Spontaneous Vaginal Delivery

Aka: Spontaneous Vaginal Delivery, Vaginal Delivery, Vaginal Birth, Normal Spontaneous Vaginal Delivery, NSVD, Second Stage of Labor

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II. Epidemiology

  1. Vaginal Birth accounts for roughly 70% of deliveries in the United States
    1. Of the 3.7 million births in the U.S. in 2021, 2.5 million were vaginal deliveries

III. Contraindications

  1. Complete Placenta Previa
  2. Active genital Herpes Simplex Virus (or prodromal symptoms) at time of labor
  3. Malpresentation
    1. Non-Frank Breech
    2. Transverse Lie
    3. Face Presentation with mentum anterior
  4. Prior uterine surgery that raises risk of labor-induced Uterine Rupture
    1. History of classic uterine incision (vertical uterine incision)
    2. History of significant transfundal uterine surgery
  5. Untreated HIV Infection
    1. Includes unknown or elevated HIV Viral Load >1000 copies/ml

IV. Management: Vertical Transmission Prevention

  1. See Group B Streptococcus Prophylaxis
  2. See Genital Herpes
  3. See HIV in Pregnancy

V. Management: Labor Stage 1

  1. See First Stage of Labor
  2. See Fetal Heart Tracing
  3. Stage 1 Definitions
    1. Divided into two phases (assuming regular contractions in both phases)
      1. Latent Phase (<6 cm cervical dilation)
      2. Active Phase (6 to 10 cm cervical dilation)
    2. Progresses until complete cervical dilation and effacement
    3. Expected progress is based on Friedman Curve
      1. Assumes regular, frequent palpable contractions
  4. Labor Progression
    1. See Labor Dystocia
    2. See Labor Augmentation and Labor Induction
    3. See Active Management of Labor
    4. See Labor Coaching
    5. See Fetal Heart Tracing
  5. Pain management
    1. See Latent Labor Anesthesia
    2. See Active Labor Anesthesia
    3. See Non-Pharmacologic Pain Control in Labor

VI. Management: Labor Stage 2

  1. Stage 2 Definitions
    1. Starts with complete cervical dilation and effacement
    2. Ends with newborn delivery
  2. Labor Progression
    1. See Labor Augmentation
    2. See Active Management of Labor
    3. See Labor Coaching
    4. See Fetal Heart Tracing
    5. Second Stage expected duration
      1. Nulliparous women: 3 hours (with Epidural Anesthesia: 4 hours)
      2. Multiparous women: 2 hours (with Epidural Anesthesia: 3 hours)
    6. Fetal Descent
      1. Head engages in the in the maternal Pelvis during the First Stage of Labor
        1. Most will descend in Occiput Anterior position (often having started in Occiput Posterior)
      2. Neck flexes and descends the vaginal canal
      3. Fetus undergoes internal rotation, neck extension and then external rotation
      4. Completed with fetal expulsion
    7. Patients may elect to use their pushing position of choice
      1. Epidural Anesthesia: Lateral decubitus position may shorten second stage
        1. (2017) BMJ 359:j4471 +PMID: 29046273 [PubMed]
      2. No Epidural Anesthesia: Upright, vertical positioning may shorten second stage
        1. Gupta (2017) Cochrane Database Syst Rev (5): CD002006 +PMID: 28539008 [PubMed]
    8. Delayed pushing (compared with immediate pushing) in second stage is not beneficial and may cause harm
      1. Delayed pushing does not reduce NSVD failure rates and may increase complication rates
      2. Di Mascio (2020) Am J Obstet Gynecol 223(2): 189-203 [PubMed]
  3. Delivery
    1. Controlled delivery of the fetal head
      1. With one hand, support the fetal head as it crowns
      2. With second hand, squeeze together the perineum toward the midline
      3. Small patient pushes allow a more controlled fetal head delivery
    2. Nuchal cord reduction
      1. Check for nuchal cord as infant's head is delivered
      2. Pull loose nuchal cord's over the infant's head
        1. Loose nuchal cords may also be reduced after delivery
      3. Tight nuchal cords are associated with increased infant complications
        1. Apply 2 clamps to the nuchal cord and cut the cord between clamps OR
        2. Summersault maneuver
          1. Deliver the anterior and posterior Shoulder
          2. Next, hold infant head by maternal thigh
          3. Next, deliver body by summersault
          4. Remove nuchal cord once body is delivered
    3. Shoulder delivery
      1. See Shoulder Dystocia Management
      2. Anterior Shoulder may be delivered from beneath Symphysis Pubis with gentle downward pressure
      3. Posterior Shoulder typically follows easily with gentle upward traction
    4. Assisted Delivery
      1. See Vacuum Assisted Delivery
      2. See Forceps Assisted Delivery
      3. See Manual Rotation in Occipitoposterior Presentation
  4. Newborn Care
    1. See Newborn Resuscitation
    2. Infants not requiring Resuscitation may be placed skin-to-skin on mothers chest (improves bonding, transition, Lactation)
    3. Neonatal suctioning at the perineum or after delivery is no longer routinely recommended
      1. Even with meconium stained amniotic fluid, oropharyngeal suctioning does not reduce aspiration risk
  5. Perineal Laceration
    1. See Perineal Laceration Repair
    2. Warm packs applied to the perineum in the second stage reduces Laceration risk and extension (2nd, 3rd degree)
  6. Cord clamping
    1. Consider delayed cord clamping in all deliveries not requiring emergent Resuscitation
    2. Wait 30-60 seconds after delivery to clamp cord or until cord stops pulsating
    3. Clamp cord with at least 2-4 cm between the infant and the closest clamp
      1. Allows for umbilical venous catheter later if needed
      2. Second clamp is placed closer to the placenta, and the cord is cut between clamps
    4. Infant does not need to be below the level of the placenta prior to cord clamping
      1. Vain (2014) Lancet 384(9939): 235-40 [PubMed]
    5. Delayed cord clamping improves infant birth weight, Hemoglobin, iron stores
      1. Slight increased risk of Hyperbilirubinemia and polycythemia
      2. McDonald (2013) Cochrane Database Syst Rev (7):CD004074 [PubMed]

