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Bukovinian State Medical University


on methodological meeting

of Department of Obstetrics and Gynecology

with course of Infant and Adolescent Gynecology

“___”______________________ 200_ year

protocol #

The Head of the department

Assistant Professor

________________ S.P.Poliova

Methodological instruction

for practical lesson

“Physiology of labor. Anesthesia in labor”

Module 1: Physiology of pregnancy, labor and puerperium

Context module 1: Physiology of pregnancy, labor and puerperium

Subject: Obstetrics and Gynecology

4th year of studying

2nd medical faculty

Number of academic hours – 4

Methodological instruction developed by:

assistant Andriy Berbets

Chernivtsi – 2008

Aim: to learn clinic duration of the first, second and third stages of labor, principles of pain relief, primary newborn care.

Professional motivation: Occiput presentations occur in about 95% of all labors. It is very important to know the biomechanism of labor in cephalic presentation for management of labor. Students have to know the normal and abnormal position of fetal head and complication coursed by pathological labor.

Careful diagnosis and conducting of each stage of labor is important for preventing complication in the puerperium and prevent maternal and perinatal mortality.

Basic level:

  1. Anatomy, structure of the fetal head. The sutures and fontanels of the fetal head. Diameters of the fetal head at term.

  2. Anatomy and topography of the uterus, pelvis and pelvic floor.

  1. External and internal examination of pregnant women.

  2. The main marks on the fetal head.

  3. Mechanism of muscles contraction.

  4. Estimation of gestational age.

  5. The structure of conceptus at the end of the pregnancy.


L Objectives for Studentsy Independent Studies

You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:


1. Give the definition of such obstetric terms as: "leading point", "fixative point".

2. Graphic documentation of the fetal head station in the true pelvis in different types of cephalic presentation.

3. Theories of the cardinal moments of labor.

4. Cardinal moments of labor in the vertex (occiput) anterior presentation.

5. Cardinal moments of labor in the vertex (occiput) posterior presentation.

6. Importance of perineal protective maneuvers.

7. Technique of perineal protective maneuvers (five moments).


1.What is labor?

2. Stages of labor.

3. Labor's expulsive forces.

4. Mechanism of cervical dilatation in primapara and multipara.

5. What is lower uterine segment, contractile ring?

6. Management of the first stage of labor.

7. Role of vaginal examination in diagnosis of labor stages.

8. Management of the second stage of labor.

9. Perineal protective maneuvers.

10. Signs of placental separation.

11. Manual removal of placenta.

12. Structure of afterbirth.

13. Blood loss during labor and its estimation.

14. Definition of physiological blood loss.


1. Anatomical substrate of pain in labor.

2. Importance of cortex, conditioned reflex in the development of pain in labor.

3. Psychoprophylactic painless labor.

4. Methods of analgesia and anesthesia during labor and indications for them:

combination of sedation, spasmolytic and analgetic medicines;

superficial anesthesia;

inhalation anesthesia;


epidural anesthesia.

Structure and prescription of apparatus for anesthesia.

6. The main analgesic and anesthetic used in obstetrics:

1) gas anesthetics;

2) intravenous anesthetics;

3) psychotropic medicines.

7. The anesthetic technique that provides pain relief during I stage of labor.

8. The anesthetic technique that provides pain relief during sec stage of labor.

9. Indications for pudendal block.

Key words and phrases: occiput presentation, biomechanism of labor, flexion, internal rotation, extension,- internal rotation, synclitism, asynclitism. normal labor, delivery, cervical effacement and dilatation, expulsion of the fetus, separation and expulsion of the placenta, manual removal of placenta. Psychoprophylaxis for pain relief, analgesia and anesthesia in obstetrics.

^ Inter-subject integration

Previous disciplines

Requested skills


To describe anatomy of female pelvis, external and internal female genitalia, pelvic floor, to define parts pf pelvis and their dimensions. To know the dimensions of fetal head


To describe physiological processes in female organism during labor. To be able to give clinical evaluation of maturity of female organism before labor. Reasons for delivery start.


To select the medication and to calculate the dosage for anesthesia of delivery.


