Ebook Williams obstetrics (24th edition): Part 2

SECTION 8

DELIVERY


536

CHAPTER 27

Vaginal Delivery

ROUTE OF DELIVERY .

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536

PREPARATION FOR DELIVERY .

. . . . . . . . . . . . . . . . . . .

536

OCCIPUT ANTERIOR POSITION

. . . . . . . . . . . . . . . . . . .

537

PERSISTENT OCCIPUT POSTERIOR POSITION .

. . . . . . . .

539

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540

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541

OCCIPUT TRANSVERSE POSITION
SHOULDER DYSTOCIA .

SPECIAL POPULATIONS .

. . . . . . . . . . . . . . . . . . . . . . . .

THIRD STAGE OF LABOR .

. . . . . . . . . . . . . . . . . . . . . . .

“FOURTH STAGE” OF LABOR.
EPISIOTOMY .

545
546

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548

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

550

associated rates of maternal infection, hemorrhage, anesthesia
complications, and peripartum hysterectomy, among others. In
contrast, for women undergoing spontaneous vaginal delivery
compared with cesarean delivery, pelvic floor disorders may be
increased (Handa, 2011; Rortveit, 2003). Longitudinal studies,
however, suggest that initial pelvic floor protection advantages
gained from cesarean delivery are lost as women age (Dolan,
2010; Glazener, 2013; Rortveit, 2001). During their State-ofthe-Science Conference, the National Institutes of Health panel
(2006) summarized that stress urinary incontinence rates after
elective cesarean delivery are lower than those following vaginal
delivery. However, the duration of this protection is unclear,
particularly in older and multiparous populations. This same
conference considered the evidence implicating vaginal delivery in other pelvic floor disorders to be weak and not favoring
either delivery route.

PREPARATION FOR DELIVERY
The natural culmination of second-stage labor is controlled
vaginal delivery of a healthy neonate with minimal trauma to
the mother. Vaginal delivery is the preferred route of delivery
for most fetuses, although certain clinical settings may favor
cesarean delivery. Spontaneous vaginal delivery is typical,
however, maternal or fetal complications may warrant operative vaginal delivery as described in Chapter 29. Last, a malpresenting fetus or multifetal gestation in many cases may be
delivered vaginally but requires special techniques. These are

described in Chapters 28—Breech Delivery and 45—Multifetal
Pregnancy.

ROUTE OF DELIVERY
In general, spontaneous vaginal vertex delivery poses the lowest risk of most maternal and fetal comorbidity. Compared
with cesarean delivery, spontaneous vaginal delivery has lower

The end of second-stage labor is heralded as the perineum
begins to distend, the overlying skin becomes stretched, and
the fetal scalp is seen through the separating labia. Increased
perineal pressure from the fetal head creates reflexive bearingdown efforts, which are encouraged when appropriate. At
this time, preparations are made for delivery. Some considerations that arise during labor and which are also discussed
in Chapter 22 (p. 451) are reiterated. For example, the bladder is palpated, and if it is distended, catheterization may be
necessary. Continued attention is also given to fetal heart rate
monitoring. As one example, a nuchal cord often tightens
with descent and may lead to deepening variable decelerations. Antibiotic prophylaxis against infective endocarditis is
not recommended for vaginal delivery in most women with
cardiac conditions. Exceptions are in women with cyanotic
heart disease or prosthetic valves or both. For these women,
prophylaxis as outlined in Table 49-10 (p.  991) is indicated


Vaginal Delivery

OCCIPUT ANTERIOR POSITION
By the time of perineal distention, the position of the presenting occiput is usually known. In some cases, however, molding
and caput formation have precluded accurate identification. At
this time, careful assessment is again performed as described
in Chapter 22 (p. 438). In most cases, presentation is directly
occiput anterior or is rotated slightly oblique. But, in perhaps

5 percent, persistent occiput posterior is identified. Rarely,
the vertex will be presenting in the occiput transverse position
when the head bulges the perineum.

CHAPTER 27

30 to 60 minutes before the anticipated procedure (American
College of Obstetricians and Gynecologists, 2011).
During second-stage labor, pushing positions may vary. But
for delivery, dorsal lithotomy position is the most widely used
and often the most satisfactory. For better exposure, leg holders or stirrups are used. Corton and associates (2012) found no
increased rates of perineal lacerations with stirrup use compared
to without their use. With positioning, legs are not separated
too widely or placed one higher than the other. Within the
leg holder, the popliteal region should rest comfortably in the
proximal portion and the heel in the distal portion. The legs are
not strapped into the stirrups, thereby allowing quick flexion of
the thighs backward onto the abdomen should shoulder dystocia develop (p. 541). Legs may cramp during the second stage,
in part, because of pressure by the fetal head on pelvic nerves.
Cramping may be relieved by repositioning the affected leg or
by brief massage.
Preparation for delivery includes vulvar and perineal cleansing. If desired, sterile drapes may be placed in such a way that
only the immediate area around the vulva is exposed. In the
past, scrubbing, gowning, gloving, and donning protective
mask and eyewear was done to protect the laboring woman
from infectious agents. Although these considerations remain
valid, infectious disease exposure concerns today must also be
extended to health-care providers.

FIGURE 27-1 Delivery of the head. The occiput is being kept

close to the symphysis by moderate pressure on the fetal chin at
the tip of the maternal coccyx.

both hands using the thumb and opposing fingers. Outward
and lateral stretch against the perineum is then repeatedly
applied. Evidence for this technique is limited and mixed
regarding efficacy for perineal protection when applied either
antepartum or intrapartum (Geranmayeh, 2012; Mei-dan,
2008; Stamp, 2001).
When the head distends the vulva and perineum enough
to open the vaginal introitus to a diameter of 5 cm or more, a
gloved hand may be used to support the perineum (Fig. 27-2).
The other hand is used to guide and control the fetal head to
avoid expulsive delivery. Slow delivery of the head may decrease

■ Delivery of the Head
With each contraction, the vulvovaginal opening is dilated by
the fetal head to gradually form an ovoid and finally, an almost
circular opening (Fig. 27-1). This encirclement of the largest
head diameter by the vulvar ring is termed crowning. Unless
an episiotomy has been made as described later, the perineum
thins and especially in nulliparous women, may undergo spontaneous laceration. The anus becomes greatly stretched, and the
anterior wall of the rectum may be easily seen through it.
There once was considerable controversy concerning routine
episiotomy use. It is now clear that episiotomy increases the risk
of a tear into the external anal sphincter, the rectum, or both.
Conversely, anterior tears involving the urethra and labia are
more common in women in whom an episiotomy is avoided.
Most, including us, advocate individualization and do not routinely perform episiotomy.
To limit spontaneous vaginal laceration, some perform

intrapartum perineal massage to widen the introitus for head
passage. With this, the perineum is grasped in the midline by

537

FIGURE 27-2 Delivery of the head. The mouth appears over the
perineum.


538

Delivery

SECTION 8
FIGURE 27-3 Modified Ritgen maneuver. Moderate upward pressure is applied to the fetal chin by the posterior hand covered
with a sterile towel, while the suboccipital region of the fetal
head is held against the symphysis.

FIGURE 27-4 The umbilical cord, if identified around the neck, is
readily slipped over the head.

lacerations (Laine, 2008). Alternatively, if expulsive efforts are
inadequate or expeditious delivery is needed, the modified Ritgen
maneuverr may be employed. With this, gloved fingers beneath
a draped towel exert forward pressure on the fetal chin through
the perineum just in front of the coccyx. Concurrently, the
other hand presses superiorly against the occiput (Fig. 27-3).
Originally described in 1855, the Ritgen maneuver allows controlled fetal head delivery (Cunningham, 2008). It also favors
neck extension so that the head passes through the introitus and
over the perineum with its smallest diameters. Comparing the

Ritgen maneuver with simple perineal support in 1623 women,
Jönsson and colleagues (2008) found a similar incidence of
third- and fourth-degree tears—5.5 percent with the maneuver and 4.4 percent with simple support. Last, some espouse a
“hands-poised” method, in which the attendant does not touch
the perineum during delivery of the head (Mayerhofer, 2002;
McCandlish, 1998). Compared with traditional perineal support, this expectant method does not appear to offer greater
third-degree laceration protection (Aasheim, 2011).

