INTRODUCTION

Pregnancy, the state of carrying a developing embryo or fetus within the female body. This condition can be indicated by positive results on an over-the-counter urine test, and confirmed through a blood test, ultrasound, detection of fetal heartbeat, or an X-ray. Pregnancy lasts for about nine months, measured from the date of the woman's last menstrual period (LMP). It is

conventionally divided into three trimesters, each roughly three months long. When gestation has completed, it goes through a process called delivery, where the developed fetus is expelled from the mothers womb. There are two options of delivery: Cesarean section and NSVD or normal spontaneous vaginal delivery. A cesarean section is a surgical incision through the mothers abdomen and uterus to deliver one or more fetuses. NSVD or normal spontaneous vaginal delivery is the delivery of the baby through vaginal route. It can also be called NSD or normal spontaneous delivery, or SVD or spontaneous vaginal delivery, where the mother delivers the baby with effort and force exertion. Normal labor is defined as the gradual subjugation and dilatation of the uterine cervix as a result of rhythmic uterine contractions leading to the expulsion of the products of conception:

the delivery of the fetus, membranes, umbilical cord, and placenta. Laboring cannot that be easy; thereby implicating that there are processes and stages to be undertaken to achieve spontaneous delivery. Through which, Obstetrics have divided labor into four (4) stages thereby explaining this continuous process. STAGE 1: It is usually the longest part of labor. It begins with regular uterine contractions and ends with complete cervical dilatation at 10 centimeters. This stage is broken down into three (3) phases: theEarly phase, where the contractions are usually very light and maybe approximately 20 minutes or more apart from the beginning, gradually becoming closer, possibly up to five minutes apart; the Active phase, where contractions are generally four or five times apart, and may last up to 60 seconds long. Cervix dilates with 4-7 cm and initiates a more rapid dilatation. It is known that to get through active labor, mobility and relaxations are done to increase contractions; and the Transition phase, where it is definitely known as the shortest phase but the hardest, contractions maybe two or three times apart, lasting up to a minute and a half, about approximately 8-10 cm of cervical dilatation. Some women will shake and may vomit during this stage, and this is regarded as normal. Most of the time, women would find a comfortable position to acquire complete dilatation. STAGE II: This stage lasts for three or more hours. However,

the length of this stage depends upon the mothers position (e.g.; upright position yields faster delivery). Once the cervix has completely dilated, the second stage had begun. This stage ends with the expulsion of the fetus. STAGE III: This stage focuses on the expulsion of the placenta from the mother. Placenta exclusion is much more easier than the delivery of the baby because it includes no bones, and this is during this stage that the baby is placed on top of the mothers womb. STAGE IV: No more expulsions of conception products for this stage as this is generally accepted as POST PARTUM juncture. This phase is from the placental delivery to full recovery of the mother. Labor and delivery of the fetus entails physiological effects both on the mother and the fetus. In the cardiovascular system, the mothers cardiac output increases because of the increase in the needed amount of blood in the uterine area. Blood pressure may also rise due to the effort exerted by the mother in order expel the fetus. There could also be a development of leukocytes or a sharp increase in the number of circulating white blood cells possibly as a result of stress and heavy exertion. Increased respiratory may also occur. This happens as a response to the increase in blood supply in order to increase also the oxygen intake.

Braxton Hicks contractions, or also known as false labor orpract ice contractions. Braxton Hicks are sporadic uterine contractions that actually start at about 6 weeks, although one will not feel them that early. Most women start feeling them during the second or third trimester of pregnancy. True labor is felt in the upper and mid abdomen and leads to the cervical changes that define true labor. With delivery imminent, the mother is usually placed supine with her knees bent (ie, the dorsal lithotomy position). An episiotomy (an incision continuous with the vaginal introitus) may be performed at this time. Episiotomy may ease delivery of the fetal head and allow some control over what may otherwise be an uncontrolled perineal laceration. However, many providers no longer perform routine episiotomy, since it may increase the risk of rectal injury and are larger than the spontaneous laceration. The labor and birth process is always accompanied by pain. Several options for pain control are available, ranging from intramuscular or intravenous doses of narcotics, such as Meperidine (Demerol), to general anesthesia. Regional nerve blocks, such as a pudendal block or local infiltration of the perineal area can also be used. Further options include epidural blocks and spinal

anesthetics.
How Procedure is Performed
Labor is allowed to progress naturally whenever possible. The mother is encouraged to assume whatever