Occiput presentations occur in about 95% of all labors. Because q the irregular shape of the pelvic canal and the relatively large dimension] of the mature fetal heard, it is evident that not all diameters of the hear can necessarily pass through all diameters of the pelvis. It follows that process of adaptation or accommodation of suitable portions of the he; to the various segments of the pelvis is required for completion of childbirth. These positional changes of the presenting part constitute the mechanism of labor.

There are 2 kinds of the occiput presentations. — anterior and posterior, The cardinal movements of labor in anterior occiput presentation are:

- flexion;

- internal rotation;

- extension;

- internal rotation of the fetal head and external rotation of the fetal body

The various movements are often described as through they occur separately and independently. In reality, the mechanism of labor consist of a combination of movements that are going on the same time, example, as part of process of engagement, there is both flexion and des of the head. It is manifestly impossible for the movements to be performed unless the presenting part descends simultaneously. The uterine contraction’s effect important modifications in the attitude, or habitus especially after the head has descended into the pelvis. These changes consists principally in a straightening of the fetus, with loss of its dorsal convexity and closer application of the extremities and small parts of the body. As a result, the fetal ovoid is transformed into cylinder with normally the smallest possible cross section passing through the birth canal.

^ Synclitism and asynclitism Synclitism is a position when the sagittal suture is in the transverse pelvic diameter. The sagittal suture is exactly midway between the symphysis and promontory.

If the sagittal suture approaches the sacral promontory, more of the anterior parietal bone presents itself to the examining fingers and condition is called anterior asynclitism. If the sagittal suture lies closer to the symphysis more of the posterior parietal bone presents and condition is called posterior asynclitism.

The cardinal movements of labor in anterior occiput presentation 1. Flexion. As soon as descending head meets resistance, whei from the cervix, the walls of the pelvis, or the pelvic floor, flexion of head are normally results. In this movement, the chin is brought into contact with the fetal thorax,and the shorter suboccipitobregmatic The leading point is the area of the small fontanel.

^ 2 Internal rotation. This movement is a manner that the occiput dually moves from its original position anteriorly towards the symphysis pubis os. The rotation begins when the fetal head descends from the plane of greatest pelvic dimensions to the least pelvic dimensions (rnidpelvis).

The rotation is complete when the head reaches the pelvic floor, the sagittal suture is in the anteroposterior diameter of the pelvic outlet and the small fontanel is under the symphysis.

3. Extension. After internal rotation the sharply flexed head reaches the pelvic floor, two forces come into play. The first, exerted by the uterus, acts more posteriorly, and the second, supplied by the resistant pelvic floor, acts more anteriorly. The resultant force is the direction of the vulvar opening, thereby causing extension. Extension begins when the fixing point (fossa suboccipitalis) is under the inferior margin of the symphysis pubis. With increasing distension of the perineum and vaginal opening, an increasingly large portion of the occiput gradually appears. The head is born by further extension as the occiput,bregma,forehead,nose,mouth.

4. Internal rotation of the fetal head and external rotation of the fetal body. During the head extension the fetal body is in the pelvic cavity. The biacromial diameter turns from the oblique to the anterioposterior diameter of the pelvic outlet. Thus one shoulder is anterior behind the symphysis and the other is posterior. This movement is brought about apparently by the same pelvic factors that effect internal rotation of the head. The anterior shoulder comes under the symphysis pubis, the fetal body flexed and posterior shoulder is born first. Then the anterior shoulder is born. Fetal head rotates as a result of the body rotation. In the I position fetal face turns towards the right, in the II position towards the left. After delivery of the shoulders,the rest of the body of the child is quickly extruded.

^ The cardinal movements of labor in posterior occiput presentation are:

1. Flexion. The fetal head flexed and presents the suboccipito-frontai (10 cm) diameter in oblique size of the pelvic inlet. The leader point is a middle part of sagittal suture,

2. Internal rotation. The fetal head passes through the pelvic cavity and in narrow plane it begins rotate. In the outlet plane of pelvis (pelvic upor) the sagittal suture became in the direct (anterioposterior) diameter oi the pelvic outlet and the small fontanel is under the sacrum os,

3. Additional flexion. After internal rotation the head reaches the Pelvic floor. Fetal head fixes with the area of the border of the hair part of head (the first fixing point) under symphysis pubis and flexes. process leads to delivery of the vertex.

