presentation definition obstetrics

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

Affiliations

Last Update: January 9, 2023 .

• Continuing Education Activity

Face and brow presentation is a malpresentation during labor when the presenting part is either the face or, in the case of brow presentation, it is the area between the orbital ridge and the anterior fontanelle. This activity reviews the evaluation and management of these two presentations and explains the interprofessional team's role in safely managing delivery for both the mother and the baby.

• Identify the mechanism of labor in the face and brow presentation.
• Differentiate potential maternal and fetal complications during the face and brow presentations.
• Evaluate different management approaches for the face and brow presentation.
• Introduction

The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference. Face presentation is an abnormal form of cephalic presentation where the presenting part is the mentum. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Incidence of face presentation is rare, accounting for approximately 1 in 600 of all presentations. [1] [2] [3]  In brow presentation, the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest of all malpresentation, with a prevalence of 1 in 500 to 1 in 4000 deliveries. [3]

Both face and brow presentations occur due to extension of the fetal neck instead of flexion; therefore, conditions that would lead to hyperextension or prevent flexion of the fetal neck can all contribute to face or brow presentation. These risk factors may be related to either the mother or the fetus. Maternal risk factors are preterm delivery, contracted maternal pelvis, platypelloid pelvis, multiparity, previous cesarean section, and black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, and polyhydramnios. [2] [4] [5]  These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. Palpating orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation is possible. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, the anterior fontanelle and face can be palpated except for the mouth and the chin. Brow presentation can then be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse. Diagnosing the exact presentation can be challenging, and face presentation may be misdiagnosed as frank breech. To avoid any confusion, a bedside ultrasound scan can be performed. [6]  Ultrasound imaging can show a reduced angle between the occiput and the spine or the chin is separated from the chest. However, ultrasound does not provide much predictive value for the outcome of labor. [7]

• Anatomy and Physiology

Before discussing the mechanism of labor in the face or brow presentation, it is crucial to highlight some anatomical landmarks and their measurements. 

Planes and Diameters of the Pelvis

The 3 most important planes in the female pelvis are the pelvic inlet, mid-pelvis, and pelvic outlet. Four diameters can describe the pelvic inlet: anteroposterior, transverse, and 2 obliques. Furthermore, based on the landmarks on the pelvic inlet, there are 3 different anteroposterior diameters named conjugates: true conjugate, obstetrical conjugate, and diagonal conjugate. Only the latter can be measured directly during the obstetric examination. The shortest of these 3 diameters is obstetrical conjugate, which measures approximately 10.5 cm and is the distance between the sacral promontory and 1 cm below the upper border of the symphysis pubis. This measurement is clinically significant as the fetal head must pass through this diameter during the engagement phase. The transverse diameter measures about 13.5 cm and is the widest distance between the innominate line on both sides. The shortest distance in the mid pelvis is the interspinous diameter and usually is only about 10 cm. 

Fetal Skull Diameters

There are 6 distinguished longitudinal fetal skull diameters:

• Suboccipito-bregmatic: from the center of anterior fontanelle (bregma) to the occipital protuberance, measuring 9.5 cm. This is the diameter presented in the vertex presentation. 
• Suboccipito-frontal: from the anterior part of bregma to the occipital protuberance, measuring 10 cm 
• Occipito-frontal: from the root of the nose to the most prominent part of the occiput, measuring 11.5 cm
• Submento-bregmatic: from the center of the bregma to the angle of the mandible, measuring 9.5 cm. This is the diameter in the face presentation where the neck is hyperextended. 
• Submento-vertical: from the midpoint between fontanelles and the angle of the mandible, measuring 11.5 cm 
• Occipito-mental: from the midpoint between fontanelles and the tip of the chin, measuring 13.5 cm. It is the presenting diameter in brow presentation. 

Cardinal Movements of Normal Labor

• Neck flexion
• Internal rotation
• Extension (delivers head)
• External rotation (restitution)
• Expulsion (delivery of anterior and posterior shoulders)

Some key movements are impossible in the face or brow presentations. Based on the information provided above, it is obvious that labor be arrested in brow presentation unless it spontaneously changes to the face or vertex, as the occipito-mental diameter of the fetal head is significantly wider than the smallest diameter of the female pelvis. Face presentation can, however, be delivered vaginally, and further mechanisms of face delivery are explained in later sections.

• Indications

As mentioned previously, spontaneous vaginal delivery can be successful in face presentation. However, the main indication for vaginal delivery in such circumstances would be a maternal choice. It is crucial to have a thorough conversation with a mother, explaining the risks and benefits of vaginal delivery with face presentation and a cesarean section. Informed consent and creating a rapport with the mother is an essential aspect of safe and successful labor.

• Contraindications

Vaginal delivery of face presentation is contraindicated if the mentum is lying posteriorly or is in a transverse position. In such a scenario, the fetal brow is pressing against the maternal symphysis pubis, and the short fetal neck, which is already maximally extended, cannot span the surface of the maternal sacrum. In this position, the diameter of the head is larger than the maternal pelvis, and it cannot descend through the birth canal. Therefore, the cesarean section is recommended as the safest mode of delivery for mentum posterior face presentations. Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated as they can be dangerous. Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large.

Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios. One study found that only 14% of the cases with face presentation had no abnormal traces on the cardiotocograph. [8]  External transducer devices are advised to prevent damage to the eyes. When internal monitoring is inevitable, monitoring devices on bony parts should be placed carefully. 

Consultations that are typically requested for patients with delivery of face/brow presentation include the following:

• Experienced midwife, preferably looking after laboring women 1:1
• Senior obstetrician 
• Neonatal team - in case of need for resuscitation 
• Anesthetic team - to provide necessary pain control (eg, epidural)
• Theatre team  - in case of failure to progress, an emergency cesarean section is required.
• Preparation

No specific preparation is required for face or brow presentation. However, discussing the labor options with the mother and birthing partner and informing members of the neonatal, anesthetic, and theatre co-ordinating teams is essential.

• Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and the pressure of the amniotic fluid initiate descent. During this descent, the fetal neck extends instead of flexing. The internal rotation determines the outcome of delivery. If the fetal chin rotates posteriorly, vaginal delivery would not be possible, and cesarean section is permitted. The approach towards mentum-posterior delivery should be individualized, as the cases are rare. Expectant management is acceptable in multiparous women with small fetuses, as a spontaneous mentum-anterior rotation can occur. However, there should be a low threshold for cesarean section in primigravida women or women with large fetuses.

The pubis is described as mentum-anterior when the fetal chin is rotated towards the maternal symphysis. In these cases, further descent through the vaginal canal continues, with approximately 73% of cases delivering spontaneously. [9]  The fetal mentum presses on the maternal symphysis pubis, and the head is delivered by flexion. The occiput is pointing towards the maternal back, and external rotation happens. Shoulders are delivered in the same manner as in vertex delivery.

Mechanism of Labor in Brow Presentation

As this presentation is considered unstable, it is usually converted into a face or an occiput presentation. Due to the cephalic diameter being wider than the maternal pelvis, the fetal head cannot engage; thus, brow delivery cannot occur. Unless the fetus is small or the pelvis is very wide, the prognosis for vaginal delivery is poor. With persistent brow presentation, a cesarean section is required for safe delivery.

• Complications

As the cesarean section is becoming a more accessible mode of delivery in malpresentations, the incidence of maternal and fetal morbidity and mortality during face presentation has dropped significantly. [10]  However, some complications are still associated with the nature of labor in face presentation. Due to the fetal head position, it is more challenging for the head to engage in the birth canal and descend, resulting in prolonged labor. Prolonged labor itself can provoke fetal distress and arrhythmias. If the labor arrests or signs of fetal distress appear on CTG, the recommended next step in management is an emergency cesarean section, which in itself carries a myriad of operative and post-operative complications. Finally, due to the nature of the fetal position and prolonged duration of labor in face presentation, neonates develop significant edema of the skull and face. Swelling of the fetal airway may also be present, resulting in respiratory distress after birth and possible intubation.

• Clinical Significance

During vertex presentation, the fetal head flexes, bringing the chin to the chest, forming the smallest possible fetal head diameter, measuring approximately 9.5 cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head engages later, and labor progresses more slowly. Failure to progress in labor is also more common in both presentations compared to the vertex presentation. Furthermore, when the fetal chin is in a posterior position, this prevents further flexion of the fetal neck, as browns are pressing on the symphysis pubis. As a result, descending through the birth canal is impossible. Such presentation is considered undeliverable vaginally and requires an emergency cesarean section. Manual attempts to change face presentation to vertex or manual or forceps rotation to mentum anterior are considered dangerous and discouraged.

• Enhancing Healthcare Team Outcomes

A multidisciplinary team of healthcare experts supports the woman and her child during labor and the perinatal period. For a face or brow presentation to be appropriately diagnosed, an experienced midwife and obstetrician must be involved in the vaginal examination and labor monitoring. As fetal anomalies, such as anencephaly or goiter, can contribute to face presentation, sonographers experienced in antenatal scanning should also be involved in the care. It is advised to inform the anesthetic and neonatal teams in advance of the possible need for emergency cesarean section and resuscitation of the neonate. [11] [12]

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Disclosure: Julija Makajeva declares no relevant financial relationships with ineligible companies.

Disclosure: Mohsina Ashraf declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Obstetric and Newborn Care I

10.02 key terms related to fetal positions.

a. “Lie” of an Infant.

Lie refers to the position of the spinal column of the fetus in relation to the spinal column of the mother. There are two types of lie, longitudinal and transverse. Longitudinal indicates that the baby is lying lengthwise in the uterus, with its head or buttocks down. Transverse indicates that the baby is lying crosswise in the uterus.

b. Presentation/Presenting Part.

Presentation refers to that part of the fetus that is coming through (or attempting to come through) the pelvis first.

(1) Types of presentations (see figure 10-1). The vertex or cephalic (head), breech, and shoulder are the three types of presentations. In vertex or cephalic, the head comes down first. In breech, the feet or buttocks comes down first, and last–in shoulder, the arm or shoulder comes down first. This is usually referred to as a transverse lie.

(2) Percentages of presentations.

(a) Head first is the most common-96 percent.

(b) Breech is the next most common-3.5 percent.

(c) Shoulder or arm is the least common-5 percent.

(3) Specific presentation may be evaluated by several ways.

(a) Abdominal palpation-this is not always accurate.

(b) Vaginal exam–this may give a good indication but not infallible.

(c) Ultrasound–this confirms assumptions made by previous methods.

(d) X-ray–this confirms the presentation, but is used only as a last resort due to possible harm to the fetus as a result of exposure to radiation.

c. Attitude.

This is the degree of flexion of the fetus body parts (body, head, and extremities) to each other. Flexion is resistance to the descent of the fetus down the birth canal, which causes the head to flex or bend so that the chin approaches the chest.

