- Clinical science
The process of normal childbirth depends on a high degree of anatomical and physiological compatibility between the mother and child. The birth canal is the passage consisting of the mother's bony pelvis and soft tissues through which a fetus passes during vaginal delivery. Fetal orientation during childbirth is described in terms of lie, presenting part, position and attitude of the presenting part, and station. Complications of labor and delivery can pose life-threatening situations to both mother and child, which is why recognizing any abnormalities early is crucial. Measures for managing abnormal labor include special maneuvers for breech presentation or cesarean section in obstructed labor.
- Definition: relation of the fetal long axis to the long axis of the maternal uterus
- Definition: part of the fetus that overlies the maternal pelvic inlet
- Cephalic presentation: head (most common)
Breech presentation: buttocks or feet
- Frank breech: flexed hips and extended knees (buttocks presenting)
- Complete breech: thighs and legs flexed (cannonball position)
- Single Footling breech: hip of one leg is flexed and the knee of the other is extended (one foot presenting)
- Double Footling breech: both thighs and legs are extended (feet presenting)
- Compound presentation: ≥ 1 anatomical presenting part (e.g., cephalic or breech presentation with presentation of an extremity)
- Shoulder presentation: shoulder presentations combined with a transverse or oblique lie
- Definition: relationship and orientation (i.e., fetal occiput pointing towards maternal left or right) of the presenting fetal part to the maternal pelvis
Occiput anterior position: Fetal occiput points towards maternal symphysis pubis; fetus faces downwards.
- Right occiput anterior (ROA): Fetal back faces the maternal right, anterior fontanelle faces the maternal left, sagittal suture lies in the left ; (most common position).
- Left occiput anterior (LOA): Fetal back faces the maternal left, anterior fontanelle faces the maternal right, sagittal suture lies in the right
- Occiput posterior position: Fetal occiput points towards the maternal sacral promontory with face to pubis symphysis; the fetus faces upward
- Sacrum in breech presentation
- Mentum (chin) in extended cephalic (face) presentation
- Occiput anterior position: Fetal occiput points towards maternal symphysis pubis; fetus faces downwards.
- Definition: degree of extension/flexion of the fetal head during cephalic presentation
- Vertex presentation (maximally flexed); most common attitude
- Brow presentation (partially extended)
- Face presentation (maximally extended)
- Forehead presentation (partially flexed; military attitude): Spontaneous vaginal delivery is possible .
Definition: measurement (in cm) of the presenting part above and below the maternal ischial spine
Station Description 0 the presenting part is at the level of the ischial spines -1, -2, -3 1, 2, and 3 cm above the level of the ischial spines, respectively +1, +2, +3 1, 2, and 3 cm below the level of the ischial spines, respectively
- Engagement (Obstetrics)
- Definition: parallelism between the pelvic plane and the plane of the fetal head
- In asynclitism, the sagittal suture is in the transverse diameter of the pelvic inlet and not between the symphysis pubis and sacral promontory.
Anterior asynclitism (Naegele's obliquity)
- The sagittal suture is positioned towards the sacral promontory
- Spontaneous vaginal delivery possible
- Posterior asynclitism (Litzmann's obliquity)
- Anterior asynclitism (Naegele's obliquity)
Adaptation to the different forms of the pelvic region requires a great deal of rotation.
- Engagement, descent, and increased flexion (occur simultaneously)
- Internal rotation: The fetal head rotates by 90° (two 45° steps) in the midpelvis, from a transverse to anterior-posterior position.
- Extension: The fetal head, lying behind the symphysis pubis bone and the pelvic floor, acts upwards and forwards.
- Restitution: The fetal head rotates 45° in the opposite direction as it passes through the pelvic outlet.
- External rotation: The anterior shoulder rotates 45° anteriorly as it meets the maternal pelvic floor. This action is transmitted to the head which also rotates 45°, placing the head in its original transverse position.
- Expulsion: Delivery of the head, posterior shoulder followed by the anterior shoulder, and the body
Arrest of vaginal delivery because of a mechanical obstruction (see for comparison)
- Fetal: malpresentations; , malpositions, congenital anomalies, macrosomia
- Maternal: bony or soft tissue masses in maternal pelvis
- High presenting part; not engaged; ruptured membranes
- Moulding: extent of overlap of the fetal skull bones; excessive during obstructed labor
- Frequent uterine contractions
- Edematous vulva
- Cesarean section for any maternal etiologies or congenital anomalies
- Compound presentation
- Transverse lie
- Persistent occiput posterior position:
Deep transverse arrest
- Lateral positioning of the mother to achieve 90° rotation of the fetal head
- Stimulate uterine contractions (e.g., with oxytocin)
- Use of forceps or a vacuum to rotate the fetal head if arrested labor ≥ 60 min
- Conservative treatment
- No intervention necessary before 37 weeks' gestation, as most fetuses spontaneously convert to cephalic presentation as they get closer to term
External cephalic version
- Should be offered in all cases ≥ 37 weeks who would like to attempt a vaginal delivery, unless there are contraindications.
- Involves manual adjustment of fetal position by applying pressure on the mother's abdomen
- external cephalic version is unsuccessful or contraindicated: if (e.g., in active labor, fetal distress)