Following its delivery, the fetal head falls posteriorly, bringing the face almost into contact with the maternal anus. The
occiput promptly turns toward one of the maternal thighs, and
the head assumes a transverse position (Fig. 27-5). This external
rotation indicates that the bisacromial diameter, which is the
transverse diameter of the thorax, has rotated into the anteroposterior diameter of the pelvis.
Most often, the shoulders appear at the vulva just after external rotation and are born spontaneously. If delayed, extraction
aids controlled delivery. The sides of the head are grasped with
two hands, and gentle downward traction is applied until the
anterior shoulder appears under the pubic arch. Next, by an
upward movement, the posterior shoulder is delivered. During
delivery, abrupt or powerful force is avoided to avert brachial
plexus injury.
The rest of the body almost always follows the shoulders
without difficulty. With prolonged delay, however, its birth
may be hastened by moderate traction on the head and moderate pressure on the uterine fundus. Hooking the fingers in
the axillae is avoided. This can injure upper extremity nerves
and produce a transient or possibly permanent paralysis.
Traction, furthermore, should be exerted only in the direction of the long axis of the neonate. If applied obliquely, it
causes neck bending and excessive brachial plexus stretching.
Immediately after delivery of the newborn, there is usually a
gush of amnionic fluid, often blood-tinged but not grossly
bloody.

Previously, immediate nasopharyngeal bulb suctioning of
the newborn was routine to remove secretions. It was found,
however, that suctioning of the nasopharynx may lead to
neonatal bradycardia (Gungor, 2006). The American Heart
Association neonatal resuscitation recommendations currently

■ Delivery of the Shoulders
Following delivery of the fetal head, a finger should be passed
across the fetal neck to determine whether it is encircled by
one or more umbilical cord loops (Fig. 27-4). A nuchal cord is
found in approximately 25 percent of deliveries and ordinarily
causes no harm. If an umbilical cord coil is felt, it should be
slipped over the head if loose enough. If applied too tightly,
the loop should be cut between two clamps. Such tight nuchal
cords complicate approximately 6 percent of all deliveries but
are not associated with worse neonatal outcome than those
without a cord loop (Henry, 2013).


Vaginal Delivery

B
FIGURE 27-5
A. Gentle downward
traction to effect descent of the anterior shoulder. B. Delivery
of the anterior shoulder completed. Gentle upward traction to
deliver the posterior shoulder.

eschew most suctioning immediately following birth—even
with meconium present. This includes bulb syringe aspiration.

Suctioning should be reserved for neonates who have obvious
obstruction to spontaneous breathing or who require positivepressure ventilation (Kattwinkel, 2010). Similarly, if meconium is present and the newborn is depressed, then intubation
and tracheal suctioning is recommended (American College of
Obstetricians and Gynecologists, 2013b). These aspects are discussed in further detail in Chapter 33 (p. 638).

■ Clamping the Cord
The umbilical cord is cut between two clamps placed 6 to 8 cm
from the fetal abdomen, and later an umbilical cord clamp is
applied 2 to 3 cm from its insertion into the fetal abdomen. A
plastic clamp that is safe, efficient, and fairly inexpensive, such
as the Double Grip Umbilical Clamp (Hollister), is used at
Parkland Hospital.
For term neonates, the timing of umbilical cord clamping
remains debatable. A delay in umbilical cord clamping for
up to 60 seconds may increase total body iron stores, expand
blood volume, and decrease anemia incidence in the neonate (Andersson, 2011; Yao, 1974). This may be particularly
valuable in populations in which iron deficiency is prevalent

PERSISTENT OCCIPUT POSTERIOR POSITION
Approximately 2 to 10 percent of singleton term cephalic
fetuses deliver in an occiput posterior (OP) position (Cheng,
2010). As shown in Figure 27-6, many fetuses delivering OP
were occiput anterior (OA) in early labor and reflect malrotation during labor. Predisposing risks include epidural analgesia,
nulliparity, greater fetal weight, and prior OP position delivery
(Cheng, 2006a; Gardberg, 2004; Lieberman, 2005).

■ Morbidity
Women with a persistent OP position have higher associated rates of prolonged second-stage labor, cesarean delivery,
and operative vaginal delivery. For women who deliver vaginally, rates of blood loss and of third- and fourth-degree laceration, so-called higher-order vaginal lacerations, are increased
(Senécal, 2005).

Infants delivered from an OP position have many more complications then those born positioned OA. Cheng and coworkers (2006b) compared outcomes of 2591 women undergoing
delivery with a persistent OP position with those of 28,801
women whose newborns were delivered OA. Virtually every
possible delivery complication was found more frequently
with persistent OP position. Only 46 percent of these women

CHAPTER 27

A

(Abalos, 2009). Conversely, and as discussed in Chapter 33
(p. 643), higher hemoglobin concentration increases risks for
hyperbilirubinemia and extended hospitalization for neonatal phototherapy (McDonald, 2008). Delayed cord clamping
may also hinder timely and needed neonatal resuscitation.
Fortunately, in general, delayed umbilical cord clamping
compared with early clamping does not worsen Apgar scores,
umbilical cord pH, or respiratory distress caused by polycythemia. Regarding maternal outcomes, rates of postpartum
hemorrhage are similar between early and delayed clamping
groups (Andersson, 2013). Fewer data are available regarding
cord “milking,” in which the operator pushes blood through
the cord toward the newborn. This maneuver appears safe and
may be advantageous if rapid cord clamping is clinically indicated (Upadhyay, 2013).
For the preterm neonate, delayed cord clamping has several
benefits. These include higher red cell volume, decreased need
for blood transfusion, better circulatory stability, and lower
rates of intraventricular hemorrhage and of necrotizing enterocolitis (Rabe, 2012; Raju, 2013; Sommers, 2012).
The American College of Obstetricians and Gynecologists
(2012c) has concluded that there is insufficient evidence to
support or refute benefits from delayed umbilical cord clamping for term neonates in resource-rich settings. For preterm
newborns, however, evidence supports delaying umbilical cord

clamping to 30 to 60 seconds after birth. This opinion is also
endorsed by the American Academy of Pediatrics (2013). Our
policy is to clamp the cord after assessing the need to clear
the airway, all of which usually requires approximately 30 seconds. The newborn is not elevated above the introitus at vaginal
delivery or much above the maternal abdominal wall at the
time of cesarean delivery.

539


540

Delivery

Term pregnancies
n = 406

SECTION 8

OA in early labor
n = 347 (85%)

OP in early labor
n = 61 (15%)

OP at delivery a
n = 13 (4%)

OP at delivery
n = 8 (13%)

Total OP at delivery
T
n = 21 (5%)
a 62%

of OP positions at delivery were OA at beginning of labor

FIGURE 27-6 Occiput posterior (OP) presentation in early labor
compared with presentation at delivery. Sonography was used to
determine position of the fetal head in early labor. OA = occiput
anterior. (Data from Gardberg, 1998.)

delivered spontaneously, and the remainder accounted for
9 percent of cesarean deliveries performed. These investigators
also found that an OP position at delivery was associated with
increased adverse short-term neonatal outcomes that included
acidemic umbilical cord gases, birth trauma, Apgar scores < 7,
and intensive care nursery admission, among others. Similar
results were reported by Ponkey (2003) and Fitzpatrick (2001)
and their associates.
Methods to prevent persistent OP position and its associated
morbidity have been investigated. First, digital examination
for identification of fetal head position can be inaccurate, and
sonography can be used to increase accuracy (Dupuis, 2005;
Souka, 2003; Zahalka, 2005). Such information may provide
an explanation for prolonged second-stage labor or may identify suitable candidates for manual rotation. In contrast, varying maternal position either before or during labor does not
appear to lower rates of persistent OP position (Desbriere,
2013; Kariminia, 2004).

■ Delivery of Persistent Occiput
Posterior Position
Delivery of a fetus with an OP position may be completed
by spontaneous or operative vaginal delivery. First, if the pelvic outlet is roomy and the vaginal outlet and perineum are
somewhat relaxed from prior deliveries, rapid spontaneous
OP delivery will often take place. Conversely, if the vaginal
outlet is resistant to stretch and the perineum is firm, secondstage labor may be appreciably prolonged. During each expulsive effort, the head is driven against the perineum to a much
greater degree than when the head position is OA. This leads to
greater rates of higher-order perineal lacerations (Groutz, 2011;
Melamed, 2013).

In some cases, spontaneous vaginal delivery from an OP
position does not appear feasible or expedited delivery is
needed. Here, manual rotation with spontaneous delivery from an OA position may be preferred. This technique
is described fully in Chapter 29 (p. 580). Successful rotation
rates range from 47 to 90 percent. And, as would be expected,
lower rates of cesarean delivery, vaginal laceration, and maternal blood loss follow rotation to OA position and vaginal
delivery (Le Ray, 2005; Sen, 2013; Shaffer, 2006, 2011).
Disadvantageously, manual rotation is linked with higher
cervical laceration rates. Thus, careful inspection of the cervix
following rotation is prudent.
For exigent delivery, forceps or vacuum device can be
applied to a persistent OP position. This is often performed in
conjunction with an episiotomy. Also, if the head is engaged,
the cervix fully dilated, and the pelvis adequate, forceps rotation may be attempted. These circumstances most likely prevail when expulsive efforts of the mother during the second
stage are ineffective. Both these operative vaginal techniques are
detailed in Chapter 29 (p. 582).
Infrequently, protrusion of fetal scalp through the introitus
is the consequence of marked elongation of the fetal head from
molding combined with formation of a large caput succedaneum. In some cases, the head may not even be engaged—that

is, the biparietal diameter may not have passed through the
pelvic inlet. In these, labor is characteristically long and descent
of the head is slow. Careful palpation above the symphysis may
disclose the fetal head to be above the pelvic inlet. Prompt
cesarean delivery is appropriate.
At Parkland Hospital, spontaneous delivery or manual rotation is preferred for management of persistent OP position. In
other cases, either manual rotation to OA position followed
by forceps delivery or forceps delivery from the OP position is
used. If neither can be completed with relative ease, cesarean
delivery is performed.

