pelvic brim in either the left or
right occipito-transverse position (this means the occiput can be facing the left
side or right side of the mother’s pelvis).
2. ENGAGEMENT
● This is when the largest diameter of the fetal head descends into the maternal
pelvis.
● The term engagement is referring to the widest part of the fetal head
successfully negotiating its way down deep into the maternal pelvis.
Engagement is identified by abdominal palpation, where the fetal head is
3/5th palpable or less.
3. FLEXION
● As the fetus descends through the pelvis, fundal dominance of uterine
contraction exerts pressure down the fetal spine towards the occiput, forcing
the occiput to come into contact with the pelvic floor. When this occurs the
fetal neck flexes (chin to chest) allowing the circumference of the fetal head to
reduce to sub-occipitobregmatic (9.5cm).
● In this position, the fetal skull has a smaller diameter which assists passage
through the pelvis.
4. INTERNAL ROTATION
 ● The pelvic floor has a gutter shape with a forward and downward slope,
encouraging the fetal head to rotate from the left or right occipito-transverse
position a total of 90-degrees, to an occipital-anterior (occiput facing forward)
position, to lie under the subpubic arch.
● With each maternal contraction, the fetal head pushes down on the pelvic
floor. Following each contraction, a rebound effect supports a small degree of
rotation. Regular contractions eventually lead to the fetal head completing the
90-degree turn.
● This rotation will occur during established labour and it is commonly
completed by the start of the second stage. Further descent leads to the fetus
moving into the vaginal canal and eventually, with each contraction, the vertex
becomes increasingly visible at the vulva.
5. CROWNING
● When the widest diameter of the fetal head successfully negotiates through
the narrowest part of the maternal bony pelvis, the fetal head is considered to
be ‘crowning’. This is clinically evident when the head, visible at the vulva, no
longer retreats between contractions. Complete delivery of the head is now
imminent and often the woman, who has been pushing, is encouraged to pant
so that the head is born with control.
6. EXTENSION OF THE PRESENTING PART
● The occiput slips beneath the suprapubic arch allowing the head to extend.
The fetal head is now born and will be facing the maternal back with its
occiput anterior.
7. EXTERNAL ROTATION & RESTITUTION
● Because the shoulders at the point of the head being delivered are only just
reaching the pelvic floor they are often still negotiating the pelvic outlet and
the fetus may naturally align its head with the shoulders. This is called
restitution and visually you may see the head externally rotate to face the right
or left medial thigh of the mother.
8. DELIVERY OF THE SHOULDERS AND BODY
● Downward traction by the healthcare professional will assist the delivery of
the anterior shoulder below the suprapubic arch.
● This is followed by upward traction assisting the delivery of the posterior
shoulder.
● The fetal body will be delivered by the contractions, the health professional’s
role is only to assist safe negotiation of this last stage.