• Chapter 8

CLINICS AND MANAGEMENT OF LABOR

IN VERTEX PRESENTATION

8.1. BASIC CONCEPTS

Labor (delivery, childbirth) is the process of expulsion or extraction of gestational

sac (product of conception: the fetus and parafetal structures) from the cavity of
uterus after the fetus has become viable. In the light of this definition, any expulsion
or extraction (vaginal or abdominal) is considered to be delivery. When the fetus is
delivered, labor is not over as the afterbirth still remains in the uterus.
International classification codes:
• 047 False labor
• 060 Preterm labor and delivery
• 048 Prolonged pregnancy
• 080 Single spontaneous delivery
• 080.0 Spontaneous vertex delivery
The causes of labor onset are not studied well enough (see Chapter 6 Onset of
Labor and Regulation of Uterine Activity).
The onset of labor is preceded, as a rule, by precursors of labor, a complex of
clinical manifestations; their emergence four to two weeks prior to childbirth indicates
that childbirth is near:
• fundus of uterus sinks as the presenting part engages the lesser pelvis inlet; this
happens in primiparous women;
• relative decrease in amniotic fluid volume;
• «show»: profuse mucous vaginal discharge as the mucous plug is discharged from
the cervix of uterus;
• some reduction in body weight;
• emergence of irregular cramplike painless sensations in the lower abdomen;
• absence of weight gain over the last two weeks.
There is another notion accepted in obstetrics: labor readiness.

The extent to which the woman’s body is prepared for labor is

NB! determined by ripeness of the cervix.

Ripeness of cervix is commonly determined using various integral scores, Bishop’s

score (1964) among them (Table 8.1).
A vaginal examination determines the cervical consistency, its length (or degree
of effacement), patency of the cervical canal and the position of cervix in relation to
the pelvic axis. Fetal station is determined in relation to the ischial spines which are
Chapter 8. Clinics and management of labor in vertex presentation 195
Table 8.1. Bishop’s score evaluating the grade of cervical ripeness (E.H. Bishop, 1964)

Parameter Points
0 1 2 3

Cervical canal diameter, cm closed 1–2 3–4 5 and more

Cervical effacement, % 0–30 40–50 60–70 80 and more
Fetal station (Bishop, Fig. 8.11) -3 -2 -1…0 +1…+2
Cervical consistency firm medium soft
Relation of cervical axis to posterior intermediate along the pelvic axis
maternal pelvic axis

in the plane of least dimensions (see below). Each parameter is accorded from 0 to
2 points. The total of the points indicates the grade of cervical ripeness:
• a score of 0–2 points indicates that the cervix is unripe;
• a score of 3–6 points indicates insufficient ripeness;
• a score of 7–13 points indicates cervical ripeness.
In Russian obstetric tradition a notion of physiological preliminary period is dis-
tinguished. There is no such term abroad, but «protracted latent phase» can serve as
an equivalent. The preliminary period is not seen in all pregnant women. In contrast
to the precursors of labor, preliminary pains are limited to several hours (no less than
6 hours) immediately preceding the onset of labor; they should not interfere with
natural vital activity (sleep, nutrition, everyday activities) of the pregnant woman.
Preliminary pains occur almost without clinical manifestations: some irregular painful
contractions of the uterus are noted.
In some pregnant women these pains grow worse, more intensive and afterwards
they turn into labor contractions.
The preliminary period coincides with the time of dominant of labor formation in
the cerebral cortex, changes in the hormonal panel, and is accompanied by additional
ripening of the cervix. The cervix softens, assumes a central position along the pelvic
axis and rapidly shortens to 2 cm.
Abnormal preliminary period (of longer than 6 hours duration) is classified as an
anomaly of labor. The painful sensations disrupt the woman’s daily routine; for in-
stance, she becomes unable to sleep. It corresponds to the notion of «dystocia during
the latent phase» (Table 8.2).

Table 8.2. Differential diagnosis of labor and preliminary pain

Parameter Labor Preliminary pain

Regularity regular irregular

Interval between contractions growing less no change
Contraction intensity growing more intense no change
Pain localization abdomen and lumbar area low abdomen
Efficiency of pain killers no yes
Structural changes in the cervix yes no
(effacement and dilation of the cervix)
196 Obstetrics

8.2. DEFINITION

The description labor at term, normal labor and delivery is applied to childbirth
occurring at gestational ages 37 to 42 weeks, when a mature, term fetus is delivered
that can easily adapt to the external surroundings. Childbirth at gestational ages
22–36 weeks yields an immature, pre-term fetus; this delivery is considered pre-term,
while delivery at gestational age 42 weeks and more is regarded as post-term delivery.
In case of pre-term or delayed development of labor the delivery is often accom-
panied by complications; the newborn’s adaptation to the new living conditions has
its specifics; such children require special attention.
During childbirth the woman who is giving birth is referred to as parturient.
The woman giving birth for the first time is called primiparous; the woman who
has given birth two and more times is referred to as multiparous.
For various reasons, pregnancy can terminate at any gestational age. The fetus
can only survive if it has developed certain anatomical and functional features that
depend on multiple conditions.

Nowadays a fetus is considered viable starting at 22 weeks gestation

NB! when its weight is 500 g, and its length is 25 cm.

Until 22 weeks gestation the fetus is non-viable. Termination of pregnancy before

22 weeks gestation is referred to as abortion rather than childbirth.

8.3. HOSPITALIZATION FOR CHILDBIRTH

Upon admission to maternity hospital the woman is given a shaving of her ex-
ternal genitals and a cleansing enema if she wishes it. Shower is administered to all
patients; an individual set of clothing and beddings is issued to her (a nightshirt, a
gown, a towel, drawsheets). She is allowed to use her own shoes and underwear.
After an examination and history-taking the admission department midwife ac-
companies the parturient woman to the ward where the woman will stay before and
during childbirth.

8.4. STAGES OF LABOR

The act of childbirth is commonly divided into three stages:

• stage one — period of dilation — from the onset of labor to complete cervical
dilation (10 cm);
• stage two — period of expulsion — from complete cervical dilation to fetus
expulsion;
• stage three — placental expulsion period — from delivery of fetus to expulsion of
placenta.
Childbirth terminates with expulsion of the afterbirth. The onset of labor is a
different matter. Childbirth begins with labor contractions which, unlike common
Chapter 8. Clinics and management of labor in vertex presentation 197

irregular uterine pains, result in structural changes in the cervix: its dilation and ef-
facement. At the same time, cervical changes are typical as early as the last one-two
weeks before childbirth, and the rate of cervical change during the latent phase is so
slow that it takes no less than three hours to note it. That is why, the onset of labor
is considered to be the time when the rate of contractions becomes no less than one
in ten minutes, as proposed by E. Friedman.

