C H AP TER 8 Normal Labor , Delivery, and Postpartum Care 109

A B

C D
FIGURE 8-10 Mechanism of labor for a vertex presentation in the left occipitotransverse position. A, Flexion and descent. B and C,
Continued descent and commencement of internal rotation. D, Completion of internal rotation to the occipitoanterior position followed
by delivery of the head by extension.

ischial spines (z ero station) and ther efore is engaged.
In the occipitoposter ior positions , the fetal head may
rotate poster iorly so that the occiput tur ns toward the
hollow of the sacr um.
Extension. The flexed head in an occipitoanter ior
position continues to descend within the pelvis .
Because the vaginal outlet is dir ected upward and
forward, extension must occur befor e the head can
pass thr ough it. As the head continues its descent,
there is bulging of the per ineum follo wed by cr owning
(see Figure 8-10, D). Crowning occurs when the lar gest
diameter of the fetal head is encir cled by the vulv ar
ring. At this time , the vertex has reached station +5.
When indicated, an incision in the per ineum (episi -
otomy) may aid in reducing per ineal resistance.
Current management is to allow the fetus to deliver
without an episiotomy when possible. Good clinical
judgment is needed to avoid traumatic tears that may
be mor e difficult to repair when they occur without an
episiotomy. The head is bor n by rapid extension as the
occiput, sinciput, nose , mouth, and chin pass over the
perineum.
In the occipitoposterior position, the head is bor n
by a combination of flexion and extension. At the time
of cr owning, the poster ior bony pelvis and the muscu -
lar sling encour age fur ther flexion. The forehead, sin -
ciput, and occiput are bor n as the fetal chin appr oaches
the chest. Subsequently, the occiput falls back as the
head extends and the nose , mouth, and chin are bor n.
External Rotation. In both the occipitoanter ior and
occipitoposterior positions , the deliv ered head now
returns to its original position at the time of engage-
ment to align itself with the fetal back and shoulders .
Further head rotation may occur as the shoulders
undergo an inter nal rotation to align themselv es
anteroposteriorly within the pelvis .