Normal Labor and

Dystocia

IMS Murah-Manoe
Labor ?
 Labor consists of regular, frequent, uterine
contractions which lead to progressive
dilatation of the cervix
 A normal delivery (eutocia) if deliver vaginally

at full term, with the baby’s head

coming first, without any
instrumentation.
Episiotomy is considered
to be normal
True labor ?

 True labor will usually be determined by

observing the patient over time and
demonstrating progressive cervical
changes, in the presence of regular,
frequent, painful uterine contractions
Fetus In Normal
Position

 Fetal is said to be in a normal position if it is facing

toward the maternal’s back with the face angled
toward the right or left, and upside down with the
head coming first (vertex
presentation), with the neck
bent forward, chin tucked
in and arms folded across
the chest
Mechanism of normal
labor: there are five
classical steps:

 Descent
 Flexion
 Internal Rotation
 Extension
 External Rotation
 Normal presentation: although it could be
sometimes the variations of the normal labour
it could be :
 Variations in the time of labour
 Variations in the positions of the fetus
 Variations in conducting the vaginal delivery
(operative vaginal delivery)
Descent assessed by abdominal palpation
Abdominal palpation for descent of the fetal
head
Assessing descent of the fetal head by vaginal
examination; 0 station is at the level of the ischial
spine (I Sp)
"0 Station" ("Zero Station")
means that the top of the fetal
head has descended through the
birth canal just to the level of the
maternal ischial spines.

This usually means that the fetal

head is "fully" engaged (or
"completely engaged"), because
the widest portion of the fetal
head has entered the opening of
the birth canal (the pelvic inlet).
Fetal head at -1 station, 1 cm above the
level of the ischial spines
Effacement and dilatation of the cervix
Progress of Labor

 For a woman experiencing

her first baby, labor usually
lasts about 12-14 hours
 If she has delivered a baby in
the past, labor is generally
quicker, lasting about 6-8
hours
 These averages are only
approximate, and there is
considerable variation from
one woman to the next, and
from one labor to the next
Four stages of labor

The first stage of labor can be divided

functionally into two phases:
 the latent phase

 the active phase

 The second stage: delivery of the baby

 The third stage: the expulsion of the placenta

 The fourth stage: 1-2 hours after delivery

Presentation and position

 The foetus' presentation and position affect

how the foetus passes through the vagina.
Most normal births involve a combination of
vertex presentation with anterior position:

 1. Presentation refers to how the foetus is

situated in the uterus, while the part of foetus
that is closest to the cervix is termed the
presenting part
There are a few different types of
presentation

 Vertex or cephalic presentation . The most

common and safest birth position where the
baby's head is the presenting part

 Transverse lie or shoulder presentation .

Here a caesarean section is always needed
Breech presntation , where the baby's
buttocks presents first.
 Accounting for about 3 to 4% of all
deliveries, the breech birth often involves a
longer labour due to the fact that the
buttocks does not as easily open the
cervix as the head
 Various types of breech exist
These include:
 complete breech is which the baby sits
cross legged at the bottom of the uterus;
 a frank breech, where the baby crosses its
legs straight up with his feet near the face;
 a footing breech, where one or both of the
baby's feet present first; very uncommon
form is the knee breech where the baby's
knee presents before the foot.
Presentation and position
 2. The position of the baby refers to the
direction that the foetus is facing.
 Most commonly the baby's position is
anterior , where the back of the head is
touching the abdomen wall.
 The less common posterior position is
where the back of the baby's head is against
the spine
 Most posterior babies rotate to an anterior
position before the second stage of labour
Cephalic presntation

 A cephalic presentation is a situation at childbirth

where the fetus is in a longitudinal lie and the
head enters the pelvis first;
 the most common form is the vertex
presentation where the occiput is the leading
part (the part that first enters the birth canal)
 All other presentations are abnormal
(malpresentations) (deflexed ) where the head
is extened which are either more difficult to
deliver or not deliverable by natural mean
 In the vertex presentation the head is
flexed and the occiput leads the way
 This is the most common configuration
and seen at term in 95% of singletons
 If the head is extended, the face becomes
the leading part
 Face presentations account for less than
1% of presentations at term
 In the sincipital presentation the large fontanelle is
the presenting part; with further labor the head will
either flex or extend more so that in the end this
presentation leads to a vertex or face
presentation.[1]
 In the brow presentation the head is slightly
extended, but less than in the face presentation.
The chin presentation is a variant of the face
presentation with maximum extension of the head.
 Non-cephalic presentations are the breech
presentation (3.5%) and the shoulder presentation
(0.5%).
Vertex presentation

 In the vertex presentation the occiput typically

is anterior and thus in an optimal position to
negotiate the pelvic curve by extending the
head.
 In an occiput posterior position, labor
becomes prolonged and more more operative
interventions are deemed necessary.[2]
 The prevalence of the persistent occiput
posterior is given as 4.7 %
 The vertex presentations are further
classified according the position of the
occiput, it being right, left, or transverse, and
anterior or posterior:
 Left Occipito-Anterior (LOA), Left Occipito-
Posterior (LOP), Left Occipito-Transverse
(LOT);
 Right Occipito-Anterior (ROA), Right
Occipito-Posterior (ROP), Right Occipito-
Transverse (ROT)
Face presentation
 Factors that predispose to face presentation are
prematurity, macrosomia, anencephaly and other
malformations, cephalopelvic disproportion, and
polyhydramnios
 In an uncomplicated face presentation duration of
labor is not altered. Perinatal losses with face
presentation occur with traumatic version and
extraction and midforceps procedures
 Duff indicates that the prevalence of face
presentations is about 1/500–600, while Benedetti
et al. found it to be 1/1.250 term deliveries
 Face presentations are classified according
to the position of the chin (mentum):
 Left Mento-Anterior (LMA), Left Mento-
Posterior (LMP), Left Mento-Transverse
(LMT);
 Right Mento-Anterior (RMA), Right Mento-
Posterior (LMP), Right Mento-Transverse
(RMT);
Brow presentation

