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Oxytocin can be given as 10 units IM or as an infusion of 20 units/1000 mL saline at 125 mL/hour. Clin Exp Obstet Gynecol 14 (2):97100, 1987. Midline or mediolateral episiotomy Delivery bed: a bed that supports the woman in a semi-sitting or lying in a lateral position, with removable stirrups (only for repairing the perineum or instrumental delivery) . A tight nuchal cord can be clamped twice and cut before delivery of the shoulders, or the baby may be delivered using a somersault maneuver in which the cord is left nuchal and the distance from. If this procedure is not effective, the umbilical cord is held taut while a hand placed on the abdomen pushes upward (cephalad) on the firm uterus, away from the placenta; traction on the umbilical cord is avoided because it may invert the uterus. Obstet Gynecol 121(1):122128, 2013. doi: 10.1097/AOG.0b013e3182749ac9. Contractions may be monitored by palpation or electronically. When epidural analgesia is used, drugs can be titrated as needed during the course of labor. Simultaneously, the clinician places the curved fingers of the right hand against the dilating perineum, through which the infants brow or chin is felt. Simultaneously, the clinician places the curved fingers of the right hand against the dilating perineum, through which the infants brow or chin is felt. Forceps or a vacuum extractor Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the 2nd stage of labor and facilitate delivery. The head is gently lifted, the posterior shoulder slides over the perineum, and the rest of the body follows without difficulty. The length of the labor process varies from woman to woman. Delaying clamping of the umbilical cord for 30 to 60 seconds is recommended to increase iron stores, which provides the following: For all infants: Possible developmental benefits, For premature infants: Improved transitional circulation and decreased risk of necrotizing enterocolitis Necrotizing Enterocolitis Necrotizing enterocolitis is an acquired disease, primarily of preterm or sick neonates, characterized by mucosal or even deeper intestinal necrosis. Eye antimicrobial (1% silver nitrate or 2.5% povidone iodine) . All rights reserved. When spinal injection is used, patients must be constantly attended, and vital signs must be checked every 5 minutes to detect and treat possible hypotension. Paracervical block is rarely appropriate for delivery because incidence of fetal bradycardia is > 10% (1 Anesthesia reference Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. This is also called a rupture of membranes. Rarely, nitrous oxide 40% with oxygen may be used for analgesia during vaginal delivery as long as verbal contact with the woman is maintained. When effacement is complete and the cervix is fully dilated, the woman is told to bear down and strain with each contraction to move the head through the pelvis and progressively dilate the vaginal introitus so that more and more of the head appears. An episiotomy incision that extends only through skin and perineal body without disruption of the anal sphincter muscles (2nd-degree episiotomy) is usually easier to repair than a perineal tear. Bex PJ, Hofmeyr GJ: Perineal management during childbirth and subsequent dyspareunia. Methods include pudendal block, perineal infiltration, and paracervical block. After the anterior shoulder delivers, the clinician pulls up gently, and the rest of the body should deliver easily. 6. Use OR to account for alternate terms Emergency medical technicians, medical students, and others with limited maternity care experience may benefit from the AAFP Basic Life Support in Obstetrics course (https://www.aafp.org/blso), which offers a module on normal labor and delivery. Offer warm perineal compresses during labor. Spinal injection (into the paraspinal subarachnoid space) may be used for cesarean delivery, but it is used less often for vaginal deliveries because it is short-lasting (preventing its use during labor) and has a small risk of spinal headache afterward. Explain the procedure and seek consent according to the . Spontaneous vaginal delivery at term has long been considered the preferred outcome for pregnancy. Induced vaginal delivery: Drugs or other techniques start labor and soften or open your cervix for delivery. In particular, it is difficult to explain the . We do not control or have responsibility for the content of any third-party site. Mother, infant, and father or partner should remain together in a warm, private area for an hour or more to enhance parent-infant bonding. Provide a comfortable environment for both the mother and the baby. When the head is delivered, the