What are the steps of a normal vaginal delivery for an uncomplicated term pregnancy?

Steps of Normal Vaginal Delivery

For an uncomplicated term pregnancy, normal vaginal delivery proceeds through three distinct stages: cervical dilation and effacement (first stage), fetal descent and expulsion (second stage), and placental separation and delivery (third stage), with specific evidence-based interventions at each phase to optimize maternal and neonatal outcomes. 1

First Stage of Labor: Cervical Dilation

• The first stage involves gradual cervical shortening and dilation from 0 to 10 cm, typically lasting up to 36 hours in nulliparous women and shorter in multiparous women 1
• Delay hospital admission until active labor (typically ≥6 cm dilation) to reduce unnecessary medical interventions during labor and delivery 2
• Provide continuous emotional support throughout labor, as this improves delivery outcomes and the birthing experience 2
• Epidural analgesia is effective for pain control and does not increase the risk of cesarean delivery, though it does prolong labor 2
• Monitor maternal vital signs and fetal heart rate continuously or intermittently based on risk stratification 1

Pain Management During First Stage

• Offer epidural analgesia when requested; do not discontinue late in labor as this does not reduce the need for operative vaginal delivery 2
• Multimodal analgesia including regional techniques, local anesthetic infiltration, and opioids as needed are safe options 1
• Adequate pain relief is a high priority, particularly to minimize rapid shallow breathing that can decrease alveolar gas exchange 1

Second Stage of Labor: Fetal Descent and Delivery

• The second stage involves descent of the fetus through the birth canal and delivery, typically lasting 30 minutes to 2 hours 1
• Allow adequate time for labor progression—up to 4 hours of arrest in the active phase with oxytocin augmentation when appropriate—before considering operative delivery 3
• Position the mother to optimize pelvic dimensions and maternal comfort during pushing 1
• Avoid routine episiotomy as it increases maternal morbidity without clear benefit 2

Immediate Newborn Care

• Delay cord clamping by at least 60 seconds for all newborns, as this reduces intraventricular hemorrhage and transfusion needs in preterm infants (<37 weeks) and increases hemoglobin and iron levels up to 6 months in term infants 4
• The possible increased risk of neonatal jaundice requiring phototherapy with delayed clamping must be weighed against the physiological benefits 4
• Initiate early skin-to-skin contact immediately after delivery, as this promotes maternal-neonatal bonding and breastfeeding 5

Third Stage of Labor: Placental Delivery

• The third stage comprises placental separation and expulsion, typically lasting up to 30 minutes if no bleeding occurs 4, 6
• Administer oxytocin 10 IU intramuscularly after delivery of the anterior shoulder to prevent postpartum hemorrhage—this is the preferred medication and route for low-risk vaginal deliveries 4
• Alternative oxytocin regimens include IV infusion of 20-40 IU in 1000 mL at 150 mL/hour, or IV bolus of 5-10 IU over 1-2 minutes 4

Active Management of Third Stage

• Apply controlled cord traction when the uterus is contracted and the placenta has separated, as this reduces blood loss and postpartum hemorrhage risk 5, 7
• Active management (oxytocic administration, controlled cord traction, early cord clamping) reduces maternal blood loss by approximately 79 mL and decreases postpartum hemorrhage >500 mL by 62% compared to expectant management 7
• Perform external uterine massage after placental delivery to promote uterine contraction 4

Timing Considerations for Placental Delivery

• In uncomplicated deliveries without bleeding, manual placental extraction is not indicated until 30 minutes have elapsed, as hemorrhage risk does not increase until this threshold 6
• If the placenta is retained beyond 30 minutes with bleeding, consider intraumbilical injection of misoprostol 800 mcg or oxytocin 10-30 IU before proceeding to manual removal 4
• The third stage duration has a median of 6 minutes with an interquartile range of 4-10 minutes in normal deliveries 6

Immediate Postpartum Monitoring

• Monitor maternal vital signs closely for the first 2-4 hours postpartum, focusing on blood pressure, pulse, uterine tone, and vaginal bleeding 1
• Assess for signs of postpartum hemorrhage using clinical markers (vital signs, symptoms) rather than visual blood loss estimation 4
• Ensure the mother voids within 4-6 hours of delivery to prevent urinary retention 2

Critical Pitfalls to Avoid

• Do not perform routine episiotomy—it increases perineal trauma, pain, and healing complications without reducing severe perineal tears 2
• Do not withhold epidural analgesia based on cervical dilation, as neuraxial analgesia does not adversely affect labor outcomes when initiated early 1
• Do not clamp the umbilical cord immediately after delivery unless there is a specific indication; delayed clamping provides significant neonatal benefits 4
• Do not administer IV oxytocin as a rapid bolus during cesarean section, as this increases hypotension risk; the recommendation for bolus administration applies to vaginal delivery only 4
• Do not use ergometrine as first-line prophylaxis due to higher rates of maternal nausea, vomiting, and hypertension compared to oxytocin 4, 7