is cephalic presentation leads to normal delivery

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The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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What Is Cephalic Position?

The ideal fetal position for labor and delivery

• Why It's Best

Risks of Other Positions

• Determining Position
• Turning a Fetus

The cephalic position is when a fetus is head down when it is ready to enter the birth canal. This is one of a few variations of how a fetus can rest in the womb and is considered the ideal one for labor and delivery.

About 96% of babies are born in the cephalic position. Most settle into it between the 32nd and 36th weeks of pregnancy . Your healthcare provider will monitor the fetus's position during the last weeks of gestation to ensure this has happened by week 36.

If the fetus is not in the cephalic position at that point, the provider may try to turn it. If this doesn't work, some—but not all—practitioners will attempt to deliver vaginally, while others will recommend a Cesarean (C-section).

Getty Images

Why Is the Cephalic Position Best?

During labor, contractions dilate the cervix so the fetus has adequate room to come through the birth canal. The cephalic position is the easiest and safest way for the baby to pass through the birth canal.

If the fetus is in a noncephalic position, delivery becomes more challenging. Different fetal positions have a range of difficulties and varying risks.

A small percentage of babies present in noncephalic positions. This can pose risks both to the fetus and the mother, and make labor and delivery more challenging. It can also influence the way in which someone can deliver.

A fetus may actually find itself in any of these positions throughout pregnancy, as the move about the uterus. But as they grow, there will be less room to tumble around and they will settle into a final position.

It is at this point that noncephalic positions can pose significant risks.

Cephalic Posterior

A fetus may also present in an occiput or cephalic posterior position. This means they are positioned head down, but they are facing the abdomen instead of the back.

This position is also nicknamed "sunny-side up."

Presenting this way increases the chance of a painful and prolonged delivery.

There are three different types of breech fetal positioning:

• Frank breech: The legs are up with the feet near the head.
• Footling breech: One or both legs is lowered over the cervix.
• Complete breech: The fetus is bottom-first with knees bent.

A vaginal delivery is most times a safe way to deliver. But with breech positions, a vaginal delivery can be complicated.

When a baby is born in the breech position, the largest part—its head—is delivered last. This can result in them getting stuck in the birth canal (entrapped). This can cause injury or death.

The umbilical cord may also be damaged or slide down into the mouth of the womb, which can reduce or cut off the baby's oxygen supply.

Some providers are still comfortable performing a vaginal birth as long as the fetus is doing well. But breech is always a riskier delivery position compared with the cephalic position, and most cases require a C-section.

Likelihood of a Breech Baby

You are more likely to have a breech baby if you:

• Go into early labor before you're full term
• Have an abnormally shaped uterus, fibroids , or too much amniotic fluid
• Are pregnant with multiples
• Have placenta previa (when the placenta covers the cervix)

Transverse Lie

In transverse lie position, the fetus is presenting sideways across the uterus rather than vertically. They may be:

• Down, with the back facing the birth canal
• With one shoulder pointing toward the birth canal
• Up, with the hands and feet facing the birth canal

If a transverse lie is not corrected before labor, a C-section will be required. This is typically the case.

Determining Fetal Position

Your healthcare provider can determine if your baby is in cephalic presentation by performing a physical exam and ultrasound.

In the final weeks of pregnancy, your healthcare provider will feel your lower abdomen with their hands to assess the positioning of the baby. This includes where the head, back, and buttocks lie

If your healthcare provider senses that the fetus is in a breech position, they can use ultrasound to confirm their suspicion.

Turning a Fetus So They Are in Cephalic Position

External cephalic version (ECV) is a common, noninvasive procedure to turn a breech baby into cephalic position while it's still in the uterus.

This is only considered if a healthcare provider monitors presentation progress in the last trimester and notices that a fetus is maintaining a noncephalic position as your delivery date approaches.

External Cephalic Version (ECV)

ECV involves the healthcare provider applying pressure to your stomach to turn the fetus from the outside. They will attempt to rotate the head forward or backward and lift the buttocks in an upward position. Sometimes, they use ultrasound to help guide the process.

The best time to perform ECV is about 37 weeks of pregnancy. Afterward, the fetal heart rate will be monitored to make sure it’s within normal levels. You should be able to go home after having ECV done.

ECV has a 50% to 60% success rate. However, even if it does work, there is still a chance the fetus will return to the breech position before birth.

Natural Methods For Turning a Fetus

There are also natural methods that can help turn a fetus into cephalic position. There is no medical research that confirms their efficacy, however.

• Changing your position: Sometimes a fetus will move when you get into certain positions. Two specific movements that your provider may recommend include: Getting on your hands and knees and gently rocking back and forth. Another you could try is pushing your hips up in the air while laying on your back with your knees bent and feet flat on the floor (bridge pose).
• Playing stimulating sounds: Fetuses gravitate to sound. You may be successful at luring a fetus out of breech position by playing music or a recording of your voice near your lower abdomen.
• Chiropractic care: A chiropractor can try the Webster technique. This is a specific chiropractic analysis and adjustment which enables chiropractors to establish balance in the pregnant person's pelvis and reduce undue stress to the uterus and supporting ligaments.
• Acupuncture: This is a considerably safe way someone can try to turn a fetus. Some practitioners incorporate moxibustion—the burning of dried mugwort on certain areas of the body—because they believe it will enhance the chances of success.

A Word From Verywell

While most babies are born in cephalic position at delivery, this is not always the case. And while some fetuses can be turned, others may be more stubborn.

This may affect your labor and delivery wishes. Try to remember that having a healthy baby, and staying well yourself, are your ultimate priorities. That may mean diverting from your best laid plans.

Speaking to your healthcare provider about turning options and the safest route of delivery may help you adjust to this twist and feel better about how you will move ahead.

Glezerman M. Planned vaginal breech delivery: current status and the need to reconsider . Expert Rev Obstet Gynecol. 2012;7(2):159-166. doi:10.1586/eog.12.2

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

UT Southwestern Medical Center. Can you turn a breech baby around?

The American College of Obstetricians and Gynecologists. If your baby is breech .

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios .  Journal of Chiropractic Medicine . 2013;12(2):74-78. doi:10.1016/j.jcm.2013.06.003

By Cherie Berkley, MS Berkley is a journalist with a certification in global health from Johns Hopkins University and a master's degree in journalism.

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 transverse 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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Your baby in the birth canal

During labor and delivery, your baby must pass through your pelvic bones to reach the vaginal opening. The goal is to find the easiest way out. Certain body positions give the baby a smaller shape, which makes it easier for your baby to get through this tight passage.

The best position for the baby to pass through the pelvis is with the head down and the body facing toward the mother's back. This position is called occiput anterior.

Information

Certain terms are used to describe your baby's position and movement through the birth canal.

FETAL STATION

Fetal station refers to where the presenting part is in your pelvis.

• The presenting part. The presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.
• Ischial spines. These are bone points on the mother's pelvis. Normally the ischial spines are the narrowest part of the pelvis.
• 0 station. This is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis.
• If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

In first-time moms, the baby's head may engage by 36 weeks into the pregnancy. However, engagement may happen later in the pregnancy, or even during labor.

This refers to how the baby's spine lines up with the mother's spine. Your baby's spine is between their head and tailbone.

Your baby will most often settle into a position in the pelvis before labor begins.

• If your baby's spine runs in the same direction (parallel) as your spine, the baby is said to be in a longitudinal lie. Nearly all babies are in a longitudinal lie.
• If the baby is sideways (at a 90-degree angle to your spine), the baby is said to be in a transverse lie.

FETAL ATTITUDE

The fetal attitude describes the position of the parts of your baby's body.

The normal fetal attitude is commonly called the fetal position.

• The head is tucked down to the chest.
• The arms and legs are drawn in towards the center of the chest.

Abnormal fetal attitudes include a head that is tilted back, so the brow or the face presents first. Other body parts may be positioned behind the back. When this happens, the presenting part will be larger as it passes through the pelvis. This makes delivery more difficult.

DELIVERY PRESENTATION

Delivery presentation describes the way the baby is positioned to come down the birth canal for delivery.

The best position for your baby inside your uterus at the time of delivery is head down. This is called cephalic presentation.

• This position makes it easier and safer for your baby to pass through the birth canal. Cephalic presentation occurs in about 97% of deliveries.
• There are different types of cephalic presentation, which depend on the position of the baby's limbs and head (fetal attitude).

If your baby is in any position other than head down, your doctor may recommend a cesarean delivery.

Breech presentation is when the baby's bottom is down. Breech presentation occurs about 3% of the time. There are a few types of breech:

• A complete breech is when the buttocks present first and both the hips and knees are flexed.
• A frank breech is when the hips are flexed so the legs are straight and completely drawn up toward the chest.
• Other breech positions occur when either the feet or knees present first.

The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common when you deliver before your due date, or have twins or triplets.

CARDINAL MOVEMENTS OF LABOR

As your baby passes through the birth canal, the baby's head will change positions. These changes are needed for your baby to fit and move through your pelvis. These movements of your baby's head are called cardinal movements of labor.

• This is when the widest part of your baby's head has entered the pelvis.
• Engagement tells your health care provider that your pelvis is large enough to allow the baby's head to move down (descend).
• This is when your baby's head moves down (descends) further through your pelvis.
• Most often, descent occurs during labor, either as the cervix dilates or after you begin pushing.
• During descent, the baby's head is flexed down so that the chin touches the chest.
• With the chin tucked, it is easier for the baby's head to pass through the pelvis.

Internal Rotation

• As your baby's head descends further, the head will most often rotate so the back of the head is just below your pubic bone. This helps the head fit the shape of your pelvis.
• Usually, the baby will be face down toward your spine.
• Sometimes, the baby will rotate so it faces up toward the pubic bone.
• As your baby's head rotates, extends, or flexes during labor, the body will stay in position with one shoulder down toward your spine and one shoulder up toward your belly.
• As your baby reaches the opening of the vagina, usually the back of the head is in contact with your pubic bone.
• At this point, the birth canal curves upward, and the baby's head must extend back. It rotates under and around the pubic bone.

External Rotation

• As the baby's head is delivered, it will rotate a quarter turn to be in line with the body.
• After the head is delivered, the top shoulder is delivered under the pubic bone.
• After the shoulder, the rest of the body is usually delivered without a problem.

Alternative Names

Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude; Fetal descent; Fetal station; Cardinal movements; Labor-birth canal; Delivery-birth canal

Barth WH. Malpresentations and malposition. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 17.

Kilpatrick SJ, Garrison E, Fairbrother E. Normal labor and delivery. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 11.

Review Date 11/10/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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• Childbirth Problems

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CHAPTER 22:  Normal Labor

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• MECHANISMS OF LABOR
• NORMAL LABOR CHARACTERISTICS
• MANAGEMENT OF NORMAL LABOR
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Labor is the process that leads to childbirth. It begins with the onset of regular uterine contractions and ends with delivery of the newborn and expulsion of the placenta. Pregnancy and birth are physiological processes. Thus, labor and delivery should be considered normal for most women.

Fetal position within the birth canal is critical to labor progress and to the delivery route. It should be determined in early labor, and sonography can be implemented for unclear cases. Important relationships include fetal lie, presentation, attitude, and position.

Of these, fetal lie describes the relationship of the fetal long axis to that of the mother. In more than 99 percent of labors at term, the fetal lie is longitudinal . A transverse lie is less frequent. Occasionally, the fetal and maternal axes may cross at a 45-degree angle to form an oblique lie . This is unstable and becomes longitudinal or transverse during labor.

Fetal Presentation

The presenting part is the portion of the fetal body either within or in closest proximity to the birth canal. It usually can be felt through the cervix on vaginal examination. In longitudinal lies, the presenting part is either the fetal head or the breech, creating cephalic and breech presentations, respectively. When the fetus lies with the long axis transversely, the shoulder is considered the presenting part.

Cephalic presentations are subclassified according to the relationship between the head and body of the fetus ( Fig. 22-1 ). Ordinarily, the head is flexed sharply so that the chin contacts the thorax. The occipital fontanel is the presenting part, and this presentation is referred to as a vertex or occiput presentation . Much less often, the fetal neck may be sharply extended so that the occiput and back come into contact, and the face is foremost in the birth canal— face presentation . The fetal head may assume a position between these extremes. When the neck is only partly flexed, the anterior (large) fontanel may present— sinciput presentation . When the neck is only partially extended, the brow may emerge— brow presentation . These latter two are usually transient. As labor progresses, sinciput and brow presentations almost always convert into occiput or face presentations by neck flexion or extension, respectively. If not, dystocia can develop ( Chap. 23 , p. 441).

FIGURE 22-1

Longitudinal lie, cephalic presentation. Differences in attitude of the fetal body in (A) occiput, (B) sinciput, (C) brow, and (D) face presentations. Note changes in fetal attitude as the fetal head becomes less flexed.

