Mechanics of childbirth

The process of normal childbirth depends on a high degree of anatomical and physiological compatibility between the mother and child. The birth canal is the passage consisting of the mother's bony pelvis and soft tissues through which a fetus passes during vaginal delivery. Fetal orientation during childbirth is described in terms of lie, presenting part, position and attitude of the presenting part, and station. Complications of labor and delivery can pose life-threatening situations to both mother and child, which is why recognizing any abnormalities early is crucial. Measures for managing abnormal labor include special maneuvers for breech presentation or cesarean delivery in obstructed labor.

Fetal lie

• Definition: relation of the fetal long axis to the long axis of the maternal uterus
• Types
  • Longitudinal lie: fetus is in the same axis (most common)
  • Transverse lie: fetus is at a 90° angle
  • Oblique lie: fetus is at a 45° angle

Fetal presentation

• Definition: part of the fetus that overlies the maternal pelvic inlet
• Types
  • Cephalic presentation: head (most common)
  • Breech presentation: buttocks or feet
    • Frank breech: flexed hips and extended knees (buttocks presenting)
    • Complete breech: thighs and legs flexed (cannonball position)
    • Single Footling breech: hip of one leg is flexed and the knee of the other is extended (one foot presenting)
    • Double Footling breech: both thighs and legs are extended (feet presenting)
  • Compound presentation: ≥ 1 anatomical presenting part (e.g., cephalic or breech presentation with presentation of an extremity)
  • Shoulder presentation: shoulder presentations combined with a transverse or oblique lie

Fetal position

• Definition: relationship and orientation (i.e., fetal occiput pointing towards maternal left or right) of the presenting fetal part to the maternal pelvis
• Types
  • Occiput anterior position: Fetal occiput points towards maternal symphysis pubis; fetus faces downwards.
    • Left occiput anterior (LOA): Fetal back faces the maternal left, anterior fontanelle faces the maternal right, sagittal suture lies in the right oblique diameter; (most common position).
    • Right occiput anterior (ROA): Fetal back faces the maternal right, anterior fontanelle faces the maternal left, sagittal suture lies in the left oblique diameter.
  • Occiput posterior position: Fetal occiput points towards the maternal sacral promontory with face to pubis symphysis; the fetus faces upward
  • Sacrum in breech presentation
  • Mentum (chin) in extended cephalic (face) presentation

Fetal attitude ^[1]

• Definition: degree of extension/flexion of the fetal head during cephalic presentation
• Types
  • Vertex presentation (maximally flexed); most common attitude
  • Brow presentation (partially extended)
  • Face presentation (maximally extended)
    • Mentum anterior face presentation : Spontaneous vaginal delivery is possible .
    • Mentum posterior face presentation
  • Forehead presentation (partially flexed; military attitude): Spontaneous vaginal delivery is possible .

Station (Obstetrics) ^[2]

• Definition: measurement (in cm) of the presenting part above and below the maternal ischial spine

  Station	Description
  0	the presenting part is at the level of the ischial spines
  -1, -2, -3	1, 2, and 3 cm above the level of the ischial spines, respectively
  +1, +2, +3	1, 2, and 3 cm below the level of the ischial spines, respectively

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

Synclitism

• Definition: parallelism between the pelvic plane and the plane of the fetal head
• In asynclitism, the sagittal suture is in the transverse diameter of the pelvic inlet and not between the symphysis pubis and sacral promontory.
  • Anterior asynclitism (Naegele obliquity)
    • The sagittal suture is positioned towards the sacral promontory
    • Spontaneous vaginal delivery possible
  • Posterior asynclitism (Litzmann obliquity)
    • The sagittal suture is positioned towards the symphysis pubis
    • Normal vaginal delivery is impossible. → premature cesarean delivery

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

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

References:^[1]

Definition ^[1]

• Arrest of vaginal delivery because of a mechanical obstruction (see “Arrested active phase” for comparison)

Etiology

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

Clinical features

• High presenting part; not engaged; ruptured membranes
• Head molding (excessive during obstructed labor)
• Caput succedaneum
• Frequent uterine contractions
• Edematous vulva

Management ^[1]

