Normal Labor and Delivery Obs&Gyn Department of 1st Clinical Hospital Wuhan University Associate Professor Ming lei (明蕾)

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1 Normal Labor and Delivery Obs&Gyn Department of 1st Clinical Hospital Wuhan University Associate Professor Ming lei (明蕾)

2 Outline Definition 1 2 Four factors for labor 3 Mechanism of labor

3 Outline Diagnosis of threatened labor and labor 4 Labor stages 5 Clinical course and management of 2nd stages 6 Clinical course and management of 1st stages 7 8 Clinical course and management of 3rd stages

4 Definition 1  Delivery is the process by which the mature or nearly mature (fetus,umbilical cord,membranes and placenta) are expelled from the maternal body after 28 weeks (定义)

5 Definition 1  The last few hours of human pregnancy are characterized by uterine contraction that effect dilatation of the cervix and force the fetus through the birth canal. Much energy is expended during this time, hence the use of term labor to describe this process  Myometrium is unresponsive during pregnancy. After the prolonged period of quiescence, a transitional phase is requires during which myometrial unresponsiveness is suspend and cervix is softened and effaced (定义)

6 Definition 1  Cause of onset of labor: Precise mechanism in initiation of labor is not defined  Endocrine  Mechanical theory  Neurological factor (定义)

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8 Definition 1 Term delivery: 37-42 weeks 1 Pre-term delivery: 28- 37 weeks 2 Post-term delivery:  42 weeks Post-term delivery:  42 weeks 3 Abortion: 4 <28 weeks (定义) LMP :last menstrual period 5 6 EDC :expected date of confinement

9 Definition 1 3 Mechanism of labor 2 Four factors for labor Outline 影响分娩的四大因素 Normal Labor and delivery Force Birth canal Fetus Psychical factors

10 影响分娩的四大因素 2 Four factors for labor Force Expulsive Force Intraabdominalpressure This is created by contraction of the abdominal muscles simutaneously with forced respiratory efforts with the glottis close. this is referred to as pushing Levator ani muscle Levator ani muscle is the most important part of pelvic floor Ancillary Force uterine contraction A rhythmic tightening in labor of the upper uterine musculature that contracts the size of the uterus and pushes the fetus toward the birth canal Major force

11 Rhythm Symmetry Polarity Retraction intermission duration 影响分娩的四大因素 2 Four factors for labor uterine Contraction feature Force Four characteristics

12  Retraction is a phenomenon of the uterus in labor in which the muscle fibres are permanently shortened. Unlike any other muscles of the body  Contraction is a temporary reduction in length of the fibres, which attain their full length during relaxation retraction

13 The effects of retraction in normal labor are:  Formation of lower uterine segment and dilatation and effacement of the cervix  Maintain the advancement of the presenting part made by the uterine contractions and help ultimate expulsion of the fetus  To reduce the surface area of the uterus favoring separation of placenta  Effective haemostasis after the separation of the placenta

14 影响分娩的四大因素 2 Four factors for labor Birth canal Normal Labor and delivery Force Fetus Psychical factors

15 影响分娩的四大因素 2 Four factors for labor Birth canal Bony canal Birth canal 产道 Soft tissue canal

16 Pelvis anatomical marks  Sacral promontory  Ischial spine (L,R)  Symphysis pubis

17 影响分娩的四大因素 2 Four factors for labor Birth canal Bony canal 骨产道 Pelvic inlet plane Superior strait Pelvic outlet plane Inferior strait Midpelvis outlet least pelvic dimension plane pelvic axis : A hypothetical line curving through the midpoint of the pelvic planes

18 4 diameters of the pelvic inlet Anteroposterior: 11cm Transverse: 13cm Two obliques: 12.75cm Pelvic inlet plane Posteriorly by the promontory and alae of the sacrum, laterally by the linea terminalis Anteriorly by the horizontal Rami of the pubic bones and symphysis pubis

19  4 types in shape – gynecoid (50%), anthropoid, android, platypelloid. Most are intermediate type.  4 diameters – anteroposterior(AP), transverse, and 2 obliques  Obstetrical conjugate – the shortest distance between promontory and symphysis pubis. Estimated by substracting 1.5 to 2 cm from the diagonal conjugate.  True conjugate – the A-P diameter of the pelvic inlet Pelvic Inlet