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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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Normal Labor, Delivery, Newborn Care, and Puerperium

Normal Labor, Delivery, Newborn Care, and Puerperium Kirsten J. Lund James McManaman The editors wish to acknowledge the contributions of Dr. Dwight J. Rouse and Elaine St. John to this chapter in the last edition of this text. Normal Labor Physiology The course of normal human labor and delivery comprises a complex relationship between several dynamic parameters, including uterine contractions, cervical dilation, fetal descent, and elapsed time. Once the diagnosis of labor is made correctly, one can apply empiric models of progress in labor to identify labor abnormalities and apply effective interventions. The onset of labor in humans occurs around 280 days, or 40 weeks, from the first day of a patient’s last menstrual period (LMP). Because the estimated date of confinement (EDC), or “due date,” is associated with much anticipation and planning on the part of patients, care must be taken to educate the patient about the uncertainties inherent in setting the EDC as well as to ensure that the assignment of the due date is based on accurate medical data, insofar as this is possible. Individual variation accounts for a range for the onset of labor that spans 2 weeks on either side of the best estimated EDC; spontaneous labor between 38 and 42 weeks is considered normal. It is then the responsibility of the health care provider, when estimating a date of confinement, to take an accurate menstrual and contraceptive history in order to avoid assigning an incorrect date. If the patient’s cycle length is anything other than 28 days, the EDC must be adjusted accordingly, as much of the variation in cycle length is associated with the follicular, or preovulatory, phase. If conception occurs while the patient is using, or had recently been using, hormonal contraception, the date of ovulation may again be something other than 14 days after the LMP. If so, early ultrasound may be warranted in order to date the pregnancy more accurately and avoid mis-timing of medical interventions. While such attention to detail may seem insignificant at the time, many interventions including unnecessary tocolysis and unindicated induction of labor may result from an inaccurately dated pregnancy. The physiology of normal labor in humans remains incompletely understood. Evidence from sheep models suggests that the causative event in labor onset is a fall in maternal serum progesterone, concomitant with a rise in estrogens, all triggered by fetal adrenal cortisol production. However, a dramatic decrease in serum progesterone at term is not seen in humans, and an intact fetal hypothalamic-pituitary-adrenal axis does not seem necessary for labor to occur, as observed in pregnancies complicated by fetal anencephaly where the average delivery date is 39 6/7 weeks. Research in murine models suggests a role for prostaglandin synthesis in the onset of labor, although such data are again limited by interspecies differences. It is likely that the human uterus, a muscular organ with significant resting tone outside of pregnancy, is under negative inhibition during the bulk of pregnancy, and only near term is that negative inhibition lifted, thus enabling coordinated uterine contractions to occur. Because of the relatively poor understanding of the physiology of human labor, effective treatments for preterm labor and for induction of labor have remained elusive. Figure 2.1 Flow sheet for following labor progress. (From Chua S, Arulkumaran S. Poor prognosis in labor, including augmentation, malpositions and malpresentations. In: James DK, Steer PJ, Weiner CP, et al., eds. High risk pregnancy , 2nd ed. London: Harcourt Brace, 1999:1105 , with permission.) Stages of Labor Clinically recognizable labor is typically divided into three stages, each with statistically derived normative rates and durations. Many of these labor values were elucidated by Emanuel Friedman, who in the 1950s published his studies of hundreds of normal and abnormal labors and plotted cervical dilation and fetal descent against time. The resulting graphic labor curve was used to recognize individual labor patterns that deviated from normal and to guide the nature and timing of interventions. A more recent evaluation of labor and delivery patterns takes into account changes in both medical management of labor (including higher induction rates, more use of oxytocin and regional anesthesia, and higher rates of continuous fetal monitoring) and in patient characteristics (including increased body mass index [BMI] and decreased smoking rates, both of which have contributed to an increase in fetal size) and suggests a significantly longer duration of the active phase of labor among the contemporary population. Regardless, the very practice of tracking labor in a formal fashion appears to improve labor outcome. In a World Health Organization study of 35,484 women, use of a “labor curve” or partogram ( Fig. 2.1 ) and an agreed on labor management protocol was associated with a reduction in the percentage of prolonged labors, the proportion of labors requiring augmentation, and postpartum sepsis. The first stage of labor consists of the time between the onset of regular contractions associated with cervical change and the occurrence of complete cervical dilation. The first stage is further divided into latent and active phases. Although the distinction between the two phases can be difficult to make, the latent phase of labor is characterized by a slower rate of cervical dilation despite strong, regular uterine contractions. The latent phase can normally last up to 14 hours in multigravid patients and up to 20 hours in nulligravidas. In the active phase of labor, there is a more rapid change in cervical dilation. Patients may move extremely rapidly through active labor, although the lower limit of normal for cervical change is about 1 cm per hour for nulliparous women. In the majority of patients, the transition between the latent and active phases occurs at some time between 3 and 5 cm of cervical dilation, although it is possible, particularly in multigravid patients, to see a patient who is 5-cm dilated and still in the latent phase of labor. It is also critical for the clinician to accurately distinguish between latent phase labor, during which incremental cervical change is occurring (although slowly), and dysfunctional uterine contractions, a condition characterized by no change in cervical dilation despite strong, painful uterine contractions. Such dysfunctional contractions do not constitute labor, and treating them as such may lead to unnecessary intervention. The second stage of labor is defined as the interval between complete cervical dilation and delivery of the baby. This stage is characterized by descent of the fetal presenting part; maternal sensation of pelvic pressure as this descent progresses; and maternal expulsive efforts, which in concert with uterine contractions effect delivery of the baby. The duration of the second stage varies with parity, ethnicity, fetal size, and the presence or absence of regional anesthesia and can range from only minutes to as much as 3 hours. Finally, the third stage of labor comprises that time period between delivery of the baby and delivery of the placenta and may take up to 30 minutes, although usually is much shorter. Mechanics of Labor Human labor differs from that of other mammals, not only with regard to physiology but also in the way in which the fetus moves through and out of the birth canal. The mechanism of human labor is complicated by two main evolutionary changes: increased brain size and changes in pelvic shape due to bipedal posture. Both present challenges to the “fit” between the fetal skull and the maternal pelvic outlet. Whereas labor complications in other mammals are mostly related to malpresentations, labor dystocia in humans may occur simply due to fetal head position or subtle differences in the shape of the maternal pelvis. Therefore, it is critical for the obstetrician to understand the anatomy of the pelvis as well as how to assess the presentation, lie, and position of the fetus. Figure 2.2 The pelvic inlet AP diameter is estimated from the diagonal conjugate. Pelvimetry Clinical assessment of the pelvis involves manual evaluation of the pelvic inlet, midpelvis, and outlet ( Figs. 2.2 , 2.3 ). Pelvic inlet —The transverse diameter of the pelvic inlet averages 13 cm. It cannot be measured clinically, but a narrow transverse inlet is a very rare cause of abnormal labor progress. The anteroposterior (AP) diameter of the inlet is more important. It is estimated clinically by determining the distance between the lower margin of the symphysis pubis and the sacral promontory. This value is known as the diagonal conjugate . The obstetric conjugate—or true AP diameter—is 1.5 to 2.0 cm shorter. The pelvic inlet is an adequate size for a normal fetus if the diagonal conjugate is 12 cm or greater. Figure 2.3 The transverse diameter of the midpelvis is estimated by evaluating the distance between the ischial spines. Midpelvis —The specific diameters of the midpelvis cannot be measured clinically. Contraction of the midpelvis is suspected if the ischial spines are quite prominent (or the sacrosciatic notch is less than two fingerbreadths wide), the pubic arch is narrow, the pelvic sidewalls converge, or the sacral concavity is quite shallow. Pelvic outlet —The transverse diameter of the pelvic outlet should be greater than 8 cm. This diameter can be estimated by placing a fist on the perineum to measure the distance between the ischial tuberosities. Consideration of these measurements allows assignment to one of the various pelvic types and thus an appreciation of how and where labor may be stalled if the pelvis is not favorable for childbirth. Careful evaluation of the midpelvis is most important, as those women found to have a contracted midpelvis are poor candidates for forceps-assisted vaginal delivery. However, because the fetal skull has the ability to mold, and because overall fetal size is variable, borderline pelvimetry is not a contraindication to a trial of labor. Fetal Orientation Clinicians who provide care for women in the third trimester of pregnancy should assess the orientation of the fetus at each visit. Early detection of abnormal fetal orientation can increase the success of interventions to correct this; for example, the chance of successful external cephalic version of a breech fetus is greater if the version is performed prior to the onset of labor. The fetal lie is the relationship between the sagittal plane of the fetus and the mother. The vast majority of patients in labor have a longitudinal fetal lie, although risk factors including multiparity and uterine or fetal anomalies may increase the rate of transverse or oblique lie. Fetal presentation refers to the part of the fetus that is closest to the pelvic inlet. Most often, the fetus is in cephalic presentation, and of those, the majority are in a vertex (posterior fontanel as the presenting landmark) presentation. Other presentations include brow and face. Breech presentation is classified into several subcategories: complete (hips and knees flexed), frank (hips flexed, knees extended), and incomplete or footling (one or both lower extremities presenting). Finally, fetal position describes the relationship of a presenting part to the maternal pelvis. For purposes of describing fetal position, the point of reference in a vertex presentation is the occiput; for a breech, it is the sacrum; and in face presentations, it is the chin (or mentum). The reference point is described in its relationship to the maternal pelvis. Thus, with a vertex presentation, the occiput on the maternal left side of the pelvis, and the fetal sagittal suture transverse in the pelvis, the position is left occiput transverse, abbreviated as LOT. Figure 2.4 Leopold maneuvers. First maneuver: The uterine contour is outlined; the fundus is palpated, allowing identification of the fetal parts. Second maneuver: By palpation of the sides of the maternal abdomen, the location of the fetal back is determined. Third maneuver: The presenting part is grasped, identified, and evaluated for engagement. Fourth maneuver: With palpation toward the pelvis, the identity of the presenting part is confirmed, and flexion or extension of the fetal head is evaluated. The clinician can often determine fetal lie and presentation by manual palpation of the gravid uterus. This process was formalized in four discrete maneuvers described by Leopold in the late 19th century ( Fig. 2.4 ). Fetal position generally cannot be determined by external examination but rather by vaginal examination and direct palpation of the fetus during active labor or by ultrasound investigation. Cardinal Movements of Labor From the perspective of the fetus, labor involves movement progressively downward through the pelvis by the following cardinal movements, described for a vertex presentation ( Fig. 2.5 ). Engagement occurs days to weeks prior to labor for primigravidas and at the onset of labor for multigravidas. Figure 2.5 Cardinal movements of labor. A: Engagement. B: Flexion. C: Descent and internal rotation. D, E: Extension. F: External rotation. Flexion of the neck allows the occiput to lead, thus presenting the smallest diameter of the fetal head to the pelvic inlet. Descent is progressive as the cervix thins and the lower uterine segment lengthens. Internal rotation occurs during descent. The occiput rotates from transverse to either a posterior or anterior position to pass the ischial spines. Extension occurs as the fetal head distends the perineum and the occiput passes beneath the symphysis. External rotation of the head after delivery to a transverse position allows the shoulders to rotate internally to an AP position. Initial Patient Evaluation and Hospital Admission Women should be advised at each antepartum visit of the circumstances under which they should seek evaluation for labor. These include: Possible rupture of membranes . In 10% of pregnancies, rupture of the membranes precedes the onset of labor. This presents as fluid leaking through the cervix and out of the vagina. The differential diagnosis includes urine leakage, vaginal infections, and passage of cervical mucus. Because prolonged rupture of the membranes is associated with higher rates of maternal and neonatal infection, optimal treatment of ruptured membranes at term is prompt induction of labor. Regular, painful uterine contractions . Although regular uterine contractions often signal the onset of labor, it can be difficult to distinguish true latent labor from false labor, or Braxton-Hicks contractions. The contractions of false labor tend to be more irregular both in intensity and in interval and the associated discomfort limited to the lower abdomen and groin. They usually abate with time, analgesia, or sedation. The contractions of true labor are progressive in intensity and are often associated with pelvic pressure as well as abdominal and back pain. In many cases, the only way to confirm the diagnosis of true labor is observation over several hours and serial examinations of the cervix. Significant vaginal bleeding . A small amount of blood mixed with mucus is a normal sign of early cervical dilation. This is called a bloody show . However, heavy vaginal bleeding may indicate placental abruption or an undiagnosed placenta previa. Pain greater than anticipated in the back, abdomen, or pelvis . Again, this may signal an untoward event such as placental abruption or, in the case of a patient with previous uterine surgery, uterine scar dehiscence. A careful history will elucidate whether there may be an indication for hospital admission. Physical examination may confirm the diagnosis, although as noted, the diagnosis of labor may take observation over time. If the woman is having contractions, their time of onset and frequency should be recorded. Questions should focus on spontaneous rupture of the membranes, presence or absence of bleeding, and fetal activity. The patient’s prenatal record should be reviewed in detail with particular attention to the reliability of the EDC; the details of any previous pregnancies; and past medical, surgical, and social history. Prenatal laboratory data should include blood type (with documentation of appropriate Rh(D) immune globulin administration); hemoglobin/hematocrit; screening for gestational diabetes, if indicated; cervical cytology; rubella antibody status; and infection screening to include syphilis, hepatitis B, gonorrhea, Chlamydia , and HIV status as well as group B streptococcal (GBS) status. The admission physical examination should include vital signs, auscultation of heart and lungs, and a brief neurologic examination with particular attention to deep tendon reflexes. Fetal orientation should be determined, and the uterus should be palpated or monitored to determine the presence, frequency, and intensity of contractions. A clinical assessment of fetal weight should be performed, and fetal heart tones should be assessed either by auscultation or via electronic monitoring, with specific attention to the response of the fetal heart rate to the uterine contractions. The external genitalia should be examined for herpetic lesions. If membrane rupture is suspected, this can be confirmed or ruled out by speculum examination. Pooling of amniotic fluid in the vagina or direct visualization of fluid leakage through the cervix is highly suggestive of ruptured membranes. A sample of the pooled fluid is collected and subjected to microscopy and pH testing. Amniotic fluid is relatively basic (compared with normal vaginal secretions that have a pH <4.5) and will turn nitrazine paper blue (although blood will as well). An air-dried sample of amniotic fluid on a slide will show, under the microscope, a characteristic “fern” pattern ( Fig 2.6 ). Because cervical mucus and maternal serum can also demonstrate a fern pattern, care must be taken when collecting the sample. An internal digital examination may be performed to assess the state of the cervix as well as fetal station and position. It may be appropriate to defer this examination in the case of ruptured membranes if the patient is not clinically deemed to be in active labor, due to the possibility of increasing risk for chorioamnionitis. Digital examinations are contraindicated in undiagnosed vaginal bleeding, as such an examination in the case of a placenta previa can lead to life-threatening hemorrhage. The internal examination includes attention to the following: dilation of the internal cervical os; assessment of consistency (soft or firm); degree of effacement ( Fig. 2.7 ); orientation of the cervical os with respect to the vaginal axis (posterior, midplane, or anterior); and identification, station, position, and attitude, if applicable, of the presenting fetal part. Station is defined as the relationship between the lowest presenting bony part and the maternal ischial spines ( Fig. 2.8 ). Position is determined by noting the orientation of a chosen fetal part—occiput, sacrum, or mentum—relative to the maternal pelvis ( Fig. 2.9 ). Fetal attitude refers to the position of the fetal head relative to the fetal chest and the presence or absence of lateral flexion of the head ( Figs. 2.10 , 2.11 , 2.12 ). Clinical pelvimetry should be performed as described previously. Figure 2.6 Typical ferning pattern of dried amniotic fluid (400×). (Original photo courtesy of Dr. Dwight Rouse.) Figure 2.7 Degree of cervical effacement. A: No effacement. B: 75% effacement. C: 100% effacement. Management of Labor Management of the First Stage of Labor The primary management goals in the first stage of labor are to monitor fetal well-being; support the woman through what can be a lengthy, uncomfortable period; and offer intervention as it becomes appropriate. One of the most important steps a clinician can take in the management of labor is to accurately diagnose whether a patient is, or is not, in active labor. Randomized trials have shown that patients in early latent labor who are encouraged to labor at home or to walk have less need for oxytocic agents and anesthesia than those who are admitted directly to the hospital. If a patient has an indication, whether fetal or maternal, for admission to the hospital in early labor, she should be encouraged to maintain as much freedom of movement as possible. Because all forms of monitoring, be it intermittent auscultation, external fetal monitoring, or internal monitoring, can be accomplished in a lying, sitting, or upright position, the only time a healthy woman’s movement must be limited is after she has received analgesia or anesthesia and would not be steady on her feet. Patients should be free to position themselves as they like except for the supine position. In the supine position, the gravid uterus may compress the vena cava, leading to decreased venus return, decreased cardiac output, and compromised blood flow to the uterus and other organs. This has been called the supine-hypotension syndrome of pregnancy . Figure 2.8 Stations of the fetal head. At the 0 station, the fetal head is at the bony ischial spines and fills the maternal sacrum. Positions above the ischial spines are referred to as –1 through –5, referring to the number of centimeters that the head is positioned above the spines. As the head descends past the ischial spines, the stations are referred to as +1 through +5 (head visible at the introitus). Figure 2.9 Fetal position. The orientation of the presenting vertex within the maternal pelvis. Figure 2.10 A, B: The bones, sutures, fontanelles, and clinically important diameters of the fetal head. Figure 2.11 Fetal attitude and dimensions of a term-size fetus. A: Full flexion presents the smallest circumference of the fetal head to the narrower planes of the pelvis. B: Military attitude usually changes to full flexion with descent into the pelvis. C: Brow presentation usually converts to full flexion or a face presentation, as the occipitomental diameter is too large for all except the largest pelves to accommodate. D: Face presentation shows dimensions that allow descent through the pelvis, unless the chin is posterior. Persistent mentum posterior must be delivered by cesarean section. Vital signs should be monitored at least every 4 hours or more frequently as clinically indicated. Placement of an intravenous line is not necessary for all women in labor. However, women who are dehydrated or for whom nausea, a common symptom in labor, prevents adequate ongoing oral hydration may benefit from intravenous hydration. It is prudent to establish intravenous access for administration of fluids and medication, should they be necessary, in women at increased risk of postpartum hemorrhage (such as those patients with prior postpartum hemorrhage, prolonged labor, or overdistended uterus). In most women, laboratory evaluation on presentation in labor can be minimized and tailored to risk factors pertinent to the patient or to the patient population. Although in many units it is customary to perform routine admission blood type and antibody screen, hemoglobin and hematocrit, and syphilis serology, the necessity and cost-effectiveness of repeating these tests in healthy women who have received adequate prenatal care is debatable. If a woman exhibits signs or symptoms of preeclampsia such as hypertension, visual disturbances, or hyperreflexia, appropriate laboratory workup should be pursued. Patients without prenatal care, or for whom such records will not be obtainable during their hospital stay, should have laboratory evaluation for blood type and Rh status; hemoglobin/hematocrit; rubella antibody titer; and hepatitis B, syphilis, and HIV screening. Patients with positive screening cultures for GBS or who have had a previously affected infant should be given prophylactic intravenous antibiotics during labor in order to decrease the risk of transmission to the fetus and resulting neonatal GBS sepsis. If screening cultures are not available, a risk-based treatment strategy is recommended by the Centers for Disease Control (CDC). Prophylaxis is given for any of the following: labor prior to 37 weeks, rupture of membranes greater than 18 hours, or clinical evidence of maternal intrauterine infection. The consensus treatment in patients without allergies is penicillin G, 5 million units initially followed by 2.5 million units every 4 hours until delivery. Acceptable alternatives include ampicillin; cefazolin (for patients with a nonanaphylactoid response to penicillin); or in cases of grave penicillin allergy, clindamycin, erythromycin, or vancomycin (depending on demonstrated antibiotic susceptibilities). (Further description of GBS infection is presented in Chapter 19

