Nonreassuring fetal heart rate patterns, such as Category II and Category III fetal

heart rate tracings that can signal fetal hypoxia or acidosis, may represent cord
compression and entrapment can indicate avoidance of vaginal delivery.[17] Trial of
Labor after Caesarean section (TOLAC) can also be attempted but is contraindicated
when there is a history of multiple cesarean sections, history of placenta previa,
and evidence of cephalopelvic disproportion as indicated by macrosomia.[18] Fetal
weight greater than 5000 grams in a mother with diabetes or fetal weight greater
than 4500 grams in a mother without diabetes are relative contraindications for
vaginal delivery.[19]

Equipment
Ensuring proper equipment is essential to a successful vaginal delivery and to
minimize fetal and maternal morbidity and mortality. Protracted labor can be
managed by augmenting labor with oxytocin, which is a uterotonic agent.[42] Women
with arrested labor are managed by conversion of vaginal delivery to a cesarean
section mode of delivery.[43]

Failure to progress during the second stage of labor is diagnosed when there is
minimal descent of the fetus in nulliparous women who have pushed for a minimum of
three hours and multiparous women who have pushed for a minimum of two hours; women
with epidural anesthesia are allowed slightly longer durations for pushing.[44]
Failure to progress during the second stage of labor due to inadequate contractions
or minimal descent of the fetus can be managed by the administration of oxytocin to
augment labor after 60-90 minutes of pushing. Conditions such as post-term
pregnancy (defined as gestation that is greater than 42 weeks and 0 days),[11] pre-
labor rupture of membranes, gestational hypertensive disorders (preeclampsia,
eclampsia), HELLP (hemolysis, elevated liver enzymes, and low platelet count)
syndrome, fetal demise, fetal growth restriction, chorioamnionitis,
oligohydramnios, placental abruption, intrahepatic cholestasis of pregnancy, among
other conditions are all indications for labor and vaginal delivery.[3]

Contraindications
Vaginal delivery is the preferred method for childbirth; however, there are certain
conditions when vaginal delivery is contraindicated. Approximately 80% of all
singleton vaginal deliveries are at full-term via spontaneous labor, whereas 11%
are preterm, and 10% are post-term.[2] Of note, with the advent of operative
delivery modalities and surgical delivery modalities, the number of patients who
reach spontaneous labor has decreased over time, and the induction of labor has
increased.[3]

CPD is most commonly observed during the second stage of labor.[45]

During a vaginal delivery, the fetal heart rate must be monitored, and
decelerations during labor, whether early decelerations or late decelerations, can
indicate head compression of the fetus, cord compression of the fetus, hypoxemia,
and even anemia of the fetus. The management of each stage varies, and exam
findings during each of the stages can help identify short-term and long-term
complications for the anticipated vaginal delivery such as fetal distress and
hypoxemia, cord prolapse, placental abruption, uterine rupture, permanent
disability, and maternal and/or fetal death.[5]

Pathologies associated with malposition of the fetus, such as face presentation

with mentum (chin in the direction of the maternal sacrum) posterior, transverse
lie or shoulder presentation, and occiput posterior, should be converted to an
abdominal delivery.[13] Twin gestations when presenting twin is in a breech
position, conjoined twins and mono-amniotic twins are contraindications for vaginal
delivery.[14] Abnormal placenta positions such as placenta previa, known placenta
accreta, or history of uterine rupture are conditions that are contraindications
for vaginal delivery.[15] Infection such as active genital herpes outbreak is also
an absolute contraindication for vaginal delivery.[16] The third stage of labor
concludes once the placenta completely separates and is delivered.[9]

