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Clinical Procedures > Obstetric and Gynecologic Procedures
Labor and Delivery, Normal Delivery of the Newborn
Article Last Updated: Feb 26, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 16  
Author: Karen Patterson, MD, Medical Intern and Resident, Department of Medicine, Boston University
Coauthor(s):
Jodi F Abbott, MD, Associate Professor of Obstetrics and Gynecology, Clerkship Director, Boston University School of Medicine; Director, Antenatal Testing Unit, Boston Medical Center
Editors: Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
normal delivery, baby delivery, infant delivery, neonate, labor, ripening, effacement, bloody show, rupture of membranes, membrane rupture, artificial rupture of membranes, AROM, premature rupture of membranes, PROM, vaginal birth after cesarean section (VBAC), McRobert’s maneuver, McRobert maneuver, fetal station, fetal lie, fetal attitude, crowning, breech, footling, dystocia, shoulder dystocia, vacuum, forceps, vacuum assist, birth, delivery
The delivery of a full-term newborn refers to delivery at a gestational age of 37-42 weeks, as determined by the last menstrual period or via ultrasonographic dating and evaluation. The Naegel rule is a commonly used formula to predict due date based on the date of the last menstrual period. This rule assumes a menstrual cycle of 28 days and mid-cycle ovulation. Ultrasonographic dating can be more accurate, especially when it is performed early in pregnancy and is used to corroborate or modify a due date based on the last menstrual period.
Approximately 11% of singleton pregnancies are delivered preterm and 10% of all deliveries are postterm. Thus, nearly 80% of newborns are delivered at full term, although only 3-5% of deliveries occur on the estimated due date.1, 2
Labor and delivery is divided into 3 stages.
- In the first stage, the cervix dilates as a result of progressive rhythmic uterine contractions. This is typically the longest stage of labor. Cervical effacement, or thinning, occurs throughout the first stage of labor, and is graded 0-100%.
- The second stage of labor is the time between complete cervical dilation and delivery of the neonate. This phase lasts minutes to hours.
- Six cardinal movements of labor occur during the second stage of labor.
- Engagement of the head into the lower pelvis
- Flexion of the head, putting the occiput in presenting position
- Descent of the neonate through the pelvis
- Internal rotation of the vertex to maneuver past the lateral ischial spines
- Extension of the head to pass beneath the maternal symphysis
- External rotation of the head after delivery to facilitate shoulder delivery
- Several clinical parameters are followed.
- The fetal presentation is determined by the first fetal body part that passes through the birth canal. Most commonly, this is the occiput or the vertex of the head.
- The fetal attitude is the degree of forward flexion of the fetal head. Full flexion is most common, followed by (in order of increasing degree of extension) military, brow, and face presentation. Asynclitism is abnormal lateral flexion of the head, which can delay labor.
- The fetal station is the relation of the fetal head to the maternal ischial spines. The station is graded -5 cm to +5 cm.
- The fetal position is the orientation of the fetal vertex (the top of the head) in relation to the plane of the maternal ischial spines. The vertex normally rotates from a transverse position to an anterior or posterior position during the fourth cardinal movement.
- The delivery of the placenta is the third and final stage of labor; it typically occurs within 30 minutes of delivery of the newborn. As the uterus contracts, a plane of separation develops at the placenta-endometrium interface. As the uterus further contracts, the placenta is expelled.
- Normal delivery of the newborn is indicated in the following circumstances:
- Spontaneous labor mediated by pituitary and placental hormone cascades
- Rupture of amniotic and chorionic membranes (suggested by the presence of a watery vaginal discharge or new oligohydramnios on ultrasonograph)
- Induction of labor (indicated after 41 weeks of gestation or earlier, if fetal or maternal medical conditions necessitate delivery)
- While sporadic contractions may occur, and the cervix may begin to soften in anticipation of delivery, the presence of contractions that lead to active cervical change defines labor.
- Not all vaginal fluid is amniotic fluid, and the diagnosis of membrane rupture may require confirmation.
