1. Normal Labor and Delivery
Erick Caesarrani A., dr., SpOG, MKes

2. Definitions
Labor – Uterine contractions that result in effacement and dilatation of the cervix.
Braxton-Hicks – Uterine contractions NOT associated with cervical change.
Shorter in duration
Less intense
Over lower abdomen and groin
Resolve with ambulation
Lightening – Descent of the fetal head into the pelvis

3. Definitions Preterm labor – Prior to 37 weeks Term – 37 to 42 weeks
Post term – After 42 weeks
Post dates – After 40 weeks

4. Normal Labor and Delivery
In order to maximize the patient’s chance at a vaginal delivery it is important to understand the basics of labor and delivery:
Stages of labor
Mechanics of labor
Cardinal movements of labor
Delivery

5. Stages of Labor 1st Stage
Interval between onset of labor and full cervical dilatation
2 phases:
Latent – period between onset of labor and point at which a change in slope of rate of cervical dilatation is noted.
Active – Greater rate of cervical dilatation and usually begins around 2-3cm

6. Stages of Labor 2nd stage 3rd stage
Interval between full cervical dilatation and delivery
Duration
Nulliparous – 2 hours
Multiparous – 1 hours
3rd stage
Delivery of the placenta and membranes
Duration – maximum of 30 minutes

7. Normal Labor and Delivery
In order to maximize the patient’s chance at a vaginal delivery it is important to understand the basics of labor and delivery:
Stages of labor
Mechanics of labor
Cardinal movements of labor
Delivery

8. Mechanics of Labor (3P) The Powers
Forces generated by uterine musculature
Frequency, amplitude, and duration of ctx’s
Observation, manual palpation, tocodynamometry, intrauterine pressure catheter (IUPC)
Measured in Montevideo units
Average strength of ctx’s (mmHG) x no. of ctx’s in 10 minutes
Adequate MVUs
External monitoring measure the change in shape of the abdominal wall as a fxn of uterine contractions, therefore qualitative rahter than quantitative. Allows accurate correlation of FHT pattern with uteirne activity, does not allow measurement of ctx intensity or basal intrauterine tone.
IUPC - Most precise. Come at a cost—require membrane rupture, risk of uterine perforation, infection

9. Mechanics of Labor Passenger Fetal size Lie
Abdominal palpation or Ultrasound
Macrosomia (>4500g) associated w/ failure to progress
Lie
Longitudinal axis of fetus relative to longitudinal axis of uterus
Longitudinal*, transverse or oblique
Fetal size calculations subject to large degree of error
Malpresentaiton – 5% of term labors

10. Mechanics of Labor Passenger (cont) Presentation
Fetal part that directly overlies pelvic inlet
Cephalic, breech, or shoulder
Compound – presence of >1 fetal part overlying the pelvic inlet
Funic – umbilical cord presenting at pelvic inlet
Malpresentation – any presentation that is not cephalic with occiput leading
Fetal size calculations subject to large degree of error
Malpresentaiton – 5% of term labors

11. Mechanics of Labor Passenger (cont) Attitude Position
Position of head with regard to fetal spine (ie: degree of flexion or extension)
Flexion allows smallest diameter of fetal head to present at pelvic inlet
Position
Relationship of a nominated site of presenting part to denominating location on internal pelvis
Example: cephalic presentation
Position – cephalic presentation, nominated site is the occiput. Breech presentation, nominated site is the sacrum
Malposition = any position NOT ROA, OA, or LOA

12. Mechanics of Labor

13. Mechanics of Labor Passenger (cont.) Station Multifetal Pregnancy
Measure of descent of presenting part of the fetus through the birth canal.
Multifetal Pregnancy
Increase probability of abnormal lie and malpresentation in labor
Station – ischial spines mark mid-point (0 station)

14. Mechanics of Labor Passenger (cont.) Leopold’s maneuvers
#1 – Correct dextrorotation of the uterus with the back of one hand and delineate the fundus with the other to determine gestational age and/or appropriate size.
#2 – Run hands down maternal abdomen on either side of fetus to determine fetal lie, identifying small parts and fetal spine
#1 - Dextrorotated b/c of sigmoid colon position
#3 -Breech is oftern larger, softer, less well defined

15. Mechanics of Labor Passenger (cont.) Leopold’s maneuvers
#3 – Firmly grasp upper and lower poles of fetus by placing fingers at uterine fundus and above symphysis to determine presentation and fetal size.
#4 – Move hands in bilaterally from anterior superior iliac crests to determine whether or not the presenting part of the fetus is engaged in maternal pelvis.
Head regarded as unengaged if examiner’s hands are see to converge below fetal head.
#1 - Dextrorotated b/c of sigmoid colon position
#3 -Breech is oftern larger, softer, less well defined

