Management of normal labor

Many obstetric hospitals offer partner births, delivery and postpartum recovery in the same room together with the husband or relatives. Husbands stay with their spouse and newborn until discharge.

Some maternity hospitals have separate prenatal rooms and a delivery room, where the woman is transferred for the birth. The baby's father or another relative may be asked to accompany the woman to the delivery room. There, the perineal area is treated and the birth canal is separated with sterile diapers. After the birth, the woman may remain in such a room, or she may be transferred to a separate postnatal room.

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Pain relief during normal labor

Pain relief includes the following types of anesthesia: regional anesthesia, pudendal block, perineal infiltration, and general anesthesia. Opioids and local anesthetics are commonly used. These drugs cross the placenta and must be given in small doses within an hour before delivery to avoid toxic effects on the neonate (eg, CNS depression and bradycardia). Opioids alone do not provide adequate analgesia and are therefore used in combination with anesthetics. Regional anesthesia involves a lumbar epidural injection of a local anesthetic. Epidural anesthesia has become increasingly used for labor and delivery, including cesarean section. It has essentially replaced pudendal and paracervical blocks. Epidural injections use local anesthetics (eg, bupivacaine), which have a longer duration of action and a slower onset of action than drugs used for pudendal anesthesia (eg, lidocaine). Other forms of regional anesthesia include caudal injection (into the sacral canal), which is rarely used, and spinal injection (into the paraspinal subarachnoid space). Spinal anesthesia can be used for cesarean section, but is less commonly used for vaginal delivery because it is short-acting (not desirable during labor); there is a small risk of postoperative headache.

When using spinal anesthesia, patients should be under constant observation, and vital signs should be monitored every 5 minutes to detect and treat possible hypotension.

Pudendal anesthesia is rarely used because epidural analgesia is widely used. Pudendal anesthesia involves local injection of anesthetic through the vaginal wall so that the anesthetic envelops the pudendal nerve. It anesthetizes the lower parts of the vagina, the perineum, and the lower third of the vulva; the upper parts of the vulva are not anesthetized. Pudendal anesthesia is a safe, simple method for uncomplicated spontaneous vaginal birth if the woman wishes to push or if labor is progressing and there is no time for epidural anesthesia.

Perineal infiltration is usually performed with an anesthetic. This method is not as effective and is used less often than pudendal anesthesia. Paracervical anesthesia is used less and less in labor because it causes bradycardia in the fetus in more than 15% of cases. This anesthesia is more often used for abortions in the first or early second trimester of pregnancy. The technique involves administering 5-10 ml of 1% lidocaine paracervically at the 3 and 9 o'clock positions; the analgesic effect is short-acting.

General anesthesia is performed using inhalational anesthetics (eg, isoflurane) and may cause depression in the mother and fetus; therefore, these drugs are not recommended for routine delivery.

Nitrous oxide 40% with oxygen is rarely used for analgesia during vaginal delivery to a depth that allows patient contact to be maintained. Sodium thiopental is given intravenously with other drugs (eg, succinylcholine, nitrous oxide with oxygen) for general anesthesia for cesarean section; sodium thiopental alone does not provide adequate analgesia. Sodium thiopental has a short duration of action. When used, the drug is concentrated in the fetal liver, preventing accumulation in the central nervous system; high doses may cause neonatal depression. Diazepam is sometimes used; however, large doses given intravenously to pregnant women before delivery may result in hypotension, hypothermia, low Apgar scores, worsening metabolic responses to cold stress, and neurologic depression in the neonate. The use of these drugs is limited, but they are used during obstetric forceps, breech birth, twins and cesarean section.

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Benefits during childbirth

A vaginal examination is performed to determine the position and location of the fetal head. When the cervix is completely effacement and dilated, the woman is asked to push with each contraction so that the head passes through the birth canal and emerges through the vulva. When approximately 3 or 4 cm of the head emerges from the genital slit in nulliparous women (slightly less in multiparous women), methods are used to help facilitate delivery and reduce the risk of perineal rupture. If necessary, the doctor places the left hand on the baby's head, which prevents premature extension of the head, and this contributes to its slower advancement. At the same time, the doctor places the bent fingers of the right hand on the perineum, covering the open genital slit with them. To advance the head, the doctor can apply pressure in the area of the superciliary arches, forehead, or chin (modified Ritgen's maneuver). The obstetrician-gynecologist regulates the advancement of the head to ensure a slow, safe delivery.