- If the cervix is ripe, oxytocin is given to induce uterine contractions. If the cervix is not ripe, a prostaglandin suppository can, if not contraindicated, be placed before therapy with oxytocin is initiated.3
- While over 75% of full-term newborns in the United States are delivered vaginally, vaginal birth is contraindicated in some recognized circumstances.
- Cord prolapse
- When cord prolapse is detected on pelvic examination, the clinician should leave the hand in place, applying pressure against the presenting fetal part to keep it as far out of the pelvis as possible to prevent cord compression.
- The incidence of cord prolapse is proportional to cord length.
- The treatment is immediate conversion to abdominal delivery. If not treated emergently, cord prolapse is associated with high perinatal mortality.
- Brow presentation
- Proceed to cesarean delivery if conversion to either face or vertex presentation does not occur with expectant management in the stable patient.
- Face presentation
- Clinicians and mothers may tolerate a trial of expectant management, if cephalopelvic disproportion is not suspected and if the face is in a mentum anterior or mentum transverse position.
- Breech presentation
- Up to 5% of all presentations and 1-3% of full-term newborns present in the breech position. Plan for abdominal delivery for a footling presentation. For frank breech (ie, hips flexed, knees extended) and complete breech (ie, hips and knees flexed) presentations detected before the onset of labor, manual pressure maneuvers called external cephalic version (ECV) may be performed to attempt conversion to a vertex presentation.
- The success rates of ECV are greater than 50% in properly selected patients, but these maneuvers should be performed at term, as they may stimulate labor or result in complications that necessitate prompt delivery.
- The American College of Gynecology (ACOG) recommends abdominal delivery if ECV fails or if a mother in labor presents with breech presentation, as the rates of fetal morbidity and mortality in these cases are increased with vaginal delivery.4
- Malposition
- Fetal positions compatible with vaginal delivery are occiput anterior (OA), right occiput anterior (ROA), and left occiput anterior (LOA).
- The occiput posterior (OP) position is generally unfavorable for passage through the birth canal. If the fetal station is high, change to abdominal delivery.
- Deep transverse arrest of the fourth cardinal movement occurs when the fetal head remains in transverse position. Unfavorable maternal pelvic anatomy is the most common cause; abdominal delivery should be considered promptly.
- Shoulder presentation is a sign of a transverse fetal lie. If this presentation is detected prior to active labor, external rotation through ECV may be attempted. When this presentation is detected during labor (ie, neglected transverse lie), fetal demise may have occurred, and maternal risk for infection, uterine rupture, or both is high. Emergent abdominal delivery is indicated.
- Twin pregnancy with a nonvertex second twin presentation is managed according to gestational age, mother preference, and practitioner comfort. The exceptions to vaginal delivery include the following:
- Presenting twin in breech position
- Conjoined twin anatomy
- Most cases of mono-amniotic twins
- Signs of fetal distress or an abnormality that warrants abdominal delivery
- Higher order births
- In the United States, abdominal delivery is planned for higher order births.
- Vaginal delivery after cesarean delivery
- While safe in most circumstances, vaginal delivery after previous cesarean delivery remains controversial because of the rare but serious complication of uterine rupture. For more information on this controversy, see Medscape articles Prior Cesarean Delivery Greatly Increases Uterine Rupture Risk and Low Risk of Uterine Rupture Seen After Prior Cesarean Delivery.
- The success rate of this procedure is greater than 50%.
- During the delivery, careful fetal and maternal monitoring are needed to detect early signs of dystocia or uterine rupture.
- An in-house anesthesiologist and obstetrician should be available in case complications arise. This type of delivery is not offered in many small hospitals because of the inconsistent availability of anesthesia or operating room staff.
- This type of delivery is contraindicated in cases of multiple prior cesarean deliveries, a history of a classic or T-shaped uterine scar, the presence of other uterine scars, or concern for true cephalopelvic disproportion.
