PHYSIOLOGIC OBSTETRICS

Topic: Normal Labor

Lecture by: Dr. Torres

LABOR 2. Fetal Presentation

 Labor is the process that leads to childbirth  The presenting part is that portion of the fetal body that is either
 It begins with the onset of regular uterine contractions and ends with foremost within the birth canal or in closest proximity to it. It can be
the delivery of the newborn and expulsion of the placenta felt through the cervix on vaginal examination
 The term labor in the obstetrical context takes on several  Longitudinal lie – the presenting part is either the fetal head or
connotations from the English language breech, creating cephalic (98.8%) and breech (2.7%) presentations
Cephalic Presentation
MECHANISMS OF LABOR  Such presentation are classified according to the relationship
between the head and body of the fetus
 Ordinarily, the head is flexed sharply so that the chin is in contact with
the thorax

 At the onset of labor, the positon of the fetus with respect to the birth
canal is critical to the route of delivery. Thus, fetal position within the
uterine cavity should be determined at the onset of labor o Vertex or Occiput presentation  the occipital fontanel
 Fetal orientation relative to the maternal pelvis is described in terms is the presenting part
of: o Face presentation  much less commonly, the fetal neck
o Fetal lie may be sharply extended so that the occiput and back
o Fetal presentation come in contact, and the face is foremost in the birth canal
 Cephalic Presentation o Sinciput presentation or Military position  the fetal
 Vertex or occiput head may assume a position between these extremes,
 Face partially flexed in some cases, with the anterior (large)
 Sinciput or military fontanel, or bregma
 Brow o Brow presentation  partially extended in other cases
 Breech Presentation
o Fetal attitude or posture
o Fetal position

1. Fetal Lie
 The relation of the fetal long axis to that of the mother is either
longitudinal or transverse. Occasionally, the fetal and the maternal
axes may cross at a 45-degree angle, forming an oblique lie, which is
unstable and always becomes longitudinal or transverse during labor
 A longitudinal lie is present in >99% of labors at term
 Predisposing factors for transverse lies:
o Multiparity – maluwag na raw
o Placenta previa – di na kasya yung head
o Hydramnios
o Uterine anomalies

 The latter two presentations (Sinciput and Brow) are usually

transient
 As labor progresses, sinciput and brow presentations almost always
convert into vertex or face presentations by neck flexion or
extension, respectively. Failure to do so can lead to dystocia
 The term fetus usually present with the vertex, most logically
because the uterus is piriform or pear shaped
 Fetal head (Cephalic pole) at term is slightly larger than the Breech
(Podalic pole)  the breech and its flexed extremities
 Until approximately 32 weeks, the amnionic cavity is large compared
with the fetal mass, and there is no crowding of the fetus by the
uterine walls. Subsequently, however, the ratio of amniotic fluid
volume decreases relative to the increasing fetal mass. As a result,
the uterine walls are apposed more closely to the fetal parts

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 PHYSIOLOGIC OBSTETRICS
Topic: Normal Labor
Lecture by: Dr. Torres

Breech Presentation
 Frank breech  thighs flexed, legs extended over anterior surfaces
of the body
 Complete breech  thighs flexed, legs flexed upon thighs
 Incomplete breech or Footling  one or both feet, or one or both
knees may be lowermost

