17.

Normal Labor and Delivery

INTRODUCTION

Noindent Childbirth is the period from the onset of regular uterine contractions until expulsion of the placenta. The process by which this normally occurs is called labor

English language. According to the New Shorter Oxford English Dictionary (1993), toil, trouble, suffering, bodily exertion, especially when painful, and an outcome of work are all characteristics of labor and thus implicated in the process of childbirth. Such connotations all seem appropriate to us and emphasize the need for all attendants to be supportive of the laboring woman's needs, particularly in regard to effective pain relief. At Parkland Hospital in 2003, only 53 percent of 12,139 women with singleton cephalic presentations at term had a spontaneous labor and delivery. The remainder had ineffective labor requiring augmentation (29 percent) or other medical and obstetrical complications requiring induction of labor. It seems excessive to consider almost 50 percent of parturients as "abnormal" because they did not spontaneously labor and deliver. Hence, the distinction between normal and abnormal is often subjective. This high prevalence of labor abnormalities, however, can be used to underscore the importance of labor events in the successful outcome of pregnancy.

MECHANISMS OF LABOR At the onset of labor, the position of the fetus with respect to the birth canal is critical to the route of delivery. It is thus of paramount importance to know the fetal position within the uterine cavity at the onset of labor.

LIE, PRESENTATION, ATTITUDE, AND POSITION. Fetal orientation relative to the maternal pelvis is described in terms of fetal lie, presentation, attitude, and position.

Fetal Lie. The lie is the relation of the long axis of the fetus to that of the mother, and is either longitudinal or transverse. Occasionally, the fetal and the maternal axes may cross at a 45-degree angle, forming an oblique lie, which is unstable and always

becomes longitudinal or transverse during the course of labor. Longitudinal lies are present in over 99 percent of labors at term. Predisposing factors for transverse lies include multiparity, placenta previa, hydramnios, and uterine anomalies.

Fetal Presentation. The presenting part is that portion of the fetal body that is either foremost within the birth canal or in closest proximity to it. It can be felt through the cervix on vaginal examination. Accordingly, in longitudinal lies, the presenting part is either the fetal head or breech, creating cephalic and breech presentations, respectively. When the fetus lies with the long axis transversely, the shoulder is the presenting part and is felt through the cervix on vaginal examination. Table 17-1 describes the incidences of the various fetal presentations.

CEPHALIC PRESENTATION. Such presentations are classified according to the relationship between the head and body of the fetus (Fig. 17-1). Ordinarily, the head is flexed sharply so that the chin is in contact with the thorax. The occipital fontanel is the presenting part, and this presentation is referred to as a vertex or occiput presentation. Much less commonly, the fetal neck may be sharply extended so that

face presentation (see Fig. 20-6, p. 507). The fetal head may assume a position between theseextremes, partially flexed in some cases, with the anterior (large) sinciput presentation other cases to have a brow presentation (see Fig. 20-9, p. 508). These latter two presentations are usually transient. As labor progresses, sinciput and brow presentations almost always are converted into vertex or face presentations by neck flexion or extension, respectively. Failure to do so can lead to dystocia, as discussed in Chapter 20. The term fetus usually presents with the vertex, most logically because the uterus is piriform shaped. Although the fetal head

bulkier and more mobile than the cephalic pole. The cephalic pole is composed of the fetal head only. Until about 32 weeks, the amnionic cavity is large compared with the fetal mass, and there is no crowding of the fetus by the uterine walls. Subsequently, however, the ratio of amnionic fluid volume decreases relative to the increasing fetal mass. As a result, the uterine walls are apposed more closely to the

fetal parts. If presenting by the breech, the fetus often changes polarity to make use of the roomier fundus for its bulkier and more mobile podalic pole. Although the incidence of breech presentation is only a little over 3 percent at term, it is much greater earlier in pregnancy. Scheer and Nubar (1976), using ultrasonography, found the incidence of breech presentation to be 14 percent between 29 and 32 weeks' gestation. Subsequently, the breech converted spontaneously to vertex in increasingly higher percentages as term approached. The high incidence of breech presentation in hydrocephalic fetuses is in accord with this theory, because in this circumstance, the cephalic pole of the fetus is larger than the podalic pole.

