Delivery of the head

a. The fetal head is delivered by extension as the flexed head passes through the vaginal introitus.

b. Once the fetal head has been delivered, external rotation to the occiput transverse position occurs.

c. The oropharynx and nose of the fetus are suctioned with the bulb syringe. A finger is passed into the vagina along the fetal neck to check for a nuchal cord. If one is present, it is lifted over the vertex. If this cannot be accomplished, the cord is doubly clamped and divided.

d. If shoulder dystocia is anticipated, the shoulders should be delivered immediately.

2. Episiotomy consists of incision of the perineum, enlarging the vaginal orifice at the time of delivery. If indicated, an episiotomy should be performed when 3-4 cm of fetal scalp is visible.

a. With adequate local or spinal anesthetic in place, a medial episiotomy is completed by incising the perineum toward the anus and into the vagina.

b. Avoid cutting into the anal sphincter or the rectum. A short perineum may require a mediolateral episiotomy.

c. Application of pressure at the perineal apex with a towel-covered hand helps to prevent extension of the episiotomy.

3. Delivery of the anterior shoulder is accomplished by gentle downward traction on the fetal head. The posterior shoulder is delivered by upward traction.

4. Delivery of the body. The infant is grasped around the back with the left hand, and the right hand is placed, near the vagina, under the baby's buttocks, supporting the infant's body. The infant's body is rotated toward the operator and supported by the operator's forearm, freeing the right hand to suction the mouth and nose. The baby's head should be kept lower than the body to facilitate drainage of secretions.

5. Suctioning of the nose and oropharynx is repeated.

6. The umbilical cord is doubly clamped and cut, leaving 2-3 cm of cord.

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