As soon as the head appears at the vulva the physician should be ready to restrain its progress. He should hold his hand in such a manner as to be able to bring it immediately into action, for in many instances the resistance of the vulva is unexpectedly overcome, and a single pain may be sufficient to push the head suddenly through it with a resulting perineal tear.
—J. Whitridge Williams (1903)
As described by Williams, the natural culmination of second-stage labor is controlled vaginal delivery of a healthy neonate with minimal trauma to the mother. Vaginal delivery is the preferred route of delivery for most fetuses, although various clinical settings may favor cesarean delivery. Of delivery routes, spontaneous vaginal vertex delivery poses the lowest risk of most maternal comorbidity, and comparisons with cesarean delivery are found in Chapter 30 (Cesarean Delivery Risks). Delivery is usually spontaneous, although some maternal or fetal complications may warrant operative vaginal delivery, described in Chapter 29 (Indications). Last, a malpresenting fetus or multifetal gestation in many cases may be delivered vaginally but requires special techniques. These are described in Chapters 28 (Labor and Delivery Management) and 45 (Evaluation of Fetal Presentation).
PREPARATION FOR DELIVERY
The end of second-stage labor is heralded as the perineum begins to distend, the overlying skin becomes stretched, and the fetal scalp is seen through the separating labia. Increased perineal pressure from the fetal head creates reflexive bearing-down efforts, which are encouraged when appropriate. At this time, preparations are made for delivery. If the bladder is distended, catheterization may be necessary. Continued attention is also given to fetal heart rate monitoring. As one example, a nuchal cord often tightens with descent and may lead to deepening variable decelerations.
During second-stage labor, pushing positions may vary. But for delivery, the dorsal lithotomy position is most common and often the most satisfactory. For better exposure, leg holders or stirrups are used. Corton and associates (2012) found no increased rates of perineal lacerations with or without their use. With positioning, legs are not separated too widely or placed one higher than the other. Within the leg holder, the popliteal region should rest comfortably in the proximal portion and the heel in the distal portion. The legs are not strapped into the stirrups, thereby allowing quick flexion of the thighs backward onto the abdomen should shoulder dystocia develop. Legs may cramp during second-stage pushing, and cramping is relieved by repositioning the affected leg or by brief massage.
Preparation for delivery includes vulvar and perineal cleansing. If desired, sterile drapes may be placed in such a way that only the immediate area around the vulva is exposed. Scrubbing, gowning, gloving, and donning protective mask and eyewear protect both the laboring woman and accoucheur from infectious agents.