Proper Management for Vaginal Delivery
The preferred mode of delivery is vaginal, with an individualized delivery plan that includes timing of delivery, method of induction (if needed), analgesia/regional anesthesia, and level of monitoring required. 1
Pre-Delivery Planning
Determine appropriate setting for delivery:
- Low-risk pregnancies can be managed in local settings
- High-risk pregnancies should be delivered in tertiary centers with multidisciplinary teams 1
Create a delivery plan that includes:
- Timing (spontaneous vs. induced)
- Method of induction if needed
- Pain management approach
- Monitoring requirements 1
Labor Induction (When Medically Indicated)
- Assess Bishop score to determine favorability of cervix
- For favorable cervix:
- For unfavorable cervix:
Labor Management
First Stage
- Position patient in lateral decubitus position to attenuate hemodynamic impact of contractions 1
- Monitor:
- Maternal vital signs (blood pressure, heart rate)
- Continuous electronic fetal monitoring
- Progress of labor 1
Pain Management
- Lumbar epidural analgesia is recommended as it:
- Reduces pain-related elevations of sympathetic activity
- Reduces urge to push
- Provides anesthesia if surgical intervention becomes necessary 1
- Monitor IV perfusion carefully with regional anesthesia 1
Second Stage
- Allow passive descent of fetal head to perineum without maternal pushing initially
- Active pushing should be encouraged when appropriate 1
- Delivery may be assisted with low forceps or vacuum extraction if needed 1
- Avoid prolonged second stage (>60 minutes of active pushing) 1
Delivery Technique
- Place woman in appropriate position for delivery
- Perform episiotomy only if indicated (not routine)
- Control delivery of the head to prevent perineal trauma
- Check for nuchal cord after delivery of the head
- Support the head while delivering the shoulders:
- Deliver anterior shoulder first by gentle downward traction
- Deliver posterior shoulder by gentle upward traction
- Complete delivery of the body with controlled traction
- Clamp and cut umbilical cord
Immediate Post-Delivery Management
- Administer oxytocin as slow IV infusion (<2 U/min) after placental delivery to prevent maternal hemorrhage 1
- Avoid methylergonovine (contraindicated due to risk of vasoconstriction and hypertension) 1
- Continue hemodynamic monitoring for at least 24 hours after delivery 1
- Implement measures to reduce thromboembolic risk:
- Meticulous leg care
- Elastic support stockings
- Early ambulation 1
Management of Complications
For postpartum hemorrhage:
- Continue oxytocin infusion
- Consider prostaglandin F analogues (unless increase in pulmonary artery pressure is undesirable) 1
- Perform uterine massage
- Assess for lacerations or retained placental fragments
For perineal tears/episiotomy:
Special Considerations
- For breech presentation: Consider cesarean section unless provider is skilled in vaginal breech delivery 4
- For vacuum-assisted delivery: Only perform when clinically indicated and after adequate critical analysis 5, 6
Common Pitfalls to Avoid
- Prolonged induction with unfavorable cervix
- Inadequate pain management leading to increased maternal stress
- Failure to monitor maternal vital signs and fetal heart rate appropriately
- Performing unnecessary interventions (episiotomy, instrumental delivery)
- Inadequate postpartum monitoring for hemorrhage
- Overlooking signs of postpartum complications
Remember that vaginal delivery is associated with less blood loss and infection risk compared to cesarean delivery, which also increases the risk of venous thrombosis and thrombo-embolism 1. Cesarean delivery should generally be reserved for obstetric indications.