(1) Types of attitude (see figure 10-2).

(a) Complete flexion. This is normal attitude in cephalic presentation. With cephalic, there is complete flexion at the head when the fetus “chin is on his chest.” This allows the smallest cephalic diameter to enter the pelvis, which gives the fewest mechanical problems with descent and delivery.

(b) Moderate flexion or military attitude. In cephalic presentation, the fetus head is only partially flexed or not flexed. It gives the appearance of a military person at attention. A larger diameter of the head would be coming through the passageway.

(c) Poor flexion or marked extension. In reference to the fetus head, it is extended or bent backwards. This would be called a brow presentation. It is difficult to deliver because the widest diameter of the head enters the pelvis first. This type of cephalic presentation may require a C/Section if the attitude cannot be changed.

(d) Hyperextended. In reference to the cephalic position, the fetus head is extended all the way back. This allows a face or chin to present first in the pelvis. If there is adequate room in the pelvis, the fetus may be delivered vaginally.

(2) Areas to look at for flexion.

(a) Head-discussed in previous paragraph, 10-2c(1).

(b) Thighs-flexed on the abdomen.

(c) Knees-flexed at the knee joints.

(d) Arches of the feet-rested on the anterior surface of the legs.

(e) Arms-crossed over the thorax.

(3) Attitude of general flexion. This is when all of the above areas are flexed appropriately as described.

d. Station.

This refers to the depth that the presenting part has descended into the pelvis in relation to the ischial spines of the mother’s pelvis. Measurement of the station is as follows:

(1) The degree of advancement of the presenting part through the pelvis is measured in centimeters.

(2) The ischial spines is the dividing line between plus and minus stations.

(3) Above the ischial spines is referred to as -1 to -5, the numbers going higher as the presenting part gets higher in the pelvis (see figure10-3).

(4) The ischial spines is zero (0) station.

(5) Below the ischial spines is referred to +1 to +5, indicating the lower the presenting part advances.

e. Engagement.

This refers to the entrance of the presenting part of the fetus into the true pelvis or the largest diameter of the presenting part into the true pelvis. In relation to the head, the fetus is said to be engaged when it reaches the midpelvis or at a zero (0) station. Once the fetus is engaged, it (fetus) does not go back up. Prior to engagement occurring, the fetus is said to be “floating” or ballottable.

f. Position.

This is the relationship between a predetermined point of reference or direction on the presenting part of the fetus to the pelvis of the mother.

(1) The maternal pelvis is divided into quadrants.

(a) Right and left side, viewed as the mother would.

(b) Anterior and posterior. This is a line cutting the pelvis in the middle from side to side. The top half is anterior and the bottom half is posterior.

(c) The quadrants never change, but sometimes it is confusing because the student or physician’s viewpoint changes.

NOTE: Remember that when you are describing the quadrants, view them as the mother would.

(2) Specific points on the fetus.

(a) Cephalic or head presentation.

1 Occiput (O). This refers to the Y sutures on the top of the head.

2 Brow or fronto (F). This refers to the diamond sutures or anterior fontanel on the head.

3 Face or chin presentation (M). This refers to the mentum or chin.

(b) Breech or butt presentation.

1 Sacrum or coccyx (S). This is the point of reference.

2 Breech birth is associated with a higher perinatal mortality.

(c) Shoulder presentation.

1 This would be seen with a transverse lie.

2. Scapula (Sc) or its upper tip, the acromion (A) would be used for the point of reference.

(3) Coding of positions.

(a) Coding simplifies explaining the various positions.

1 The first letter of the code tells which side of the pelvis the fetus reference point is on (R for right, L for left).

2 The second letter tells what reference point on the fetus is being used (Occiput-O, Fronto-F, Mentum-M, Breech-S, Shoulder-Sc or A).

3 The last letter tells which half of the pelvis the reference point is in (anterior-A, posterior-P, transverse or in the middle-T).

(b) Each presenting part has the possibility of six positions. They are normally recognized for each position–using “occiput” as the reference point.

1 Left occiput anterior (LOA).

2 Left occiput posterior (LOP).

3 Left occiput transverse (LOT).

4 Right occiput anterior (ROA).

5. Right occiput posterior (ROP).

6 Right occiput transverse (ROT).

(c) A transverse position does not use a first letter and is not the same as a transverse lie or presentation.

1 Occiput at sacrum (O.S.) or occiput at posterior (O.P.).

2 Occiput at pubis (O.P.) or occiput at anterior (O.A.).

(4) Types of breech presentations (see figure10-4).

(a) Complete or full breech. This involves flexion of the fetus legs. It looks like the fetus is sitting in a tailor fashion. The buttocks and feet appear at the vaginal opening almost simultaneously.

A–Complete. B–Frank. C–Incomplete.

(b) Frank and single breech. The fetus thighs are flexed on his abdomen. His legs are against his trunk and feet are in his face (foot-in-mouth posture). This is the most common and easiest breech presentation to deliver.

(c) Incomplete breech. The fetus feet or knees will appear first. His feet are labeled single or double footing, depending on whether 1 or 2 feet appear first.

(5) Observations about positions (see figure 10-5).

(a) LOA and ROA positions are the most common and permit relatively easy delivery.

(b) LOP and ROP positions usually indicate labor may be longer and harder, and the mother will experience severe backache.

(c) Knowing positions will help you to identify where to look for FHT’s.

1 Breech. This will be upper R or L quad, above the umbilicus.

2 Vertex. This will be lower R or L quad, below the umbilicus.

(d) An occiput in the posterior quadrant means that you will feel lumpy fetal parts, arms and legs (see figure 10-5 A). If delivered in that position, the infant will come out looking up.

(e) An occiput in the anterior quadrant means that you will feel a more smooth back (see figure 10-5 B). If delivered in that position, the infant will come out looking down at the floor.

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presentation

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• MedlinePlus - Your baby in the birth canal

presentation , in childbirth , the position of the fetus at the time of delivery. The presenting part is the part of the fetus that can be touched by the obstetrician when he probes with his finger through the opening in the cervix, the outermost portion of the uterus, which projects into the vagina. In nearly all deliveries the presenting part is the vertex, the top of the head; in 3 or 4 percent of deliveries, it is the breech (buttocks). Face presentation and transverse (cross) presentation are rare.

In vertex presentations the head of the fetus most commonly faces to the right and slightly to the rear. This position is said to be the most usual one because the fetus is thus best accommodated to the shape of the uterus. In breech presentation the buttocks or the legs are the first to pass through the pelvis. The feet may be alongside the buttocks, or the legs may be extended against the face. Because the head is the last part of the fetus to be delivered in breech birth, there is some danger that the fetus will be asphyxiated; there is also danger that the umbilical cord will be compressed during birth of the head. In face presentation it may be necessary to turn the fetus before delivery if the chin is directed backward. Transverse presentation, which occurs only once in several hundred labours, requires turning of the fetus before vaginal delivery or else delivery by cesarean section .

Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for vertex presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Chapter 27:  Compound Presentations

George Tawagi

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Prolapse of hand and arm or foot and leg.

• MANAGEMENT OF COMPOUND PRESENTATIONS
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A presentation is compound when there is prolapse of one or more of the limbs along with the head or the breech, both entering the pelvis at the same time. Footling breech or shoulder presentations are not included in this group. Associated prolapse of the umbilical cord occurs in 15 to 20 percent of cases.

Easily detectable compound presentations occur probably once in 500 to 1000 confinements. It is impossible to establish the exact incidence because:

Spontaneous correction occurs frequently, and examination late in labor cannot provide the diagnosis

Minor degrees of prolapse are detected only by early and careful vaginal examination

Classification of Compound Presentation

Upper limb (arm–hand), one or both

Lower limb (leg–foot), one or both

Arm and leg together

Breech presentation with prolapse of the hand or arm

By far the most frequent combination is that of the head with the hand ( Fig. 27-1 ) or arm. In contrast, the head–foot and breech–arm groups are uncommon, about equally so. Prolapse of both hand and foot alongside the head is rare. All combinations may be complicated by prolapse of the umbilical cord, which then becomes the major problem.

FIGURE 27-1.

Compound presentation: head and hand.

The etiology of compound presentation includes all conditions that prevent complete filling and occlusion of the pelvic inlet by the presenting part. The most common causal factor is prematurity. Others include high presenting part with ruptured membranes, polyhydramnios, multiparity, a contracted pelvis, pelvic masses, and twins. It is also more common with inductions of labor involving floating presenting parts. Another predisposing factor is external cephalic version. During the process of external version, a fetal limb (commonly the hand–arm, but occasionally the foot) can become “trapped” before the fetal head and thus become the presenting part when labor ensues.

Diagnosis is made by vaginal examination, and in many cases, the condition is not noted until labor is well advanced and the cervix is fully dilated.

The condition is suspected when:

There is delay of progress in the active phase of labor

Engagement fails to occur

The fetal head remains high and deviated from the midline during labor, especially after the membranes rupture

In the absence of complications and with conservative management, the results should be no worse than with other presentations.

Mechanism of Labor

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Presentation (Obstetrics)

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• 2 Types of Presentations
• 4 References

Presentation in Obstetrics refers to the relationship between the leading fetal part and the pelvic inlet: cephalic, breech, or shoulder presentation. A malpresentation is an abnormal (non-vertex) presentation.

Types of Presentations

Thus the various presentations are:

• Vertex —commonest and associated with least complications
• Sinciput (forehead)
• Brow (Eye brows)
• Complete breech
• Footling breech
• Frank breech
• Child birth
• Fetal relations

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Obstetric abdominal examination frequently appears in OSCEs and you’ll be expected to pick up the relevant clinical signs using your examination skills. This obstetric abdominal examination OSCE guide provides a clear step-by-step approach to examining the pregnant abdomen, with an included video demonstration.

• Gather equipment

Gather relevant equipment including:

• Measuring tape
• Pinard stethoscope
• Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role .

Confirm the patient’s name and date of birth .

Briefly explain what the examination will involve using patient-friendly language: “Today I need to examine your tummy as part of the assessment of your pregnancy. This will involve me looking and feeling the tummy, in addition to performing some measurements. Although it may be a little uncomfortable, it shouldn’t be painful. If at any point you’d like me to stop then please just let me know.”

Offer a chaperone .

Gain consent to proceed with the examination: “Do you understand everything I’ve said? Are you happy for me to carry out the examination?”

Position the patient on the clinical examination couch with the head of the bed at a 30-45° angle for the initial assessment.

Adequately expose the patient’s abdomen for the examination from the pubic symphysis to the xiphisternum (offer a blanket to allow exposure only when required).

Provide the patient with the opportunity to pass urine before the examination.

Ask the patient if they have any pain before proceeding with the clinical examination.