positions are the most comfortable for her during contractions. Lying on either side may both reduce pain and increase maternal blood flow. Vertical positions such as standing or kneeling may be preferable, if tolerated. Walking, showering, and soaking in a hot tub can ease labor pain and allow it to progress more rapidly. Pain medication administered locally, by injection or into the spine (epidural), may be given at the mother's request. The baby usually presents head first, with its face rotated toward the mother's spine and crowns to spontaneously deliver vaginally with maternal pushing efforts that are coordinated with contractions. If the baby's head does not spontaneously rotate and descend, instruments such as forceps or a vacuum extractor may be used to gently turn or turn and assist with the final expulsion of the baby's head (assisted vaginal delivery). This type of assistance may also be used for more rapid delivery if the mother tires of pushing, or contractions cease prior to delivery, or fetal or maternal distress develops. For use of either forceps or vacuum extraction, the cervix must be almost completely dilated and the mother's bladder must be empty. The mother's feet/legs are placed in stirrups to maximally expose her perineum. An incision to enlarge the vaginal opening (episiotomy) may or may not be necessary, based on the likelihood of the mother's tissues tearing during delivery. For a vacuum extraction, a soft or metal cup is applied to the crown of the baby's head, and suction traction is applied to the cup while the mother pushes. The traction, combined with maternal pushing, propels the baby from the vagina. The cup is removed once the baby's head is entirely delivered. For forceps assistance, the metal forceps are applied to the sides of the baby's head and can be used to turn or turn and lift the baby's head from the vagina, with the assistance of the mother's contractions and efforts at pushing. Local or regional anesthesia (spinal or epidural) may be used for all types of vaginal deliveries and is more commonly used if assistance with forceps or a vacuum extractor is necessary. Other techniques that can be used to assist with stimulation of labor include artificially rupturing the bag of amniotic fluid surrounding the baby (amniotomy), inducting (stimulating) contractions, or using the hormone oxytocin to enhance inefficient contractions. Oxytocin is also usually given after delivery of the baby and placenta to contract the uterus and reduce postpartum bleeding.
Source: Medical Disability Advisor

How Procedure is Performed

Labor is allowed to progress naturally whenever possible. The mother is encouraged to assume whatever positions are the most comfortable for her during contractions. Lying on either side may both reduce pain and increase maternal blood flow. Vertical positions such as standing or kneeling may be preferable, if tolerated. Walking, showering, and soaking in a hot tub can ease labor pain and allow it to progress more rapidly. Pain medication administered locally, by injection or into the spine (epidural), may be given at the mother's request. The baby usually presents head first, with its face rotated toward the mother's spine and crowns to spontaneously deliver vaginally with maternal pushing efforts that are coordinated with contractions. If the baby's head does not spontaneously rotate and descend, instruments such as forceps or a vacuum extractor may be used to gently turn or turn and assist with the final expulsion of the baby's head (assisted vaginal delivery). This type of assistance may also be used for more rapid delivery if the mother tires of pushing, or contractions cease prior to delivery, or fetal or maternal distress develops. For use of either forceps or vacuum extraction, the cervix must be almost completely dilated and the mother's bladder must be empty. The mother's feet/legs are placed in stirrups to maximally expose her perineum. An incision to enlarge the vaginal opening (episiotomy) may or may not be necessary, based on the likelihood of the mother's tissues tearing during delivery. For a vacuum extraction, a soft or metal

cup is applied to the crown of the baby's head, and suction traction is applied to the cup while the mother pushes. The traction, combined with maternal pushing, propels the baby from the vagina. The cup is removed once the baby's head is entirely delivered. For forceps assistance, the metal forceps are applied to the sides of the baby's head and can be used to turn or turn and lift the baby's head from the vagina, with the assistance of the mother's contractions and efforts at pushing. Local or regional anesthesia (spinal or epidural) may be used for all types of vaginal deliveries and is more commonly used if assistance with forceps or a vacuum extractor is necessary. Other techniques that can be used to assist with stimulation of labor include artificially rupturing the bag of amniotic fluid surrounding the baby (amniotomy), inducting (stimulating) contractions, or using the hormone oxytocin to enhance inefficient contractions. Oxytocin is also usually given after delivery of the baby and placenta to contract the uterus and reduce postpartum bleeding.

Source: Medical Disability Advisor

Definition
Delivery presentation describes the way the baby (fetus) is positioned to come down the birth canal for delivery.

Alternative Names
Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude

Information
THE DELIVERY PROCESS The delivery process is described in terms of fetal station, lie, attitude, and presentation. Fetal station: This is the relationship between the presenting part of the baby -- the head, shoulder, buttocks, or feet -- and two parts of the mother's pelvis called

Read more: http://www.righthealth.com/topic/About_Normal_Delivery#ixzz1OOSA5heCDefinition

Delivery presentation describes the way the baby (fetus) is positioned to come down the birth canal for delivery.

