Normal Vaginal Birth: Step-by-Step Delivery Guide | OSCE Training

Anemic patients (hemoglobin <7) have increased PPH risk. Active management of third stage prevents PPH: 1) Uterotonic administration (oxytocin 10 IU IV/IM/infusion), 2) Delayed cord clamping (1-3 minutes), 3) Controlled cord traction (modified Brandt-Andrews technique), 4) Intermittent uterine tone assessment. Early cord clamping and balloon tamponade are not part of active management. Oxytocin should be given at least one hour after delivery.

This section covers active management of third stage of labor and PPH management. Components of active management include: injection of uterotonic after delivery of fetus (not placenta), controlled cord traction, and uterine massage. Early cord clamping is NOT part of active management (delayed cord clamping is preferred). Carboprost (dinoprost) is the most potent uterotonic for TREATING PPH (not preventing PPH). It is given intramuscularly (never IV), dose is 250 mcg, maximum 8 injections (2000 mcg total). It is contraindicated in asthma. For PPH prevention, oxytocin is first-line, followed by methylergonovine, syntometrine, and misoprostol. Carboprost is NOT used in active management of third stage to prevent PPH.

Active management of the third stage of labor is recommended by WHO and FIGO. Oxytocin 10 units IV or IM is the first-line uterotonic for PPH prevention in vaginal and cesarean deliveries. In settings where oxytocin is unavailable, alternatives include methylergonovine (contraindicated in hypertensive disorders), misoprostol, or carboprost. Combination therapies may be more effective but carry higher risks of adverse effects. In settings without trained birth attendants, misoprostol (600 mcg sublingual) is recommended by community health workers. Controlled cord traction should not be performed by untrained personnel due to risk of uterine inversion. Sustained uterine massage is not recommended for PPH prevention in women who have received prophylactic oxytocin.

Active Management of Third Stage of Labor (AMTSL) has three components: (1) Injection of uterotonic drug (oxytocin 10 units IM is first-line), (2) Controlled cord traction (Brandt-Andrews maneuver with up-down motion, not side-to-side), and (3) Uterine massage using the side of the palm when the uterus is soft. AMTSL reduces postpartum hemorrhage compared to expectant management. Ergometrine is the second-choice uterotonic, contraindicated in hypertension, pre-eclampsia, and cardiac conditions.

The Active Management of Third Stage of Labor (AMTSL) is a WHO-recommended protocol for all pregnant women to prevent postpartum hemorrhage and reduce maternal mortality. The four essential components are: (1) Uterotonic injection - oxytocin 10 IU administered intramuscularly within 1 minute of birth, (2) Delayed cord clamping - clamping the umbilical cord after 1 minute, (3) Controlled cord traction for placental delivery, and (4) Intermittent assessment of uterine tone. Uterine massage is no longer included in the standard AMTSL protocol. The uterotonic injection is considered the most important component of AMTSL.

Perineal tears are classified into four degrees based on tissue involvement: First-degree involves only vaginal mucosa; Second-degree extends to perineal muscles but preserves the anal sphincter; Third-degree involves the anal sphincter complex (subdivided into 3a for external sphincter <50% injury, 3b for external sphincter >50% injury, and 3c for internal sphincter injury); Fourth-degree extends to rectal mucosa or anal epithelium. Complete perineal tears can cause rectovaginal fistulas leading to fecal or flatus incontinence, requiring surgical repair ideally within 24 hours if recognized during delivery, with women advised to wait at least one year before subsequent pregnancies.

Obstetric lacerations are classified by severity: first-degree (perineal mucosa only), second-degree (musculature disrupted without reaching rectum, most common), third-degree (extends to rectal sphincter), and fourth-degree (completely through to rectal mucosa, causing rectovaginal fistula). Proper repair requires suturing in layers (muscle, perineum, skin) under sterile conditions. Fourth-degree tears cause persistent fecal-vaginal fistulas requiring complex repair. Episiotomies are now performed in only ~10% of deliveries. Midline episiotomy risks fourth-degree tears but causes less pain; mediolateral episiotomy reduces serious complications but causes more pain. Mediolateral is preferred as benefits outweigh discomfort.