• General inspection

Clinical signs

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology:

• Pain: if the patient appears uncomfortable, ask where the pain is and whether they are still happy for you to examine them.
• Obvious scars:  may provide clues regarding previous abdominal surgery (e.g. caesarean section ).
• Pallor: a pale colour of the skin that can suggest underlying anaemia. It should be noted that healthy individuals may have a pale complexion that mimics pallor.
• Jaundice:  a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. obstetric cholestasis).
• Oedema: a small amount of oedema is normal in the later stages of pregnancy however if there is widespread oedema affecting the arms, legs and face consider the possibility of pre-eclampsia.

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:

• Mobility aids : items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
• Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time (e.g. blood pressure).
• Fluid balance: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
• Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.

Obstetric cholestasis

Obstetric cholestasis is a multifactorial condition that is characterised by abnormal liver function tests , jaundice and intense pruritis (typically affecting the palms and soles of the feet). The disease usually presents in the third trimester and is associated with an increased risk of intrauterine death and premature delivery.

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

Inspect the hands for relevant clinical signs:

• Colour: pale hands suggest poor peripheral perfusion (e.g. hypovolaemic shock, aortocaval compression) and cyanosis may suggest underlying hypoxaemia.
• Peripheral oedema: may be a normal finding in late pregnancy, but if widespread consider pre-eclampsia. If pre-eclampsia is suspected, you should check the patient’s blood pressure and perform urinalysis (looking for proteinuria).
• Palmar erythema: a redness involving the heel of the palm that is a normal finding in pregnancy.

Temperature

Place the dorsal aspect of your hand onto the patient’s to assess temperature :

• In healthy individuals, the hands should be symmetrically warm , suggesting adequate perfusion.
• Cool hands may suggest poor peripheral perfusion (e.g. hypovolaemic shock, aortocaval compression).

Capillary refill time (CRT)

Measuring capillary refill time (CRT) in the hands is a useful way of assessing peripheral perfusion :

• Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release .
• In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds .
• A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. antepartum haemorrhage, aortocaval compression) and the need to assess central capillary refill time.

Radial pulse

Palpate the patient’s radial pulse , located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.

Once you have located the radial pulse, assess the rate and rhythm .

Assessing heart rate:

• You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and multiplying by 2 or measuring for 15 seconds and multiplying by 4.
• For irregular rhythms , you should measure the pulse for a full 60 seconds to improve accuracy.
• Women typically have a higher baseline heart rate during pregnancy (80-90 beats per minute).

Inspect the patient’s face  for relevant clinical signs :

• Jaundice: most evident in the superior portion of the sclera (ask the patient to look downwards as you lift their upper eyelid). In the context of an obstetric abdominal examination, it is most likely secondary to obstetric cholestasis.
• Melasma: benign dark and irregular hyperpigmented macules which are normal in pregnancy.
• Oedema: may be a normal finding in late pregnancy, but if widespread consider pre-eclampsia.
• Conjunctival pallor: ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva for pallor. Conjunctival pallor is associated with anaemia.

• Abdominal inspection

Position the patient

The recommended positioning for a patient during pregnancy varies, depending on the current gestation:

• Early pregnancy: position the patient supine on the couch, with the head end of the bed elevated to 15-30°.
• Late pregnancy: position the patient in the left lateral position (tilted 15° to the horizontal level) to avoid compression of the abdominal aorta and inferior vena cava by the gravid uterus (known as aortocaval compression).

Closely inspect the abdomen

Expose the abdomen appropriately, from the xiphisternum to the pubic symphysis and inspect for relevant clinical signs:

• Abdominal shape: this may give an initial indication of the fetal lie.
• Fetal movements: these are typically visible from 24 weeks gestation.
• Surgical scars: may provide clues regarding previous abdominal surgery (e.g. caesarian section).
• Linea nigra:  a dark line running vertically down the middle of the abdomen (a normal finding in pregnancy).
• Striae gravidarum: reddish or purple lesions that develop due to overstretching of the abdominal skin as the gravid uterus expands (commonly referred to as stretch marks).
• Striae albicans: mature stretch marks which appear silver-like in colour and are less pronounced.

Aortocaval compression syndrome

Aortocaval compression syndrome occurs due to compression of the abdominal aorta  and  inferior vena cava  by the gravid uterus when a pregnant woman is supine. Aortocaval compression can result in maternal hypotension , loss of consciousness and in rare cases fetal demise . Women in late pregnancy are positioned in the left lateral position when supine to reduce pressure on the aorta and inferior vena cava.

• Abdominal palpation

Ask about abdominal tenderness before palpating the abdomen and continue to monitor the patient’s face for signs of discomfort throughout the examination.

Palpate the abdomen

Briefly perform light palpation over each of the nine regions of the abdomen to identify any tenderness or masses that may not relate to the pregnancy (e.g. appendicitis). See the abdominal examination guide for more details.

Palpate the uterus

Palpate the uterus to identify its borders, including the upper and lateral edges.

The uterine fundus can be found at different locations during pregnancy, depending on the patient’s current gestation:

• 12 weeks gestation:  pubic symphysis
• 20 weeks gestation:  umbilicus
• 36 weeks gestation:  the xiphoid process of the sternum

Fetal lie  refers to the relationship between the long axis of the  fetus  with respect to the long axis of the mother .

Assess the gravid uterus to determine the fetal lie :

1. Place your hands on either side of the patient’s uterus (ensuring you are facing the patient).

2. Gently palpate each side of the uterus:

• One side of the uterus should feel full in nature (due to the presence of the fetal back).
• On the other side of the uterus, you may be able to feel the fetus’s limbs.

Types of fetal lie

There are three main types of fetal lie which include:

• Longitudinal lie: the head and buttocks are palpable at each end of the uterus.
• Oblique lie: the head and buttocks are palpable in one of the iliac fossae.
• Transverse lie: the fetus is lying directly across the uterus.

Fetal presentation

Fetal presentation refers to which anatomical part of the fetus is closest to the pelvic inlet .

Assess the gravid uterus to determine fetal presentation :

1. Ensure you are facing the patient to observe for signs of discomfort and warn the patient this may feel a little uncomfortable.

2. Place your hands either side of the lower pole of the uterus, just above the pubic symphysis.

3. Apply firm pressure to the uterus angled medially, palpating for the presenting part:

• A hard round presenting part is suggestive of a cephalic presentation (normal).
• A broader, softer, less defined presenting part (i.e. the fetal bottom or legs) is suggestive of a breech presentation (abnormal).

Fetal engagement

In late pregnancy, the level of fetal engagement should be assessed. A fetus is considered ‘engaged’ when more than 50% of the presenting part (usually the head) has descended into the pelvis.

The fetal head is divided into fifths when assessing engagement:

• If you are able to feel the entire head in the abdomen, it is five fifths palpable (i.e. not engaged).
• If you are not able to feel the head at all abdominally, it is  zero fifths palpable (i.e. fully engaged).

Symphyseal-fundal height

Symphyseal-fundal height is the distance between the fundus and the upper border of the pubic symphysis. After 20 weeks gestation, the symphyseal-fundal height should correlate with the gestational age of the fetus in weeks (+/- 2cm).

To measure the symphyseal-fundal height :

1. Begin palpation of the abdomen just inferior to the xiphisternum using the ulnar border of your left hand.

2. Locate the fundus of the uterus (a firm feeling edge at the upper border of the bump).

3. Once the fundus has been identified, locate the upper border of the pubic symphysis.

4. Measure the distance between the upper uterine border and the pubic symphysis in centimetres using a tape measure. The distance measured should correlate with the gestational age in weeks (+/- 2cm).

To avoid bias, it’s best to place the tape measure facing down and only turn to view the numbers once in position.

• Fetal heartbeat

You may be asked to identify the fetal heartbeat using a Pinard stethoscope (or a Doppler ultrasound probe). As a result, it is important to have a basic understanding of how to locate and identify the fetal heartbeat.

1. Based on your assessment of the fetus’s position, you should place the Pinard stethoscope aiming between the fetal shoulders on the fetal back.

2. Palpate the patient’s radial pulse (i.e. maternal pulse).

3. Place your ear to the Pinard and take your hand away (so the Pinard is held against the abdomen using your ear only):

• You should be applying gentle pressure, to ensure a good seal between your ear and the Pinard, as well as between the Pinard and the abdomen.
• Pressing too hard will be uncomfortable for the patient and pressing too softly will make it difficult to hear anything at all.

4. Listen for the fetal heartbeat:

• If the maternal pulse coincides with the pulse you can hear, you are most likely listening to the flow through the uterine vessels, rather than the fetal heartbeat.

To complete the examination…

Explain to the patient that the examination is now finished .

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands .

Summarise your findings.

Example summary

“Today I examined Mrs Smith , a 28-year-old female who is currently at 36 weeks gestation . On general inspection , the patient appeared comfortable at rest. There were no objects or medical equipment around the bed of relevance. There was no evidence of oedema of the face or peripheries on assessment.”

“Symphyseal-fundal height was 36cm, which is in keeping with the patient’s current gestation. The fetus was positioned in a longitudinal lie with a cephalic presentation. The fetal head was three fifths palpable.”

“In summary , these findings are consistent with a normal obstetric abdominal examination .”

“For completeness, I would like to perform the following further assessments and investigations .”

Further assessments and investigations

• Assessment of the fetal heartbeat: using a Pinard stethoscope or Doppler ultrasound.
• Blood pressure measurement: to assess for evidence of hypertension (e.g. pre-eclampsia).
• Urinalysis: to assess for evidence of proteinuria (pre-eclampsia) and urinary tract infection.
• Speculum examination: if there are concerns about vaginal bleeding or premature rupture of membranes.
• Weight and height measurement
• Ultrasound scan:  to assess the position and wellbeing of the fetus.

Mr Isaac Magani

Consultant Obstetrician

Mr Gareth Waring

Senior Obstetric Registrar

Illustrator

Medical Student and Illustrator

• Elord. Adapted by Geeky Medics. Melasma. Licence: CC BY-SA .
• Azoreg. Adapted by Geeky Medics. Caesarian section scar. Licence: CC BY-SA-3.0 .
• James Heilman, MD. Adapted by Geeky Medics. Linea nigra. Licence: CC BY-SA .
• FatM1ke. Adapted by Geeky Medics. Striae. Licence: CC BY-SA .
• ParentingPatch. Adapted by Geeky Medics. Striae albicans. Licence: CC BY-SA .