8.4.1. The first stage of labor

The first stage of labor begins with appearance of regular contractions and ends
with complete cervical opening (10 cm). The characteristic sign of the first stage is
contractions.
Contractions are assessed against four parameters: their rate, duration, intensity
and painfulness.

Uterine contractions are involuntary rhythmical contractions of the

NB! uterine muscle at a rate no less than one in ten minutes.

At the beginning of labor contractions are rare, of short duration and not too pain-
ful: they occur every 10 minutes, of 10–15–20 s duration. Afterwards the intervals
gradually diminish to 1–2 minutes (at the end of the first stage). In the middle of
labor the duration of contractions is 30–40 s, at the end of labor it is 50–60 s. The
painfulness of contractions depends on their intensity, as well as on the quality of
psychoprophylaxis (childbirth education).
The tone and intensity of uterine contractions are assessed by palpation placing a
hand on the fundus and noting with a stopwatch the time from the beginning of one
contraction to the beginning of another. Instrumental methods of registering labor
(hysterography using fetal electronic monitor) are useful in obtaining more detailed
information about the intensity of uterine contractions (Fig. 8.1). A hysterogram
helps to assess the rate of contractions in 10 minutes, their duration, amplitude, and
the interval between contractions. The effectiveness of contractions can be evaluated
with a vaginal examination judging the structural changes in the cervix: its shortening,
effacement, and later its dilation.
Effacement and dilation of cervix proceed in different manner in primiparous and
multiparous women.
• In primiparous women dilation starts with the internal os; the cervical canal and
the cervix grow shorter, then the cervical canal stretches more and more, and the
cervix shortens and effaces; it is as if the cervix is pulled into the lower uterine
segment. Only the external os remains open. Then the external os begins to open.
Upon complete opening it appears as a thin border in the birth canal formed by
the vaginal walls and uterus fused into one whole.
• In multiparous women the opening of the canal and cervical effacement proceed
simultaneously, as a rule (Fig. 8.2).
The opening of the mouth of uterus occurs due to contraction and retraction
(shifting in relation to each other) of muscular fibers in the body of uterus and ex-
tension (distraction) of the cervix and lower uterine segment.
198 Obstetrics
240 240

210 210

CONTRACTIONS
180 180

150 150

90 90
UA UA
UA
60 100 60 100
12
30 75 10 30 75
FHR ppm 8 FHR ppm
50 6 50
25 4 25
2

Fig. 8.1. Registration of myometrial contractile activity (hysterography) using an electronic

fetal monitor

2 2
2
2
1
1 1 1

2 2
2

1 1
1

b
Fig. 8.2. Specifics of cervical dilation in primiparous (a) and multiparous (b) women: 1 —
external os; 2 — internal os.

The lower uterine segment is a portion of the isthmic area in the body of uterus that
forms the birth canal in the first stage of labor as a result of retraction and distraction
processes. As the birth canal is formed, a furrow called contraction ring emerges at
the border between the upper and lower uterine segments (see Fig. 8.7). The con-
traction ring is determined by palpation after the rupture of the amniotic sac. The
height of its station above the pubis corresponds to the degree of cervical opening.
The lower uterine segment hugs the presenting head tightly and forms the inner
belt of adherence, or contact. The belt of adherence divides the amniotic fluid into
«anterior waters» situated below the belt of adherence, and «posterior waters» situated
above the belt of adherence. When the head hugged by the lower segment presses
Chapter 8. Clinics and management of labor in vertex presentation 199

against the pelvic walls, an external belt of adherence is formed along the entire
circumference. That is why posterior waters do not pass when the gestational sac is
ruptured and anterior waters move away (Fig. 8.3).
Term rupture of membranes should occur when the cervix is almost completely
open. If membranes rupture during the first stage of labor while the cervix is not
dilated 7 cm, this rupture is considered early. Passing of waters before the onset of
regular labor is called preterm rupture of membranes, PROM.
Two phases are distinguished in the first stage of labor:
• latent phase: from the onset of contractions to cervical dilation 4 cm;
• active phase: from 4 cm to complete dilation.
The active phase, in its turn, is divided into the following periods:
• acceleration;
• maximum slope;
• deceleration.
The rate of cervical dilation is an important indicator that labor proceeds normally
(Fig. 8.4).
The rate of cervical dilation at the beginning of labor (latent phase) is 0.35 cm per
hour, in the active phase — 1.5–2 cm per hour in primiparous women, and 2–2.5 cm
per hour in multiparous women.
Cervical dilation (deceleration period) proceeds more slowly: 1–1.5 cm per hour.
The rate of cervical dilation depends on the contractile capacity of the myometrium,
the possibility of physiological remodeling of the cervix, which depends on endog-
enous factors and external influences.

Posterior waters

External belt
of adherence

Anterior waters

Fig. 8.3. Division of amniotic fluid into posterior and anterior waters
200
Cervical dilation, cm Obstetrics

Second stage of labor

Latent phase Active phase

Time, h

Fig. 8.4. Partogram. Phases of the fi rst stage of labor

Duration of the first stage of labor is 10–14 hours on average in primiparous

women, and it is twice as short in multiparous women. If the woman is active during
the first stage (she walks, takes a shower, rests in a sitting position) labor is almost
2 hours shorter compared with those parturient women who spend the time passively
in bed (lying flat on the back is most unfavorable).
Partogram. In order to perform a dynamic assessment of labor, one uses linear
graphic representation of cervical shortening and dilation depending on the duration
of labor. The same graph shows the progress of fetal head in relation to the planes
of the true pelvis (Fig. 8.5). The WHO partogram shows two lines: alert line and
action line. The alert line is the border beyond which the rate of cervical dilation is
less than 3 cm/hour, and he patient can be observed further. The dynamic represen-
tation of cervical dilation in physiological labor should go parallel to the alert line.
The action line is drawn four hours to the right of the alert line showing that if the
patient has crossed the action line, induction of labor should be started or the plan
of management should be revised.
Intranatal assessment of perinatal risk. Calculating the points of prenatal risk while
the pregnant woman receives care at a maternity welfare clinic helps to distinguish
the groups of perinatal risk (low, medium, and high risk groups). The next stage in
determining the risk strategy is taking into account the intranatal risk factors: com-
plications of labor affecting the perinatal outcomes. The act of childbirth affects the
perinatal outcome to a greater degree than the course of pregnancy.
S.J. Hobel (1973) who studied the effect of antenatal and intranatal factors on
labor outcomes established that intranatal complications affect perinatal morbidity
and mortality twice as much compared with the effect of antenatal factors, including
high risk situations.
Chapter 8. Clinics and management of labor in vertex presentation 201

