VAGINAL DELIVERY
Dr. Roselyn Collado-Garcia – December 01, 2021
OUTLINE
I. MANAGEMENT OF SECOND STAGE LABOR
A. LITHOTOMY POSITION
B. OCCIPUT ANTERIOR POSITION
1. MODIFIED RITGEN MANEUVER
2. DELIVERY OF THE SHOULDERS
3. CLAMPING OF THE CORD
C. PERSISTENT OCCIPUT POSTERIOR
1. MANAGEMENT
D. PERSISTENT OCCIPUT TRANSVERSE
E. SHOULDER DYSTOCIA
1. TURTLE SIGN
2. MANAGEMENT
● SUPRAPUBIC PRESSURE
● McROBERTS MANEUVER
● DELIVERY OF THE POSTERIOR
SHOULDER
● WOOD’S CORKSCREW
● RUBIN MANEUVER
● GASKIN MANEUVER
● POSTERIOR AXILLA
TRACTION
● DELIBERATE FRACTURE
ANTERIOR CLAVICLE
● HIBBARD MANEUVER
● ZAVANELLI MANEUVER
● SYMPHYSIOTOMY
● CLEIDOTOMY
II. MANAGEMENT OF THIRD STAGE LABOR
A. EXPECTANT OF PHYSIOLOGICAL
B. ACTIVE MANAGEMENT (AMTSL)
1. STEPS OF AMTSL
2. MEDICATIONS
C. MANUAL REMOVAL
III. FOURTH STAGE OF LABOR
A. BIRTH CANAL LACERATIONS
1. FIRST DEGREE
2. SECOND DEGREE
3. THIRD DEGREE
4. FOURTH DEGREE
B. EPISIOTOMY
References:
William’s Obstetrics, 25th Edition
Dr. Garcia’s Lecture
Notes
OBJECTIVES
At the end of the session, a second year medical student must
be able to:
● Discuss the management of 2nd stage of labor and
the mechanics of vaginal delivery in variety of fetal
position
○ Occiput Anterior
○ Occiput Posterior
○ Occiput Transverse
USE AT YOUR OWN RISK
● Describe the maneuvers employed in the
management of shoulder dystocia
● Outline the management of the 3rd stage of labor
● Differentiate the degrees of perineal laceration
● Differentiate the median from mediolateral episiotomy
MANAGEMENT OF SECOND STAGE OF LABOR
● When caring for a mother at the labor room in
monitoring the contractions, its interval and cervical
dilatation, effacement and maximal descending part,
all this constitutes the 2nd stage of Labor
● Primiparous
○ Full cervical dilatation may be monitored in
the labor room
○ Maternal expulsive efforts may help bring
down the present part further down the birth
canal
● Multiparous
SLING ○ Better monitored on the delivery table,
equipped with stirrups
OF
● Expulsive efforts - distend the perineum
● Prepare the woman for delivery
○ Dorsal lithotomy
○ Proper positioning at the delivery table
○ Perineal Prep
○ Observe aseptic technique
● The end of second-stage labor is heralded as:
○ The perineum begins to distend
○ Overlying skin becomes stretched,
○ Fetal scalp is seen through the separating
labia.
● Increased perineal pressure from the fetal head
creates reflexive bearing-down efforts, which are
encouraged when appropriate.
● At this time, preparations are made for delivery.
● If the bladder is distended, catheterization may be
necessary
● Continued attention is also given to fetal heart rate
monitoring.
● As one example, a nuchal cord often tightens with
descent and may lead to deepening variable
decelerations
LITHOTOMY POSITION
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 VAGINAL DELIVERY