 Breech presentation may result from circumstances that prevent

normal version from taking place, for example, a septum that
protrudes into the uterine cavity. A peculiarity of fetal attitude,
DIAGNOSIS OF FETAL PRESENTATION AND POSITION
particularly extension of the vertebral column as seen in frank
1. Abdominal Palpation
breeches, also may prevent the fetus from turning. If the placenta is
Leopold Maneuvers
implanted in the lower uterine segment, it may distort normal
 Difficulty or not possible to perform:
intrauterine anatomy and result in a breech presentation
o Obese
 Transverse lie  the SHOULDER (0.3%) is the presenting part and is
o Polyhydramnios
felt through the cervix on vaginal examination
o Placenta is anteriorly implanted
1st Maneuver
3. Fetal Attitude/Posture
 Assess – uterine fundus
 Attitude or Habitus – characteristic posture assumed by the fetus in
 Which fetal pole – that is, cephalic
the latter months of pregnancy
or podalic – occupies the uterine
 Fetus forms an ovoid mass that corresponds roughly to the shape of
fundus
the uterine cavity
 The breech – gives the sensation
 Fetus becomes folded or bent upon itself
of a large, nodular mass
o Fetus becomes folded or bent upon itself
 The head – feels hard and round
o Back becomes markedly convex
and is more mobile and ballottable
o Head is sharply flexed so that the chin is almost in contact
with the chin
2nd Maneuver
o Thighs are flexed over the abdomen
 Assess – Fetal extremities
o Legs are bent at the knees
 On one side, a hard, resistant
o Arms are usually crossed over the thorax or become
structure is felt – the back
parallel to the sides
o Umbilical cord lies in the space between them and the  On the other, numerous small
lower extremities irregular, mobile parts are felt – the
fetal extremities
Note:  By noting whether the back is
o Abnormal exception to this attitude occur as the fetal head becomes directed anteriorly, transversely, or
progressively more extended from the vertex to the face presentation
posteriorly, the orientation of the
o Face Presentation  fetal head becomes progressively extended;
fetus can be determined
progressive change in fetal attitude from a convex (flexed) to a
concave (extended) contour of the vertebral column
3rd Maneuver
4. Fetal Position  Assess – Fetal presentation
“engagement”
 Refers to the relationship of an arbitrarily chosen portion of the
presenting part to the right or left side of the birth canal  Performed by grasping with the
thumb and fingers of one hand the
lower portion of the maternal
Cephalic presentation Breech presentation Shoulder presentation
(Longitudinal) (Longitudinal) (Transverse) abdomen just above the symphysis
 Occiput  Sacrum  Acromion pubis
 Mentum – chin  If the presenting part is not engaged,
a movable mass will be felt, usually
the head. The differentiation between head and breech is made as in
the first maneuver. If the presenting part is deeply engaged,
however, the findings from this maneuver are simply indicative that
the lower fetal pole is in the pelvis, and details are then defined by
the fourth maneuver

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 PHYSIOLOGIC OBSTETRICS
Topic: Normal Labor
Lecture by: Dr. Torres

Leopold Maneuvers continued….. Note:

4th Maneuver  Vertex – palpation of suture and fontanels
 Assess – degree of descent  Face – facial features
 Examiner faces the mother’s feet  Breech – fetal sacrum and perineum
and, with the tips of the first three  Station +3 – lowest part
fingers of each hand, exerts deep
pressure in the direction of the axis
of the pelvic inlet. In many
instances, when the head has
descended into the pelvis, the
anterior shoulder may be
differentiated readily by the third
maneuver
 When the head descended into the pelvis, the anterior shoulder may
be differentiated readily by the third maneuver 3. Auscultation
o LM 1 and LM3 – magkasama daw ginagawa 4. Sonography
o LM 1, 2, 3 – face the mother’s face  Sonographic techniques can aid identification of fetal position,
o LM 4 – face the mother’s feet especially in obese women or in women with rigid abdominal walls.
In some clinical situations, information obtained radiographically
2. Vaginal Examination justifies the minimal risk from a single x-ray exposure
 During examination, it is advisable to pursue a definite routine,  Digital examinations with transvaginal and transabdominal
comprising 4 movements sonography for fetal head position determination during second-
1st movement stage labor and reported that transvaginal sonography was superior
 Insert 2 fingers into the vagina and the presenting part is found
 Differentiation of vertex, face, breech is then accomplish readily 5. Plain Radiographs, Computed Tomography, or Magnetic Resonance
Imaging
2nd movement
 If the vertex is presenting, the fingers are directed posteriorly and MECHANISMS OF LABOR WITH OCCIPUT ANTERIOR PRESENTATION
then swept forward over the fetal head toward the symphysis pubis  Most cases, the vertex enters the pelvis with the sagittal suture lying
 During this movement, the fingers necessarily cross the sagittal in the transverse pelvic diameter
suture and its linear course is delineated o LOT – 40%  most fetuses enter in this position
o ROT – 20%
o LOA or ROA – the head either enters the pelvis with
occiput rotated 45 degrees anteriorly from the transverse
position
 The positional changes in the presenting part required to navigate
the pelvic canal
 These changes consist:
o Principally of fetal straightening
o With loss of dorsal convexity
3rd movement o And closer application of the extremities to the body
 The positions of the two fontanels found at either end of the sagittal  As a result, the fetal ovoid is transformed into a cylinder, with the
suture is ascertained smallest possible cross section typically passing through the birth
 For this, fingers are passed to the most anterior extension of the canal
sagittal suture and the fontal encountered there is examined and
identified Cardinal Movements of Labor
 The finger pass along the suture to the other end of the head until “ED-FIRE-ERE”
the other fontanel is felt and differentiated  Engagement
 Descent
 Flexion
 Internal Rotation
 Extension
 External Rotation
 Expulsion

