516

C H A PT E R 2 7

Va g i n a l De l ive ry

PREPARATION FOR DELIVERY . . . . . . . . . . . . . . . . . . . . 516 may warrant operative vaginal delivery, described in Chapter
29 (p. 553) . Last, a malpresenting fetus or multifetal gestation
OCCI PUT ANTERIOR POSITION . . . . . . . . . . . . . . . . . . . . 517 in many cases may be delivered vaginally but requires special
PERSISTENT OCCI PUT POSTERIOR POSITION . . . . . . . . 519 techniques. These are described in Chapters 28 (p. 543) and
45 (p. 888).
SHOULDER DYSTOCI A . . . . . . . . . . . . . . . . . . . . . . . . . . . 520

SPECIAL POPU LATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 524 PREPARATION FOR DELIVERY

THIRD STAGE OF LABOR . . . . . . . . . . . . . . . . . . . . . . . . . 525 he end of second-stage labor is heralded as the perineum begins
to distend, the overlying skin becomes stretched, and the fetal scalp
I M M EDIATE POSTPARTUM CARE 527
. . . . . . . . . . . . . . . . . .
is seen through the separating labia. Increased perineal pressure
LACE RATION AND EPISIOTOMY REPAI RS . . . . . . . . . . . 531 from the fetal head creates reflexive bearing-down eforts, which
are encouraged when appropriate. At this time, preparations are
made for delivery. If the bladder is distended, catheterization may

monitoring. s one example, a nuchal cord oten tightens with

be necessary. Continued attention is also given to fetal heart rate

descent and may lead to deepening variable decelerations.

D uring second-stage labor, pushing positions may vary. But
As soon as the head appears at the vulva the physician should for delivery, the dorsal lithotomy position is most common
be ready to restrain its progress. He should hold his hand in and often the most satisfactory. For better exposure, leg hold­
such a manner as to be able to bring it immediatey into ers or stirrups are used. Corton and associates (20 1 2) found no
action, or in many instances the resistance of the vulva is increased rates of perineal lacerations with or without their use.
unexpectedy overcome, and a single pain may be suicient With positioning, legs are not separated too widely or placed
to push the head suddeny through it with a resulting peri­ one higher than the other. Within the leg holder, the popliteal
neal tea. region should rest comfortably in the proximal portion and the
-J. hitridge Williams ( 1 903) heel in the distal portion. he legs are not strapped into the
stirrups, thereby allowing quick flexion of the thighs backward
As described by Williams, the natural culmination of second­ onto the abdomen should shoulder dystocia develop. Legs may
stage labor is controlled vaginal delivery of a healthy neonate cramp during second-stage pushing, and cramping is relieved
with minimal trauma to the mother. Vaginal delivery is the by repositioning the afected leg or by brief massage.
preferred route of delivery for most fetuses, although various Preparation for delivery includes vulvar and perineal cleans­
clinical settings may favor cesarean delivery. Of delivery routes, ing. If desired, sterile drapes may be placed in such a way that
spontaneous vaginal vertex delivery poses the lowest risk of only the immediate area around the vulva is exposed. Scrub­
most maternal comorbidity, and comparisons with cesarean bing, gowning, gloving, and donning protective mask and eye­
delivery are found in Chapter 30 (p. 568). Delivery is usually wear protect both the laboring woman and accoucheur from
spontaneous, although some maternal or fetal complications infectious agents.
 Vag i nal D e l i very 517

OCCIPUT ANTERIOR POSITION

• Delivery of the Head

By the time of perineal distention, the position of the occiput
is usually known. In some cases, however, molding and caput
formation may have precluded early accurate identifi c ation. At
this time, careful assessment is again performed as described in
Chapter 22 (p. 426) . In most cases, position is directly occiput
anterior (OA) or is rotated slightly oblique. B ut, in perhaps 5
percent, occiput posterior (OP) positioning persists.
With each contraction, the vulvovaginal opening is dilated
by the fetal head to gradually form an ovoid and inally, an
almost circular opening (Fig. 27- 1 ) . his encirclement of the
largest head diameter by the vulvar ring is termed crowning.
he perineum thins and may spontaneously lacerate. he anus
becomes greatly stretched, and the anterior wall of the rectum
can easily be seen through it.
Routine episiotomy is no longer recommended, and selective
use aims to enlarge the vaginal opening for specific indications
(p. 529). To limit spontaneous vaginal laceration, some perform F I G U R E 27-2 Del ivery of the head. Th e mouth a ppears over the
antenatal massage of the perineal body to increase perineal dis­ perineu m .
tensibility or intrapartum perineal massage to widen the introitus
for head passage. D uring massage with a lubricant, the perineum avoid expulsive delivery. Slow delivery o f the head may decrease
is grasped in the midline by both hands using the thumb and lacerations (Laine, 2008) . Overall, bracing the perineum low­
opposing ingers. Outward and lateral stretching to thin the ers rates of anal sphincter injury compared with a "hands of'
perineum is repeatedly performed. But in randomized studies, approach to delivery (Bulchandani, 20 1 5 ; McCandlish, 1 998) .
this technique did not significantly prevent perineal laceration Alternatively, if expulsive eforts are inadequate or expeditious
(Beckmann, 20 1 3; Mei-dan, 2008; Stamp, 200 1 ) . Antepartum delivery is needed, the modied Ritgen maneuver may be employed
use of the Epi-No intravaginal pump balloon has a similar aim, or an episiotomy cut. With the modified maneuver, gloved ingers
but it also fails to prevent perineal trauma or levator injury (Brito, beneath a draped towel exert forward pressure on the fetal chin
20 1 5; Kamisan Atan, 20 1 6) . through the perineum j ust in front of the coccyx. Concurrently,
When the head distends the vulva and perineum enough the other hand presses against the occiput (Fig. 27-3) . Originally
to open the vaginal introitus to a diameter of 5 cm or more, a described in 1 85 5 , the maneuver allows controlled fetal head
gloved hand may be used to support the perineum (Fig. 27-2) .
he other hand i s used to guide and control the fetal head to
deliver the smallest head diameter through the introitus and to

F I G U R E 27-3 Mod ified Ritgen ma neuver. Moderate u pwa rd pres­

s u re is applied to the feta l c h i n by the posterior h a n d covered by a
F I G U R E 27-1 Peri n e u m is supported as the head crowns. steri le towel. The other h a nd a ppl ies occi pita l pressu re.
518 Del ive ry

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 1 623 women, Jonsson and colleagues
(2008) found a similar incidence of third- and fourth-degree tears,
defined later (p. 528) .

• Delivery of the Shoulders

Following delivery of the fetal head, a inger is passed across the
fetal neck to determine whether it is encircled by one or more
umbilical cord loops. he nuchal cord incidence increases with
gestational age and is found in nearly 25 percent of deliveries
A
at term (Larson, 1 997; Ogueh, 2006) . If an umbilical cord coil
is felt, it is slipped over the head if loose enough. If applied too
tightly, the loop is cut between two clamps. 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, 20 1 3) .
Following its delivery, the fetal head falls posteriorly, bring­
ing the face almost into contact with the maternal anus. he
occiput promptly turns toward one of the maternal thighs, and
the head assumes a transverse position. This external rotation
indicates that the bisacromial diameter, which is the distance
between the shoulders, has rotated into the anteroposterior
diameter of the pelvis.
Most often, the shoulders appear at the vulva j ust after exter­
nal rotation and are born spontaneously. If delayed, extraction
F I G U R E 27-4 Delivery of the shou lders. A. Gentle d ownward trac­
B
aids controlled delivery. The sides of the head are grasped with
two hands, and genle downward traction is applied until the tion to effect descent of the a nterior shou lder. B. Del ivery of the
anterior shoulder appears under the pubic arch (Fig. 27-4) . a nterior shoulder com pleted. Gentle u pwa rd traction to del iver the
Next, b y a n upward movement, the posterior shoulder i s deliv­ posterior shou lder.
ered. D uring delivery, abrupt or powerful force is avoided to