Alternative Names
Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude

Information
THE DELIVERY PROCESS The delivery process is described in terms of fetal station, lie, attitude, and presentation. Fetal station: This is the relationship between the presenting part of the baby -- the head, shoulder, buttocks, or feet -- and two parts of the mother's pelvis called the ischial spines. Normally the ischial spines are the narrowest part of the pelvis. They are a natural measuring point for the delivery progress. If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5 (each number is a centimeter). If the presenting part lies below the ischial spines, the station is reported as a positive number from 1 to 5. The baby is said to be "engaged" in the pelvis when it is even with the ischial spines at 0 station. Fetal lie: This is the relationship between the head to tailbone axis of the fetus and the head to tailbone axis of the mother. If the two are parallel, then the fetus is said to be in a longitudinal lie. If the two are at 90-degree angles to each other, the fetus is said to be in a transverse lie. Nearly all (99.5%) fetuses are in a longitudinal lie. Fetal attitude: The fetal attitude describes the relationship of the fetus' body parts to one another. The normal fetal attitude is commonly referred to as the fetal position. The head is tucked down to the chest, with arms and legs drawn in towards the center of the chest. Abnormal fetal attitudes may include a head that is extended back or other body parts extended or positioned behind the back. Abnormal fetal attitudes can increase the diameter of the presenting part as it passes through the pelvis, increasing the difficulty of birth. Fetal presentation: Cephalic (head-first) presentation: Cephalic presentation is considered normal and occurs in about 97% of deliveries. There are different types of cephalic presentation, which depend on the fetal attitude. Rarely, the fetus' head is extended back, and the chin, face, or forehead will present first depending on the degree of extension. This is a more difficult delivery, because this is not the smallest part of the fetus' head. It may result in a need for cesarean delivery. A cesarean delivery may be recommended for any of the fetal positions other than cephalic. Breech presentation:

Breech presentation is considered abnormal and occurs about 3% of the time. A complete breech presentation occurs when the buttocks present first, and both the hips and knees are flexed. A frank breech occurs when the hips are flexed so the legs are straight and completely drawn up toward the chest. Other breech positions occur when either the feet or knees come out first. Shoulder presentation: The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common with premature delivery or multiple pregnancies.

Read more: http://www.righthealth.com/topic/About_Normal_Delivery/overview/adam20_s#ixzz1OOSyufn3Fetal lie: This is the relationship between the head to tailbone axis of the fetus and the head to tailbone axis of the mother. If the two are parallel, then the fetus is said to be in a longitudinal lie. If the two are at 90-degree angles to each other, the fetus is said to be in a transverse lie. Nearly all (99.5%) fetuses are in a longitudinal lie. Fetal attitude: The fetal attitude describes the relationship of the fetus' body parts to one another. The normal fetal attitude is commonly referred to as the fetal position. The head is tucked down to the chest, with arms and legs drawn in towards the center of the chest. Abnormal fetal attitudes may include a head that is extended back or other body parts extended or positioned behind the back. Abnormal fetal attitudes can increase the diameter of the presenting part as it passes through the pelvis, increasing the difficulty of birth. Fetal presentation: Cephalic (head-first) presentation: Cephalic presentation is considered normal and occurs in about 97% of deliveries. There are different types of cephalic presentation, which depend on the fetal attitude. Rarely, the fetus' head is extended back, and the chin, face, or forehead will present first depending on the degree of extension. This is a more difficult delivery, because this is not the smallest part of the fetus' head. It may result in a need for cesarean delivery. A cesarean delivery may be recommended for any of the fetal positions other than cephalic. Breech presentation: Breech presentation is considered abnormal and occurs about 3% of the time. A complete breech presentation occurs when the buttocks present first, and both the hips and knees are flexed. A frank breech occurs when the hips are flexed so the legs are straight and completely drawn up toward the chest. Other breech positions occur when either the feet or knees come out first.

Shoulder presentation: The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common with premature delivery or multiple pregnancies.

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Normal Spontaneous Vaginal Delivery a.k.a. Vaginal Birth, Spontaneous Vaginal Delivery, Normal Vaginal Delivery, is the term used to describe any delivery of the baby through the vagina (versus a c-section delivery). The baby typically comes through head first. If the baby is not head first, (e.g., breech) it may need to be delivered by c-section. Variations When the amniotic sac has not ruptured during labor or pushing, the infant can be born with the membranes intact. This is referred to as "being born in the caul." The caul is harmless and easily wiped away by the doctor or person assisting with the childbirth. In medieval times, a caul was seen as a sign of good fortune for the baby, in some cultures was seen as protection against drowning, and the caul was often impressed onto paper and stored away as an heirloom for the child. With the advent of modern interventive obstetrics, premature artificial rupture of the membranes has become common and it is rare for infants to be born in the caul in Western births. Pain control Due to the relatively-large size of the human skull and the shape of the human pelvis forced by the erect posture, childbirth is more difficult and painful for human mothers than other mammals. Many methods are available to reduce the pain of

labor, including psychological preparation, emotional support, epidural analgesia, spinal anesthesia, nitrous oxide and opioids, the Lamaze Technique. Each method has its own advantages and disadvantages. Complications Complications occasionally arise during childbirth; these generally require management by an obstetrician. Non-progression of labor (longterm contractions without adequate cervical dilation) is generally treated with cervical prostaglandin gel or intravenous synthetic oxytocin preparations. If this is ineffective, Caesarean section may be necessary. Fetal distress is the development of signs of distress by the child. These may include rising or decreasing heartbeat (monitored on cardiotocography/CTG), shedding of meconium in the amniotic fluid, and other signs. Non-progression of expulsion (the head or presenting parts are not delivered despite adequate contractions): this can require interventions such as vacuum extraction, forceps extraction and Caesarian section. In the past, a great many women died during or shortly after childbirth but modern medical techniques available in industrialized countries have greatly reduced this total. Social aspects In modern times, participation of the father during childbirth is now the norm. However, before the 1960's, in most cultures the father was forbidden to enter childbirth area, as were other men with the exception of the doctor. The exception to this rule were Poleshuks from Polesie. In this culture the wife gave birth sitting on her husband's knees. Legal aspects In many legal systems, the place of childbirth decides nationality of a child. The birth certificate is the basic document, which proves that the individual is a human being. References

