presentation for normal delivery

Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in Fetal Position and Presentation

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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Normal Delivery of the Infant

• Author: Elizabeth Gittinger, MD; Chief Editor: Christine Isaacs, MD  more...
• Sections Normal Delivery of the Infant
• Epidemiology
• Indications
• Contraindications
• Positioning
• Complications
• Special Procedures
• Media Gallery

The delivery of a full-term newborn refers to delivery at a gestational age of 37-42 weeks, as determined by the last menstrual period or via ultrasonographic dating and evaluation. The Naegel rule is a commonly used formula to predict the due date based on the date of the last menstrual period. This rule assumes a menstrual cycle of 28 days and mid-cycle ovulation. Ultrasonographic dating can be more accurate, especially when it is performed early in pregnancy and is used to corroborate or modify a due date based on the last menstrual period.

Approximately 11% of singleton pregnancies are delivered preterm, and 10% of all deliveries are postterm. Thus, nearly 80% of newborns are delivered at full term, although only 3-5% of deliveries occur on the estimated due date. [ 1 , 2 ] Over the past few decades, the number of patients who go into spontaneous labor has decreased, and the percentage of inductions (iatrogenic labor) has increased to 22% of all pregnancies. [ 3 ]

Labor and delivery is divided into 3 stages:

In the first stage, the cervix dilates as a result of progressive rhythmic uterine contractions. This is typically the longest stage of labor. Cervical effacement, or thinning, occurs throughout the first stage of labor, and is graded 0-100%.

The first stage of labor is divided into the latent and active phases.

The latent phase can last for many hours. The cervix dilates, usually slowly, from closed to approximately 4-5 cm.

The active phase lasts from the end of the latent phase until delivery. It is characterized by rapid cervical dilation. The cervix usually dilates at a rate of 1.0 cm/h in nulliparous persons and 1.2 cm/h in multiparous persons during the active phase.

The second stage of labor is the time between complete cervical dilation and delivery of the neonate. This phase lasts minutes to hours. The maximum accepted time for the second stage depends on the patient's parity and whether the patient has an epidural.

Six cardinal movements of labor occur during the second stage of labor.

Engagement of the head into the lower pelvis

Flexion of the head, putting the occiput in presenting position

Descent of the neonate through the pelvis

Internal rotation of the vertex to maneuver past the lateral ischial spines

Extension of the head to pass beneath the maternal symphysis

External rotation of the head after delivery to facilitate shoulder delivery

Several clinical parameters are followed.

The fetal presentation is determined by the first fetal body part that passes through the birth canal. Most commonly, this is the occiput or the vertex of the head.

The fetal station is the relation of the fetal head to the maternal ischial spines. The station is defined as -5 cm to +5 cm; 0 station is at the level of the ischial spines.

The fetal position is the orientation of the fetal vertex (the top of the head) in relation to the plane of the maternal ischial spines. The vertex normally rotates from a transverse position to an anterior or posterior position as the vertex internally rotates.

The delivery of the placenta is the third and final stage of labor; it normally occurs within 30 minutes of delivery of the newborn. As the uterus contracts, a plane of separation develops at the placenta-endometrium interface. As the uterus further contracts, the placenta is expelled.

In 2013, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) released a committee opinion revising the definition of term pregnancy. The recommended change, as devised by a work group that included representatives from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, ACOG, SMFM, and other societies and organizations, replaces the designation “term” with the following [ 4 ] :

Early term: 37 weeks, 0 days, through 38 weeks, 6 days, of gestation

Full term: 39 weeks, 0 days, through 40 weeks, 6 days, of gestation

Late term: 41 weeks, 0 days, through 41 weeks, 6 days, of gestation

Postterm: At least 42 weeks, 0 days, of gestation

Birth and natality statistics for the end of 2017 are as follows [ 5 ] :

• Number of births: 3,855,500
• Birth rate: 11.8 births per 1000 population
• Fertility rate: 60.3 births per 1000 women aged 15-44 years
• Low birthweight rate: 8.3%
• Preterm birth rate: 9.9%
• Unmarried birth rate: 39.8%
• Mean age at first birth: 26.8 years

Statistics for type of delivery (2017) are as follows [ 5 ] :

• Vaginal deliveries: 2,621,010
• Cesarean deliveries: 1,232,339 (32%)

Statistics for multiple births (2017) are as follows [ 5 ] :

• Twin births: 128,310
• Triplet births: 3,675
• Quadruplet births: 193
• Quintuplets and other higher order births: 49

Normal vaginal delivery of the newborn includes the following circumstances:

Spontaneous labor mediated by pituitary and placental hormone cascades

Rupture of amniotic and chorionic membranes (suggested by the presence of a watery vaginal discharge or new oligohydramnios on ultrasonograph)

Induction of labor (indicated if fetal or maternal medical conditions necessitate delivery)

While sporadic contractions may occur, and the cervix may begin to soften in anticipation of delivery, the presence of contractions that lead to active cervical change defines labor.

Not all vaginal fluid is amniotic fluid, and membrane rupture requires confirmation.

If the cervix is favorable, oxytocin is given to induce uterine contractions. A favorable cervix is defined by the Bishop score, which includes parameters like cervical dilation, softening, effacement, and station. If the cervix is not favorable and no contraindications are present, cervical ripening can be facilitated with intravaginal prostaglandins before oxytocin is initiated. [ 6 ]

There are several medications available for cervical ripening. Misoprostol or prostaglandin E1(Cytotec) is most often used for cervical ripening. Since 2002, it has been FDA approved for cervical ripening and induction of labor. Dosing is 25-50 mcg given vaginally, buccally, or sublingually. prostaglandin E2 (dinoprostone) can also be used for cervical ripening, although it is more expensive than misoprostol and has an increased rate of tachysystole (too many contractions). [ 3 ]

A balloon catheter can also be used for ripening. Pennell et al compared 3 methods of ripening the cervix in nulliparous women at term and found that the single-balloon catheter offers the best combination of safety and patient comfort. In a randomized controlled trial, 330 nulliparous women with unfavorable cervices induced at term were treated with 1 of 3 methods: double-balloon catheters, single-balloon catheters, or prostaglandin gel.

Cesarean delivery rates were high with all 3 methods. Single-balloon catheter use was associated with earlier delivery and with significantly less pain: 36% of patients had a pain score of ≥4, vs 55% of patients treated with double-balloon catheterization and 63% of those treated with prostaglandin gel ( P < .001). Induction was complicated by uterine stimulation in 14% of patients in the prostaglandin arm, but none of those in the catheter arms, and mean cord arterial pH was lower in the prostaglandin arm (7.25 vs 7.26 in the catheter arms [ P =.050]). [ 7 ]

For more information, see Cervical Ripening article.

While most full-term newborns in the United States are delivered vaginally, vaginal birth is contraindicated in some circumstances, including those described in this section. Among the contraindications are the following:

Cord prolapse

When cord prolapse is detected on pelvic examination, the clinician should leave the hand in place, applying pressure against the presenting fetal part to keep it as far out of the pelvis as possible to prevent cord compression.

The incidence of cord prolapse is directly proportional to cord length.

The treatment is immediate conversion to cesarean delivery. If not treated emergently, cord prolapse is associated with high perinatal mortality.

Brow presentation

This may convert to face or vertex presentation and may be managed expectantly.

If the patient is unstable or no conversion occurs, cesarean delivery is recommended.

Face presentation

Clinicians and patients may tolerate a trial of expectant management, if cephalopelvic disproportion is not suspected and if the face is in a mentum anterior or mentum transverse position.

If the face is mentum posterior (chin facing the maternal sacrum), a cesarean delivery is required.

Breech presentation

Up to 5% of all fetuses and 1-3% of full-term pregnancies present in the breech position. Plan for abdominal delivery for a footling presentation. For frank breech (ie, hips flexed, knees extended) and complete breech (ie, hips and knees flexed) presentations detected before the onset of labor, manual pressure maneuvers called external cephalic version (ECV) may be performed to attempt conversion to a vertex presentation.

The success rates of ECV are greater than 50% in properly selected patients, but these maneuvers should be performed at term, as they may stimulate labor or result in complications that necessitate prompt delivery.

The American Congress of Obstetricians and Gynecologists (ACOG) recommends abdominal delivery if ECV fails or if a patient in labor presents with breech presentation, as the rates of fetal morbidity and mortality in these cases are increased with vaginal delivery. [ 8 ]

Malposition

Fetal positions compatible with vaginal delivery are occiput anterior (OA), right occiput anterior (ROA), and left occiput anterior (LOA).

The occiput posterior (OP) position can be unfavorable for passage through the birth canal. Labor progress should be monitored for progression. If the fetal station is high and without descent during labor, change to abdominal delivery should be considered.

Deep transverse arrest occurs when the fetal head remains in transverse position without descent. Unfavorable maternal pelvic anatomy is the most common cause; abdominal delivery should be considered promptly.