Partogram
Name Gravida Para Hospital number
Date of admission Time of admission Ruptured membranes hours

Fetal
heart
rate

Amniotic fluid
Moulding

Action

t
Cervix (cm)
er io
n
[Plot Х]
Al t
Ac

Descent of head
[Plot 0] Latent phase

Hours
Time

Contractions
per 10 min

Oxytocin U/L
drop/min

Drugs given
and IV fluids

Pulse

BP

Temp °С

Protein
Urine Acetone
Volume

Fig. 8.5. Partogram (WHO)

The staff of the Chair of Gynecology and Obstetrics at PFUR developed an original
system for evaluation of risk factors based on a bulk of clinical data accumulated over
years of clinical practice. New risk factors were added to the prenatal score and, which
is most important, the main intranatal factors were determined and estimated. Based
on this study, it was established that the main intranatal factors affecting the perinatal
outcomes are fetal hypoxia, changed color of amniotic fluid, and anomalies of labor.
202 Obstetrics

That is why in the course of childbirth the obstetrician has to reevaluate the pre-
natal risk factors worked out by the end of pregnancy: as complications set in, the
parturient woman can be transferred from a low risk group to a medium, and even
to a high prenatal risk group.
If intranatal risks accrue at a considerable rate, the obstetric situation has to be
reevaluated, and sometimes the plan of childbirth management has to be changed
radically.
In the first stage of labor the obstetrician monitors the general condition of the
parturient woman and fetal heartbeat, the progress and painfulness of labor contrac-
tions, the condition of the cervix and mouth of the uterus. Special attention is paid
to the condition of the woman’s cardiovascular system: skin coloration should be
noted, arterial pressure measured regularly. One should ask the parturient woman
about her wellbeing, whether she feels tired, or has a headache, dizziness, vision
disorder, pain in the upper abdomen.
Fetal monitors are in widespread use nowadays; this device registers the contrac-
tions of smooth uterine musculature evaluating simultaneously the parameters of fetal
cardiac activity (heart rate) (Fig. 8.6).
An external obstetric examination during the period of dilation is done systemati-
cally, no less than once an hour. Data are entered into the woman’s record no less
than every three hours.
To monitor the pattern of labor, one performs external and internal obstetric
examinations.
Doing an external obstetric examination one notes the shape of the uterus, its
consistency during and outside contractions, fundal height, the condition of the
contraction ring.
The intensity and duration of contractions can be assessed with a hand placed at
the fundal area; the degree of its relaxation is assessed by palpation. After a contrac-
tion the uterus should relax completely.

Fig. 8.6. Fetal monitors: portable and pocket monitors

Chapter 8. Clinics and management of labor in vertex presentation 203

In normal labor the contraction ring is palpated as a transverse furrow which

goes upwards as the cervix dilates (Fig. 8.7). The height of contraction ring station
is indicative of the degree of dilation: the distance between the ring and pubis in cm
is approximately equal to the degree of cervical dilation in cm. At the end of dilation
period the contraction ring is situated 10 cm above the pubis (Schatz-Winterberg
sign). One should also determine the lie, position, variety and presentation of the
fetus, and the relation of the presenting part to the pelvic inlet.
However, an external obstetric examination alone does not always give an idea of
labor progress, which is why a vaginal examination is done as well.
A vaginal obstetric examination during the period of dilation is performed every
6 hours if there are no emergency indications. Irrespectively of labor duration a vagi-
nal examination should be done upon admission of the parturient woman to maternity
hospital, immediately upon rupture of membranes, and if there are signs of fetal
hypoxia, vaginal bleeding, before administering anesthesia, and on other indications.
A vaginal examination is done with two fingers: the index finger and middle finger
(like a gynecological examination, but with one hand, the inner one). The ring finger
and little finger are bent and tucked to the palm, the thumb is straight and drawn
aside. The obstetrician uses the other hand to separate labia majora and labia minora
baring the vaginal vestibule. First the middle finger is introduced into the vagina
pressing it against the posterior vaginal wall, and then the index finger is introduced.
The vaginal examination serves to determine the following:
• condition of the perineum (presence of scars, old lacerations, varicose veins;
• condition of the vagina (wide or narrow, short or long, presence of scars,
partitions, tumors) and muscles of the pelvic floor;
• condition of the cervix (intact, shortened, effaced, thickness and resilience of its
edges, degree of dilation);

Fig. 8.7. Contraction ring of the uterus

204 Obstetrics

• condition of the membranes sac (intact, absent; if it is intact, one checks for the
degree of its filling and tension during and outside contractions);
• condition of the fetal presenting part, its position in the true pelvis, sutures,
fontanelles and the leading point (Fig. 8.8);
• condition of the true pelvis bones (the shape of promontory and symphysis pubis,
depth of sacral fossa, mobility of sacrococcygeal symphysis, etc.);
• size of diagonal conjugate.
As the fetal head passes through the plane of pelvic inlet, the largest and least
head diameters are distinguished.
• Head above pelvic inlet. In this obstetric situation the head can be floating, or
pressed against the true pelvic inlet. Performing the fourth obstetric maneuver
one can place the fi ngers under the head (Fig. 8.9). During a vaginal examination
the true pelvis is free, innominate lines can be palpated as well as the promontory
and symphysis pubis. The sagittal suture is in one of oblique diameters, the
anterior and posterior fontanelles — at the same level.
• Head stationed with the small diameter in pelvic inlet. In this obstetric situation
the head is immobile, its greater diameter stationed above the inlet plane. In
external obstetric examination the fi ngers fan out (Fig. 8.10). In a vaginal
examination the promontory can only be reached with a bent fi nger. The inner
surface of symphysis and the sacral fossa are free. The sagittal suture is in the
oblique diameter.
• Head stationed with the greater diameter in pelvic inlet. In this obstetric situation
the head is stationed with its greater circumference in the inlet plane of true
pelvis. In external obstetric examination the fi ngers of both hands join upon

