Mechanism of Normal Labor

Mechanism of Normal Labor

There are five classical steps in the normal mechanism of labor. They are:
Descent
Flexion
Internal Rotation
Extension
External Rotation
Usually, labor progresses in this fashion, if the fetus is of average size, with a
normally positioned head, in a normal labor pattern in a woman whose pelvis is of
average size and gynecoid in shape.
There is overlap of these mechanisms. The fetal head, for example, may continue to
flex or increase its flexion while it is also internally rotating and descending.



Descent: As the fetal head
engages and descends, it
assumes an occiput transverse
position because that is the widest
pelvic diameter available for the
widest part of the fetal head.

Flexion: While descending through
the pelvis, the fetal head flexes so
that the fetal chin is touching the
fetal chest. This functionally
creates a smaller structure to pass
through the maternal pelvis. When
flexion occurs, the occipital
(posterior) fontanel slides into the
center of the birth canal and the
anterior fontanel becomes more
remote and difficult to feel. The
fetal position remains occiput
transverse.

Internal Rotation: With further
descent, the occiput rotates
anteriorly and the fetal head
assumes an oblique orientation. In
some cases, the head may rotate
completely to the occiput anterior
position.

Extension: The curve of the hollow
of the sacrum favors extension of
the fetal head as further descent
occurs. This means that the fetal
chin is no longer touching the fetal
chest.

External Rotation: The shoulders
rotate into an oblique or frankly
anterior-posterior orientation with
further descent. This encourages
the fetal head to return to its
transverse position. This is also
known as restitution.




Terms Definitions
ENGAGEMENT Engagement takes place when the biparietal
diameter of the fetal head has passed through the
pelvic inlet. The fetus enters inlet in a transverse
or oblique position as the widest point of inlet is
the transverse diameter
DESCENT Descent occurs throughout labor as a result of
uterine contractions and maternal muscle effort
(contraction of abdominal muscles).
FLEXION Flexion occurs when the fetal head meets
resistance, such as the cervix, side walls of the
pelvis, and finally the pelvic floor.
INTERNAL ROTATION Internal rotation brings the smallest diameter of
the fetal head (the suboccipitobregmatic diameter)
into alignment with the largest diameter of the
midplane, the AP diameter. The fetal head rotates
45 degrees to an OA position.

from LOA to OA 45 degrees
LOT to OA 90 degrees

accomplished when head reaches the
spines...Levator ani muscle forms a "V" shaped
sling that tends to

complete 2/3's of the time by the time the head
reaches the pelvic floor
EXTENSION Birth of the head is by extension (for OA
deliveries). The occiput, sagittal suture, anterior
fontanel, brow, orbits, nose, mouth, and chin
sequentially sweep over the perineum.

occurs when flexed head reaches vulva; occiput in
direct contact with inferior margin of symphysis of
pubis
RESTITUTION Fetal head rotates 45 degrees from OA to
LOA/ROA, to realign the head with the shoulders
(which are entering the midplane).

this is a return to the oblique position
EXTERNAL ROTATION Shoulder rotate 45 degrees bringing the
bisacromial diameter into alignment with the AP
diameter of the pelvic outlet. This causes the fetal
head (occiput) to rotate 45 degrees into the
LOT/ROT position.

one shoulder rotates under the symphysis pubis
EXPULSION Birth of the shoulders and body is by lateral
flexion via the curve of Carus.
anterior shoulder first
posterior shoulder second
The posterior parietal bone should be
leading during birth.
True or False
TRUE

if the anterior parietal bone is leading this will
create and arrest of descent.
Fetal Lie is: the relationship of the long axis of the fetus to
that of the mother

longitudinal 99% of all labors at term
Longitudinal Lie
what 2 positions will the fetus be in?
cephalic presentation
breech presentation
Transverse Lie
What position will the fetus be in?
shoulder presentation
Presenting part is: the most dependent part of the fetus in relation to
the cervix
Cephalic presentation= vertex
brow
face
Breech presentation= feet
buttocks
knees
Shoulder presentation= shoulder
arm
trunk
Cephalic presentation can occur in 4
different presentations.
1. head is flexed sharply- vtx/ occiput
presentation; suboccipitobregmatic = 9.5 cm

2. Head is extended sharply- face presentation;
submentobrematic = 9.5 cm
NOT ABLE TO BIRTH FACE POSTERIOR

3. head partially flexed - bregma presenting
/sinciput presentation/military; occipital frontal =
11.5 cm

4. head partially extended - brow presentation;
vertigo-mental = 12.5-13.5 cm
Breech presentation can occur in 3
different presentations.
1. frank breech

