INTRODUCTION

Childbirth =the period from the onset of regular uterine

contractions until expulsion of the placenta NORMAL = labor
In Parkland hospital : 50% spontaneous labor and delivery
MECHANISMS OF LABOR
1. FETAL LIE : The relation of the fetal long axis to that
of the mother.
longitudinal (99 % labor at term) , transverse
(multiparity, placenta previa, hydramnios, & uterine
anomalies) , oblique lie (45-degree unstable
longitudinal or transverse during labor).

2. FETAL PRESENTATION : portion of the fetal body

that is either foremost within the birth canal or in closest
proximity to it.
2. FETAL PRESENTATION
a. Cephalic Presentation
head is flexed sharply so that the chin is in contact with the
thorax occipital fontanel : vertex /occiput presentation.
fetal neck may be sharply extended face presentation
between these extremes :
- anterior (large) fontanel/ bregma sinciput presentation
- partially extended a brow presentation (usually transient)
term fetus : vertex, uterus is piriform/pear shaped (podalic pole >
cephalic pole) until 32 w, ratio of amnionic fluid volume decreases
relative to the increasing fetal mass

Longitudinal lie. Cephalic

presentation. Differences in
attitude of the fetal body in
(A) vertex, (B) sinciput, (C)
brow, and (D) face
presentations. Note changes
in fetal attitude in relation to
fetal vertex as the fetal head
becomes less flexed.
2. FETAL PRESENTATION

b. Breech Presentation
Breech presentation : 25 % (28 w), 17 % (30 w), 11 % (32 w), 3 %
(term).
Hydrocephalic fetuses > breech
frank, complete, and footling presentations
Septum in uterine cavity , placenta pre via
3. FETAL ATTITUDE OR POSTURE flexi

4. FETAL POSITION : fetal occiput, chin (mentum), sacrum

vertex, face, breech presentations
left & right occipital, left & right mental, left & right sacral (LO
(2/3) & RO (1/3), LM & RM, LS & RS)
A.LOA , B. LOP, C. ROP, D. ROT
Longitudinal lie. Vertex presentation. Right
occiput anterior (ROA).
Longitudinal lie. Face presentation. Left and right mentum
anterior and right mentum posterior positions.
 Approximately two thirds of all vertex
presentations are in the left occiput position,
and one third in the right.

Transverse lie.
Right
acromiodorsopos
terior (RADP).
The shoulder of
the fetus is to the
Longitudinal lie. Breech mother's right,
presentation. Left sacrum and the back is
posterior (LSP) posterior
 Diagnosis of Fetal Presentation
and Position
Abdominal PalpationLeopold Maneuvers
Vaginal Examination
Sonography and Radiography
 1. Abdominal
palpation -Manuver
Leopold
FIRST MANEUVER fetal pole at
fundus: breech (large, nodular
mass) / head (hard, round, mobile,
ballottable).
SECOND MANEUVER a hard,
resistant structure (back) ,numerous
small, irregular, mobile parts (
extremities).
THIRD MANEUVER thumb and
fingers grasped just above the
symphysis pubis. not engaged
movable
FOURTH MANEUVER faces the
mother's feet , deep pressure in the
direction of the axis of the pelvic
inlet
Experienced clinicians Leopold
maneuvers :high sensitivity (88%),
Leopold maneuvers (A-D) performed in fetus specificity (94 %), ppv (74 %), npv (97
with a longitudinal lie in the left occiput %).
anterior position (LOA).
2.VAGINAL
EXAMINATION
1. 2 fingers vagina
Differ vertex, face, breech
2. If vertex fingers
posteriorly swept
forward toward maternal
symphysis cross
sagittal suture and its
course is delineated
3. positions of the two
fontanels fingers to
most anterior extension
sagittal suture fontanel
identified. sweeping
motion other fontanel
4. The station
Locating the sagittal suture by vaginal
examination
Mekanisme persalinan dengan presentasi
oksiput anterior
1. Engagement : mekanisme ketika D biparietal (D
terbesar pres. oksiput) melewati apertura pelvis
superior
- >> Multipara awitan persalinan
mengambang
- Engage bbrp minggu terakhir / tidak engage
hingga mulai persalinan
- Kepala tidak engage dgn SS anteroposterior,
namun tranversal/ oblik
2. Desensus
- Nulipara : engagement sblm awitan persalian,
desensus tidak terjadi hingga awitan kala 2
- Multipara : desensus dimulai dg engagement
- 4 kekuatan : tekanan cairan amnion, tekanan
fundus saat kontraksi, tekanan ke bawah otot-
otot abdomen maternal, ekstensi & pelurusan
tubuh janin
3. Fleksi
- Desensus : hambatan serviks, dinding pelvis,
dasar pelvis fleksi kepala dagu semakin
dekat ke dada
Asinklitismus
Kepala berakomodasi dengan aksis tranversal apertura pelvis superior
sutura sagitalis (paralel aksis) tidak tepat garis tengah antara simfisis &
promontorium os. sakri.
Asinklitismus : defleksi lateral ke arah posisi anterior/ posterior pelvis
SS >> promontorium os sacri, teraba >> os. Parietalis anterior asinklitismus
anterior
SS >> simfisis, teraba >> os parietalis posterior asinklitismus posterior
(ekstrem : telinga posterior teraba)
Asinklitismus derajat sedang normal. Berat CPD (pd pelvis normal)
Perubahan asinklitismus posterior anterior : bantu desensus
Fleksi

Gerakan pengungkit menimbulkan

fleksi kepala. Perubahan D
oksipitofrontal D
suboksipitobregmatika mengurangi
D AP (12 9,5 cm)
Fleksi
4 derajat fleksi kepala.
Garis tegas: D
mentooksipital, garis
putus : pusat fontikulus
anterior dg fontikulus
posterior.
A.Fleksi ringan
B.Fleksi sedang
C.Fleksi tingkat lanjut
D.Fleksi lengkap dagu
menempel toraks. D
suboksipitobregmatiak
a, D AP terpendek pd
kepala janin melewati
apertura pelvis
superior
3. Rotasi internal: perputaran kepala oksiput bertahap
bergerak ke simfisis pubis (anterior), / lebih jarang ke
lengkung sakrum (posterior).
- 2/3 selesai saat kepala mencapai dasar pelvis.
segera setelah mencapai dasar pelvis. 5%--. Tdk terjadi
rotasi(multi 1-2 kontraksi, nuli3-5 kontraksi)

4. Ekstensi : kepala (fleksi maksimal) mencapai vulva

ekstensi (kalau tetap fleksi merusak posterior perineum &
terathan perineum). Kekuatan: uterus (bekerja > ke
posterior) & daya resistensi dasar pelvis& simfisis
(bekerja > arah anterior) ekstensi kepala lahir kepala
5. Rotasi eksternal : setelah kepala lahir
restitusi (awal kiri, oksiput berotasi ke tuber
iskiadikum kiri. Awal kanan , oksiput ke
kanan) rotasi ke tranversal D
bisakromial berkolerasi D anteroposterior
apertura pelvis inferior.
- Bahu anterior di bawah simfisis

6. Ekspulsi : bahu anterior terlihat bawah

simfisis, perineum segera terdistensi bahu
posterior lainnya lahir cepat.
Persalinan kala 4
Laserasi jalan lahir:
1. Derajat 1 : fourchette, kulit perineal, mukosa vagina, tdk kena fasia/otot
di bawahnya
2. Derajat 2 : fasia & otot korpus perineum, tdk spingter ani
3. Derajat 3 : spinkter ani
4. Derajat 4 : ke mukosa rektum, terlihat lumen rektum