Fig. 8.8. Determining the localization of sutures and fontanelles by a vaginal examination
Chapter 8. Clinics and management of labor in vertex presentation 205

Fig. 8.9. Fetal head above the true pelvis inlet (fi ngers of both hands can be placed
under the head)

Fig. 8.10. Fetal head stationed with the small diameter above the true pelvis inlet
(gliding on the head the fi ngers of both hands fan out)
206 Obstetrics

a reverse movement of the palms. A vaginal examination reveals that the head
covers the upper third of symphysis pubis and sacrum, the promontory is not
palpated. The posterior fontanelle is below the anterior fontanelle, the sagittal
suture is in the oblique diameter.
• Head stationed in the plane of greatest pelvic dimensions. In this obstetric situation
the head is only slightly palpable above the pubis. A vaginal examination reveals
that a half of the inner surface of symphysis pubis and the upper third of sacral
fossa is occupied by the head. Ischial spines are palpable.
• Head stationed in the plane of least pelvic dimensions. Upon external examination
the head is not palpable. A vaginal examination reveals that the entire inner
surface of symphysis pubis and the entire sacral fossa are occupied by the head.
Ischial spines cannot be reached. The sagittal suture is situated in the oblique
diameter, but closer to the anteroposterior diameter.
• Head stationed in the pelvic outlet. In this obstetric situation the sacral fossa and
coccyx are completely occupied by the head. The inner surface of ischial spines
is not palpable. The sagittal suture is stationed in the anteroposterior diameter of
lesser pelvis outlet.
In American school of obstetrics one determines the relationship of the presenting
fetal part to the true pelvis planes as the head progresses through the birth canal,
using Bishop’s notion of true pelvis levels. The following levels are distinguished:
• the line passing through ischial spines: zero level (the fetal head is with its greater
diameter in the pelvic inlet);
• planes above the zero level are designated as negative levels: -1, -2, -3;
• planes below the zero level are designated as positive levels: +1, +2, +3; level
+3 indicates that the head is stationed at the pelvic floor (Fig. 8.11) modified
attitude to distinguish 5 levels above and 5 levels follow zero plane.
Monitoring fetal cardiac activity during labor
• regular auscultation of fetal heartbeat is the main and sufficient criterion for
monitoring the fetal condition during labor if there are no emergency indications;

Fig. 8.11. Relationship of fetal head to pelvic planes (Bishop)

Chapter 8. Clinics and management of labor in vertex presentation 207

• auscultation of fetal heartbeat (normal heart rate is 120–160 beats per minute) is
done in the fi rst stage of labor every 15–30 minutes for one full minute after the
contraction is over; during bearing down efforts — after each effort;
• routine administration of CTG to all parturient women is not justified, especially
in case of low risk as this technique yields a high rate of false positive results thus
increasing the incidence of interventions, operative delivery among them;
• continuous CTG monitoring should be administered to patients in the risk group
according to indications;
• the findings of monitoring the fetal cardiac activity and uterine activity should be
entered in the appropriate field of the partogram;
• ultrasound observation of fetus during delivery can be done if necessary.
During the first stage of labor one should monitor the function of the bladder and
bowels as their fullness interferes with normal progress of labor. Bladder fullness may
develop due to its atony or result from urethra being pressed to the symphysis by the
fetal head. The patient should be encouraged to empty the bladder every 2–3 hours,
if there is no spontaneous urination, catheterization can be resorted to.
The patient should remain active during the first stage of labor. The parturient
woman should employ non-medicamentous methods of pain killing that she was
taught at her psychoprophylaxis training classes. The notion of «childbirth with the
partner» implies the presence of the husband or other relatives. If the membranes
are intact, bed rest is only recommended in case of polyhydramnios, preterm delivery
and breech presentation.
Labor is always accompanied by pain of varying degree of intensity. If psychopro-
phylactic methods of pain killing are ineffective and the patient complains of acutely
painful contractions, the obstetrician can administer analgesia. Administration of
analgesia is more expedient when the latent phase of labor is over. The choice of
analgesia technique depends on the condition of the patient and fetus and the ob-
stetric situation (see Chapter 9 Obstetric Anesthesia).
The following is not recommended in the first stage of normally progressing labor:
• induction of labor with amniotomy and oxytocin;
• routine amniotomy if cervical dilation is less than 7 cm;
• medicamentous enhancement of uterine contractions in the fi rst stage of
normally progressing labor: routine administration of uterotonics (oxytocin) for
acceleration of labor should be given up;
• making the patient bear down before she herself complains of a sensation of
strong pressure in the rectum.

8.4.2. The second stage of labor

Once cervical dilation is 10 cm, the second stage of labor sets in: expulsion period,
which ends in delivery of the fetus. The end of the second stage of labor (besides
contractions) is characterized by bearing down efforts, or pushing.
Bearing down efforts are controlled contractions of straight
NB! abdominal muscles, diaphragm and pelvic floor which are simulta-
neous with uterine contractions.
208 Obstetrics

Bearing down begins when the presenting part drops to the pelvic floor. At this
instance the presenting part is found in the pelvic plane of least dimensions.
Bearing down recurs every 1–3 minutes lasting for 50–60 s.
The duration of the second stage is one hour on average (no more than 2 hours
at most) in primiparous women and 30 minutes on average (one hour at most) in
multiparous women.
In the second stage of labor the obstetrician should carefully watch the following:
• the patient’s condition;
• nature of labor;
• fetal heartbeat: heart rate should be auscultated after each bearing down; one
should also note the rhythm and volume of fetal heart tones;
• progress of the presenting part;
• nature of discharge from the birth canal.
During delivery, the fetal head begins to show through the vaginal opening with
each contraction. When the head remains visible without slipping back in, it is known
as crowning.
Normal spontaneous delivery in cephalic presentation does not imply administra-
tion of uterotonics or dissection of the perineum (episiotomy).
At present there are two rival approaches to managing the end of the expulsion
period.
• The first — traditional, so to say — approach when the obstetrician or midwife
render manual help to the delivering fetus in cephalic presentation.
• The second approach implies non-interference («hands-off»), no manipulations
with the head or perineum (hands-off approach), but verbal directions about
respiration and pushing can be given. With this management of childbirth the
patient can assume the position that is most comfortable, squatting or in the
knee-elbow position; this delivery is referred to as vertical.
Free position during labor. Vertical delivery. The term «vertical delivery» is mostly
applied to the patient assuming a vertical position during the second stage of labor
only. Free activity (position) during labor refers both to the first and second stage;
it means that the patient is free to do and move about as she likes.
During the first stage the patient can sit, stand, walk, lie down (lying on the back
protracts the duration of labor, so this is most unfavorable), take a warm shower or
a bath — all this promotes pain relief during contractions, shortens labor, reduces
administration of uterotonics, and has undeniable psychological advantages.
In the first stage the vertical position provides a greater pressure of gestational sac on
the area of lower segment and mouth of the uterus exciting the receptors of this area,
which makes contractions more effective and shortens the dilation period by 2–3 hours.
Besides, in a vertical position the uterus does not compress great vessels of the
abdominal cavity, which preserves good uteroplacental circulation without causing
fetal hypoxia during contractions, especially during the second stage1.
During the second stage any vertical position can be assumed: half squatting,
kneeling down, standing up or sitting in a transformer chair (Fig. 8.12).