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22 DC:distance from the lower margin of symphysis to promontory of the sacrum OC:From result according to the height and inclination of the symphysis pubis,OC can be measured by substracting 1.5-2cm, it should be 10cm or more

23 Anteroposterior diameter through the level of the ischial spines >11.5cm Interspinous diameter is 10cm or somewhat more 中骨盆平面 mid plane of pelvis The midpelvis at the level of Ischial spines is of particular importance following engagement of the fetal head in obstructed labor

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25 pelvic outlet plane Consists of two approximately triangular areas not in the same plane but having a common base, Which is a line drawn between the two ischial tuberosities

26 影响分娩的四大因素 2 Four factors for labor Birth canal Soft canal 软产道 Lower uterine segment Lower uterine segment Cervix, floor of pelvis, vagina Soft tissue part canal

27 Soft part of birth canal Formation of uterine lower segment Formation of uterine lower segment Cervix effacement and dilatation

28 Isthmus : between anatomical internal OS and histological internal OS Physiological retraction ring :develops at the junction of the upper and lower uterine segment. As labor progresses, a boundary ridge on the inner uterine surface is marked between the thinning of the lower segment and the concomitant thickening of the upper Pathological retraction ring : also called Bandl ring, develops from the physiological ring when the thinning of the lower uterine segment is extreme, as in obstructed labor, the ring is very prominent, forming it.

29 影响分娩的四大因素 2 Four factors for labor Birth canal Soft canal 软产道 cervical effacement and dilatation 宫颈管

30 影响分娩的四大因素 2 Four factors for labor Fetus Normal Labor and delivery Force Birth canal Psychical factors 产 力产 力产 道产 道胎 儿胎 儿精神因素 Fetus 胎儿 Fetal size 胎儿大小 Fetal lie 胎产式 Fetal attitude 胎姿势 Fetal station 胎先露高低 Fetal presentation 胎先露 Fetal position 胎方位

31 影响分娩的四大因素 2 Four factors for labor Fetus Fetal lie Relation of long axis of fetus to that of the mother. Longitudinal (99%), transverse or oblique

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33 影响分娩的四大因素 2 Four factors for labor Fetus Fetal presentation Fetal part that directly overlies pelvic inlet Cephalic, breech, or shoulder

34 影响分娩的四大因素 2 Four factors for labor Fetus Fetal position The relation of a chosen portion of the presenting part of the fetus to the right or left side of the maternal birth canal. For more accurately – anterior, transverse, posterior

35 影响分娩的四大因素 2 Four factors for labor Fetus LOA (left occipito-anterior) ROA (right occipito-anterior) Denominator:bony fixed point on presenting part occiput

36 影响分娩的四大因素 2 Four factors for labor Fetus LOT(left occipito-transverse)ROT(right occipito-transverse)

37 影响分娩的四大因素 2 Four factors for labor Fetus LOP(left occipito-posterior)ROP(right occipito-posterior)

38 影响分娩的四大因素 2 Four factors for labor Fetus

39 影响分娩的四大因素 2 Four factors for labor Fetus The fetus is in the occiput or vertex presentation in approximately 95% of all labor In majority of cases, the vertex enters the pelvis with the sagittal suture in the transverse pelvic diameter or the oblique lines The fetus enters the pelvis in the left occiput transverse(LOT) or LOA position in 40%;in the ROT or ROA in 20%; in OP position in 20%

40 1 step Leopold’s maneuvers 4 step Run hands down maternal abdomen on either side of fetus to determine fetal lie, identifying small parts and fetal spine Using the thumb and fingers of one hand, the lower portion of the maternal abdomen is grasped just above the symphysis pubis to determine the presentation With the tips of the fingers of each hand, exerts deep pressure in the direction of the axis of the pelvic inlet to determine if the head or breech descended into the pelvis Gently palpate the fundus with the tip of the fingers of both hand in order to define which fetal pole is present in the fundus and appropriate size. 2 step 3 step

41 1.The mother should be supine and comfortable position with her abdomen bared 2.During the first three maneuvers the examiner stands at the side of the bed that is most convenient and faces the patient 3.The examiner reverses this position and face the feet for the last maneuver

42 1 step Gently palpate the fundus with the tip of the fingers of both hand in order to define which fetal pole is present in the fundus and appropriate size.

