Obstetric Intervention

Obstetric
Intervention
Obstetric
Interventions
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Edited by
P. Joep Dorr
Vincent M. Khouw
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Frank A. Chervenak
Amos Grunebaum ♦
Yves Jacquemyn
Jan G. Nijhuis
C a m b r id g e Medicine
Obstetric Interventions
Edited by
P. Joep Dorr
Formerly of HMC Haaglanden Medical Centre, Wesleinde, The Hague, the Netherlands
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Vincent M. Khouw
VMK Designs, Utrecht, the Netherlands
Frank A. Chervenak
Department of Obstetrics and Gynecology, Weill Cornell Medical Center, New York, USA
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Amos Grunebaum
Department of Obstetrics and Gynecology, Weill Cornell Medical Center, New York, USA
Yves Jacquemyn
Department of Obstetrics and Gynecology, Antwerp University Hospital, Edegem, Belgium
Jan G. Nijhuis -li

Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, the Netherlands
h er
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Cam b r id g e
U N I V E R S IT Y P R E S S
Cam b r id g e
U N IV E R S I T Y P R E S S
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© Cambridge University Press 2017
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no reproduction of any part may take place without the written
permission of Cambridge University Press.
b.
First published 2017
Printed in the United Kingdom by Clays, St Ives pic
A catalogue record fo r this p ublication is available fr o m the British Library
Library o f Congress Cataloguing in Publication data

Dorr, P.J. (P. Joep), -2014, editor.
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Obstetric interventions / edited by P.J. Dorr, V.M. Khouw, F.A. Chervenak, A. Grunebaum, Y. Jacquemyn,
J.G. Nijhuis.
Obstetrische interventies. English
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Cambridge, United Kingdom ; New York : Cambridge University Press, 2017. | Translation o f the Obstetrische
interventies / redactie P. Joep Dorr, Vincent M. Khouw, Yves Jacquemyn, Frank A. Chervenak, Jan G. Nijhuis ;
tekeningen: Vincent M. Khouw. Derde druk. 2014. Translated by Robert Croese. | Includes bibliographical
references and index.
LCCN 2016057369 | ISBN 9781316632567 (alk. paper)
| MESH: Obstetric Labor Complications - surgery | Obstetric Surgical Procedures
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LCC RG701 | NLM WQ 330 | DDC 618.5-dc23

LC record available at https://lccn.loc.gov/2016057369
ISBN 978-1-316-63256-7 Mixed Media
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ISBN 978-1-316-63258-1 Paperback

ISBN 978-1-316-85028-2 Cambridge Core
Additional resources for this publication at www.cambridge.org/9781316632567

Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
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accurate or appropriate.
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and practice
at the time o f publication. Although case histories are drawn from actual cases,
every effort has been made to disguise the identities o f the individuals involved.
Nevertheless, the authors, editors, and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors, and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
Contents
List o f Anim ations vi
List o f Contributors vii
Preface ix
Classification o f Evidence Levels x
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Section 1-Anatomy 8 Shoulder Dystocia 158
P.P. van den Berg and S.G. Oei
1 Anatom y 3
9 Retained Placenta 165
P.J. D orr, S. Keizer, M. W eemhoff, M.C. de
b.
H.J. van Beekhuizen and J.H. Schagen van
Ruiter, and V.M. Khouw
Leeuwen
10 Placenta Accreta, Increta, and Percreta 171

Section 2-Normal Labor and Delivery W. M ingelen, F.M. van Dunne, and P.J.
2 Normal Labor and Delivery 19
H.W. Torij, K.M . Heetkam p,
A. Grunebaum , M. van Dillen-Putman,
and J. van Dillen
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11 Inversion of the Uterus 177

J.B. Derks and J. van Roosm alen
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12 Technique for Cesarean Delivery 181
S.A. Scherjon, J.G. Nijhuis, and W.J.A.
Section 3-Pathology of Labor and Labor Gyselaers
and Delivery 13 Sphincter Injury 211

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M. W eemhoff, C. Willekes, and M.E.

3 Com pound Presentation and Umbilical Cord
Vierhout
Prolapse 81
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A.J. Schneider and J.J. Duvekot
4 Delivery of Tw ins 91 Section 4-Ethics of Obstetrical

M. Laubach and Y. Jacquem yn Interventions
5 External Cephalic Version 100 14 Ethical Dim ensions of Obstetrical
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E. Roets, M. H anssens, and M. Kok Interventions 227

6 Vaginal Breech Delivery 107 F.A. Chervenak, A. Grunebaum , and L.B.
A.T.M . Verhoeven, J.P. de Leeuw, H.W. M cCullough
Bruinse, H .C.J. Scheepers, and B. W ibbens
7 Operative Vaginal Delivery (Vacuum and

Forceps Extraction) 137
Index 231
P.J. Dorr, G.G.M . Essed, and F.K.
Lotgering
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Animations
Animations will appear in the online version o f this title on Cambridge Core.
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A nim ation 2.1 Delivery in occiput presentation, A nim ation 6.4 Lovset maneuver.
occiput anterior side view. A nim ation 6.5 M auriceau maneuver.
Anim ation 2.2 Delivery in occiput presentation, Anim ation 6.6 M auriceau m aneuver close up.
occiput anterior perspective. A nim ation 6.7 De Snoo m aneuver from above.
b.
Anim ation 2.3 Delivery in sinciput presentation A nim ation 6.8 De Snoo m aneuver from
side view. underneath.
Anim ation 2.4 Delivery in sinciput presentation A nim ation 6.9 Forceps on aftercom ing head side
perspective. view.
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Anim ation 2.5 Occiput presentation, occiput
posterior side view.
A nim ation 2.6 Occiput presentation, occiput
posterior perspective.
A nim ation 6.10
A nim ation 6.11

A nim ation 6.12
Forceps on aftercom ing head from
underneath.
Breech extraction.
Pinard maneuver.
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A nim ation 2.7 Delivery in brow presentation side Anim ation 6.13 Breech extraction deeply engaged
view. breech.
A nim ation 2.8 Delivery in brow presentation A nim ation 6.14 Breech delivery.
perspective. Anim ation 7.1 Forceps extraction OA.
A nim ation 2.9 Delivery in face presentation side Anim ation 7.2 Forceps extraction LOA.
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view. Anim ation 7.3 Forceps extraction face

Anim ation 2.10 Delivery in face presentation presentation.
perspective. Anim ation 7.4 Forceps extraction face presentation
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Anim ation 3.1 Prolapsed arm. side view.

Anim ation 3.2 Prolapsed hand. A nim ation 7.5 V acuum extraction OA.
Anim ation 3.3 Repositioning o f a prolapsed arm. A nim ation 7.6 V acuum extraction LOA.
Anim ation 3.4 Internal version and extraction. A nim ation 8.1 M cRoberts maneuver.
Anim ation 3.5 Internal version and extraction two A nim ation 8.2 Pressure suprapubic.
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feet. A nim ation 8.3 Rubin method.

Anim ation 3.6 Filling o f the bladder with saline A nim ation 8.4 W oods maneuver.
solution. A nim ation 8.5 Remove the posterior arm.
Anim ation 4.1 Delivery o f twins. A nim ation 8.6 All-fours maneuver.
A nim ation 4.2 Internal version and extraction o f A nim ation 8.7 Symphysiotom y.
the second twin. A nim ation 9.1 Retained placenta.
Anim ation 5.1 Forward roll. A nim ation 11.1 Repositioning o f the uterus cranial
A nim ation 5.2 Back flip. view.
A nim ation 6.1 According to Bracht. A nim ation 11.2 Repositioning o f the uterus caudal
A nim ation 6.2 Classical m aneuver to deliver the view.
posterior arm. A nim ation 13.1 Suturing with overlapping
Anim ation 6.3 Muller maneuver to deliver the technique.
anterior arm.
Contributors
H J . van Beekhuizen, MD, PhD J J . Duvekot, MD, PhD
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Department o f Obstetrics and Gynecology, Erasmus Departm ent o f Obstetrics and Gynecology, Erasm us
University Medical Centre, Rotterdam, the Netherlands University M edical Centre, Rotterdam , the
Netherlands
P.P. van den Berg, MD, PhD
Department o f Obstetrics and Gynecology, Groningen G.G.M. Essed, MD, PhD
b.
University Medical Centre, Groningen, the Netherlands Form er Gynaecologist, D epartm ent o f Obstetrics and
Gynecology, M aastricht University M edical Centre,
H.W. Bruinse, MD, PhD M aastricht, the Netherlands; Anton de Kom
Form er Professor o f Clinical Obstetrics, Departm ent University o f Surinam e, Param aribo, Suriname
F.A. Chervenak, MD
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o f Obstetrics and Gynecology, Utrecht University
M edical Centre, Utrecht, the Netherlands
D epartm ent o f Obstetrics and Gynecology, Weill

A. Grunebaum , MD
Departm ent o f Obstetrics and Gynecology, Weill
Cornell M edical Center, New York, USA
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Cornell M edical Center, New York, USA W J.A . Gyselaers, MD, PhD
D epartm ent o f Obstetrics and Gynecology, East
J.B. Derks, MD, PhD Lim burg H ospital, Genk, Belgium
D epartm ent o f Obstetrics and Gynecology, Utrecht
University M edical Centre, Utrecht, the Netherlands M. Hanssens, MD, PhD
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D epartm ent o f Obstetrics and Gynecology, University

J. van Dillen, MD, PhD H ospital, Leuven, Belgium
D epartm ent o f Obstetrics and Gynecology, Radboud
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University N ijm egen M edical Centre, Nijm egen, the K.M. Heetkam p, MSc
Netherlands The School o f Midwifery at the Rotterdam University
o f Applied Sciences, Rotterdam, the Netherlands
M. van Dillen-Putm an, midwife
D epartm ent o f Obstetrics and Gynecology, Radboud Y. Jacquem yn, MD, PhD
University N ijm egen M edical Centre, Nijm egen, the Departm ent o f Obstetrics and Gynecology, Antwerp
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Netherlands University H ospital, Edegem, Belgium
P J . Dorr, MD, PhD S. Keizer, midwife

Gynaecologist, form erly o f H M C H aaglanden Midwifery Practice M undo Midwives, The Hague, the
M edical Centre, The H ague, the Netherlands; Netherlands
Professor, form erly o f D epartm ent o f Education
V.M. Khouw, MSc
and Teaching, Leiden University M edical Centre,
Leiden, the Netherlands V M K Designs, Utrecht, the Netherlands
F.M. van Dunne, MD, PhD M. Kok, MD, PhD

D epartm ent o f Obstetrics and Gynecology, M edical Departm ent o f Obstetrics and Gynecology, Academic
Centre H aaglanden, The H ague, the Netherlands M edical Centre, Am sterdam , the Netherlands
List of Contributors
M. Laubach, MD J.H. Schagen van Leeuwen, MD, PhD

D epartm ent o f Obstetrics, University H ospital Departm ent o f Obstetrics and Gynecology,
Brussels, Brussels, Belgium St. Antonius H ospital, Nieuwegein, the Netherlands
J.P. de Leeuw, MD, PhD H .C J. Scheepers, MD, PhD

Form er Gynaecologist, Alrijne H ospital, Leiderdorp, Department o f Obstetrics and Gynecology, Maastricht
the Netherlands University Medical Centre, Maastricht, the Netherlands
F.K. Lotgering, MD, PhD S.A. Scherjon, MD, PhD

D epartm ent o f Obstetrics and Gynecology, Utrecht D epartm ent o f Obstetrics and Gynecology,
University Medical Centre, Utrecht, the Netherlands Groningen University M edical Centre, Groningen,
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the Netherlands
L.B, M cCullough, PhD
Center for M edical Ethics and Health Policy, Baylor A.J. Schneider, MD, PhD
College o f Medicine, H ouston, USA Department o f Obstetrics and Gynecology, Erasmus
University Medical Centre, Rotterdam, the Netherlands
W. M ingelen, MD
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D epartm ent o f Obstetrics and Gynecology, H M C H.W. Torij, MSc
H aaglanden M edical Centre, The Hague, the Rotterdam University o f Applied Sciences,
Netherlands Rotterdam , the Netherlands
J.G. Nijhuis, MD, PhD

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D epartm ent o f Obstetrics and Gynecology,
M aastricht University M edical Centre, Maastricht,
the Netherlands
A.T.M. Verhoeven, MD, PhD
Form er Gynaecologist, Rijnstate H ospital, Arnhem ,
the Netherlands
M.E. Vierhout, MD, PhD

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S.G. Oei, MD, PhD D epartm ent o f Obstetrics and Gynecology, Radboud
D epartm ent o f Obstetrics and Gynecology, M axim a U niversity N ijm egen M edical Centre, Nijm egen, the
M edical Centre, Veldhoven; Eindhoven University o f Netherlands
Technology, Eindhoven, the Netherlands
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M. W eemhoff, MD, PhD

E. Roets, MD D epartm ent o f Obstetrics and Gynecology,
D epartm ent o f Obstetrics and Gynecology, University Zuyderland M edical Centre, Heerlen, the Netherlands
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H ospital Ghent, Ghent, Belgium

B. W ibbens, MD
J. van Roosmalen, MD, PhD D epartm ent o f Obstetrics and Gynecology,
D epartm ent o f Obstetrics and Gynecology, Leiden Am stelland H ospital, Amstelveen, the Netherlands
University M edical Centre, Leiden, the Netherlands
C. Willekes, MD, PhD
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M.C. de Ruiter, MD, PhD D epartm ent o f Obstetrics and Gynecology,

D epartm ent o f Obstetrics and Gynecology, Leiden M aastricht University M edical Centre, M aastricht,
University M edical Centre, Leiden, the Netherlands the Netherlands
Preface
This past century has seen significant changes in im portant topic o f ethical dim ensions o f the birth
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obstetrics due to dram atic technological advances. process including the crucial aspect o f inform ed
M ore often than not these changes have led to positive consent.
im provem ents in antepartum and intrapartum care. Furtherm ore, by using the code that com es with
Nonetheless, a tim eless challenge for all providers the book, one can open the 3D anim ations, which
continues to be how to best take care o f a pregnant are even m ore pow erful than the static pictures
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w om an and her soon to be born child on labor and alone.
delivery. The first two editions o f this book were based on
The purpose o f this book is to m erge traditional a Dutch initiative and therefore written in Dutch.
obstetrics with what we have learned through tech However, because obstetrics in the twenty-first cen
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nology and evidence-based m edicine illustrated by
state o f the art 3D illustrations and anim ations.
Too often tradition and local custom s have deter
mined our approach to labor and delivery management
tury has truly becom e a global enterprise, we decided
to have international collaboration as m aternal and
perinatal m orbidity and mortality are a global prob
lem. We hope that this book will facilitate education
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and training. It is essential today that managem ent and and help all those who care for pregnant wom en and
training are based on the best available evidence so that their children throughout the world to improve
optimal care can be given to pregnant women and soon their basic understanding o f the birth process and
to be born children. Each chapter in our text is refer understand and prevent potential com plications that
enced by a comprehensive literature review seeking the can arise.
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best available international evidence. It is very sad that the initiator o f this project, Joep
The anatom y chapter lays the foundation for the Dorr, died in 2014, just before the book was com
pletely ready. We have honored him by keeping his
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book, by explicating the passage o f the child through

the birth canal during norm al and pathological child nam e as first author on this edition.
birth. A nim ations are used to further clarify the dif
ferent birth m echanism s. Throughout the book we P. Joep Dorr
provide insight into the m echanism s o f norm al child Vincent M. Khouw
birth and the choices o f obstetric interventions in the Frank A. Chervenak
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delivery room and operating room using text, 3D Amos Grunebaum

drawings, and anim ations. This com bination gives Yves Jacquemyn
our book a unique perspective. We also discuss the Jan G. Nijhuis
Classification of Evidence Levels
LE A l: Systematic reviews covering at least som e Randomized clinical trials o f moderate qual
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A2-level studies, in which the results o f the ity or insufficient size, or other comparative
individual studies are consistent studies (non-randomized, comparative
LE A2: Random ized com parative clinical studies cohort study, patient-control study)
o f good quality, sufficient size, and N on-com parative study
Expert opinion
b.
consistency
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Anatomy
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C h a p te r
Anatomy
1 P.J. Dorr, S. Keizer, M. Weemhoff, M.C. de Ruiter, and V.M. Khouw
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atlases and textbooks. The m ost im portant publica
Introduction tions are listed in the bibliography.1-3
Knowledge o f the anatom y, the fetal skull, and the
bony and soft-tissue birth canal is required to under
Fetal Skull
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stand the passage o f the infant through the birth canal
in either norm al or pathological birth. The five skull bones (the two frontal bones, the two
T o produce the graphic figures depicting the fetal parietal bones, and the one occipital bone) o f the fetus
skull and the birth canal, the authors used m any are not joined together yet, but separated from each
other by sutures and fontanels (Figure 1.1).
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sagittal suture sagittal suture
coronal suture
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anterior fontanel
bone
frontal fontanel
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suture
frontal
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glabella
coronal suture
lambdoid suture
Figure 1.1 Skull bones, skull sutures, and fontanels o f the fetus.
O b ste tric In te r v e n tio n s , ed. P. Joep D orr, V incent M. Khouw , Fran k A. Chervenak, A m os G runebaum , Yves Jacquem yn,
and Jan G. N ijhuis. Published by C am bridge U niversity Press. © C am bridge University Press 2017.
Sectio n 1: A n a to m y
The fetal skull is malleable since the parietal bones (attitude and position) o f the head in the true pelvis.
can slide over the frontal bones and the occipital bone: The posterior fontanel (triangular), the sagittal suture,
this is called m olding (or moulage). M olding allows and the anterior fontanel (diam ond-shaped) are crucial
the skull to adapt to the birth canal. orientation points in this examination (Figure 1.2).
The sutures and fontanels can be determined The m ost im portant skull dim ensions are shown
through internal examination for the orientation in Table 1.1 and Figure 1.3.
Table 1.1 Skull dimensions
D istan ce (d.) a n d circu m fe re n ce (c.) cm From - to Presen ta tio n
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d. suboccipitobregm atic 9.5-10 Neck - m iddle anterior O ccip ut presentation with m axim um
fontanel flexion
c. suboccipitobregm atic 32-33
b.
d. suboccipitofrontal 10 Neck - forehead Normal o ccipu t presentation
c. suboccipitofrontal 34
d. fronto-occipital 12 Glabella - back o f head Sinciput presentation
c. fronto-occipital 34-35
d. m ento-occipital
c. m ento-occipital
d. subm entobregm atic

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35
9.5
Chin - back o f head
Lower jaw - m iddle anterior

Brow presentation
Facial presentation
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fontanel
c. subm entobregm atic 34
d. biparietal 9.5 Greatest transverse diameter
d. bitem poral 8-8.5

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Smallest transverse diam eter
posterior fontanel
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sagittal
anterior fontanel
Figure 1.2 Fontanels and sagittal suture.

C h a p te r 1: A n a to m y
d. suboccipitobregmatic
d. suboccipitofrontal
d. fronto-occipital
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d. mento-occipital
b.
d. submentobregmatic
C
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c. suboccipitobregmatic
c. suboccipitofrontal
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c. fronto-occipital
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c. mento-occipital
c. submentobregmatic
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Figure 1.3A-C Distances (A, B) and circum ferences (C).
Birth Canal pubic bone. Anteriorly, the pubic bones are conjoined
The birth canal consists of: by the pubic symphysis. Posteriorly, the ilium bones
are conjoined to the sacrum by m eans o f the sacroiliac
• the bony birth canal: the true pelvis;
joints. The sacrum is connected to the coccyx by
• the soft-tissue birth canal: the lower uterine seg
m eans o f the sacrococcygeal joint. D uring pregnancy,
ment, the cervix, the vagina, the vulva, and the
a slight and individually varying relaxation occurs to
pelvic floor m usculature.
the connective tissue o f the pubic sym physis and the
sacroiliac joints. Because o f this relaxation, m ore
The Bony Birth Canal room is created in the pelvis (Figure 1.4).
The bony pelvis consists o f the two innom inate or The bou ndary between the false and the -
hip bones, the sacrum , and the coccyx. The innom i obstetrically m ore im portant - true pelvis is form ed
nate bones consist o f the ilium, the ischium, and the by the plane o f the (true) pelvic inlet. The true
Section 1: A n a to m y
pelvis has different dim ensions at different points. shape. The plane o f the pelvic outlet has an oval
The plane o f the m idpelvis, with the ischial spines as shape in an terop osterior direction (T able 1.2,
reference points, has the sm allest diam eter. Figures 1.5 and 1.6).
The plane o f the pelvic inlet has a transverse oval The pelvic axis passes through the m idpoints o f
the above-m entioned planes. This central axis o f the
Table 1.2 Pelvic planes birth canal runs in a straight line from the pelvic inlet
to the m idpelvis and then bends at an angle o f
P lane B ou nd aries: F(ront), D im en sio n s
approxim ately 90° around the pubic sym physis to
L(ateral), B(ack) (cm): F(ront),
B(ack),
the pelvic outlet (Figure 1.7).
Tr(ansverse)
Pelvic inlet F: upper edge o f pubic FB: 10.5-11.5
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symphysis
sacroiliac joints
L: innom inate line Tr: 13 sacrum
B: prom ontory
Maxim um pelvic F: m iddle posterior FB: 12-13

breadth plane o f pubic
b.
symphysis
L: obturator foramen Tr: 12-13
B: third sacral vertebra
Midpelvis F: lower edge o f pubic FB: 11-12

symphysis
Pelvic outlet
L: ischial spine
B: boundary o f fourth/
fifth sacral vertebra
Anterior triangle:
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FB: 9.5-12
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Two triangles F: low er edge o f pubic Tr: 11-12
symphysis
L: ischial tuberosity
isc h iu m
Posterior triangle:
pubic bone pubic symphysis
L: ischial tuberosity
B: sacrococcygeal joint
Figure 1.4 Pelvis.
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pubic symphysis pubic symphysis
promontory
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round
3 sacral vertebra
pubic symphysis pubic symphysis
f ischial
tuberosity
longitudinal ischial
ovai spine sacrococcygeal joint
4 /5 sacral vertebra
Figure 1.5 Pelvic inlet plane (A), maxim um pelvic breadth (B), midpelvis (C), pelvic outlet (D).
Figure 1.6 Pelvic planes.

