normal labor and delivery obs&gyn department of 1st clinical hospital wuhan university associate...

Normal Labor and Delivery

Obs&Gyn Department of 1st Clinical Hospital

Wuhan University

Associate Professor Ming lei （明蕾）

Outline

Definition1

2 Four factors for labor

3 Mechanism of labor

Outline

Diagnosis of threatened labor and labor4

Labor stages5

Clinical course andmanagement of 2nd stages

6Clinical course andmanagement of 1st stages

7

8Clinical course andmanagement of 3rd stages

Definition1

Delivery is the process by which the mature or nearly mature (fetus ,umbilical cord,membranes and placenta) are expelled from the maternal body after 28 weeks

（定义）

Definition1

The last few hours of human pregnancy are characterized by uterine contraction that effect dilatation of the cervix and force the fetus through the birth canal. Much energy is expended during this time, hence the use of term labor to describe this process

Myometrium is unresponsive during pregnancy. After the prolonged period of quiescence, a transitional phase is requires during which myometrial unresponsiveness is suspend and cervix is softened and effaced

（定义）

Definition1

Cause of onset of labor: Precise mechanism in initiation of labor is not defined

Endocrine Mechanical theory Neurological factor

（定义）

Definition1

Term delivery: Term delivery: 37-4237-42 weeks weeks1

Pre-term delivery: Pre-term delivery: 28- 3728- 37 weeks weeks2

Post-term delivery: Post-term delivery: 42 42 weeks weeks3

Abortion:Abortion:4 <28<28 weeks weeks

（定义）

LMP :last menstrual period LMP :last menstrual period 5

6 EDC :expected date of confinement

Definition1



Outline影响分娩的四大因素

Normal Labor and deliveryNormal Labor and deliveryNormal Labor and deliveryNormal Labor and delivery

Force Birth canal

Fetus Psychical factors

影响分娩的四大因素2 Four factors for labor

ForceExpulsive Force

IntraIntraabdominalabdominalpressurepressure

This is created by contraction of the abdominal muscles simutaneously with forced respiratory efforts with the glottis close. this is referred to as pushing

Levator ani muscle

Levator ani muscle is the most important part of pelvic floor

AncillaryForce

uterine contraction

A rhythmic tightening in labor of the upper uterine musculature that contracts the size of the uterus and pushes the fetus toward the birth canal

Major force

RhythmRhythm

SymmetrySymmetry

PolarityPolarity

Retraction

intermissionduration duration

影响分娩的四大因素2 Four factors for labor uterine

Contractionfeature

Force

Four characteristics

Retraction is a phenomenon of the uterus in labor in which the muscle fibres are permanently shortened. Unlike any other muscles of the body

Contraction is a temporary reduction in length of the fibres, which attain their full length during relaxation

retractionretraction

retractionretraction

The effects of retraction in normal labor are: Formation of lower uterine segment and dilatation

and effacement of the cervix Maintain the advancement of the presenting part

made by the uterine contractions and help ultimate expulsion of the fetus

To reduce the surface area of the uterus favoring separation of placenta

Effective haemostasis after the separation of the placenta


Birth canal


Force Fetus Psychical factors


Birth canal

Bony canal

Birth canalBirth canal 产道产道

Soft tissue canal

Pelvis anatomical marks

Sacral promontory

Ischial spine (L,R)

Symphysis pubis


Birth canal

Bony canal骨产道

Pelvic inlet planeSuperior strait

Pelvic outlet planeInferior strait

Midpelvis outletleast pelvic dimension plane

pelvic axis: A hypothetical line curving through the midpoint of the pelvic planes

4 diameters of the pelvic inletAnteroposterior: 11cmTransverse: 13cm Two obliques: 12.75cm

Pelvic inlet plane

Posteriorly by the promontory and alae of the sacrum, laterallyby the linea terminalis

Anteriorly by the horizontal Rami of the pubic bones and symphysis pubis

4 types in shape – gynecoid (50%), anthropoid, android, platypelloid. Most are intermediate type.

4 diameters – anteroposterior(AP), transverse, and 2 obliques

Obstetrical conjugate – the shortest distance between promontory and symphysis pubis. Estimated by substracting 1.5 to 2 cm from the diagonal conjugate.

