DELIVERY (2):

HOW DOES THE EXPULSION PHASE OF A NORMAL DELIVERY TAKE PLACE IN PRACTICE 

Dr Claude Allouche, gynecologist
Ahuza Clinic, Raanana
058 726 02 64

We will discuss here the last stage of childbirth called the fetal expulsion phase which constitutes the 2nd part of labor.
It begins at full dilation and ends with birth

Before allowing the mother-to-be to begin her pushing efforts, the baby must first engage in the pelvis.
This phenomenon of commitment is very important, because it will condition the route of delivery and determine whether it can be done by natural means or not, some explanations to understand:

The pool is divided into 3 parts:

- The upper part called the upper strait, limited at the front by the top of the pubis and at the back by the upper part of the sacrum.

- The middle part called the middle strait: it is the narrowest part of the pelvis marked by the protrusion of the sciatic spines.

- The lower part corresponding to the lower strait, limited at the front by the lower edge of the pubic symphysis and at the rear by the tip of the sacrum.

Childbirth is therefore divided into 3 stages that the baby will have to go through one by one before being able to get to know his parents.

1/ 1st step: commitment

It corresponds to the passage of the baby's head into the upper strait.
The diagnosis of engagement is made by the midwife or obstetrician during the vaginal examination.

To be able to overcome this first obstacle, the baby's head has the capacity to adapt to the anatomy of his mother's pelvis and to reduce its dimensions to slip and orient itself correctly in the pelvis, thanks in particular to a flexion of the head on the thorax and flexibility of the bones of the skull.

To facilitate the orientation and progress of the baby in the upper strait, the midwife may advise adopting specific positions.

The diagnosis of engagement is sometimes made difficult by the presence of a serosanguineous bump which has gradually created in the preceding hours, which can hinder the interpretation of the height of the fetal head.

But it is essential to make the diagnosis before starting the pushing efforts because if the head does not engage in the upper strait, they will be ineffective and will not allow birth by natural means.
Thus, in the absence of engagement of the fetal head after a certain time, despite effective contractions, a cesarean section will have to be performed.

2/ The descent

After crossing the upper strait, descent and rotation in the basin can begin in the middle strait.
This is the most delicate part of the pelvis, due to the presence of the sciatic spines which reduces the available space and can make this descent phase a little long.
However, at this stage of childbirth, we no longer talk about cesarean section: if we need to shorten the duration of childbirth, we can resort to instrumental extraction by suction cup or forceps.

It is through vaginal examination that the midwife or obstetrician follows the descent and rotation of the head in the pelvis (thanks to the identification of the fontanels and sutures). The midwife may also ask you to adopt certain positions to facilitate this progression.

3/ Clearance

The baby's head finally arrives in the lower part of the pelvis, called the lower strait.
The midwife will place the patient in the birthing position and the pushing efforts will begin so that the baby's head settles under the pubic symphysis and is released through a deflection movement.
At this stage, the patient can concretely realize the imminence of birth: if the Midwife shows her the top of the baby's head using a mirror, or makes her touch the head with her finger, this contact can indeed give a boost of energy for the last pushes.

From the outside, we observe a distension of the perineal muscles by the baby's forehead and a rise of it upwards. The vulva gradually distends and the face appears from top to bottom.

This release can be sudden and cause damage to the perineum if it is not controlled. It is therefore important to follow the instructions of the doctor and midwife.

After completely releasing the head to the outside, it turns to find itself in line with the back.
A final effort is required to release the shoulders. It is also important to follow the instructions of the doctor or midwife, so that this phase does not last too long or cause damage to the perineum.

Once the shoulders are out, the rest of the body follows without difficulty and the newborn will be placed directly on his mother's stomach.

The umbilical cord is then clamped and cut by the father if he wishes.

In the absence of complications or bleeding, in this moment of intense emotion, a time of rest and calm in privacy will be offered so that the newborn and his parents can finally get to know each other...

EPISIOTOMY IS NOT SYSTEMATIC!

What is an episiotomy?

An episiotomy is an incision made by the gynecologist or midwife in the perineum during childbirth.
It is performed using sterile surgical scissors.
It is painless and performed under anesthesia (local or epidural).

It can be performed mediolaterally or medially.
Far from being systematic, for many years it has been recommended by learned societies to avoid performing an episiotomy as much as possible. The recommendations to use this procedure systematically in certain situations such as macrosomia, breech or vacuum extraction have been obsolete for a long time.

It is only at the last moment, during the last phase of expulsion, that the midwife can decide to use this gesture to protect the perineum if he considers that an imminent tear could be more serious.

We can therefore reassure patients who fear that this procedure will be carried out: episiotomy is much more rarely carried out, the midwife only performing it if he has no other choice to protect the muscles of the perineum, in order to ' avoid more serious lesions.

Note, however, that it is more easily carried out in the event of extraction by forceps or to accelerate the expulsion of the child in the event of an abnormal fetal heart rate.

After delivery and expulsion of the placenta, careful disinfection of the perineum is carried out.
Sterile fields are then put in place so that the gynecologist then sutures the incision in 3 layers with absorbable thread.

Postpartum care consists of intimate cleansing with a simple disinfectant.
Healing is most often rapid and painless and generally allows a resumption of sexual activity, approximately one month after childbirth.

However, a reassessment of the perineum by the gynecologist will be necessary during the postnatal visit 4 to 6 weeks after delivery.

Other publications on the same subject:
- Childbirth (1): at what term do we give birth?
- Childbirth (2): when should you go to the maternity ward?
- Childbirth (3): how is the fetus monitored during labor?
- Childbirth (4): what maternal supervision
- Childbirth (5): how does the expulsion phase of a normal childbirth work in practice?
- Childbirth (6): episiotomy is not systematic!
- Childbirth (7): artificial induction of labor, how does it happen in practice?
- Childbirth (8): instrumental aids, what are they?
- Childbirth (9): deliverance, what is it, mazé?

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