are said to have a normal delivery if you deliver
your child vaginally at full term, with the baby’s
head coming first, without any instrumentation.
Episiotomy is considered to be normal.Even twins are
considered to be abnormal-medically speaking .Though
in layman's term a normal delivery is
In Normal Position
every woman experiences a text book pattern of
delivery. You may have variations in the course
of labour. Inspite of these variations you may
have safe delivery and a healthy baby.
The variations are:
in the time of labour.
in the positions of the baby.
in conducting the vaginal delivery (operative
word ‘difficult labour’ or ‘dystocia’ suggests
that labour has failed to progress normally and
is causing difficulties for you and your baby.
Delayed progress of labour can be due to various
the labour doesn’t complete within-18 hours in
case of the first time pregnant woman and 12 hours in case
of those who have had a prior delivery,it is considered
of prolonged labour:
causing delayed progress of labour are:
- Inadequate intensity
and frequency of uterine contractions.
of the uterus (in cases like twins or large
- The position of
the baby in your uterus is not favorable.
- Pelvis is not
adequate for the passage of the baby’s head.
Caesarean section is a best option .
- Some medications have been
given to you for pain relief or to decrease
the perception of contractions (epidural anaesthesia)
These sometimes have an effect of prolonging
labour, particularly the second stage.
This difficulty in progress of labour may lead
- Increased post
- Increased chances
of trauma to the genital tract.
Your doctor will
do the following things.
- Try and rule out the different causes of
- Assess your condition
by checking your pulse, blood pressure, uterine
activity and cervical dilatation.
Assess your baby’s
hasten the process of labour your doctor might
adopt various measures.
- Rupture the membrane.
- To augment the labour.
- To see the colour of the amniotic fluid.
intravenous drip of oxytocin if needed after
ruling out inadequacy of pelvis.
- Give antibiotics to prevent infections.
- Your doctor may
consider operative vaginal delivery by the
forceps or vacuum .
- May consider caesarean
section, if no satisfactory progress in cervical
dilatation / descent of the head of the baby/
any irregularities in your baby’s heart rate
suggestive of foetal condition being compromised.
Your baby is said to be in a normal position
if it is facing toward the mother’s back with
the face angled toward the right or left, and
upside down with the head coming first (vertex
presentation), with the neck bent forward, chin
tucked in and arms folded across the chest. Any
variation from this position makes your baby’s
journey through the birth canal difficult, sometimes
hazardous and occasionally impossible. Hence known
Causes of Malpresentations:
lead to malpresentations such as:
Multiple pregnancy.i.e twins,triplets etc.
Excessive / less amount of amniotic fluid
in the uterine.
Some congenital abnormalities in the baby.
Any abnormality of the uterus.
Occipito posterior position.(Back labour)
the buttocks of your baby is the presenting part
(i.e. the 1st part of your baby to
be delivered) your baby is in a breech presentation.
change in position
most cases, the breech detected earlier in the
pregnancy spontaneously turns to the head down
position as the pregnancy progresses.
Your doctor can confirm the position of the baby
by an abdominal examination / USG.
spontaneous change of position of breech does
not occur in and may persist as breech in:
- Breech baby with extended legs.
- Less amount of amniotic fluid.
- Any abnormality of the uterus.
in vaginal deliveries
- Trauma to your genital tract.
- If the umbilical cord gets compressed after
the delivery of the buttocks, but before the
head delivers out, then there may be decreased
supply of oxygen to your baby.
- There may be some injuries to baby while
delivering despite best care by your
- Excessive pull on the neck while the head
is being delivered out.
vaginal delivery, the buttock comes out early
as they are easily compressible. But the after
coming head being hard and less compressible may
(occasionally) get stuck at the outlet of the birth canal
such head can be removed by using forceps .
of breech position:
IF near full term,
the position of the baby is breech, your doctor
can change the position of the baby to head down
by the maneuver called ‘external cephalic version'
The procedure is not done if:
- You are having marked increased in blood
- Previous births by caesarean section .
- Your pelvis is not adequate for the passage
of your baby’s head.
