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Spontaneous Vaginal Delivery

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Spontaneous Vaginal Delivery, Vaginal Delivery, Vaginal Birth, Normal Spontaneous Vaginal Delivery, NSVD, Second Stage of Labor

  • See Also
  1. Vaginal Birth after Cesarean
  2. Cesarean Section
  • Epidemiology
  1. Vaginal Birth accounts for roughly 70% of deliveries in the United States
    1. Of the 3.7 million births in the U.S. in 2021, 2.5 million were vaginal deliveries
  • Contraindications
  1. Complete Placenta Previa
  2. Active genital Herpes Simplex Virus (or prodromal symptoms) at time of labor
  3. Malpresentation
    1. Non-Frank Breech
    2. Transverse Lie
    3. Face Presentation with mentum anterior
  4. Prior uterine surgery that raises risk of labor-induced Uterine Rupture
    1. History of classic uterine incision (vertical uterine incision)
    2. History of significant transfundal uterine surgery
  5. Untreated HIV Infection
    1. Includes unknown or elevated HIV Viral Load >1000 copies/ml
  • Management
  • Vertical Transmission Prevention
  1. See Group B Streptococcus Prophylaxis
  2. See Genital Herpes
  3. See HIV in Pregnancy
  • Management
  • Labor Stage 1
  1. See First Stage of Labor
  2. See Fetal Heart Tracing
  3. Stage 1 Definitions
    1. Divided into two phases (assuming regular contractions in both phases)
      1. Latent Phase (<6 cm cervical dilation)
      2. Active Phase (6 to 10 cm cervical dilation)
    2. Progresses until complete cervical dilation and effacement
    3. Expected progress is based on Friedman Curve
      1. Assumes regular, frequent palpable contractions
  4. Labor Progression
    1. See Labor Dystocia
    2. See Labor Augmentation and Labor Induction
    3. See Active Management of Labor
    4. See Labor Coaching
    5. See Fetal Heart Tracing
  5. Pain management
    1. See Latent Labor Anesthesia
    2. See Active Labor Anesthesia
    3. See Non-Pharmacologic Pain Control in Labor
  • Management
  • Labor Stage 2
  1. Stage 2 Definitions
    1. Starts with complete cervical dilation and effacement
    2. Ends with newborn delivery
  2. Labor Progression
    1. See Labor Augmentation
    2. See Active Management of Labor
    3. See Labor Coaching
    4. See Fetal Heart Tracing
    5. Second Stage expected duration
      1. Nulliparous women: 3 hours (with Epidural Anesthesia: 4 hours)
      2. Multiparous women: 2 hours (with Epidural Anesthesia: 3 hours)
    6. Fetal Descent
      1. Head engages in the in the maternal Pelvis during the First Stage of Labor
        1. Most will descend in Occiput Anterior position (often having started in Occiput Posterior)
      2. Neck flexes and descends the vaginal canal
      3. Fetus undergoes internal rotation, neck extension and then external rotation
      4. Completed with fetal expulsion
    7. Patients may elect to use their pushing position of choice
      1. Epidural Anesthesia: Lateral decubitus position may shorten second stage
        1. (2017) BMJ 359:j4471 +PMID: 29046273 [PubMed]
      2. No Epidural Anesthesia: Upright, vertical positioning may shorten second stage
        1. Gupta (2017) Cochrane Database Syst Rev (5): CD002006 +PMID: 28539008 [PubMed]
    8. Delayed pushing (compared with immediate pushing) in second stage is not beneficial and may cause harm
      1. Delayed pushing does not reduce NSVD failure rates and may increase complication rates
      2. Di Mascio (2020) Am J Obstet Gynecol 223(2): 189-203 [PubMed]
  3. Delivery
    1. Controlled delivery of the fetal head
      1. With one hand, support the fetal head as it crowns
      2. With second hand, squeeze together the perineum toward the midline
      3. Small patient pushes allow a more controlled fetal head delivery
    2. Nuchal cord reduction
      1. Check for nuchal cord as infant's head is delivered
      2. Pull loose nuchal cord's over the infant's head
        1. Loose nuchal cords may also be reduced after delivery
      3. Tight nuchal cords are associated with increased infant complications
        1. Apply 2 clamps to the nuchal cord and cut the cord between clamps OR
        2. Summersault maneuver
          1. Deliver the anterior and posterior Shoulder
          2. Next, hold infant head by maternal thigh
          3. Next, deliver body by summersault
          4. Remove nuchal cord once body is delivered
    3. Shoulder delivery
      1. See Shoulder Dystocia Management
      2. Anterior Shoulder may be delivered from beneath Symphysis Pubis with gentle downward pressure
      3. Posterior Shoulder typically follows easily with gentle upward traction
    4. Assisted Delivery
      1. See Vacuum Assisted Delivery
      2. See Forceps Assisted Delivery
      3. See Manual Rotation in Occipitoposterior Presentation
  4. Newborn Care
    1. See Newborn Resuscitation
    2. Infants not requiring Resuscitation may be placed skin-to-skin on mothers chest (improves bonding, transition, Lactation)
    3. Neonatal suctioning at the perineum or after delivery is no longer routinely recommended
      1. Even with meconium stained amniotic fluid, oropharyngeal suctioning does not reduce aspiration risk
  5. Perineal Laceration
    1. See Perineal Laceration Repair
    2. Warm packs applied to the perineum in the second stage reduces Laceration risk and extension (2nd, 3rd degree)
  6. Cord clamping
    1. Consider delayed cord clamping in all deliveries not requiring emergent Resuscitation
    2. Wait 30-60 seconds after delivery to clamp cord or until cord stops pulsating
    3. Clamp cord with at least 2-4 cm between the infant and the closest clamp
      1. Allows for umbilical venous catheter later if needed
      2. Second clamp is placed closer to the placenta, and the cord is cut between clamps
    4. Infant does not need to be below the level of the placenta prior to cord clamping
      1. Vain (2014) Lancet 384(9939): 235-40 [PubMed]
    5. Delayed cord clamping improves infant birth weight, Hemoglobin, iron stores
      1. Slight increased risk of Hyperbilirubinemia and polycythemia
      2. McDonald (2013) Cochrane Database Syst Rev (7):CD004074 [PubMed]
  • Management
  • Labor Stage 3
  1. See Third Stage of Labor
  2. See Postpartum Hemorrhage
  3. See Retained Placenta
  4. See Uterine Inversion
  5. Stage 3 Definitions
    1. See Third Stage of Labor
    2. Starts with newborn delivery
    3. Ends with delivery of the placenta and fetal membranes
  • References
  1. Dresang (2015) Am Fam Physician 92(3): 202-8 [PubMed]
  2. McKenna (2024) Am Fam Physician 109(6): 525-32 [PubMed]