MSD Manual

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Raul Artal-Mittelmark

, MD, Saint Louis University School of Medicine

Reviewed/Revised May 2021 | Modified Sep 2022
Topic Resources

Delivery is the passage of the fetus and placenta (afterbirth) from the uterus to the outside world.

For delivery in a hospital, a woman may be moved from a labor room to a birthing or delivery room, a room used only for deliveries. Usually, the father, partner, or another support person is encouraged to accompany her. Or she may already be in a private room where she stays from labor through delivery until discharge—a labor, delivery, recovery, and postpartum (LDRP) room. The intravenous line remains in place.

The Uterus, Cervix, and Cervical Canal

When a woman is about to give birth, she may be placed in a semi-upright position, between lying down and sitting up. Her back can be supported by pillows or a backrest. The semi-upright position uses gravity: The downward pressure of the fetus helps the vagina and surrounding area stretch gradually, decreasing the risk of tearing. This position also puts less strain on the woman’s back and pelvis. Some women prefer to deliver lying down. However, with this position, delivery may take longer.

Positions for Birth
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    Women in maternities around the world most often give birth lying flat on their backs. This is a familiar position and convenient for the birth attendant, however there are alternative positions that are more effective for birthing women. This video shows a variety of birthing positions to give women choices.

    These positions help the normal natural process of birth and support a woman’s pushing efforts. Lying on her back can hinder the woman’s pushing efforts, reduce oxygen to the baby, and slow down the birth. Encourage different positions for giving birth, but if the woman prefers to lie on her back, suggest she raise her head to help her pushing efforts; or, better, help her to raise her upper body. Women who choose other birthing positions may give birth more quickly and easily.

    Let’s see some examples.

    Here the woman is sitting up in the bed, supported by her partner behind her. This position is comfortable for many women, and makes it easy to see the progress of the birth. Support the perineum as you keep the head flexed, then guide the slow birth of the baby’s head. Once the baby rotates, assist the birth of the shoulders.

    In this next example, the woman is lying on her side. This position is restful yet allows contractions to remain strong and powerful. It relaxes the perineum and may help prevent tears. The woman can have her companion help support her leg or she may hold her leg by herself. In a side lying position, as in all other positions, support the perineum as you keep the baby’s head flexed; then let the head slowly birth. As the baby rotates, the shoulders come on their own.

    Upright positions, such as squatting, are very effective in bringing the baby down. The uterus often contracts more effectively plus gravity helps the baby move more easily through the pelvis. The pelvic opening also becomes wider in upright positions. Here the midwife keeps her hand on the baby’s head to monitor progress. Just as the head comes, the woman chooses to lie back. A woman’s legs may tire quickly if she’s not used to squatting. Here the woman supports herself with bars that are attached to the birthing bed. The baby’s head slowly emerges, then the top shoulder; and the bottom shoulder. The baby is born. This woman is in a squatting position supported by the back of the bed. With a few effective pushes, the baby is born.

    Hands and knees, another upright position, is a favorite position of many women and is helpful when the woman feels her labor in her back. The perineum will often naturally stretch which can prevent tears. The woman cannot see your face – so talk to her often to let her know her progress. Checking the baby’s heart rate is easiest with a doppler or a stethoscope. Wipe away any fecal material that may appear while she’s pushing. Support the perineum and apply light pressure on the back of the baby’s head to keep it flexed. Remember, the birth movements will be the opposite of the way they appear when the woman is on her back. The baby’s face will be looking at the ceiling when it appears. The next contraction brings the baby. Support her as she’s born, then dry her on the blanket at the feet of the mother. Pass the baby through the mother’s legs with her cord intact. The mother then turns over and rests with her baby skin to skin. Keep in mind that the hands and knees position increases the room in the pelvis and is one of the maneuvers to try if a baby’s shoulders are tight.

    This woman is pushing very effectively in this half kneeling position. As with the hands and knees position, you’ll need to be behind the woman to catch the baby. After the baby rotates, assist the shoulders to deliver, one and then the other. Encourage women in your care to try different positions. You will gain confidence in your ability to support a woman’s choice in how she’ll give birth. Often she will find the most comfortable position for herself, which is also the one that helps her push most effectively.

    Remember, active upright positions help the natural process of birth. Upright positions can help bring the baby out when the birth is slow. Demonstrate and encourage different positions during birth.

Copyright Global Health Media

Delivery of the baby

As delivery progresses, the doctor or midwife examines the vagina to determine the position of the fetus’s head. When the cervix is fully open (dilated) and thinned and pulled back (effaced), the woman is asked to bear down and push with each contraction to help move the fetus’s head down through her pelvis and to widen the vaginal opening so that more and more of the head appears. The midwife may massage the area around the opening of the vagina (called the perineum) and apply warm compresses to it. These techniques may help the tissues around the vaginal opening stretch slowly and help prevent tears, but they may increase the risk of infection.

When more than 1 inch (3 to 4 centimeters) of the head appears, the doctor or midwife places a hand over the fetus’s head during a contraction to control the fetus’s progress. As the head crowns (when the widest part of the head passes through the vaginal opening), the head and chin are eased out of the vaginal opening to prevent the woman’s tissues from tearing.

Assisted Delivery
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    During pregnancy, a woman's uterus houses and protects the developing fetus for approximately 40 weeks.