VII. Management: Labor Stage 3

  1. See Third Stage of Labor
  2. See Postpartum Hemorrhage
  3. See Retained Placenta
  4. See Uterine Inversion
  5. Stage 3 Definitions
    1. See Third Stage of Labor
    2. Starts with newborn delivery
    3. Ends with delivery of the placenta and fetal membranes

VIII. References

  1. Dresang (2015) Am Fam Physician 92(3): 202-8 [PubMed]
  2. McKenna (2024) Am Fam Physician 109(6): 525-32 [PubMed]

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Related Studies

Ontology: Labor Stage, Second (C0022872)

Definition (NCI) A stage during labor and childbirth when the cervix is effaced totally and remains dilated until the birth of the baby.
Definition (MSH) The period of OBSTETRIC LABOR that is from the complete dilatation of the CERVIX UTERI to the expulsion of the FETUS.
Concepts Temporal Concept (T079)
MSH D007748
SnomedCT 42857002, 289216002
English Labor Stage, Second, Labor Stages, Second, Labor, Second Stage, Second Labor Stage, Second Labor Stages, Second Stage Labor, Stage, Second Labor, Stages, Second Labor, Obs second stage labor, Obs second stage labour, labor second stage, second stage of labor, second stage of labour, second stage labor, second stage labour, Second Stage of Labor, Birthing Stage, labor stage second, labor stage second (physical finding), Second stage of labor, Second stage of labour, Observation of second stage of labor, Observation of second stage of labour, Finding of second stage of labor (finding), Finding of second stage of labor, Finding of second stage of labour, Second stage of labor (finding)
Portuguese Segundo Estágio do Trabalho de Parto, Segundo Período do Trabalho de Parto, Segunda Fase do Trabalho de Parto
Swedish Förlossningens utdrivningsskede
Czech porodní doba druhá
Finnish Ponnistusvaihe
French Second stade du travail
Russian RODY, VTORAIA STADIIA, PERIOD IZGNANIIA, ПЕРИОД ИЗГНАНИЯ, РОДЫ, ВТОРАЯ СТАДИЯ
Japanese 分娩第2期, 娩出期, 娩出陣痛
Spanish hallazgo relacionado con la segunda etapa del trabajo de parto (hallazgo), segunda etapa del trabajo de parto - hallazgo, hallazgo relacionado con la segunda etapa del trabajo de parto, segunda etapa del trabajo de parto - hallazgo (hallazgo), período expulsivo (hallazgo), período expulsivo, segundo período del parto, segundo período del trabajo de parto, Segundo Periodo del Trabajo de Parto
Polish Okres porodu drugi
German Austreibungsperiode, Geburt, zweite Phase, Geburtsphase, zweite
Italian Secondo stadio del travaglio di parto
Dutch Geboorte, tweede fase van de, Tweede fase van de bevalling
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Normal delivery (C1384485)