True conjugate – the A-P diameter of the pelvic inlet

Pelvic InletPelvic Inlet

DC:distance from the lower margin of symphysis to promontory of the sacrum

OC:From result according to the height and inclination of the symphysis pubis,OC can be measured by substracting 1.5-2cm, it should be 10cm or more

Anteroposterior diameter Anteroposterior diameter through the level of the ischial through the level of the ischial spinesspines >>11.5cm11.5cm

Interspinous diameter is 10cm or somewhat more

中骨盆平面 mid plane of pelvis

The midpelvis at the level ofIschial spines is of particular importance following engagement of the fetal head in obstructed labor

pelvic outlet plane

Consists of two approximately triangular areas not in the same plane but having a common base, Which is a line drawn between the two ischial tuberosities

影响分娩的四大因素2 Four factors for labor Birth

canalSoft canal软产道

Lower uterine segment

Lower uterine segment

Cervix, floor of pelvis, vagina

Soft tissue part canal

Soft part of birth canal Formation of uterine lower segmentFormation of uterine lower segment

Cervix effacement and dilatationCervix effacement and dilatation

Isthmus: between anatomical internal OS and histological internal OS

Physiological retraction ring :develops at the junction of the upper and lower uterine segment. As labor progresses, a boundary ridge on the inner uterine surface is marked between the thinning of the lower segment and the concomitant thickening of the upper

Pathological retraction ring: also called Bandl ring, develops from the physiological ring when the thinning of the lower uterine segment is extreme, as in obstructed labor, the ring is very prominent, forming it.

影响分娩的四大因素2 Four factors for labor Birth

canalSoft canal软产道

cervical effacement and dilatationcervical effacement and dilatation

宫颈管


Fetus


Force Birth canal

Psychical factors

产力产道胎儿精神因素

Fetus 胎儿

Fetal size 胎儿大小Fetal lie 胎产式

Fetal attitude胎姿势

Fetal station胎先露高低

Fetal presentation胎先露

Fetal position胎方位


Fetus

Fetal lie Relation of long axis of fetus to that of the mother. Longitudinal (99%), transverse or oblique


Fetus

Fetal presentation Fetal part that directly overlies pelvic inletCephalic , breech , or shoulder


Fetus

Fetal position

The relation of a chosen portion of the The relation of a chosen portion of the presenting part of the fetus to the right or presenting part of the fetus to the right or left side of the maternal birth canal. left side of the maternal birth canal. For For more accurately more accurately –– anterior, transverse, anterior, transverse, posteriorposterior


Fetus

LOA (left occipito-anterior) ROA (right occipito-anterior)

Denominator:bony fixed point on presenting partocciput


Fetus

LOT(left occipito-transverse) ROT(right occipito-transverse)


Fetus

LOP(left occipito-posterior) ROP(right occipito-posterior)


Fetus


Fetus

The fetus is in the occiput or vertex presentation in approximately 95% of all labor

In majority of cases, the vertex enters the pelvis with the sagittal suture in the transverse pelvic diameter or the oblique lines

The fetus enters the pelvis in the left occiput transverse(LOT) or LOA position in 40%;in the ROT or ROA in 20%; in OP position in 20%

1 step1 step

Leopold’s maneuvers

4 step

Run hands down maternal abdomen on either side of fetus to determine fetal lie, identifying small parts and fetal spine

Using the thumb and fingers of one hand, the lower portion of the maternal abdomen is grasped just above the symphysis pubis to determine the presentation

With the tips of the fingers of each hand, exerts deep pressure in the direction of the axis of the pelvic inlet to determine if the head or breech descended into the pelvis

Gently palpate the fundus with the tip of the fingers of both hand in order to define which fetal pole is present in the fundus and appropriate size.

2 step

3 step

1. The mother should be supineand comfortable position withher abdomen bared

2.During the first three maneuversthe examiner stands at the sideof the bed that is most convenientand faces the patient

3.The examiner reverses thisposition and face the feet for the last maneuver

1 step1 stepGently palpate the fundus with the tip of the fingers of both hand in order to define which fetal pole is present in the fundus and appropriate size.