• General: cesarean delivery for any maternal etiologies or congenital anomalies
• Compound presentation
  • If the head is engaged: forceps delivery with/without repositioning of the arm
  • If head is not engaged: cesarean delivery
• Transverse lie
  • Neglected transverse lie: additional impaction of the fetus (prolapsed arm, wedged-in shoulder) ^[3]
  • Cesarean delivery is recommended
• Persistent occiput posterior position
  • Lateral positioning of the mother to achieve a 90° rotation of the fetal head, stimulate uterine contractions (e.g., with oxytocin)
  • In the case of arrested labor: cesarean delivery
• Deep transverse arrest
  • Conservative treatment
    • Lateral positioning of the mother to achieve 90° rotation of the fetal head
    • Stimulate uterine contractions (e.g., with oxytocin)
  • Use of forceps or a vacuum to rotate the fetal head if arrested labor ≥ 60 min
• Breech presentation
  • No intervention necessary before 37 weeks' gestation, as most fetuses spontaneously convert to cephalic presentation as they get closer to term
  • External cephalic version
    • Should be offered in all cases ≥ 37 weeks who would like to attempt a vaginal delivery, unless there are contraindications.
    • Involves manual adjustment of fetal position by applying pressure on the mother's abdomen
    • Contraindications for external cephalic version
      • Multiple pregnancy
      • Ruptured membranes
      • Fetal anatomical abnormalities
      • Hyperextension of fetal neck
      • Non-reassuring fetal status
      • Oligohydramnios
      • Antepartum hemorrhage
      • Placental abnormalities
      • Patient in active labor
  • Cesarean delivery: if external cephalic version is unsuccessful or contraindicated (e.g., in active labor, fetal distress)
  • Assisted vaginal delivery
    • In emergency cases where cesarean delivery was not possible
    • For a low-risk pregnancy, if the patient wishes to avoid surgery
• Shoulder dystocia: various obstetrical maneuvers may be tried (e.g., McRoberts, Zavanelli) to deliver the infant and avoid fetal demise from umbilical cord compression.

Neonatal complications ^[4][5]

• Birth asphyxia
• Infections (intrauterine and neonatal)
• Intracranial hemorrhage
• Birth injuries
• Perinatal death

Maternal complications ^[6]

Vesicovaginal fistula and ureterovaginal fistula

• Pathogenesis
  • Development of maternal soft tissue necrosis caused by prolonged compression between the maternal pelvic bones and fetal head.
  • Tissue necrosis of the structures separating the vagina from the bladder and distal ureter lead to the formation of fistulas.
  • Usually develops up to 2 weeks after delivery
• Clinical features
  • Vesicovaginal fistula: painless urinary leakage from the vagina after delivery
  • Ureterovaginal fistula: continuous urine loss after delivery
• Diagnostics
  • Vaginal examination
    • A small, erythematous area with no visible opening or opening on visualization
    • Urine leakage or pooling on direct visualization
  • Dye test
    • The dye (e.g., methylene blue) is instilled through a catheter into the bladder.
    • A tampon or cotton swab is inserted into the vagina
    • Positive for vesicovaginal fistula: blue staining on the tampon or swab
    • Positive for ureterovaginal fistula: clear fluid with wetness
  • Other tests
    • Cystoscopy
    • Retrograde pyelography
• Treatment: surgical repair

Other

• Uterine rupture
• Infections (e.g., puerperal sepsis)
• Postpartum hemorrhage
• Stress urinary incontinence
• Perinatal death

1. Dutta DC, Konar H. Textbook of Obstetrics. Jaypee Brothers Medical Publishers ; 2015
2. Buchmann EJ, Guidozzi F. Level of fetal head above brim: comparison of three transabdominal methods of estimation, and interobserver agreement.. J Obstet Gynaecol. 2007; 27 (8): p.787-790. doi: 10.1080/01443610701667387 . | Open in Read by QxMD
3. Dudenhausen JW, Obladen M. Practical Obstetrics. Walter de Gruyter GmbH & Co KG ; 2014
4. Van Beekhuizen HJ, Unkels R, Mmuni NS, Kaiser M. Complications of obstructed labour: pressure necrosis of neonatal scalp and vesicovaginal fistula. The Lancet. 2006; 368 (9542): p.1210. doi: 10.1016/s0140-6736(06)69477-4 . | Open in Read by QxMD
5. Fantu S, Segni H, Alemseged F. Incidence, Causes and Outcome of Obstructed Labor in Jimma University Specialized Hospital. Ethiopian Journal of Health Sciences. 2011; 20 (3). doi: 10.4314/ejhs.v20i3.69443 . | Open in Read by QxMD
6. Global burden of obstructed labour in the year 2000. https://www.who.int/healthinfo/statistics/bod_obstructedlabour.pdf. . Accessed: July 26, 2021.
7. Kaplan. USMLE Step 2 CK Lecture Notes 2017: Obstetrics/Gynecology . Kaplan Medical ; 2016