Shoulder presentation is a sign of a transverse fetal lie. If this presentation is detected prior to active labor, external rotation through ECV may be attempted. When this presentation is detected during labor, maternal risk for infection, uterine rupture, or both is high. Emergent abdominal delivery is indicated.

Twin pregnancy

If a nonvertex second twin presentation occurs, it is managed according to gestational age , maternal preference, and practitioner comfort. The exceptions to vaginal delivery include the following:

Presenting twin in breech position

Conjoined twin anatomy

Most cases of mono-amniotic twins

Signs of fetal distress or an abnormality that warrants abdominal delivery

Higher order births

In the United States, cesarean delivery is planned for higher order births.

Vaginal delivery after cesarean delivery [ 9 ]

While safe in most circumstances, vaginal delivery after previous cesarean delivery remains controversial because of the rare but serious complication of uterine rupture. The risk of uterine rupture is approximately 0.5% in patients who have had one prior low transverse cesarean delivery.

The success rate of this procedure is greater than 50%.

During the delivery, careful fetal and maternal monitoring are needed to detect early signs of dystocia or uterine rupture .

An in-house anesthesiologist and obstetrician should be available in case complications arise. This type of delivery is not offered in many small hospitals because of the inconsistent availability of anesthesia or operating room staff. This has led to an increase in the cesarean delivery rate to approximately 30% in 2006.

Vaginal birth after cesarean is contraindicated in cases of multiple prior cesarean deliveries (>2), a history of a classical or T-shaped uterine scar, the presence of placenta previa, the presence of other uterine scars, or concern for true cephalopelvic disproportion.

Nonreassuring fetal heart rate patterns

Hospital protocols in the United States recommend some form of fetal heart rate monitoring. The need for continuous fetal heart rate monitoring remains unproven in low-risk, full-term pregnancies; however, changes in fetal heart rate monitoring can signal fetal hypoxemia and may indicate the need for emergent abdominal delivery.

Causes of fetal hypoxemia include placental abruption, placental insufficiency, or a tight nuchal cord. Most cesarean deliveries undertaken for suspected fetal distress result in healthy birth outcomes.

Fetal weight greater than 4000-4500 g is associated with a higher risk of shoulder dystocia and birth trauma during vaginal delivery. [ 10 ]

Patients with diabetes have a higher incidence of macrosomia and risk of shoulder dystocia.

If the estimated fetal weight is greater than 4500 g in a patient with diabetes, ACOG recommends abdominal delivery.

If the patient does not have diabetes, abdominal delivery is not recommended until an estimated fetal weight of 5000 g.

Abnormal placentation

Placenta previa (the placenta implanted over the cervical os) is a contraindication to vaginal delivery because of the risk of hemorrhage as the cervix dilates.

Placenta previa complicates up to 2% of all pregnancies. Risk factors include artificial reproductive technology and prior cesarean delivery.

Known placenta accreta (the placenta invades at least the myometrium of the uterus) is also a contraindication to a vaginal delivery. Risk factors include prior cesarean delivery.

The pain of labor and delivery is a result of muscular contractions and pelvic pressure from organ distention. In the first stage of labor, autonomic innervation of the visceral uterus senses pain from contractions and cervical dilation. In the second stage of labor, somatic innervation of the vagina, vulva, and perineum sense pressure pain from the newborn passing through the birth canal.

Regional epidural anesthesia

Regional epidural anesthesia is used in more than 50% of laboring persons in the United States. It is relatively easy to perform, generally low in risk for complications, and provides good pain control. ACOG guidelines recommend placement of epidural at maternal request regardless of cervical dilatation. [ 11 ]

Risks include short-term backache, puncture headache, hypotension, maternal fever, and delayed labor. [ 12 ] Another possible risk is increased rate of instrumental delivery. [ 13 ]  In a Cochrane review, a subgroup analysis of studies published since 2005 showed epidural analgesia was not associated with an increase in assisted vaginal delivery. [ 14 , 15 ]

Epidural anesthesia may be combined with a dose of spinal anesthesia; this is called combined spinal-epidural anesthesia. This permits delivery of a potent, fast-acting spinal anesthetic with the placement of a stable epidural catheter for subsequent anesthesia needs.

Pudendal block

The pudendal block is rarely used because it is not very effective for pain control. [ 16 ] It is a local anesthetic given during the second stage of labor for somatic sensory blockade. It may provide some degree of motor blockade of the levator ani, mediating relaxation of pelvic floor muscles.

Systemic analgesia

Narcotics are sometimes used for short-term pain control; they can all cross the placenta, but only some cross the fetal blood-brain barrier. Narcotic agonists and antagonists are most commonly used. Morphine crosses the fetal blood-brain barrier and is infrequently used.

Risks include hypotension, nausea, vomiting, respiratory depression, depressed mental status, and decreased GI motility.

If narcotics are used, resuscitation medication and equipment for the newborn should be readily available.

Nonpharmacologic pain management

Nonpharmacologic pain management can be used alone or in conjunction with pharmacologic options.

Nonpharmacologic options include the following:

Breathing and meditation methods

Acupuncture

Labor exercise techniques (eg, walking, squatting)

Therapeutic massages

Social support, including a birth doula

Warm baths or showers

Monitors include the following:

External fetal heart rate monitor (see normal tracing in image below)

Note the following:

Most labor and delivery units use continuous monitoring. The monitoring assesses the baseline, variability, presence, or absence of accelerations or decelerations. In 2008, the following consensus guidelines were developed to unify the interpretation of fetal heart tracings.

Category One: Normal fetal heart tracings. Continue expectant management.

Category Two: Indeterminate fetal heart tracings. These tracings require close observation or interventions to determine whether the fetus has acidemia.

Category Three: Abnormal fetal heart tracings. These tracings require immediate intervention. They are not reassuring and are indicative of fetal acidemia. If the strip does not improve with conservative measures, movement should be made toward delivery. [ 17 ]

Standard noninvasive labor monitoring includes the use of 2 sensors attached to the outside of the patient's abdomen. One sensor detects the fetal heart rate via ultrasonography, and the other monitors the timing and relative strength of contractions via a tocodynamometer.

The fetal heart rate is variable and ranges from 120-160 beats per minute (bpm). The heart rate may drop briefly to < 120 bpm, especially during contractions. Persistence of a fetal heart rate lower than 120 bpm defines fetal bradycardia; in labor, a heart rate >100 bpm with reassuring variation is not considered an emergency. Persistence of a rate >160 bpm is called fetal tachycardia.

Internal fetal heart rate monitor (fetal scalp electrode)

An internal fetal heart rate monitor may be placed to more accurately assess fetal heart rate patterns when the external monitor tracing may be inaccurate or difficult to trace.

A small electrode is passed through the cervix, after the membranes have ruptured, and placed on the fetal scalp.

Intrauterine pressure catheter (IUPC)

External monitoring of contractions only measures the timing of contractions. The strength of contractions can only be measured with an IUPC.

This catheter is placed in the uterus transcervically, next to the fetal head. It allows for more accurate measurement of strength and timing of contractions.

Delivery assistance (operative vaginal delivery)

Instruments used in delivery assistance include the following:

This is a handheld metal instrument with blade extensions that are applied to each side of the fetal head. The traction force of the blades aids in neonate delivery.

The use of forceps has decreased over the past several decades. [ 18 ]

The indications for forceps use include prolonged second stage of labor or ineffective maternal push power. The presenting part needs to be at +2 station before forceps should be applied. If the presenting part is at a higher station, abdominal delivery should be chosen.

Forceps use is associated with less fetal hematoma formation and quicker delivery times compared with vacuum assist [ 19 ] but is associated with increased maternal trauma and lacerations.

When compared with conversion to abdominal delivery, forceps use is associated with lower risk of maternal hemorrhage and a better chance that the patient will be able to deliver vaginally in subsequent pregnancies.

This instrument consists of a suction cup that attaches to the fetal head to assist with extraction. Traction pressure is created by a negative pressure handle system. Types include metal cup vacuums, plastic cup vacuums, and a mushroom-shaped vacuum cup that combines the advantages of the metal and plastic designs. [ 20 ]

Indications for use include the need for urgent delivery because of fetal distress, poor maternal push power, or maternal medical conditions that contraindicate strong pushing. Like forceps assistance, vacuum assistance should only be used when indicated, as it carries the risk of harm to the fetus and birthing parent.

Fetal complications from vacuum delivery include hematomas of the scalp, retina, and intracranium. Maternal complications are less than those with forceps but also include vaginal and perineal lacerations.

The decision to use forceps or a vacuum assistance is guided by the particular indication for an instrumented delivery and the clinician’s experience with each technique. In cases of a nonreassuring fetal tracing, the decision to perform an assisted vaginal delivery over rapid conversion to abdominal delivery is based on fetal position and presentation and the availability of personnel for emergency surgical delivery.

