Normal Labor and Delivery

Dr. H. R. Siswosudarmo
Faculty of Medicine, UGM
Yogyakarta
 Terminologies

 Contraction: uterine contraction leading to

cervical dilatation
 Effacement: shortening or thinning of the
cervix
 Dilatation: dilatation of the external os
 Station or plane: arbitrary level or plane in
the birth canal
 Descent: level of the presenting part in the
birth canal
 Presenting part: the lowermost part of the
fetus
 Terminologies
 Lies: relation between fetal long axis against
maternal long axis
 Longitudinal
 Transverse
 Oblique (transient)
 Presentation: portion of the fetus that lies in the
most caudal (inferior) part of the mother
 Vertex or cephalic
 Breech
 Shoulder (transverse lie)
 Face (maximally deflexed in vertex presentation)
 Terminologies
 Position: relation of the arbitrarily point of the
presenting part (denominator) against plane of the
birth canal
 In vertex presentation (occiput): LOT, ROT or LOA, RCA,
and less common, LOP and ROP
 In breech presentation (sacrum): LST, RST, LSA and LSP
 In face presentation, chin is the denominator
 Attitude: relation between fetal longitudinal axis of
the head against fetal longitudinal axis of the body
 Flexion Denominator: occiput
 Mild deflexion Sinsiput
 Moderate deflexion Brow
 Maximal deflexion Chin
 Labor or Persalinan: definition:

 Labor: All processes from the onset of contraction

to the end of the forth stage (2 hours after delivery
of he placenta)
 Four stages of labor:
 First: Dilatation of the cervix (1-10 cm)
 Second: Expulsion of the fetus, or delivery
 Third: Expulsion of the placenta
 Fourth: Hemostasis period, 2 hours after expulsion of
the placenta
 Delivery or Kelahiran

 Definition: Expulsion of the fetus (second stage)

 Delivery is included in labor.
 Types:
 Spontaneous delivery vs. Assisted delivery
 Kelahiran spontan vs kelahiran berbantu
 Operative delivery
 vaginal (vacuum or forceps, embryotomy)
 Abdominla (C section)
 Vaginal vs. Abdominal (Cesarean section)
 Kelahiran vaginal vs kelahiran abdominal
 Normal labor and delivery,
definition
 Spontaneous initiation
 Pregnancy age: 37-42 weeks
 Longitudinal lie, occiput presentation
 Duration of the first stage: 4-18 hours
 Spontaneous and vaginal expulsion
 Amount of bleeding: < 500 ml
 Pregnancy outcome: good
Leopold maneuver
Pelvic or Bimanual examination
Clinical pelvimetry
 Cervix during labor,

 Unripe: Ripe:
 Closed  Dilated
 Stiff  Soft
 No effacement  Effaced
 Posterior  Mid or anterior position
position
Cervical dilatation
Effacement, dilatation and retraction ring
Engagemnt & descent
 First stage
 PARTOGRAPH
 Uterine contraction: frequency, duration, intensity
 Fetal heart rate: every 30 ‘ (uncomplicated) and 15 ‘ for high
risk fetus or electronic fetal monitoring
 Descent (external and internal)
 Maternal vital signs: BP, T, PR every 4 hours
 First vaginal ex: dilatation, thickness, and consistency of the
cervix, presentation, position, station, membrane, and
cephalopelvic balance (clinical pelvimetry)
 Next vaginal ex: 2-4 hours  dilatation, internal rotation and
descent)
 Oral intake: avoid dehydration especially for prolonged labor
 Intravenous fluid: indicated for potential bleeders
 Analgesia: indicated in certain condition
First stage
Dilatation and descent of fetal head
Station
 Longitudinal lies, cephalic presentation
Different attitudes, different presentation
Position of the Occiput
Position of the Occiput
Vertex presentation, different position
Position of the Occiput
Deflexed head, face presentation
Longitudinal lie, breech position
Transverse lie, position of the acromion
Cardinal mouvement
Engagement
 Cardinal mouvement
Further decent and Internal rotation
 Cardinal mouvement
Extensoin and external rotation
 Cardinal mouvement
Delivery of the anterior and posterior shouldes
Synclitism and asynclitism
Lever action
Flexed head, shorter diameter is
suboccipito bregmatica
Second stage, Episiotomy
Delivery of the head
Suction of the nose
Umbilical cord rounds the neck
Third stage, delivery of placenta
 Prevensi: MAKT
J Obstet Gynaecol Can 2003;25(11):952–3.

