Coaching may be required for optimal pushing efforts. Flex the patient's legs to increase and improve her pushing efficacy. Encourage her to take a deep breath at the onset of a contraction and then push downward or Valsalva. Advise her to rest between contractions, as both she and the fetus need to recover from the effects of uterine contractions, breath holding, and the muscular effort. The perineum will bulge as the fetus descends into the maternal pelvis. Sponge downward any stool that is expelled with a sterile towel or piece of gauze. The woman and the fetus are prepared for delivery when the scalp of the fetus becomes visible at the introitus.
The fetal head becomes increasingly visible at the introitus as labor progresses. Once the bony occiput can be seen and palpated at the vaginal introitus, apply gentle downward pressure on the occiput to aid in the controlled delivery of the head. The fetal head stretches the vaginal outlet and the vulva until they encircle the largest diameter of the fetal head, known as crowning. Gentle digital stretching of the inferior portion of the perineum may aide delivery. The routine use of an episiotomy for delivery has been discouraged due to increases in third-degree and fourth-degree lacerations. However, an episiotomy can be performed when the baby is crowning if there appears to be inadequate stretching of the perineum. Refer to Chapter 132 for the complete details regarding an episiotomy.
Apply manual perineal support and control the head by performing the modified Ritgen maneuver as the fetal head emerges from the introitus (Figure 131-13). Using a towel-draped hand to protect against fecal contamination, apply pressure on the fetal chin through the perineum, anterior to the coccyx. Place the other hand on the fetal occiput to hold the suboccipital region against the mother's pubic symphysis. This maneuver helps to extend the fetal neck, ease the delivery of the fetus, and reduce the incidence of third-degree and fourth-degree perineal lacerations. However, a recent study did not show a decrease in perineal lacerations with this maneuver.13 Despite this, the premise still holds true that one should control the speed at which the fetal head delivers and ease the pressure on the perineum in an attempt to decrease perineal tears.
The modified Ritgen maneuver. A hand covered with a sterile towel applies moderate upward pressure on the perineum between the anus and the introitus. The other hand extends the fetal head to maintain the suboccipital region against the maternal pubic symphysis. This maneuver assists in the delivery of the fetal head.
After crowning occurs, encourage the mother to push with smaller pulses of force to control delivery of head and minimize perineal trauma. Slowly deliver the fetal head using the modified Ritgen maneuver.6,9 The base of the occiput will rotate, or restitute, toward the posterior aspect of the pubic symphysis while the fetal brow, face, and chin pass over the perineum. Instruct the mother to stop pushing once the head is delivered. Gently rotate the infant's head slightly if this does not spontaneously rotate. The routine intrapartum and peripartum suctioning of the nasal cavities and oropharynx of infants with or without meconium-stained amniotic fluid is no longer recommended.14–16
Pass one hand around the neck of the fetus to assess for a nuchal cord.6,9 The umbilical cord must be unwound from the fetal neck, if present, prior to continuing with the delivery.10 The umbilical cord can be found entangled around the neck in approximately 25% of deliveries.10 Slip it over the infant's head if possible (Figure 131-14). The umbilical cord can occasionally be wrapped so tight around the fetal neck that it cannot be slipped over the head. Carefully grasp and clamp the umbilical cord between two clamps placed 1 to 2 cm apart. Carefully cut the umbilical cord between the two clamps with sterile scissors. Unwind the umbilical cord from around the fetal neck. Immediately deliver the fetus as it no longer can rely on the maternal circulation once the umbilical cord is clamped and cut.
Slip any loops of umbilical cord that are wrapped around the fetal neck over the head.
Deliver the body of the fetus (Figure 131-15). Gently grasp the sides of the fetal head with two hands (Figure 131-15). Apply steady and gentle downward traction until the anterior shoulder appears under the pubic symphysis (Figure 131-15A). Apply steady and gentle upward traction until the posterior shoulder is delivered (Figure 131-15B). The use of gentle traction with both these maneuvers is important to avoid brachial plexus injuries.
Delivery of the body. Grasp the head with both hands. A. Apply gentle and steady downward traction to deliver the anterior shoulder. B. Apply gentle and steady upward traction to deliver the posterior shoulder.
The rest of the infant will spontaneously deliver once the shoulders are delivered. It is still very important to control the delivery of the body to prevent maternal perineal lacerations. A combination of amniotic fluid, blood, and vernix makes delivery of the infant very slippery. Proper hand positioning is important during the delivery of the body. Position the posterior or left hand underneath the infant's axilla prior to delivering the rest of the body. Use the anterior or right hand to grasp the infant's ankles as they are delivered. This ensures a firm grip on the infant.