- Your baby’s head is hyper-extended, i.e.
the back of head touches the back of the
- You are having any malformation of uterus
or fibroids or other problems in the birth
- If you have previous pre-term delivery or
the placenta is low lying .
admission to the hospital :
doctor will examine you and will monitor your
uterine contractions, your progress of labour
and your baby’s condition and decide about the
mode of delivery.
time pregnant woman) the
vaginal delivery of breech is difficult because
the mother’s birth canal has not been stretched
by a previous delivery. In such cases, caesarean
section gives the option of well-planned delivery,
under controlled conditions. Although, the delivery
maneuver is the same, it is done under anaesthesia
as an ‘open’ procedure. Hence, it is easier to
handle any difficulties in the delivery of your
multigravidas ( women
who have delivered a child before ) vaginal
delivery can be considered as a good option before
going for a caesarean section.
a must in cases like;
- Large baby
- Suspicion of an inadequacy of the pelvis.
- Prolonged labour
- Baby with intrauterine growth retardation.
- Previous caesarean section.
- Oligohydramnios (less aminiotic fluid)
- Pre-term labour.
- Other associated complications like placenta
praevia, hypertension in pregnancy.
However it is a question of personal choice
as risks of vaginal
breech delivery cannot be completely
ruled out. So the doctor will be the right person
to guide you. The aim is to have a safe birth
for you and your baby, regardless of the route
This is a rare variety of presentations of your
baby in which there is complete extension of your
baby’s head almost touching to the back. In this
case, the baby's face is delivered first rather
than the top of the head.
of face presentations:
- Lax and pendulous abdomen due to multiple
- Pelvis is inadequate or flat.
- Congetial malformations of the baby
such as cysts in the neck, thyroid problem.
- Increased tone of the baby's muscles present
at the back of its neck.
- Loops of cord around the neck.
admission to the hospital:
of the face presentation is usually made at the
time of labour. It can only be suspected on abdominal
Your doctor will do your internal examination
- Feel the mouth,
nose, cheekbone and chin of your baby thus confirming
if your baby is in a face presentation.
- Check for the adequacy of the pelvis.
will also rule out associated complicating factors like increased blood pressure,
post caesarean pregnancy, post caesarean pregnancy,
post maturity etc.
confirm the diagnosis USG can be done if available.
In case of emergency an X-ray of your abdomen
may be required.
can also help:
- To exclude bony congenital malformation
of the baby.
- To note the size of the baby.
doctor is the best person to decide the mode of
delivery. i.e. either by vaginal delivery or by
a caesarean section
caesarean section is done in cases of:
- Inadequacy of your pelvis.
- Big baby. .
- Associated complicating factors.
- A chance of umbilical cord coming out first
- Prolonged labour
- Injury to the birth canal.
- Excessive post partum bleeding.
your baby’s neck is moderately arched so that
the brow presents first i.e. the head lies in
between the normal position and the face presentation.
This is a very rare type of presentation, commonly
unstable and converts to either the normal position
or the face presentation.
admission to the hospital:
Similar to the face presentation, the diagnosis
of the brow presentation is made at the time of
the delivery.This position is confirmed by your
internal examination and USG.
Your doctor will do an internal examination to:
- Confirm the brow presentation.
- Check for the adequacy of your pelvis.
doctor will rule out any associated complicating
a while your doctor may observe the progress of
labour. If your baby spontaneously converts to
the face presentation or the normal position,
vaginal delivery is possible. Caesarean section
is the best option for the persistent brow presentation
associated with complicating factors.
When baby’s spine lies perpendicular to your
spine, it is called as transverse lie.
the baby’s spine is placed oblique to the maternal
spine. This is known as ‘oblique lie’.
uterus with transverse lie.
oblique lie, if the head of the baby is above
the navel of the baby then during labour this
position is mostly changed to the breech position.
with oblique lie
Causes of transverse and oblique lies
- Lax and pendulous abdomen.
- Twins – more common for the 2nd
- Excessive amniotic fluid.
- Inadequate pelvis.
- Pelvic tumours like fibroids, ovarian cysts.
- Congenital malformation of the uterus like
both the transverse and oblique lie, commonly
during the delivery the shoulder comes first and
is known as shoulder presentation
(Occipito Posterior Position):
the baby lies facing the mother’s spine in an
upside down position.In occipito posterior type
of malpresentation, the baby faces infront, with
its back towards the mother’s side (right / left)
doctor will do an internal examination to confirm
the occipito posterior position and to check for
the adequacy of pelvis.
