Normal Spontaneous Delivery — Independent Conduct & Hands-On Technique - Concept Map
Independent Management of Normal Spontaneous Vaginal Delivery by the Midwife
Related concepts
Mechanisms of Labor — Cardinal Movements
Sub concepts
- Engagement — biparietal diameter passes pelvic inlet
- Descent — downward movement throughout labor
- Flexion — chin tucks to present smallest diameter (suboccipitobregmatic ~9.5 cm)
- Internal rotation — occiput rotates anteriorly toward symphysis pubis
- Extension — head extends under pubic arch (how the head is actually born)
- External rotation (restitution) — head realigns with shoulders after birth
- Expulsion — anterior shoulder, posterior shoulder, and body delivered
Relationship to central
Foundation for understanding normal descent and recognizing when the delivery is progressing appropriately
Pre-Delivery Preparation and Readiness
Sub concepts
- Confirm full dilation (10 cm) and station before allowing pushing
- Assess readiness: perineum distends, does not recede between contractions, anus gapes
- Prepare newborn corner with clean, dry, warm surface and two clean cloths
- Ensure oxytocin and delivery set within reach
- Empty bladder if distended
- Hand hygiene and sterile glove application
Relationship to central
Essential steps that ensure safe, clean, and organized delivery environment aligned with EINC standards
Maternal Positioning and Second-Stage Management
Sub concepts
- Allow mother to choose comfortable position: upright, semi-sitting, squatting, side-lying, semi-recumbent
- Avoid routine flat lithotomy position
- Encourage gentle, spontaneous pushing with contractions
- Avoid prolonged, forceful breath-holding (Valsalva)
- Between contractions: ask mother to pant/breathe rather than push
- Ensure perineum is visible and accessible to midwife
Relationship to central
Optimizes labor progression, uses gravity, reduces complications, and respects maternal choice
Controlled Delivery of the Head and Perineal Support
Sub concepts
- Apply gentle pressure on occiput to keep head flexed and slowly advancing
- Use Ritgen maneuver: support perineum with clean pad while head extends
- Guard tissue as head is delivered
- Support perineum throughout to reduce 3rd and 4th-degree tears
- Routine episiotomy is NOT performed
- Episiotomy only on clear indication: imminent severe tear, fetal distress, some assisted deliveries
Relationship to central
The single most important skill in preventing perineal trauma and intracranial injury
Nuchal Cord Management and Face Clearing
Sub concepts
- Feel gently around newborn's neck for nuchal cord
- If loose: slip over head
- If tight: attempt somersault maneuver (keep baby close to perineum, deliver through loop)
- Only clamp and cut tight cord if impossible to loosen
- Protects placental transfusion by avoiding early cord cutting
- Wipe face with clean cloth
- Routine suctioning of mouth/nose NOT done for baby with clear liquor who is crying/breathing
Relationship to central
Safety check after head delivery to prevent complications and follow EINC guidelines on unnecessary interventions
Delivery of Shoulders and Body
Sub concepts
- Apply gentle downward traction with next contraction to deliver anterior shoulder
- Apply gentle upward traction to deliver posterior shoulder over perineum
- Support perineum throughout
- Deliver body slowly with firm but gentle grasp
- Note and announce time of birth
- Place newborn prone on mother's abdomen/chest (skin-to-skin)
- Begin immediate and thorough drying (EINC step 1)
- Never apply fundal pressure to deliver baby
Relationship to central
Completes the expulsion phase of labor with proper traction and handling
Active Management of Third Stage of Labor (AMTSL)
Sub concepts
- Component 1: Uterotonic (Oxytocin)
- Component 2: Controlled Cord Traction (Brandt-Andrews Maneuver)
- Component 3: Uterine Massage
- Rule out second baby BEFORE giving uterotonic
- Oxytocin 10 IU IM within one minute of baby's birth
- Oxytocin is drug of choice — effective, few side effects, safe in hypertension
Relationship to central
Evidence-based standard for preventing postpartum hemorrhage and a defining midwifery competency
Uterotonic Selection and Dosing
