A Quick Synopsis of AFP's "Spontaneous Vaginal Delivery"

Spontaneous Vaginal Delivery
Dale a. Patterson,MD, Family Medicine Residency Program at Memorial Hospital of South Bend, South Bend, Indiana Marguerite Winslow, MD, and Coral D. Matus, MD, The Toledo Hospital Family Medicine Residency Program, Toledo, Ohio
Am Fam Physician. 2008 Aug 1;78(3):336-341.
http://www.aafp.org/afp/2008/0801/p336.pdf

     before labor starts, some screening tests may be important. Group B strep (GBS) screening is done on all women at 35-37 weeks. GBS positive women (and those that were not screened) are prophylaxed with penicillin four hours before delivery and every four hours until birth. Ampicillin, cefazolin, erythromycin or vancomycin are alternative medications. Patients with HSV2 during pregnancy can be treated with acyclovir, ganciclovir, or valacyclovir from week 36 until delivery. Patients with active lesions during delivery should have a c-section. All patients should also be screened for HIV. Patients who test positive should get therapy throughout pregnancy as well as a c-section at 38 weeks.
    Labor is divided into three stages. Stage one is from onset of labor to complete dilatation of the cervix. There is a latent and an active stage in stage one. The latent stage becomes active when the cervix dilates to 4 cm. Stage two is from dilatation to delivery. Stage three is delivery to delivery of the placenta. The stages typically last longer than the times previously documented on the Friedman curve.  Patients in the first stage of labor should not be admitted to "L and D" until they reach the active phase. Pain control is the most important intervention in this stage. Narcotics and epidural anesthesia are the two choices, but they can be given in combination. Epidurals increase the incidence of instrument delivery and the lengthen the second stage of labor. Fetal heart rate monitoring is commonly used. Due to its high false positive rates, it has increased the use for c-sections without lowering perinatal mortality or incidence or cerebral palsy. Fetal pulse oximetry and fetal ECG monitoring are other  modalities that have not been well studied (at the time of this article).
     The second stage of labor is where all the pushing occurs. Coached pushing with sustained breath holding leads to a shorter second stage. Delayed pushing prolongs the second stage, but shortens the duration of pushing. The patient can push in any position that she is most comfortable in. Episiotomies increase the risk of perinatal trauma, third degree tears, sexual dysfunction and urinary incontinence. They should not be done. antenatal perineal massage can lower the incidence of perineal trauma. First and second degree perineal tears do not need to be sutured.
     In the third stage of labor, the placenta separated from the uterus. Oxytocin is usually given to help the uterine contract, which decreases blood loss. It also lowers the risk of postpartum hemorrhage.