● Dorsal lithotomy position is most common and often ■ Mediolateral episiotomy

the most satisfactory ○ Routine episiotomy is no longer
● For better exposure, leg holders or stirrups are used recommended, and selective use aims to
● The delivery bed is enough to accommodate the body enlarge the vaginal opening for specific
of the mother indications
● The popliteal fossa rests on the curvature of the ● To limit vaginal lacerations - perineal massage
stirrups ○ With the perineal massage, you would know
○ Within the leg holder, the popliteal region that the support is placed there
should rest comfortably in the proximal ○ Aside from perineal massage, you may also
portion and the heel in the distal portion use perineal support
● The stirrups are padded so the legs of the mother are ● RITGEN MANEUVER
comfortable ○ As the head distends the vulva and
○ The legs are not strapped into the stirrups, perineum, perineal support allows fetal head
thereby allowing quick flexion of the thighs delivery
backward onto the abdomen should shoulder
dystocia develop
○ Legs may cramp during second-stage
pushing, and cramping is relieved by
repositioning the affected leg or by brief
massage
● The distance between the thighs must be comfortable
enough not to strain the legs
○ If too much distance or the legs are wider
apart, this may cause temporary paralysis of ● Following the WHO Practice Guideline, they would
the lower extremities only advocate perineal support
● Properly drape the upper body of the mother ○ But it is quite difficult, because in the real
● The buttocks should be flat on the delivery table world, you would rather suture or care of a
● Make sure the perineal area is aseptic and properly wound that is cleanly cut
draped
○ Scrubbing, gowning, gloving, and donning
protective mask and eyewear protect both
MODIFIED RITGEN MANEUVER
the laboring woman and accoucheur from
infectious agents

OCCIPUT ANTERIOR POSITION

● Most common form of rotation
● Delivery of the head
○ Encirclement of the largest diameter by the
vulvar ring (crowning)
○ Perineum thins
■ When the mother bears down, it
propels the head downwards,
pushing and stretching the perineal
body then thinning it out
■ May spontaneously lacerate
○ Anus becomes greatly stretched and ● Alternatively done if expulsive efforts are inadequate
distended or expeditious delivery is needed
■ Anterior wall of the rectum is seen ● As the head emerges down the perineum or pelvic
● ~90% of cases, the fetal head would present at floor and through the birth canal, you can hook the
occiput anterior position (triangular occipital chin, the head is pushed even forward, you assume
fontanelle) - vertex or occiput presentation exaggerated extension of the head
○ Anterior towards the symphysis pubis ● Image: Moderate upward pressure is applied to the
○ The head descends in full flexion fetal chin by the posterior hand covered by a sterile
● Episiotomy may be employed towel. The other hand applies occipital pressure.
○ Incision = episiotomy ● Now, you favor neck extension
■ Median episiotomy

