Vaginal delivery explained

A vaginal delivery is the birth of offspring in mammals (babies in humans) through the vagina (also called the "birth canal").[1] It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, as it is correlated with lower morbidity and mortality than caesarean sections (C-sections),[2] though it is not clear whether this is causal.[3]

Epidemiology

United States

70% of births in the United States in 2019 were vaginal deliveries.[4]

Global

80% of births globally in 2021 were vaginal deliveries, with rates varying from 95% in sub-Saharan Africa to 45% in the Caribbean.[5]

Benefits of vaginal delivery

Mother

Benefits for the mother include

Infant

Benefits for the infant include:

Types of vaginal delivery

Different types of vaginal deliveries have different terms:

Stages of labor

Labor is characterized by uterine contractions which push the fetus through the birth canal and results in delivery.[14] Labor is divided into three stages.

  1. First stage of labor starts with the onset of contractions and finishes when the cervix is fully dilated at 10 cm. This stage can further be divided into latent and active labor. The latent phase is defined by cervical dilation of 0 to 6 cm. The active phase is defined by cervical dilation of 6 cm to 10 cm.
  2. Second stage of labor starts when the cervix is dilated to 10 cm and finishes with the birth of the baby. This stage is characterized by strong contractions and active pushing by the mother. It can last from 20 minutes to 2 hours.[15]
  3. Third stage of labor starts after the birth of the baby and is finished when the placenta is delivered. It can last from 5 to 30 minutes.

Risks and complications of vaginal delivery

Complications of vaginal delivery can be grouped into the following criteria; failure to progress, abnormal fetal heart rate tracing, intrapartum hemorrhage, and post-partum hemorrhage.

Failure to progress occurs when the labor process slows or stops entirely, indicated by slowed cervical dilation. Factors that place a woman's pregnancy at higher risk include advanced maternal age, Premature Rupture of Membranes (PROM) and induction of labor.[16] Pitocin, a synthetic version of oxytocin, is often administered to induce labour. Oxytocin is a natural hormone and a uterotonic agent which stimulates the uterine muscles to contract and initiate labour. [17] Caesarean section is also commonly considered when the pregnancy fails to progress.[18]

Abnormal fetal heart tracing suggests that the fetus's heart rate has slowed during labor due to head compression, cord compression, hypoxemia or anemia. Uterine tachysystole, the most common adverse effect of oxytocin (usually as a result of a problematic dosage), can result in nonreassuring fetal heart tracing. It can usually be reversed when oxytocin infusion is decreased or stopped.[19] If the abnormal fetal heart rate persists, and uterine tachysystole continues, tocolytic remedies, such as terbutaline, may be used. Afterward, if beneficial and uterine tone has returned to baseline and fetal status is stable, oxytocin as a labor augmenting agent may be resumed.[20] The persistence of an abnormal fetal heart rate may also indicate that a caesarean section is necessary.[21]

Intrapartum hemorrhage is characterized by the presence of copious blood during labor. The bleeding may be due to placental abruption, uterine rupture, placenta accrete, undiagnosed placenta previa, or vasa previa. Caesarean section is indicated.

Post-partum hemorrhage is defined by the loss of at least 1,000 mL of blood accompanied with symptoms of hypovolemia within 24 hours after delivery. Typically, the first symptom is excessive bleeding accompanied by tachycardia. Significant loss of blood may also result in hypotension, nausea, dyspnea, and chest pain.[22] It is estimated that between 3% and 5% of women giving birth vaginally will experience post-partum hemorrhage. Risk factors include fetal macrosomia, pre-eclampsia, and prolonged labor. Prevention consists of administering oxytocin (Pitocin) at delivery and early umbilical cord clamping.[23] Post-partum hemorrhage is usually attributed to uterus atony, when the uterus fails to contract after delivering the baby.[24]

As a result of discrepancies in diagnostic criteria and human variability, there is wide variation in data on maternal and fetal death associated with poor progress.[18]

More than 1 in 10 women with assisted vaginal births develop an infection.[25] Preventive antibiotics are recommended to women who have had an assisted vaginal birth by the World Health Organization.[26] An analysis has showed that preventive antibiotics reduce the risk of infection after an assisted vaginal birth, irrespective of whether a woman has had a perineal tear, an episiotomy, or both. Delays in receiving antibiotics also increases the risk of infection.[27] [28]

Contraindications to vaginal delivery

Spontaneous vaginal delivery at term is the preferred outcome of pregnancy, and according to the International Federation of Gynecology and Obstetrics, will be recommended if there are no evidence-based clinical indications for caesarean section.[29] However, there are some contraindications for vaginal delivery that would result in conversion to caesarean delivery. The decision to switch to caesarean delivery is made by the health care provider and mother and is sometimes delayed until the mother is in labor.

