Routine Vaginal Delivery

1) List the signs and symptoms of labor.

2) Describe the three stages of labor & the cardinal movements.

3) Describe the steps of a vaginal delivery.

1 – List the signs and symptoms of labor

Labor is the process by which products of conception expelled from uterus. Progressive effacement
and dilation of uterine cervix occur via contractions of the uterine musculature. True labor must be
differentiated clinically from false labor, defined as uterine contractions without effacement and
dilation of cervix. False labor contractions are generally shorter in duration and less intense than true
labor contractions, with discomfort over the lower abdomen and groin areas. These contractions
resolve with ambulation. By contrast, true labor contractions are felt over the uterine fundus with
radiation of discomfort to the low back and low abdomen. Contractions of true labor become
increasingly intense and frequent, and are associated with cervical effacement and dilation.

Evaluation for labor is indicated when contractions occur every 5 minutes for 1 hour, if there is a
history of sudden gush of fluid or constant leakage, bleeding, or if the patient reports a significant
decrease in fetal movement. The complete evaluation includes review of prenatal records, focused
history, review of systems, and physical exam. The physical exam includes evaluation of vital signs,
contraction intensity and duration, auscultation of fetal heart tones, and determination of fetal lie,
presentation, and position. In some cases transabdominal ultrasound is considered to evaluate amniotic
fluid volume and placental location. A sterile vaginal exam is also done to evaluate for rupture of
membranes and to determine cervical dilation, effacement, and fetal station.

2 – Describe the three stages of labor and the cardinal movements

The first stage of labor pertains to the interval between onset and full cervical dilation. A normal first
stage lasts between 6-20 hours in nulliparous patients and between 6 to 8 hours in a multiparous patient.
The first stage is composed of a latent and active phase. During the latent phase cervical effacement
and early dilation occur. During the active phase rapid cervical dilation occurs, usually beginning at 4
cm. The transit time during the active phase is determined by the strength and frequency of uterine
contractions, the size of the fetal head, and the shape of the pelvis. Cephalopelvic disproportion results
if the fetal head is too large for the pelvis and may present with molding of the fetal skull with
overlapping sutures. The strength of uterine contractions can be measured with IUPC, and is
considered adequate when greater than 200 Montevideo units, calculated by multiplying the number of
contractions over a 10 minute span by the average contraction strength in mm Hg.

The second stage of labor begins at complete cervical dilation and ends with delivery of the fetus. The
third stage begins immediately after delivery of the infant and ends with delivery of placenta. The
fourth stage of labor begins immediately after delivery of the placenta and ends 2 hours later.
The cardinal movements of labor describe the changes of position of the fetus as it passes through the
birth canal. The first movement is engagement, or descent of the biparietal diameter below the pelvic
inlet. Engagement is suggested by palpation of the fetal presenting part below 0 station. Successful
engagement suggests that the maternal pelvis is adequate to accommodate the fetal head. Engagement
commonly occurs days to weeks before labor in primagravidas. In multigravid women it is more likely
to occur at the onset of active labor. Flexion follows engagement and directs the smallest diameters of
the fetal head fo the maternal pelvis. Descent of the presenting part typically occurs during the latter
portions of the first stage and through the second stage of labor. Internal rotation from a transverse to
anterior/posterior orientation follows descent. This facilitates presentation of the the smallest diameters
of the fetal head to the bony pelvis. Extension of the fetal head occurs as it reaches the introitus in
order to accommodate the curve of the birth canal. Finally, external rotation of the fetal head occurs to
restore the neutral angle of the fetal head with respect to the shoulders.

3 – Describe the steps of a vaginal delivery

Delivery of the head typically occurs first as the vaginal opening becomes progressively dilated with
each contraction. The perineum thins and may spontaneously lacerate. After the vaginal introitus is
distended beyond 5cm in diameter the Ritgen maneuver is employed. One hand draped with a towel is
used to exert forward pressure on the fetal chin by pushing on the perineum just anterior to the coccyx.
The other hand exerts gentle downward pressure against the fetal occiput to control delivery with
normal extension. The goal is delivery of the head with its smallest diameters passing over the
perineum to decrease the risk of spontaneous laceration. Once delivered, the fetal head undergoes
external rotation to assume a transverse position. This movement indicates that the fetal thorax has
rotated into the AP diameter of the pelvis. The nose and mouth are then aspirated and the neck checked
for a nuchal cord. If a nuchal cord is found, it is gently slipped over the fetal head or clamped and cut if
tight. The anterior shoulder is born spontaneously in most cases shortly after external rotation. If
delivery of the shoulders is delayed, the sides of the head may be grasped to apply downward traction
until the anterior shoulder is born. Next, delivery of the posterior shoulder is facilitated by applying an
upward movement. The rest of the body is most often spontaneously delivered. If delayed, gentle
traction of the head is exerted in the direction of the long axis of the neonate to assist delivery.

Delivery of the placenta occurs after signs of placental separation appear. Common signs include a
sudden gush of blood, rise of the uterus in the abdomen, globular shape and increased firmness of the
uterus, and protrusion of the umbilical cord. The mother is asked to bear down to expel the placenta.
The delivery may be assisted after uterine contraction by applying pressure on the fundus. Traction on
the umbilical cord before signs of placental separation may result in uterine inversion ultimately leading
to severe hemorrhage.