When comparing forceps to vacuum, the vacuum has less maternal morbidity, including need for anesthesia and trauma to birth canal; however, there are increased risks to the fetus, including increased risk of cephalohematoma, retinal hemorrhage, and neonatal jaundice. [ 21 ]

The combination of vacuum followed by forceps delivery carries increased risk of neonatal intracranial hemorrhage and should be avoided. This increased risk is also present if a failed operative vaginal delivery proceeds to a cesarean delivery. [ 21 ]

First stage of labor

The patient may alternate positions frequently and is permitted to be out of bed if not under anesthesia motor blockade. Taking walks during this time can ease pain. Some clinicians report that labor may be shorter when the patient is intermittently upright. Swaying motions, such as rocking or slow dancing, may be soothing.

Second stage of labor

The patient may choose a delivery position that is most comfortable and still conducive for clinical monitoring. Most commonly, patients assume a partially sitting position, with the knees flexed and the back supported. The gravity advantage of being at least partially upright can help during delivery.

Other acceptable delivery positions include the following:

Dangling and supported by the arms of a partner

Kneeling on the knees or on both the hands and knees

Lying on one side with the upper leg supported

In some circumstances, repositioning of the patient may be indicated during delivery. Such circumstances include the following:

Maternal back pain

Shoulder dystocia

Posterior presentation of the occiput

Clinicians are also becoming more familiar with water immersion and water birthing. In a Cochrane review of 11 trials on this topic, 6 reported that water immersion during the first stage of labor significantly reduced regional analgesia without increasing duration of labor, operative delivery rates, or neonatal outcome. One study showed that immersion in water during the second stage of labor increased women's reported satisfaction with pushing. [ 22 ]

The first stage of labor includes the following:

Take a complete history and perform a complete physical examination. The physical examination should include a vaginal examination to assess the cervix. If the patient is not ruptured, a sterile digital examination should be performed.

If the membranes may be ruptured, minimize digital examinations. Membrane rupture should be confirmed by at least two of the following:

Positive nitrazine pH test results

Evidence of microscopic ferning pattern of the dried fluid (positive fern test)

Observation of amniotic fluid in the vaginal vault (pooling)

Assess fetal and maternal vital signs.

Obtain an external fetal heart monitor strip.

A duration of 20-30 minutes is standard to assess fetal well-being and to record contraction patterns.

Provide continuous fetal heart rate monitoring for indicated maternal or fetal reasons. Intermittent monitoring may be used if the fetal strip is reassuring.

Monitor maternal vital signs regularly.

All patients should be screened for group B Streptococcus (GBS) colonization during pregnancy. A patient who is GBS-positive needs to receive antibiotics during labor. This applies to 10-30% of patients.

The first choice of antibiotic is penicillin. An acceptable alternative is ampicillin.

If the patient is allergic to penicillin, cefazolin is the next choice (if the patient did not have an anaphylactic response). Penicillin allergy testing is an alternative for patients who report a penicillin allergy, particularly an allergy that is likely to be IgE mediated or is of unknown severity.

If anaphylaxis occurs, evaluate sensitivities to clindamycin. If sensitivities are not performed or if resistance is exhibited to clindamycin, then vancomycin should be administered. [ 23 , 24 ]

Monitor and chart cervical effacement and dilatation. Patients should be re-evaluated every few hours.

Review anesthesia options with the patient early so that appropriate plans can be made.

Record medications given. Consider the use of oxytocin in cases of prolonged labor.

Encourage frequent spontaneous bladder voiding or provide catheter drainage. This prevents bladder distension, especially in patients with an epidural, and allows for better abdominal palpation and external maneuvers in cases of dystocia.

Discuss positioning options for the upcoming second stage of labor.

Patients may ambulate and reposition themselves to maximize comfort.

They may also eat small amounts of food throughout this stage, unless concern exists for impending difficulty during vaginal delivery and the possible need to convert to abdominal delivery.

The second stage of labor includes the following:

Follow and chart fetal station as the neonate descends in the pelvis.

Assess fetal position by palpation or by inspection (as the head becomes visible).

Monitor fetal and maternal vital signs closely.

Reassess pain status frequently and provide anesthesia as indicated. Pudendal blocks may take 15 minutes to reach full effect.

Delivery is imminent at crowning (+5 station).

Crowning occurs when the fetal head bulges the perineum as the head moves through the birth canal.

Distention pressure on the perineum creates a tremendous urge to push for most patients.

If the patient does not instinctively feel when to push, as can occur with heavy anesthesia, instruct her to push with contractions to aid in expulsion.

Delivery of the head

Drape and prepare for delivery when the fetal station is low.

Drapes and gowns protect the clinician from the fluid of delivery; sterile preparation is not required.

Use one hand to support and maintain the head in the flexed position as it delivers.

Use the other hand to support the perineum (see image below).

Control the pace of the delivery of the head. Maternal pushing is often helpful, but forceful pushing can cause the head to deliver too precipitously.

Have the patient momentarily withhold pushing once the head is delivered to check for nuchal cords.

Reduce nuchal cords (if present) if the patient and newborn are sufficiently stable to permit a pause in delivery.

Routine suctioning of the nares is no longer recommended by the AAP. [ 25 ]

Delivery of the shoulders

With both hands on the head, support delivery of the shoulders one at a time as the patient pushes with a contraction.

Without pulling, apply gentle posterior traction of the head at an angle of 45° to deliver the anterior shoulder followed by gentle anterior traction of the head to deliver the posterior shoulder (see images below).

Delivery of the body

With one hand still holding the head, use the other hand to catch the newborn (see image below).

Guide the newborn’s body as it is delivered.

Clamp the umbilical cord in 2 locations, several centimeters apart. The clinician or the patient’s partner can cut the cord between the clamps. There has been increasing data over the past few years advocating for delayed cord clamping. It has been shown to decrease intraventricular hemorrhage and necrotizing enterocolitis in preterm infants, and to decrease anemia in term infants. Delayed cord clamping is defined as >30 seconds after delivery. [ 26 , 27 ]

After delivery

Clean the newborn or place directly with the birthing parent, assuming a normal appearance and Apgar evaluation.

If the newborn is given directly to the birthing parent, wrap the newborn and place on the patient’s bare chest; the newborn's wet skin or the patient’s wet clothes, combined with exposure to ambient air, lead to significant heat loss. Encourage skin to skin contact between the birthing parent and newborn as much as possible. [ 28 ]

Continue to monitor the patient during progression to the third stage of labor.

Third stage of labor

Placental separation is evidenced by the following:

An increase in umbilical cord slack

A bolus of blood from the uterus

Superior migration of the uterus within the abdomen with an increase in uterine firmness

The clinician can facilitate placental delivery.

Apply gentle traction on the umbilical cord with one hand.

Apply vertical pressure just superior to the pubic symphysis with the other hand to prevent inversion of the uterus.

Administer intravenous oxytocin to expedite the third stage of labor. Oxytocin should be started at delivery of the anterior shoulder.

Inspect the placenta after delivery.

Manually explore the uterus if the placenta is not intact.

Retained placenta fragments increase the risk of postpartum hemorrhage.

The medical view regarding the best position for delivery has evolved over time. Patient preference should influence positioning as much as possible.

Epidural anesthesia is the most common form of obstetric anesthesia and is used in over half of deliveries in the United States.

Contraindications to vaginal delivery include cord prolapse, persistent fetal distress on monitoring, placental abruption when delivery is not imminent, placenta previa, suspected or confirmed cephalopelvic disproportion, fetal malpresentation, maternal instability, a history of multiple prior abdominal deliveries or of a vertical uterine scar, or active genital herpes.

Controlled maternal pushing helps prevent deep perineal tearing. Prophylactic episiotomy is not recommended for routine births.

The incidence of shoulder dystocia is increasing. A higher incidence is associated with macrosomia, although most cases occur in infants of normal birth weight. The McRobert and suprapubic pressure maneuvers are successful in nearly 50% of cases.

Indications for a forceps or vacuum assist include development of fetal distress when delivery is imminent or an inability of the patient to push secondary to fatigue, anesthesia effect, or a medical condition that contraindicates strong pushing. For more information, see Special Procedures section below.

An essential part of the third stage of labor is assessing the integrity of the placenta to rule out a retained placental fragment.

Blood loss in excess of 500 mL from vaginal delivery is abnormal. The most common causes for postpartum hemorrhage are uterine atony and deep tears within the birth canal.

Failure to progress

Dystocia is, literally, difficult labor. It is traditionally qualified as a problem of power (contractibility of the uterus), passage (maternal pelvic properties), or passenger (presentation or size of the fetus).

On average, cervical dilation progresses at a rate of 1 cm per hour in nulliparous persons and 1.2 cm per hour in multiparous persons.

Multiple sites within the uterus can stimulate weak, uncoordinated contractions early in labor, but the pacing of contractions becomes centralized and more effective as labor progresses. If this does not happen, the contractile power needed to complete cervical dilation may be inadequate.

Nulliparous patients and those with anatomical uterine abnormalities have a higher risk for this type of dystocia.

When needed, oxytocin improves the frequency and strength of contractions.