 While some consider the brow presentation

as an intermediate stage towards the face
presentation,[1] others disagree.
 Thus Bhal et al. indicated that both conditions
are about equally common (1/994 face and
1/755 brow positions), and that prematurity
was more common with face while
postmaturity was more common with brow
positions
Reasons for predominance of
cephalic presentations
 The piriform (pear-shaped) morphology of the
uterus has been given as the major cause for
the finding that most singletons favor the
cephalic presentation at term.[1]
 The fundus is larger and thus a fetus will
adapt its position so that the bulkier and more
movable podalic pole makes use of it, while
the head moves to the others side
Diagnosis
 Factors that influence this positioning include the
gestational age (earlier in gestation breech
presentations are more common as the head is
relatively bigger), size of the head,
malformations, amount of amniotic fluid,
presence of multiple gestations, presence of
tumors, and others.
 Two-thirds of all vertex presentations are LOA,
possibly because of the asymmetry created by
the descending colon that is on the left side of
the pelvis
Management
 Many factors determine the optimal way to deliver a baby.
 A vertex presentation is the ideal situation for a vaginal
birth, however, occiput posterior positions tend to proceed
more slowly, often requiring an intervention in the form of
forceps, vacuum extraction, or Cesarean section
 In a large study, a majority of brow presentations were
delivered by Cesarean section, however, because of
postmaturity, factors other than labour dynamics may have
play a role
 Most face presentations can be delivered
vaginally as long as the chin is anterior; there
is no increase in fetal or maternal mortality

 Mento-posterior positions cannot be delivered

vaginally (unless rotated) and are candidates
for Cesarean section in contemporary
management
Partograph What is it?
 The Partograph is a tool that can be used by
midwifery personnel or medical doctor to
assess the progress of labor and to identify
when intervention is necessary.
 Studies have shown that using the
partograph can be highly effective in reducing
complications from prolonged labor for the
mother (postpartum hemorrhage, sepsis,
uterine rupture and its sequelae) and for the
newborn (death, anoxia, infections, etc.).
Who uses it?
 Nurse midwife, medical doctor.

Why use it?

 To assist in making the correct decision
about transfer, Caesarean section, or other
life-saving interventions.

When to use it?

 To monitor all stages of labor of all women
arriving at the maternity or health facility
How to use it?
 A partograph WHO must be started only
when a women is in labor.
 In the latent phase (cervix dilatation not more
than 2 cm), she should have two or more
contractions in 10 minutes, each lasting 20
seconds or more.
 In the active phase (cervix dilatation more
than 3 cm), she should have two or more
contractions in 10 minutes, each lasting 40
seconds or more
 The partograph is used to plot the following
parameters for the progress of labor:
 cervical dilatation, descent of fetal head, and
uterine contractions.
 It will also be used for monitoring fetal
conditions with the following parameters: fetal
heart rate, membranes and liquor and
moulding of fetal skull.
 Additionally, the partograph can be used to
monitor maternal condition: pulse, blood
pressure
WHO
Partograph
Modified
Partograph
Modified
partograph:
Normal active
phase of 1st stage
Prolonged Labour

 The word ‘difficult labour’ or ‘dystocia’ suggests that

labour has failed to progress normally and is
causing difficulties for maternal and fetal

 Delayed progress of labour can be due to various

causes
 If the labour doesn’t complete within-18 hours in
case of the first time pregnant woman and 12 hours
in case of those who have had a prior delivery, it is
considered prolonged labor
Factors causing delayed progress of labour
are:
 Inadequate intensity and frequency of uterine
contractions
 Overdistention of the uterus (in cases like
twins or large baby)
 The position of the fetus in the uterus is not
favorable
 Pelvis is not adequate for the passage of the
fetal’s head
 Some medications have been given for pain
relief or to decrease the perception of
contractions (epidural anaesthesia) These
sometimes have an effect of prolonging
labour, particularly the second stage

 If not completely evacuated the urinary

bladder / bowels, may rarely cause failure of
progress of labour.In most hospital enema is
given during the 1st stage of labour if the last
defaecation ≥ 1 day ago
Effects of prolonged labour:

This difficulty in progress of labour may lead to:

 Exhaustion of the mother.

 Increased post partum bleeding.

 Increased chances of trauma to the genital

tract.
 Increased chances of operative deliveries –
like, forceps, vacuum.
 Decreased supply of oxygen to the fetus.

 Increased chances of infection in the uterus.

If prolonged labour:

 Check the membrane, intack do artificial rupture of

the membrane
 Decsent < 3/5, cesarean section.
 If obstructed labour sign negative and the opening
of cervical canal incompletely try oxytocin drips
 If cervical canal completely open descent 1/5 or
0/5,assisted vacuum or forceps extraction
 If obstruction sign positive or fetal distress cesarean
section is the choice of delivery
General management

Rapid maternal and fetal condition evaluation

Maternal: e,g pulse, respiration, temperature,
blood pressure
Fetal: FHR, fetal membrane intact or not?
Meconial? Amniotic fluid absent?
Support maternal physically, nutrition and fluid
intake give
Support her emotional need, give her chance to
change her position.
Inadequate uterine
contraction,
correction by
oxytocin
Prolonged active
phase 
prolonged labor (
weak of
contraction, no
progressive
cervical dilatation
and failure of
descent , meconeal
bradycardia)
Obstructed labor
(prolonged active
phase, contraction
normal, arrest of
decsent and
dilatation, molding
++, bradycardia )