see also: labour; ED Mx of emergency breech delivery; Mx of shoulder dystocia in labour; Mx of cord prolapse; neonatal resuscitation

• Youtube animation of cephalic delivery

• have mother grasp post. aspect of distal portion thighs with hips & knees flexed
• encourage mother to “bear down” during contractions by holding breath with chin on chest for count of 10, repeated 2 or more times during each contraction, with quick breath between each pushing effort
• check fetal descent occasionally with sterile gloved hand

• when fetal head maintains labial separation b/n contractions it is said to be “crowning”
  • ⇒ place pressure on perineum to decrease risk of uncontrolled delivery & possible extensive vaginal laceration

• consider intra-contraction episiotomy when posterior vaginal wall stretched & thin if:
  • pre-term neonate (risk of intraventricular haemorrhages)
  • prolonged crowning (this quickly results in profound fetal hypoxia)
  • fetal compromise (eg. abnormal CTG)
  • risk of shoulder dystocia
  • forceps or vacuum delivery are likely to be needed

• encourage mother to gradually increase her bearing down efforts to allow fetal head to dilate vaginal opening in a controlled fashion whilst supporting perinuem with sterile towel
• when fetal head is delivered (usually face towards perineum then it will rotate 90deg):
  • ask mother to stop pushing & to breathe
  • cleanse face from contamination
  • suction mouth then nose
  • check neck for evidence of nuchal cord & if present:
    • gently reduce it over its head to prevent constriction with delivery
    • if too tight, clamp with 2 haemastats & divide between clamps

• encourage mother to again bear down gently as you apply gentle posterolateral traction on side of head to aid delivery of anterior shoulder (see also shoulder dystocia)
• once anterior shoulder free, redirect traction in an anterior direction to deliver baby's posterior shoulder

• support the remainder of the baby's body as it subsequently delivers spontaneously
• hold back of infants head whilst trapping legs & body between your forearm & body (ie. don't drop the slippery little critter!!)
• double clamp cord & divide approx. 2-2.5“ from umbilicus
• recent studies strongly suggest the benefit of “delayed clamping” of the cord to the neonate with no harm to the mother:
  • term baby: 2-3 minutes after delivery, or after pulsations cease
  • pre-term baby: 20-30 secs after delivery.

• place on sterile dry towel & dry thoroughly
• if crying, give to mother otherwise stimulate & consider placing under radiant heater for resuscitation
• if oxygen is used, use low oxygen levels - avoid 100% oxygen.
• see also neonatal resuscitation