Overview
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 the 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] Over the past few decades, the number of patients who go into spontaneous labor has decreased, and the percentage of inductions (iatrogenic labor) has increased to 22% of all pregnancies. [22] 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%. o The first stage of labor is divided into the latent and active phases. o The latent phase can last for many hours. The cervix dilates, usually slowly, from closed to approximately 4-5 cm. o The active phase lasts from the end of the latent phase until delivery. It is characterized by rapid cervical dilation. The cervix usually dilates at a rate of 1.0 cm/h in nulliparous women and 1.2 cm/h in multiparous women during the active phase. The second stage of labor is the time between complete cervical dilation and delivery of the neonate. This phase lasts minutes to hours. o 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 o 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 station is the relation of the fetal head to the maternal ischial spines. The station is defined as -5 cm to +5 cm; 0 station is at the level of the ischial spines. 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 as the vertex internally rotates. The delivery of the placenta is the third and final stage of labor; it normally 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.

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Normal vaginal delivery of the newborn includes the following circumstances: o Spontaneous labor mediated by pituitary and placental hormone cascades o Rupture of amniotic and chorionic membranes (suggested by the presence of a watery vaginal discharge or new oligohydramnios on ultrasonograph) o Induction of labor (indicated 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 membrane rupture requires confirmation. If the cervix is favorable, oxytocin is given to induce uterine contractions. A favorable cervix is defined by the Bishop score, which includes parameters like cervical dilation, softening, effacement, and station. If the cervix is not favorable and no contraindications are present, cervical ripening can be facilitated with intravaginal prostaglandins before oxytocin is initiated.[3] A balloon catheter can also be used for ripening. Pennell et al compared 3 methods of ripening the cervix in nulliparous women at term and found that the single-balloon catheter offers the best combination of safety and patient comfort. In a randomized controlled trial, 330 nulliparous women with unfavorable cervices induced at term were treated with 1 of 3 methods: double-balloon catheters, single-balloon catheters, or prostaglandin gel. Cesarean delivery rates were high with all 3 methods. Single-balloon catheter use was associated with earlier delivery and with significantly less pain: 36% of patients had a pain score of 4, vs 55% of

patients treated with double-balloon catheterization and 63% of those treated with prostaglandin gel (P < 0.001). Induction was complicated by uterine stimulation in 14% of patients in the prostaglandin arm, but none of those in the catheter arms, and mean cord arterial pH was lower in the prostaglandin arm (7.25 vs 7.26 in the catheter arms [P =0.050]).[24] For more information, see eMedicine's Cervical Ripening article. Normal vaginal delivery of the newborn includes the following circumstances: o Spontaneous labor mediated by pituitary and placental hormone cascades o Rupture of amniotic and chorionic membranes (suggested by the presence of a watery vaginal discharge or new oligohydramnios on ultrasonograph) o Induction of labor (indicated 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 membrane rupture requires confirmation. If the cervix is favorable, oxytocin is given to induce uterine contractions. A favorable cervix is defined by the Bishop score, which includes parameters like cervical dilation, softening, effacement, and station. If the cervix is not favorable and no contraindications are present, cervical ripening can be facilitated with intravaginal prostaglandins before oxytocin is initiated.[3] A balloon catheter can also be used for ripening. Pennell et al compared 3 methods of ripening the cervix in nulliparous women at term and found that the single-balloon catheter offers the best combination of safety and patient comfort. In a randomized controlled trial, 330 nulliparous women with unfavorable cervices induced at term were treated with 1 of 3 methods: double-balloon catheters, single-balloon catheters, or prostaglandin gel. Cesarean delivery rates were high with all 3 methods. Single-balloon catheter use was associated with earlier delivery and with significantly less pain: 36% of patients had a pain score of 4, vs 55% of patients treated with double-balloon catheterization and 63% of those treated with prostaglandin gel (P < 0.001). Induction was complicated by uterine stimulation in 14% of patients in the prostaglandin arm, but none of those in the catheter arms, and mean cord arterial pH was lower in the prostaglandin arm (7.25 vs 7.26 in the catheter arms [P =0.050]).[24] For more information, see eMedicine's Cervical Ripening article. Normal vaginal delivery of the newborn includes the following circumstances: o Spontaneous labor mediated by pituitary and placental hormone cascades o Rupture of amniotic and chorionic membranes (suggested by the presence of a watery vaginal discharge or new oligohydramnios on ultrasonograph) o Induction of labor (indicated 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 membrane rupture requires confirmation. If the cervix is favorable, oxytocin is given to induce uterine contractions. A favorable cervix is defined by the Bishop score, which includes parameters like cervical dilation, softening, effacement, and station. If the cervix is not favorable and no contraindications are present, cervical ripening can be facilitated with intravaginal prostaglandins before oxytocin is initiated.[3] A balloon catheter can also be used for ripening. Pennell et al compared 3 methods of ripening the cervix in nulliparous women at term and found that the single-balloon catheter offers the best combination of safety and patient comfort. In a randomized controlled trial, 330 nulliparous women with unfavorable cervices induced at term were treated with 1 of 3 methods: double-balloon catheters, single-balloon catheters, or prostaglandin gel. Cesarean delivery rates were high with all 3 methods. Single-balloon catheter use was associated with earlier delivery and with significantly less pain: 36% of patients had a pain score of 4, vs 55% of