4. Extension. Extension begins when the second fixing point (fossa suboccipitalis) become under the tip of the sacrum. The head is born bj further extension.

5. Internal rotation of the fetal head and external rotation of the fetal body. Shoulder enter to the inlet of small pelvis in oblique size and in pelvic cavity perform the internal rotation to 45 °, in the pelvic floor they stand in the direct (anterioposterior) size. The anterior shoulder comes under the margin of symphysis pubis, the fetal body flexed. The posterior shoulder is born first and then the anterior shoulder is born] The head rotation realize as in anterior occiput presentation.

Labor is a physiologic process that permits a series of extensive physiologic changes in the mother to allow for the delivery of her fetus through the birth canal.

It is defined as progressive cervical effacement, dilatation, or both,-resulting from regular uterine contractions that occur at least every 5 minutes and last 30-60 seconds.

^ Labor forces:

1, Uterine contractions - is a regular contractions of uteri musculature. Typically, contractions occur every 5 to 10 minutes and la: for 20-25 seconds in the onset of labor. As labor proceeds, the contractio. become more frequent,more intense,and last longer. In the end of la the contractions occur every 2-3 minutes and last for 50-to 60 seconds They are characterized be strength, duration, and frequency which a important in generating a normal labor pattern.

^ 2. Bearing-down efforts (or pushing) ~ is the periodic contractions diaphragm, pelvic floor muscles and prelum abdominal which are add* to the force of uterine contractions. Its voluntary expulsive force.

There are three stages of labor, each of which is considered separately.

The first stage (cervical) is from the onset of true labor to comp dilatation of the cervix.

The second stage (pelvic) starts from complete dilatation of cervix to the delivery of the baby.

The third stage (placental) starts from the birth of the baby till delivery of the placenta. It is divided into two phases: placental separation and its expulsion.

Labor begins with cervical effacementl ^ Cervical effacement is thinning of the cervix.

Although cervical softening and early effacement may occur be labor, during the first stage of labor the entire cervical length is retracted into lower uterine segment as a result of myometrial contractile foi and pressure exerted by either the presenting part of fetal membrane

The length of the first stage may vary in relation to parity; primipar patients generally experience a longer first stage than do multipar patients. The minimal dilatation during the first stage is for primipar 1-1,2cm/hour and multiparous women: 1,2-1,5 cm/hour. If the progi is slower than this, evaluation for uterine dysfunction, fetal malposition cephalopelvic disproportion should be undertaken.

During the first stage, the progress of labor may be measured in cervical effacement, cervical dilatation and descent of the fetal head. Uterine contractions should be monitored every 30 minutes by palpation or machine monitoring for their frequency, duration, and intensity. For high-risk

egnancies, uterine contractions should be monitored continuously along with the fetal heart rate.

^ Vaginal examination should be done sparingly to decrease the risk of an intrauterine infection. Cervical effacement and dilatation, the station and position of the presenting part, the presence of molding or caput in vertex presentation should be recorded- Additional examinations may be performed if the patient reports the urge to push ( to determine if the full dilatation has occurred) or if a significant fetal heart rate deceleration occurs ( to examine for a prolapsed umbilical cord).

The fetal heart rate should be evaluated by either auscultation with a stethoscope,by external monitoring with Doppler equipment. In patients with no significant obstetric risk factors, the fetal heart rate should be auscultated at least every 30 minutes in the first stage of labor and after each uterine contraction in the second stage of the labor.

At the beginning of the second stage, the mother usually has a desire to bear down with each contraction. This abdominal pressure, together with uterine contractile force, combines to expel the fetus. In cephalic presentation, the shape of the fetal head may be altered during labor, making the assessment t>f descent more difficult. Molding is the alteration of the relationship of the fetal cranial bones to each other as the result of the compressive forces exerted by the bony maternal pelvis.

^ The second stage generally takes from 30 minutes to 2 hours in primigravid women and from 10*50 minutes in multigravid women. The median duration is 50 minutes in a primipara and slightly under 20 minutes in a multipara.

