Normal Labor and Stages of Delivery

Normal labor occurs spontaneously with low-risk at the beginning and throughout labor and delivery.
The baby is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy.
Both mother and infant are in good condition after birth.

First Stage: Begins with uterine contractions and ends when the cervix is fully dilated (10cm).
- Latent Phase: Cervix dilates to about 4cm.
- Active Phase: Cervix dilates from 4cm to 10cm.
Second Stage: Starts at full cervical dilation and ends with the baby being delivered.
Third Stage: Begins when the baby is delivered and ends with the placenta being delivered.

Fetal Lie: Describes the relationship between the long axis of the fetus and the long axis of the mother.
- Longitudinal lie is the most common. (99% of births)
- Transverse lie is less frequent.
- Oblique lie is rare.
Presentation: Describes the fetal part that enters the pelvic inlet first.
- Vertex presentation, where the head is presenting, is the most common.
Attitude: Describes the relationship of various fetal parts to each other.
- Normal attitude is universal flexion where the chin is flexed onto the chest.
Position: Refers to the location of a specific fetal landmark as it relates to the maternal pelvis.
- The occiput is the landmark used for the vertex presentation.
- Left occiput anterior position (LOA) is the most common.

Engagement: Occurs when the biparietal diameter of the fetal skull reaches the level of the pelvic inlet.
Descent: The fetal head descends through the pelvis.
Flexion: Flexion of the fetal head occurs due to resistance from the pelvic floor muscles.
Internal Rotation: The fetal head will rotate to the symphysis pubis, the widest area of the pelvic floor.
Extension: The fetal head extends as it emerges from the vagina.
External Rotation: Alignment of the fetal head with its spine causes the head to externally rotate to the shoulder.
Expulsion: The shoulders are delivered, followed by the rest of the body.

Maternal Well-being:
- Pulse rate every 30 minutes.
- Blood pressure and temperature every 4 hours.
- Urine output and protein, ketones, and glucose levels after voiding.
- Record all fluids and drugs administered.
Fetal Well-being:
- Fetal heart rate every 15-30 minutes after a contraction in the first stage, and every 5 minutes in the second stage.
Liquor:
- Check liquor every 30 minutes:
  - Clear: normal
  - Meconium stained: thick or thin - thicker indicates fetal distress.
  - Bloody: indicates fetal distress.
  - Absent: may indicate fetal distress.
Uterine Contractions:
- Frequency, duration, and strength should be recorded every 30 minutes.
Abdominal Examination:
- Assess descent of the fetal head.
Vaginal Examination:
- Every 4 hours to assess cervical dilation, descent of the fetal head, and moulding of skull bones.

A graphic record of labor progress and maternal/fetal well-being.
It begins in the active phase of labor (when the cervix is at least 4cm dilated).
Used to prevent prolonged labor, reduce operative interventions, and improve neonatal outcomes.

Crowning: The largest head diameter is encircled by the vulvar ring.
Perineum Thinning: The perineum may undergo spontaneous laceration in nulliparous women (women who have not given birth before).
Anus Stretching: The anus becomes stretched and the anterior rectal wall may be visible.

Occurs when the anterior shoulder is impacted on the maternal pubic symphysis or the posterior shoulder is impacted on the sacral promontory.
Obstetric emergency with an incidence of 0.2-3% of deliveries.

Difficulty delivering fetal head or chin.
Failure of restitution: The fetal head does not turn to the side after delivery.
"Turtle Neck Sign": The fetal head retracts into the pelvis.

Call for Help: It is an obstetric emergency, so gather a senior obstetrician, senior midwife, and pediatrician.
Stop Pushing: Advise the woman to stop pushing, as it can worsen the impaction.
Avoid Downward Traction: Only use axial traction (keep head aligned with spine).
Avoid Fundal Pressure: Increases the risk of uterine rupture.
Consider Episiotomy: May make access for maneuvers easier.

McRoberts Maneuver: Sharp flexion of the thighs onto the abdomen.
Suprapubic Pressure: Pressure is applied with the heel of the hand to the anterior shoulder.
Delivery of Posterior Shoulder: The posterior arm is swept across the chest followed by delivery of the arm.
Fracture of Anterior Clavicle: May be attempted to free the shoulder impaction.

Begins immediately after fetal birth and ends with the placenta being delivered.
Goals:
- Deliver an intact placenta.
- Avoid uterine inversion.
- Avoid postpartum hemorrhage.

Active Management:
- Administration of uterotonics.
- Early clamping of the cord.
- Controlled cord traction.
Expectant Management:
- No prophylactic uterotonics.
- Cord not clamped or cut until delivery or pulsation ceases.
- Placenta delivered spontaneously.

Complete Breech: Buttocks present first with legs flexed at the knees and feet near the buttocks.
Frank Breech: Buttocks present first with legs extended upwards.
Footling Breech: One or both feet present first.

Vaginal breech birth should occur in a hospital with emergency C-section facilities available.
C-section is recommended if there is a delay in the descent of the breech at any stage of labor.
Women should be advised to deliver in the dorsal or lithotomy position.
Episiotomy should be performed when indicated, not routinely.

Contraindications to vaginal birth (placenta previa, compromised fetal condition).
Clinically inadequate pelvis.
Footling or kneeling breech presentation.
Large baby (over 3800g).
Growth-restricted baby (smaller than 2000g).
Hyperextended fetal neck in labor.
Lack of a clinician trained in vaginal breech delivery.
Previous cesarean section.