Delivery of the baby

Conduction of delivery -
It divided into three phases -
                - Delivery of the head
                - Delivery of the shoulders
                - Delivery of the trunk

Delivery of the head - 
The principles to be followed are
- to maintain flexion of the head.
- to prevent its early extension.
- to regulate its slow escape out of the vulval outlet.

General measures -
- The patient is encouraged for the bearing down efforts during uterine contractions.
  This facilitates descent of the head.
- When the scalp is visible for about 5 cm in diameter, flexion of the head is maintained
  during contractions.
- At this stage, the maximum diameter of the head (biparietal diameter) stretches the vulval
  outlet without any   recession of the head even after the contraction is over and it is called
  ''crowning of the head''.
- When the perineum is fully stretched, episiotomy is done.
- Slow delivery of the head in between the contractions is to be regulated.
- The forehead, nose, mouth and the chin are thus born successively over the stretched
  perineum by extension.

Care following delivery of the head -
- Immediately following delivery of the head, the mucus and blood in the mouth and pharynx
  are to be wiped   with sterile gauze piece on a little finger. Alternatively, mechanical or
  electrical sucker may be used.
- The eyelids are then wiped with sterile dry cotton swabs using one for each eye starting
  from the medial to the lateral canthus to minimize contamination of the conjunctival sac.
- The neck is then palpated to exclude the presence of any loop of cord.

Prevention of perineal laceration -
More attention should be paid not to the perineum but to the controlled delivery of head.
- Delivery by early extension is to be avoided.
- Spontaneous forcible delivery of the head is to be avoided.
- To deliver the head in between contractions.
- To perform timely episiotomy.
- To take care during delivery of the shoulders.

Delivery of the shoulders -
- Do not be hasty in delivery of the shoulders. Wait for the uterine contractions to come
  and for the movements of restitution and external rotation of the head to occur.
- External rotation shows that the shoulders are rotating into the antero-posterior diameter
  of the pelvic outlet, which is largest space.
- During the next contraction, the anterior shoulder is born behind the symphysis. If there is
  delay, the head is grasped by both hands and is gently drawn posteriorly until the anterior
  shoulder is released from under the pubis.

Delivery of the trunk -
After the delivery of the shoulders, the fore finger of each hand are inserted under the axillae
and the trunk is delivered gently by lateral flexion.

Management of second stage of labour

Principles -
1. To assist in the natural expulsion of the fetus slowly and steadily.
2. To prevent perineal injuries.

General measures -
- The patient should be in bed.
- Constant supervision is mandatory and the FHR is recorded at every minutes.
- To administer inhalation analgesics, if available, in the form of Gas  N2O  and  O2  to
  relieve pain during contractions.
- Vaginal examination is done at the beginning of the second stage not only to conform
  its onset but to detect any accidental cord prolapse.

Preparation for delivery -
- Position :- Positions of the woman during delivery may be lateral or dorsal.
- The accoucheur scrubs up and puts on sterile gown, mask and gloves and stands on
  the right side of table.
- Toileting the external genitalia and inner side of the thighs is done with cotton swabs
  soaked in Savlon and or Dettol solution.
- Essential aseptic procedures are remembered as 3 'C's -
                       - Clean hands  
                       - Clean surface
                       - Clean cutting and ligaturing of the cord
- To catheterise the bladder, if it is full.

Conduction of delivery -
The assistance required in spontaneous delivery. It divided into three phases -
                       - Delivery of the head
                       - Delivery of the shoulders
                       - Delivery of the trunk
For details, visit the page Delivery of the baby.

Immediate care of the newborn -
-  Soon after the delivery of the baby, it should be placed on a tray covered with clean dry
   linen with the head slightly downwards. It facilitates drainage of the mucus accumulated
   in the trachco-bronchial tree by gravity. The tray is placed between the legs of the mother
   and should be at a lower level than the uterus to facilitate gravitation of blood from the 
   placenta to the infant.
-  Air passage should be cleared of mucus and liquor by gentle suction.
-  Apgar rating at one minute and at five minutes is to be recorded.
-  Clamping and ligature of the cord - The cord is clamped by two Kocher's forceps, the near
   one is placed 5 cm away from the umbilicus and is cut in between. The cut end is then
   covered with sterile gauze piece after making sure that there is no bleeding. The purpose 
   of clamping the cord on the maternal end is to prevent soiling of the bed with blood.

Events in second stage of labour

The second stage begins with the complete dilatation of the cervix and ends with
the expulsion of the fetus. This stage is concerned with
                       a) The descent
                       b) Delivery of the fetus through the birth canal

The descent -
Descent of the fetal presenting part, which begin during the first stage of labour and
reached its maximum speed towards the end of the first stage, continuous its rapid
pace through the second stage of labour. The average maximum rate of descent is
1.6 cm/hour in nullipara and 5.4 cm/hour in multipara.

