What is the proper management for a vaginal delivery?

Management of Vaginal Delivery

Vaginal delivery is the preferred mode of delivery in most cases, with an individualized delivery plan that includes timing, method of induction (if needed), analgesia/regional anesthesia, and level of monitoring required. 1

Pre-Delivery Assessment and Planning

• Assess maternal cardiac status, Bishop score (station of presenting part and cervical characteristics: dilatation, effacement, consistency, position), fetal well-being, and lung maturity
• For high-risk pregnancies, delivery should take place in a tertiary center with specialist multidisciplinary team care
• Create an individualized delivery plan that communicates to the team:
  • Timing of delivery (spontaneous vs. induced)
  • Method of induction if needed
  • Analgesia/regional anesthesia plan
  • Level of monitoring required

Labor Induction (When Necessary)

• Oxytocin and artificial rupture of membranes are indicated when Bishop score is favorable 1
• Oxytocin administration:
  • Initial dose should be no more than 1-2 mU/min
  • May gradually increase in increments of 1-2 mU/min until normal labor contraction pattern is established
  • Monitor fetal heart rate, uterine tone, and contraction frequency/duration/force 2
  • Discontinue immediately if uterine hyperactivity or fetal distress occurs 2
• Avoid long induction times with unfavorable cervix
• Mechanical methods (e.g., Foley catheter) are preferable to pharmacological agents in patients with cardiovascular concerns 1

Labor Management

Positioning and Monitoring

• Position woman in lateral decubitus position to attenuate hemodynamic impact of uterine contractions 1
• Monitor maternal vital signs:
  • Blood pressure and heart rate
  • Continuous electronic fetal monitoring
  • Pulse oximetry and ECG monitoring as required 1

Analgesia/Anesthesia

• Lumbar epidural analgesia is recommended as it:
  • Reduces pain-related elevations of sympathetic activity
  • Reduces urge to push
  • Provides anesthesia if surgery becomes necessary 1
• Monitor intravenous perfusion carefully, especially with regional anesthesia 1
• Be cautious with regional anesthesia in patients with obstructive valve lesions due to risk of hypotension 1

Second Stage Management

• Allow passive second stage without active pushing (up to 90 minutes) to permit descent of fetal head to perineum 1, 3
• Avoid prolonged maternal pushing efforts (consider assisted delivery if delivery not imminent after 60 minutes of active pushing) 3
• Position woman to facilitate delivery:
  • Lateral or semi-recumbent position
  • Lithotomy position for assisted delivery if needed

Assisted Vaginal Delivery (When Indicated)

• May be performed with vacuum extraction or forceps when medically indicated 4
• Common indications include:
  • Abnormal fetal heart rate patterns
  • Prolonged second stage
  • Maternal exhaustion or medical conditions requiring shortened pushing 5, 4
• Ensure provider has requisite skills and experience 3

Delivery of the Baby

• Allow spontaneous delivery of the fetal head when possible
• Protect the perineum during delivery to minimize trauma
• Consider episiotomy only when clinically indicated
• After delivery of the head:
  • Check for nuchal cord
  • Suction mouth and nose if needed
  • Support the head while delivering anterior then posterior shoulders
  • Deliver the body with gentle traction

Third Stage Management

• After delivery of the baby, administer slow IV infusion of oxytocin (≤2 U/min) to prevent maternal hemorrhage 1, 2
• Avoid rapid oxytocin administration which can cause hypotension 1
• Deliver placenta with controlled cord traction
• Inspect placenta for completeness
• Inspect birth canal for lacerations and repair as needed
• For post-partum hemorrhage:
  • Prostaglandin F analogues are useful unless increase in pulmonary artery pressure is undesirable
  • Avoid methylergonovine (contraindicated due to risk of vasoconstriction and hypertension) 1

Post-Delivery Care

• Continue hemodynamic monitoring for at least 24 hours after delivery 1
• Monitor for:
  • Blood pressure, heart rate, bleeding
  • Uterine involution
  • Genital pain
  • Urination
  • Temperature
  • Signs of phlebitis 6
• Implement thromboembolic prophylaxis:
  • Early ambulation
  • Elastic support stockings
  • Consider LMWH based on risk factors 1, 6
• Assess for anemia (Hb <11 g/dL at 48 hours) in women who bled during delivery or present with symptoms 6

Special Considerations

• For women with cardiac disease, vaginal delivery is still preferred in most cases 1
• Cesarean delivery should be considered in specific situations:
  • 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
  • Some centers recommend cesarean for severe aortic stenosis, severe pulmonary hypertension, or Eisenmenger syndrome 1

By following this structured approach to vaginal delivery, providers can optimize maternal and neonatal outcomes while minimizing complications.