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.[3]
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.

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. The maximum
accepted time for the second stage depends on the
patient's parity and whether the patient has an epidural.
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
o

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.
In November 2013, the American College of Obstetricians
and Gynecologists (ACOG) and the Society for MaternalFetal Medicine (SMFM) released a committee opinion
revising the definition of term pregnancy. The
recommended change, as devised by a work group that
included representatives from the Eunice Kennedy Shriver
National Institute of Child Health and Human
Development, ACOG, SMFM, and other societies and
organizations, replaces the designation term with the
following[4] :

Early term: 37 weeks, 0 days, through 38 weeks, 6

days, of gestation

Full term: 39 weeks, 0 days, through 40 weeks, 6

days, of gestation

Late term: 41 weeks, 0 days, through 41 weeks, 6

days, of gestation

Postterm: At least 42 weeks, 0 days, of gestation

Indications
Normal vaginal delivery of the newborn includes the
following circumstances:

Spontaneous labor mediated by pituitary and

placental hormone cascades

Rupture of amniotic and chorionic membranes

(suggested by the presence of a watery vaginal discharge
or new oligohydramnios on ultrasonograph)

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.[5]

There are several medications available for cervical

ripening. Misoprostol or prostaglandin E1(Cytotec) is most
often used for cervical ripening. Since 2002, it has been
FDA approved for cervical ripening and induction of labor.
Dosing is 25-50 mcg given vaginally, buccally, or
sublingually. prostaglandin E2 (dinoprostone) can also be
used for cervical ripening, although it is more expensive
than misoprostol and has an increased rate of
tachysystole (too many contractions).[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 singleballoon 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 < .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=.050]).[6]
For more information, see Cervical Ripening article.

Contraindications
See the list below:

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.

If the face is mentum posterior (chin facing the

maternal sacrum), a cesarean delivery is required.

Breech presentation
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.[7]

Malposition

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

o
o
o

In the United States, cesarean delivery is

planned for higher order births.
Vaginal delivery after cesarean delivery [8]
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.
The success rate of this procedure is greater
than 50%.
During the delivery, careful fetal and maternal
monitoring are needed to detect early signs of dystocia
or uterine rupture.
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. This has led to an increase in the
cesarean delivery rate to approximately 30% in 2006.
Vaginal birth after cesarean is contraindicated in
cases of multiple prior cesarean deliveries (>2), 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
Hospital protocols in the United States
recommend some form of fetal heart rate monitoring.
The need for continuous fetal heart rate monitoring
remains unproven in low-risk, full-term pregnancies;

o
o
o
o

o
o
o

however, changes in fetal heart rate monitoring can

signal fetal hypoxemia and may indicate the need for
emergent abdominal delivery.
Causes of fetal hypoxemia include placental
abruption, placental insufficiency, or a tight nuchal cord.
Most cesarean deliveries undertaken for suspected fetal
distress result in healthy birth outcomes.
Macrosomia
Fetal weight greater than 4000-4500 g is
associated with a higher risk of shoulder dystocia and
birth trauma during vaginal delivery.[9]
Mothers with diabetes have a higher incidence of
macrosomia and risk of shoulder dystocia.
If the estimated fetal weight is greater than 4500
g in a mother with diabetes, ACOG recommends
abdominal delivery.
If the mother does not have diabetes, abdominal
delivery is not recommended until an estimated fetal
weight of 5000 g.
Abnormal placentation
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.
Known placenta accreta (the placenta invades at
least the myometrium of the uterus) is also a
contraindication to a vaginal delivery. Risk factors
include prior cesarean delivery.

Anesthesia
See the list below:

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

o
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.[10]
o
Risks include short-term backache, puncture
headache, hypotension, maternal fever, and delayed
labor.[11] Another possible risk is increased rate of
instrumental delivery.[12]
o
Epidural anesthesia may be combined with a
dose of spinal anesthesia; this is called combined spinalepidural 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

The pudendal block is rarely used because it is

not very effective for pain control.[13] 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 alone or 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

o

Warm baths or showers

Equipment

Monitors
See the list below:

External fetal heart rate monitor (see normal tracing in

image below)
Normal
fetal heart rate tracing.See the list below:
o
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.[14]
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.
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)
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.
A small electrode is passed through the cervix,
after the membranes have ruptured, and placed on the
fetal scalp.
Intrauterine pressure catheter (IUPC)
External monitoring of contractions only
measures the timing of contractions. The strength of
contractions can only be measured with an IUPC.

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)

See the list below:

o
o

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.
The use of forceps has decreased over the past
several decades.[15]
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.
Forceps use is associated with less fetal
hematoma formation and quicker delivery times
compared with vacuum assist[16] but is associated with
increased maternal trauma and lacerations.
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
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 include metal cup vacuums,
plastic cup vacuums, and a mushroom-shaped vacuum
cup that combines the advantages of the metal and
plastic designs.[17]
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.