1. Tujuan
a. meningkatkan kontraksi uterus
b. mempercepat lahirnya plasenta
c. menurunkan kejadian perdarahan
pascasalin karena atoni uteri

2. Tiga komponen utama yakni:

(a) pemberian uterotonika,
(b) tarikan tali pusat terkendali dan
(c) masase uterus setelah plasenta lahir.
 Manajemen Aktif Kala III
Risanto Siswosudarmo, Bagian OBGIN FK UGM
(J Obstet Gynaecol Can 2003;25(11):952–3)

 Suntik 10 unit oksitosin (1 ampul) segera setelah janin lahir.

 Tunggu uterus kontraksi
 Ibu merasa mules, Uterus berbentuk globuler, Uterus terasa
keras
 Lakukan tarikan terkendali pada talipusat kearah ventro kaudal,
sambil melakukan counter-pressure kearah dorsokranial untuk
menghindari inversi uterus, sambil ibu diminta mengejan.
 Lakukan masase fundus uterus
 segera setelah plasenta lahir sampai uterus berkontraksi
kuat
 ulangi masase tiap 15 menit dan yakinkan uterus tidak lembek
setelah masase berhenti.
 Observasi di kamar bersalin sampai 2 jam pascasalin
Degree of perineal rupture
Repair of perineum (perineorraphy)
Repair of perineum (perineorraphy)
Delivery room
Handheld Doppler fetal heart
rate monitor
Cardiotocography
Reactive Non-Stress Test (CTG)
Normal Contraction Stress Test
(CTG)
Abnormal Contraction Stress Test
(CTG)
Late deceleration
 Second stage
 Signs and symptoms:
 Bearing down sensation
 Dilated anus
 Vomiting
 Ruptured membrane
 Bimanual (Vaginal) examination
 Check for dilatation and descent
 Determine: station, position of denominator
 Check for cord prolapsed
 Preparation
 Dorsal lithotomy with leg holder
 Supine with flexed, semi-abducted hip and flexed knee
 Catheterization, if bladder is disturbing
 Delivery the head (1)
 Engagement: Sagital suture fits the transverse
diameter of the inlet (occiput in 3 or 9 o’clock)
 Flexion
 Descent
 Internal rotation (occiput moves to 12 o’clock, to fits
the mid pelvis)
 More descent
 Crowning (distension of the head on the vaginal
opening as wide as 3-4 cm diameter)
 Delivery the head (2)
 Episiotomy (if necessary)
 Extension of the head
 External rotation
 Delivery of the anterior followed by posterior
shoulders
 Delivery of the rest of the body
 Clamp the cord on two points, cut
 Deliver the newborn to baby nurse
 Third stage
 Delivery of the placenta, active management
 Oxytocin 10 IU soon after delivery of the fetus
 Or, 3 tablets of 200 mg misoprostol orally or rectally
 Catheterization in case of full bladder
 Examine signs of separation of the placenta
 Controlled cord traction and counter pressure on the
suprasymphisis dorsocranially to avoid inverted
uterus
 Examine maternal surface to detect missing
cotyledon
 Methylergonovin maleat 0.3 mg i. m. only if indicated
(bleeding or weak contraction)
 Massage on the fundus
 Forth stage

 Monitor vital sign

 Every 15 minutes: the first hour
 Every 30 minutes: the second hour
 Monitor uterine contraction
 Repair episiotomy
 Monitor bleeding especially for potential
bleeders
Synclitism and asynclitism
Engagement, descent to delivery of the head
Delivery of the placenta
Repair of episiotomy or perineal rupture
Transverse lie with subseptate
uterus & low lying placenta
Deflection of the head