• Wash your hands and don PPE if appropriate
• Introduce yourself to the patient including your name and role
• Confirm the patient's name and date of birth
• Briefly explain what the examination will involve using patient-friendly language
• Gain consent to proceed with the examination & offer a chaperone
• Position the patient on the clinical examination couch with the head of the bed at a 30-45° angle for the initial assessment
• Provide the patient with the opportunity to pass urine before the examination
• Adequately expose the patient's abdomen for the examination from the pubic symphysis to the xiphisternum (offer a blanket to allow exposure only when required)
• Ask the patient if they have any pain before proceeding with the clinical examination
• Inspect the patient whilst at rest, looking for clinical signs suggestive of underlying pathology
• Inspect the hands for relevant clinical signs (e.g. oedema)
• Assess and compare the temperature of the hands
• Assess capillary refill time (CRT)
• Assess the radial pulse
• Inspect the patient’s face for relevant clinical signs (e.g. oedema, jaundice, conjunctival pallor)
• Position the patient appropriately for abdominal inspection
• Inspect the abdomen closely (scars, linea nigra, striae)
• Briefly palpate the nine regions of the abdomen for tenderness or masses
• Palpate the borders of the uterus
• Determine fetal lie
• Assess fetal presentation
• Assess fetal engagement
• Measure symphyseal-fundal height
• Listen to the fetal heartbeat using a Pinard stethoscope or Doppler ultrasound
• To complete the examination…
• Explain to the patient that the examination is now finished
• Thank the patient for their time
• Dispose of PPE appropriately and wash your hands
• Summarise your findings
• Suggest further assessments and investigations (e.g. blood pressure, urinalysis, speculum, ultrasound scan)

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Normal Labor and Delivery

• Author: Sarah Hagood Milton, MD; Chief Editor: Christine Isaacs, MD  more...
• Sections Normal Labor and Delivery
• Practice Essentials
• Stages of Labor and Epidemiology
• Mechanism of Labor
• Clinical History and Physical Examination
• Intrapartum Management of Labor
• Pain Control
• Questions & Answers

Labor is a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus.

Stages of labor

Obstetricians have divided labor into 3 stages that delineate milestones in a continuous process.

First stage of labor

Begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm

Divided into a latent phase and an active phase

The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix

Contractions become progressively more rhythmic and stronger

The active phase usually begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part

Second stage of labor

Begins with complete cervical dilatation and ends with the delivery of the fetus

In nulliparous persons, the second stage should be considered prolonged if it exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia

In multiparous persons, the second stage should be considered prolonged if it exceeds 2 hours with regional anesthesia or 1 hour without it [ 1 ]

Third stage of labor

The period between the delivery of the fetus and the delivery of the placenta and fetal membranes

Delivery of the placenta often takes less than 10 minutes, but the third stage may last as long as 30 minutes

Expectant management involves spontaneous delivery of the placenta

The third stage of labor is considered prolonged after 30 minutes, and active intervention is commonly considered [ 2 ]

Active management often involves prophylactic administration of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord clamping/cutting, and controlled traction of the umbilical cord

Mechanism of labor

The mechanisms of labor, also known as the cardinal movements, involve changes in the position of the fetus’s head during its passage in labor. These are described in relation to a vertex presentation. Although labor and delivery occurs in a continuous fashion, the cardinal movements are described as the following 7 discrete sequences [ 2 ] :

Internal rotation

Restitution and external rotation.

The initial assessment of labor should include a review of the patient's prenatal care, including confirmation of the estimated date of delivery. Focused history taking should elicit the following information:

Frequency and time of onset of contractions

Status of the amniotic membranes (whether spontaneous rupture of the membranes has occurred, and if so, whether the amniotic fluid is clear or meconium stained)

Fetal movements

Presence or absence of vaginal bleeding.

Braxton-Hicks contractions must be differentiated from true contractions. Typical features of Braxton-Hicks contractions are as follows:

Usually occur no more often than once or twice per hour, and often just a few times per day

Irregular and do not increase in frequency with increasing intensity

Resolve with ambulation or a change in activity

Contractions that lead to labor have the following characteristics:

May start as infrequently as every 10-15 minutes, but usually accelerate over time, increasing to contractions that occur every 2-3 minutes

Tend to last longer and are more intense than Braxton-Hicks contractions

Lead to cervical change

Physical examination

The physical examination should include documentation of the following:

Maternal vital signs

Fetal presentation

Assessment of fetal well-being

Frequency, duration, and intensity of uterine contractions

Abdominal examination with Leopold maneuvers

Pelvic examination with sterile gloves

Digital examination allows the clinician to determine the following aspects of the cervix:

Degree of dilatation, which ranges from 0 cm (closed or fingertip) to 10 cm (complete or fully dilated)

Effacement (assessment of the cervical length, which can be reported as a percentage of the normal 3- to 4-cm–long cervix or described as the actual cervical length)

Position (ie, anterior or posterior)

Consistency (ie, soft or firm)

Palpation of the presenting part of the fetus allows the examiner to establish its station, by quantifying the distance of the body (-5 to +5 cm) that is presenting relative to the maternal ischial spines, where 0 station is in line with the plane of the maternal ischial spines. [ 2 ]

Intrapartum management of labor

On admission to the labor and delivery suite, persons having normal labor should be encouraged to assume the position that they find most comfortable. Possibilities including the following:

Lying supine

Resting in a left lateral decubitus position

Management includes the following:

Periodic assessment of the frequency and strength of uterine contractions and changes in cervix and in the fetus' station and position

Monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately after uterine contractions; in most obstetric units, the fetal heart rate is assessed continuously [ 3 ]

With complete cervical dilatation, the fetal heart rate should be monitored or auscultated at least every 5 minutes and after each contraction. [ 3 ] Prolonged duration of the second stage alone does not mandate operative delivery if progress is being made, but management options for second-stage arrest include the following:

Continuing observation/expectant management

Operative vaginal delivery by forceps or vacuum-assisted vaginal delivery, or cesarean delivery.

Delivery of the fetus

Positioning of the patient for delivery can be any of the following [ 2 ] :

Supine with the knees bent (ie, dorsal lithotomy position; the usual choice)

Lateral (Sims) position

Partial sitting or squatting position

On the hands and knees

Episiotomy used to be routinely performed at this time, but current recommendations restrict its use to maternal or fetal indications

Delivery maneuvers are as follows:

The head is held in mid position until it is delivered, followed by suctioning of the oropharynx and nares

Check the fetus's neck for a wrapped umbilical cord, and promptly reduce it if possible

If the cord is wrapped too tightly to be removed, the cord can be double clamped and cut

The fetus's anterior shoulder is delivered with gentle downward traction on its head and chin

Subsequent upward pressure in the opposite direction facilitates delivery of the posterior shoulder

The rest of the fetus should now be easily delivered with gentle traction away from the birthing parent

If not done previously, the cord is clamped and cut

The baby is vigorously stimulated and dried and then transferred to the care of the waiting attendants or placed on the birthing parent's abdomen

The following 3 classic signs indicate that the placenta has separated from the uterus [ 2 ] :

The uterus contracts and rises

The umbilical cord suddenly lengthens

A gush of blood occurs

Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30 minutes after delivery of the fetus.

Pain control

Agents given in intermittent doses for systemic pain control include the following [ 4 ] :

Meperidine, 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours

Fentanyl, 50-100 mcg IV every hour

Nalbuphine, 10 mg IV or IM every 3 hours

Butorphanol, 1-2 mg IV or IM every 4 hours

Morphine, 2-5 mg IV or 10 mg IM every 4 hours

As an alternative, regional anesthesia may be given. Anesthesia options include the following:

Combined spinal-epidural

Labor is a physiologic process during which the products of conception (ie, the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient frequency, intensity, and duration. [ 1 , 2 ]

Labor is a clinical diagnosis. The onset of labor is defined as regular, painful uterine contractions resulting in progressive cervical effacement and dilatation. Cervical dilatation in the absence of uterine contraction suggests cervical insufficiency, whereas uterine contraction without cervical change does not meet the definition of labor.

The first stage begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm. In Friedman’s landmark studies of 500 nulliparas, [ 5 ]  he subdivided the first stage into an early latent phase and an ensuing active phase. The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix. The contractions become progressively more rhythmic and stronger. This is followed by the active phase of labor, which usually begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part. The first stage of labor ends with complete cervical dilation at 10 cm. According to Friedman, the active phase is further divided into an acceleration phase, a phase of maximum slope, and a deceleration phase.

Characteristics of the average cervical dilatation curve is known as the Friedman labor curve, and a series of definitions of labor protraction and arrest were subsequently established. [ 6 , 7 ] However, subsequent data of modern obstetric population suggest that the rate of cervical dilatation is slower and the progression of labor may be significantly different from that suggested by the Friedman labor curve. [ 8 , 9 , 10 ]

The second stage begins with complete cervical dilatation and ends with the delivery of the fetus. The American College of Obstetricians and Gynecologists (ACOG) has suggested that a prolonged second stage of labor should be considered when the second stage of labor exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia for nulliparas. In multiparous persons, such a diagnosis can be made if the second stage of labor exceeds 2 hours with regional anesthesia or 1 hour without it. [ 1 ]

Studies performed to examine perinatal outcomes associated with a prolonged second stage of labor revealed increased risks of operative deliveries and maternal morbidities but no differences in neonatal outcomes. [ 11 , 12 , 13 , 14 ] Maternal risk factors associated with a prolonged second stage include nulliparity, increasing maternal weight and/or weight gain, use of regional anesthesia, induction of labor, fetal occiput in a posterior or transverse position, and increased birthweight. [ 13 , 14 , 15 , 16 ]

The third stage of labor is defined by the time period between the delivery of the fetus and the delivery of the placenta and fetal membranes. During this period, uterine contraction decreases basal blood flow, which results in thickening and reduction in the surface area of the myometrium underlying the placenta with subsequent detachment of the placenta. [ 17 ] Although delivery of the placenta often requires less than 10 minutes, the duration of the third stage of labor may last as long as 30 minutes.

Expectant management of the third stage of labor involves spontaneous delivery of the placenta. Active management often involves prophylactic administration of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord clamping/cutting, and controlled cord traction of the umbilical cord. Andersson et al found that delayed cord clamping (≥180 seconds after delivery) improved iron status and reduced prevalence of iron deficiency at age 4 months and also reduced prevalence of neonatal anemia, without apparent adverse effects. [ 18 ]

A systematic review of the literature that included 5 randomized controlled trials comparing active and expectant management of the third stage reports that active management shortens the duration of the third stage and is superior to expectant management with respect to blood loss/risk of postpartum hemorrhage; however, active management is associated with an increased risk of unpleasant side effects. [ 19 ]

The third stage of labor is considered prolonged after 30 minutes, and active intervention, such as manual extraction of the placenta, is commonly considered. [ 2 ]

Epidemiology

As the childbearing population in the United States has changed, the clinical obstetric management of labor also has evolved since Friedman's studies. Data from number a studies have suggested that normal labor can progress at a rate much slower than that Friedman and Sachtleben [ 6 , 7 ] had described. Zhang et al examined the labor progression of 1162 nulliparas who presented in spontaneous labor and constructed a labor curve that was markedly different from Friedman's: The average interval to progress from 4-10 cm of cervical dilatation was 5.5 hours compared with 2.5 hours of Friedman's labor curve. [ 20 ] Kilpatrick et al [ 8 ] and Albers et al [ 9 ] also reported that the median lengths of first and second stages of labor were longer than those Friedman suggested.

