The document discusses various topics related to fetal lie, presentation, position, and labor including: - The fetal lie can be longitudinal, transverse, or oblique relative to the mother's long axis. - Cephalic presentation is most common, with other possibilities including breech, face, brow, and transverse lie. - Fetal position describes the relationship of parts of the presenting fetal head to the mother's right or left side. - Leopold's maneuvers are used to determine fetal position and presentation during vaginal exams. - The cardinal movements of labor are engagement, descent, flexion, internal rotation, extension, and external rotation.

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2. FETAL LIE The lie is the relationship of the long axis of the fetus to that of the mother Longitudinal – 99% Transverse - multiparity, placenta previa, hydramnios, uterine anomalies Oblique - unstable

4. FETAL PRESENTATION The presenting part is the portion of the body that is foremost within the birth canal or in close proximity to it CEPHALIC PRESENTATION Vertex or occiput presentation– occipital fontanel Face presentation Sinciput presentation – anterior fontanel Brow presentation

5. Why does the term fetus usually presents with the vertex? The uterus is piriform shaped. Breech and its flexed extremities is bulkier and more mobile than the cephalic pole

6. FETAL PRESENTATION BREECH PRESENTATION Incidence: 3-4% at term 14% between 29 and 32 weeks gestation Types: Frank breech Complete breech Incomplete breech

7. FETAL ATTITUDE or POSTURE or HABITUS The fetus becomes folded or bent upon itself in such a manner that the back becomes markedly convex , the head is sharply flexed so that the chin is in contact with chest, the thighs are flexed over the abdomen, the legs are bent at the knees, and the arches of the feet rest upon the anterior surfaces of the legs. The arms are usually crossed over the thorax.

8. FETAL POSITION Relationship of an arbitrarily chosen portion of the feral presenting part to the right or left side of the maternal birth canal Fetal occiput, mentum, sacrum are the determining points OA ROA LOA ROT LOT ROP LOP OP

9. LEOPOLD’S MANEUVER FIRST MANEUVER what occupies the uterine fundus SECOND MANEUVER palms placed on either side of the maternal abdomen THIRD MANEUVER if presenting part not engaged FOURTH MANEUVER if presenting part deeply engaged

10. LEOPOLD’S MANEUVER CEPHALIC PRESENTATION

11. CARDINAL MOVEMENTS OF LABOR ENGAGEMENT DESCENT FLEXION INTERNAL ROTATION EXTENSION EXTERNAL ROTATION EXPULSION The fetal ovoid is transformed into a cylinder, with the smallest possible cross section passing through the birth canal.

13. ENGAGEMENT The mechanism by which the biparietal diameter, the greatest transverse diameter of the fetal head in occiput presentations, passes through the pelvic inlet Fetal head usually enters the pelvic inlet either transversely or obliquely

14. ASYNCLITISM The sagittal suture of the fetal head may not lie exactly midway between the symphysis and the sacral promontory. Lateral deflection of the fetal head to a more anterior or posterior position in the pelvis ANTERIOR ASYNCLITISM – when the sagittal suture approaches the sacral promontory so that more of the anterior parietal bone presents itself to the examining finger POSTERIOR ASYNCLITISM – the sagittal suture lies close to the symphysis and more of the posterior parietal bone will present

15. ASYNCLITISM

16. DESCENT The first requisite for birth of the newborn. Usually begins with engagement Brought about by the ff. forces: 1. pressure of the amnionic fluid 2. direct pressure of the fundus upon the breech with contractions 3. bearing down efforts of maternal abdominal muscles 4. extension and straightening of the fetal body

17. OCCIPUT POSTERIOR POSITION With effective contractions, adequate flexion of the head, and a fetus of average size, the great majority of posteriorly positioned occiput rotates promptly as soon as they reach the pelvic floor Factors that predispose to incomplete rotation: poor contractions faulty flexion of the fetal head epidural analgesia PERSISTENT OCCIPUT POSTERIOR - if no rotation towards the symphysis takes place and the occiput remains in direct occiput posterior position

18. CHANGES IN THE SHAPE OF THE FETAL HEAD CAPUT SUCCEDANEUM swelling at the portion of the fetal scalp immediately over the cervical os seen in prolonged labors before complete cervical dilatation MOLDING change in fetal head shape from external compressive forces results in shortened suboccipitobregmatic diameter and a lengthened mentovertical diameter

19. When does labor start? Presence of painful uterine contractions accompanied by any of the following: 1. ruptured membranes 2. bloody “show” 3. complete cervical effacement