patients treated with double-balloon catheterization and 63% of those treated with prostaglandin gel (P < 0.001). Induction was complicated by uterine stimulation in 14% of patients in the prostaglandin arm, but none of those in the catheter arms, and mean cord arterial pH was lower in the prostaglandin arm (7.25 vs 7.26 in the catheter arms [P =0.050]).[24] For more information, see eMedicine's Cervical Ripening article. While most full-term newborns in the United States are delivered vaginally, vaginal birth is contraindicated in some circumstances, including those described in this section. Cord prolapse o 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. o The incidence of cord prolapse is directly proportional to cord length. o The treatment is immediate conversion to cesarean delivery. If not treated emergently, cord prolapse is associated with high perinatal mortality. Brow presentation o This may convert to face or vertex presentation and may be managed expectantly. o If the patient is unstable or no conversion occurs, cesarean delivery is recommended. Face presentation o 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. o If the face is mentum posterior (chin facing the maternal sacrum), a cesarean delivery is required. Breech presentation o Up to 5% of all fetuses and 1-3% of full-term pregnancies 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. o 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. o The American Congress of Obstetricians and Gynecologists (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 o Fetal positions compatible with vaginal delivery are occiput anterior (OA), right occiput anterior (ROA), and left occiput anterior (LOA). o The occiput posterior (OP) position can be unfavorable for passage through the birth canal. Labor progress should be monitored for progression. If the fetal station is high and without descent during labor, change to abdominal delivery should be considered. o Deep transverse arrest occurs when the fetal head remains in transverse position without descent. Unfavorable maternal pelvic anatomy is the most common cause; abdominal delivery should be considered promptly. o 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, maternal risk for infection, uterine rupture, or both is high. Emergent abdominal delivery is indicated. Twin pregnancy o If a nonvertex second twin presentation occurs, it is managed according to gestational age, maternal 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 o In the United States, cesarean delivery is planned for higher order births. Vaginal delivery after cesarean delivery o While safe in most circumstances, vaginal delivery after previous cesarean delivery remains controversial because of the rare but serious complication of uterine rupture. The risk of uterine rupture is approximately 0.5% in patients who have had one prior low transverse cesarean delivery. o The success rate of this procedure is greater than 50%. o During the delivery, careful fetal and maternal monitoring are needed to detect early signs of dystocia or uterine rupture. o 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. o This type of delivery is contraindicated in cases of multiple prior cesarean deliveries, a history of a classical or T-shaped uterine scar, the presence of placenta previa, the presence of other uterine scars, or concern for true cephalopelvic disproportion. Nonreassuring fetal heart rate patterns o 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. o Causes of fetal distress include placental abruption, placental insufficiency, or a tight nuchal cord. Most cesarean deliveries undertaken for suspected fetal distress result in healthy birth outcomes. Macrosomia o Fetal weight greater than 4000-4500 g is associated with a higher risk of shoulder dystocia and birth trauma during vaginal delivery.[5] o Mothers with diabetes have a higher incidence of macrosomia and risk of shoulder dystocia. o If the estimated fetal weight is greater than 4500 g in a mother with diabetes, ACOG recommends abdominal delivery. o If the mother does not have diabetes, abdominal delivery is not recommended until an estimated fetal weight of 5000 g. Abnormal placentation o Placenta previa (the placenta implanted over the cervical os) is a contraindication to vaginal delivery because of the risk of hemorrhage as the cervix dilates.

Placenta previa complicates up to 2% of all pregnancies. Risk factors include artificial reproductive technology and prior cesarean delivery. While most full-term newborns in the United States are delivered vaginally, vaginal birth is contraindicated in some circumstances, including those described in this section. Cord prolapse o 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. o The incidence of cord prolapse is directly proportional to cord length. o The treatment is immediate conversion to cesarean delivery. If not treated emergently, cord prolapse is associated with high perinatal mortality. Brow presentation o This may convert to face or vertex presentation and may be managed expectantly. o If the patient is unstable or no conversion occurs, cesarean delivery is recommended. Face presentation o 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. o If the face is mentum posterior (chin facing the maternal sacrum), a cesarean delivery is required. Breech presentation o Up to 5% of all fetuses and 1-3% of full-term pregnancies 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. o 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. o The American Congress of Obstetricians and Gynecologists (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 o Fetal positions compatible with vaginal delivery are occiput anterior (OA), right occiput anterior (ROA), and left occiput anterior (LOA). o The occiput posterior (OP) position can be unfavorable for passage through the birth canal. Labor progress should be monitored for progression. If the fetal station is high and without descent during labor, change to abdominal delivery should be considered. o Deep transverse arrest occurs when the fetal head remains in transverse position without descent. Unfavorable maternal pelvic anatomy is the most common cause; abdominal delivery should be considered promptly. o 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, maternal risk for infection, uterine rupture, or both is high. Emergent abdominal delivery is indicated. Twin pregnancy

