Assisting a normal vaginal birth
6 steps2 videos
The second and third stages, hands and words: guiding the head, checking the cord, delivering the shoulders, and the active third stage.
Engagement, descent, flexion, internal rotation, extension, restitution and external rotation, animated on the pelvis.
Consent and trauma-informed practice
- Ask before each intervention, including touch of the perineum; the person giving birth directs the room
The sequence
6 steps- 01
Crowning
Support the perineum with one hand and control the pace of the head with the other, encouraging small pushes or panting as the head crowns to reduce tearing; warm compresses help.
- 02
The head
Delivers by extension; allow restitution. Check for a nuchal cord: slip it over the head, or deliver through it, or clamp and cut if tight.
- 03
The shoulders
With the next contraction, gentle downward guidance delivers the anterior shoulder under the symphysis, then upward guidance delivers the posterior shoulder. Note the time of birth.
- 04
The baby
Onto the mother's abdomen, dried and stimulated; delayed cord clamping for at least 60 seconds in a vigorous infant; clamp and cut; skin to skin.
- 05
Third stage
Oxytocin 10 units intramuscularly at or immediately after birth; watch for the signs of separation (a gush, cord lengthening, the fundus rising and firming); controlled cord traction with counter-pressure on the uterus above the symphysis; deliver the placenta and membranes with a twisting motion.
- 06
After
Check the placenta and membranes are complete; check the fundus is firm and the bleeding minimal; inspect the perineum, vagina and cervix for trauma; estimate the loss by weighing.
Indications
- Every spontaneous vaginal birth; a student assists under direct supervision
Preparation
- Introduce yourself and ask permission to be present and to assist; the patient's position is her choice
- Gloves, gown, warm towels, oxytocin drawn up, the neonatal team's readiness known, the resuscitaire checked
- Continuous or intermittent monitoring per plan
Complications
- Perineal trauma
- Shoulder dystocia
- Postpartum haemorrhage
- Retained placenta (no delivery within 30 minutes of active management)
- Uterine inversion with traction on an unseparated placenta
Watch for
- The turtle sign: the head retracts against the perineum after delivery; call shoulder dystocia and start the manoeuvres
- A boggy fundus with bleeding after the placenta: atony, rub up a contraction and start the PPH sequence