USE AT YOUR OWN RISK page 2 of 12

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MANAGEMENT OF NORMAL LABOR AND DELIVERY
● Sequence of fetal head movement upon delivery
○ Emerging
■ Flexion
■ Extension
■ Rotation to the side
DELIVERY OF THE SHOULDERS
● As the head goes into extension, it rotates
○ The most common rotation, as it enters the
birth canal or pelvic inlet in >90% of cases, is
the left occiput transverse rotation
● Following delivery of the fetal head, a finger is passed
across the fetal neck to determine whether it is
encircled by one or more umbilical cord loops.
● If an umbilical cord coil is felt, it is slipped over the
head if loose enough. If applied too tightly, the loop is
cut between two clamps.
● External rotation allows head to assume transverse
position
● Sh- Sh occupies the AP diameter
● Check for cord loops ( found in 25% of cases)
● Observe for the rest of the cardinal movements to
proceed
● Assist delivery of the rest of the body
● Over traction may cause injury
● Suctioning of nasopharynx - was the previous practice
○ Previously, immediate nasopharyngeal bulb
suctioning of the newborn was routine to
remove secretions. It was found that
suctioning of the nasopharynx may lead to
neonatal bradycardia.
● Observe EINC ( Essential Intrapartum Newborn Care)
● Should assume the AP diameter
● Following its delivery, the fetal head falls posteriorly,
bringing the face almost into contact with the maternal
anus. The occiput promptly turns toward one of the
maternal thighs, and the head assumes a transverse
position.
● This external rotation indicates that the bisacromial
diameter, which is the distance between the
shoulders, has rotated into the anteroposterior
diameter of the pelvis.
● Most often, the shoulders appear at the vulva just
after external rotation and are born spontaneously. If
delayed, extraction aids controlled delivery.
USE AT YOUR OWN RISK
● The sides of the head are grasped with two hands,
and gentle downward traction is applied until the
anterior shoulder appears under the pubic arch.
● Next, by an upward movement, the posterior shoulder
is delivered. During delivery, abrupt or powerful force
is avoided to avert fetal brachial plexus injury.
CLAMPING OF THE CORD
● The umbilical cord is cut between two clamps placed
6 to 8 cm from the fetal abdomen and later an
umbilical cord clamp is applied 2 to 3 cm from its
insertion into the fetal abdomen
● Umbilical cord cut in between clamps
○ 2 to 3 cms plastic clamp from fetal
abdomen
● Delayed cord clamping ( 60 seconds ) benefits:
○ Increase total body iron stores
○ Expand blood volume
○ Decrease neonatal anemia
● Downside: Increase bilirubin, causing
hyperbilirubinemia
● For the preterm neonates, delayed cord clamping has
several benefits:
○ Higher red cell volume
○ Decreased need for blood transfusion
○ Lower rates of intraventricular hemorrhage
and of necrotizing enterocolitis
● “Milking” the cord - benefits the baby if rapid cord
clamping is to be done
○ If baby is asphyxiated,has non-reassuring
fetal heart rate pattern or fetal distress what
you can do is milk the cord towards the fetus
● Preterm neonates: delayed clamping benefits:
○ High red cell volume
○ Decrease need for transfusion
○ Better circulatory stability
○ Lower rate for UVH/Necrotizing Enterocolitis
PERSISTENT OCCIPUT POSTERIOR
● As it subtends the birth canal, it undergoes rotation to
occiput posterior
● Occurs in 2-10% of singleton term
● Predisposing factors:
○ Epidural analgesia
■ During labor, when there is strong
contraction, it arrests the baby’s
rotation in occiput posterior
○ Nulliparity
■ Tout abdomen
○ Big baby
■ No room for rotation
○ Prior OP delivery
○ Anthropoid pelvis
○ Narrow subpubic angle
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● Complications:
○ Higher rates for prolonged second stage of
labor
○ Cesarean deliveries
○ Operative vaginal delivery
○ Increased rate for higher-order vaginal
lacerations
MANAGEMENT
● Manual rotation to OA
○ Do an internal examination, grasp and rotate
it 180 degrees.
○ Lower rates of cesarean
○ Lower incidence of vaginal laceration
■ Because the occipito bregmatic
subtending the symphysis pubis
and at a shorter duration
○ Few cases of maternal blood loss
○ Disadvantage: increase incidence for
cervical laceration (inspect after delivery)
■ Due to the grasping of the head
● Delivery in OP
○ **both may be accomplished by Forceps
● Cesarean delivery
PERSISTENT OCCIPUT TRANSVERSE
● When the head enters the birth canal it is often in this
rotation more than 95%
● OT is a transitory position
● Spontaneously rotates to anterior
● Persistence: Platypelloid/android
● Management:
○ Manual rotation to OA (90 degree rotation)
○ Rotation by kielland forceps
SHOULDER DYSTOCIA
● Vaginal delivery→ complete emergence of fetal
head→ remainder of body may not rapidly follow
○ The anterior fetal shoulder can become
wedged behind the symphysis pubis and fail
to deliver using normally exerted downward
traction & maternal pushing
● Obstetric emergency
○ umbilical cord is compressed within the birth
canal
● Increasing birthweight has been associated with
increasing incidence for SD
● not a very common finding
● Material characteristics that favor increase BW:
○ Maternal obesity - obese/ big fetus
○ Postterm pregnancy
○ Multiparity
○ DM- babies have smaller heads with wider
shoulder to shoulder diameter
○ GDM
USE AT YOUR OWN RISK
○ fetal macrosomia + maternal diabetes= ↑
frequency of shoulder dystocia
● Greater risk to the fetus than the mother
○ significant neonatal neuromuscular injury
and asphyxia
○ brachial plexus injury (11%)
○ Clavicular & humeral fracture (2%)
○ Acidosis at delivery (7%)
○ Required cardiac resuscitation or developed
hypoxic ischemic encephalopathy (1.5%)
○ Severe fetal acidosis & HIE (0.5% if delivery
completed w/in 5 mins)
■ case rate increase 6 and 24 % w/
delivery delays > 5 minutes
● Main maternal risk:
○ Serious perineal tears
○ Postpartum hemorrhage
■ usually from uterine atony but also
from lacerations
● Fetal macrosomia, maternal obesity, prolonged
second-stage labor and a prior event raise risks for
shoulder dystocia
● The American college of obstetricians and
gynecologist reviewed studies & concluded that:
1. Most cases of shoulder dystocia cannot be
accurately predicted or prevented
2. Elective induction of labor or elective
cesarean delivery for all women suspected
of having a macrosomic fetus is not
appropriate
3. Planned cesarean delivery may be
considered for the nondiabetic woman with
a fetus whose estimated fetal weight is
>5000g or for the diabetic woman whose
fetus is estimated to weigh >4500 g
● Risk of recurrent shoulder dystocia (1-3%)
● Trial of labor- reasonable for women with prior
shoulder dystocia
● The American college of obstetricians and
gynecologist recommends that Estimated fetal
weight, Gestational age, Maternal glucose
tolerance & severity of prior neonatal injury be
evaluated & risks and benefits of cesarean delivery
discussed with any woman with a history of shoulder
dystocia
TURTLE SIGN
● Inability of the head, opposed
to the perineum / tightly opposing
head? (not clear)
● As the head emerges, it does
not spontaneously rotate
● If a turtle sign is present, you
will know that you are dealing with
a shoulder dystocia
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MANAGEMENT
● Shoulder dystocia cannot be accurately predicted,
clinicians should be well versed in its management
and principles
○ Know that you are dealing with shoulder
dystocia. It is a must that you need help, you
cannot do it on your own
● Goals:
○ Reduce the head-to-body delivery time
○ Avoid fetal and maternal injury from
aggressive manipulation
● Recommended: initial gentle attempt at traction,
assisted by maternal expulsive efforts
○ Adequate analgesia- ideal
● Generous episiotomy- to provide room for
manipulation
○ Do mediolateral episiotomy→ can extend
to the rectal mucosa
○ Episiotomy→ does not lower brachial plexus
injury rates but raises third- and fourth-
degree laceration rates
● Lifting the popliteal fossa away from the stirrups, and
the thigh is pushed against the maternal abdomen or
side, the pelvic tilt is now orienting the pubic
symphysis more horizontally leading to 1.5cm
allowance to deliver the shoulders of the feus
DELIVERY OF THE POSTERIOR SHOULDER
● Arm is splinted, swept across chest, keep the elbow
flexed
● Fetal head is grasped and the arm extended along
the side of the face
● Posterior arm delivered
● Posterior shoulder girdle rotated obliquely to deliver
the anterior shoulder