Delivery of the fetus through the birth canal -
With the full dilatation of the cervix, the membranes usually rupture and there is escape
of good amount of liquor amnii. The volume of the uterine cavity is thereby reduced.
Simultaneously, uterine contraction and retraction become stronger.
                      Delivery of the fetus is accomplished by the downward thrust offered by
uterine contractions supplemented by voluntary contraction of abdominal muscles against
the resistance offered by bony and soft tissue of the birth canal. Endowed with power of
retraction, the fetus is gradually expelled from the uterus against the resistance offered by
the pelvic floor.
                      The expulsive force of uterine contractions is added by voluntary contraction
of the abdominal muscles called ''bearing down'' efforts.


Que. - What is bearing down efforts ?
Ans. -  It is an additional voluntary expulsive efforts that appear during the second stage
          of labour (expulsive phage). It is initiated by nerve reflex set up due to stretching of
          the vagina by the presenting part. In majority, this expulsive effort start spontaneously
          with the full dialatation of the cervix. Along with uterine contraction, the woman, the
          woman is instructed to exert downward pressure as done during straining at stool.
          There may be slowing of the FHR during pushing and it should come back to normal
          once the contraction is over.

Management of first stage of labour

Principles -

1. Non-interference with watchful expectancy so as to prepare the patient for natural birth.

2. To monitor carefully the progress of labour, maternal conditions and fetal behaviour so 
    as to detect any intrapartum complication early.

Actual management -
General -

- Antiseptic dressing.
- Encouragement and assurance are given to keep up the morale.
- Constant supervision is ensured.

Bowel - 
An enema with soap and water or glycerine suppository is traditionally given in early stage. 
This may be given if the rectum feels loaded on vaginal examination. But enema neither 
shortens the duration of labour nor reduces the infection rate.

Rest and ambulation -
If the membranes are intact, the patient is allowed to walk about. Ambulation can reduce
the duration of labour.

Perineal shave -
The purpose of perineal shave is to prevent infection, preparation of perineum involving
the shaving of mons pubis, vulva and anal region provide for cleanliness and early viewing
of perineum.

Diet -
A woman in labour, even in early stage, should not eat solid food. Gastric contents are really
dangerous if aspirated following general anaesthesia. So food is withheld during active labour.

Bladder care -
Patient is encouraged to pass urine by herself as full bladder often inhibits uterine contraction
and may lead to infection. If the woman can not go to the toilet, she is given a bed pan.
Privacy must be maintained and comfort must be ensured. If the patient fails to pass urine
specially in late stage, catheterisation is to be done with strict aseptic precaution.

Relief of pain -
The common analgesic drug used is pethidine 50-100 mg intramuscularly (IM) when the pain
are well established in the active phase of labour. Pethidine is an effective analgesic as well as
a sedative. The drug should not be given if delivery is anticipated within two hours.

Assessment of progress of labour and partograph recording -
Information in the partograph include -
1. Maternal vital signs - Temperature, pulse and BP.
2. Uterine activity - Duration and frequency of contractions.
3. Fetal heart rate.
4. Vaginal examination findings -
    - Cervical dilatation in cm.
    - Cervical effacement.
    - Descent/ station of presenting part.
    - Status of membranes.
    - Status of the liquor amini.
5. Fluid examination.
6. Urine analysis.
7. Drug administration.

Fetal heart rate (FHR) -
FHR along with its rhythm and intensity should be noted every half hour in the first stage
and every 15 min in second stage or following rupture of the membrane. To avoid confusion 
of maternal and fetal heart rates, maternal pulse should be counted. Otherwise maternal
tachycardia may be wrongly treated as fetal heart rate. Normal fetal heart rate ranges
from 110-150 per minute.

Que. - What is partograph recording ?
Ans. -  Partograph is a graphic recording of the silent feature of labour status. In the management 
           of woman in labour, partograph search to validated the normal progress of labour and to 
           facilitate early identification of deviation from normal pattern. The number of contraction
           in 10 min and duration of each contaction in second are recorded in the partograph.

Management of normal labour

General considerations -
labour events have got great psychological, emotional and social impact to the woman and her family. She experiences stress, physical pain and fear of dangers. The caregiver should be tactful, sensitive and respectful to her. The woman is allowed to have her chosen companion (family member). Privacy must be maintained.

Management of normal labour aims at maximal observation with minimal active intervention. The idea is to maintain the normalcy and to detect any deviation from the normal at the earliest possible moment.

Antiseptics and aspesis -
Scrupulous surgical cleanliness and asepsis on the part of the patient and the attendants involved in the delivery process are to be maintained.

Patient care -
- Shaving or hair clipping of the vulva is done. The vulva and the perineum are washed liberally
   with soap and water and then with 10% dettol solution.
- The woman take a shower or bath, wear laundered gown and stay mobile.
- Antiseptic and aseptic precautions are to be taken during vaginal examination and during
   conduction of delivery.