- Nonreassuring fetal heart rate changes
- Hospital protocols in the United States recommend some form of intermittent fetal heart rate monitoring. The need for continuous fetal heart rate monitoring remains unproven in low-risk, full-term pregnancies; however, changes in fetal heart rate monitoring can signal fetal distress and may indicate the need for emergent abdominal delivery.
- Causes of fetal distress include placental abruption, placenta previa, or a tight or wrapped cord. Most cesarean deliveries undertaken for suspected fetal distress result in healthy birth outcomes.
- Macrosomia
- Fetal weight greater than 4000-4500 g is associated with a higher risk of shoulder dystocia and birth trauma during vaginal delivery.5 Mothers with diabetes have a higher incidence of macrosomia.
- Therefore, if the estimated fetal weight is greater than 4000 g in a mother with diabetes, ACOG recommends abdominal delivery.
- Data are lacking to support prophylactic induction of labor or abdominal delivery in cases of macrosomia in mothers without diabetes.
- The pain of labor and delivery is a result of muscular contractions and pelvic pressure from organ distention. In the first stage of labor, autonomic innervation of the visceral uterus senses pain from contractions and cervical dilation. In the second stage of labor, somatic innervation of the vagina, vulva, and perineum sense pressure pain from the newborn passing through the birth canal.
- Regional epidural anesthesia
- Regional epidural anesthesia is used in more than 50% of laboring women in the United States. It is relatively easy to perform, generally low in risk for complications, and provides good pain control.
- To decrease the risk of prolonging labor, the epidural catheter should be placed when the cervix is dilated at least 4 cm. Risks include short-term backache, puncture headache, hypotension, maternal fever, and delayed labor.6 Another possible risk is increased rate of instrumented delivery.7
- Epidural anesthesia may be combined with a dose of spinal anesthesia; this is called combined spinal-epidural anesthesia. This permits delivery of a potent, fast-acting spinal anesthetic with the placement of a stable epidural catheter for subsequent anesthesia needs.
- Pudendal block
- The pudendal block is a local anesthetic given during the second stage of labor for somatic sensory blockade. It may provide some degree of motor blockade of the levator ani, mediating relaxation of pelvic floor muscles. However, it is not very effective for pain control and is now rarely used.8
- Systemic analgesia
- Narcotics are sometimes used for short-term pain control; they can all cross the placenta, but only some cross the fetal blood-brain barrier. Narcotic agonists and antagonists are most commonly used. Morphine crosses the fetal blood-brain barrier and is infrequently used.
- Risks include hypotension, nausea, vomiting, respiratory depression, depressed mental status, and decreased GI motility.
- If narcotics are used, resuscitation medication and equipment for the newborn should be readily available.
- Nonpharmacologic pain management
- Nonpharmacologic pain management can be used in conjunction with pharmacologic options.
- Nonpharmacologic options include the following:
- Breathing and meditation methods
- Hypnosis
- Acupuncture
- Labor exercise techniques (eg, walking, squatting)
- Therapeutic massages
- Social support, including a birth doula
- Warm baths or showers
- Monitors
- External fetal heart rate monitor
Normal fetal heart rate tracing. - Standard noninvasive labor monitoring includes the use of 2 sensors attached to the outside of the mother’s abdomen. One sensor tracks the fetal heart rate via ultrasonography, and the other tracks the timing and strength of contractions via a tocodynamometer.
- The fetal heart rate is variable and ranges from 120-160 beats per minute (bpm). The heart rate may drop briefly to lower than 120 bpm, especially during contractions. Persistence of a fetal heart rate lower than 120 bpm defines fetal bradycardia. Persistence of a rate higher than 160 bpm is called fetal tachycardia.
- Internal fetal heart rate monitor
- An internal fetal heart rate monitor may be placed to more accurately assess fetal heart rate patterns when the external monitor tracing may be inaccurate.
- A small electrode is passed through the cervix, after the membranes have ruptured, and placed on the fetal scalp. An adjacently placed monitor into the uterus simultaneously tracks contraction patterns.
