Section 22. Women's Health Issues

Chapter 260. Normal Labor and Delivery

Topics: Introduction | Labor | Delivery

Delivery

Delivery is the passage of the fetus and placenta (afterbirth) from the uterus to the outside world.

For delivery in a hospital, a woman may be moved from a labor room to a birthing or delivery room, a room used only for deliveries. Usually, the father or other support people are encouraged to accompany her. If she is already in an LDRP (for labor, delivery, recovery, and postpartum), she remains there. The intravenous line remains in place.

When a woman is about to give birth, she may be placed in a semi-upright position, between lying down and sitting up. Her back can be supported by pillows or a backrest. The semi-upright position uses gravity: The downward pressure of the fetus helps the vagina and surrounding area stretch gradually, decreasing the risk of tearing. This position also puts less strain on the woman's back and pelvis. Some women prefer to deliver lying down. However, with this position, delivery may take longer.

As delivery progresses, the doctor or midwife examines the vagina to determine the position of the fetus's head. The woman is asked to bear down and push with each contraction to help move the fetus's head down through her pelvis and to widen the vaginal opening so that more and more of the head appears. When about 1½ to 2 inches of the head appears, the doctor or midwife places a hand over the fetus's head during a contraction to control the fetus's progress. As the head crowns (when the widest part of the head passes through the vaginal opening), the head and chin are eased out of the vaginal opening to prevent the woman's tissues from tearing.

Forceps are metal instruments, similar to tongs, with rounded edges that fit around the fetus's head (see Section 22, Chapter 261). Forceps are used when the fetus is in distress, when the woman is having difficulty pushing, or when labor is not progressing well.

An episiotomy is no longer considered a routine procedure. It is used only when necessary for immediate delivery. For this procedure, the doctor injects a local anesthetic to numb the area and makes an incision in the area between the openings of the vagina and anus. If the muscle around the opening of the anus (rectal sphincter) is damaged during an episiotomy or is torn during delivery, it usually heals well if the doctor repairs it immediately.

After the baby's head has emerged, the body is rotated sideways so that the shoulders can emerge easily, one at a time. The rest of the baby usually slips out quickly. Mucus and fluid are suctioned out of the baby's nose, mouth, and throat. The umbilical cord is clamped and cut. The baby is then wrapped in a lightweight blanket and placed on the woman's abdomen or in a warmed bassinet.

After delivery of the baby, the doctor or midwife places a hand gently on the woman's abdomen to make sure the uterus is contracting. After delivery, the placenta usually detaches from the uterus within 3 to 10 minutes, and a gush of blood soon follows. Usually, the woman can push the placenta out on her own. If she cannot and particularly if she is bleeding excessively, the doctor or midwife applies firm downward pressure on the woman's abdomen, causing the placenta to detach from the uterus and come out. If the placenta has not been delivered within 30 minutes of delivery, the doctor or midwife may insert a hand into the uterus, separating the placenta from the uterus and removing it.

After the placenta is removed, it is examined for completeness. Fragments left in the uterus prevent the uterus from contracting. Contractions are essential to prevent further bleeding from the area where the placenta was attached to the uterus. So if fragments remain, bleeding can occur after delivery and may be substantial. Infections can also occur. If the placenta is incomplete, the doctor or midwife may remove the remaining fragments by hand. Sometimes fragments have to be surgically removed.

In many hospitals, as soon as the placenta is delivered or removed, the woman is given oxytocin (intravenously or intramuscularly), and her abdomen is periodically massaged to help the uterus contract.

The doctor stitches up any tears in the cervix, vagina, or nearby muscles and, if an episiotomy was performed, the episiotomy incision. The woman is then moved to the recovery room or remains in the LDRP. Often, a baby who does not need further medical attention stays with the mother. Typically, the woman and her baby remain together in a warm, private area for 3 to 4 hours so that bonding can begin. Many women wish to begin breastfeeding soon after delivery. Later, the baby may be taken to the hospital nursery. In many hospitals, the woman may choose to have the baby remain with her--a practice called rooming-in. All hospitals with LDRPs require it. With rooming-in, the baby is usually fed on demand, and the woman is taught how to care for the baby before they leave the hospital. If a woman needs a rest, she may have the baby taken to the nursery.

Because most complications, particularly bleeding, occur within the first 24 hours after delivery, nurses and doctors carefully observe the woman and baby during this time.