pubic symphysis
ischial tuberosity
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ischial spine
b.
promontory
sacrococcygeal
joint
4th / 5th sacral
vertebra
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3rd sacral
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Figure 1.7 Pelvic axis.
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Engagement o f the presenting part is determ ined Table 1.3Planes o f Hodge classification
by the lower-most engaged presenting (bony) part o f
Plan e o f H o d g e P o sition in th e tru e pelvis
the infant (the head in a cephalic presentation) rela
tive to the true pelvis. For this purpose, the true pelvis Hodge 1 Plane o f the pelvic inlet
is divided into four parallel planes: the planes o f
Hodge 2 Plane parallel to HI, through the lower
H odge (Table 1.3 and Figure 1.8). edge o f the pub ic symphysis
In the English-language literature, the engagement
H odge 3 Plane parallel to HI and H2, through the
o f the presenting part is described relative to the ischial ischial spines
spines. The level o f the interspinal line (Hodge 3) is
Hodge 4 Plane parallel to HI, H2, and H3,
referred to as the “zero (0) station.” The indication of
through the Sacrococcygeal joint
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b.
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Figure 1.8 (A) Planes o f Hodge. (B) The indication of the engagement o f the presenting part on passage from the pelvic inlet to the pelvic floor.
biparietal distance Figure 1.9 Head is engaged past the H3/0

station.
H3 /
0 station
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b.
pelvic axis
posterior fontanel
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the engagement o f the presenting part on passage from the largest diameter o f the head (the biparietal distance)
the pelvic inlet to the interspinal line is - 5 through -1 has essentially passed the pelvic inlet and the child can
(cm) and from the interspinal line to the pelvic floor is in principle be born vaginally (Figure 1.9).
+ 1 through +5 (cm) (Figure 1.8B). “Station +5” means In firm m olding o f the fetal head, with the lower
h
that the presenting part is positioned on the pelvic m ost engaged part at or past the third plane o f Hodge,
floor. If the head (in an occiput presentation) is the largest diam eter o f the head m ay not have passed
the pelvic inlet yet (Figure 1.10).
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engaged past the third plane o f Hodge (“0 station”),

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Figure 1.10 Firmly m olded head is

engaged up to the H3/0 station.
biparietal distance
H 1 1-5 station
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H3 /
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0 station
ischial spine
pelvic axis
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Pelvic Shapes
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• The android or male-like pelvis: has a “triangular”

The classification o f Caldwell and M oloy (1933, 1934) pelvic inlet, the pubic arch is narrow, the true
is based on the shape o f the pelvis. Knowledge o f this pelvis is funnel-shaped, the sacrum is less concave,
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classification provides an understanding o f the and the ischial spines are prom inent.
m echanism o f childbirth with different pelvic shapes • The anthropoid pelvis: the pelvic inlet is oval
(Figure 1.11). shaped in an anteroposterior direction; the other
• The gynecoid pelvis: has a transverse oval pelvic characteristics are the sam e as the android pelvis.
entry, the pubic arch is wide, the true pelvis is • The platypelloid pelvis: has a pelvic inlet with
a short anteroposterior dim ension and further
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cylinder-shaped, the ischial spines are not p rom i

nent, and the sacrum is biconcave. characteristics as in the gynecoid pelvis.
10
gynecoid
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anthropoid
Figure 1.11 Pelvic shapes: gynecoid (A), android (B), anthropoid (C), and platypelloid (D).
Internal Pelvic Examination however, the prom ontory is reached, the diagonal
The internal pelvic exam ination can give an indica conjugate - the distance from the lower edge of the
pubic symphysis to the promontory (normal
tion o f the pelvic dim ensions. The orientation points
12-13 cm) - can be “measured.” The true conjugate
are at the following anatom ical structures:
(the distance from the upper edge o f the pubic
• The promontory: can usually not be reached
symphysis to the promontory) is the
with the examination fingers (Figure 1.12). If,
anteroposterior diameter o f the pelvic inlet and is

1.5 cm shorter than the diagonal conjugate, and
therefore 10.5-11.5 cm (Figures 1.13 and 1.14).
• The innominate line: in a norm al pelvis, the lateral
and the posterior part o f the innom inate line
cannot be reached.
• The rear o f the pubic symphysis: is norm ally
sm ooth. Be aware o f exostoses.
• The sacrum: is norm ally hollow in two directions
(biconcave). Be aware o f ridges.
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• The coccyx: is norm ally located at the end o f the
sacrum and points to the front.
• The ischial spines: are not norm ally prom inent.
• The distance between the ischial tuberosity: the
transverse distance o f the pelvic outlet is deter
b.
m ined by placing the knuckles (bend o f the fingers
at the m argin o f the m iddle and distal phalanges)
from the second to the fourth fingers between the
Figure 1.12 Examination fingers. ischial tuberosity- There is norm ally room for four
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promontory
knuckles.
Figure 1.13 Diagonal conjugate and true

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conjugate.
pubic symphysis
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diagonal conjugate
12
promontory sacroiliac joint Figure 1.14 Pelvic orientation points.
anterior inferior
iliac spine
sacrum
anterior inferior
sacrococcygeal
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iliac spine
joint
coccyx
innominate line
ischial spine
b.
ischial
pubic symphysis
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A bnorm al pelves can develop due to p o o r diet in the
past, vitam in D shortage (rickets), and traum as.
An internal pelvic exam ination is frequently painful
and has lim ited value. A dditionally, the rep ro d u ci
in a horizontal position. A nteriorly the perineal
m em brane is continuous with the insertion o f the
tendinous arch to the pubic bone. Posteriorly the
m em brane is connected to the m em branous perineal
er
bility o f the exam ination is poor. The only ju stifica body.
tion for an internal pelvic exam ination in pregnant The erectile tissue and the clitoris are located in
w om en is a baby in breech position . If on internal the superficial perineal space and fused into the peri
pelvic exam ination ab n orm alities are encountered, neal m embrane. The erectile tissue is covered by the
h
a decision will be m ade to perform a cesarean ischiocavernosus and the bulbospongiosus muscles.
section. The superficial transverse perineal m uscle divides
The added value o f pelvic exam inations with the the perineum into the urogenital and anal triangles.
us
use o f X-rays, C T scans, or m agnetic resonance im Together with the urethrovaginal muscle, the axons of
aging (MRI) has not been dem onstrated.4,5 the bulbospongiosus muscle, and the external anal
sphincter, this muscle form s the perineal body
between the vagina and the anus (Figure 1.16).
The Soft-Tissue Birth Canal The perineal m em brane consists o f an anterior
The soft-tissue birth canal is m ade up o f the lower and a posterior part. The posterior part consists of
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uterine segm ent, the com pletely effaced and opened a bilateral transverse fibrous layer that connects the
cervix, the vagina, the vulva, and the pelvic floor lateral vaginal walls and the perineal body to the
m usculature (Figure 1.15). inferior ram i o f the pubic bone and the ram i o f
D uring the final phase o f the expulsion the birth the ischium. The anterior part o f the perineal
canal is elongated due to the diastasis o f the pelvic m em brane covers three m uscles situated in the deep
floor m usculature. perineal space. A longside the circular external ure
thral sphincter there is the com pressor urethra muscle
Pelvic Floor o f the inferior pubic ram us in front o f the urethra to
the contralateral side, to unite there with this muscle
The perineum can be divided into an anterior
from the other side. Next to that, there is a sling
urogenital triangle and a posterior anal triangle.
shaped muscle - the urethrovaginal muscle - that
The anterior urogenital triangle is divided by the
runs from the inferior pubic ram us and fuses behind
perineal m em brane into a superficial and a deep
the vagina in the perineal body (Figure 1.17).6
perineal space. The perineal m em brane is situated
Figure 1.15 Soft-tissue birth canal.
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pelvic axis
b.
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h er
inferior pubic ramus Figure 1.16 Superficial peri
superior pubic ramus
neal space.
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ischiocavernosus muscles
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bulbospongiosus
muscles
erectile tissue
ischial ramus
perineal body
perineal membrane
superficial transverse
perineal muscle anal sphincter muscle
levator ani muscle

external urethral sphincter Figure 1.17 Deep perineal

space.
urethra
perineal
membrane
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b.
vagina
compressor urethra
muscle
urethrovaginal anal canal

muscle
levator ani muscle
-lipuborectai sling
er
The anal triangle contains the anal canal, the anal 2 C unningham F, Leveno K, B loom S, et al. W illiam s
sphincters, and laterally the ischioanal fossae. Obstetrics. New York: M cGraw -Hill, 2009
The boundary o f the bottom o f the anal triangle is 3 Putz R, Pabst R. Sobotta, Atlas van de m enselijke
h
form ed by the levator ani muscle, o f which the p ubo anatom ie. H outen: Bohn Stafleu van Loghum , 2006.
rectai m uscle, the m edial part o f the levator, form s 4 Rozenburg P. Is there a role for X-ray pelvimetry in the
a sling-shaped loop around the anal canal and twenty-first century. Gynecol Obstet Fertil. 2007;35:6-12.
us
attaches ventrally to the pubic bone. 5 Sporri S, Gyr T, Schollerer A, et al. M ethods, techniques
and assessm ent criteria in obstetric pelvimetry.
Z Geburtshilfe Perinatol. 1994;198:37-46.
References 6 Stoker J, W allner C. The anatom y o f the pelvic floor and
1 D udenhausen JW. Praktische G eburtshilfe mit sphincters. In: Stoker J, Taylor S, D eLancey JO L (eds).
geburtshilflichen O perationen. Berlin-N ew York: W alter Im aging pelvic floor disorders. New York: Springer
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de Gruyter, 2011. V erlag, 2008.
15
Normal Labor and Delivery
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Normal Labor and Delivery
R H.W. Torij, K.M. Heetkamp, A. Grunebaum, M. van DiUen-Putman,

and J. van Dillen
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cephalic presentation s (96%) and breech p resen
Introduction
tations (3-4% ). A dditionally, transverse and
In this chapter the m ech an ism s o f labor and deliv
b.
divergent presentation s are differentiated
ery with vario u s cephalic p resen tation s will be
(<0.5% ) (Figure 2.1). The percentages refer to
explained as in sightfully as possible through the
term pregnancies.
use o f text, graphics, and anim ations. T o describe
• Presenting part: T his refers to the part o f the
the m ech an ism s o f labor and delivery a variety o f
fetus that lies deepest in the birth canal and
u se d .1' 14 -li
existing m an u als and reference bo ok s have been
The so-called “planes o f H od ge” and the

station s - representing the different levels o f
that therefore is the closest to the outlet o f the
birth canal. T hus, in the case o f a vertex p re s
entation, the occiput is the presenting part and
in a transverse presentation, the shoulder, the
er
descending through the birth canal - will be
trunk, or the hip are the presenting parts
described and used to explain, illustrate, and
(Figure 2.1).
anim ate labor and delivery m echanism s. T h is p ro
• Attitude: Attitude refers to the position o f the head
vides g oo d insight into the different and changing
relative to the trunk (Figure 2.2).
attitudes and p ositio n s o f the fetal head as it
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descends through the birth channel in the various The following are differentiated:
cephalic presentation s. - flexion presentations (m ost common): in
which the chin o f the fetus is pointed tow ard
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the chest; these include the occiput and the

Definitions sinciput presentations;
In order to com prehend the passage o f the - extension presentations: in which the occiput o f
fetus through the birth canal, an understanding o f the fetus points toward the dorsum ; these
the m echanism s o f norm al labor and delivery is include the brow and face presentations.
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required. To describe these m echanism s, • Position: This refers to the orientation o f the pre
the following definitions will be used in this chapter. senting part o f the fetus relative to the pelvis
(Figure 2.3).
Orientation of the Fetus Position is determ ined by the determining point:
The orientation o f the fetus in the uterus is - in a flexion presentation, the determining
determ ined by lie, presenting part, attitude, and point is the occiput (occiput presentation);
position . - in an extension presentation, the determining
• Lie: T h is refers to the relationship between point is the chin (mental presentation);
the long axis o f the fetus and that o f the - in a breech presentation, the determining
w om an. Longitudinal lies differentiate between point is the sacrum (sacral presentation).
O b ste tric In te rv e n tio n s , ed. P. Joep D orr, V incent M. Khouw , Frank A. Chervenak, A m os G runebaum , Yves Jacquem yn,
and Jan G. N ijhuis. Published by C am bridge U niversity Press. © C am bridge U niversity Press 2017.
Section 2: N orm al La bo r a n d D e live ry
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b.
Longitudinal lie Longitudinal lie Transverse lie
Vertex presentation Breech presentation Shoulder presentation
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Figure 2.1 Presentations and presenting parts.
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Figure 2.2 Flexion and
extension presentations.
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flexion presentation extension presentation
20
C h a p te r 2: N orm al La bo r a n d D elivery
# = determining point
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b.
eccentric pole
P (posterior fontanel)
Figure 2.3 Positions o f the head in occip u t presentation (the Figure 2.4 Eccentric pole,
determ ining point is the occiput).
Notation of the Fetal Presentation

Attitude and Position
-li Eccentric Pole
The eccentric pole is the deepest point o f the presenting
er
part lying outside the pelvic axis (Figure 2.4).
Presentation and attitude are indicated with capital
letters.
Rotation
While descending into the pelvis and during
P resen ta tio n /a ttitu d e D e te rm in in g p o in t
h
expulsion the head rotates (sim ultaneously) around

O ccip ut presentation O cciput (0) the frontal, sagittal, and vertical axes.
Sinciput presentation O ccip ut (0) • Rotation around the frontal axis (Figure 2.5): On
us
M entum (M)
engagement, the head usually flexes, thereby
Brow presentation
allowing the sm allest circumference to pass
Face presentation M entum (M)
through the pelvic cavity.
Breech presentation Sacrum (S) • Rotation around the sagittal axis (Figure 2.6): The
following are differentiated (Figure 2.7):
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Exam ple - synclitism: the sagittal suture transverses the

In an occiput presentation, the determ ining point is pelvic axis;
the occiput (O). The occiput can have the following - anterior asynclitism: the sagittal suture lies
positions relative to the pelvis: behind the pelvic axis;
- posterior asynclitism: the sagittal suture lies in
A = anterior P = posterior front o f the pelvic axis.
LOA = left anterior LOP = left posterior
• Rotation around the longitudinal axis (lengthwise
ROA = right anterior ROP = right posterior rotation) (Figure 2.8): The following are
ROT = right transverse
differentiated:
LOT = left transverse
- internal rotation: rotation o f the infant’s head
Thus, LOA stands for a left occiput anterior around the longitudinal axis, whereby the
presentation. eccentric pole usually turns to the front;
Section 2: N orm al La bo r a n d D elivery
rotation around frontal axis rotation around sagittal axis
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Figure 2.6 Rotation around the sagittal axis in occiput
presentation.
Figure 2.5 Rotation around the frontal axis.
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rotation around longitudinal axis

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Hodge 1 -
-5 station
Hodge 2 -
-2 /-3 station
Hodge 3 -
0 station
Figure 2.7 Synclitism.
Figure 2.8 Rotation around the longitudinal axis.

C h a p te r 2: N orm al La b o r a n d D elivery
point of rotation: nape of the neck Characteristics

In an occiput presentation:
• the lie is: cephalic presentation;
• the presenting part is: the occiput;
. the attitude is: flexion presentation;
• the determ ining point is: the occiput;
. the eccentric pole is: the occiput;
• the diam eters o f the head descending through the
pelvis are: the suboccipitofrontal (10 cm) diam eter
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and the biparietal (9.5 cm) diameter;
• the point o f rotation is: the posterior hairline.
Incidence
b.
Occiput presentation births occur in 85-88% o f all
deliveries.15 M ost often it is an occiput presentation
Figure 2.9 Point o f rotation in o ccip u t presentation. with the occiput anterior.
- external rotation: rotation o f the infant’s head Notation
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around the longitudinal axis following delivery
o f the head, in which the occiput turns to the
right or the left tow ard the infant’s dorsum .
Occiput presentation: determ ining point (O) anterior
(A), thus: OA.
Diagnosis
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Point of Rotation (Hypomochlion) • External exam ination: cephalic presentation.
The point o f rotation is that part o f the fetal head that • Vaginal exam ination: posterior fontanel in or near
passes over the sym physis pubis during delivery the pelvic axis.
(Figure 2.9).
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In this chapter we describe the passage o f the fetus

in cephalic presentation through the pelvis with
Mechanism of Labor from Hodge
different attitudes and positions o f the fetal head. It 1, - 5 Station Through Birth
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is im portant to realize that - besides attitude and See Anim ations 2.1 and 2.2.
position - there are m any other factors that influence In the m ajority o f nulliparous women with preg
the passage through the birth canal. The duration o f nancy duration o f 36 weeks, the head is already
labor, determ ining whether a wom an is in labor at the engaged, whereas in the m ajority o f m ultiparous
right m om ent (not too early and not too late), women the head is just barely or not yet engaged at
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the strength o f contractions, and o f course the size the start o f the delivery process.
o f the fetal head in relation to the size o f the pelvis
influence the passage through the birth canal. Hodge 1, - 5 Station
Owing to the focus o f this chapter on m echanism s • At term, the dorsum of approximately 70% o f infants
o f labor and delivery, other characteristics o f the first is left anterior, 25% right posterior, and 5% right
and second stage o f labor will not be described. anterior or left posterior. Therefore, m ost infants
start the descent into the pelvis with the occiput left
Mechanisms of Labor and Delivery anterior (LOA). Owing to the transverse-oval shape
o f the pelvic inlet, the head descends in a transverse
in Occiput Presentation, Occiput or oblique orientation (usually LOT) (Figure 2.10).
Anterior • Since the head has to pass over the promontory
Labor in vertex presentation with the occiput to the (rotation around the sagittal axis), the skull at
front is the m ost efficient way for a normally p rop or Hodge 1 is in asynclitic position (Figure 2.10). The
tioned infant to pass through a gynecoid pelvis and be sagittal suture is anterior to the pelvic axis, making
born. this a posterior asynclitism.
Section 2: N orm al La bo r and D elivery
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Hodge 2, —2/—3 Station . The head passes a little m ore over the sacral prom
ontory at this point. The sagittal suture is now
• In this plane, the head has descended about one-
alm ost positioned in the pelvic axis. Synclitism
third o f the way.
is reached between H odge 2, -2 1 -3 station and
• Flexion increases (rotation around the frontal
H odge 3, 0 station (Figure 2.11).
axis), causing the posterior fontanel to be p osi
tioned closer to the pelvic axis.
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b.
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<4
/
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sagittal suture
F ig u r e 2 .1 1 A - C Head at H odge 2, —2/—3 station.

Section 2: N orm al La b o r a n d D elivery
Hodge 3, 0 Station The head has now pivoted com pletely around the
• A t this point the head has descended about sacral prom ontory. The sagittal suture is p osi
h alf way. The largest d iam eter o f the head (the tioned behind the pelvic axis (anterior asynclit
ism ) (Figure 2.12).
biparietal diam eter) has p assed the pelvic inlet.
In principle, the infant can now be born The flexion o f the head increases som e m ore. The
vaginally. posterior fontanel gets closer to the pelvic axis and
an eccentric pole develops (Figure 2.13).
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pelvic axis
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sagittal suture
Figure 2.12A-C Head at Hodge 3 ,0 station.
26
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b.
eccentric pole
(posterior fontanel)
Figure 2.13 Eccentric pole.
-li Figure 2.14 Rotated head on pelvic floor.

er
• the shape o f the birth canal: from H odge 3, 0
Internal Rotation station, the birth canal curves 90° toward the
Through this m aneuver, the occiput rotates to the front (Figure 2.15);
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front. This is a rotation around the long axis. This • the flexibility o f the head relative to the trunk: in a
internal rotation is necessary to be able to pass the flexion attitude, the head will flex further while
pelvic outlet, whose anteroposterior dim ension is
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descending (and extends further in an extension

greater than the transverse dim ension (Figure 2.14). attitude);
In m ost women the internal rotation is com plete • the eccentric pole: due to the contractions, the
when the head reaches the pelvic floor. eccentric pole rotates to the front on passing the
Internal rotation occurs due to:
bend in the birth canal.
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27
pelvic axis Figure 2.15 Pelvic axis.
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Figure 2.16A-B Persistent mechanism.
Persistent Mechanism that the head is flexed at m axim u m and the pos-
Som etim es, in an occiput presentation , the head terior fontanel (the deepest point) is p osition ed in
is situated in a persistent m echanism . T his m eans the pelvic axis (Figure 2.16). In that p osition
C h a p te r 2: N orm a l La bo r a n d D elivery
there is no eccentric pole, which som etim es Hodge 4, +5 Station

causes the rotation to take place later. An occiput # The hgad is nQW at the levd o f the peM c outlet
presentation with persisten t m echanism can occur The internal rotation is usually complete. The posi-
when there is a discrepancy betw een the head and tion ^ QA (pjgure 2 17)
the pelvis.
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Figure 2.17A-C Head at H odge 4 , +5 station.