1 In term pregnancy the weight of uterus is 6 kg on average (3,500 g accounting for the fetus, 1 kg for
the uterus per se, 1 l for the amniotic fluid, and 0.5 l—for the blood).
Chapter 8. Clinics and management of labor in vertex presentation 209

Fig. 8.12. Obstetric bed

When the patient is in a vertical position, she has a better coordinated function
of abdominal muscles, muscles of the back, pelvic floor and of the entire skeletal
musculature; its function is enhanced due to gravitation. The vertical position is more
physiological for pushing. No obstetric maneuvers are performed on a patient who
is giving birth in a vertical position. The midwife watches the patient’s condition,
fetal hearbeat and supports the fetus while the head is delivered, and after that she
takes the child out of the maternal passages. In some cases the parturient woman
can deliver the child herself (Fig. 8.13).
When managing delivery with the patient in a free position one can hardly employ
the traditional obstetric stethoscope for auscultation of fetal heartbeat, especially
when the patient is pushing. At this time it is preferable to use obstetric stethopho-
nendoscope, portable or pocket Doppler device.
During the second stage, any vertical position shortens its duration, reduces
the rate of operative delivery, episiotomy, painful sensations, the incidence of fetal
heartbeat disturbance.
The traditional position lying on the back (lithotomy position) is most convenient
for the midwife, but not so for the mother or fetus.
During the third stage the patient can assume a reclining position while breastfeed-
ing her newborn. This position promotes a faster placental separation and reduces
the blood loss.
In whatever position delivery takes place, this must not prevent an immediate
placing of the newborn on the mother’s breast (Fig. 8.14).
Obstetric maneuver is a complex of consecutive manipulations at the end of the
second stage of labor that are aimed at promoting the physiological delivery process
210 Obstetrics

Fig. 8.13. Vertical delivery

and preventing intrapartum injury of the mother. Traditionally, the patient is lying
on her back in a tilting bed with the head raised, her legs bent and drawn aside, her
feet bearing against the bed. Obstetric maneuver can be also given to a patient lying
on her side with her thighs drawn aside (Sim’s position) or squatting as it is done
in some maternity hospitals (Fig. 8.15).
In traditional delivery (the patient lying on her back) obstetric manual help is
given from the moment the head begins to crown.
• The first point in obstetric manual help is to prevent early head extension. This
is necessary for the head to be delivered in a flexed position with its smallest
circumference (32 cm) leading the way, passing in the suboccipitobregmatic
diameter (9.5 cm). The midwife places her left hand’s palm on the pubis so that
the palmar surfaces of her joined fi ngers are situated on the head preventing its
extension, but she must not press on the head on any account.
Chapter 8. Clinics and management of labor in vertex presentation 211

Fig. 8.14. Placing the newborn on the mother’s breast

• The second point is to deliver the head from the pudendal ring outside bearing down
efforts. As soon as bearing down is over, the midwife carefully stretches the vulvar
ring with the right thumb and index fi nger above the crowning head (Fig. 8.15a).
• These two actions are performed until the head approaches the level of ischial
tuberosities (transverse diameter of pelvic outlet) with its parietal tubers.
• The third point is reducing the tension of perineum during crowning and
delivery of parietal tubers. The midwife places her left hand’s palmar surface
on the perineum, so that her four fingers are in the area of the left labium
majus, and her thumb drawn aside, in the area of the right labium majus.
With all her fingers she carefully moves the soft tissues in the direction of the
perineum providing some spare tissue and thus reducing the perineal tension.
The palm of the same hand supports the perineum without pressing the palm to
the crowning head on any account. Thus the spare tissues reduce the perineal
tension restoring the blood circulation and preventing perineal laceration
(Fig. 8.15b).
• The fourth point is regulating the bearing down efforts (occurs simultaneously with
point three). This is necessary as perineal tissues experience maximum tension
during crowning. If the parturient woman does not suppress her pushing, her
perineum can be torn. The bearing down efforts are regulated in the following
way: when the fetal head with its parietal tubers is stationed in the pudendal
fissure, and its suboccipital fossa is under the symphysis pubis, the patient is told
to give deep frequent breaths with her mouth open. With this respiration pushing
becomes impossible. All the while the midwife carefully moves the perineum
above the fetae face with her right hand, and extends the head slowly and raises it
with her left hand. If pushing is needed at this moment, the patient is offered to
push with a force sufficient for delivering the head.
212 Obstetrics

b
Fig. 8.15. Obstetric maneuver in occipitoanterior variety of vertex presentation: the second
and third points

• The fifth point is freeing the shoulders and delivering the trunk. Now the midwife
waits for internal rotation of shoulders and external rotation of the head under the
impact of pushing, and then she starts upon the fifth point of maneuver. When
the external rotation of the head is complete, she needs to help the shoulders to
get out so she takes the fetal head with both hands and pulls it back slightly until
the anterior shoulder passes under the symphysis pubis. Then she grasps the head
with her left hand so that her palm is on the posterior fetal cheek. Lifting the head
forward, the perineum is carefully pushed from the posterior shoulder. As a result,
first the posterior shoulder is delivered, and then—the anterior shoulder (Fig. 8.16).
When the head is delivered, the head and shoulders should be given time to rotate
on their own, at the same time the midwife checks for cord entanglement. If the
cord is tight, it should be clamped in two places; if it is loose, it should be loosened
Chapter 8. Clinics and management of labor in vertex presentation 213

b
Fig. 8.16. The fi fth point of maneuver: a — the head is extended, the brow, face and chin are
delivered, the fi fth point is beginning; b — delivering the posterior shoulder

further; then the midwife waits for the next pushing (cyanosis of the face is not a
sign of danger).
Once the shoulder girdle is delivered, index fingers are introduced under the
armpits from the back side raising the trunk forward; as a result the lower part of
the trunk is delivered without a difficulty.
Physiological delivery is attended by a midwife.

