• Delivery of head (non dominant hand on baby's head)
• Check for nuchal cord
• Allow head to restitute (rotate)
• Step to back of baby's head (in broken bed birth)
• Pinkies to perineum to support head (hands off neck)
• Traction towards woman's back until anterior shoulder axillary fold is visable
• Traction toward woman's belly
• As soon as both shoulders are out, slip lower hand down to grasp baby with thumb on back and other fingers on chest.
• Lower hand runs along baby's back toward ankles (grasp ankles)
• Hand baby to mom

If baby is going to peds:

• Rotate feet towards axilla of the arm holding baby's head.  Tuck the baby's feet into your axilla 

1. Anchor stitch in mucosa
2. Visualize spacing of stitches 
3. If internal (interrupted) stitches are necessary do them now
4. Use locked stitches to level of hymenal ring
5. Use nondominant hand to bring last locked stitch square
6. Insert needle to outside corner of lock and bring it down into the tissue on the same side (internal).
7. Place continuous stitches down perineum until about 1 cm from apex.  Come out apex.

1. Come up perineum with subcuticular closure

2. Continue up the perineum, then stop 1/2 cm below the introitus

3. Insert the needle across from your exit point.  Travel back behind the hymenal ring

4.  Insert needle next to where you came up and take a bite to other side

5. Leaving a loop of suture on the side you just left, tie your other end to the loop, using the two sides of one loop as one thread.

2 cm dilatation 

Rupture of membranes

• Unknown presentation or presenting part=face, genital, fontanels
• Active herpes, hep C, HIV
• Avoid with Hep B, GC, Chlamydia, GBS
• Placenta previa (known or suspected)
• Woman is a confirmed carrier of hemophilia and fetus status is unknown or is affected

ROM

2 cm dilation

Uterine bleeding of undetermined origin

Placenta previa