Run hands down maternal abdomen on either side of fetus to determine fetal lie, identifying small parts and fetal spine

2 step

3 step

Using the thumb and fingers of one hand, the lower portion of the maternal abdomen is grasped just above the symphysis pubis to determine the presentation

4 stepWith the tips of the fingers of each hand, exerts deep pressure in the direction of the axis of the pelvic inlet to determine if the head or breech descended into the pelvis

bregma

Adult fetus

Suture: it permits gliding movement of one bone over the other during moulding of the head while the head passes through the pelvis;During Internal examination in labor, palpation of sagittal suture give anidea of the manner of engagement of the head

post fontanelle(lambda)

Bregma(Ant fontanelle)

BPD(parietal bones diameter)

frontal bones

Occipital bone

Sagittal suture

The bones of the vault are not joined thus changes in the shape of the fetal head during labor can occur due to molding

fontanelle:wide gap in suture line

Outline

Definition1



Occiput presentation( 枕先露的分娩机转 )

1. The ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of its head during its passage in labor

2. The mechanisms of labor, also known as the cardinal movements, are described in relation to a vertex presentation, as is the case in 95% of all pregnancies

3. In reality, the mechanism of labor consists of a combination movements that are ongoing simultaneously

4. For purposes of instruction, the various movements often are described as though they occurred separately and independently the cardinal movements are described as 7 discrete sequences, as discussed below

Outline

Definition1



Occiput presentation( 枕先露的分娩机转 )

1 1

engagement

22

descent

33

flexion

44

internal rotation

55

extension

66

external rotation

7. expulsion

Mechanism of labor

( 枕先露的分娩机转 )

Occiput presentation3

1. Engagement

Passage of widest diameter of presenting part to level below the plane of the pelvic inlet

Occurs earlier in primigravidae, usually before the onset of labor while in multiparae, the same may occur in late 1st stage with rupture of the membrane

ischial spines

Mechanism of labor Occiput presentation3

2 、 3. Descent &FlexionDownward passage of presenting part through the pelvisOccurs passively as the head descends due to the shape of the bony pelvis and resistance of pelvic floor soft tissues resulting in passive flexion of the fetal occiput. The chin is brought into contact with the fetal thorax, and the presenting diameter changes from occipitofrontal (12cm) to suboccipitobregmatic (9.5 cm) which is the smallest diameter of fetal head for optimal passage through the pelvis

Occipitofrontal Diameter 12cm

Suboccipitobregmatic Diameter 9.5cm

Occipito frontal diameter 枕额径　 12cmOccipito subregmatic diameter 枕下前囟径　9.5cmOccipito mental diameter 枕颏径　 13cm

LOT

ROT

Mechanism of labor



4. Internal rotation As the head descends, the presenting part, usually in the

transverse position, is rotated about 45°to anteroposterior (AP) position under the symphysis. Internal rotation brings the AP diameter of the head in line with the AP diameter of the pelvic outlet

Mechanism of labor



5. Extension

1) With further descent and full

flexion of the head, the base

of the occiput comes in contact

with the inferior margin of the

pubic symphysis

2) Upward resistance from the

pelvic floor and the downward

forces from the uterine contractions

cause the occiput to extend and

rotate around the symphysis

Forces Concerned in LaborForces Concerned in Labor

Positive forces * Uterine contractions * Abdominal pressure by rectus muscles * Fundal pressure* Forceps delivery and vacuum extraction

Resistance * The uterine cervix * The muscles of the pelvic floor

Positive forces * Uterine contractions * Abdominal pressure by rectus muscles * Fundal pressure* Forceps delivery and vacuum extraction

Resistance * The uterine cervix * The muscles of the pelvic floor

Mechanism of labor



6. External Rotation When the fetus' head is free of resistance, it

untwists about 45°left or right, returning to its original anatomic position in relation to the body

Mechanism of labor Occiput presentation3

7. Expulsion After the fetus' head is delivered, further descent brings the anterior shoulder to the level of the pubic symphysis

The anterior shoulder is then rotated under the symphysis, followed by the posterior shoulder and the rest of the fetus

Mechanism of labor



Mechanism of labor for left occiput anterior position

4

FalseFalselaborlabor

Diagnosis of threatened labor

As the fetal presenting part descends into the pelvic inlet, the fundal height decreases. Theprimigravida feels comfort of the upper abdomen, eats more, and respires briskly.