When comparing forceps to vacuum, the vacuum has

less maternal morbidity, including need for anesthesia
and trauma to birth canal; however, there are increased
risks to the fetus, including increased risk of

cephalohematoma, retinal hemorrhage, and neonatal

jaundice. [18]

The combination of vacuum followed by forceps

delivery carries increased risk of neonatal intracranial
hemorrhage and should be avoided. This increased risk
is also present if a failed operative vaginal delivery
proceeds to a cesarean delivery. [18]
Positioning
See the list below:

First stage of labor

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. [19]
Technique

First stage of labor

See the list below:

Take a complete history and perform a complete

physical examination. The physical examination should
include a vaginal examination to assess the cervix. If the
patient is not ruptured, a sterile digital examination should
be performed.

If the membranes may be ruptured, minimize digital

examinations. Membrane rupture should be confirmed by
at least 2 of the following:
o
Positive Nitrazine pH test results
o
Evidence of microscopic ferning pattern of the
dried fluid (positive fern test)
o
Observation of amniotic fluid in the vaginal vault
(pooling)

Assess 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. Intermittent
monitoring may be used if the fetal strip is reassuring.
o
Monitor maternal vital signs regularly.

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).

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.[20, 21]

Monitor and chart cervical effacement and dilatation.

Patients should be re-evaluated every few hours.

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 bladder
distension, especially in patients with an epidural, and
allows for 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
o

See the list below:

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.
o
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
o
o
o

o
o

Use the other hand to support the perineum (see

image below).
Perineal support during delivery of the head.
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.
Have the mother momentarily withhold pushing
once the head is delivered to check for nuchal cords.
Reduce nuchal cords (if present) if the mother
and newborn are sufficiently stable to permit a pause in
delivery.
Routine suctioning of the nares is no longer
recommended by the AAP.[22]
Delivery of the shoulders
With both hands on the head, support delivery of
the shoulders one at a time as the mother pushes with a
contraction.
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.

Delivery of the body

o
With one hand still holding the head, use the
other hand to catch the newborn (see image below).
Delivery of the body.
o
o

Guide the newborns body as it is delivered.

Clamp the umbilical cord in 2 locations, several
centimeters apart. The clinician or the mothers partner
can cut the cord between the clamps. There has been
increasing data over the past few years advocating for
delayed cord clamping. It has been shown to decrease


o
o

intraventricular hemorrhage and necrotizing enterocolitis

in preterm infants, and to decrease anemia in term
infants. Delayed cord clamping is defined as >30
seconds after delivery.[23, 24]
After delivery
Clean the newborn or place directly with the
mother, assuming a normal appearance and Apgar
evaluation.
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. Encourage skin to skin contact
between mother and newborn as much as possible.[25]
Continue to monitor the mother as she
progresses to the third stage of labor.

Third stage of labor

o
o
o

Placental separation is evidenced by the following:

An increase in umbilical cord slack
A bolus of blood from the uterus
Superior migration of the uterus within the
abdomen with an increase in uterine firmness

The clinician can facilitate placental delivery.

o
Apply gentle 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.
o

Pearls
See the list below:

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.
Complications

Failure to progress
See the list below:

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
o

o
o
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.
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.
Nulliparous women and women with anatomical
uterine abnormalities have a higher risk for this type of
dystocia.
Oxytocin
When needed, oxytocin improves the frequency
and strength of contractions.
It may also cause uterine tachysystole (>5
contractions in 10 minutes); stopping the infusion works
quickly to remove the medication effect if this occurs
Because oxytocin increases the strength of
contractions, women tend to report more pain while on
oxytocin.
Passage and passenger
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.
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
See the list below:

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. [26]
Premature rupture of membranes
See the list below:

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. [27]

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
See the list below:

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. If this
cannot be accomplished safely in the delivery room, the
patient should be moved to the operating room for further
evaluation.
Special Procedures

Episiotomy
See the list below:

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. [7]

In 2000, episiotomies were performed in

approximately 27.5% of deliveries; it is one of the most
common obstetrical surgical procedures. [28] By 2006, the
national episiotomy rate was 9%. [29]

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:
o
Make a 0.75-1.5-in incision from the midpoint of
the posterior fourchette, directing back toward the
rectum (see image below).

Episiotomy.

The Cochrane database compared restrictive use to

liberal use of episiotomy. There is an increased risk of
anterior perineal trauma with restrictive use. The
advantages, however, include decreased posterior
perineal trauma, fewer sutures, and fewer healing
complications. There has been no quality research on
midline vs mediolateral episiotomy. [29]

Amniotomy
See the list below:

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
See the list below:

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%.[30]

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.

Liberally lubricate the abdomen.

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.
o
o

Induction of labor [3]

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. There has been a
concerted effort by the March of Dimes, ACOG, and other
governing bodies to eliminate elective deliveries less than
39 weeks because of increased morbidity to the infant. [31]