NORMAL LABOR

AND DELIVERY

Galicia, Joaquin T., Jr.

Junior Intern
 DIFFERENT TERMS TO DESCRIBE THE
ORIENTATON OF THE FETUS
FETAL LIE Relation of the fetal long axis to that of the
mother

FETAL PRESENTATION Portion of the body that is the foremost within

the birth canal

FETAL ATTITUDE Posture or habitus

FETAL POSITION Relationship of the fetal presenting part to the
right or left of the birth canal
TYPES OF FETAL PRESENTATION
Cephalic presentation
Vertex/occiput
Sinciput
Brow
Face

Breech presentation
Frank
Complete
Footling
TYPES OF FETAL PRESENTATION
FETAL POSITIONS AND LANDMARKS
PRESENTATION LANDMARK

Vertex Occiput (posterior fontanel)

Sinciput Anterior fontanel

Face Mentum

Breech Sacrum

Shoulder Scapula (back up, back down)

 Caput Succedaneum VS. Molding
Caput Succedaneum
local edema of the scalp that
appears as a lump after childbirth
Molding
bony changes in the fetal head,
which results in shortened
suboccipitobregmatic diameter
and a lengthened mentovertical
diameter
PHASES, DIVISIONS, and STAGES of LABOR
Phases of parturition
PHASE 1: QUISCENCE
Prelude to parturition
Contractile unresponsiveness
Cervical ripening
PHASE 3: STIMULATION
Process of labor
Uterine contraction
Cervical dilatation
Fetal and placental expulsion
PHASE 2: ACTIVATION
Preparation for labor
Uterine preparedness for labor
Cervical ripening
PHASE 4: INVOLUTION
Preparation for labor
Uterine involution
Cervical repair
breastfeeding
PHASE 1: QUIESCENT PHASE – Prelude to
parturition
- Begins even before implantation
- Contractile unresponsiveness
- Cervical softening:
o Functionally: increased compliance yet maintaining structural
integrity
o Anatomically: increased vascularity, stromal hypertrophy, and
glandular hypertrophy and hyperplasia
o Where Braxton-Hicks contraction maybe felt
PHASE 2: ACTIVATION PHASE – preparation for
labor
- During the last 6-8 weeks of pregnancy
- Myometrial unresponsiveness suspended -> oxytocin receptors
increase -> formation of the lower uterine segment -> lightening: “the
baby dropped”
- Cervical ripening, effacement and loss of structural integrity: collagen
diameter is decreased leading to increased spacing between fibrils
Treatment to promote cervical ripening includes prostaglandin E2 (PGE2), prostaglandin F (PGFα)
agonists, and progesterone antagonist
PHASE 3: STIMULATION PHASE – processes of
labor
- Synonymous to active labor
- Uterine contraction
- Cervical dilatation, fetal and placental expulsion (the 3 stages of labor)
PHASE 4: INVOLUTION PHASE – Parturient
recovery (the puerperium)

- Uterine involution
- Cervical repair
- Breastfeeding
STAGES OF LABOR
Definition of labor:

• Uterine contractions that bring about demonstrable effacement and

dilatation of cervix
STAGES OF LABOR
FIRST STAGE SECOND STAGE THIRD STAGE
Starts with painful Starts with full cervical Starts with fetal
and regular dilatation delivery
contractions

Ends with cervical Ends with fetal Ends with delivery of

dilatation delivery placenta and
membranes
STAGES OF LABOR
• FIRST STAGE
- Starts when painful contractions become regular (every 5 minutes for 1 hour OR ≥
12 contractions per hour) and ends with cervical dilatation
- In some people, labor initiation is heralded by “bloody show” – spontaneous
release of blood-tinged mucus plug from the cervical canal
- Ferguson reflex – mechanical stretching of the cervix enhances uterine activity
- Contractions are painful possibly because of:
o Hypoxia of the myometrium
o Compression of the nerve ganglia
o Cervical stretching during dilatation
STAGES OF LABOR
• SECOND STAGE
- Begins with complete dilatation and ends with fetal delivery
- Uterine contraction averages from 30-90 seconds, averaging around 1 minute.
Interval between contractions is around 1 minute or less.
- The most important force in fetal expulsion is produced by maternal
intraabdominal pressure
- Station describes the descent of the fetal biparietal diameter in relation to a line
drawn between 2 maternal ischial spines
STAGES OF LABOR
• THIRD STAGE
- Starts with fetal delivery and ends with expulsion of placenta and membranes
The Seven Cardinal Movements of Labor
(EDFIREERE) Engagement BPD passes thru the pelvic inlet; in many nulliparas,
engagement happens even before labor begins

Due to 4 forces:
Descent - Pressure of amniotic fluid
- Pressure of fundal contractions
- Maternal effort
- Straightening of fetal body
Flexion OFD shifts to SOBD
Internal rotation Occiput moves toward symphysis pubis
Due to 2 opposing forces:
Extension - Pressure of fundal contractions
- Resistance of pelvic floor
External rotation (restitution) BSD to APD to pelvic outlet
Expulsion

*BPD – biparietal diameter, OFD – occipitofrontal diameter, SOBD – suboccipitobregmatic diameter, BSD – bisacromial diameter, APD –
anteroposterior diameter
FUNCTIONAL DIVISIONS OF LABOR
FUNCTIONAL DIVISIONS OF LABOR
PREPARATORY DIVISION
- Latent and acceleration phase (of cervical dilatation)
- Little change in cervical dilatation but marked change in cervical
CT components
*sedation and conduction analgesia are capable of arresting this
division
FUNCTIONAL DIVISIONS OF LABOR
DILATATION DIVISION
- Phase of maximum slope (of cervical dilatation)
- Occurs most commonly after 6 cm dilatation (Zhang curve, 2010)
- Unaffected by sedation
FUNCTIONAL DIVISIONS OF LABOR
PELVIC DIVISION
- Deceleration phase (cervical dilatation) and second stage of labor
- Includes the cardinal movements of labor
PHASES OF CERVICAL DILATATION
LATENT PHASE
• Duration is more variable and sensitive to extraneous factors
• Ends once dilation of 3-5cm is reached
• Considered prolong if it lasts:
> 14 hours in multipara
> 20 hours in nullipara
PHASES OF CERVICAL DILATATION
ACTIVE PHASE
• Acceleration phase
o Predictive of labor outcome
• Phase of maximum slope
o Reflective of overall efficiency of the contractile mechanism
o Usually the descent in nulliparas occur here
• Deceleration phase
o Heralds entry into the pelvic division of labor
DELIVERY OF THE PLACENTA
Signs of placental separation (in order):
1. Uterus becomes globular and firmer (Calkin’s sign)
2. Sudden gush of blood
3. Uterus rises in the abdomen
4. Lengthening of the umbilical cord
Mechanism of Placental Expulsion
1. Schultze mechanism
a.Blood from the placental site pours into the membrane sac and
does not escape externally until after extrusion of the placenta.
b.Retroplacental hematoma follows the placenta or is found within
the inverted sac.
2. Duncan mechanism
a.Placenta separates first at the periphery and the blood collects
between the membranes and the uterine wall and the escapes
the vagina.
b.Placenta descends sideways, maternal surface appears first
References:
Cunningham F. Gary, Leveno Kenneth, Bloom Steven, Spong Catherine, Dashe Jodi, Hoffman Barbara, Casey Brian,
and Sheffield Jeanne. (2014). “Williams Obstetrics, 24th edition.” McGraw-Hill Education. USA.
Nothing is impossible. The word itself is “I’m Possible.”
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Thank you!