SUPRAPUBIC PRESSURE

● Used to free the

anterior shoulder from its
impacted position behind
the symphysis pubis
WOOD’S CORKSCREW
● Applied by an
● Rotate posterior shoulder in a 180° degrees fashion
assistant, while
freeing the anterior shoulder
downward traction is
● High risk for humeral fracture
applied to fetal head
● Pressure is applied
with the heel of the hand
to the anterior shoulder
wedged above and
behind the symphysis
● The anterior shoulder is thus either depressed or RUBIN MANEUVER
rotated, or both, so the shoulders occupy the oblique ● 1st maneuver – Fetal shoulder are rocked from side
plane of the pelvis to side by applying force to the maternal abdomen
○ anterior shoulder can be freed ● 2nd maneuver – Fetal shoulder which pushed
toward the anterior surface of the chest
McROBERTS MANEUVER ● This maneuver abducts both shoulders, that turn
● Removing the legs from the stirrups and sharply produces a smaller bisacromial diameter
flexing them up towards the abdomen ○ smaller S-S diameter
● Caused – straightening of the sacrum relative to the ● This permits displacement of the anterior shoulder
lumbar vertebrae, rotation of the symphysis pubis from behind the symphysis
toward the maternal head, and decrease in the angle
of pelvic inclination
● Does not – increase pelvic dimension, pelvic rotation
cephalad tends to free the impacted anterior shoulder

USE AT YOUR OWN RISK page 5 of 12

 VAGINAL DELIVERY

GASKIN MANEUVER
● “all-fours maneuver”
● “knees and hand position” against the bed
● Downward traction on head and neck to free the
posterior shoulder

POSTERIOR AXILLA SLING TRACTION

● Suction catheter hooked under the axilla and tied
around the posterior shoulder
SYMPHYSIOTOMY or PUBIOTOMY
● Upward and outward traction applied
● Complication: ● Old technique of 1960s when there was no possibility
○ Humeral fracture to do emergent C-section
○ Erb’s palsy

DELIBERATE FRACTURE OF ANTERIOR CLAVICLE

● Thumb pressing the clavicle against the pubic rami
● Decrease the transverse diameter of the chest and
shoulders

● Look at where the incision is made, we know that the

symphysis pubis is held together by a membranous
and the fibrous tissue, so that is where you incise the
symphysis pubis.
● When the bones are separated, now it is easy for you
to remove that head.