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5.1 Normal delivery

5.1.1 general recommendations.

Personnel should wear personal protective equipment (gloves, goggles, clothing and eye protection) to prevent infection from blood and other body fluids. 

Ensure a calm reassuring environment and provide the woman as much privacy as possible during examinations and delivery. Encourage her to move about freely if desired and to have a person of her choice to accompany her.

Anticipate the need for resuscitation at every birth. The necessary equipment should be ready at hand and ready for use.

5.1.2 Diagnosing the start of labour

• Onset of uterine contractions: intermittent, rhythmic pains accompanied by a hardening of the uterus, progressively increasing in strength and frequency;
• in a primipara, the cervix will first efface then, dilate;
• in a multipara, effacement and dilation occur simultaneously.

Repeated contractions without cervical changes should not be considered as the start of labour. Repeated contractions that are ineffective (unaccompanied by cervical changes) and irregular, which spontaneously stop and then possibly start up again, represent false labour. In this case, do not rupture the membranes, do not administer oxytocin.

Likewise, cervical dilation with few or no contractions should not be considered the start of labour. Multiparous women in particular may have a dilated cervix (up to 5 cm) at term before the onset of labour. If in doubt, in both cases, re-examine 4 hours later. If the cervix has not changed labour has not begun and the woman does not need to be admitted to the delivery room.

5.1.3 Stages of labour

First stage: dilation and foetal descent, divided into 2 phases.

1) Latent phase: from the start of labour to approximately 5 cm of dilation. Its duration varies depending on the number of prior deliveries. 2) Active phase: from approximately 5 cm to complete dilation [1] Citation 1. World Health Organization. WHO recommendations Intrapartum care for a positive childbirth experience, Geneva, 2018. http://apps.who.int/iris/bitstream/handle/10665/272447/WHO-RHR-18.12-eng.pdf?ua=1  [Accessed 18 june 2018] . During this phase the cervix dilates faster than during the latent phase. The time to dilate varies with the number of previous deliveries. As a rule, it does not last longer than 10 hours in a multipara and 12 hours in a primipara.

Second stage: delivery of the infant

Begins at full dilation.

Third stage: delivery of the placenta

See Chapter 8 .

5.1.4 First stage: dilation and descent of the foetus

The indicators being monitored are noted on the partograph ( Section 5.2 ).

Uterine contractions

• Contractions progressively increase in strength and frequency: sometimes 30 minutes apart early in labour; closer together (every 2 to 3 minutes) at the end of labour.
• A contraction can last up to a minute.
• The uterus should relax between contractions.
• Watch the shape of the uterus in order to spot a Bandl’s ring (Chapter 3, Section 3.3.2 ).

General condition of the patient

• Monitor the heart rate, blood pressure and temperature every 4 hours or more often in case of abnormality.
• Ask the woman to empty her bladder regularly (e.g. every 2 hours).
• Keep the woman hydrated (offer her water or tea).
• Encourage the woman to move about freely during labour. Position changes and walking around help relieve the pain, enhances the progress of labour and helps foetal descent. Pain can also be relieved by massage or hot or cold compresses. Midwife support helps manage pain.
• Routinely insert an IV line in the following situations: excessively large uterus (foetal macrosomia, multiple pregnancy or polyhydramnios), known anaemia and hypertension.

Foetal heart rate

Foetal heart rate monitoring.

Use a Pinard stethoscope or foetal Doppler, every 30 minutes during the active phase and every 5 minutes during active second stage, or as often as possible. Listen to and count for at least one whole minute immediately after the contraction. Normal foetal heart rate is 110 to 160 beats per minute. The foetal heart rate may slow down during a contraction. If it becomes completely normal again as soon as the uterus relaxes, there is probably no foetal distress. If the foetal heart rate heard immediately after the end of a contraction is abnormal (less than 100 beats per minute or more than 180 beats per minute), continue foetal heart rate monitoring for the next 3 contractions to confirm the abnormality.

Management of abnormal foetal heart rate

• Insert an IV line.
• Check maternal vital signs: heart rate, blood pressure and temperature.
• Check the uterine tonus. If hypertonic, look for excessive administration of oxytocin (which should therefore be stopped) or placental abruption (Chapter 3,  Section 3.2 ).
• Check the colour of the amniotic fluid: meconium-stained (greenish) amniotic fluid combined with foetal heart rate abnormalities is suggestive of true foetal distress.
• Stop administering oxytocin if an infusion is in progress.
• Check for vaginal bleeding: bleeding may suggest placental abruption or uterine rupture.
• Raise the patient or place her on her left side. Laying on her back the uterus creates pressure on the vena cava, which may be the cause of low foetal heart rate.
• Correct possible hypotension by fluid replacement (Ringer lactate) to bring the systolic blood pressure ≥ 90 mmHg.
• Perform a vaginal examination to look for cord prolapse.
• If the foetal heart rate is more than 180 beats/minute:

The most common cause is maternal febrile infection.

• Look for the cause of the infection (uterine infection, pyelonephritis, malaria, etc.) and treat. 
• Treat the fever (paracetamol).
• In case of fever of unknown origin, administer antibiotics as for a prolonged rupture of membranes (Chapter 4, Section 4.9 ).

If the abnormal foetal heart rate persists or the amniotic fluid becomes stained with meconium, deliver quickly. If the cervix is fully dilated and the head engaged, perform instrumental delivery (vacuum extractor or forceps, depending on the operator’s skill and experience); otherwise consider caesarean section.

Dilation during active phase

• The cervix should remain soft, and dilate progressively. Dilation should be checked by vaginal examination every 4 hours if there are no particular problems (Figures 5.2).
• No progress in cervical dilation between two vaginal examinations is a warning sign.
• Action must be taken if there is no progress for 4 hours: artificial rupture of membranes, administration of oxytocin,  caesarean section, depending on the circumstances.

Figures 5.2 - Estimating cervical dilation

Amniotic sac

• The amniotic sac bulges during contractions and usually breaks spontaneously after 5 cm of dilation or at full dilation during delivery. Immediately after rupture, check the foetal heart rate and if necessary perform a vaginal examination in order to identify a potential prolapse of the umbilical cord ( Section 5.4 ). Once the membranes are ruptured, always use sterile gloves for vaginal examination.
• Note the colour of the amniotic fluid: clear, blood-stained, or meconium-stained.
• Meconium staining by itself, without abnormal foetal heart rate, is not diagnostic of foetal distress, but does require closer monitoring—in particular, a vaginal examination every 2 hours. Action must be taken if dilation fails to progress after 2 hours.

Foetal progress

• Assess foetal descent by palpating the abdomen (portion of the foetal head felt above the symphysis pubis) before performing the vaginal examination.
• At each vaginal examination, in addition to dilation, check the presentation, the position and the degree of foetal descent.
• Look for signs that the foetal head is engaged:

On vaginal examination, the presenting part prevents the examiner's fingers from reaching the sacral concavity (Figures 5.3a and 5.3b). The presence of caput (benign diffuse swelling of the foetal head) can lead to the mistaken conclusion that the foetal head is engaged. The distance between the foetal shoulder and the upper edge of the symphysis pubis is less than 2 finger widths (Figures 5.3c and 5.3d).

• Use reference points on the foetal skull to determine the position of the head in the mother's pelvis. It is easier to determine the position of the head after the membranes have ruptured, and the cervix is more than 5 cm dilated. When the head is well flexed, the anterior (diamond-shaped) fontanelle is not palpable; only the sagittal suture and the posterior (triangular) fontanelle are. The posterior fontanelle is the landmark for the foetal occiput, and thus helps give the foetal position. In most cases, once the head is engaged, rotation of the head within the pelvis brings the foetal occiput under the mother's symphysis, with the posterior fontanelle along the anterior midline.

5.1.5 Second stage: delivery of the infant

This stage is often rapid in a multipara, and slower in a primipara. It should not, however, take longer than 2 hours in a multipara and 3 hours in a primipara

If there is a traditional delivery position and no specific risk for the mother or child has been established, it is possible to assist a delivery in a woman on her back, on her left side, squatting or on all fours (Figures 5.4).

Figures 5.4 - Delivery position

• Rinse the vulva and perineum with clean water.
• The bladder should be emptied, naturally if possible. In cases of urinary retention only, insert a urinary catheter using sterile technique (sterile gloves; sterile, single use catheter).
• If labour is progressing well and there is no foetal heart rate abnormality, let the woman follow her own urge to push. In other cases, expulsive effort should be directed. The woman should push during the uterine contraction. Pushing may be done either with held breath (after a deep inhalation, glottis closed, abdominal muscles and diaphragm contracted, directed toward the perineum) or with exhalation. Expulsive effort is maintained for long as possible: in general, 2 to 3 pushes per contraction.
• Between contractions, the woman should rest and breathe deeply. The birth attendant should monitor the foetal heart rate after each contraction.
• The head begins to stretch the perineum, which becomes progressively thinner; the vaginal opening distends, the labia spread apart, and the occiput appears. In a cephalic presentation, the head usually emerges occiput anterior: the infant is born looking down, the occiput pivoting against the symphysis (Figures 5.5). The head goes into slight extension. The birth attendant must guide this motion and prevent any abrupt expulsive movement, with one hand supporting the occiput. The other hand can support the chin through the perineum. Cover the anal area with a compress (Figures 5.6).

During this final phase—an active one for the birth attendant—the woman should stop all expulsive efforts and breathe deeply. With one hand, the birth attendant controls the extension of the head and moves it slightly side-to-side, in order to gradually free the parietal protuberances; if necessary (not routinely), the chin can be lifted with the other hand (Figure 5.7).

• At the moment of delivery, the perineum is extremely distended. Controlling the expulsion can help reduce the risk of a tear. Episiotomy ( Section 5.8 ) is not routinely indicated. In an occiput-posterior delivery (Figure 5.8), where perineal distension is at a maximum, episiotomy may be helpful.

• The head, once delivered, rotates spontaneously by at least 90°. The birth attendant helps this movement by grasping the head in both hands and exerting gentle downward traction to bring the anterior shoulder under the symphysis and then deliver it then, smooth upward traction to deliver the posterior shoulder (Figures 5.9).