20. CONTRACTIONS OF CONTRACTIONS OF TRUE LABOR FALSE LABOR Regular intervals Intervals gradually shortens Intensity gradually increases Discomfort is in the back and abdomen Cervix dilates Discomfort is not stopped by sedation Irregular intervals Intervals remain long Intensity remains unchanged Discomfort in the lower abdomen Cervix does not dilate Discomfort is usually relieved by sedation

21. FUNCTIONAL DIVISIONS OF LABOR

22. FRIEDMAN LABOR CURVE

23. LATENT PHASE The onset of latent labor is the point when the mother perceives uterine contractions and ends at between 3 and 5 cm of dilatation PROLONGED LATENT PHASE – greater than 20 hours in nullipara and 14 hours in multipara Affected by excessive sedation or epidural analgesia, unfavorable cervical dilatation and false labor

24. ACTIVE PHASE Cervical dilatation of 3 to 5 cm or more + uterine contractions represent he threshold of active labor Mean duration in nulliparas was 4.9 hours Descent begins at about 7-8 cm in nulliparas Protracted active phase – slow rate of cervical dilatation or descent , which for nulliparas < 1.2 cm dilatation/hour or < 1 cm descent/hour and for multiparas < 1.5 cm/hour or < 2 cm descent/hour Arrest of dilatation – 2 hours with no cervical change Arrest of descent – 1 hour without fetal descent

25. ACTIVE PHASE Factors contributing to protraction and arrest disorders: excessive sedation, vaginal analgesia, fetal malposition Treatment for protraction disorders: expectant management Treatment for arrest disorders: oxytocin in absence of CPD Epidural anesthesia lengthened the active phase by 1 hour

26. SECOND STAGE OF LABOR Begins when cervical dilatation is complete and ends with fetal delivery Mean duration : 50 minutes for nulliparas 20 minutes for multiparas

27. DURATION OF LABOR Mean length of 1 st and 2 nd stage of labor 9 hours in nulliparas 6 hours in multiparas

28. MANAGEMENT OF NORMAL LABOR AND DELIVERY VAGINAL EXAMINATION Detection of ruptured membranes pH of vagina = 4.5-5.5 pH of amnionic fluid = 7.0-7.5 Nitrazine paper Cervical effacement Cervical dilatation Position of the cervix Station

29. SPONTANEOUS DELIVERY The encirclement of the largest head diameter by the vulvar ring is known as crowning. RITGEN MANEUVER * gloved hand is used to exert pressure on the chin of the fetus through the perineum just in front of the coccyx * allows controlled delivery of the fetal head * favors extension of the fetal head

30. RITGEN MANEUVER

31. SIGNS OF PLACENTAL SEPARATION The uterus becomes globular and firmer There is sudden gush of blood The uterus rises in the abdomen The umbilical cord protrudes These signs appear usually within 5 minutes after delivery of the newborn

32. DELIVERY OF THE PLACENTA Traction on the umbilical cord must not be used to pull the placenta out of the uterus Inversion of the uterus is a complication

33. “FOURTH STAGE” OF LABOR The hour immediately following delivery Postpartum hemorrhage as a result of atony may occur

34. OXYTOCIN Half life of I.V. oxytocin is 3 minutes I.V. bolus of 10 units can cause transient but marked fall in arterial BP followed by an abrupt increase in cardiac output Antidiuretic action can cause water intoxication

35. ERGONOVINE AND METHYLERGONOVINE May result in a tetanic contraction I.V. route initiates transient but severe hypertension

36. PROSTAGLANDINS Misoprostol Prostglandin F2a

37. LACERATIONS OF THE BIRTH CANAL FIRST DEGREE LACERATIONS involve the fourchette, perineal skin, and vaginal mucosa SECOND DEGREE LACERATIONS involve the skin, mucuc membrane, fascia and muscles of the perineal body THIRD DEGREE LACERATIONS involve the skin, mucus membrane, perineal body and anal sphincter FOURTH DEGREE LACERATIONS extends to the rectal mucosa to expose the lumen of the rectum, tears of the region of the urethra

38. EPISIOTOMY AND REPAIR Purposes of episiotomy: Substitution of a straight surgical incision, which was easier to repair, for the ragged laceration Prevention of pelvic relaxation Increased incidence of anal sphincter and rectal tear Increased fecal and flatus incontinence Restricted use of episiotomy – lower rates of posterior perineal trauma, surgical repair, and healing complications

39. TYPES OF EPISIOTOMY: MIDLINE MEDIOLATERAL Surgical repair Easy More difficult Faulty healing Rare More common Postoperative pain Minimal Common Anatomical results Excellent Occ. faulty Blood loss Less More Dyspareunia Rare Occasional Extensions Common Uncommon

