The Seven Cardinal Movements

Labor is a physical and emotional event for the laboring woman. For the infant,
however, there are many positional changes that assist the baby in the passage through the
birth canal. Because of the resistance met by the baby, positional changes are specific,
deliberate and precise as they allow the smallest diameter of the baby to pass through a
corresponding diameter of the woman's pelvic structure. Neither care providers nor the
laboring woman is directly responsible for these position changes. The baby is the one
responsible for these position changes ~ the cardinal movements.
Engagement. the entering of
the biparietal diameter
(measuring ear tip to ear tip
across the top of the baby's
head) into the pelvic inlet.
Descent. The baby's head
moves deep into the pelvic
cavity and is commonly called
lightening. The baby's head
becomes markedly molded
when these distances are
closely the same. When the
occiput is at the level of the
ischial spines, it can be
assumed that the biparietal
diameter is engaged and then
descends into the pelvic inlet.
Flexion. This movement
occurs during descent and is
brought about by the
resistance felt by the baby's head against the soft tissues of the pelvis. The resistance brings
about a flexion in the baby's head so that the chin meets the chest. The smallest diameter of
the baby's head (or
suboccipitobregmatic plane) presents into the pelvis.
Internal rotation. As the head reaches the pelvic floor, it typically rotates to accommodate
for the change in diameters of the pelvis. At the pelvic inlet, the diameter of the pelvis is
widest from right to left. At the pelvic outlet, the diameter is widest from front to back. So the
baby must move from a sideways position to one where the sagittal suture is in the
anteroposterior diameter of the outlet (where the face of the baby is against the back of the
laboring woman and the back of the baby's head is against the front of the pelvis). If anterior
rotation does not occur, the occiput (or head) rotates to the occipitoposterior position. The
ocipitoposterior position is also called persistent occipitoposterior and is the common cause
for true back labor.
Extension. After internal rotation is complete and the head passes through the pelvis at the
nape of the neck, a rest occurs as the neck is under the pubic arch. Extension occurs as the
head, face and chin are born.
External rotation. After the head of the baby is born, there is a slight pause in the action of
labor. During this pause, the baby must rotate so that his/her face moves from face-down to
facing either of the laboring woman's inner thighs. This movement, also called restitution, is
necessary as the shoulders must fit around and under the pubic arch.
It is at this point that shoulder dystocia may be identified. Shoulder dystocia occurs when the
baby's shoulders are halted at the pelvic outlet due to inadequate space through which to pass.
Mother's birthing babies who are identified as macrosomatic (in excess of 9.9 lbs.) are more
likely to experience sho ulder dystocia. Additionally, 15-30% of macrosomatic babies
experiencing shoulder dystocia sustain some injury to the brachial plexus. Most of these
injuries (80%) resolve by the baby's first birthday.
Commonly, the McRobert's technique is used to resolve shoulder dystocia. This technique
involves a sharp flexing of the maternal thighs against the maternal abdomen to reduce the
angle between the sacrum and the spine.
Expulsion. Almost immediately after external rotation, the anterior shoulder moves out from
under the pubic bone (or symphisis pubis). The perineum becomes distended by the posterior
shoulder, which is then also born. The rest of the baby's body is then born, with an upward
motion of the baby's body by the care provider.
Signs of labour
Sign
Feeling as if the baby has
dropped
lower.
Discharging a thick plug of
mucus or an increase in
vaginal discharge (clear,
pink or slight bloody).
Discharging a continuous
trickle or a gush of watery
fluid from your vagina.
Differences between false labour and labour
Contractions
What is is
Lightening: This is
commonly referred to as the
"baby dropping". The baby's
head has settled deep into
your pelvis.
Show: A thick mucus plug
has accumulated at the
cervix during pregnancy.
When the cervix begins to
open wider, the plug is
pushed into the vagina.
Rupture of Membranes:
The fluid-filled sac that
surrounded the baby during
pregnancy breaks (your
"water breaks").
False Labor
Often are irregular and do
not consistently get closer
together (called Braxton-
Hicks contractions).
Often felt in the abdomen.
Contractions usually stop
when you walk or may even
stop with a change of
position.
What it Happens
From a few weeks to a few
hours before labour begins.
Several days before labour
begins or at the onset of
labour.
From several hours before
labour begins at anytime
during labour.
Labor
Come at regular intervals
and, as time goes on, get
closer and closer together.
Usually felt in the back
coming around to the front.
Contractions continue,
despite movement.
Indications for episiotomy
The recent trend in Australia has been away a routine use of episiotomy in favour of
restrictive use. This transition came from evidence showing restrictive policy to be
associated with less posterior perineal trauma, less suturing and fewer healing complications
as compared to routine episiotomy. Importantly, no difference was found between restrictive
and routine episiotomy in rates of severe lacerations, dyspareunuria, urinary incontinence or
pain measurements. Restrictive episiotomy is, however, associated with more anterior
perineal traumas.
As per the RANZCOG College Statement, episiotomy should be considered where
there is:
a high likelihood of severe laceration;
soft tissue dystocia;
a requirement to accelerate the birth delivery of a compromised fetus;
a need to facilitate operative vaginal delivery; or
a history of female genital mutilation.

Operative vaginal delivery is one instance in which the decision of whether to

employ episiotomy or not must be made on a case-by-case basis, using well-considered
clinical judgement. The literature is unclear as to whether a routine episiotomy in this setting
is advisable.