• Cord Clamping
avert fetal brachial plexus injury.
he rest of the body almost always follows the shoulders
without diiculty. With prolonged delay, however, its birth The umbilical cord is cut between two clamps placed 6 to

and moderate pressre on the uterine fu nd u s Hooking the fin­

may be hastened by moderate outward traction on the head
. is applied 2 to 3 cm from its insertion into the fetal abdomen.
gers in the axillae is avoided. This can injure upper extremity
nerves and produce a transient or possibly permanent paralysis.
Immediately after delivery of the newborn, a gush of amnionic
luid that is often blood-tinged but not grossly bloody usually
follows.
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) . he current American
Heart Association neonatal resuscitation recommendations
eschew most suctioning immediately following birth-even
with meconium present (Chap. 33, p. 620) . And with meco­
nium-stained luid, routine intubation for tracheal suction is
not recommended for vigorous or for nonvigorous neonates.
Suctioning is reserved for neonates who have obvious obstruc­
tion to spontaneous breathing or who require positive-pressure
ventilation (Wyckof, 20 1 5) . For suctioning, options are bulb
syringe or suction catheter aspiration and may include intuba­
tion and suctioning if the airway is obstructed.
8 cm from the fetal abdomen, and later an umbilical cord clamp
For term neonates, the timing of umbilical cord clamping
remains debatable. Delayed umbilical cord clamping transfers
a greater volume of blood to the newborn. A delay for up to
60 seconds may increase total body iron stores, expand blood
volume, and decrease anemia incidence in the neonate (Anders­
son, 20 1 1 ; Yao, 1 974) . his practice may be particularly valu­
able in populations in which iron deficiency is prevalent (Kc,
20 1 7; World Health Organization, 20 1 4) .
Conversely, a higher hemoglobin concentration increases
risks for hyperbilirubinemia and extended hospitalization
for neonatal phototherapy (McDonald, 20 1 3) . Delayed cord
clamping may also hinder timely and needed neonatal resus­
citation. That said, early pilot studies are assessing the value of
resuscitating newborns at the bedside to permit delayed clamp­
ing (Katheria, 20 1 7; Winter 20 1 7) . Fortunately, in general,
delayed umbilical cord clamping compared with early clamp­
ing does not worsen Apgar scores, umbilical cord pH, or respi­
ratory distress caused by polycythemia. Regarding maternal
outcomes, rates of postpartum hemorrhage are similar between

early and delayed clamping groups (Andersson, 20 1 3) . Fewer
data are available regarding cord "milking," in which the opera­
tor pushes blood through the cord toward the newborn. his
maneuver appears safe and may be advantageous if rapid cord
clamping is clinically indicated (Upadhyay, 20 1 3) .
For the preterm neonate, delayed cord clamping has sev­
eral benefits. hese include higher red cell volume, decreased
need for blood transfusion, and lower rates of intraventricu­
lar hemorrhage and of necrotizing enterocolitis (Backes, 20 1 4;
Rabe, 20 1 2) . For neonates who require expedited resuscitation,
cord milking may have beneits to quickly transfer volume
(Al-Wassia, 20 1 5 ; Katheria, 20 1 5 ; Patel, 20 1 4) . Still, because
of rapid blood volume changes, the American Heart Associa­
tion currently suggests against the routine use of cord milking
for neonates born < 29 weeks' gestation (Wyckof, 20 1 5) .
The American College o f Obstetricians and Gynecologists
(20 1 7a) notes suicient evidence to support delayed umbili­
cal cord clamping for term and preterm neonates for at least
30 to 60 seconds after birth. This opinion is also endorsed by
the American Academy of Pediatrics (20 1 7 a) . The American
Heart Association guidelines advise that the practice may have
beneits for term or preterm neonates not needing immediate
resuscitation at birth (Wyckof, 20 1 5).
• Occiput Transverse Position
In the absence of a pelvic architecture abnormalit) or asyn­
clitism, the occiput transverse (OT) position is usually transi­
toly. Thus, unless contractions are hypotonic, the head usually
spontaneously rotates to an OA posItion. If rotation ceases
because of poor expulsive forces, vaginal deliveY usually can
be accomplished readily in several ways. he easiest is manual
rotation of the occiput either anteriorly to OA or less com­
monly, posteriorly to occiput posterior. 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 OT position
as outlined in Chapter 29 (p. 5 6 1 ) . These forceps are used
to rotate the occiput to the anterior position, and delivery is
accomplished with the same forceps or by substitution with
Simpson, Tucker-McLane, or similar forceps.
In some cases, pelvic shape leads to a persistent OT posi­
tion that is not easily overcome. For example, a platypelloid
pelvis is lattened anteroposteriorly and an android pelvis is
heart shaped. With these, space may be inadequate for occipital
rotation to either an anterior or posterior position (Fig. 2- 1 7,
p. 3 1 ) . Because of these concerns, undue force is avoided if
forceps delivery is attempted.
PERSISTENT OCCI PUT POSTERIOR POSITION
Approximately 2 to 1 0 percent of singleton term cephalic fetuses
deliver in an occiput posterior (OP) position (Cheng, 20 1 0) .
Many fetuses delivering OP are O A i n early labor and relect
malrotation during labor. Predisposing risks include epidural
analgesia, nulliparity, greater fetal weight, and prior delivery
Vag i na l Del ivery 519
with O P positioning (Cheng, 2006a; Gardberg, 2004; Lieber­
man, 2005 ) . Regarding pelvic shape, an anthropoid pelvis and
narrow subpubic angle can predispose (Barth, 20 1 5 ; Ghi, 20 1 6) .
• 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 lacerations
are increased (Senecal, 2005).
Newborns delivered from an OP position have higher com­
plication rates then those born positioned OA. Cheng and
coworkers (2006b) compared outcomes of 259 1 women under­
going delivery with a persistent OP position with those of 28,80 1
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 deliv­
ered spontaneously, and the remainder accounted for 9 percent
of cesarean deliveries performed. hese investigators also found
that an OP position at delivery was associated with more adverse
short-term neonatal ourcomes 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 (200 1 ) and their associates.
Methods to prevent persistent OP position and its associ­
ated morbidity have been investigated. First, digital examina­
tion for identiication of fetal head position can be inaccurate,
and transabdominal sonography can be used to increase accu­
racy (Dupuis, 2005 ; Zahalka, 2005) . The transducer is placed
transversely j ust cephalad to the maternal mons pubis. In the
sonogram, fetal orbits and nasal bridge lie ventrally, whereas
the occiput apposes the lower sacrum. Such information may
provide an explanation for prolonged second-stage labor or
may identiy suitable candidates for rotation. Of other possible
interventions, varying maternal position either antepartum or
during labor does not appear to lower rates of persistent OP
position (Desbriere, 20 1 3; Kariminia, 2004; Le Ray, 20 1 6) .
• Delivery
The fetus in an OP position may be delivered either spontane­
ously or by operative vaginal delivery. First, if the bony pelvic
outlet is roomy and the perineum is somewhat relaxed from
prior deliveries, rapid spontaneous OP delivery will often take
place. Conversely, if the perineum is resistant to stretch, second­
stage labor may be appreciably prolonged. During each expul­
sive efort, 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 third- and fourth-degree lacerations (Groutz,
20 1 1 ; Melamed, 20 1 3) .
I n some cases, spontaneous vaginal delivery from a n 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. 560) . Successful rotation rates range from
47 to 90 percent. And, as would be expected, lower rates of
520 Del ivery
cesarean delivery, vaginal laceration, and maternal blood loss
follow rotation to OA position and vaginal delivery (Le Ray,
2005; Sen, 20 1 3 ; Shafer, 2006, 20 1 1 ) . Disadvantageously,
manual rotation is linked with higher cervical laceration rates.
Thus, careful inspection of the cervix following rotation is
mandatory.
For exigent delivery, forceps or vacuum device can be applied
to a persistent OP position. This is often performed in conjunc­
tion with an episiotomy. Also, if the head is engaged, the cervix
fully dilated, and the pelvis adequate, forceps rotation may be
attempted for those with suitable skills. These operative vaginal
techniques are detailed in Chapter 29 (p. 5 6 1 ) .
Infrequently, protrusion o f fetal scalp through the introitus
is the consequence of marked elongation of the fetal head from
molding combined with formation of a large caput succeda­
neum. 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 rota­
tion is preferred for management of persistent OP position.
When needed, 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 ease and safety, cesarean
delivery is performed.
SHOU LDER 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 symphy­
sis pubis and fail to deliver using normally exerted downward
traction and maternal pushing. Because the umbilical cord is
compressed within the birth canal, this dystocia is an emer­
gency. Several maneuvers, in addition to downward traction on
the fetal head and neck, may be performed to free the shoulder.
This requires a team approach, in which efective communica­
tion and leadership are critical.
Consensus regarding a speciic defi n ition of shoulder dys­
tocia is lacking. Some focus on whether maneuvers to free the
shoulder are needed, whereas others use the head-to-body deliv­
ery time interval as deining (Beall, 1 998) . Spong and cowork­
ers ( 1 995) 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 inefective.
Because of these difering deinitions, the incidence of shoul­
der dystocia varies. One recent review cites a clinically useful
average of 1 percent of all deliveries (Ouzounian, 20 1 6) . The
incidence has increased in recent decades, likely due to increas­
ing fetal birthweight (MacKenzie, 2007; 0verland, 20 1 4) .
Increased identiication and documentation may also raise the
incidence (Kim, 20 1 6) .
• Maternal a n d Neonatal Consequences
In general, shoulder dystocia poses greater risk to the fetus than
to the mother. The main maternal risks are serious perineal tears
and postpartum hemorrhage, usually from uterine atony but
also from lacerations (Gauthaman, 20 1 6; Rahman, 2009) . In
contrast, significant neonatal neuromusculoskeletal injury and
asphyxia are concerns. These specific injuries are described in
Chapter 33 (p. 630) . In one review of 1 1 77 shoulder dystocia
cases, brachial plexus injury was diagnosed in 1 1 percent and
clavicular or humeral fracture in 2 percent (Chauhan, 20 1 4) .
MacKenzie and associates (2007) reviewed 5 1 4 cases. Of the
neonates, 7 percent showed evidence of acidosis at delivery,
and 1 . 5 percent required cardiac resuscitation or developed
hypoxic ischemic encephalopathy (HIE) . In another review
of 200 cases, rates of severe fetal acidosis and HIE were each
0.5 percent if delivery was completed within 5 minutes. These
rates rose to 6 and 24 percent, respectively, with delivery delays
� 5 minutes (Leung, 20 1 1 a) .
• Prediction and Prevention
Fetal macrosomia, maternal obesity, prolonged second-stage
labor, and a prior event raise risks for shoulder dystocia (Mehta,
2004; Overland, 2009; Schummers, 20 1 5) . Although these fac­
tors are clearly associated with this complication, identification
of individual instances before the fact has proved to be impos­
sible. The American College of Obstetricians and Gynecologists
(20 1 7c) reviewed studies and concluded that:
1 . Most cases of shoulder dystocia cannot be accurately pre­
dicted 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 non­
diabetic woman with a fetus whose estimated fetal weight is
> 5000 g or for the diabetic woman whose fetus is estimated
to weigh > 4500 g.
Bi rthweight
There is a corresponding rise in the incidence of shoulder dysto­
cia with increasing birthweight (Acker, 1 98 5 ; 0verland, 20 1 2;
Stotland, 2004) . Commonly cited maternal characteristics
associated with increased fetal birthweight are obesity, postterm
pregnancy, multiparity, and diabetes (Jolly, 2003; Koyanagi,
20 1 3) . The combination of fetal macrosomia and maternal
diabetes mellitus escalates the frequency of shoulder dystocia
(Langer, 1 99 1 ; Nesbitt, 1 998) . This predisposition may stem
from the fact that fetuses of diabetic women have larger shoul­
der and extremity circumferences and greater shoulder-to-head
and chest-to-head size diferences relative to comparable-weight
fetuses of nondiabetic mothers (McFarland, 1 998; Modanlou,
1 982) . That said, translating these specific measurements into
stand-alone sonographic clinical thresholds has shown poor
predictive sensitivity (Burkhardt, 20 1 4) .
Preventively, early labor induction has yielded conflicting
results. In one study, approximately 800 women with suspected
macrosomic fetuses were randomized either to early induction