43 Run hands down maternal abdomen on either side of fetus to determine fetal lie, identifying small parts and fetal spine 2 step

44 3 step Using the thumb and fingers of one hand, the lower portion of the maternal abdomen is grasped just above the symphysis pubis to determine the presentation

45 4 step With the tips of the fingers of each hand, exerts deep pressure in the direction of the axis of the pelvic inlet to determine if the head or breech descended into the pelvis

46 bregma Adult fetus Suture: it permits gliding movement of one bone over the other during moulding of the head while the head passes through the pelvis; During Internal examination in labor, palpation of sagittal suture give an idea of the manner of engagement of the head

47 post fontanelle(lambda) Bregma(Ant fontanelle) BPD(parietal bones diameter) frontal bones Occipital bone Sagittal suture The bones of the vault are not joined thus changes in the shape of the fetal head during labor can occur due to molding fontanelle:wide gap in suture line

48 Outline Definition 1 3 Mechanism of labor 2 Four factors for labor Occiput presentation ( 枕先露的分娩机转 ) 1. The ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of its head during its passage in labor 2. The mechanisms of labor, also known as the cardinal movements, are described in relation to a vertex presentation, as is the case in 95% of all pregnancies 3. In reality, the mechanism of labor consists of a combination movements that are ongoing simultaneously 4. For purposes of instruction, the various movements often are described as though they occurred separately and independently the cardinal movements are described as 7 discrete sequences, as discussed below

49 Outline Definition 1 3 Mechanism of labor 2 Four factors for labor Occiput presentation ( 枕先露的分娩机转 ) 1 1 engagement 2 2 descent 3 3 flexion 4 4 internal rotation 5 5 extension 6 6 external rotation 7. expulsion

50 Mechanism of labor ( 枕先露的分娩机转 ) Occiput presentation 3 1. Engagement  Passage of widest diameter of presenting part to level below the plane of the pelvic inlet  Occurs earlier in primigravidae, usually before the onset of labor while in multiparae, the same may occur in late 1 st stage with rupture of the membrane ischial spines

51 Mechanism of labor Occiput presentation 3 2 、 3. Descent &Flexion Downward passage of presenting part through the pelvis Occurs passively as the head descends due to the shape of the bony pelvis and resistance of pelvic floor soft tissues resulting in passive flexion of the fetal occiput. The chin is brought into contact with the fetal thorax, and the presenting diameter changes from occipitofrontal (12cm) to suboccipitobregmatic (9.5 cm) which is the smallest diameter of fetal head for optimal passage through the pelvis Occipitofrontal Diameter 12cm Suboccipitobregmatic Diameter 9.5cm

52 Occipito frontal diameter 枕额径 12cm Occipito subregmatic diameter 枕下前囟径 9.5cm Occipito mental diameter 枕颏径 13cm

53 LOT ROT

54 Mechanism of labor ( 枕先露的分娩机转 ) Occiput presentation 3 4. Internal rotation  As the head descends, the presenting part, usually in the transverse position, is rotated about 45°to anteroposterior (AP) position under the symphysis. Internal rotation brings the AP diameter of the head in line with the AP diameter of the pelvic outlet

55 Mechanism of labor ( 枕先露的分娩机转 ) Occiput presentation 3 5. Extension 1) With further descent and full flexion of the head, the base of the occiput comes in contact with the inferior margin of the pubic symphysis 2) Upward resistance from the pelvic floor and the downward forces from the uterine contractions cause the occiput to extend and rotate around the symphysis

56 Forces Concerned in Labor  Positive forces * Uterine contractions * Abdominal pressure by rectus muscles * Fundal pressure * Forceps delivery and vacuum extraction  Resistance * The uterine cervix * The muscles of the pelvic floor  Positive forces * Uterine contractions * Abdominal pressure by rectus muscles * Fundal pressure * Forceps delivery and vacuum extraction  Resistance * The uterine cervix * The muscles of the pelvic floor

57 Mechanism of labor ( 枕先露的分娩机转 ) Occiput presentation 3 6. External Rotation  When the fetus' head is free of resistance, it untwists about 45°left or right, returning to its original anatomic position in relation to the body

