a. Check for Presence of an Intact Amniotic Sac.

(1) If the membranes do not break spontaneously, they should be ruptured just prior to or with the delivery of the head.

(2) Caution must be taken to prevent the membranes from covering the infant’s mouth as the first breath is taken, otherwise aspiration of amniotic fluid can occur.

b. Support the Perineum and Infant’s Head.

(1) Apply support to the perineum with your dominant hand (usually right hand) using a towel or cloth. When available, turn your hand with your palm facing the fetal head and fingers pointed downward, and apply firm pressure against the perineum with the flattened fingers.

(2) Apply support to the fetal head with your nondominant hand. Spread your middle three fingers; place your fingers against the anterior aspect of the head.

(3) Increase the pressure of the dominant hand in a downward motion against the perineum as the fetal head extends. This will assist in “sliding” the perineum over the fetal face. If the perineum is not flexible enough to deliver the fetus without lacerations, maintain firm pressure. This will help to minimize the extent of lacerations.

(4) Provide mild downward pressure with the nondominant hand against the fetal head as the fetal head extends. This will guide the head away from the anterior vulva and minimize lacerations around the urethra.

(5) Take special care to avoid excessive pressure on the fetal head. Never attempt to delay delivery by applying pressure on the fetal head.

(6) Combine efforts of the right and left hand. This will result in a slow, controlled extension of the fetal head.

c. Assist With the Actual Delivery of the Head.

This should be accomplished between contractions to slow the force of expulsion.

d. Coach the Patient to Pant/Blow.

This should be done as the head delivers. However, she may be required to bear down slightly to assist with delivery of the large diameter of the head. Panting and blowing helps to avoid pushing after delivery of the head to allow time to bulb suction amniotic fluid from the infant’s mouth.

e. Bulb Suction Amniotic Fluid from the Infant’s Mouth.

Place your finger into the infant’s mouth to allow insertion of the syringe.

f. Allow Rotation.

Allow the infant to spontaneously accomplish external rotation.

g. Check for a Nuchal Umbilical Cord.

Slide one or two fingers along the anterior side of the infant’s head and neck to the shoulder to assess for the presence of a nuchal (around the neck) umbilical cord.

(1) If there is a loosely wrapped cord, the cord should be lifted and slid over the infant’s head. This is known as “reducing” the cord.

(2) If there is a tight nuchal cord, the cord must be clamped twice and cut between the clamps.

(3) If the cord is loose, but cannot be lifted over the infant’s head, it may be slid over the delivering body.

NOTE: A nuchal cord occurs in about 25 percent of all deliveries.

h. Allow Infant to Complete External Rotation.

After complete rotation, place your hands so that the palms are flat against the sides of the infant’s head.

i. Coach the Patient to Push and to Pant/Blow.

Tell the patient when to push and when to pant/blow. This will assist with a controlled delivery of the shoulders.

(1) The nurse applies gentle downward pressure on the head until the anterior shoulder delivers from under the pubic arch and becomes visible.

(2) Support the infant’s head and neck. The infant is gently pushed or lifted upward to facilitate delivery of the posterior shoulder.

Brookside Associates Note: Pulling down on the fetal head is dangerous because of potential injury to the fetal brachial plexus nerves in the shoulder. While considered a reasonably safe procedure among well-trained birth attendants, it requires experience and judgement to know when “gentle downward traction” is being exceeded. Some experienced obstetricians make it their own policy to never exert downward traction on the head during deliveries. Please review the following video before giving further consideration to “applying downward traction.”

j. Assist With Delivery of the Posterior Shoulder.

After the delivery of the posterior shoulder, the infant’s body is generally expelled rapidly. However, if the infant is large, the mother may have to assist by pushing.

k. Care for the Infant.

(1) The nurse should cradle the infant against his (the nurse’s) body with the infant’s head supported by the palm of his hand and the body supported by the forearm. This method allows the nurse a free hand.

(2) The infant should be held with his head tilted downward to facilitate the drainage of mucus and  fluid from the upper airway.

(3) The infant should be held at or below the level of the uterus until the umbilical cord stops pulsating to prevent loss of neonatal blood to the placenta.

NOTE: The infant may cry or breathe spontaneously or with the clamping of the cord.

(4) If the infant does not begin spontaneous respiration, he should be stimulated to breathe. You should place the infant on a flat surface and rub his back briskly. This can be achieved with the same motions required to dry the infant. Slap the soles of the infant’s feet if more aggressive stimulation is required.

(5) Do not “slap” the infant’s buttocks. This action may produce sufficient bruising of a large surface area and may result in compromising circulatory volume.

(6) Never suspend the infant by his feet. This action hyperextends the infant’s spine which has been flexed throughout fetal development. Also, it increases the intracranial pressure and may cause capillary rupture and increases the chances of dropping the infant.

(7) Dry and wrap the infant immediately to prevent heat loss. In an emergency setting, place wrapped infant in the mother’s arms to be held close to her body to maintain warmth.

(8) Check the infant frequently to assess for regular respirations.

(9) Determine one (1) and five (5) minute APGAR scores.

l. Assist with Delivery of the Placenta.

CAUTION: Never tug on the cord to attempt to speed delivery. This may avulse or tear the cord from the placenta. It may, also, encourage the uterus to invert.

(1) Observe for signs of placenta separation. There may be a sudden gush of blood, sudden lengthening of the cord, or a sudden rise in position of the uterus. This usually occurs 5 to 10 minutes after delivery.

(2) Coach the mother to bear down after these placental separation signs are noted. Bearing down will promote delivery of the placenta.

(3) Massage the uterus immediately after delivery of the placenta to promote uterine contraction – in emergency settings.

(4) Encourage the patient to breast-feed or to stimulate nipples to promote release of oxytocin – in emergency settings.