Breech birth presentations occur when the fetus's buttocks or lower extremities are poised to deliver before the fetus's upper extremities or head. The three types of breech positions are footling breech, frank breech, and complete breech. These births occur in 3% to 4% of all term pregnancies.[30] They usually result in caesarean sections because it is more difficult to deliver the baby through the birth canal and there is a lack of expertise in vaginal breech delivery and therefore fewer vaginal breech deliveries performed. It is also associated with cord prolapse and an elevated risk for birth defects in breech babies.[30] Controversy and debate surround the topic due to different views on the preferred route of delivery when breech presentation occurs.[30] [31] Some health professionals believe that vaginal breech delivery can be a safe alternative to planned caesarean in certain instances.[30]

Complete placenta previa occurs when the placenta covers the opening of the cervix. If placenta previa is present at the time of delivery, vaginal delivery is contraindicated because the placenta is blocking the fetus's passageway to the vaginal canal.

Herpes simplex virus with active genital lesions or prodromal symptoms is a contraindication for vaginal delivery so as to avoid mother-fetal transfer of HSV lesions.

Untreated human immunodeficiency virus (HIV) infection is a contraindication for vaginal delivery to avoid mother-fetal transfer of human immunodeficiency virus.[32]

See also

References

  1. Patterson DA, Winslow M, Matus CD . Spontaneous vaginal delivery . American Family Physician . 78 . 3 . 336–41 . August 2008 . 18711948 . 2021-08-30 . 2021-08-30 . https://web.archive.org/web/20210830172211/https://www.aafp.org/afp/2008/0801/p336.html . live .
  2. Book: Desai NM, Tsukerman A. Vaginal Delivery. 2021. http://www.ncbi.nlm.nih.gov/books/NBK559197/. StatPearls. Treasure Island (FL). StatPearls Publishing. 32644623. 2021-08-30. 2022-10-17. https://web.archive.org/web/20221017001320/https://www.ncbi.nlm.nih.gov/books/NBK559197/. live.
  3. Web site: Caesarean section for non-medical reasons at term . 2024-05-27 . www.cochrane.org . en.
  4. Web site: 2021-03-24. FastStats. 2021-08-30. www.cdc.gov. en-us. 2021-08-31. https://web.archive.org/web/20210831215610/https://www.cdc.gov/nchs/fastats/delivery.htm. live.
  5. Web site: Caesarean section rates continue to rise, amid growing inequalities in access: WHO. 2021-08-30. www.who.int. en. 2021-08-30. https://web.archive.org/web/20210830171528/https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-to-rise-amid-growing-inequalities-in-access-who. live.
  6. Gregory KD, Jackson S, Korst L, Fridman M . Cesarean versus vaginal delivery: whose risks? Whose benefits? . American Journal of Perinatology . 29 . 1 . 7–18 . January 2012 . 21833896 . 10.1055/s-0031-1285829 . 206322596 .
  7. Chapman DJ, Pérez-Escamilla R . Identification of risk factors for delayed onset of lactation . Journal of the American Dietetic Association . 99 . 4 . 450–4; quiz 455–6 . April 1999 . 10207398 . 10.1016/s0002-8223(99)00109-1 .
  8. Gurol-Urganci I, Cromwell DA, Edozien LC, Smith GC, Onwere C, Mahmood TA, Templeton A, van der Meulen JH . 6 . Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis . BMC Pregnancy and Childbirth . 11 . 1 . 95 . November 2011 . 22103697 . 3247856 . 10.1186/1471-2393-11-95 . free .
  9. Web site: Babies' gut bacteria affected by delivery method: Vaginal delivery promotes mother's gut bacteria in babies' gut . Wellcome Trust Sanger Institute . 18 September 2019 . ScienceDaily . 31 May 2022 . https://web.archive.org/web/20211124205102/www.sciencedaily.com/releases/2019/09/190918131447.htm . 24 November 2021. live.
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  11. Gunay T, Turgut A, Demircivi Bor E, Hocaoglu M . Comparison of maternal and fetal complications in pregnant women with breech presentation undergoing spontaneous or induced vaginal delivery, or cesarean delivery . Taiwanese Journal of Obstetrics & Gynecology . 59 . 3 . 392–397 . May 2020 . 32416886 . 10.1016/j.tjog.2020.03.010 . free .