16. Mechanics of Labor Passage Bony pelvis + soft tissues
X-ray pelvimetry now rarely used, having been replaced by a trial of labor
4 types of the female bony pelvis
Bony pelvis = sacrum, ilium, ischium, and pubis
Soft Tissue = 1st stage of labor  cervix
2nd stage of labor  pelvic floor muscles
Gynecoid – preferred; oval shaped, far-space ischial spines
Anthropoid – exaggerated oval shape to the inelt with alrgest diameter being A-P. More often associated w/ occiput deliveries.
Android – male pattern, heart-shaped, prominent sacral promonitory and ischial spines. Increased risk of CPD.
Platypelloid – Broad, flat, exaggerated oval-shaped inlet

17. Mechanics of Labor Passage
Bony pelvis = sacrum, ilium, ischium, and pubis
Soft Tissue = 1st stage of labor  cervix
2nd stage of labor  pelvic floor muscles
Gynecoid – preferred; oval shaped, far-space ischial spines
Anthropoid – exaggerated oval shape to the inelt with alrgest diameter being A-P. More often associated w/ occiput deliveries.
Android – male pattern, heart-shaped, prominent sacral promonitory and ischial spines. Increased risk of CPD.
Platypelloid – Broad, flat, exaggerated oval-shaped inlet

18. Normal Labor and Delivery
In order to maximize the patient’s chance at a vaginal delivery it is important to understand the basics of labor and delivery:
Stages of labor
Mechanics of labor
Cardinal movements of labor
Delivery

19. Cardinal Movements of Labor
Engagement
Passage of widest diameter of presenting part to level below the plane of the pelvic inlet
0 station
Occurs earlier in nulliparous women (36 wks)
Descent
Downward passage of presenting part through the pelvis.
Flexion
Occurs passively as the head descends due to the shape of the bony pelvis and resistance of pelvic floor soft tissues
Allows smallest diameter of fetal head to pass through the pelvis.

20. Cardinal Movements of Labor
Internal Rotation
Rotation of presenting part from original position (transverse) to anteroposterior position
Extension
Occurs once fetus has descended to the level of the introitus
Base of occiput in contact with inferior margin of symphysis pubis

21. Cardinal Movements of Labor
External Rotation
Return of fetal head to correct anatomic position in relation to the fetal torso
Expulsion
Delivery of rest of fetus
Anterior shoulder delivered first with rotation under the symphysis pubis

22. Normal Labor and Delivery
In order to maximize the patient’s chance at a vaginal delivery it is important to understand the basics of labor and delivery:
Stages of labor
Mechanics of labor
Cardinal movements of labor
Delivery

23. How to effectively deliver a baby
Prepare for the delivery taking into account parity, progression of labor, presentation of fetus, complications of labor
When head crowns and delivery is eminent, protect the perineum + downward pressure to keep head flexed
Ritgen’s maneuver my help if delay in delivery of the fetal head
Sterile towel used to palpate fetal chin through the rectum to apply upward pressure to facilitate extension of fetal head
After delivery of head
Allow for external rotation (restitution).
Reduce nuchal cord
Suction fetal mouth and nares
After clearing fetal airway
Place a hand on each parietal eminence to apply downward traction to deliver anterior shoulder
Followed by upward traction to deliver posterior shoulder
With traction, avoid perineal injury and brachial plexus

24. How to effectively deliver a baby
After complete delivery of infant
Cradle in a single arm below the perineum to allow maximal blood transfer to infant
Delivery of the placenta
3 classic signs of placental separation:
Lengthening of the umbilical cord
Gush of blood from vagina
Change in shape of the uterine fundus to a more globular appearance

25. How to effectively deliver a baby
Delivery of the placenta
Active management of 3rd stage has been shown to reduce total blood loss
Brandt-Andrews Maneuver: abdominal hand secures the uterine fundus to prevent uterine inversion while the other hand exerts sustained downward traction on umbilical cord
Crede maneuver – cord is fixed with lower hand while the uterine fundus is secured and sustained upward traction is applied using abdominal hand

26. How to effectively deliver a baby
Inspect the placenta
Abnormalities of lobulation
Site of insertion of umbilical cord into the placenta
Marginal insertion –inserts into edge of placenta
Membranous insertion – vessels course through the membranes prior to attaching to placental disk
Length (50-60cm)
2 arteries and 1 vein
Single umbilical artery associated with 20% risk of other structural anomalies.