Definition (NCI) Birth of the fetus through the vagina without the application of vacuum or forceps or any other instrument. (adapted from reVITALize)(NICHD)
Concepts Finding (T033)
ICD9 650
SnomedCT 48782003, 267325009, 267353009, 281686002, 200477006, 199313007
English FTND - Full term norm delivery, SVD - Spont vaginal delivery, Spontaneous vaginal delivery, ND - Normal delivery, Normal delivery (live child), Delivery in a completely normal case, Delivery of fetus, completely normal case, normal delivery (diagnosis), normal delivery, Normal Spontaneous Vaginal Delivery, Normal delivery in normal case, Normal pregnancy &/or delivery (& [spontaneous vaginal delivery]) (disorder), Delivery - normal, Normal delivery in a completely normal case, Normal pregnancy &/or delivery (& [spontaneous vaginal delivery]), Normal pregnancy+deliv., Delivery: [normal in a completely normal case] or [spontaneous vaginal], Delivery: [normal in a completely normal case] or [spontaneous vaginal] (disorder), Normal foaling, Parturition normal, Normal Delivery, NSVD, FTND - Full term normal delivery, SVD - Spontaneous vaginal delivery, Delivery normal, delivery; normal, normal; delivery, Normal delivery, Delivery normal (disorder), Delivery normal (finding)
Spanish parto normal (hallazgo), parto normal (trastorno), Parto en un caso completamente normal, Fase expulsiva del parto normal, Parto normal (niño vivo), parto normal de término, alumbramiento del feto, caso completamente normal (trastorno), alumbramiento del feto, caso completamente normal, parto vaginal espontáneo
French Accouchement normal (enfant vivant), Accouchement normal, Accouchement dans un cas complètement normal
Dutch bevalling volledig normaal, normale bevalling, bevalling normaal (levendgeborene), bevalling; normaal, normaal; bevalling
Portuguese Dequitadura normal, Expulsão normal (nado-vivo), Expulsão num caso completamente normal
German Entbindung in einem ganz normalen Fall, normale Entbindung, normale Geburt (Lebendgeburt)
Italian Parto normale (bambino vivo), Parto normale, Parto in caso completamente normale
Japanese 正常分娩（生児出生）, 正常分娩, 完全に正常な状態における分娩, ｶﾝｾﾞﾝﾆｾｲｼﾞｮｳﾅｼﾞｮｳﾀｲﾆｵｹﾙﾌﾞﾝﾍﾞﾝ, ｾｲｼﾞｮｳﾌﾞﾝﾍﾞﾝ, ｾｲｼﾞｮｳﾌﾞﾝﾍﾞﾝｾｲｼﾞｼｭｯｾｲ
Czech Normální porod, Porod ve zcela normálním případě, Normální porod (živé dítě)
Hungarian Normális szülés, Normális szülés (élő gyermek), Szülés teljesen normális esetben
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Vaginal delivery procedure (C1541822)

Definition (NCI) Birth of the fetus through the vagina.(NICHD)
Concepts Therapeutic or Preventive Procedure (T061)
CPT 59409, 59410, 59614, 59612
English Vaginal delivery, Vaginal Delivery, Vaginal delivery procedure
Spanish Parto vaginal
French Accouchement vaginal
Dutch vaginale bevalling
Portuguese Parto vaginal
German vaginale Entbindung
Italian Parto vaginale
Japanese 経腟分娩, ｹｲﾁﾂﾌﾞﾝﾍﾞﾝ
Czech Vaginální porod
Hungarian Hüvelyi szülés
Derived from the NIH UMLS (Unified Medical Language System)

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