Birth of the Head in the vulva during a contraction and will retract
Crowning of the Head again between contractions. This is called crowning
(Figure 2.18).
When the head is rotated, flexion decreases due to the
forw ard-bending curve in the birth canal. With each
Extension of the Head
contraction the skull pushes against the pelvic floor.
The head becom es m ore visible as it descends. When
The perineum becom es increasingly m ore curved due
the neck groove is under the sym physis (brow under
to the pressure from the pushing skull. With each
the posterior edge o f the vulva), the head no longer
contraction the anus is open and the vulva becom es
retracts during a pause in the contractions: the head is
wider. The back o f the head finally becom es visible
extended (Figure 2.19).
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A B
b.
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Figure 2.18 A - B Crowning o f the head.
30
C h a p te r 2: N orm a l La b o r a n d D elivery
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b.
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Figure 2.19A-B Extension of the head.
Delivery of the Head H ands O ff— In the hands-off method, the hands are
D uring one o f the follow ing con traction s the not on the head or on the perineum.
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head extends and is bo rn by rotation aroun d the Research outcom es are not unequivocal concern
sym physis. The pivot p oin t is the nape o f the neck ing the hands-on versus the hands-off m ethod related
(Figure 2.20). W hen the largest dim ension o f the to the effect on perineal tears. The hands-on versus
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head is expelled, it is referred to as the delivery o f h ands-off method shows no effect on the incidence of
the head. an intact perineum or on third- or fourth-degree tears
D uring delivery o f the head, a choice can be m ade [LE A l ].16 An episiotom y has been seen significantly
between two m ethods: hands on or hands o ff. m ore often when the hands on method is perform ed
(RR 0.69; 95% C l 0.50-0.96).15 A training program
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H ands On — In the hands-on m ethod the perineum (hands-on m ethod, correct perform ing o f episiotom y)
is supported by holding one hand on the perineum . focusing on protection o f the perineum m ay result in
The other hand is placed on the head o f the infant a reduction o f anal sphincter injuries.17
during the extension o f the head and pressure m ay be
exerted on the head to prom ote deflection o f the Engagement of the Shoulders
head (Figure 2.21). W arm com presses reduce the The shoulders follow the shape o f the birth canal: the
chance o f third- and fourth-degree perineal tears scapular arch passes the pelvic inlet in a transverse
(relative risk [RR] 0.48; 95% C l 0 .2 8 -0 .8 4 )16 direction and the plane o f the pelvic outlet in the
(Figure 2.21). anteroposterior direction.
31
point of rotation: nape of the neck
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b.
Figure 2.20A-B Delivery o f the head.
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Figure 2.22 External rotation.
head, in which the occiput turns to the left or to the

right (depending on the location o f the dorsum )
Figure 2.21 Hands on. (Figure 2.22).
External Rotation Delivery of the Shoulders

The external rotation is a rotation o f the in fant’s After the external rotation the head is grasped bipar-
head around the long axis after delivery o f the ietally and m ildly bent tow ard the sacrum , causing the
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b.
Figure 2.23A-B Delivery o f th e anterior shoulder.
anterior shoulder to be delivered first from below the

pubic arch (Figure 2.23).
-li Next, the head is m oved toward the symphysis,

whereupon the posterior shoulder is delivered over
the perineum (Figure 2.24).
D uring delivery o f the posterior shoulder close
er
attention m ust be paid to the perineum, m aking sure
that it does not rupture. In a vertical delivery, in which
the wom an leans forward, or in an ‘all-fours’ position
(on hands and knees), the posterior shoulder is som e
tim es delivered first.
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Delivery of the Trunk

After delivery o f the shoulders and the axillary folds
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are visible, the axillas are hooked with the pinkies.

Then the trunk, the buttocks, and the extremities
Figure 2.24 Delivery o f the posterior shoulder. are delivered in the direction o f the birth canal
(Figure 2.25).
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33
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b.
Figure 2.25A-B Delivery o f the trunk.
Mechanisms of Labor and Delivery

-li •
The causes for sinciput presentation could be:
fetal disorders:
er
in Sinciput Presentation
- congenital disorders, such as a neck tum or
Characteristics (strum a, hygrom a colli);
In a sinciput presentation: - round shape o f the head (no eccentric pole);
- dead fetus;
h

• the presenting part is: the part o f the head that lies
• m inim al resistance between the head and the birth
at or near the anterior fontanel;
canal (sm all head, wide birth canal);
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• the attitude is: a position between a flexion and an

• entwinement (often multiple);
extended presentation;
• a platypelloid pelvis (short anteroposterior dim en
sion): in sinciput presentations the head engages
• there is no eccentric pole; with the bitem poral diam eter (which is sm aller
• the dim ensions o f the head that pass through the than the biparietal diam eter in an occipital pre
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pelvis are: the fronto-occipital diam eter (12 cm); sentation) and adapts itself thereby to the platy
the transverse distance is the bitem poral diam eter pelloid pelvis;
(8-8.5 cm); • weak contractions.
• the point o f rotation is: the glabella.
Notation Diagnosis
Sinciput presentation, with the occiput (determining • External exam ination: cephalic presentation.
point) posterior: sinciput OP.
• V agin al exam ination: an terior fontanel in or
near the pelvic axis: in com plete dilation -
Causes depending on the engagem ent - the posterior
Normally, the reasons for a sinciput presentation will fontanel and the orb ital ridges can som etim es
not be known. also be felt.
Table 2.1 Differences between sinciput presentation and occiput presentation with th e occiput posterior
S in cip u t p o ste rio r O c c ip u t p o sterio r
A bsence o f flexion Flexion
Greatest circum ference o f the head has passed the pelvic inlet Greatest circum ference o f the head has passed the pelvic inlet at
past H 3 ,0 station H 3 ,0 station
On crow ning o f th e head, the anterior fontanel lies in the pelvic O n crow ning o f the head, the anterior fontanel lies closely
axis (at the level o f the posterior commissure) beneath the symphysis; this is sometim es difficult to feel because
o f the flexion
The posterior fontanel cannot be reached on the pelvic floor; The posterior fontanel can be reached w ithout difficulty in the
higher in the pelvis th e posterior fontanel should be palpable pelvic floor, although it is usually masked by a large caput
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tow ard the back and the orbital margins further to the front succedaneum
The point o f rotation is the glabella The point o f rotation is the anterior hairline
On delivery, the frontal bone appears in the vulva On delivery, the anterior fontanel appears in the vulva
Caput succedaneum near the posterior fontanel
b.
Caput succedaneum near the anterior fontanel
Comment Labor Mechanism in Sinciput Presentation

A sinciput presentation with the occiput posterior
-li
(OP) is som etim es difficult to differentiate from an
occiput presentation with the OP (Table 2.1). Both are
presentations with the back in posterior position, in
from Hodge 1 through Birth
See Anim ations 2.3 and 2.4.
Hodge 1, - 5 Station
er
which the infant is born face forward. In both pre The sinciput descends with the sagittal suture in oblique
sentations the dilation and expulsion duration m ay be or transverse direction. The head then descends with the
prolonged. Som etim es the posterior fontanel is bitemporal diameter (8-8.5 cm), which is smaller than
equally distant from the pelvic axis as the anterior the biparietal diameter (9.5 cm) (Figure 2.26).
fontanel. This is a medial position between sinciput
h
T o be able to pass the prom ontory the head lies in

posterior and occiput posterior and is called the mili asynclitism. The sagittal suture lies in front o f the
tary attitude. pelvic axis, thus there is a posterior asynclitism.
us
ak
35
bitemporal diameter
ru
b.
-li
er
C
h
us
ak
Figure 2.26A-C Head at H odge 1, - 5 station.
Hodge 2, -2 / - 3 Station Hodge 3, 0 Station

If the sinciput presentation persists, the head will At this point the head has descended a little less
descend deeper, but engagem ent will be slower due than h alf way becau se the head is less flexed c o m
to the larger dim ensions o f the penetration plane pared to a head in occipu t an terior (O A ) p resen ta
(fronto-occipital circumference, 34-35 cm). tion. W hen the head h as descended p ast H 3, the
The head tilts (rotation around the sagittal axis) largest d iam eter o f the head (the biparietal d ia
over the sacral prom ontory and goes tow ard synclit- m eter) h as p assed the pelvic inlet. It can then be
ism (Figure 2.27). assu m ed that when a fetus in sin ciput presen tation
ru
b.
-li
er
C
h
us
ak
Figure 2.27A-C Head at H odge 2, - 2 / - 3 station.
h as descended p ast the H3 plane, the in fant can be Rotation

delivered vaginally. If flexion does not occur during the descent, the sin
The m om ent at which the head has completely ciput presentation persists. Rotation does not take
rotated around the prom ontory and lies in anterior place because the rotation factors are lacking.
asynclitism occurs later than in an OA presentation In a sinciput LOP or ROP a rotation o f the head
(Figure 2.28). occurs at H 3 ,0 station in which the sagittal suture lies
ru
b.
-li
h er
us
ak
Figure 2.28A-C Head at H odge 3.
in the anteroposterior diam eter o f the pelvis. In this than in front p ast the curve o f the pelvic axis),
rotation the posterior fontanel will turn to the rear. giving rise to an eccentric pole. The occiput
In case o f a sin ciput presentation in the LOA rotates to the front and the delivery takes place
or ROA p osition at H3, 0 station, the sinciput as in an OA delivery.
presentation will in m ost cases evolve into an A sinciput OP does not evolve easily into an occi
occiput presentation. In these p osition s flexion put OP, as the head at this pelvic location is no longer
occurs quite easily (greater resistance in back able to inflect from this position.
ru
b.
-li
h er
us
ak
Figure 2 .2 9 A-C Head at H odge 4, +5 station.
Hodge 4, +5 Station cau ses the occiput to be born first over the p eri
neum , after which the face is born through
In a sinciput presentation the anterior fontanel lies in
the pelvic axis. This m eans that at the plane o f the extension.
D uring the crowning, extension, and delivery p ro
pelvic outlet the anterior fontanel lies at the level o f
cess there is an increased chance o f perineal laceration
the posterior com m issure (Figure 2.29).
in both sinciput and occiput posterior positions
Birth of the Head com pared to O A position, since:
T he brow and the an terior fon tanel are the first to • the head passes the pelvic outlet with the fronto-
penetrate the vulva (Figure 2.30). In a sin ciput OP occipital diam eter (12 cm). In an OA delivery the
birth, the glabella (po in t o f rotation) is located suboccipito frontal diam eter (10 cm) passes
under the sym physis p ubis (Figure 2.31). Flexion through;
• the head descends straight down to the glabella,

before rotation around the sym physis pubis takes
Possible Interventions in Sinciput
place; Presentations
• the occiput is wider than the forehead; • In the event o f an engaged head in the presence o f
• the shape o f the forehead fits less perfectly under a norm al pelvis, the m other m ay be asked to lie in a
the pubic arch than the neck. side position on the side o f the fetal back
After the head is born, the delivery continues as in (Figure 2.32). This is done to prom ote flexion
occiput OA. and attem pt a transition from a sinciput to a
norm al occiput presentation. Through flexion an
eccentric pole develops again.
• By changing position or by m oving around. This
ru
m ay also help to im prove flexion.
anterior fontanel
b.
point of rotation: glabella
-li
h er
Figure 2.30 Crowning o f the head. Figure 2.31 Point o f rotation: glabella.
us
A
ak
Figure 2.32A-B Stimulation o f flexion.

The causes for an occiput presentation with the

Mechanism of Labor and Delivery occiput posterior could be:
in Occiput Presentation, Occiput • sm all infant;
Posterior • dead infant;
• incongruency between head and pelvis.
Characteristics
In an occiput presentation with the occiput in Diagnosis
posterior position:
• External exam ination: cephalic presentation.
• Vaginal exam ination: the posterior fontanel is
• the presenting part is: the head;
ru
situated (left or right) posterior; the anterior fon
. the attitude is: flexion position; tanel (left or right) is located anterior.
• the eccentric pole is: the posterior fontanel;
. the dim ensions o f the head that pass through the
Comment
b.
pelvis are: the suboccipitofrontal diam eter (10 cm) For an explanation o f the difference between an
and the biparietal diam eter (9.5 cm); occiput presentation with the occiput posterior and
• the point o f rotation is: the anterior hairline. a sinciput presentation with the occiput posterior, see
Section: M echanism s o f Labor and Delivery in
Sinciput Presentation.
Incidence -li
Occiput presentation births with the occiput in p o s
terior position occur in 5.5% o f all deliveries.18
Labor Mechanism with Occiput
Presentation with Occiput Posterior from
er
Hodge 1 through Birth
Notation See Anim ations 2.5 and 2.6.
Occiput presentation with the occiput (determining
point: O) posterior: OP.
h
In 25-30% o f the infants, descent into the pelvis starts

with the dorsum in posterior position. The head
Causes engages with the occiput left or right transverse or
us
Usually, the reason for an occiput posterior presenta left or right posterior (LOT, ROT, LOP, or ROP)
tion is not known. (Figure 2.33).
ak
41
ru
b.
-li
h er
us
ak
Figure 2.33A-C Head at H odge 1, - 5 station.
42
C h a p te r 2: N orm a l La b o r a n d D e live ry
Hodge 2, —2/—3 Station A t this level the head p asses over the p ro m o n
tory and m oves tow ard synclitism . Synclitism
At this plane the head is com ing a little deeper and
is reached between H odge 2, - 2 1 - 3 station and
inflects (rotation around the frontal axis). The poster
H odge 3, 0 station (rotation arou nd the sagittal
ior fontanel com es situated a little closer to the pelvic
axis).
axis (Figure 2.34).
A B
ru
b.
-li
h er
us
ak
Figure 2.34A-C Head at H odge 2, —2/—3 station.
43
S ectio n 2: N orm a l La b o r a n d D elivery
Hodge 3, 0 Station Rotation

At this point the head has descended about half way. If the head presents at H3, 0 station in ROP or LOP,
The largest diam eter o f the head (the biparietal diam there are two possibilities:
eter) has passed the pelvic inlet. • The occiput rotates 135° forw ard to an O A and
The head has now rotated completely around the the labor will proceed as in an occiput OA
sacral prom ontory and the sagittal suture is p osi delivery.
tioned behind the pelvic axis. There is now anterior
• The occiput rotates 45° to the back, to an occi
asynclitism (Figure 2.35).
put OP.
A B
ru
b.
-li
h er
us
ak
Figure 2.3SA-C Head at Hodge 3, 0 station.
44
ru
b.
-li
er
Figure 2 .36A-B Head at H odge 4, +5 station.
Hodge 4, +5 Station
h
At H odge 4, +5 station, the head lies at the level o f the

pelvic outlet in OP position (Figure 2.36).
us
Birth of the Head

A fter m axim u m flexion o f the head, the occiput
is born up to the neck groove (the point o f ro ta
tion is the an terior hairline, the area o f the an te
rior fontanel) (Figure 2.37). Then the head
ak
becom es extended, w hereby the sin ciput, the

brow, and the face are expelled under the sym
physis (Figure 2.38).
In an occiput posterior birth, the tension on the
perineum is even greater than in a sinciput presenta
tion birth, since the head engages “straight down”
until after the birth o f the occiput.
From the m om ent the head is born, labor proceeds
Figure 2.37 Point o f rotation is th e anterior hairline. as in occiput OA.
45
Figure 2.38 Birth o f the head.
point of rotation: anterior hairline
ru
b.
-li
er
Mechanism of Labor and Delivery Causes
in Brow Presentation As in a face presentation, the reasons for brow presenta
tion are circumstances that produce extension instead o f
h
Characteristics flexion o f the head. These circumstances could be:

In a brow presentation: • disorders in the infant, for instance:
us
• the lie is: cephalic presentation; - anencephaly;

• the presenting part is: the brow o f the head; - neck tum or (strum a, hygrom a colli);
• the attitude is: a (moderate) extension presentation; • entwinement;
• the determ ining point is: the chin (mentum ); • weak abdom inal wall (m ultipara);
• the eccentric pole is: the chin (mentum ); • incongruency between head and pelvis.
ak
• the diam eter that has to pass the pelvis: the m ento-
occipital diam eter (13.5-14 cm); For m ost brow presentations the causes will not be
known.
• the point o f rotation is: the fossae caninae
(cheekbones).
Diagnosis
• External exam ination: cephalic presentation, in
Incidence which:
The incidence o f brow presentation is 0.01-0.05% . - the m ost am ount o f resistance can be felt on
the side o f the sm all extremities;
- the (back o f the) head rem ains palpable for a
Notation long time above the pelvic inlet;
Brow presentation with the chin (determ ining point: - the heart tones o f the infant can be heard best
m entum ) anterior: MA. on the side o f the sm all extremities.
• Vaginal exam ination, in which: Hodge 2, —2/—3 Station and Hodge 3, 0 Station
- the an terior fontanel and the orbital ridges U sually the head cannot descend further. If,
are palpable on both sides o f the pelvic however, this is the case, the head descends further
axis; with the chin left or right anterior (Figures 2.40
- the bridge o f the nose, the frontal suture, the and 2.41).
glabella, and som etim es the m outh are also
palpable, but the chin can never be felt (in Internal Rotation
contrast with the face presentation, in which The rotation takes place when the brow is on the
the chin is always palpable and the anterior pelvic floor, since only at that point the occiput has
fontanel is never palpable). passed the prom ontory. The eccentric pole is the chin.
ru
The chin turns to the front with the cheekbones under
the symphysis.
Comment
In an incom plete dilation it is possible that only
Hodge 4, +5 Station
the anterior fontanel will be palpable and that the
b.
orbital ridges are not palpable yet. This could cause The rotation takes place at H odge 4, +5 station. The
confusion with the sinciput presentation. But in the chin turns to the front with the fossae caninae (cheek
brow position the anterior fontanel does not lie in the bones) under the sym physis (Figure 2.42).
pelvic axis, such as is the case in a sinciput
Birth of the Head
presentation.
Labor Mechanism with Brow Presentation

from Hodge 1, - 5 Station through Birth
-li The head rotates around the sym physis with the
fossae caninae (cheekbones) as the point o f rotation,
whereby the occiput is born first through flexion.
er
After that the face is born under the symphysis
See A nim ations 2.7 and 2.8. through extension.
U sually, when a brow presentation occurs a The head is often born with the sagittal suture
cesarean section is indicated. The greatest diam eter in the oblique d iam eter o f the pelvic outlet, since
in a brow presentation, the m ento-occipital diam eter ad ap tation o f one o f the cheekbones under the
h
(13.5-14 cm ), is larger than the transverse diam eter o f sym physis creates m ore room (Figure 2.43).
the pelvic inlet (13 cm). Often the head cannot des After the head has been born in a brow presenta
cend further than the second plane o f H odge, —21—3 tion, the labor proceeds from that point onward as in
us
station. Therefore, a spontaneous birth is only p ossi an occiput OP delivery.

ble in the case o f a sm all fetus and/or a large pelvis. In
this case, a face presentation will present due to
Possible Interventions in a Brow Presentation
increased extension or a sinciput presentation as a
result o f flexion (see sinciput presentation and face • Choose a side-lying position: on the side o f the
presentation). abdom en o f the fetus to prom ote extension (face
ak
presentation).
Hodge 1, - 5 Station • Choose a side-lying position: on the side o f the
In a brow presen tation the head usually descends back o f the infant to prom ote flexion (sinciput
with the chin left or right an terior (Figure 2.39). presentation).
47
Sectio n 2: N orm al La b o r a n d D elivery
ru
b.
-li
h er
us
Figure 2 .3 9 A -C Head at Hodge 1, - 5 station.

ak
48
ru
b.
-li B
h er
us
ak
Figure 2.4 0 A -D Head at H odge 2, —2/—3 station: descent stagnates between H odge 2, —2/—3 station and H odge 3, 0 station.
49
ru
b.
-li
h er
us
ak
Figure 2.41 A -C Head at Hodge 3, 0 station.
50
ru
b.
-li
h er
us
ak
Figure 2 .4 2 A-C Head at H odge 4, +5 station.
51
• disorders in the infant, such as:

- anencephaly;
- neck tum or (strum a, hygrom a colli);
fossa canina
• entwinement;
• weak abdom inal wall (m ultipara);
• incongruency between head and pelvis.
For m ost face presentations the causes will not be

known.
Diagnosis
ru
• External exam ination: cephalic presentation, in
which:
- the m ost am ount o f resistance can be felt on
b.
the side o f the sm all extremities;
- the (back o f the) head rem ains palpable for a
long time above the pelvic inlet;
Figure 2.43 Point o f rotation. - the heart tones o f the infant can be heard best
Mechanism of Labor and Delivery

in Face Presentation
-li •
-
on the side o f the sm all extremities.
Vaginal exam ination, in which:
the orbital ridges and the chin with the
m outh are palpable on both sides o f the pelvic
er
axis;
Characteristics - the caput succedaneum develops in the face;
In a face presentation: the eyelids, nose, and lips m ay be acutely swol
• the lie is: a cephalic presentation; len, m aking it som etim es difficult to determ ine
h
a face presentation.
• the presenting part is: the face o f the head;
• the attitude is: hyperextended presentation;
• the determ ining point is: the chin (mentum ); Comment
us
• the eccentric pole is: the chin (mentum ); U pon internal exam ination it is som etim es difficult
• the dim ension o f the head that passes the pelvis: to differentiate between a face presentation and
the subm entobregm atic diam eter (9.5 cm); a breech presentation. A m istake is possible if
• the point o f rotation: the larynx. the anus is m istaken for the m outh. A distinction
can be m ade by rem em bering that the anus lies
ak
Incidence central in an im aginary line that connects the two

Face presentation births occur in 0.05-0.5% o f all (palpable) ischial tuberosities, while these bony iden
deliveries. tification points cannot be felt on both sides o f the
m outh.
Notation
Face presentation with chin (determ ining point: Labor Mechanism in a Face Presentation
m entum) anterior: MA. from H1 through Birth
There is usually no face presentation at the onset o f
Causes the descent, but a brow presentation. W hen descend
Causes for face presentations are circum stances in ing into the pelvis, the head will extend further and
which extension o f the head occurs rather than flex thereby becom e a face presentation (see Anim ations
ion. These circum stances could be: 2.9 and 2.10).
Hodge 1, - 5 Station will have to rotate around the sagittal axis to be able
If the head is in face presentation at the start o f the t0 Pass the prom ontory in a face presentation
descent, this will usually be with the chin at LA /LT (Figure 2.44).
or R A /RT. A s in an occiput presentation, the head
ru
b.
-li
h er
us
ak
Figure 2.44A-C Head at H odge 1 ,- 5 station.
53
Sectio n 2: N orm a l La b o r a n d D elivery
Hodge 2, —2/—3 Station p art and on the other han d because the head
The head descends deeper in the sam e position as crow ns with the su bm en to-occipital diam eter
at H odge 1. The descent is slower, on the one (1 3 .5 -1 4 cm ) com pared to the su boccipitofro n tal
hand because o f the irregularly shaped presenting diam eter (10 cm ) in an occipital p resentation
(Figure 2.45).
ru
b.
-li
h er
us
ak
Figure 2.45A-C Head at H odge 2, —2/—3 station.
54
Hodge 3, 0 Station
The head descends deeper in the sam e position as at
H odge 1 and will extend further (rotation around the
frontal axis) (Figure 2.46).
ru
b.
-li
h er
us
ak
Figure 2.46A-C Head at H odge 3 ,0 station.
55
Sectio n 2: N orm al La b o r a n d D elivery
Internal rotation pole and when going deeper it is the first part to reach
Internal rotation ultimately takes place at H odge 4, +5 the bend o f the birth canal (Figure 2.47).
station. The largest dim ension o f the head has finally If in the rotation the chin turns to the back, a
passed the pelvic inlet when the face is on the pelvic spontaneous birth is not possible (the head is hyper
floor (Hodge 4, +5 station). The chin is the eccentric extended and cannot descend further) (Figure 2.48).
eccentric pole
(the
ru
b.
-li
er
Figure 2.47 Eccentric pole.
h
us
ak
Figure 2.48A-B Chin rotated to the back.
56
point of rotation: larynx
ru
b.
Figure 2.51 Point o f rotation: the larynx.
-li
h er
us
Figure 2 .52A-B Stimulation o f extension.