● Babies with fractured clavicles when delivered, are CLEIDOTOMY

treated with splinting which is formed in a figure 8. ● Usually done on a dead fetus
Neonate bones heal rapidly.

HIBBARD MANEUVER
● Apply pressure to the fetal jaw and neck in the
direction of maternal anus with strong fundal pressure ● We don’t want to end up doing this that’s why it's a
must that planning the delivery of the baby would
There are 3 destructive maneuvers for shoulder dystocia be the better and most acceptable fashion
which are:
● Zavanelli maneuver SHOULDER DYSTOCIA VIDEO
● Symphysiotomy or pubiotomy
● Cleidotomy ● Shoulder dystocia is a complication that can occur
during a vaginal delivery
○ An obstetrical emergency
ZAVANELLI MANEUVER
○ Occurs when after delivery of the fetal head
● Replacement of the fetal head into the pelvis followed additional obstetrical maneuvers are
by CS delivery required to deliver the fetal shoulders
● Flexing the fetal head and pushing it back up into the (occurs in approximately 1% of births)
vagina to get the fetal head back into the pelvis ○ Can be caused by impaction of the anterior
● Perform an emergency CS or posterior shoulder during vaginal delivery
● Complication: ■ Anterior shoulder is more common
○ Neonatal death and is caused by impaction at the
○ Stillbirth maternal pubic symphysis
○ Brain damage ■ Posterior shoulder is less common
○ Uterine rupture and is caused by impaction at the
maternal sacral promontory

