MECHANISMS OF NORMAL LABOR

Hidayat Wijayanegara
I. Lie, presentation, attitude and position

 Fetal orientation can be established

clinically :
 abdominal palpation
 vaginal examination
 auscultation
 sonography
 X-Ray
Fetal lie

 Is the relation of the long axis of the fetus to that

of mother
 Longitudinal - transverse - oblique
 Longitudinal lies are present in over 99 percent
of labor at term
 Predisposing factors for transverse lie :
 multi parity
 placenta previa
 hydramnios
 uterine anomalies
 Fetal presentation

 The presenting part :

 portion of the body of the fetus is either
foremost within the birth canal or in
proximity to it
 Can be felt through the cervix on vaginal
examination
 Determines the presentation
 Inlongitudinal lie  creating cephalic and
breech
presentation

 In transverse lie  the shoulder

presentation
 Cephalic presentation

1. The head is flexed sharply


The chin is contact with the thorax

The occipital fontanel is the presenting
part

Vertex or occiput presentation
 Cephalic presentation

2. Face presentation :
Fetal neck  extended

Occiput & back come in contact

The face is foremost in the birth canal

Face presentation
Vertex presentation --- Face presentation

Sinciput presentation Brow presentation

 The fetal head  Partially extended
partially flexed  Brow is the
.
 Anterior/large presenting part
fontanel is the
presenting part
Labor Labor
progresses progresses

Vertex Face
presentation Transient presentation
 Breech presentation

There are three general configuration :

Frank breech Complete breech Incomplete;

presentation : presentation : footling breech
presentation :
 The thighs are  The thighs are  One or both
flexed flexed on the feet/knees are
 The legs extended abdomen & the lowermost
over the anterior legs upon the
surfaces of the thighs
body
 Fetal attitude or posture

 The head is sharply flexed

 The chin is almost contact with the chest
 The thighs are flexed over the abdomen
 The legs are bent at the knees
 The arms usually crossed over the thorax

Accomodation to the uterine cavity
 Fetal position

 The relation of an arbitrarily chosen portion of

the fetal presenting part to the right or left side
of the maternal birth canal
 Each presentation there maybe two position,
right or left
 The determining part of :
 vertex  occiput
 face  chin (mentum)
 breech  sacrum
Varieties of presentation and position

OA
ROA LOA

ROT LOT

ROP LOP
OP
 Diagnosis of fetal presentation and position

A. Abdominal
palpation -
Leopold
maneuvers
 Conducted
systematically
B. Vaginal examination

Three maneuvers :
1. Two fingers of either gloved hand are
introduced into the vagina and carried up
to the presenting part
The differentiation :
 vertex
 face
 breech
2. If the vertex is presenting :
 Sagittal suture (?)
 Small & large fontanels
3. The station  is established
C. Auscultation

Does not provide reliable information

concerning fetal presentation & position

D. Sonography
Fetal head & body can be located
Labor with occiput presentation

 95% of all labors  the fetus is in the occiput

or vertex presentation
 In the majority of cases  the vertex enters
the pelvis with the sagital suture in the
transverse pelvic diameter
 Left occiput transverse (LOT) : 40% of
labors
 Right occiput transverse (ROT) : 20% of
Cardinal movement of labor

 Irregular shape of the pelvic canal

 Therelatively large dimensions of the
mature fetal head

A process of adaptation or accomodation of

suitable portion of the head to the various
segments of the pelvis is required for
vaginal delivery
The cardinal movements of labor :
- engagement - extension
- descent - external rotation
- flexion - expulsion
- internal rotation
For purposes of instruction, the various
movement often are described as though they
occurred separately and independently  in
reality the mechanism of labor consists of a
combination of movements that are ongoing
simultaneously
For example :
- as part of the process of engagement 
there is both flexion and descent of the head
Engagement :

 The greatest transverse diameter (BPD) in

occiput presentation, passes through the pelvis
inlet
 In many primigravida this phenomena may
takes place during the last weeks of pregnancy
 In many multiparous and some nulliparous
 the fetal head is still freely movable above
the pelvic inlet (floating)
Asyinclitism

