NORMAL LABOR

Agenda
Primary goals

Fetal Orientation
• Fetal Lie
• Fetal Presentation
• Fetal Attitude
• Fetal Position
• Leopold’s Maneuver

Characteristics of Normal Labor

• 1st Stage
• 2nd Stage
• 3rd Stage
• 4th Stage

Management of Normal Labor

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 Goals
Define labor
Determine the types of fetal orientation and describe normal fetal
orientation
Describe normal labor characteristics during each division, stage and phases
Define the mechanism of labor/ the cardinal movements of labor
Enumerate the management for each stage of normal labor

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 Labor
“A series of continuous, progressive contractions of the uterus which help
the cervix to open (dilate) and to thin (efface), allowing the fetus to move
through the birth canal”

“The process of childbirth beginning with the latent phase of labor

continuing through delivery of the placenta”

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FETAL ORIENTATION
 Fetal Lie

Relationship of the fetal long

axis to the mother

Longitudinal Transverse Oblique

long axis of fetus is axis of the baby is the fetal and maternal axes cross
perpendicular to the axis at a 45-degree angle, unstable,
same with the of the mother and and becomes longitudinal or
mother presents with transverse during
scapula/shoulders labor

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 Fetal Presentation
(Cephalic)

Portion of the fetal

Occiput body either within
Sinciput Brow Face
(Vertex) or in closest to the
birth canal neck is partially
occipital fontanel neck is partly flexed extended neck is sharply
(posterior fontanel) or neither flexed extended
presents; the diameter is the
nor extended STARGAZING
occipitomental
neck is flexed MILITARY measuring 12.5 cm. ATTITUDE
the diameter is the ATTITUDE diameter is
suboccipito- the diameter occipitomental
bregmatic diameter presenting is the diameter measuring
measuring 9.5 cm occipitofrontal 13.5 cm
diameter measuring
12 cm
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 Fetal Presentation
(Breech)
Portion of the fetal
body either within or in
closest to the birth
canal

Frank Complete Footling

Lower extremities ● Both hips flexed with both ● One or both hips are
● flexed at hips knees flexed over thighs extended
● extended at the knees ● Feet above level of the ● one or both knees or feet
buttocks lie below the buttocks

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 Fetal Attitude
the characteristic
posture or habitus of
the fetus

• Conforms to the shape of

the uterine cavity
• Head is flexed
• Chin is almost in contact with the
chest
• Thighs are flexed over the abdomen
• Legs are bent over the knees
• Arms lie across the abdomen or
along the sides of the body

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 Fetal Position

Refers to the relationship to

an arbitrarily chosen fetal
presenting part to the right
of left side of the birth canal

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 Fetal Position

Still under “position”, the

term “varieties” indicate
whether the
presenting part is anterior,
posterior, or transverse

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 Leopold’s Maneuver

FUNDAL GRIP UMBILICAL GRIP PAWLIK’S GRIP PELVIC GRIP

LM1 LM2 LM3 LM4
Identify the fetal pole Identify the fetal This maneuver This maneuver
that occupies the back, defines confirms the fetal determines the degree
Fundus, confirms the presenting presentation of descent of the
fetal lie and part’s position presenting part
presentation

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 Normal Labor Characteristics
1st Stage of Labor: Regular Uterine Contractions – Full Cervical Dilation
 Uterine Contractions

Note the frequency, interval,

duration, intensity
• EARLY FIRST STAGE
• Every 3-5 mins, 30-40 secs, mild

• LATE FIRST STAGE

• Every 2-3 mins, 40-60 secs,
moderate

• SECOND STAGE
• Every 1-2 mins., 60-90 secs,
strong

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 Montevideo Unit

• Uterine activity is calculated as a

product of intensity of
contraction in mmHg and
contraction frequency per 10
minutes
• Adequate contractions must be at
least 200Mu
• Intensity = peak of contraction –
basal tone
• Goal: 200 to 250 Montevideo units for
4 hours before dystocia is diagnosed

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 Friedman’s Curve
Functional Labor
Divisions
• PREPARATORY
• Latent phase and acceleration phase
• Connective tissues changes happen considerably
• Minimal cervical dilatation, affected by sedation and
conduction anesthesia
• DILATATIONAL
• Cervical dilatation proceeds rapidly
• Progress not affected by sedation
• Phase of maximum slope
• PELVIS/PELVIC DIVISION
• Deceleration Phase and the second stage
• Fetal head navigates the pelvic canal, Cardinal
movements occur

