Version June 2024
| 1. Call for help. The mother and the baby should each have at least one clinician caring for them. |
| 2. Briefly assess the mother to determine if delivery is imminent (baby's head is visible or distending the perineum). Ask her if there are obstetrical or medical problems of which you should be aware, such as twin gestation, preterm fetus, congenital anomalies, or maternal bleeding diathesis. |
| 3. Position the mother on pillows or towels so her hips are raised, flexed, and abducted. |
| 4. Use an antibacterial cleanser to clean your hands and the perineum. Put on gloves. |
| 5. Ask the mother to pant or make only modest expulsive efforts in an attempt to achieve a controlled delivery. |
| 6. Place one hand on the baby's head and apply gentle downward pressure to maintain it in a flexed position and keep it from popping out of the vagina, and use the other hand to ease the perineum over the baby's face. Don't pull on the head, let the mother gradually push it into your hands. |
| 7. Feel for a loop of umbilical cord around the baby's neck. If present, gently slip it over the head. If it resists, either doubly clamp and cut it or leave it alone. |
| 8. With the next push, guide the head slightly downward so that the anterior shoulder slips under the symphysis pubis and delivers, then guide the head slightly upward to deliver the posterior shoulder over, rather than through, the perineum. Once both shoulders have delivered, the rest of the baby immediately follows. |
| 9. The mouth and nose should be wiped out with a clean cloth. There is no strong evidence that routine suctioning with a bulb or catheter is beneficial. However, if the infant appears to have an airway obstruction, use a bulb to gently suction the mouth first (avoid the posterior pharynx) and then the nose. The mouth is cleared first so its contents are not aspirated if the newborn gasps when the nose is suctioned. Do not raise the baby higher than the mother's abdomen to avoid backflow of blood into the placenta. |
| 10. Doubly clamp the umbilical cord and cut between the clamps. |
| 11. Dry the baby to reduce heat loss. Keep the baby warm by swaddling in warm towels/blankets, providing "skin to skin" contact with the mother, and keeping the room temperature warm. |
| 12. The three classic signs of placental separation are (1) lengthening of the umbilical cord, (2) a gush of blood from the vagina signifying separation of the placenta from the uterine wall, and (3) change in the shape of the uterine fundus from discoid to globular with elevation of the fundal height. Placental separation occurs naturally, usually within 5 minutes of delivery, although intervals of 30 to 60 minutes are reasonable if bleeding is not profuse. Controlled cord traction can be helpful, with counter traction applied over the woman's pubic symphysis. |
| If the placenta is not expelled naturally, ask the mother to bear down and gently tug on the umbilical cord to deliver it. Place a hand on the abdomen to secure the uterine fundus to prevent uterine inversion. The postpartum fundus is palpable as a soft or firm mass at about the level of the umbilicus. |
| 13. After placental expulsion, massage the uterine fundus to help it contract into a firm globular mass. A flabby fundus suggests atony, which is the most common cause of postpartum hemorrhage. |
| 14. Administer oxytocin (20 units in 500 mL saline over one hour or 10 units intramuscularly). |
| 15. Inspect the perineum for lacerations. Deep lacerations should be evaluated and treated by an obstetrician. Apply pressure to lacerations that are bleeding briskly until these lacerations can be repaired. |
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