58 Mechanism of labor Occiput presentation 3 7. Expulsion  After the fetus' head is delivered, further descent brings the anterior shoulder to the level of the pubic symphysis The anterior shoulder is then rotated under the symphysis, followed by the posterior shoulder and the rest of the fetus

59 Mechanism of labor ( 枕先露的分娩机转 ) Occiput presentation 3 Mechanism of labor for left occiput anterior position

60 4 Falselabor Diagnosis of threatened labor As the fetal presenting part descends into the pelvic inlet, the fundal height decreases. The primigravida feels comfort of the upper abdomen, eats more, and respires briskly. Braxon Hicks contractions,during the last 4-8weeks of pregnancy irregular,generally painless uterine contractions occur with slowly increasing frequency lightening show Cervical effacement, the mucus plug within the cervical canal may be released.And a small amount of blood creating by the ruptured capillary and the mucous in the cervix are mixed together and are discharged, this is called show

61 Diagnosis of in labor 4 1 2 3 Regular uterine contraction cervical effacement cervical dilatation 4 descent

62 False labor vs. True labor

63 Stage of labor TOTAL STAGE 2nd stage expulsion of the fetus 1st stage cervical dilatation 3rd stage expulsion of the placenta primipara 11-12 hours 1-2hours5-15mins<30mins multipara 6-8hours. a few mins<1hour5-15mins<30mins 5

64 Three stages of labor  The first stage begins when uterine contractions of sufficient frequency, intensity and duration are attained to bring about effacement and progressive dilatation of the cervix and ends when the cervix is fully dilated  The second stage begins when dilatation of the cervix is complete, and ends with delivery of the fetus  The third stage begins immediately after delivery of the fetus, and ends with the delivery of the placenta and fetal membranes  “The fourth stage” is the stage of observation for 2 hours after expulsion of the placenta

65 The first stage is divided into a relatively flat latent phase and a rapidly progressive active phase. In active phase, there are 3 identifiable component parts: an acceleration phase, a linear phase of maximum slope, and a deceleration phase

66 Clinical course and management of 1st stages Clinical manifestations Add Your Text 6 Regular contraction 1 cervical effacement and dilatation cervical effacement and dilatation 2 fetodescent 3 Rupture of membranes 4

67 2 6 Clinical manifestations 1. At the beginning of the first stage of labor, it is weak 2. intermission lasts a little longer about 5-6mins; duration is about 30s 3. As labor progresses, the intermission lasts 2-3mins; duration is 50-60s 4. intensity increases when the cervix is fully dilated, intermission only last one min or more longer; duration can last more than one min Uterine contraction 1

68 intensity duration intermission duration Intensity: describes the degree of uterine systole, it gradually increases with the advancement of labor until it becomes maximum in the second stage during delivery of the baby Duration: In the 1st stage,the contraction last for about 30s initially but Gradually increase in duration with the progress of labor. Thus in the 2nd stage, the contractions last longer than in the 1st stage

69 2 6 Clinical manifestations Cervical changes and descent 2-3 Cervical effacement: the obliteration of the cervix is the shortening of the cervical canal from a length of about 2cm to a mere circular orifice with almost paper-thin edges Compared with the body of the uterus, the lower segment and the cervix are regions of lesser resistance, these structures are subjected to distention. As the uterine contraction cause pressure on the membranes, the hydrostatic action of the aminionic sac in turn dilates the cervical canal. In absence of intact membranes, the pressure of the presenting part against the cervix and lower uterine segment is effective. It won’t retard cervical dilatation

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71 2 6 Clinical manifestations LATENT PHASE It begins with the regular contractions after in labor ends when the cervix dilates to 2cm. 8-16h; 1cm/2-3h ACTIVE PHASE It refers the cervix dilated from 2cm to complete dilatation. 4-8h; Cervical changes and descent 2-3

72 The first stage is divided into a relatively flat latent phase and a rapidly progressive active phase. In active phase, there are 3 identifiable component parts: an acceleration phase, a linear phase of maximum slope, and a deceleration phase

73 2 6 Clinical manifestations The fetal membrane is always ruptured when the cervix is completely dilated and the amnionic fluid runs out, this is called rupture of membranes When the membrane rupture before the onset of labor, it is called premature rupture 4 Rupture of membrane

