PASSENGER, PASSAGEWAY & POWER

Ma. Ruzena D. Opulencia, MD, FPOGS, FPSUOG, FPCS

January 27, 2014;8:00-10:00 AM
Obstetrics and Gynecology

February 4, 2014, 3:00-5:00 PM

PASSENGER, PASSAGEWAY & POWER
Pediatrics
OUTLINE:
Passenger
 Determine the effects of the various fetal orientation in reference to normal labor
Passageway
 Characterize the normal birth passage
Power
 Characterize the powers involved in normal labor

PASSENGER
Definition of different fetal orientation  Presenting part
 Lie  Attitude
 Presentation  Position

FETAL LIE
Relation of the Long Axis of the Fetus to that of the Mother
LONGITUDINAL LIE
The Long Axis of the Fetus
parallels the Longitudinal
Axis of the Uterus
Fetus lies in same
plane/long axis of the
mother
Present in 99% of labors
at term
Can be cephalic or breech
TRANSVERSE LIE OBLIQUE LIE
The Long Axis of the Fetus is perpendicular to The fetal and the maternal
the Longitudinal Axis of the Uterus axes cross at a 45 degree
The Fetus lies in Transverse or in one of the angle.
Oblique diameters of the Uterus This is an UNSTABLE /
Shoulder usually over the Pelvic Inlet with the Fetal TRANSIENT Lie
Head lying in One Iliac Fossa & the Breech in the It may become
Other Longitudinal or Transverse
Predisposing factors: during the course of labor
 Multiparity
 easily distended
 assume different position
 Placenta Previa
 placenta is located in the lower uterine
segment, the baby will assume the
transverse lie
 Polyhydramnios/Hydramnios
 Excess amniotic fluid, in single packet, there
is more than 8cm)
 Four 'packets' or quadrants of fluid are
measured by ultrasound and added up
resulting in an Amniotic Fluid Index (AFI)
 Uterine anomalies
 septate or bicornuate uterus

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna DLSHSI Medicine Ba tch 201 6 |1
Editor: Jan David C. Monzon
FETAL PRESENTATION
Presenting part – portion of the fetal body that is foremost within the birth canal or in closest proximity to it.
 Internal Examination
 Through Leopold’s maneuver (abdominal exam)
IN LONGITUDINAL LIE IN TRANSVERSE LIE
Cephalic Shoulder
Breech
Compound

FETAL PRESENTATION – CEPHALIC PRESENTATION

Further classified according to degree of flexion or extension of the head
OCCIPUT/VERTEX SINCIPUT/BREGMA
Most Common
Head Sharply flexed
chin touches chest
Occipital or Posterior
Fontanel
Triangle-shaped
Suboccipitobregmatic
~ 9.5 cms
BROW FACE
Usually transient and Rarest Presentation Occiput touches fetal back
becomes Vertex as Usually transient & Internal Examination = soft
labor progresses becomes Face as labor like breech
progresses Vaginal delivery may result
in Cervical Spinal Cord injury
ATTITUDE
Head only Partially Head Partially Neck Hyperextended
flexed Extended Markedly extended
‘Military Attitude’ Occiput touches the fetal
back
PRESENTING FIXED REFERENCE POINT
Bregma or Anterior Frontum Mentum (Chin)
Fontanel
Diamond-shaped
PRESENTING AP DIAMETER
Occipitofrontal Occipitomental Submento- or
~ 12.5 cms ~ 12.5 cms Trachelobregmatic
~ 9.5 cms
Mouth and zygoma forms a
triangle and that serves as a
landmark

THE PASSENGER – FETAL HEAD DIAMETERS

ATTITUDE PRESENTING DIAMETER DENOMINATOR

Flexion* Suboccipitobregmatic (SOB) = 9.5 cm Occiput

Military** Occipitofrontal (FO) = 12.5 cm Sinciput

Partial Extension** Occipitomental (MO) = 12.5 cm Forehead (Brow)

Complete Extension* Submentobregmatic (SMB) = 9.5 cm Chin / Mentum (Face)

*Vaginal delivery
** Unstable / transient presentation – likelihood of dystocia is high
*Sinciput and brow are transient and if not converted, it may result to dystocia because diameter of the head is greater in this
positions.