- Delivery assistance
- Forceps
- This is a handheld metal instrument with blade extensions that are applied to each side of the fetal head. The traction force of the blades aids in neonate delivery.
- The use of forceps has decreased over the past several decades.9
- The indications for forceps use include delayed labor or ineffective maternal push power.
- Forceps use is associated with less fetal hematoma formation and quicker delivery times compared with vacuum assist.10
- When compared with conversion to abdominal delivery, forceps use is associated with lower risk of maternal hemorrhage and a better chance that the mother will be able to deliver vaginally in subsequent pregnancies.
- Vacuum
- This instrument consists of a suction cup that attaches to the fetal head to assist with extraction. Traction pressure is created by a negative pressure handle system. Types include metal cup vacuums, plastic cup vacuums, and a mushroom-shaped vacuum cup that combines the advantages of the metal and plastic designs.11
- Indications for use include the need for urgent delivery because of fetal distress, poor maternal push power, or maternal medical conditions that contraindicate strong pushing. Vacuum assistance should only be used when indicated, as it carries the risk of harm to the fetus and mother.
- The decision between using forceps or a vacuum assist is guided by the particular indication for an instrumented delivery and the clinician’s experience with each technique. In cases of fetal distress, the decision to perform an assisted vaginal delivery over rapid conversion to abdominal delivery is based on fetal position and presentation and the availability of personnel for emergency surgical delivery
- Other equipment
- Other equipment that might be used during normal delivery of the neonate includes the following:
- Sterile gloves
- Amniotic hooks
- Episiotomy tools
- Suture materials
- Fetal resuscitation equipment
- First stage of labor
- The mother may alternate positions frequently and is permitted to be out of bed if not under anesthesia motor blockade. Taking walks during this time can ease pain. Some clinicians report that labor may be shorter when the mother is intermittently upright. Swaying motions, such as rocking or slow dancing, may be soothing.
- Second stage of labor
- The mother may choose a delivery position that is most comfortable and still conducive for clinical monitoring. Most commonly, women assume a partially sitting position, with the knees flexed and the back supported. The gravity advantage of being at least partially upright can help during delivery.
- Other acceptable delivery positions include the following:
- Squatting
- Dangling and supported by the arms of a partner
- Kneeling on the knees or on both the hands and knees
- Lying on one side with the upper leg supported
- In some circumstances, repositioning of the mother may be indicated during delivery. Such circumstances include the following:
- Maternal back pain
- Shoulder dystocia
- Posterior presentation of the occiput
- Clinicians are also becoming more familiar with water immersion and water birthing. Evidence from randomized controlled trials on water immersion does not support a significant benefit for pain control, length of labor, or infant morbidity.
First Stage of Labor- Take a complete history and perform a complete physical examination. The physical should include a vaginal examination to assess the cervix.
- Inspect for the presence of herpetic lesions, as active lesions contraindicate vaginal delivery.
- Access and monitor fetal and maternal vital signs.
- Obtain an external fetal heart monitor strip.
- A duration of 20-30 minutes is standard to assess fetal well-being and to record contraction patterns.
- Provide continuous fetal heart rate monitoring for indicated maternal or fetal reasons.
- Monitor maternal vital signs regularly.
- Assess cervical change and for the rupture of membranes through vaginal examinations every few hours in an average-risk mother.
- More frequent examination may be indicated by the mother’s clinical status.
- Diagnose rupture of membranes by at least 2 of the following criteria:
- Positive Nitrazine pH test results
- Evidence of microscopic ferning pattern of the dried fluid
- Observation of amniotic fluid in the vaginal vault
- Monitor and chart cervical effacement and dilatation.
- Review anesthesia options with the patient early so that appropriate plans can be made.
- Record medications given. Consider the use of oxytocin in cases of prolonged labor.
- Encourage frequent spontaneous bladder voiding or provide catheter drainage. This prevents unintended voiding during second stage pushing and permits better abdominal palpation and external maneuvers in cases of dystocia.
- Discuss positioning options for the upcoming second stage of labor.
