Protocol for Conducting a Normal Spontaneous Vaginal Delivery
Preparation and Labor Management
Position the laboring woman in lateral decubitus (left side-lying) to optimize hemodynamics during contractions and prevent aortocaval compression. 1, 2 This positioning is critical as the gravid uterus can compress the inferior vena cava starting at approximately 20 weeks gestational age, reducing venous return and cardiac output. 1
Key Labor Management Steps:
Allow uterine contractions to descend the fetal head to the perineum without maternal pushing until the head is crowning to avoid unwanted hemodynamic effects of the Valsalva maneuver. 1, 2
Administer continuous lumbar epidural analgesia as it reduces pain-related sympathetic activity, reduces the urge to push, provides anesthesia if surgery becomes necessary, and stabilizes cardiac output. 1, 2 However, use caution as regional anesthesia can cause systemic hypotension and requires careful IV fluid monitoring. 1
Implement continuous electronic fetal heart rate monitoring throughout labor. 1, 2
Prepare for assisted delivery with low forceps or vacuum extraction if needed, though vacuum should be avoided in women with coagulation disorders or high hepatitis C viral loads. 2, 3
Delivery of the Baby
Once crowning occurs, support the perineum and control delivery of the head, then deliver the anterior shoulder followed by the posterior shoulder. 2
Immediate Newborn Care:
Immediately dry and stimulate the newborn while assessing for first breath and cry. 2
Place the newborn skin-to-skin on the mother's chest with the umbilical cord still attached. 2
Delay cord clamping for at least 1 minute or until after placenta delivery to allow physiologic circulatory transition. 2
Continue drying the entire newborn except the hands (to allow infant to suckle hands bathed in amniotic fluid, facilitating rooting and first breastfeeding). 2
Cover the baby's body with prewarmed blankets while maintaining skin-to-skin contact. 2
Critical Safety Positioning During Skin-to-Skin:
Ensure continuous staff observation with frequent vital sign recording during the first 2 hours when 73% of sudden unexpected postnatal collapse (SUPC) events occur. 2
Verify the infant's face can be seen, head is in "sniffing" position, nose and mouth are not covered, head is turned to one side, neck is straight, and shoulders and chest face mother. 2
Delivery of the Placenta (Third Stage)
Administer 10 units of intramuscular oxytocin after placental delivery to prevent postpartum hemorrhage. 1, 2, 4 If IV administration is necessary, use slow infusion at less than 2 units per minute to avoid systemic hypotension. 1, 2
Critical Medication Precautions:
Never administer methylergonovine (ergometrine) as it causes vasoconstriction and hypertension in more than 10% of cases. 1, 2
Prostaglandin F analogues may be used to treat postpartum hemorrhage unless an increase in pulmonary artery pressure is undesirable. 1
Immediate Postpartum Maternal Care
Continue hemodynamic monitoring for at least 24 hours after delivery as this period is associated with significant fluid shifts and hemodynamic changes that may precipitate heart failure or other complications. 1, 2
Specific Postpartum Interventions:
Administer a single IV dose of furosemide to manage increased preload from autotransfusion of uteroplacental blood. 2
Implement meticulous leg care, elastic support stockings, and early ambulation to reduce thromboembolic risk. 1, 2
Continue monitoring systemic arterial pressure, maternal heart rate, pulse oximetry, and continuous ECG as required. 1
Immediate Newborn Monitoring
Maintain continuous staff observation with frequent recording of neonatal vital signs during the first hours of life. 2
Assess the five-minute Apgar score. 2
Observe newborn breathing, activity, color, tone, and position to prevent positions that obstruct breathing. 2
Facilitate early breastfeeding during skin-to-skin contact. 2
Critical Pitfalls to Avoid
Never leave the mother-infant dyad unobserved during the first 2 hours as this is when most sudden collapse events occur. 2
Never administer oxytocin as a rapid IV bolus due to risk of severe hypotension; always use slow infusion. 1, 2
Never use ergometrine for third stage management due to vasoconstriction and hypertension risk. 1, 2
Never encourage prolonged maternal pushing before crowning as this causes unwanted Valsalva effects with hemodynamic compromise. 1, 2
Never position the infant where the face cannot be seen or airway may be obstructed during skin-to-skin care. 2
Special Considerations for Anticoagulated Patients
For women on anticoagulation with prosthetic valves, switch oral anticoagulants to LMWH or UFH from 36 weeks, then to IV UFH at least 36 hours before planned delivery. 1 Discontinue UFH 4-6 hours before delivery and restart 4-6 hours after if no bleeding complications occur. 1 If emergent delivery is necessary while on therapeutic anticoagulation, cesarean delivery is preferred to reduce risk of intracranial hemorrhage in the fully anticoagulated fetus. 1