USE AT YOUR OWN RISK page 6 of 12

 VAGINAL DELIVERY
● Risk factors:
○ Maternal diabetes
○ Suspected macrosomia
○ Gestational age >42 weeks
○ Previous shoulder dystocia
○ Operative delivery
● Over 50% of cases are not predictable and have no
risk factors so you need to be prepared for the
possibility of shoulder dystocia at every delivery
● Shoulder dystocia is a clinical diagnosis that should
be made promptly.
○ Diagnosis is made when the routine practice
of gentle downward traction of the fetal head
fails to deliver the anterior shoulder
○ It is very important to diagnose shoulder
dystocia as soon as it occurs so that the
obstetrical team can start to manage it right
away
● Goal of management: To deliver the infant before
asphyxia from umbilical cord compression occurs
without causing any fetal or maternal trauma
CASE STUDY:
● SARAH is a 28 year old G1 at 40 weeks gestation
that has been laboring for the past 10 hours. She is
healthy and takes no medications. She has had a
normal pregnancy so far. Sarah had an epidural to
manage her labor pain when she was 4cms dilated.
Now, she is fully dilated and has been pushing well
for the past 2 hours. You and the resident notice
that the fetal head delivered but then retracted
back into the perineum (turtle sign). What do you
and the resident do next?
● Management: (ALARMER)
○ Ask for help
○ Legs (McRoberts maneuver)
■ The patient’s legs should be flexed
all the way back so that her thighs
are above her abdomen.
■ This movement rotates the pubis
symphysis and flattens the sacrum
to relieve obstruction in up to 42%
of patients
■ if shoulder dystocia persists move
on to the next step
USE AT YOUR OWN RISK
○ Apply Suprapubic Pressure & Anterior
Shoulder Disimpaction
■ To do this, one of the team
members should grab a stool to
stand on and then use their palm or
fist to apply downward and lateral
pressure suprapubicly
■ This maneuver adducts and rotates
the fetal shoulders to disimpact the
anterior shoulder
■ Another way to disimpact the
anterior shoulder is using the Rubin
maneuver
■ Done by placing one hand into
vagina and on the back surface
of the posterior fetal shoulder
and rotating it anteriorly to
disimpact the anterior shoulder
■ If you’re unable to do so, move
on to the next step
○ Release the posterior shoulder
■ One hand is in the vagina after
finding the fetal arm, flex the
elbow crossed the chest to grasp
the forearm or hand and pull it out
of the vagina
■ If you can’t deliver the fetal arm it
may be possible to deliver the
shoulder. If not, move on to the
next step.
○ Maneuver of Woods (Screw maneuver)
■ Rotate the fetus or unscrew it by
putting pressure on the clavicle of
the posterior shoulder and rotating
it until it becomes anterior
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 VAGINAL DELIVERY
○ Episiotomy
■ surgical cut made at the opening of
the vagina to allow more room and
better access to the posterior arm
○ Roll onto all fours
■ The patient is helped onto her
hands and knees
■ This is an effort to take advantage
of gravity to facilitate delivery
○ If none of the steps of the acronym work
there are several last resort methods that
can be considered. However, these are
associated with a significant increase in fetal
and maternal morbidity. These include:
■ Fracture of the fetal clavicle
■ Zavanelli maneuver
● Returning the fetal head &
Attempting Cesarean
delivery
■ Symphysiotomy
● separation of the maternal
pubic bones
Back in the case…
● You and your resident suspect shoulder dystocia
and initiate the ALARMER acronym.
MANAGEMENT OF THIRD STAGE OF LABOR
● Delivery of the placenta
EXPECTANT OR PHYSIOLOGICAL
● Waiting for placental separation signs and allow
spontaneous placental delivery
● By nipple stimulation
● By gravity
● Median time: 4-12 minutes
● Cut the umbilical cord in between the two clamps.
After cutting, you will end up with one clamp, roll it
and do a gentle traction horizontally.
ACTIVE MANAGEMENT (AMTSL)
● Triad of:
○ Early cord clamping
■ Though we do not advocate early
cord clamping, it goes without
saying that once the umbilical
pulsation has cease, clamp the cord
immediately
○ Controlled cord traction during placental
delivery
○ Immediate administration of prophylactic
uterotonics
● AIM of AMTSL: Limit Postpartum Hemorrhage
USE AT YOUR OWN RISK
STEPS OF AMTSL IN SEQUENCE
1. Check the uterus for the presence of a second baby
2. In less that 1 minute, administer a uterotonic drug
● Uterotonics play an important role to
decrease postpartum blood loss
3. Apply controlled cord traction
● Do not jerk the delivery of the placenta
because it might still be attached to the
borders/walls of the uterus
● Deliberate cord traction- eversion of the
fundus
4. After delivery of the placenta, immediate massage of
uterus
5. Check for completeness of placenta
● Lay it down on the side table and make sure
that you have complete cotyledon
6. Examine the woman’s vagina, perineum and external
genitalia for lacerations or active bleeding
MEDICATIONS USED FOR AMTSL
OXYTOCIN
● High dose, produced in the posterior pituitary
● Effects in 1 min; mean half-life of 3-5 min
● Can cause hypotension- if given in bolus
○ It should be given as dilute solution by
continuous intravenous infusion or as an
intramuscular injection
● Has an antidiuretic hormone effect- can cause
water intoxication
○ If administered in high doses for a
considerable amount of time, concentration
should be increased instead of the infusion
flow rate
● Contraindicated in patients with heart disease and
hypovolemic hemorrhage
● Dose: 20 U/L (10-20mL/min infusion) until the uterus
remains firmly contracted and bleeding is controlled
● The infusion rate is then reduced to 1 to 2mL/min until
the mother is ready for transfer from recovery to the
postpartum unit
ERGONOVINE AND METHYLERGONOVINE
● Ergot alkaloids
● Alternative in settings that lack oxytocin
● Strict storage requirements
● IM or oral (dose: 0.2mg)
● Never given antepartum- can cause tetanic
contraction
● Recommended as given 12 hourly due to its
sustained effect
● Causes maternal hypertension
● Less effective compared to oxytocin
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MISOPROSTOL
● Off-label drug 2. When the placenta
○ This drug is used for gastrointestinal detaches, it is grasped
problems, however, its side effect is smooth and removed.
muscle contraction and therefore very good ● Once the hand is inside
for contracting the uterus the uterine cavity, like
● Prostaglandin E1 analog turning the pages of
● Alternative in settings that lack oxytocin the book, you try to
● Given as a single oral dose of 600mcg detach its attachment
● Side effects: to the uterine fundus or
○ chills- 30% to the uterine surface -
○ fever- 5% until you are able to
grasp the full detached
OTHER ALTERNATIVE DRUG placenta before the
● Carboprost- synthetic prostaglandin analogue of placenta is grasped and removed.
PGF2α with oxytocic properties ● Never grasp the placenta without it being
● Carbetocin- an alternative uterotonic drug detached from its attachment, otherwise you
might puncture of perforate the uterine cavity or
MANUAL REMOVAL OF PLACENTA uterine musculature
● If the placenta could not be delivered spontaneously,
then you can go for manual removal of the placenta FOURTH STAGE OF LABOR
○ In approximately 2 percent of singleton ● An hour immediately following delivery of the
births, the placenta may not deliver promptly. placenta.
● Threshold for spontaneous delivery for placenta ○ The hour immediately following delivery of
range: 15 - 60 minutes the placenta is critical.
● Retained placenta: ○ During this time, lacerations are repaired.
○ Placenta adherens ● Check for laceration as cause for bleeding
■ Adherent placenta that would not ○ Although uterotonics are administered,
separate on its own. postpartum hemorrhage as the result of
■ Uterine contractions are insufficient uterine atony is most likely at this time.
to detach the placenta ● Hematoma may likely expand.
○ Lower uterine segment constriction ○ Consequently, uterine tone and the perineum
■ Detached but trapped placenta are frequently evaluated.
■ The placenta has detached already ● Uterine atony is most likely at this time
but gets trapped inside.
○ Morbidly adherent placenta ● The American Academy of Pediatrics and the
● Consistent risks for retained placenta include: American College of Obstetricians and Gynecologists
○ Stillbirth (2017b) recommend that:
○ Prior cesarean delivery ○ Maternal blood pressure and pulse are
○ Prior retention recorded immediately after delivery and
○ Preterm delivery every 15 minutes for the first 2 hours.
○ The placenta, membranes, and umbilical
cord are examined for completeness and for
STEPS IN MANUAL REMOVAL OF PLACENTA
anomalies.