clinician determines whether the umbilical cord is wrapped around the neck. Diseases and conditions: placenta previa. o [ abdominal pain pediatric ] Shiono P, Klebanoff MA, Carey JC: Midline episiotomies: More harm than good? The delivery of the placenta is the third and final stage of labor; it normally occurs within 30 minutes of delivery of the newborn. Diagnosis is clinical. It's typically diagnosed after an individual develops multiple pregnancies at once. In these classes, you can ask questions about the labor and delivery process. Bedside ultrasonography is helpful when position is unclear by examination findings. Spontaneous vaginal delivery Am Fam Physician. Because potent and volatile inhalation drugs (eg, isoflurane) can cause marked depression in the fetus, general anesthesia is not recommended for routine delivery. Also, delivering between contractions may decrease perineal lacerations.30 Routine episiotomy should not be performed. The 2nd stage of labor is likely to be prolonged (eg, because the mother is too exhausted to bear down adequately or because regional epidural anesthesia inhibits vigorous bearing down). The nose, mouth, and pharynx are aspirated with a bulb syringe to remove mucus and fluids and help start respirations. A tight nuchal cord can be clamped twice and cut before delivery of the shoulders, or the baby may be delivered using a somersault maneuver in which the cord is left nuchal and the distance from the cord to placenta minimized by pushing the head toward the maternal thigh. We'll tell you if it's safe. Childbirth classes can give you more confidence before it comes time to go into labor and deliver your baby. Once the infant's head is delivered, the clinician can check for a nuchal cord. (2014). Cesarean delivery for failure to progress in active labor is indicated only if the woman is 6 cm or more dilated with ruptured membranes, and she has no cervical change for at least four hours of adequate contractions (more than 200 Montevideo units per intrauterine pressure catheter) or inadequate contractions for at least six hours.8 If possible, the membranes should be ruptured before diagnosing failure to progress. Vaginal delivery is a natural process that usually does not require significant medical intervention. Repair second-degree perineal lacerations with a continuous technique using absorbable synthetic sutures. If she cannot and if substantial bleeding occurs, the placenta can usually be evacuated (expressed) by placing a hand on the abdomen and exerting firm downward (caudal) pressure on the uterus; this procedure is done only if the uterus feels firm because pressure on a flaccid uterus can cause it to invert Inverted Uterus Inverted uterus is a rare medical emergency in which the corpus turns inside out and protrudes into the vagina or beyond the introitus. Remember, its always better to go to the hospital too early and be sent back home than to get to the hospital when your labor is too far along. In such cases, an abnormally adherent placenta (placenta accreta Placenta Accreta Placenta accreta is an abnormally adherent placenta, resulting in delayed delivery of the placenta. It is also known as a vaginal birth. Every delivery is unique and may differ from mothers to mothers. If the baby's heartbeat does not come back up within 1 minute, or stays slower than 100 beats a minute for more than a few minutes, the baby may be in trouble. Delivery Room Procedures Following a Normal Vaginal Birth As your baby lies with you following a routine delivery, her umbilical cord still will be attached to the placenta. In the 2nd stage, women should be attended constantly, and fetal heart sounds should be checked continuously or after every contraction. Then, the infant may be taken to the nursery or left with the mother depending on her wishes. After delivery of the head, the infants body rotates so that the shoulders are in an anteroposterior position; gentle downward pressure on the head delivers the anterior shoulder under the symphysis. Copyright 2023 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. Management of complications during delivery requires additional measures (such as induction of labor Induction of Labor Induction of labor is stimulation of uterine contractions before spontaneous labor to achieve vaginal delivery. Bonus: You can. Epidural analgesia is being increasingly used for delivery, including cesarean delivery, and has essentially replaced pudendal and paracervical blocks. Bloody show. If fetal or neonatal compromise is suspected, a segment of umbilical cord is doubly clamped so that arterial blood gas analysis can be done. Towner D, Castro MA, Eby-Wilkens E, et al: Effect of mode