Indications
For full-term pregnancies, vaginal delivery is indicated when spontaneous labor
occurs or if amniotic and chorionic membranes rupture. Systemic antibiotics are
indicated for a known positive Group B streptococcus (GBS) culture or unknown
maternal GBS status.[28] There is no evidence in the literature supporting
intrapartum chlorhexidine to prevent maternal or neonatal infections during vaginal
delivery; conversely, this can lead to vaginal irritation and discomfort.[29]
However, some institutions and providers routinely use povidone-iodine solutions,
especially if there is intrapartum defecation during labor and delivery. In women
without a history of vaginal birth, perineal massage reduced the incidence of
perineal trauma and the need for episiotomies but did not reduce the incidence of
perineal trauma of any degree.[33] The second stage of labor can continue as long
as needed as long as fetal heart rate tracing is normal, and progress is achieved,
which can be quantified by progression in the fetal station. It is important to
apply the least amount of traction during the delivery of fetal shoulders to
minimize the risk of traction-induced perineal injury and fetal brachial plexus
injuries.[37] After the shoulders are delivered, care must be maintained as the
rest of the delivery is spontaneous and requires minimal maternal effort, but it is
important to guide the newborn child’s body as it passes the birth canal. For women
in spontaneous labor, the consensus in the review of the literature reveals that if
the woman has regular contractions that require her focus and attention combined
with either sufficient effacement (greater than or equal to 80%) and/or 4-5 cm of
cervical dilation, the woman is in spontaneous labor and should be admitted to the
hospital for a normal spontaneous vaginal delivery. Other benefits include better
long-term growth, immunity, and development compared to children born as a result
of a cesarean section.[49]

Enhancing Healthcare Team Outcomes

Vaginal delivery is a major and ubiquitous procedure that can be associated with
serious morbidities and potential mortality to the mother and the neonate due to a
number of intrapartum and postpartum complications related to the procedure. PPH
can be due to atony of the uterus, trauma to the birth canal, retained products of
conception or due to a coagulopathy; uterine atony is the most common cause of PPH.
[7]

Clinical Significance
Proper preparation, monitoring, and technique during vaginal delivery are important
to minimize morbidity and mortality to both the mother and the fetus. During this
time, the mother should be encouraged to stop pushing, and then use small
contractions to enable the physician to control the pace of the fetal head
delivery; precipitous delivery of the head can cause perineal trauma. Certain
conditions require immediate conversion of vaginal delivery to an emergent cesarean
section for childbirth, while some conditions can spontaneously resolve, and trial
of vaginal delivery can be attempted. Appropriate equipment is necessary to
anticipate and appropriately manage improbable but realistic complications of low-
risk vaginal deliveries, as 20% to 25% of all perinatal morbidity and mortality
occurs in pregnancies devoid of risk factors for adverse outcomes.[20]

Appropriate preparation includes a warm and clean room with adequate lighting and
supplemental light source, a delivery bed with clean linen whose height can be
adjusted, a plastic sheet to place under the mother, chlorhexidine, and wipes.

Conditions that require prompt cesarean section and are contraindications to

vaginal delivery can be categorized by the system; certain presentations such as
footling breech, frank breech, complete breech, and cord prolapse are indications
for emergent conversion to cesarean section.[12] Once the fetus is delivered,
during the third stage of labor, optimally, the fetus is placed on the mother’s
chest with the umbilical cord initially clamped then cut, while the mother
continues to maintain the same position until the placenta is delivered. The third
stage of labor is defined as the time from the delivery of the fetus until the
delivery of the placenta.

Complications
There are numerous complications associated with vaginal delivery; these
complications vary by stages of labor and are dependent on numerous factors.

While some women opt for home births, pregnant women are unable to confirm the
rupture of membranes, check for cervical dilation or effacement, and the healthcare
team's goal is to ensure safe progression through labor and to lead to the
successful delivery of the baby. The second stage of labor includes the time from
complete cervical dilation, which is the end of the first stage to delivery of the
fetus. The list of equipment needed also includes a tocodynamometer to monitor
uterine contractions using an external monitor or an intrauterine pressure catheter
and fetal heart rate monitor with either external heart rate monitor or an internal
fetal heart rate monitor (scalp electrode). The fetal station is determined by the
relationship between the fetal head and maternal ischial spines; the station is
defined from a range of -5 to +5, and 0 indicates that the fetal head is level with
the maternal ischial spines.