Clinical management of the second stage of labor. When delivery is imminent, the patient is usually placed in the lithotomy position.

With each contraction, the mother should be encouraged to hold her breath and bear down with expulsive efforts. As the perineum becomes fattened by the crowning head, an episiotomy may be performed, to prevent perineal lacerations.

As the fetal head crowns (i.e., distends the vaginal opening), ^ Perineal protective maneuvers are performed to avoid injury of the fetus and laceration of the perineum:

The first one is prevention of preterm fetal head extension (during Pushing efforts the fetal head is flexed).

Second is the delivery of the fetal head out of the pushing by extens of vulvar muscles.

^ Third one is decreasing of perineal tension by borrowing of the tissue from the upper part of vulva ring to the lower.

Forth is regulations of voluntary maternal effort (pushing) - woo-in labor breaths deeply when the fetus is delivered to the level if parie tubes. At this moment pushing efforts are contraindicated.

Fifth is the delivery of shoulders - first downward, later upward; direction of traction are indicated.

The delivery of the placenta occurs during the third stage labor, Separation of the placenta generally occurs within 2 to 10 minutes of the end of the second stage of labor. Squeezing of the fundus to hasl placental separation is not recommended because it may increase the| likelihood of passage of fetal cells into the maternal circulation. Signs of placental separation are follows: a fresh show of the blood from ttuj vagina, the umbilical cord lengthens outside the vagina, the fundus of thel uterus rises up, the uterus becomes firm and globular. Only when the signs have appeared the attempt to remove of separated placenta can be performed. The placenta should be examined to ensure its complete removal and to detect placental abnormalities. If the patient is at risk of postpartum hemorrhage (e.g., because of anemia, prolonged oxytocin augmentation labor, multiple gestation or hydroamnion), manual removal of the placen manual exploration of the uterus, or both may be necessary. After t placental delivery, the cervix and vagina should be thoroughly inspection for lacerations and surgical repair performed if necessary.

^ Aneathesia in labor. The intensity of pain with labor is related to a large degree of emotional tension.

Psychoprophylaxis for pain relief with pregnant women bej at the 35-36 gestational age, and composes of four lessons. Themes of lessons are:

1-st lesson - anatomy and physiology of female sex org; labor and its stages;

2-nd lesson — training in breathing, counting of pains, compression of spines iliac anterior superior, muscle relaxatior instituted well in advance of labor;

3-d lesson - women have to be informed about the various hospital procedures to which they would subjected during labor and delivery;

4-th lesson - regimen of puerperium period, preparing of breasts to lactation, care of infant.

Women who attempt psychoprophylaxis but find the discomfort labor to be too great should not be denied relief provided by appropriate analgetics and nerve block anesthesia for delivery.

Any analgesic or anesthetic technique used during labor and delh process should take into account those sensory pathways involved and points at which they may be affected. During the first stage of labor, j results from contraction of the uterus and dilation of the cervix. This j travels along the visceral afferents, which accompany sympathetic nerves entering the spinal cord at T10, Til, T12, and LI. As the head descei there is also distension of the lower birth canal and perineum. This pain transmitted along somatic afferents that comprise portions of the pudendal nerves that enter the spinal cord at S2, S3, and S4.

^ Spinal anesthesia - introduction of a local anesthetic into the subarachnoidal space can be used for vaginal or abdominal delivery also, but it is typically just before delivery. Complications with spinal anesthesia: maternal hypotension total spinal blockage, anxiety and discomfort, spinal headaches, arachnoiditis

The anesthetic technique that provides pain relief during labor is epidural (peridural) block (a block from T10 to 85).

A pudendal block with l the time of delivery to provid Indications for pudendal block

^ A local block (i.e., local area of an episiotomy or tear.

General anesthesia is reserved only for cesarean section in selected ases. During this anesthesia gas, volatile and intravenous anesthetics should be administrated. Two anesthetics gases, nitrous oxide and cyclopropane, are used currently in obstetrics. The gas is highly explosive and must always be given in a closed system. Volatile anesthetics, ether, halothane, methoxyflurane, enflurane cross the placenta readily and are capable of producing narcosis in the fetus. Intravenous anesthetics in obstetrics, such as thiopental, cetamin, phentanil offers the advantages of ease and extreme rapidly induction, ample oxygenation, ready controliabiiity, minimal postpartum bleeding, and promptness of recovery without vomiting.

