NORMAL LABOR World Health Organization (WHO) defines normal labor based on the following features; (1) spontaneous

onset of labor between 37 and 42 completed weeks of pregnancy, (2) low risk at the start and remaining so throughout labor and delivery, (3) spontaneous birth of an infant in the vertex presentation, (4) mother and baby in good condition after birth. 1 Society of Obstetricians and Gynaecologists of Canada (SOGC), defines normal labor same as WHO, plus; (1) normal birth includes the opportunity for skin-skin holding and breastfeeding in the first hour after the birth, (2) a normal birth does not preclude possible complications such as postpartum haemorrhage, perineal trauma and repair, and admission to the neonatal intensive care unit. A normal birth does not include elective induction of labor prior to 41+0 weeks, spinal analgesia, general anaesthetic, instrumental delivery, cesarean delivery, routine episiotomy, continuous electronics fetal monitoring for low risk birth and fetal malpresentation.1 Mechanisms of Labor with Occiput Anterior Presentation The 7 Cardinal Movements of Labor The positional changes in the presenting part required to navigate the pelvic canal constitute the mechanisms of labor. The cardinal movements of labor are engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion.2

Mechanism of labor for left occiput anterior position.2 I.Engagement

Left occipitoanterior engagement.3 The mechanism by which the biparietal diameter (the greatest transverse diameter in an occiput presentation) passes through the pelvic inlet is designated engagement. The fetal

head may engage during the last few weeks of pregnancy or not until after labor commencement. In many multiparous and some nulliparous women, the fetal head is freely movable above the pelvic inlet at labor onset. In this circumstance, the head is sometimes referred to as "floating." A normal-sized head usually does not engage with its sagittal suture directed anteroposteriorly. Instead, the fetal head usually enters the pelvic inlet either transversely or obliquely. II. Descent

Descent in left occipitoanterior position.3 In nulliparas, engagement may take place before the onset of labor, and further descent may not follow until the onset of the second stage. In multiparous women, descent usually begins with engagement. Descent is brought about by one or more of four forces: (1) pressure of the amnionic fluid, (2) direct pressure of the fundus upon the breech with contractions, (3) bearing-down efforts of maternal abdominal muscles, and (4) extension and straightening of the fetal body. III. Flexion In this movement, the chin is brought into more intimate contact with the fetal thorax, and the appreciably shorter suboccipitobregmatic diameter is substituted for the longer occipitofrontal diameter.2 IV. Internal Rotation

Anterior rotation of head.3 This movement consists of a turning of the head in such a manner that the occiput gradually moves toward the symphysis pubis anteriorly from its original position or less commonly,
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posteriorly toward the hollow of the sacrum. Internal rotation is essential for the completion of labor, except when the fetus is unusually small.2

V. Extension After internal rotation, the sharply flexed head reaches the vulva and undergoes extension. If the sharply flexed head, on reaching the pelvic floor, did not extend but was driven farther downward, it would impinge on the posterior portion of the perineum and would eventually be forced through the tissues of the perineum. When the head presses upon the pelvic floor, however, two forces come into play. The first force, exerted by the uterus, acts more posteriorly, and the second, supplied by the resistant pelvic floor and the symphysis, acts more anteriorly. The resultant vector is in the direction of the vulvar opening, thereby causing head extension. This brings the base of the occiput into direct contact with the inferior margin of the symphysis pubis.2

Extension of the head.3 With progressive distension of the perineum and vaginal opening, an increasingly larger portion of the occiput gradually appears. The head is born as the occiput, bregma, forehead, nose, mouth, and finally the chin pass successively over the anterior margin of the perineum. Immediately after its delivery, the head drops downward so that the chin lies over the maternal anus.2 VI. External Rotation

External rotation of the head.3

The delivered head next undergoes restitution. If the occiput was originally directed toward the left, it rotates toward the left ischial tuberosity. If it was originally directed toward the right, the occiput rotates to the right. Restitution of the head to the oblique position is followed by completion of external rotation to the transverse position. This movement corresponds to rotation of the fetal body and serves to bring its bisacromial diameter into relation with the anteroposterior diameter of the pelvic outlet. Thus, one shoulder is anterior behind the symphysis and the other is posterior. This movement apparently is brought about by the same pelvic factors that produced internal rotation of the head. 2 VII. Expulsion Almost immediately after external rotation, the anterior shoulder appears under the symphysis pubis, and the perineum soon becomes distended by the posterior shoulder. After delivery of the shoulders, the rest of the body quickly passes.2

Delivery of anterior shoulder.3

Delivery of posterior shoulder.3

REFERENCES

1. Simkin P., Ancheta R. What is normal labor? Chapter 2: Dysfunctional Labor : General Considerations. In The Labor Progress Handbook; Early Interventions to Prevent and Treat Dystocia. 3rd Edition. UK. Wiley-Blackwell. 2011; pp 16-7. 2. Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. Williams Obstetrics. Mechanisms Of Labor. Normal Labor and Delivery. 23rd Edition. United States of America. The McGraw-Hill Companies. 2010; Pp 378-83. 3. Decherney A.H., Nathan L., Goodwin T.M., Laufer N. Current Diagnosis & Treatment Obstetrics & Gynecology. Chapter 10; The Course & Conduct of Normal Labor & Delivery. 10th Edition. US. The McGraw-Hill Companies. 2007.