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 Friedman’s Curve
Latent and Active Phase
• LATENT PHASE (preparation)
• early phase of labor, stage 1 of labor
• curve is linear
• regular contractions
• ends with 4 cm cervical dilatation
• Prolonged Latent Phase:
• Nullipara - 20 hrs
• Multipara - 14 hrs
• Factors for prolonged latent phase:
• Heavy sedation and epidural anesthesia
• Unfavorable cervix (firm hence, difficult for cervix to
dilate even with contractions)
• False labor

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 Friedman’s Curve
Latent and Active Phase
• ACTIVE PHASE
• starts at around 3-4 cm
• Composed of:
• Acceleration phase
• Phase of maximum slope
• sharp increase in dilatation
• Deceleration phase
• starts at around 8cm
• Rate of cervical dilatation
• Primigravids 1.2cm/hour
• Multigravids 1.5 cm/hour

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 WHO Partograph
• Intended for the use birth
attendance in the 3rd world
• Latent phase
• not longer than 8 hours
• Active phase
• starts at 3 cm with progressive
cervical dilatation
• Rate of dilatation should not be
slower than 1 cm/hr
• Labor is graphed and analysis
includes alert and action line
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 Normal Labor Characteristics
2nd Stage of Labor: Full Cervical Dilation – Delivery of the Fetus
 Mechanisms of Labor
● Positional changes of the presenting part needed to navigate the pelvic canal
● Cardinal movements of labor
● Occurs in sequence with temporal overlap
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 Engagement

• In an occiput presentation, occurs

when the passage of the biparietal
diameter through the pelvic inlet
• Clinically determined by a fetus in
occiput presentation at station 0
• fetal head is freely movable above the
pelvic inlet at labor onset and is often
referred to as “floating”

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 Engagement: Asynclitism

• In most cases, the vertex enters the pelvis

with the sagittal suture lying in the
transverse pelvic diameter
• LOT>ROT
• sagittal suture frequently is deflected of the
midline, either posteriorly toward the
promontory or anteriorly toward the
symphysis called asynclitism
• if severe, the condition is a common reason
for cephalopelvic disproportion even with
an otherwise normal-sized pelvis
• Successive shifting from anterior to
posterior asynclitism aids in descent in an
adequate pelvis.

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 Descent

• first requisite for vaginal birth

• Forces responsible:
• Pressure of the amniotic fluid
• Direct pressure of the fundus on the
breech with each uterine contraction
• Extension and straightening of the
fetal body
• Bearing down efforts of the mother’s
abdominal muscles

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 Flexion

• Brought about as the descending head

encounters resistance from the cervix, pelvic
wall, or pelvic floor
• Fetal chin is brought in close contact with the
fetal thorax
• There is flexion once the chin touches the
head of the baby
• Longer occipitofrontal diameter (12cm) is
converted to the shorter suboccipitobregmatic
diameter (9.5cm)
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 Internal Rotation

• Turning of the head so that the occiput

approaches the symphysis pubis from its
original position
• Internal rotation is essential for completion of
labor, unless for unusually small fetus
• Usually is complete as the head reaches the
pelvic floor
• Bring the occiput below the symphysis pubis

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 Extension

• After internal rotation, the flexed head reaches the

vulva and extension occurs. Two forces acting:
• Exerted by the uterus pushing the fetus posteriorly
• Resistance of the pelvic floor and the symphysis pubis
causing acting anteriorly
• Resultant vector force is towards the vulva causing
extension
• Bringing the base of the occiput directly under the
symphysis pubis.
• If no extension will occur, the fetal head will impinge
on the posterior portion of the perineum and will
be forced through the perineal tissues.

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 External Rotation

• Delivered head undergoes restitution

• The head rotates to its original side with
consequent rotation of the fetal body.
• This brings the bisacromial diameter of the pelvic
outlet
• Brought about by the same force as in internal
rotation
• Thus one shoulder is anterior behind the
symphysis pubis.

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 Expulsion

• Anterior shoulder is delivered first by

gentle traction on the fetal head
• Followed by delivery of the posterior
shoulder
• After delivery of the shoulders, the rest of
the body follows.

