What happens during delivery?

The Delivery

When it's time for the baby's head to deliver, the doctor will do his best to protect the delivery of the head and the mother's perineum to reduce or minimize any tears that might occur. Once the baby's head is delivered, the doctor will ask the mother to stop pushing temporarily. He will suction the mouth and nose of the baby, removing mucous secretion and amniotic fluid that may be present. He will check around the baby's neck to make sure the umbilical cord isn't wrapped around it. If it is, depending on how loose it is, he may unwrap the cord around the baby's neck. Sometimes, the cord may be tightly wrapped around the baby's neck; in that event, the doctor will clamp the cord in two places, cut the cord in-between the two clamps, unwrap the cord manually, and deliver the rest of the baby.

It's a wonderful time for the mother to watch as her entire baby is delivered. Many times a large amount of amniotic fluid that was behind the baby will now flow out. The doctor will also maintain support of the perineum so that there is a minimal chance of tearing. After the baby is delivered, the umbilical cord will be clamped and cut. If the father is interested, he can be given the opportunity to cut the cord. Again, this is a great way of making the extra person feel included in the process.

The baby will be gently stimulated by the delivering doctor and may be placed on the mother's chest or belly and covered with a blanket to provide warmth. The mother is asked to gently stimulate the baby during this time by rubbing the baby's back. Alternatively, the baby may be transferred to the baby warmer station where the medical staff will clean him, warm him, and check his heart rate. If the baby is not doing well, then there may not be time for him to go to his mother. Out of medical necessity, in this case, the baby will go immediately to the warmer or the nursery.

After the baby is born, the doctor and nurse return their attention to their primary patient, the mother. The doctor will reassess the mother's physical status, vital signs will be checked, and the amount of bleeding from the vagina will be determined. The doctor will assess his patient for tears or lacerations that might have occurred in the perineum or vagina or vulva. If any repairs are necessary, the doctor may proceed to do the repairs or opt to do them after the placenta is delivered. The doctor will also see if the cervix has any tears or lacerations, as well as examining the rectum for tears.

If there are any tears from a natural occurrence or from an episiotomy, the doctor will stitch the tears with absorbable sutures, meaning that the suture material will degrade on its own based on the body's ability to break down the suture.

The placenta will be delivered within half an hour after the baby's birth. After the delivery, there is a tendency for the uterus to squeeze down upon itself and return to a contracted state. The placenta will begin to sheer off with the contractions. As it sheers off, there is usually a visible sign of this by a large amount of blood coming out of the vagina and the umbilical cord will lengthen and advance out.

The doctor may aid this process by gentle traction (pulling), but he must be careful not to exert any unnecessary traction, as it could tear the cord off. After the placenta is delivered, the doctor will check to make sure that all of it is intact and no pieces remain in the uterus (which could cause bleeding and infection). The doctor will advise the nurse that the placenta has been delivered, so that she can note the time.

He will ask for pitocin to be administered intravenously, which aids in the contraction of the uterus and stops bleeding. To aid this process, the doctor will massage the uterus and stimulate it physically. The doctor will then check for any remaining clots before the placenta was delivered and evacuate those as necessary. Once the bleeding is under control and all lacerations have been repaired, the patient can be cleaned and her bed will be put back together. She can begin to rest. This is still a potentially dangerous time for the mother as bleeding may resume, so the nurse will continue to check her vital signs (including blood pressure) for the next several hours. The nurse will also check the uterus by pushing down on the abdomen, to make sure that the uterus is contracted and firm to touch. A soft, boggy or enlarged uterus could indicate that bleeding has occurred and the uterus is expanding with blood. That condition may necessitate additional measures, such as checking for clots remaining inside the vagina and uterus, recommendation for additional medications, and a possible blood transfusion. And if bleeding is extreme, surgical measures may be recommended, such as a D & C or a full hysterectomy.

Episiotomy

Often the baby may not be delivered because the vaginal opening is too small or constricted. At other times, the vaginal opening may be appropriate in size, but it has not had enough time to stretch for the baby. Or the baby's heart rate may be of concern to the doctor, so an attempt to expedite delivery may occur. These are all good examples of why an episiotomy might need to be performed.

An episiotomy is a process by which a doctor will make an incision or cut in the space between the vagina and rectum in order to expand the opening for the baby's head. Most doctors do not do this routinely, but rather only when a medical indication arises. When the doctor makes the cut, the vaginal space is enlarged. Of course, after the baby is delivered, the incision or episiotomy must be repaired to restore it to its original anatomy. Occasionally, the episiotomy may be so extensive that it extends to the rectal area. Obviously, this will necessitate more extensive repair afterwards.

Forceps or a Vacuum

In rare circumstances, your baby may need to be delivered with the aid of forceps or a vacuum device. The concept of doing an instrumented vaginal delivery is not new. Forceps have been utilized over the centuries, and they can provide a means to assist in the delivery of a baby when certain conditions arise. For example, if a mother is too tired to push or if the fetal heart rate becomes worrisome, then conditions may warrant the use of forceps or a vacuum. Very strict criteria need to be met before the use of these instruments can be offered to the patient.

If the doctor thinks the conditions are ideal for an instrumented vaginal delivery, then he should discuss his thoughts with the patient so the patient understands the indications, risks, and benefits. Unfortunately, sometimes there isn't time to have a lengthy discussion when the baby's life is at stake, so it's good to go over these procedures with your doctor in advance of the delivery.

The benefit to these two procedures is obvious: They may assist in getting the baby out quickly when there is a fetal heartrate problem.

The risks of using either vacuum or forceps are also obvious. They include the potential to injure the baby and create vaginal tears in the mother. You may see slight bruising of the side of the head on a baby where forceps were used. This bruising usually goes away in a few days.

The choice between using a vacuum or forceps is up to the doctor, depending on the patient's condition. The clinical situation will dictate which instrument is chosen. Safety for both the patient and the baby is of utmost importance.

The Absolute Minimum

A normal delivery is never really normal, simply because it's yours, and that makes it special. However, many of the procedures that you will encounter are easily decipherable and predictable if you simply do your homework in advance.

• Try to study and recognize the phases and stages of labor so you know where you are in the process. Make sure that your partner is equally well informed.
• Pay attention to what the doctors and nurses say to you. Often, they are asking for or giving you information that will expedite your delivery.
• Don't allow too many people into the labor and delivery room with you. Remember – you're there to do a job – deliver your baby. Doing that job requires your full attention and focus. The baby's health is at stake, as is yours.
• When it's all finished, take a moment to bask in what you've accomplished. You've just delivered a new life into the world. Congratulations! It's a miracle each and every time.