4th movement
 The station, or extent to which the presenting part has descended Continued next page…..
into the pelvis, can be established at this time
 This time, the sutures and fontanels are determined

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 PHYSIOLOGIC OBSTETRICS
Topic: Normal Labor
Lecture by: Dr. Torres

Engagement Extension
 Mechanism by which the biparietal diameter – the greatest  After internal rotation, the sharply flexed head reaches the vulva and
transverse diameter in an occiput presentation-passes through the undergoes extension
pelvic inlet  When the head presses upon the pelvic floor
 The fetal head usually enters the pelvic inlet either transversely or  2 forces come into play:
obliquely 1. 1st force – exerted by the uterus, acts more posteriorly
 Asynclitism – the sagittal suture, while remaining parallel to that axis, 2. 2nd force – supplied by the resistant pelvic floor and the
may not lie exactly midway between the symphysis and the sacral symphysis, acts more anteriorly
promontory. The sagittal suture frequently is deflected either
posteriorly toward the promontory or anteriorly toward the o Resultant vector is in the direction of the vulvar opening
symphysis o This brings the base of the occiput into direct contact with
o Anterior Asynclitism – the sagittal suture approaches the the inferior margin of the symphysis pubis
sacral promontory, more of the anterior parietal bone
presents External Rotation
o Posterior Asynclitism – the sagittal suture lies close to the  The delivered head next undergoes restitution  goes back to
symphysis, more of the posterior parietal bone will original position
present  Restitution of the head to the oblique position  completion of
external rotation to the transverse position  to rotation of the fetal
body and serves to brings its bisacromial diameter into relation with
the anteroposterior diameter of the pelvic outlet

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 deliver of the shoulders, the rest of the body quickly passes