Braxon Hicks contractions,during the last 4-8weeks of pregnancy irregular,generally painless uterine contractions occur with slowly increasing frequency

lightening

showCervical effacement, the mucus plug within the cervical canal may be released .And a small amount of blood creating by the ruptured capillary and the mucous in the cervix are mixed together and are discharged , this is called show

Diagnosis of in labor4

1

2

3

Regular uterine contractionRegular uterine contraction

cervical effacementcervical effacement

cervical dilatationcervical dilatation

4 descentdescent

False labor vs. True laborFalse labor vs. True labor

Stage of labor

TOTAL STAGE

2nd stageexpulsion of the fetus

1st stage cervical dilatation

3rd stageexpulsion

of the placenta

primipara 11-12 hours 1-2hours 5-15mins<30minsmultipara 6-8hours. a few mins<1hour 5-15mins<30mins

5

Three stages of labor

The first stage begins when uterine contractions of sufficient frequency, intensity and duration are attained to bring about effacement and progressive dilatation of the cervix and ends when the cervix is fully dilated

The second stage begins when dilatation of the cervix is complete, and ends with delivery of the fetus

The third stage begins immediately after delivery of the fetus, and ends with the delivery of the placenta and fetal membranes

“The fourth stage” is the stage of observation for 2 hours after expulsion of the placenta

The first stage is divided into a relatively flat latent phase and a rapidly progressive active phase. In active phase, there are 3 identifiable component parts: an acceleration phase, a linear phase of maximum slope, and a deceleration phase

Clinical course andmanagement of 1st stages

Clinical manifestationsClinical manifestationsClinical manifestationsClinical manifestations

Add Your Text

6

Regular contractionRegular contraction1

cervical effacement and dilatationcervical effacement and dilatation2

fetodescentfetodescent3

Rupture of membranes Rupture of membranes 4

2

6 Clinical manifestationsClinical manifestationsClinical manifestationsClinical manifestations

1. At the beginning of the first stage of labor, it is weak

2. intermission lasts a little longer about 5-6mins; duration is about 30s

3. As labor progresses, the intermission lasts 2-3mins; duration is 50-60s

4. intensity increases when the cervix is fully dilated, intermission only last one min or more longer; duration can last more than one min

Uterine contraction1

intensity

duration intermission duration

Intensity: describes the degree of uterine systole, it gradually increases with the advancement of labor until it becomes maximum in the second stage during delivery of the baby

Duration: In the 1st stage,the contraction last for about 30s initially but Gradually increase in duration with the progress of labor. Thus in the 2nd stage, the contractions last longer than in the 1st stage

2


Cervical changes and descent2-3

Cervical effacement: the obliteration of the cervix is the shortening of the cervical canal from a length of about 2cm to a mere circular orifice with almost paper-thin edges

Compared with the body of the uterus, the lower segment and the cervix are regions of lesser resistance, these structures are subjected to distention. As the uterinecontraction cause pressure on the membranes, the hydrostatic action of the aminionic sac in turn dilates the cervical canal. In absence of intact membranes, the pressure of the presenting part against the cervix and lower uterine segment is effective. It won’t retard cervical dilatation

2


LATENT PHASE

It begins with theregular contractionsafter in labor ends when the cervix dilates to 2cm.8-16h; 1cm/2-3h

ACTIVE PHASE

It refers the cervix dilated from 2cm to complete dilatation.4-8h;

Cervical changes and descent2-3

The first stage is divided into a relatively flat latent phase and a rapidly progressive active phase. In active phase, there are 3 identifiable component parts: an acceleration phase, a linear phase of maximum slope, and a deceleration phase

2


The fetal membrane is always ruptured when the cervix is completely dilated and the amnionic fluid runs out , this is called rupture of membranesWhen the membrane rupture before the onset of labor, it is called premature rupture

4 Rupture of membrane

management of 1st stages

education, eating, voidingeducation, eating, voiding1

position(sitting, reclining, recumbent)position(sitting, reclining, recumbent)2

monitoring of the fetal heart ratemonitoring of the fetal heart rate3

dilation of cervix and frequencydilation of cervix and frequency

severity of uterus contractionsseverity of uterus contractions5

6

4

Management principles of 1st stage

Non-interference with watchful expectancy so as to prepare the patient for natural birth

To monitor carefully the progress of labor, maternal conditions and fetal behavior so as to detect any intrapartum complicating early

Actual management of 1st stage

General: antiseptic dressing, encouragement and assurance constant supervision

Bowel: an enema with soap or glycerine suppository is traditionally given in early stage. Reduce infection rate and increase the progress of the laborRest and ambulation:

Diet: food is withheld during active labor; water,fluid juice can be given

Bladder care: full bladder often inhibits uterine contraction and may lead to infection, so encourage the patient to pass urine by herself or catheterisation to be done to her with strict aseptic precautions

Actual management of 1st stage

Relief of pain: analgesia in labor can be used on primigravida. The analgesic drugs should not be given if delivery is anticipated within two hoursMaternal condition: routine check up includes

to record per 2 hours about P,BP, T, cervical dilatation and fetal presentation descent by anal or vaginal examinationto note the urine outputI.V fluid, drugs