To reduce the risk of perineal tears, control the delivery of the posterior shoulder.

• Place the neonate on mother's chest. For neonatal care, see Chapter 10,  Section 10.1 .

5.1.6 Oxytocin administration

Administer oxytocin to the mother immediately and then deliver the placenta (Chapter 8, Section 8.1.2 ).

5.1.7 Umbilical cord clamping

See Chapter 10,  Section 10.1.1 .

• 1. World Health Organization. WHO recommendations Intrapartum care for a positive childbirth experience, Geneva, 2018. http://apps.who.int/iris/bitstream/handle/10665/272447/WHO-RHR-18.12-eng.pdf?ua=1  [Accessed 18 june 2018]

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Presentation and position of baby through pregnancy and at birth

9-minute read

If you are concerned about your baby’s movements, contact your doctor or midwife for advice immediately.

• If you baby is in a breech presentation, your doctor may recommend trying a technique called an external cephalic version to try and move your baby while they are still in the uterus for an easier birth.

What does presentation and position mean?

Presentation refers to the part of your baby’s body that is facing downwards in the direction of the birth canal.

Position refers to where your baby’s occiput (the bottom part of the back of their head) is in relation to your body.

If your baby is in a breech presentation , then position refers to where your baby’s sacrum (lower back) is in relation to your body.

People — including medical professionals — sometimes use these terms incorrectly. Sometimes when speaking about babies in breech presentation, the word ‘position’ will be used to refer to their presentation. For example, you may read information or hear people say ‘breech position’ instead of ‘breech presentation’.

What are the different types of presentation my baby could be in during pregnancy and birth?

Most babies present headfirst, also known as cephalic presentation. Most babies that are headfirst will be vertex presentation. This means that the crown of their head sits at the opening of your birth canal.

In rare cases, your baby can be headfirst but in face or brow presentation, which may not be suitable for vaginal birth.

If your baby is in a breech presentation, their feet or bottom will be closest to your birth canal. The 3 most common types of breech presentation are:

• frank or extended breech — where your baby’s legs are straight up in front of their body, with their feet up near their face
• complete or flexed breech — where your baby is in a sitting position with their legs crossed in front of their body and their feet near their bottom
• footling breech — where one or both of your baby’s feet are hanging below their bottom, so the foot or feet are coming first

Read more on breech presentation .

What are the different positions my baby could be in during pregnancy and birth?

If your baby is headfirst, the 3 main types of presentation are:

• anterior – when the back of your baby’s head is at the front of your belly
• lateral – when the back of your baby’s head is facing your side
• posterior – when the back of your baby’s head is towards your back

How will I know what presentation and position my baby is in?

Your doctor or midwife can usually work out your baby’s presentation by feeling your abdomen. They may also double check it with a portable ultrasound. Your baby’s presentation is usually checked around 36 weeks .

Your doctor or midwife will also confirm your baby’s head position in labour by examining your belly and using an ultrasound , and they may also do a vaginal examination . During the vaginal examination they are feeling for certain ridges on your baby’s head called sutures and fontanelles that help them work out which way your baby is positioned.

What is the ideal presentation and position for baby to be in for a vaginal birth?

For a vaginal birth, your baby will ideally be headfirst with the back of their head at the front of your belly, also known as being in the anterior position. This position is best for labour and birth since it means that the smallest part of your baby’s head goes down the birth canal first.

When does a baby usually get in the ideal presentation and position for birth?

Your baby will usually be in a headfirst position by 37 weeks of pregnancy. Around 3 in every 100 babies will be in breech presentation after 37 weeks.

Your baby’s position can change with your contractions during labour as they move down the birth canal, so their exact position can change during labour.

What are my options if baby isn't in the ideal presentation or position for a vaginal birth?

If your baby is in a breech presentation, your doctor may recommend a technique called an external cephalic version (ECV) to try and move your baby while they are still in the uterus . An ECV involves your doctor using their hands to apply pressure on your belly and help turn your baby to a headfirst position. It has a 1 in 2 chance of success and is a safe option in most pregnancies.

There is no evidence to show that alternative therapies, such as exercises, acupuncture or chiropractic treatments, help your baby change from a breech presentation to headfirst.

If your baby remains breech, your doctor may discuss having a breech vaginal birth. Not all doctors and hospitals offer this option. They may also suggest you birth your baby with a planned caesarean section .

If your baby’s presentation is headfirst but the position of your baby’s head is not ideal for labour, it can lead to a longer labour, and potential complications . The position of your baby’s head will often change as your labour progresses. If it doesn’t, sometimes you can still give birth without assistance, or you may need your doctor to help turn your baby’s head or help your birth with a vacuum or forceps .

Any procedure or decision for a type of birth will only go ahead with your consent . You will be able to discuss all the options with your doctor, and based on your preferences for yourself and your baby’s safety, make a decision together .

Resources and support

The Royal Australian and New Zealand College of Obstetrics and Gynaecology has a factsheet about the options available to you if your baby is in a breech presentation at the end of your pregnancy .

Mercy Perinatal has information on external cephalic version (ECV) safety and benefits if your baby is in a breech presentation at the end of your pregnancy.

The Women’s Hospital has information about the different presentations and positions your baby could be in, and how it can affect your birthing experience.

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Last reviewed: October 2023

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Breech presentation and turning the baby

In preparation for a safe birth, your health team will need to turn your baby if it is in a bottom first ‘breech’ position.

Read more on WA Health website

Breech Presentation at the End of your Pregnancy

Breech presentation occurs when your baby is lying bottom first or feet first in the uterus (womb) rather than the usual head first position. In early pregnancy, a breech position is very common.

Read more on RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists website

External Cephalic Version for Breech Presentation - Pregnancy and the first five years

This information brochure provides information about an External Cephalic Version (ECV) for breech presentation

Read more on NSW Health website

When a baby is positioned bottom-down late in pregnancy, this is called the breech position. Find out about 3 main types and safe birthing options.

Read more on Pregnancy, Birth & Baby website

Malpresentation is when your baby is in an unusual position as the birth approaches. Sometimes it’s possible to move the baby, but a caesarean maybe safer.

Labour complications

Even if you’re healthy and well prepared for childbirth, there’s always a chance of unexpected problems. Learn more about labour complications.

ECV is a procedure to try to move your baby from a breech position to a head-down position. This is performed by a trained doctor.

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The articles in this section relate to having a baby – what to consider before becoming pregnant, pregnancy and birth, and after your baby is born.

Anatomy of pregnancy and birth - pelvis

Your pelvis helps to carry your growing baby and is tailored for vaginal births. Learn more about the structure and function of the female pelvis.

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There are important things to consider if you are having a planned or elective caesarean such as what happens during and after the procedure.

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In this Article

The ABCs of Cephalic Presentation: A Comprehensive Guide for Moms-to-Be

Updated on 24 November 2023

As expectant mothers eagerly anticipate the arrival of their little ones, understanding the intricacies of pregnancy becomes crucial. One term that frequently arises in discussions about childbirth is "cephalic presentation." In this article, we will understand its meaning, types, benefits associated with it, the likelihood of normal delivery and address common concerns expectant mothers might have.

What is the meaning of cephalic presentation in pregnancy?

Cephalic presentation means the baby's head is positioned down towards the birth canal, which is the ideal fetal position for childbirth. This position is considered optimal for a smoother and safer delivery. In medical terms, a baby in cephalic presentation is said to be in a "vertex" position.

The majority of babies naturally assume a cephalic presentation before birth. Other presentations, such as breech presentation (where the baby's buttocks or feet are positioned to enter the birth canal first) or transverse presentation (where the baby is lying sideways), may complicate the delivery process and may require medical intervention.

Cephalic presentation types

There are different types of cephalic presentation, each influencing the birthing process. The primary types include:

1. Vertex Presentation

The most common type where the baby's head is down, facing the mother's spine.

2. Brow Presentation

The baby's head is slightly extended, and the forehead presents first.

3. Face Presentation

The baby is positioned headfirst, but the face is the presenting part instead of the crown of the head.

Understanding these variations is essential for expectant mothers and healthcare providers to navigate potential challenges during labor.

You may also like: How to Get Baby in Right Position for Birth?

What are the benefits of cephalic presentation?

In order to understand whether cephalic presentation is good or bad, let’s take a look at its key advantages:

1. Easier Engagement

This presentation facilitates the baby's engagement in the pelvis, aiding in a smoother descent during labor.

2. Reduced Risk of Complications

Babies in head-first position typically experience fewer complications during delivery compared to other presentations.

3. Faster Labor Progression

This position is associated with quicker labor progression, leading to a potentially shorter and less stressful birthing process.

4. Lower Cesarean Section Rates

The chances of a cesarean section are significantly reduced when the baby is in cephalic presentation in pregnancy.

5. Optimal Fetal Oxygenation

The head-first position allows for optimal oxygenation of the baby as the head can easily pass through the birth canal, promoting a healthy start to life.

What are the chances of normal delivery in cephalic presentation?

The chances of a normal delivery are significantly higher when the baby is in cephalic or head-first presentation. Vaginal births are the natural outcome when the baby's head leads the way, aligning with the natural mechanics of childbirth.

While this presentation increases the chances of a normal delivery, it's important to note that individual factors, such as the mother's pelvic shape, the size of the baby, and the progress of labor, can also influence the delivery process. Sometimes complications may arise during labor and medical interventions or a cesarean section may be necessary.

You may also like: Normal Delivery Tips: An Expecting Mother's Guide to a Smooth Childbirth Experience

How to achieve cephalic presentation in pregnancy?

While fetal positioning is largely influenced by genetic and environmental factors, there are strategies to encourage head-first fetal position:

1. Regular Exercise

Engaging in exercises such as pelvic tilts and knee-chest exercises may help promote optimal fetal positioning.

2. Correct Posture

Maintaining good posture, particularly during the third trimester , can influence fetal positioning.

3. Hands and Knees Position

Spend some time on your hands and knees. This position may help the baby settle into the pelvis with the head down.

4. Forward-leaning Inversion

Under the guidance of a qualified professional, some women try forward-leaning inversions to encourage the baby to move into a head-down position. This involves positioning the body with the hips higher than the head.

5. Prenatal Yoga

Prenatal yoga focuses on strengthening the pelvic floor and promoting flexibility, potentially aiding in cephalic presentation.

6. Professional Guidance

Seeking guidance from a healthcare provider or a certified doula can provide personalized advice tailored to individual needs.

1. Cephalic presentation is good or bad?

Cephalic position is generally considered good as it aligns with the natural process of childbirth. It reduces the likelihood of complications and increases the chances of a successful vaginal delivery . However, it's essential to note that the overall health of both the mother and baby determines its appropriateness.

2. How to increase the chances of normal delivery in cephalic presentation?

Increasing the chances of normal delivery in cephalic presentation involves adopting healthy practices during pregnancy, such as maintaining good posture, engaging in appropriate exercises, and seeking professional guidance. However, individual circumstances vary, and consultation with a healthcare provider is paramount.

Final Thoughts

Navigating the journey of pregnancy involves understanding various aspects, and cephalic presentation plays a crucial role in determining the birthing experience. The benefits of a head-first position, coupled with strategies to encourage it, empower expectant mothers to actively participate in promoting optimal fetal positioning. As always, consulting with healthcare professionals ensures personalized care and guidance, fostering a positive and informed approach towards childbirth.

1. Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. (2023). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing

2. Boos R, Hendrik HJ, Schmidt W. (1987). Das fetale Lageverhalten in der zweiten Schwangerschaftshälfte bei Geburten aus Beckenendlage und Schädellage [Behavior of fetal position in the 2d half of pregnancy in labor with breech and vertex presentations]. Geburtshilfe Frauenheilkd

Anupama Chadha

Anupama Chadha, born and raised in Delhi is a content writer who has written extensively for industries such as HR, Healthcare, Finance, Retail and Tech.

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Why Is Cephalic Presentation Ideal For Childbirth?

5   Dec   2017 | 8 min Read

During labour, contractions stretch your birth canal so that your baby has adequate room to come through during birth. The cephalic presentation is the safest and easiest way for your baby to pass through the birth canal.

If your baby is in a non-cephalic position, delivery can become more challenging. Different fetal positions pose a range of difficulties and varying risks and may not be considered ideal birthing positions.

Two Kinds of Cephalic Positions

There are two kinds of cephalic positions:

• Cephalic occiput anterior , where your baby’s head is down and is facing toward your back.
• Cephalic occiput posterior , where your baby is positioned head down, but they are facing your abdomen instead of your back. This position is also nicknamed ‘sunny-side-up’ and can increase the chances of prolonged and painful delivery. 

How to Know if Your Baby is In a Cephalic Position?

You can feel your baby’s position by rubbing your hand on your belly. If you feel your little one’s stomach in the upper stomach, then your baby is in a cephalic position. But if you feel their kicks in the lower stomach, then it could mean that your baby is in a breech position.

You can also determine whether your baby is in the anterior or posterior cephalic position. If your baby is in the anterior position, you may feel their movement underneath your ribs and your belly button could also pop out. If your baby is in the posterior position, then you may feel their kicks in their abdomen, and your stomach may appear rounded up instead of flat. 

You can also determine your baby’s position through an ultrasound scan or a physical examination at your healthcare provider’s office. 

Benefits of Cephalic Presentation in Pregnancy

Cephalic presentation is one of the most ideal birth positions, and has the following benefits:

• It is the safest way to give birth as your baby’s position is head-down and prevents the risk of any injuries.
• It can help your baby move through the delivery canal as safely and easily as possible.
• It increases the chances of smooth labour and delivery.

Are There Any Risks Involved in Cephalic Position?

Conditions like a cephalic posterior position in addition to a narrow pelvis of the mother can increase the risk of pregnancy complications during delivery. Some babies in the head-first cephalic presentation might have their heads tilted backward. This may, in some rare cases, cause preterm delivery.

What are the Risks Associated with Other Birth Positions?

A small percentage of babies may settle into a non-cephalic position before their birth. This can pose risks to both your and your baby’s health, and also influence the way in which you deliver. 

In the next section, we have discussed a few positions that your baby can settle in throughout pregnancy, as they move around the uterus. But as they grow old, there will be less space for them to tumble around, and they will settle into their final position. This is when non-cephalic positions can pose a risk.  