 The sagital suture, entering the pelvic inlet may

not lie exactly midway between the symphysis
and sacral promontory
 The sagital suture deflected either posteriorly
toward the promontory or anteriorly toward the
symphysis
 Such lateral deflection of the head to a more
anterior or posterior position is called
asynclitism  anterior & posterior asynclitism
Descent

 The first requisite for birth of the infant

 In nulliparas, engagement may take place before
the onset of labor  and further descent takes
place at the second stage
 Four forces :
a. pressure of amniotic fluid
b. direct pressure of the fundus upon the breech
with contraction
c. bearing down effort
d. extension and straightening of the fetal body
Flexion

 Resistance from the cervix, wall of the

pelvis, pelvic floor  flexion of the head
 The chin more contact with the fetal thorax
 Suboccipito bregmatic diameter is
substituted for the longer occipito frontal
diameter
Internal rotation

 The occiput gradually moves anteriorly

toward the symphysis pubis or less
commonly, posteriorly toward the hollow of
the sacrum
 Is always associated with descent
 Is not accomplished until the head has
reached the level of the spine and thereafter
is engaged
Calkins (1939)

 Concluded :
 Two thirds  internal rotation is completed
by the time the head reaches the pelvic
floor
 A fourth  internal rotation is completed
very shortly after the head reaches the
pelvic floor
 5 percent  internal rotation does not take
place
 Extension

 Extension brings the base of the occiput into

direct contact with the interior margin of the
symphysis pubis
 Causes of extension :
 The vulva outlet is directed upward and
forward
 Two forces come into play :

a. Exerted by the uterus  act more posteriorly

b. Resistant pelvic floor and the symphysis
acts more anteriorly  the resultant vector is
in the direction of the vulva opening 
causing extension
 External Rotation

 The delivered head next undergoes restitution

 If the occiput was originally directed toward

the left  it rotates toward the left ischial
tuberosity
 Expulsion

 After delivery of the shoulders, the rest

of the left body is quickly extruded
 Changes in shape of the fetal head

1. Caput Succedaneum
 The formation of swelling due to stagnation
of fluid in the layers of the scalp beneath the
girdle of contact
 The girdle of contact is either :
 Bony
 Dilating cervix
 Vulval ring
 The swelling :
 Diffuse
 Boggy
 Not limited by the suture line
 Disappears spontaneously within 24
hours after birth
 Occurs after rupture of the membranes
 Importance
 It signifies static position of the head for a long
period of time
 Location of the caput  gives an idea about the
position of the head occupied in the pelvis and the
degree of flexion achieved :
 in left position  caput in right parietal bone
 in right position  on left parietal bone
 With the increasing flexion  the caput is placed
more posteriorly
 Moulding
 The alteration of the shape of the forecoming head
while passing through the risistant birth passage
during labor
 Mechanism :
 There is compression of the engaging diameter
of the head with corresponding elongation of
the diameter at right angle to it
 Moulding disappears within few hours after birth
 Grading

 Grade 1 : The bones touching but not overlapping

 Grade 2 : Overlapping but easily separated
 Grade 3 : Fixed overlapping
 Importance

 Slight molding is irritable and beneficial  the

head to pass more easily through the birth canal
 Extreme molding (CPD)  may produce severe
intracranial disturbance in the form of tearing of
tentorium serebelli or subdural haemorrhage
 Shape of the molding  give an information about
the position of the head occupied in the pelvis
 Cephalhematoma

 A collection of blood in between the

pericranium in the flat bone of the skull
 Unilateral
 Over a parietal bone
 Due to rupture of a small emissary vein from
the skull and may be associated with fracture
of the skull bone
 Causes : - following normal delivery
- forceps delivery
 The swelling is limited by the suture lines
 It is circumscribed, soft, fluctuant, incompressible
 Prognosis is good  the blood is absorbed in
cause of time (6-8 weeks) leaving an entirely
normal skull.