Normal Delivery

Part of Midwifery and Childbirth

Step-by-step management of the second and third stages of labor — from full dilation to delivery of the placenta.

Why This Matters

The moment of birth is simultaneously the most dangerous moment in a woman’s obstetric journey and the moment where a skilled attendant’s presence makes the most difference. Across human history, unattended or poorly attended births have caused the majority of maternal and neonatal deaths. The risks are real: uncontrolled hemorrhage from perineal tears, oxygen deprivation in a baby whose cord is wrapped around its neck, a retained placenta that causes fatal bleeding hours after a successful delivery.

The encouraging truth is that the vast majority of normal deliveries require remarkably little active intervention. The uterus and the birth canal evolved over millions of years to accomplish this task. A competent attendant’s primary role is to observe carefully, support the mother, detect abnormalities early, and intervene precisely when necessary — not to rush or direct a process that usually proceeds best when undisturbed.

This article covers normal (vertex, head-first) presentation deliveries in a woman with no complications. Abnormal presentations, multiple pregnancies, and complicated labors require additional skills beyond what is described here.

Setting Up for Delivery

Preparation before the critical moment prevents scrambling during it. Everything needed should be within reach before the second stage begins.

Environment:

• Birth surface at a comfortable height (floor level or bed — whatever allows good access and support)
• Good lighting — natural daylight is ideal; a bright lamp positioned over the perineum for nighttime
• Warm room; drafts blocked
• Clean cloths and blankets warming if possible

Equipment (prepared and within reach):

• Two clean cord ties (boiled string or commercial clamps)
• Sterilized scissors for cord cutting
• Clean cloths for drying and wrapping the baby
• Hat for the baby’s head
• Basin for the placenta
• Clean gloves if available
• Bowl of clean water for handwashing
• Towels for perineal support

Position review: Position the mother for delivery based on her comfort and your ability to monitor and assist. No single position is ideal for all women.

Position	Advantages	Disadvantages
Semi-recumbent (back at 45°)	Good visibility; familiar	Can slow labor; more perineal tears
Left lateral (on side)	Less perineal tearing; good for tired mothers	Limited visibility for attendant
All fours (hands and knees)	Reduces back pain; helps large babies	Limited attendant access
Upright/squatting	Gravity assists; wider pelvic outlet	Attendant must be below; tiring
Water (tub or basin)	Pain relief; perineal softening	Requires clean water; harder to monitor

Second Stage: Pushing and Descent

The second stage begins when the cervix reaches full dilation (10 cm) and ends with delivery of the baby. In first-time mothers, this stage typically lasts 1-2 hours. In subsequent births, it may be as short as 15-30 minutes.

Recognizing transition to second stage:

• Mother feels an overwhelming urge to push, often described as the most intense pressure she has ever felt
• Involuntary pushing efforts — she may grunt and bear down without conscious decision
• Visible perineal bulging with pushing efforts
• If performing internal assessment: no cervical lip palpable; baby’s head low in the birth canal

Supporting effective pushing: Many modern obstetric practices involving coached “purple pushing” (forcing 10-second breath-holds while pushing) have been abandoned. Physiological pushing — following the woman’s own urge — produces better outcomes.

• Encourage the mother to follow her body’s urges
• Some women push best when making sound — do not suppress grunting or vocalizing
• Between contractions, encourage complete rest
• Breathing is more important than silence — hyperventilation from panic breathing will cause faintness

Monitoring during second stage:

• Listen to fetal heart rate (fetoscope or ear against abdomen) between every 2-3 contractions
• Normal range: 110-160 bpm. Check for at least 30 seconds immediately after a contraction
• A rate below 100 or above 180 sustained after the contraction ends is abnormal
• Monitor progress: the baby should be descending with each series of pushes. No descent after 60 minutes of active pushing in a second-time mother, or 120 minutes in a first-time mother, is abnormal

Crowning: When the widest part of the baby’s head becomes visible at the vaginal opening with a pushing effort and does not fully retract between contractions, crowning is imminent. This is often accompanied by intense burning or stinging as the tissues stretch.

• Inform the mother that this sensation is normal
• Ask her to pant (short, shallow breaths) rather than push hard during crowning — this slows the final delivery and reduces the force of head emergence, giving the perineum time to stretch rather than tear
• Apply gentle counterpressure with your palm against the baby’s head if it is emerging very rapidly — not to stop delivery, but to control the speed

Delivering the Head and Shoulders

Head delivery: Once the head emerges, keep your hands near but do not pull. Allow the head to be delivered by the mother’s expulsive efforts.

1. As the head emerges, feel along the baby’s neck with two fingers for the umbilical cord
2. If the cord is loosely draped around the neck, gently slip it over the head — this is common and is not an emergency
3. If the cord is tight around the neck: a loose cord can be pulled through and over the head, but if too tight to slip over, the baby must be delivered through the loop — keep shoulders close to the chest and deliver the body while the cord remains around the neck, then immediately unwrap

Restitution: After the head is delivered, it will rotate spontaneously to face one of the mother’s inner thighs — this is called restitution, and it is normal and automatic. Do not attempt to turn the head.