74 management of 1st stages education, eating, voiding 1 position(sitting, reclining, recumbent) 2 monitoring of the fetal heart rate monitoring of the fetal heart rate 3 dilation of cervix and frequency severity of uterus contractions 5 6 4

75 Management principles of 1st stage  Non-interference with watchful expectancy so as to prepare the patient for natural birth  To monitor carefully the progress of labor, maternal conditions and fetal behavior so as to detect any intrapartum complicating early

76 Actual management of 1st stage General: antiseptic dressing, encouragement and assurance constant supervision Bowel: an enema with soap or glycerine suppository is traditionally given in early stage. Reduce infection rate and increase the progress of the labor Rest and ambulation: Diet: food is withheld during active labor; water,fluid juice can be given Bladder care: full bladder often inhibits uterine contraction and may lead to infection, so encourage the patient to pass urine by herself or catheterisation to be done to her with strict aseptic precautions

77 Actual management of 1st stage Relief of pain: analgesia in labor can be used on primigravida. The analgesic drugs should not be given if delivery is anticipated within two hours Maternal condition: routine check up includes to record per 2 hours about P,BP, T, cervical dilatation and fetal presentation descent by anal or vaginal examination to note the urine output I.V fluid, drugs auscultation Electronic fetal monitoring, auscultation,doppler Monitor the uterus contraction(intensity,duration,frequency)

78 Clinical course and management of 2nd stages Clinical manifestations Add Your Text More intensive contraction with defecation 1 Head visible on vulval gapping 2 Crowning of head 3 7

79 Head visible on vulval gapping Crowning of head Crowning refers to when the widest part of the baby's head (or their crown) is emerging. At this point, the baby's crown, part of their forehead and the back of the baby's head can be clearly seen.

80  Crowning refers to when the widest part of the baby's head (or their crown) is emerging. At this point, the baby's crown, part of their forehead (nearly to their eyebrows) and the back of the baby's head can be clearly seen.  As the baby's head crowns, the woman's perineum is stretched to its maximum, being nearly paper-thin. There is usually an intense burning (or stinging sensation) for a few seconds as this occurs, generally easing as the perineum numbs. The burning can trigger panic for some women, causing them to cry out, or scream.

81 management of 2nd stages fetal heart rate 1 maternal conditions maternal conditions 2 Pushing 3 Head visible on vulval gapping Crowning of head 8 7 Laceration or Episiotomy Delivery of fetus Deal with umbilical cord aiding in fetal descent through birth canal 5 9 6 7 4

82 Management principles of 2nd stage  To assist in the natural expulsion of the fetus slowly and steadily  To prevent perineal injuries

83 Actual management of 2nd stage General: constant supervision is mandatory and the FHR is recorded at every 5mins vaginal examination is done at the beginning of the 2nd stage not only to comfirm its onset but to detect any accidental cord prolapse. The position and the station of the head are once more to be reviewed and the progressive descent of the head is ensured Preparation for delivery: position the accoucheur scrubs up, put on the sterile gown, mask and gloves and stands on the right side of the table Toileting the external genitalia To catheterise the bladder

84 Actual management of 2nd stage Conduction of delivery: Episiotomy is done selectively, usually as a routine in China Slowly delivery of the head in between the contractions is to be regulated The mucus and blood in the mouth and pharynx are to be wiped with sterile gauze piece on a little finger or electrical sucker Prevention of perineal laceration Delivery by early extension is to be avoided Spontaneous forcible delivery of the head is to be avoided To deliver the head in between contractions To perform timely episiotomy(

85 Actual management of 2nd stage  Immediate care of the newborn air passage should be cleared of mucus and liquor by gentle suction apgar rating at 1min and at 5mins is to be recorded clamping and ligature of the cord baby is wrapped with a dry warm towel, the identification tape is tied both on the wrist of the baby and the mom

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90 Clinical course and management of 3rd stages Clinical manifestations Add Your Text the uterus decreases in size 1 delivery of placenta(spontaneously, manually 2 inspection of the birth canal 3 8 evaluated for lacerations 4

91 Management principles of 3rd stage  To ensure strict vigilance and to follow the management guidelines strictly in practice so as to prevent the complications

