420 Labor
Vaginal examination complements Leopold maneuvers. and the sacral promontory. Te sagittal suture requently is
Beore labor, the diagnosis o etal presentation and position
by vaginal examination is challenging because the presenting
part must be palpated through a closed cervix and lower uterine
Section 7
segment. However, with labor and cervical dilation, cephalic
presentations and their positions are recognized by palpation
o the various etal sutures and ontanels (Fig. 29-1, p. 534).
Palpation o acial eatures signals a ace presentation, whereas
digital delineation o the etal sacrum and perineum suggests
breech presentation. With a transverse lie, ribs, scapula, or clav-
icle may be identied. Sonography is used to conrm suspected
abnormal etal presentation or lie.
Sonography can also help clariy etal position. For the
occiput presenting etus, a transducer is placed transversely on
the lower maternal abdomen and moved toward the symphysis.
In a etus positioned occiput anterior, its spine is identied
anteriorly and ollowed to its union with its occiput. Te angle
between the two is wide and increases as the head exes and
descends into the maternal pelvis. In occiput posterior posi-
tions, etal orbits and nasal bridge lie anteriorly (Bellussi,
2017). Compared with digital interrogation, sonography or
etal head position determination during second-stage labor is
more accurate (Ramphul, 2014; Wiae, 2016).
MECHANISMS OF LABOR
Positional changes o the presenting part are needed or the
etus to navigate through the pelvic canal. Called the mecha-
nisms o labor or cardinal movements o labor, these are engage-
ment, descent, exion, internal rotation, extension, external
rotation, and expulsion. During labor, these movements show
great temporal overlap. For example, as part o engagement,
the head both exes and descends (Fig. 22-4). Concurrently,
uterine contractions efect important modications in etal
attitude, especially ater the head has descended into the pel-
vis. Tese changes consist mainly o etal straightening, loss o
dorsal convexity, and closer application o the extremities to
the body. As a result, the etal ovoid is transormed into a cyl-
inder, with the smallest possible cross section typically passing
through the birth canal.
■ Engagement
In an occiput presentation, passage o the biparietal diameter
through the pelvic inlet denes engagement. Te etal head may
engage during the last ew weeks o pregnancy or not until ater
labor commences. In many multiparas and some nulliparas, the
etal head is reely movable above the pelvic inlet at labor onset
and is oten reerred to as “oating.” In one study o 5341 nul-
liparas, lack o etal head engagement beore labor onset did not
afect vaginal delivery rates in either spontaneous or induced
labor (Segel, 2012).
In most cases, the vertex enters the pelvis with the sagittal
suture lying in the transverse pelvic diameter. Let occiput trans-
verse (LO) position is slightly more common than right occiput
transverse (RO) position (Caldwell, 1934). However, the sag-
ittal suture may not lie exactly midway between the symphysis
deected of the midline, either posteriorly toward the prom-
ontory or anteriorly toward the symphysis (Fig. 22-5). Such
lateral deection to a more anterior or posterior position in
the pelvis is called asynclitism. I the sagittal suture approaches
the sacral promontory, more o the anterior parietal bone pres-
ents itsel to the examining ngers, and the condition is called
anterior asynclitism. I, however, the sagittal suture lies close to
the symphysis, more o the posterior parietal bone will present,
and the condition is called posterior asynclitism. With extreme
asynclitism, an ear may be palpable.
Moderate degrees o asynclitism are the rule in normal
labor. Successive etal head shiting rom posterior to anterior
asynclitism aids descent. However, i severe, the condition is a
common reason or cephalopelvic disproportion even with an
otherwise normal-sized pelvis.
■ Descent
Tis movement is the rst requisite or vaginal birth. In nul-
liparas, engagement may take place beore labor onset, and
urther descent may not ollow until second-stage labor. In
multiparas, descent usually begins with engagement. Descent
stems rom one or more o three orces: (1) direct myometrial
pressure o the undus upon the breech with contractions, (2)
bearing-down eforts o maternal abdominal muscles, and (3)
extension and straightening o the etal body.
■ Flexion
As soon as the descending head meets resistance, whether rom
the cervix, pelvic walls, or pelvic oor, it normally exes. With
this movement, the chin draws closer to the etal thorax, and the
appreciably shorter suboccipitobregmatic diameter replaces the
longer occipitorontal diameter (Fig. 29-1, p. 534). Tis is an
essential requisite or descent because it allows the smallest head
diameter to progress.
■ Internal Rotation
Tis movement turns the occiput gradually away rom the
transverse axis. Usually the occiput rotates anteriorly toward
the symphysis pubis. LO positions transition to let occiput
anterior (LOA) positions (Fig. 22-6). RO positions rotate to
right occiput anterior (ROA) positions. Less commonly, the
head may rotate posteriorly toward the hollow o the sacrum to
generate occiput posterior positions. Internal rotation is essen-
tial or completion o labor, except when the etus is unusually
small.
Calkins (1939) studied more than 5000 women in labor to
ascertain the time o internal rotation. He concluded that in
approximately two thirds, internal rotation is completed by the
time the head reaches the pelvic oor; in about another ourth,
internal rotation is completed shortly ater the head reaches the
pelvic oor; and in the remaining 5 percent, rotation does not
take place. When the head ails to turn until reaching the pelvic
oor, it typically rotates during the next one or two contractions
 Normal Labor 421