Routine dissection of the perineum (perineo- and episiotomy)

NB! during labor is not advisable.

Dissection of the perineum during labor should not be done in patients with third
or fourth degree perineal tears in past history.
214 Obstetrics

At present the WHO limits intrapartum episiotomy to the following:

• complicated vaginal delivery (breech presentation, fetal shoulder dystocia,
application of forceps);
• cicatricial changes of the genitals due to female circumcision or poorly healed
third or fourth degree tears;
• fetal distress (acute hypoxia).
A neonatologist should always be present at a delivery; the specialist examines the
newborn immediately, desirably on the mother’s chest.
Care of the cord is performed in two stages. Primary care of the cord: after vascular
pulsation is over or in 1–3 minutes but not later than 10 minutes after the delivery
the cord processed with a skin antiseptic is cut between two clamps with a sterile
instrument (Fig. 8.17). The midwife performs the secondary care of the cord on a
heated newborn table having scrubbed and disinfected her hands and having put on a
sterile gown. A plastic clamp is applied to the cord aseptically; the optimum distance
from abdominal skin to the clamp is 1 cm. The cord is swabbed with a sterile gauze
napkin with an antiseptic. The umbilical stump is not covered with a gauze napkin.
During childbirth one should not do any of the following:
• transfer the parturient woman to the delivery room (on a delivery bed) until the
head crowns (the head is visible 2–4 cm in the pudendal fissure; between bearing
down efforts the head does not go away);
• perform early episio-, perineotomy. The notion of rigid perineum implies there
is obstacle to fetal head progress for 1 hour and longer;
• administer uterotonics to shorten the second stage of labor;
• counteract fetal head extension;
• regulate the pushing with breath-holding on a full inspiration (Valsalva’s
maneuver);
• try to deliver the baby during one pushing;
• lift the baby above the mother’s body (the level of the placenta) if the cord has
not been clamped;
• administer methylergometrine during the second stage of labor to prevent blood loss.

Fig. 8.17. Primary care of the cord

Chapter 8. Clinics and management of labor in vertex presentation 215

8.4.3. The third stage of labor

When the fetus has been delivered, the third—placental—stage of labor begins; it
lasts until the placenta is expelled. The placental stage lasts 10–15 minutes on aver-
age; it should not be protracted by more than 30 minutes.

There are three different notions which must not be con-

NB! fused:
• mechanisms of placenta separation, two of them;
• signs of placenta separation, several of them;
• techniques of afterbirth removal (several manual techniques).

8.4.3.1. Mechanism of placenta separation

Placenta separation begins in the centre where a retroplacental hematoma de-
velops, which promotes further separation of the placenta. This way of placenta
separation is referred to as central (Schultze mechanism). In central separation of
the placenta there is no external hemorrhage, and the retroplacental hematoma is
delivered together with the placenta.
Separation of the placenta can begin at its edge (Duncan mechanism), in this case
no retroplacental hematoma develops; however, each contraction increases the area
of placental separation. In this type of separation there is vaginal bleeding once the
separation process begins (Fig. 8.18).

Fig. 8.18. Placenta separation: a — by Schultze mechanism; b — by Duncan mechanism

216 Obstetrics
8.4.3.2. Signs of placenta separation
In certain cases the separated placenta can be retained. That is why it is essential
to know the signs indicating that the placenta has detached from the uterus and is
situated in its lower segment, in the cervix or vagina:
• Kustner sign: when the sharp of the hand is pressed over the symphysis pubis, the
cord is not pulled into the genital tract (Fig. 8.19);
• Alfeld sign: the detached placenta sinks to the lower uterine segment or
vagina so that the ligature or clamp placed on the cord when ligating it goes
down;
• Schroeder sign: change in the shape of uterus or fundal height. Immediately
upon delivery of the fetus the uterus becomes oval and positions itself along
the middle line. The fundus is at the navel level. After placental separation the
uterus extends, shifts to the right, and the fundus rises to the right subcostal
space.
As administration of uterotonics at the end of the second and at the beginning of
the third stage of labor has become widespread practice, Schroeder sign has lost its
utility. Other signs of placenta separation were proposed; however, they did not find
recognition in clinical practice:
• Dovzhenko sign: retraction of the cord upon deep respiration indicates that the
placenta has not detached;
• absence of cord retraction upon inspiration indicates separation of the placenta;
• Strassman sign: oscillating motions of blood in the placenta upon tapping the
uterus are transmitted along the cord if the placenta has not detached;
• Klein sign: upon pushing or slight pressing down on the uterus the cord moves
outside and does not retract if the placenta has detached.
The main function of the obstetrician is to provide aseptic management of the
delivery with continuous monitoring of the mother’s and fetal condition.
Delivery of fetus in vertex presentations is performed by the midwife. During the
expulsion stage the obstetrician monitors the fetal heartbeat and the progress of labor.
(S)he prescribes drugs, performs surgery (perineo-, episiotomy).
All abnormal deliveries, including those in breech presentation, are performed by
the obstetrician; (s)he manages forceps delivery, vacuum extraction of the fetus and
the like.

Fig. 8.19. Kustner sign

Chapter 8. Clinics and management of labor in vertex presentation 217
8.4.3.3. Methods of delivery of placenta (afterbirth)
If, according to all signs, placental separation has occurred, it should be delivered
at once: the patient is asked to push. Under the impact of abdominal muscles the
separated placenta is usually delivered without a problem. If this technique fails, one
resorts to delivery of the placenta by external techniques.
• Baier method: the abdominal wall is taken by both hands forming a longitudinal
fold, and the patient is asked to push.
• The separated afterbirth is then easily delivered due to a considerable increase in
the intraabdominal pressure (Fig. 8.20).
• Genter method: the fundus is brought to the middle line. The obstetrician stands
at the patient’s side facing her legs. The obstetrician clenches hands into fists
and places the dorsal surface of proximal phalanges at the fundus angles and
gradually presses on the fundus in the downside and inside direction. When this
technique is performed, the patient should not push (Fig. 8.21).

