Vaginal Delivery (Family Medicine)

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS
  • Vertex presentation, active labor, vulva distended, and deliverable baby
  • Fetal distress in a deliverable baby
CONTRAINDICATIONS

Absolute

  • Cord prolapse
  • Complete placenta previa or vasa previa
  • Abnormal fetal lie (e.g., footling breech, transverse lie, persistent brow presentation)
  • Previous classical cesarean section or transfundal uterine surgery
  • Herpes simplex infection with active genital lesions or prodromal symptoms
  • Untreated HIV infection

Relative

  • Pelvic deformities
  • Congenital deformities (hydrocephalus)
  • Invasive cervical carcinoma
  • Treated HIV infection
  • Macrosomia
  • Malpresentation (including breech)
  • Previous low transverse cesarean deliveries
  • Multiple gestation
EQUIPMENT
  • Oxygen with flowmeter (one setup for mother and another for infant)
  • Delivery bed
  • Setup for infant (infant warmer, oxygen with bag and mask, suction with DeLee, infant laryngoscope, intubation equipment, umbilical catheter, medications, and monitoring equipment for resuscitation)
  • Sterile equipment tray or table containing the following:
    • 10-mL tube for cord blood
    • Two scissors (blunt Mayo-Noble straight scissors for cutting the cord and/or episiotomy and sharp scissors for cutting suture and dressings)
    • Bulb syringe
    • One plastic cord clamp (may use curved forceps for the other)
    • Four curved hemostats
    • Two straight forceps
    • Two ring forceps clamps (also called a sponge stick or placenta forceps)
    • Drapes and towels (including under buttocks drape with fluid pouch)
    • Placenta basin
    • Gown (optional) and sterile gloves (latex free recommended)
  • Optional equipment for sterile tray or table:
    • Two needle holders
    • Nontraumatic forceps, Allis clamps (for third- or fourth-degree repair)
    • Two thumb-tissue forceps (one with teeth and one without teeth)
    • Gelpi retractor (for added visualization during a third- or fourth-degree repair)
    • Weighted speculum (offers greater visualization of the vaginal wall and cervix)
    • 10-mL syringe
    • 1½-inch, 22-gauge needle (for local anesthesia)
    • 1% lidocaine, without epinephrine
    • Two 3-0 absorbable sutures with tapered needles
    • Gauze pads (4 × 4)
    • Sterile speculum
    • Povidone-iodine, chlorhexidine, or surgical solution for preparation.
  • Emergency kit (for precipitous deliveries):
    • Sterile gloves (large)
    • Two sterile towels
    • One pair of blunt-ended scissors
    • One plastic cord clamp
    • Two curved forceps
    • Gauze pads (4 × 4)
    • Bulb syringe
    • Placenta basin
ANATOMY
  • Labor
    • Labor is divided into three progressive stages: First stage, from onset of labor until complete cervical dilation; second stage, from complete dilation to delivery of the infant; third stage, from delivery of the infant to delivery of the placenta.
    • The average time of each stage is different for nulliparas than for multiparas.
    • The first stage of labor may be subdivided into two phases. Latent phase labor may occur before the onset of the active phase. A prolonged latent phase is defined as greater than 25 hours for nulliparas and 14 hours for multiparas. Progression at a rate below these defined numbers may warrant intervention.
    • The cardinal movements of labor:
      • Engagement
      • Descent
      • Flexion
      • Internal rotation
      • Extension
      • External rotation and restitution

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Unless delivered in a labor-delivery-recovery-postpartum (LDRP) room, transfer the patient to a postpartum room approximately 2 hours after a normal spontaneous delivery. She can be discharged home approximately 2 days later.
  • While in the recovery stage, assess the patient regularly for postpartum hemorrhage.
  • Assess the patient at least daily after she has been transferred to the postpartum room.
    • Assessment should include evaluation of vaginal bleeding and infection.
    • Instruct the patient on what to expect.
    • Monitor the patient for signs and symptoms of complications.
    • Provide pain control.
    • Treat constipation.
    • Routine blood count measurements generally are not indicated.
  • Before discharge, birth control measures should be discussed and instructions given.
  • At the time of discharge from the hospital, give the patient specific instructions about her medications and other postpartum care.
COMPLICATIONS

Maternal Complications

  • Perineal pain and dyspareunia
  • Postpartum hemorrhage
  • Endometritis
  • Uterine inversion
  • Amniotic fluid embolism

Fetal Complications

  • The main risks to a fetus throughout the delivery process are trauma and hypoxia.
  • Respiratory distress.
  • Hemodynamic instability.
  • Neonatal sepsis.
  • Intracranial hemorrhage.
  • Brachial plexus damage.
  • Fracture (humerus and clavicle common).
  • Asphyxia and associated problems.
RESULT ANALYSIS
  • The pH, PCO2, PO2, CO2, hemoglobin, and oxygen content of the blood can be measured; and the bicarbonate concentration, oxygen saturation, and base excess/deficit can be calculated from these measurements.
  • The most useful value for assessing fetal condition is the pH. Fetal pH is typically 0.1 unit lower than maternal pH. The mean arterial fetal pH is 7.28. The risk for neonatal morbidity is inversely related to pH.
  • A calculated base deficit greater than 12 mmol/L is predictive of neonatal complications.
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