A number of investigators have identified several maternal characteristics obstetric factors that are associated with the length of labor. One group reported that increasing maternal age was associated with a prolonged second stage but not first stage of labor. [ 21 ]

While nulliparity is associated with a longer labor compared to multiparas, increasing parity does not further shorten the duration of labor. [ 22 ] Some authors have observed that the length of labor differs among racial/ethnic groups. One group reported that Asian women have the longest first and second stages of labor compared with Caucasian or African American women [ 23 ] , and American Indian women had second stages shorter than those of non-Hispanic Caucasian women. [ 9 ] However, others report conflicting findings. [ 24 , 25 ] Differences in the results may have been due to variations in study designs, study populations, labor management, or statistical power.

In one large retrospective study of the length of labor, specifically with respect to race and/or ethnicity, the authors observed no significant differences in the length of the first stage of labor among different racial/ethnic groups. However, the second stage was shorter in African American women than in Caucasian women for both nulliparas (-22 min) and multiparas (-7.5 min). Hispanic nulliparas, compared with their Caucasian counterparts, also had a shortened second stage, whereas no differences were seen for multiparas. In contrast, Asian nulliparas had a significantly prolonged second stage compared with their Caucasian counterparts, and no differences were seen for multiparas. [ 26 ]

According to a systematic review of 13 trials involving 16,242 women, most women whose prenatal and childbirth care were led by a midwife had better outcomes compared with those whose care was led by a physician or shared among disciplines. Patients who received midwife-led pregnancy care were less likely to have regional analgesia, episiotomy, and instrumental birth and more likely to have no intrapartum analgesia or anesthesia, spontaneous vaginal birth, attendance at birth by a known midwife, and a longer mean length of labor. They were also less likely to have preterm birth and fetal loss before 24 weeks' gestation. However, the average risk ratio for caesarean births did not differ between groups, and there were no differences in fetal loss/neonatal death at 24 or more weeks' gestation or in overall fetal/neonatal death. [ 1 , 27 ]

Concerns associated with midwife-attended home births

However, concerns about the effect of midwife-attended home births on neonatal health were raised by an analysis of nearly 14 million singleton, full-term births, from 2007-2010, of infants of normal weight. The data, from the National Center for Health Statistics, indicated that delivering at home was associated with a greater than 10-fold increased risk for an Apgar score of 0 and a nearly 4-fold increased risk for neonatal seizure or serious neurologic dysfunction, as compared with hospital delivery. [ 28 , 29 ]

Compared with delivery by a hospital physician, midwife-attended home birth was associated with a relative risk (RR) of 10.55 for an Apgar score of 0. For midwife deliveries at freestanding birth centers, the RR was 3.56, and for hospital midwife deliveries, the RR was 0.55. [ 28 , 29 ]

In the same study, the RR for neonatal seizures or serious neurologic disorders for midwife-attended home births, compared with physician-attended hospital delivery, was 3.80. Compared with in-hospital physician delivery, the RR for midwife delivery at freestanding birth centers was 1.88, and for hospital midwife delivery, the RR was 0.74. [ 28 , 29 ]

The ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of its head during its passage in labor. 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. Although labor and delivery occurs in a continuous fashion, the cardinal movements are described as 7 discrete sequences, as discussed below. [ 2 ]

The widest diameter of the presenting part (with a well-flexed head, where the largest transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a level below the plane of the pelvic inlet. On the pelvic examination, the presenting part is at 0 station, or at the level of the maternal ischial spines.

The downward passage of the presenting part through the pelvis. This occurs intermittently with contractions. The rate is greatest during the second stage of labor.

As the fetal vertex descents, it encounters resistance from the bony pelvis or the soft tissues of the pelvic floor, 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 (11.0 cm) to suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis.

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.

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. Upward resistance from the pelvic floor and the downward forces from the uterine contractions cause the occiput to extend and rotate around the symphysis. This is followed by the delivery of the fetus' head.

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.

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.

The initial assessment of labor should include a review of the patient's prenatal care, including confirmation of the estimated date of delivery. Focused history taking should be conducted to include information, such as the frequency and time of onset of contractions, the status of the amniotic membranes (whether spontaneous rupture of the membranes has occurred, and if so, whether the amniotic fluid is clear or meconium stained), the fetus' movements, and the presence or absence of vaginal bleeding.

Braxton-Hicks contractions, which are often irregular and do not increase in frequency with increasing intensity, must be differentiated from true contractions. Braxton-Hicks contractions often resolve with ambulation or a change in activity. However, contractions that lead to labor tend to last longer and are more intense, leading to cervical change. True labor is defined as uterine contractions leading to cervical changes. If contractions occur without cervical changes, it is not labor. Other causes for the cramping should be diagnosed. Gestational age is not a part of the definition of labor.

In addition, Braxton-Hicks contractions occur occasionally, usually no more than 1-2 per hour, and they often occur just a few times per day. Labor contractions are persistent, they may start as infrequently as every 10-15 minutes, but they usually accelerate over time, increasing to contractions that occur every 2-3 minutes.

Patients may also describe what has been called lightening, ie, physical changes felt because the fetus' head is advancing into the pelvis. The patient may feel that the baby has become light. As the presenting fetal part starts to drop, the shape of the patient's abdomen may change to reflect descent of the fetus. Breathing may be relieved because tension on the diaphragm is reduced, whereas urination may become more frequent due to the added pressure on the urinary bladder.

Physical examination should include documentation of the patient's vital signs, the fetus' presentation, and assessment of the fetal well-being. The frequency, duration, and intensity of uterine contractions should be assessed, particularly the abdominal and pelvic examinations in patients who present in possible labor.

Abdominal examination begins with the Leopold maneuvers described below [ 2 ] :

The initial maneuver involves the examiner placing both of his or her hands on each upper quadrant of the patient's abdomen and gently palpating the fundus with the tips of the fingers to define which fetal pole is present in the fundus. If it is the fetus' head, it should feel hard and round. In a breech presentation, a large, nodular body is felt.

The second maneuver involves palpation in the paraumbilical regions with both hands by applying gentle but deep pressure. The purpose is to differentiate the fetal spine (a hard, resistant structure) from its limbs (irregular, mobile small parts) to determinate the fetus' position.

The third maneuver is suprapubic palpation by using the thumb and fingers of the dominant hand. As with the first maneuver, the examiner ascertains the fetus' presentation and estimates its station. If the presenting part is not engaged, a movable body (usually the fetal occiput) can be felt. This maneuver also allows for an assessment of the fetal weight and of the volume of amniotic fluid.

The fourth maneuver involves palpation of bilateral lower quadrants with the aim of determining if the presenting part of the fetus is engaged in the patient's pelvis. The examiner stands facing the patient's feet. With the tips of the first 3 fingers of both hands, the examiner exerts deep pressure in the direction of the axis of the pelvic inlet. In a cephalic presentation, the fetus' head is considered engaged if the examiner's hands diverge as they trace the fetus' head into the pelvis.

Pelvic examination is often performed using sterile gloves to decrease the risk of infection. If membrane rupture is suspected, examination with a sterile speculum is performed to visually confirm pooling of amniotic fluid in the posterior fornix. The examiner also looks for fern on a dried sample of the vaginal fluid under a microscope and checks the pH of the fluid by using a nitrazine stick or litmus paper, which turns blue if the amniotic fluid is alkalotic. If frank bleeding is present, pelvic examination should be deferred until placenta previa is excluded with ultrasonography. Furthermore, the pattern of contraction and the patient's presenting history may provide clues about placental abruption.

Digital examination of the vagina allows the clinician to determine the following: (1) the degree of cervical dilatation, which ranges from 0 cm (closed or fingertip) to 10 cm (complete or fully dilated), (2) the effacement (assessment of the cervical length, which is can be reported as a percentage of the normal 3- to 4-cm-long cervix or described as the actual cervical length); actual reporting of cervical length may decrease potential ambiguity in percent-effacement reporting, (3) the position, ie, anterior or posterior, and (4) the consistency, ie, soft or firm. Palpation of the presenting part of the fetus allows the examiner to establish its station, by quantifying the distance of the body (-5 to +5 cm) that is presenting relative to the maternal ischial spines, where 0 station is in line with the plane of the maternal ischial spines). [ 2 ]

The pelvis can also be assessed either by clinical examination (clinical pelvimetry) or radiographically (CT or MRI). The pelvic planes include the following:

Pelvic inlet: The obstetrical conjugate is the distance between the sacral promontory and the inner pubic arch; it should measure 11.5 cm or more. The diagonal conjugate is the distance from the undersurface of the pubic arch to sacral promontory; it is 2 cm longer than the obstetrical conjugate. The transverse diameter of the pelvic inlet measures 13.5 cm.

Midpelvis: The midpelvis is the distance between the bony points of ischial spines, and it typically exceeds 12 cm.

Pelvic outlet: The pelvic outlet is the distance between the ischial tuberosities and the pubic arch. It usually exceeds 10 cm.

The shape of the patient's pelvis can also be assessed and classified into 4 broad categories based on the descriptions of Caldwell and Moloy: gynecoid, anthropoid, android, and platypelloid. [ 30 ] Although the gynecoid and anthropoid pelvic shapes are thought to be most favorable for vaginal delivery, many patients can be classified into 1 or more pelvic types, and such distinctions can be arbitrary. [ 2 ]

High-risk pregnancies can account for up to 80% of all perinatal morbidity and mortality. The remaining perinatal complications arise in pregnancies without identifiable risk factors for adverse outcomes. [ 31 ] Therefore, all pregnancies require a thorough evaluation of risks and close surveillance. As soon as the patient arrives at the labor and delivery suite, external tocometric monitoring for the onset and duration of uterine contractions and use of a Doppler device to detect fetal heart tones and rate should be started.

In the presence of labor progression, monitoring of uterine contractions by external tocodynamometry is often adequate. However, if a laboring person is confirmed to have rupture of the membranes and if the intensity/duration of the contractions cannot be adequately assessed, an intrauterine pressure catheter can be inserted into the uterine cavity past the fetus to determine the onset, duration, and intensity of the contractions. Because the external tocometer records only the timing of contractions, an intrauterine pressure catheter can be used to measure the intrauterine pressure generated during uterine contractions if their strength is a concern. While it is considered safe, placental abruption has been reported as a rare complication of an intrauterine pressure catheter placed extramembraneously. [ 32 , 33 ]

Bedside ultrasonography may be used to assess the risk of gastric content aspiration in pregnant persons during labor, by measuring the antral cross-sectional area (CSA), according to a study by Bataille et al. [ 34 , 35 ] In the report, which involved 60 women in labor who were under epidural analgesia, the investigators found that at epidural insertion, half of the women had an antral CSA of over 320 mm 2 , indicating that they were at increased risk of gastric content aspiration while under anesthesia. [ 34 , 35 ]

It was also found that the antral CSA was reduced during labor, falling from a median of 319 mm 2 at epidural insertion to 203 mm 2 at full cervical dilatation, with only 13% of the women at that time still considered at risk of aspiration. [ 34 , 35 ] This change, according to the investigators, suggested that even under epidural anesthesia, gastric motility is preserved.