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna DLSHSI Medicine Ba tch 201 6 |2
Editor: Jan David C. Monzon
FETAL PRESENTATION – BREECH PRESENTATION
frank, complete, and footling presentations
May result from circumstances that prevents normal versions from taking place
 Uterine anomalies – septum
 CS if the patient is primigravid breech. Those who are multigravid who previously had NSD can deliver vaginally
breech presenting fetus.* NOWADAYS, all breech are delivered CS due to its litiginous nature of patients but you
can deliver the baby vaginally as long as you know the exact position of head, estimated fetal weight because the
first part that will come out is the softer portion and the last will be the least compressible (head)
 Placenta previa
POSSIBLE ETIOLOGIES
Prematurity – the head is bigger then buttocks Hydrocephaly – will not convert because the lower part of
Uterine relaxation/Multiparity uterus is smaller
Multiple pregnancy – one baby cephalic the other Anencephaly
breech Uterine anomalies/Tumor
Hydramnios – large space to move around Placenta previa
Oligohydramnios – will not rotate at 32-34 weeks Habitual breech – first, second and third baby is breech
 Change of position from breech to cephalic: 32 to
34 weeks
INCOMPLETE/FOOTLING
FRANK BREECH COMPLETE BREECH
BREECH
Most Common Thighs are flexed over the abdomen One or Both Feet are
Thighs are Flexed Legs are flexed upon the thighs Lowermost – Footling Breech
Legs are Extended over the Feet present above the level of the Or One of Both Knees are
Anterior Surface of the Baby buttocks Lowermost – (Genu or knee
Legs and thighs flexed presentation)
Feet & Legs are below the level
of the Buttocks
THIGHS
FLEXED FLEXED FLEXED
KNEES
EXTENDED FLEXED FLEXED
SACRUM
(+) (+) (-)
FEET
(-) (-) (+)

FETAL PRESENTATION – COMPOUND PRESENTATION

Fetal hand or foot prolapses alongside the presenting vertex or breech
Hand varieties – tend to resolve spontaneously ; more common
Foot varieties – tend to be complicated with cord prolapse
*multiparous – can be removed the hand spontaneously or by pushing the hand upward

VARIETIES

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna DLSHSI Medicine Ba tch 201 6 |3
Editor: Jan David C. Monzon
FETAL PRESENTATION – SHOULDER PRESENTATION/TRANSVERSE LIE
The shoulder of the acromion is usually presenting into the
pelvic inlet in transverse lie and the bisacromial diameter (11.0
cm) presents
IE = Acromion Process through the Cervix
Shoulder or Acromion Process usually presenting in the Pelvis
in Transverse Lie
Long axis of fetus perpendicular to mother
No mechanism of labor, always CS (Caesarian Section)
Abdomen: squat uterus
 Usually wide
 Fundus only slightly above umbilicus
Leopold’s Maneuver:
 1 : empty
 2 : fetal back readily identified
 If anterior: hard resistant plane – back up
 If posterior: irregular nodulations (FSP)

FETAL ATTITUDE OR POSTURE

Defines the relation of fetal parts to one another
In later months of pregnancy, the fetus assumes a characteristic posture or habitus
Fetus forms an ovoid mass that corresponds roughly to the shape of uterine cavity
Results from the mode of fetal growth and its accommodation to the uterine cavity
The fetus becomes folded or bent upon itself in such a manner that the:
 back becomes markedly convex
 head is sharply flexed so that the chin is almost in contact with the chest
 thighs are flexed over the abdomen
 legs are bent at the knees
In all cephalic presentations, the arms are usually crossed over the thorax or become parallel to the sides
Generalized flexion