between 37 and 39 weeks or to expectant care (Boulvain, 20 1 5) .
Dystocia rates were lowered b y two thirds i n the intervention
group, and neither group sufered brachial plexus injury. Although
not measured, this practice is balanced against morbidity of early
delivery. Moreover, the poor accuracy of antepartum fetal weight
prediction should be considered as well (Hoopmann, 20 1 0; Mlin,
20 1 6; Noumi, 2005) . In contrast, an earlier randomized study of
284 women showed that rates of shoulder dystocia were not low­
ered by early induction at 38 weeks (Gonen, 1 997) .
As previously discussed, cesarean delivery may b e consid­
ered to prevent shoulder dystocia. hat said, Rouse and Owen
( 1 999) concluded that a prophylactic cesarean delivery policy
for macrosomic fetuses would require more than 1 000 cesarean
deliveries with attendant morbidity to avert a single permanent
brachial plexus injury.
Prior S h o u l d e r Dystocia
he risk of recurrent shoulder dystocia ranges from 1 to 1 3
percent (Bingham, 20 1 0; Moore, 2008; Ouzounian, 20 1 3) .
F o r many women with prior shoulder dystocia, a trial o f labor
may be reasonable. he American College of Obstetricians and
Gynecologists (20 1 7 c) 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
/ selected next if additional steps are needed.
F I G U R E 27-5 The McRoberts m a n e uver. The m a neuver consists of removing the legs
from the sti rrups a nd sha rply flexing the thighs u p toward the abdomen. The assista nt is
a l so provi d i n g su prapu bic pressu re s i m u ltaneously (arrow).
Vag i na l D e l ivery 52 1
shoulder dystocia. After discussion, either mode of delivery may
be appropriate.
• Management
Because shoulder dystocia cannot be accurately predicted, cli­
nicians 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 bal­
anced against the second goal, which is avoiding fetal and
maternal injury from aggressive manipulations. Accordingly,
an initial gentle attempt at traction, assisted by maternal expul­
sive eforts, is recommended. Adequate analgesia is certainly
ideal. Some clinicians advocate performing a large episiotomy
to provide room for manipulations. Episiotomy itself does not
lower brachial plexus injury rates but raises third- and fourth­
degree laceration rates (Gurewitsch, 2004; Paris, 201 1 ; Sagi­
Dain, 20 1 5) . Episiotomy may be elected to complete needed
maneuvers.
After gentle traction, various techniques can be used to free
the anterior shoulder from its impacted position behind the sym­
is found in Cunningham and Gilstrap s Operative Obstetrics, 3rd
physis pubis. A more detailed discussion of these and the topic
edition (Cunningham, 20 1 7) . Of these, moderate suprapubic
pressure can be applied by an assistant, while downward trac-
tion 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 shoul­
der is thus either depressed or rotated, or
both, so the shoulders occupy the oblique
plane of the pelvis. Here, the anterior
shoulder can be freed.
The McRoberts maneuver is often
The maneuver consists of removing the
legs from the stirrups and sharply lexing
them up toward the abdomen. Suprapu­
bic pressure is often concurrently applied
(Fig. 27-5) . Gherman and associates
(2000) analyzed the McRoberts maneuver
using x-ray pelvimetry. hey 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, pel­
vic rotation cephalad tends to free the
impacted anterior shoulder. Gonik and
coworkers ( 1 989) tested the McRoberts
position objectively with laboratory mod­
els and found that the maneuver reduced
the forces needed to free the fetal shoul-
der. If unsuccessful, most move next either
to free the posterior shoulder or to rotate
the bisacromial diameter into one of the
oblique diameters of the maternal pelvis.
522 Del ivery

With delivey of the posterior shoulder, the accoucheur care­

fully sweeps the posterior arm of the fetus across its chest,
followed by deliveY of the arm (Fig. 27-6) . If possible, the
operator's ingers are aligned parallel to the long axis of the
fetal humerus to lower bone fracture risks. The shoulder girdle
is then rotated into one of the oblique diameters of the pelvis
with subsequent delivery of the anterior shoulder.
Of rotational maneuvers, Woods ( 1 943) reported that by pro­
gressively rotating the posterior shoulder 1 80 degrees in a cork­
screw fashion, the impacted anterior shoulder could be released.
his is frequently referred to as the Woods corkscrew maneuver
(Fig. 27-7) . Rubin ( 1 964) 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
A
most oten abducts both shoulders, which in turn produces a
smaller bisacromial diameter. This permits displacement of the
anterior shoulder from behind the symphysis (Fig. 27-8) .
If the above are initially unsuccessful, they may b e repeated,
and finally other methods may be elected. With an allours
maneuver, also called the Gaskin maneuver, the parturient rolls
onto her knees and hands. Here, downward traction against the
head and neck attempts to free the posterior shoulder (Bruner,
1 998). Challenges with this include immobility from regional
analgesia and time lost in patient repositioning.
In some, the posterior arm is inaccessible for delivery. Clu­
ver and Hofmeyr (2009) described posterior axila sling traction
to deliver the posterior arm. With this alternative method, a
suction catheter is threaded under the axilla and both ends are
brought together above the shoulder. Upward and outward trac­
tion on the catheter loop delivers the shoulder. In a small series
of 1 9 cases, this maneuver was successful in 1 8 cases. However,
8
neonatal injury included three cases of humeral fracture and one
permanent and four transient cases of Erb palsy (Cluver, 20 1 5) .

c
... " . t J. r�. -.i
. . ... '

der dystocia . A. The operator's hand is introd uced i nto the vag i n a
..F . .�
FIGURE 27-6 Del ivery of the posterior shoulder for rel ief of s h o u l­

across the chest, keeping the a rm flexed at the el bow. C. The feta l
a long t h e feta l posterior hu merus. B . T h e a rm is spli nted a n d swept

hand is g rasped a n d the arm extended a long the side of the face. F I G U R E 27-7 Woods ma neuver. The h a nd is placed beh i nd the
The posterior arm is del ivered from the vag i n a . posterior shoulder of the fetus. The shou lder is then rotated in
a corkscrew m a n ner so that the i m pacted anterior shou lder is
released .

