Normal Labor

Kevin Marcial I. Aralar, MD

1st Year Resident
 Outline
• Fetal Orientation
• Mechanisms of Labor
• Fetal Orientation
• Mechanisms of labor
• Normal labor characteristics
• Management of normal labor
• Management of first-stage labor
• Management of second-stage labor
 Fetal Orientation
● FETAL LIE
○ Relationship of the fetal long axis to that of the mother

Longitudinal Oblique Transverse

 FETAL ORIENTATION
◎ FETAL PRESENTATION: CEPHALIC

VERTEX SINCIPUT BROW FACE

Sharply flexed Partially flexed Partially extended Sharply extended
 FETAL ORIENTATION
◎ FETAL PRESENTATION: BREECH

FRANK COMPLETE FOOTLING

 FETAL ORIENTATION
◎ FETAL PRESENTATION: SHOULDER
 FETAL ORIENTATION
◎ FETAL ATTITUDE:

• Characteristic posture assumed by the fetus

• Ovoid mass = shape of the uterine cavity
• Convex back
• Sharply flexed head
• Chin contacts thorax
• Thighs flexed
• Knee flexed
 FETAL ORIENTATION
◎ FETAL ATTITUDE:

• Exception
 FETAL ORIENTATION
◎ FETAL POSITION:
 DIAGNOSIS OF FETAL
PRESENTATION AND
1. LEOPOLD
POSITION
MANEUVERS
2. VAGINAL
EXAMINATION
3. SONOGRAPHY AND
RADIOLOGY
 1. LEOPOLD
MANEUVERS
1st - Assess the uterine fundus
• Breech = large, nodular mass
• Head = hard, round, ballotable

2nd – help define the presenting part’s

position

3rd – confirmation of fetal presentation

4th – degree of descent

2. VAGINAL
EXAMINATION

3. SONOGRAPHY AND
RADIOGRAPHY
Mechanisms of labor
● the cardinal movements of labor
are engagement, descent, flexion,
internal rotation, extension, external
rotation, and expulsion

● During labor, these movements not

only are sequential but also show
great temporal overlap.
ENGAGEMENT
• Biparietal diameter passes
through the pelvic inlet is
designated engagement
▶ In nulliparas, engagement may take
place before the onset of labor, and
further descent may not follow until the Descent
onset of the second stage.
▶ In multiparas, descent usually begins with
engagement.

▶ Descent is brought about by one or more of four

forces:
▶ (1) pressure of the amnionic fluid
▶ (2) direct pressure of the fundus upon the
breech with contractions
▶ (3) bearing-down efforts of maternal
abdominal muscles
▶ (4) extension and straightening of the fetal
body.
 FLEXION
As soon as the descending h e a d meets
resistance, whether from the cervix, pelvic walls,
or pelvic floor, it normally flexes.

▶ With this movement, the chin is brought into

more intimate c o n tac t with the fetal thorax, and
the appreciably shorter suboccipitobregmatic
diameter is substituted for the longer
occipitofrontal diameter
 L
ROTATIO
N

this movement consists of turning of the head in such a

manner that the occiput gradually moves toward
the symphysis pubis anteriorly from its original position
or, less commonly,

posteriorly toward the hollow of the sacrum

▶ Internal rotation is essential for completion of labor,

except when the fetus is unusually small.
EXTENSION
EXTERNAL
ROTATION
EXPULSION
OCCIPUT POSTERIOR
PRESENTATION
• 20%
• Right more common
• Transverse arrest
• Persistent Occiput Posterior
FETAL HEAD CHANGES
CHARACTERISTICS
OF NORMAL LABOR
▪ LABOR- uterine contractions that bring about
demonstrable effacement and dilatation of the
cervix
▪ Several methods to define start of labor:
▪ Painful contractions become regular
▪ cervical dilatation of ≥ 3-4 cm
FIRST STAGE
LATENT PHASE
• Onset of labor to cervical
dilatation of 4 cm

• Prolonged Latent Phase

▪ Nullipara: ≥ 20 hours
▪ Multipara: ≥ 14 hours
ACTIVE PHASE
SECOND STAGE
• Complete cervical dilation and
ends with fetal delivery

• Most women in spontaneous

labor will deliver within
approximately 10 hours after
admission for spontaneous labor
MANAGEMENT OF
NORMAL LABOR
IDENTIFICATION OF LABOR

Uterine contractions 5 minutes

apart for 1 hour
(≥ 12 contractions in one hour)
≥4 cm cervical dilatation
 MANAGEMENT OF
NORMAL LABOR
INITIAL EVALUATION
• Ruptured membranes
▪ Umbilical cord prolapse
▪ Intrauterine infection
 MANAGEMENT OF
NORMAL LABOR
CERVICAL ASSESSMENT
▶ Cervical dilatation estimates the average diameter of
the cervical opening measured in centimeters

▶ Approximated by sweeping the examining finger from

the margin of the cervical opening on one side to that
on the opposite side.

▶ the cervix is said to b e dilated fully when the

diameter measures 10 cm, be c au s e the presenting
part of a term-size newborn usually c a n pass
through a cervix this widely dilated.
 MANAGEMENT OF
NORMAL LABOR
CERVICAL ASSESSMENT
▶ cervical effacement is the gradual thinning an d
shortening of the cervix measured in percentage

▶ When the length of the cervix is reduc ed by

one half, it is 50- percent effaced. When the
cervix be c o me s as thin as the
adjacent lower uterine segment, it is completely, or
100-percent, effaced.
 MANAGEMENT OF
NORMAL LABOR
CERVICAL ASSESSMENT
▶ cervical position is determined by the relationship of the
cervical os to the fetal head and is categorized as posterior, mid-
position, or anterior.
▶ Cervical consistency is determined to be soft, firm, or
intermediate if between these two.
 MANAGEMENT OF
NORMAL LABOR
CERVICAL ASSESSMENT
▶ Fetal station— level of the presenting fetal part in the birth c anal relative to the ischial spines

▶ When the lowermost portion of the presenting fetal part is at the level of the spines, it is
designated as being at zero (0) station.