FETAL POSITION
Position refers to the relationship of an arbitrarily chosen portion (occiput, mentum, sacrum) of the fetal presenting
part to the right or left side of the birth canal.
DETERMINING POINTS
VERTEX FACE BREECH
Occiput Chin (mentum) Sacrum
LO or RO LM or RM LS or RS

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna DLSHSI Medicine Ba tch 201 6 |4
Editor: Jan David C. Monzon
VARIETIES OF PRESENTATIONS AND FETAL POSITONS
For still more accurate orientation, the relationship of a given portion of the presenting part to the anterior,
transverse, or posterior portion of the maternal pelvis is considered
The presenting part in right or left positions may be directed anteriorly (A), transversely (T), or posteriorly (P)
There are six varieties of each of the three presentations:
(shown next page)

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna DLSHSI Medicine Ba tch 201 6 |5
Editor: Jan David C. Monzon
 **MASTER THIS FOR YOU TO BE ABLE TO LABEL THE PICTURES ABOVE.

DIAGNOSIS OF AN OCCIPUT PRESENTATION BY:

LEOPOLD’S MANEUVER PELVIC / VAGINAL EXAMINATION
Systematic abdominal examination 1. The examiner inserts two fingers
Mother is supine and comfortably positioned with her abdomen bared into the vagina and the presenting
Limitations: part is found. Differentiation of
 Obese – you will palpate the fats vertex, face, and breech is then
 Excessive amniotic fluid – palpation of amniotic fluid accomplished readily.
 Anteriorly implanted placenta – obstruction in palpation of the
fetal parts
2. If the vertex is presenting, the
LEOPOLD’S MANEUVER 1 (FUNDAL GRIP)
fingers are directed posteriorly and
Identification of which fetal pole (cephalic or podalic) occupies the
uterine fundus then swept forward over the fetal
Breech gives the sensation of a large, nodular mass head toward the maternal
Head feels hard and round and is more mobile and ballottable symphysis. During this movement,
the fingers necessarily cross the
LEOPOLD’S MANEUVER 2 (UMBILICAL GRIP) sagittal suture and its course is
Performed after determination of fetal lie delineated.
The second maneuver is accomplished as the palms are placed on
either side of the maternal abdomen, and gentle but deep pressure is 3. The positions of the two fontanels
exerted then are ascertained. The fingers are
On one side, a hard, resistant structure is felt (back) passed to the most anterior
On the other, numerous small, irregular, mobile parts are felt extension of the sagittal suture, and
(fetal extremities) the fontanel encountered there is
By noting whether the back is directed anteriorly, transversely, or
examined and identified. Then, with
posteriorly, the orientation of the fetus can be determined
a sweeping motion, the fingers pass
LEOPOLD’S MANEUVER 3 (PAWLIK’S GRIP) along the suture to the other end of
The third maneuver is performed by grasping with the thumb and the head until the other fontanel is
fingers of one hand the lower portion of the maternal abdomen felt and differentiated.
just above the symphysis pubis
If the presenting part is not engaged, a movable mass will be felt,
usually the head 4. The station, or extent to which the
If the presenting part is deeply engaged: lower fetal pole is in the presenting part has descended into
pelvis the pelvis, can also be established at
*IF HEAD IS NOT BALLOTABLE OR ENGAGED, DO THE LM 4 this time. Using these maneuvers,
the various sutures and fontanels
LEOPOLD’S MANEUVER 4 (PELVIC GRIP) are located readily.
To perform the fourth maneuver, the examiner faces the mother’s
feet and, with the tips of the first three fingers of each hand, exerts FONTANELS: (REITERATED Again!)
deep pressure in the direction of the axis of the pelvic inlet.
Diamond Shaped – Anterior
Point of Reference: CEPHALIC PROMINENCE! When you slide you
Triangle – Posterior / Occiput
hand on the maternal pelvis and your hand is arrested on one side –
CEPHALIC PROMINENCE
If you palpate the head on the same side of the back, then the head
is extended. (visualize)