It may also cause uterine tachysystole (>5 contractions in 10 minutes); stopping the infusion works quickly to remove the medication effect if this occurs

Because oxytocin increases the strength of contractions, patients tend to report more pain while on oxytocin.

Passage and passenger

During the second stage of labor, the fetal head typically descends within the pelvis at a rate of 1 cm per hour. Abnormal fetal presentation or position or cephalopelvic disproportion (CPD) can slow this progress.

True CPD, due to a small pelvic outlet or fetal macrosomia, is rare. While macrosomia occurs in up to 10% of pregnancies in the United States, notably in patients who are delivering post term or who have diabetes, it does not always obstruct labor and cause CPD.

Nonreassuring fetal heart rate

Fetal heart rate monitoring is used to assess baseline heart rate, variability, and the presence of accelerations, and to compare deceleration patterns against the timing of maternal contractions. Indications for operative delivery for fetal well-being include abnormal fetal heart rate patterns suspicious for fetal hypoxia and persistent fetal heart rate decelerations in the context of a fetus remote from delivery.

Bradycardia is mediated by vagal tone. Preserved variability in the setting of mild bradycardia is reassuring. Significant bradycardia may result from cord compression, fetal cardiac anomalies, or fetal hypoxia. Infrequently, it may represent a deceased fetus with monitor capture of the underlying slower maternal heart rate. Ultrasonography can discriminate between fetal bradycardia and maternal heart rate.

Tachycardia is less specific than bradycardia for fetal distress. A high sympathetic tone drives tachycardia and may abolish vagally mediated heart rate variability. Causes of sympathetic surges include maternal fever, hypotension, the use of sympathomimetic drugs, and fetal anemia.

Decelerations are classified as early, late, or variable. Early decelerations are associated with uterine contractions (when compression of the fetal head causes an increase in vagal tone). Late decelerations are more concerning. They may represent uteroplacental insufficiency and signal fetal hypoxia. Variable decelerations vary in the timing of onset and length of duration; they represent cord compression. [ 29 ]

Premature rupture of membranes

Premature rupture of membranes (PROM) means rupture of membranes at term before onset of labor.

The most recent ACOG guidelines suggest that augmentation of labor should occur on presentation to the hospital. [ 30 ]

Antibiotic treatment is no longer routinely recommended unless the patient develops a fever >100.5 º F.

PROM is most concerning in preterm newborns (PPROM). In those cases, the risk of infection and of the loss of supportive amniotic fluid must be weighed against the risk of premature delivery.

Intrapartum hemorrhage

During labor and delivery, a small amount of blood may be mixed with amniotic fluid, creating a serosanguineous appearance. A bloody show may herald the onset of labor. Significant blood loss, however, is abnormal.

Causes of intrapartum hemorrhage include the following:

Placental abruption is the premature separation of the placenta from the uterus.

Placenta previa is when the placenta covers the cervical os. In the United States, where most birthing parents have prenatal ultrasonographic evaluations, placenta previa is usually diagnosed by ultrasonographic evaluation prior to labor onset.

Placenta accreta is the extension of the placenta into the uterine wall.

Ruptured vasa previa (abnormal fetal vessels covering the cervix)

Uterine rupture can also cause intrapartum hemorrhage.

Postpartum hemorrhage

Loss of >500 mL of blood during vaginal delivery is abnormal.

Uterine atony, or failure of the uterus to contract following delivery of the placenta, is the most common cause. The uterine blood vessels that are torn and exposed during placental separation are not adequately compressed and may bleed excessively.

Retained placental tissue, the use of uterine muscle relaxants during labor, prolonged labor, or an abnormally distended uterus are causes of uterine atony.

Deep vaginal or cervical lacerations are also a cause of postpartum hemorrhage.

Rarely, coagulopathies can cause postpartum hemorrhage. Von Willebrand disease is sometimes first noted in patients after a vaginal delivery.

To treat postpartum hemorrhage, perform bimanual uterine massage and start an oxytocin drip if uterine atony is suspected; misoprostol or other prostaglandins may also be indicated. If these interventions do not control bleeding, reexplore the vagina, cervix, and uterus for tears or for retained products of conception. If this cannot be accomplished safely in the delivery room, the patient should be moved to the operating room for further evaluation.

The decision to perform an episiotomy is often made as the newborn crowns. Until recently, episiotomies were routinely performed during most deliveries with the assumption that this minimized deep traumatic tearing. Evidence, however, does not support the routine practice of episiotomy. [ 8 ]

In 2000, episiotomies were performed in approximately 27.5% of deliveries; it is one of the most common obstetrical surgical procedures. [ 31 ] By 2006, the national episiotomy rate was 9%. [ 32 ]

When indicated, episiotomies are made in a midline (or mediolateral) position. The depth of the incision is directly proportional to how precipitous the delivery is and to the stiffness of the perineum. The procedure for episiotomy is as follows:

Make a 0.75-1.5-in incision from the midpoint of the posterior fourchette, directing back toward the rectum (see image below).

The Cochrane database compared restrictive use to liberal use of episiotomy. There is an increased risk of anterior perineal trauma with restrictive use. The advantages, however, include decreased posterior perineal trauma, fewer sutures, and fewer healing complications. There has been no quality research on midline vs mediolateral episiotomy. [ 32 ]

Amniotomy is a procedure by which the provider artificially ruptures the fetal membranes to induce or expedite labor.

Advance the amniohook until it touches the membranes.

Once the hook is engaged, pull back slightly; fluid should slowly leak out.

Inspect for the presence of meconium, a discolored (yellow to green) fluid due to the presence of fetal stool.

ACOG recommends amniotomy for patients undergoing augmentation or induction of labor to shorten the duration of labor. [ 33 ]

External cephalic version

External cephalic version (ECV) is a prelabor maneuver used to convert a breech fetus to a vertex presentation. ECV may reduce the rate of abdominal delivery; success rates in carefully selected full-term patients approach 60%. [ 34 ]

Risks include premature rupture of membranes, inadvertent induction of labor, fetal distress or demise, and maternal pain.

Contraindications include multiple gestations or placental, fetal, or maternal abnormalities.

The procedure for ECV is as follows:

Position the patient supine.

Liberally lubricate the abdomen.

Attempt a forward roll first. To do this, apply upward pressure on the breech while guiding the head gently downward to rotate the fetus clockwise.

Attempt a reverse, backward roll if the forward roll is unsuccessful.

Induction of labor

Induction of labor can be performed for maternal indications, fetal indications, or electively. [ 3 , 33 ]

Maternal indications include hypertensive complications of pregnancy and exacerbation of maternal illness in pregnancy.

Fetal indications include postterm pregnancy, intrauterine growth restriction, fetal demise, oligohydramnios, abnormal fetal heart rate testing, history of stillbirth, and chorioamnionitis.

Elective induction of labor should not occur prior to 39 weeks' gestation because of an increased risk of respiratory problems for the newborn. There has been a concerted effort by the March of Dimes, ACOG, and other governing bodies to eliminate elective deliveries less than 39 weeks because of increased morbidity to the infant. [ 35 ]

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[Guideline] American College of Obstetrics and Gynecology. ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol . 2010 Aug. 116(2 Pt 1):450-63. [QxMD MEDLINE Link] .

Baxley EG, Gobbo RW. Shoulder dystocia. Am Fam Physician . 2004 Apr 1. 69(7):1707-14. [QxMD MEDLINE Link] .

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Leighton BL, Halpern SH. The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review. Am J Obstet Gynecol . 2002 May. 186(5 Suppl Nature):S69-77. [QxMD MEDLINE Link] .

Zhang J, Yancey MK, Klebanoff MA, Schwarz J, Schweitzer D. Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment. Am J Obstet Gynecol . 2001 Jul. 185(1):128-34. [QxMD MEDLINE Link] .

Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev . 2018 May 21. 5 (5):CD000331. [QxMD MEDLINE Link] . [Full Text] .

Callahan EC, Lee W, Aleshi P, George RB. Modern labor epidural analgesia: implications for labor outcomes and maternal-fetal health. Am J Obstet Gynecol . 2023 May. 228 (5S):S1260-9. [QxMD MEDLINE Link] .

Guaderrama NM, Liu J, Nager CW, Pretorius DH, Sheean G, Kassab G. Evidence for the innervation of pelvic floor muscles by the pudendal nerve. Obstet Gynecol . 2005 Oct. 106(4):774-81. [QxMD MEDLINE Link] .

Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol . 2008 Sep. 112(3):661-6. [QxMD MEDLINE Link] .

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Cluett, ER. Burns, E. Immersion in Water in Labour and Birth. Cochrane Database of Systemic Reviews . 11/20/08. 2: [Full Text] .

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[Guideline] Prevention of Group B Streptococcal Early-Onset Disease in Newborns: ACOG Committee Opinion Summary, Number 797. Obstet Gynecol . 2020 Feb. 135 (2):489-92. [QxMD MEDLINE Link] . [Full Text] .

