OBSTETRIC TERMS

I. Presentation:

 Presentation - is the part of the fetus found in the

lower pole of the uterus and first felt during
vaginal examination
 The normal presentation is vertex,
 Abnormal presentations are breech, face, brow
and shoulder.
Normal Labor and Childbirth
 II. Fetal lie
The relation of the fetal long axis to that of
the mother long axis is termed fetal lie and
is either
 longitudinal or
transverse
oblique lie, which is unstable and always
becomes longitudinal or transverse during
labor
• The normal lie is longitudinal and the
abnormal lie is transverse, or oblique lie.
Normal Labor and Childbirth
 III. ATTITUDE

• The position of head with regard to the fetal spines (the degree
of flexion and/or extension of the fetal head).

- Flexion in the majority of cases

- Extension in face and brow presentation

- The normal attitude is flexion, the abnormal are extension or

deflection

Normal Labor and Childbirth

Longitudinal lie & Cephalic presentation Differences in attitude of the fetal body

Normal Labor and Childbirth

 IV.Position
• Position of the fetus refers to the relationship of
the fetal presenting part to the maternal pelvis.
• It can be assessed most accurately on vaginal
examination.
• Malposition is any position in labor which is not
ROA, LOA or OA
V. Denominator - The part of the fetus which
determines the position (Vertex-occiput, breech–
sacrum, Face - mentum).
Normal Labor and Childbirth
Normal Labor and Childbirth
Normal Labor and Childbirth
Normal Labor and Childbirth
Normal Labor and Childbirth
Normal Labor and Childbirth
Normal Labor and Childbirth
Right occiput anterior

Normal Labor and Childbirth

Right occiput posterior

Normal Labor and Childbirth

 VI. STATION
• Is the level of presenting part in relation to the
ischial spines
• New classification attempts to quantitate in
centimeter the distance of the leading bony edge
from the ischial spines of the maternal pelvis(-5
to +5).

Normal Labor and Childbirth

 STATIONS

Station 0 = the vertex is at the level of ischial spines

 Stations -1,-2, -3, -4 and-5 represents 1, 2, 3,4 and 5

cm respectively above the level of ischial spines

 Stations +1, +2 +3 +4 and +5 represents 1, 2, 3,4

and 5 cm respectively below the level of ischial

spines

Normal Labor and Childbirth

station

Normal Labor and Childbirth

Normal Labour

17
Introduction

• Labor is a sequence of uterine contractions that results in

effacement and dilatation of the cervix and voluntary

bearing down efforts leading to the expulsion per vagina

of the products of conception.

Causes of the Onset of Labour

• The exact causes of the onset of labour remains

uncertain but multi factors appear combination of

hormonal and mechanical factors. 18

Cont….
1. Hormonal Factors
A. Oestrogen Increasing Theory

• In the last 2 weeks of pregnancy there is a surge of

maternal oestrogen these stimulate prostaglandin

production.

B. Progesterone Withdrawal Theory

• Progesterone has a sedative action on uterine muscle so

it’s withdrawal at the end of pregnancy may facilitate the

onset of labour 19
Cont.....

C. Oxytocin Releasing Theory

• The increase in oxytocin receptor number in myometrium

at term may be attributable to increased oxytocin.

D. Prostaglandins Releasing Theory

• The local releases of prostaglandins from the uterus may

be major elements in the onset of labour.

20
Cont......

E. Relaxin Decline Theory

• Plasma levels of relaxin are greatest at between 8 and 12

weeks that promotes myometrium relaxation and there
after decline to lower levels that persist until term.

F. Collagen Breaks Down Theory

• Around term there is a continuous decrease amount of

collagen in the last few days or weeks of pregnancy.

21
Cont......

G. Fetal Contribution to the Initiation of Labour

• The installation of cortisol in to the amniotic fluid has

been shown to induce labour which may in turn act up on
the placenta to increase the production of estrogen.

22
Cont…..

2. Mechanical Factors

Engagement of the Presenting Part

• The pressure of the presenting part on the nerve
endings in the cervix may play some part experience
shows that labour is more likely to start on time.