I
-
A 8
F I G U R E 27-8 The second Rubin ma ne uver. A. The bisacromial d ia meter is a l ig ned vertica l ly. B. The more easily accessi b le feta l shou l der
(the a nterior is s hown here) is pus hed towa rd the a nterior chest wa l l of the fetus (arrow). Most often, this res u lts i n a bd u ction of both s houl­
ders, wh ich red uces the bisacromial diameter a n d frees the i m pacted a nterior s h o u lder.
Deliberate fracture ofthe anterior clavicle 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's clavicle is diicult. If successful, the
fracture will heal rapidly and is usually trivial compared with
brachial nerve injury, asphyxia, or death.
he Zavanelli maneuver involves replacement of the fetal
head into the pelvis followed by cesarean delivery (Sandberg,
1 98 5 ) . Terbutaline, 0.25 mg, is given subcutaneously to pro­
duce uterine relaxation. he irst part of the maneuver consists
of returning the head to an OA or OP position. The operator
flexes the head and slowly pushes it back into the vagina. Cesar­
ean delivery is then performed. Sandberg ( 1 999) reviewed 1 03
reported cases. It was successful in 9 1 percent of cephalic cases
and in all cases of breech head entrapments. Despite successful
replacement, fetal injuries were common bur may have resulted
from the multiple manipulations used before the Zavanelli
maneuver (Sandberg, 2007) .
Symphysiotomy, in which the intervening symphyseal carti­
lage and much of its ligamentous support is cut to widen the
symphysis pubis, is described in Chapter 28 (p. 548) . It has
been used successfully for shoulder dystocia (Goodwin, 1 997;
Hartield, 1 986). Maternal morbidity can be signiicant due to
urinary tract injury. Cleidotomy consists of cutting the clavicle
with scissors or other sharp instruments and is usually done for
a dead fetus (Schramm, 1 983).
S h o u l d e r Dystocia Dri l l
Hernandez and Wendel ( 1 990) suggest use o f a shoulder dysto­
cia drill to better organize emergency management:
1 . Call for help-mobilize assistants and anesthesia and pediat­
ric personnel. Initially, a gentle attempt at traction is made.
Drain the bladder if it is distended.
Vag i n a l De l ivery 523
2. A generous episiotomy may be desired at this time to aford
room posteriorly.
3. Suprapubic pressure is used initially by most practitioners
because it has the advantage of simplicity. Only one assis­
tant is needed to provide suprapubic pressure, while normal
downward traction is applied to the fetal head.
4. The McRoberts maneuver requires two assistants. Each assis­
tant grasps a leg and sharply lexes the maternal thigh toward
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 diicult to accomplish.
6. Woods screw maneuver is applied.
7. Rubin maneuver is attempted.
The American College of Obstetricians and Gynecologists
(20 1 7c) 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, is deemed a reasonable initial approach. In one review
of more than 2000 cases, Hofman and colleagues (20 1 1 ) noted
an 84-percent success rate with posterior shoulder delivery
and comparable rates of neonatal injury compared with other
standard methods. This contrasts with a review of 205 cases,
in which posterior shoulder delivery yielded greater neonatal
injury rates than rotational methods (Leung, 2 0 1 1 b) . Spain
and associates (20 1 5) found that duration rather than a speciic
maneuver increased neonatal injury.
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
524 Del ivery
lnJurious traction forces and manipulations. Lerner and
coworkers (20 1 l ) in their evaluation of 1 27 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 o f depressed neonates rose sharply
after 3 minutes.
Shoulder dystocia training and protocols using simulation­
based education and drills has evidence-based support. These
tools improve performance and retention of drill steps (Buerkle,
20 1 2; Crofts, 2008; Grobman, 20 1 l ) . Their use has translated
into improved neonatal outcome in some, but not all, inves­
tigations (Crofts, 20 1 6; Fransen, 20 1 7; Kim, 20 1 6 ; Walsh,
20 1 l ) . The American College of Obstetricians and Gynecolo­
gists (20 1 2) also has created a Patient Safety Checklist to guide
the documentation process with shoulder dystocia.
SPECIAL POPULATIONS
• Home Birth
In 20 1 4, 0.7 percent of deliveries in the United States were
planned home births and 0.2 percent were unplanned (Mac­
Dorman, 20 1 6) . Of unplanned births in a 1 5-year epoch in
Norway, 69 of 6027 or 1 . 1 percent resulted in fetal or neonatal
death. This high rate was attributable to infection, prematu­
rity, and placental abruption (Gunnarsson, 20 1 7) . Multiparity
and distance from the hospital were ascribed risks (Gunnars­
son, 20 1 4) . In the United States, youth, lack of prenatal care,
minority race, and lower educational attainment were associ­
ated risks for unplanned home birth (Declercq, 20 1 0) .
I n contrast, the demographics o f women choosing planned
home birth in the United States favor those who are white,
nonsmoking, self-pay, college-educated, and multiparous
(MacDorman, 20 1 6) . As perceived beneits, planned delivery
at home for those with low-risk pregnancies results in fewer
medical interventions that include labor augmentation, episi­
otomy, operative vaginal delivery, and cesarean delivery (Bol­
ten, 20 1 6; Cheyney, 20 1 4) . Regarding the safety of planned
home birth, data from randomized trial are lacking, and large
observational studies derive from heterogeneous care systems,
whose results may not be generalizable. For example, several
developed countries deliver at home a large volume of carefully
screened women, delivered by midwives with substantial train­
ing and in a setting closely integrated with the local health-care
system (Birthplace in England Collaborative Group, 20 1 1 ; de
Jonge, 20 1 5; Hutton, 20 1 6) . The level of such coordination in
the United States is less uniform.
Overall, risks of home births in the United States are small
but greater than those of hospital delivery. Midwife-attended
home births carry a neonatal mortality risk of 1 .3 per 1 000
births. This is a nearly fourfold greater rate compared with mid­
wife-attended hospital births. The most common underlying
causes of death are those attributed to labor and delivery events,
to congenital anomalies, and to infection. Of neonatal injuries,
rates of neonatal seizure and serious neurological dysfunction
are similarly elevated in home-birth groups (Grunebaum, 2 0 1 3 ,
20 14, 20 1 7; Snowden, 20 1 5; Wasden, 20 1 6) . Importantly,
substantial risks attend home birth for those with prior cesarean
delivery, with breech presentation, and with multifetal gestation
(Cheyney, 20 1 4; Cox, 20 1 5) . The American College of Obste­
tricians and Gynecologists (20 1 7b) considers these to be abso­
lute contraindications. Further, the College considers accredited
hospitals and birthing centers to be the safest site for birth but
recognizes the autonomy of the well-counseled patient.
• Water Birth
As one option for pain relief, some women choose to spend part
of first-stage labor in a large water tub. With this practice, one
Cochrane review found lower rates of anesthesia block use and
no greater adverse neonatal or maternal efects compared with
traditional labor (Cluett, 2009) .
For delivery, however, water birth carries greater concern
for neonatal harm and without proven benefits. Case reports
describe aspiration leading to fresh-water drowning (Pinette,
2004) . The risk of cord avulsion during water birth approxi­
mates 3 per 1 000 births, and stems primary from abruptly
bringing the newborn out of the water (Schafer, 20 1 4) . Last,
case reports also enumerate serious infections, which emphasize
the need for rigorous sanitizing protocols. hat said, in most
large studies comparing land and water births, overall maternal
or neonatal infection rates are not increased (Bovbjerg, 20 1 6;
Burns, 20 1 2; Thoeni, 2005). In sum, several reviews comment
on study shortcomings and isolated complications but do not
identiy definitive evidence for overall greater rates of neonatal
harm from water birth in low-risk populations (Davies, 20 1 5 ;
Taylor, 20 1 6) . However, given the paucity of robust data and
potential for serious complications, the American College of
Obstetricians and Gynecologists (20 1 6a) currently recommend
that "birth occur on land, not in water."
• Female Genital Mutilation
This practice refers to medically unnecessary vulvar and peri­
neal modification. In the United States, it is a federal crime
to perform unnecessary genital surgery on a girl younger than
1 8 years. That said, forms of female genital mutilation are prac­
ticed in countries throughout Africa, the Middle East, and Asia.
As many as 200 million women worldwide have undergone
one of these procedures, and approximately 5 1 3,000 girls in
the United States were at risk for this practice in 20 1 2 (Gold­
berg, 20 1 6; UNICEF, 20 1 6) . Cultural sensitivity is imperative,
because many women may be ofended by the suggestion that
they have been assaulted or mutilated (merican College of
Obstetricians and Gynecologists, 20 1 4) .
The World Health Organization (2008) classifies genital
mutilations into four types (Table 27- 1 ) . Long-term complica­
tions from surgery and its associated scarring include infertility,
genital pain, diminished sexual quality of life, and propensity
for urogenital infection (Almroth, 2005; Andersson, 20 1 2;
Nour, 20 1 5) . In general, women with significant symptoms
following type III procedures are candidates for corrective sur­
gery. Specifically, division of midline scar tissue to reopen the
vulva is termed deinibulation.
Female genital mutilation has been associated with some
adverse maternal and neonatal complications. The World
 Vag i n a l De l ivery 525

TABLE 27-1 . World Health O rga n ization Classifi cation of

Female Gen ita l M uti lation

Type I Parti a l or tota l remova l of the c l ito ris a nd/or

prepuce
Type I I Pa rtia l or tota l rem ova l of the cl itoris a n d the l a b ia
m i nora, with or without l a bia majora excision
Type III Pa rti a l o r tota l l a b i a l m i no ra a n d/or maj o ra
excision, fol l owed by fu sion of t h e wou n d,
termed i nfi bu lation, to cove r a n d narrow t h e

J
vag i n a. With o r without cl itoridectomy
I
I
Type IV Pricking, pierci ng, i nc i s i n g , scra p i n g, caute ry, o r
other i nj u ry t o fe m a l e g e n ita l i a

Ada pted from the World H e a l t h Org a n ization, 2008.