OCCIPUT TRANSVERSE POSITION
In the absence of a pelvic architecture abnormality or asynclitism, the occiput transverse position is usually transitory.
Thus, unless contractions are hypotonic, the head usually
spontaneously rotates to an OA position. If hypotonic uterine contractions are suspected and cephalopelvic disproportion is absent, then an oxytocin infusion can be used to
stimulate labor.
If rotation ceases because of poor expulsive forces, vaginal delivery usually can be accomplished readily in a number
of ways. The easiest is manual rotation of the occiput either
anteriorly to OA or less commonly, posteriorly to OP. If
either is successful, Le Ray and coworkers (2007) reported a
4-percent cesarean delivery rate compared with a 60-percent
rate in women in whom manual rotation was not successful.
Some recommend rotation with Kielland forceps for the persistent occiput transverse position as outlined in Chapter 29
(p. 582). These forceps are used to rotate the occiput to the
anterior position, and delivery is accomplished with the same
forceps or by substitution with either Simpson or Tucker–
McLane forceps.


Vaginal Delivery

SHOULDER DYSTOCIA
Following complete emergence of the fetal head during vaginal
delivery, the remainder of the body may not rapidly follow. The
anterior fetal shoulder can become wedged behind the symphysis pubis and fail to deliver using normally exerted downward
traction and maternal pushing. Because the umbilical cord is
compressed within the birth canal, such dystocia is an emergency. Several maneuvers, in addition to downward traction
on the fetal head, may be performed to free the shoulder. This
requires a team approach, in which effective communication
and leadership are critical.
Consensus regarding a specific definition of shoulder dystocia is lacking. Some investigators focus on whether maneuvers
to free the shoulder are needed, whereas others use the headto-body delivery time interval as defining (Beall, 1998). Spong
and coworkers (1995) reported that the mean head-to-body
delivery time in normal births was 24 seconds compared with
79 seconds in those with shoulder dystocia. These investigators proposed that a head-to-body delivery time > 60 seconds
be used to define shoulder dystocia. Currently, however, the
diagnosis continues to rely on the clinical perception that the
normal downward traction needed for fetal shoulder delivery
is ineffective.
Because of these differing definitions, the incidence of
shoulder dystocia varies. Current reports cite an incidence
between 0.6 percent and 1.4 percent (American College of
Obstetricians and Gynecologists, 2012b). There is evidence
that the incidence has increased in recent decades, likely due to
increasing fetal birthweight (MacKenzie, 2007). Alternatively,
this increase may be due to more attention given to appropriate
documentation of dystocia (Nocon, 1993).

Again, most involved the brachial plexus. These specific injuries
are described more fully in Chapter 33 (p. 648). Of predictors,

increasing fetal weight, maternal body mass index, and secondstage duration and a prior shoulder dystocia appear to raise the
neonatal injury risk with shoulder dystocia (Bingham, 2010;
Mehta, 2006).

■ Prediction and Prevention
There has been considerable evolution in obstetrical thinking
regarding the preventability of shoulder dystocia. Although
there are clearly several risk factors associated with this complication, identification of individual instances before the
fact has proved to be impossible. The American College of
Obstetricians and Gynecologists (2012b) reviewed studies and
concluded that:
1. Most cases of shoulder dystocia cannot be accurately predicted or prevented.
2. Elective induction of labor or elective cesarean delivery for
all women suspected of having a macrosomic fetus is not
appropriate.
3. Planned cesarean delivery may be considered for the nondiabetic woman with a fetus whose estimated fetal weight is
> 5000 g or for the diabetic woman whose fetus is estimated
to weigh > 4500 g.

Birthweight
Commonly cited maternal characteristics associated with
increased fetal birthweight are obesity, postterm pregnancy,
multiparity, diabetes, and gestational diabetes. There is universal agreement that increasing birthweight is associated with
an increasing incidence of shoulder dystocia. In one study of
nearly 2 million vaginal deliveries, Overland and coworkers
(2012) noted that in 75 percent of shoulder dystocia cases,
newborns weighed > 4000 g. That said, the concept that cesarean delivery is indicated for large fetuses, even those estimated
to weigh 4500 g, should be tempered. Rouse and Owen (1999)
concluded that a prophylactic cesarean delivery policy for macrosomic fetuses would require more than 1000 cesarean deliveries with attendant morbidity as well as millions of dollars to
avert a single permanent brachial plexus injury.

■ Maternal and Neonatal Consequences

Intrapartum Factors

In general, shoulder dystocia poses greater risk to the fetus
than the mother. Postpartum hemorrhage, usually from uterine atony but also from vaginal lacerations, is the main maternal risk (Jangö, 2012; Rahman, 2009). In contrast, significant
neonatal neuromusculoskeletal injury and even mortality are
concerns. MacKenzie and associates (2007) reviewed 514 cases
of shoulder dystocia and found that 11 percent were associated
with serious neonatal trauma. Brachial plexus injury was diagnosed in 8 percent, and 2 percent suffered a clavicle, humeral,
or rib fracture. Seven percent showed evidence of acidosis at
delivery, and 1.5 percent required cardiac resuscitation or
developed hypoxic ischemic encephalopathy. Mehta and colleagues (2007) found a similar number of injuries in a study of
205 shoulder dystocia cases, in which 17 percent had injury.

Some labor characteristics have been associated with an
increased shoulder dystocia risk and include prolonged secondstage labor, operative vaginal delivery, and prior shoulder dystocia (Mehta, 2004; Moragianni, 2012; Overland, 2009). Of
these, the risk of recurrent shoulder dystocia ranges from 1 to
13 percent (Bingham, 2010; Moore, 2008; Ouzounian, 2013).
For many women with prior shoulder dystocia, a trial of labor
may be reasonable. The American College of Obstetricians
and Gynecologists (2012b) recommends that estimated fetal
weight, gestational age, maternal glucose intolerance, and
severity of prior neonatal injury be evaluated and risks and
benefits of cesarean delivery discussed with any woman with a
history of shoulder dystocia. After discussion, either mode of
delivery is appropriate.

CHAPTER 27

In some cases, there may be an underlying cause leading
to the persistent occiput transverse position that is not easily overcome. For example, a platypelloid pelvis is flattened
anteroposteriorly and an android pelvis is heart shaped. With
these, there may be inadequate space for occipital rotation to
either an OA or OP position (Fig. 2-20, p. 34). Because of
these concerns, undue force should be avoided if forceps delivery is attempted.

541


542

Delivery

■ Management
SECTION 8

Because shoulder dystocia cannot be accurately predicted,
clinicians should be well versed in its management principles.
Because of ongoing cord compression with this dystocia, one
goal is to reduce the head-to-body delivery time. This is balanced against the second goal, which is avoidance of fetal and
maternal injury from aggressive manipulations. Accordingly,
an initial gentle attempt at traction, assisted by maternal
expulsive efforts, is recommended. Adequate analgesia is certainly ideal. Some clinicians advocate performing a large episiotomy to provide room for manipulations. Of note, Paris
(2011) and Gurewitsch (2004) and their colleagues reported
no change in the brachial plexus injury rate for groups in
which episiotomy was not performed during shoulder dystocia management.
After gentle traction, various techniques can be used to free
the anterior shoulder from its impacted position behind the

symphysis pubis. Of these, moderate suprapubic pressuree can be
applied by an assistant, while downward traction is applied to
the fetal head. Pressure is applied with the heel of the hand to

the anterior shoulder wedged above and behind the symphysis.
The anterior shoulder is thus either depressed or rotated, or
both, so the shoulders occupy the oblique plane of the pelvis
and the anterior shoulder can be freed.
The McRoberts maneuverr was described by Gonik and
associates (1983) and named for William A. McRoberts,
Jr., who popularized its use at the University of Texas at
Houston. The maneuver consists of removing the legs from
the stirrups and sharply flexing them up onto the abdomen
(Fig. 27-7). Gherman and associates (2000) analyzed the
McRoberts maneuver using x-ray pelvimetry. They found
that the procedure caused straightening of the sacrum relative to the lumbar vertebrae, rotation of the symphysis pubis
toward the maternal head, and a decrease in the angle of pelvic inclination. Although this does not increase pelvic dimensions, pelvic rotation cephalad tends to free the impacted
anterior shoulder. Gonik and coworkers (1989) tested the
McRoberts position objectively with laboratory models and
found that the maneuver reduced the forces needed to free
the fetal shoulder.