Often, fetal monitoring is achieved using cardiotography, or electronic fetal monitoring. Cardiotography as a form of fetal assessment in labor was reviewed using randomized and quasirandomized controlled trials involving a comparison of continuous cardiotocography with no monitoring, intermittent auscultation, or intermittent cardiotocography. This review concluded that continuous cardiotocography during labor is associated with a reduction in neonatal seizures but not cerebral palsy or infant mortality; however, continuous monitoring is associated with increased cesarean and operative vaginal deliveries. [ 36 ]

If nonreassuring fetal heart rate tracings by cardiotography (eg, late decelerations) are noted, a fetal scalp electrode may be applied to generate sensitive readings of beat-to-beat variability. However, a fetal scalp electrode should be avoided if the birthing parent has HIV, hepatitis B or hepatitis C infections, or if fetal thrombocytopenia is suspected. A framework has been suggested to classify and standardize the interpretation of a fetal heart rate monitoring pattern according to the risk of fetal acidemia with the intention of minimizing neonatal acidemia without excessive obstetric intervention. [ 37 ]

The question of whether fetal pulse oximetry may be useful for fetal surveillance in labor was examined in a review of 5 published trials comparing fetal pulse oximetry and cardiotography with cardiotography alone. It concluded that existing data provide limited support for the use of fetal pulse oximetry when used in the presence of a nonreassuring fetal heart rate tracing to reduce caesarean delivery for nonreassuring fetal status. The addition of fetal pulse oximetry does not reduce overall caesarean deliveries. [ 38 ]

Further evaluation of a fetus at risk for labor intolerance or distress can be accomplished with blood sampling from fetal scalp capillaries. This procedure allows for a direct assessment of fetal oxygenation and blood pH. A pH of < 7.20 warrants further investigation for the fetus' well-being and for possible resuscitation or surgical intervention.

Routine laboratory studies of the parturient, such as complete blood cell (CBC) count, blood typing and screening, and urinalysis, are usually performed. Intravenous (IV) access is established.

Cervical change occurs at a slow, gradual pace during the latent phase of the first stage of labor. Latent phase of labor is complex and not well-studied since determination of onset is subjective and may be challenging as women present for assessment at different time duration and cervical dilation during labor. In a cohort of women undergoing induction of labor, the median duration of latent labor was 384 min with an interquartile range of 240-604 min. The authors report that cervical status at admission for labor induction, but not other risk factors typically associated with cesarean delivery , is associated with length of the latent phase. [ 39 ]

Most patients experience onset of labor without premature rupture of the membranes (PROM); however, approximately 8% of term pregnancies is complicated by PROM. Spontaneous onset of labor usually follows PROM such that 50% of women with PROM who were expectantly managed delivered within 5 hours, and 95% gave birth within 28 hours of PROM. [ 40 ]  The American College of Obstetricians and Gynecologists (ACOG) recommends that fetal heart rate monitoring should be used to assess fetal status and dating criteria reviewed, and group B streptococcal prophylaxis be given based on prior culture results or risk factors of cultures not available. Additionally, randomized controlled trials to date suggest that for women with PROM at term, labor induction, usually with oxytocin infusion, at time of presentation can reduce the risk of chorioamnionitis. [ 41 ]

According to Friedman and colleagues, [ 6 ] the rate of cervical dilation should be at least 1 cm/h in a nulliparous woman and 1.2 cm/h in a multiparous woman during the active phase of labor. However, labor management has changed substantially during the last quarter century. Particularly, obstetric interventions such as induction of labor, augmentation of labor with oxytocin administration, use of regional anesthesia for pain control, and continuous fetal heart rate monitoring are increasingly common practice in the management of labor in today’s obstetric population. [ 42 , 43 , 20 ] Vaginal breech and mid- or high- forceps deliveries are now rarely performed. [ 44 , 45 , 46 ] Therefore, subsequent authors have suggested normal labor may precede at a rate less rapid than those previously described. [ 8 , 9 , 20 ]

Data collected from the Consortium on Safe Labor suggests that allowing labor to continue longer before 6-cm dilation may reduce the rate of intrapartum and subsequent cesarean deliveries in the United States. [ 47 ] In the study, the authors noted that the 95 th percentile for advancing from 4-cm dilation to 5-cm dilation was longer than 6 hours; and the 95 th percentile for advancing from 5-cm dilation to 6-cm dilation was longer than 3 hours, regardless of the patient’s parity.

On admission to the labor and delivery suite, a person having normal labor should be encouraged to assume the position that is most comfortable. Possibilities including walking, lying supine, sitting, or resting in a left lateral decubitus position. Of note, ambulating during labor did not change the progression of labor in a large randomized controlled study of >1000 women in active labor. [ 48 ]

The patient and family or support team should be consulted regarding the risks and benefits of various interventions, such as the augmentation of labor using oxytocin, artificial rupture of the membranes, methods and pharmacologic agents for pain control, and operative vaginal delivery (including forceps or vacuum-assisted vaginal deliveries ) or cesarean delivery. They should be actively involved, and their preferences should be considered in the management decisions made during labor and delivery. [ 2 ]

The frequency and strength of uterine contractions and changes in cervix and in the fetus' station and position should be assessed periodically to evaluate the progression of labor. Although progression must be monitored, vaginal examinations should be performed only when necessary to minimize the risk of chorioamnionitis, particularly in patients whose amniotic membrane has ruptured. During the first stage of labor, fetal well-being can be assessed by monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately after uterine contractions. In most labor and delivery units, the fetal heart rate is assessed continuously. [ 3 ]

Two methods of augmenting labor have been established. The traditional method involves the use of low doses of oxytocin with long intervals between dose increments. For example, low-dose infusion of oxytocin is started at 1 mili IU/min and increased by 1-2 mili IU/min every 20-30 minutes until adequate uterine contraction is obtained. [ 2 ]

The second method, or active management of labor, involves a protocol of clinical management that aims to optimize uterine contractions and shorten labor. This protocol includes strict criteria for admission to the labor and delivery unit, early amniotomy, hourly cervical examinations, early diagnosis of inefficient uterine activity (if the cervical dilation rate is < 1.0 cm/h), and high-dose oxytocin infusion if uterine activity is inefficient. Oxytocin infusion starts at 4 mili IU/min (or even 6 mili IU/min) and increases by 4 mili IU/min (or 6 mili IU/min) every 15 minutes until a rate of 7 contractions per 15 minutes is achieved or until the maximum infusion rate of 36 mili IU/min is reached. [ 49 , 2 ]

ACOG recommends amniotomy for patients undergoing augmentation or induction of labor to shorten the duration of labor. Additionally, either low- or high-dose oxytocin administration can be used for the active management of labor to reduce operative deliveries. [ 50 ]

Although active management of labor was originally intended to shorten the length of labor in nulliparous women, its application at the National Maternity Hospital in Dublin produced a primary cesarean delivery rate of 5-6% in nulliparas. [ 51 ] Data from randomized controlled trials confirmed that active management of labor shortens the first stage of labor and reduces the likelihood of maternal febrile morbidity, but it does not consistently decrease the probability of cesarean delivery. [ 52 , 53 , 54 ]

Although the active management protocol likely leads to early diagnosis and interventions for labor dystocia, a number of risk factors are associated with a failure of labor to progress during the first stage. These risk factors include premature rupture of the membranes (PROM), nulliparity, induction of labor, increasing maternal age, and or other complications (eg, previous perinatal death, pregestational or gestational diabetes mellitus, hypertension, infertility treatment). [ 55 , 56 ]

While the ACOG defines labor dystocia as abnormal labor that results form abnormalities of the power (uterine contractions or maternal expulsive forces), the passenger (position, size, or presentation of the fetus), or the passage (pelvis or soft tissues), labor dystocia can rarely be diagnosed with certainty. [ 1 , 50 ] Often, a "failure to progress" in the first stage is diagnosed if uterine contraction pattern exceeds 200 Montevideo units for 2 hours without cervical change during the active phase of labor is encountered. [ 1 ] Thus, the traditional criteria to diagnose active-phase arrest are cervical dilatation of at least 4 cm, cervical changes of < 1 cm in 2 hours, and a uterine contraction pattern of >200 Montevideo units. These findings are also a common indication for cesarean delivery.

Proceeding to cesarean delivery in this setting, or the "2-hour rule," was challenged in a clinical trial of 542 women with active phase arrest. [ 57 ] In this cohort of women diagnosed with active phase arrest, oxytocin was started, and cesarean delivery was not performed for labor arrest until adequate uterine contraction lasted at least 4 hours (>200 Montevideo units) or until oxytocin augmentation was given for 6 hours if this contraction pattern could not be achieved. This protocol achieved vaginal delivery rates of 56-61% in nulliparas and 88% in multiparas without severe adverse maternal or neonatal outcomes. Therefore, extending the criteria for active-phase labor arrest from 2 to at least 4 hours appears to be effective in achieving vaginal birth. [ 57 , 1 ]

When the patient enters the second stage of labor with complete cervical dilatation, the fetal heart rate should be monitored or auscultated at least every 5 minutes and after each contraction during the second stage. [ 3 ] Although the parturient may be encouraged to actively push in concordance with the contractions during the second stage, many persons with epidural anesthesia who do not feel the urge to push may allow the fetus to descend passively, with a period of rest before active pushing begins.

A number of randomized controlled trials have shown that, in nulliparous women, delayed pushing, or passive descend, is not associated with adverse perinatal outcomes or an increased risk for operative deliveries despite an often prolonged second stage of labor. [ 58 , 59 , 40 ] Furthermore, investigators who compared obstetric outcomes associated with coached versus uncoached pushing during the second stage reported a slightly shortened second stage (13 min) in the coached group, with no differences in the immediate maternal or neonatal outcomes. [ 60 ]

Le Ray et al reported that manual rotation of fetuses who were in occiput posterior or occiput transverse position at full dilatation was associated with reduced rates of operative delivery (ie, cesarean or instrumental vaginal delivery). [ 61 , 62 ] In a study involving 2 French hospitals, operative delivery rates were significantly lower at the institution whose policy favored manual rotation than at the one that favored modification of maternal position (23.2% vs 38.7%), mainly because of lower rates of instrumental deliveries (15.0% vs 28.8%).