ak
D uring crowning, extension, and delivery there Comment

is a greater chance o f perineal laceration than with • To reach optimal extension, the mother may
delivery in an OA position. be asked to move into a side-lying position on the
• The head crowns and extends with the subm ento side o f the abdomen o f the infant (Figure 2.52).
bregm atic diam eter (9.5 cm). • Edem a o f the larynx m ay occur due to p ro
• Through flexion, the head delivers with the longed hyperextension o f the neck. T his m ay
subm ento-occipital diam eter (11.5 cm). cause stridor after birth. The presence o f a
After the birth o f the head the delivery proceeds in the pediatrician or a neonatologist is therefore
same m anner as in an occiput OP delivery. recom m ended.
59
Mechanism of Labor in Persistent p o sterior fontanel is either an terior or

posterior.
Occiput Anterior or Posterior Position
If the labor progresses past H odge 1, - 5 station, it is
There are two form s o f persistent occiput position:
no longer a persistent occipital position. Increased
• the persistent occiput anterior position (occipito-
flexion will cause the vertex to descend.
pubic position);
• the persistent occiput posterior position (occipito-
sacral position).
Labor Mechanism of Persistent Occipital
Position from H1, - 5 station, through
Characteristics the Birth of the Infant
ru
In a persistent occiput position: In a delivery with the head in a persistent occipital
• the lie is: cephalic presentation; position at H I (Figure 2.53) the dilatation and engage
• the presenting part is: the head; ment will often progress slowly.
• the sagittal suture lies nearly or completely in the If the sagittal suture still com es to lie in an oblique
anteroposterior diam eter (true conjugate) before or transverse position, the labor and delivery will
b.
the largest circumference o f the head has passed proceed as in an occiput OA or occiput OP delivery.
the pelvic inlet;
• there usually is an occiput presentation;
The head lies in the persistent occipital anterior or
• the attitude is: flexion position;
•
•
-li
the determ ining point is: the occiput;
the dim ensions o f the head that pass through the
pelvis are: the suboccipitofrontal diam eter (10 cm)
and the biparietal diam eter (9.5 cm).
posterior position at the level o f the pelvic inlet.
The persistent occiput anterior position is the more
favorable, since the brow is only blocked by the pro
montory. By turning a little to the left or to the right,
er
the head can som etim es pass the prom ontory and then
a vaginal delivery can take place. The persistent occiput
Incidence posterior position is much less favorable. The broad
O f all vertex presentations, 0.7-1.6% are persistent forehead often gets stuck on the symphysis and the
occiput anterior or posterior presentations. pubic bone. Frequently, labor does not progress in
h
the persistent occiput posterior position and a cesarean

Notation section will be necessary (Figure 2.54).
us
In a persistent occiput position with the occiput

anterior or posterior, respectively, the notations are:
Hodge 2, —2/—3 Station
• OA - occipitopubic position; With adequate contraction activity, the head will be

able to engage through rotational m ovem ents and
• OP - occipitosacral position.
increased flexion.
Causes
ak
Hodge 3, 0 Station
The reasons for a persistent occipital position are not Through increased flexion, the head engages without
clear. internal rotation and passes through the birth canal in
a forward direction.
Diagnosis Rotation
• External examination: The rotation consists o f zig-zagging m otions. The
- cephalic presentation with movable head head does not rotate. The entire passage through the
above or in the pelvic inlet. birth canal takes place with the sagittal suture in an
anteroposterior direction. The head is born in the
• Internal examination: sam e position as the position with which it entered
- non-engaged head; the pelvic inlet.
- the sagittal suture lies straight in the pelvic After that, the labor proceeds in the sam e m anner
axis at H odge 1, - 5 station, w hereby the as the labor in occiput OA or occiput OP.
ru
b.
Hodge 1 - Hodge 1 -
- 5 station - 5 station
Hodge 2 -
-2 /-3 station
Figure 2 .53A-B Persistent o ccip u t position.

-li -2 /-3 station
h er
us
ak
Figure 2 .5 4 A -B Persistent occip u t anterior (A) and posterior (B).
• the sagittal suture lies at or near the pelvic floor;

Mechanism of Labor in Persistent
• the lie is a cephalic presentation;
Occiput Transverse Position • the presenting part is the head;
• the attitude is a flexion presentation, in which
Characteristics there is dim inished flexion and both fontanels
A persistent occiput transverse position is a position can be felt on palpation;
in which: • the determ ining point is the occiput;
• the deepest point is the area around the sagittal - both the anterior and the posterior fontanels
suture, between the posterior and anterior fonta can be felt.
nel, and therefore there is no eccentric pole;
• the dimensions o f the head that pass through the
pelvis are between those o f the occiput presentation Labor Mechanism of Persistent Transverse
and the sinciput presentation (military attitude). Position from HI, - 5 Station, through the
Birth of the Infant
Incidence A persistent transverse occiput position presents
The incidence is 1.5-1.9%. itself between H odge 2, —2/—3 station and H odge 4,
+5 station. Until that m om ent, the descent proceeds
Notation
ru
as in an occiput presentation (Figure 2.55).
Occiput presentation with the occiput (determ ining
Rotation
point: O) left or right transverse presentation (posi
tion: LO T or ROT). In a normal pelvis, with or without stimulation of
contractions, rotation can often still take place
b.
spontaneously and the infant can be born in occiput
Causes presentation. In case o f a narrow pelvis, such as in a
Causes o f a persistent occiput transverse position are: funnel-shaped android pelvis, there m ay not be enough
• sm all or large fetus; room for rotation and often the head cannot engage.
•
•
•
dead fetus;
little resistance o f the birth
multiparity);
android or platypelloid pelvis;
-li canal (grand Possible Interventions in Persistent Occiput
Transverse Positions
The interventions are:
er
• insufficient contraction activity with or without • stim ulation o f contractions;
the foregoing causes. • side-lying position o f the m other on the side o f the
infant’s back: this causes flexion o f the head to be
Diagnosis stim ulated, allowing an eccentric pole to develop,
h
rotation becom es possible and a norm al occiput

• External examination:
presentation occurs;
- cephalic presentation. • if the conditions o f an assisted delivery are satisfied:
us
• Vaginal exam ination: - digital correction (digital correction is done dur

ing a contraction; by placing two fingers on the
- sagittal suture (nearly) transverse with the
side o f the head, the head is flexed and rotated);
head on the pelvic floor;
- vacuum extraction.
ak
62
ru
A
b.
Hodge 2 -
-2 /-3 station Ho d g e 3 - Hodge 4 -
0 station +5 station
-li
h er
us
posterior fontanel sagittal suture

Hodge 2 -
-2 /-3 station Hodge 3 _
4- D
0 station +5 station
ak
Figure 2 .5 5 A -D Persistent transverse position.
Mechanism of Labor in Persistent Characteristics

The contrast betw een physiological asynclitism and
Asynclitism
a persisten t asyn clitism is the degree o f asynclitism .
There are two types o f persistent asynclitism:
In a persisten t asyn clitism a fetal ear is felt.
• a persistent anterior asynclitism (Naegele’s In a persistent asynclitism:
obliquity);
• a persistent posterior asynclitism (Litzm ann’s
• the presenting part is: the parietal bone o f the
obliquity).
head;
63
• the attitude is: a flexion presentation (occiput or - In a p osterior parietal bone presentation the
sinciput presentation); fetal ear is posterior and the sagittal suture
• the determ ining part is: the occiput; lies in front o f the pelvic axis (under the
• the skull is often acutely deform ed and the sym physis).
dim ensions o f the head that pass through the
pelvis depend on the attitude.
Labor Mechanism of Parietal Bone
Notation Presentation from HI, - 5 Station through
Asynclitism anterior or posterior with the occiput (O) Birth
left (L) or right (R) transverse (T). Hodge 1, - 5 Station
ru
• Anterior asynclitism: anterior asynclitism (Figure
Causes 2.56) is m ore favorable than posterior, since in
The causes o f a persistent asynclitism could be: anterior parietal bone presentation the posterior
• a tum or on the lateral side o f the neck o f the infant, parietal bone upon engagem ent only needs to slide
b.
torticollis; over the prom ontory and there is room in the
• platypelloid pelvis. sacral cavity. The risk o f this presentation is
overstretching at the front o f the uterine segment
by the protruding shoulder, with signs o f a threat
Diagnosis ening uterus rupture.
•
•
External exam ination:
- cephalic presentation.
Vaginal examination:
-li • Posterior asynclitism: posterior asynclitism (Figure
2.57) is less favorable than anterior, since in
posterior parietal bone presentation the anterior
parietal bone becom es stuck on the prom ontory.
er
- In an anterior parietal bone presentation The risk o f this presentation is overstretching at
the fetal ear is anterior (under the sym physis) the rear o f the lower uterine segm ent by the p ro
and the sagittal suture lies behind the pelvic truding shoulder.
axis.
h
us
ak
Figure 2.56A-B Anterior asynclitism.

C h a p te r 2: N orm al La b o r and D elivery
ru
b.
Figure 2 .5 7 A - B Posterior asynclitism.
-li behind these pleats the placenta tears away from the
er
Hodge 2, —2/—3 Station
decidua and a hemorrhage appears behind the placenta.
• Anterior asynclitism: if the posterior parietal bone
After the placenta is completely or partially sepa
was able to slide over the prom ontory, the head
rated, it is expelled into the lower uterine segment and
descends further and the labor proceeds as in an
the vagina.
occiput OA delivery.
h
The placenta can be delivered via two different

• Posterior asynclitism : frequently, a head in
m ethods:
p osterior parietal presentation does not p ass
• according to Schultze: centrally behind the placenta
H odge 2, - 2 1 - 3 station and a cesarean section
us
a hem atom a develops, whereupon the fetal side o f

will have to be perform ed.
the placenta is expelled first, followed by the
If the persistent asynclitism anterior presentation
(inside out) m em branes and the hem atom a
rotates to occiput OA, the rest o f the delivery proceeds
(“Shiny Schultze”) (Figure 2.58);
as in an occiput OA delivery.
• according to Duncan: the hem atom a develops on
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the lateral side o f the placenta and discharges itself

Delivery of the Placenta before the expulsion o f the placenta, after which
After the birth o f the infant the height o f the uterine the placenta and the m em branes along with the
fundus is determ ined. The fundus at that point is edge o f the placenta are born first (“Dirty
located at the level o f the um bilicus. D uncan”) (Figure 2.59).
The - due to retraction and contraction - com
Mechanism pressed blood vessels o f the placenta bed ensure that
The uterine volume becomes smaller after the birth of there is relatively little blood loss after the separation
the infant. The reduction o f the uterus takes place o f the placenta.
through retraction (passive) and contraction (active,
afterbirth contractions). The afterbirth contractions Procedure
usually start 5 to 10 minutes after the birth o f the There are spontaneous and active m anagem ent
child. The placenta is unable to keep up with the reduc methods.
tion o f the uterus. The placenta starts to pleat and
hematoma cavum
hematoma
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placenta
placenta
b.
Figure 2.58A-B Delivery o f the placenta according to Schultze.
-li hematoma
placenta
h er
us
hematoma
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Figure 2.59A-B Delivery o f the placenta according to Duncan.
In any o f the m aneuvers during the afterbirth, it • the um bilical cord protrudes slightly out o f the
m ust be borne in m ind that they can only be applied if vulva (Ahlfeld’s sign);
the uterus is properly contracted. • the uterine fundus rises;
• the uterus veers to the right.
Spontaneous Management
Check the foregoing points at regular intervals.
Spontaneous m anagem ent m eans that everybody
Aided by Kiistner’s maneuver, it can be ascer
waits until the placenta is spontaneously detached.
tained whether the placenta lies in the lower uterine
Signs indicating that the placenta is detached are:
segm ent (the placenta is separated).
• abdom inal pain; Kiistner’s m aneuver is perform ed with a con
• m ore blood loss; tracted uterus and a reclined woman.
ru
lower uterine
b.
corpus (body)
segment
ring
Figure 2 .60A-B Kiistner's maneuver.

-li
The procedure works as follows (Figure 2.60):
er
• Take the end o f the um bilical cord in one hand at
the Kocher forceps and tighten the um bilical cord
carefully.
• At the sam e time, press the abdom inal wall with
the ulnar side o f the other hand at the location of
h
the contraction ring (just above the sym physis

pubis).
When the placenta lies detached in the lower uterine
us
segm ent (LU S), the um bilical cord com es out

(Kiistner positive) or ju st stays in place. If the placenta
is still in the body o f the uterus, the um bilical cord will
be pulled along to the inside (Kiistner negative).
Only after the placenta is detached, apply the
ak
(m odified) Baer’s maneuver.

The Baer’s m aneuver works as follows
(Figure 2.61):
• T o support the abdom inal m uscles, place the palm Figure 2.61 Baer's maneuver.
o f one hand slightly below the naval, at right
angles to the direction o f the rectus muscles.
• Catch the placenta with the free hand and then let
• With the other hand, take the end o f the umbilical
the m em branes follow slowly.
cord at the Kocher forceps and carefully tighten
the um bilical cord. Use the following procedure if the m em branes do not
. A sk the m other to push along during a uterine follow:
contraction. • Put the placenta down.
• Allow the placenta to be delivered in the direction • Place a Kocher forceps on the m em branes at the
o f the birth canal. level o f the vaginal introitus. M assage the uterine
ru
b.
-li
Figure 2.62A-B Rotation o f the placenta (A) or Kocher (B).
fundus lightly and put slight traction on the m em Active Management

er
branes with the Kocher forceps. Active m anagem ent m eans that after the birth o f the
• Or: rotate the placenta (or the Kocher) until the infant there is an active effort to cause the placenta to
m em branes let go (Figure 2.62). be expelled. Thus, there is no waiting for signs of
detachm ent o f the placenta.
h
Monitoring The m ethodology is as follows (Figure 2.63):

A fter the placenta has been delivered, regularly • Adm inister 5 or 1 0 IU o f oxytocin intram uscularly
check the m other for at least 1 hour after the or intravenously im m ediately after the birth o f the
us
birth, for: infant.

• the position o f the fundus (this m ay not rise); • Clam p the um bilical cord.
• the contraction condition o f the uterus; • W ait for a good contraction o f the uterus.
• blood loss. • Place one hand above the sym physis pubis with
Check the placenta, including the following im portant the palm o f the hand in the direction o f the
ak
points: m other’s navel. This hand provides counterpres

• whether the placenta and the m em branes are sure to the uterus.
complete; • With the other hand, apply traction to the umbilical
• abnorm alities o f shape (lobes, m em branacea); cord, either with the aid o f a Kocher forceps or by
• abnorm alities o f m aternal and fetal surface wrapping the umbilical cord twice around several
(infarcts, chorioangiom a, abrupt); fingers. The traction is applied in the direction o f
• cord abnorm alities (the num ber o f vessels, knots, the birth canal, first toward the perineum and
velam antous insertion). upward when the placenta follows. This is called
“controlled cord traction.”
Then check:
• The placenta m ust be delivered in a sm ooth
• the total am ount o f blood loss (estim ate and weigh motion.
if necessary);
• If this m aneuver m ust be interrupted, it is im por
• the vulva, the perineum, and the vagina for tant to first release the tension to the umbilical
lacerations.
ru
b.
Figure 2 .63A-B Active procedure.
-li
cord and only let go o f the counterpressure on the effective way to prevent the use o f uterus tonica, but
er
uterus after that. there is less literature about method and duration of
• Check for blood loss and wait for a uterine m assage [LE B ].21,22 Also recent disadvantages of
contraction. early cord clam ping have been described: postponing
cord clam ping for at least 1 m inute does not increase
Active versus Spontaneous Management the risk for H PP.23 For the baby, later clam ping o f the
h
Active m anagem ent o f the third stage o f labor m eans a cord leads to a decrease in the risk o f anemia. It can
com bination o f the following actions19: though lead to a light increase in the num ber o f
children with hyperbilirubinemia [LE A l ].24 A com
us
Adm inister oxytocin, 1 0 IU im/iv.

bination o f active (adm inistering oxytocin) and
The um bilical cord is clam ped soon after birth. expectative (cord clam ping between 1 and 3 m inutes
D uring the first contraction (after 3-5 minutes) post partum using Baer) policy appears to give the
birth o f the placenta with controlled cord traction best outcom es for mother and baby.19
(C C T), followed by:
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M assage o f the uterus. Episiotomy and Perineal Lacerations

Active m anagem ent o f the third stage o f labor
using uterotonics is advised by the W orld Health
(Grade 1 and 2)
Perineal lacerations are lacerations o f the vagina, the
Organization (W HO) because even women with a
vulva, and the perineum that m ay occur during child
low risk for hem orrhage can have a hem orrhage post
birth. For a classification o f perineal lacerations, we
partum (HPP). Active m anagem ent reduces the risk
will use the international classification o f perineal and
for severe hem orrhage (> 1000 ml) (RR 0.34; 95% Cl
sphincter lacerations proposed by Sultan in 2002
0.14-0.87) [LE A l]. O f all actions that are part of
(Table 2.2).25 In this section we will describe the
active m anagem ent, giving oxytocin is the m ost
first- and second-degree lacerations as well as episi-
im portant action.20 For all other actions it is not
otomies. Obstetric anal sphincter injuries (OASIS) are
evident whether they contribute to reducing HPP.
third- and fourth-degree lacerations which are
Recent research shows that C C T contributes less to
discussed in Chapter 13 on sphincter lesions.
decreasing HPP [LE A 2].20 M assage o f the uterus is an
Table 2.2 Classification o f lacerations according to Sultan
Grade 1 Skin laceration
Grade 2 Skin and perineal laceration w ithout

sphincter involvem ent
Grade 3 Perineal and anal sphincter laceration

Grade 3a Laceration <50% o f external anal sphincter
Grade 3b Laceration >50% o f external anal sphincter
Grade 3c Laceration o f both internal anal sphincter
and external anal sphincter
Grade 4 Laceration o f perineum, anal sphincter,

and anal mucosa
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Episiotomy
Episiotom ies are probably the m ost frequently applied
obstetric interventions. It is also one o f the few surgi
b.
cal interventions for which patient consent is gener
ally not requested. An episiotom y is an incision o f the
vagina, the perineum, and the underlying muscles. An
episiotom y enlarges the outlet o f the soft-tissue birth Figure 2.64 M idline and mediolateral episiotomies.
canal.26
-li
A prim ary episiotom y is defined if the indication
to perform episiotom y was already established
before the labor with the idea o f preventing extrem e
episiotom y in nulliparous women (RR 0.83; 95% C l
0.73-0.95) [LE A l ].29 Furtherm ore, hands o ff (or
er
pressure to the pelvic floor or to the head o f the poised) versus hands on the perineum during the
infant. The indication for a secondary episiotom y second stage o f labor reduces the rate o f episiotom y
is determ ined during the expulsion. Usually, a (RR 0.69; 95% C l 0.50-0.96) [LE A l ].16 Finally,
m ediolateral episiotom y is em ployed (Figure 2.64). com paring the position in the second stage o f labor
A m idline episiotom y, in which an incision is m ade for women without epidural anesthesia, fewer episi
h
from the posterior com m issure in the m idline in the otom ies are perform ed in an upright position versus
direction o f the anal sphincter, is not often applied supine or lithotom y position (RR 0.79; 95% C l 0.70-
in the N etherlands, Flanders, and in China. This 0.90) [LE A l ].30 Delivery in an upright position
us
type o f episiotom y is com m only used in the U SA increases the risk o f perineal traum a (RR 1.35: 95%
and C an ad a.26 C l 1.20-1.51), but not for O A SIS (RR 0.58; 95% C l
0.22-1.52).
Incidence Nevertheless, at present there are enorm ous
In the mid-twentieth century it was standard proce international differences in episiotom y incidence,
ak
dure in m any countries to perform an episiotom y in varying from 10% in Scandinavia to m ore than 90%
nulliparous women. A m ore restrictive episiotom y in South A m erica.31 The incidence o f episiotom y
policy, however, leads to less posterior perineal in the Netherlands is 26% and in Flanders 55% (nulli
traum a than a policy in which an episiotom y is parous women 75%, m ultiparous wom en 41% ).32,33
perform ed routinely (RR 0.88; 95% C l 0.84-0.92) Within the N etherlands there are also large
and less OASIS (RR 0.67; 95% C l 0.49-0.91) differences in the incidence o f episiotom y: o f the
[LE A l ].27 M oreover, by not perform ing an episiot nulliparous women who give birth in first-line care
om y there is a greater chance o f an unblem ished (midwife), 22% are given an episiotom y, while am ong
perineum: a routine episiotom y leads to 26% more the nulliparous wom en who give birth in second-line
need for suturing (RR 1.26; 95% C l 1.08-1.48) [LE care (obstetrician), 51% are given an episiotom y.
A l ].28 Prenatal perineal m assage, perform ed by the A m ong m ultiparous w om en giving birth in first-line
patient or partner once to twice a week from 35 weeks’ care, 7% are given an episiotom y, com pared to 17%
pregnancy, appears to dim inish the incidence o f o f m ultiparous wom en giving birth in second-line
care.32 In Finland, the hospital-based lateral episiot-

omy rate ranges from 38% to 86% for prim iparous
and from 6% to 30% for m ultiparous w om en.34
Indications
The only real indication for perform ing an episiotom y
is the reduction o f delivery time for the infant (signs o f
fetal emergency) or the m other (fatigue, m aternal
illnesses).
A num ber o f other indications have been reported
for perform ing an episiotom y. Possible indications
ru
for perform ing an episiotom y are:
• fetal emergency;
• shoulder dystocia;
• vaginal assisted deliveries and breech deliveries;
b.
• reduction o f time o f delivery in case o f m aternal
illnesses;
• prolapse surgery or other vulvovaginal operation
in the m edical history.
Figure 2.65 Open scissors are inserted as deeply as possible while
-li
The literature is not in complete agreement on the
protective function o f mediolateral episiotomy for the
incidence o f sphincter lesions. In a Cochrane review
com paring routine episiotomy (episiotomy performed
guided by the fingers.
Flanders an episiotom y is placed at the left side o f

er
in 75% o f participants) versus restrictive episiotomy the patient. With respect to the episiotom y placement
(episiotomy perform ed in 28% o f participants), a technique, this chapter will assum e this location.
restrictive policy results in less severe perineal traum a I f tolerated by the labor, local anesthesia with 1%
(RR 0.67; 95% C l 0.49-0.91), especially in the group lidocaine is adm inistered.25 When the head is alm ost
with mediolateral episiotom y (RR 0.55; 95% C l 0.31- extended, the index and m iddle fingers o f the left hand
h
0.96) [LE A l ].27 In a Finnish study, however, restricting are placed between the skull and the pelvic floor. Then
lateral episiotom y use to lower incidences may result in the open scissors are inserted as deeply as possible
higher rates o f sphincter lesions and the optimal level of while guided by the fingers (Figure 2.65).
us
episiotom y is not yet known [LE B ].34 At the peak o f the contraction, the skin, the sub
It could be that the m anner in which the episiot cutis, and the pelvic floor m uscles are cut with a
om y is placed, particularly the angle o f the episiotom y slightly pushing, yet sm ooth motion. The episiotom y
relative to the m idline, is o f im portance in the pre starts from the center o f the posterior com m issure
vention o f O A SIS.35 Based on a large observational and is placed at an oblique angle in the direction of
ak
study in the Netherlands, it seem s that in an assisted the left ischial tuberosity. Based on observational stu
vaginal delivery, sphincter lesions can be prevented by dies it appears that the average length o f an episiot
perform ing m ediolateral episiotom ies. This is true for om y is 4 cm and the m axim um length is 6 cm .38,39 An
both vacuum extractions (odds ratio [OR] 0.11; 95% insufficient angle increases the chance o f sphincter
C l 0.09-0.13) and forceps extractions (O R 0.08; 95% injury and in order to obtain a postpartum angle of
C l 0.07-0.11) [LE B ].36 A third- or fourth-degree 45° the episiotom y m ust be placed at an approxim ate
laceration in the m edical history is no indication for angle o f 60° (Figures 2.66 and 2.67) [LE C ].40
prim ary episiotom y [LE C ].25
Preparation for Suturing
The preparation for suturing an episiotom y
Technique for Episiotomy Placement consists o f 25,41:
There is no international consensus on the definition • explanation about the suturing;
o f a m ediolateral episiotom y.37 In contrast with m ost • proper positioning and adequate lighting;
Anglo-Saxon countries, in the Netherlands and
ru
b.
Figure 2.66 Episiotomy at an approxim ate angle o f 60°.
Figure 2.67 Postpartum angle o f 45°.