FIGURE 27-7 The McRoberts maneuver. The maneuver consists of removing the legs from the stirrups and sharply flexing the thighs up
onto the abdomen. The assistant is also providing suprapubic pressure simultaneously (arrow).


Vaginal Delivery

543

CHAPTER 27

A
FIGURE 27-9 Woods maneuver. The hand is placed behind the
posterior shoulder of the fetus. The shoulder is then rotated
progressively 180 degrees in a corkscrew manner so that the
impacted anterior shoulder is released.

B

C
FIGURE 27-8 Delivery of the posterior shoulder for relief of
shoulder dystocia. A. The operator’s hand is introduced into
the vagina along the fetal posterior humerus. B. The arm is
splinted and swept across the chest, keeping the arm flexed at
the elbow. C. The fetal hand is grasped and the arm extended
along the side of the face. The posterior arm is delivered from
the vagina.

Another maneuver, delivery of the posterior shoulder, consists
of carefully sweeping the posterior arm of the fetus across its
chest, followed by delivery of the arm. The shoulder girdle is
then rotated into one of the oblique diameters of the pelvis with
subsequent delivery of the anterior shoulder (Fig. 27-8).
Woods (1943) reported that by progressively rotating the
posterior shoulder 180 degrees in a corkscrew fashion, the
impacted anterior shoulder could be released. This is frequently
referred to as the Woods corkscrew maneuverr (Fig.  27-9).
Rubin (1964) recommended two maneuvers. First, the fetal
shoulders are rocked from side to side by applying force to

the maternal abdomen. If this is not successful, the pelvic
hand reaches the most easily accessible fetal shoulder, which
is then pushed toward the anterior surface of the chest. This
maneuver most often abducts both shoulders, which in turn
produces a smaller shoulder-to-shoulder diameter. This permits displacement of the anterior shoulder from behind the
symphysis (Fig. 27-10).
Importantly, progression from one maneuver to the next
should be organized and methodical. As noted, the urgency to
relieve the dystocia should be balanced against potentially injurious traction forces and manipulations. Lerner and coworkers (2011) in their evaluation of 127 shoulder dystocia cases
reported that all neonates without sequelae from shoulder
dystocia were born by 4 minutes. Conversely, most depressed
neonates—57 percent—had head-to-body delivery intervals
> 4 minutes. The percentage of depressed neonates rose sharply
after 3 minutes.
Deliberate fracture of the anterior claviclee by using the thumb
to press it toward and against the pubic ramus can be attempted
to free the shoulder impaction. In practice, however, deliberate
fracture of a large neonate clavicle is difficult. If successful, the
fracture will heal rapidly and is usually trivial compared with
brachial nerve injury, asphyxia, or death.


544

Delivery

SECTION 8
A

B

FIGURE 27-10 The second Rubin maneuver. A. The shoulder-to-shoulder diameter is aligned vertically. B. The more easily accessible
fetal shoulder (the anterior is shown here) is pushed toward the anterior chest wall of the fetus (arrow). Most often, this results in
abduction of both shoulders, which reduces the shoulder-to-shoulder diameter and frees the impacted anterior shoulder.

Hibbard (1982) recommended that pressure be applied to
the fetal jaw and neck in the direction of the maternal rectum,
with strong fundal pressure applied by an assistant as the anterior shoulder is freed. Strong fundal pressure, however, applied
at the wrong time may result in even further impaction of the
anterior shoulder. Gross and associates (1987) reported that
fundal pressure in the absence of other maneuvers “resulted in
a 77-percent complication rate and was strongly associated with
(fetal) orthopedic and neurologic damage.”
Sandberg (1985) reported the Zavanelli maneuverr for cephalic
replacement into the pelvis followed by cesarean delivery. The
first part of the maneuver consists of returning the head to the
occiput anterior or posterior position. Terbutaline, 0.25 mg, is
given subcutaneously to produce uterine relaxation. The operator flexes the head and slowly pushes it back into the vagina.
Cesarean delivery is then performed. Sandberg (1999) reviewed
103 reported cases in which the Zavanelli maneuver was used.
It was successful in 91 percent of cephalic cases and in all cases
of breech head entrapments. Despite successful replacement,
fetal injuries were common but may have resulted from the
multiple manipulations used before the Zavanelli maneuver
(Sandberg, 2007). Six stillbirths, eight neonatal deaths, and 10
neonates who suffered brain damage were described. Uterine
rupture also was reported.
Symphysiotomy, in which the intervening symphyseal cartilage and much of its ligamentous support is cut to widen the
symphysis pubis, is described in Chapter 28 (p. 567). It has
been used successfully for shoulder dystocia (Hartfield, 1986).

Goodwin and colleagues (1997) reported three cases in which
symphysiotomy was performed after the Zavanelli maneuver
had failed. All three neonates died, and maternal morbidity was
significant due to urinary tract injury. Cleidotomyy consists of
cutting the clavicle with scissors or other sharp instruments and
is usually done for a dead fetus (Schramm, 1983).

Hernandez and Wendel (1990) suggested use of a shoulder
dystocia drilll to better organize emergency management:
1. Call for help—mobilize assistants and anesthesia and pediatric personnel. Initially, a gentle attempt at traction is made.
Drain the bladder if it is distended.
2. A generous episiotomy may be desired to afford room posteriorly.
3. Suprapubic pressure is used initially by most practitioners
because it has the advantage of simplicity. Only one assistant is needed to provide suprapubic pressure, while normal
downward traction is applied to the fetal head.
4. The McRoberts maneuver requires two assistants. Each assistant grasps a leg and sharply flexes the maternal thigh against
the abdomen.
These maneuvers will resolve most cases of shoulder dystocia.
If the above listed steps fail, the following steps may be
attempted, and any of the maneuvers may be repeated:
5. Delivery of the posterior arm is attempted. With a
fully extended arm, however, this is usually difficult to
accomplish.
6. Woods screw maneuver is applied.
7. Rubin maneuver is attempted.
Other techniques generally should be reserved for cases in
which all other maneuvers have failed. These include intentional
fracture of the anterior clavicle and the Zavanelli maneuver. The
American College of Obstetricians and Gynecologists (2012b)
has concluded that no one maneuver is superior to another

in releasing an impacted shoulder or reducing the chance of
injury. Performance of the McRoberts maneuver, however, was
deemed a reasonable initial approach. The College (2012a) also
has created a Patient Safety Checklist to guide the documentation process with shoulder dystocia.


Vaginal Delivery

CHAPTER 27

Shoulder dystocia training and protocols using simulationbased education and drills has evidence-based support. These
tools improve performance and retention of drill steps (Buerkle,
2012; Crofts, 2008; Grobman, 2011). Their use has translated
into improved neonatal outcome in some, but not all, investigations (Draycott, 2008; Inglis, 2011; Walsh, 2011).

SPECIAL POPULATIONS
Typical vaginal delivery may be challenging in women with
perineal limitations or with a large anomalous fetus. Delivery in
women with prior pelvic reconstructive surgeries and in those
with scarring from female genital mutilation is described here.
The special needs of women with congenital vaginal septa, giant
condyloma, Crohn disease, or connective-tissue disorders are
discussed in chapters covering those topics.

■ Female Genital Mutilation
Inaccurately called female circumcision, mutilation refers to
medically unnecessary vulvar and perineal modification. In
the United States it is a federal crime to perform unnecessary genital surgery on a girl younger than 18 years. That said,
forms of female genital mutilation are practiced in countries
throughout Africa, the Middle East, and Asia. As many as 130

million women worldwide have undergone one of these procedures, and approximately 230,000 live in the United States
(Nour, 2006). Cultural sensitivity is imperative, because many
women may be offended by the suggestion that they have been
assaulted or mutilated (American College of Obstetricians and
Gynecologists, 2007).
The World Health Organization (1997) classifies genital mutilations into four types (Table 27-1). Complications
include infertility, dysmenorrhea, diminished sexual quality of
life, and propensity for vulvovaginal infection (Almroth, 2005;
Andersson, 2012; Nour, 2006). In general, women with significant symptoms following type III procedures are candidates for
corrective surgery. Specifically, division of midline scar tissue
to reopen the vulva is termed defibulation or deinfibulation.
Female genital mutilation has been associated with some
adverse maternal and neonatal complications. The World Health

TABLE 27-1. World Health Organization Classification
of Female Genital Mutilation
Type I Prepuce excision with or without clitoral excision
Type II Clitoral excision with or without partial or total
labia minora excision
Type III Partial or complete labial minora and/or majora
excision with or without clitoridectomy and
then fusion of the wound, termed
infibulation.
Type IV Unclassified and includes pricking, piercing,
incision, stretching, and introduction of
corrosive substances into the vagina
Adapted from the World Health Organization, 1997.