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna DLSHSI Medicine Ba tch 201 6 |6
Editor: Jan David C. Monzon
 FACTORS RESPONSIBLE FOR NORMAL LIE, PRESENTATION, ATTITUDE AND POSITION:
PLACENTAL MODE OF FETAL
AOG UTERUS AMNIOTIC FLUID
LOCALIZATION GROWTH
Term fetus – vertex Piriform or pear After 32 weeks, the Lower uterine and its
Fetal head at term shaped ratio of amniotic segment – accommodation
is slightly larger The fetus in fluid volume breech or to the uterine
than the breech breech changes decreases relative to transverse lie cavity results to
Entire podalic pole polarity to make the increasing fetal fetal attitude or
of the fetus use of the mass –time should posture
(breech and flexed roomier fundus change position
extremities) is for its bulkier and
bulkier and more more mobile
mobile than the podalic pole
cephalic pole (fetal
head only)

PASSAGEWAY BONY PELVIS

Characterize a normal birth passage based on: Bones:
 Bony pelvis  Sacrum
 Enumeration of the bones of the pelvis  Coccyx
 Description of the types of pelvis  2 innominate bones (ilium and ischium)
 Description of the planes of the pelvis and
corresponding diameters PUBIC BONES
Assessment of a normal pelvis: Joints – 4 (softens when the Term is near)
 Clinical pelvimetry  2 Sacroiliac
 Imaging studies  Sacrococcygeal
Soft tissues – pelvic floor  Symphysis pubis

TYPES OF PELVIS
FALSE PELVIS TRUE PELVIS
Lies above the linea terminalis Important in childbearing where the baby passes through
Boundaries: Boundaries:
 Posteriorly: lumbar  Above by the promontory and alae of the sacrum, the linea terminalis, and
vertebra the upper margins of the pubic bones
 Laterally: iliac fossa  Below by the pelvic outlet
 Anteriorly: the boundary is  The cavity of the true pelvis can be described as an obliquely truncated, bent
formed by the lower cylinder with its greatest height posteriorly
portion of the anterior The cavity is formed by:
abdominal wall  Pubic bones, Ischium, Ilium, Sacrum, Sacrosciatic notches and ligaments
Shape: obliquely truncated, bent cylinder with greatest height posteriorly
Pelvic axis: directed downward and forward
Sidewalls: converge, if extended would meet near knee
Ischial spines: felt vaginally, laterally, MIDPLANE
 Serves as index in determining station of presenting part
Sacral promontory: upper margin of sacrum,
 Landmark for PELVIC INLET
Tuberosities – Landmark for PELVIC OUTLET

PELVIC INLET1 MIDPELVIS PELVIC OUTLET2

Boundaries:
 Posteriorly: promontory and
alae of the sacrum
 Laterally: linea terminalis
 Anteriorly: horizontal pubic
rami and symphysis pubis
Typically more nearly round than
ovoid
Gynecoid pelvic inlet (Caldwell,
1934) nearly 50% of white
women
Measured at the level of the
ischial spines—the midplane, or
plane of least pelvic dimensions
It is of particular importance
following engagement of the
fetal head in obstructed labor
The interspinous diameter, 10 cm
or slightly greater, is usually the
smallest pelvic diameter
The anteroposterior diameter
through the level of the ischial
spines normally measures at least
11.5 cm
Consists of two approximately
triangular areas that are not in the
same plane
They have a common base, which is a
line drawn between the two ischial
tuberosities
Posterior triangle:
 Apex of the posterior triangle is at
the tip of the sacrum
 Lateral boundaries: sacrosciatic
ligaments and ischial tuberosities.
Anterior triangle: area under the
pubic arch