If a nonvertex second twin presentation occurs, it is managed according to gestational age, maternal 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 o In the United States, cesarean delivery is planned for higher order births. Vaginal delivery after cesarean delivery o While safe in most circumstances, vaginal delivery after previous cesarean delivery remains controversial because of the rare but serious complication of uterine rupture. The risk of uterine rupture is approximately 0.5% in patients who have had one prior low transverse cesarean delivery. o The success rate of this procedure is greater than 50%. o During the delivery, careful fetal and maternal monitoring are needed to detect early signs of dystocia or uterine rupture. o 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. o This type of delivery is contraindicated in cases of multiple prior cesarean deliveries, a history of a classical or T-shaped uterine scar, the presence of placenta previa, the presence of other uterine scars, or concern for true cephalopelvic disproportion. Nonreassuring fetal heart rate patterns o 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. o Causes of fetal distress include placental abruption, placental insufficiency, or a tight nuchal cord. Most cesarean deliveries undertaken for suspected fetal distress result in healthy birth outcomes. Macrosomia o Fetal weight greater than 4000-4500 g is associated with a higher risk of shoulder dystocia and birth trauma during vaginal delivery.[5] o Mothers with diabetes have a higher incidence of macrosomia and risk of shoulder dystocia. o If the estimated fetal weight is greater than 4500 g in a mother with diabetes, ACOG recommends abdominal delivery. o If the mother does not have diabetes, abdominal delivery is not recommended until an estimated fetal weight of 5000 g. Abnormal placentation o Placenta previa (the placenta implanted over the cervical os) is a contraindication to vaginal delivery because of the risk of hemorrhage as the cervix dilates. o Placenta previa complicates up to 2% of all pregnancies. Risk factors include artificial reproductive technology and prior cesarean delivery. While most full-term newborns in the United States are delivered vaginally, vaginal birth is contraindicated in some circumstances, including those described in this section.

Cord prolapse o 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. o The incidence of cord prolapse is directly proportional to cord length. o The treatment is immediate conversion to cesarean delivery. If not treated emergently, cord prolapse is associated with high perinatal mortality. Brow presentation o This may convert to face or vertex presentation and may be managed expectantly. o If the patient is unstable or no conversion occurs, cesarean delivery is recommended. Face presentation o 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. o If the face is mentum posterior (chin facing the maternal sacrum), a cesarean delivery is required. Breech presentation o Up to 5% of all fetuses and 1-3% of full-term pregnancies 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. o 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. o The American Congress of Obstetricians and Gynecologists (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 o Fetal positions compatible with vaginal delivery are occiput anterior (OA), right occiput anterior (ROA), and left occiput anterior (LOA). o The occiput posterior (OP) position can be unfavorable for passage through the birth canal. Labor progress should be monitored for progression. If the fetal station is high and without descent during labor, change to abdominal delivery should be considered. o Deep transverse arrest occurs when the fetal head remains in transverse position without descent. Unfavorable maternal pelvic anatomy is the most common cause; abdominal delivery should be considered promptly. o 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, maternal risk for infection, uterine rupture, or both is high. Emergent abdominal delivery is indicated. Twin pregnancy o If a nonvertex second twin presentation occurs, it is managed according to gestational age, maternal 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 o In the United States, cesarean delivery is planned for higher order births. Vaginal delivery after cesarean delivery o While safe in most circumstances, vaginal delivery after previous cesarean delivery remains controversial because of the rare but serious complication of uterine rupture. The risk of uterine rupture is approximately 0.5% in patients who have had one prior low transverse cesarean delivery. o The success rate of this procedure is greater than 50%. o During the delivery, careful fetal and maternal monitoring are needed to detect early signs of dystocia or uterine rupture. o 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. o This type of delivery is contraindicated in cases of multiple prior cesarean deliveries, a history of a classical or T-shaped uterine scar, the presence of placenta previa, the presence of other uterine scars, or concern for true cephalopelvic disproportion. Nonreassuring fetal heart rate patterns o 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. o Causes of fetal distress include placental abruption, placental insufficiency, or a tight nuchal cord. Most cesarean deliveries undertaken for suspected fetal distress result in healthy birth outcomes. Macrosomia o Fetal weight greater than 4000-4500 g is associated with a higher risk of shoulder dystocia and birth trauma during vaginal delivery.[5] o Mothers with diabetes have a higher incidence of macrosomia and risk of shoulder dystocia. o If the estimated fetal weight is greater than 4500 g in a mother with diabetes, ACOG recommends abdominal delivery. o If the mother does not have diabetes, abdominal delivery is not recommended until an estimated fetal weight of 5000 g. Abnormal placentation o Placenta previa (the placenta implanted over the cervical os) is a contraindication to vaginal delivery because of the risk of hemorrhage as the cervix dilates. o Placenta previa complicates up to 2% of all pregnancies. Risk factors include artificial reproductive technology and prior cesarean delivery.

