MECHANISMS OF NORMAL LABOR

I. Lie, presentation, attitude and

position
Fetal orientation can be
established clinically :
abdominal palpation
vaginal examination
auscultation
sonography
X-Ray

Fetal lie
Is the relation of the long axis of the
fetus to that of mother
Longitudinal - transverse - oblique
Longitudinal lies are present in over 99
percent of labor at term
Predisposing factors for transverse
lie :
multi parity
placenta previa
hydramnios

Fetal presentation

The presenting part :

portion of the body of the fetus is
either foremost within the birth
canal or in proximity to it

Can be felt through the cervix on

vaginal examination

Determines the presentation

longitudinal lie creating

cephalic and
breech
presentation

In

In

transverse lie

presentation

the shoulder

Cephalic presentation
1. The head is flexed sharply

The chin is contact with the thorax

The occipital fontanel is the

presenting part

Vertex or occiput presentation

Cephalic presentation
2. Face presentation :
Fetal neck extended

Occiput & back come in contact

The face is foremost in the birth

canal

Face presentation

Vertex presentation --- Face

presentation
Sinciput
presentation
The fetal head
partially flexed
.
Anterior/large
frontal is the
presenting part
Labor
progresse
s

Vertex
presentation
presentation

Brow
presentation
Partially
extended
Brow is the
presenting part
Labor
progress
es

Face
Transient

Breech presentation
There are three general
configuration :
Frank breech
presentation :
The thighs are
flexed
The legs
extended over
the anterior
surfaces of the
body

Complete
breech
presentation :

Incomplete;
footling breech
presentation :
One or both
The thighs are
feet/knees are
flexed on the
lowermost
abdomen &
the legs upon
the thighs

Fetal attitude or
posture

The head is sharply flexed

The chin is almost contact with the

chest

The thighs are flexed over the

abdomen

The legs are bent at the knees

The arms usually crossed over the

thorax

Fetal position
The relation of an arbitrarily chosen
portion of the fetal presenting part
to the right or left side of the
maternal birth canal
Each presentation there maybe two
position, right or left
The determining part of :
vertex
occiput

face

chin (mentum)

Varieties of presentation and

position
OA
ROA
LOA
ROT
ROP

LOT

Diagnosis of fetal presentation and

position

A. Abdominal
palpation Leopold
maneuvers
Conducted
systematic
ally

B. Vaginal examination
Comprised of three maneuvers :
1. Two fingers of either gloved
hand are introduced into the
vagina and carried up to the
presenting part
The differentiation :
vertex
face

2. If the vertex is presenting :

Sagittal suture (?)

Small & large fontanels

3. The station is established

C. Auscultation
Does not provide reliable
information
concerning fetal
presentation & position

D. Sonography
Fetal head & body can be located

Labor with occiput presentation

of all labors the fetus is in the
occiput or vertex presentation

95%

the majority of cases the vertex

enters the pelvis with the sagital
suture in the transverse pelvic
diameter
Left occiput transverse (LOT)
:
40% of labors
In

Cardinal movement of labor

Irregular

shape of the pelvic canal

The

relatively large dimensions of

the mature fetal head

process of adaptation or
accomodation of suitable portion
of the head to the various
segments of the pelvis is required

The cardinal movements of labor :

- engagement
- extension
- descent
- external
rotation
- flexion
- expulsion
- internal rotation

For purposes of instruction, the

various movement often are
described as though they occurred
separately and independently in
reality the mechanism of labor
consists of a combination of
movements that are ongoing
simultaneously
For example :

Engagement :

The greatest transverse diameter

(BPD) in occiput presentation, passes
through the pelvis inlet

In many primigravida this phenomena

may takes place during the last weeks
of pregnancy

In many multiparous and some

nulliparous
the fetal head is still
freely movable above
the pelvic

Asyinclitism

The sagital suture, entering the pelvic

inlet may not lie exactly midway
between the symphysis and sacral
promontory

The sagital suture deflected either

posteriorly toward the promontory or
anteriorly toward the symphysis

Such lateral deflection of the head to

a more anterior or posterior position

Descent
The first requisite for birth of the
infant
In nulliparas, engagement may take
place before the onset of labor and
further descent takes place at the
second stage
Four forces :

a. pressure of amniotic fluid

b. direct pressure of the fundus upon the
breech with contraction
c. bearing down effort

Flexion
Resistance

from the cervix, wall of

the pelvis, pelvic floor flexion of
the head

The

chin more contact with the fetal

thorax

Suboccipito

bregmatic diameter is
substituted for the longer occipito
frontal diameter

Internal rotation
The

occiput gradually moves

anteriorly toward the symphysis
pubis or less commonly, posteriorly
toward the hollow of the sacrum
Is always associated with descent
Is not accomplished until the head
has reached the level of the spine
and thereafter is engaged

Calkins (1939)
Concluded

Two thirds internal rotation is

completed by the time the head
reaches the pelvic floor
A fourth internal rotation is
completed very shortly after the
head reaches the pelvic floor
5 percent internal rotation does
not take place

Extension
Extension

brings the base of the

occiput into direct contact with the
interior margin of the symphysis pubis

Causes
The

of extension :

vulva outlet is directed upward

and forward

 Two

forces come into play :

a. Exerted by the uterus act more

posteriorly
b. Resistant pelvic floor and the
symphysis acts more anteriorly
the resultant vector is in the
direction of the vulva opening
causing extension

External Rotation

The delivered head next undergoes

restitution

If the occiput was originally directed

toward the left it rotates toward
the left ischial tuberosity

Expulsion

After delivery of the shoulders,

the rest of the left body is
quickly extruded

Changes in shape of the fetal head

1. Caput Succedaneum
The formation of swelling due to
stagnation of fluid in the layers of
the scalp beneath the girdle of
contact
The

girdle of contact is either :

Bony
Dilating cervix

The swelling :
Diffuse
Boggy
Not limited by the suture line
Disappears spontaneously within
24 hours after birth
Occurs after rupture of the
membranes

Importance
It signifies static position of the head for
a long period of time
Location of the caput gives an idea
about the position of the head occupied
in the pelvis and the degree of flexion
achieved :
in left position
caput in right
parietal bone
in right position on left parietal
bone

Moulding

The alteration of the shape of the

forecoming head while passing through
the risistant birth passage during labor

Mechanism :

There is compression of the engaging

diameter of the head with
corresponding elongation of the
diameter at right angle to it

Moulding disappears within few hours

Grading

Grade 1 : The bones touching but not

overlapping

Grade 2 : Overlapping but easily

separated

Grade 3 : Fixed overlapping

Importance

Slight molding is irritable and beneficial

the head to pass more easily through
the birth canal

Extreme molding (CPD) may produce

severe intracranial disturbance in the
form of tearing of tentorium serebelli or
subdural haemorrhage

Shape of the molding give an

information about the position of the

Cephalhematoma

A collection of blood in between the

pericranium in the flat bone of the
skull

Unilateral

Over a parietal bone

Due to rupture of a small emissary

vein from the skull and may be
associated with fracture of the skull

Causes : - following normal delivery

- forceps delivery

The swelling is limited by the suture

lines

It is circumscribed, soft, fluctuant,

incompressible

Prognosis is good the blood is