545

FIGURE 27-11 Process of defibulation. Although not shown here,
lidocaine is first infiltrated along the planned incision. As protection, two fingers of one hand are insinuated behind the shelf
created by fused labia but in front of the urethra and crowning
head. The shelf is then incised in the midline. After delivery, the
raw edges are sutured with rapidly absorbable material to secure
hemostasis. (From Rouzi, 2012, with permission.)

Organization (2006) estimated that these procedures increased
perinatal morbidity rates by 10 to 20 per 1000. Small increased
risks for prolonged labor, cesarean delivery, postpartum hemorrhage, and early neonatal death are found by some but not all
(Chibber, 2011; Rouzi, 2012; Wuest, 2009). Importantly, the
psychiatric consequences can be profound.
For those women who do not desire defibulation until
they become pregnant, the procedure can be done at midpregnancy using spinal analgesia (Nour, 2006). Or, as shown
in Figure  27-11, another option is to wait until delivery. In
women not undergoing defibulation, anal sphincter tear rates
with vaginal delivery may be increased (Berggren, 2013;
Wuest, 2009). In our experiences, intrapartum defibulation
in many cases allows successful vaginal delivery without major
complications.

■ Prior Pelvic Reconstructive Surgery
These surgeries are performed with increasing frequency in
reproductive-aged women, and thus pregnancy following these
procedures is not uncommon. Logically, there are concerns
for symptom recurrence following vaginal delivery, and highquality data to aid evidenced-based decisions are limited.
For women with prior stress urinary incontinence surgery,
slightly greater protection against postpartum incontinence is
gained by elective cesarean delivery (Pollard, 2012; Pradhan,
2013). Stated another way, most women with prior anti-incontinence surgery can be delivered vaginally without symptom

recurrence. Also, cesarean delivery is not always protective.


546

Delivery

SECTION 8

Obviously, symptom recurrence and the need for additional
vaginal surgery should be weighed against the surgical risk of
cesarean delivery (Groenen, 2008). In those with prior surgeries for anal incontinence or pelvic organ prolapse, only scant
information regarding outcomes is available. Such cases require
individualization.

■ Anomalous Fetuses
Rarely, delivery can be obstructed by extreme macrocephaly secondary to hydrocephaly or by massive fetal abdomen
enlargement from a greatly distended bladder, ascites, or large
kidneys or liver. With milder forms of hydrocephaly, if the
biparietal diameter is < 10 cm or if the head circumference
is < 36 cm, then vaginal delivery may be permitted (Anteby,
2003).
In rare cases in which neonatal death has occurred or is
certain due to associated anomalies, vaginal delivery may be
reasonable, but the head or abdomen must be reduced in size
for delivery. Removal of fluid by cephalocentesis or paracentesis with sonographic guidance can be performed intrapartum.
For hydrocephalic fetuses that are breech, cephalocentesis can
be accomplished suprapubically when the aftercoming head
enters the pelvis. For those that require cesarean delivery, fluid
removal before hysterotomy circumvents extending a low transverse or lengthening a vertical incision.

FIGURE 27-12 Expression of placenta. Note that the hand is not
trying to push the fundus of the uterus through the birth canal! As
the placenta leaves the uterus and enters the vagina, the uterus
is elevated by the hand on the abdomen while the cord is held
in position. The mother can aid in the delivery of the placenta by
bearing down. As the placenta reaches the perineum, the cord is
lifted, which in turn lifts the placenta out of the vagina.

THIRD STAGE OF LABOR
■ Delivery of the Placenta
Third-stage labor begins immediately after fetal birth and ends
with placental delivery. Goals include delivery of an intact
placenta and avoidance of uterine inversion or postpartum
hemorrhage. The latter two are grave intrapartum complications and constitute emergencies, as described in Chapter 41
(p. 783).
Immediately after newborn birth, uterine fundal size
and consistency are examined. If the uterus remains firm
and there is no unusual bleeding, watchful waiting until
the placenta separates is the usual practice. Massage is not
employed, but the fundus is frequently palpated to ensure
that it does not become atonic and filled with blood from
placental separation. To prevent uterine inversion, umbilical
cord traction must not be used to pull the placenta from the
uterus. Moreover, placental expression is not forced before
placental separation. Signs of separation include a sudden
gush of blood into the vagina, a globular and firmer fundus,
a lengthening of the umbilical cord as the placenta descends
into the vagina, and a rise of the uterus into the abdomen.
With the last, the placenta, having separated, passes down

into the lower uterine segment and vagina. Here, its bulk
pushes the uterus upward.
These signs sometimes appear within 1 minute after
newborn delivery and usually within 5 minutes. Once the
placenta has detached from the uterine wall, it should be
determined that the uterus is firmly contracted. The mother

may be asked to bear down, and the intraabdominal pressure
often expels the placenta into the vagina. These efforts may
fail or may not be possible because of analgesia. After ensuring that the uterus is contracted firmly, pressure is exerted by
a hand wrapped around the fundus to propel the detached
placenta into the vagina (Fig. 27-12). The umbilical cord is
kept slightly taut but is not pulled. Concurrently, the heel of
the hand exerts downward pressure between the symphysis
pubis and the uterine fundus. This also aids inversion prevention. Once the placenta passes through the introitus, pressure
on the uterus is relieved. The placenta is then gently lifted
away (Fig. 27-13). Care is taken to prevent placental membranes from being torn off and left behind. If the membranes
begin to tear, they are grasped with a clamp and removed by
gentle teasing (Fig. 27-14).

■ Manual Removal of Placenta
Occasionally, the placenta will not separate promptly. This is
especially common with preterm delivery (Dombrowski, 1995).
If there is brisk bleeding and the placenta cannot be delivered
by the above technique, manual removal of the placenta is indicated, using the safeguards described in Chapter 41 (p. 784).
It is unclear how much time should elapse in the absence of
bleeding before the placenta is manually removed (DeneuxTharaux, 2009). If labor analgesia is still intact, some obstetricians practice routine manual removal of any placenta that has
not separated spontaneously by the time they have completed

Vaginal Delivery

547

■ Management of the Third Stage

delivery of the newborn and care of the cord. The benefits of
this practice, however, have not been proven, and most obstetricians await spontaneous placental detachment unless bleeding
is excessive. When manual removal is performed, some administer a single dose of intravenous antibiotics similar to that used
for cesarean infection prophylaxis (Chap. 30, p. 590). The
American College of Obstetricians and Gynecologists (2011)
has concluded that there are no data to either support or refute
this practice.

High-Dose Oxytocin

FIGURE 27-14 Membranes that were somewhat adhered to the
uterine lining are separated by gentle traction with a ring forceps.

Synthetic oxytocin is identical to that produced by the posterior
pituitary. Its action is noted at approximately 1 minute, and it
has a mean half-life of 3 to 5 minutes. When given as a bolus,
oxytocin can cause profound hypotension. Secher and coworkers (1978) reported that an intravenous bolus of 10 units of
oxytocin caused a marked transient fall in blood pressure with
an abrupt increase in cardiac output. Svanström and associates
(2008) confirmed those findings in 10 healthy women following cesarean delivery. Mean pulse rate increased 28 bpm, mean
arterial pressure decreased 33 mm Hg, and electrocardiogram
changes of myocardial ischemia as well as chest pain and subjective discomfort were noted. These hemodynamic changes could
be dangerous for women hypovolemic from hemorrhage or
those with cardiac disease. Thus, oxytocin should not be given

CHAPTER 27

FIGURE 27-13 The placenta is removed from the vagina by
lifting the cord.

Practices within the third stage of labor may be broadly
considered as either physiological or active management.
Physiological or expectant management involves waiting for
placental separation signs and allowing the placenta to deliver
either spontaneously or aided by nipple stimulation or gravity (World Health Organization, 2012). In contrast, active
management of third-stage labor consists of early cord clamping, controlled cord traction during placental delivery, and
immediate administration of prophylactic uterotonics. The
goal of this triad is to limit postpartum hemorrhage (Begley,
2011; Jangsten, 2011; Prendiville, 1988). In addition, uterine massage following placental delivery is recommended by
many but not all to prevent postpartum hemorrhage. We
support this with the caveat that evidence for this practice is
not strong (Abdel-Aleem, 2010). As noted earlier (p. 539),
immediate cord clamping does not increase postpartum
hemorrhage rates and thus is a less important component
of this trio. Similarly, cord traction may also be less critical
(Gülmezoglu, 2012).
Therefore, uterotonics appear to be the most important factor to decrease postpartum blood loss. Choices include oxytocin (Pitocin), misoprostol (Cytotec), carboprost (Hemabate),
and the ergots, namely ergonovine (Ergotrate) and methylergonovine (Methergine). In addition, a combination agent of
oxytocin and ergonovine (Syntometrine) is used outside the
United States. Also in other countries, carbetocin (Duratocin),
a long-acting oxytocin analogue, is available and effective for
hemorrhage prevention during cesarean delivery (Attilakos,
2010; Su, 2012). Of these, the World Health Organization
(2012) recommends oxytocin as a first-line agent. Ergot-based

drugs and misoprostol are alternatives in settings that lack
oxytocin.
Uterotonics may be given before or after placental expulsion without increasing rates of postpartum hemorrhage, placental retention, or third-stage labor length (Soltani, 2010).
If they are given before delivery of the placenta, however,
they may entrap an undiagnosed, undelivered second twin.
Thus, abdominal palpation should confirm no additional
fetuses.