When a prolonged second stage of labor is encountered, clinical assessment of the parturient, the fetus, and the expulsive forces is warranted. A randomized controlled trial performed by Api et al determined that application of fundal pressure on the uterus does not shorten the second stage of labor. [ 63 ] Although the 2003 ACOG practice guidelines state that the duration of the second stage alone does not mandate intervention by operative vaginal delivery or cesarean delivery if progress is being made, the clinician has several management options (continuing observation/expectant management, operative vaginal delivery by forceps or vacuum-assisted vaginal delivery, or cesarean delivery) when second-stage arrest is diagnosed.

The association between a prolonged second stage of labor and adverse maternal or neonatal outcome has been examined. While a prolonged second stage is not associated with adverse neonatal outcomes in nulliparas, possibly because of close fetal surveillance during labor, but it is associated with increased maternal morbidity, including higher likelihood of operative vaginal delivery and cesarean delivery, postpartum hemorrhage, third- or fourth-degree perineal lacerations, and peripartum infection. [ 11 , 12 , 13 , 14 ] Therefore, it is crucial to weigh the risks of operative delivery against the potential benefits of continuing labor in hopes to achieve vaginal delivery. The question of when to intervene should involve a thorough evaluation of the ongoing risks of further expectant management versus the risks of intervention with vaginal or cesarean delivery, as well as the patients' preferences.

When delivery is imminent, the patient is usually positioned supine with her knees bent (ie, dorsal lithotomy position), though delivery can occur with the patient in any position, including the lateral (Sims) position, the partial sitting or squatting position, or on her hands and knees. [ 2 ] Although an episiotomy (an incision continuous with the vaginal introitus) used to be routinely performed at this time, the ACOG recommended in 2006 that its use be restricted to maternal or fetal indications. Studies have also shown that routine episiotomy does not decrease the risk of severe perineal lacerations during forceps or vacuum-assisted vaginal deliveries. [ 64 , 65 ]

Crowning is the word used to describe when the fetal head forcibly extends the vaginal outlet. A modified Ritgen maneuver can be performed to deliver the head. Draped with a sterile towel, the heel of the clinician's hand is placed over the posterior perineum overlying the fetal chin, and pressure is applied upward to extend the fetus' head. The other hand is placed over the fetus' occiput, with pressure applied downward to flex its head. Thus, the head is held in mid position until it is delivered, followed by suctioning of the oropharynx and nares. Check the fetus' neck for a wrapped umbilical cord, and promptly reduce it if possible. If the cord is wrapped too tightly to be removed, the cord can be double clamped and cut. Of note, some providers, in an attempt to avoid shoulder dystocia, deliver the anterior shoulder prior to restitution of the fetal head.

Next, the fetus' anterior shoulder is delivered with gentle downward traction on its head and chin. Subsequent upward pressure in the opposite direction facilitates delivery of the posterior shoulder. The rest of the fetus should now be easily delivered with gentle traction away from the birthing parent. If not done previously, the cord is clamped and cut. The baby is vigorously stimulated and dried and then transferred to the care of the waiting attendants or placed on the birthing parent's abdomen.

Third stage of labor - Delivery of the placenta and the fetal membranes

The labor process has now entered the third stage, ie, delivery of the placenta. Three classic signs indicate that the placenta has separated from the uterus: (1) The uterus contracts and rises, (2) the cord suddenly lengthens, and (3) a gush of blood occurs. [ 2 ]

Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30 minutes after delivery of the fetus. Excessive traction should not be applied to the cord to avoid inverting the uterus, which can cause severe postpartum hemorrhage and is an obstetric emergency. The placenta can also be manually separated by passing a hand between the placenta and uterine wall. After the placenta is delivered, inspect it for completeness and for the presence of 1 umbilical vein and 2 umbilical arteries. Oxytocin can be administered throughout the third stage to facilitate placental separation by inducing uterine contractions and to decrease bleeding.

Expectant management of the third stage involves allowing the placenta to deliver spontaneously, whereas active management involves administration of uterotonic agent (usually oxytocin, an ergot alkaloid, or prostaglandins) before the placenta is delivered. This is done with early clamping and cutting of the cord and with controlled traction on the cord while placental separation and delivery are awaited.

A review of 5 randomized trials comparing active versus expectant management of the third stage demonstrated that active management was associated with lowered risks of maternal blood loss, postpartum hemorrhage, and prolongation of the third stage, but it increased maternal nausea, vomiting, and blood pressure (when ergometrine was used). However, given the reduced risk of complications, this review recommends that active management is superior to expectant management and should be the routine management of choice. [ 19 ]

A multicenter, randomized, controlled trial of the efficacy of misoprostol (prostaglandin E1 analog) compared with oxytocin showed that oxytocin 10 IU IV or given intramuscularly (IM) was preferable to oral misoprostol 600 mcg for active management of the third stage of labor in hospital settings. [ 66 ] Therefore, if the risks and benefits are balanced, active management with oxytocin may be considered a part of routine management of the third stage. A study by Adnan et al that included 1075 women to compare intravenous oxytocin and intramuscular oxytocin for the third stage of labor reported that although intravenous oxytocin did not lower the incidence of standard postpartum hemorrhage, it significantly lowered the incidence of severe postpartum hemorrhage as well as lowering the frequency of blood transfusion and admission to a high dependency unit. [ 67 ]

After the placenta is delivered, the labor and delivery period is complete. Palpate the patient's abdomen to confirm reduction in the size of the uterus and its firmness. Ongoing blood loss and a boggy uterus suggest uterine atony. A thorough examination of the birth canal, including the cervix and the vagina, the perineum, and the distal rectum, is warranted, and repair of episiotomy or perineal/vaginal lacerations should be carried out.

Franchi et al found that topically applied lidocaine-prilocaine (EMLA) cream was an effective and satisfactory alternative to mepivacaine infiltration for pain relief during perineal repair. In a randomized trial of 61 women with either an episiotomy or a perineal laceration after vaginal delivery, women in the EMLA group had lower pain scores than those in the mepivacaine group (1.7 +/- 2.4 vs 3.9 +/- 2.4; P = .0002), and a significantly higher proportion of women expressed satisfaction with anesthesia method in the EMLA group than in the mepivacaine group (83.8% vs 53.3%; P = .01). [ 68 ]

In a Cochrane review, Aasheim et al suggest that evidence is sufficient to support the use of warm compresses to prevent perineal tears. They also found a reduction in third-degree and fourth-degree tears with massage of the perineum to reduce the rate of episiotomy. [ 69 ]

The World Health Organization developed a checklist to address the major causes of maternal death (hemorrhage, infection, obstructed labor and hypertensive disorders), intrapartum-related stillbirths (inadequate intrapartum care), and neonatal deaths (birth asphyxia, infection and complications related to prematurity). [ 70 , 71 ]

Laboring patients often experience intense pain. Uterine contractions result in visceral pain, which is innervated by T10-L1. While in descent, the fetus' head exerts pressure on the pelvic floor, vagina, and perineum, causing somatic pain transmitted by the pudendal nerve (innervated by S2-4). [ 4 ] Therefore, optimal pain control during labor should relieve both sources of pain.

A number of opioid agonists and opioid agonist-antagonists can be given in intermittent doses for systemic pain control. These include meperidine 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours, fentanyl 50-100 mcg IV every hour, nalbuphine 10 mg IV or IM every 3 hours, butorphanol 1-2 mg IV or IM every 4 hours, and morphine 2-5 mg IV or 10 mg IM every 4 hours. [ 4 ] As an alternative, regional anesthesia may be given. Options are epidural, spinal, or combined spinal epidural anesthesia. These provide partial to complete blockage of pain sensation below T8-10, with various degree of motor blockade. These blocks can be used during labor and for surgical deliveries.

Studies performed to compare the analgesic effect of regional anesthesia and parenteral agents showed that regional anesthesia provides superior pain relief. [ 72 , 45 , 73 ] Although some researchers reported that epidural anesthesia is associated with a slight increase in the duration of labor and in the rate of operative vaginal delivery, [ 74 , 75 ] large randomized controlled studies did not reveal a difference in frequency of cesarean delivery between women who received parenteral analgesics compared with women who received epidural anesthesia [ 72 , 73 , 75 , 76 , 77 ] given during early-stage or later in labor. [ 78 ]

Additionally, an analysis of studies published since 2005 in a Cochrane review showed epidural analgesia was not associated with an increase in the rate of assisted vaginal delivery. [ 76 , 77 ] Although regional anesthesia is effective as a method of pain control, common adverse effects include maternal hypotension, maternal temperature >100.4°F, postdural puncture headache, transient fetal heart deceleration, and pruritus (with added opioids). [ 4 ]

Despite the many methods available for analgesia and anesthesia to manage labor pain, some persons may not wish to use conventional pain medications during labor, opting instead for a natural childbirth. Although these patients may use breathing and mental exercises to help alleviate labor pain, they should be assured that pain relief can be administered at any time during labor.

A Cochrane review update concluded that relaxation techniques and yoga may offer some relief and improve management of pain. Studies in the review noted increased satisfaction with pain relief and lower assisted vaginal delivery rates with relaxation techniques. One trial involving yoga noted reduced pain, increased satisfaction with pain relief, increased satisfaction with the childbirth experience, and reduced length of labor. [ 79 ]

Of note, use of nonsteroidal anti-inflammatory drugs (NSAIDs) are relatively contraindicated in the third trimester of pregnancy. The repeated use of NSAIDs has been associated with early closure of the fetal ductus arteriosus in utero and with decreasing fetal renal function leading to oligohydramnios.

ACOG made the following recommendations concerning delivery of a newborn with meconium-stained amniotic fluid [ 80 ] :

• Infants with meconium-stained amniotic fluid should no longer routinely receive intrapartum suctioning. However, a team with full resuscitation skills that include endotracheal intubation should be available.
• The same procedures for resuscitation for infants with clear fluid should be followed for infants with meconium-stained fluid. 

What is labor?

How many stages of labor are there?

How is the first stage of labor characterized?

How is the second stage of labor characterized?

How is the third stage of labor characterized?

How are the cardinal movements of labor characterized?

What is included in the initial assessment of labor?

What are Braxton-Hicks labor contractions?

What are the characteristics of contractions that lead to labor?

What is included in the physical exam for evaluation of normal labor?

What is the role of a digital exam in the evaluation of normal labor?

How should a woman be positioned during the first stage of labor?

What monitoring is performed during the first stage of labor?

What are the options for management of a prolonged second stage of labor?

How is the mother positioned for delivery?

What maneuvers are used in the delivery of a fetus?

What are the classic signs of placenta separation from the uterus during labor?

How is pain managed during labor?

What are the local anesthesia options for normal labor and delivery?

How is labor defined?

What do the stages of labor delineate?