MECHANISM OF LABOR WITH OCCIPUT POSTERIOR PRESENTATION

Descent  Occiput Posterior Presentation  20%
 First requisite for birth of the newborn  Associated with:
 Nulliparas – engagement may take place before the onset of labor, o Narrow forepelvis
and further descent may not follow until the onset of the second o Anterior placentation
stage labor  The right occiput posterior (ROP) is slightly more common than the
 Multiparas – descent usually begins with engagement left (LOP)
 Brought about by:  Mechanism of labor is identical to that observed in the transverse
o Pressure of amniotic fluid and anterior varieties  internally rotate to the symphysis pubis
o Pressure of fundus on the breech through 135 degrees instead of 90 and 45 degrees
o Bearing down efforts of mother  Rotate promptly by:
o Extension and straightening of fetal body o Effective contractions
o Adequate flexion of the head
Flexion o Average size fetus
 When the descending head meets resistance, whether from the  If no rotation toward the symphysis takes place, the occiput may
cervix, walls of the pelvis, or pelvic floor remain in the direct occiput posterior position, a condition known as
 The chin is brought into more intimate contact with the fetal thorax persistent occiput posterior
 And the appreciably shorter suboccipitobregmatic diameter is  May have incomplete or no rotation in cases of:
substituted for the longer occipitofrontal diameter o Large fetus
o Poor contractions
Internal Rotation o Faulty flexion of the head
 This movement consists of a turning of the head in such a manner o Epidural analgesia
that the occiput gradually moves toward the symphysis pubis
anteriorly from its original position or less commonly, posteriorly CHANGES IN SHAPE OF THE FETAL HEAD
toward the hollow of the sacrum A. Caput Succedaneum
 Internal rotation is essential for the completion of labor, except  The fetal head changes shape as the result of labor forces
when the fetus is unusually small  In prolonged labors before complete cervical dilatation, the portion
of the fetal scalp immediately over the cervical os becomes
edematous
 Develops over the most dependent area of the head  may deduce
the original fetal head position by noting the location of the caput
succedaneum

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Topic: Normal Labor
Lecture by: Dr. Torres

Changes in Shape of the Fetal Head continued…… STAGES OF LABOR

B. Molding First Stage of Labor
 The changes in fetal head shape from external compressive forces 1. Preparatory Division
 There is seldom overlapping of the parietal bones  Little cervical dilatation, with changes in connective tissue
 A “locking” mechanism at the coronal and lambdoidal connections component of cervix
actually prevents such overlapping  Sensitive to sedation and conduction anesthesia
 Shortened SOB diameter and a lengthened mentovertical diameter
2. Dilatational Division
 Dilatation occurs at a most rapid rate
 Unaffected by sedation and conduction anesthesia

3. Pelvic Division
 Commences with deceleration phase
 Mechanism of labor occur: engagement, flexion, descent, internal
rotation, extension, external rotation

CHARACTERISTICS OF NORMAL LABOR

 Uterine contractions that bring about demonstrable effacement and
dilatation of the cervix
 The onset of labor as beginning at the time of admission to the labor
unit
Cervical Dilatation
 Admission criteria (O’Driscoll and colleagues, 1984); painful uterine
 Latent Phase
contractions accompanied by any one of the following:
o The point at which the mother perceives regular
o Ruptured membranes
contractions
o Bloody “show”
o Ends at between 3 and 5 cm of dilatation
o Complete cervical effacement
 Prolonged Latent Phase
 Admission for labor (US):
o Nullipara = >20 hrs
o Painful contractions
o Multipara = >14 hrs
o Cervical dilatation of 3 to 4 cm or greater
o Factors that affected duration:
o Intact membrane
 Excessive sedation or epidural anesthesia
 Unfavorable cervical condition
 False labor
o Amniotomy  discouraged
This is because it increases the risk for false labor

o Latent phase prolongation did not adversely influence

fetal or maternal morbidity or mortality rates
 Active Labor
o A rapid change in the slope of cervical dilatation rates
between 3 and 5 cm
o Thus, cervical dilatation of 3 to 5 cm or more, in the
presence of uterine contractions, can be taken to reliably
represent the threshold for active labor
o Mean duration of active-phase labor in nulliparas was 4.9
hrs
o The active phase was reported to have a statistical
maximum of 11.7 hrs
o Rates of cervical dilatation ranged from a minimum of 1.2
up to 8.6 cm/hr
o Multiparas – progress somewhat faster in active-phase
labor, with a minimum rate of 1.5 cm/hr.