92 Actual management of 3rd stage  Expectant management(traditional)  Active management Control cord traction Fundal pressure Oxytocin iv drop Manual removal

93 Actual management of 3rd stage  Examination of the placenta membranes and cord  Vulva, vagina and perineum are inspected

94 Placental Separation begins immediately after delivery of fetus, begins immediately after delivery of fetus, involve separation & expulsion of placenta involve separation & expulsion of placenta Diminution in Ut size  PL implantation site area ↓  PL accommodate to reduced area  thickness because of limited PL elasiticity  forced to buckle Resulting tension  weakest layer of decidua (D. spongiosa) cleavage take place at that site As separation proceed  hematoma forms between separtating PL & remaining Decidua  result of separation

95 Placental Separation begins immediately after delivery of fetus, involve separation & expulsion of placenta begins immediately after delivery of fetus, involve separation & expulsion of placenta Diminution in Ut size  PL implantation site area ↓  PL accommodate to reduced area  thickness because of limited PL elasiticity  forced to buckle -Resulting tension  weakest layer of decidua (D. spongiosa) cleavage take place at that site -As separation proceed  hematoma forms between separtating PL & remaining Decidua  result of separation

96 Placental Extrusion  some caseabdominal pr↑ PL be expelled  some case abdominal pr↑ PL be expelled  women in recumbent position frequently cannot expel placenta spontaneously  → artificial means generally required  → compress & elevate fundus while exerting minimal traction on umbilical cord

97 Mechanisms of Placental Extrusion (1) Schultze mechanism(central separation) PL separation occurs 1st at central areas PL separation occurs 1st at central areas → retroplacental hematoma → retroplacental hematoma → push placenta toward uterine cavity → push placenta toward uterine cavity (2) Duncan mechanism(marginal separation) ① placental separation occurs first at periphery ② blood collects between membranes & uterine wall → escapes from vagina→Maternal surface first to appear at vulva

98 1 Signs of placental separation A sudden gush of blood from vagina The uterus becomes globular and firmer.This sign is the earliest to appear 2 3 The uterus rises in the abdomen because the placenta, having separated, passes down into the lower uterine segment and vagina, where its bulk pushes the uterus upward 4 The umbilical cord lengthens out of the vagina, indicating that the placenta has descended

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101 manual placental removal

102 副胎盘 succenturiate placenta

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104 Mechanism of control of bleeding  After placental separation,innumerable torn sinuses which have free circulation of blood from uterine and ovarian vessels have to be obliterated. The occlusion is effected by complete retraction where by the arterioles, as they pass tortuously through the interlacing intermediate layer of the myometrium, are literally clamped  Thrombosis occurs to occlude the torn sinuses  Apposition of the wall of the uterus following expulsion of the placenta also contributes to minimize blood loss

105 Perineum,Cervical,Vaginal laceration First degree tear : involves only skin and a minor part of the perineal body

106 Perineum,Cervical,Vaginal laceration Second degree tear : involves perineal body and vaginal wall

107 Perineum,Cervical,Vaginal laceration Third degree tear : involves the anal sphincter and anal canal

108 Perineum,Cervical,Vaginal laceration

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111 “The fourth stage”  General condition of the patient and behavior of the uterus are to be carefully watched  postpartum uterine hemorrhage,1%  uterus palpation through the abdominal wall is repeats  the amount of blood on pads are monitored  pulse and BP are monitored  use of drug : oxytocin

112 Questions  Definition Delivery; physiological retraction ring ; Obstetrical conjugate; fetal lie; fetal position rowning of head Braxon Hicks contractions; crowning of head The first stage; the second stage; the third stage

113 essays  Mechanism of normal labor  Identify false labor or true labor  Talk about the signs of placental separation  Describe two mechanisms of Placental Extrusion  What is the most common fetal position at onset of labor?  What is active phase?  What are you going to do after the 3rd stages?

114  What is the correct order of the cardinal movements of labor?  A). Flexion, descent, engagement, internal rotation, extension, external rotation  B). Descent, engagement, flexion, internal rotation, external rotation, extension  C). Engagement, flexion, descent, external rotation, extension, internal rotation  D). Engagement, flexion, decent, internal rotation, extension, external rotation


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