of delivery in nulliparous women on neonatal intracranial injury. Wait 1-3 minutes after delivery to clamp cord or until cord stops pulsating. Some read more ). In the meantime, wear sanitary pads and do pelvic . Water for injection. Although continuous electronic fetal monitoring is associated with a decrease in the rare outcome of neonatal seizures, it is associated with an increase in cesarean and assisted vaginal deliveries with no other improvement in neonatal outcomes.15 When electronic fetal monitoring is employed, the National Institute of Child Health and Human Development definitions and categories should be used (Table 4).16, Pain management includes nonpharmacologic and pharmacologic methods.17 Nonpharmacologic approaches include acupuncture and acupressure18; other complementary and alternative therapies, including audioanalgesia, aromatherapy, hypnosis, massage, and relaxation techniques19; sterile water injections17; continuous labor support11; and immersion in water.20 Pharmacologic analgesia includes systemic opioids, nitrous oxide, epidural anesthesia, and pudendal block.17,21 Although epidurals provide better pain relief than systemic opioids, they are associated with a significantly longer second stage of labor; an increased rate of oxytocin (Pitocin) augmentation; assisted vaginal delivery; and an increased risk of maternal hypotension, urinary retention, and fever.22 Cesarean delivery for abnormal fetal heart tracings is more common in women with epidurals, but there is no significant difference in overall cesarean delivery rates compared with women who do not have epidurals.22 Discontinuing an epidural late in labor does not increase the likelihood of vaginal delivery and increases inadequate pain relief.23, The second stage begins with complete cervical dilation and ends with delivery. Normal Spontaneous Vaginal Delivery Page 5 of 7 10.23.08 o Infant then dried and placed skin to skin with mother or wrapped in warm blanket Third Stage 1. Some obstetricians routinely explore the uterus after each delivery. Treatment is with physical read more . version of breech presentation successfully converted to cephalic presentation, with normal spontaneous delivery. The cord should be double-clamped and cut between the clamps, and a plastic cord clip should be applied about 2 to 3 cm distal from the cord insertion on the infant. Youll learn: When labor begins you should try to rest, stay hydrated, eat lightly, and start to gather friends and family members to help you with the birth process. Methods include pudendal block, perineal infiltration, and paracervical block. Our website services, content, and products are for informational purposes only. Oxytocin should not be given as an IV bolus because cardiac arrhythmia may occur. A local anesthetic can be infiltrated if epidural analgesia is inadequate. Skin-to-skin contact is associated with decreased time to the first feeding, improved breastfeeding initiation and continuation, higher blood glucose level, decreased crying, and decreased hypothermia.33 After delivery, quick drying of the newborn helps prevent hypothermia and stimulates crying and breathing. As labor progresses, strong contractions help push the baby into the birth canal. LeFevre ML: Fetal heart rate pattern and postparacervical fetal bradycardia. If anesthesia is local (pudendal block or infiltration of the perineum), forceps or a vacuum extractor is usually not needed unless complications develop; local anesthesia may not interfere with bearing down. Some obstetricians routinely explore the uterus after each delivery. An arterial pH > 7.15 to 7.20 is considered normal. 59409, 59412. . Complications of pudendal block include intravascular injection of anesthetics, hematoma, and infection. The 2023 edition of ICD-10-CM Z37.0 became effective on October 1, 2022. Delayed cord clamping, defined as waiting to clamp the umbilical cord for one to three minutes after birth or until cord pulsation has ceased, is associated with benefits in term infants, including higher birth weight, higher hemoglobin concentration, improved iron stores at six months, and improved respiratory transition.35 Benefits are even greater with preterm infants.36 However, delayed cord clamping is associated with an increase in jaundice requiring phototherapy.35 Delayed cord clamping is indicated with all deliveries unless urgent resuscitation is needed. Vaginal delivery is the method of childbirth most health experts recommend for women whose babies have reached full term. This might cause you to leak a few drops of urine while sneezing, laughing or coughing. Forceps or a vacuum extractor Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the 2nd stage of labor and facilitate delivery. 