Normal delivery is the mainstay of our Obstetrics practice. The ultimate ending of a pregnancy is labor and delivery—a journey to be made safe. Every woman risks her life and that of the unborn fetus during this event. It is the person who conducts the delivery who holds 2 lives in his or her hands. There can hardly be anything more valuable than that. At the end, when the baby is born healthy there is a great sense of relief both for the mother and the one who conducts the delivery.

To conduct a delivery requires knowledge, experience and dedication. Health professional needs to be well trained. What's more, continuous retraining, updating of knowledge, using of modern drugs are all part of an ongoing Continuing Medical Education which are required. This book will fulfill many of these needs. It should become a “Companion” to all those devoted to this profession.

We live in a strange world! Advanced technology has made Obstetrics safe and unravelled so many mysteries of the art and science of Reproduction. However, we cannot forget the fact that 80% of the women of this world are delivered by traditional birth attendants with very little formal education. This has to be remedied and we need “Skilled Birth Attendants” to conduct the deliveries.

We in India consider ourselves a privileged group. We live and work in what is termed as “a developing world”.6

Unfortunately the maternal mortality rate in our country continues to be unacceptably high. A lot is being done to improve matters. “Safe Motherhood” is not a mere slogan but it is our aim and ultimate goal. We hope this book will contribute towards making pregnancy and delivery safer for the vast majority of our women who are at risk.

Health is the reflection of the status of the person. Women's health is a challenge and is closely related to social issues such as empowerment, gender equality, education and above all financial stability.

Therefore, Health professionals have to necessarily be aware of the broader perspectives and help the women to improve not only their health status but also social status.

Health through Empowerment

Or

Empowerment through Health is required.

The person who conducts the delivery is a privileged person. She is the first person to whom women will turn in case of difficulties. It is a long-term relationship. The greatest reward is to become a friend, philosopher and guide to the family.

I would like to congratulate the Author and the publisher for bringing out a much needed epistle. To all Readers I wish “Happy Reading and Best Wishes.”

An obstetrician plays the role of observer, caregiver, helper, intruder, sometimes life saver and sometimes failure as well, in the birthing process. This is difficult, strenuous, and nerve racking role, who is being given unpredictable situations and scripts at unpredictable hours and days.

While I write this preface and take the opportunity to talk to you, I look back and feel that unknowingly this book became not a mere book of medicine focused on some technical issues, which is fast becoming face of medicine today, but rather it was sharing of experience with myself.

It was a hard knock on the memories which began since when a tender and ignorant medical student entered in tough and chaotic world of labor room. It was amalgamation of intense mixed feeling of moments of pleasure and pain, awe and relief, anger and amusement, solitude and companionship.

Preparation, writing, searching, researching, shooting, editing and reediting of every chapter of this book evoked and surfaced so many forgotten events and stories of obstetric career of twenty five years.

It is like flashback of events, sometimes sequenced and sometime bizarre—A normally progressing delivery suddenly changing into life threatening emergency, 9pouring obstetric hemorrhage, vaginal delivery of patient in operation theatre while preparing for cesarean section, and cesarean after failed instrumental delivery, uterus inversion suddenly in hand, unexplained maternal collapse just after delivery, entrapment of after coming head or breech, arrest of shoulder, unanticipated fetal apnea and fetal death, sometimes technology helping us and at other time befooling us, maneuver saving us and failing us—A collage of picture haunting the dream and thoughts of obstetrician. And also scenes of emotional reactions of women, relatives, revealing the shades of character of human beings from extreme sacrifice and care to total apathy and detachment.

Obstetric career teaches us not only lessons of obstetrics but also lessons of life.

This book is an attempt to share the fundamentals of obstetric skill and technique, current reviews and recommendation of medical world in various situations, and evolving needs of society in respect to different obstetric practices. With faith that exploring and sharing true stories is not only valuable for self help and improvement but also for community and organizational bonding and development. At the same time it is also true that while a particular story can open us all to the same idea or teach us a general lesson, really responding to a story is an extremely personal process.

So while I present this book Step by Step Vaginal Delivery before readers, I hope, with full respect to knowledge and experience of each and every reader that this book will be able to connect, change, stimulate and improve their responses to obstetrics and institutional management to a certain extent.