Health Organization (2006, 2008) estimated that these proce­

dures increased perinatal morbidity rates by 1 0 to 20 per 1 000.
Small increased risks for prolonged labor, cesarean delivery, and
postpartum hemorrhage are also found (Berg, 20 1 4; Chibber,
20 1 1 ; Wuest, 2009) . Importantly, the psychiatric consequences
can be profound.
To prevent obstetrical complications, deinibulation can be
performed either antepartum or intrapartum (Fig. 27-9) (Esu, FIGURE 27-9 Deinfi bulation. Altho u g h not shown here, lidoca i ne
20 1 7) . In women not undergoing deinibulation, anal sphinc­ is fi rst i nfi ltrated a long the plan ned incision if reg ional a na lgesia
i s not i n p l ace a l ready. As protection, two fi ngers of one hand a re
ter tear rates with vaginal delivery may be increased (Berggren,
i ns i n uated beh i n d the shelf created by fused labia but in fro n t of
20 1 3; Rodriguez, 20 1 6) . In our experiences, intrapartum dein­ the u reth ra a n d crown ing head. The shelf is then incised in the
ibulation in many cases allows successful vaginal delivery with­ m i d l i ne. After del ivery, the raw edges a re sutured with ra pidly
out major complications. a bsorba ble material to secure hemostasis. (Reprod uced with
perm ission from Hawki ns JS: Lower gen ita l tract procedures. I n

• Prior Pelvic Reconstructive Surgery

hese 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 high-quality
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, 20 1 2; Pradhan, 20 1 3) . Stated another
way, most women with prior corrective surgery for incontinence
can be delivered vaginally without symptom recurrence. Also,
cesarean delivery is not always protective. 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 pel­
vic organ prolapse, only scant information regarding outcomes
is available. Such cases require individualization.
Yeo m a n s ER, Hoffm a n BL, Gilstrap L C I I I, et a l (ed s): C u n n i ngha m
a nd G i l stra p's Operative Obstetrics, 3 rd ed. New York, McGraw- H i l i
Education, 2 0 1 7.)
In rare cases in which neonatal death has occurred or is cer­
tain due to associated anomalies, vaginal delivery may be rea­
sonable, but the head or abdomen must be reduced in size for
delivery. Removal of luid by cephalocentesis or paracentesis
with sonographic guidance can be performed intrapartum. As
described on page 523, cleidotomy can shorten the bisacromial
diameter. For hydrocephalic fetuses that are breech, cephalo­
centesis can be accomplished suprapubically when the after­
coming head enters the pelvis. Currently, these practices are
more germane in developing countries.
TH IRD STAGE OF LABOR
• Delivery of the Placenta

• Anomalous Fetuses
Rarely, delivery can be obstructed by extreme hydrocephaly, by
body stalk anomaly, or by massive fetal abdominal enlargement
from a greatly distended bladder, ascites, or organomegaly
(Costa, 20 1 2; Sikka, 20 1 1 ) . With milder forms of hydroceph­
aly, if the biparietal diameter is < 1 0 cm or if the head cir­
cumference is < 36 cm, then vaginal delivery may be permitted
(Anteby, 2003) .
hird-stage labor begins immediately after fetal birth and ends
with placental delivery. Goals include delivery of an intact pla­
centa and avoidance of uterine inversion or postpartum hemor­
rhage. The latter two are grave intrapartum complications and
constitute emergencies, as described in Chapter 4 1 (p. 755).
Immediately after newborn birth, uterine fundal size and
consistency are examined. If the uterus remains irm and there
is no unusual bleeding, watchful waiting until the placenta
separates is the usual practice. Neither massage nor downward
526 Del ivery

fundal pressure is employed, but the fundus is frequently pal­

pated to ensure that it does not become atonic and illed with
blood from placental separation. To prevent uterine inversion,
umbilical cord traction must not be used to pul the placenta rom
the uterus. 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 elevation 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 uterine body
upward.
These signs appear within minutes after newborn delivery,
and the median time ranges from 4 to 1 2 minutes (Combs,
1 99 1 ; Frolova, 20 1 6; Shinar, 20 1 6b) . Once the placenta has
detached from the uterine wall, the mother may be asked
to bear down, and the intraabdominal pressure often expels
the placenta into the vagina. These eforts may fail or may
not be possible because of analgesia. After ensuring that
the uterus is contracted irmly, the umbilical cord is kept
slightly taut but is not pulled. Pressure is exerted by a hand F I G U R E 27- 1 1 Mem bra nes t h a t were somewhat ad hered t o the
uteri ne l i n i ng a re sepa rated by g e ntle traction with ring forceps.
wrapped around the fundus to propel the detached placenta
into the vagina ( Fig. 27- 1 0) . Concurrently, the heel of the

• Management of the Third Stage

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.
Care is taken to prevent placental membranes from being
torn of and left behind. If the membranes begin to tear,
they are grasped with a clamp and removed by gentle teasing
(Fig. 27- 1 1 ) .
F I G U RE 27- 1 0 Expression of placenta. Note that the h a nd i s not
tryi ng to push the fu n d u s of the uterus through the birth ca n a l ! As
the placenta leaves the uterus and enters the vag i na, the uterus
is elevated by the hand on the abdomen while the cord is held
i n position. The mother ca n a i d i n the del ivery of the placenta by
bea ring down. As the placenta reaches the perineum, the cord i s
l ifted, w h i c h i n t u r n l ifts t h e placenta out o f t h e vag i n a .
Practices within the third stage of labor may be broadly con­
sidered as either expectant or active management. 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,
20 1 2) . In contrast, active management of third-stage labor con­
sists of early cord clamping, controlled cord traction during pla­
cental delivery, and immediate administration of prophylactic
oxytocin. The goal of this triad is to limit postpartum hemor­
rhage (Begley, 20 1 5; Jangsten, 20 1 1 ; Westhof, 20 1 3) .
As noted earlier, delayed cord clamping does not increase
postpartum hemorrhage rates, and thus early clamping is a less
important component of this trio. Similarly, cord traction may
also be less critical (Deneux-haraux, 20 1 3 ; Du, 20 14; Giil­
mezoglu, 20 1 2) . 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, 20 1 0) .
Therefore, utero tonics play a n essential role t o decrease post­
partum blood loss. Choices include oxytocin (Pitocin) , misopro­
stol (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 ana­
logue, is available and efective for hemorrhage prevention dur­
ing cesarean delivery (Attilakos, 20 1 0; Su, 20 1 2) . Of these, the
World Health Organization (20 1 2) recommends oxytocin as a
first-line agent. Ergot-based drugs and misoprostol are alterna­
tives in settings that lack oxytocin.
Utero tonics may be given before or after placental expul­
sion without afecting rates of postpartum hemorrhage, pla­
cental retention, or third-stage labor length (Soltani, 20 1 0) . If
they are given before delivery of the placenta, however, they

