self-consumption

2. VAGINAL DELIVERY
A Morning Report by OB Intern Baring

3. WHAT IS THE NATURAL CULMINATION OF THE
SECOND STAGE OF LABOR?
?
QUESTION:

4. Controlled vaginal delivery of
a healthy neonate with
minimal trauma to the mother
ANSWER:

5. Vaginal Delivery
-Vaginal delivery is the preferred route of delivery for most
fetuses
-Certain clinical settings may favor cesarean delivery
-A malpresenting fetus or multifetal gestation
may be delivered vaginally but require special techniques

6. Route of Delivery
-Spontaneous vaginal vertex delivery poses the lowest risk of
most maternal and fetal comorbidity
-Compared with cesarean delivery, spontaneous vaginal
delivery has lower associated rates of:
+maternal infection +hemorrhage
+anesthesia complications +peripartum hysterectomy
- Pelvic floor disorders may be increased in those initial
undergoing NSVD
-Pelvic floor protection advantages gained from Cesarean
delivery are lost as women age

7. -The end of second-stage labor is heralded as:
+the perineum begins to distend
+the overlying skin becomes stretched
+the fetal scalp is seen through the separating labia
-Increased perineal pressure from the fetal head creates
reflexive bearing- down efforts, which are encouraged when
appropriate
-Preparations are made for delivery
Preparation for Delivery

8. -Some considerations that arise during labor are reiterated
+the bladder is palpated > if distended > catheterization
+continued attention is given to FHR monitoring
+antibiotic prophylaxis against infective endocarditis
not to be given in most women w/ cardiac conditions
except those with cyanotic heart disease or
prosthetic valves or both.
-Pushing positions may vary, but for
delivery > dorsal lithotomy position
is the most widely used and often the most satisfactory
-For better exposure > leg holders or stirrups are used
Preparation for Delivery

9. -No increased rates of perineal lacerations with stirrup use
compared to without their use
-With positioning, legs are not separated too widely or placed
one higher than the other
-Within the leg holder, the popliteal region should rest
comfortably in the proximal portion and the heel in the distal
portion
-The legs are not strapped into the stirrups, thereby allowing
quick flexion of the thighs backward onto the abdomen should
shoulder dystocia develop
Preparation for Delivery

10. -Legs may cramp during the second stage, in part, because of
pressure by the fetal head on pelvic nerves
-Cramping may be relieved by:
+repositioning the affected leg
+brief massage
-Preparation for delivery includes vulvar and perineal
cleansing
-Sterile drapes may be placed in such a way that only the
immediate area around the vulva is exposed
Preparation for Delivery

11. -By the time of perineal distention, the position of the presenting
occiput is usually known
-Molding and caput formation have precluded accurate
identification
-Most cases, presentation is directly occiput anterior or is
rotated slightly oblique
-In perhaps 5 percent, persistent occiput posterior is identified
-Rarely, the vertex will be presenting in the occiput transverse
position
Occiput Anterior Position

12. -Vulvovaginal opening is dilated by the fetal head to gradually
form an ovoid and finally, an almost circular opening
*CROWNING - encirclement of the largest head diameter by the
vulvar ring
-Perineum thins; may undergo spontaneous laceration
*unless an episiotomy is done
-Anus becomes greatly stretched, and the anterior wall of the
rectum may be easily seen through it
Occiput Anterior Position
THE NEXT STEP
Delivery of the Head

13. Occiput Anterior Position
Episiotomy?
-Increases the risk of a tear into the external anal sphincter,
the rectum, or both
-Anterior tears involving the urethra and labia are more common in
women in whom an episiotomy is avoided
-Do not routinely perform episiotomy
Delivery of the Head

14. Occiput Anterior Position
How to Limit Vaginal Laceration?
-Intrapartum perineal massage - widens the introitus for head passage
STEPS:
1st: The perineum is grasped in the midline by both hands using
the thumb and opposing fingers
2nd: Outward and lateral stretch against the perineum is then
repeatedly applied
Delivery of the Head

15. Occiput Anterior Position
-When the head distends the vulva and perineum enough to open the
vaginal introitus to a diameter of 5 cm or more, a gloved hand may be
used to support the perineum
-The other hand is used to guide and control the fetal head to avoid
expulsive delivery
-Slow delivery of the head may decrease lacerations
Delivery of the Head