Kattwinkel J, Perlman JM, Aziz K, et al. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics . 2010 Nov. 126(5):e1400-13. [QxMD MEDLINE Link] .

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Andersson O, Hellström-Westas L, Andersson D, Domellöf M. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ . 2011 Nov 15. 343:d7157. [QxMD MEDLINE Link] . [Full Text] .

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American College of Obstetrics and Gynecology (ACOG). ACOG Practice Bulletin No. 80: premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol . 2007 Apr. 109(4):1007-19. [QxMD MEDLINE Link] .

American College of Obstetrics and Gynecology (ACOG). ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol . 2006 Apr. 107(4):957-62. [QxMD MEDLINE Link] .

Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev . 2009 Jan 21. CD000081. [QxMD MEDLINE Link] .

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• Normal fetal heart rate tracing.
• Perineal support during delivery of the head.
• Delivery of the anterior shoulder.
• Delivery of the posterior shoulder.
• Episiotomy.
• Delivery of the body.

Contributor Information and Disclosures

Elizabeth Gittinger, MD Assistant Professor in Obstetrics and Gynecology, Boston University School of Medicine Elizabeth Gittinger, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists Disclosure: Nothing to disclose.

Jodi F Abbott, MD Associate Professor of Obstetrics and Gynecology, Clerkship Director, Boston University School of Medicine; Director, Antenatal Testing Unit, Boston Medical Center Jodi F Abbott, MD is a member of the following medical societies: Alpha Omega Alpha , American College of Obstetricians and Gynecologists , American Medical Women's Association , Association of Professors of Gynecology and Obstetrics , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose.

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha , American College of Emergency Physicians , Society for Academic Emergency Medicine Disclosure: Nothing to disclose.

Special thanks to the Obstetrics department at Boston Medical Center.

Video and photos courtesy of Dartmouth-Hitchcock Medical Center, copyright 1994.

Fetal heart rate tracing courtesy of Dr. Amir Sweha, Methodist Hospital, and the family practice program, Sacramento, CA.

Dr. Mike Hughey of Brookside Associates, for the Web link to the episiotomy video.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Karen Patterson, MD, to the development and writing of this article.

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• Labor and delivery, postpartum care

Stages of labor and birth: Baby, it's time!

Labor is a natural process. Here's what to expect during the stages of labor and birth — along with some tips to make labor more comfortable.

Labor is a unique experience. For some people, it's over in a matter of hours or less. For others, a long labor may test the limits of physical and emotional stamina.

You won't know how labor and childbirth will unfold until it happens. But you can prepare by understanding the series of events that typically takes place during labor and delivery.

Stage 1: Early labor and active labor

Cervical effacement and dilation

During the first stage of labor, the cervix opens. The medical term for this is dilation. The cervix also thins out. The medical term for this is effacement. Dilation and effacement usually happen together. This process allows the baby to move into the birth canal. In figures A and B, the cervix is tightly closed. In figure C, the cervix is 60% effaced and 1 to 2 cm dilated. In figure D, the cervix is 90% effaced and 4 to 5 cm dilated. The cervix must be 100% effaced and 10 cm dilated before a vaginal delivery.

The first stage of labor and birth happens when you begin to feel ongoing contractions. These contractions become stronger, and they happen more often as time goes on. They cause the cervix to open. This is called dilation. The contractions also soften, shorten and thin the cervix. That process is called effacement. It allows the baby to move into the birth canal.

The first stage of labor is the longest of the three stages. It's divided into two phases — early labor and active labor.

Early labor

During early labor, also called latent labor, the cervix opens and softens. It also gets shorter and thinner. The cervix opens less than 6 centimeters (cm) in early labor. Contractions tend to be mild, and they may not happen consistently.

As the cervix begins to open, you might notice a clear pink or slightly bloody discharge from your vagina. This likely is the mucus plug that blocks the cervical opening during pregnancy.

How long it lasts: Early labor isn't predictable. It may stop and start. The average length varies from hours to days. It's often shorter for people who have had a baby before.

What you can do: For many people, early labor isn't particularly uncomfortable. But contractions may be more intense for some. And sometimes contractions may continue for a long period of time during early labor. Try to stay relaxed.

The following may help keep you comfortable during early labor:

• Go for a walk.
• Take a shower or bath.
• Listen to relaxing music.
• Try breathing or relaxation techniques taught in childbirth class.
• Change positions.

If your pregnancy isn't high risk, you may spend most of your early labor at home. Most of the time, pregnant people don't need to go to a hospital or birthing center until contractions start to get more intense and happen more often. Talk to your healthcare professional about when to leave for the hospital or birthing center. If your water breaks or you have a lot of vaginal bleeding, contact your healthcare professional right away.

Active labor

During active labor, the cervix opens from 6 cm to 10 cm. Contractions become stronger and closer together. They also happen more consistently. Your legs might cramp. Your stomach may feel upset. If it didn't happen earlier, you might feel your water break. You also may feel more pressure in your back. If you haven't headed to your labor and delivery facility yet, now's the time.

Your initial excitement may fade as labor goes on and you get more uncomfortable. Ask for pain medication or anesthesia if you want it. Your healthcare team works with you to make the best choice for you and your baby. Remember, you're the only one who can judge your need for pain relief.

How long it lasts: Active labor often lasts 4 to 8 hours or more. On average, the cervix opens at approximately 1 cm an hour. But it may take longer for people who haven't had a baby before.

What you can do: Look to your labor partner and healthcare team for encouragement and support. Try breathing and relaxation techniques to ease pain. Use what you learned in childbirth class or ask your healthcare team for suggestions.

Unless you need to be in a specific position to allow for close monitoring of you and your baby, try the following to be more comfortable during active labor:

• Roll on a large rubber ball (birthing ball).
• Take a warm shower or bath.
• Take a walk, stopping to breathe through contractions.
• Have a gentle massage between contractions.

If you need a Cesarean delivery, also called a C-section, having food in your stomach can lead to complications. If your healthcare professional thinks you might need a C-section, or if you have an epidural for pain relief, you may be limited to small amounts of clear liquids, such as water, ice chips, popsicles and juice, instead of solid foods.

The last part of active labor can be particularly intense and painful. Contractions come close together and can last 60 to 90 seconds. You may have pressure in your lower back and rectum. Tell a member of your healthcare team if you feel the urge to push.

If you want to push but your cervix isn't fully open, you'll likely need to wait. Pushing too soon could make you tired and cause your cervix to swell. That might delay delivery. Pant or blow through the contractions. This part of labor typically is short, lasting about 15 to 60 minutes.

Stage 2: The birth of your baby

It's time! You deliver your baby during the second stage of labor.

How long it lasts: It can take from a few minutes to a few hours to push your baby into the world. People who haven't had a baby before and those who have an epidural typically need longer to push compared to those who've had a baby or don't have an epidural.

What you can do: Push! Your healthcare professional asks you to bear down during each contraction or tells you when to push. Or you might be asked to push when you feel the urge to do so.

When it's time to push, you may experiment with different positions until you find one that feels best. You can push while squatting, sitting, kneeling — even on your hands and knees. A member of your healthcare team can check progress during pushing to help you know if your efforts are working.

At some point, you might be asked to push more gently — or not at all. Slowing down gives your vaginal tissues time to stretch rather than tear. To stay motivated, you might ask if you could feel the baby's head between your legs or see it in a mirror.

After your baby's head is delivered, the shoulders are delivered. Then the rest of the baby's body follows shortly. The baby's airway is cleared if necessary. If the delivery didn't involve any health concerns for you or your baby, your healthcare professional may wait a few seconds to a few minutes before the umbilical cord is cut. Waiting to clamp and cut the umbilical cord after delivery increases the flow of nutrient-rich blood from the cord and the placenta to the baby. This raises the baby's iron stores and lowers the risk of anemia. That helps with healthy development and growth.

Stage 3: Delivery of the placenta

After your baby is born, you'll likely feel a great sense of relief. You might hold the baby in your arms or on your belly. Cherish the moment. But there's still a little more to do. During the third stage of labor, you deliver the placenta.

How long it lasts: The placenta typically is delivered within 30 minutes.

Mild, less painful contractions that are close together continue after delivery. The contractions help move the placenta into the birth canal. You push gently one more time to deliver the placenta. You might be given medicine before or after the placenta is delivered to encourage uterine contractions and minimize bleeding.

Your healthcare professional examines the placenta to make sure it's in one piece. If any pieces of the placenta are left in the uterus, they must be removed to prevent bleeding and infection. If you're interested, ask to see the placenta.

After you deliver the placenta, your uterus continues to contract to help it return to its usual size.

A member of your healthcare team may massage your belly. This helps the uterus contract to lessen bleeding.

Your healthcare professional checks to see whether you need repair of any tears of your vaginal area. If you didn't have an epidural, you'll receive an injection of local anesthetic in the area to be repaired.

Savor this special time with your baby. Your preparation, pain and effort have paid off. Enjoy the miracle of birth.

