MECHANISMS (CARDINAL MOVEMENTS) OF LABOR

Effective passage of a fetus through the birth canal involves not only position and
presentation but also a number of different position changes in order to keep the smallest
diameter of the fetal head (in cephalic presentations) always presenting to the smallest diameter.
These position changes are termed the cardinal movements of labor: engagement, descent,
flexion, internal rotation, extension, external rotation, and expulsion.

1. Engagement
Refers to the settling of the presenting part of a fetus far enough into the pelvis that it rests at the
level of the ischial spines, the midpoint of the pelvis.

2. Descent
The downward movement of the biparietal diameter of the fetal head within the pelvic inlet. Full
descent occurs when the fetal head protrudes beyond the dilated cervix and touches the posterior
vaginal floor.

3. Flexion
As descent is completed and the fetal head touches the pelvic floor, the head bends forward onto
the chest, causing the smallest anteroposterior diameter (the suboccipitobregmatic diameter) to
present to the birth canal.

4. Internal Rotation
During descent, the biparietal diameter of the fetal skull was aligned to fit through the
anteroposterior diameter of the mother’s pelvis. As the head flexes at the end of descent, the
occiput rotates so the head is brought into the best relationship to the outlet of the pelvis, or the
anteroposterior diameter is now in the anteroposterior plane of the pelvis. This movement brings
the shoulders, coming next, into the optimal position to enter the inlet, or puts the widest
diameter of the shoulders (a transverse one) in line with the wide transverse diameter of the inlet.

5. Extension
As the occiput of the fetal head is born, the back of the neck stops beneath the pubic arch and
acts as a pivot for the rest of the head. The head extends, and the foremost parts of the head, the
face and chin, are born.

6. External Rotation
In external rotation, almost immediately after the head of the infant is born, the head rotates a
final time (from the anteroposterior position it assumed to enter the outlet) back to the diagonal
or transverse position of the early part of labor. This brings the after coming shoulders into an
anteroposterior, which is best for entering the outlet. The anterior shoulder is born first, assisted
perhaps by downward flexion of the infant’s head.

7. Expulsion
Once the shoulders are born, the rest of the baby is born easily and smoothly because of its
smaller size. This movement, called expulsion, is the end of the pelvic division of labor.

FETAL PRESENTATION AND POSITION

Other factors that play a part in whether a fetus is properly aligned in the pelvis
and is in the best position to be born are fetal attitude, fetal lie, fetal
presentation, and fetal position.

1. Attitude. Describe the degree of flexion a fetus assumes during labor or the
relation of the fetal parts to each other.

2. Lie. Relationship between the long (cephalocaudal) axis of the fetal body
and the long (cephalocaudal) axis of a woman’s body.

3. Presentation. Denotes the body part that will first contact the cervix or be
born first and is determined by the combination of fetal lie and the degree of
fetal flexion.

 Cephalic Presentation is the most frequent type of presentation, occurring as

often as 96% of the time. With this type of presentation, the fetal head is the
body part that first contacts the cervix.

 Breech Presentation means either the buttocks or the feet are the first body
parts that will contact the cervix. Breech presentations occur in approximately
4% of births and we are affected by fetal attitude the same as vertex
 Shoulder Presentation. In a transverse, a fetus lies horizontally in the pelvis
so the longest fetal axis is perpendicular to that of the mother. The presenting
part is usually one of the shoulders, an iliac crest, a hand, or an elbow.

4. Position. Relationship of the presenting part to a specific quadrant and side

of a woman’s pelvis.

5. Engagement. Refers to the settling of the presenting part of a fetus far

enough into the pelvis that it rests at the level of the ischial spines, the
midpoint of the pelvis.

6. Station. Refers to the relationship of the presenting part of the fetus to the
level of the ischial spines.

 When the presenting fetal part is at the level of the ischial spines, it is at a 0
station
 If the presenting part is above the spines, the distance is measured and
described as minus stations, which range from -1 to -4 cm.

SIGNS OF LABOR

 Effacement: Thinning of the cervix

Before labor, the lower part of your uterus called the cervix is typically 3.5 cm to 4 cm long. As
labor begins, your cervix softens, shortens and thins (effacement). You might feel uncomfortable,
but irregular, not very painful contractions or nothing at all.

 Dilation: Opening of the cervix

Another sign of labor is your cervix beginning to open (dilate). Your health care provider will
measure the dilation in centimeters from zero (no dilation) to 10 (fully dilated).
At first, these cervical changes can be very slow. Once you're in active labor, expect to dilate
more quickly.

 Increase in vaginal discharge

During pregnancy, a thick plug of mucus blocks the cervical opening to prevent bacteria from
entering the uterus. During the late third trimester, this plug might be pushed into your vagina.
You might notice an increase in vaginal discharge that's clear, pink or slightly bloody. This
might happen several days before labor begins or at the start of labor.
If vaginal bleeding is as heavy as a normal menstrual period, however, contact your health care
provider immediately. Heavy vaginal bleeding could be a sign of a problem.

 Nesting: Spurt of energy

You might wake up one morning feeling energetic, eager to fill the freezer with prepared meals,
set up the crib and arrange your baby's outfits according to color. This urge is commonly known
as the nesting instinct.
Nesting can begin at any time during pregnancy but for some women it's a sign that labor is
approaching.

 Feeling the baby has dropped lower

Lightening is the term used to describe when the baby's head settles deep into your pelvis. This
might cause a change in the shape of your abdomen. This change can happen anywhere from a
few weeks to a few hours before labor begins.

 Rupture of membranes: Your water breaks

The amniotic sac is a fluid-filled membrane that cushions your baby in the uterus. At the
beginning of or during labor, your membranes will rupture — also known as your water
breaking.
When your water breaks you might experience an irregular or continuous trickle of small
amounts of watery fluid from your vagina or a more obvious gush of fluid. If your water breaks
— or if you're uncertain whether the fluid is amniotic fluid, urine or something else — consult
your health care provider or head to your delivery facility right away. You and your baby will be
evaluated to determine the next steps.
Once your amniotic sac is no longer intact, timing becomes important. The longer it takes for
labor to start after your water breaks — if it hasn't started already — the greater you or your
baby's risk of developing an infection. Your health care provider might stimulate uterine
contractions before labor begins on its own (labor induction).