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. Current ACOG guidelines recommend placement of epidural at maternal request regardless of cervical dilatation. o Risks include short-term backache, puncture headache, hypotension, maternal fever, and delayed labor.[6] Another possible risk is increased rate of instrumental delivery.[7] o 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 [8] o The pudendal block is rarely used because it is not very effective for pain control. It 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

Systemic analgesia o 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. o Risks include hypotension, nausea, vomiting, respiratory depression, depressed mental status, and decreased GI motility. o If narcotics are used, resuscitation medication and equipment for the newborn should be readily available Nonpharmacologic pain management o Nonpharmacologic pain management can be used in conjunction with pharmacologic options. o 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 (see normal tracing in image below)

Normal fetal heart rate tracing. Most labor and delivery units use continuous monitoring. The monitoring assesses the baseline, variability, presence, or absence of accelerations or decelerations. In 2008, the

following consensus guidelines were developed to unify the interpretation of fetal heart tracings. Category One: Normal fetal heart tracings. Continue expectant management. Category Two: Indeterminate fetal heart tracings. These tracings require close observation or interventions to determine whether the fetus has acidemia. Category Three: Abnormal fetal heart tracings. These tracings require immediate intervention. They are not reassuring and are indicative of fetal acidemia. If the strip does not improve with conservative measures, movement should be made toward delivery. o Standard noninvasive labor monitoring includes the use of 2 sensors attached to the outside of the mother's abdomen. One sensor detects the fetal heart rate via ultrasonography, and the other monitors the timing and relative strength of contractions via a tocodynamometer. o The fetal heart rate is variable and ranges from 120-160 beats per minute (bpm). The heart rate may drop briefly to < 120 bpm, especially during contractions. Persistence of a fetal heart rate lower than 120 bpm defines fetal bradycardia; in labor, a heart rate >100 bpm with reassuring variation is not considered an emergency. Persistence of a rate >160 bpm is called fetal tachycardia. Internal fetal heart rate monitor (fetal scalp electrode) o 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 or difficult to trace. o A small electrode is passed through the cervix, after the membranes have ruptured, and placed on the fetal scalp. Intrauterine pressure catheter (IUPC) o External monitoring of contractions only measures the timing of contractions. The strength of contractions can only be measured with an IUPC. o This catheter is placed in the uterus transcervically, next to the fetal head. It allows for more accurate measurement of strength and timing of contractions.

Delivery assistance (operative vaginal delivery)

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. [9] o The use of forceps has decreased over the past several decades. o The indications for forceps use include prolonged second stage of labor or ineffective maternal push power. The presenting part needs to be at +2 station before forceps should be applied. If the presenting part is at a higher station, abdominal delivery should be chosen. o Forceps use is associated with less fetal hematoma formation and quicker delivery times compared with vacuum assist[10] but is associated with increased maternal trauma and lacerations. o 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 o 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
o

include metal cup vacuums, plastic cup vacuums, and a mushroom-shaped vacuum cup that combines the advantages of the metal and plastic designs.[11] o 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. Like forceps assistance, vacuum assistance should only be used when indicated, as it carries the risk of harm to the fetus and mother. o Fetal complications from vacuum delivery include hematomas of the scalp, retina, and intracranium. Maternal complications are less than those with forceps but also include vaginal and perineal lacerations. The decision to use forceps or a vacuum assistance is guided by the particular indication for an instrumented delivery and the clinicians experience with each technique. In cases of a nonreassuring fetal tracing, 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. The combination of vacuum followed by forceps delivery carries increased risk of morbidity and should be avoided

First stage of labor o 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 o 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. o 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: o Maternal back pain o Shoulder dystocia o Posterior presentation of the occiput Clinicians are also becoming more familiar with water immersion and water birthing. Cochrane Database reviewed 11 trials on this topic. Six reported that water immersion during the first stage of labor significantly reduced regional analgesia without increasing duration of labor, operative delivery rates, or neonatal outcome. One study showed that immersion in water during the second stage of labor increased women's reported satisfaction with pushing. More research needs to be done on this topic.