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Active Labor continued……  Nurse-patient ratio:

o Also pag multiparas – sabay and engage at descend
o Descent begins in the later stage of active dilatation,
commencing at 7 to 8 cm in nulliparas and becoming
most rapid after 8 cm

Active Phase Abnormalities:

 25% of nulliparous labors
 15% of multiparous labors
Management:
Protraction disorder
First Stage of Labor Second Stage of Labor
 Slow rate of cervical dilatation or descent
Intrapartum fetal monitoring Expulsive efforts
 Nulliparas = <1.2 cm dilatation/hr or <1 cm descent/hr Uterine contractions Partograph
 Multiparas = <1.5 cm dilatation/hr or <2 cm descent/hr Maternal vital signs
Subsequent cervical examinations
Arrest Disorder Oral Intake
 Complete cessation of dilatation or descent IV fluids
 Arrest of dilatation = 2 hours with no cervical change Maternal position
 Arrest of descent = 1 hour without fetal descent Analgesia
Amniotomy
Urinary bladder function
Second Stage of Labor
 Begins when cervical dilatation is complete and ends with fetal
Identification of Labor
delivery
 Although the differentiation between false and true labor is difficult
 Median duration
at times, the diagnosis usually can be clarified by contraction
o Nulliparas = 50 mins.
frequency and intensity and by cervical dilatation
o Multiparas = 20 mins.
 Duration of Labor
Emergency Medical Treatment and Labor Act – EMTALA
o Mean length of first- and second-stage labor = 9 hours in
 A woman experiencing contractions in true labor unless a physician
nulliparous women without regional analgesia,
certifies that after a reasonable time of observation the woman is in
multiparas = 6 hrs
“false labor.” A woman in true labor is considered “unstable” for
o Median time from admission to spontaneous delivery for
interhospital transfer purposes until the newborn and placenta are
all parturients was 3.5 hours
delivered
 Longer duration of SECOND STAGE OF LABOR:
o With a contracted pelvis
Electronic Fetal Heart Rate Monitoring
o With a large fetus, or with impaired expulsive efforts
 Electronic fetal hear rate monitoring is routinely used for high-risk
from conduction analgesia or sedation
pregnancies commencing at admission
 Some investigators recommend monitoring women with low-risk
SUMMARY OF NORMAL LABOR
pregnancies upon admission as a test of fetal well-being- the so-
 Active labor can be reliably diagnosed when cervical dilatation is 
called fetal admission test
3 cm or more in the presence of uterine contractions
 Once this cervical dilatation threshold is reached, normal
Initial Evaluation
progression to delivery can be expected, depending on parity, in the
 Maternal vital signs
ensuing 4 to 6 hours
 FHR monitoring – Doppler, sonography or fetoscope
 If left unaided, will deliver within approximately 10 hours
 Promptly reviewed – identify early complications
 Insufficient uterine activity is a common and correctable cause of
abnormal labor progress  oxytocin administration  Cervical examination is performed – there has been bleeding in
excess of bloody show
 Therefore, when time breaches in normal labor boundaries are the
only pregnancy complications, interventions other than cesarean
Ruptured Membranes
delivery must be considered before resorting to this method of
delivery for failure to progress  Instruct the patient to aware of fluid leakage from the vagina and
report promptly
 Reasons:
MANAGEMENT OF NORMAL LABOR
o The presenting part is not fixed in the pelvis, the
 Birthing should be recognizable as normal physiological process that
umbilical cord can prolapse and be compressed
most women experience without complications
o Labor is likely to begin soon if the pregnancy is at or near
 Intrapartum complications, often arising quickly and unexpectedly,
term
should be anticipated
o If the delivery is delayed after membrane rupture,
 Every women and her supported feel comfortable yet ensure safety
intrauterine and neonatal infection is more likely as the
for the mother and newborn if complication suddenly develop
time interval increases
 Sterile speculum examination
o At lithotomy position
o Diagnosed of the amniotic fluid leak – pools in the
posterior fornix or clear fluid from the cervical canal

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Topic: Normal Labor
Lecture by: Dr. Torres

Rupture of Membrane continued….. Laboratory Studies

 pH  A final sample is collected for syphilis and HIV serology
o vagina – 4.5 to 5.5  Women who have had no prenatal care should be considered to be
o amniotic fluid - >7.0 at risk for syphilis, hepatitis B, and HIV