II. Tests and Assignments for Self-assessment


Multiple choice.

Choose ike correct answer / statement:

1, The fetal presentation with the estimated incidence of its occurrence in anterior occiput presentation is: A - 95% B-1%;-C - 4 %; D - 20 %.

2. The fetal presentation with the estimated incidence of its occurre in posterior occiput presentation is:

A - 95%; B- 1%; C - 3,5 %; D- 15 %.

3. The first movement of the labor in the anterior occiput presentation A - Flexion;

B - Rotation;

C - Extension;

D - Additional flexion.

4. What is the fixing point in the anterior occiput presentation:

A - Occiput;

B - Sinciput;

C - Fossa suboccipitalis;

D - The area of the border of the hair part.

5. What is the first fixing point in the posterior occiput presentatio.

A - Occiput;

B - The root of the nose;

C - Fossa suboccipitalis;

D - The area of the border of the hair part.

6. What is the leading point in the anterior occiput presentation:

A - Anterior fontanel;

B - Posterior fontanel;

C - Fossa suboccipitalis;

D - The area of the border of the hair part.

Real - life situations to be solved:

1. M., 28 years old, para 2. Full term of pregnancy. Initiation of labor was 8 hours ago. The membranes ruptured 20 minutes ago. Pelvic sizes: 25,28,31,20. Fetal head rate 132 per minute with satisfactory characteristics.

Per vaginum: the cervix is completely dilated. The amniotic sac is absent. Fetal head is in outlet plane of pelvic. Sagittal suture is in the anterioposterior diameter of pelvic outlet. Small fontanel is in the anterior side. Diagnosis? What is the moment of labor biomechanisrn?

2. Primipara N.,25 years old. Delivery at term. Initiation of labor was 8 hours ago. The amniotic sac is ruptured. Pelvic sizes: 25,28,31,20. Fetal heart rate is 140 per minute with satisfactory characteristics. Uterine contractions are occurring every 8 minutes and judged to be mild in intensity.

Per vaginum: the uterine cervix dilatation is 6 cm. The amniotic sac is absent. Fetal head is fixed to the inlet of pelvis. Sagittal suture is in the right oblique size. Small fontanel is in the left anterior side. Diagnosis? What is the moment of labor biomechanism?

III. Answers to the Self- Assessment.

1. A. 2. B. 3. A. 4= C. 5. D. 6. B. 7. Labour 2, at term, 2 period of labor. Anterior occiput presentation. Third moment of the labor biomechanism, extension of the fetal head. Management: normal vaginal delivery.8. Labor I,at term. First stage of labor. Anterior occiput presentation. First moment of the labor biomechanism. Management: normal vaginal delivery.

Students must know:

1. The cardinal movements of labor in anterior occiput presentation.

2. The cardinal movements of labor in posterior occiput presentation.

3. The definition of synclitism and asynclitism.

4. The mechanism of the head's flexion, rotation, extension, internal body's rotation and external head's rotation.

5. The definition of the leading point and the fixing point.

Students should be able:

1. To make the external obstetric physical examination.

2. To make the internal obstetric physical examination.

3. To show the cardinal movements of labor in anterior and poste: occiput presentation on phantom.

4. To determine the suture and fontanels on the fetal head.

5. To determine the movements of the labor.

6. To determine normal and pathological course of the labor.


Multiple Choice.

Choose the correct answer / statement:

1. Cervical effacement relates to:

A - How far the cervix is opened; B - The degree of cervical thinning;

C - The relation of the presenting part to the cervix; D - The softness of the cervix.

2. During second stage of labor in the absence of electronic let monitoring, fetal heart rate auscultation should be performed after:

A - Each uterine contraction;

B - Every other uterine contraction;

C - Every third uterine contraction;

D - Every contraction generating more than 15-20 mm Hg pressure.

3. The second stage of labor is diagnose when:

A - Compete dilatation of the cervix to delivery of the infant;

B - Delivery of infant to delivery of the placenta;

C - Onset of labor to full cervical dilatation;

D - Period extending up to 2 hours after delivery of the placenta.