16. Occiput Anterior Position
-If expulsive efforts are inadequate or expeditious delivery is needed,
the modified Ritgen maneuver may be employed
STEPS:
1st: Gloved fingers beneath a draped towel exert forward
pressure on the fetal chin through the perineum just in
front of the coccyx
2nd: The other hand presses superiorly against the occiput
-The Ritgen maneuver allows controlled fetal head delivery
-It also favors neck extension so that the head passes through the
introitus and over the perineum with its smallest diameters
Delivery of the Head

17. The occiput is being kept close to the symphysis by moderate
pressure on the fetal chin at the tip of the maternal coccyx
Occiput Anterior Position
Delivery of the Head: Modified Ritgen Maneuver

18. Moderate upward pressure is applied to the fetal chin by the posterior
hand covered with a sterile towel, while the suboccipital region of the
fetal head is held against the symphysis.
Occiput Anterior Position
Delivery of the Head: Modified Ritgen Maneuver

19. Occiput Anterior Position
-Following delivery of the fetal head, a finger should be passed across
the fetal neck to determine whether it is encircled by one or more
umbilical cord loops
-A nuchal cord is found in approximately 25 percent of deliveries and
ordinarily causes no harm
*if an umbilical cord coil is felt:
loose: slipped over the head
applied too tightly: the loop should be cut between two clamps
Delivery of the Shoulders

20. The umbilical cord, if identified around the neck, is readily slipped
over the head
Occiput Anterior Position
Delivery of the Shoulders

21. Occiput Anterior Position
-Following its delivery, the fetal head falls posteriorly, bringing the
face almost into contact with the maternal anus
-The occiput promptly turns toward one of the maternal thighs, and
the head assumes a transverse position
*This external rotation indicates that the bisacromial diameter has
rotated into the antero-posterior diameter of the pelvis
Delivery of the Shoulders

22. Occiput Anterior Position
-Most often, the shoulders appear at the vulva just after external
rotation and are born spontaneously
-If delayed, extraction aids controlled delivery
-The sides of the head are grasped with two hands, and gentle
downward traction is applied until the anterior shoulder appears
under the pubic arch
-Next, by an upward movement, the posterior shoulder is delivered.
*abrupt or powerful force is avoided to avert brachial plexus injury
Delivery of the Shoulders

23. Occiput Anterior Position
Gentle downward traction to effect
descent of the anterior shoulder
After the delivery of the anterior
shoulder completed > Gentle upward
traction to deliver the posterior
shoulder
Delivery of the Shoulders

24. Occiput Anterior Position
-The rest of the body almost always follows the shoulders without
difficulty
-With prolonged delay, its birth may be hastened by moderate
traction on the head and moderate pressure on the uterine fundus
-Hooking the fingers in the axillae is avoided > can injure upper
extremity nerves and produce paralysis
-Traction, furthermore, should be exerted only in the direction of
the long axis of the neonate; applied obliquely, it causes neck
bending and excessive brachial plexus stretching
Delivery of the Shoulders

25. Occiput Anterior Position
-The umbilical cord is cut between two clamps placed 6 to 8 cm from
the fetal abdomen
-Umbilical cord clamp is applied 2 to 3 cm from its insertion into the
fetal abdomen
*using for example the Double Grip Umbilical Clamp (Hollister)
Clamping the Cord

26. Occiput Anterior Position
-TERM: delay in umbilical cord clamping for up to 60 seconds may:
+increase total body iron stores
+expand blood volume
+decrease anemia incidence
*valuable in populations in which iron deficiency is prevalent
-PRETERM: delayed cord clamping for 30-60 seconds has benefits:
+higher red cell volume
+decreased need for blood transfusion
+better circulatory stability
+lower rates of intraventricular hemorrhage and
necrotizing enterocolitis
Clamping the Cord

27. Other Positions
-Persistent occiput posterior
-Occiput transverse

28. WHEN DOES THE
THIRD STAGE OF LABOR
BEGIN AND WHEN DOES IT END?
?
QUESTION:

29. Third-stage labor begins
immediately after fetal birth
and ends with placental
delivery
ANSWER:

30. Delivery of the Placenta
-Delivery of an intact placenta
-Avoidance of uterine inversion or postpartum hemorrhage
Goals