27. Episiotomy Indications : Shoulder dystocia Breech delivery
Forceps or Vacuum extractor deliveries
Occiput Posterior Positions
Instances in which failure to perform an episiotomy will result in perineal rupture.
Type of Episiotomy
Characteristic
Midline
Mediolateral
Surgical repair
Easy
More difficult
Faulty healing
Rare
More common
Postoperative pain
Minimal
Common
Anatomical results
Excellent
Occasionally faulty
Blood loss
Less
More
Dyspareunia
Occasional
Extensions
Uncommon

28. Dystocia Abnormalities of the maternal pelvis Contracted Inlet
Dystocia literally means difficult labor, characterized by abnormally slow labor progress.
Abnormalities of the expulsive forces
Active Phase Disorder
Second Stage Disorder
Chorioamnionitis
Ruptured Membrane w/o Labor
Precipitous Labor
Abnormalities of the maternal pelvis
Contracted Inlet
Contracted Midpelvic
Contracted Outlet
Pelvic Fracture
Abnormalities of soft tissues of the reproductive tract that form an obstacle to fetal descent

29. Dystocia Complication Uterine Rupture Fistula Formation
Abnormalities of presentation, position, or development of the fetus
Face Presentation
Brow Presentation
Transverse Lie
Compound Presentation
Persistent Occiput Posterior Position
Persistent Occiput Transverse Position
Hydrocephalus
Fetal Abdominal Distension
Shoulder Dystocia
Complication
Uterine Rupture
Fistula Formation
Pelvic Floor Injury
Post Partum Lower Extremity Nerve Injury
Perinatal Complication

30. Incompetent Cervix
Discrete obstetrical entity characterized by painless cervical dilatation in the second trimester. It can be followed by prolapse and ballooning of membranes into the vagina, and ultimately, expulsion of an immature fetus. Unless effectively treated, this sequence may repeat in future pregnancies.
Transvaginal sonography to identify cervical incompetence.
Etiology
Previous trauma to the cervix such as dilatation and curettage
Conization
Cauterization
Trachelectomy
Exposure to DES in utero
Evaluation and Treatment
Decrease physical activity and abstain from intercourse.
Cervical examinations each week or every 2 weeks to assess effacement and dilatation.
Cerclage

31. Assisted Vaginal Delivery
Indications for performing an assisted vaginal  delivery
Maternal:
ineffective contractions
ineffective pushing
maternal exhaustion.
Fetal:
suspected fetal compromise in the second stage of labour
fetal malposition [OT, OP].
Prophylactic shortening of the second stage:
maternal intracranial pathology
hypertensive problems
cardiac disease class III or IV.
Contraindications for performing an instrumental delivery
Fetal position undetermined
Fetal head still above the ischial spines
Malpositions brow or mento-posterior
Known fetal malformations, e.g. neck teratomas
Suspected fetal macrosomia in mother with diabetes
Previous shoulder dystocia and current fetal size thought to be similar to previous pregnancy.

32. Forcep VS Vacuum
Specific contraindications for the use of a vacuum extraction:
fetal position undetermined
fetal head still above the ischial spines
malpresentations such as face or breech
inability to achieve a proper application of cup
prematurity <34 weeks of gestation
suspected fetal bleeding problems
assisted delivery under general anaesthesia
any contraindication to maternal pushing.
Specific situations where forceps delivery is preferred:
where excessive caput is present over the vertex
prematurity (gestation less than 34 weeks)
face presentation
after-coming head of a breech.
maternal conditions that preclude pushing e.g. maternal cardiac disease
suspected coagulopathy in the fetus.

33. Assisted Vaginal Delivery
Complication
Laceration and Episiotomy
Urinary and Fecal Incontinence
Scalp lacerations and bruising
Subgaleal hematomas,
Cephalohematomas
Intracranial hemorrhage
Neonatal jaundice
Subconjunctival hemorrhage
Clavicular fracture
Shoulder dystocia
Injury of sixth and seventh cranial nerves
Erb palsy
Retinal hemorrhage
Fetal death
Recomendation
The classification of vacuum deliveries should be the same as that used for forceps deliveries (including station).
The same indications and contraindications used for forceps deliveries should be applied to vacuum-assisted deliveries.
The vacuum should not be applied to an unengaged vertex, that is, above 0 station.
The individual performing or supervising the procedure should be an experienced operator.
The operator should be willing to abandon the procedure if it does not proceed easily or if the cup dislodges more than three times

34. Cesarean Section Primary Indication Dystocia
Nonreassuring fetal heart rate
Abnormal presentation
Unsuccessful trial of forceps or vacuum
Placenta Previa
Repeated Indication
No VBAC attempt
Failed VBAC
Unsuccessful trial of forceps or vacuum

35. Terima Kasih