  12. Verma. Ganga L.. Spalding. Jessica J.. Wilkinson. Marc D.. Hofmeyr. G. Justus. Vannevel. Valerie. O'Mahony. Fidelma. 2021-09-24. Instruments for assisted vaginal birth. The Cochrane Database of Systematic Reviews. 2021. 9. CD005455. 10.1002/14651858.CD005455.pub3. 1469-493X. 8462579. 34559884.
  13. Book: Wilson. John. Schnettler. William. Lubert. Adam. Veldtman. Gruschen. Girnius. Andrea. Maternal Cardiac Care A Guide to Managing Pregnant Women with Heart Disease. Elsevier Health Sciences. 2022. 978-0-323-82465-1. 1. 42. en. 6 - Obstetric Events That Affect Cardiac Patients. 2022-09-21. 2022-09-21. https://web.archive.org/web/20220921155525/https://www.elsevier.com/books/maternal-cardiac-care/wilson/978-0-323-82464-4. live.
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  17. Book: Husain. Tauqeer. Fernando. Roshan. Segal. Scott. Obstetric Anesthesiology An Illustrated Case-Based Approach. Cambridge University Press. 2019. 978-1-107-09564-9. 134. en. 25 - Uterotonic Use.
  18. Book: James. David. Steer. Philip . Weiner. Carl. Gonik. Bernard. Robson. Stephen. High-Risk Pregnancy: Management Options. Cambridge University Press. 2017. 978-1-108-42615-2. 2. 1750. en. 61.
  19. Book: Bienstock. Jessica. Fox. Harold. Wallach. Edward. Johnson. Clark. Hallock. Jennifer. Johns Hopkins Manual of Gynecology and Obstetrics. Lippincott Williams & Wilkins. 2015. 978-9-351-29590-7. 5. 140. en.
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  22. Evensen. Ann. Anderson. Janice M.. Fontaine. Patricia. 2017-04-01. Postpartum Hemorrhage: Prevention and Treatment. American Family Physician. 95. 7. 442–449. 28409600. 0002-838X. 2021-09-13. 2021-09-13. https://web.archive.org/web/20210913061949/https://www.aafp.org/afp/2017/0401/p442.html. live.
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  24. Ray. C. Le. Fraser. W.. Rozenberg. P.. Langer. B.. Subtil. D.. Goffinet. F.. 2011-10-01. Duration of passive and active phases of the second stage of labour and risk of severe postpartum haemorrhage in low-risk nulliparous women. European Journal of Obstetrics and Gynecology and Reproductive Biology. English. 158. 2. 167–172. 10.1016/j.ejogrb.2011.04.035. 0301-2115. 21640464. 659698 .
  25. Mohamed-Ahmed . Olaa . Hinshaw . Kim . Knight . Marian . 2019-04-01 . Operative vaginal delivery and post-partum infection . Best Practice & Research Clinical Obstetrics & Gynaecology . en . 56 . 93–106 . 10.1016/j.bpobgyn.2018.09.005 . 30992125 . 81098617 . 1521-6934.
  26. Book: World Health Organization . WHO recommendation on routine antibiotic prophylaxis for women undergoing operative vaginal birth . 2021 . World Health Organization . 10665/341862 . 978-92-4-002799-2 . en . 2023-05-26 . 2023-05-26 . https://web.archive.org/web/20230526130820/https://apps.who.int/iris/handle/10665/341862 . live .
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  29. Web site: International Federation Gynecology and Obstetrics . FIGO Ethics and Professionalism Guideline: Decision Making about Vaginal and Caesarean Delivery . 2021-09-12 . 2022-05-08 . https://web.archive.org/web/20220508160919/https://www.figo.org/sites/default/files/2020-06/FIGO%20Ethics%20and%20Professionalism%20Guideline_English.pdf . live .
  30. Book: Gray. Caron. Shanahan. Meaghan. Breech Presentation. StatPearls Publishing. 2022. 28846227. en. 2022-09-25. 2022-04-17. https://web.archive.org/web/20220417172352/https://www.ncbi.nlm.nih.gov/books/NBK448063/. live.
  31. Mattuizzi. A. [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. Gynecol Obstet Fertil Senol. January 2020. 48. 1. 70–80. 10.1016/j.gofs.2019.10.027. 31682966. 209270296. free.
  32. Patterson D, Winslow M, Matus C . Spontaneous Vaginal Delivery . American Family Physician . 78 . 3 . 336–341 . August 2008 . 18711948 .

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