31. Delivery of the Placenta
-Immediately after newborn birth, uterine fundal size and consistency
are examined...
+uterus remains firm, no unusual bleeding:
-watchful waiting until the placenta separates
-massage is not employed
-fundus is frequently palpated
-umbilical cord traction must not be used

32. Delivery of the Placenta
-Signs of Placental Separation:
+sudden gush of blood into the vagina
+globular and firmer fundus
+lengthening of the umbilical cord
as the placenta descends into the vagina
+rise of the uterus into the abdomen
*concurrently, the placenta, having separated,
passes down into the lower uterine segment and vagina
*appear within 1 minute after delivery; usually within 5 minutes

33. Delivery of the Placenta
-Once the placenta has detached from the uterine wall, it should be
determined that the uterus is firmly contracted
-Mother may be asked to bear down, and the intraabdominal pressure
often expels the placenta into the vagina
-After ensuring that the uterus is contracted firmly, pressure is
exerted by a hand wrapped around the fundus to propel the detached
placenta into the vagina
- The umbilical cord is kept slightly taut but is not pulled

34. Delivery of the Placenta
-Concurrently, the heel of the hand exerts downward pressure
between the symphysis pubis and the uterine fundus
-Once the placenta passes through the introitus, pressure on the
uterus is relieved
-The placenta is then gently lifted away

35. Delivery of the Placenta
The hand is not trying to
push the fundus of the
uterus through the birth
canal!
As the placenta leaves the
uterus and enters the
vagina, the uterus is
elevated by the hand on
the abdomen while the
cord is held in position.

36. Delivery of the Placenta
The placenta is removed
from the vagina by lifting
the cord

37. Delivery of the Placenta
Membranes that were
somewhat adhered to the
uterine lining are
separated by gentle
traction with a ring
forceps

38. Manual Delivery of the Placenta
-Occasionally, the placenta will not separate promptly;
common with preterm delivery (Dombrowski, 1995)
-If there is brisk bleeding and the placenta cannot be delivered
spontaneously, manual removal of the placenta is indicated

39. -One hand grasps the fundus
-The other hand is inserted into
the uterine cavity, and the
fingers are swept from side to
side as they are advanced
-When the placenta has
become detached, it is
grasped and removed
Manual Delivery of the Placenta

40. Management of the 3rd Stage of Labor
-Practices within the 3rd stage of labor may be considered as either:
+Physiological or Expectant Management
+Active management

41. Management of the 3rd Stage of Labor
Physiological or
expectant management
-involves waiting for placental
separation signs and allowing
the placenta to deliver either
spontaneously or aided by
nipple stimulation or gravity
(World Health Organization,
2012)
Active management
-consists of:
+early cord clamping
+controlled cord traction
during placental delivery
+immediate administration
of prophylactic uterotonics
*goal - limit postpartum
hemorrhage
-may include uterine massage

42. Management of the 3rd Stage of Labor
Active management
-Uterotonics appear to be the most important factor to decrease
postpartum blood loss
-Choices include:
+oxytocin (Pitocin) - first-line agent
+misoprostol (Cytotec)
+carboprost (Hemabate)
+The Ergots - second-line agents
-ergonovine (Ergotrate)
-methylergonovine (Methergine)

43. Management of the 3rd Stage of Labor
Active management
-Uterotonics may be given before or after placental expulsion without
increasing rates of postpartum hemorrhage, placental retention, or
third-stage labor length (Soltani, 2010)
-If given before delivery of the placenta > may entrap an undiagnosed,
undelivered second twin
*abdominal palpation should confirm no additional fetuses

44. Management of the 3rd Stage of Labor
Uterotonics: OXYTOCIN
-Synthetic oxytocin is identical to that produced by the posterior
pituitary
-Action is noted at approximately 1 minute, and it has a mean half-
life of 3 to 5 minutes
-Not given Intravenously as a large bolus
-Given as a dilute solution by continuous intravenous infusion or as
an intramuscular injection

