Vaginal Delivery Technique: Step-by-Step Guide
Maternal Positioning and Labor Management
Position the woman in lateral decubitus (side-lying) once labor begins to minimize hemodynamic stress from uterine contractions 1. This positioning is superior to supine positioning for maternal cardiovascular stability.
- Allow uterine contractions to naturally descend the fetal head to the perineum without active maternal pushing to avoid adverse effects of the Valsalva maneuver 1
- Avoid instructing the mother to perform sustained breath-holding or forced pushing during contractions 1
- Consider epidural analgesia as it reduces pain-related sympathetic activity and decreases the urge to push prematurely 1
Hand Positioning During Crowning: The Critical Decision
Use the "hands-poised" method rather than the traditional "hands-on" approach for routine deliveries 2, 3. This represents a significant shift from traditional practice but is supported by the highest quality evidence.
Hands-Poised Technique (Preferred):
- Keep your hands ready but not touching the perineum or fetal head during crowning 2, 3
- Position hands approximately 1-2 cm away, prepared to apply light pressure to the infant's head only if needed 2
- Allow spontaneous delivery of the shoulders without manual manipulation 3
- This method reduces episiotomy rates by 21% (10.1% vs 17.9%) and significantly decreases third-degree tears (0.9% vs 2.7%) 2, 3
Hands-On Technique (Alternative):
If you choose the traditional approach, proper execution is critical 4:
- Place your non-dominant hand on the infant's head to control the speed of delivery
- Position your dominant hand's thumb and index finger against the perineal body at a 30-45° angle 4
- Apply gentle, firm pressure to support the perineum and reduce tissue tension by approximately 30-39% 4
- This reduces perineal pain at 10 days postpartum by 3% compared to hands-poised (31.1% vs 34.1%) 3
Clinical caveat: The hands-on method shows slightly less pain at 10 days but higher rates of severe tears and episiotomies 2, 3. The hands-poised method is safer overall despite marginally more short-term discomfort.
Managing Shoulder Dystocia
If the shoulders do not deliver spontaneously after the head, immediately perform the McRoberts maneuver 5:
- Call for help immediately - this is an obstetric emergency
- Hyperflex the mother's thighs tightly against her abdomen 5
- Apply suprapubic pressure (not fundal pressure) with the palm of your hand just above the pubic symphysis 5
- Direct pressure posteriorly and laterally to dislodge the anterior shoulder 5
- Never use fundal pressure - this can cause uterine rupture, rib fractures, and worsen the impaction 6
If McRoberts fails:
- Introduce your hand into the vagina to manually rotate or push the fetal head upward (vaginal push method) 5
- Apply pressure carefully to avoid further deflexion of the head 5
Delivery of the Body
- Support the infant's head and neck as the body delivers
- Allow the shoulders to deliver spontaneously or assist with gentle downward traction for the anterior shoulder, then upward for the posterior shoulder 1
- Avoid excessive traction or twisting motions
Immediate Post-Delivery Management
Administer oxytocin immediately after placental delivery to prevent hemorrhage 1:
- Give 5-10 IU oxytocin via slow IV infusion at less than 2 U/min 1
- Rapid bolus causes dangerous hypotension - always infuse slowly 1
- Never use methylergonovine as first-line agent due to >10% risk of severe hypertension and vasoconstriction 1
Critical Pitfalls to Avoid
- Do not perform routine episiotomy - it does not reduce anal sphincter injury risk and increases overall trauma 5
- Do not apply fundal pressure during delivery - associated with uterine rupture, severe perineal trauma, and neonatal distress 6
- Do not use forceps or vacuum as a lever to disimpact a stuck head - this is dangerous 7
- Do not allow prolonged Valsalva pushing - passive descent is safer 1
Special Circumstances
For assisted delivery (forceps/vacuum):