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First vaginal delivery and episiotomy

There is a belief that an episiotomy is inevitable when a woman is having her first vaginal delivery. It is never wise to be dogmatic in these things.

The truth is, many, if not most first-timers will have an episiotomy, but there is a significant minority where this will be correctly judged to be unnecessary. It is up to the midwife or doctors assisting in the delivery to make that decision rather than hide behind a blanket policy. By the same token, some mothers who have had a previous baby may require an episiotomy.

With forceps delivery, an episiotomy is necessary, regardless of the number of past deliveries. This is because the risk of a tear is quite high with this method of instrumental delivery.

Panting at delivery to prevent brain damage

It is customary for the mother to be asked to pant or take repeated quick deep breaths just as the head of the baby is about to be deivered. The reason for this is the fact that the head is quite considerably compressed in the birth canal. Because the woman at this stage will be trying to get the baby out, there is a risk of sudden decompression of the head if the expulsion is forceful and sudden. Panting removes this risk, as the assisting person can gently ease the head out. Sudden decompression of the head carries a risk of causing brain injury.

Once the head is delivered, in most cases, another single push will help facilitate delivery of the shoulders. After that, the rest of the baby is eased out without the need of any maternal contribution. In fact, delivery of the shoulders does not necessarily require a uterine contraction

Shoulder dystocia

Shoulder dystocia is a difficult but fortunately rare complication of delivery. With a big baby, sometimes the head is delivered but the broad shoulders are stuck above the pelvic brim, with the neck stretched in the birth canal.

This complication requires quick action where the mother will be put in a special position, a large episiotomy (if not already there) is applied and special manipulations of the baby are made to facilitate delivery. This can be quite difficult and some bones may fracture as a result. Most vulnerable are the baby’s collarbones and the bone in the upper arm (humerus).

Shoulder dystocia and the maneuvers applied to deliver the baby could also lead to neurological injury (see picture above) which, in some cases, could be permanent. Every midwife and obstetrician is supposed to be well versed in how to deal with shoulder dystocia.

It is virtually impossible to predict shoulder dystocia. This topic is discussed in more detail on this section:

Third stage of labour: Next page

The classic position of the baby’s arm seen in Erb’s palsy. This is the commonest neurological complication of shoulder dystocia