Vaginal Delivery: Chapter 27 of Williams Obstetrics 24th Edition

Book Reading
Vaginal Delivery
Chapter 27 of Williams Obstetrics 24th
Edition
presented by: dr. Uci Elisa

Section 8 Delivery
NATURAL CULMINATION OF THE
SECOND STAGE OF LABOR:
controlled vaginal delivery of a

healthy neonate with minimal trauma
to the mother
Vaginal delivery is the preferred
route of delivery for most fetuses
Certain clinical settings may favor
cesarean delivery
A malpresenting fetus (breech
delivery) or multifetal gestation may
be delivered vaginally but require
special techniques
Compared with cesarean delivery, spontaneous
vaginal delivery has lower associated rates of:
maternal infection
hemorrhage
anesthesia complications
peripartum hysterectomy
In contrast, pelvic floor disorders may be
increased in those initial undergoing vaginal
delivery
Pelvic floor protection advantages gained from
Cesarean delivery are lost as women age
Preparations for delivery
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 introitus vagina
separating labia
Increased perineal pressure from the fetal head
creates reflexive bearing- down efforts, which
are encouraged when appropriate -
Some considerations during labor
1. The bladder is palpated/distended ->catheterization
2. Continued attention is given to FHR monitoring (ex:
deceleration FHR lead by nuchal cord tightens with
descent)
3. Antibiotic prophylaxis against infective endocarditis
not to be given in women with cardiac conditions
except cyanotic heart disease or prosthetic valves
4. Pushing positions may vary, or stirrups are used
5. The most widely used & satisfactory for pushing
positions is dorsal lithotomy position. Leg holders
or stirrups are used for better exposure
5. Within the leg holders, 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.
6. Legs may cramp during the second stage
(because of pressure by the fetal head on
pelvic nerves) and may be relieved by:
repositioning the affected leg, brief massage
7. Preparation for delivery includes: vulvar and
perineal cleansing, placing sterile drapes in
the immediate area around the vulva is
exposed
OCCIPUT ANTERIOR POSITION
By the time of perineal distention, position of
the presenting occiput is usually known
(Molding and caput formation have precluded
accurate identification)
most presentation is directly occiput anterior
or is rotated slightly oblique
Persistent occiput posterior is identified rarely
(5 %), the vertex will be presenting in the
occiput transverse position
Delivery of the Head
Fetal head gradually widen vulvovaginal from
ovoid into 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
Routine Episiotomy ?
Episiotomy increases the risk of a tear into the
external anal sphincter, the rectum, or both
In contrast, in women in whom an episiotomy is
avoided : anterior tears involving the urethra
and labia are more common
Do not routinely perform episiotomy

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
Delivery of the Head
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
Ritgen Maneuver
allows controlled fetal head delivery
favors neck extension so that the head passes
through the introitus and over the perineum
with its smallest diameters
may be employed if expulsive efforts are
inadequate or expeditious delivery is needed
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
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% 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
the umbilical cord, if identified around the neck, is
readily slipped over the head
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 (external rotation: indicates
that the bisacromial diameter has rotated into
the antero-posterior diameter of the pelvis) ,
and the head assumes a transverse position.
Shoulders appear at the vulva after external rotation &
born spontaneously. If delayed, extraction aids controlled
delivery (The sides of the head are grasped with 2 hands,
downward traction is applied until the anterior shoulder
appears under the pubic arch
Delivery of the Shoulders
1. Gentle downward
traction to effect
descent of the
anterior shoulder
After the delivery of
the anterior shoulder
completed
2. Gentle upward traction to deliver the
posterior shoulder. *abrupt or powerful force is
avoided to avert brachial plexus injury
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
because 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
Clamping the Cord
The umbilical cord is cut
between 2 clamps placed 6-8
cm from the fetal abdomen
Umbilical cord clamp is
applied 2-3 cm from its
insertion into the fetal
abdomen
*using for example the
Double Grip Umbilical
Clamp (Hollister)
TERM: delay 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

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Vaginal Delivery: Chapter 27 of Williams Obstetrics 24th Edition

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Book Reading

presented by: dr. Uci Elisa

controlled vaginal delivery of a

The end of second-stage labor is heralded as:

Do not routinely perform episiotomy

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