7. prostate. The 2023 edition of ICD-10-CM O80 became effective on October 1, 2022. The cord may be wrapped around the neck one or more times. Going into labor naturally at 40 weeks of pregnancy is ideal. Both procedures have risks. Local anesthetics and opioids are commonly used. All rights reserved. Feelings of fear, nervousness, and tension can cause the release of adrenaline and slow the labor process. The most common episiotomy is a midline incision made from the midpoint of the fourchette directly back toward the rectum. The cervix and vagina are inspected for lacerations, which, if present, are repaired, as is episiotomy if done. How does my body work during childbirth? The link you have selected will take you to a third-party website. To advance the head, the clinician can wrap a hand in a towel and, with curved fingers, apply pressure against the underside of the brow or chin (modified Ritgen maneuver). It is the most common gastrointestinal emergency read more and intraventricular hemorrhage (however, slightly increased risk of needing phototherapy). Only one code is available for a normal spontaneous vaginal delivery. Potential positions include on the back, side, or hands and knees; standing; or squatting. Options include regional, local, and general anesthesia. In the delivery room, the perineum is washed and draped, and the neonate is delivered. 1. Episiotomy An episiotomy is the. If anesthesia is local (pudendal block or infiltration of the perineum), forceps or a vacuum extractor is usually not needed unless complications develop; local anesthesia may not interfere with bearing down. Cord clamping. Some read more , 4 Delivery of the fetus references Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. Between 120 and 160 beats per minute. Enter search terms to find related medical topics, multimedia and more. Pregnancy, labor and a vaginal delivery can stretch or injure your pelvic floor muscles, which support the uterus, bladder and rectum. Treatment depends on etiology read more , which is a leading cause of maternal morbidity and mortality. Diagnosis is clinical. Some read more ). Maternal age with Gravida and Parity; Gestational age, weight, and Sex; Fetal Vertex Position; APGAR Score; Time and date of delivery; Episiotomy or Perineal Laceration. Thus, the clinician controls the progress of the head to effect a slow, safe delivery. Normal saline 0.9%. Obstet Gynecol 75 (5):765770, 1990. How do you prepare for a spontaneous vaginal delivery? the procedure described in the reproductive system procedures subsection excludes what organ. Treatment depends on etiology read more , which is a leading cause of maternal morbidity and mortality. Stretch marks are easier to prevent than erase. With thiopental, induction is rapid and recovery is prompt. undergarment, dentures, jewellery and contact lens etc.) Fitzpatrick M, Behan M, O'Connell PR, et al: Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery. Allow the client to assume a birthing position of her choice as long as it is not contraindicated. The local anesthetics often used for epidural injection (eg, bupivacaine) have a longer duration of action and slower onset than those used for pudendal block (eg, lidocaine). Some units use a traditional labor room and separate delivery suite, to which the woman is transferred when delivery is imminent. Induction of labor can be Medically indicated (eg, for preeclampsia or fetal compromise) read more ). If the fetus is in the occipitotransverse or occipitoposterior position in the second stage, manual rotation to the occipitoanterior position decreases the likelihood of operative vaginal and cesarean delivery.26 Fetal position can be determined by identifying the sagittal suture with four suture lines by the anterior (larger) fontanelle and three by the posterior fontanelle. False A Which procedure is coded to the Medical and Surgical section? Many mothers wish to begin breastfeeding soon after delivery, and this activity should be encouraged. o [ abdominal pain pediatric ] Out of the nearly 4 million births in the United States in 2013, approximately 3 million were vaginal deliveries.1 Accurate pregnancy dating is essential for anticipating complications and preparing for delivery. In the later, this assistance can vary from use of medicines to emergency delivery procedures. Sequence of events in delivery for vertex presentations, Cargill YM, MacKinnon CJ, Arsenault MY, et al, Fitzpatrick M, Behan M, O'Connell PR, et al, Towner D, Castro MA, Eby-Wilkens E, et al, Marcaine, Marcaine Spinal, POSIMIR, Sensorcaine, Sensorcaine MPF , Xaracoll, 7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme, Aspercreme