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. o Obtain an external fetal heart monitor strip. o A duration of 20-30 minutes is standard to assess fetal well-being and to record contraction patterns. o Provide continuous fetal heart rate monitoring for indicated maternal or fetal reasons. o 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. o More frequent examination may be indicated by the mothers clinical status. o 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 (positive fern test) Observation of amniotic fluid in the vaginal vault (pooling) All patients should be screened for group B Streptococcus (GBS) colonization during pregnancy. If a patient is GBS+, she needs to receive antibiotics during labor. This applies to 10-30% of women. o The first choice of antibiotic is penicillin. o If the patient is allergic to penicillin, cefazolin is the next choice (if the patient did not have an anaphylactic response). o If anaphylaxis occurs, evaluate sensitivities to clindamycin or erythromycin. If sensitivities are not performed or if resistance is exhibited to both clindamycin and erythromycin, then vancomycin should be administered.[26, 27] 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 (+5 station). o Crowning occurs when the fetal head bulges the perineum as the head moves through the birth canal. o 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 o Drape and prepare for delivery when the fetal station is low. o Drapes and gowns protect the clinician from the fluid of delivery; sterile preparation is not required. o Use one hand to support and maintain the head in the flexed position as it delivers. o Use the other hand to support the perineum (see image below).

Perineal support during delivery of the head. o 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. o Have the mother momentarily withhold pushing once the head is delivered to check for nuchal cords. o Reduce nuchal cords (if present) if the mother and newborn are sufficiently stable to permit a pause in delivery. o Suction the nares quickly. Delivery of the shoulders o With both hands on the head, support delivery of the shoulders one at a time as the mother pushes with a contraction. o 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 (see images below).

Delivery of the

anterior shoulder. Delivery of the posterior shoulder. o 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 (see image below).

Delivery of the body. Guide the newborns 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 mothers partner can cut the cord between the clamps. After delivery o Clean the newborn or place directly with the mother, assuming a normal appearance and Apgar evaluation. o If the newborn is given directly to the mother, wrap the newborn and place on the mothers bare chest; the newborn's wet skin or the mothers wet clothes, combined with exposure to ambient air, lead to significant heat loss. o Continue to monitor the mother as she progresses to the third stage of labor.
o o o

Third stage of labor

Placental separation is evidenced by the following: o An increase in umbilical cord slack o A bolus of blood from the uterus o Superior migration of the uterus within the abdomen with an increase in uterine firmness The clinician can facilitate placental delivery. o Apply gentle horizontal traction on the umbilical cord with one hand. o Apply vertical pressure just superior to the pubic symphysis with the other hand to prevent inversion of the uterus.

Administer intravenous oxytocin to expedite the third stage of labor. Oxytocin should be started at delivery of the anterior shoulder. Inspect the placenta after delivery. o Manually explore the uterus if the placenta is not intact. o 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, placenta previa, 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. For more information, see Special Procedures section below. 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. It 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 o 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. o 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. o Nulliparous women and women with anatomical uterine abnormalities have a higher risk for this type of dystocia. Oxytocin o When needed, oxytocin improves the frequency and strength of contractions. o 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 o 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. o 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. Ultrasonography can discriminate between fetal bradycardia and 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

Premature rupture of membranes (PROM) means rupture of membranes at term before onset of labor. The most recent ACOG guidelines suggest that augmentation of labor should occur on presentation to the hospital.[21] Antibiotic treatment is no longer routinely recommended unless the mother develops a fever >100.5 F. PROM is most concerning in preterm newborns (PPROM). 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: o Placental abruption is the premature separation of the placenta from the uterus. o Placenta previa is when the placenta covers the cervical os. In the United States, where most women have prenatal ultrasonographic evaluations, placenta previa is usually diagnosed by ultrasonographic evaluation prior to labor onset. o Placenta accreta is the extension of the placenta into the uterine wall. o Ruptured vasa previa (abnormal fetal vessels covering the cervix) o Uterine rupture can also cause intrapartum hemorrhage.

Postpartum hemorrhage

Loss of >500 mL of blood during vaginal delivery is abnormal. Uterine atony, or failure of the uterus to contract following delivery of the placenta, is the most common cause. 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 or cervical lacerations are also a cause of postpartum hemorrhage. Rarely, coagulopathies can cause postpartum hemorrhage. Von Willebrand disease is sometimes first noted in women after a vaginal delivery. 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] In 2000, episiotomies were performed in approximately 27.5% of deliveries; it is one of the most common obstetrical surgical procedures.[20] 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 (see image below). Amniotomy

Episiotomy.

Amniotomy is a procedure by which the provider artificially ruptures the fetal membranes to induce or expedite labor. o Advance the amniohook until it touches the membranes. o Once the hook is engaged, pull back slightly; fluid should slowly leak out. o Inspect for the presence of meconium, a discolored (yellow to green) fluid due to the presence of fetal stool.

External cephalic version

External cephalic version (ECV) is a prelabor maneuver used to 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: o Position the mother supine. o Liberally lubricate the abdomen. o 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. o Attempt a reverse, backward roll if the forward roll is unsuccessful.

Induction of labor [22]

Induction of labor can be performed for maternal indications, fetal indications, or electively. o Maternal indications include hypertensive complications of pregnancy and exacerbation of maternal illness in pregnancy. o Fetal indications include postterm pregnancy, intrauterine growth restriction, fetal demise, oligohydramnios, abnormal fetal heart rate testing, history of stillbirth, and chorioamnionitis. Elective induction of labor should not occur prior to 39 weeks' gestation because of an increased risk of respiratory problems for the newborn