- Mothers may ambulate and reposition themselves to maximize comfort.
- They may also eat small amounts of food throughout this stage, unless concern exists for impending difficulty during vaginal delivery and the possible need to convert to abdominal delivery.
Second Stage of Labor- Follow and chart fetal station as the neonate descends in the pelvis.
- Assess fetal position by palpation or by inspection (as the head becomes visible).
- Monitor fetal and maternal vital signs closely.
- Reassess pain status frequently and provide anesthesia as indicated. Pudendal blocks may take 15 minutes to reach full effect.
- Delivery is imminent at crowning.
- Crowning occurs when the fetal head bulges the perineum as the head moves through the birth canal.
- Distention pressure on the perineum creates a tremendous urge to push for most women.
- If the mother does not instinctively feel when to push, as can occur with heavy anesthesia, instruct her to push with contractions to aid in expulsion.
- Delivery of the head
- Drape and prepare for delivery when the fetal station is low.
- Drapes and gowns protect the clinician from the fluid of delivery; sterile preparation is not required.
- Use one hand to support and maintain the head in the flexed position as it delivers.
- Use the other hand to support the perineum.
Perineal support during delivery of the head. - Control the pace of the delivery of the head. Maternal pushing is often helpful, but forceful pushing can cause the head to deliver too precipitously.
- Have the mother momentarily withhold pushing once the head is delivered to check for nuchal cords.
- Reduce nuchal cords if the mother and newborn are sufficiently stable to permit a pause in delivery.
- Suction the nares quickly.
- Delivery of the shoulders
- With both hands on the head, support delivery of the shoulders one at a time as the mother pushes with a contraction.
- Without pulling, apply gentle posterior traction of the head at an angle of 45° to deliver the anterior shoulder followed by gentle anterior traction of the head to deliver the posterior shoulder.
Delivery of the anterior shoulder.
Delivery of the posterior shoulder. - Some clinicians deliver the head and the anterior shoulder together and then pause to suction the nares before delivering the posterior shoulder.
- Delivery of the body
- With one hand still holding the head, use the other hand to catch the newborn.
Delivery of the body. - Guide the newborn’s body as it is delivered.
- Suction the nares again and perform an initial assessment of the newborn.
- Clamp the umbilical cord in 2 locations, several centimeters apart. The clinician or the mother’s partner can cut the cord between the clamps.
- After delivery
- Clean the newborn or place directly with the mother, assuming a normal appearance and Apgar evaluation.
- If the newborn is given directly to the mother, wrap the newborn and place on the mother’s bare chest; the newborn's wet skin or the mother’s wet clothes, combined with exposure to ambient air, lead to significant heat loss.
- Continue to monitor the mother as she progresses to the final stage of labor.
Third Stage of Labor- Placental separation is evidenced by any of the following:
- An increase in umbilical cord slack
- A bolus of blood from the uterus
- Superior migration of the uterus within the abdomen with an increase in uterine firmness
- The clinician can facilitate placental delivery.
- Apply gentle horizontal traction on the umbilical cord with one hand.
- Apply vertical pressure just superior to the pubic symphysis with the other hand to prevent inversion of the uterus.
- Inspect the placenta after delivery.
- Manually explore the uterus if the placenta is not intact.
- Retained placenta fragments increase the risk of postpartum hemorrhage.
- The medical view regarding the best position for delivery has evolved over time. Patient preference should influence positioning as much as possible.
- Epidural anesthesia is the most common form of obstetric anesthesia and is used in over half of deliveries in the United States.
- Contraindications to vaginal delivery include cord prolapse, persistent fetal distress on monitoring, placental abruption when delivery is not imminent, suspected or confirmed cephalopelvic disproportion, fetal malpresentation, maternal instability, a history of multiple prior abdominal deliveries or of a vertical uterine scar, or active genital herpes.
- Controlled maternal pushing helps prevent deep perineal tearing. Prophylactic episiotomy is not recommended for routine births.
