**6.2 Analgesia**

In other studies, analgesia is recommended [17]. In this case, an attempt with a peridural approach or with the use of short-acting narcotics is advisable. Platelet counts more than 50,000/mL for cesarean delivery, more than 20,000/mL for vaginal delivery, more than 75,000/mL for epidural anesthesia, and more than 50,000/ mL for spinal anesthesia in that order are considered safe for delivery.

#### **6.3 Delivery of the fetus**

In order to fully comprehend the delivery of fetus, one needs to know the mechanism of labour well. It involves the passive movement the fetus must undertake in order to negotiate through the maternal bony pelvis. Thus labour can be broken down into the following respective stages; descent, engagement, neck flexion, internal rotation, crowning, extension of the presenting part, restitution, internal rotation and lateral flexion. The readers are advised to read other chapter of this book, where labour was discussed in details. Knowledge of pelvic anatomy and perimetry becomes vital, which is lacking in this section.

Thus, in delivering the fetus, a vaginal examination is done to ascertain the position and station of the fetal head. The head is usually the presenting part of the fetus, bu. rarely the buttock [13]. If effacement is completed and the cervix is fully dilated, then the mother is asked to bear down and strain with each uterine contraction. This helps to move the head through the pelvis and progressively dilate the vaginal introitus so that more and more of the head comes out. The moment about 3 or 4 cm of the head is visible during a uterine contraction in nulliparas, the following maneuvers can then facilitate vaginal delivery and reduce risk of perineal tear;


An **episiotomy** many be performed as necessary. However, episiotomy is not commonly desired for most normal vaginal deliveries. It should be considered only and only if the perineum does not stretch adequately, so that it is obstructing delivery of the baby. In this case, consider infiltrating a local anesthetic if epidural analgesia seems inadequate. Episiotomy relieves excessive stretching and possible irregular tear of the perineal tissues, including anterior tears, which could ensue in it absence. The recommended episiotomy incision which should be preferred is one that extends only through the skin and perineal body without disrupting the anal sphincter muscles (2nd -degree episiotomy). This is because it is easier to repair than a perineal tear. See **Figure 3** below for possible sites of episiotomy.

## **6.4 Delivery of the placenta**

It is common knowledge that active management of the 3rd stage of labour reduces the risk of postpartum hemorrhage. Active management of 3rd stage of labour includes giving the mother a uterotonic drug such as oxytocin as immediate as the fetus is delivered. This uterotonic drug helps the uterus to contract effectively and decrease bleeding due to uterine atony.

Oxytocin, given as 10 units intramuscularly or infusion of 20 units/1000 mL of normal saline at 125 mL/hour is considered. It should not be given as an intravenous bolus in order to minimize the risk of cardiac arrhythmia which might otherwise occur.

**Figure 3.** *Possible sites of episiotomy in vaginal delivery [13].*

Upon successful delivery of the baby and administration of oxytocin, the doctor or midwife should gently and controllably pull the cord and place his or her hand gently on the mother's abdomen over the uterine fundus. This is to detect contractions [13]. Note that separation of placenta from uterus usually occurs during the 1st or 2nd contraction. This often occurs with a gush of blood from behind the separating placenta. The mother can help to deliver the placenta by bearing down. In case the mother cannot bear down and substantial bleeding occurs, the placenta should be evacuated by the doctor or midwife placing his or her hand on the abdomen and then exerting firm downward (caudal) pressure on the uterus. This kind of procedure must be done only on condition that the uterus feels firm, otherwise, pressure on a flaccid uterus can cause the uterus to invert, thus worsening the problem.
