UBC Objectives: Maternity Care & Procedure: Normal Vaginal Delivery

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate ability to interact appropriately with other members of the obstetrical team
• Assess and manage normal labour and delivery
  
• Consult obstetricians appropriately
  

My approach to a normal (without complicating features) vaginal delivery is as follows:

1. Complete admission history and physical examination if the women is in active labour (cervical dilation of 4 or more cm) or if there is another reason warranting admission (rupture of membranes, complications identified)
   • If the woman is still only in latent first stage of labour (regular contractions but cervix not yet dilated to 4 cm), we want to avoid early admission to hospital as evidence shows this increases risk of intervention that overall causes more harm than good. If the patient is being discharged home to continue early labour but is in significant pain (she is in labour, after all), provide her with injections of morphine and dimenhydrinate (because opioids can cause nausea). If latent labour is prolonged (>20 hours in a nulliparous woman or >14 hours in a multiparous woman), consider augmentation as there is increased risk of complications when latent labour is significantly prolonged. Once the woman is admitted, give antibiotics for GBS prophylaxis, if indicated.
2. Once admitted, regularly reassess maternal and fetal status. Nursing 1:1 support is standard of care if a woman is admitted in labour. 
   1. Frequency of reassessment 
      1. If the woman is in active first stage of labour, I reassess every 2-4 hours
      2. If the woman is in the passive second stage of labour, I reassess every 1 hour
      3. Also reassess whenever the patient feels the urge to push, prior to augmentation or anesthesia, of if there are any concerns regarding fetal or maternal status. 
   2. Components of maternal assessment
      1. How she is coping (ex: pain control, hydration, fatigue, emotional support)
      2. Physical exam includes reassessing vital signs and contractions (frequency, duration, intensity, and resting tone), along with vaginal exam (cervical dilation and effacement, fetal station and position)
   3. Components of fetal assessment
      1. FHR interpretation (unless there is an indication for continuous electronic fetal monitoring, fetal heart rate monitoring is preferably done by intermittent auscultation)
3. Once the woman has transitioned to stage 2 of labour (complete cervical dilation), she may begin pushing if she has the urge to push. If there is no urge to push and the fetal station is still high, then it is advised to delay pushing up to 2 hours to allow passive fetal descent (evidence shows that this lengthens the overall time in labour but shortens the time when the woman is actively pushing, which promotes better outcomes). If there is no urge to push and there is no passive descent at one hour from onset of 2nd stage, consider initiating directed pushing.
4. Active stage 2 begins with active pushing. There is no evidence that coaching women on how to push makes a difference, except if there is an epidural (because they just can't feel what's going on down there as well).
   1. Prepare for delivery
      1. Ready equipment and place sterile drapes under patient. Be sure to have 2 clamps and a pair of blunt scissors close by in case there is a irreducible nuchal cord. 
   2. Controlled delivery of the head
      1. Protect the perineum by performing perineal massage, and when crowning, applying midline pressure with a warm compress, can help to prevent tears. With the hand that isn't protecting the perineum, use it to control rate of extension of the fetal head when crowning. Just enough pressure is applied so as to prevent rapid extension and associated perineal tears, and pressure should be applied to the infant's occiput to maintain the head in a flexed position. Never take your eyes off the perineum once crowning has begun. Once crowning, encourage the woman to pant as opposed to push the baby out. Preferably, the head is delivered between contractions when the force of propulsion is decreased.
   3. Restitution and checking for a nuchal cord
      1. After delivery of the fetal head, all the head to naturally restitute (watch for the turtle sign, which could signify shoulder dystocia). While allowing the head to restitute, check for a nuchal cord by sliding your fingers around the fetal neck. If there is a lot of thick mucus covering the infants nose and mouth, wipe gently with a sterile towel or sponge. If a nuchal cord is present (up to 25% of deliveries), attempt to reduce it by slipping it over the fetal head. If this is difficult to do but the cord is not tight, you can instead try to slip it over the fetal shoulder, which will essentially mean that baby is delivered through the cord, otherwise known as the somersault maneuver. If the cord is unable to be displaced, it will need to be clamped and cut, followed by prompt delivery of the infant 
   4. Deliver anterior shoulder and body
      1. Apply gentle downward pressure on infant toward sacrum with flat fingers while mom pushes with the next contraction. Following delivery of the anterior shoulder, the posterior shoulder is immediately delivered with gentle upward traction. Standard of care is to give mom an injection of oxytocin at this time to prevent postpartum hemorrhage.
   5. Delayed cord clamping
      1. Baby is placed skin-to-skin with mom, and delayed cord clamping for at least one minute in a full term infant is instituted. Once the cord is cut, blood is taken from the cord for cord blood gases. 
5. Third stage of labour is from the time the infant is delivered until delivery of the placenta. Generally it takes about 5-10 minutes, but can last up to 30 minutes. The placenta is delivered with gentle cord traction while providing suprapubic support, and after delivery it is immediately inspected for completeness and for whether the umbilical cord has 3 vessels (normal). Assess uterine tone and apply gentle uterine massage as indicated to promote tonicity, which prevents postpartum bleeding. Then inspect the perineum for tears and repair as indicated.

Note that in my above outline of the delivery process I have focused specifically on my actions in direct relation to the labouring mother. However, there are many key team players in the delivery process, including the nursing team, the obstetrical team (who may be consulted at any time for more support), the patient's social supports who may attend the labour and delivery, and oftentimes the anesthesiologist who provides epidural analgesia. The labour and delivery process is an incredible team feat, and having a strong mode of functioning that depends on effective communication and understanding others' roles is an irreplaceable asset for a smooth delivery.