Sub concepts
- First choice: Oxytocin 10 IU IM
- Alternative 1: Misoprostol 600 mcg orally (if oxytocin unavailable)
- Alternative 2: Ergometrine/methylergometrine 0.2 mg IM
- Ergometrine CONTRAINDICATED in hypertension and pre-eclampsia
- Oxytocin safe in hypertension
- Give within one minute of baby's birth for effectiveness
Relationship to central
Critical pharmacological component of AMTSL with specific contraindications in high-risk conditions
Controlled Cord Traction and Brandt-Andrews Maneuver
Sub concepts
- Wait for strong uterine contraction
- Wait for signs of placental separation: gush of blood, cord lengthening, uterus becomes globular and rises
- Apply counter-traction on uterus above symphysis pubis (prevent inversion)
- Apply steady, gentle downward traction on cord in direction of birth canal
- If placenta does not descend in 30-40 seconds, STOP
- Wait for next contraction and repeat
- Never yank the cord
- Deliver placenta with both hands
- Gently twist membranes into rope so they peel out intact
Relationship to central
Technique for efficient, safe placental delivery that prevents uterine inversion
Uterine Massage and Postpartum Monitoring
Sub concepts
- Massage uterine fundus immediately after placenta delivery until firm and well-contracted
- Check fundus every 15 minutes for first 2 hours postpartum
- Teach mother to feel and massage her own fundus
- Monitor vital signs every 15 minutes for first 2 hours
- Monitor lochia amount and character
- Highest-risk window for hemorrhage: immediate postpartum period
- Sustained uterine tone and early oxytocin prevent hemorrhage
Relationship to central
Maintains uterine contraction to control bleeding and monitors for hemorrhage warning signs
Placental Inspection and Completeness Assessment
Sub concepts
- Inspect maternal (cotyledon) side: confirm all cotyledons present, none missing
- Inspect fetal (shiny) side: trace vessels
- Suspect succenturiate (accessory) lobe if vessel runs to membrane edge and stops
- Check membranes: confirm amnion and chorion complete
- Count cord vessels: normal = 2 arteries and 1 vein
- Estimate and record blood loss
- If doubt about completeness: treat as retained tissue and REFER
Relationship to central
Systematic evaluation ensures retained fragments are detected and appropriate referral made
Immediate Postpartum Maternal Care
Sub concepts
- Inspect perineum, vagina, and cervix for lacerations and bleeding
- Keep uterus contracted: massage, empty bladder, encourage breastfeeding
- Monitor vital signs regularly
- Monitor fundal tone and lochia every 15 minutes for first 2 hours
- Keep mother and baby together, skin-to-skin
- Support early breastfeeding within first hour (non-separation, EINC)
- Ensure mother is warm, clean, comfortable, hydrated
- Ensure mother has voided
Relationship to central
Essential interventions in first hours postpartum to promote recovery and detect complications
Perineal Tear Assessment and Repair
Sub concepts
- First-degree tear: skin and superficial fascia only — repair by midwife
- Second-degree tear: includes perineal body muscle — repair by midwife
- Third-degree tear: extends into anal sphincter — REFER
- Fourth-degree tear: involves rectal mucosa — REFER
- Routine episiotomy NOT performed
- Episiotomy only on clear indication
- Systematic inspection of entire genital tract after delivery
Relationship to central
Distinguishes within-scope midwifery repairs from complications requiring referral
Danger Signs Requiring Referral and Detection
Sub concepts
- Heavy or continuous bleeding
- Soft, boggy uterus that will not stay contracted
- Retained placenta beyond ~30 minutes
- Incomplete placenta or membranes
- Rising pulse, falling blood pressure, pallor, dizziness (shock signs)
- Tear extending into anal sphincter or rectum
- Prolonged second stage without descent
- Any obstructed labor signs
- PPH defined as ≥500 mL blood loss after vaginal delivery
Relationship to central
Red flags that signal complications necessitating immediate detection and referral to BEmONC facility
EINC and DOH Alignment — Midwife as Independent Provider
Sub concepts
- RA 7392: Midwife may independently manage normal spontaneous vaginal delivery