2. complete breech

3. footling breech
Shoulder presentation shoulder
Attitude- relationship of fetal parts in relation to each other
flexion or extension
What is the best attitude for the fetus? fetus folded on itself to accommodate the shape of
the uterus bi-parietal diameter, which is best at
9.5 cm

flexed head, thighs, knees & feet
arms crossed over chew
Is a face presentation a good attitude to
birth a baby in?
NO
the fetal vertebral column is extended and concave
in contour
Denominator is: the relation of an arbitrary chosen point of the the
fetal presenting part to the R or L side of the
maternal canal
VERTEX PRESENTATION OCCIPUT (below posterior fontanelle and
lamboidal sutures)
Face Presentation mentum (chin)
Breech Presentation sacrum
Position the relationship of denominator to front, back, or
sides of maternal pelvisOA
LOA
LOT
LOP
OP
ROP
ROT
ROA
What % of babies present in vertex? 96%
What percentage of babies present LO? 2/3
or
66%
WHat percentage of babies present RO? 1/3
or
33%
What percentage of babies present
breech?
3.5%
What percentage of babies present face
first?
0.3%
What percentage of babies present
shoulder first?
0.4%
Station is: the relationship between the presenting part in
imaginary lines
defines the depth in centimeters into and through
the pelvis
The Curve of Carus is also called the: Birth Canal Axis
The Curve of Carus is: the course taken by the presenting part

down and backward from the inlet to the ischial
spines and tip of sacrum

forward and upward after the spines and tip of
sacrum
How does the baby engage? sagital suture transverse or oblique
What does floating mean? fetus out of pelvis
What does the term dipping mean? fetus has passed through inlet, but has not
engaged
Engaged means: the widest diameter of the presenting part has
passed through the inlet

Most women the presenting part is close to or at
the ischial spines
What is the cephalic BPD? 9.5cm
When does engagement occur in
primps?
2-3 weeks before birth
When does engagement occur in
multips?
in labor
What percentage of infants engage in
LOT?
ROT?
OP?
ROA/LOA?
LOT = 40%
ROT = 20%
OP = 20%
ROA/LOA = 20%
Synclitism is: when the head enters the pelvis in transverse
diameter the BPD is 9.5cm is parallel to the plane
of the inlet and the sagital sutures is midway
between the S pubis and the S promontory

This is normal
Asynclitism is: sagittal suture deflect anterior towards the
symphysis pubis or posterior towards the sacrum
Posterior or Litzmann Obliquity 8.75 cm normal

posterior parietal bone enters the pelvis first so
sagital suture is anterior and close to symphysis

*****THIS IS THE MOST NORMAL********

head becomes synclitic as it moves down in pelvis
Anterior Asynclitism or Nagele Obliquity lax abdominal muscles, fetus falls forward and
sagital suture is close to promontory: not Normal

good pic in notes
What two diameters determine the
degree of flexion?
1. occipitomental diameter

2. center of anterior fontanel with posterior
fontanel
Flexions is complete when the chin is
on the chest and the
suboccipitobregmatic diameter or the
shortest AP diameter of the fetal head is
passing through the pelvic inlet.

True or False
True
What are the 4 degrees of flexion? flexion poor
flexion moderate
flexion advanced
flexion complete
Internal Degrees of Rotation

When does crowning occur? during extention
What does crowning look like? larges diameter of the fetal head is encircled by
the vulva ring
When the head is born what is
happening to the shoulders?
entering pelvic inlet
What are the 8 Cardinal Movements of
Labor
ENGAGEMENT
DESCENT
FLEXION
INTERNAL ROTATION
EXTENSION
RESTITUTION
EXTERNAL ROTATION
EXPULSION
What are the factors that effect the
Mechanisms of Labor and Birth?
(P's)
PASSENGER (fetus)
PASSAGEWAY (pelvis, pelvic floor, abdominal
support)
POWERS (UCs and maternal muscle effort)
POSITIONING (maternal)
PAIN
PSYCHE
PARTNER
PICTURE OF CARDINAL MOVEMENTS 1-4

PICTURE OF CARDINAL MOVEMENTS 5-8

Mechanism of labor is identical to OT &
anterior varieties.
True or False
True
fetal is OT what is the change in
rotation?
the occiput rotates to the symphysis pubis through
135 degrees instead of 90 or 45 degrees

From LOP or ROP; long arc to OA



Mechanism of Labor: 7 Cardinal Movements
Posted: June 17, 2011 in Health
0
1. Engagement fetal presenting part as its widest diameter reaches the level of the
ischial spine of the pelvis
2. Descent movement of the bi-parietal diameter of the fetal head downwards until it
reaches the pelvic inlet.
3. Flexion Fetal head reaches the pelvic floor; head bends forward onto chest,
presenting the smallest anteroposterior diameter.
4. Internal Rotation fetus enters pelvic inlet to the maternal pelvis, allows longest
fetal head to match the longest maternal pelvic diameter.
5. Extension Internal rotation is complete, fetal head passes beneath the synthesis
pubis while in flexion.
6. External Rotation allow the shoulders to rotate internally to fit the pelvis.
7. Expulsion occurs first as the anterior, then the posterior shoulder passes under the
symphysis pubis.