Women should be guided by their own urge to push. Pushing effort should allow for an unhurried, gentle delivery of the fetal head and this can be achieved by combining short pushing spells with periods of panting, thus giving the vaginal and perineal tissues time to relax and stretch over the advancing head (Fig. 12.1). Several contractions may occur before the head crowns and is delivered. For the delivery of the head, either the ‘hands on’ technique – supporting the perineum and flexing the baby’s head – or the ‘hands poised’ method – with the hands off the perineum but in readiness – can be used to facilitate spontaneous birth.

Episiotomy is not routinely required for spontaneous vaginal birth but may be indicated if the perineum begins to tear, if the perineal resistance prevents delivery of the head or if concern for the wellbeing of the fetus requires that the birth be expedited. Where an episiotomy is performed, the recommended technique is a mediolateral incision originating at the vaginal fourchette and directed usually to the mother’s right side (Fig. 12.2).

With the next contraction, the head is gently pulled downwards along the longitudinal axis of the baby until the anterior shoulder is delivered under the sub-pubic arch and then the baby is pulled anteriorly to deliver the posterior shoulder and the remainder of the trunk.

The infant will normally cry immediately after birth but if breathing is delayed the nasopharynx should be aspirated and the baby’s lungs inflated with oxygen using a face mask. If the onset of breathing is further delayed, intubation and ventilation may become necessary. The condition of the baby is assessed at 1 and 5 minutes using the Apgar scoring system (Table 12.1) and again at 10 minutes if the baby is depressed. If the baby is born in poor condition (Apgar score at 1 minute is 5 or less), the cord should be double-clamped for paired cord blood gas analysis.

Management of the third stage

Active management of the third stage of labour is recommended, which includes the administration of oxytocin (10 I/U) intramuscularly to the mother, followed by late clamping (>2 minutes) and cutting of the cord. When the signs of placental separation are seen, i.e. the lengthening of the cord, trickle of blood and the uterus becoming globular and hard due to contraction and extruding the placenta into the lower segment, the placenta is delivered by controlled cord traction, a method commonly referred to as the Brandt-Andrews technique (Fig. 12.3).

For episiotomy repair, the woman should be placed in the lithotomy position so that a good view of the extent of the wound can be obtained (Fig. 12.4). Repair should only be undertaken with effective analgesia in place using either local anaesthetic agent infiltration or epidural or spinal anaesthesia. Closure of the vaginal wound requires a clear view of the apex of the incision. It is recommended that an absorbable synthetic suture material be used for the repair using a continuous technique for the vaginal wall and muscle layer and a continuous subcuticular technique for the skin.

On completion of the procedure it is important to ensure that the vagina is not constricted and that it can admit two fingers easily. In addition, a rectal examination should be performed to confirm that none of the sutures has penetrated the rectal mucosa. If this occurs, the suture must be removed as it may otherwise result in the formation of a rectovaginal fistula.

Accurate repair of an episiotomy is important. Over-vigorous suturing of the wound or shortening of the vagina may result in dyspareunia and sexual disharmony with the partner. Failure to recognize and repair damage to the anal sphincter may result in varying degrees of incontinence of flatus and faeces.