Vaginal examination -
- First vaginal examination should be done by a senior doctor to be more reliable and informative.
  The examination is done with the patient lying in dorsal position.
- Whatever aseptic technique is employed, there is always some chance of introducing infection
   specially after rupture of the membranes. Hence vaginal examination should be restricted to
   a minimum.

Preliminaries -
- Toileting - The hands and forearms should be washed with soap and running water.
- Sterile pair of gloves is to be put on.
- Vulva should once more be swabbed from before backwards with antiseptic lotion.
- Vaginal examination should be kept as minimum as possible to avoid risks of infection.

Events in first stage of labour

The first stage is chiefly concerned with the preparation of the birth
canal so as to facilitate expulsion of the fetus in the second stage.
The main events that occur in the first stage are -

             a) Dilatation and effacement of the cervix.

             b) Full formation of lower uterine segment.

Dilatation of the cervix - 

Dilation of cervix is the process of enlargement of the external cervical os
(opening) from an orifice of a few mm to an opening large enough for the baby
to pass through. Dilatation is clinically evaluated by measuring the diameter of
the cervical opening in cm, with '0' (zero) cm being a closed external cervical os
(opening) and 10 cm complete dilatation.

Actual factors responsible are -

i) Uterine contraction and retraction -: The longitudinal muscle fibers of the upper
segment are attached with circular muscle fibers of the lower segment and upper
part of the cervix in a bucket holding fashion. Thus, with each uterine contraction,
not only the canal is opened up from above down but it also becomes shortened
and retracted. There is some co-ordination between fundal contraction and cervical
dilatation called ''polarity of uterus''.
ii) Bag of membranes -: The membranes (amnion and chorion) are attached loosely to
the decidua lining the uterine cavity except over the internal os. In vertex presentation,
the girdle of contact of the head (that part of the circumference of the head which first
comes in contact with the pelvic brim) being spherical, may well fit with the wall of the
lower uterine segment. Thus the amniotic cavity is divided into two compartments.
The part above the girdle of contact contains the fetus with bulk of the liquor called
hindwaters and the one below it containing small amount of liquor called forewaters.
iii) Fetal axis pressure -: During each contraction the uterus rears forward (become upright)
and the force of fundal contraction is transmitted to the upper pole of the uterus,
down the long axis of the fetus is applied by the presenting part of the cervix. This is
known as fetal axis pressure. It becomes more significant after rupture of the membrane
and during the second stage of labour.
iv) Vis-a-tergo -: The final phage of dilatation and retraction of the cervix is achieved by
download thrust of the presenting part of the fetus and upward pull of the cervix over
the lower segment.

Effacement or taking up of cervix -
Effacement is the process by which the muscular fibers of the cervix are pulled upward 
and merge with the fibers of the lower uterine segment. The cervix becomes thin during
the first stage of labour or even before that in primigravidae. In primigravidae, effacement
precedes dilatation of the cervix, whereas in multiparae, both occur simultaneously.
Expulsion of mucus plug is caused by effacement.

Physiology of normal labour

Physiology of normal labour complete into two steps -

                1. Uterine contraction.
                2. Retraction.

Uterine contraction -
During contraction, uterus becomes hard and somewhat pushed anteriorly
to make the long axis of the uterus in the line with that of pelvic axis.
Simultaneously, the patient experiences pain which is situated more on the
hypogastric region, often radiating to the thighs.
Probable cause of pain are -
   - Myometrial hypoxia during contractions.
   - Stretching of the peritoneum over the fundus.
   - Stretching of the cervix during dilatation.
   - Compression of the nerve ganglion.
The pain of uterine contractions is distributed along the cutaneous nerve
distribution of T10 to L1.

Intensity - The intensity of uterine contractions describes the degree of uterine
systole. The intensity gradually increases with advancement of labour until it
becomes maximum in the second stage during delivery of the baby. Intrauterine
pressure is raised to 40-50 mm Hg during first stage and about 100-120 mm Hg
in the second stage of labour during contractions.

Duration - In the first stage, the contractions last for about 30 second initially but
gradually increases in duration with the progress of labour. Thus in the second stage,
the contractions last longer than in the first stage.

Frequency - In the early stage of labour, the contractions come at intervals of ten to
fifteen minutes. The intervals gradually shorten with advancement of labour until in
the second stage, when it comes every two or three minutes.

Retraction -
Retraction is a phenomenon of the uterus in labour in which the muscle fibers are
permanently shortened. Unlike any other muscle of the body, the uterine muscles
have this property to become shortened once and for all. Contraction is a temporary
reduction in length of the fibers, which attain their full length during relaxation. In contrast,
retraction results in permanent shortening and the fibers are shortened once and for all.
The net effect of retraction on normal labour are -
- Essential property in the formation of lower uterine segment and dilatation and 
   effacement up of the cervix.
- To maintain the advancement of the presenting part made by the uterine contractions 
   and to help in ultimate expulsion of the fetus.
- To reduce the surface area of the uterus favouring separation of placenta.
- Effective haemostasis after the separation of the placenta.