Over Distension of the Uterus

• This may be brought about by over stretching as in the
case of a multiple pregnancy and Polyhydramnios. 23
Criteria for Normal Labour

• Delivery of a single baby and vertex presentation

• No fetopelvic disproportion, Vaginally (no operative

intervention)

• Delivery occur at or near term and with spontaneous onset

• The whole process of delivery getting over within 24 hours

• With minimal intervention

• No heavy sedation or analgesia and oxytocin

• Labour complete with healthy mother and a healthy foetus

24
Cont…..
The Premonitory Sign of Labour

• Lightening (2-3 weeks before the onset of labour)

• Frequency of Micturation

• False Pains (Spurious Labour)

• Taking Up of the Cervix (Effacement)

25
Cont.....

Signs and Symptoms of Normal Labour

• Uterine contractions (regular and painful)

• Show (operculum released with little blood from the

dilating cervix)

• Dilation of the cervix (this is the surest sign)

• Rupture of the membranes

26
Types of Labour
Labour has been divided in to two the true and false labour:
Features True Labour False Labour

Cervix Softens, effaces and dilates May soften but no change in

dilation and effacement
Presenting part Starts descent in to the pelvis No change

Show It is a release of operculum and little blood from the No show

dilating Cervix.
Uterine Pains occur at regular intervals (rhythmic) Pains occur at irregular intervals
contraction
Intervals gradually shorten No change

Duration and intensity gradually increase No change

Intensity increase with walking May stop with walking or position

change
Contraction usually felt in lower back radiating to lower Are usually felt in back and upper
abdomen funds
Are not stopped by relaxation techniques such as hot bath, Will eventually stop with
alcoholic drink and sedation relaxation techniques.
27
Cont...

Stages of Labour

• Labour is a continuous process but we divided in to 4

stages in order to study the process:-

1. First stage

2. Second stage

3. Third stage

4. Fourth stage
28
Cont…..
I. First Stage of Labour
• Is the stage of dilation of the cervix
• It lasts from the onset of true labour until full dilatation
of the. i.e.10 cm
• It takes about 12 hours in primigravida and about 6
hours in multipara.
• Longest stage of labor

29
Cont....
• It has 2 phases: - Latent Phase of Labour and Active
Phase of Labour
First Stage Latent Phase First Stage Active Phase

Lasts until cervical dilatation is 4 cm and is Starts when the cervix is 5cm dilated and is
accompanied effacement of the cervix completed at full dilatation

Contraction irregular in interval, strength Contraction regular in interval, strength and

and duration duration

Cervix is < 90% effaced and < 4 cm dilated Cervix effaced > 90% and dilated above 5
cm.

Completed up to 8 hour Completed within 12 hours

30
Cont…..
Recognizing the First Stage of Labour
Recognition by the Mother
• Show
• Contraction
• Rupture of the Membrane

Confirmation by the Nurse

• Uterine Contraction and Vaginal Examination

31
Cont…..
Performing Vaginal Examination during the 1st Stage of Labor

Indication of Vaginal Examination

• To make a positive diagnosis of labour

• To make a positive identification of presentation

• To determine whether the head is engaged in case of doubt

• To ascertain whether the fore waters have ruptured or to

rupture them artificially

• To exclude cord prolapse after rupture of the fore waters

• To assess progress of labor in second twin 32

Partograph
• Partograph is the graphic recording of the progress of labor and

the salient condition of the mother and the fetus.

Importance of partograph

• Early detection of abnormal progress of a labour

• Prevention of prolonged labour

• Recognize cephalopelvic disproportion

• Assist in early decision on transfer and augmentation

• Early recognition of maternal or fetal problems

• Decrease the rate of unnecessary Cesarean Section

33
Cont….
Components of the partograph
1. Personal Information
• Includes Name, Gravida, para, hospital number, and
date of admission, time of admission and time of
ruptured membranes are written at the top of the
graph.

34
Cont……
2. Fetal condition

• Fetal heart rate: Record every half hour (.)

• Membranes & liquor:

 Intact membranes (I)

 Ruptured membranes and clear liquor (C), meconium stained

liquor (M)and blood stained liquor (B).

• Moulding of the fetal skull bones

 Separated bones sutures felt easily (0), sutures apposed (+),

Overlapping bones and reducible(++), Severely overlapping

bones and non reducible (+++) 35
Cont….
3. Progress of labour

Cervical dilatation:

• Assessed at every vaginal examination and marked with a cross (X).

• Alert line: A line starts at 5 cm of cervical dilatation to the point of

expected full dilatation at the rate of 1 cm per hour. When progress

of labour is normal and satisfactory, plotting of cervical dilatation

remains on the alert line or to left of it

• Action line: Parallel and 4 hours to the right of the alert line. This is

the critical line at which specific management decisions must be

36
made at the hospital.
Cont….

Descent of the fetal head

• Assessed by abdominal examination, using the rule of fifth to assess

engagement. Assessed at every vaginal examination and recorded as a circle (O).

• Hours: Refers to the time elapsed since onset of active phase of labour.

• Time: Record actual time.

Uterine contractions
• Chart every half hour; palpate the number of contractions in 10 minutes and

their duration in seconds. Each square represents one contraction.

• Less than 20 seconds: , Between 20 and 40 second: , More than 40

seconds: 37
Cont…..
4. Maternal condition

• Oxytocin: If labour is augmented, Record the amount of

oxytocin and drops per minute every 30 minutes

• Drugs IV fluids: Record any additional drugs given.