Place two clamps on the umbilical cord, approximately 4 to 5 cm from the infant and 1 cm apart. Cut the umbilical cord between the two clamps using sterile scissors. Obtain a 10 to 20 mL sample of umbilical cord blood from the placental end for cord blood pH to determine fetal acid–base status and other required tests.17
Dry the infant while simultaneously stimulating and assessing for appropriate physiological responses. The mother may immediately hold the infant, and if desired breastfeed the infant, while the umbilical cord is cut in an uncomplicated birth. The child should respond well to initial stimulation and have an adequately clear airway and good respiratory effort. The infant can be further dried and stimulated in a warm incubator if necessary. Calculate the APGAR scores at 1 minute and 5 minutes after delivery. If the APGAR scores are low at 5 minutes, they should be repeated every 5 minutes in the immediate postpartum period. The acronym APGAR was coined as a mnemonic learning aid. It stands for Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (Table 131-1).
Table 131-1 The APGAR Score ||Download (.pdf)
Table 131-1 The APGAR Score
|Sign||Score = 0||Score = 1||Score = 2|
|Skin color (Appearance)||Blue or pale||Pink body and blue extremities||Completely pink|
|Heart rate (Pulse rate)||Absent||Slow (<100)||>100|
|Reflex irritability (Grimace)||No response||Grimace||Vigorous crying|
|Muscle tone (Activity)||Flaccid||Some extremity flexion||Active motion|
|Respiratory effort (Respiration)||Absent||Slow or irregular||Good and crying|
Maternal and Fetal Monitoring
The ACOG recommends that providers evaluate and record the fetal heart rate (FHR) at least every 30 minutes in the active phase of the first stage of labor and every 15 minutes in the second stage in patients without complications or risk factors. On the other hand, if complications (e.g., suspected fetal growth retardation, preeclampsia, and type I diabetes) are present, the ACOG recommends continuous FHR monitoring. If that is not possible, evaluate and record the FHR at least every 15 minutes in the active phase of the first stage of labor and every 5 minutes in the second stage.5 Suspect fetal distress if the heart rate following a contraction is repeatedly below 120 beats per minute. If fetal distress is appreciated, place the mother on oxygen, move her to the left lateral decubitus position, and check for umbilical cord prolapse in the absence of vaginal bleeding. Fetal heart rate decelerations may occur with contractions as the head descends. Allow labor to continue if prompt recovery occurs as the contraction diminishes. Decelerations may also occur from progressive compression of the umbilical cord around the fetus, premature placental separation, or reduction in uterine blood flow; all of which lead to fetal compromise.10 Prolonged FHR decelerations are worrisome and warrant action such as supplemental maternal oxygen, reposition of mother, and immediate delivery of the baby by cesarean section.5
The intensity of a contraction is determined by the degree of firmness that the uterus achieves. The frequency of contractions may be palpated or monitored by an external transducer (tocodynamometer) placed upon the mother's abdomen. Remember to monitor the maternal vital signs during active labor and intervene as needed when abnormal vital signs present themselves.
Watchful waiting until the placenta separates from the uterus is an acceptable practice if there is no unusual bleeding after delivery of the infant. Watch for the signs of placental separation during expectant management. These include a firm and globular uterus, a sudden gush of blood, uterine elevation in the abdomen, and a lengthening of the umbilical cord. These signs are generally present within 5 to 10 minutes after delivery of the infant, but up to 30 minutes is still within normal limits. Times longer than 30 minutes raise concern for a potential retained placenta.
Some Physicians may choose to actively manage the third stage of labor with early clamping of the umbilical cord, applying controlled umbilical cord traction, and the administration of a uterotonic drug such as oxytocin in an effort to stem postpartum hemorrhage.18,19 The literature is mixed with respect to whether or not active management of labor is beneficial when compared to expectant management.18–20
Instruct the patient to bear down when the placenta has separated. This results in increased intraabdominal pressure that aids in expelling the placenta. Apply suprapubic pressure (Figure 131-16A). Apply gentle traction on the umbilical cord to keep it taut without the use of excessive traction (Figure 131-16A). Aggressive traction on the umbilical cord can result in disruption of the placenta, uterine inversion, or tearing of the umbilical cord; all of which can result in excessive bleeding. Apply suprapubic pressure as the placenta exits the uterus helps to prevent uterine inversion (Figure 131-16B). Deliver the placenta from the uterus (Figure 131-16C). Take care to prevent tearing of the placenta and its membranes as it passes through the introitus. Grasp the placenta and membranes with your hands or ring forceps and guide them out the vagina with gentle twisting traction (Figure 131-16D). Gently massage the uterus through the anterior abdominal wall to maintain uterine contraction. Carefully examine the maternal surface of the placenta for completeness. Any missing pieces represent retained products and must be removed.
Delivery of the placenta. A. Apply gentle traction on the umbilical cord. B. Apply suprapubic pressure to help expel the placenta and prevent inversion of the uterus. C. Delivery of the placenta. D. The membranes or placenta are grasped with a ring forceps and delivered.