Management of Normal Delivery



Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) rooms, so That the woman, support person, and neonate Remain In The Same Room Throughout Their stay. Some units use a traditional separate labor rooms and delivery suites, to the which the woman is Transferred Pls delivery is imminent. The father or other support person Should Be Offered the opportunity to accompany her. In the delivery room, the perineum is washed and draped, and the neonate is delivered. After delivery, the woman May Remain there or be Transferred to a postpartum unit. Management of complications During delivery requires additional measures (see abnormalities and Complications of Labor and Delivery ).

Anesthesia

Options include regional, local, and general anesthesia. Local anesthetics and opioids are commonly Used. These drugs pass through the placenta, thus, During the hour before delivery, Should Be Such drugs given in small doses to Avoid toxicity (eg, CNS depression, bradycardia) in the neonate. Opioids Used alone do not Provide adequate analgesia and so are most Often used with anesthetics.

Regional anesthesia: Several methods are available.

Lumbar epidural injection of a local anesthetic (see Normal Pregnancy, Labor, and Delivery: Analgesia ) is the most commonly Used method. Epidural injection is being increasingly Used for delivery, Including cesarean section, and has essentially Replaced pudenda and paracervical blocks. The local anesthetics for epidural injection Often used (eg, bupivacaine
MARCAINE
SENSORCAINE
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) Have a longer duration of action and slower onset Than Used for those pudenda block (eg, lidocaine
XYLOCAINE
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.)

Other methods include caudal injection (into the sacral canal), the which is rarely Used, and spinal injection (into the paraspinal subarachnoid space). Spinal Injection May be Used for cesarean section, but it is Used Less Often for vaginal deliveries Because it is short-lasting (preventing its use During labor) and has a small risk of spinal headache afterward. When spinal injection is Used, Patients must be Constantly Attended, and Vital Signs must be checked every 5 min to detect and treat possible hypotension.

Local anesthesia: Methods include pudenda block, perineal infiltration, and paracervical block.

Pudenda block, rarely Used Because epidural injections are Used instead, involves injecting a local anesthetic through the vaginal wall so That the anesthetic bathes the pudenda nerve as it crosses the ischial spine. This block anesthetizes the lower vagina, perineum, and posterior to the vulva, the anterior vulva, innervated by lumbar dermatomes, is not anesthetized. Pudenda block is a safe, simple method for uncomplicated spontaneous vaginal deliveries if women wish to bear down and push or if labor is advanced and there is no time for epidural injection.

Infiltration of the perineum with an anesthetic is commonly Used, although this method is not as effective as a well-administered pudenda block.

Paracervical block is rarely Appropriate for delivery Because incidence of fetal bradycardia is> 15%. It is Used mainly for 1st-or early 2nd-trimester abortion. The technique involves injecting 5 to 10 mL of 1% lidocaine
XYLOCAINE
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at the 3 and 9 o'clock positions; the analgesic response is short-lasting.

General anesthesia: Because potent and volatile inhalation drugs (eg, isoflurane) cans cause marked depression in mother and fetus, general anesthesia is not recommended for routine delivery. Rarely, 40% nitrous oxide with O 2 May be Used for analgesia During vaginal delivery as long as verbal contact with the woman is maintained. thiopental
Pentothal
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, A hypnotic, is commonly given IV with other drugs (eg, succinylcholine
ANECTINE
QUELICIN
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, Nitrous oxide plus O 2) for induction of general anesthesia During cesarean delivery; Used alone, thiopental
Pentothal
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Provides inadequate analgesia. With thiopental
Pentothal
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, Induction is rapid and recovery is prompt. It Becomes concentrated in the fetal liver, preventing from Becoming high levels in the CNS; high levels in the CNS May cause neonatal depression. Increased interest in preparation for Childbirth has reduced the need for general anesthesia except for cesarean section.

Delivery Procedures

A vaginal examination is done to determine position and station of the fetal head, the head is usually the presenting part (see Fig. 2: Normal Pregnancy, Labor, and Delivery: Sequence of events in delivery for vertex presentations. Figures .) When effacement is complete and the cervix is ​​fully dilated, the woman is toll to bear down and strain with EACH contraction to move the head through the pelvis and progressively dilate the vaginal introitus so That more and more of the head appears. When about 3 or 4 cm of the head is visible During a contraction in nulliparas (Somewhat less in multiparas), the Following maneuvers cans facilitate delivery and reduce risk of perineal laceration.

The clinician, if right-handed, places the left palm over the infant's head During a contraction to control and, if Necessary, Slightly slow progress.
Simultaneously, the clinician places the curved fingers of the right hand against the dilating perineum, through the which the infant's Brow or chin is felt.
To advance the head, the clinician cans wrap a hand in a towel and, with curved fingers, apply pressure against the underside of the chin or Brow (modified Ritgen maneuvers).

Thus, the clinician controls the progress of the head to effect a slow, safe delivery.

Fig. 2


Sequence of events in delivery for vertex presentations.
Sequence of events in delivery for vertex presentations.