41. DYSTOCIA ABNORMAL LABOR Abnormalities of the expulsive forces, either uterine forces insufficiently strong or inappropriately coordinated to efface or dilate the cervix – uterine dysfunction – or inadequate voluntary muscle effort during the 2 nd stage of labor Abnormalities of presentation, position or development of the fetus Abnormalities of the maternal bony pelvis – that is, pelvic contraction Abnormalities of soft tissues of the reproductive tract that form an obstacle to fetal descent

42. CATEGORIES OF DYSTOCIA Abnormalities of the powers – uterine contractility and maternal expulsive effort Abnormalities involving the passenger – the fetus Abnormalities of the passage – the pelvis

43. COMMON CLINICAL FINDINGS IN WOMEN WITH INEFFECTIVE LABOR Inadequate cervical dilatation or fetal descent Protracted labor – slow progress Arrested labor – no progress Inadequate expulsive effort – ineffective pushing Fetopelvic disproportion Excessive fetal size Inadequate pelvic capacity Malpresentation or position of fetus Ruptured membranes without labor

44. MECHANISM OF DYSTOCIA Uterine contractions, cervical resistance, and the forward pressure exerted by the leading fetal head are the factors influencing the progress of the 1 st stage of labor Uterine muscle malfunction can result from uterine overdistension or obstructed labor

45. TYPES OF UTERINE DYSFUNCTION HYPOTONIC UTERINE DYSFUNCTION There is no basal hypertonus and uterine contractions have a normal gradient, but the slight rise in pressure during a contraction is insufficient to dilate the cervix HYPERTONIC UTERINE DYSFUNCTION or INCOORDINATE UTERINE DYSFUNCTION Either basal tone is elevated or the pressure gradient is distorted

46. ACTIVE PHASE DISORDERS Inadequate uterine contractions defined as less than 180 Montevideo units were diagnosed in 80% of women with active phase disorders Protraction is defined as less than 1 cm /hr cervical dilatation for a minimum of 4 hours Criteria for dx of arrest during the 1 st stage of labor: 1. The latent phase has been completed, with the cervix dilated 4 cm or more 2. A uterine contraction pattern of 200 MVU or more in a 10 minute period has been present for 2 hours without cervical change

49. SECOND STAGE DISORDERS The 2 nd stage in nulliparas was limited to 2 hours and extended to 3 hours when regional analgesia was used For multiparas, 1 hour was the limit, extended to 2 hours with regional analgesia

50. CAUSES OF UTERINE DYSFUNCTION Epidural analgesia Chorioamnionitis Maternal position during labor Ambulation in labor is not harmful and mobility may increase in greater comfort Birthing position in the 2 nd stage of labor

51. RUPTURED MEMBRANES WITHOUT LABOR Stimulation of contractions when labor did not begin after 6 to 12 hours Labor is induced when ruptured membranes is diagnosed at term

52. PRECIPITOUS LABOR AND DELIVERY Precipitous labor terminates in expulsion of the fetus in less than 3 hours Short labors, defined as a rate of cervical dilatation of 5 cm/hr or faster for nulliparas and 10 cm/hr for multiparas , were associated with abruption, meconium, postpartum hemorrhage, cocainre abuse and low Apgar scores May lead to uterine rupture, or extensive lacerations of the cervix, vagina , vulva, perineum The uterus that contracts vigorously before delivery is likely to be hypotonic after delivery Increased perinatal mortality and morbiditry

53. CLINICALLY ADEQUATE PELVIS The diagonal conjugate is normal The pelvic sidewalls are nearly parallel. The ischial spines are not prominent. The sacrum is not flat. The subpubic angle is not narrow. The occiput is known to be the presenting part. The fetal head is engaged or descends through the pelvic inlet with pressure.

54. FETOPELVIC DISPROPORTION CONTRACTED PELVIC INLET AP diameter < 10 cm Greatest transverse diameter < 12 cm Diagonal conjugate < 11.5 cm Face and shoulder presentation and cord prolapse occurs more frequently

55. FETOPELVIC DISPROPORTION CONTRACTED MIDPELVIS More common than inlet contraction Frequently causes transverse arrest of the fetal head Sum of ischial spine and posterior sagittal diameters of the midpelvis ( normal , 10.5 + 5 cm, or 15.5 cm) falls 13.5 and below Clinical pelvimetry: spines are prominent, pelvic sidewalls converge, sacrosciatic notch is narrow