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna DLSHSI Medicine Ba tch 201 6 |7
Editor: Jan David C. Monzon
 DIAMETERS OF THE PELVIC INLET1
ANTEROPOSTERIOR (AP) TRANSVERSE DIAMETER
OBSTETRICAL DIAGONAL Constructed at right angles of the
TRUE CONJUGATE
CONJUGATE CONJUGATE obstetrical conjugates
Obstetrically Anteroposterior Determined by Represent the greatest distance
important – diameter of the measuring the between the linea terminalis on either
shortest distance pelvic inlet distance from the side
between the lower margin of Intersects the obstetrical conjugate at a
promontory of the the symphysis to point approximately 4cm in front of the
sacrum and the the sacral promontory
symphysis pubis promontory Each of the two oblique diameters
(10cm or more), extends from one of the sacroiliac
subtracting 1.5 to synchondroses to the iliopectineal
2cm from the eminence on the opposite side. They
diagonal conjugate average less than 13 cm.
Cannot be
measured clinically
Most important

If there is no further descent after engaging of the fetal head, it is called ARRESTING DESCENT. Do CS.

DIAMETERS OF THE PELVIC OUTLET

Anteroposterior
Transverse – ischial spine
Posterior sagittal
If there’s an outlet contraction, almost always, you
have a midplane contraction

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna DLSHSI Medicine Ba tch 201 6 |8
Editor: Jan David C. Monzon
 PELVIC SHAPES: CALDWELL-MOLOY CLASSIFICATION
Based on measurement of the greatest transverse diameter of the inlet and its division into anterior and posterior segments.
The character of the posterior segment determines the type of pelvis
The character of the anterior segment determines the tendency
These are both determined because many pelves are not pure but are mixed types.
For example, a gynecoid pelvis with an android tendency means that the posterior pelvis is gynecoid and the anterior pelvis is android in shape.
GYNECOID ANDROID ANTHROPOID PLATYPELLOID
Ideal pelvis favouring a normal delivery; 50.6% Male-type pelvis favouring OP positions and Ape-like pelvis favouring OP positions often Often leads to cephalo-pelvic
of women. apt to cause deep transverse arrest of head requiring operative vaginal deliveries (forcep disproportion (CPD); 4.4% of
Brim slightly oval transversely but almost (nakatihaya, occiput transverse is common extraction); 22.7% of women. women.
rounded here); 22.4% of women. Vacuum extraction Brim oval transversely
Sacrum curved Brim heart-shaped Brim AP oval Sacrum very slightly curved
Ischial spines not prominent Sacrum curved Sacrum very slightly curved Ischial spines prominent
Short-cone pelvis Ischial spines prominent Ischial spines prominent Short-cone shallow pelvis
Obtuse greater sciatic notch Long-cone funnel pelvis Long-cone funnel pelvis with straight Acute greater sciatic notch
Triangular obturator foramen Acute greater sciatic notch sidewalls Triangular obturator foramen
Sub-pubic arch rounded [Roman arch] angle Oval obturator foramen Obtuse greater sciatic notch Wide pubic arch
at least 90 degress Sub-pubic arch very narrow Oval obturator foramen Flat
[Gothic arch] Sub-pubic arch narrow