Breech Position

There are three types of breech fetal positioning:

• Frank breech : Your baby’s legs stick straight up along with their feet near their head.
• Footling breech: One or both of your baby’s legs are lowered over your cervix.
• Complete breech: Your baby is positioned bottom-first with their knees bent.

If your baby is in a breech position , vaginal delivery is considered complicated. When a baby is born in breech position, the largest part of their body, that is, their head is delivered last. This can lead to injury or even fetal distress. Moreover, the umbilical cord may also get damaged or get wrapped around your baby’s neck, cutting off their oxygen supply.  

If your baby is in a breech position, your healthcare provider may recommend a c-section, or they may try ways to flip your baby’s position in a cephalic presentation.

Transverse Lie

In this position, your baby settles in sideways across the uterus rather than being in a vertical position. They may be:

• Head-down, with their back facing the birth canal
• One shoulder pointing toward the birth canal
• Up with their hands and feet facing the birth canal

If your baby settles in this position, then your healthcare provider may suggest a c-section to reduce the risk of distress in your baby and other pregnancy complications.

Turning Your Baby Into A Cephalic Position

External cephalic version (ECV) is a common, and non-invasive procedure that helps turn your baby into a cephalic position while they are in the womb. However, your healthcare provider may only consider this procedure if they consider you have a stable health condition in the last trimester, and if your baby hasn’t changed their position by the 36th week.

You can also try some natural remedies to change your baby’s position, such as:

• Lying in a bridge position: Movements like bridge position can sometimes help move your baby into a more suitable position. Lie on your back with your feet flat on the ground and your legs bent. Raise your pelvis and hips into a bridge position and hold for 5-10 minutes. Repeat several times daily.
• Chiropractic care: A chiropractor can help with the adjustment of your baby’s position and also reduce stress in them.
• Acupuncture: After your doctor’s go-ahead, you can also consider acupuncture to get your baby to settle into an ideal birthing position.

While most babies settle in a cephalic presentation by the 36th week of pregnancy, some may lie in a breech or transverse position before birth. Since the cephalic position is considered the safest, your doctor may recommend certain procedures to flip your baby’s position to make your labour and delivery smooth. You may also try the natural methods that we discussed above to get your baby into a safe birthing position and prevent risks or other pregnancy complications. 

When Should A Baby Be In A Cephalic Position?

Your baby would likely naturally drop into a cephalic position between weeks 37 to 40 of your pregnancy .

Is Cephalic Position Safe?

Research shows that 95% of babies take the cephalic position a few weeks or days before their due date. It is considered to be the safest position. It ensures a smooth birthing process.

While most of the babies are in cephalic position at delivery, this is not always the case. If you have a breech baby, you can discuss the available options for delivery with your doctor.

Does cephalic presentation mean labour is near?

Head-down is the ideal position for your baby within your uterus during birth. This is known as the cephalic position. This posture allows your baby to pass through the delivery canal more easily and safely.

Can babies change from cephalic to breech?

The external cephalic version (ECV) is the most frequent procedure used for turning a breech infant.

How can I keep my baby in a cephalic position?

While your baby naturally gets into this position, you can try some exercises to ensure that they settle in cephalic presentation. Exercises such as breech tilt, forward-leaning position (spinning babies program), cat and camel pose can help.

Stitches after a normal delivery : How many stitches do you need after a vaginal delivery? Tap this post to know.

Vaginal birth after caesarean delivery : Learn all about the precautions to consider before having a vaginal delivery after a c-section procedure. 

How many c-sections can you have : Tap this post to know the total number of c-sections that you can safely have.

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• v.6(Suppl 2); 2020 Jul

Clinical Tips of Cesarean Section in Case of Breech, Transverse Presentation, and Incarcerated Uterus

1 Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Tokyo, Japan

Gen Ishikawa

2 Department of Obstetrics and Gynecology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan

Satoru Takeda

Cesarean section in breech or transverse presentation involves more complicated procedures than cesarean section in cephalic presentation because the former requires additional manipulations for guiding the presenting part of the fetus, liberation of the arms, and the after-coming head delivery; therefore, those cesarean sections are likely to be more invasive. Making a rather wide uterine incision to prevent uterine injury during delivery of the fetus facilitates smooth delivery of the fetus. Furthermore, in cases of breech or transverse presentation, it is important to initially identify the presenting part of the fetus and guide it to the incision opening in the lower uterine segment, because delivering the presenting part of the fetus first is a basic rule of delivery of the fetus. Smooth delivery of the fetus by means of breech extraction can prevent excessive stress or injury to the fetus. Therefore, it is important to acquire the knowledge and skills necessary to perform these techniques, including the internal version. Smooth delivery of the fetus is also less invasive for the mother because an extension of the uterine excision or injury to arteries and veins in the uterus and parametrium can be avoided. Incarcerated uterus occurring in cases of pregnancy with intrapelvic adhesion, endometriosis, cervical myoma, or extended cervix may result in excessive uterine and cervical injury when a transverse incision of the lower uterine segment is performed without caution. These conditions may result in difficulty in fetal delivery. Therefore, it is important to identify risks in advance and to choose the incision line with great care. Countermeasures for difficult delivery of the fetus need to be mastered by all practitioners of obstetrics. If the transverse incision fails to reach the uterine cavity, an inverted T-shaped or J-shaped incision should be made. Risks of complications such as injury to the cervical canal, the vagina, the bladder or ureter, and massive hemorrhage must be kept in mind.

Cesarean Section in Case of Breech or Transverse Presentation

Preoperative evaluation.

The presentation, position, and attitude of the fetus should be confirmed by transabdominal ultrasonography on admission and at departure from the ward for cesarean section. It is important to have images of the course of the surgery and delivery of the fetus by confirming the fetal position, location of the placenta and umbilical cord, and volume of amniotic fluid. The operation should be performed by imaging the descent, presentation, position, and attitude of the fetus through external examination according to Leopold's maneuver before laparotomy. Such imaging facilitates learning of the cesarean section techniques and obstetric management in the long run.

We basically use a transverse incision or a subumbilical longitudinal midline incision technique for skin incision. However, in cases of transverse or oblique presentation, a longitudinal incision is recommended by considering the possible extension of the incision wound. When performing a transverse incision, the Pfannenstiel incision is used as a rule, and the site of incision should be 3 to 5 cm above the pubic bone. It is important to secure the field of view; an incision at a higher site may cause difficulty in delivery of the fetus or may exacerbate uterine injury. If a higher incision site is required, caution should be exercised to secure the field of view for an incision of the rectus abdominis muscle, according to the original Maylard incision. In cases with a history of cesarean section or laparotomy or those with obesity, a sufficient field of view may be difficult to obtain; the selection and length of the skin incision line can affect the subsequent course of the operation.

Explanation of Procedures

Before the surgical procedure is initiated, the surgeon studies the images of the course of the operation and delivery of the fetus based on the findings obtained by ultrasonography in the ward or by external examination prior to the incision. The gravid uterus is not bilaterally symmetrical. In particular, the midline is difficult to find when left uterine displacement has been provided for preventing supine hypotensive syndrome or when the operating table is tilted ( Fig. 1 ). 3 When performing fasciotomy and peritoneotomy, caution should be exercised to avoid tearing of the abundant subfascial vessels. Before incision of the uterus wall, the position of presentation, leg position, and location and descent of the presenting part of the fetus should be confirmed by palpation from the serous surface of the uterus. Then, the uterine rotation status should be confirmed, and the incision line decided. This is useful for avoiding injury to the fetus and allows us to quickly reach the uterine cavity.

Selection of the skin incision line. In cases of cesarean section, it is common to perform left uterine displacement by placing a pillow under the right side of the waist or by tilting the operating table immediately after inducing spinal subarachnoid anesthesia, aiming at preventing the occurrence of supine hypotensive syndrome. Because the surgical field is subsequently disinfected and the patient is draped, the midline becomes more difficult to identify. In addition, the abdominal skin is not bilaterally equal or symmetrical, depending on the position of presentation, fetal attitude, and rotation of the uterus. Therefore, the location of the skin incision line should be decided promptly but with care. (Reproduced with permission from Ishikawa G. Cesarean section for breech, transverse presentation and incarcerated uterus. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.3. Cesarean section. (Japanese). Tokyo: Medical View; 2010: 72–81. Copyright © Medical View).

Incision of the Lower Uterine Segment

To facilitate delivery of the fetus, the presenting part of the fetus should be touched from the serosal side of the uterus and manually elevated toward the maternal head. Then, the loose vesicouterine serosa is grasped with tweezers and incised transversely with scissors. The bladder is gently dissected from the underlying lower uterine segment. After this bladder separation, a transverse incision should be made in the lower uterine segment, in the same manner as in a cesarean section for a cephalic presentation ( Fig. 2 ). 3 The incision made with a surgical knife to reach the uterine cavity can be extended manually or sharply with Cooper scissors ( Fig. 3 ). 3 In either case, it is necessary to take care to avoid injury to the uterine artery and vein that lie on the extension line of the incision. Surgical techniques performed without due caution may cause additional injuries while guiding the fetus, liberating the arms, or after-coming head delivery in breech presentation, leading to major bleeding.

Transverse incision in the lower uterine segment. While holding the lower uterine segment with two fingers of the left hand, the operator incises the lower segment with a round-edged knife to prevent bleeding and identify the location. The assistant aids in securing the field of view with the left hand and supports the wound surface with Pean forceps to facilitate a prompt incision. (Reproduced with permission from Ishikawa G. Cesarean section for breech, transverse presentation and incarcerated uterus. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.3. Cesarean section. (Japanese). Tokyo: Medical View; 2010: 72–81. Copyright © Medical View).

Extension of the transverse incision in the lower uterine segment. In our institution, it is common to extend the uterine incision manually by “smiling up” the lateral apices. In cases of malpresentation, such as breech presentation at the cesarean section, Cooper scissors may be used, considering the possibility that subsequent delivery of the fetus might extend or injure the incision. The incision in the uterus is extended with Cooper scissors. Guiding with two fingers of the left hand, the lateral apices of the incision are cut in an arc shape toward the uterine fundus to make the “smiling up” incision. (Reproduced with permission from Ishikawa G. Cesarean section for breech, transverse presentation and incarcerated uterus. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.3. Cesarean section. (Japanese). Tokyo: Medical View; 2010: 72–81. Copyright © Medical View).

In a transverse or oblique presentation, smooth delivery of the fetus may be achieved by transverse incision of the uterine body based on the fetal presentation, as carefully determined in advance. The operator preoccupied with the lower uterine segment may make an incision in a narrow lower uterine segment, thereby possibly inducing injury at the incision site while guiding the fetus manually. Incising the lower segment is advantageous, considering the concerns of repeated cesarean section in the future and protection of the wound by suture and repair after incision of the peritoneal reflection of the vesicouterine pouch. However, a transverse incision of the uterine body might be more advantageous with regard to the patency of the guiding path for the fetus. A J-shaped or U-shaped incision may be superior on the assumption that the fetus in oblique or transverse presentation will be delivered without rotation ( Fig. 4 ). 1 4 However, if an incision is made at a high position without considering the positional relationship between the fetus and uterus, it may be difficult to guide the fetal buttocks located at a lower position to the incised opening.

Extension of the uterine incision. A slightly wider incision is made into the myometrium. For a difficult delivery, the incision is preferably extended upward to a J-shape ( A ) or U-shape ( B ) or an inverted T-shape ( C ). If a transverse incision does not reach the uterine cavity such as uterine incarceration, the incision should be extended upward to make a J shape or be extended into an inverted T shape. (Reproduced with permission from Takeda S. Important point of emergency cesarean section. In: Takeda S, Makino S, Takeda J, eds. Management of Breech Delivery and Shoulder Dystocia. (Japanese). Tokyo: Medical View;2019:106–110. Copyright © Takeda S).

Delivery of the Fetus

The presenting part of the fetus should be identified by finding the fetus from the incision in the uterus. In cases of footling presentation, the operator should hold the legs and proceed to the subsequent guiding process. Because holding the legs and subsequent guiding and extraction place a burden on the joints of the lower limbs (ankle, knee, and hip joints) of the fetus, it is recommended that both hips be held if possible. In cases of complete or frank breech presentation, both hips (iliac crest to inguinal region) should be held. In cases of fetal presentation in which the fetal back is facing the maternal back (sacrum posterior positions: sacrum posterior, left sacrum posterior, and right sacrum posterior), the fetal back should be guided to rotate around the long axis of the fetal body toward the maternal ventral side, to allow the spinal column in the fetal back to move toward the anterior portion of the maternal body (sacrum anterior position). This corresponds to the position of presentation at the end of the second rotation during vaginal delivery in breech presentation. This maneuver is advantageous in that it facilitates liberation of the arms and delivery of the fetal head following delivery of the fetal legs and trunk. Furthermore, this maneuver allows the passage of the fetus to more appropriately correspond to the incisional opening of the uterus.

In case of transverse or oblique presentation, since the presenting part is not often palpable, the operator probes the foot to grasp and deliver the infant. To touch the foot, the operator rotates the fetus, using fingers inserted through the vagina and placed on the external uterine wall. If the foot is palpable, the operator should grasp the ankle ( Fig. 5 ). 1 Grasping of the lower legs or thighs may cause fractures. If the foot is difficult to find, extending the incision of the myometrium in the direction where the foot may be located would facilitate grasping of the foot for performing the internal version. If the delivery is difficult, one should not hesitate to extend the incision to a J- or U-shape, or an inverted T-shape to facilitate the delivery ( Fig. 4 ). 1 4 There is a question as to whether the fetal head or the buttocks should be guided as the presenting part. Because the hips and legs of the fetus are easier to hold and guide than the fetal head, the buttocks are guided as the presenting part in principle. However, there is no concern as to setting the fetal head as the presenting part if smooth manipulation is secured. In this case, delivery of the fetus is in accordance with a cesarean section in cephalic presentation.

Internal version technique by grasping of the fetal feet. The operator grasps the fetal ankle over the medial and lateral malleoli with three fingers (thumb, index, and middle fingers), pulling toward the incision. Simultaneously, the operator leads the fetal buttocks to the incision, placing the hand on the external uterine wall. 1 (Reproduced with permission from Takeda S. Important point of emergency cesarean section. In: Takeda S, Makino S, Takeda J, eds. Management of Breech Delivery and Shoulder Dystocia. (Japanese). Tokyo: Medical View;2019:106–110. Copyright © Takeda S).