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• Funai EF, et al. Management of normal labor and delivery. https://www.uptodate.com/contents/search. Accessed Oct. 28, 2021.
• Caughey AB, et al. Nonpharmacologic approaches to management of labor pain. https://www.uptodate.com/contents/search. Accessed Oct. 28, 2021.
• Satin AJ. Labor: Diagnosis and management of the latent phase. https://www.uptodate.com/contents/search. Accessed Oct. 28, 2021.
• American College of Obstetricians and Gynecologists. Labor and delivery. In: Your Pregnancy and Childbirth: Month to Month. Kindle edition. 7th ed. American College of Obstetricians and Gynecologists; 2021. Accessed Oct. 28, 2021.
• Landon MB, et al. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. http://www.clinicalkey.com. Accessed Oct. 28, 2021.
• Meek JY, et al. The first feedings. In: The American Academy of Pediatrics New Mother's Guide to Breastfeeding. Kindle edition. 3rd ed. Bantam Books; 2017. Accessed Oct. 28, 2021.
• Cunningham FG, et al. Normal labor. In: Williams Obstetrics. 25th ed. McGraw-Hill Education; 2018. https://www.accessmedicine.mhmedical.com. Accessed Oct. 28, 2021.
• Larish AM (expert opinion). Mayo Clinic. Feb. 27, 2024.

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5.1 Normal delivery

5.1.1 general recommendations.

Personnel should wear personal protective equipment (gloves, goggles, clothing and eye protection) to prevent infection from blood and other body fluids. 

Ensure a calm reassuring environment and provide the woman as much privacy as possible during examinations and delivery. Encourage her to move about freely if desired and to have a person of her choice to accompany her.

Anticipate the need for resuscitation at every birth. The necessary equipment should be ready at hand and ready for use.

5.1.2 Diagnosing the start of labour

• Onset of uterine contractions: intermittent, rhythmic pains accompanied by a hardening of the uterus, progressively increasing in strength and frequency;
• in a primipara, the cervix will first efface then, dilate;
• in a multipara, effacement and dilation occur simultaneously.

Repeated contractions without cervical changes should not be considered as the start of labour. Repeated contractions that are ineffective (unaccompanied by cervical changes) and irregular, which spontaneously stop and then possibly start up again, represent false labour. In this case, do not rupture the membranes, do not administer oxytocin.

Likewise, cervical dilation with few or no contractions should not be considered the start of labour. Multiparous women in particular may have a dilated cervix (up to 5 cm) at term before the onset of labour. If in doubt, in both cases, re-examine 4 hours later. If the cervix has not changed labour has not begun and the woman does not need to be admitted to the delivery room.

5.1.3 Stages of labour

First stage: dilation and foetal descent, divided into 2 phases.

1) Latent phase: from the start of labour to approximately 5 cm of dilation. Its duration varies depending on the number of prior deliveries. 2) Active phase: from approximately 5 cm to complete dilation [1] Citation 1. World Health Organization. WHO recommendations Intrapartum care for a positive childbirth experience, Geneva, 2018. http://apps.who.int/iris/bitstream/handle/10665/272447/WHO-RHR-18.12-eng.pdf?ua=1  [Accessed 18 june 2018] . During this phase the cervix dilates faster than during the latent phase. The time to dilate varies with the number of previous deliveries. As a rule, it does not last longer than 10 hours in a multipara and 12 hours in a primipara.

Second stage: delivery of the infant

Begins at full dilation.

Third stage: delivery of the placenta

See Chapter 8 .

5.1.4 First stage: dilation and descent of the foetus

The indicators being monitored are noted on the partograph ( Section 5.2 ).

Uterine contractions

• Contractions progressively increase in strength and frequency: sometimes 30 minutes apart early in labour; closer together (every 2 to 3 minutes) at the end of labour.
• A contraction can last up to a minute.
• The uterus should relax between contractions.
• Watch the shape of the uterus in order to spot a Bandl’s ring (Chapter 3, Section 3.3.2 ).

General condition of the patient

• Monitor the heart rate, blood pressure and temperature every 4 hours or more often in case of abnormality.
• Ask the woman to empty her bladder regularly (e.g. every 2 hours).
• Keep the woman hydrated (offer her water or tea).
• Encourage the woman to move about freely during labour. Position changes and walking around help relieve the pain, enhances the progress of labour and helps foetal descent. Pain can also be relieved by massage or hot or cold compresses. Midwife support helps manage pain.
• Routinely insert an IV line in the following situations: excessively large uterus (foetal macrosomia, multiple pregnancy or polyhydramnios), known anaemia and hypertension.

Foetal heart rate

Foetal heart rate monitoring.

Use a Pinard stethoscope or foetal Doppler, every 30 minutes during the active phase and every 5 minutes during active second stage, or as often as possible. Listen to and count for at least one whole minute immediately after the contraction. Normal foetal heart rate is 110 to 160 beats per minute. The foetal heart rate may slow down during a contraction. If it becomes completely normal again as soon as the uterus relaxes, there is probably no foetal distress. If the foetal heart rate heard immediately after the end of a contraction is abnormal (less than 100 beats per minute or more than 180 beats per minute), continue foetal heart rate monitoring for the next 3 contractions to confirm the abnormality.

Management of abnormal foetal heart rate

• Insert an IV line.
• Check maternal vital signs: heart rate, blood pressure and temperature.
• Check the uterine tonus. If hypertonic, look for excessive administration of oxytocin (which should therefore be stopped) or placental abruption (Chapter 3,  Section 3.2 ).
• Check the colour of the amniotic fluid: meconium-stained (greenish) amniotic fluid combined with foetal heart rate abnormalities is suggestive of true foetal distress.
• Stop administering oxytocin if an infusion is in progress.
• Check for vaginal bleeding: bleeding may suggest placental abruption or uterine rupture.
• Raise the patient or place her on her left side. Laying on her back the uterus creates pressure on the vena cava, which may be the cause of low foetal heart rate.
• Correct possible hypotension by fluid replacement (Ringer lactate) to bring the systolic blood pressure ≥ 90 mmHg.
• Perform a vaginal examination to look for cord prolapse.
• If the foetal heart rate is more than 180 beats/minute:

The most common cause is maternal febrile infection.

• Look for the cause of the infection (uterine infection, pyelonephritis, malaria, etc.) and treat. 
• Treat the fever (paracetamol).
• In case of fever of unknown origin, administer antibiotics as for a prolonged rupture of membranes (Chapter 4, Section 4.9 ).

If the abnormal foetal heart rate persists or the amniotic fluid becomes stained with meconium, deliver quickly. If the cervix is fully dilated and the head engaged, perform instrumental delivery (vacuum extractor or forceps, depending on the operator’s skill and experience); otherwise consider caesarean section.

Dilation during active phase

• The cervix should remain soft, and dilate progressively. Dilation should be checked by vaginal examination every 4 hours if there are no particular problems (Figures 5.2).
• No progress in cervical dilation between two vaginal examinations is a warning sign.
• Action must be taken if there is no progress for 4 hours: artificial rupture of membranes, administration of oxytocin,  caesarean section, depending on the circumstances.

Figures 5.2 - Estimating cervical dilation

Amniotic sac

• The amniotic sac bulges during contractions and usually breaks spontaneously after 5 cm of dilation or at full dilation during delivery. Immediately after rupture, check the foetal heart rate and if necessary perform a vaginal examination in order to identify a potential prolapse of the umbilical cord ( Section 5.4 ). Once the membranes are ruptured, always use sterile gloves for vaginal examination.
• Note the colour of the amniotic fluid: clear, blood-stained, or meconium-stained.
• Meconium staining by itself, without abnormal foetal heart rate, is not diagnostic of foetal distress, but does require closer monitoring—in particular, a vaginal examination every 2 hours. Action must be taken if dilation fails to progress after 2 hours.

Foetal progress

• Assess foetal descent by palpating the abdomen (portion of the foetal head felt above the symphysis pubis) before performing the vaginal examination.
• At each vaginal examination, in addition to dilation, check the presentation, the position and the degree of foetal descent.
• Look for signs that the foetal head is engaged:

On vaginal examination, the presenting part prevents the examiner's fingers from reaching the sacral concavity (Figures 5.3a and 5.3b). The presence of caput (benign diffuse swelling of the foetal head) can lead to the mistaken conclusion that the foetal head is engaged. The distance between the foetal shoulder and the upper edge of the symphysis pubis is less than 2 finger widths (Figures 5.3c and 5.3d).

• Use reference points on the foetal skull to determine the position of the head in the mother's pelvis. It is easier to determine the position of the head after the membranes have ruptured, and the cervix is more than 5 cm dilated. When the head is well flexed, the anterior (diamond-shaped) fontanelle is not palpable; only the sagittal suture and the posterior (triangular) fontanelle are. The posterior fontanelle is the landmark for the foetal occiput, and thus helps give the foetal position. In most cases, once the head is engaged, rotation of the head within the pelvis brings the foetal occiput under the mother's symphysis, with the posterior fontanelle along the anterior midline.