• thorough inspection o f the vagina and the peri
-li
neum. Rectal examination is essential to ascertain
whether a sphincter laceration developed and must
take place in the inspection o f each laceration. In a
rectal examination the index finger is inserted in the
The first suture inside the vagina is placed above
the upper m argin o f the incision to prevent the for
m ation o f a hem atom a due to blood vessel retraction.
er
anus, and the thumb is placed on the sphincter. The Next, the vaginal m ucosa is sutured with a continuous
sphincter is palpated between the thumb and suture - possibly a m attress stitch - out to the hy
the index finger. In a study by Andrews et al., 56% m enal ring (Figures 2.68 to 2.71).
o f all sphincter lacerations were m issed [LE C]42; Next, the pelvic floor m uscles (the transverse peri
neal muscle, the bulbospongiosus muscle, and the
• suturing under aseptic circum stances;
h
urethrovaginal m uscle) are sutured with a continuous

• adequate anesthesia ( 10-20 ml lidocaine 1%);
stitch (Figure 2.72). However, som e argue that the
• suturing must take place as soon as possible to pre
bulbospongiosus m uscle should be deliberately
us
vent blood loss and infections. Suturing before the

sought and anchored by a separate suture prim arily
delivery o f the placenta may lead to less blood loss
for anatom ical correction but also for possibly pre
[LE B], but carries the risk that the sutures may be
venting vaginal widening [LE D],
removed if a manual placenta removal is still
In practice, however, these m uscles are usually not
necessary43 If additional time is lost between the
distinguishable and are approxim ated with the help o f
placement o f the episiotomy and the suturing, the
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one or m ore sutures. Finally, the skin is closed with

chance of bacterial contamination and thereby pos
rapidly absorbable continuous intracutaneous sutures
sibly also the chance o f wound infection increases.
(Figures 2.73 and 2.74).45 T o suture an episiotom y,
preference is given to a continuous suturing
Suturing Technique
technique.
To suture an episiotom y, (atraum atic) synthetic
If all the layers are closed with a continuous sutur
absorbable suture m aterial is used, such as polygalac-
ing technique, there are significantly less pain sym p
tin 910 (Vicryl) or polyglycolic acid (Surgicryl, Safyl,
tom s com pared to interrupted sutures during the first
Dexon).
10 days postpartum (RR 0.76; 95% C l 0.66-0.88) and
The repair o f an episiotom y can be divided into
an overall reduction in analgesia use (RR 0.70; 95% Cl
three layers: vaginal traum a, deep and superficial peri 0.59-0.84) [LE A l ].46
neal muscles, and the skin. Traditionally, repair was
Removal o f suture m aterial from the skin is
done according to these three layers, but nowadays, considerably less frequently necessary if rapidly
continuous suturing techniques are also often used.44
absorbable sutures are used (3-0 thickness Rapide)
ru
b.
Figure 2.68 Initial situation w hen suturing.
-li
h er
us
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Figure 2.69 First suture inside the vagina is placed above the Figure 2.70 Suturing o f the vaginal mucosa out to the
margin o f the incision. hymenal ring.
com pared to standard m aterial (22/769 [3%] versus absorbable material m ay lead to m ore wound
98/770 [13%], p < 0.0001), and also in the continuous dehiscence.38
suturing technique com pared to the interrupted If after suturing the subcutis, the skin is properly
suturing technique (24/770 [3%] versus 96/769 positioned, it m ay be considered to withhold the
[12%], p < 0.0001) [LE A 2].45 However, rapidly intracutaneous suturing.41 As an alternative to
ru
b.
Figure 2.71 Continuous stitching o f the vaginal mucosa out to the Figure 2.72 Pelvic floor muscles are sutured w ith a continuous
hymenal ring.
-li stitch.
h er
us
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Figure 2.73 The skin is sutured intracutaneously with a continuous Figure 2.74 The skin is sutured intracutaneously with a continuous
stitch. stitch (continuation phase Figure 2.73).
continuous sutures for each layer, the vaginal m ucosa, all o f the sutures m ust be rem oved and the suturing
the pelvic floor muscles, subcutis, and intracutaneous m ust be done again.
suturing can be done with one continuous suture.41
After com pleting the suturing, a rectal exam ination Complications
m ust always be perform ed to ensure that no sutures The com plications can be classified into short- and
were placed in the rectum. If this is the case, however, long-term com plications. D uring the initial
postpartum days the com plications o f an episiotom y exception that the wound m argins are usually less
are pain, infection, and bleeding. It appears that a sharp (see Section: Episiotomy).
spontaneous second-degree laceration causes less
pain sym ptom s and dyspareunia than a m ediolateral Prevention of First- and Second-Degree Ruptures
episiotom y [LE B ].47 A m idline episiotom y is a recog There are no indications that perineal lacerations
nized risk factor for sphincter lesions.31 A non steroi can be prevented through perineum m assage during
dal anti-inflam matory drug (N SA ID ) such as the expulsion or an episiotom y (see Section:
indom ethacin or diclofenac provides significant pain Episiotom y).25 Perineal injury can possibly be pre
reduction during the first 24 hours postpartum and vented through heat com pression ([LE B]: nulli OR
some argue that this should be standard treatment for 0.7; 95% C l 0.4-1.0 and m ulti OR 0.6; 95% C l 0.3-0.9)
all wom en after a laceration or an episiotom y, except and lidocaine spray for pain relief during the expul
ru
in the case o f contraindications [LE D ].25 Even though sion ([LE A2]: RR 0.63; 95% C l 0.42-0.93), but both
small quantities o f this m edication pass into the breast outcom es are based on only one random ized study.25
milk, in norm al doses (indom ethacin 25 m g three Although prenatal perineal m assage in nulliparous
times a day, diclofenac 50 m g three tim es a day) no women seem s to dim inish the chance o f episiotom y
(RR 0.83; 95% C l 0.73-0.95), there is no difference in
b.
effect is expected in the infant.
Late com plications o f an episiotom y are pain and the incidence o f first- and second-degree laceration
dyspareunia. There appears to be no difference in the [LE A l ].29
incidence o f urinary and/or fecal incontinence and An observational study o f alm ost 3000 sponta
genital prolapse after an episiotom y com pared to an neous deliveries in Australia illustrates that lateral
laceration [LE B ].47
First- and Second-Degree Lacerations

-li
uninjured perineum or a first- and second-degree position deliveries produce the least am ount o f peri
neal lacerations (33.3%) and delivery in a sitting p osi
tion has the greatest chance o f perineal lacerations
(58%). The study also dem onstrated a significant dif
er
ference in uninjured perinea if the delivery was guided
Preparation and Technique for Suturing
by a gynecologist (31.9%) as com pared to that by a
The preparation for suturing a first- or second-degree midwife (56-61% ) [LE B] 48 In a recent systematic
laceration is com parable to that o f an episiotom y (see review, Epi-N o birth trainer (a device for training of
Section: Episiotom y) (Figure 2.75). the pelvic floor m uscles with an inflatable balloon) did
h
Suturing a first- or second-degree laceration is not reduce episiotom y rates and had no influence on
com parable to suturing an episiotom y, with the reducing perineal tears [LE B ].49
us
Essential Points and Recommendations

• Thorough inspection o f each perineal laceration,
including rectal examination, is im portant because
ak
(superficial) sphincter lesions can be m issed (see

Chapter 13 on sphincter lesions) [LE C],
• It is recom m ended to classify perineal lacerations
j
according to the internationally accepted classifi
lit •
cation [LE D].
Perineal laceration m ay be prevented through
pain relief during the expulsion with the use
o f lidocaine spray [LE A2] or hot com presses
[LE B]. A lthough prenatal perineal m assage in
n ulliparous w om en seem s to reduce the chance
o f episiotom y, there is no difference between the
incidence o f first- and second-degree laceration
first-degree laceration second-degree laceration [LE A l].
Figure 2.75 First- and second-degree lacerations.
Sectio n 2: N orm a l La b o r a n d D e live ry
• An episiotom y is an obstetric intervention 12. Stables D, Rankin J. Physiology in childbearing with

that should only be perform ed on indication. anatom y and related biosciences. London: Bailliere
The routine perform ance o f an episiotom y does Tindall, 2005.
not prevent sphincter lesion s [LE A l], leads to 13. T iran D. Bailliere’s m idw ives’ dictionary. London:
additional need for suturing the perineum [LE Bailliere Tindall, 2003.
A l] , and is probably coupled with increased 14. W orld H ealth O rganization. C are in n orm al birth: a
p ain and dyspareunia in the short and long practical guide. Geneva: W orld H ealth O rganization,
M aternal an d N ew born H ealth/Safe M otherhood Unit,
term [LE B],
1996.
• If an episiotom y is needed, it m ust be perform ed
15. Stichting Perinatale R egistratie N ederland. Perinatale
adequately, from the center o f the posterior
zorg in N ederland: Jaarboeken 2003-2012. Utrecht:
com m issure and in a bulging perineum at a 60° PRN, 2014. http://w w w .perinatreg.nl
ru
angle from the midline [LE C],
16. A asheim V, N ilsen ABV , Lukasse M , Reinar LM.
• Suturing an episiotom y m ust be perform ed under Perineal techniques during the second stage o f labour
proper positioning, illumination, adequate local for reducing perineal traum a. C ochrane D atabase Syst
pain relief, and after careful inspection concerning Rev. 2011; 12:CD 006672.
b.
the classification o f the lesion, including a rectal 17. Laine K, Skjeldestad FE, Sandvik L, et al. Incidence o f
exam ination [LE D]. obstetric anal sphincter injuries after training to
• Preference is given to a continuous suturing tech protect the perineum : cohort study. B M J O pen. 2012;2:
e001649.
nique with absorbable suturing material [LE A l].
18. Ponkey SE, C oh en A P, H effn er LJ, L ieb erm an E.
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Cunningham F, Leveno K, Bloom S, et al. W illiam s
obstetrics. N ew York: M cGraw -Hill, 2009. 19.
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2. Fraser D M , C ooper M A. M yles’ textbook for midwives. the prevention and treatm ent o f postpartum
haem orrhage and retained placenta. Geneva: W H O,
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London: Churchill Livingstone, 2003.
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3. H als E, Olan P, Pirhonen T, et al. A m ulticentre
interventional program to reduce the incidence o f anal 20. G iilm ezoglu AM , L um biganon P, Lan dou lsi S, et al.
sphincter tears. O bstet Gynecol. 2010; 116(4):901-8. Active m anagem ent o f the third stage o f lab our with
h
and w ithout controlled cord traction: a random ized,

4. H einem an M J, Evers JL H , M assuger LFA G , Steegers
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van de m ens. 7th edn. A m sterdam : Reed Business,
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2012 21. Jangsten E, M attsson LA, Lyckestam I, et al. A

com parison o f active m anagem ent an d expectant
5. H enderson C, M acdonald S. M ayes’ midwifery.
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6. H olm er AJM. Leerboek der verloskunde. Bussum : V an
22. Hofm eyr GJ, Abdel-Aleem H, Abdel-Aleem M A. Uterine
D ishoeck, V an H olkem a & W arendorf N V , 1967.
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7. Kloosterm an GJ. D e V oortplanting V an D e Mens.
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Leerboek voor obstetrie en gynaecologie. Weesp: 23. Begley CM , Gyte GM , D evane D , et al. Active versus
Centen, 1985. expectant m anagem ent for w om en in the third stage o f
8. L eidraad bij de studie der obstetrie en gynaecologie in labour. C ochrane D atabase Syst Rev. 2 0 1 1;( 11):
drie delen. Deel I en III. Excerpta lectionum. CD007412.
9. N ational Collaborating Centre for W om en’s Health. 24. M cD onald SJ, M iddleton P, Dowswell T, M orris PS
Intrapartum care o f healthy women and their Effect o f tim ing o f um bilical cord clam pin g o f term
babies during childbirth. Clinical Guideline. 2009. infants on m aternal and neonatal outcom es. Cochrane
http://w w w .guidance.nice.org.uk/CG 55. D atabase Syst Rev. 2013;(7):C D 004074.
10. D udenhausen JW. Praktische Geburtshilfe m it 25. N ational Institute for Health and Clinical Excellence.
geburtshilflichen O perationen. Berlin/N ew York; Intrapartum care: care o f healthy w om en and their
W alter de Gruyter, 2011. babies during childbirth. London: R C O G , 2007.
11. Reuwer P, Bruinse H, Franx A. Proactive support 26. K alis V, Laine K, de Leeuw JW, et al. Classification o f
o f labor. Cam bridge: C am bridge U niversity Press, episiotom y: tow ards stan dardization o f term inology.
2009. BJO G . 2012;119:522-6.
27. C arroli G, M ignini L. Episiotom y for vaginal birth. 39. van D illen J, Spaan s M , van K eijsteren W, et al. A
C ochrane D atabase Syst Rev. 2009;(1):C D 000081. doi: prospective m ulticenter audit o f labor-room
10.1002/14651858.C D 000081.pub2. episiotom y an d an al sphincter injury assessm ent in
the N etherlands. Int J G ynecol O bstet.
28. H artm an n K, V isw anathan M, Palm ieri R, et al.
O utcom es o f routine episiotom y: a system atic review. 2010;108:97-100.
JA M A . 2005;293:2141-8. 40. Kalis V, K arbanova J, H orak M, et al. The incision
angle o f m ediolateral episiotom y before delivery and
29. Beckm ann M M , G arrett AJ. A ntenatal perineal
after repair. Int J Gynecol Obstet. 2008;103:5-8.
m assage for reducing perineal traum a. Cochrane
D atab ase Syst Rev. 2006;(1):C D 005123. doi: 10.1002/ 41. Sultan A H , Thakar R. Low er genital track and anal
14651858.CD 005123.pub2 sphincter traum a. Best Pract Res Clin O bstet Gynaecol.
2002;16:99-115.
30. G up ta JK , H ofm eyr G J, Shehm ar M. Position in the
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second stage o f lab ou r for w om en without epidural 42. Andrew s V, Sultan A, Thakar R, et al. Risk factor for
anaesthesia. C ochrane D atabase Syst Rev. 2012;5: obstetric anal sphincter injury: a prospective study.
CD 002006. doi: 1002/ 14652858.CD 002002.pub3. Birth. 2006;33:117-22.
31. G rah am ID, C arroli G, D avies C, et al. E pisiotom y rates 43. Baksu B, D avas I, Akyol A, et al. Effect o f tim ing o f
aroun d the world: an update. Birth. 2005;32:219-23. episiotom y repair on peripartum blood loss. Gynecol
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32. Stichting Perinatal Registratie N ederland. Perinatale Obstet Invest. 2008;65:169-73.
zorg in N ederland 2012. U trecht: PRN , 2013. 44. Kettle C, Fenner D. Repair o f episiotom y, first and
second degree tears. In: Sultan AH . Perineal and anal
33. C hristiaens W, N ieuw enhuijze M J, de V ries R. T rends
sphincter traum a. Springer: London, 2008, pp. 20-32.
in m edicalisation o f childbirth in Flanders and the
N etherlands. M idwifery. 2 0 1 3 ;2 9 :e l-8 . 45. Kettle C, Hills R, Jones P, et al. C ontinuous versus
34.
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Raisanen S, V ehlvilainen-Julkunen K, G issler M,
H einonen S. H ospital b ased lateral episiotom y and
obstetric anal sphincter injury rates: a retrospective
population b ased register study. A m J O bstet Gynecol.
interrupted perineal repair with stan dard or rapidly
absorbed sutures after spontaneous vaginal birth: a
ran dom ised controlled trial. Lancet.
2002;359:2217-23.
er
2012;206(4):347.el-6. doi: 10.1016/j.ajog.2012.02.019. 46. Kettle C, Hills RK, Ism ail KM K. C ontinuous versus
Epub 2012 Feb 28. interrupted sutures for repair o f episiotom y or second
degree tears. Cochrane D atabase Syst Rev. 2007(4):
35. Eogan M, D aly L, O ’Connell PR, et al. D oes the angle o f
CD 000947. doi: 10.1002/14651858.CD000947.pub2.
episiotom y affect the incidence o f anal sphincter
injury? BJO G . 2006;113:190-4. 47. Sartore A, de Seta F, M aso G, et al. The effects o f
h
m ediolateral episiotom y on pelvic floor function after

36. de Leeuw JW , de W it C, K u ijken JP, et al.
vaginal delivery. Obstet Gynecol. 2004;103:669-73.
M ed io lateral e p isio to m y redu ces the risk fo r anal
sp h in cter in jury d u rin g operativ e v agin al delivery. 48. Shorten A, D onsante I, Shorten B. Birth position,
us
B JO G . 2 0 0 8 ;1 1 5 :1 0 4 -8 . accoucheur, and perineal outcom es: inform ing

w om en about choices for vaginal birth. Birth.
37. Kalis V, Stepan Jr J, H orak M , et al. D efinitions o f
2002;29:18-27.
m ediolateral episiotom y in Europe. Int J Gynecol
Obstet. 2008;100(2): 188-9. 49. Brito I,G, Ferreira C H , D uarte G, N ogu era AA,
M arcolin A C . A ntepartum use o f Epi-N o birth trainer
38. V erspyck E, Sentilhes L, Rom an H , et al. Episiotom y
for preventing perineal traum a: system atic review. In
techniques. J Gynecol O bstet Biol Reprod.
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U rogynecol J. 2015;10:1429-36,
2006;35:1540-51.
77
Section 3 Pathology of Labor and Labor and Delivery
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b.
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Compound Presentation and Umbilical
j» j Cord Prolapse
A.J. Schneider and J.J. Duvekot
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General Information Prolapsed Extremities
Introduction Incidence
In this chapter we discuss the obstetric aspects o f A cephalic presentation with a presenting or prolapsed
b.
com pound presentation (extremity prolapse) and hand or arm is a rare occurrence. The incidence varies
umbilical cord prolapse o f an infant in cephalic or between 0.4 and 1.3 in 1000 childbirths.2 5 Prolapsed
breech presentation. extremities are quite frequently combined with
The recom m endations m ade in this chapter are a prolapsed umbilical cord. It is prudent to be aware
indicated otherwise.1
Definition
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based on the opinion o f experts [LE D ], except where o f this and to conduct a specific examination for this.
Diagnosis
A diagnosis o f presenting extremities can be m ade
er
The extrem ities and um bilical cord are presenting if by internal exam ination and especially by m eans of
they are positioned next to or lower than the fetal head ultrasound. In the event o f prolapsed sm all parts, the
with unruptured m em branes. If the m em branes are
ruptured, we speak o f prolapsed extrem ities or um bil
h
ical cord in those cases (Figures 3.1 and 3.2).

ruptured membranes
us
unruptured membranes
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Figure 3.2 Prolapsed hand.