• Pulse: Record every 30 minutes and mark with a dot (●).

• Blood pressure: Record every 4 hours and mark with arrows.

• Temperature: Record every 2 hours.

• Urine volume, analysis for protein and acetone: Record every

time urine is passed. 38
39
Cont…..
II. Second Stage of Labor
• The stage of descent and delivery of the baby.
• Begins with full cervical dilatation and ends with the
delivery of the fetus.
• The median duration of the second stage is 1hour in
primigravida and 30minutes in multiparas.

40
Cont……

Sign and Symptoms of Second Stage of Labour

Positive Sign

• No Cervix felt on vaginal examination

Probable Signs

• Expulsive uterine contraction and Trickling of blood

• Rupture of the membranes

• Anus and vulval gaping , Bulging of the perineum

• Tenseness between coccyx and anus

• Presenting part appearing at the vulva

41
Cont……
The Mechanism of Normal Labor (Cardinal Movements)

1. Descent 6. Restitution of the head

7. Internal rotation of the

2. Flexion of the head
shoulders
3. Internal rotation of
8. External rotation of the
the head
head
4. Crowning of the head 9. Lateral flexion of the

5. Extension of the head body (Delivery of

shoulders & body) 42
The mechanism of normal labor

43
Preparations for conducting normal delivery

• Put personal protective equipment’s (PPE)

• Wash hands and Put on surgical glove

• The vulva should washed with an antiseptic solution

• A sterile drapes should be placed under the mother and

over abdomen

• An anal pad should cover the anus

• Once again check delivery set

44
Conducting Normal Delivery
a. Flexion of the Head
• Press one hand firmly on the perineum. This hand will
keep the baby’s chin close to its chest and making it
easier for the head to come out.

45
Cont……
b. Crowing and Extension of the Head
• Crowning needs to take place in a slow controlled
manner ideally towards the end of the contraction with
the mother breathing the head out you should place the
flat of one hand over the fetal head to guide its
expulsion in a slow and graduated manner.

46
Cont….
c. Delivery of the Head
• The head can be slightly extended until it is completely
born. Swab the eyes, nose and mouth. Then check that
there is no cord around the neck (Nuchal cord). Then
after wait for restitution.

47
Cont…..
d. Delivery of Shoulders
• After its birth the head falls posteriorly bringing the face
almost in to contact with the anus and the occiput
promptly turns toward one of the maternal thighs
(restitution).
• Gentle downward traction with the next contraction will
bring the anterior shoulder under the symphysis pubis,
Gentle upward traction will then deliver the posterior
shoulder over the Perineum.
48
Cont…..

e. Delivery of the Baby’s Body

• After the shoulders are born, the rest of the body
usually slides out without any trouble.
49
III. Third stage of labour
• It is the stage of expulsion of the placenta and
membranes
• Begins after delivery of the fetus and ends with
expulsion of the placenta and membranes and bleeding
is controlled.
• Its duration is about 15 minutes in both primi and
multiparas.
• Shortest stage of labor and the most dangerous stage
50
Cont....
Physiology of the Third Stage of Labour
1. Separation of the placenta
2. Descent of the placenta
3. Expulsion of the placenta
4. Control of bleeding shear

51
Cont…..

Components of Active Management of Third Stage of

Labour (AMTSL)

1. Giving uterotonic (uterine contracting) drug within

one minute of birth of the newborn.

2. Tying and cutting of the cord

3. Controlled cord traction

4. Uterine massage after delivery of the placenta to

52
keep the uterus contracted
IV. Fourth stage of labour
• Is the stage of observation or early recovery
• Begins immediately after expulsion of the placenta and
membranes and lasts for 1hour.
• Careful observation of the patient for signs of PPH is
essential.

53
Performing Episiotomy in Second Stage of Labor

• Is making of an incision in to the perineum to enlarge the

vaginal orifice

Indications for Episiotomy

• Rigid or narrow vaginal introits

• Maternal illness to shorten second stage of labor

• Prolonged second stage of labor

• To make more room during instrumental delivery

• Fetal distress, Big head

54
• Mal position or Malpresantation
Types of Episiotomy
Medio- lateral (Recommended)
Median
J-shaped
Lateral

55
Cont……

1. Medio-lateral

• The incision is begun in the center of the fourchette and

directed postero- laterally usually to the woman’s right.

• It should be not more than 3cm long and it must be far

2.5cm from the anus

2. Median

• The incision begun in the center of the fourchette is directed

approximately 2.5 cm down to the anus. 56

Cont……

3. J-shaped
• The incision is begun in the center of the fourchette and
directed posterior in the midline for about 2 cm and
then directed towards to lateral.

4. Lateral

• This incision is begun one or more cm distant from the

center of the fourchette.