External rotation and shoulder delivery: After restitution, the shoulders align with the birth canal and descend. Delivery of the shoulders follows within 1-2 contractions.

1. Place hands on either side of the baby’s head — do not pull on the head
2. With the next contraction and pushing effort, apply gentle downward traction (toward the floor) to deliver the upper shoulder from under the pubic bone
3. Once the upper shoulder is free, apply gentle upward traction to deliver the lower shoulder
4. After both shoulders are delivered, the body follows rapidly — support it as it slides out

Shoulder Dystocia

If the head delivers but the shoulders do not follow with the next one or two contractions, suspect shoulder dystocia — the upper shoulder is impacted behind the pubic bone. This is an emergency. Do not pull on the head. Immediately position the mother in the McRoberts position (flat on back, legs pulled far back toward the chest by assistants). Apply suprapubic pressure (not fundal pressure) with the heel of one hand above the pubic bone, pressing the impacted shoulder downward. If this fails, try rotating the baby’s shoulders or delivering the posterior arm first. Shoulder dystocia can cause brain damage or death within minutes.

Immediate Post-Delivery Care

First 60 seconds:

1. Note the time of birth
2. Call out the baby’s condition — is it crying, breathing, good color and tone?
3. Place the baby on the mother’s bare abdomen or chest
4. Dry vigorously with a warm cloth — remove the wet cloth and replace with dry
5. Leave the cord unclamped for 1-2 minutes (delayed cord clamping)
6. Assess the baby using the APGAR framework

Cord clamping and cutting: After 1-2 minutes, or when cord pulsation has stopped:

1. Place first tie 2-3 cm from the baby’s abdomen
2. Place second tie 5 cm from the baby
3. Cut between ties with sterilized scissors
4. Place the baby on the mother’s breast for skin-to-skin contact

Third Stage: Placental Delivery

The third stage — delivery of the placenta — carries the highest risk of the entire birth process. Postpartum hemorrhage (excessive bleeding after delivery) causes 25% of all maternal deaths globally, and most cases involve the third stage.

Wait time: The placenta normally delivers within 5-30 minutes after the baby. Do not attempt to manually remove the placenta during this time — the uterus is contracting and the placental site is sealing.

Signs that the placenta is ready to deliver:

• A gush of blood from the vagina
• The umbilical cord appears to lengthen (placenta moving down)
• The uterus changes shape from discoid to globular
• The mother may feel a new urge to push

Delivering the placenta:

1. Ask the mother to push — gravity and her efforts are usually sufficient
2. Do not pull on the cord — traction before the placenta has separated can invert the uterus (a catastrophic emergency)
3. If the mother cannot push effectively, support the delivery by asking her to squat or by applying gentle controlled cord traction while simultaneously pressing the uterus upward (Brandt-Andrews technique)
4. Receive the placenta in a basin — keep it for inspection

Placental inspection: Examine the placenta after delivery. It should be complete — any retained fragments will cause ongoing hemorrhage.

• Maternal surface (rough, lobulated, dark red): Run a hand over all lobes — should feel complete
• Fetal surface (smooth, shiny, with cord insertion): Inspect membranes — the rupture point should be identifiable; membranes should be intact
• Count the cord vessels: 2 arteries and 1 vein

Uterine massage: After placental delivery, immediately feel the uterus through the abdomen. It should be firm (like a grapefruit) at the level of the umbilicus. If it feels soft and boggy:

1. Massage the fundus firmly with a circular motion until it firms up
2. A soft uterus is not contracting — this is the leading cause of postpartum hemorrhage
3. Encourage breastfeeding — infant suckling releases oxytocin, which contracts the uterus

Normal blood loss: Up to 500 mL of blood loss is considered normal after delivery. This can appear alarming (a half-liter of bright red blood) but is physiologically normal if the uterus is firm. Blood loss exceeding 500 mL (enough to soak through multiple thick cloths), especially with a soft uterus, is postpartum hemorrhage requiring immediate action.

Perineal Assessment

After placental delivery, inspect the perineum for tears.

Tear classification:

• First degree: Skin only — usually heals without suturing
• Second degree: Skin and muscle — generally requires suturing
• Third degree: Extends to the anal sphincter — requires careful repair
• Fourth degree: Through the anal sphincter into the rectum — difficult to repair without surgical expertise

If suturing is indicated:

• Use clean technique, boiled instruments, and suture material stored in antiseptic
• Approximate the wound edges without excessive tension
• Begin with the deepest layer and work outward
• A clean wound approximated immediately after delivery heals far better than one left open

The normal delivery, managed attentively and with respect for physiological processes, results in a healthy mother and newborn in the vast majority of cases. The attendant’s greatest skill is knowing when to act and when to wait.