Figure 3.1 Presenting hand.
O b ste tric In te rv e n tio n s , ed. P. Joep D orr, V incent M. Khouw, Fran k A. Chervenak, A m os G runebaum , Yves Jacquem yn,
an d Jan G. N ijhuis. Published by C am bridge U niversity Press. © C am bridge U niversity Press 2017.
Sectio n 3: P a th o lo g y o f La b o r a n d La b o r a n d D e live ry
diagnosis can usually be established m ore precisely by a relatively small pelvis, engagement does not take
internal examination. place. This discrepancy is m ost prevalent in small
A hand can be differentiated from a foot because, women (<1.60 m) with a large infant in the first
if the clasping reflex is still intact, the hand will grasp pregnancy.
the exam ination finger. Moreover, the foot is usually • H ead not engaged: This occurs after spontaneous
located at a right angle to the lower leg, in contrast m em brane rupture or by inducing labor by artifi
with the position o f the hand to the lower arm. cially rupturing o f the m em branes in a situation o f
If a knee or elbow is palpable, it is im portant to a not (yet) engaged presenting part.
indicate whether this is positioned deeper than the • Rupturing o f the membranes in case o f polyhydram
largest diam eter o f the head. A knee and an elbow can nios: After rupturing o f the m em branes, the sm all
be difficult to distinguish, therefore the accom pany parts m ay flow out next to the head that is not (yet)
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ing hand or foot m ust always be sought. in close contact with the pelvic inlet.
The need to distinguish a prolapsed arm from • Small, prem ature (dead, macerated) infant.
a prolapsed hand is to ascertain whether the wrist
• Space-occupying process in the true pelvis: In a low-
joint is located lower than the largest diam eter o f the
lying m yom a in the true pelvis or with a m arginal
head. We can also speak o f a com plete or incomplete
b.
placenta previa or low-lying placenta. Frequently
arm presentation.5
an oblique lie will be present.
• Second o f a set o f twins: After the birth o f the first
Causes and Risk Factors infant, the second infant often engages so rapidly
Extremities m ay prolapse due to insufficient closure that the chance o f presenting/prolapsed extrem i
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o f the pelvic inlet by the presenting part. Predisposing
factors for this phenom enon are as follows.
• Parity: In prim iparous women the head generally
ties or um bilical cord is increased.
Therapy
er
descends during the last weeks o f pregnancy
Vaginal Delivery Impossibility
and closes o ff the pelvic inlet. In m ultiparous
There is a (relative) im possibility o f vaginal delivery in
women the presenting part som etim es rem ains
case o f the following prolapsed sm all extrem ities in
above the pelvic inlet until the start o f contrac
com bination with a cephalic presentation2,6:
tions. The chance o f presenting/prolapsed parts is
h
therefore 10 tim es higher in m ultiparous w om en.5 • head and two hands (Figure 3.3);
• Anatomical discrepancy between head and pelvis: • head and arm (Figure 3.4);
In the event o f a relatively large head and/or
us
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Figure 3.3 Head and tw o hands.

C h a p te r 3: C o m p o u n d P resenta tio n a n d U m b ilica l C o rd P rolap se
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b.
Figure 3.5 Head and foot.
Figure 3.6 Head w ith hand and foot.
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Figure 3.7 Head w ith hand and tw o feet.

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Figure 3.8 Head with foot and tw o hands.

• head and foot (Figure 3.5);
• head with one arm and one foot (Figure 3.6);
• head with one hand and two feet (Figure 3.7); dilation phase, the wom an can be positioned on the
• head with one foot and two hands (Figure 3.8). opposite side o f the presenting hand or arm, whereby
Vaginal delivery in these situations will only be p o s space is created so that the hand or arm can pull back
sible in case o f a very sm all or dead infant. In case o f spontaneously.
a living infant, it m akes no sense to wait for im prove
ment in the situation and a cesarean section will be Prolapsed Hand or Arm
necessary. See A n im a tio n s 3.1 and 3.2.
The clinical procedure is determ ined by ascertain
Presenting Hand or Arm ing whether the wrist joint and/or the elbow joint are
In case o f a presenting hand or arm , the m em branes located below the largest diam eter o f the head
should not be ruptured artificially. D uring the early (Figure 3 .9 ). Anatomically, the wrist form s the
ru
b.
Figure 3.9A-B Prolapsed hand (A) and prolapsed arm (B).
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thickest part between the fingers and the lower arm with
the shape o f a double wedge. If we look at this merely
mechanically, the arm - if the wrist is positioned lower
than the head at the start o f the labor - slides in front o f
Special Situations
Repositioning of a Prolapsed Arm
A method recom mended by W HO to use in case of
er
a prolapsed arm - only to be used in situations with
the head as it gets deeper into the true pelvis.
lack o f m odern facilities - is as follows (see Animation
I f the head and the hand have not yet engaged very
3.3). Repositioning o f a prolapsed arm can be
much, a repositioning o f the hand can be attempted
attempted in a motivated patient: after positioning the
by stim ulating the infant to pull the arm back by softly
wom an in a knee-elbow position, the arm is pushed
h
squeezing the hand. I f this is not effective and the

past the head to above the pelvic inlet and held there
wrist rem ains deeper than the head, we have a case
until the head has occupied the vacated space
o f a prolapsed arm or a com plete arm presentation.
(Figure 3.10). In the western world it is recommended
us
Because o f the lack o f space and an unconquerable

that this procedure be perform ed in an operating room.
obstacle, the delivery com es to a sudden halt. W aiting
In case o f failure o f this maneuver or if the umbilical
until com plete dilation is reached m ay cause a uterine
cord prolapses, a cesarean section can then be per
rupture due to excessive stretching.7 In addition to the
form ed immediately. If the procedure is successful,
fact that the delivery cannot proceed because o f this,
the rest would be a norm al delivery.8
this presentation is further com plicated in one-third
ak
o f the cases due to the sim ultaneous prolapse o f the Internal Version and Extraction
umbilical cord.5 In addition to the above-m entioned repositioning of
It would be different if the head engages and the the arm , internal version can be perform ed only on
wrist is not situated below the largest diam eter o f the the second o f a set o f twins with a presenting arm and
head, which would prevent the arm from prolapsing only when the obstetrician has experience with this
further. This presentation does not present clinical procedure: after locating the back by ultrasound,
problem s.5 search for the foot with your hand on the abdom inal
If, in addition to the wrist, the elbow is also palp side o f the fetus, grasp the ankle between the index
ably lower than the largest diam eter o f the head, we and m iddle fingers, and pull the leg firmly down (see
have a case o f absolute delivery obstruction due to the C hapter 6 on delivery in breech presentation) (see
presenting part. Anim ation 3.4). If possible, pull the second foot
C h a p te r 3: C o m p o u n d P resenta tio n a n d U m b ilica l C o rd P rola p se
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Figure 3 .10A-B Repositioning o f a prolapsed arm.
down at the sam e time so that the infant can be called for. An example o f this is a non-engaged head in
delivered vaginally (Figure 3.11) (see Anim ation combination with unruptured membranes. It is better to
b.
3 .5). Internal version and extraction is best perform ed rupture the membranes only while at the same time the
under locoregional or general anesthesia in the oper head is pressed down into the pelvic inlet by a helper.
ating theatre. The bladder should be emptied beforehand.
In case o f ruptured m em branes and a non
Adjacent or Occult Hand
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In the case o f vacuum extractions it is reported that
m ore force is needed to extract the head in the pres
ence o f an occult hand (Figure 3.12) [LE B ].9
engaged presenting part, clinical bed rest m ay be pre
scribed. If, in the case o f a non-engaged head, the
m em branes rupture outside the hospital, it is prudent
to instruct the patient to com e to the hospital as soon
er
as possible. In m ost cases this will be faster than wait
Prognosis and Therapy ing for an am bulance and certainly if the contractions
have not yet started, instances o f prolapsed extrem i
The prognosis o f a prolapsed hand or arm depends on
ties or um bilical cord will not present a problem .
any sim ultaneously existing disorders (for instance,
a prolapsed um bilical cord). In m ost instances o f
h
a prolapsed arm , the problem will have to be solved Important Points and Recommendations
by perform ing an em ergency cesarean section.
• In case o f a smoothly progressing dilation and
us
engagement, all combinations o f cephalic presenta

Complications tion with presenting or prolapsed extremities can in
Com plications in the event o f presenting or prolapsed principle be monitored to see how the further devel
extrem ities are rare. opment o f the labor and delivery progresses [LE D).
In a stagnated dilation there is a chance of • By softly squeezing a finger o f a presenting or
overstretching and rupture o f the uterus with a
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prolapsed hand the infant m ay be inclined to

prolapsed arm. retract the hand [LE D ].
A very rare com plication (three published cases) is • If the infant does not retract the arm after stim ula
necrosis o f a prolapsed arm due to the circulation tion, the location o f the thickest part - the double
being cut o ff by the head. This is so uncom m on that wedge form ed by the wrist - is an indicator o f the
in those cases an investigation should be perform ed prognosis. If the wedge is located below the head,
into the increased coagulation tendency in the it will be pushed along on further engagem ent and
neonate.10 Less serious consequences o f im pingem ent constitute an obstacle. Delivery m ust then be done
are hem atom as on the arm or the hand. by cesarean section [LE D],
• A vaginal delivery with a prolapsed arm is only
Prevention possible if the fetus is very small or if it is dead.
In general, prevention is not very successful. There are, In other situations, contractions will reduce when
however, som e situations in which the presenting part pushing. After reaching complete dilation, there is
does not close o ff the pelvic inlet very well and caution is a risk o f uterine rupture [LE D],
Section 3: P a th o lo g y o f La b o r a n d La b o r a n d D elivery
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b.
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Figure 3.11A-D Version and extraction.
Prolapsed Umbilical Cord If the um bilical cord is situated alongside the pre
senting part during labor, it is called an occult um bil
Definition ical cord prolapse.
The umbilical cord is presenting if, with unruptured

m em branes, the umbilical cord is palpably lower than Incidence
the presenting part. The incidence o f a prolapsed um bilical cord in ceph
If the m em branes are ruptured, then there is a case alic presentations varies between 1 and 6 per 1000
o f prolapsed um bilical cord (Figure 3.13). births.11,12 In breech presentations the incidence
C h a p te r 3: C o m p o u n d P resenta tio n a n d U m b ilica l C o rd P rolap se
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Figure 3.13 Prolapsed um bilical cord.
b.
or assisted rupturing o f the membranes, a prolapsed
umbilical cord m ust be ruled out by m eans o f internal
or speculum examination. In case o f preterm ruptured
Figure 3.12 O ccult hand.
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ranges from 4% to 6% and is lower with a com plete
membranes, in which it is the rule to perform as few
internal examinations as possible, this situation form s
the exception to the rule.
In an occult um bilical cord, because o f the pinch
er
breech presentation than with a footling breech.12’13
ing o f the um bilical cord between the presenting part
In preterm deliveries with a fetus in breech presenta
and the cervix, decelerations will develop on the
tion the incidence is even higher. The longer the
cardiotocogram (C TG ) and thereby provide an initial
um bilical cord, the greater the chance o f prolapse.
indication. The definitive diagnosis is usually only
A prolapsed um bilical cord occurs m ore in male
h
m ade during a cesarean section.

fetuses, who on average have longer um bilical cords
than fem ale fetuses.
The exact frequency o f occult um bilical cord p ro Causes and Risk Factors
us
lapses is not known, but it probably occurs m ore than The risk factors for developing a prolapsed umbilical
is clinically acknowledged. cord are listed in Table 3.1. A distinction is m ade
between general and procedure-related risk factors.
At least 50% o f all prolapsed um bilical cord cases are
Diagnosis preceded by an obstetric procedure.13
A presenting um bilical cord d iagn osis can be m ade
ak
by internal exam ination and especially by m eans o f

an u ltrasou n d exam ination. A presenting um bilical Therapy
cord is difficult to detect by palpation ; ultrasoun d A prolapsed um bilical cord constitutes an emergency
(color flow D oppler) exam ination can therefore be that dem ands im m ediate action. The danger o f
helpful. a prolapsed um bilical cord is twofold, i.e., mechanical:
In case o f a prolapsed um bilical cord, the diagnosis the im pingem ent o f the um bilical cord between the
can often be m ade very well through internal exam infant and the wall o f the birth canal, and vasospasm :
ination. Often the um bilical cord is still pulsating and the contraction o f blood vessels in the umbilical cord
is therefore easy to detect. The fetal heart rhythm through cooling and m anipulation. This will, in both
pattern can still be norm al with a prolapsed umbilical cases, lead to a decrease in the blood flow to the fetus
cord, but the m ajority o f cases present with brady with asphyxia as a result.
cardia or variable decelerations.14,15 Especially when In the event o f a p rolap sed um bilical cord, the
fetal heart rhythm disorders develop after spontaneous procedure m ust be aim ed at having the delivery take
Section 3: P a th o lo g y o f La b o r a n d La bo r a n d D elivery
Table 3.1 Risk factors for umbilical cord prolapse1
G enera l risk factors P roced u re-rela ted risk

factors
Multi parity Artificial rupturing of

membranes
Low birthw eight (<2500 g) Vaginal m anipulation o f fetus
in case o f ruptured
membranes
Premature birth Version and extraction
Congenital fetal disorders Insertion o f intrauterine
pressure catheter
Breech presentation Insertion o f skull electrode
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Transverse lie or oblique lie External version
Second o f set o f twins Application o f forceps or
vacuum cup
Polyhydramnios
Non-engaged presenting
part Figure 3.14 Filling o f the bladder with saline solution.
b.
Low-lying placenta
Extremely long um bilical cord
(>80 cm)
Anencephaly
a pregnancy duration before viability
(24-25 weeks) an expectative approach
m ay be chosen. A s a rule, cesarean sections
m anner:
•
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place as soon as possible and in the follow ing
Call for help: in addition to extra obstetricians/

gynecologists and nurses, a pediatrician and
are not perform ed before this time in the
Netherlands due to the moderate neonatal
prognosis at this early stage. This situation is
different in other countries.
er
anesthesiologist should be notified.
• Determ ine the fetal heart rhythm: • In case o f an abnorm al fetal heart rhythm pattern,
the choice is also between an em ergency cesarean
- In the absence offetal heart action, this m ust be
section or an operative vaginal delivery, depend
determ ined by ultrasound. It m ay at tim es be
ing on the degree o f dilation, the nature o f the
h
difficult to determ ine if indeed no pulsations

presenting part, and the engagem ent. I f it is
can be felt in the umbilical cord. In case o f fetal
decided to proceed with an assisted vaginal deliv
death, the policy m ust follow local protocol.
ery, the outlet position m ust be such that the
us
- In case o f a normal fetal heart rhythm pattern,

delivery can take place quickly and without
the choice between an emergency cesarean sec
problem s.
tion and an assisted vaginal delivery will
depend on the degree o f dilation and the nat - I f it is decided to do an em ergency cesarean
ure o f the engagem ent o f the presenting part. section, it is useful to push the presenting
part upw ard. T h is can be done through the
ak
I f it is decided to proceed with an assisted retrograde filling o f the bladder with

vaginal delivery, the outlet position m ust 500-750 ml saline solution via a 16-G Foley
be such that the delivery can take place catheter, which is then clam ped o ff (see
quickly and without problem s. The con d i A nim ation 3.6). A possible side effect o f this
tions m ust be the sam e here as with an could be a decrease in the contraction activ
operative vaginal delivery in other in dica ity. N aturally, the balloon o f the catheter
tions. This is not a situation in which extra m ust be inflated to hold it in place. O nly at
risks should have to be taken. A total the m om ent o f the incision, the K ocher
breech extraction or version and extrac forceps are released from the indw elling
tion should only be perform ed under catheter. F or this reason, every delivery
favorable circum stances. room should be equipped with an indw elling
If it is decided to perform a cesarean section, catheter, a bag o f in fusion liquid, Kocher
acute tocolysis can be considered. With forceps, and an inflator (Figure 3.14).
C h a p te r 3: C o m p o u n d P resenta tio n a n d U m b ilica l C o rd Prolapse
- A second possibility is to push the presenting

part up with the exam ining hand. This uncom
fortable procedure can best be done with half
o f the hand (three fingers) or the entire hand.
An alternative to this is internally pushing the
presenting part out o f the pelvis and then
suprapubically fix the presenting part with
the other hand. After the presenting part has
been fixed externally, the internal hand m ay be
rem oved and the presenting part should
rem ain in the pushed-up position until arrival
ru
in the operating roo m .15
- A th ird m ethod is to place the patient in
a kn ee-elb ow position . An alternative to
this is the head-down o r T rendelenburg
b.
p osition . T he latter p osition is com bined
with a left side lie. Im provem ent o f the fetal
condition after the presenting part has been
Figure 3.15 Duhrssen's incisions.
pu sh ed up sh ould not be a reason to slow
down or change the procedure that w as set
in m otion. -li
Push ing the um bilical cord back into the uterus
m ust be avoided [LE D ]. T his has never appeared
Complications
Perinatal death due to a prolapsed umbilical cord
er
appears to be on the decrease. D uring the first half
to be very beneficial. There is only one p u blica
o f the twentieth century the death rate was still
tion in which this m ethod has been applied with
32-47% . In the last 20 years the death rate has gone
reasonable success. T ouch in g or cooling o f the
down to less than 10%.12,16,17 The liberal perform ance
um bilical cord m ust be avoided to prevent v a so
o f cesarean sections and im provem ents in neonatal
sp asm . W hether actively keeping the um bilical
h
care has contributed greatly to this decline.

cord w arm helps is a question that still needs to
The location in which a prolapse o f the umbilical
be answ ered. O ne p ossibility is to place an u m b il
cord occurs is prognostically one o f the m ost im por
ical cord that is han ging outsid e the vagin a back
us
tant factors. If the um bilical cord prolapse occurs

into the vagina.
outside the hospital, the perinatal death rate is 10
In the past, if dilation was not com plete yet, an
tim es higher than when this occurs in the hospital.11
assisted vaginal delivery w as attem pted by m eans o f
The literature sporadically reports on the success
Diihrssen’s incisions in the cervix (Figure 3.15).
ful outcom e o f conservative treatment o f an umbilical
Now adays this m ethod m ust be used for emergency
ak
cord prolapse in a pregnancy duration o f less than 24

cases only.
weeks.14 Usually, however, these cases result in fetal
O f all in dications for a cesarean section,
death within a few hours.
a p rolap sed um bilical cord is one o f the few real
em ergency indications. Prognostically there is no
clear relationship with the tim e elapsed between Prevention
the decision to do a cesarean section and the delivery Just as in the case o f a prolapsed arm or hand, pre
o f the infant. T his is probably because in p u blica vention is not very successful. There are, however,
tions with m any patients, this decision-delivery-time som e situations in which the presenting part does
does not am ount to m ore than 30 m inutes and is not block the pelvic inlet completely and caution
therefore already very short. m ust be exercised. In that case, we would offer the
Training o f the obstetrics team in the handling o f sam e advice as in the prevention o f a prolapsed arm or
em ergencies, such as a prolapsed um bilical cord, hand.
probably leads to a decline in the perinatal death For women with an infant in an oblique lie or with
and m orbidity rate. a non-engaged presenting part it m ay be suggested to
S e ctio n 3: P a th o lo g y o f L a b o r a n d La b o r a n d D e live ry
hospitalize them for observation at a certain p oin t in 3 El-M ow afi D . G eneva Fou ndation for M edical
pregnancy and, if possible, introduce labor and Education an d Research. C om p lex an d breech
delivery in a controlled m anner after external ver presentation, http://w w w.gfm er.ch
sion. Nethertheless, this does not prevent com pound 4 Perkins R. C om p ou n d presentations. eM edicine,
presentation or um bilical cord prolapse after sp on 2015. h ttp://em edicine.m edscape.com /article/262444-
overview.
taneous rupture o f the m em branes. These wom en
m u st always be properly instructed to com e im m e 5 M artius G. Pathologie der Geburt. In: M artius G (ed).
Lehrbuch der G eburtshilfe. Stuttgart: G eorg Thiem e
diately to the hospital after spontaneous rupture o f
V erlag, 1971, pp. 374-6.
the m em branes. The recom m endation to be tran s
6 A sim akopulos N . C om p ou n d presentation: prolap se o f
ported in a reclined position is obsolete and leads to
three extrem ities with the head. C an M ed A ssoc J.
unnecessary delays.
ru
1965;92:929-31.
When obstetric procedures are necessary in the
7 Newton P. Foetal arm prolap se an d presu m ed m aternal
event o f a non-engaged presenting part, there m ust
death in a w ild h anum an lan gur (Presbytis entellus).
be the possibility to perform an em ergency cesarean Prim ates. 1990;31:143-5.
section. In this situation, artificial rupturing o f the
8 W orld Health Organization, U N FPA , U N ICEF, W orld
b.
m em branes should be avoided. Bank (eds). Com pound presentation. In: M anaging
In the Netherlands, patients with preterm prelabor com plications in pregnancy and childbirth. A guide for
rupture o f m embranes are usually adm itted to the midwives and doctors. Geneva: W H O , 2003. http://www
hospital. Especially in the case o f a breech presentation .who.int/reproductive-health/impact/index.html
there is a greater chance o f a prolapsed umbilical cord. 9 V acca A. The ‘sacral h and w edge’; a cause o f arrest o f
-li
It is difficult to predict this type o f emergency.
Routine ultrasound exam ination to locate the um bil
ical cord beforehand is not very effective for predict
ing a prolapsed um bilical cord [LE B ],18
descent o f the fetal h ead during vacuum assisted
delivery. BJO G . 2002;109:1063-5.
10 Tebes C C , M ehta P, C alhoun D A , et al. C ongenital
ischem ic forearm necrosis associated with
er
a com po un d presentation. J M atern Fetal M ed.
1999;8:231-3.
Important Points and Recommendations 11 Siassak os D , F ox R, D raycott T J. U m bilical cord
• Anyone who guides labor and deliveries m ust be prolapse. G reen-top G uideline N o 50. R C O G , A pril
2008.
aware o f the risk factors that can lead to umbilical
h
cord prolapse [LE D]. 12 Lin M G . U m bilical co rd prolapse. O bstet G ynecol Surv.
2006;61:269-77.
• In the event o f a prolapsed um bilical cord, the
fastest way to deliver m ust be sought [LE D]. 13 Barclay M . U m bilical cord prolap se an d other cord
us
accidents. In: Sciarra JJ (ed). G ynecology an d obstetrics.