Certain conditions necessitate the induction of labor as timely delivery of

pregnancy is important to peripartum outcomes of both the mother and fetus. With a
vaginal delivery, there is a higher chance of being able to breastfeed successfully
shortly after delivery, decreased hospital stay after childbirth, rapid recovery
physically and psychologically, and increased mother-child bond and attachment.
There are many factors to consider in preparing a patient for a vaginal delivery
and the position of the patient changes based on the progression of labor through
its various stages. Complications arise during each of the three stages, which can
lead to the conversion of the anticipated vaginal delivery to operative cesarean
delivery. Nurses and midwives are needed to help the patient get ready and motivate
her through labor, and even facilitate the delivery of the baby, physicians are
responsible for monitoring the fetal and maternal well-being while being cognizant
of possible complications and treating those. Failure to progress in the first
stage of labor can be either protraction of active phase of labor, which is defined
as cervical dilation rate less than one to two centimeters per hour in women who’s
cervix is at least six centimeters dilated.[41] The vertex, which is the top of the
fetus’ head, normal rotates in either direction during the internal rotation
portion of the cardinal movements during childbirth.[3]

There are six cardinal movements of childbirth, all of which occur during the
second stage of labor. During a normal vaginal delivery, some blood from the
effacement of the cervix or minor trauma of the vaginal canal can mix with amniotic
fluid and can present as a serosanguineous appearance. The arrest of the first
stage of labor is defined as no change in cervical dilation for more than four
hours in a woman with adequate uterine contraction strength (defined as 200
Montevideo units or greater) or no change in cervical dilation in a woman for more
than six hours with inadequate contraction strength. During labor, if the fetus
presents in a brow situation, this may spontaneously convert to face or vertex
presentations, which can then progress to vaginal delivery. Once the patient is
prepared for the delivery, it is important to ensure proper positioning for the
vaginal delivery. In addition, for complicated gestations or for post-term
pregnancies, induction of labor is indicated, which is also an indication for
vaginal delivery. If the delivery needs assistance, either forceps or vacuum can be
kept bedside to assist in vaginal delivery.[22]

Analgesia can be kept bedside, but is not absolutely needed, as the use of oral or
epidural analgesia is based on maternal preference. Once the head crowns, a sterile
towel or lap pad can be used to hold the fetal head; one hand should support the
fetal head and maintain it in the flexion position while the other hand should be
used to support the lower edge of the perineum by pinching it to avoid tearing or
trauma.[34]
Introduction
Vaginal delivery is safest for the fetus and the mother when the newborn is full-
term at the gestational age of 37 to 42 weeks. The active management of the third
stage begins before the delivery of the placenta and includes uterotonic agent
administration, application of gentle traction to umbilical cord after clamping it,
and uterine massage.[40] For the first stage of labor, the patient should be
connected to monitors to assess fetal and maternal vital signs, as well as maternal
uterine contractions. The first stage of labor is the longest stage of labor; it is
the result of progressive and rhythmic uterine contraction which causes the cervix
to dilate. It is important to note that woman near labor can feel regular
contractions, but can present without cervical effacement or dilation and can be
discharged with a follow up after routine monitoring of the fetus’ heart rate and
monitoring contractions with a tocodynamometer.

Conversely, advantages of a successful vaginal delivery are numerous to both the

baby and the mother. The final stage of labor includes the time after the child is
born to the delivery of the placenta. Duration of this phase is variable and can
last from minutes to hours; however, the maximum amount of time that a woman can be
in this phase of labor depends on the parity of the patient and whether the patient
has an epidural catheter placed for anesthesia.[7]

During this stage, three clinical parameters are important to be aware of, which
include fetal presentation, fetal station, and fetal position.

Personnel
For a normally anticipated vaginal delivery, a physician or a midwife with the aide
of a nurse can appropriately and safely perform the procedure. At this time, the
head of the fetus exerts dilatory pressure on the perineum, which leads to a
tremendous urge for mothers to push, but appropriate steps of delivery should be
followed in order to minimize perineal trauma.

Patients should be adequately hydrated, as hypovolemia during labor can cause fetal
heart tracing abnormalities.[24] Routine administration of antacids, routine
enemas, and perineal shaving is not indicated.[25][26][27][26][25] A collaborative
effort between the patient, her support system, the nurses, technicians, and
physicians is required for successful vaginal delivery to minimize morbidity and
mortality. While cesarean section deliveries are absolutely necessary for certain
peripartum conditions, cesarean section deliveries have been shown to increase the
long-term risk of small bowel obstruction in women.[48]