This video demonstrates the surgical repair technique for 1st and 2nd degree perineal tears, emphasizing systematic steps including cleaning the area, identifying the tear apex, placing initial sutures 5mm above the apex, repairing the posterior vaginal wall with continuous non-locking sutures, approximating perineal muscles (bulbospongiosus and transverse perineal), using subcuticular sutures for skin closure, and performing final checks with vaginal and rectal examination to ensure adequate repair and prevent complications like chronic pain.

Perineal tears are classified into four grades: Grade 1 (vaginal epithelium), Grade 2 (vaginal epithelium and muscles), Grade 3A (less than 50% external anal sphincter), Grade 3B (more than 50% external anal sphincter), Grade 3C (internal anal sphincter), and Grade 4 (anal epithelium). Risk factors include prolonged labor, macrosomia, instrumental deliveries, and rigid perineum. Repair involves suturing vaginal epithelium, muscles, and sphincters with appropriate techniques. Postoperative care includes sitz baths, analgesia, and follow-up at 2, 6, and 12 weeks. Complications include fecal incontinence and rectovaginal fistula. Prevention includes liberal mediolateral episiotomy and avoiding fundal pressure.

Complete perineal tear repair under general anesthesia involves systematic dissection starting from the hymen at 4 o'clock and 8 o'clock positions, identifying the correct plane between vaginal epithelium and fibromuscular layers using fine scissors with tips up; the repair proceeds from rectal mucosa (using 4-0 rapid kill running continuous sutures) to bilateral elevator muscles, then rectovaginal septum, external anal sphincter (using figure-of-eight sutures), perineal transverse muscles, vaginal epithelium, and finally perineal skin, with the sphincter repair being the most critical step to prevent future rectal incontinence; fourth-degree perineal tears are associated with increased risk of recurrent severe obstetrical laceration and sexual dysfunction, necessitating caesarean section for subsequent deliveries in women with successful secondary sphincter repair.

This comprehensive nursing session covers essential neonatal assessment and emergency care protocols, including the Apgar score system (developed by Virginia Apgar in 1952) with its five parameters (Appearance, Pulse, Grimace, Activity, Respiration) scored from 0-10, where scores of 8-10 indicate normal condition requiring routine care, 4-7 require NICU admission and phototherapy, and 0-3 necessitate neonatal resuscitation (CPR); the Glasgow Coma Scale (GCS) introduced in 1974 by Graham Teasdale with three parameters (Eye, Verbal, Motor) scored 3-15, where scores of 8 or less indicate coma; and immediate newborn care protocols including airway clearance, umbilical cord clamping (1-3 minutes, or immediately for birth asphyxia), identification band application, Vitamin K injection, and eye medication, with WHO guidelines updated to define postpartum hemorrhage as blood loss exceeding 300ml with unstable vital signs.

Immediately after birth, the neonatologist performs the APGAR score assessment (evaluating Appearance, Pulse, Grimace, Activity, and Respiration at 1 and 5 minutes) to evaluate the newborn's adaptation to extrauterine life, while also providing essential care including skin-to-skin contact, umbilical cord clamping and stump care, and initial health screening for congenital anomalies.

This video covers the comprehensive care and resuscitation of newborns, including immediate postpartum care (placing the baby on pre-warmed linen with head slightly lowered, clamping the umbilical cord 2-3 minutes after delivery for mature babies, and performing APGAR scoring at 1 and 5 minutes), nursery care (maintaining thermal neutrality, kangaroo method, early breastfeeding, eye care with sterile saline, and Vitamin K injection), and neonatal resuscitation following the ABC algorithm (Airway, Breathing, Circulation) with equipment including radiant warmer, neonatal resuscitation bag, laryngoscope, and medications like epinephrine and sodium bicarbonate.

Newborn care begins with viability assessment using three questions: term status, breathing/crying, and muscle tone. If all positive, no resuscitation is needed. The Apgar score evaluates five parameters (heart rate, respiratory effort, muscle tone, reflex irritability, skin color) with scores of 0-2 each. Scores below 7 at 5 minutes indicate depression requiring intervention. Routine interventions (nasogastric/rectal tubes, airway aspiration) are contraindicated for healthy newborns. Delayed cord clamping (1-3 minutes for vigorous term newborns, 60+ seconds for preterm) provides significant benefits including increased iron stores at 6 months, reduced intraventricular hemorrhage in preterms, and improved oxygen transport without maternal risks. Approximately 70-75% of placental blood transfuses to the fetus in the first minute.