- The incidence of shoulder dystocia is increasing. A higher incidence is associated with macrosomia, although most cases occur in infants of normal birth weight. The McRobert and suprapubic pressure maneuvers are successful in nearly 50% of cases.
- Indications for a forceps or vacuum assist include development of fetal distress when delivery is imminent or an inability of the mother to push secondary to fatigue, anesthesia effect, or a medical condition that contraindicates strong pushing.
- An essential part of the third stage of labor is assessing the integrity of the placenta to rule out a retained placental fragment.
- Blood loss in excess of 500 mL from vaginal delivery is abnormal. The most common causes for postpartum hemorrhage are uterine atony and deep tears within the birth canal.
- Failure to progress: dystocia is, literally, difficult labor.
- Dystocia is traditionally qualified as a problem of power (contractibility of the uterus), passage (maternal pelvic properties), or passenger (presentation or size of the fetus).
- Power
- On average, cervical dilation progresses at a rate of 1 cm per hour in nulliparous women and 1.2 cm per hour in multiparous women.
- Multiple sites within the uterus can stimulate weak, uncoordinated contractions early in labor, but the pacing of contractions becomes centralized and more effective as labor progresses. If this does not happen, the contractile power needed to complete cervical dilation may be inadequate.
- Nulliparous women and women with anatomical uterine abnormalities have a higher risk for this type of dystocia.
- Oxytocin
- When needed, oxytocin improves the frequency and strength of contractions.
- It may also cause uterine hypersensitivity; stopping the infusion works quickly to remove the medication effect if signs of maternal or fetal distress develop.
- Because oxytocin increases the strength of contractions, women tend to report more pain while on oxytocin.
- Passage and passenger
- During the second stage of labor, the fetal head typically descends within the pelvis at a rate of 1 cm per hour. Abnormal fetal presentation or position or cephalopelvic disproportion (CPD) can slow this progress.
- True CPD, due to a small pelvic outlet or fetal macrosomia, is rare. While macrosomia occurs in up to 10% of pregnancies in the United States, notably in mothers who are delivering post term or who have diabetes, it does not always obstruct labor and cause CPD.
- Nonreassuring fetal heart rate
- Fetal heart rate monitoring is used to assess baseline heart rate, variability, and the presence of accelerations, and to compare deceleration patterns against the timing of maternal contractions. Indications for operative delivery for fetal well-being include abnormal fetal heart rate patterns suspicious for fetal hypoxia and persistent fetal heart rate decelerations in the context of a fetus remote from delivery.
- Bradycardia is mediated by vagal tone. Preserved variability in the setting of mild bradycardia is reassuring. Significant bradycardia may result from cord compression, fetal cardiac anomalies, or fetal hypoxia. Infrequently, it may represent a deceased fetus with monitor capture of the underlying slower maternal heart rate.
- Tachycardia is less specific than bradycardia for fetal distress. A high sympathetic tone drives tachycardia and may abolish vagally mediated heart rate variability. Causes of sympathetic surges include maternal fever, hypotension, the use of sympathomimetic drugs, and fetal anemia.
- Decelerations are classified as early, late, or variable. Early decelerations are associated with uterine contractions (when compression of the fetal head causes an increase in vagal tone). Late decelerations are more concerning. They may represent uteroplacental insufficiency and signal fetal hypoxia. Variable decelerations vary in the timing of onset and length of duration; they represent cord compression.12
- Premature rupture of membranes
- Expectant management of premature rupture of membranes (PROM) is indicated if the mother and fetus are doing well.
- Antibiotic treatment is begun after 18 hours of membrane rupture (similar to the management of artificial rupture of membranes [AROM]).
- PROM is most concerning in preterm newborns. In those cases, the risk of infection and of the loss of supportive amniotic fluid must be weighed against the risk of premature delivery.
- Intrapartum hemorrhage
- During labor and delivery, a small amount of blood may be mixed with amniotic fluid, creating a serosanguineous appearance. A bloody show may herald the onset of labor.