548

Delivery

SECTION 8

intravenously as a large bolus. Rather, it should be given as
a dilute solution by continuous intravenous infusion or as an
intramuscular injection.
Water intoxication can result from the antidiuretic action
of high-dose oxytocin if administered in a large volume of
electrolyte-free dextrose solution (Whalley, 1963). In a case
report, Schwartz and Jones (1978) described convulsions in
both a mother and her newborn following administration of
6.5 liters of 5-percent dextrose solution and 36 units of oxytocin before delivery. The cord plasma sodium concentration was
114 mEq/L. Accordingly, if oxytocin is to be administered in
high doses for a considerable period of time, its concentration
should be increased rather than increasing the infusion flow
rate (Chap. 26, p. 530).
Despite the routine use of oxytocin, no standard prophylactic dose has been established for its use following either
vaginal or cesarean delivery. In an analysis of studies that

compared oxytocin dosage, investigators found higher infusion doses to be more effective than lower doses or protracted
fixed-dose administration (Roach, 2013; Tita, 2012). Our
standard practice, if an intravenous infusion is established, is
to add 20 units (2 mL) of oxytocin per liter of infusate. This
solution is administered after delivery of the placenta at a rate
of 10 to 20 mL/min (200 to 400 mU/min) for a few minutes until the uterus remains firmly contracted and bleeding
is controlled. The infusion rate then is reduced to 1 to 2 mL/
min until the mother is ready for transfer from the recovery
suite to the postpartum unit. The infusion is usually then discontinued. For women without intravenous access, 10  units
of intramuscular oxytocin are provided.

Ergonovine and Methylergonovine
These ergot alkaloids have similar activity levels in myometrium, and only methylergonovine is currently manufactured
in the United States. These agents require very specific storage
conditions, as they deteriorate rapidly with exposure to light,
heat, and humidity.
Whether given intramuscularly or orally, both are
powerful stimulants of myometrial contraction, exerting
an effect that may persist for hours. In pregnant women,
an intramuscular or oral dose of 0.2 mg results in tetanic
uterine contractions. Effects develop within a few minutes
after intramuscular or oral administration. Moreover, the
response is sustained with little tendency toward relaxation.
Ergots are dangerous for the fetus and mother when given before
delivery. Moreover, cases of serious injury and death have
been reported when methylergonovine was administered
accidentally to newborns in the labor and delivery room
instead of vitamin K, hepatitis B vaccine, or naloxone (Aeby,
2003; American Regent, 2012a; Bangh, 2005). The Food
and Drug Administration (2012) has added a warning to the

package insert recommending a 12-hour delay between the
last methylergonovine dose and breast feeding. Despite this,
no adverse effects attributable to this drug in breast milk
have been reported (Briggs, 2011).
In addition to neonatal concerns, parenteral administration of ergot alkaloids, especially by the intravenous route,
may induce transient maternal hypertension. Other reported

side effects include nausea, vomiting, tinnitus, headache, and
painful uterine contractions. Hypertension is more likely to be
severe in women with gestational hypertension. These drugs
are contraindicated in patients with hypertension, cardiac disease or occlusive vascular disorders, severe hepatic or renal
disease, and sepsis (Novartis, 2012; Sanders-Bush, 2011).
Moreover, this drug is not routinely given intravenously to
avoid inducing sudden hypertensive and cerebrovascular accidents. If considered a lifesaving measure, however, intravenous methylergonovine should be given slowly during no less
than 60 seconds with careful monitoring of blood pressure
(American Reagent, 2012b).
Ergot alkaloid agents do not provide superior protection against
postpartum hemorrhage compared with oxytocin. Moreover,
safety and tolerability are greater with oxytocin (Liabsuetrakul,
2007). For these reasons, ergot alkaloid agents are considered
second-line for third-stage labor prevention of hemorrhage.

Misoprostol
This prostaglandin E1 analogue has proved inferior to oxytocin for postpartum hemorrhage prevention (Tunçalp, 2012).
Although oxytocin is preferred, in resource-poor settings that
lack oxytocin, misoprostol is suitable for hemorrhage prophylaxis and is given as a single oral 600-μg dose (Mobeen, 2011;
World Health Organization, 2012). Side effects include shivering in 30 percent and fever in 5 percent. Unlike some other
prostaglandins, nausea or diarrhea is infrequent (Derman,
2006; Lumbiganon, 1999; Walraven, 2005).

“FOURTH STAGE” OF LABOR
The hour immediately following delivery of the placenta is
critical, and it has been designated by some as the fourth
stage of labor. During this time, lacerations are repaired.
Although uterotonics are administered, postpartum hemorrhage as the result of uterine atony is most likely at this
time. Hematomas may expand. Consequently, uterine tone
and the perineum should be frequently evaluated. The
American Academy of Pediatrics and the American College
of Obstetricians and Gynecologists (2012) recommend that
maternal blood pressure and pulse be recorded immediately
after delivery and every 15 minutes for the first 2 hours. The
placenta, membranes, and umbilical cord should be examined for completeness and for anomalies, as described in
Chapter 6 (p. 117).

■ Birth Canal Lacerations
Lower genital tract lacerations may involve the cervix, vagina,
or perineum. Those of the cervix and vagina are described in
Chapter 41 (p. 788). Perineal tears may follow any vaginal
delivery and are classified by their depth. Complete definitions and visual examples are given in Figure 27-15. As noted,
third- and fourth-degree lacerations are considered higher-order
lacerations. Short-term, these are associated with greater blood
loss, puerperal pain, and wound disruption or infection risk.


Vaginal Delivery

549

CHAPTER 27

Bulbocavernosus
Bu
e
m.

Superficia
al
transverse
e
perineal m
m.

A

First degree
g

B

Seco d deg
Second
degree
ee

External
anal
sphincter

Internal
In

n anal
sphincter
Recta
al
muco
osa

C

Third degree
g

D

Four th degree
g

FIGURE 27-15 Classification of perineal lacerations. A. First-degree lacerations involve the fourchette, perineal skin, and vaginal mucous
membrane but not the underlying fascia and muscle. These included periurethral lacerations, which may bleed profusely. B. Seconddegree lacerations involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter. These tears may be
midline, but often extend upward on one or both sides of the vagina, forming an irregular triangle. C. Third-degree lacerations extend
farther to involve the external anal sphincter. D. Fourth-degree lacerations extend completely through the rectal mucosa to expose
its lumen and thus involves disruption of both the external and internal anal sphincters. (Used with permission from Drs. Shayzreen
Roshanravan and Marlene Corton.)

Long-term, they are linked with higher rates of anal incontinence
and dyspareunia. The incidence of higher-order lacerations
varies from 0.25 to 6 percent (Garrett, 2014; Groutz, 2011;
Melamed, 2013; Stock, 2013). Risk factors for these more complex lacerations include midline episiotomy, nulliparity, longer second-stage labor, precipitous delivery, persistent occiput
posterior position, operative vaginal delivery, Asian race, and
increasing fetal birthweight (Landy, 2011; Melamed, 2013).

Epidural analgesia was found to be protective (Jango, 2014).
Morbidity rates rise as laceration severity increases. Stock
and coworkers (2013) reported that approximately 7 percent of

909 higher-order lacerations had complications. Williams and
Chames (2006) found that mediolateral episiotomy was the
most powerful predictor of wound disruption. Goldaber and
associates (1993) found that 21 of 390 or 5.4 percent of women
with fourth-degree lacerations experienced significant morbidity. There were 1.8 percent dehiscences, 2.8 percent infections
plus a dehiscence, and 0.8 percent with isolated infections.
The repair of perineal lacerations is virtually the same as
that of episiotomy incisions, albeit sometimes less satisfactory
because of tear irregularities. Thus, laceration repair technique
is discussed with episiotomy repair.


550

Delivery

SECTION 8
FIGURE 27-16 Midline episiotomy. Two fingers are insinuated
between the perineum and fetal head, and the episiotomy is
then cut vertically downward.

■ Episiotomy
The word episiotomy derives from the Greek episton—pubic
region—plus –tomy—to
y
cut. In a strict sense, episiotomy

is incision of the pudendum—the external genital organs.
Perineotomy is incision of the perineum. In common parlance,
however, the term episiotomy often is used synonymously with
perineotomy,
y a practice that we follow here. The incision may
be made in the midline, creating a median or midline episiotomy (Fig. 27-16). It may also begin off the midline and
directed laterally and downward away from the rectum, termed
a mediolateral episiotomy.