BIRTH CANAL LACERATIONS

1. One hand grasps the ● Lower genital tract lacerations may involve the cervix,
fundus and the other vagina, or perineum.
hand into the uterine ○ Those of the perineum often follow vaginal
cavity and and the delivery, and most are first- and second-
fingers are swept from degree lacerations.
side to side as they are ● Lacerations are classified by their depth, and
advanced. complete definitions.

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FIRST DEGREE
● Superficial only
○ Fourchette
○ Perineal skin C. Third-degree laceration: EAS
○ Vaginal mucous and IAS are torn.
membrane
● May Include periurethral
lacerations
● First-degree perineal
laceration: injury to only the
vaginal epithelium or FOURTH DEGREE
perineal skin. ● The perineal body, entire anal sphincter complex, and
anorectal mucosa are lacerated.
SECOND DEGREE ● Third- and fourth-degree lacerations are considered
● Fascia and muscles of obstetrical anal sphincter injuries (OASIS), and their
perineal body combined incidence varies from 0.5 to 5 percent.
● May be midline ○ Risk factors for these more complex
● May extend upward or to both lacerations include:
sides of vagina ■ Nulliparity
● Second-degree laceration: ■ Midline episiotomy
injury to perineum that spares ■ Persistent OP position
the anal sphincter complex ■ Operative vaginal delivery
but involves the perineal ■ Asian race
muscles, which are the ■ Short perineal length
bulbospongiosus and ■ Increasing fetal birth weight
superficial transverse ● Morbidity rates rise as laceration severity increases.
perineal muscles. ○ Compared with simpler lacerations, anal
sphincter injuries are associated with greater
blood loss and puerperal pain.
THIRD DEGREE
○ Wound disruption and infection rates are
other risks

EPISIOTOMY
● Episiotomy is an incision of the pudendum–the
A. <50 percent of the external external genital organs.
anal sphincter (EAS) is torn. ○ In contrast to spontaneous lacerations,
perineotomy is an intended incision of the
perineum.
● Midline and mediolateral episiotomies
○ The two main types
○ Vary by the angle of perineal incision.

MIDLINE MEDIOLATERAL

The midline episiotomy The mediolateral episiotomy

B. >50 percent of the EAS is
torn, but the internal anal
sphincter (IAS) remains intact.
begins at the fourchette,
incises the perineal body in
the midline, and ends well
before the external anal
sphincter is reached. The
incision length varies from 2
to 3 cm depending on
perineal length and degree
of tissue thinning.
begins at the midline of the
fourchette and is directed to
the right or left at an angle
60 degrees off the midline.
This angle accounts for
perineal anatomy distortion
during crowning and
ultimately yields an incision
45 degrees off the midline
for suturing.