• A case o f a prolapsed um bilical cord can be deliv
Philadelphia, PA: Lippincott, 1989, p. 1.
ered vaginally if the delivery can be perform ed
14 K oonin gs PP, Paul R H , C am pbell K. U m bilical cord
quickly and safely [LE D],
prolapse. A contem porary lo o k J R eprod M ed. 1990;35:
• Pushing the presenting part back is essential in the 690-2.
treatment o f the prolapsed um bilical cord with an 15 U sta JM , M ercer BM , Sibai BM . C urrent obstetrical
ak
abnorm al fetal heart rhythm pattern [LE D]. practice an d um bilical co rd prolapse. A m J Perinatol.
• Pushing the presenting part up can be done m anu 1999;16:479-84.
ally, by filling the bladder or through a different 16 W orld Health Organization, U N FPA , U N IC EF, W orld
reclining position o f the wom an [LE D], Bank (eds). Prolapsed cord. In: M anaging com plications
in pregnancy an d childbirth. A guide for m idwives and
doctors. Geneva: W H O , 2003. http://www.who.int/
References reproductive-health/impact/index.html
1 van Everdingen JE, Burgers JS, A ssendelft W JJ, et al. 17 C arlin A, Alfirevic Z. In trapartum fetal em ergencies.
Evidence-based richtlijn ontwikkeling. H outen: Bohn Sem in Fetal N eon atal M ed. 2006;11:150-7.
Stafleu V an Loghum , 2004.
18 E zra Y, Strasberg SR, Farine D . D oes cord presentation
2 Bhose L. C om p oun d presentation. A review o f 91 cases. on ultrasou nd predict co rd prolapse? G ynecol O bstet
Br J O bstet Gynaecol. 1961;68:307-14. Invest. 2005;56:6-9.
C h a p te r
Delivery of Twins
4 M. Laubach and Y. Jacquemyn
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pregnancy duration.4 The lowest incidence o f perinatal
General Information death was encountered during the 38th week o f the
pregnancy. After 38 weeks, the perinatal death rate
Introduction increases comparably to the rise in post-term singleton
b.
A twin pregnancy is an obstetrically high-risk pregnancies after 41 weeks. Considering both the birth
pregnancy that is characterized by a higher perinatal weight and the pregnancy duration, the lowest perinatal
m orbidity and m ortality in com parison with singleton mortality rate (PMR) (3.9/1000) was reported in neo
pregnancies. T his is due, am ong other things, to an nates weighing between 2.5 and 2.9 kg and between 36
increased incidence o f intrauterine growth restriction
-li
and prem ature birth. M ore than 50% o f all twins are
bom before the 37th week o f pregnancy. The average
gestational age at birth is 36.7 + 2.7 weeks.1
Therefore, the peripartum approach surrounding
and 39 weeks o f pregnancy duration [LE B].
There is little good evidence on optimum timing o f
delivery taking chorionicity into account. In uncompli
cated monochorionic diamniotic twin pregnancies early
er
delivery between 34 and 36 weeks is recommended in
the delivery o f twins must, on the one hand, take these order to reduce the risk o f stillbirth [LE B].5 7
factors into account and, on the other hand, contem Monochorionic diamniotic twins with successfully
plate som e additional specific elements, such as an treated twin-to-twin transfusion syndrome require
abnormal fetal lie before and during the labor and close observation throughout pregnancy [LE C ].8
h
delivery. The risk for intrauterine fetal death in m onochori

See Anim ation 4.1. onic diam niotic twin pregnancies beyond 34 weeks o f
gestational age is 1.5-1,7%.9 11 This incidence is even
us
Incidence three tim es lower in dichorionic twin pregnancies

The incidence o f twin pregnancies in the western (0.5%). The perinatal m ortality drops from 8% to 1%
w orld has continued to rise since the 1970s and cur in dichorionic twins between 36 and 38 weeks. (LE B)
rently fluctuates between 16 and 24 per 1000 The perinatal morbidity seems to remain high in all
pregnancies.2’3 T his m ay be attributed to the use o f twin pregnancies even after 34 weeks, suggesting poten
ak
assisted reproduction techniques, but could also be tial benefits o f prolonging pregnancy beyond 36 weeks.
the result o f the rise in m aternal age. Additionally, neonatal morbidity (especially respiratory
distress syndrome) is significantly increased in case of
Timing of Delivery an elective induction o f labor prior to 37 weeks and

neonatal intensive care hospitalization has been
For twin pregnancies beyond 36 weeks o f gestational
reported m ore frequently. This increase is even greater
age an attem pt has to be m ade to plan the delivery in
in the case o f twins b o m by cesarean section (13% before
such a way that perinatal m ortality and m orbidity
37 weeks com pared to 2% after this term) [LE B ].12
continue to be as low as possible.
Today, one sufficiently powered random ized
Epidemiological studies have shown that the peri
controlled trial (R CT) has dem onstrated that, in
natal death rate o f twins is five to seven times higher
uncom plicated twin pregnancies, elective induction
than that o f singleton pregnancies with the same
O b ste tric I n te r v e n tio n s , ed. P. Joep D orr, V incent M. Khouw , Fran k A. Chervenak, A m os G runebaum , Yves Jacquem yn,
and Jan G. N ijh uis. Published by C am bridge U niversity Press. © C am bridge U niversity Press 2017.
o f labor at 37 weeks versus an expectant m anagem ent 1/817 births was deduced. The reported mortality
results in significantly less adverse neonatal outcom e rate was between 30% and 43%. Actually only eight
without an increased num ber o f com plications. observational studies have been published, which
[LE A 2].13 were analyzed in a recent systematic review/ 15 N o
O ptim um tim ing for delivery in uncom plicated benefit was found supporting cesarean delivery in
m onochorionic twin pregnancies after 35 com pleted pregnancy with non-vertex first twins after 32
weeks o f pregnancy has to be discussed with the weeks and with a birth weight o f >1500 g. These
parents, taking the consequences o f a late intrauterine conclusions pertain to both twins. Considering the
fetal death in these cases into account com pared to Term Breech Trial21 and the lack o f experience in
potential respiratory com plications o f prem ature vaginal breech deliveries in m any centers, it appears
induced delivery [LE B].6’ that currendy an elective cesarean section is the
ru
recommended delivery m ethod o f twins with the
Cesarean Section first fetus in breech presentation [LE D]. In a trans
verse presentation o f the presenting twin, a planned
Indications for Planned Cesarean Delivery cesarean delivery is always indicated.
b.
In twin pregnancies, certain indications for cesarean • Som e authors have proposed elective cesarean
delivery are sim ilar to those am ong singleton delivery in all cases in which at least one o f the
pregnancies and include placenta previa, placental twins has an estim ated birthweight o f <1500 g.
abruption, abnorm al fetal evaluation, breech, and There are no prospective random ized studies.
intrauterine growth restriction.
-li
There is growing evidence in the literature that
there is no indication for a routine policy o f scheduled
cesarean delivery in all twin pregnancies.14-17 The
N um erous observational studies have not been
able to dem onstrate a difference in perinatal
results [LE B ].22-24 Only one study indicates a
significantly better perinatal survival after cesar
ean delivery o f infants with a birthweight of
er
results o f a large random ized multicenter study
(Twin Birth Study) dem onstrated no significant <1000 g [LE B ].25 It can be concluded that the
im provem ent in neonatal outcom e for cesarean sec discussion on whether or not a cesarean delivery
tion after 32 gestational weeks in cases where the should be perform ed on the basis o f the estimated
presenting twin is in a vertex position [LE A 2].18 birthweight is not fully crystallized.
h
Indications for delivering twins in a planned • The gestational age as such is no indication for a
cesarean section are: cesarean delivery and birthweight is more predictive
in terms o f intrapartum complications [LE B ].23’24
• conjoined twins, except in an extremely im m ature
us
delivery [LE D]; • N o study exists that investigates the influence o f

an elective cesarean delivery on the perinatal result
• m onochorionic m onoam niotic twins [LE D ]19;
in the presence o f a weight difference o f >25%
• first twin in breech or transverse presentation.
between the twins. A difference in estimated
[LE D]
weight is currently no indication for a cesarean
ak
delivery [LE C ].25'26

Considerations • A scarred uterus after a cesarean delivery with an
• During labor, in 19% o f cases the first twin is not incision in the lower uterine segm ent from a pre
presenting in a vertex position (non-vertex). vious pregnancy does not im ply an increased risk
Historically, these pregnancies have been resolved o f uterine rupture in a twin pregnancy, com pared
by m eans o f cesarean delivery. This policy is to a singleton pregnancy (90/10 000 deliveries).
inspired by the fear o f being confronted with the The chance o f success in a vaginal delivery lies
between 65% and 85% [LE C ].27
so-called locked twins phenomenon. This occurs
when delivery o f the head o f the first twin is pre
vented by the presenting part o f the second twin
when the body o f the first twin has already been
Vaginal Delivery
delivered. The initial evidence for this comes from a D uring labor, in 81% o f cases the first twin is in vertex
compilation o f 145 case reports, from which an presentation (vertex twin A). In 40?/o to 50% o f cases,
incidence o f locked twins o f between 1/645 and both fetuses are in vertex presentation and in 30% to
C h a p te r 4: D e live ry o f Tw ins
vertex - vertex vertex - breech breech - transverse

40-50% 30-40% 20%
ru
b.
-li
er
Figure 4.1 M ost prevalent com binations o f presentations.
40% o f cases there is a com bination o f vertex twin A such as diabetes or hypertension. At term, malpresen-
and non-vertex twin B (Figure 4 .1).3 tation o f the second twin som etim es is associated with
h
In the literature, vaginal delivery o f sets o f twins the failure o f vaginal delivery [LE B ].30 It seems ad
is (still) universally accepted.3’15-17 But in clinical visable to take these factors into consideration when
reality, it appears that only 50% o f twins are born determ ining the delivery m ode o f term twin
us
spontaneously by vaginal delivery. Epidem iological pregnancies.

research shows that between 40% and 45% o f sets of
twins are born by planned cesarean delivery and 8% Labor and Delivery Management
by assisted vaginal delivery.2
The choice o f a planned cesarean delivery is
in Vaginal Deliveries3,8,31,2
Vaginal delivery o f twins is considered a high-risk
ak
prim arily dictated by the in dication o f increased

risk (RR 1.62) o f perin atal m orbidity for the second birth in terms o f the risk o f peripartal com plications.
child after vaginal delivery. The reported increase Therefore, these deliveries should be conducted in
is independent o f the prelabor lie and chorionicity, centers with adequate infrastructure to react rapidly
but is associated with a long interval between to com plications.
the tw ins (intertw in interval) in a planned vaginal General guidelines for a vaginal delivery o f twins
delivery [LE B ].22'28'29 are as follows:
Since a secondary cesarean delivery has higher • All women pregnant with twins should receive
m aternal and neonatal m orbidity, it is im portant to inform ation about the possible obstetrical atti
select the twin that would be the m ost likely candidate tudes concerning twin delivery.
for vaginal delivery. This m ay also be decided on the • For each wom an who is pregnant with twins there
basis o f the obstetric history. The literature shows that should be an individual plan that anticipates all
the probability o f a successful vaginal delivery possible scenarios during the first (dilatation) and
decreases if antepartum m aternal pathology exists, second (expulsion) stage o f labor.
• The presence o f an experienced gynecologist with the second twin increase as the delivery takes longer.
sufficient assistants, such as a resident or midwife, Lim iting the intertwin tim e interval to less than 15
is o f utm ost importance. m inutes is linked to a significant decrease in the
• An operating room with a surgical team and the num ber o f cases o f low A pgar scores and m etabolic
possibility o f neonatal resuscitation m ust be acidosis, com pared to a time interval o f m ore than 60
available. minutes. 29'34,35 it seem s prudent therefore to lim it
• On adm ission, an ultrasound evaluation o f the the duration o f the intertwin time interval. Recent
fetal position m ust be made. literature recom m ends an intertwin tim e interval o f
• An intravenous line is needed during the dilation a m axim um o f 15 to 30 m inutes [LE C ].3’36
stage. A blood cross-m atch is m ade and blood
m ust be available. Delivery of Vertex-Vertex Twins
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• Fetal heart tones are recorded by cardiotocogra- After the birth o f the first twin, one in every five twins -
phy (CTG ) that is equipped for recording twins. depending on the pregnancy duration - will change its
A s soon as the m em branes o f the presenting twin presentation.23 Therefore, an ultrasound confirm a
are ruptured, a C T G by (scalp) electrode o f the tion o f the presentation o f the second fetus is recom
b.
fetus is recom mended. m ended before the intravenous oxytocin infusion is
• Contraction stim ulation with oxytocin is not started or increased. The uterine activity is evaluated
always necessary during the delivery o f the first manually. Initial pushing takes place with unruptured
infant, but is started after delivery o f the first m em branes. An am niotom y is only perform ed if the
infant to prevent weak contractions.
•
-li
From the time o f complete dilation and until the
delivery o f the second infant a pediatrician must be
present near the delivery room. A resident, midwife,
or a second gynecologist experienced in conducting
head is sufficiently connected to the com pletely
dilated cervix. Owing to com plications, such as um bil
ical cord prolapse or a lack o f engagement progress, in
4% to 10% o f the cases the procedure will change to an
assisted delivery with vacuum or forceps, a cesarean
er
ultrasound examinations and helping in assisted section, o r internal version, followed by breech
vaginal deliveries and cesarean sections must also extraction (Figure 4 .2 ).35,37
be present in the delivery room. It is the aim to have
an anesthesiologist present at the hospital during Delivery of Vertex-Non-vertex Twins
h
the second and third stage o f labor.

Technically, there are various options when perform
• After the birth o f the first infant, the position o f
ing these deliveries:
twin B is determ ined by ultrasound, as well as the
us
• vaginal breech delivery;

location o f the fetal heart. After that, the C T G
registration is continued. • breech extraction (possibly preceded by internal
version in case o f transverse presentation);
• Active m anagem ent o f the third stage o f labor is
pursued during the third phase.
ak
Intertwin Time Interval

There is insufficient evidence in the literature on the
m axim um duration o f the intertwin interval. The
notion that the intertwin time interval should not be
m ore than 30 m inutes is based on a study dating back
to the tim e before the system atic use o f C T G .33 Later
publications do not report an increase in neonatal
com plications in longer intertwin time intervals as
long as fetal heart rate is reassuring.29,34,35 It appears
that with a longer duration o f the intertwin time
interval the risk in a cesarean delivery for the second
twin increases by a factor o f 6 to 8. Studies from recent
years also show that the peripartal com plications for Figure 4.2 Vacuum extraction in case o f prolapsed um bilical cord.
Table 4.1 Non-vertex tw in 2: way o f delivery and neonatal results
N Breech V a g in a l Fetal EC V (N) V a g in a l Fetal C-section

extraction d e liv e ry e m e rg e n cy d e liv e ry (%) e m e rg e n cy ratio
(BE) (N) (%)
Gocke et al.39 96a 55 96 0/55 41 70 16/41 p < 0.001
Wells et al.40 66 43 98 0/43 23 48 11/23 p < 0.001
Chauhan et al.38 44 23 96 0/23 21 52 10/21 p = 0.001
Sm ith et al.41 76 43 97 1/43 33 76 13/33 p = 0.008
Barrett& Ritchie42 206 183 98.8 11/183 23 26+12 (2ary BE) 7/23 p = 0.001
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Total 523 347 12/347 (3.5%) 176 57/176(32%) p < 0.001
p < 0.001
3 The publication also includes the study o f w om en with a planned cesarean delivery. This subgroup was not included in the table.
b.
BE = breech extraction.
• external cephalic version (ECV) and vaginal deliv The presentation o f the fetus is determ ined by
•
ery in vertex presentation;
cesarean delivery o f the second twin. -li
After a breech extraction, as confirm ed in several
studies, m ore infants are delivered vaginally than
ultrasound prior to the extraction. The fetal breech
and the position o f the feet and o f the fetal back
should be clearly identified.
In order to rotate a transverse or non-engaging
er
after ECV. This is not linked to a greater risk o f fetal vertex presentation internally into a breech presen
em ergency (Table 4.1). For this reason, breech extrac tation and then to proceed with a breech extraction,
tion is preferred with regard to vaginal delivery in this one hand is entered into the uterus along the ante
rior side o f the fetal abdom en. T hrough the u n ru p
situation [LE B ],38-44
A com bined vaginal delivery (twin A) and cesar tured m em branes, one or both feet are grasp ed at the
h
ean section (twin B) has the greatest risk o f perinatal level o f the ankle and guided with m ild traction
asphyxia, defined as an A pgar score o f <4 after 5 through the cervix to the pelvic outlet. At the sam e
minutes. This was determ ined in com parison with a tim e, the obstetrician’s external hand m ay be able to
us
vaginal delivery o f both infants and in com parison su p port the rotation o f the body. A s soon as the fetus
with a planned cesarean delivery. Therefore, it is best is in a longitudinal lie and the feet are at the level o f
to avoid this situation [LE c ].22,37,44 At centers with the vulva, the m em branes are ruptured m anually.
insufficient experience in vaginal breech delivery or A fter that the breech extraction takes place (see
breech extraction, it is best to handle these pregnan Ch apter 6 ).
ak
cies by planned cesarean section or to refer them to

another m edical center [LE D], Specific Situations
The techniques o f external version and breech
extraction do not differ from the techniques used in Monochorionic Diamniotic Twins
single births and are described in Chapters 5 and 6. In the absence o f specific complications such as a twin-
Internal version and extraction are reserved in to-twin transfusion syndrome (TTTS), the manner o f
m odern-day obstetrics for the delivery o f the second delivery does not differ between monochorionic and
twin and for som e cases o f cesarean delivery (see dichorionic twins. The above-indicated problem s of
A nim ation 4.2). This procedure can be perform ed fetal presentation determine the procedure.45,46
on the condition that the cervix is com pletely effaced The mode o f delivery in monochorionic diamniotic
and dilated and that the presenting part has not (MCBA) pregnancies complicated by TTTS has to be
engaged yet. A dequate anesthesia (epidural, m idazo evaluated case by case. Yet, in the absence o f complica
lam , or general anesthesia) is also necessary. tions after laser treatment, planned delivery is
recommended from 34 weeks and no later than 37 following head o f the first twin can enter the pelvis,
weeks [LE C ].8 which can then be born by means o f the necessary
maneuvers or by forceps extraction. Zavanelli’s m aneu
Monoamniotic Twins ver followed by an emergency cesarean section has also
been reported.
Delivery with a planned cesarean section between 32
and 34 weeks is recom m ended [LE B ].47-49
Important Points and
Acute Intrapartum Tocolysis Recommendations
If uterine relaxation is needed to perform a breech • The average gestation period o f a twin pregnancy
extraction or other maneuvers, general anesthesia with is 3 6 .7 weeks [LE B].
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short-term administration o f anesthetic gases can be
• If spontaneous labor is delayed, the delivery o f
used. As an alternative, intravenous administration of
twins can be discussed with the parents as from
nitroglycerin can be used. The dose is 0.1 to 0.2 m g per
3 7 weeks but should not be postponed beyond 38
10 kg body weight and rarely leads to a serious decrease
weeks [LE A2],
in blood pressure in the mother.50 The clinical experi
b.
• The delivery will be by planned cesarean section in
ence reports that the use o f ritodrine or atosiban is
the following situations (Figure 4.4):
equally effective, but usage o f these agents is not expli-
cidy mentioned in the literature; ritodrine is no longer - Non-vertex presentation o f the presenting
available. fetus [LE B];
Locked Twin -li

As mentioned above, the locked twin phenomenon
is primarily known from historical publications
- Non-vertex presentation o f one o f the twins if a
gynecologist with experience in vaginal breech
deliveries and breech extraction is not available
[LE C];
er
- m onochorionic m onoam niotic twins [LE B];
(Figure 4.3). In this unusual situation, the diagnosis is
- conjoined twins [LEC];
made during the expulsion stage. The techniques are
- obstetric reasons (placenta previa, fetal em er
used after stopping the oxytocics and under acute toco
gency on the C TG , T T T S, etc.);
lysis. In practice, an attempt is made to push the head o f
- maternal contraindications for a vaginal
h
the second twin up and out o f the pelvis, so that the

delivery.
us
ak
Figure 4.3 Locked twins.

ru
b.
-li
Figure 4.4 Delivery o f dichorionic diam niotic or m onochorionic diam niotic twins.
er
All other sets o f twins can (in anticipation o f the References
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1 L oos RJF, D erom C, Eeckels R, et al. Length o f gestation
nally, provided enough experienced personnel are and birthw eight in dizygotic twins. Lancet.
present [LE B]. 2001;358:560-1.
In a planned vaginal delivery, the presence o f
h
2 Breart G, Barros H , W agener Y, et al. C haracteristics o f

personnel with experience in vaginal twin deliv the childbearing population in Europe. Eur J Obstet
ery, vaginal breech delivery, and breech extraction Gynecol Reprod Biol. 2 0 0 3 ;lll:S 4 5 - 5 2 .
us
is m andatory [LE B ]. 3 C ruikshank DP. Intrapartum m anagem ent o f twin

After the birth o f the first infant and ultrasound gestations. O bstet Gynecol. 2007;109:1167-76.
m onitoring o f the fetal position, intravenous oxy- 4 Cheung YB, Yip P, Karlberg L. M ortality o f twins and
tocics are adm inistered in order to lim it the inter singletons by gestational age: a varying-coefficient
twin time interval to less than 30 m inutes [LE B]. approach. A m J Epidem iol. 2000;152:1107-16.
If the second child is in a longitudinal lie (vertex or 5 Lee YM , Wylie B, Sim pson L, D ’Alton M E. Twin
ak
breech), a spontaneous delivery is attempted [LE B]. chorionicity and the risk o f stillbirth. O bstet Gynecol.
2008;111:301-8.
In the case o f a lack o f progress in the delivery o f
6 H ack KE, D erks JB, Elias SG , et al. Increased perinatal
the second twin in breech position, a breech
m ortality and m orbidity in m onochorionic versus
extraction - in experienced hands - is the best
dichorionic twin pregnancies: clinical im plications o f a
delivery m ethod [LE B], large D utch cohort study. BJO G . 2008;115:58-67.
If the second twin is in a transverse position, breech 7 V ergani P, Russo FM , Follesa I, et al. Perinatal
extraction, preceded by internal version - in experi com plications in twin pregnancies after 34 weeks: etfects
enced hands - is the best delivery method for the o f gestational age at delivery and chorionicity. A m J
second twin in non-vertex presentation [LE B]. Perinatol. 2013;30(7):545-50.
Active m anagem ent is practiced during the third 8 V ayssiere C, Benoist G, Blondel B, et al. Twin
stage. Im m ediately after the birth o f the second pregnancies: guidelines for clinical practice from the
twin (intravenous or intram uscular) oxytocin French College o f Gynaecologists and O bstetricians
(C N G O F). Eur J Obstet Gynecol Reprod Biol.
m ust be adm inistered to the m other [LE B].
2 0 1 1;156( 1): 12—17. D OI: 10.1016/j.ejogrb.2010.12.045
S e ctio n 3: P a th o lo g y o f L a b o r a n d La b o r a n d D e live ry
9 H ack K E , D erks JB , E lias SG , et al Perinatal m ortality 23 A rm son BA , O ’Connell C , Persa V , et al. D eterm inants
an d m ode o f delivery in m on och orion ic d iam n iotic o f perinatal m ortality and serious m orbidity in the
twin pregn an cies >32 w eeks o f gestation : a secon d twin. O bstet Gynecol. 2006;108:556-64.
m ulticen ter retrosp ective coh ort study. BJO G , 24 Z hang J, Bow es W A Jr, G rey TW , et al. Tw in delivery
2 011;118:1090-7. an d neonatal an d infant m ortality: a population -based
10 Breathnach FM , McAulifFe FM , G eary M , et al. study. O bstet Gynecol. 1996;88:593-8.
O ptim um tim ing for planned delivery o f
25 G in sberg N A , Levine EM . D elivery o f the second twin.
uncom plicated m onochorionic and dichorionic twin
Int J G ynaecol O bstet. 2005;91:217-20.
pregnancies. O bstet Gynecol. 2012;119:50-9.
26 A m aru R C , B ush M C , Berkow itz RL, et al. Is
11 Sullivan AE, H opkins PN , H soin-Y i W , et al. Delivery
d isco rd an t grow th in tw ins an in depen den t risk factor
o f m onochorionic diam niotic twins in the absence o f
fo r adverse n eon atal ou tcom e? O b stet G ynecol.
com plications: analysis o f neonatal outcom e and costs.
ru
2 0 0 4;103:71-6.
Am J O bstet Gynecol. 2012;206:257el-7,
27 Ford AA, B atem an BT , Sim pson L. V agin al birth after
12 Bakr A F, K arko u r T. W hat is the op tim al gestation al
cesarean delivery in twin gestations: a large, nationw ide
age for twin delivery. B M C Pregnancy Childbirth.
sam ple o f deliveries. A m J O bstet Gynecol.
2006;6:3.
2006;195(4): 1138-42.
b.
13 D o d d JM , Crow ther CA , H aslam RR, R obinson JD S;
28 Y an g Q , W alker M C , C h en X K , et al. Im p a c ts o f
Tw ins T im in g o f Birth Study group. Elective birth at 37
operativ e delivery fo r the first twin on n eon atal
w eeks o f gestation versus stan dard care for w om en with
o u tco m es in the seco n d twin. A m J Perinatol.
an uncom plicated twin pregnancy near term : the Tw ins
2 0 0 6 ;2 3 (7 ):3 8 1 -6 .
T im in g o f Birth R andom ized Trial. BJO G . 2012;
29 E d ris F, O p pen h eim er L, Y an g Q , et al. R elatio n sh ip
119:964-73.
Clin O bstet Gynecol. 2006;49:154-66.

