II. Epidemiology
- Vaginal Birth accounts for roughly 70% of deliveries in the United States
- Of the 3.7 million births in the U.S. in 2021, 2.5 million were vaginal deliveries
III. Contraindications
- Complete Placenta Previa
- Active genital Herpes Simplex Virus (or prodromal symptoms) at time of labor
- Malpresentation
- Non-Frank Breech
- Transverse Lie
- Face Presentation with mentum anterior
- Prior uterine surgery that raises risk of labor-induced Uterine Rupture
- History of classic uterine incision (vertical uterine incision)
- History of significant transfundal uterine surgery
- Untreated HIV Infection
- Includes unknown or elevated HIV Viral Load >1000 copies/ml
IV. Management: Vertical Transmission Prevention
V. Management: Labor Stage 1
- See First Stage of Labor
- See Fetal Heart Tracing
- Stage 1 Definitions
- Divided into two phases (assuming regular contractions in both phases)
- Latent Phase (<6 cm cervical dilation)
- Active Phase (6 to 10 cm cervical dilation)
- Progresses until complete cervical dilation and effacement
- Expected progress is based on Friedman Curve
- Assumes regular, frequent palpable contractions
- Divided into two phases (assuming regular contractions in both phases)
- Labor Progression
- Pain management
VI. Management: Labor Stage 2
- Stage 2 Definitions
- Starts with complete cervical dilation and effacement
- Ends with newborn delivery
- Labor Progression
- See Labor Augmentation
- See Active Management of Labor
- See Labor Coaching
- See Fetal Heart Tracing
- Second Stage expected duration
- Nulliparous women: 3 hours (with Epidural Anesthesia: 4 hours)
- Multiparous women: 2 hours (with Epidural Anesthesia: 3 hours)
- Fetal Descent
- Head engages in the in the maternal Pelvis during the First Stage of Labor
- Most will descend in Occiput Anterior position (often having started in Occiput Posterior)
- Neck flexes and descends the vaginal canal
- Fetus undergoes internal rotation, neck extension and then external rotation
- Completed with fetal expulsion
- Head engages in the in the maternal Pelvis during the First Stage of Labor
- Patients may elect to use their pushing position of choice
- Epidural Anesthesia: Lateral decubitus position may shorten second stage
- No Epidural Anesthesia: Upright, vertical positioning may shorten second stage
- Delayed pushing (compared with immediate pushing) in second stage is not beneficial and may cause harm
- Delayed pushing does not reduce NSVD failure rates and may increase complication rates
- Di Mascio (2020) Am J Obstet Gynecol 223(2): 189-203 [PubMed]
- Delivery
- Controlled delivery of the fetal head
- With one hand, support the fetal head as it crowns
- With second hand, squeeze together the perineum toward the midline
- Small patient pushes allow a more controlled fetal head delivery
- Nuchal cord reduction
- Check for nuchal cord as infant's head is delivered
- Pull loose nuchal cord's over the infant's head
- Loose nuchal cords may also be reduced after delivery
- Tight nuchal cords are associated with increased infant complications
- Apply 2 clamps to the nuchal cord and cut the cord between clamps OR
- Summersault maneuver
- Deliver the anterior and posterior Shoulder
- Next, hold infant head by maternal thigh
- Next, deliver body by summersault
- Remove nuchal cord once body is delivered
- Shoulder delivery
- See Shoulder Dystocia Management
- Anterior Shoulder may be delivered from beneath Symphysis Pubis with gentle downward pressure
- Posterior Shoulder typically follows easily with gentle upward traction
- Assisted Delivery
- Controlled delivery of the fetal head
- Newborn Care
- See Newborn Resuscitation
- Infants not requiring Resuscitation may be placed skin-to-skin on mothers chest (improves bonding, transition, Lactation)
- Neonatal suctioning at the perineum or after delivery is no longer routinely recommended
- Even with meconium stained amniotic fluid, oropharyngeal suctioning does not reduce aspiration risk
- Perineal Laceration
- See Perineal Laceration Repair
- Warm packs applied to the perineum in the second stage reduces Laceration risk and extension (2nd, 3rd degree)
- Cord clamping
- Consider delayed cord clamping in all deliveries not requiring emergent Resuscitation
- Wait 30-60 seconds after delivery to clamp cord or until cord stops pulsating
- Clamp cord with at least 2-4 cm between the infant and the closest clamp
- Allows for umbilical venous catheter later if needed
- Second clamp is placed closer to the placenta, and the cord is cut between clamps
- Infant does not need to be below the level of the placenta prior to cord clamping
- Delayed cord clamping improves infant birth weight, Hemoglobin, iron stores
- Slight increased risk of Hyperbilirubinemia and polycythemia
- McDonald (2013) Cochrane Database Syst Rev (7):CD004074 [PubMed]
VII. Management: Labor Stage 3
- See Third Stage of Labor
- See Postpartum Hemorrhage
- See Retained Placenta
- See Uterine Inversion
- Stage 3 Definitions
- See Third Stage of Labor
- Starts with newborn delivery
- Ends with delivery of the placenta and fetal membranes