Carroli and Mignini (2009) reviewed the Cochrane
Pregnancy and Childbirth Group trials registry. There were
lower rates of posterior perineal trauma, surgical repair, and
healing complications in women managed with a restrictive use
of episiotomy. Alternatively, the incidence of anterior perineal
trauma was lower in the group managed with routine use of
episiotomy.
With these findings came the realization that episiotomy did
not protect the perineal body but contributed to anal sphincter
incontinence by increasing the risk of higher-order lacerations.
Signorello and associates (2000) reported that fecal and flatal
incontinence was increased four- to sixfold in women with an
episiotomy compared with a group of women delivered with an
intact perineum. Even compared with spontaneous lacerations,
episiotomy tripled the risk of fecal incontinence and doubled
it for flatal incontinence. Episiotomy without extension did
not lower this risk. Despite repair of a third-degree extension,
30 to 40 percent of women have long-term anal incontinence
(Gjessing, 1998; Poen, 1998). Finally, Alperin and associates
(2008) reported that episiotomy performed for the first delivery
conferred a fivefold risk for second-degree or higher-order laceration with the second delivery.

The American College of Obstetricians and Gynecologists
(2013a) has concluded that restricted use of episiotomy is
preferred to routine use. We are of the view that the procedure should be applied selectively for appropriate indications.
Thus, episiotomy should be consideredd for indications such
as shoulder dystocia, breech delivery, macrosomic fetuses,
operative vaginal deliveries, persistent occiput posterior positions, and other instances in which failure to perform an episiotomy will result in significant perineal rupture. The final
rule is that there is no substitute for surgical judgment and
common sense.

Episiotomy Type and Timing
Episiotomy Indications and Consequences
Although episiotomy is still a common obstetrical procedure, its use has decreased remarkably over the past 30 years.
Oliphant and coworkers (2010) used the National Hospital
Discharge Survey to analyze episiotomy rates between 1979
and 2006 in the United States. They noted a 75-percent
decline in the episiotomy age-adjusted rate. Through the
1970s, however, it was common practice to cut an episiotomy for almost all women having their first delivery. The
reasons for its popularity included substitution of a straight
surgical incision, which was easier to repair, for the ragged
laceration that otherwise might result. The long-held beliefs
that postoperative pain is less and healing improved with an
episiotomy compared with a tear, however, appeared to be
incorrect (Larsson, 1991).
Another commonly cited but unproven benefit of routine
episiotomy was that it prevented pelvic floor disorders. A number of observational studies and randomized trials, however,
showed that routine episiotomy is associated with an increased
incidence of anal sphincter and rectal tears (Angioli, 2000;
Nager, 2001; Rodriguez, 2008).

Before episiotomy, analgesia may be provided by existing labor

epidural analgesia, by bilateral pudendal nerve blockade, or by
infiltration of 1-percent lidocaine. If performed unnecessarily early, bleeding from the episiotomy may be considerable
during the interval between incision and delivery. If it is performed too late, lacerations will not be prevented. Typically,
episiotomy is completed when the head is visible during a
contraction to a diameter of approximately 4 cm, that is,
crowning. When used in conjunction with forceps delivery,
most perform an episiotomy after application of the blades
(Chap. 29, p. 580).

Technique
For midline episiotomy, fingers are insinuated between the
crowning head and the perineum. The scissors are positioned at
6 o’clock on the vaginal opening and directed posteriorly (see
Fig. 27-16). The incision length varies from 2 to 3 cm depending
on perineal length and degree of tissue thinning. The incision
is customized for specific delivery needs but should stop well
before reaching the external anal sphincter. With mediolateral


Vaginal Delivery

TABLE 27-2. Midline versus Mediolateral Episiotomy
Type of Episiotomy
Midline

Mediolateral

Surgical repair
Faulty healing
Postoperative pain

Anatomical results
Blood loss
Dyspareunia
Extensions

Easy
Rare
Minimal
Excellent
Less
Rare
Common

More difficult
More common
Common
Occasionally faulty
More
Occasional
Uncommon

operative vaginal delivery, several studies have reported a protective effect from mediolateral episiotomy against higher-order perineal lacerations (de Leeuw, 2008; de Vogel, 2012; Hirsch, 2008).

Repair of Episiotomy or Perineal Laceration

episiotomy, scissors are positioned at 7 o’clock or at 5 o’clock,
and the incision is extended 3 to 4 cm toward the ipsilateral
ischial tuberosity.
Differences between the two types of episiotomies are summarized in Table 27-2. Except for the important issue of thirdand fourth-degree extensions, midline episiotomy is superior.
Anthony and colleagues (1994) presented data from the Dutch

National Obstetric Database of more than 43,000 deliveries.
They found a more than fourfold decrease in severe perineal lacerations following mediolateral episiotomy compared with rates
after midline incision. Proper selection of cases can minimize this
one disadvantage. For example, if episiotomy is required during

Typically, episiotomy repair is deferred until the placenta has
been delivered. This policy permits undivided attention to the
signs of placental separation and delivery. A further advantage
is that episiotomy repair is not interrupted or disrupted by the
obvious necessity of delivering the placenta, especially if manual
removal must be performed that may disrupt a newly repaired
episiotomy. The major disadvantage is continuing blood loss
until the repair is completed. Direct pressure from an applied
gauze sponge will help to limit this loss.
For suitable repair, an understanding of perineal support
and anatomy is necessary and is discussed in Chapter 2 (p. 21).
Adequate analgesia is imperative, and Sanders and coworkers
(2002) emphasized that women without regional analgesia
can experience high levels of pain during perineal suturing.
Again, local lidocaine can be used solely or as a supplement
to bilateral pudendal nerve blockade. In those with epidural
analgesia, additional dosing may be necessary.
There are many ways to repair an episiotomy incision,
but hemostasis and anatomical restoration without excessive suturing are essential. A technique that commonly is
employed for midline repair is shown in Figure 27-17. Some

A

B

FIGURE 27-17 Repair of midline episiotomy. A. Disruption of the hymenal ring and bulbocavernosus and superficial transverse perineal muscles are seen within the diamond-shaped episiotomy incision. B. An anchor stitch is placed above the wound apex to begin
a running closure. Absorbable 2–0 or 3–0 suture is used for continuous closure of the vaginal mucosa and submucosa with interlocking
stitches. (continued)

CHAPTER 27

Characteristic

551


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C

D

E

FIGURE 27-17 (Continued) C. After closing the vaginal incision and reapproximating the cut margins of the hymenal ring, the needle
and suture are positioned to close the perineal incision. D. A continuous closure with absorbable 2–0 or 3–0 suture is used to close the
fascia and muscles of the incised perineum. This aids restoration of the perineal body for long-term support. E. The continuous suture is
then carried upward as a subcuticular stitch. The final knot is tied proximal to the hymenal ring.

studies have found similar postoperative pain scores using
either continuous or interrupted closure (Kindberg, 2008;
Valenzuela, 2009). Others note less pain with continuous

suturing (Kettle, 2012). Moreover, continuous suturing is
faster and uses less suture material. Mornar and Perlow (2008)
have shown that blunt needles are suitable and likely decrease
the incidence of needlestick injuries. The suture material commonly used is 2–0 chromic catgut. Sutures made of polyglycolic acid derivatives are also frequently used. A decrease in
postsurgical pain is cited as the major advantage of synthetic
materials. Closures with these materials, however, occasionally require suture removal from the repair site because of pain
or dyspareunia. According to Kettle and associates (2002),
this disadvantage may be reduced using a rapidly absorbed
polyglactin 910 (Vicryl Rapide).
Repair of a mediolateral episiotomy is similar to a midline
repair. The technique is shown in Figure 27-18.

Fourth-Degree Laceration Repair

FIGURE 27-18 Mediolateral episiotomy repair. The vaginal
mucosa is shown as already closed using 2–0 absorbable suture
in a running interlocking stitch similar to that for midline repair.
As illustrated, perineal reapproximation begins with reunion of
bulbocavernosus and transverse perineal muscles. These will
assist reestablishment of perineal body support. Distal to these
muscles, abundant fat in the ischiorectal fossa is incorporated in
the same running closure. A second layer atop this first perineal
layer may be required to adequately close dead space. The skin is
then closed with a subcuticular stitch as used for midline closure.

Two methods are used to repair a laceration involving the
anal sphincter and rectal mucosa. The first is the end-to-end
technique, which we prefer, and the second is the overlapping
technique.
The end-to-end techniquee is shown in Figure 27-19. In all

techniques that have been described, it is essential to approximate the torn edges of the rectal mucosa with sutures placed in
the rectal muscularis approximately 0.5 cm apart. One suitable
choice is 2–0 or 3–0 chromic gut. This muscular layer then
is covered by reapproximation of the internal anal sphincter.
Finally, the cut ends of the external anal sphincter are isolated,
approximated, and sutured together end-to-end with three or
four interrupted stitches. The remainder of the repair is the
same as for a midline episiotomy.