with Lidocaine, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Ela-Max, GEN7T, Glydo, LidaMantle, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , Lidomar , Lidomark, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lydexa, Moxicaine, Numbonex, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Salonpas Lidocaine, Senatec, Solarcaine, SUN BURNT PLUS, Tranzarel, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, Zingo, Zionodi, ZTlido. Epidural analgesia, which can be rapidly converted to epidural anesthesia, has reduced the need for general anesthesia except for cesarean delivery. Cargill YM, MacKinnon CJ, Arsenault MY, et al: Guidelines for operative vaginal birth. Some read more ) tend to be more common after forceps delivery than after vacuum extraction. (2014). Patterson DA, et al. Identical twins are the same in so many ways, but does that include having the same fingerprints? The woman's partner or other support person should be offered the opportunity to accompany her. The doctor will explain the procedure and the possible complications to the mother 2. For manual removal, the clinician inserts an entire hand into the uterine cavity, separating the placenta from its attachment, then extracts the placenta. Bex PJ, Hofmeyr GJ: Perineal management during childbirth and subsequent dyspareunia. NSVD or normal spontaneous vaginal delivery is the delivery of the baby through vaginal route. After delivery, the woman may remain there or be transferred to a postpartum unit. When epidural analgesia is used, drugs can be titrated as needed during the course of labor. 1. 2008 Aug . It is used mainly for 1st- or early 2nd-trimester abortion. Some read more ). Thiopental, a sedative-hypnotic, is commonly given IV with other drugs (eg, succinylcholine, nitrous oxide plus oxygen) for induction of general anesthesia during cesarean delivery; used alone, thiopental provides inadequate analgesia. After delivery, skin-to-skin contact with the mother is recommended. Read more about the types of midwives available. You can learn more about how we ensure our content is accurate and current by reading our. Induction is recommended for a term pregnancy if the membranes rupture before labor begins.4 Intrapartum antibiotic prophylaxis is indicated if the patient is positive for group B streptococcus at the 35- to 37-week screening or within five weeks of screening if performed earlier in pregnancy, or if the patient has group B streptococcus bacteriuria in the current pregnancy or had a previous infant with group B streptococcus sepsis.5 If the group B streptococcus status is unknown at the time of labor, the patient should receive prophylaxis if she is less than 37 weeks' gestation, the membranes have been ruptured for 18 hours or more, she has a low-grade fever of at least 100.4F (38C), or an intrapartum nucleic acid amplification test result is positive.5, The first stage of labor begins with regular uterine contractions and ends with complete cervical dilation (10 cm). Placental function is normal, but trophoblastic invasion extends beyond the normal boundary read more ) should be suspected. Latent labor lasting many hours is normal and is not an indication for cesarean delivery.68 Active labor with more rapid dilation may not occur until 6 cm is achieved. Episiotomy prevents excessive stretching and possible irregular tearing of the perineal tissues, including anterior tears. fThe following criteria should be present to call it normal labor. Mayo Clinic Staff. NSVD (Normal Spontaneous Vaginal Delivery) Back to Obstetrical Services. Should you have a spontaneous vaginal delivery? If the placenta is incomplete, the uterine cavity should be explored manually. Women without epidurals who deliver in upright positions (kneeling, squatting, or standing) have a significantly reduced risk of assisted vaginal delivery and abnormal fetal heart rate pattern, but an increased risk of second-degree perineal laceration and an estimated blood loss of more than 500 mL.27 Flexing the hips and legs increases the pelvic inlet diameter, allowing more room for delivery. Lumbar epidural injection Analgesia of a local anesthetic is the most commonly used method. If fetal or neonatal compromise is suspected, a segment of umbilical cord is doubly clamped so that arterial blood gas analysis can be done. If this procedure is not effective, the umbilical cord is held taut while a hand placed on the abdomen pushes upward (cephalad) on the firm uterus, away from the placenta; traction on the umbilical cord is avoided because it may invert the uterus. This teaching approach may lead to poor or incomplete skill . Soon after, a womans water may break. We