Unit wise distribution of subject, live, still and video photograph of maneuvers and obstetric operations, labor 10management in special situations and birth emergencies, labor room management and record keeping, current hot debates, dilemma and recommendation—Reader will find almost each and every aspect related to subject of vaginal delivery.

I acknowledge with profound respect, gratitude and fondness, everybody and every moment which was part of this experience.

Laboring women deliver young ones for future of family and humanity, obstetricians are fortunate, favored and lone persons of God and Mother nature, to accompany those women in their lone and difficult journey.

May this companionship always be serene, safe, successful and sanct.

Wishing you a thoughtful reading.

I acknowledge my family members with pride and fondness, my parents who have sown the seeds of hard work, my loving sister Smita for always believing in me, my husband PP Gupta for his constant support and my sons Shubhankur and Anindya, whom interaction has always helped me in having an idea of what makes the difference between excellent, good and not so good book.

I am thankful to my hospital team—Dr KM Singh (Senior Anesthetic), Dr Devendra Bhagwani (Pediatrician), Dr Achla Sinha, Dr Pratima Singh, Dr Mamta, Junior residents and students, and sisters Ms Nalini Powell, Ms Kanchan John, Ms Poonam Sharma for their contribution in preparing photographs for this book. I am thankful to Mr Naim, and Mr Santosh (Artist) for preparing line diagrams for this book.

Last but not the least I heartily acknowledge Shyam Ji, who is virtually integral part of the book, for his constant motivation, encouragement, dedication and endless hard work, right from beginning to final editing.

I pray, wish, hope and believe that this association will always bring out the work of academicians, which will have brain as well as soul, truth and beauty.

Though vaginal birth is one of the most common events of human life, still it is mysterious, unpredictable and can be most difficult moments of human life, be it mother or baby.

Process of vaginal delivery does not start at onset of labor. Success of uneventful vaginal delivery is hidden in factors, which have been operative and decided much before the actual birth process. Racial, genetic and familial characteristics of pelvis, maternal nutrition, medical and obstetric condition of mother associated with pregnancy, fetal weight, presentation, attitude are the factors which lay the foundation for success or failure of vaginal delivery. Beside this event at onset and course of labor can be sudden, which may change course of vaginal birth dramatically.

Beside maternal and fetal factor there is third pole of vaginal delivery that is obstetrician or person caring for laboring women, i.e. midwife with its varied knowledge, experience, skills and courage.

Obstetric skills are obtained throughout lifetime observation of course of labor in varied situations. Often these lessons are learnt with exhaustive, humiliating experiences. With conduct of each delivery, truly learning obstetrician is enriched in experience, become more humble, 17cautious and fine not only in technique of obstetric procedure but also in anticipating obstetrical problems.

Every obstetrical maneuver has been developed from experience and observation of laboring women for hundred of years. With evolution of cesarean section in technique and safety, many obstetrical maneuvers are being lost in history of medicine, but it is ironic that still for many women in developing and poor countries, facility of safe cesarean section is still a distant dream.

Majority of primary health centers are lacking in qualified personnel and equipments. So obstetrician and treating doctor face various obstetric emergencies at odd places and time. In these situations, different obstetric maneuver and operative obstetrics have definite and specific role to save the mother from life threatening obstetric complications, especially in malpresentations, shoulder dystocia, congenital abnormalities or dead babies.

It is a need of time that different standard obstetrical maneuver should be taught in residency period and refreshed throughout the obstetric career so that procedure can be performed by doctor patiently and efficiently in emergency situation. Knowledge and skill of these obstetric procedures will also enable the doctor to offer alternative method of treatment to women and relatives with explanation of risk and benefits.

Technology in form of ultrasound, color Doppler, electronic fetal surveillance has become another pole of obstetrics and added to obstetrician's armamentarium in decision-making and management. But like any other arm, they can be double-edged, if not interpreted and managed with in-depth and updated knowledge of that particular technique.18

Despite all technological advancement and experimental knowledge, mystery of human labor remains unresolved and it is amazing that each labor of every woman is unique and different. In all chapters we have taken an insight into behavioral observation of laboring women to assess various clinical situations.

In situation of dilemma and difficulties current practice recommendations are clearly summarized for quick decision-making.

It is real challenging task to go through all aspects of vaginal delivery, that too step by step as more often obstetrical event take zigzag and see-saw turn to dismay of obstetrician. This book is a humble attempt to understand mystic riddle of human creation.