- EINC principles: non-separation of mother and baby, early breastfeeding, delayed cord clamping where possible
- Eliminate unnecessary practices: routine episiotomy, routine suctioning, routine fundal pressure
- Emphasis on clean, safe delivery in primary-care setting (RHU, BHS, lying-in)
- Unang Yakap program integration: skin-to-skin contact immediately after birth
- Recognition and referral of complications to BEmONC facilities
- Detect and refer model: midwife identifies but does not manage complex cases
Relationship to central
Frames the midwife's independent scope under RA 7392 and aligns with national guidelines
Concept connections
- Mechanisms of Labor — Cardinal MovementsControlled Delivery of the Head and Perineal SupportUnderstanding the cardinal movements, especially flexion and extension, enables the midwife to recognize when the head is in the correct position and delivers it safely with controlled traction
- Pre-Delivery Preparation and ReadinessControlled Delivery of the Head and Perineal SupportProper preparation ensures sterile equipment, supplies, and positioning are ready before delivery begins, enabling smooth execution of the critical head delivery technique
- Maternal Positioning and Second-Stage ManagementControlled Delivery of the Head and Perineal SupportMaternal positioning affects perineal visibility and accessibility; upright positions facilitate gravity-assisted descent and midwife's ability to support and control the perineum
- Controlled Delivery of the Head and Perineal SupportPerineal Tear Assessment and RepairProper controlled technique during head delivery significantly reduces perineal trauma risk; tears that do occur are then assessed for midwife scope (1st/2nd degree repair) versus referral (3rd/4th degree)
- Nucleal Cord Management and Face ClearingDelivery of Shoulders and BodyAfter the head is delivered and nuchal cord managed, the midwife proceeds to deliver the shoulders and body with gentle traction
- Delivery of Shoulders and BodyActive Management of Third Stage of Labor (AMTSL)Once the baby is completely delivered and placed skin-to-skin, the third stage of labor begins; AMTSL is initiated immediately with oxytocin within one minute of birth
- Active Management of Third Stage of Labor (AMTSL)Uterotonic Selection and DosingAMTSL's first component is uterotonic administration; oxytocin is the drug of choice at 10 IU IM, with specific contraindications in hypertension requiring alternative agents
- Uterotonic Selection and DosingControlled Cord Traction and Brandt-Andrews ManeuverAfter oxytocin is given, the midwife waits for signs of placental separation before performing controlled cord traction, which is the second AMTSL component
- Controlled Cord Traction and Brandt-Andrews ManeuverUterine Massage and Postpartum MonitoringFollowing placental delivery via CCT, uterine massage is immediately begun to maintain contraction; monitoring continues every 15 minutes for 2 hours
- Placental Inspection and Completeness AssessmentDanger Signs Requiring Referral and DetectionSystematic placental inspection identifies retained tissue or incomplete membranes, which trigger danger sign assessment and potential referral to BEmONC
- Immediate Postpartum Maternal CareUterine Massage and Postpartum MonitoringPostpartum maternal care includes regular assessment of fundal tone, lochia, and vital signs every 15 minutes in the highest-risk window, supported by continued uterine massage
- Immediate Postpartum Maternal CareDanger Signs Requiring Referral and DetectionDuring immediate postpartum care, the midwife continuously monitors for danger signs such as heavy bleeding, soft uterus, shock signs, and retained placenta
- Perineal Tear Assessment and RepairImmediate Postpartum Maternal CareAfter delivery, the perineum is systematically inspected for lacerations; first and second-degree tears are repaired by the midwife while third and fourth-degree tears require referral
- All Delivery PhasesEINC and DOH Alignment — Midwife as Independent ProviderAll steps of normal spontaneous delivery management are conducted independently by the midwife under RA 7392, with strict adherence to EINC principles, elimination of unnecessary practices, and recognition of complications requiring referral