Real - life situations to be solved:

4. Woman with in-time pregnancy. Bears down during 40-45 seconds with intervals 1-2 minutes. The rupture of the membrane has occurred 10 minutes ago. Vaginal examination: fetus head is on the pelvic floor. Saggitai suture is in anterior-posterior diameter of pelvic outlet. Amniotic sac is absent. What is the stage of labor?

5. The bleeding began after childbirth. The blood loss is 300 mi-There aren't the signs of the placental separation. What is the diagnosis? What you have to do?

III. Answers to the Self- Assessment.

1. B.2. A. 3. A. 4. Second - pelvic stage of labor. 5. Placenta accreta. Manual removal of the placenta.

Students must know:

1. Stages of labor.

2. Clinic of the first stage of labor.

3. Significance of vaginal examination for estimation of the patient's Progress of labor.

4. Management of the first stage of labor.

5. Clinic and management of second stage of labor. Perineal protective Maneuvers.

6. Primary newborn care.

7. Clinic and management of third stage of labor.

8. Methods of removal of placenta which is separated.

9. Estimation of blood lost during labor.

10. Manual removal of placenta.

11. Manual revision of uterine cavity.

Students should be able:

1. To diagnose true labor.

2. To estimate the character of uterus contractions.

3. To estimate fetal station.

4. To estimate of fetal well-being.

5. To choose the analgesic and anesthetic agents.

6. To perform perineal protective maneuvers.

7. To perform primary newborn care.

8. To estimate the maternal vital signs.


Multiple Choice,

Choose the correct answer / statement:

1. Pudendal anesthesia or block:

A - Provides perineal anesthesia for vaginal delivery;

B - Anesthesia for the active phase of labor and delivery;

C - Short-term anesthesia for vaginal or abdominal delivery;

D - Anesthesia for latent phase of labor;

E - All of the above.

2. Which of the following is an associated maternal risk when spinal anesthesia is used?

A- Hypotension;

B - Loss of desire to push;

C - Headache;

D - All of the above.

3. Maternal aspiration syndrome is a particularly high risk of general anesthesia in obstetric cases because of:

A - High alkaline content of the maternal gut during pregnancy;

B r decreased gastrointestinal function during labor;

C - Pica-like eating habits of women just before labor;

D - Most general anesthetics causing reflex spasm of the stomach;

E - All of the above.

^ Real — life situations to be solved:

4. A 22-year - old woman at term comes to labor unit complaining of increasingly severe, painfulness and frequent uterine contractions Contractile ring is placed 2 fingers above pubis, cephalic presentation Fetal heart rate — 140 bprn. Which method of anesthesia and analgesia should be administrated ?

5. A 22-year - old woman in thirty-fifth - thirty-six week of gestatk age is present in the labor unit in the second stage of the first pre-term la in cephalic presentation. Which method of anesthesia should be administrated?

6. Which method of anesthesia may be used at the area of episiotom

III. Answers to the Self- Assessment.

LA, 2.D. 3. B. 4. Intramuscular administration of spasmolytics an analgetics. 5. Pudendal block. 6. Episiotomy shouldn't used anesthesia because it performs at the high of push during labor, when the sensor pathways compressed by descended fetal head.

Students must know:

1. Anatomical substrate of pain in labor.

2. Methods of analgesia and anesthesia during the first and secon stages labor.

3. Structure and prescription of apparatus for anesthesia.

4. The main analgesic and anesthetic agents used in obstetrics.

Students should be able:

1. Diagnose the first and second stages of labor.

2. Determine the importance of administration of anesthesia during labo|

3. Give the prescriptions of analgesia and anesthetic agents in correct doses.

4. Determine the sites for pudendal block.

5. Organize a psychoprophylactic lesson with pregnant.


1. Danforth's Obstetrics and gynaecology. - Seventh edition. - 1994. ~ P 1 117.

2. Obstetrics and gynaecology. Williams & Wilkins Waverly Company. - Tl Edition.- 1998. - P. 91-93.

3. Basic Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunninghad 1993. - P. 308-310".


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