The presenting part should be guided to the incision opening of the uterus and extracted toward the maternal feet while holding both fetal hips securely. The goal is to keep the fetus horizontal while extracting the fetus until the upper back (inferior scapular angle) of the fetus is delivered ( Fig. 6 ). 3

Delivery of the fetus. The presenting part of the fetus is extracted while holding both fetal hips securely. If the fetus is deflected or elevated upward with excessive consideration of the subsequent delivery of the fetal head, it increases the risk of injuries at the incision, such as extension of the uterine incision. (Reproduced with permission from Ishikawa G. Cesarean section for breech, transverse presentation and incarcerated uterus. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.3. Cesarean section. (Japanese). Tokyo: Medical View; 2010: 72–81. Copyright © Medical View).

In cases of footling presentation, the fetus is initially guided and extracted while holding both legs, and then the hip (iliac crest to inguinal region), of the fetus. However, in cases of breech presentation, the hip of the fetus is held basically from the beginning. In cases of complete breech presentation, the operator may be tempted to guide the fetal legs first, but caution is necessary because there is concern that the uterine incision might be damaged because of the process by which the fetal legs bent at the hip and knee joints extend during passage through the incisional opening. If the fetus is guided while holding the hips after elevating the lowest part of the fetus toward the maternal head, a frank breech presentation in the uterus may be obtained, leading to smooth delivery of the trunk.

After delivering the fetus horizontally toward the maternal feet until the inferior scapular angle emerges, the operator should proceed to deliver the fetus in the manner of the Bracht maneuver for vaginal delivery in breech presentation ( Figs. 6 , ​ ,7 7 ). 3 Namely, the fetal trunk should be elevated and dorsiflexed ( Fig. 7A ), 3 and then rotated toward the maternal ventral side in an arc with the uterine incision serving as the fulcrum ( Fig. 7B ). 3

Delivery of the arms and the after-coming head using the Bracht maneuver. After extracting the trunk horizontally ( Fig. 6 ), the operator should proceed to liberation of the arms and delivery of the fetal head in the manner of the Bracht maneuver ( A, B ). The operator should try to achieve smooth delivery without interruption following delivery of the trunk. Whenever liberation of the arms is performed using the classic technique, with delivery of the fetal head according to the Mauriceau maneuver, these manipulations should be conducted smoothly at a constant pace and in a consistent manner with flexibility, as needed, to adapt to circumstances. (Reproduced with permission from Ishikawa G. Cesarean section for breech, transverse presentation and incarcerated uterus. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.3. Cesarean section. (Japanese). Tokyo: Medical View; 2010: 72–81. Copyright © Medical View).

When the arms are not brought down by the Bracht maneuver during delivery of the fetus, the procedures of liberation of the arms and delivery of the after-coming head should be performed. In cases of difficult delivery, the arms should be liberated in the manner of the classic method of liberating the arms. More specifically, while the fetal trunk is elevated anteriorly to the maternal body, the arm emerging on the maternal feet side of the uterine incision opening should be liberated with the index finger hooked in the fetal elbow joint. After both arms are liberated in this manner, the fetus should be kept dorsiflexed and elevated anteriorly to the maternal body; the after-coming head is subsequently delivered ( Fig. 7B ). 3 In cases of vaginal delivery in breech presentation, the fetal back is rotated laterally to the maternal body, and the arms located posteriorly are liberated in the first and second breech presentations. In cases of cesarean section, uniaxial rotation of the fetus should not be performed by exerting force. This is because the uterine incision wound extends in the horizontal direction of the maternal body, and the mode of spread of the birth canal is different from that in vaginal delivery in breech presentation. The key to successful liberation of the arms is to guide the arm to be liberated in the manner of wiping the forehead of the fetus with the palmar side of the arm. If the arm is initially guided without due caution in the downward direction, the uterine incision may be damaged by the fetal elbow, the fetal upper arm may be injured as fracture, or an excessive burden may be imposed on joints of the fetus. Although successful liberation of the arms usually leads to delivery of the after-coming head without difficulty, delivery of the fetal head is assisted by the Mauriceau or Veit-Smellie maneuver. The fetal trunk is already dorsiflexed and elevated anteriorly to the maternal body by the Bracht maneuver, showing the occipital protuberance of the fetal head. Therefore, it is not necessary to perform extraction posteroinferiorly to the maternal body according to the Mauriceau maneuver during vaginal delivery in breech presentation.

When the head is entrapped, the incision should be extended to a J-shape to deliver the infant. If time permits, administration of nitroglycerin can release the myometrial tone to enable a smooth delivery. In cases of cesarean delivery of preterm infants and those with a sufficient descent of the head or breech presentation, the anesthesiologists should be alerted beforehand to prepare nitroglycerin.

After removal of the placenta, the cervical os should be observed. If the cervical os is closed, it should be dilated during or after the operation to allow the lochia to flow outward. The uterine cavity should be bluntly removed using gauze to eliminate retained membranes.

Closure of the Abdomen

The uterine incision wound should be closed by suture using 0-synthetic absorbable suture, such as Vicryl or Monocryl. The interrupted suture or Z-suture on the bilateral cut end should be performed for ligation of thick branches of the uterine artery and prevention of dead space or hematoma. The uterine incision is closed basically with two layers. The first layer is sutured by employing interrupted sutures such that both endometrial layers meet precisely. Continuous sutures on the inner side of the uterine wall are not employed because a history of continuous sutures on the inner side of the uterine wall might influence the development of placenta accreta in patients with prior cesarean section. 5 The second layers may be sutured by employing a continuous interlocking suture or interrupted sutures.

There is no need for suturing the serosa on the vesicouterine pouch to prevent elevation and adhesion of the bladder, covering over the uterine wound. Douglas pouch, both sides of the peritoneal cavity, and the vesicouterine pouch should be examined to determine the hemostasis state and presence/absence of any abnormalities. The uterine adnexa should also be checked for any lesions or abnormalities.

The peritoneal cavity is sufficiently irrigated with 2000 to 3000 mL of physiological saline. A continuous closed suction drain is inserted into the Douglas pouch, if needed.

Absorbable adhesion barrier, such as Seprafilm, is applied to the wounds on the uterus and abdominal wall to prevent development of subsequent adhesion. The serosa, fascia, subcutaneous tissue, and epidermis are sutured to close the wound. The patency of the uterine os and outflow of lochia are confirmed by speculum and pelvic examinations. Then, the position of the uterine fundus and propriety of uterine contractions are confirmed to complete the operation.

Cesarean Section in Case of Incarcerated Uterus or the Cervical Elongation

Preoperative preparation.

In cases of cesarean section for an incarcerated uterus, the success of the operation depends on whether cervical elongation and retroverted uterus can be detected preoperatively and whether the cesarean section procedure is smooth and minimally invasive to the maternal body. Incarceration of the uterus may not be recognized in early pregnancy. However, when extreme anterior-upward displacement of the cervix of the uterus or globular tumorous sensation in the posterior vaginal fornix is found by vaginal examination on admission for cesarean section or preoperative examination before departure from the hospital ward, the uterine cervix located anterosuperior to the bladder should be further examined by transabdominal ultrasonography to determine whether there is either elongation of the cervix or incarceration of the uterus. The height of the lower uterine segment and site of the uterine cavity should be examined by ultrasonography to decide the cutting level of the uterus before the operation.

If a diagnosis of the incarcerated uterus was made at term, elective cesarean section should be performed with special attention. When a cesarean section is performed without the recognition of an incarcerated uterus, it might be difficult to deliver the fetus because it will not reach the uterine cavity and consequently result in fetal asphyxia. Several complications such as complete cutting of the cervix or the vagina, extended uterine incision, incision on the posterior wall of the uterus through the vagina, or laceration due to massive hemorrhage may occur, because the lower uterine segment is dislocated extremely to the upper site compared with that in an ordinary cesarean section. 3 4 6 Therefore, a strategy for a safe cesarean section to avoid special complications of incarceration should be developed.

The incarcerated gravid uterus is recognized as being in a state of uterine retroflexion by pelvic examination or transvaginal ultrasonography in early pregnancy. As gestational weeks increase, the degree of retroflexion increases, resulting in embedding of the uterine fundus in the Douglas' pouch at the end of pregnancy ( Fig. 8 ). 4 When there is elongation and elevation of the cervix due to cervical myoma in the posterior wall of the uterus or myoma in the lower uterine segment, cervical findings are similar to those in cases with an incarcerated gravid uterus ( Fig. 9 ). 4

Incarcerated uterus. Pelvic examination readily leads to a diagnosis of incarcerated gravid uterus because this examination yields characteristic findings. However, it is likely to be overlooked on ultrasonography alone. Because the cervix and uterine wall are thin at the end of pregnancy, it is difficult to diagnose retroflexion and incarceration of the uterus. The placenta attached to the posterior wall can be misdiagnosed as low-lying placenta or placenta previa. (Reproduced with permission from Takeda S. Cesarean section for incarcerated uterus and elongation of the uterine cervix. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.10. Massive Obstetric Hemorrhage: Critical Care for Intractable Bleeding and Definite Strategies of Hemostasis. (Japanese). Tokyo: Medical View; 2012: 154–159. Copyright © Medical View).

Cervical elongation due to a myoma in the cervix. ( A ) In cases with cervical myoma in the posterior wall of the uterus or myoma in the lower uterine segment, the cervix is elongated. Therefore, myometrial incision at the usual level fails to reach the uterine cavity. In particular, in the case of performing a Pfannenstiel transverse incision, upward deviation of the lower uterine segment may be overlooked because the field of view in the peritoneal cavity is limited. Therefore, a transverse incision in the myometrium at the usual site fails to reach the amniotic cavity and the cervix is cut instead. ( B ) Incision at the usual site will result in cutting the cervix cross-sectionally or cutting into myoma in the posterior wall. (Reproduced with permission from Takeda S. Cesarean section for incarcerated uterus and elongation of the uterine cervix. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.10. Massive Obstetric Hemorrhage: Critical Care for Intractable Bleeding and Definite Strategies of Hemostasis. (Japanese). Tokyo: Medical View; 2012: 154–159. Copyright © Medical View).

There are characteristic pelvic examination findings; the uterovaginal region is deviated anteriorly and superiorly to the pubis to an extreme degree. The protruded uterus and myoma are palpable in the Douglas' pouch. Colposcopy may fail to identify the uterovaginal region because it is deviated superiorly. It is common for the uterine fundus to be lower according to the gestational week, causing elongation of the bladder.

If the incarcerated gravid uterus is not recognized until the end of pregnancy, pelvic examination may raise suspicion because the uterovaginal region is deviated anteriorly and superiorly to an extreme degree, although the cervix is difficult to identify on transabdominal ultrasonography. 7

On ultrasonography, the cervix is deviated anteriorly and superiorly, and the bladder appears to be suspended upward. 7 If incarcerated gravid uterus is suspected, magnetic resonance imaging can provide a definitive diagnosis based on the locations of the vagina, cervix, and bladder in the sagittal view. 8 It is important to determine the level of the skin incision and the site of the uterine incision wound in advance, by confirming the level of entry into the uterine cavity by ultrasonography prior to implementation of cesarean section. 3 4 Intraoperative ultrasonography is also useful.

Cesarean section for an incarcerated uterus is basically the same as a routine cesarean section. However, to facilitate subsequent surgical manipulations, a longer than usual incision should be made to provide a large field of view. A subumbilical longitudinal midline skin incision is preferred because of a wider field of view. The possibility that the incision is cut upward to the navel during the operation should be assumed.

When the cervix is elongated because of myoma, the positional relationships between the myoma, the cervix, the uterine body, and the round ligament of the uterus, and the bladder need to be confirmed. The bladder may be located extremely low but can also be elevated. The bladder should be palpated directly, and the urethral catheter be confirmed. If the bladder is extremely elevated, the upper end must be confirmed and separated.

Uterine Incision

As for incision in the myometrium, the peritoneal reflection of the vesicouterine pouch cannot be the target, as would routinely be the case, and the boundary between the uterine body and isthmus is ambiguous. Therefore, we can rely only on preoperative ultrasonographic findings in such cases.

The location of the uterine cavity should be confirmed by intraoperative ultrasonography, whenever possible. Because the vaginal wall and cervical canal in the final stages of pregnancy are thin, it may not be possible to confirm the location of the internal cervical os. It is also important to make sure of the distance to the uterine cavity. There is no need to strictly adhere to the use of deep transverse incision. If the cervix and the lower uterine segment are not distinguishable, longitudinal uterine incision is also a reasonable choice. Depending on the length of the elongated cervix, a longitudinal or transverse incision is made in the muscular layer near the umbilical region. When a transverse incision does not reach the amniotic cavity, the incision should be extended upward in the direction toward the uterine body in the manner of an inverted T-shaped or J-shaped incision.

In cases of cephalic presentation, cephalic delivery should be performed by employing a mild Kristeller maneuver via the incision opening of the uterus. In cases of breech presentation, the trunk should be delivered according to the cesarean section in breech presentation procedure, followed by liberation of the arms and delivery of the fetal head. These procedures are the same as those in cesarean section in breech or transverse presentation, but the patency of the uterine os is more difficult to confirm.

The myometrium should be sutured by placing simple interrupted sutures with absorbable thread. The second layer of suturing is performed for reinforcement. When an inverted T-shaped incision is made, the intersecting point should be joined firmly by Z or equivalent sutures. Suture and ligation should be carefully performed to obtain accurate matching of the layered planes to avoid piercing penetration of the myometrium. These procedures are the same as in those for cesarean section in breech or transverse presentation.

Postoperative Management

When there is a cervical myoma ( Fig. 9 ), 4 outflow of lochia from the cervical canal may be inhibited by the myoma. Therefore, frequent and meticulous follow-up observations for retention of lochia are necessary. Although incarcerated uterus may undergo reduction spontaneously after cesarean section, a careful follow-up is also necessary because there is concern about retention of lochia when there are no distinct changes in cervical elongation or incarceration status.

Complications

Repair of the cut cervical canal, control of bleeding.

If there is bleeding or difficulty in delivering the fetus, it is important to secure the field of view. If the skin incision is narrow, and the field of view is insufficient, the incision should be extended. When the Pfannenstiel transverse incision is performed, the rectus abdominis muscle may be cut unilaterally or bilaterally (Maylard method), or the rectus abdominis fascia can be cut in a T shape toward the pubis or separated and cut in an inverted T shape. Alternatively, both of these procedures may be performed to secure the field of view.