Forceps or a vacuum extractor (see abnormalities and Complications of Labor and Delivery: Operative vaginal delivery ) is Often used for vaginal delivery Pls the 2nd stage of labor is likely, to be prolonged (eg, Because the mother is too exhausted to bear down adequately or Because regional epidural anesthesia precludes vigorous bearing down). If general anesthesia is local (pudenda block or infiltration of the perineum), forceps or a vacuum extractor is usually not needed unless complications develop; local anesthesia May not interfere with bearing down. Indications for forceps and vacuum extractor are essentially the Same.

An episiotomy is not routine and is done only if the perineum does not stretch adequately and is obstructing the delivery, usually only for first deliveries at term. A local anesthetic infiltrated few cans if epidural analgesia is inadequate. Episiotomy prevents excessive stretching and possible tearing of the perineal tissues, Including anterior tears. The incision is Easier to repair than a tear. The most common type is a midline incision made from the midpoint of the fourchette directly back toward the rectum. Extension into the rectal sphincter or rectum is a risk, but if Recognized promptly, the extension cans be repaired successfully and heals well. Tears or extensions into the rectum cans usually be prevented by keeping the infant's head well flexed Until the occipital Prominence passes under the symphysis pubis. Another type of episiotomy is a mediolateral incision made ​​from the midpoint of the fourchette at a 45 ° angle laterally on Either Side. This type usually does not extend into the sphincter or rectum, but it causes the Greater postoperative pain and takes longer to heal Than midline episiotomy. Thus, for episiotomy, a midline cut is preferred. However, use of episiotomy is decreasing Because extension or tearing into the sphincter or rectum is a concern. Episioproctotomy (intentionally cutting into the rectum) is not recommended Because rectovaginal fistula is a risk.

When the head is delivered, the clinician determines whether the umbilical cord is wrapped around the neck. If it is, the clinician Should try to Unwrap the cord, if the cord can not be rapidly removed this way, the cord clamped and cut some of May. After delivery of the head, the infant's body rotates so That the shoulders are in an anteroposterior position; gentle downward pressure on the head delivers the anterior shoulder under the symphysis. Gently The head is lifted, the posterior shoulder slides over the perineum, and the rest of the body follows without difficulty. The nose, mouth, and pharynx are aspirated with a bulb syringe to remove mucus and fluids and help start respirations. The cord Should Be double-clamped and cut Between the clamps, and a plastic cord clip Should Be applied about 2 to 3 cm distal from the cord insertion on the infant. If fetal or neonatal compromise is suspected, a segment of umbilical cord is doubly clamped so That cans arterial blood gas analysis be done. An arterial pH> 7.l5 to 7:20 is Considered normal. The infant is thoroughly dried, then placed on the mother's abdomen or, if resuscitation is needed, in a warmed resuscitation bassinet.

After delivery of the infant, the clinician places a hand Gently on the abdomen over the fundus to detect uterine contractions, placental separation usually occurs During the 1st or 2nd contraction, Often with a Gush of blood from behind the separating placenta. The mother cans usually help deliver the placenta by bearing down. If she can not and if substantial bleeding occurs, the placenta usually be evacuated cans (expressed) by Placing a hand on the abdomen and exerting firm downward (caudal) pressure on the uterus, this procedure is done only if the uterus feels firm Because pressure on a flaccid uterus cans cause it to invert. If this procedure is not effective, the umbilical cord is held on the link while a hand placed on the abdomen pushes upward (cephalad) on the firm uterus, away from the placenta; traction on the umbilical cord is avoided Because it May invert the uterus. If the placenta has not been delivered Within 45 to 60 min of delivery, manual removal May be Necessary; the clinician inserts an entire hand into the uterine cavity, separating the placenta from its attachment, then extracts the placenta. In Such cases, an abnormally adherent placenta (placenta accreta-see abnormalities and Complications of Labor and Delivery: Placenta Accreta ) Should be suspected.

The placenta is examined for completeness Should Be Because fragments left in the uterus cans cause hemorrhage or infection later. If the placenta is incomplete, the uterine cavity Should Be explored manually. Some obstetricians routinely EACH explore the uterus after delivery. However, exploration is uncomfortable and is not routinely recommended. Immediately after delivery of the placenta, an oxytocic drug ( oxytocin
PITOCIN
SYNTOCINON
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10 units IM or as an infusion of 20 units/1000 mL saline at 125 mL / h) is given to help the uterus contract firmly. oxytocin
PITOCIN
SYNTOCINON
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Should not be given as an IV bolus Because cardiac arrhythmia May occur.

The cervix and vagina are inspected for lacerations, the which, if present, are repaired, as is episiotomy if done. Then if the mother and infant are recovering normally, cans They begin bonding. Many mothers wish to begin breastfeeding soon after delivery, and Should Be encouraged this activity. Mother, infant, and father Should Remain together in a warm, private area for an hour or more to enhance parent-infant bonding. Then, the infant May be taken to the nursery or left with the mother depending on her wishes. For the first hour after delivery, the mother Should Be observed closely to make sure the uterus is contracting (detected by palpation During abdominal examination) and to check for bleeding, BP abnormalities, and general well-being. The time from delivery of the placenta to 4 h postpartum has been Called the 4th stage of labor; most complications, especially hemorrhage (see abnormalities and Complications of Labor and Delivery: Postpartum Hemorrhage ), occur at this time, and frequent observation is mandatory.