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 Normal Labor Characteristics
3rd Stage of Labor: Delivery of the Fetus – Delivery of the Placenta
 SIGNS OF PLACENTAL SEPARATION
• Uterus from discoid becomes
globular and firmer (CALKIN’S
SIGN ) -- earliest sign
• From being a flat structure, the
uterus becomes globular again
and contracts, this facilitates
placental separation.
• Sudden gush of blood
• Uterus rises into the abdomen
• Lengthening of the umbilical cord
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 Normal Labor Characteristics
4th Stage of Labor: Delivery of the Placenta – 2 hrs Postpartum
Management of Normal Labor
 Identification of
Labor
• Uterine contractions - it is only
considered true labor if there is a
concomitant cervical dilatation and
effacement
• DILATATION - opening up of cervix
• EFFACEMENT - obliteration/ thinning of cervical
canal

• Quality of contractions
• Duration, Frequency, Intensity (mild, moderate,
strong), Interval

• Peak of contractions is on the uterine

fundus with radiation to the lumbar
area

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 PHYSICAL EXAMINATION
Vital Signs
Abdominal Examination
• Fundic height
• Leopold’s Maneuver
Estimated Fetal weight

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 FETAL
EVALUATION
• CARDIOTOCOGRAM (CTG)
• Electronic Fetal Heart Rate
Monitoring
• Determines condition of the baby
• Objectively records the frequency,
intensity, and duration of the
uterine contractions
• High risk - routine electronic FHR
from admission to delivery
• Low risk - Fetal Admission Test
(CTG)
• If normal, intermittent monitoring for
the remainder of labor.

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 EXTERNAL+INTERNAL EXAMINATION
Cervical Evaluation
Position/variety
Station of the head
+/- BOW (Bag of Water)
Clinical Pelvimetry

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 EXTERNAL+INTERNAL EXAMINATION
Cervical Evaluation
Position/variety
Station of the head
+/- BOW (Bag of Water)
Clinical Pelvimetry

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 EXTERNAL+INTERNAL EXAMINATION
Cervical Evaluation • Dilatation (in cm)
• Effacement (in %)
Position/variety • Position of the cervix (anterior,
midline or posterior)
Station of the head • Consistency (soft, firm)
+/- BOW (Bag of Water)
Clinical Pelvimetry

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 EXTERNAL+INTERNAL EXAMINATION
•
Cervical Evaluation Determine if the presentation is vertex, face
or breech

Position/variety
• If vertex presenting, the fingers are
directed posteriorly and then swept
forward over the fetal head toward the
maternal symphysis anteriorly to feel
Station of the head the symphysis pubis (determination of
the sagittal suture’s orientation)
+/- BOW (Bag of Water)
Clinical Pelvimetry

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 EXTERNAL+INTERNAL EXAMINATION
• Ischial spine = landmark for
Cervical Evaluation •
Station 0
Level of the presenting part in
Position/variety the birth canal in relation to the
ischial spines (reference point)

Station of the head

• At station 0 fetal head should be
engaged
• with molded head or
+/- BOW (Bag of Water) extensive caput formation,
or both, engagement might
Clinical Pelvimetry not have taken place even
thought the head appears
to be at station

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 EXTERNAL+INTERNAL EXAMINATION
Cervical Evaluation
Position/variety
Station of the head
•
+/- BOW (Bag of
Determine presence of BOW, if delivery is
delayed for 24 hours or more after

Water)
membrane rupture, intrauterine infection is
increased
• Umbilical cord prolapse and compression if
presenting part is not fixed in the pelvis
Clinical Pelvimetry • Labor is likely to begin soon if pregnancy is at or
near term

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 EXTERNAL+INTERNAL EXAMINATION
Cervical Evaluation • Examines the pelvic diameters using digits
• Inlet
• sacral promontory is not reached
Position/variety •
•
movable
measure about > 11.5 cm
•
Station of the head
Sacrum
• concave or curved, wide, deep
• last 3 sacral vertebrae may be

+/- BOW (Bag of Water) •

palpated
Midpelvis/ Midplane
• ischial spines are not prominent

Clinical Pelvimetry
• side walls are parallel or divergent
• Outlet
• measured by placing a closed fist,
• must be > 8cm

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 BISHOP SCORE

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 Laboratory Studies
Complete Blood Count
Blood typing
Saving of blood for possible cross matching
Urine protein and glucose
Hepatitis B surface antigen (HBsAg)
VDRL or RPR (blood test for syphilis)
HIV

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 Fetal Monitoring
• FETAL HEART TONE
• Low risk : every 30 minutes
• High risk: every 15 minutes
• ELECTRONIC FETAL MONITORING
• Low risk: tracing evaluated every 30
minutes
• High risk: tracing evaluated every 15
minutes