Electronic fetal monitoring, auscultationauscultation ,dopplerMonitor the uterus contraction(intensity,duration,frequency)

Clinical course andmanagement of 2nd stages


Add Your TextMore intensive contraction with defecationMore intensive contraction with defecation1

Head visible on vulval gappingHead visible on vulval gapping2

Crowning of headCrowning of head3

7

Head visible on vulval gappingHead visible on vulval gapping Crowning of headCrowning of head

Crowning refers to when the widest part of the baby's head (or their crown) is emerging. At this point, the baby's crown, part of their forehead and the back of the baby's head can be clearly seen.

Crowning refers to when the widest part of the baby's head (or their crown) is emerging. At this point, the baby's crown, part of their forehead (nearly to their eyebrows) and the back of the baby's head can be clearly seen.

As the baby's head crowns, the woman's perineum is stretched to its maximum, being nearly paper-thin. There is usually an intense burning (or stinging sensation) for a few seconds as this occurs, generally easing as the perineum numbs. The burning can trigger panic for some women, causing them to cry out, or scream.

management of 2nd stages

fetal heart ratefetal heart rate1

maternal conditionsmaternal conditions2

PushingPushing3

Head visible on vulval gappingHead visible on vulval gapping

Crowning of head Crowning of head

8

7

Laceration or Episiotomy Laceration or Episiotomy

Delivery of fetus Delivery of fetus

Deal with umbilical cord Deal with umbilical cord

aiding in fetal descent through birth canalaiding in fetal descent through birth canal

5

9

6

7

4

Management principles of 2nd stage

To assist in the natural expulsion of the fetus slowly and steadily

To prevent perineal injuries

Actual management of 2nd stageGeneral: constant supervision is mandatory and the FHR is recorded at

every 5minsvaginal examination is done at the beginning of the 2nd stage not

only to comfirm its onset but to detect any accidental cord prolapse. The position and the station of the head are once more to be reviewed and the progressive descent of the head is ensured

Preparation for delivery: position the accoucheur scrubs up, put on the sterile gown, mask

and gloves and stands on the right side of the tableToileting the external genitaliaTo catheterise the bladder

Actual management of 2nd stage

Conduction of delivery: Episiotomy is done selectively, usually as a routine in ChinaSlowly delivery of the head in between the contractions is to be

regulatedThe mucus and blood in the mouth and pharynx are to be wiped with sterile gauze piece on a little finger or electrical sucker

Prevention of perineal lacerationDelivery by early extension is to be avoidedSpontaneous forcible delivery of the head is to be avoidedTo deliver the head in between contractionsTo perform timely episiotomy(

Actual management of 2nd stage

Immediate care of the newborn air passage should be cleared of mucus and

liquor by gentle suction apgar rating at 1min and at 5mins is to be

recorded clamping and ligature of the cord

baby is wrapped with a dry warm towel, the identification tape is tied both on the wrist of the baby and the mom

Clinical course andmanagement of 3rd stages


Add Your Textthe uterus decreases in sizethe uterus decreases in size1

delivery of placenta(spontaneously, manuallydelivery of placenta(spontaneously, manually2

inspection of the birth canalinspection of the birth canal3

8

evaluated for lacerationsevaluated for lacerations4

Management principles of 3rd stage

To ensure strict vigilance and to follow the management guidelines strictly in practice so as to prevent the complications

Actual management of 3rd stage

Expectant management(traditional) Active management

Control cord traction

Fundal pressure

Oxytocin iv drop

Manual removal

Actual management of 3rd stage

Examination of the placenta membranes and cord

Vulva, vagina and perineum are inspected

Placental SeparationPlacental Separation

• • begins immediately after delivery of fetus,begins immediately after delivery of fetus, involve separation & expulsion of placentainvolve separation & expulsion of placenta••Diminution in Ut sizeDiminution in Ut size PL implantation site areaPL implantation site area ↓ ↓ PL accommodate to reduced PL accommodate to reduced area area thickness because of limited PL elasiticity thickness because of limited PL elasiticity forced to buckle forced to buckleResulting tension Resulting tension weakest layer of decidua (D. spongiosa) cleavage take place weakest layer of decidua (D. spongiosa) cleavage take place at that siteat that siteAs separation proceed As separation proceed hematoma forms between separtating PL & remaining hematoma forms between separtating PL & remaining Decidua Decidua result of separation result of separation