BREECH PRESENTATION. When the fetus presents as a breech, the three general configurations are frank, complete, and footling presentations. These all are described in Chapter 24 on management of breech presentations. Breech presentation may result from circumstances that prevent normal version from taking place, for example, a septum that protrudes into the uterine cavity (see Chap. 40, p. 953). A peculiarity of fetal attitude, particularly extension of the vertebral column as seen in frank breeches, also may prevent the fetus from turning. Placentas implanted in the lower uterine segment may distort normal intrauterine anatomy and result in a higher incidence of breech presentation.

Fetal Attitude or Posture. In the later months of pregnancy the fetus assumes a characteristic posture described as attitude or habitus (see Fig. 17-1). As a rule, the fetus forms an ovoid mass that corresponds roughly to the shape of the uterine cavity. The fetus becomes folded or bent upon itself in such a manner that the back becomes markedly convex; the head is sharply flexed so that the chin is almost in contact with the chest; the thighs are flexed over the abdomen; the legs are bent at the knees; and the arches of the feet rest upon the anterior surfaces of the legs. In all cephalic presentations, the arms are usually crossed over the thorax or become parallel to the sides, and the umbilical cord lies in the space between them and the lower extremities. This characteristic posture results from the mode of growth of the fetus and its accommodation to the uterine cavity. Abnormal exceptions to this attitude occur as the fetal head becomes progressively more extended from the vertex to the face presentation (see Fig. 17-1D). This results in a progressive change

in fetal attitude from a convex (flexed) to a concave (extended) contour of the vertebral column.

Fetal Position. Position refers to the relationship of an arbitrarily chosen portion of the fetal presenting part to the right or left side of the maternal birth canal. Accordingly, with each presentation there may be two positions, right or left. The fetal occiput, chin (mentum), and sacrum are the determining points in vertex, face, and breech presentations, respectively (Figs. 17-2, 17-3, 17-4, 17-5, and 17-6). Because the presenting part may be in either the left or right position, there are left and right occipital, left and right mental, and left and right sacral presentations, abbreviated as LO and RO, LM and RM, and LS and RS, respectively.

Varieties of Presentations and Positions. For still more accurate orientation, the relationship of a given portion of the presenting part to the anterior, transverse, or posterior portion of the maternal pelvis is considered. Because the presenting part in right or left positions may be directed anteriorly (A), transversely (T), or posteriorly (P), there are six varieties of each of the three presentations (see Figs. 17-2, 17-3, 17-4, 17-5, and 17-6). Thus, in an occiput presentation, the presentation, position, and variety may be abbreviated in clockwise fashion as: Approximately two thirds of all vertex presentations are in the left occiput position, and one third in the right. In shoulder presentations, the acromion (scapula) is the portion of the fetus arbitrarily chosen for orientation with the maternal pelvis. One example of the terminology sometimes employed for this purpose is illustrated in Figure 17-7. The acromion or back of the fetus may be directed either posteriorly or anteriorly and superiorly or inferiorly (see Chap. 20, p. 509). Because it is impossible to differentiate exactly the several varieties of shoulder presentation by clinical examination, and because such differentiation serves no practical purpose, it is customary to refer to all transverse lies simply as shoulder presentations. Another term used is transverse lie, with back up or back down.

Figure 17-1. Longitudinal lie. Cephalic presentation. Differences in attitude of the fetal body in (A) vertex, (B) sinciput, (C) brow, and (D) face presentations. Note changes in fetal attitude in relation to fetal vertex as the fetal head becomes less flexed.

Figure 17-2. Longitudinal lie. Vertex presentation. A. Left occiput anterior (LOA). B. Left occiput posterior (LOP). Figure 17-3. Longitudinal lie. Vertex presentation. A. Right occiput posterior (ROP). B. Right occiput transverse (ROT). Figure 17-4. Longitudinal lie. Vertex presentation. Right occiput anterior (ROA). Figure 17-5. Longitudinal lie. Face presentation. Left and right anterior and right posterior positions. Figure 17-6. Longitudinal lie. Breech presentation. Left sacrum posterior (LSP). Figure 17-7. Transverse lie. Right acromiodorsoposterior (RADP). The shoulder of the fetus is to the mother's right, and the back is posterior. Figure 20-6. Face presentation. The occiput is the longer end of the head lever. The chin is directly posterior. Vaginal delivery is impossible unless the chin rotates anteriorly.