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 Maternal Monitoring
• Vital Signs - BP, PR, RR, temperature
• Low risk: Checked every 4 hours
• High risk: Checked every hour
• Temperature is checked hourly if with
Ruptured Of Membrane or borderline
temperature elevation
• Uterine contractions Manually or by
electronic monitoring
• Vaginal Examination Internal examination
should be every 2-3 hours, plotted on a
Partograph

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 Maternal Monitoring
Oral Intake - sips of clear liquids, occasional ice chips, small
amounts allowed during the first stage of labor
Intravenous Fluid - given at 60-120 ml/hour, helps prevent
dehydration and acidosis (long labors in fasting women)
Maternal Position During Labor - No need to be confined to
bed early in labor, Lateral recumbent position better than
supine
Urinary Bladder Function - Inspect suprapubic area, avoid
bladder distention
Enema and Vulvar Clipping of Hair - Traditionally done to
prevent infection, evidence shows both procedures are not
necessary to prevent infection.

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 Active Management of Labor
Admission is done if:
→ patient is experiencing painful
uterine contractions
→ there is complete or full cervical
effacement
→ bloody show
→ ruptured membranes

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 Active Management of Labor
• Membrane rupture with the intention of accelerating
labor is commonly performed
• If cervical dilatation is less than 1cm/hour = do
amniotomy
• Amniotomy – Artificial rupture of fetal membranes
• Indications:
• Protracted labor - amniotomy at about 5 cm dilation
accelerated spontaneous labor by 1 to 2 hours
• Assess the character of amniotic fluid
• Risks (especially if done early) :
• Chorioamnionitis
• Cord prolapse
• Bleeding in vasa previa

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 Active Management of Labor
Augmentation with Oxytocin
• Progress assessed in two hours and if
no/slow progress = start Oxytocin drip
• If membranes are raptures on admission and
no progress in one hour = start Oxytocin drip
• Should be discontinued if:
• Contraction persists with a frequency
greater than five in a 10-minute
period or seven in a 15-minute period
• with persistent nonreassuring fetal
heart rate pattern

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 Labor Management Protocol
(Parkland Hospital)
• Admission is done if (1) the cervix is 3-4cm dilated or
more, (2) presence of regular uterine contractions.
• Pelvic examination done every 2 hours
• If not or poor progress - do amniotomy
• Re-assess for the next two hours with assessment of
uterine contractions.
• If poor progress in 2-3 hours with uterine hypotonia –
start Oxytocin drip; must attain uterine pressure on
200-250
• Measurement of montevedeo units (can be done
using CTG machine)
• With Oxytocin drip, cervical dilatation is expected at 1
to 2 cm per hour.
• Wait and monitor progress of labor for eight hours
before dystocia is diagnosed and CS is done.
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 • Immediate drying prevents hypothermia,
which is extremely important to survival.

• Delayed cord clamping until the umbilical

cord stops pulsating (2-3 minutes)
• Additional 80 mL of blood = 50 mg iron
• Increased risk of hyperbilirubinemia
• 1 minute delay - increase Hg concentration 2.2
g/dL

• Keeping the mother and baby in

uninterrupted skin-to-skin contact:
• Prevents hypothermia
• Increases colonization of protective bacteria
• Improves breastfeeding initiation, exclusivity, and
bonding.

• Breastfeeding within the first hour of life

prevents an estimated 19.1% of all neonatal
deaths
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 MANEUVERS IN THE DELIVERY OF THE
PLACENTA

Brandt-Andrews Maneuver Crede’s Maneuver

• Abdominal hand secures the uterine fundus • Cord is fixed with lower hand while the uterine
and exerts upward traction to prevent uterine fundus is pushed towards the birth canal
inversion while the other hand exerts • May lead to uterine inversion
sustained downward traction on umbilical
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cord
 Lacerations and Perineal Tears

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 POSTPARTUM

Immediately After Labor

Care of the vulva BLADDER FUNCTION
FIRST HOUR
Cleanse and wipe the vulva from ensure that the postpartum
Vital Signs, Assess Vaginal
front to back (toward the anus) woman has voided within 4-6 hr
Bleeding, Ensure adequate
contraction of uterus of delivery

Early ambulation
typically well healed and asymptomatic by
First Several Hours week 3 of the puerperium.
EPISIOTOMY/LACERATION REPAIR

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 Summary

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Thank you