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 VAGINAL DELIVERY

● Benefit: easier to repair compared to a laceration ○ You may see a brownish or reddish mucus
○ Proven Incorrect: discharge which could be the mucus plug at
■ Less post op pain the opening of your cervix falling out.
■ Healing is improved ○ Your water may break which can either be a
■ Prevents pelvic floor disorders large gush of fluid or continuous trickle.
■ If you experience any of these
COMPARISON symptoms, contact your doctor or
midwife to see if you should go to
the hospital.
TYPE OF EPISIOTOMY

CHARACTERISTICS MIDLINE MEDIOLATERAL

● At the beginning of stage two of the labor which can
last from a few minutes to three hours, your cervix is
Surgical Repair Easy More difficult fully dilated top 10 cm and your baby’s head has
moved beyond the cervical opening into your birth
Faulty Healing Rare More common
canal.
Post operative pain Minimal Common ○ During this stage, you will begin to push your
baby out.
Anatomical Results Excellent Occasionally faulty ■ You may instinctively push when
you feel the urge or you may need
Blood loss Less More
coaching from your doctor, midwife
Dyspareunia Rare Occasional or labor nurse as when to push and
when to rest.
Extensions Common Uncommon ● In a normal delivery your baby’s head will rotate to
face your back.
● During active labor, your uterus is divided into an
○ Active segment that contracts pushing the
baby downward
○ Flexible passive segment that remains
relaxed, stretching to provide more room for
the baby to pass through.
● In some cases, when the top of your baby’s head
appears or crowns, your doctor may make a small cut
called an episiotomy to enlarge the vaginal opening.
○ Then you will continue pushing your baby
out.
● As your baby’s head passess through the birth canal,
A mediolateral episiotomy is cut as the baby’s head crowns. it molds into an elongated shape.
Fingers are insinuated between the perineum and head. The ○ An elongated head shape will resolve itself
incision begins in the midline and is directed toward the within a few days as the skull bones shift
ipsilateral ischial tuberosity at an angle 60 degrees off the
midline. back into place.
● After your baby’s head exits the birth canal his or her
head and shoulders will rotate to help the shoulders
VIDEO pass through the birth canal.
● Your baby’s shoulders are delivered one after the
LABOR AND DELIVERY other in order to fit through your pelvis.
● Once the shoulders emerge, the rest of your baby
● During a vaginal childbirth the first stage of labor slides out easily.
lasts about 12 to 19 hours and starts when your baby ● After your baby is born, his or her umbilical cord will
settles lower into your pelvis. be cut.
● In response, your cervix begins to efface or become
thinner and dilate or widen. ● In stage 3 of labor which may last 5 - 30 minutes,
○ During this time you may feel strong, mild contractions will help to push the placenta out of
regular contractions occurring every 5 - the uterus.
20 minutes and lower back pain and ● During this stage, you and your baby may begin
cramping that does not go away. bonding through skin to skin contact or through breast
feeding

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 VAGINAL DELIVERY

EPISIOTOMY
● If you are having a vaginal delivery, your doctor may
perform an episiotomy to enlarge the vaginal opening.
● During pregnancy, your baby grows inside your uterus
or womb and is nourished by the placenta.
● When your baby is ready to be born, labor begins.
● During labor, your uterus squeezes or contracts to
push your baby through the open cervix and into the
vagina which expands to allow your baby to pass
through and be born.
● An episiotomy may be done in an effort to avoid
spontaneous tearing during delivery if your baby is
large, or in the breech position, labor is going on too
quickly or if instruments such as forceps or a vacuum
extractor are needed to remove your baby from the
birth canal.
● An episiotomy may be done to help speed up delivery
if your labor is going too slowly or if you or the baby
are in distress.
● If you have not already received anesthesia before
your delivery, your doctor will inject medication to
numb your vaginal opening and perineum, which is
the area separating the vagina and anus.
● Using surgical scissors, your doctor will make a 1 to 3
inch midline or mediolateral incision in the perineum.
○ A midline incision extends straight down
from the vagina towards the anus.
○ A mediolateral incision is made on an angle
from the vagina in the direction of the anus.
● The benefit of the mediolateral incision is that it is less
likely to tear through to the anus.
● The downside however is that it can also be more
painful and take longer to heal.
● Once your doctor delivers your baby and the
placenta, he or she will close the episiotomy incision
with stitches.
● These stitches will be absorbed by your body and do
not need to be removed.
● An episiotomy usually heals without complications,
although it may take several weeks.
● Within the first 24 hours, your nurse will likely help
you apply ice packs to the stiches.

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