45. Management of the 3rd Stage of Labor
-Despite the routine use of oxytocin, no standard prophylactic dose
is established for its use following either vaginal delivery or CS
-Standard practice:
+Intravenous infusion
-add 20 units (2 mL) of oxytocin per liter of infusate
*administered after delivery of the placenta at
a rate of 10 to 20 mL/min (200 to 400 mU/min) for a
few minutes until the uterus remains firmly contracted
and bleeding is controlled
*reduced to 1 to 2 mL/ min until the mother is
ready for transfer from the RR to the postpartum unit
+Intramuscular: 10 units is given

46. Management of the 3rd Stage of Labor
Uterotonics: ERGOT ALKALOIDS
-Ergonovine and Methylergonovine have similar activity levels in
myometrium
-Powerful stimulants of myometrial contraction exerting an effect
which may persist for hours
-Require very specific storage conditions
-DANGEROUS to the fetus when given before delivery
-Side effects: transient maternal hypertension, N/V, headache,
tinnitus, painful uterine contractions

47. Management of the 3rd Stage of Labor
Uterotonics: MISOPROSTOL
-This prostaglandin E1 analogue has proved inferior to oxytocin for
postpartum hemorrhage prevention (Tunçalp, 2012)
-In resource-poor settings that lack oxytocin, misoprostol is
suitable for hemorrhage prophylaxis and is given as a single oral
600-µg dose
-Side effects include:
+shivering - 30 percent
+fever - 5 percent
-Unlike other prostaglandins, nausea or diarrhea is infrequent

48. WHAT IS THE
FOURTH STAGE OF LABOR?
?
QUESTION:

49. The hour immediately
following delivery of the
placenta has been designated
by some as the critical
fourth stage of labor
ANSWER:

50. Why Critical?
-Lacerations are repaired
-Postpartum hemorrhage
despite uterotonics as the
result of uterine atony is most
likely
-Hematomas may expand
-Uterine tone and the
perineum should be frequently
evaluated
-Maternal blood pressure and
pulse be recorded immediately
after delivery and every 15
minutes for the first 2 hours
-Placenta, membranes, and
umbilical cord should be
examined for completeness
and for anomalies
What can be done?

51. Birth Canal Lacerations
-Lower genital tract lacerations may involve the cervix, vagina, or
perineum
-Perineal tears may follow any vaginal delivery and are classified by
their depth
-Third and fourth-degree lacerations are considered higher-order
lacerations and are associated with greater blood loss, puerperal
pain, and wound disruption or infection risk

52. First
Degree
Second
Degree
Third
Degree
Fourth
Degree

53. First
Degree
-Involve the fourchette, perineal skin, and vaginal mucous membrane
but not the underlying fascia and muscle
-These included periurethral lacerations, which may bleed profusely

54. Second
Degree
-Involve, in
addition, the fascia
and muscles of the
perineal body but
not the anal
sphincter
-These tears may
be midline, but
often extend
upward on one or
both sides of the
vagina, forming an
irregular triangle

55. Third
Degree
-Extend farther to
involve the external
anal sphincter

56. Fourth
Degree
-Extend completely through the rectal mucosa to expose
its lumen and thus involves disruption of both the external and
internal anal sphincters

57. Episiotomy
-The word episiotomy derives from the Greek episton—pubic
region—plus –tomy—to cut
-Definitions:
+Episiotomy - incision of the pudendum—the external
genital organs
+Perineotomy - incision of the perineum
-Incision may be made in the midline, creating a median or midline
episiotomy or begin off the midline and directed laterally and
downward away from the rectum, termed a mediolateral episiotomy

58. Episiotomy
-Should be considered for indications such as:
+shoulder dystocia
+breech delivery
+macrosomic fetuses
+operative vaginal deliveries
+persistent occiput posterior positions
+other instances in which failure to perform will result
in significant perineal rupture

59. Episiotomy
Midline VS Mediolateral

60. Episiotomy
Midline
Cut

61. Repair
Midline Episiotomy
1st 2nd

62. Repair
Midline Episiotomy
3rd 4th 5th

63. Repair
Mediolateral
Episiotomy

64. Repair
Fourth-degree Laceration
1st 2nd

65. Repair
Fourth-degree Laceration
3rd

66. Repair
Fourth-degree Laceration
4th

67. Repair
Fourth-degree Laceration
5th

68. Thank You
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