may entrap an undiagnosed, undelivered second (Win. hus,
abdominal palpation should conirm no additional fetuses.
Notably, this concern is less relevant with current widespread
sonography use.
H ig h -Dose Oxytoci n
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 cowork­
ers ( 1 978) reported that an intravenous bolus of 1 0 units of
oxytocin caused a marked transient fall in blood pressure with
an abrupt increase in cardiac output. Svansrrom and associates
(2008) conirmed those findings. hese hemodynamic changes
could be dangerous for women hypovolemic from hemorrhage
or those with certain types of cardiac disease. Thus, oxytocin
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 electro­
lyte-free dextrose solution (Whalley, 1 963) . Thus, if oxytocin
is to be administered in high doses for a considerable period of
time, its concentration should be increased rather than increas­
ing the infusion flow rate.
Despite the routine use of oxytocin, no standard prophylac­
tic dose has been established for its use following either vaginal
or cesarean delivery. Our practice is to add 20 units (2 mL) of
oxytocin per liter of infusate. his solution is administered after
delivery of the placenta at a rate of 10 to 20 mUmin-200
to 400 mU/min-for a few minutes until the uterus remains
irmly contracted and bleeding is controlled. he infusion rate
then is reduced to 1 to 2 mUmin until the mother is ready for
transfer from the recovery suite to the postpartum unit. The
infusion is usually then discontinued. For women without intra­
venous access, 1 0 units of intramuscular oxytocin are injected.
Other Uteroto n ics
Ergonovine and methylergonovine have similar activity levels
in myometrium, and only methylergonovine is currently man­
ufactured in the United States. These ergot alkaloid agents do
not provide superior protection against postpartum hemorrhage
compared with oxytocin. \10reover, safety and tolerability are
greater with oxytocin (Liabsuetrakul, 2 0 1 1 ) . For these reasons,
ergot alkaloid agents are considered second-line for preven­
tion of postpartum hemorrhage. If selected, a 0.2-mg dose of
methylergonovine is slowly given intravenously in a period not
less than 60 seconds to avoid sudden hypertension (Novartis,
20 1 2) . Methylergonovine is relatively contraindicated in the
hypertensive woman.
Misoprostol is a prostaglandin E, analogue, which has
proved inferior to oxytocin for postpartum hemorrhage pre­
vention (Tun:alp, 20 1 2) . However, in resource-poor settings
that lack oxytocin, misoprostol is s uitable for hemorrhage pro­
phylaxis and is given as a single oral 600-�g dose (Mobeen,
20 1 1 ; World Health Organization, 20 1 2) . Notably, although
oxytocin is preferred for prevention of hemorrhage, ergot alka­
loids and prostaglandins play a greater role in postpartum hem­
orrhage treatment, discussed in Chapter 4 1 (p. 759) .
Va g i na l Del ivery 527
• Manual Removal of Placenta
In approximately 2 percent of singleton births, the placenta may
not deliver promptly (Cheung, 20 1 1 ) . Three possibilities include
pacenta adherens, in which uterine contractions are insuicient
to detach the placenta; lower uterine segment constriction and a
detached but trapped placenta; or a morbidly adherent placenta.
Consistent risks for retained placenta include stillbirth, prior
cesarean delivery, prior retention, and preterm delivery (Belachew,
20 1 4; Coviello, 20 1 5; Endler, 20 1 4; Nikolajsen, 20 1 3) . For the
last, in one study with nearly 46,000 deliveries, analysis predicted
that 90 percent of placentas would spontaneously deliver by 1 80
minutes for gestations at 20 weeks; 2 1 minutes at 30 weeks; and
14 minutes at 40 weeks (Dombrowski, 1 995) .
Postpartum hemorrhage can complicate a retained placenta,
and bleeding risk accrues with third-stage length. Thus, in the
absence of bleeding, some recommend expectant management
for 30 minutes, whereas others use a 1 5-minute threshold
(Cummings, 20 1 6; Deneux-Tharaux, 2009; Shinar, 20 1 6a) .
he World Health Organization (20 1 2) cites a 60-minute
threshold. Notably, if brisk bleeding ensues and the placenta
cannot be delivered by standard technique, manual removal of
the placenta is indicated (Fig. 27- 1 2) . When performed, some
administer a single dose of intravenous antibiotics, however,
one systematic review of observational studies found no beneits
(Chibueze, 20 1 5) . Although the American College of Obste­
tricians and Gynecologists (20 1 6c) concludes that data neither
support nor refute this practice, the World Health Organization
(20 1 2) recommends prophylaxis. At our institution, we admin­
ister a single dose to women not already receiving antibiotics.
IMMEDIATE POSTPARTUM CARE
The hour immediately following delivery of the placenta is
critical. During this time, lacerations are repaired. Although
utero tonics 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
are frequently evaluated. The American Academy of Pediatrics
and the American College of Obstetricians and Gynecologists
(20 1 7b) recommend that maternal blood pressure and pulse be
recorded immediately after delivery and every 1 5 minutes for
the first 2 hours. The placenta, membranes, and umbilical cord
are examined for completeness and for anomalies, as described
in Chapter 6 (p. 1 1 1 ) .
• 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. 763). Those of the perineum oten follow vaginal deliv­
ery, and most are irst- and second-degree lacerations. Lacerations
are classified by their depth, and complete deinitions and visual
examples are given in Figure 27- 1 3. Of these, third-degree lacera­
tions relect anal sphincter injury and are now subcategorized as:
(3a) < 50 percent external anal sphincter (EAS) tear;
(3b) > 50 percent EAS tear; and
(3c) EAS plus internal anal sphincter (lAS) tears.
528 Del ivery

A 8
F I G U R E 27- 1 2 M a n u a l re mova l of placenta. A. One hand g rasps the fu n d u s a n d the other hand is i n serted i nto the uterine cavity a n d the
fi ngers a re swept from side to side a s they a re adva nced. B. When the placenta detaches, it is g rasped and re moved .

2 4

38 3b 3c

F I G U R E 27- 1 3 1 . Fi rst-deg ree peri neal laceration: i nj u ry to o n ly the vag i n a l e pith e l i u m or peri nea l ski n . 2. Second-deg ree laceration: i nj u ry
to peri neum that spares the a n a l s p h i n cter com plex but i nvolves the peri nea l m u scles, which a re the b u l bospongiosus and su perficial
tra n sverse peri nea l mu scles. 3a. Th i rd-deg ree laceration: <50 percent of the external a n a l sphincter (EAS) is torn. 3b. Th ird-deg ree lacera­
tion: >50 percent of the EAS i s torn, but the i nternal a n a l sphincter (lAS) rem a i n s i ntact. 3c. Th ird-deg ree laceratio n : EAS and lAS a re torn.
4. Fourth-deg ree laceration: the peri neal body, entire anal s p h i n cter com plex, a nd a norecta l mucosa a re l acerated . (Reproduced with per­
m i ssion from Kenton K, Muel ler M: Episiotomy a n d obstetric a n a l s p h i n cter lacerations. I n Yeoma n s ER, H offma n B L, Gi lstra p LC I I I, et al (eds) :
C u n n i n g h a m and Gilstra p's Operative Obstetrics, 3 rd ed. New York, McGraw- H i l i Ed ucatio n, 201 7.)

hird- and fourth-degree lacerations are considered obstetrical
anal sphincter injuries (OASIS) , and their combined incidence
varies from 0.5 to 5 percent (Blondel, 20 1 6; Friedman, 20 1 5) .
Risk factors for these more complex lacerations include nullipar­
ity, midline episiotomy, persistent OP position, operative vaginal
delivery, Asian race, short perineal length, and increasing fetal
birthweight (Ampt, 20 1 3; Dua, 2009; Gurol-Urganci, 20 1 3 ;
Landy, 20 1 1 ) . Mediolateral episiotomy i s protective i n most, but
not all, studies Ganga, 20 1 4; Raisanen, 20 1 1 ; Shmueli, 20 1 6) .
Morbidity rates rise as laceration severity increases. Compared
with simpler lacerations, anal sphincter injuries are associated with
greater blood loss and puerperal pain. Wound disruption and
infection rates are other risks (Goldaber, 1 993; Lewicy-Gaupp,
20 1 5). Stock and coworkers (20 1 3) reported that approximately 7
percent of 909 OASIS lacerations had complications. Long term,
anal sphincter injuries are linked with approximately doubled
rates of fecal incontinence compared with vaginl delivery without
OASIS (Evers, 20 1 2; Gyhagen, 20 1 4) . Data on long-term dyspa­
reunia are limited, and rates are increased in some but not all stud­
ies (MoS, 2008; Otero, 2006; Salim, 2014; Sundquist, 20 1 2) .
T o ensure appropriate repair, identiication and correct cat­
egorization is essential. Diagnosis rates of OASIS improve with
clinical experience (ndrews, 2006) . Intrapartum endoanal
ultrasound, performed in research studies, also boosts detection,
and rates of clinically occult tears in primiparas range from 6 to
1 2 percent (Corton, 20 1 3; Faltin, 2005; Ozyurt, 20 1 5) . hat
said, few data currently support routine intrapartum endoanal
sonography, and the American College of Obstetricians and
Gynecologists (20 1 6b) does not recommended i t (Walsh, 20 1 5) .
Women with a prior OASIS have a higher recurrence rate
compared with multiparas without prior OASIS (Baghestan,
20 1 2; Edozien, 20 14; Elfaghi, 2004) . That said, the risk mir­
rors that of primiparas in the general population and is low
(Basham, 20 1 3 ; Boggs, 20 1 4; Priddis, 20 1 3) . Fetal macrosomia
and operative vaginal delivery are notable risks in this cohort
of parturients and can influence counseling in future pregnan­
cies. Speciically, patients may choose to deliver by cesarean to
avoid repeat OASIS. his consideration may be most pertinent
for those with prior postpartum anal incontinence, with OASIS
complications requiring corrective surgery, or with psychological
trauma (American College of Obstetricians and Gynecologists,
20 1 6b) . However, planned cesarean delivery is balanced against
its associated operative risks discussed in Chapter 30 (p. 568) .
• Episiotomy
Types
In contrast to spontaneous lacerations, perineotomy is intended
incision of the perineum. Episiotomy is incision of the puden­
dum-the external genital organs. In common parlance, how­
ever, the term episiotomy often is used synonymously with
perineotomy, a practice that we follow here. Obstetrical text­
books and organizational guidelines difer considerably in their
description of episiotomy techniques. Kalis and associates
(20 1 2) have presented a classifi c ation, and we agree with the
need for terminology standardization.
Midline and mediolateral episiotomies are the two main types
and vary by the angle of perineal incision. Involved structures
Vag i nal Del ivery 529
mirror those found with second-degree laceration, and their
repairs are analogous. The midline episiotomy begins at the
fourchette, incises the perineal body in the midline, and ends
well before the external anal sphincter is reached. he incision
length varies from 2 to 3 cm depending on perineal length and
degree of tissue thinning. The mediolateral episiotomy begins at
the midline of the fourchette and is directed to the right or left
at an angle 60 degrees of the midline (Fig. 27- 14) . This angle
accounts for perineal anatomy distortion during crowning and
ultimately yields an incision 45 degrees of the midline for sutur­
ing (El-Din, 20 14; Kalis, 20 1 1 ) . The lateral episiotomy begins at
point 1 to 2 cm lateral from the midline. It too is angled toward
either the right or the left ischial tuberosity.
Before episiotomy, analgesia may be provided by existing
labor regional analgesia, by bilateral pudendal nerve blockade, or
by local infiltration of I -percent lidocaine. Some instead advo­
cate 2.5-percent lidocaine-prilocaine cream (EMLA cream) , but
this requires application an hour before expected delivery, which
may be logistically diicult (Franchi, 2009; Kargar, 20 1 6) .
I f episiotomy is performed unnecessarily early, incisional
bleeding may be considerable before delivery. If it is performed
too late, lacerations will not be prevented. Typically, episiot­
omy 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 epi­
siotomy after application of the blades.
Few data directly compare midline and mediolateral types. As
noted, midline episiotomy has a greater likelihood of associated
anal sphincter lacerations (Coats, 1 980; de Leeuw, 200 1 ) . Short­
term rates of self-perceived pain and dyspareunia are similar or
increased with mediolateral episiotomy (Fodstad, 20 1 3, 2 0 1 4;
Sartore, 2004) .
--�-
F I G U R E 27- 1 4 A mediolatera l episiotomy is cut as the ba by's
head crowns. Fingers a re insinuated between the peri neum a n d
head. T h e i ncision beg ins i n the m id l i n e a n d is d irected toward the
i psi latera l ischia l tu berosity at a n a ng l e 60 deg rees of the mid l i ne.
(Reproduced with permission from Kenton K, Mueller M: Episiotomy
and obstetric anal sphi ncter lacerations. In Yeom a n s ER, Hoffm a n
BL, Gilstra p L C I I I , e t a l (eds): C u n n i n g h a m a n d G i l stra p's Operative
Obstetrics, 3 rd ed. New York, McGraw- H i l i Ed u cation, 20 1 7.)
530 De l ivery