 Nitrazine
o Fairly and reliable method MANAGEMENT OF 1ST STAGE OF LABOR
o Impregnated with the dye  Longest duration
o pH of >6.5 – rupture membrane  Uterine contraction to full cervical dilation
o false positive – coexistent blood, semen, bacterial
vaginosis Intrapartum Fetal Monitoring
o false negative test may result with scant fluid  Low risk pregnancy – Immediately after uterine contraction
 Ferning or Arborization test o Every 30 mins – 1st stage of labor
o Suggests amniotic rather than cervical fluid o Every 15 mins – 2nd stage of labor
o Amniotic fluid – crystallizes to form fernlike pattern due  High risk pregnancy
to its relative concentration of NaCl, CHO and CHON o Every 15 mins – 1st stage of labor
 Detection of Alpha-fetoprotein in the vaginal vault to identify o Every 5 mins – 2nd stage of labor
amniotic fluid  Continuous electronic monitoring
 Transabdominal dye injection o Every 15 mins – 1st stage of labor
o Indigo carmine dye injected transabdominally into the o Every 5 mins – 2nd stage of labor
amniotic sac
Maternal Monitoring
o Least favored due to invasive
 Anisure  Vital Signs (Temp, PR, RR, BP):
o every 4 hours
o Specific for amniotic fluid
o every 1 hour – ruptured membrane – fever
o This binds placental alpha macroglobulin-1 and ROM plus
to detect insulin growth factor binding protein-1 plus  Uterine contraction:
alpha-fetoprotein o With the palm of the hand resting lightly on the uterus,
the time of contraction onset is determined
Cervical Assessment o Its intensity is gauged from the degree of firmness the
 The degree of cervical effacement usually is expressed in terms of uterus achieves
the length of the cervical canal compared with that of an uneffaced o Checking the intensity (mild, moderate, strong), and
cervix duration of contraction
 Cervical dilatation is determined by estimating the average diameter o Measured acme to acme
of the cervical opening by sweeping the examining finger from the  During 1st stage of labor:
margin of the cervical opening on one side to that on the opposite o Subsequent vaginal examination – cervical change and
side presenting part position
 The cervix is said to be dilated fully when the diameter measures 10  FHR:
cm o Checked immediately and during the next uterine
 The position of the cervix is determined by the relationship of the contraction – to detect umbilical cord compression
cervical os to the fetal head and is categorized as posterior, mid-  Pelvic examination:
position, or anterior o 2 to 3 hours interval – to evaluate labor progress
 The level- or station- of the presenting fetal part in the birth canal is Notes:
described in relationship to the ischial spines, which are halfway o 40 to 90 seconds – normal duration of uterine contraction
between the pelvic inlet and the pelvic outlet o >90 seconds – tachysystole or tetanic contraction
o Indicator of chorioamnionitis - fever
 Thus, as the presenting fetal part descends from the inlet toward the
ischial spins, the designation is -5, -4, -3, -2, -1 then 0 station
Oral Intake
 Below the spines, as the presenting fetal part descends, it passes +1,
 During active labor and delivery – NPO
+2, +3, +4 and +5 stations to delivery
o In anticipating of analgesia due to risk of aspiration and
 Station +5 cm corresponds to the fetal head being visible at the
vomiting
introitus
 Gastric emptying time is remarkably prolonged once labor is
 9 – favorable cervix
established and analgesics are administered
 4 or less – unfavorable cervix
 Oral intake of moderate amounts of clear liquid is allowed for
uncomplicated pregnancy
o CS delivery – liquid is withheld 2 hours before and solid
stopped for 6 – 8 hours prior to surgery

IV Fluid
 IV in normal pregnancy is limited at least analgesia is administered
 Advantage during the immediate puerperium to administer oxytocin
prophylactically and at times therapeutically when uterine atony is
present
 Long labors – administration of glucose sodium and water to fasting
pregnant at 60-120ml/hr