- Significant blood loss, however, is abnormal.
- Causes of intrapartum hemorrhage include the following:
- Placental abruption is the premature separation of the placenta from the uterus.
- Placenta previa is a low-lying placenta. In the United States, where most women have prenatal ultrasonographic evaluations, placenta previa is usually diagnosed by ultrasonographic evaluation prior to labor onset.
- Placenta accreta is the extension of the placenta into the uterine wall.
- Ruptured vasa previa (abnormal fetal vessels covering the cervix)
- Uterine rupture can also cause intrapartum hemorrhage.
- Postpartum hemorrhage
- Loss of more than 500 mL of blood during delivery is abnormal.
- Uterine atony, or failure of the uterus to contract following delivery of the placenta, is the most common cause. During atony, the uterine blood vessels that are torn and exposed during placental separation are not adequately compressed and may bleed excessively.
- Retained placental tissue, the use of uterine muscle relaxants during labor, prolonged labor, or an abnormally distended uterus are causes of uterine atony.
- Deep vaginal lacerations are also a cause of postpartum hemorrhage, as are coagulopathies, which may lead to excessive bleeding from the uterus, cervix, or vagina.
- To treat postpartum hemorrhage, perform bimanual uterine massage and start an oxytocin drip if uterine atony is suspected; misoprostol or other prostaglandins may also be indicated. If these interventions do not control bleeding, reexplore the vagina, cervix, and uterus for tears or for retained products of conception.
- Episiotomy
- The decision to perform an episiotomy is often made as the newborn crowns. Until recently, episiotomies were routinely performed during most deliveries with the assumption that this minimized deep traumatic tearing. Evidence, however, does not support the routine practice of episiotomy.4
- When indicated, episiotomies are made in a midline (or mediolateral) position. The depth of the incision is directly proportional to how precipitous the delivery is and to the stiffness of the perineum. The procedure for episiotomy is as follows:
- Make a 0.75-1.5-in incision from the midpoint of the posterior fourchette, directing back toward the rectum.
Episiotomy. - Advance the amniohook until it touches the membranes.
- Once the hook is engaged, pull back slightly; fluid slowly leaks out.
- Inspect for the presence of meconium, a discolored (yellow to green) fluid due to the presence of fetal stool.
- Once membranes rupture, consider induction or augmentation of labor if it does not progress spontaneously.
- External cephalic version
- External cephalic version (ECV) is a prelabor maneuver to externally convert a breech fetus to a vertex presentation. ECV may reduce the rate of abdominal delivery; success rates in carefully selected full-term patients approach 60%.13
- Risks include premature rupture of membranes, inadvertent induction of labor, fetal distress or demise, and maternal pain.
- Contraindications include multiple gestations or placental, fetal, or maternal abnormalities.
- The procedure for ECV is as follows:
- Position the mother supine.
- Liberally lubricate the abdomen.
- Attempt a forward roll first. To do this, apply upward pressure on the breech while guiding the head gently downward to rotate the fetus clockwise.
- Attempt a reverse, backward roll if the forward roll is unsuccessful.
Web Links
Managing Complications in Pregnancy and Childbirth (from the World Health Organization)
Obstetrics, gynecology (from the Geneva Foundation for Medical Education and Research)
Episiotomy and repair (from Operational Medicine)
Scott JR, Gibbs RS, Karlan BY, Haney AF. Danforth's Obstetrics and Gynecology. 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2003.
Practice bulletins from the American College of Obstetrics and Gynecology:
- Operative vaginal delivery. Obstet Gynecol. 2000;95(6).
- Shoulder dystocia. Obstet Gynecol. 2002;100:1045-50.
- Dystocia and augmentation of labor. Obstet Gynecol. 2003;102:1445-54.
- Obstetric analgesia and anesthesia. Int J Gynaecol Obstet. 2002;78(3):321-35.
- Antepartum fetal surveillance. Int J Gynaecol Obstet. 2000;68(2):175-85.