Forceps or a vacuum extractor are often used for deliveries in the second stage of labor when labor is prolonged (for example, when the mother is too tired to push fully). Forceps may also be used when an epidural anesthetic stops pushing. Local anesthesia usually does not affect pushing, so forceps or a vacuum extractor are not usually used unless there are complications. The indications for forceps and a vacuum extractor are identical.

Episiotomy is performed only in cases of threatened perineal rupture and if the perineum interferes with normal delivery, it is usually performed in primiparous women. If epidural analgesia is inadequate, local infiltrative anesthesia may be used. Episiotomy prevents excessive stretching and possible rupture of the perineal tissues, including previous ruptures. An incision is easier to repair than a rupture. The most common incision is in the midline, from the posterior commissure towards the rectum. Rupture of this incision with capture of the sphincter or rectum is possible, but if this is quickly diagnosed, such a rupture is successfully repaired and undergoes good healing.

Episiotomy lacerations involving the rectum can be prevented by maintaining the fetal head in a well-flexed position until the occipital protuberance fits under the pubic arch. Episioproctotomy (intentional dissection of the rectum) is not recommended because of the high risk of rectovaginal fistula.

Another type of episiotomy is the medial-lateral incision, made from the middle of the posterior commissure at a 45° angle on both sides. This type of episiotomy does not extend into the sphincter or rectum, but the incision causes more pain in the postpartum period and takes longer to heal than a midline episiotomy. Thus, the midline incision is preferred for episiotomy. However, the use of episiotomy is decreasing in modern times due to the high risk of sphincter or rectal rupture.

After delivery of the head, the baby's body is grasped with the shoulders in an anteroposterior position; gentle pressure on the fetal head helps to position the anterior shoulder under the symphysis. If the cord is wrapped around the neck, the cord may be clamped and divided. The head is gently lifted upward and the posterior shoulder emerges from the perineum; the rest of the body is easily removed. The nose, mouth, and pharynx are aspirated with a syringe to remove mucus and fluid and to facilitate breathing. Two clamps are applied to the cord, the cord is divided, and a plastic clamp is applied to the stump. If fetal or neonatal abnormalities are suspected, the cord segment is ligated again so that arterial blood can be collected for gas analysis. Normal arterial blood pH is 7.157.20. The baby is placed in a warm crib or on the mother's abdomen for better adaptation.

After the birth of the baby, the doctor places a hand on the abdominal wall in the area of the fundus of the uterus to detect its contractions; the placenta separates during the 1st or 2nd contraction, often bloody discharge is noted due to the separated placenta. The woman should push to help the placenta to be delivered. If she cannot push and if there is significant bleeding, the placenta can be evacuated by manual pressure on the abdominal wall and by performing downward pressure on the uterus. This manipulation can be performed only if the uterus is dense and well contracted, because pressure on a flaccid uterus can contribute to its eversion. If this procedure is not effective, the doctor presses with his fists on the abdominal wall in the area of the corners of the uterus far from the placenta; traction on the umbilical cord is avoided, because this can contribute to the eversion of the uterus. If the placenta has not separated within 45-60 minutes, then manual separation and extraction of the placenta is performed; the doctor inserts his entire hand into the uterine cavity, separating the placenta, and then removes it. In such cases, one should suspect a tight attachment of the placenta (placenta accreta).

The placenta should be examined for defects because fragments left in the uterus may cause bleeding or infection. If the placenta is not completely delivered, the uterine cavity is manually examined. Some obstetricians examine the uterus after each delivery. However, this is not recommended in routine practice. An oxytotic agent (oxytocin 10 U intramuscularly or as an infusion of 20 U/1000 ml of saline at a rate of 125 ml/h) is administered immediately after delivery of the placenta. This may improve uterine contractility. Oxytocin should not be used as an intravenous bolus because cardiac arrhythmia may develop.

The birth canal should be examined for cervical lacerations; any lacerations present should be sutured; the episiotomy wound should be sutured. If the mother and baby are healthy, they may be kept together. Many mothers wish to begin breastfeeding soon after delivery, and this should be encouraged. The mother, baby, and father should remain together in a warm, separate room for an hour or more. The baby may then be placed in a nursery or left with the mother, depending on her wishes. For 1 hour after delivery, the mother should be closely monitored, including monitoring of uterine contractions, checking the amount of bloody discharge from the vagina, and measuring blood pressure. The time from delivery of the placenta to 4 hours after delivery is called the 4th stage of labor; most complications, especially hemorrhage, occur during this time, and therefore careful observation of the patient is necessary.

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