Diagram of structure felt
on internal exam:
also rule out other risk factors, which will need
a caesarean section like:
posterior per say does not require a caesarean
section.Vaginal delivery may be opted but a careful
watch has to be kept.A liberal episiotomy may
be required. There may be a slight delay. In most
cases delivery is spontaneous. In other few cases
forceps / vacuum may be required.
Caesarean section is opted in cases of:
more than one foetus simultaneously develops in
the uterus, it is called multiple pregnancy. The
most commonly seen type of multiple pregnancy
is the twin pregnancy. I.e. two babies in the
uterus. Rarely, development of three foetuses
(triplets) four foetuses (quadruplets) may also
Identical (maternal) twins are
the result of a single ovum fertilised by a single
sperm, which later divides in 2 separate cells.
These form 2 different foetus. Both foetuses have
same placenta, same sex and look similar.
Identical (fraternal) twins are the result of
2 eggs being fertilized by 2 different sperms
at the same time. Each foetus has its own placenta.
The sex of the babies may differ / may be same,
depending on the sperm.
factors related to twin pregnancy are:
Advancing age of mother, between 30 – 35
Family history of twins from the maternal
Drugs used for induction of ovulation in
infertility cases e.g. Gonadotriophin therapy
H/O ovulation inducing drugs for infertility.
Family h/o twinning.
The symptoms of normal pregnancy are exaggerated.
Increase nausea and vomiting in early months
Increase chances of swelling of the legs
Unusual enlargement of abdomen
Excessive foetal movements.
Increased weight gain as there are 2 babies
growing in the uterus.
Your doctor can also locate two separate
spots with two distinct heart sounds.
Sonography is the best investigation to
show about the twin pregnancy.
management of twins:
Increased dietary intake of 300 Calories more
than in a normal pregnancy (600 Calories more
than pre-pregnancy diet
of Iron, folic acid other vitamins, Calcium
Avoid excessive physical strains.
Antenatal visits should be more frequent.
depends on the position of the foetuses in the
If both the babies are lifting vertically
in the uterus a vaginal delivery may be possible.
If both are in a transverse
/ oblique lie ,
a caesarean section
is a must.
If one is vertical and other is transverse
than your doctor will be a better person to
judge and decide the mode of delivery.
Forceps and Vacuum
Forceps and vacuum
extractors are used to assist the mother to deliver
her baby in certain cases when spontaneous birth
is not possible.
Common indications include:
- Prolonged second stage.
- Maternal exhaustion (pulse, respiratory,
temperature elevated, too tired to push).
- Foetal distress (irregular heart beat, meconium
in amniotic fluid).
- Mother unable
to push (e.g. under epidural anaesthesia, suffering
from respiratory or cardiac disease).
are twin steel blades that are placed in the vagina
and secured on either side of the baby's head.
The blades are locked and the doctor pulls until
the head is delivered.
The forceps that is in use in modern day obstetrics
is the low or outlet forceps. There are certain
pre-requisites required before the use of forceps,
the main being that the head of the baby is almost
fully rotated, the scalp is easily visible, the
cervix is fully dilated, and the mother’s urinary
bladder is empty.
Vacuum extractor (or ventouse) is a cup made
of steel or a soft flexible plastic cup. It is
attached to a suction device to help pull out
the baby. The vacuum extractor is placed on the
top of the baby's head and the suction is activated.
With activation of the suction, the scalp of the
baby is sucked into the cup helping in creating
traction. The doctor then pulls and during pulling
if the head is not rotated, it will spontaneously
rotate till the head is born. The vacuum extractor
can also be applied to an un-rotated head, which
is more commonly done.
both of these instruments, mothers may very well
need an episiotomy to facilitate insertion of the instrument.
the past ‘forceps’ was thought to be a fairly
dangerous or risky procedure.In today’s obstetric
practice, the forceps is used to facilitate easy
delivery of the head of the baby.
Risks of the vacuum extractor to the baby
are less than forceps. Complications occur much
less often with the vacuum extractor than with
and Vacuum for epidural anaesthesia
anaesthesia may interfere with your ability to
push your baby out. So in case you have been given
an epidural anaesthesia there are chances of application
of forceps or vacuum even though you do not have
any medical indications.
Another rare occasion where instrument delivery
is required is when the mother has an established
heart disease and the exertion of pushing and
exhaustion may lead to a further reduction of
the efficiency of the heart.
Your doctor will discuss the procedure with you
if it is required. In experinced
person's hands, the risks are minimum.