After delivery of the fetus, it is difficult to move the uterus outside the body because of adhesions to the Douglas pouch, which makes suturing difficult. The bleeding point should be clamped with serrated forceps, and the positional relationships between the cesarean section wound, vagina, cervix, body of the uterus, and surrounding organs including the bladder, ureter, uterine artery and vein, and the cardinal ligament need to be ascertained and well understood. Bleeding from the paravaginal tissue and cardinal ligament is an important issue. If the bladder is located low or separated sufficiently, injury to the bladder and ureter is avoidable.

Suture and Hemostasis of the Cervical Canal

If the lumen of the cervical canal is obscure, orientation can be obtained by insertion of the fingers or forceps from the vagina or by insertion of a urethral balloon catheter into the cervical canal. Even when the cervical canal is cut cross-sectionally, a catheter should be passed through it, and the upper and lower cut ends can then be sutured by simple interrupted suture with 2–0 or 1–0 absorbable thread. Attention should be paid to possible rupturing of the suture after repair, and it should thus be ensured that a drain is inserted in the vicinity of the sutured portion.

Injuries of the Bladder and the Ureter

If abdominal closure is performed without recognizing the presence of injury to the bladder or ureter, an echo free space will appear in the peritoneal cavity alongside an increase in blood urea nitrogen and creatinine within a few days. Patients may complain of mild symptoms such as a vague feeling of discomfort and lassitude, or may sometimes be minimally symptomatic. There may also be leukocytosis and a slight increase in C-reactive protein. Caution should be exercised regarding massive transfusion-related hyperpotassemia, hepatic dysfunction, hemolytic reaction, etc.

Conflict of Interest None.

Tips and Warnings

Characteristics of Emergency Cesarean Sections in Breech Delivery

Emergency cesarean sections that have been switched from vaginal breech delivery involve the following specific characteristics: in most cases, the indication is non-reassuring fetal status caused by a sudden and rapid onset of cord compression due to a forelying or prolapsed cord; the baby must be delivered as quickly as possible; and it may be associated with rupture of the membranes and/or thin myometrium caused by effacement and elongation of the uterine isthmus because of progression in the descent of the presenting part ( Table 1 ). 1 Thus, caution should be exercised during an incision of the myometrium because the fetus can be injured. To deliver the fetus, the operator grasps the fetal buttocks, hooking his/her index finger on the fetal bilateral groins, and pulls the fetal body gently, similar to the usual breech extraction maneuver. The femoral region must never be pulled with a finger over it. This can result in fetal femur fractures, which have been reported after cesarean breech delivery.

Obstetricians should understand and learn such characteristics of and strategies for cesarean delivery for breech presentation and establish a system to conduct an emergency cesarean section at any given time. For this purpose, obstetricians should consult with each other and form a multidisciplinary team that includes anesthesiologists, pediatricians, midwives, nurses, and paramedical staff to share information, cooperate immediately and closely, and receive simulation training. 1 2

Management of a Case with Cord Prolapse or Non-Reassuring Fetal Heart Rate Patterns

In cases of sudden onset of persistent fetal bradycardia and/or cord prolapse, vaginal examination should be performed to identify the causes and position of the cord. To relieve cord compression, the fetal presenting part should be elevated and tocolysis with nitroglycerin or ritodrine hydrochloride should be considered before transfer to the operating room. In most cases, the fetal heart rate is restored. Elevation of the presenting part using fingers through the vagina should be continued until delivery of the fetus. 1

Finally, the incision sizes of the skin and fascia should be confirmed at this point before a transverse incision is made on the lower uterine segment. An incision that is too small and excessive tension of the fascia and rectus abdominis muscle may cause difficulty during the delivery of the fetus. Therefore, the incision should be extended at this point, if necessary. After making a transverse incision of the lower uterine segment, the operation usually proceeds expeditiously enough that no modifications can be made.

A cesarean section in breech presentation involves more complicated procedures than a cesarean section in cephalic presentation because the former requires additional manipulations for guiding the presenting part of the fetus, liberation of the arms, and the after-coming head delivery. Therefore, a cesarean section in breech presentation is likely to be more invasive. Making a rather wide uterine incision to prevent uterine injury during the delivery of a fetus facilitates smooth delivery of the fetus. At this point, it is important to “smile up” the lateral apices of the incision in an arc shape toward the uterine fundus.

A “smile up” rather than a straight-line, incision is commonly used.

For identifying the lowest presenting part of the fetus, four fingers (index to little fingers) of one hand (on the maternal caudal side) of the operator, in principle, are initially used. Later, the fetus should be held mainly with two or three fingers, that is, the index finger, (middle finger) and thumb, of both hands. There is concern that careless holding with five fingers may result in extension of the uterine incision and injury to the uterine artery and vein. When the operator is not skilled enough in performing cesarean section in breech presentation or when a sufficient abdominal incision or uterine incision is lacking (such as in patients with a history of surgery or obesity), the operator is apt to apply excessive force when attempting to hold the fetus. It is useful to place gauze between the holding fingers and fetus to prevent slippage. This allows the fetus to be held more firmly and facilitates smooth delivery of the fetus. If the presenting part descends deeply, the assistant manually elevates the presenting part through the vagina and then the operator attempts to deliver the infant.

In cases of transverse or oblique presentation, the operator's hand tends to be inserted deeply into the uterus. Therefore, more attention is needed to avoid extension of the uterine incision or injury to the uterine artery and vein in transverse or oblique presentation than in breech presentation. Namely, careless manipulation during manual exploration and rotation of the fetus may result in extension of the uterine incision, injury to lateral blood vessels of the uterus, or laceration on the cervical side of the uterine incision. Due caution is necessary to avoid these problems.

If liberation of the arms and delivery of the after-coming head are found to be difficult, the operator should not hesitate to attempt extension of the uterine incision. It is important to extend the incision in an upward direction toward the uterine fundus as a J-shaped incision to prevent injury to the uterine artery and vein. It may also be helpful to add an incision at the center of the uterine incision toward the uterine fundus to make an inverted T-shaped incision. It is recommended that the decision to perform extension of the uterine incision or add an inverted T-shaped incision should be made in advance as the second-best procedure, which should be performed without hesitation by the operator or the first assistant in the event of a difficult delivery. Continuation of surgical manipulations, without sufficient caution, which reduces the success in liberation of the arms and delivery of the fetal head, may unnecessarily exacerbate injury to the uterine incision and result in complications. The J-shaped and inverted T-shaped incisions are methods that allow for extension of the incision, but do not cause injury to the incision. They not only facilitate delivery in difficult cases but also prevent maternal injury, thereby leading to decreased surgical stress to the maternal body and decreased blood loss.

Pathophysiology of the Incarcerated Uterus

Pregnancies complicated by myoma, endometriosis, and/or pelvic adhesion have been increasing with recent tendencies toward later marriages, increased pregnancy rates in women of advanced maternal age, and advancements in fertility treatments. Along with these trends, elongation of the uterine cervix has been attracting close attention as a reason for near-misses during cesarean section. Related near-miss cases, such as delivery of the fetus from the posterior wall of the uterus after incising the cervix and vaginal wall, failure to reach the uterine cavity during uterine myometrium incision, and massive hemorrhage, have been reported. Although uterine retroflexion before 12 gestational weeks is found at a frequency of 11 to 19% (15%), incarcerated gravid uterus is recognized in 1 out of 3,000 pregnant cases. 7 Risk factors include pelvic inflammatory disease, adhesion after gynecological surgery, endometriosis, myoma in the posterior wall of the uterus, and congenital anomalies of the uterus. 7

There are complications such as injury to the bladder or ureter, difficulty delivering the fetus, cervical incision, vaginal wall incision, and delivery of the fetus from the posterior wall of the uterus. Massive hemorrhage resulting in hysterectomy has also been reported.

Because uterine ruptures resulting from an attempt at vaginal delivery have occurred in the past, the current rule is that cesarean section should basically be selected for delivery in all cases with an incarcerated gravid uterus.

Symptoms become prominent after 13 to 17 gestational weeks, varying from none to pollakiuria, urinary retention, dysuria, incontinence, abdominal pain, suprapubic pain, low back pain, feeling of anal pressure, feeling of abdominal distension, and constipation. Symptoms may be intermittent or improve in some cases.

If the same doctor is in charge of ongoing medical check-ups of the patient from early in the pregnancy, it is relatively easy for the doctor to diagnose incarcerated gravid uterus, and cesarean section can be performed with this risk in mind. However, if multiple doctors see this patient, as in university hospitals, a problem may arise. Namely, uterine retroflexion might be missed as the uterus grows larger because of poor processes when one doctor takes over from another.

If transvaginal ultrasonography alone is used for medical check-ups of pregnant women, without performing the proper pelvic examinations, incarcerated gravid uterus may be overlooked. Placenta attached to the posterior wall of the uterus may be misdiagnosed as placenta previa or low-lying placenta.

In pregnancy with uterine myoma, cervical myoma and myoma in the lower uterine segment can cause the problem of cervical elongation. In particular, in cases with myoma in the posterior wall of the uterus, it is possible for cesarean section to be performed without due caution because there is no myoma at the site of incision in the myometrium. However, problems may arise during surgery because the cervix might be unexpectedly elongated.

It is common for the posterior wall of the uterus to be firmly adherent to the Douglas pouch in cases with an incarcerated gravid uterus, and the uterus may not be elevated outside the body cavity at the time of myometrial suture. If the wound area is elongated or the cervical canal is cut inadvertently, it is difficult to secure the field of view, and this results in difficulty with suturing. Suture during heavy bleeding and suture of the uterine wound without orientation may result in misalignment of the wound edges or failure in achieving clean closure of the wound.

In Cases of Failure to Reach the Uterine Cavity

If pregnancy progresses with the uterus in an incarcerated state, the uterine cervix becomes extended and elongated. In this case, if a uterine incision is made in the peritoneal reflection of the vesicouterine pouch, it enters the cervical canal. As a result, delivery of the fetus cannot be achieved, and the paracervical tissue or posterior wall of the uterus may be incised erroneously, leading to massive hemorrhage. The cervical canal may also be cross-sectioned. In any event, the operator may lose orientation and become disconcerted.

If the uterine cavity is not reached by incising the expected thickness of the myometrium, an inverted T-shaped or J-shaped incision should be made from the midline without hesitation, keeping this condition in mind ( Fig. 4 ). When cutting upward, the intestinal tract should be protected using a bladder spatula or intestinal spatula. If the uterine cavity is reached, the fetal membranes will bulge and may even rupture. Because the fetus is to be delivered from the lower part, rupture may occur unless a wide incision is made.

If the incision is deepened without recognizing this condition, the uterine cavity is reached from the posterior wall of the uterus. There is a report of the fetus being delivered twice via the vagina. 6 There are also cases in which the cervical canal was cut cross-sectionally without realizing that this had taken place or in which the fetus was delivered from the posterior wall of the uterus after partial incision.

Precautions to Avoid Complications of the Bladder Injury

When performing laparotomy for cesarean section, it is important to routinely confirm the location of the bladder. The trainer should make sure that the trainee understands the location of the bladder, initially by direct palpation of the organ. Even when the bladder is elevated and thereby mimics the appearance of the uterine wall, manually holding it up from the both sides allows palpation and confirmation of the bladder, preventing injury to this organ.

In cesarean section cases, it is important to routinely estimate the amount of amniotic fluid, thickness of the myometrium in the lower uterine segment, space between the lowest part of the fetus and the myometrium, etc., by palpating the lowest part of the fetus via the uterine wall prior to making an incision in the myometrium. This will provide a clue as to whether, in this condition, an incision made to the depth of the estimated thickness of the myometrium would fail to reach the uterine cavity.

Introducing Copilot+ PCs

May 20, 2024 | Yusuf Mehdi - Executive Vice President, Consumer Chief Marketing Officer

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An on-demand recording of our May 20 event is available .

Today, at a special event on our new Microsoft campus, we introduced the world to a new category of Windows PCs designed for AI, Copilot+ PCs.    

Copilot+ PCs are the fastest, most intelligent Windows PCs ever built. With powerful new silicon capable of an incredible 40+ TOPS (trillion operations per second), all – day battery life and access to the most advanced AI models, Copilot+ PCs will enable you to do things you can’t on any other PC. Easily find and remember what you have seen in your PC with Recall, generate and refine AI images in near real-time directly on the device using Cocreator, and bridge language barriers with Live Captions, translating audio from 40+ languages into English .  

These experiences come to life on a set of thin, light and beautiful devices from Microsoft Surface and our OEM partners Acer, ASUS, Dell, HP, Lenovo and Samsung, with pre-orders beginning today and availability starting on June 18. Starting at $999, Copilot+ PCs offer incredible value.  

This first wave of Copilot+ PCs is just the beginning. Over the past year, we have seen an incredible pace of innovation of AI in the cloud with Copilot allowing us to do things that we never dreamed possible. Now, we begin a new chapter with AI innovation on the device. We have completely reimagined the entirety of the PC – from silicon to the operating system, the application layer to the cloud – with AI at the center, marking the most significant change to the Windows platform in decades.  

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The fastest, most secure Windows PCs ever built  

We introduced an all-new system architecture to bring the power of the CPU, GPU, and now a new high performance Neural Processing Unit (NPU) together. Connected to and enhanced by the large language models (LLMs) running in our Azure Cloud in concert with small language models (SLMs), Copilot+ PCs can now achieve a level of performance never seen before. They are up to 20x more powerful [1] and up to 100x as efficient [2] for running AI workloads and deliver industry-leading AI acceleration. They outperform Apple’s MacBook Air 15” by up to 58% in sustained multithreaded performance [3] , all while delivering all-day battery life.  With incredible efficiency, Copilot+ PCs can deliver up to 22 hours of local video playback or 15 hours of web browsing on a single charge. [4] That is up to 20% more battery in local video playback than the MacBook Air 15”. [5]

Windows now has the best implementation of apps on the fastest chip, starting with Qualcomm. We now offer more native Arm64 experiences than ever before, including our fastest implementation of Microsoft 365 apps like Teams, PowerPoint, Outlook, Word, Excel, OneDrive and OneNote. Chrome, Spotify, Zoom, WhatsApp, Adobe Photoshop, Adobe Lightroom, Blender, Affinity Suite, DaVinci Resolve and many more now run​ natively on Arm to give you great performance with additional apps, like Slack, releasing later this year. In fact, 87% of the total app minutes people spend in apps today have native Arm versions. [6] With a powerful new emulator, Prism, your apps run great, whether native or emulated.