▶ A b o v e the spines, the designation is –3, –2, –1, then 0 station.

▶ Below the spines, as the presenting fetal part descends, it passes

+1, +2, +3, stations to delivery.

▶ Station +3 c m corresponds to the fetal h e a d being visible at the introitus.

▶ If the leading part of the fetal h e a d is at 0 station or below, most often the fetal h e a d has
e n g a g e d — thus, the biparietal plane has passed through the pelvic inlet. I
CERVICAL ASSESSMENT
• A quantifiable method used to predict labor induction
outcomes
• A Bishop score of 9 conveys a high likelihood for a
successful induction.
• A Bishop score of 4 or less identifies an unfavorable cervix
and may be an indication for cervical ripening.
 MANAGEMENT OF FIRST
STAGE LABOR
INTRAPARTUM FETAL MONITORING
▶ in the absence of any abnormalities, the fetal heart rate should be
checked immediately after a contraction at least every 30 minutes
every 15 mins 2nd stage

High risk = every 15mins during 1st stage, then 5 mins during the 2nd
 MANAGEMENT OF FIRST
STAGE LABOR
• Maternal Vital Signs
▶ Temperature, pulse, and blood pressure are evaluated at
least every 4 hours.
▶ If membranes have been ruptured for many hours
before labor onset or if there is a borderline temperature
elevation, the temperature is checked hourly.
▶ Moreover, with prolonged membrane rupture (> than 18
hours) antimicrobial administration for prevention of group
B streptococcal infections is recommended.
UTERINE CONTRACTIONS
▶ contractions c a n be both quantitatively and
qualitatively evaluated manually.

▶ With the palm of the hand resting lightly on the uterus,

the
time of contraction onset is determined. Its intensity is
g a u g e d from the degree of firmness the uterus
achieves (palpation)
▶ At the peak of contractions, the finger or thumb
cannot readily indent the uterus during a “ firm”
contraction.
▶ the time at which the contraction disappears
is noted next.

▶ this sequence is repeated to evaluate the

frequency, duration, and intensity of uterine
contractions.
 MANAGEMENT OF FIRST
STAGE LABOR
Subsequent Cervical Examinations
▶ periodic pelvic examinations are typically
performed at 2 – 3 hour intervals to evaluate labor
progress.
▶ When the membranes rupture, an examination to
exclude cord prolapse should be performed
expeditiously if the fetal head was not definitely
engaged at the previous examination.
▶ the fetal heart rate should also be checked
immediately and during the next uterine contraction
 MANAGEMENT OF FIRST
STAGE LABOR
Maternal Position
▶ the normal laboring woman ne e d not b e confined to
b e d early in labor.
▶ In bed, the laboring woman should b e allowed to
assume the position she finds most comfortable—this will
b e lateral recumbency most of the time.
▶ she must not b e restricted to lying supine bec aus e of
resultant aortocaval compression an d its potential to lower
uterine perfusion

▶ walking neither e n h a n c e d nor impaired active labor an d

is not harmful.
 MANAGEMENT OF FIRST
STAGE LABOR
Oral Intake
▶ sips of clear liquids, occasional ice chips, and lip
moisturizers are permitted.
▶ Food should b e withheld during active labor and
delivery.

▶ Gastric emptying time is remarkably prolonged o n c e

labor is established an d analgesics are administered.
▶ As a consequence, ingested food an d most
medications remain in the stomach an d are not
absorbed. Instead, they may b e vomited and
aspirated
 MANAGEMENT OF FIRST
STAGE LABOR
Intravenous Fluids
▶ there is seldom any real need for this in the normal
pregnant woman, at least until analgesia is
administered.
▶ An intravenous infusion system is advantageous during the
immediate puerperium to administer oxytocin
prophylactically and at times therapeutically when uterine
atony persists.
▶ Moreover, with longer labors, the administration of
glucose, sodium, and water to the otherwise fasting
woman at the rate of 60 to 120 mL/hr prevents
dehydration and acidosis.
 MANAGEMENT OF FIRST
AMNIOTOMY
STAGE LABOR
▶ Should not b e done routinely
▶ Membrane rupture with the intention of accelerating labor is
often performed when labor is abnormally slow

▶ presumed benefits are more rapid labor or earlier detection of

meconium- stained amnionic fluid
▶ American College of Obstetricians and Gynecologists (2013a)
recommends the
use of amniotomy to e nh anc e progress in active labor, but cautions
that this may increase the risks of infection (chorioamnionitis) and
maternal fever.
▶ Early amniotomy (< 5cm cervical dilatation) is associated
with a significant reduction in labor duration. With early
amniotomy, however, there was an
increased incidence of chorioamnionitis.
MANAGEMENT OF SECOND
STAGE LABOR
• Coaching
• Fetal heart rate assessed
after each contraction
 LABOR MANAGEMENT
PROTOCOLS
ACTIVE MANAGEMENT OF
LABOR
Components: AMNIOTOMY and
OXYTOCIN

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