What are the steps for delivering a normal spontaneous delivery (NSD) and providing post-delivery care?

Normal Spontaneous Delivery (NSD) and Immediate Postpartum Care: Step-by-Step Guide

Preparation and Labor Management

For a normal spontaneous vaginal delivery, position the laboring woman in lateral decubitus to optimize hemodynamics during contractions, allow spontaneous descent of the fetal head without maternal pushing until crowning, and prepare for assisted delivery with low forceps or vacuum if needed. 1

Positioning During Labor

• Place the woman in lateral decubitus position to attenuate hemodynamic impact of uterine contractions 1
• Alternatively, a sitting-up position may be used if needed for maternal comfort or cardiac status 1
• No single position needs to be mandated or proscribed for most women 2

Labor Progress

• Allow uterine contractions to descend the fetal head to the perineum without maternal pushing to avoid unwanted effects of the Valsalva maneuver 1
• Continuous electronic fetal heart rate monitoring is recommended 1
• Epidural analgesia is preferred during labor as it reduces pain-related sympathetic activity, reduces the urge to push, and stabilizes cardiac output 1

Delivery of the Baby

Immediate Steps at Delivery

1. As the baby delivers, immediately dry and stimulate for first breath/cry while assessing the newborn 1
2. Place the newborn skin-to-skin with cord still attached 1
3. Clamp the umbilical cord after 1 minute or after placenta delivery to allow physiologic circulatory transition 1
4. Continue drying the entire newborn except hands (to allow infant to suckle hands bathed in amniotic fluid, which facilitates rooting and first breastfeeding) 1
5. Cover the baby's body with prewarmed blankets 1

Assisted Delivery if Needed

• Delivery may be assisted by low forceps or vacuum extraction to reduce maternal exertion and shorten the second stage 1
• Vacuum-assisted delivery should be avoided in women with coagulation disorders or high hepatitis C viral load 3
• Use of vacuum as a lever to disimpact the fetal head is dangerous and should be avoided 3

Safe Positioning for Skin-to-Skin Care

Continuous staff observation with frequent vital sign recording is essential during the first 2 hours when sudden unexpected postnatal collapse (SUPC) events are most likely to occur. 1

Safety Checklist for Skin-to-Skin

• Infant's face can be seen 1
• Infant's head is in "sniffing" position 1
• Infant's nose and mouth are not covered 1
• Infant's head is turned to one side 1
• Infant's neck is straight, not bent 1
• Infant's shoulders and chest face mother 1
• Infant's legs are flexed 1
• Mother-infant dyad is monitored continuously by staff 1
• When mother wants to sleep, place infant in bassinet or with another alert support person 1

Delivery of the Placenta (Third Stage)

Administer a single dose of intramuscular oxytocin after placental delivery; ergometrine is contraindicated. 1

Active Management of Third Stage

• Use a single dose of intramuscular oxytocin (10 units) after delivery of the placenta 1, 4
• Ergometrine (methylergonovine) is contraindicated due to risk of vasoconstriction and hypertension 1
• If postpartum hemorrhage occurs, use slow intravenous infusion of oxytocin (less than 2 units/min) to avoid systemic hypotension 1
• For severe bleeding, 10 to 40 units of oxytocin may be added to 1000 mL of non-hydrating diluent and run at a rate necessary to control uterine atony 4
• Prostaglandin F analogues are useful for postpartum hemorrhage unless increased pulmonary artery pressure is undesirable 1

Immediate Postpartum Care for Mother

After delivery, auto-transfusion from the lower limbs and contracted uterus significantly increases preload, requiring close monitoring for at least 24 hours when hemodynamic changes may precipitate complications. 1, 5

Monitoring and Medications

• A single IV dose of furosemide is commonly given after delivery to manage increased preload 1, 5
• Continue haemodynamic monitoring for at least 24 hours after delivery 1, 5
• Meticulous leg care, elastic support stockings, and early ambulation reduce thromboembolic risk 1
• Restart anticoagulants in consultation with obstetrician and anesthesiologist when postpartum bleeding has stopped and epidural catheter removed 1, 5

Immediate Newborn Care

Assessment and Monitoring

• Continuous staff observation with frequent recording of neonatal vital signs during the first hours of life 1
• Observe newborn breathing, activity, color, tone, and position to avert positions that obstruct breathing 1
• Assess five-minute Apgar score 1

Thermal Regulation

• Maintain thermal regulation as a key area of delivery room quality improvement 6
• Keep baby covered with prewarmed blankets during skin-to-skin care 1

Feeding Support

• Facilitate early breastfeeding during skin-to-skin contact 1
• Continuous support during the immediate postpartum period improves breastfeeding outcomes 7, 8

Common Pitfalls to Avoid

• Do not use ergometrine for third stage management - it causes vasoconstriction and hypertension 1
• Do not allow prolonged maternal pushing before crowning - this causes unwanted Valsalva effects 1
• Do not leave mother-infant dyad unobserved during first 2 hours - 73% of sudden collapse events occur in this period 1
• Do not position infant where face cannot be seen or airway may be obstructed during skin-to-skin care 1
• Do not administer oxytocin as rapid IV bolus - use slow infusion (less than 2 units/min) to avoid hypotension 1, 4