The APGAR scoring system, developed by Dr. Virginia Apgar in 1952, assesses newborn condition at 1 and 5 minutes post-birth using five parameters (Pulse, Respiration, Activity, Grimace, Appearance) each scored 0-2, with scores of 7-10 indicating no depression requiring only supportive care, 4-6 indicating mild depression needing stimulation and oxygen, and 0-3 indicating severe depression requiring resuscitation; the resuscitation protocol follows the ABC approach (Airway, Breathing, Circulation) with bag-mask ventilation and chest compressions if heart rate remains below 60 bpm, and epinephrine administration at 0.01-0.03 mg/kg if needed.

Ventouse (vacuum extraction) and forceps delivery are operative obstetric interventions used to assist vaginal delivery when maternal exhaustion, hypotonic uterine contractions, or fetal macrosomia necessitate assisted delivery. Forceps are indicated for vertex presentation with full cervical dilation, ruptured membranes, and adequate pelvis, while contraindicated in breech/shoulder presentation, preterm fetus, or cephalopelvic disproportion. The three main forceps types are outlet forceps (Regla) for +4 station, mid-cavity forceps (Kielland) for arrested rotation, and low-cavity forceps (Simpson/Neville) for -1 station. Ventouse is preferred for its higher success rate and less maternal trauma, with vacuum applied 3 cm anterior to the posterior fontanelle at 0.8 kg/m² pressure. Common complications include fetal skull injury, facial nerve injury, and subgaleal hemorrhage.

Vacuum extraction (ventouse) is only for vertex presentation, contraindicated in face/breech (causes eye injury) and <34 weeks (increases intraventricular hemorrhage risk). Indications: prolonged second stage, maternal exhaustion, fetal distress. Forceps can be used for vertex and face presentations. Both require adequate pelvis and fully dilated cervix. Forceps is slightly faster than vacuum.

Forceps delivery indications include: maternal lack of pushing effort (exhaustion, epidural), maternal medical conditions (heart, lung disease, hypertension), prolonged second stage, poor uterine contractions; fetal indications include distress, abnormal position, breech presentation. Prerequisites: confirmed position, no cephalopelvic disproportion, engaged head, fully dilated cervix, ruptured membranes, empty bladder, adequate anesthesia. Procedure: anesthesia, forceps insertion, gentle traction, maternal pushing, episiotomy if needed, head delivery, forceps removal, body delivery. Vacuum extraction requires midwives to understand correct steps and indications for assisted delivery.

Assisted deliveries include vacuum-assisted delivery, where a suction cup is applied to the fetal head to aid descent, and forceps-assisted delivery, which is now uncommon in many facilities. Vacuum-assisted delivery leaves marks called cephalohematoma or caput on the baby's head. Complications include birth trauma, maternal/fetal lacerations, and potential infant subdural hematoma. Indications for assisted delivery include prolonged second stage of labor, abnormal fetal presentation, fetal distress, maternal exhaustion, or ineffective pushing. Nursing care requires lithotomy positioning, empty bladder, ruptured membranes, and engaged fetal presenting part.

Operative vaginal deliveries include vacuum extraction and forceps delivery, both requiring proper indications (prolonged second stage, maternal exhaustion, fetal distress, cord prolapse), adequate pelvis, engaged fetal head, ruptured membranes, and uterine contractions; vacuum uses cups placed at the flexion point (2cm anterior to posterior fontanelle) with pressure around 0.8 kg/cm², limited to 30 minutes and 3 pulls, while forceps are classified as high, mid-cavity, low-cavity, or outlet based on fetal station, with forceps being more versatile for breech aftercoming heads but causing more maternal injuries, and vacuum causing more fetal injuries but being easier to learn; both require skilled practitioners competent in normal vaginal delivery and proper documentation of all procedural details.