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Maternal Position  Prolonged sitting or squatting during the 2nd stage may cause
 Lateral recumbent – most comfortable position neuropathy of the common fibular (common peroneal) nerve
 Supine – avoided to avert aortocaval compression and potential to  As the head descends through the pelvis – the perineum begins to
lower uterine perfusion bulge and the overlaying skin becomes stretched
 Walking – neither enhance nor impair active labor  Crowning:
 Labor in ambulant or upright positions shorted 1st stage of labor by o As the scalp of the fetus is visible to the vulvar opening
about 1 hour and lowered CS delivery and epidural analgesia rates o At this time, the women and her fetus prepared for
delivery
Rupture of Membranes
 If the membranes are intact, temptation is great even during normal
labor to perform amniotomy
 The resumed benefits are more rapid labor, earlier detection of
meconium-stained amniotic fluid and the opportunity to apply an
electrode to the fetus or insert a pressure catheter into the uterine
cavity for monitoring
 Fetal head must well applied to the cervix and not be dislodged from
the pelvis during the procedure to avoid umbilical cord prolapse
 >18 hours – prolonged membrane ruptured
LABOR AND MANAGEMENT PROTOCOLS
 Anti-microbial – for prevention of group B streptococcal infection to
lower rate of chorioamnionitis and endometritis  Amniotomy and oxytocin – used in active labor
 Labor is diagnosed when painful contraction are accompanied by
Urinary Bladder Function complete cervical effacement, bloody “show” or ruptured of
 Distended bladder – hinder descent of the fetal presenting part and membrane – must delivered within 12 hours
lead to subsequent bladder hypotonia and infection  Pelvic examination
 Factors of distended bladder: o Performed each hour for the next 3 hours, thereafter at 2
o Operational vaginal delivery hours interval
o Regional analgesia  When dilation is NOT increase by 1cm/hr – amniotomy is performed
 If membrane rupture before admission – oxytocin is begun for no
MANAGEMENT OF 2ND STAGE OF LABOR progress at the 1 hour mark
 From: full cervical dilatation to delivery of neonate  Partograph
 With descent of the presenting part – urge to defecate o Designed by WHO
 Duration of 2nd stage of labor: o Labor is divided into a latent phase, which should last no
o Nullipara – 50 mins longer than 8 hours and an active phase
o Multipara – 20 mins o The active phase starts at 3cm dilation and progress
 Uterine contraction with expulsive forces: should no slower 1cm/hr
o May last 1 min and recur at an interval no longer of 90 secs o 4 hours wait is recommended before intervention when
o reflective vs coached the active phase slow
o open glottis pushing superior to closed glottis Valsalva o Labor is graphed and analysis includes use of alert and
type action lines
 During 2nd stage of labor:
o bearing down is reflective and spontaneous
o couching – for women who did not employ expulsive
forces
 Her legs should be half-flexes so that she can push with them against
the mattress
 When the uterine contraction begins:
o Instruct to exert downward pressure as through were
straining at stool
 Not encourage to push beyond the completion of each contraction –
allow fetus to rest and recover
o During this period, FHR auscultated during the contraction
is likely to be slow but should recover to normal range
before the next expulsive effort
 Recumbent position – women with regional analgesia and higher
rate of vaginal delivery
 Upright position including sitting, kneeling, squatting or resting with
the back at a 300 elevation (semi fowlers)  Montevideo units
o Shorter interval to delivery o Goal: 200-250 Mvu
o Fewer episiotomies and operative vaginal deliveries o For 2-4 hrs before dystocia can be diagnosed
o >500 ml blood lost and increase laceration
o Less intense aortocaval compression References:
o Improved fetal alignment  Williams Obstetrics (25th ed.)
o Larger pelvic outlet diameter  Lecture Notes
 Increase pelvic diameter in squatting compared with supine position

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Strength in knowledge