What is the process for a vaginal delivery?

Vaginal Delivery Process

Vaginal delivery is the preferred mode of delivery with less blood loss, lower infection risk, and reduced risk of venous thrombosis compared to cesarean delivery. 1

Pre-Labor Preparation

• Assess maternal cardiac status and fetal well-being
• Evaluate Bishop score (based on cervical dilation, effacement, consistency, position, and station of presenting part)
• For women with normal cardiac function or mild unrepaired congenital heart disease, spontaneous onset of labor is appropriate and preferable to induced labor 1

Labor Induction (When Necessary)

• Indicated when Bishop score is favorable
• Options include:
  • Oxytocin administration (indicated for initiation of uterine contractions when medically necessary, not for elective induction) 2
  • Artificial rupture of membranes
• Avoid long induction times with unfavorable cervix
• Mechanical methods like Foley catheter may be preferable to pharmacological agents in certain cases 1

First Stage of Labor Management

1. Position patient in lateral decubitus position to reduce hemodynamic impact of contractions 1
2. Monitor:
   • Systemic arterial pressure
   • Maternal heart rate
   • Continuous electronic fetal heart monitoring
   • Pulse oximetry and continuous ECG as required 1
3. When membranes rupture, perform immediate vaginal examination to rule out prolapsed cord 1
4. Pain management:
   • Lumbar epidural analgesia is often recommended as it:
     • Reduces pain-related elevations of sympathetic activity
     • Reduces urge to push
     • Provides anesthesia if surgery becomes necessary 1

Second Stage of Labor

1. Allow passive descent:
   • A passive second stage without active pushing may last up to 90 minutes, allowing the fetal head to descend well into the pelvis
2. Active pushing:
   • The uterine contractions should help descend the fetal head to the perineum
   • Maternal pushing efforts are essential for safe delivery 1
3. Delivery techniques:
   • Allow spontaneous delivery when possible
   • Operative vaginal delivery (vacuum or forceps) may be necessary in approximately 5% of deliveries when indicated for maternal or fetal reasons 3
   • Avoid unnecessary operative interventions, as they can lead to neonatal complications 4

Third Stage of Labor

1. After delivery of the baby:
   • Administer slow IV infusion of oxytocin (less than 2 U/min) after placental delivery to prevent maternal hemorrhage 1
   • Avoid rapid infusion to prevent systemic hypotension
2. Deliver the placenta:
   • Allow for spontaneous delivery with gentle traction
   • Assess for completeness of placenta and membranes

Post-Delivery Care

1. Continue hemodynamic monitoring for at least 24 hours after delivery, particularly in women with structural heart disease 1
2. Implement measures to reduce thromboembolic risk:
   • Meticulous leg care
   • Elastic support stockings
   • Early ambulation 1
3. Monitor for postpartum hemorrhage:
   • Prostaglandin F analogues can be used to treat postpartum hemorrhage if needed
   • Avoid methylergonovine (contraindicated due to risk of vasoconstriction and hypertension) 1

Important Considerations and Pitfalls

• Cesarean delivery should generally be reserved for obstetric indications 1
• Specific medical conditions may warrant consideration of cesarean delivery:
  • Patients on oral anticoagulants in pre-term labor
  • Marfan syndrome with aortic diameter >45 mm
  • Acute or chronic aortic dissection
  • Acute intractable heart failure 1
• Decision-making for operative vaginal delivery should involve careful clinical assessment rather than rushed intervention 4
• Vacuum-assisted deliveries should only be performed when clinically indicated and after adequate critical analysis 4

By following this structured approach to vaginal delivery, healthcare providers can optimize outcomes while minimizing risks to both mother and baby.