Steps of conducting normal delivery

Principles of conducting delivery

The skill and judgment of the midwife play a critical role in reducing maternal trauma and ensuring a safe delivery for the baby. These qualities are acquired through experience and one should apply specific principles accordingly.

1. It is important to never leave the woman alone on the delivery bed.
2. Maintain a vigilant observation of the perineum and the progress of labour.
3. Take preventive measures to avoid infection or injury for both the woman and the baby.
4. Prioritize the emotional and physical comfort of the woman throughout the process
5. Anticipate the occurrence of normal events during labor.
6. Be able to identify any abnormal developments that may arise.
7. Exercise full control over the baby’s head during the delivery process.
8. Provide proper support to the perineum to minimize the risk of tears or injuries.
9. Check for the presence of the umbilical cord around the baby’s neck.
10. Allow time for the process of restitution and rotation to occur naturally.
11. Ensure proper clamping of the umbilical cord before proceeding to cut it.
12. Place an identification tag or mark on the baby to establish proper identification.

These principles are primarily upheld to achieve the following objectives:

• Ensure the delivery of an uninjured neonate with minimal trauma to the woman.
• Promptly establish respiration of the neonate.
• Effectively control excessive postpartum vaginal bleeding after delivery.

During normal delivery assistance is required in following phases

1. Delivery of the head
2. Prevention of perineal injury
3. Relieving cord around the neck
4. Delivery of the shoulder
5. Delivery of the trunk and body

Assisting during delivery

When assisting during delivery, it’s important to adhere to certain principles. These include maintaining continuous flexion of the baby’s head, preventing early extension, and ensuring a controlled and gradual emergence from the vulval outlet.

1. Encouraging bearing down efforts: The woman should be encouraged to bear down with increased effort during uterine contractions. This active participation aids in the descent of the baby’s head, facilitating the stretching of the perineum.
2. Maintaining hand hygiene: Prior to any procedures, it’s essential to wash hands thoroughly with soap and water. Hands should be dried using a clean cloth or allowed to air dry.
3. Cleaning the perineum: Using a cloth or pad soaked in antiseptic solution, carefully cleanse the woman’s perineum. The cleaning motion should move from front to back, and a separate pad should be used to cover the anus.
4. Wearing sterile gloves: Ensure both hands are gloved with sterile gloves before any direct contact with the birthing process.
5. Using sterile drapes: Position a sterile drape under the woman’s buttocks and another over her abdomen. The third sterile drape should be readied to receive the baby during delivery.

i. Delivering the head with control:

• Instruct the woman to pant or provide gentle pushes during contractions as the baby’s head emerges.

ii. Preventing perineal Injury:

• As the pressure from the baby’s head causes the perineum to thin, guide the head’s birth using the fingers of one hand. Apply firm yet gentle downward pressure to maintain flexion, promoting the natural stretching of perineal tissue and preventing tears.
• Use the other hand to support the perineum using a pad or cloth. Allow the head to gradually crown and be born spontaneously.
• To prevent sudden head expulsion during contractions, advise the woman to avoid bearing down as the head extends.
• Regulating the slow delivery of the head between contractions involves using sterile gauze-covered fingers of the right hand to push the chin. This action is performed over the ano-coccygeal region, while the left hand applies pressure to the occiput.
• Successive emergence of the forehead, nose, mouth, and chin occurs as an extension over the stretched perineum. It’s crucial not to manipulate the labia or perineum, as doing so increases the risk of tears.
• Upon the completion of the head’s delivery, it’s advised to instruct the woman not to push.
• Immediately after the head’s delivery, use gauze pieces to wipe the eyes, mouth, nose, and pharynx.

iii. Relieving the cord around the neck:

• Begin by assessing the baby’s neck to ensure that the umbilical cord is not wrapped around it.
• If the cord is loosely encircling the neck, carefully slip it over the baby’s head.
• In cases where the cord is loosely looped but cannot be moved over the head, gently slide it backward over the baby’s shoulder.
• If the cord is tightly constricting the neck:
• Secure the cord in two separate places, approximately 2 cm apart, by using artery forceps to tie or clamp it.
• Proceed to cut the cord between the tied/clamped sections.
• Carefully unwind the cord from around the baby’s neck.
• Following the cord-cutting procedure, it is crucial not to delay the expulsion of the baby to prevent potential hypoxia.

iv. Preventing Injury to the Woman:

• Focus attention not only on the perineum but also on the controlled delivery of the head.
• Avoid delivering the head through early extension.
• Steer clear of forcibly and spontaneously delivering the head.

v. Delivery of the anterior and posterior shoulders:

• Permit the baby to turn spontaneously for restitution and external rotation of the head. This positioning aids in the safe delivery of the shoulders and minimizes the risk of perineal laceration.
• Once the head has turned, position a hand on each side of the baby’s head, resembling a ‘Namaste position.’ Instruct the woman to exert gentle pushing during the next contraction.
• Progress to deliver one shoulder at a time to prevent excessive perineal stretching. Place a hand on each side of the baby’s head, covering the ears, and apply downward traction. This maneuver facilitates the anterior shoulder’s passage beneath the symphysis pubis, while the posterior shoulder remains within the vagina.

Vi. Lateral flexion of the body:

• When the axillary creases become visible, gently guide the head upward toward the woman’s abdomen while the posterior shoulder is born over the perineum.
• Lift the baby’s head anteriorly to facilitate the delivery of the posterior shoulder.
• Transition the uppermost hand from the head to provide support for the remaining part of the baby’s body as it smoothly slides out.
• Place the baby on the woman’s abdomen. Thoroughly dry the baby, wipe its eyes, and assess its breathing.
• If the baby is crying or breathing (with the chest rising at least 30 times per minute), leave the baby with the woman.
• If the baby does not initiate breathing within 30 seconds, CALL FOR HELP, proceed to take measures for baby resuscitation.
• Clamp and cut the umbilical cord.
• Ensure that the baby is kept warm and in skin-to-skin contact on the woman’s chest. Wrap the baby in a soft, dry cloth, cover with a blanket, and ensure the head is covered to prevent heat loss.
• If the woman is unwell, arrange for an assistant to care for the baby.
• Palpate the abdomen to rule out the presence of an additional baby, and proceed with the active management of the 3rd stage.
• Note the time of birth.
• Record the APGAR score of the baby.
• If the woman’s blood group is negative or O group, draw 5 ml of blood from the umbilical cord for the Coomb’s test.
• After resuscitation, place the baby in a lateral position with the woman or under a warmer.

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