5.1.5 Second stage: delivery of the infant

This stage is often rapid in a multipara, and slower in a primipara. It should not, however, take longer than 2 hours in a multipara and 3 hours in a primipara

If there is a traditional delivery position and no specific risk for the mother or child has been established, it is possible to assist a delivery in a woman on her back, on her left side, squatting or on all fours (Figures 5.4).

Figures 5.4 - Delivery position

• Rinse the vulva and perineum with clean water.
• The bladder should be emptied, naturally if possible. In cases of urinary retention only, insert a urinary catheter using sterile technique (sterile gloves; sterile, single use catheter).
• If labour is progressing well and there is no foetal heart rate abnormality, let the woman follow her own urge to push. In other cases, expulsive effort should be directed. The woman should push during the uterine contraction. Pushing may be done either with held breath (after a deep inhalation, glottis closed, abdominal muscles and diaphragm contracted, directed toward the perineum) or with exhalation. Expulsive effort is maintained for long as possible: in general, 2 to 3 pushes per contraction.
• Between contractions, the woman should rest and breathe deeply. The birth attendant should monitor the foetal heart rate after each contraction.
• The head begins to stretch the perineum, which becomes progressively thinner; the vaginal opening distends, the labia spread apart, and the occiput appears. In a cephalic presentation, the head usually emerges occiput anterior: the infant is born looking down, the occiput pivoting against the symphysis (Figures 5.5). The head goes into slight extension. The birth attendant must guide this motion and prevent any abrupt expulsive movement, with one hand supporting the occiput. The other hand can support the chin through the perineum. Cover the anal area with a compress (Figures 5.6).

During this final phase—an active one for the birth attendant—the woman should stop all expulsive efforts and breathe deeply. With one hand, the birth attendant controls the extension of the head and moves it slightly side-to-side, in order to gradually free the parietal protuberances; if necessary (not routinely), the chin can be lifted with the other hand (Figure 5.7).

• At the moment of delivery, the perineum is extremely distended. Controlling the expulsion can help reduce the risk of a tear. Episiotomy ( Section 5.8 ) is not routinely indicated. In an occiput-posterior delivery (Figure 5.8), where perineal distension is at a maximum, episiotomy may be helpful.

• The head, once delivered, rotates spontaneously by at least 90°. The birth attendant helps this movement by grasping the head in both hands and exerting gentle downward traction to bring the anterior shoulder under the symphysis and then deliver it then, smooth upward traction to deliver the posterior shoulder (Figures 5.9).

To reduce the risk of perineal tears, control the delivery of the posterior shoulder.

• Place the neonate on mother's chest. For neonatal care, see Chapter 10,  Section 10.1 .

5.1.6 Oxytocin administration

Administer oxytocin to the mother immediately and then deliver the placenta (Chapter 8, Section 8.1.2 ).

5.1.7 Umbilical cord clamping

See Chapter 10,  Section 10.1.1 .

• 1. World Health Organization. WHO recommendations Intrapartum care for a positive childbirth experience, Geneva, 2018. http://apps.who.int/iris/bitstream/handle/10665/272447/WHO-RHR-18.12-eng.pdf?ua=1  [Accessed 18 june 2018]

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NORMAL LABOR AND DELIVERY

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Normal labor and delivery

Jun 10, 2012

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Normal labor and delivery. Definition of labor Causes of onset of labor Changes before labor (premonitory symptoms) True labor Essential factors of labor Stages of labor Clinical course and management of stages. Definition (1).

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• groin areas
• otherwise causeless
• actual birth
• optimal distension theory

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Normal labor and delivery • Definition of labor • Causes of onset of labor • Changes before labor (premonitory symptoms) • True labor • Essential factors of labor • Stages of labor • Clinical course and management of stages

Definition (1) Labor and delivery are the culmination of approximately 280days of preparation. Labor is the process by which the viable products ofconception (fetus, placenta, cord and membrane ) are expelled from the uterus. (whole process, series of events ,viable fetus) It is defined as the progress effacement and dilation of the cervix, resulting from rhythmic contraction of the uterine musculature. preterm labor—prior to 37 completed weeks

Definition (2) The term delivery refers only to the actual birth of the infant at the end of the second stage of labor. it is the expulsion or extraction of a viable fetus out of the womb. it is not synonymous with labor,delivery can take place without labor as in elective C.S. Delivery may be vaginal either spontaneous or aided or it may be abdominal.

Definition (3) • Normal labor (eutocia) : labor is called normal if it fulfils the following criteria. 1) spontaneous in onset and at term. 2) with vertex presentation. 3) without undue prolongation. 4) natural termination with minimal aids. 5) without having any complications affecting the health of the mother and /or the baby.

Definition (4) • Abnormal labor (dystocia): any deviation from the definition of normal labor. • Date of onset of labor:it is very much unpredictable to foretell precisely the exact dete of onset of labor.it not only varies from case to case but even in different pregnancies of the same individual.

Causes of onset of labor (1) • uterine distension: over-stretching of the uterus may play some part in onset of labor. Stretching effect on the myometrium by the growing size of the fetus and amniotic liquor can explain the onset of labor at least in twins or hydramnios. However “optimal distension theory” fails to account for the otherwise causeless preterm labor. • Feto-placental contribution: unknown factors stimulates fetal pituitary prior to onset of labor increased release of ACTH stimulates fetal adrenals increased cortisol secretion accelerated production of estrogen and prostaglandins from the placenta.

Causes of onset of labor (2) • The probable modes of action of oestrogen are: --increase the release of oxytocin from maternal pituitary --promotes the synthesis of receptors for oxytocin in the myometrium and decidua. --accelerates lysosomal disintegration inside the decidual cells resulting in increased prostaglandin synthesis. --stimulates the synthesis of myometrial contractile protein ---increase the excitability of the myometrial cell membranes.

Causes of onset of labor (3) • Progesterone: increased fetal production of dehydroepiandrosterone sulphate and cortisol may inhibit the conversion of fetal pregnenolone to progesterone, altering the estrogen : progesterone ratio. The alteration in the estrogen:progesterone ratio rather than the fall in the absolute concentration of progesterone which is linked with prostaglandin synthesis.

Causes of onset of labor (4) • prostaglandins: the major sites of synthesis of prostaglandins are placenta,fetal membranes,decidual cells and myometrium. Synthesis is trigged by ---rise in estrogen level, altered estrogen-progesterone balance, mechanical stretching in late pregnancy, increase in oxytocin receptors specially in the decidua vera, infection, separation or rupture of the membranes. • Oxytocin:it is probable that myometrial contraction is more dependent on its own readiness to respond to oxytocin. oxytocin level reaches the maximum at the monent of the birth.

Causes of onset of labor (5) • Nervous factors: labor may also be initiated through nerve pathways.

Premonitory symptoms (1) The premonitory stages may begin 2-3 weeks before the onset of true labor in primigravidae and a few days before in multiparae. The symptoms are inconsistent and may consist of the following: false labor (false pain) lightening blood show cervical changes

Premonitory symptoms (2) • False labor It usually appears prior to the onset of true labor pain, by one or two weeks in primigravidae and by a few days in multiparae. The woman feels pain and discomfort in the abdomen and these are mistaken for labor pain.

Premonitory symptoms (3) These Braxton-Hicks contractions cause the patient’s discomfort, it occur throughout pregnancy, late in pregnancy they become stronger and more frequent. But these contractions are not associated with progressive dilation of the cervix, and therefore do not fit the definition of labor. It is irregular and ineffective. It is not only a distressing feature to the woman but also annoying to the relatives.

Premonitory symptoms (4) • False pain has the following features: 1.discomfort is characterized as over the lower abdomen and groin areas 2.without effect on dilation of the cervix (not associated with progressive dilation ) 3.typically shorter in duration 4.less intense 5.relieved by administration of a sedative or ambulation

Premonitory symptoms (5) • Lightening Few weeks prior to the onset of labor specially in primigravdae, the presenting part sinks into the pelvis. The patient reports the sensation that the baby has gotten less heavy, the result of the fetal head descending into the pelvis. The patient often notice that the lower abdomen is more prominent and the upper abdomen is flatter, and there may be more frequent urination as the bladder is compressed by the fetal head.

Premonitory symptoms (6) This descending diminishes the fundal height and hence minimises the pressure on the diaphragm. This makes the woman more comfortable and has an easier time breathing. It is a welcome sign, as it rules out cephalopelvic disproportion and other conditions preventing the head from entering the pelvic inlet.

Premonitory symptoms (7) • Blood show With the onset of labor, there is profuse cervical secretion. Simultaneously, there is slight oozing of blood from rupture of capillary vessels of the cervix and from the raw decidual surface caused by separation of the membranes due to stretching of the lower uterine segment. Expulsion of cervical mucus plug, mixed with blood is called show. This bloody show results as the cervix begins thinning out with the concomitant extrusion of mucus from the endocervical glands. Patients often report the passage of blood-tinged mucus late in pregnancy.