Vaginal Delivery

A

Postepisiotomy Pain
Pudendal nerve blockade can aid relief of perineal pain postoperatively (Aissaoui, 2008). Locally applied ice packs help
reduce swelling and allay discomfort. Topical application of
5-percent lidocaine ointment was not effective in relieving
episiotomy or perineal laceration discomfort in one randomized trial (Minassian, 2002). Analgesics such as codeine give
considerable relief. Because pain may be a signal of a large
vulvar, paravaginal, or ischiorectal fossa hematoma or perineal cellulitis, these sites should be examined carefully if pain
is severe or persistent. Management of these complications
is discussed in Chapters 37 and 41 (p. 689 and p. 790). In
addition to pain, urinary retention may complicate episiotomy recovery (Mulder, 2012). Its management is described
in Chapter 36 (p. 676).
For those with second-degree or greater lacerations, intercourse is usually proscribed until after the first puerperal visit
at 4 to 6 weeks. Signorello and coworkers (2001) surveyed 615
women 6 months postpartum and reported that those delivered with an intact perineum reported better sexual function
compared with those who had perineal trauma. In another

B

FIGURE 27-19 Layered repair of a fourth-degree perineal laceration. A. Approximation of the anorectal mucosa and submucosa in
a running or interrupted fashion using fine absorbable suture such as 3–0 or 4–0 chromic or Vicryl. During this suturing, the superior
extent of the anterior anal laceration is identified, and the sutures are placed through the submucosa of the anorectum approximately
0.5 cm apart down to the anal verge. B. A second layer is placed through the rectal muscularis using 3–0 Vicryl suture in a running or
interrupted fashion. This “reinforcing layer” should incorporate the torn ends of the internal anal sphincter, which is identified as the
thickening of the circular smooth muscle layer at the distal 2 to 3 cm of the anal canal. It can be identified as the glistening white
fibrous structure lying between the anal canal submucosa and the fibers of the external anal sphincter (EAS). In many cases, the internal
sphincter retracts laterally and must be sought and retrieved for repair. (continued)

CHAPTER 27

The overlapping techniquee is an alternative method to approximate the external anal sphincter. Data based on randomized
controlled trials do not support that this method yields superior
anatomical or functional results compared with those of the traditional end-to-end method (Farrell, 2012; Fitzpatrick, 2000).
We, as well as others, recommend perioperative antimicrobial prophylaxis for the reduction of infectious morbidity associated with higher-order perineal injury repair (Goldaber, 1993;
Stock, 2013). A single dose of a second-generation cephalosporin is suitable, or clindamycin for penicillin-allergic women.
Although such prophylaxis has some evidence-based support,
the American College of Obstetricians and Gynecologists
(2011) has concluded that this practice has not been extensively studied (Duggal, 2008; Stock, 2013). Postoperatively,
stool softeners should be prescribed for a week, and enemas
and suppositories should be avoided.
Unfortunately, normal function is not always ensured even
with correct and complete surgical repair. Some women may
experience continuing fecal incontinence caused by injury
to the innervation of the pelvic floor musculature (Roberts,
1990).

553

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C

D

E

follow-up of 2490 women, Rådestad and associates (2008)
reported delayed intercourse at 3 and 6 months, but not at 1
year, in women with and without perineal trauma.

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558

CHAPTER 28

Breech Delivery

CLASSIFICATION OF BREECH PRESENTATIONS .
DIAGNOSIS .

. . . . . . .

559

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

559

ROUTE OF DELIVERY .

. . . . . . . . . . . . . . . . . . . . . . . . . .

TERM AND PRETERM BREECH FETUS.

. . . . . . . . . . . . . .

560

. . . . . . . . . . . . . . . . . . . . .

561

. . . . . . . . . . . . . . . . . . . . . . . . .

561

DELIVERY COMPLICATIONS .
IMAGING TECHNIQUES

560

DECISION-MAKING SUMMARY

. . . . . . . . . . . . . . . . . . .

MANAGEMENT OF LABOR AND DELIVERY .

. . . . . . . . . .

562

. . . . . . . . . . . . . . . . . . .

563

. . . . . . . . . . . . . . . . . . . .

567

PARTIAL BREECH EXTRACTION
TOTAL BREECH EXTRACTION .

562

ANALGESIA AND ANESTHESIA

. . . . . . . . . . . . . . . . . . .

570

EXTERNAL CEPHALIC VERSION

. . . . . . . . . . . . . . . . . . .

570

INTERNAL PODALIC VERSION .

. . . . . . . . . . . . . . . . . . .

571

Near term, the fetus typically turns spontaneously to a cephalic
presentation as the increasing bulk of the buttocks seeks the
more spacious fundus. However, if the fetal buttocks or legs
enter the pelvis before the head, the presentation is breech. This
fetal lie is more common remote from term as each fetal pole
is of similar bulk earlier in pregnancy (Fig. 28-1). That said,
breech presentation persists at term in 3 to 4 percent of singleton deliveries. The annual rate of breech presentation at delivery
in nearly 270,000 singleton newborns at Parkland Hospital has
varied from only 3.3 to 3.9 percent during the past 30 years.
Current obstetrical thinking regarding vaginal delivery of
the breech fetus has been tremendously influenced by results

reported from the Term Breech Trial Collaborative Group
(Hannah, 2000). This trial included 1041 women randomly
assigned to planned cesarean and 1042 to planned vaginal
delivery. In the planned vaginal delivery group, 57 percent
were actually delivered vaginally. Planned cesarean delivery was
associated with a lower risk of perinatal mortality compared
with planned vaginal delivery—3 per 1000 versus 13 per 1000.
Cesarean delivery was also associated with a lower risk of “serious” neonatal morbidity—1.4 versus 3.8 percent.
The reaction to these findings by the American College of
Obstetricians and Gynecologists (2001) resulted in an abrupt
decline in the rate of attempted vaginal breech deliveries. Since
those times, however, a more moderate plan was reached for
management of breech delivery.
Critics of the Term Breech Trial emphasized that most
of the outcomes included in the “serious” neonatal morbidity composite did not actually portend long-term disability.
Moreover, as data from countries with low perinatal mortality rates became available, they showed infrequent perinatal
deaths, and rates did not differ significantly between modeof-delivery groups. Also, only nulliparas were included in the

Term Breech Trial, and fewer than 10 percent underwent
radiological pelvimetry. And last, the 2-year outcomes for children born during the original multicenter trial showed that
planned cesarean delivery was not associated with a reduction
in the rate of death or developmental delay (Whyte, 2004).
Some of the large studies reporting the safety and risks of vaginal delivery for the term breech singleton are discussed further
on page 561.
These findings prompted the American College of
Obstetricians and Gynecologists (2012b) to modify its stance
on breech presentation, and it currently recommends that “the
decision regarding the mode of delivery should depend on the
experience of the health care provider” and that “planned vaginal
delivery of a term singleton breech fetus may be reasonable under
hospital-specific protocol guidelines.” This has been echoed by


Breech Delivery
50

40
35
30
25
20
15
10
5
24

26

28

30

32
34
Weeks’’ gestation

36

38

40

42

FIGURE 28-1 Prevalence of breech presentation by gestational age at delivery in
58,842 singleton pregnancies at the University of Alabama at Birmingham Hospitals
1991 to 2006. (Data courtesy of Dr. John Hauth and Ms. Sue Cliver.)

other obstetrical organizations (Carbonne, 2001; Kotaska, 2009;
Royal College of Obstetricians and Gynaecologists, 2009).

DIAGNOSIS

CLASSIFICATION OF BREECH PRESENTATIONS

■ Risk Factors

The varying relations between the lower extremities and buttocks of breech fetuses form the categories of frank, complete,

Understanding the clinical settings that predispose to breech
presentation can aid early recognition. Other than early gestational age, risk factors include abnormal amnionic fluid

FIGURE 28-2 Frank breech presentation.

FIGURE 28-3 Complete breech presentation.

CHAPTER 28

Breech presentation (percent)

45

and incomplete breech presentations.
With a frank breech presentation, the
lower extremities are flexed at the hips and
extended at the knees, and thus the feet lie
in close proximity to the head (Fig. 28-2).
A complete breech differs in that one or
both knees are flexed (Fig. 28-3). With
incomplete breech presentation, one or
both hips are not flexed, and one or both
feet or knees lie below the breech, such
that a foot or knee is lowermost in the
birth canal (Fig. 28-4). A footling breech
is an incomplete breech with one or both
feet below the breech.
In perhaps 5 percent of term breech
fetuses, the head may be in extreme

hyperextension. These presentations have
been referred to as the stargazer fetus, and
in Britain as the flying foetus. With such
hyperextension, vaginal delivery may
result in injury to the cervical spinal cord.
Thus, if present after labor has begun,
this is an indication for cesarean delivery
(Svenningsen, 1985).

559