Every Copilot+ PC comes secured out of the box. The Microsoft Pluton Security processor will be enabled by default on all Copilot+ PCs and we have introduced a number of new features, updates and defaults to Windows 11 that make it easy for users to stay secure. And, we’ve built in personalized privacy controls to help you protect what’s important to you. You can read more about how we are making Windows more secure here .

Entirely new, powerful AI experiences   

Copilot+ PCs leverage powerful processors and multiple state-of-the-art AI models, including several of Microsoft’s world-class SLMs, to unlock a new set of experiences you can run locally, directly on the device. This removes previous limitations on things like latency, cost and even privacy to help you be more productive, creative and communicate more effectively.  

Recall instantly  

We set out to solve one of the most frustrating problems we encounter daily – finding something we know we have seen before on our PC. Today, we must remember what file folder it was stored in, what website it was on, or scroll through hundreds of emails trying to find it.   

Now with Recall, in preview starting June 18, you can access virtually what you have seen or done on your PC in a way that feels like having photographic memory. Copilot+ PCs organize information like we do – based on relationships and associations unique to each of our individual experiences. This helps you remember things you may have forgotten so you can find what you’re looking for quickly and intuitively by simply using the cues you remember. [7]

You can scroll across time to find the content you need in your timeline across any application, website, document, or more. Interact intuitively using snapshots with screenray to help you take the next step using suggested actions based on object recognition. And get back to where you were, whether to a specific email in Outlook or the right chat in Teams.

Recall leverages your personal semantic index, built and stored entirely on your device. Your snapshots are yours; they stay locally on your PC. You can delete individual snapshots, adjust and delete ranges of time in Settings, or pause at any point right from the icon in the System Tray on your Taskbar. You can also filter apps and websites from ever being saved. You are always in control with privacy you can trust.

Cocreate with AI-powered image creation and editing, built into Windows

Since the launch of Image Creator, almost 10 billion images have been generated, helping more people bring their ideas to life easily by using natural language to describe what they want to create. Yet, today’s cloud offerings may limit the number of images you can create, keep you waiting while the artwork processes or even present privacy concerns. By using the Neural Processing Units (NPUs) and powerful local small language models, we are bringing innovative new experiences to your favorite creative applications like Paint and Photos.

Combine your ink strokes with text prompts to generate new images in nearly real time with Cocreator. As you iterate, so does the artwork, helping you more easily refine, edit and evolve your ideas. Powerful diffusion-based algorithms optimize for the highest quality output over minimum steps to make it feel like you are creating alongside AI. Use the creativity slider to choose from a range of artwork from more literal to more expressive. Once you select your artwork, you can continue iterating on top of it, helping you express your ideas, regardless of your creative skills.

Take photo editing and image creation to the next level. With Restyle Image, you can reimagine your personal photos with a new style combining image generation and photo editing in Photos. Use a pre-set style like Cyberpunk or Claymation to change the background, foreground or full picture to create an entirely new image. Or jumpstart your next creative project and get visual inspiration with Image Creator in Photos. On Copilot+ PCs you can generate endless images for free, fast, with the ability to fine tune images to your liking and to save your favorites to collections.

Innovative AI experiences from the creative apps you love

We are also partnering with some of the biggest and most-loved applications on the planet to leverage the power of the NPU to deliver new innovative AI experiences.

Together with Adobe, we are thrilled to announce Adobe’s flagship apps are coming to Copilot+ PCs, including Photoshop, Lightroom and Express – available today. Illustrator, Premiere Pro and more are coming this summer. And we’re continuing to partner to optimize AI in these apps for the NPU. For Adobe Creative Cloud customers, they will benefit from the full performance advantages of Copilot+ PCs to express their creativity faster than ever before.

DaVinci Resolve Studio    

Effortlessly apply visual effects to objects and people using NPU-accelerated Magic Mask in DaVinci Resolve Studio.  

Remove the background from any video clip in a snap using Auto Cutout running on the NPU in CapCut.  

Stay in your flow with faster, more responsive adaptive input controls, like head movement or facial expressions via the new NPU-powered camera pipeline in Cephable.  

LiquidText  

Make quicker and smarter annotations to documents, using AI features that run entirely on-device via NPU, so data stays private in LiquidText. 

Have fun breaking down and remixing any music track, with a new, higher-quality version of NeuralMix™ that’s exclusive to NPU in Algoriddim’s djay Pro.  

Connect and communicate effortlessly with live captions  

In an increasingly connected and global world, Windows wants to bring people closer together. Whether catching up on your favorite podcast from a different country, or watching your favorite international sports team, or even collaborating with friends and colleagues across the world, we want to make more content accessible to more people.   

Live Captions now has live translations and will turn any audio that passes through your PC into a single, English-language caption experience, in real time on your screen across all your apps consistently. You can translate any live or pre-recorded audio in any app or video platform from over 40 languages into English subtitles instantly, automatically and even while you’re offline. Powered by the NPU and available across all Copilot+ PCs, now you can have confidence your words are understood as intended.   

New and enhanced Windows Studio Effects  

Look and sound your best automatically with easily accessible controls at your fingertips in Quick Settings. Portrait light automatically adjusts the image to improve your perceived illumination in a dark environment or brighten the foreground pixels when in a low-light environment. Three new creative filters (illustrated, animated or watercolor) add an artistic flare. Eye contact teleprompter helps you maintain eye contact while reading your screen. New improvements to voice focus and portrait blur help ensure you’re always in focus.   

Copilot, your everyday AI companion

Every Copilot+ PC comes with your personal powerful AI agent that is just a single tap away on keyboards with the new Copilot key. [8] Copilot will now have the full application experience customers have been asking for in a streamlined, simple yet powerful and personal design. Copilot puts the most advanced AI models at your fingertips. In the coming weeks, get access to the latest models including GPT-4o from our partners at OpenAI, so you can have voice conversations that feel more natural.

Advancing AI responsibly

At Microsoft, we have a company-wide commitment to develop ethical, safe and secure AI. Our responsible AI principles guided the development of these new experiences, and all AI features are aligned with our standards. Learn more here .

New Copilot+ PCs from Microsoft Surface and our partners

We have worked with each of the top OEMs — Acer, ASUS, Dell, HP, Lenovo, Samsung — and of course Surface, to bring exciting new Copilot+ PCs that will begin to launch on June 18. Starting at $999, these devices are up to $200 less than similar spec’d devices [9] .

Surface plays a key role in the Windows ecosystem, as we design software and hardware together to deliver innovative designs and meaningful experiences to our customers and fans. We are introducing the first-ever Copilot+ PCs from Surface: The all-new Surface Pro and Surface Laptop.

The new Surface Laptop is a powerhouse in an updated, modern laptop design with razor-thin bezels, a brilliant touchscreen display, AI-enhanced camera, premium audio, and now with a haptic touchpad.

Choose between a 13.8” and 15” display and four stunning colors. Enjoy up to 22 hours of local video playback on Surface Laptop 15” or up to 20 hours on Surface Laptop13.8” on top of incredible performance and all-new AI experiences.

The new Surface Pro is the most flexible 2-in-1 laptop, now reimagined with more speed and battery life to power all-new AI experiences. It introduces a new, optional OLED with HDR display, and ultrawide field of view camera perfect for Windows Studio Effects. The new Surface Pro Flex Keyboard is the first 2-in-1 keyboard designed to be used both attached or detached. It delivers enhanced stability, with Surface Slim Pen storage and charging integrated seamlessly, as well as a quiet, haptic touchpad. Learn more here.

New Copilot+ PCs from the biggest brands available starting June 18:

• Acer : Acer’s Swift 14 AI 2.5K touchscreen enables you to draw and edit your vision with greater accuracy and with color-accurate imagery. Launch and discover AI-enhanced features, like Acer PurifiedVoice 2.0 and Purified View, with a touch of the dedicated AcerSense button.
• ASUS : The ASUS Vivobook S 15 is a powerful device that brings AI experiences to life with its Snapdragon X Elite Platform and built-in Qualcomm® AI. It boasts 40+ NPU TOPS, a dual-fan cooling system, and up to 1 TB of storage. Next-gen AI enhancements include Windows Studio effects v2 and ASUS AiSense camera, with presence-detection capabilities for Adaptive Dimming and Lock. Built for portability, it has an ultra-slim and light all-metal design, a high-capacity battery, and premium styling with a single-zone RGB backlit keyboard.
• Dell : Dell is launching five new Copilot+ PCs, including the XPS 13, Inspiron 14 Plus, Inspiron 14, Latitude 7455, and Latitude 5455, offering a range of consumer and commercial options that deliver groundbreaking battery life and unique AI experiences. The XPS 13 is powered by Snapdragon X Elite processors and features a premium, futuristic design, while the Latitude 7455 boasts a stunning QHD+ display and quad speakers with AI noise reduction. The Inspiron14 and Inspiron 14 Plus feature a Snapdragon X Plus 1and are crafted with lightweight, low carbon aluminum and are energy efficient with EPEAT Gold rating.
• HP : HP’s OmniBook X AI PC and HP EliteBook Ultra G1q AI PC with Snapdragon X Elite are slim and sleek designs, delivering advanced performance and mobility for a more personalized computing experience. Features include long-lasting battery life and AI-powered productivity tools, such as real-time transcription and meeting summaries. A 5MP camera with automatic framing and eye focus is supported by Poly Studio’s crystal-clear audio for enhanced virtual interactions.
• Lenovo : Lenovo is launching two AI PCs: one built for consumers, Yoga Slim 7x, and one for commercial, ThinkPad T14s Gen 6. The Yoga Slim 7x brings efficiency for creatives, featuring a 14.5” touchscreen with 3K Dolby Vision and optimized power for 3D rendering and video editing. The T14s Gen 6 brings enterprise-level experiences and AI performance to your work tasks, with features including a webcam privacy shutter, Wi-Fi 7 connectivity and up to 64GB RAM.
• Samsung : Samsung’s new Galaxy Book4 Edge is ultra-thin and light, with a 3K resolution, Dynamic AMOLED 2X display and Wi-Fi 7 connectivity. It has a long-lasting battery that provides up to 22 hours of video playback, making it perfect for work or entertainment on the go.

Learn more about new Copilot+ PCs and pre-order today at Microsoft.com and from major PC manufacturers, as well as other leading global retailers.

Start testing for commercial deployment today

Copilot+ PCs offer businesses the most performant Windows 11 devices with unique AI capabilities to unlock productivity, improve collaboration and drive efficiency. As a Windows PC, businesses can deploy and manage a Copilot+ PC with the same tools and processes used today including IT controls for new features and AppAssure support. We recommend IT admins begin testing and readying for deployment to start empowering your workforce with access to powerful AI features on these high-performance devices. You can read more about our commercial experiences here .

AI innovation across the Windows ecosystem  

Like we’ve always done with Windows, we have built a platform for our ecosystem partners to build on.  

The first Copilot+ PCs will launch with both the Snapdragon® X Elite and Snapdragon® X Plus processors and feature leading performance per watt thanks to the custom Qualcomm Oryon™ CPU, which delivers unrivaled performance and battery efficiency. Snapdragon X Series delivers 45 NPU TOPS all-in-one system on a chip (SoC). The premium integrated Qualcomm® Adreno ™ GPU delivers stunning graphics for immersive entertainment. We look forward to expanding through deep partnerships with Intel and AMD, starting with Lunar Lake and Strix Point. We will bring new Copilot+ PC experiences at a later date. In the future we expect to see devices with this silicon paired with powerful graphics cards like NVIDIA GeForce RTX and AMD Radeon™, bringing Copilot+ PC experiences to reach even broader audiences like advanced gamers and creators.  

We are at an inflection point where the PC will accelerate AI innovation. We believe the richest AI experiences will only be possible when the cloud and device work together in concert. Together with our partners, we’re setting the frame for the next decade of Windows innovation.  

Editor’s note: This blog has been updated to note that Recall is launching in preview on June 18.

[1] Based on snapshot of aggregated, non-gaming app usage data as of April 2024 for iGPU-based laptops and 2-in-1 devices running Windows 10 and Windows 11 in US, UK, CA, FR, AU, DE, JP.

[2] Tested April 2024 using Phi SLM workload running 512-token prompt processing in a loop with default settings comparing pre-release Copilot+ PC builds with Snapdragon Elite X 12 Core and Snapdragon X Plus 10 core configurations (QNN build) to Windows 11 PC with NVIDIA 4080 GPU configuration (CUDA build).

[3] Tested May 2024 using Cinebench 2024 Multi-Core benchmark comparing Copilot+ PCs with Snapdragon X Elite 12 core and Snapdragon X Plus 10 core configurations to MacBook Air 15” with M3 8 core CPU / 10 Core GPU configuration. Performance will vary significantly between device configuration and usage.

[4] *Battery life varies significantly by device and with settings, usage and other factors. See aka.ms/cpclaims*

[5] *Battery life varies significantly based on device configuration, usage, network and feature configuration, signal strength, settings and other factors. Testing conducted May 2024 using the prelease Windows ADK full screen local video playback assessment under standard testing conditions, with the device connected to Wi-Fi and screen brightness set to 150 nits, comparing Copilot+ PCs with Snapdragon X Elite 12 core and Snapdragon X Plus 10 core configurations running Windows Version 26097.5003 (24H2) to MacBook Air 15” M3 8-Core CPU/ 10 Core GPU running macOS 14.4 with similar device configurations and testing scenario.

[6] Based on snapshot of aggregated, non-gaming app usage data as of April 2024 for iGPU-based laptops and 2-in-1 devices running Windows 10 and Windows 11 in US, UK, CA, FR, AU, DE, JP.

[7] Recall is optimized for select languages (English, Chinese (simplified), French, German, Japanese, and Spanish.) Content-based and storage limitations apply. Learn more here .

[8] Copilot key functionality may vary. See aka.ms/keysupport

[9] Based on MSRPs; actual savings may vary

Tags: AI , Copilot+ PC

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