- Vaginal birth after previous cesarean delivery. Int J Gynaecol Obstet. 1999;66(2):197-204.
- Premature rupture of membranes. Int J Gynaecol Obstet. 1998;63(1):75-84.
- Monitoring during induction of labor with dinoprostone. Int J Gynaecol Obstet. 1999;64(2):200.
Special thanks to the Obstetrics department at Boston Medical Center.
Video and photos courtesy of Dartmouth-Hitchcock Medical Center, copyright 1994.
Fetal heart rate tracing courtesy of Dr. Amir Sweha, Methodist Hospital, and the family practice program, Sacramento, CA.
Dr. Mike Hughey of Brookside Associates, for the Web link to the episiotomy video.
- Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and problem pregnancies. 4th. Philadelphia, Pa: Churchill and Livingstone; 2002.
- Iams JD. Prediction and early detection of preterm labor. Obstet Gynecol. Feb 2003;101(2):402-12. [Medline].
- Tenore JL. Methods for cervical ripening and induction of labor. Am Fam Physician. May 15 2003;67(10):2123-8. [Medline].
- Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, et al. Planned cesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Lancet. 2000;356:1375-83.
- Baxley EG, Gobbo RW. Shoulder dystocia. Am Fam Physician. Apr 1 2004;69(7):1707-14. [Medline].
- Leighton BL, Halpern SH. The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review. Am J Obstet Gynecol. May 2002;186(5 Suppl Nature):S69-77. [Medline].
- Zhang J, Yancey MK, Klebanoff MA, Schwarz J, Schweitzer D. Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment. Am J Obstet Gynecol. Jul 2001;185(1):128-34. [Medline].
- Guaderrama NM, Liu J, Nager CW, Pretorius DH, Sheean G, Kassab G. Evidence for the innervation of pelvic floor muscles by the pudendal nerve. Obstet Gynecol. Oct 2005;106(4):774-81. [Medline].
- Bofill JA, Rust OA, Perry KG, Roberts WE, Martin RW, Morrison JC. Operative vaginal delivery: a survey of fellows of ACOG. Obstet Gynecol. Dec 1996;88(6):1007-10. [Medline].
- Patel RR, Murphy DJ. Forceps delivery in modern obstetric practice. BMJ. May 29 2004;328(7451):1302-5. [Medline].
- Putta LV, Spencer JP. Assisted vaginal delivery using the vacuum extractor. Am Fam Physician. Sep 15 2000;62(6):1316-20. [Medline].
- Freeman B, Garite T, Nageotte M. Fetal Heart Rate Monitoring. 2nd ed. Baltimore, Md: Williams & Wilkins; 1991.
- Coco AS, Silverman SD. External cephalic version. Am Fam Physician. Sep 1 1998;58(3):731-8, 742-4. [Medline].
- Gherman RB, Goodwin TM, Souter I, Neumann K, Ouzounian JG, Paul RH. The McRoberts' maneuver for the alleviation of shoulder dystocia: how successful is it?. Am J Obstet Gynecol. Mar 1997;176(3):656-61. [Medline].
- Guise JM. Vaginal delivery after caesarean section. BMJ. Aug 14 2004;329(7462):359-60. [Medline].
- Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. Oct 21 2000;356(9239):1375-83. [Medline].
- Hansen SL, Clark SL, Foster JC. Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial. Obstet Gynecol. Jan 2002;99(1):29-34. [Medline].
- Minkoff H, Burns DN, Landesman S, Youchah J, Goedert JJ, Nugent RP. The relationship of the duration of ruptured membranes to vertical transmission of human immunodeficiency virus. Am J Obstet Gynecol. Aug 1995;173(2):585-9. [Medline].
- Poole JH. Neuraxial analgesia for labor and birth: implications for mother and fetus. J Perinat Neonatal Nurs. Oct-Nov 2003;17(4):252-67. [Medline].
Labor and Delivery, Normal Delivery of the Newborn excerpt Article Last Updated: Feb 26, 2008
Topic originally published: Feb 26, 2008
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