Even fewer studies compare lateral episiotomy to either medio­
lateral or midline. One randomized trial compared lateral and
mediolateral tpes in nulliparas. Groups did not difer in pain
scores, in sexual qulity of life, or in vaginal or perineal trauma,
including OASIS (Karbanova, 2014a,b; Necesalova, 20 1 6) . The
authors also reported that mediolateral episiotomies required less
time and suture for the repair. Thus, among the three, mediolateral
episiotomy may be the preferred incision to reduce OASIS rates.
I nd icati o n s
In the past, routine episiotomy was practiced to avoid a ragged
laceration and to limit postoperative pain and anal sphinc­
ter injury rates. But, a Cochrane review of randomized trials
showed lower rates of severe perineal/vaginal trauma in women
managed with a restrictive, that is, selective use of episiotomy
for spontaneous delivery rather than with routine episiotomy
Qiang, 20 1 7) . Importantly, this review did not discern between
midline and mediolateral episiotomies.
The American College of Obstetricians and Gynecologists
(20 1 6b) has concluded that restricted use of episiotomy is pre­
ferred to routine use. We are of the view that the procedure
should be applied selectively for appropriate indications. Thus,
episiotomy can be considered for indications such as shoulder dys­
tocia, breech delivery, fetal macrosomia, operative vaginal deliv­
eries, persistent OP positions, markedly short perineal length,
and other instances in which failure to perform an episiotomy
will result in signiicant perineal rupture. The final rule is that
there is no substitute for surgical judgment and common sense.

A B

c o

F I G U R E 27-1 5 Med iolatera l episiotomy repair. A. The vag inal epithel i u m and deeper tissues a re closed with a sing le, contin uous, locking
sutu re. The angle seems less acute now (a pproximately 45°) since the perineum is no longer distended. B. Ater the vag i n a l component of the

this deeper layer. C. With a similar contin uous, non locki ng techniq ue, the su perficial transverse perineal and b u l bospongiosus muscles are reap­
laceration is repaired, deeper peri nea l tissues a re reapproxi mated by a sing le, conti n uous, nonlocki ng sutu re. Small episiotomies may not require

proxi mated. D. Last, the perineal skin is closed using a su bcuticu lar stitch . (Reproduced with permission from Kenton K, M ueller M: Episiotomy

3 rd ed. New York, McGraw-Hili Ed ucation, 201 7.)

and o bstetric anal sphincter lacerations. In Yeomans ER, Hoffma n BL, Gilstrap LC I I I, et al (eds): Cunningham and Gilstrap's Operative Obstetrics,
 Vag i n a l Del ivery 531

With this new approach, epIsIotomy rates have dropped.
Oliphant and coworkers (20 1 0) used the National Hospital
Discharge Survey to analyze episiotomy rates between 1 979
and 2006 in the United States. hey noted a 75-percent decline
in the age-adjusted episiotomy rate. In the United States in
20 1 2 episiotomy was performed in approximately 12 percent
of vaginal births (Friedman, 20 1 5) .
For suitable repair, an understanding of perineal support
and anatomy is necessary and is discussed in Chapter 2 (p.
1 9) . Adequate analgesia is imperative, and women without
regional analgesia can experience high levels of pain during
perineal suturing. Again, locally injected lidocaine can be
used solely or as a supplement to bilateral pudendal nerve
blockade. In those with epidural analgesia, additional dosing
may be necessary.

• Laceration and Episiotomy Repairs

Typically, perineal repairs are deferred until the placenta has
been delivered. his policy permits undivided attention to the
signs of placental separation and delivery. A further advantage is
that the repair is not interrupted or disrupted by placenta deliv­
ery. his is especially true if manual removal must be performed.
The major disadvantage is continuing blood loss until the repair
is completed. Direct pressure from an applied gauze sponge will
help to limit this volume.
First-degree lacerations do not always require repair, and
sutures are placed to control bleeding or restore anatomy. Here,
few data guide suture selection, and ine-gauge absorbable or
delayed-absorbable suture or adhesive glue is suitable.
Second-degree laceration correction as well as midline
and mediolateral episiotomy repairs include similar steps.
Namely, these close the vaginal epithelium and reapp roxi­
mate the bulbospongiosus and supericial transverse perineal
muscles during restoration of the perineal body ( Figs. 2 7- 1 5
and 27- 1 6) . For this, most studies support a continuous

A B

c D

F I G U R E 27- 1 6 Midline episiotomy repair. A. An a nchor stitch is placed a bove the wou nd a pex to beg i n a running, locki n g closure with
2-0 suture to close the vag i n a l epithe l i u m a nd deeper tissues a nd rea pprox i mate the hymeneal ri ng. B. A tra nsition stitch red i rects s u t u r­
ing from the vag i n a to the peri neu m . C. The superficial tra n sverse peri neal a n d b u l bos po ngiosus m uscles a re rea pproxi mated u s i ng a
conti n uous, non locki ng tech n i q u e with the same length of sutu re. This aids restoration of the peri neal body for long-term su pport. D. The
conti n uous suture is then ca rried u pward a s a s u bcuticu lar stitch. The fi nal knot is tied proxim a l to the hymeneal ring. (Reproduced with