Placental SeparationPlacental Separation

• • begins immediately after delivery of fetus, involve begins immediately after delivery of fetus, involve separation & expulsion of placentaseparation & expulsion of placenta

••Diminution in Ut sizeDiminution in Ut size PL implantation site areaPL implantation site area ↓ ↓ PL PL accommodate to reduced area accommodate to reduced area thickness because of thickness because of limited PL elasiticity limited PL elasiticity forced to buckle forced to buckle

--Resulting tension Resulting tension weakest layer of decidua (D. weakest layer of decidua (D. spongiosa) cleavage take place at that sitespongiosa) cleavage take place at that site

--As separation proceed As separation proceed hematoma forms between hematoma forms between separtating PL & remaining Decidua separtating PL & remaining Decidua result of result of separationseparation

Placental ExtrusionPlacental Extrusion

some casesome case abdominal pr↑ PL be expelled abdominal pr↑ PL be expelled women in recumbent position frequently women in recumbent position frequently

cannot expel placenta spontaneouslycannot expel placenta spontaneously → → artificial means generally requiredartificial means generally required → → compress & elevate fundus while exerting compress & elevate fundus while exerting

minimal traction on umbilical cordminimal traction on umbilical cord

Mechanisms of Placental ExtrusionMechanisms of Placental Extrusion

(1) Schultze mechanism((1) Schultze mechanism(centralcentral separationseparation))

• • PL separation occurs 1st at central areasPL separation occurs 1st at central areas

→ → retroplacental hematomaretroplacental hematoma

→ → push placenta toward uterine cavitypush placenta toward uterine cavity

(2) Duncan mechanism((2) Duncan mechanism(marginalmarginal separationseparation))

① ① placental separation occurs first at peripheryplacental separation occurs first at periphery

② ② blood collects between membranes & uterine blood collects between membranes & uterine wall → escapes from vagina→Maternal surface wall → escapes from vagina→Maternal surface first to appear at vulvafirst to appear at vulva

11

Signs of placental separation

A sudden gush of blood from vagina

The uterus becomes globular and firmer.This sign is the earliest to appear

2

3

The uterus rises in the abdomen because the placenta, having separated, passes down into the lower uterine segment and vagina, where its bulk pushes the uterus upward

4 The umbilical cord lengthens out of the vagina,indicating that the placenta has descended

manual placental removal

副胎盘 succenturiateplacenta

Mechanism of control of bleeding

After placental separation,innumerable torn sinuses which have free circulation of blood from uterine and ovarian vessels have to be obliterated. The occlusion is effected by complete retraction where by the arterioles, as they pass tortuously through the interlacing intermediate layer of the myometrium, are literally clamped

Thrombosis occurs to occlude the torn sinuses Apposition of the wall of the uterus following expulsion of

the placenta also contributes to minimize blood loss

Perineum ,Cervical,Vaginal laceration

First degree tear :involves only skin and a minor part of the perineal body


Second degree tear :involves perineal body and vaginal wall


Third degree tear :involves the anal sphincter and anal canal

“The fourth stage”

General condition of the patient and behavior

of the uterus are to be carefully watched postpartum uterine hemorrhage ,1% uterus palpation through the abdominal wall

is repeats the amount of blood on pads are monitored pulse and BP are monitored use of drug : oxytocin

Questions

DefinitionDelivery; physiological retraction ring ; Obstetrical

conjugate; fetal lie; fetal position

Braxon Hicks contractions; crowning of headrowning of head

The first stage; the second stage; the third stage

essays

Mechanism of normal labor Identify false labor or true labor Talk about the signs of placental separation Describe two mDescribe two mechanisms of Placental Extrusionechanisms of Placental Extrusion What is the most common fetal position at onset of

labor? What is active phase? What are you going to do after the 3rd stages?

What is the correct order of the cardinal movements of labor?

A). Flexion, descent, engagement, internal rotation, extension, external rotation

B). Descent, engagement, flexion, internal rotation, external rotation, extension

C). Engagement, flexion, descent, external rotation, extension, internal rotation

D). Engagement, flexion, decent, internal rotation, extension, external rotation

normal labor and delivery obs&gyn department of 1st clinical hospital wuhan university associate...

Documents

threatened labor

initiation of labor

use of term labor

uterine contractions

pelvic inletdc

pelvic inletanteroposterior

mature fetus

pelvic planes4 diameters