How To Manage A Normal Delivery "Instructions + Video"

Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, father or other support person, and neonate remain in the same room throughout their stay. Some units use a traditional labor room and separate delivery suite, to which the woman is transferred when delivery is imminent. The support person should be offered the opportunity to accompany her. In the delivery room, the perineum is washed and draped, and the neonate is delivered. After delivery, the woman may remain there or be transferred to a postpartum unit. Management of complications during delivery requires additional measures.

Anesthesia
Options include regional, local, and general anesthesia. Local anesthetics and opioids are commonly used. These drugs pass through the placenta; thus, during the hour before delivery, such drugs should be given in small doses to avoid toxicity (eg, CNS depression, bradycardia) in the neonate. Opioids used alone do not provide adequate analgesia and so are most often used with anesthetics.

Delivery Procedures
A vaginal examination is done to determine position and station of the fetal head; the head is usually the presenting part. When effacement is complete and the cervix is fully dilated, the woman is told to bear down and strain with each contraction to move the head through the pelvis and progressively dilate the vaginal introitus so that more and more of the head appears. When about 3 or 4 cm of the head is visible during a contraction in nulliparas (somewhat less in multiparas), the following maneuvers can facilitate delivery and reduce risk of perineal laceration.

The clinician, if right-handed, places the left palm over the infant's head during a contraction to control and, if necessary, slightly slow progress.
Simultaneously, the clinician places the curved fingers of the right hand against the dilating perineum, through which the infant's brow or chin is felt.
To advance the head, the clinician can wrap a hand in a towel and, with curved fingers, apply pressure against the underside of the brow or chin (modified Ritgen maneuver).
Thus, the clinician controls the progress of the head to effect a slow, safe delivery.

Forceps or a vacuum extractor is often used for vaginal delivery when the 2nd stage of labor is likely to be prolonged (eg, because the mother is too exhausted to bear down adequately or because regional epidural anesthesia precludes vigorous bearing down). If anesthesia is local (pudendal block or infiltration of the perineum), forceps or a vacuum extractor is usually not needed unless complications develop; local anesthesia may not interfere with bearing down. Indications for forceps and vacuum extractor are essentially the same.

An episiotomy is not routine and is done only if the perineum does not stretch adequately and is obstructing delivery, usually only for first deliveries at term. A local anesthetic can be infiltrated if epidural analgesia is inadequate. Episiotomy prevents excessive stretching and possible tearing of the perineal tissues, including anterior tears. The incision is easier to repair than a tear.

The most common type is a midline incision made from the midpoint of the fourchette directly back toward the rectum. Extension into the rectal sphincter or rectum is a risk, but if recognized promptly, the extension can be repaired successfully and heals well. Tears or extensions into the rectum can usually be prevented by keeping the infant's head well flexed until the occipital prominence passes under the symphysis pubis.

Another type of episiotomy is a mediolateral incision made from the midpoint of the fourchette at a 45° angle laterally on either side. This type usually does not extend into the sphincter or rectum, but it causes greater postoperative pain and takes longer to heal than midline episiotomy. Thus, for episiotomy, a midline cut is preferred. However, use of episiotomy is decreasing because extension or tearing into the sphincter or rectum is a concern. Episioproctotomy (intentionally cutting into the rectum) is not recommended because rectovaginal fistula is a risk.

When the head is delivered, the clinician determines whether the umbilical cord is wrapped around the neck. If it is, the clinician should try to unwrap the cord; if the cord cannot be rapidly removed this way, the cord may be clamped and cut. After delivery of the head, the infant's body rotates so that the shoulders are in an anteroposterior position; gentle downward pressure on the head delivers the anterior shoulder under the symphysis. The head is gently lifted, the posterior shoulder slides over the perineum, and the rest of the body follows without difficulty. The nose, mouth, and pharynx are aspirated with a bulb syringe to remove mucus and fluids and help start respirations. The cord should be double-clamped and cut between the clamps, and a plastic cord clip should be applied about 2 to 3 cm distal from the cord insertion on the infant. If fetal or neonatal compromise is suspected, a segment of umbilical cord is doubly clamped so that arterial blood gas analysis can be done. An arterial pH > 7.l5 to 7.20 is considered normal. The infant is thoroughly dried, then placed on the mother's abdomen or, if resuscitation is needed, in a warmed resuscitation bassinet.