Premonitory symptoms (8) Cervical changes: several days prior to the onset of labor the cervix becomes ripe. A ripe cervix is soft, less than 1.3cm in length, admits a finger easily and is dilatable. Cervical effacement is common before the onset of true labor.

Ture labor or in labor • Painful uterine contractions • Increasingly intense and frequent • Is associated with progressive cervical effacement and dilation • Regular contraction occur every 5 minutes, duration lasts more than 30 seconds

False labor and true labor 1.discomfort is characterized as over the lower abdomen and groin areas 2.without effect on dilation of the cervix (not associated with progressive dilation ) 3.typically shorter in duration 4.less intense 5.relieved by administration of a sedative or ambulation 1.over the uterine fundus,with radiation of discomfort to the low back and low abdomen. 2. Associated with effacement and dilation 3. Increasingly intense and frequent 4. Regular and effective

Essential factors of labor(1) The progress and final outcome of labor are influenced by 4 factors: 1) the labor force 2) the passage (the bony and soft tissues of the maternal pelvis) 3) the passenger (fetus) 4) the psyche. Abnormalities of any of these components, singly or in combination, may result in dystocia.

Essential factors of labor(2) Uterine contraction. Labor force Abdominal muscle. Levator ani muscle Bony canal (pelvis) (no change) Birth canal vulvar, vagina, cervix, Lower uterine segment Fetal position Fetus Fetal size Psychic factors. A high level of anxiety during pregnancy has been associated with decreased uterine activity and with longer and dysfunctional labor.

Essential factors of labor(3) LABOR FORCE 1) Uterine contraction. It is the major force through the whole course of labor. It includes contraction and retraction. There are three effective features. Rhythmy and Intermittent Dominance and pacemaker Retraction.

Essential factors of labor(4) LABOR FORCE-uterine contraction (1) Dominance and pacemaker Uterine contraction in labor (patterns of contraction) there is good synchronisation of the contraction waves of both halves of the uterus. The pacemaker of uterine contractions is probably situated in the region of the cornu from where waves of contraction spread downwards.

Essential factors of labor(5) LABOR FORCE

Essential factors of labor(6)LABOR FORCE • Electrical traces of the pattern of uterine contraction show that in normal labor each contraction wave starts near one or other uterine cornu. The contraction spreads as a wave in the myometrium, taking 10-30 seconds to spread over the whole uterus.

Essential factors of labor(7)LABOR FORCE Dominance :The upper segment contracts more strongly than the lower part, and the duration is longer than in the lower segment, this dominance of the upper segment leads to the stretching and thinning of the lower segment and to dilation of the cervix.

Essential factors of labor(8)LABOR FORCE • (2) The contractions are regular and rhymic.

Essential factors of labor(9)LABOR FORCE After contractions there is a intermittent. As labor progress, the intensity increase, frequency increase, contractile duration prolong and intermittent shorten gradually, by the end of the first stage of labor the contraction may come every 1 to 2 minutes and may last as longas a minute.

Essential factors of labor(10)LABOR FORCE • Intermittent : The intermittent nature of the contractions is of great importance to both the fetus and the mother. During a contraction the circulation to the placental bed through the uterine wall is stopped; if the uterus contracted continuously the fetus would die from lack of oxygen. The intermittent allow the placental circulation to be re-established and give the mother time to recover from the fatigue effect of the contraction. The uterus is a large muscle and contractions use up a lot of energy, if continued too long this would produce maternal exhaustion.

Essential factors of laborLABOR FORCE uterine contraction include three parts: intensity duration frequency

Essential factors of laborLABOR FORCE • Intensity of contraction: it describes the degree of uterine systole. The intensity gradually increases with advancement of labor until it becomes maximum in the second stage during delivery of the baby. During the first stage intrauterine cavity pressure is raised to 40-50mmHg and during second stage it is raised about to 100-120 mmHg. Frequency: in the early stage of labor, the contraction come at intervals of 10-15 min. The intervals gradually shorten with advancement of labor until in the second stage, when it comes every one or two minutes.

Essential factors of laborLABOR FORCE Duration: in the first stage, the contraction lasts for about 30-40 seconds initially but gradually increases in duration with the progress of labor. Thus in the second stage, the contractions last longer than in the first stage.

Essential factors of labor(11)LABOR FORCE-- retraction • Uterine contraction and retraction is throughout the full labor. The uterus not only contract but also retract. The dilation of the cervix, descent of presenting part and progress of labor depend on the uterine contraction and retraction.

Essential factors of labor(12)LABOR FORCE-- retraction • Retraction: retraction is a phenomenon of the uterus in labor in which the muscle fibres are permanently shortened, it is different from the contraction. Retraction is specially a property of upper uterine segment. Contraction is a temporary reduction in length of the fibres, which attain their full length after the contraction passes off. In contrast, retraction results in permanent shortening and the fibres are shortened once and for all. When the active contraction passes off the fibres lengthen again, but not to their original length.

Essential factors of labor(13)LABOR FORCE-- retraction

Essential factors of labor(14)LABOR FORCE-- retraction If contraction was followed by complete relaxation no progress would be made, in retraction some of the shortening of the fibres is maintained. So the uterine cavity becomes progressively smaller with each contraction. The net effect of retraction in normal labor are: -- essential property in the formation of lower segment and dilation and taking up of the cervix -- to maintain the advancement of the presenting part made by the uterine contraction and to help in ultimate expulsion of the fetus -- to reduce the surface area of the uterus favouring separation of placenta

Essential factors of labor(15)LABOR FORCE • Abdomenal muscle and diaphram. • In second stage,delivery of the fetus is accomplished by the downward thrust offered by uterine contractions supplemented by voluntary contraction of abdominal muscles against the resistance offered by bony and soft tissues of the birth canal. • Help fetus and placenta delivery in the second stage and third stage.

Essential factors of labor(16)LABOR FORCE • the expulsive force of uterine contraction is added by voluntary contraction of the abdominal muscles called “bearing down” efforts. • Pelvic floor (levator ani muscle.) Help fetus internal rotation

Essential factors of laborbirth canal The bony canal The bony canal means true pelvis, its size and shape is relation with delivery closely. There three plane. Pelvic inlet plane. The true conjugate describe the anteroposterior dimension of the inlet, it is average 11cm. The transverse diameter of the inlet is average 13cm. An oblique diameter is average 12.75cm.

Essential factors of laborbirth canal Pelvic midplane. it is the smallest plane of the pelvic canal. Its anteroposterior diameter is average 11.5cm. its transverse diameter between the ischial spines( interspinous diameter) is average 10cm The plane of least dimensions is an important obstetric plane because shortening of its diameters frequently is associated with obstructed labor.

Essential factors of laborbirth canal pelvic outlet plane. The plane of the pelvic outlet is actually two triangular planes at different inclinations that share the same base. The transverse diameter, between the inner margins of the ischial tuberosites, average 9cm. • pelvic axis and inclination of pelvis

Essential factors of laborbirth canalThe soft birth canal The formation of lower segment. • Before labor begins, the uterine body appears to be a single unit. However, uterine contractions soon cause it to differentiate into visibly different upper and lower segments. • The upper segment is actively contractile, thick, and powerful. The lower segment is passive, thin, and distensible. • The physiologic retraction ring separates the two segments.

Essential factors of laborbirth canal

Essential factors of laborbirth canal This powerful segment draws the weaker, thinner and more passive lower segment up over its contents, and in so doing pulls up and then dilates the cervix. The wall of the upper segment becomes progressively thicker with progressive thinning of the lower segment. This is pronounced in late first stage, specially after rupture of the membranes and attains its maximum in second stage. A distinct ridge is produced at the junction of the two segments, called physiological retracting ring.

Essential factors of laborbirth canal • The change of cervix After cervical effacement ,dilation of cervix begins in primigravidae. But in multiparae the effacement and dilation occur together.

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Debunking the Myths of Older Adult Falls

Stay falls and injury free.

Did you know you have the power to lower your risk of falling? Take our 2-minute Falls Free CheckUp to see what causes falls and how to prevent them.

NCOA Partners in Falls Prevention

Exercise Snacks: How to Fit Some Movement into Your Day

Get the Facts on Healthy Aging

Maintaining your medication record form, video: 6 steps to prevent a fall, how to detect falls with tech.

Learn more about medical alert systems with automatic fall detection, how they sense falls, and how their immediate alerts can help when it's needed.

Falls Prevention Success Stories

Dorothy wall's falls prevention story.

Sandy Perry's Falls Prevention Story

Elizabeth goldfarb's falls prevention story, marjorie brown's falls prevention story, marjorie franck's falls prevention story.

John Feirich's Falls Prevention Story

Can Exercising Prevent Falls?

Anyone of any age or ability can get stronger and improve their balance. And staying strong and having good balance are especially important for older adults. Why?

More Stories

Get the facts on osteoporosis, falls, and broken bones.

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