    When the fetus has matured and labor begins, the baby goes through a series of movements that help it navigate through the birth canal.

    Occasionally, however, a baby may become stuck in the birth canal. This may occur

    • If the baby does not attain the proper position

    • If labor ceases unexpectedly

    • Or if the baby is too large to fit through the birth canal

    In these situations, a vacuum extractor may be used to assist the delivery process.

    In order for vacuum extraction to be performed, a bell- or funnel-shaped cup is inserted into the vagina and placed on the baby's head. Suction is then applied to the cup using a manual or electric pump apparatus. The suction gently pulls the baby outward until the head has emerged from the birth canal. At this point, the cup is removed, and delivery proceeds as normal.

Episiotomy is an incision that widens the opening of the vagina to make delivery of a baby easier. It is no longer done routinely. It is used only when the tissues around the vagina's opening do not stretch enough and are preventing the baby from being delivered. This procedure prevents tissues from overstretching and may help tissues from tearing raggedly. For this procedure, the doctor injects a local anesthetic to numb the area and makes an incision in the area between the openings of the vagina and anus (called the perineum). If the muscle around the opening of the anus (rectal sphincter) is damaged during an episiotomy or is torn during delivery, it usually heals well if the doctor repairs it immediately.

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    During pregnancy, a woman's uterus houses and protects the developing fetus. After approximately 40 weeks, the fetus reaches full term and is ready to be born.

    At the time of delivery, the opening to the uterus, called the cervix, dilates to allow the baby to pass from the uterus into the vagina. The vagina is a muscular tube that expands to accommodate the head and shoulders of the baby while uterine contractions continue to push the baby outward.

    Occasionally, the vaginal opening is too narrow to allow the baby to be born without tearing the vagina. When this risk is present, a procedure called an episiotomy may be performed.

    During an episiotomy, a doctor makes an incision at the bottom of the vagina. This enlarges the vaginal opening to prevent vaginal tears as the baby's head is delivered. Following delivery, the incision is then stitched closed for healing. However, this procedure lengthens the time of the mother's recovery.

    There are several potential complications associated with this procedure that should be discussed with a doctor prior to the procedure.

After the baby’s head has emerged, the body is rotated sideways so that the shoulders can emerge easily, one at a time. The rest of the baby usually slips out quickly after the first shoulder comes out. Mucus and fluid are suctioned out of the baby’s nose, mouth, and throat. The umbilical cord is clamped and cut. This procedure is painless. (One clamp is left on the stump of cord near the baby's navel, until the cord has sealed, usually within 24 hours.) The baby is then dried, wrapped in a lightweight blanket, and placed on the woman’s abdomen or in a warmed bassinet.

Delivery of the placenta

After delivery of the baby, the doctor or midwife places a hand gently on the woman’s abdomen to make sure the uterus is contracting. After delivery, the placenta usually detaches from the uterus within 3 to 10 minutes, and a gush of blood soon follows. Usually, the woman can push the placenta out on her own. However, in many hospitals, as soon as the baby is delivered, the woman is given oxytocin (intravenously or intramuscularly), and her abdomen is periodically massaged to help the uterus contract and expel the placenta. If the woman cannot push it out and particularly if she is bleeding excessively, the doctor or midwife applies firm pressure on the woman’s abdomen, causing the placenta to detach from the uterus and come out. If the placenta has not been delivered within 45 to 60 minutes of delivery, the doctor or midwife may insert a hand into the uterus, separating the placenta from the uterus and removing it. Pain relievers or anesthesia is needed for this procedure.

After the placenta is removed, it is examined for completeness. Fragments left in the uterus prevent the uterus from contracting. Contractions are essential to prevent further bleeding from the area where the placenta was attached to the uterus. So if fragments remain, bleeding Excessive Uterine Bleeding at Delivery Excessive bleeding from the uterus refers to loss of more than 2 pints of blood or symptoms of significant blood loss that occur within 24 hours after childbirth. After the baby is delivered... read more can occur after delivery and may be substantial. Infections of the uterus Infections of the Uterus After Delivery Infections that develop after delivery of a baby ( postpartum infections) usually begin in the uterus. Bacteria can infect the uterus and surrounding areas soon after delivery. Such infections... read more can also occur. If the placenta is incomplete, the doctor or midwife may remove the remaining fragments by hand. Sometimes fragments have to be surgically removed.

After delivery

Oxytocin is given to the woman after the baby is delivered. This drug causes the uterus to contract and minimizes blood loss. Usually, breastfeeding the newborn also causes the uterus to contract.

The doctor stitches up any tears in the genital tissues and, if an episiotomy was done, the episiotomy incision. If these tissues are not repaired, women may be more likely to miscarry or have a baby born prematurely in future pregnancies.

The woman is then moved to the recovery room or remains in the LDRP. Typically, a baby who does not need further medical attention stays with the mother. Typically, the woman, baby, and father or partner remain together in a warm, private area for an hour or more so that bonding can begin. Many women wish to begin breastfeeding soon after delivery.

Later, the baby may be taken to the hospital nursery. In many hospitals, the woman may choose to have the baby remain with her—a practice called rooming-in. All hospitals with LDRPs require it. With rooming-in, the baby is usually fed on demand, and the woman is taught how to care for the baby before she leaves the hospital. If a woman needs a rest, she may have the baby taken to the nursery.

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