(eds): C u n n i n g h a m and G i l strap's Operative Obstetrics, 3 rd ed. New York, McGraw- H i l i Ed ucation, 20 1 7.)
perm ission from Kenton K, Mueller M : E pisiotomy a nd obstetric anal sphi ncter lacerations. I n Yeomans E R, Hoffm a n BL, G i lstrap LC I I I, et al
532 Del ivery

suturing method, which is faster than placing interrupted sutures incorporate sphincter fibers and perisphincter connec­
sutures and, with few exceptions, yields less pain (Grant, tive tissue, to bring sphincter ends together. here are few
200 1 ; Kettle, 20 1 2; Kindberg, 2008; Valenzuela, 2009) . evidence-based data to guide suture selection for sphincter
Blunt needles are suitable and likely decrease the incidence of repair, but delayed-absorbable material can provide sustained
needle-stick injuries (El-Refaie, 20 1 2; Mornar, 2008). Com­ tensile strength during healing. This theory is supported
monly used suture materials are 2-0 polyglactin 9 1 0 (Vicryl) by the above study by J all ad and coworkers (20 1 6) , which
or chromic catgut. With the former, a decrease in postsur­ showed higher perineal breakdown rate following OASIS
gical pain and lower risk of wound dehiscence are cited as repair with chromic gut.
major advantages Q allad, 20 1 6; Kettle, 20 1 0) . Closures with With the overlapping technique, the ends of the external anal
traditional polyglactin 9 1 0, however, occasionally require sphincter are brought to the midline and lie atop one another.
removal of residual suture from the repair site because of pain This method is only suitable for type 3c lacerations-those
or dyspareunia. This disadvantage may be reduced by using a involving the external and internal anal sphincter. Two rows
rapidly absorbed polyglactin 9 1 0 (Vicryl Rapide) (Bharathi, of mattress sutures travel through both sphincter ends to recre­
20 1 3; Kettle, 2002; Leroux, 2006) . ate the anal ring. In comparing the two methods, neither yields
For third-degree laceration repair, two methods are avail­ superior long-term anatomical or functional results (Farrell,
able to repair the external anal sphincter. The irst is an end­ 20 1 2; Fernando, 20 1 3; Fitzpatrick, 2000) . Also with type 3c
to-end technique, which we prefer, and is shown in Figure lacerations, the lAS is repaired before the EAS and is described
27- 1 7. Initially, the cut ends of the external anal sphincter, next.
which often retract, are isolated and brought to the midline. With fourth-degree laceration repairs, the torn edges of the
I mportantly, the strength of this closure is derived from the rectal mucosa are reapproximated (Fig. 27- 1 8) . At a point 1 cm
connective tissue surrounding the sphincter-often called the proximal to the wound apex, sutures are placed approximately
capsule-and not the striated muscle. Thus, serial interrupted 0.5 cm apart in the rectal muscularis and do not enter the ano-
rectal lumen. Clinicians oten use 4-0
polyglactin 9 1 0 or chromic gut for
this running suture line. Some recom­
mend a second reinforcing layer above
this (Hale, 2007) . If this is not done,
then the next layer to cover the anorec­
tal mucosa is formed by reapproxima­
tion of the internal anal sphincter. his
running, nonlocking closure is com­
pleted with 3-0 or 4-0 suture (see Fig.
27- 1 8B). Following any repair, needle
and sponge counts are reconciled and
Superior
recorded in the delivery note.
Posterior capsule For reduction of infectious mor­
bidity associated with anal sphincter
lacerations, a single dose of antibiotic
at the time of repair is recommended
by the American College of Obste­
Inferior Anterior
tricians and Gynecologists (20 1 6c) .
his practice is supported by evi­

I�
dence (Buppasiri, 20 1 4; Duggal,
2008; Lewicky-Gaupp, 20 1 5 ; Stock,
20 1 3) . A single dose of a second­
generation cephalosporin is suitable,
or clindamycin for penicillin-allergic
Figure of eight women. With OASIS, postopera­
F I G U R E 27- 1 7 In overview, with end-to-end a pproxi mation of the external anal sphincter (EAS), tively, stool softeners are prescribed
a sutu re is placed through the EAS muscle, and four to six simple i nterru pted 2-0 or 3-0 sutu res for a week, and enemas and supposi­
of polyg lactin 9 1 0 a re placed at the 3, 6, 9, and 1 2 o'clock positions through the perisphincter con­ tories are avoided.
nective tissue. To begin, disrupted ends of the striated EAS muscle and ca psule a re identified and Unfortunately, normal function is
g rasped. The first suture is placed posteriorly to maintai n clear exposu re. Another suture is then not always ensured even with correct
placed i nferiorly at the 6 o'clock position. The sphincter muscle fibers a re next reapposed by a
and complete surgical repair. Some
fig u re-of-eight stitch. Last, the remainder of the fascia is closed with a stitch placed a nterior to the
sphincter cyli nder and again with once placed su perior to it. (Reprod uced with perm ission from
women may experience continuing
Kenton K, Mueller M: Episiotomy a nd obstetric anal sphi ncter lacerations. In Yeomans ER, Hofman fecal incontinence caused by injury
BL, Gi lstrap LC I I I, et al (eds): Cunningham and Gilstra p's Operative ObstetriCS, 3 rd ed. New York, to the innervation of the pelvic Boor
McGraw-Hili Ed ucation, 20 1 7.) musculature (Roberts, 1 990) .
 Vag i nal Del ivery 533

A B

F I G U R E 27- 1 8 A. Sutu ring of the a norectal mucosa beg i ns above the laceration a pex using a conti n uous, non locki ng method with fine­
gauge a bsorba ble sutu re such as 3-0 or 4-0 chromic g ut or polyg lacti n 9 1 0. Sutu res a re placed through the anorectal s u bmucosa approxi­
mately 0.5 cm apart down to the a n a l verge. B. A second rei nforci ng layer uses 3-0 delayed-absorba ble suture in a conti n uous, nonlocking
fashion. This incorporate the torn ends of the internal a nal sphincter (lAS), which can be identified as the glistening white fibrous structure lyi ng
between the anal ca nal subm ucosa a nd the fibers of the external anal sphincter. I n many cases, the lAS retracts latera lly a nd m u st be soug ht and
retrieved for repa ir. (Reprod uced with permission from Kenton K, Mueller M: Episiotomy a n d obstetric anal sphi ncter lacerations. I n Yeoma n s ER,
Hofman BL, Gilstra p LC I I I, et al (eds): Cu n n ingham and Gilstrap's Operative Obstetrics, 3 rd ed. New York, McGraw-Hili Ed ucation, 201 7.)

• Perineal Laceration Care
Initially, locally applied ice packs help reduce swelling and allay
discomfort (de Souza Bosco Paiva, 20 1 6) . In subsequent days,
warm sitz baths aid comfort and hygiene. Additionally, a small
squirt botde of warm water can cleanse the site after voiding or
stooling. For pain, topical application of 5-percent lidocaine
ointment was not efective in relieving episiotomy or perineal
laceration discomfort in one randomized trial (Minassian,
2002) . Oral analgesics containing codeine provide considerable
relie. For lesser degree of discomfort, NSAID tablets can be
given.
Because pain may signal a large vulvar, paravaginal, or ischio­
rectal fossa hematoma or perineal cellulitis, these sites should
be examined carefully if pain is severe or persistent. Manage­
ment of these complications is discussed in Chapters 37 and
4 1 (pp. 674 and 764). In addition to pain, urinary retention
may complicate episiotomy recovery (Mulder, 20 1 2, 20 1 6) . Its
management is described in Chapter 36 (p. 660) .
For those with second-degree lacerations or anal sphinc­
ter tears, intercourse is usually proscribed until after the irst
puerperal visit at 6 weeks. Compared with women with intact
perineum, those with perineal trauma show higher rates
of delayed intercourse at 3 and 6 months, but not at 1 year
(McDonald, 20 1 5 ; Rldestad, 2008; Signorello, 200 1 ) .
Almroth L, Elmusharaf S, El Hadi N, et al: Primary infertility ater genital muti­
lation in girlhood in Sudan: a case-control study. Lancet 366:385, 2005
Al-Wassia H , Shah PS: Eicacy and safety of umbilical cord milking at birth: a
systematic review and meta-analysis. ]AMA Pediatr 1 69 ( 1 ) : 1 8 , 20 1 5
American Academy of Pediatrics: Delayed umbilical cord clamping after birth.
Pediatrics 1 39 (6) :e20 1 0957, 20 1 7a
American Academy of Pediatrics, American College of Obstetricians and
Gynecologists: Guidelines for Perinatal Care, 8th ed. Elk Grove Village,
AAP, 20 1 7b
American College of Obstetricians and Gynecologists: Documenting shoulder
dystocia. Patient Safety Checklist No. 6, August 20 1 2
American College of Obstetricians and Gynecologists: Guidelines for Women's
Health Care, 4th ed. Washington, ACOG, 2 0 1 4
American College o f Obstetricians and Gynecologists: I mmersion i n water
during labor and delivery. Committee Opinion No. 679, November
20 1 6a
American College of Obstetricians and Gynecologists: Prevention and manage­
ment of obstetric lacerations at vaginal delivery. Practice Bulletin No. 1 65 ,
July 20 1 6b
American College of Obstetricians and Gynecologists: Prophylactic antibiotics
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20 1 6c
American College of Obstetricians and Gynecologists: Delayed umbilical cord
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American College of Obstetricians and Gynecologists: Planned home birth.
Committee Opinion No. 697, April 20 1 b
American College of Obstetricians and Gynecologists: Shoulder dystocia. Prac­
tice B ulletin No. 1 78, November 2002, Reairmed May 20 1 7c
Ampt A], Ford ]B, Roberts CL, et al: Trends in obstetric anal sphincter i njuries
and associated risk factors for vaginal singleton term births in New South
Andersson 0 , Hellstrom-Westas L , Andersson D, e t al: Efect o f delayed versus
Wales 200 1 -2009. Aust N Z ] Obstet Gynaecol 5 3 ( 1 ) :9 , 20 1 3
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Andersson 0 , Hellstrom-Westas L, Andersson D , et al: Efects of delayed com­

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