Fig. 8.20.

Fig. 8.21. Genter method of placenta delivery

218 Obstetrics

• Crede’s method: the uterus is brought to median position, applying gentle

massage the obstetrician induces uterine contractions. The fundus is grasped by
4 fi ngers behind and the thumb in front to squeeze the placenta. After that the
placenta is expressed: the uterus is compressed in the anteroposterior direction,
and the fundus is pushed downwards and backwards along the pelvic axis to expel
the placenta (Fig. 8.22).
The placenta is usually delivered as an entire whole, but sometimes the membranes
connected with the placenta are retained in the uterus. In this case the obstetrician
takes the delivered placenta and rotates it slowly in one direction. The membranes
are thus twisted, which promotes their detachment from the walls of uterus and
expression outside without a rupture.
There is another technique of membrane expression (Genter method). After the
placenta has been delivered, the patient is asked to bear down on her feet and raise
the pelvis. In this case the placenta hangs down, its weight making the membranes
detach and express.
If fetal membranes have ruptured, the obstetrician explores carefully the upper
portion of the vagina wearing sterile gloves; fenestrated forceps are operated to re-
move all the retained parts of fetal membranes that can be discovered.

8.4.3.4. Prevention of postpartum hemorrhage

According to WHO recommendations (2012) prevention of postpartum hem-
orrhage consists in routine administration of oxytocin (within the first min-
ute upon delivery of the fetus 10 units by intramuscular or slow intravenous
administration) and performing controlled cord traction (if there are trained
specialists).
• intravenous administration of 10 units of oxytocin 2 minutes after delivery of the
fetus;
• gentle external massage of the uterus;
• manual maneuver: one hand of the obstetrician above the pubis presses on
the contracted uterus and shifts in the direction of the navel; the other hand

Fig. 8.22. Crede’s method of placenta expression

Chapter 8. Clinics and management of labor in vertex presentation 219

performs traction of the cord (performed by a trained specialist) (Andrew-Brandt

manevues).
The opponents of this method believe that its disadvantage is the increased risk of
uterus inversion, cord rupture and retaining of placental tissue in the uterus.
Considering the fact that controlled cord traction has no significant effect on the
rate of massive bleeding, it should not be performed by untrained personnel; instead,
only oxytocin should be administered.
The upper limit of physiological blood loss is 0.5% of body weight (5 ml per 1 kg
of body weight).
Management of postpartum period should consist in expectant attitude and careful
observation of the patient. If the woman is in a satisfactory condition and there are
no signs of external or internal bleeding, one can expect spontaneous separation and
delivery of the placenta within 30 minutes.

The afterbirth period should not exceed 30 minutes.

NB!
After delivery of the placenta it should be carefully examined including the mem-
branes to make sure they are intact.
If the cord has ruptured or the placenta was not expressed within 30 minutes,
manual expression of the placenta is performed. When the placenta is delivered, the
tone of uterus is assessed at once through the anterior abdominal wall.
The uterine tone should be assessed every 15 minutes within the first 2 hours of
the postpartum period (early postpartum period). The midwife or the obstetrician
evaluating the uterine tone must make sure that the uterus has contracted satisfac-
torily and does not relax (become soft).
Duration of labor is:
• 12–16 hours in primiparous women:
– the first stage 10–14 hours;
– the second stage up to 2 hours;
– the third stage up to 30 minutes;
• 6–8 hours in multiparous women:
– the first stage 5.5–7 hours;
– the second stage up to 1 hour;
– the third stage up to 30 minutes.

Labor is considered rapid if it lasts less than six hours in primipa-

NB! rous women, and less than four hours in multiparous women. Labor
is termed precipitous if it lasts less than four hours in primiparous,
and less than two hours in multiparous women.

There is a notion of precipitous labor which lasts less than one to two hours.
The birth canal — the perineum, vagina and cervix — are inspected immediately
after childbirth to estimate possible maternal injury. If lacerations are detected, they
are repaired aseptically according to all rules of surgery. The puerpera (the woman
who gave birth is referred to as puerpera) should remain for 2 hours in the delivery
220 Obstetrics

room for observation. The obstetrician evaluates her general condition, tone of the
uterus (every 15 minutes), the nature of discharge from the genital tract, measures
her BP and pulse.
If all goes well, in 2 hours the puerpera is transferred to the postdelivery depart-
ment together with the newborn.

8.4.3.5. Care of newborn in the delivery room

While in the delivery room, heat loss by the newborn should be prevented, and
principles of modern perinatal care should be observed.
After birth the baby is wiped, the first wet diaper is replaced with a dry one. After
that it should be determined whether the baby requires rehabilitation procedures.
When examining the baby one pays attention to the following:
• presence of spontaneous respiration, cardiac contractions, skin coloration;
• presence of congenital defects or diseases;
• the degree of maturity and signs of fetal growth restriction.
Signs of satisfactory condition at birth:
• spontaneous respiration within 30 minutes upon delivery;
• loud crying;
• heart rate above 100 per minute;
• pink skin color.
The first examination of the newborn is best of all performed immediately after
birth, on the mother’s chest. Sanation of the upper airway is performed only if indi-
cated; the same applies to gastric intubation. If the baby is in a satisfactory condition,
after being wiped it is placed on the mother’s (father’s) abdomen and covered with
a thick diaper (blanket).
There is no need for special processing of the skin, removal of vernix
caseosa or complete washing of the newborn’s body. Vernix caseosa is not
removed in the delivery room. It is not recommended to wash the newborn
with tap water in the delivery room. If the baby’s skin is dirtied with blood
or meconium, it is removed carefully with a piece of cotton wool moistened
with warm water.
The newborn is covered with a thick dry diaper and / or blanket, a bonnet is put
on the head. The skin-to-skin contact with mother should last from 40 minutes to
2 hours. The mother and baby should be covered with one blanket.
The first breastfeeding of the newborn should take place as soon as possible
after delivery and not later than after 1.5 hour. At the end of the first hour after
birth preventive administration of ointment (prevention of gonoblennorrhea) to the
newborn’s eyes (1% tetracycline or 10 000 units per 1 g erythromycin in individual
container) or of eye drops (20% sulfacetamide solution) is performed. It is not
recommended to administer silver nitrate which can cause chemical conjunctivitis
and pain reaction in newborns. To date there is no evidence supporting the ef-
fectiveness of sulfacetamide.
Primary care of the newborn, anthropometry and wrapping is performed no earlier
than the first hour after birth, after skin-to-skin contact with the mother. In all new-
borns the temperature is measured 4 times during 2 hours in the delivery room and
after transfer to the postpartum ward. In 2 hours, if there are no complications on
Chapter 8. Clinics and management of labor in vertex presentation 221

the part of the mother or the newborn, the midwife takes them both in a wheelchair
or on a stretcher to the postpartum ward for rooming-in.
When the puerpera has been transferred, the delivery room is cleaned in the mode
of terminal disinfection.

