• Clinical science

Mechanics of childbirth

Abstract

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.

Orientation in utero

Lie

  • Definition: relation of the fetal long axis to the long axis of the maternal uterus
  • Types

Presentation

Position

  • Definition: : relationship and orientation (i.e., fetal occiput pointing towards maternal left or right) of the presenting fetal part to the maternal pelvis
  • Types
    • 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 oblique diameter; (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 oblique diameter.
    • 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

Attitude

Station (Obstetrics)

  • 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)
    • When the widest transverse diameter of the head (presenting part) passes through the pelvic inlet
    • Use the rule of fifths: engagement is clinically identified when ≤ 2/5 of the fetal head are felt above the symphysis pubis through the maternal abdomen

Synclitism

  • 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.

References:[1][2]

Normal labor and delivery

Adaptation to the different forms of the pelvic region requires a great deal of rotation.

  1. Engagement, descent, and increased flexion (occur simultaneously)
    • The head engages below the plane of the pelvic inlet.
    • The presenting part begins to descend into the birth canal.
    • The chin of the fetus moves towards its chest.
  2. Internal rotation: : The fetal head rotates by 90° (two 45° steps) in the midpelvis, from a transverse to anterior-posterior position.
  3. Extension: : The fetal head, lying behind the symphysis pubis bone and the pelvic floor, acts upwards and forwards.
  4. Restitution: : The fetal head rotates 45° in the opposite direction as it passes through the pelvic outlet.
  5. 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.
  6. Expulsion: : Delivery of the head, posterior shoulder followed by the anterior shoulder, and the body

References:[1]

Obstructed labor

Definition

Arrest of vaginal delivery because of a mechanical obstruction (see arrested active phase for comparison)

Etiology

  • Fetal: malpresentations; , malpositions, congenital anomalies, macrosomia
  • Maternal: bony or soft tissue masses in maternal pelvis

Clinical features

Management

References:[3][4][1][5][6]

  • 1. Dutta DC, Konar H. Textbook of Obstetrics. New Delhi, India: Jaypee Brothers Medical Publishers; 2015.
  • 2. Buchmann EJ, Guidozzi F. Level of fetal head above brim: comparison of three transabdominal methods of estimation, and interobserver agreement. J Obstet Gynaecol. 2007; 27(8): pp. 787–790. doi: 10.1080/01443610701667387.
  • 3. Hofmeyr GJ, Lockwood CJ, Barss VA. Overview of Issues Related to Breech Presentation. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-issues-related-to-breech-presentation. Last updated July 8, 2016. Accessed July 3, 2017.
  • 4. Dudenhausen JW, Obladen M. Practical Obstetrics. Berlin, Germany: Walter de Gruyter GmbH & Co KG; 2014.
  • 5. Caughey AB, Berghella V, Barss VA. Occiput Transverse Position. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/occiput-transverse-position. Last updated August 17, 2016. Accessed September 6, 2017.
  • 6. Hofmeyr GJ, Lockwood CJ, Barss VA. External Cephalic Version. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/external-cephalic-version. Last updated July 18, 2017. Accessed September 6, 2017.
  • Kaplan. USMLE Step 2 CK Lecture Notes 2017: Obstetrics/Gynecology . New York, NY: Kaplan Medical; 2016.
last updated 07/30/2018
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