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Management of Spontaneous Vaginal Delivery

Kathryn A. McKenna, MD, MPH
Laura Leaman, MD

American Family Physician. 2024;109(6):525-532.

Author disclosure: No relevant financial relationships.

Pregnancy dating is determined by the patient's last menstrual period or an ultrasound measurement. A full-term pregnancy is considered 37 weeks' gestation or more. Spontaneous labor begins when regular painful uterine contractions result in a cervical change. Active labor begins at 6 cm dilation and is marked by more predictable, accelerated cervical change. In the absence of pregnancy complications, intermittent fetal auscultation may be considered as an alternative to continuous electronic fetal monitoring, which is associated with a high false-positive rate. Intravenous antibiotic prophylaxis is indicated in patients with group B streptococcus colonization or those at high risk to prevent newborn early-onset group B streptococcus. The likelihood of vaginal delivery is increased by providing continuous nonmedical support during labor, encouraging mobility, and using a peanut ball with epidural analgesia. Neuraxial analgesia is more effective for pain control than systemic opioids and is associated with fewer adverse effects. Delayed pushing during the second stage of labor has risks but does not affect the mode of delivery. Routine oropharyngeal suctioning of the newborn is not recommended, even with meconium-stained amniotic fluid. Delayed cord clamping reduces newborn anemia. Prevention of postpartum hemorrhage in patients at risk includes prophylactic uterotonic administration and controlled cord traction. Perineal lacerations that alter anatomy or are not hemostatic should be repaired. (Am Fam Physician. 2024;109(6):525-532. Copyright © 2024 American Academy of Family Physicians.)

Approximately 2.5 million infants were born via spontaneous vaginal delivery in the United States in 2021.1 The estimated due date of a pregnancy is 40 weeks after the first day of the patient's last menstrual period; a full-term pregnancy is considered 37 weeks' gestation or more.2 Pregnancy dating can be confirmed by an ultrasound measurement of the fetal crown-rump length early in the first trimester. Ultrasound dating should be used for irregular or unknown menstrual timing or a significant discrepancy between menstrual and ultrasound dating (Table 1).2 Accurate dating guides surveillance and management, including the timing of medically indicated delivery when needed.3

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Do not routinely admit patients who are full-term and in uncomplicated labor before active labor begins when patient and fetal status is reassuring and accelerated dilation is expected (often starting at 6 cm dilation).13,17 C Consensus guidelines
Continuous nonmedical support during labor from a hospital staff member, doula, or personal companion is recommended to shorten the first stage of labor and increase the chance of vaginal delivery.18,19 B Randomized controlled trials that were limited by lower-quality evidence
Consider intermittent auscultation in place of continuous electronic fetal monitoring in low-risk pregnancies. Continuous electronic fetal monitoring improves recognition of fetal hypoxia but has a high false-positive rate and may increase unnecessary interventions.17,30–32 C Consensus guidelines
Patients with GBS colonization on a universal 36-week screening culture, GBS bacteriuria during the pregnancy, a history of a newborn with GBS infection, or unknown GBS status in those at risk of GBS early-onset disease should receive intravenous antibiotic prophylaxis during labor to decrease the risk of GBS early-onset disease in the newborn. Antibiotic prophylaxis should be initiated in active labor or after premature rupture of membranes, with a goal of at least 4 hours before delivery.33–35 B Consensus guideline and consistent findings from cohort studies
Immediate pushing in nulliparous patients with epidural analgesia is recommended. Immediate pushing does not affect the mode of delivery, and risks of delayed pushing include small increases in infection, hemorrhage, and neonatal acidemia.52,53 B Patient-oriented evidence from lower-quality randomized controlled trials and a systematic review
Do not routinely perform nasal, oral, or oropharyngeal suctioning at the perineum, even with meconium-stained amniotic fluid. Suctioning does not prevent meconium aspiration syndrome or improve outcomes.62,63 B Large multicenter randomized controlled trial and expert guideline
Delayed clamping of the umbilical cord for at least 30 to 60 seconds after delivery of a stable newborn reduces newborn anemia while slightly increasing the risk of hyperbilirubinemia and polycythemia.63–65 B Limited-quality patient-oriented evidence from randomized controlled trials, meta-analyses, and expert guideline
Administer prophylactic uterotonics and provide controlled cord traction for active management of the third stage of labor to prevent postpartum hemorrhage in patients at risk of bleeding.66–71 B Limited-quality patient-oriented evidence from randomized controlled trials, meta-analyses, and practice guidelines

GBS = group B streptococcus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

KATHRYN A. MCKENNA, MD, MPH, is associate director of the Penn Medicine Lancaster (Penn.) General Health Family Medicine Residency Program.

LAURA LEAMAN, MD, is associate director of the Penn Medicine Lancaster General Health Family Medicine Residency Program.

Address correspondence to Kathryn A. McKenna MD, MPH, Lancaster General Health Family Medicine Residency Program, 540 N. Duke St., 3rd Floor, Lancaster, PA 17604 (kathryn.mckenna@pennmedicine.upenn.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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