*ang puso ng mga lalaki andito HAHAHA

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna DLSHSI Medicine Ba tch 201 6 |9
Editor: Jan David C. Monzon
ASSESSMENT OF A NORMAL PELVIS
 *measures obstetric conjugate; X- ray if clinical, diagnonal conjugate
CLINICAL PELVIMETRY  Done at term if there is no spontaneous labor
Examiner attempts to judge the:  AP and Lateral Views
 AP diameter of the inlet - the diagonal conjugate  OBSTETRIC CONJUGATE is measured!
 Interspinous diameter of the midpelvis
 Intertuberous distances of the pelvic outlet CT Scanning
 A narrow pelvic arch of less than 90 degrees can signify a narrow pelvis  Advantages:
 An unengaged fetal head can indicate either excessive fetal head size or reduced  Reduced radiation exposure
pelvic inlet capacity  Greater accuracy
 PRIMIGRAVIDA – 2 weeks prior the onset of labor, head will already engage, very  Easier performance
good chance of successful vaginal delivery  Fetal dose may range from 250 to 1500mrad
 40 – 41 weeks with unengaged head – CONTRACTED PELVIC DIAMETERS   Expensive
 Not advisable!
IMAGING STUDIES
X-ray Pelvimetry Magnetic Resonance (MR) Imaging
 Widely used  Advantages:
 Prognosis for successful vaginal delivery cannot be established using x-ray  Lack of ionizing radiation
pelvimetry alone  Accurate measurements
 Considered to be of limited value in the management of labor with a cephalic  Complete fetal imaging
presentation (ACOG,1995b)  Potential for evaluating soft tissue dystocia – studies have shown that this
 A mean gonadal exposure is estimated to be 885mrad cannot be used as basis for CS
 Consequence: blood dyscrasia (1 out of 5000; leukemia, anemia)

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 10
Editor: Jan David C. Monzon
 COMPARISON OF FOUR BASIC TYPES FEMALE BONY PELVIS

CLINICAL PELVIMETRY

PARAMETERS ASSESSED ADEQUATE CONTRACTED

SACRAL PROMONTORY Not reached Easily reached

CURVATURE OF SACRUM Concave Straight or flat

SACROSCIATIC NOTCH Admits 2 fingers < 2 fingers

ISCHIAL SPINE Blunt Prominent

BISPINOUS DIAMETER Not reached by 2 fingers Reached by 2 fingers

PELVIC SIDEWALLS Parallel or divergent Convergent

PUBIC ARCH Obtuse angle acute angle

ISCHIAL TUBEROSITIES > Closed fist dia < closed fist dia

ANTEROPOSTERIOR DIAMETER TRANSVERSE DIAMETER

NORMAL CONTRACTED NORMAL CONTRACTED
INLET > 11.5 cm < 10 cm > 13 cm < 12 cm
MIDPLANE > 11.5 cm < 10 cm > 10.5 cm < 8 cm
OUTLET > 9.5 cm < 8 cm

SOFT TISSUES – PELVIC FLOOR

PELVIC DIAPHRAGM The pubococcygeus muscle now is preferably
Forms a broad muscular sling and provides termed the pubovisceral muscle and is
substantial support to the pelvic viscera subdivided based on points of insertion and
comprised of the levator ani and the function. These includes the following muscles:
coccygeusmuscle.  Pubovaginalis
The levator ani is composed of:  Puboperinealis
 Pubococcygeus  Puboanalis
 Puborectalis
 Ileococcygeus muscles.

POWER  2nd stage: Uterine contractions and intra-

Characterize the powers involved in normal labor abdominal pressure
 1st stage: uterine contractions

Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna

Formatting: Aibhen B. Naguna D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 11
Editor: Jan David C. Monzon
SIGNS OF TRUE LABOR
Regular contractions (1 in 10 or 4 in 20 mins)
Intervals gradually shorten;
Intensity gradually increases
Cervix dilates 3cm or more
Cervical effacement 70-80%
Abdomen becomes tense and becomes more round
Discomfort from fundus (pacemaker) to lower
abdomen and back
Discomfort not relieved by sedation
Pain is perceived variably- different pain thresholds
Do verbal analgesia to appease patient
METHODS TO QUANTIFY UTERINE ACTIVITY
Palpation – mild to strong
 Mild to moderate: denting of abdomen;
 if severe – very hard, cannot dent
External tocodynamometry
Internal uterine pressure sensors
 insert catether inside, for heart rate
UTERINE CONTRACTIONS DURING LABOR:
UTERINE CONTRACTIONS ARE PAINFUL
(3) Theories on its cause:
 Hypoxia of contracting myometrium
 Compression of the nerve ganglia in the cervix
and lower uterus by interlocking muscle fibers
 Stretching of the peritoneum overlying the
fundus
UTERINE CONTRACTIONS BECOME MORE FREQUENT,
LONGER AND INCREASING INTENSITY AS LABOR
PROGRESSES
Interval every 10 minutes at the start to every
minute during 2nd stage of labor every minute or
every 2 minutes
Uterine relaxation in between contractions
necessary for fetal recovery
if persistent contraction = TETANIC CONTRACTIONS
can lead to FETAL ASPHYXIA OR UTERINE RUPTURE
 Duration: 30 to 60 seconds
 Pressure: 20 to 60 mmHg
UTERINE CONTRACTIONS ARE INVOLUNTARY AND
INDEPENDENT OF ANY EXTERNAL CONTROL
Analgesia and anesthesia may affect uterine
contractions during the latent phase but not during
the active phase of labor
Only give analgesic if the cervix is 3-4cm
DO NOT give if cervix is less than 3 or 4 cm – labor
maybe arrested
IV or Epidural anesthesia however during 2nd stage, no
urge to bear down so you need to coach the patient
-END-
TRANSCRIPTION DETAILS
Lecture, Handout;
BASIS RECORDINGS + NOTES
Books
E-mail me at bhen44@gmail.com for any comments, suggestions, and corrections for this topic.
REMARKS
See William’s Book of Obstetrics and Sumpaico Book of Obstetrics for clearer images
-DLSHSI Medicine Batch 2016 Transcriptions. Version 1.0.0.0.0 Build 2201-
Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna
Formatting: Aibhen B. Naguna
Editor: Jan David C. Monzon
UTERINE CONTRACTIONS ARE ENHANCED BY
MECHANICAL STRETCHING OF THE CERVIX
FERGUSON REFLEX – Mechanical cervical
stretching or stripping of the membranes are
associated with increased levels of Prostaglandin
F2a (uterine contractions, same as when you have
dysmenorrhea)
FUNDAL DOMINANCE OF UTERINE CONTRACTIONS
Gradient of uterine contractions with fundal
dominance at least in the lower uterine segment
Upper segment contract and retracts, thus
becoming thicker
Lower segment relax and elongates, thus becoming
thinner
Uterine cornu – is the source of uterine contractions,
“pacemaker” (fundus)
UTERINE CONTRACTIONS DURING LABOR
Uterine activity – Montevideo units (MvU)
MVU = Intensity x Frequency / 10 minutes
Intensity (Intrauterine pressure) = Peak contraction
minus baseline contaction
200 MvU or more = adequate uterine contraction
CHANGES IN THE UTERINE MUSCULATURE
Anatomic and Histologic Internal OS – becomes thin
and pulled out >> Physiologic Retraction Ring
2nd stage – 10 cm full dilatation in term, obliteration
of Internal Os; In primigravida, 8cm
if abnormal 2nd stage, pathologic contractions
increases, impending uterine rupture because of
dystocia
Active – upper uterine segment
Passive – lower uterine segment or isthmus
MECHANICAL FORCES OF LABOR
FACTORS RESPONSIBLE FOR PROGRESSION AND
COMPLETION OF LABOR
FIRST STAGE
Uterine power – to dilate the cervix to allow baby to
pass through
Cervical resistance – effacement/thinning
Forward pressure of the fetal head – to dilate
SECOND STAGE
Intra-abdominal pressure – bearing down of mother
Mechanical relationship between fetal heal and
pelvic capacity –whether the pelvis is adequate
enough to allow passage of baby if not, dystocia
Uterine power too but be careful – tetanic
contractions
+ DEVIATIONS 25% CREDITS Aubrey-cordings
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 12
Transcriber: Felise Tiffany S. Ong, Aibhen B. Naguna
Formatting: Aibhen B. Naguna D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 13
Editor: Jan David C. Monzon