REMEMBER!

Definitions Labor is the process of expulsion or extraction of gestational

sac (product of conception: the fetus and parafetal structures)
from the cavity of uterus after the fetus has become viable.
Precursors of labor constitute a complex of clinical
manifestations; their emergence four to two weeks prior to
childbirth indicates that childbirth is near

Classification The act of childbirth is commonly divided into three stages:

• stage one — period of dilation;
• stage two — period of fetus expulsion
• stage three — placental expulsion period (separation of
placenta, afterbirth delivery)

Clinical Effacement and dilation of the cervix proceed differently in

manifestations primiparous and multiparous women.
and management A vaginal obstetric examination during the period of dilation is
performed regularly every 6 hours if there are no emergency
indications. Irrespectively of the duration of labor, the patient
is given a vaginal examination upon admission to maternity
hospital, immediately upon rupture of membranes, developing
signs of fetal hypoxia, vaginal bleeding, before administering
anesthesia and for other indications. Obstetric maneuver is a
complex of consecutive manipulations at the end of the second
stage of labor that are aimed at promoting the physiological
delivery process and preventing intrapartum injury of the
mother.
The placental period lasts for 10–15 minutes on average; it
should not be protracted over 30 minutes. The upper limit of
physiological blood loss is 0.5% of body weight (5 ml per 1 kg
of body weight).

CONTROL QUESTIONS

1. What are precursors of labor?

2. What is the preliminary period?
3. What are the stages of labor?
4. What are the principles of managing a normal delivery?
5. What is an obstetric maneuver?
6. What signs of placental separation do you know?
7. What is the primary care of the cord?
8. What is the secondary care of the cord?
222 Obstetrics

CHECK YOURSELF!

Level 1. Test
Select one or more correct answers

1. The preliminary period corresponds to:

a) passing of amniotic fluid;
b) formation of delivery dominant;
c) onset of labor;
d) ripening of the cervix;
e) engagement of fetal head in the lesser pelvis inlet.

2. The beginning of labor is:

a) onset of contractions that leads to structural changes in the cervix;
b) passing of amniotic fluid;
c) progress of fetal head along the birth canal;
d) onset of cramp-like pain;
e) pushing.

3. During the second stage the following typically happens:

a) passing of amniotic fluid;
b) pushing;
c) cervical dilation 10 cm;
d) accelerated fetal heartbeat;
e) engagement of fetal head in the pelvic inlet.

4. The first stage ends with:

a) birth of the newborn;
b) birth of the placenta;
c) complete cervical dilation;
d) fetal head crowning;
5. Cervical dilation takes place due to:
a) contraction of muscular fibers;
b) shifting of muscular fibers;
c) shortening of the cervix;
d) passing of amniotic fluid;
e) firm adherence of the lower segment to the fetal head.

6. Obstetric maneuver during labor is rendered upon:

a) bleeding from the vagina;
b) fetal head delivery;
c) development of perineal edema;
d) fetal head crowning;
e) threat of perineal tear.
Chapter 8. Clinics and management of labor in vertex presentation 223

7. The afterbirth period begins upon:

a) delivery of the fetus;
b) separation of the placenta;
c) cutting the umbilical cord;
d) complete cervical dilation.

8. Baier method is applied if:

a) there are no signs of placental separation for 2 hours;
b) there are no signs of placental separation for 30 minutes;
c) there is vaginal bleeding;
d) there are signs of placental separation;
e) placental lobules are retained in the uterus.

9. Maximum blood loss in normal delivery is:

a) 600 ml;
b) 350 ml;
c) 0.5% of body weight;
d) 1000 ml.

10. The first toilet of the newborn does not include:

a) auscultation of fetal heartbeat;
b) treatment of the eyes;
c) two-step cutting of the cord;
d) treatment of the skin;
e) fetal anthropometry.

Level 2. Clinical situations

1. A primigravida aged 20 was brought to the maternal hospital with contractions
at 5–6 min interval, of 40–45 s duration, of medium strength and painfulness, which
had lasted for 7 hours. BP 115/70 mm Hg, pulse 80 bpm, of satisfactory strength.
Obstetric examination: abdominal circumference 96 cm, fundal height 32 cm, pelvis
dimensions 26–29–32–21. The fetus is in longitudinal lie, cephalic presentation,
fetal head tight at the lesser pelvis inlet. Fetal heartbeat clear, rhythmical, 146 per
minute, on the left below the navel. The cervix is effaced, dilation 5 cm, edges thin,
extensible. The gestational sac is intact, fills well upon contractions. The posterior
fontanelle is anterior and left, the anterior fontanelle—posterior and right, it is higher
than the posterior fontanelle; the sagittal suture is in the right oblique diameter. The
promontory is not palpable. No exostoses in the lesser pelvis. Mucous discharge.
What is your diagnosis? Substantiate it.
2. A secundigravida aged 26 was brought to the maternity hospital upon onset of
contractions. Her first pregnancy outcome was physiological delivery. Fetal weight
3200 g, length 52 cm. The present pregnancy is the second one. Pelvis dimensions
25–28–31–20. The fetus is in longitudinal lie. Fetal head is in the lesser pelvis
cavity. Fetal heartbeat clear, rhythmical, 132 per minute. The cervix is effaced,
complete dilation. No gestational sac. The fetal head is in the lesser pelvis cavity; it
224 Obstetrics

accommodates the entire surface of symphysis pubis, the entire sacral fossa, coccyx,
and ischial spines on the sides. The posterior fontanelle is anterior at the pubis, the
anterior fontanelle is posterior at the sacrum, above the posterior fontanelle. The
sagittal suture is in the anteroposterior diameter. What is your diagnosis? Substantiate
it. In which plane of the lesser pelvis is the fetal head stationed?

NOTES

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