- Danger Signs Requiring Referral and DetectionEINC and DOH Alignment — Midwife as Independent ProviderThe midwife's role in the detect-and-refer model is exemplified by systematic danger sign monitoring and immediate referral to BEmONC facilities when complications arise
- Mechanisms of Labor — Cardinal MovementsMaternal Positioning and Second-Stage ManagementUnderstanding the cardinal movements guides the midwife to position the mother in ways that facilitate normal descent and rotation of the fetal head
- Pre-Delivery Preparation and ReadinessMaternal Positioning and Second-Stage ManagementBefore delivery, the midwife explains positioning options and ensures the mother is comfortable and the perineum is visible and accessible
- Placental Inspection and Completeness AssessmentImmediate Postpartum Maternal CareSystematic placental inspection provides information about completeness; findings guide postpartum management decisions and referral indications
- Uterine Massage and Postpartum MonitoringDanger Signs Requiring Referral and DetectionUterine massage maintains contraction to prevent hemorrhage; during monitoring, failure of the uterus to remain firm is a danger sign triggering further assessment and possible referral
- Controlled Delivery of the Head and Perineal SupportNucleal Cord Management and Face ClearingImmediately after the head is delivered, the midwife assesses for nuchal cord and performs appropriate management before proceeding to shoulder delivery
Diagrams
Normal Spontaneous Delivery — Complete Concept Hierarchy
Comprehensive mind map showing all major concepts in normal spontaneous delivery management, from mechanisms of labor through postpartum monitoring. Organized hierarchically to show relationships between pre-delivery, delivery, and postpartum phases.
Cardinal Movements of Labor — Sequential Descent Through Pelvis
Sequential flowchart of the seven cardinal movements showing the anatomical progression of fetal descent through the pelvis. Essential for understanding normal labor mechanics and recognizing deviation from normal descent.
Active Management of Third Stage of Labor — AMTSL Protocol
Detailed flowchart of AMTSL protocol with three components: uterotonic administration, controlled cord traction with Brandt-Andrews maneuver, and uterine massage. Includes critical safety steps like ruling out a second baby before giving oxytocin and decision points for referral.
Controlled Delivery of Fetal Head — Technique to Prevent Perineal Trauma
Step-by-step technique for slow, controlled delivery of the fetal head to minimize perineal trauma. Emphasizes the key elements: gentle pressure keeping head flexed, maternal panting between contractions, perineal support with Ritgen maneuver, and proper handling of nuchal cord.
Danger Signs in Postpartum Period — Detect & Refer Pathway
Decision tree for identifying postpartum danger signs within the critical 2-hour window. Shows systematic assessment of bleeding, uterine tone, placental delivery, vital signs, and perineal status — all requiring immediate detection and appropriate referral to BEmONC facility.
Preparation for Delivery — Readiness Checklist & Setup
Comprehensive checklist and flowchart for pre-delivery preparation ensuring EINC readiness. Covers critical elements including confirmation of full dilation, hand hygiene, newborn corner setup with clean cloths and warm environment, supply availability, and maternal positioning options.
Phases of Normal Spontaneous Delivery — State Transitions
State diagram showing the progression through all phases of normal spontaneous delivery — from first stage through postpartum monitoring. Illustrates the transition points and key assessments at each phase, emphasizing the continuous flow when delivery is normal.
Placental Inspection — Systematic Assessment for Completeness
Detailed systematic inspection protocol for placental and membrane completeness. Covers maternal surface (cotyledons), fetal surface (vessels/succenturiate lobes), membranes (amnion/chorion), cord (2+1 vessels), and blood loss estimation — critical for detecting retained tissue requiring referral.