56. FETOPELVIC DISPROPORTION CONTRACTED PELVIC OUTLET Interischial tuberous diameter of 8 cm or less Outlet contraction without concomitant midplane contraction is rare

57. FETAL DIMENSIONS IN FETOPELVIC DISPROPORTION Excessive fetal size was considered to be 4500 g Malposition of the fetal head MUELLER-HILLIS MANEUVER Fundal pressure followed by vaginal examination

58. BREECH PRESENTATION Frank breech presentation Complete breech presentation Incomplete breech presentation

61. LEOPOLD’S MANEUVER BREECH PRESENTATION

62. VAGINAL EXAMINATION IN A BREECH PRESENTATION Ischial tuberosities and anus are in a straight line while the mouth and malar prominences form a trianguLar shape

63. VAGINAL BREECH DELIVERY ACOG has concluded that, except in cases of “advanced labor” and “imminent delivery”, women with persistent singleton breech presentation should undergo a planned cesarean delivery

64. RECOMMENDATIONS FOR CESAREAN DELIVERY Large fetus Any degree of contraction or unfavorable shape of the pelvis A hyperextended head When delivery is indicated in the absence of spontaneous labor Uterine dysfunction Incomplete or footling breech An apparently healthy and viable preterm fetus with the mother in labor or in whom delivery is indicated Several growth restriction Previous perinatal death A request for sterilization Lack of an experienced operator

65. METHODS OF VAGINAL DELIVERY IN BREECH PRESENTATION Spontaneous breech delivery Partial breech extraction Total breech extraction

68. PINARD MANEUVER

69. MAURICEU MANEUVER

70. PRAGUE MANEUVER

72. EXTERNAL CEPHALIC VERSION

73. FACE PRESENTATION Flexion of the head and vaginal delivery are typical with mento anterior presentation . Vaginal delivery is impossible with mento posterior presentation unless the chin rotates anteriorly Causes: Marked enlargement of the neck or cord coils around the neck may prevent extension Anencephalic fetuses Inlet contractions Pendulous abdomen High parity

74. BROW PRESENTATION Rarest Unstable

75. TRANSVERSE LIE 0.3 % incidence Shoulder presentation Causes: Abdominal wall relaxation Preterm fetus Placenta previa Abnormal uterine anatomy Excessive amnionic fluid Contracted pelvis Neglected transverse lie Conduplicato corpore

76. LEOPOLD’S MANEUVER TRANSVERSE LIE

77. COMPOUND PRESENTATION Extremity prolapses alongside the presenting part Causes: conditions that prevent complete occlusion of the pelvic inlet by the fetal head, including preterm birth

78. COMPOUND PRESENTATION

79. PERSISTENT OCCIPUT POSTERIOR POSITION Reasons for failure of spontaneous rotation: Transverse narrowing of the midpelvis Malrotation of occiput anterior during labor Possibilities for vaginal delivery: Spontaneous delivery Forceps delivery with occiput directly posterior Manual rotation to anterior position Forceps rotation to anterior position

80. SHOULDER DYSTOCIA 0.6% - 1.4% incidence Head to body delivery time exceeding 60 seconds Mean head to body delivery time in normal births was 24 seconds compared with 79 seconds in shoulder dystocia Risk factors: Obesity, Multiparity Gestational diabetes Postterm pregnancy

81. SHOULDER DYSTOCIA Most cases of shoulder dystocia cannot be accurately predicted or prevented Elective induction of labor or elective cesarean delivery for all women suspected of carrying a macrosomic fetus is not appropriate Planned cesarean delivery may be considered for the non-diabetic woman carrying a fetus with an estimated fetal weight exceeding 5000 g or the diabetic woman whose fetus is estimated to weigh more than 4500 g

82. MANAGEMENT OF SHOULDER DYSTOCIA Suprapubic pressure McRoberts maneuver Woods corkscrew maneuver Delivery for the posterior shoulder Rubin maneuver Fracture of the clavicle Strong fundal pressure Zavanelli maneuver Cleidotomy Symphysiotomy

83. McROBERT’S MANEUVER

84. WOODS CORKCREW MANEUVER

85. OTHER CAUSES OF DYSTOCIA Hydrocephalus Enlargement of the fetal abdomen Soft tissue dystocia

86. SOFT TISSUE DYSTOCIA

87. MATERNAL EFFECTS OF DYSTOCIA Intrapartum infection Uterine rupture Pathological retraction ring Fistula formation Pelvic floor injury Postpartum lower extremity nerve injury

88. FETAL EFFECTS OF DYSTOCIA Caput succedaneum Fetal head molding Skull fractures

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