CHAPTER 22
1. Head floating, before engagement 5. Complete extension

2. Engagement, descent, flexion 6. Restitution (external rotation)

3. Further descent, internal rotation 7. Delivery of anterior shoulder

4. Complete rotation, beginning extension 8. Delivery of posterior shoulder

FIGURE 22-4 Cardinal movements of labor and delivery from a left occiput anterior position.
 422 Labor

Anterior asynclitism Normal synclitism Posterior asynclitism

Section 7

Occipito-
Sagittal frontal plane
Anterior Posterior
parietal suture Pelvic inlet
parietal
plane

FIGURE 22-5 Synclitism and asynclitism.

in multiparas. In nulliparas, rotation usually occurs during the
next three to ve contractions.
■ Extension
Ater internal rotation, the sharply exed head reaches the vulva
and undergoes extension. I the sharply exed head, on reaching
the pelvic oor, did not extend but was driven arther downward,
it would impinge on the posterior portion o the perineum and
would eventually be orced through the perineal tissues. When
the head presses on the pelvic oor, however, two orces come
into play. Te rst orce, exerted by the uterus, acts more poste-
riorly, and the second, supplied by the resistant pelvic oor and
the symphysis, acts more anteriorly. Te resultant vector is in the

A B

C D
FIGURE 22-6 Mechanisms of labor for the left occiput transverse position, lateral view. A. Engagement with posterior asynclitism at the
pelvic brim. During descent, the sagittal suture is then deflected toward the sacrum. B.This leads to anterior asynclitism. This corrects during
additional descent C. Internal rotation moves the occiput toward the symphysis. Farther simultaneous descent. D. Additional descent with
extension of the neck.

direction o the vulvar opening, thereby causing head extension.
Tis brings the base o the occiput into direct contact with the
inerior margin o the symphysis pubis (see Fig. 22-6).
With progressive distention o the perineum and vaginal
opening, an increasingly large portion o the occiput gradu-
ally appears. Te head is born as the occiput, anterior ontanel,
brow, nose, mouth, and chin pass successively over the perineal
body. Immediately ater its delivery, the head drops so that the
chin lies over the maternal anus.
■ External Rotation
Te delivered head next undergoes restitution (see Fig. 22-4).
I the occiput was originally directed toward the maternal let,
it rotates toward the mother’s let ischial tuberosity. I it was
originally directed toward the right, the occiput rotates to the
right. With restitution, the head reaches a transverse position.
Te etal body aligns its bisacromial diameter, which is the dis-
tance across the shoulders, with the anteroposterior diameter
o the pelvic outlet. Tus, one shoulder is anterior behind the
symphysis and the other is posterior.
■ Expulsion
Almost immediately ater external rotation, the anterior shoul-
der appears under the symphysis pubis, and the perineum soon
becomes distended by the posterior shoulder. Ater delivery o
the shoulders, the rest o the body quickly passes. I the anterior
shoulder tightly wedges behind the symphysis, shoulder dystocia
is diagnosed and is described in Chapter 27 (p. 501).
■ Occiput Posterior Position
In approximately 20 percent o labors, the etus enters the pel-
vis in an occiput posterior (OP) position (Caldwell, 1934). It
appears likely rom radiographic evidence that posterior posi-
tions are more oten associated with a narrow orepelvis (Gard-
berg, 1994a). Efective contractions, adequate head exion, and
A B
FIGURE 22-7 Fetal head molding and caput succedaneum formation. A. This newborn was delivered by cesarean for failure to progress
and active labor arrest. The obvious caput succedaneum, which developed far from and to the left of the sagittal midline (arrow), reflects
marked asynclitism during labor. B. This neonate after vaginal birth shows significant caput succedaneum and elongated molding.
Normal Labor 423
average etal size together permit most posteriorly positioned
occiputs to rotate anteriorly toward the symphysis promptly as
soon as they reach the pelvic oor. In perhaps 5 to 10 percent
CHAPTER 22
o cases, however, rotation may be incomplete or may not take
place at all, especially i the etus is large (Gardberg, 1994b).
Poor contractions, aulty head exion, or epidural analgesia,
which diminishes maternal muscular pushing and relaxes pelvic
oor muscles, may predispose to incomplete rotation. I rota-
tion is incomplete, transverse arrest may result. I no rotation
toward the symphysis proceeds, the occiput may remain in the
direct OP position, a condition known as persistent occiput poste-
rior. Both can lead to dystocia and cesarean delivery. Risk actors
and labor management o a persistent OP position are ound in
Chapter 27 (p. 500). echniques to manually rotate rom OP to
OA positions are illustrated in Chapter 29 (p. 540).
■ Fetal Head Shape Changes
In occiput presentations, labor orces alter etal head shape. In
prolonged labors beore complete cervical dilation, the por-
tion o the etal scalp immediately over the cervical os becomes
edematous. Tis swelling is called caput succedaneum. It usually
attains a thickness o only a ew millimeters, but in prolonged
labors it may be suciently extensive to prevent diferentia-
tion o the various sutures and ontanels. More commonly, the
caput is ormed when the head is in the lower portion o the
birth canal and requently only ater the resistance o a rigid
vaginal outlet is encountered. Because it develops over the most
dependent area o the head, one may deduce the original etal
head position. In cases o marked asynclitism and dystocia, the
caput succedaneum may orm ar rom the sagittal midline
(Fig. 22-7).
Molding reers to changes in the bony etal head shape as a
result o external compressive orces (see Fig. 22-7B). Possibly
related to Braxton Hicks contractions, some molding develops
beore labor. Despite these shape changes, most studies indicate
that the parietal bones seldom overlap. A “locking” mechanism