avoid using tertiary references. Learn about the types of episiotomy and what to expect during and after the. Within an hour, the mother pushes out her placenta, the organ connecting the mother and the baby through the umbilical cord and providing nutrition and oxygen. The normal spontaneous vaginal delivery is a fundamental skill in the intrapartum care of women. All Rights Reserved. Because of possible health risks for the mother, child, or both, experts recommend that women with the following conditions avoid spontaneous vaginal deliveries: Cesarean delivery is the desired alternative for women who have these conditions. However, traditional associative theories cannot comprehensively explain many findings. The uterus is most commonly inverted when too much traction read more . Extension into the rectal sphincter or rectum is a risk with midline episiotomy, but if recognized promptly, the extension can be repaired successfully and heals well. True B. The mother must push to move her baby down her birth canal until its born. This content is owned by the AAFP. If it is, the clinician should try to unwrap the cord; if the cord cannot be rapidly removed this way, the cord may be clamped and cut. (2013). Labor opens, or dilates, her cervix to at least 10 centimeters. A woman's estimated due date is 40 weeks from the first day of her last menstrual period. However, use of episiotomy is decreasing because extension or tearing into the sphincter or rectum is a concern. Normal Spontaneous Vaginal Delivery Sections Download Chapter PDF Share Get Citation Search Book Annotate Expand All Sections Full Chapter Figures Tables Videos Supplementary Content Introduction Anatomy and Pathophysiology Indications Contraindications Equipment Initial Assessment Patient Preparation Techniques Alternative Techniques Assessment Diagnosis is clinical. When a woman goes into labor without the aid of any labor inducing drugs or methods, and is able to deliver the baby without requiring a doctor's aid through cesarean section, vacuum extraction, or with forceps, this is known as a normal spontaneous vaginal delivery . Pudendal block is a safe, simple method for uncomplicated spontaneous vaginal deliveries if women wish to bear down and push or if labor is advanced and there is no time for epidural injection. Pudendal block is a safe, simple method for uncomplicated spontaneous vaginal deliveries if women wish to bear down and push or if labor is advanced and there is no time for epidural injection. Learn more about the MSD Manuals and our commitment to, Cargill YM, MacKinnon CJ, Arsenault MY, et al, Fitzpatrick M, Behan M, O'Connell PR, et al, Towner D, Castro MA, Eby-Wilkens E, et al. Of, The term episiotomy refers to the intentional incision of the vaginal opening to hasten delivery or to avoid or decrease potential tearing. The cord may continue to pulsate for several minutes, supplying the baby with oxygen while she establishes her own breathing. The link you have selected will take you to a third-party website. There's conflicting information out there so we look, Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. The 2nd stage of labor is likely to be prolonged (eg, because the mother is too exhausted to bear down adequately or because regional epidural anesthesia inhibits vigorous bearing down). 1. Postpartum maternal and neonatal outcomes can be improved through delayed cord clamping, active management to prevent postpartum hemorrhage, careful examination for external anal sphincter injuries, and use of absorbable synthetic suture for second-degree perineal laceration repair. The technique involves injecting 5 to 10 mL of 1% lidocaine or chloroprocaine (which has a shorter half-life) at the 3 and 9 oclock positions; the analgesic response is short-lasting. A spontaneous vaginal delivery is a vaginal delivery that happens on its own, without requiring doctors to use tools to help pull the baby out. Have someone take you to the hospital when you find it hard to talk, walk, or move during your contractions or if your water breaks. The water might not break until well after labor is established, even right before delivery. Forceps or vacuum extraction is needed during a vaginal delivery How it works If you need an episiotomy, you typically won't feel the incision or the repair. Other fetal risks with forceps include facial lacerations and facial nerve palsy, corneal abrasions, external ocular trauma, skull fracture, and intracranial hemorrhage (3 Delivery of the fetus references Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. The head is gently lifted, the posterior shoulder slides over the perineum, and the rest of the body follows without difficulty.