After delivery of the head, the infant's body rotates so that the shoulders are in an anteroposterior position; gentle downward pressure on the head delivers the anterior shoulder under the symphysis. The head is gently lifted, the posterior shoulder slides over the perineum, and the rest of the body follows without difficulty. The nose, mouth, and pharynx are aspirated with a bulb syringe to remove mucus and fluids and help start respirations. The cord should be double-clamped and cut between the clamps, and a plastic cord clip should be applied about 2 to 3 cm distal from the cord insertion on the infant. If fetal or neonatal compromise is suspected, a segment of umbilical cord is double-clamped so that arterial blood gas analysis can be done. An arterial pH > 7.l5 to 7.20 is considered normal. The infant is thoroughly dried, then placed on the mother's abdomen or, if resuscitation is needed, in a warmed resuscitation bassinet.

Placenta: After delivery of the infant, the clinician places a hand gently on the abdomen over the uterine fundus to detect contractions; placental separation usually occurs during the 1st or 2nd contraction, often with a gush of blood from behind the separating placenta. The mother can usually help deliver the placenta by bearing down. If she cannot and if substantial bleeding occurs, the placenta can usually be evacuated (expressed) by placing a hand on the abdomen and exerting firm downward (caudal) pressure on the uterus; this procedure is done only if the uterus feels firm because pressure on a flaccid uterus can cause it to invert. If this procedure is not effective, the clinician holds the umbilical cord taut while placing the other hand on the abdomen and pushing upward (cephalad) on the firm uterus, away from the placenta; traction on the umbilical cord is avoided because it may invert the uterus. If the placenta has not been delivered within 45 to 60 min of delivery, manual removal may be necessary; the clinician inserts an entire hand into the uterine cavity, separating the placenta from its attachment, then extracts the placenta. In such cases, an abnormally adherent placenta placenta accreta should be suspected.

The placenta should be examined for completeness because fragments left in the uterus can cause hemorrhage or infection later. If the placenta is incomplete, the uterine cavity should be explored manually. Some obstetricians routinely explore the uterus after each delivery. However, exploration is uncomfortable and is not routinely recommended. Immediately after delivery of the placenta, an oxytocic drug (oxytocin

10 units IM or as an infusion of 20 units/1000 mL saline at 125 mL/h) is given to help the uterus contract firmly. Oxytocin

should not be given as an IV bolus because cardiac arrhythmia may occur.

Postdelivery: The cervix and vagina are inspected for lacerations, which, if present, are repaired, as is episiotomy if done. Then if the mother and infant are recovering normally, they can begin bonding. Many mothers wish to begin breastfeeding soon after delivery, and this activity should be encouraged. Mother, infant, and father should remain together in a warm, private area for an hour or more to enhance parent-infant bonding. Then, the infant may be taken to the nursery or left with the mother depending on her wishes.

For the first hour after delivery, the mother should be observed closely to make sure the uterus is contracting (detected by palpation during abdominal examination) and to check for bleeding, BP abnormalities, and general well-being. The time from delivery of the placenta to 4 h postpartum has been called the 4th stage of labor; most complications, especially hemorrhage , occur at this time, and frequent observation is mandatory.

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I dislike this video.
It shows old obstetric practices.

Here in Quebec we do not use traditional rooms deliveries and the medical staff are no longer hidden whith there mask.. The baby is put directly the skin-to-skin on the mother after childbirth. There is never a mother child separation except for medical reasons.