What is the first stage of labor?

What is the second stage of labor?

Which factors increase the risk for a prolonged second stage of labor?

What is the third stage of labor?

What is the difference between expectant and active management of the third stage of labor?

What are the benefits of active management of the third stage of labor?

How is a prolonged third stage of labor managed?

What is the average interval of the first and second stages of labor?

Which factors are associated with longer labor?

What maternal outcomes have been reported for midwife led labor and delivery?

What fetal outcomes have been reported for midwife-attended home labor and delivery?

What are the mechanisms of labor?

How is engagement during labor defined?

How is descent during labor defined?

How is flexion during labor defined?

How is internal rotation during labor defined?

How is extension during labor defined?

How is external rotation during labor defined?

How is expulsion during labor defined?

Which clinical history findings are characteristic of labor?

How is abdominal exam performed to evaluate normal labor?

How is a pelvic exam performed to evaluate normal labor?

Why is a digital exam performed in the evaluation of normal labor?

What is the anatomy of the pelvis relevant to labor and delivery?

What is the initial monitoring performed when a woman is in labor?

When is an intrauterine pressure catheter indicated for monitoring of women in labor?

What is the role of bedside ultrasonography in the monitoring of women in labor?

How is fetal monitoring performed during labor?

How is the first-stage of labor managed?

How is labor augmented?

What are the reported outcomes for active management of the first stage of labor?

Which factors increase the risk of failure to progress during the first stage of labor?

What is labor dystocia and how is it diagnosed and managed?

How is second-stage of labor managed?

How is prolonged second-stage labor managed?

What are the steps in the delivery of a fetus?

How is the third-stage of labor managed?

What is included in maternal care following the delivery of the placenta?

What is the role of pain management during labor and delivery?

What are the ACOG recommendations for the delivery of a newborn with meconium-stained amniotic fluid?

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Contributor Information and Disclosures

Sarah Hagood Milton, MD Resident Physician, Department of Obstetrics and Gynecology, Virginia Commonwealth University Health System Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

A David Barnes, MD, MPH, PhD, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, CA), Pioneer Valley Hospital (Salt Lake City, UT), Warren General Hospital (Warren, PA), and Mountain West Hospital (Tooele, UT) A David Barnes, MD, MPH, PhD, FACOG is a member of the following medical societies: American College of Forensic Examiners Institute , American College of Obstetricians and Gynecologists , The Society of Federal Health Professionals (AMSUS) , American Medical Association , Utah Medical Association Disclosure: Nothing to disclose.

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists Disclosure: Nothing to disclose.

Bruce A Meyer, MD, MBA Executive Vice President for Health System Affairs, Executive Director, Faculty Practice Plan, Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School Bruce A Meyer, MD, MBA is a member of the following medical societies: Medical Group Management Association , American College of Obstetricians and Gynecologists , American Association for Physician Leadership , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Massachusetts Medical Society , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Aaron B Caughey, MD, MPH, PhD Department Chair, Department of Obstetrics and Gynecology, Julie Newpert Stott Director of Center for Women's Health, Oregon Health and Science University School of Medicine Aaron B Caughey, MD, MPH, PhD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , Society for Medical Decision Making , Society for Reproductive Investigation Disclosure: Nothing to disclose.

Yvonne Cheng, MD, MPH Adjunct Assistance Professor, Division of Maternal-Fetal Medicine, Departments of Obstetrics, Gynecology and Reproductive Science, University of California at San Francisco School of Medicine Yvonne Cheng, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Medical Association , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Faraaz Omar Khan, MD, and Mahpara Syed Razi, MD, to the development and writing of this article.

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Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

Introduction:.

During childbirth, the position of the baby plays a significant role in the delivery process. While the most common fetal presentation is the head-down position (vertex presentation), variations can occur, such as face presentation and brow presentation. This comprehensive article aims to provide a thorough understanding of delivery, face presentation, and brow presentation, including their definitions, causes, complications, and management approaches.

Delivery Process:

• Normal Vertex Presentation: In a typical delivery, the baby is positioned head-down, with the back of the head (occiput) leading the way through the birth canal.
• Engagement and Descent: Prior to delivery, the baby's head engages in the pelvis and gradually descends, preparing for birth.
• Cardinal Movements: The baby undergoes a series of cardinal movements, including flexion, internal rotation, extension, external rotation, and restitution, which facilitate the passage through the birth canal.

Face Presentation:

• Definition: Face presentation occurs when the baby's face is positioned to lead the way through the birth canal instead of the vertex (head).
• Causes: Face presentation can occur due to factors such as abnormal fetal positioning, multiple pregnancies, uterine abnormalities, or maternal pelvic anatomy.
• Complications: Face presentation is associated with an increased risk of prolonged labor, difficulties in delivery, increased fetal malposition, birth injuries, and the need for instrumental delivery.
• Management: The management of face presentation depends on several factors, including the progression of labor, the size of the baby, and the expertise of the healthcare provider. Options may include closely monitoring the progress of labor, attempting a vaginal delivery with careful maneuvers, or considering a cesarean section if complications arise.

Brow Presentation:

• Definition: Brow presentation occurs when the baby's head is partially extended, causing the brow (forehead) to lead the way through the birth canal.
• Causes: Brow presentation may result from abnormal fetal positioning, poor engagement of the fetal head, or other factors that prevent full flexion or extension.
• Complications: Brow presentation is associated with a higher risk of prolonged labor, difficulty in descent, increased chances of fetal head entrapment, birth injuries, and the potential need for instrumental delivery or cesarean section.
• Management: The management of brow presentation depends on various factors, such as cervical dilation, progress of labor, fetal size, and the presence of complications. Close monitoring, expert assessment, and a multidisciplinary approach may be necessary to determine the safest delivery method, which can include vaginal delivery with careful maneuvers, instrumental assistance, or cesarean section if warranted.

Delivery Techniques and Intervention:

• Obstetric Maneuvers: In certain situations, skilled healthcare providers may use obstetric maneuvers, such as manual rotation or the use of forceps or vacuum extraction, to facilitate delivery, reposition the baby, or prevent complications.
• Cesarean Section: In cases where vaginal delivery is not possible or poses risks to the mother or baby, a cesarean section may be performed to ensure a safe delivery.

Conclusion:

Delivery, face presentation, and brow presentation are important aspects of childbirth that require careful management and consideration. Understanding the definitions, causes, complications, and appropriate management approaches associated with these fetal positions can help healthcare providers ensure safe and successful deliveries. Individualized care, close monitoring, and multidisciplinary collaboration are crucial in optimizing maternal and fetal outcomes during these unique delivery scenarios.

Hashtags: #Delivery #FacePresentation #BrowPresentation #Childbirth #ObstetricDelivery

On the Article

Krish Tangella MD, MBA

Alexander Enabnit

Alexandra Warren

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Breech presentation

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head.

Associated with increased morbidity and mortality for the mother in terms of emergency caesarean section and placenta praevia; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal mortality.

Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies.

Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned caesarean section, the optimal gestation being 37 and 39 weeks, respectively.

Planned caesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term.

Breech presentation in pregnancy occurs when a baby presents with the buttocks or feet rather than the head first (cephalic presentation) and is associated with increased morbidity and mortality for both the mother and the baby. [1] Cunningham F, Gant N, Leveno K, et al. Williams obstetrics. 21st ed. New York: McGraw-Hill; 1997. [2] Kish K, Collea JV. Malpresentation and cord prolapse. In: DeCherney AH, Nathan L, eds. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill Professional; 2002. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned caesarean section.

History and exam

Key diagnostic factors.

• presence of risk factors
• buttocks or feet as the presenting part
• fetal head under costal margin
• fetal heartbeat above the maternal umbilicus

Other diagnostic factors

• subcostal tenderness
• pelvic or bladder pain

Risk factors

• premature fetus
• small for gestational age fetus
• nulliparity
• fetal congenital anomalies
• previous breech delivery
• uterine abnormalities
• abnormal amniotic fluid volume
• placental abnormalities
• female fetus

Diagnostic investigations

1st investigations to order.

• transabdominal/transvaginal ultrasound

Treatment algorithm

<37 weeks' gestation and in labour, ≥37 weeks' gestation not in labour, ≥37 weeks' gestation in labour: no imminent delivery, ≥37 weeks' gestation in labour: imminent delivery, contributors, natasha nassar, phd.

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Disclosures

NN has received salary support from Australian National Health and a Medical Research Council Career Development Fellowship; she is an author of a number of references cited in this topic.

Christine L. Roberts, MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

CLR declares that she has no competing interests.

Jonathan Morris, MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

JM declares that he has no competing interests.

Peer reviewers

John w. bachman, md.

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

JWB declares that he has no competing interests.

Rhona Hughes, MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

RH declares that she has no competing interests.

Brian Peat, MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

BP declares that he has no competing interests.

Lelia Duley, MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

LD declares that she has no competing interests.

Justus Hofmeyr, MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

JH is an author of a number of references cited in this topic.

Differentials

• Transverse lie
• Caesarean birth
• Mode of term singleton breech delivery

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California teachers union drops 'BIPOC' board position after discrimination lawsuit

by KRISTINA WATROBSKI | Crisis in the Classroom

ELK GROVE, Calif. (CITC) — A California teachers union agreed Thursday to drop its "BIPOC" executive board position after a member filed a discrimination lawsuit.

The lawsuit filed in late May centered around the “BIPOC At-Large” board position for the Elk Grove Education Association (EGEA). The executive role, created by the teachers union in 2023, was reserved for educators who identify as a member of a racial minority group, according to the lawsuit.

History teacher Issac Newman claimed he was denied the ability to run for the position due to being White. He accused EGEA of discrimination, alleging the board position's criteria permanently damaged his "future prospects of attaining a union leadership role.”

EGEA agreed Thursday to end the "BIPOC At-Large" position, as well as to demonstrate commitment to "non-discriminatory practices" in other positions, Newman's attorneys announced . A judge also entered an order requiring EGEA to pay Newman $12,000 and to pay his attorney fees.

Newman told Crisis in the Classroom (CITC) Friday that while the decision is "enormous progress," he feels someone must still "hold the union to its word." The teacher said he plans to run for a new executive position "on a platform of diversity of thought, equity that fairly rewards merit, and inclusion of all employees without regard to race.”

“I did everything I could to persuade my union to see the injustice of segregating teachers through this discriminatory board position, but they refused to see reason. Yet as soon as they heard from my lawyers, they backtracked, removed the racial requirement to run for election, and promised to never practice discrimination in other positions," Newman said.

Some supported the EGEA board position while the lawsuit was ongoing. Lorreen Pryor, a parent in the Elk Grove Unified School District, told CBS News in June that such positions are often created due to a lack of representation and "the need for diverse voices."

CITC reached out to EGEA for comment, but did not receive a response prior to publication.

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