INTRODUCTION Vaginal delivery is a natural process that has gradually become a medical procedure. Although early medical efforts were successful in decreasing maternal and fetal death rates, more recent and advanced interventions have not been shown to be as successful. Despite routine use in numerous settings, interventions such as electronic fetal monitoring, routine amniotomy, and fetal pulse oximetry have not been shown to improve outcomes. A few medical interventions, including routine episiotomy, have actually been shown to be harmful to the mother or the baby. As with all aspects of modern medicine, new information is available on a regular basis, and it is prudent to stay up-to-date with this information if attending deliveries. Although it is a natural process, labor and delivery is very complex and varies among patients. Labor can last for as little as an hour or less in some patients, or it can take several days in others. The underlying hormonal changes associated with labor are understood only superficially. It is beyond the scope of this text to explore all of the possible variables and complications that could occur during a vaginal delivery. The focus of this chapter will be on the uncomplicated vaginal delivery of a single newborn in the vertex position. When available, evidence-based recommendations will be made regarding the delivery technique. INDICATIONS Vertex presentation, active labor, vulva distended, and deliverable baby Fetal distress in a deliverable baby Delivery Observe the perineum for distention caused by the fetal head. When the head is visible ("crowning"), it is appropriate to apply pressure to the infant's head to control the force of delivery and to support the perineum with gentle pressure. If an episiotomy is to be performed, the best time to perform it is when the introital opening is 5 to 6 cm. Maintain flexion of the head with pressure applied through a towel placed on the perineum. The head should be delivered slowly, in a controlled manner, as it edges forward with each contraction. If a rapid delivery is necessary (e.g., fetal distress) or assistance is needed, a modified Ritgen maneuver can be used. To perform the Ritgen maneuver, palpate the infant's chin (through the towel on the perineum) and pull outward on the fetal chin, and then press upward to extend the head. For an OP delivery, deliver the head by applying flexion, not extension. Assisting and controlling the amount of flexion with one hand, through the towel on the perineum, may minimize the risk for lacerations. As the head is slowly delivered, check for a nuchal cord. If a nuchal cord is present, reduce it by pulling the cord over the delivered head. If the nuchal cord cannot be reduced, it can be doubly clamped and cut at the perineum. Wipe the mucus off the infant's nose and mouth while suctioning both orifices with a bulb syringe. Next, rotate the head to allow the shoulders to assume an AP position. Deliver the shoulders with slow and deliberate motions and without exerting excessive traction. Gently depress the head toward the maternal coccyx, and when the anterior shoulder has passed the symphysis, lift the fetal head upward. If shoulder dystocia is a concern, attempt to deliver the head and shoulders in one continuous motion, or use appropriate maneuvers to reduce the dystocia. Next, grasp the baby around the neck, and place a finger in the infant's axilla to maintain lateral flexion of the trunk. Deliver the trunk with gentle, continuous traction. Third Stage of Labor Once the anterior shoulder has been delivered, administer an oxytocic agent (20-40 units of oxytocin added to a liter of intravenous fluid is a common choice). Hold the infant with head down at the introitus, or place the infant on the mother's abdomen. Suction the mouth and nose with a bulb syringe. Clamp the cord soon after delivery about 3 to 4 cm from the umbilicus with a plastic cord clamp proximal to the infant and a curved artery clamp 3 to 5 cm distally.

• published: 01 Jan 2014
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