57
Technique of Infiltration of Local Analgesia for Episiotomy
• First explanation to mother is very important then after
10 ml of 0.5% or 5ml of 1% solution of lidocaine
should be prepared with 10 ml of syringe .
• Then left hand guards fetal head to prevent infiltration
in to the head. With the other hand infiltrate the
lidocaine.

58
Making the Episiotomy
• Made when the head distends the vulva and nearly
crowning.
• Two left hand fingers are inserted between the
perineum and the fetal scalp to protect it from injury by
the scissors. Right hand positioned correctly with
episiotomy scissors
• During contraction one deliberate cut should be made 3
cm in length and directed 2.5 cm away from the anus.
59
Repair of the Episiotomy
• Episiotomy should be repaired within one hour while
local anesthetic is still working.
• Episiotomy is sutured in three layers.
• Starting at the apex and suturing the vaginal wall from
side to side or continuous method, then suture the
muscle either interrupted or continuous and lastly the
skin sutured interruptedly.

60
Managing Perineal Tear (Lacerations)
• A tear in to the perineum they cannot always be
avoided and it is better to have a laceration than a
damaged.
Causes of Perineal Lacerations
• A large baby
• Malpresantation and malposition
• A rigid perineum/Precipitate labour
• Instrumental delivery
61
Types of Perineal Lacerations (Degree of Perineal Tear)

Anterior labial tears

• It is debatable whether or not these should be sutured
much depends up on the control of bleeding as the labia
are very vascular.
• A suture may be necessary to secure haemostasis.

62
Cont.....
Posterior Perineal trauma

• First Degree: Damage to the skin and involves the fourchette

only.

• Second degree: Involves the fourchette and the superficial

perineal muscles.

• Third degree: In addition to the above structures there is

damage to the anal sphincter.

• Forth degree: Trauma extends in to the rectal mucosa that

there is one opening. 63

 Giving Immediate Care of the New Born
1. Clearing the Air Passages

• This is an urgent duty that must be performed without

delay for the baby.

• If the baby cries immediately there should be no need to

use any means of clearing the air way. But the trachea of

the asphyxiated baby is often blocked with thick mucus or

meconium that has been removed without delay by the

use of suction. 64
Cont.....
2. The Need for Warmth
• While the baby is being attended not allowed to become
chilled.
• The baby loses much heat by evaporation from his wet
skin.
• After delivery baby should dried and head also wrapped.

65
Cont.....
3. APGAR Scoring
• This is a means of standardising the method of evaluating
and recording the condition of the baby in numerical
terms at one minute and five minutes after birth.
Signs Scores

0 1 2

A Appearance (colour) Blue /pale Body pink limbs blue Completely pink

P Pulse (Heart beat) Absent Slow less than 100 Over 100
G Grimace (reflex response to Absent Facial grimace Crying
flicking foot)

A Activity ( muscle tone) Limp Some flexion of limbs Active movement

R Respiration Absent Slow irregular week cry Strong cry
66
Cont.....

NB:

1. One minute score:

 No asphyxia ( normal) : 7 - 10

 Mild asphyxia : 5 - 6

 Moderate asphyxia : 3 - 4

 Severe asphyxia : 0 - 2

2. The score at 5 minutes gives a more accurate

prediction regarding survival. 67
Cont....
4. Care of the Eyes
• The eyes should be wiped free of blood and vernix
immediately after the delivery of the head.
• It is believed that silver nitrate 1% or TTC 1 % eye
ointment can prevent neonatal ophthalmia.

68
Cont.......
5. Means of Identification
• Means of identification should be applied before cutting
the cord to identified one from the other and prevent
danger of mixing babies in delivery ward.
• Name bands are applied on the infant’s wrist and having
the following written words name of mother, sex of new
born, date and time of birth and bed number.

69
Cont.....
6. Tying and Cutting the Cord
• Plastic clamps or cord ligatures are applied to the
umbilical cord to act as a haemostasis to the umbilical
blood vessels.
• Putting a double knot on the cord and cut between 1st
and 2nd tie with a sterile scissors.
• If the baby does not need resuscitation, wait for cord
pulsations to cease or approximately 1-3 minutes after
birth. 70
Cont.....
7. Breast Feeding
• WHO strongly recommend initiating breastfeeding
within one hour of birth.
8. Applying Chlorhexidine
• Applying Chlorhexidine 4 % daily for seven days is
efficacious broad spectrum topical antiseptic agents
active against aerobic and anaerobic organism.
• Never apply Chlorhexidine to the eye.
71
Cont…..
9. Vitamin K
• To prevent vitamin K dependent hemorrhagic disease of
the newborn, routine intramuscular single dose of
vitamin K 1mg is given.
10. Immunization
• BCG and polio 0 should be given to the infants before
the mother discharged.

72