-li
14 C arroll M A, Y eom ans ER. V aginal delivery o f twins.
15 R o ssi A C , M u llin PM , C h m ait RH . N eon atal

30
betw een intertw in delivery in terval an d m etab olic
ac id o sis in the seco n d twin. A m J Perinatol.
2 0 0 6 ;2 3 (8 ):4 8 1 -5 .
W en SW , Fung Kee Fung K, O ppenheim er L, et al.
er
ou tcom es o f tw ins accord in g to birth order,
N eonatal m ortality in secon d twin according to cause o f
presen tatio n an d m o d e o f delivery: a system atic
death, gestational age, and m ode o f delivery. A m J
review an d m eta-an alysis. B JO G . 2011;118
O bstet Gynecol. 2004;191(3):778-83.
(5 ):5 2 3 -3 2 .
31 Barrett J, Bocking A. The SO G C C on sen sus Statem ent:
16 H o fm ey r G J, B arrett JF , C row th er CA . Plann ed
m anagem ent o f twin pregnancies. Part 2. J Soc O bstet
h
caesarean section fo r w om en w ith a twin

Gynecol C an. 2000;22:623.
pregn an cy. C och ran e D atab ase Syst Rev. 2011;12:
C D 006553. 32 R obinson C, C h auh an SP. Intrapartum m anagem ent o f
twins. Clin O bstet Gynaecol. 2004;47:248-62.
us
17 Vendetelli F, Riviere O, Crenn-H ebert C, et al. Is a

planned cesarean necessary in twin pregnancies? A cta 33 Rayburn W F, Lavin JP Jr, M iodovn ik M , et al. M ultiple
O bstet Gynecol Scand. 2011;90:1147-58. gestation: tim e interval between delivery o f first and
second twins. O bstet Gynecol. 1984;63:502-5.
18 Barrett JFR, H annah M E, H utton EK, et al. Tw in Birth
Study Collaborative G roup: a random ized trial o f 34 Brow n H L, M iller JM Jr, N eum an n D E, et al. U m bilical
planned cesarean o r vaginal delivery for twin cord b lood gas assessm en t o f twins. O bstet Gynecol
1990;75:826-9.
ak
pregnancy. N Engl J M ed. 2013;369:1295-305.

19 Griffith H B. M onoam niotic twin pregnancy. B r J Clin 35 Stein W, M isselw itz B, Schm idt S. Tw in-to-twin
Pract. 1996;40:294-7. delivery tim e interval: influencing factors and effect on
short-term outcom e o f the second twin. Acta Obstet
20 Steins B isschop C N , V ogelvang TE, M ay AM ,
Gynecol Scand. 2008;87:346-53.
Schuitem aker NW . M ode o f delivery in non-cephalic
presenting twins: a system atic review. A rch Gynecol 36 Sentilhes L, Bonh ours A C , B iqu ard F, et al. M ode
Obstet. 2 0 12;286(l):237-47. d ’accouchem ent des grosses gem ellaires. Gynecol
21 H annah M E, H annah W J, Hew son SA , et al. Planned O bstet Fertil. 2009;37:432-41.
caesarean section versus planned vaginal birth for 37 U sta IM , N assar A H , Awwad JT , et al. C om p arison o f
breech presentation at term: a ran dom ised m ulticentre the perinatal m orbidity and m ortality o f the presenting
trial. Lancet. 2000;356:1375-83. twin an d its co-twin. J Perinatol. 2002;22:391-6.
22 Sch m itz T , de C arn avalet C , A zria E, et al. N eo n atal 38 C h auh an SP, Roberts W E, M cLaren RA, et al. Delivery
ou tcom es o f twin p regn an cy acco rd in g to the o f the nonvertex second twin: breech extraction versus
plan n ed m ode o f delivery. O b stet Gynecol. external cephalic version. A m J O bstet Gynecol.
2008;111 :6 9 5 -7 0 3 . 1995;173:1015-20.
C h a p te r 4: D e liv e ry o f Tw in s
39 G ocke SE, N ageotte M P, G arite T, et al. M anagem ent o f 45 B agh dadi S, Gee H, W hittle M J. Twin pregnancy
the nonvertex second twin: prim ary cesarean section, outcom e and chorionicity. A cta O bstet Gynecol Scand.
external version, or prim ary breech extraction. A m J 2003;82:18-21.
O bstet Gynecol. 1989;161:111-14. 46 Sau A, C halm ers S, Shennan A H , et al.
40 W ells SR, T h orp JM Jr, Bow es W A Jr. M anagem ent o f V aginal delivery can be considered in
the nonvertex secon d twin. Surg Gynecol Obstet. m onochorionic diam niotic twins. BJO G .
1991;172:383-5. 2006;113:602-4.
41 Sm ith SJ, Zebrow itz J, Latta RA. M ethod o f delivery o f 47 Riethm uller D , Lantheaum e S, Teffaud O , et al.
the nonvertex secon d twin: a com m unity hospital [O bstetrical an d neonatal progn osis o f m onoam niotic
experience. J M atern Fetal M ed. 1997;6:146-50. twin gestations.] J Gynecol O bstet Biol Reprod (Paris).
42 Barrett JF, Ritchie W K. Tw in delivery. Best Pract Res 2004;33(7):632-6.
ru
Clin O bstet Gynaecol. 2002;16:43-56. 48 Sau AK, Langford K, Elliott C, et al. M onoam niotic
43 R abinovici J, B arkai G, Reichm ann B, et al. Internal twins, what should be the optim al antenatal
podalic version with un ruptured m em branes for the m anagem ent. Tw in Res. 2003;6:270-4.
secon d twin in transverse lie. O bstet Gynecol. 49 Kurzel RB. Tw in entanglem ent revisited. Tw in Res.
1988;71:428-30. 1998;1(3): 138-41.
b.
44 Caukw ell S, M urphy D J. The effect o f m ode o f 50 D ufour P, V inatyier D, V anderstichele S, et al.
delivery and gestational age on n eonatal outcom e o f the Intravenous nitroglycerin for internal podalic version
non-cephalic-presenting second twin. A m J Obstet o f the second twin in transverse lie. O bstet Gynecol.
Gynecol. 2002;187:1356-61. 1998;92:416-19.
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99
Chapter
External Cephalic Version
E. Roets, M. Hanssens, and M. Kok
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General Information no general con sen su s on the eligibility o f patients for
external cephalic version, and p rop osed to lim it
Introduction contraindications to clear em pirical evidence or to
a clear pathoph ysiological relevance. The prop osed
External cephalic version (EC V ) or external
b.
list o f contraindications is all based on level
rotation refers to the ab dom in al m an ipulation o f
D evidence6:
the fetus from a transverse, oblique, or breech
• placental abruption in history or signs o f placental
p resentation to a cephalic presentation. D uring
abruption;
recent years, especially since the publication o f
-li
the T erm Breech T rial, there has been a tendency
in breech presentation s to deliver by cesarean
section in order to dim inish direct fetal com plica
tions associated with vaginal breech delivery.1
• severe preeclam psia or H ELLP syndrom e;
• signs o f fetal distress (abnorm al C T G and/or
abnorm al D oppler flow).
The following factors are not contraindications in so
er
T hrough ECV , an attem pt is m ade to reduce the m any words, but they m ay influence the success rate
incidence o f term breech presentation s, resultin g o f an external cephalic version procedure to a greater
in a decreased num ber o f cesarean deliveries due or lesser extent. The following division between
to breech presentation s. Since the num ber o f m aternal and fetal factors is som ewhat artificial,
cesarean sections in breech p resentation is on the since som e factors cannot be classified sim ply under
h
increase, E C V is gainin g in im portance. one or the other (e.g., am niotic fluid quantity).
Maternal Factors
Prevalence and Success Rate
us
A pproxim ately 3% to 4% o f term fetuses (and • Uterine tonicity: The extent to which the uterus is
a larger prop ortion o f preterm fetuses) present relaxed will increase the success rate o f EC V (OR
in breech presentation. The success rate o f EC V 1.8, 95% C l 1.2-2.9) [LE A l ].7
differs drastically depending on who is doing the • Multiparity: This is closely related to uterine ton
reporting, and varies between 29% and 97%.2 icity: a m ultiparous uterus is often m ore relaxed
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The m ost recent m eta-analysis included 84 studies (O R 2.5, 95% C l 2.3-2.8) [LE A l ].8
and reported a success rate o f 16-100% (95% C l • Nature o f the abdominal wall (obesity - muscle
56 -5 7 ) [LE A l ].3 tone): These are factors that influence the ease of
palpability o f the fetus. Obesity lessens the success
Contraindications and Factors rate o f ECV (OR 1.8 in the absence o f obesity, 95%
C l 1.2-2.6) [LE A'l]. Also with increasing muscular
Influencing ECV tone o f the abdominal wall muscles (in case of
There are several opinions on the question o f whether maternal anxiety or stress) the fetus is more difficult
a particular factor constitutes a contraindication for to manipulate, which will lower the success rate of
ECV. A recent review on this topic showed there is version [LE D],
O b stetric In te rv e n tio n s , ed. P. Joep D orr, V incent M. Khouw, Frank A. Chervenak, A m os G runebaum , Yves Jacquem yn,
C h a p te r 5: External C e p h a lic V ersio n
• Ethnicity: In African wom en the presenting part Technique

engages later in the pelvic inlet than in C aucasian
women. This increases the probability o f success Technical Execution of ECV2,12-14
(see Section: Fetal factors [engagem ent o f the pre
In advance o f an ECV, cardiotocography and
senting part]).9
a (repeated) ultrasonography (to determ ine the p osi
tion o f the fetal spine) should be perform ed.
Fetal Factors
External cephalic version o f the fetus is achieved
• Am niotic flu id quantity: A lthough not statisti by subjecting the infant to a som ersault. This can be
cally significant, there appears to be a greater a forw ard roll or a back flip. The pregnant woman is
probability o f success o f EC V in the clinical p res placed in a supine position.
ru
ence o f a sufficient quantity o f am niotic fluid.10 It is easiest to turn a fetus that is lying with its
In an ultrasoun d evaluation, an A m niotic back to the side (left or right). A fetus with the back
F luid Index (A FI) >10 leads to a greater p ro b forw ard is preferably first turned to a side-lying
ability o f success o f the EC V (O R 1.8, 95% C l p osition . N ext, the follow ing m aneuvers are
1.5-2.1) [LE A l ].11 applied:
b.
• P alpability o f (the head of) the fetus: T o the • Forward roll (see Animation 5.1)
extent that the fetal head is m ore easily p alp
- The fetal buttocks are lifted out o f the pelvis
able, the probability o f su ccess o f an ECV
and pushed with one hand to the side (the side
in creases (O R 6.3, 95% C l 4 .3 -9 .2 ) [LE A l ].8
o f the fetal back) and gently cranially
-li
N aturally, this is related in part to the uterine
tonicity, but also to m aternal obesity and
ab do m in al wall m u scu lar tonicity (see Section:
M aternal facto rs [uterine tonicity and nature
-
(Figure 5.1).
W ith the other hand, the fetal head is brought
into flexion, so that the head and the buttocks
are encom passed by both hands (Figure 5.2).
er
o f the ab do m in al w all]). The p osition o f the
- The head is pressed gently contralaterally (the
placen ta also determ ines the palpability o f
side o f the fetal abdom en) and gently caudally
the fetus: a p osteriorly located placen ta is
(Figure 5.3).
related to a greater probability o f success (O R
1.9, 95% C l 1.5-2.4) than an an terior placenta
h
or a fundally located placen ta [LE A l ] .11

• Engagement o f the presenting part: The probability
o f success increases if the presenting part has not
us
engaged (O R 9.4, 95% C l 6.3-14) [LE A l ].8

• N ature o f the breech presentation: Com plete breech
presentation (complete breech: hips and knees in
flexion) has a greater probability o f success with
EC V than incom plete breech (frank breech: hips in
ak
flexion, knees in extension) (O R 1.8, 95% C l

1.1-1.7) [LE A l ].11
• Fetal weight: Experienced practitioners agree that
a fetus o f >4000 g is m ore difficult to turn than
a fetus o f <3000 g. However, no specific cut-off
values are available on this [LE D],
Operator-Related Factors
Although it has never been the subject o f
a random ized study, it seem s logical that ECV has
a greater chance o f success if perform ed by an experi
enced practitioner [LE D], Figure 5.1 Mobilization o f the buttocks.
Section 3: P a th o lo g y o f La b o r a n d La b o r a n d D e live ry
ru
b.
Figure 5.2 Head is brought into flexion. -li Figure 5.3 Forward roll.
h er
us
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Figure 5.5 Head is brought into flexion.

Figure 5.4 M obilization o f the buttocks.
- With the other hand, the fetal head is brought

• B ackflip (see Animation 5.2)
into flexion, so that the head and the buttocks
- The fetal buttocks are lifted out o f the pelvis are encom passed by both hands (Figure 5.5).
and pushed with one hand to the side (the - The head is pressed gently contralaterally (the
side o f the fetal abdom en) and gently cra- side o f the fetal back) and gendy caudally
nially (Figure 5.4). (Figure 5.6).
C h a p te r 5: External C e p h a lic V ersion
ru
b.
Figure 5.7 Switching hands.
Figure 5.6 Back flip. -li

er
W hen a tran sverse p osition is achieved in this double-blind, placebo-controlled study with 310
m anner, it is recom m en ded to pau se a m om ent patients, the administration o f oral nifedipine did
and hold the fetus in this p osition . A t this p oin t an not prove to lead to more success in attempted ECV
assistan t can hold the fetus stable, so that the op era (RR 1.1, 95% C l 0.85-1.5) [LE A l ].17
tor can switch h an ds (Figure 5.7). • Epidural/spinal analgesia: A significantly higher
h
Frequently, the rest o f the version is enacted chance o f success is reported in a Cochrane review
“ alm ost spontaneously” by the fetus, provided it is with the use o f epidural, but not with spinal
properly guided. analgesia [LE A l ].16 Still, we have to warn against
us
The entire procedure is perform ed with jerking the possible danger o f using too much force when
(intermittent) m otions. It is im portant not to use using epidural analgesia, since the pain sensation
excessive force. The m ovem ents can best be per o f the m other is elim inated.2 Additionally, the
form ed by ballottem ent, i.e., with alternating pressure risks and extra cost o f this type o f analgesia m ust
between the head and the buttocks [LE D]. be taken into consideration.
ak
A m axim um o f three attem pts is recom m ended A s for other m ethods, such as the use o f vibroa-
[L E D ].15 coustic stim ulation or am nioinfusion, there is insuffi
It is especially im portant to provide am ple expla cient evidence in term s o f practical recom m endations.
nation to the pregnant wom an and try to provide
m axim um m aternal relaxation through reassurance.
Timing
The success rate o f ECV is evidently larger when
Measures for Increasing the Success Rate perform ed earlier during the pregnancy (smaller
• Tocolysis: The use o f betamimetics is associated with fetus, less chance o f engaging). However, in case o f
an increased chance o f success o f an ECV attempt com plications such as ruptured m em branes or
(OR 0.74 for failure with the use o f betamimetics; placental abruption the consequences for the neonate
95% C l 0.64-0.87) [LE A l ].16 Blinding is not are greater due to preterm delivery. A random ized
practical in these types o f studies. In a randomized, trial reporting on 1543 women random ly assigned to
having a first ECV procedure between the gestational that this is not associated with an inferior perinatal
ages o f 34(0/7) and 35(6/7) weeks o f gestation (early result and is therefore irrelevant to clinical practice
ECV) or at or after 37(0/7) weeks o f gestation (delayed [LE B ].20 In the above-mentioned meta-analysis,
ECV group) showed fewer fetuses in a non-cephalic umbilical cord prolapse was studied in five clinical
presentation at birth in the early ECV group (41.1%) trials; it occurred in eight cases (0.06%) [LE A l ].3
versus (49.1%) in the delayed ECV group (RR 0.84, • CTG changes: Transitory changes in the heartbeat
95% C l 0.75, 0.94, p = 0.002). There were no differ pattern occur in 4% o f the cases o f term ECV
ences in rates o f C-section (52.0% versus 56.0%) (RR [LE B ].2 This especially concerns bradycardia or
0.93, 95% C l 0.85, 1.02, p = 0.12) or in risk o f preterm decelerations, which disappear after stopping the
birth (6.5% versus 4.4%) (RR 1.48, 95% C l 0.97, 2.26, m anipulation. The aforem entioned m eta-analysis
p = 0.07) in early versus delayed ECV. It was reports an abnorm al C T G pattern in 6.1% (95% C l
ru
concluded that ECV at 34-35 weeks versus 37 or 5.7-6.5) o f the version attem pts, which led to an
m ore weeks o f gestation increases the likelihood o f emergency C-section in 0.2% (95% C l 0.1-0.3) of
cephalic presentation at birth but does not reduce the the cases.3 The end result in all o f these cases was
rate o f cesarean section and m ay increase the rate o f good.
preterm birth [LE A l ].18
b.
• Fetomaternal transfusion: In a review on ECV-
There is no upper time lim it on the appropriate related risks, seven studies were found in which a
gestation for ECV. Successes have been reported at 42 Kleihauer test was performed [LE A l ].14 Significant
weeks o f gestation and can be perform ed in early labor fetomaternal transfusion was found in 3.7%, but
provided that the m em branes are intact [LE C ].19 massive fetal hemorrhage was not reported.
Complications
During/Soon After ECV
-li • Other complications: Other reported complications
are limited to case reports and they are rare. There
are two known cases o f spinal cord trauma, one of
which had a fatal outcome (1978) and the other one
er
had a complete neurological recovery.2,21 This
ECV is a safe procedure. Nevertheless, (rare) com pli could be caused by traction on the fetal spinal
cations such as fetal death have been reported. cord when the head is abruptly m oved from hyper
Transitory changes in the heartbeat pattern, abruptio extension to flexion. For that reason, despite little
placentae, fetomaternal transfusion, and umbilical
h
evidence, hyperextension o f the fetal head is

cord accidents constitute the m ore frequently considered to be a contraindication for attempted
m entioned com plications. version. One case o f ECV-related hip fracture is
In a m eta-analysis with 12 955 versions,
us
known.19
a com plication ratio o f 6.1% (95% C l 4.7-7.8) was
found, including 0.24% serious com plications (95%
C l 0.17-0.34) and 0.35% emergency C-sections (95% In a Vaginal Delivery After Successful ECV
C l 0.26-0.47). Com plications were not related to the
Patients who underwent successful EC V still appear
result o f the version (O R 1.2, 95% C l 0.93-1.7).3
to have an increased susceptibility to cesarean section.
ak
• Fetal death and placental abruption: In the m eta In a m eta-analysis o f 11 studies there was a C-section
analysis o f Grootscholten et al. fetal death and rate o f 21% in the post-EC V group versus 11% in
placenta detachment are defined as serious m em bers o f the control group. The com bined relative
com plications.3 Only 2 out o f the 12 (0.09%) fetal risks (95% C l) were 2.21 (1.64-2.97) for dystocia
deaths in a total o f 12 955 version attem pts were and 2.16 (1.62-2.88) for threatened fetal well-being
attributed to the (attempted) ECV. Abruptio [LE B ].22 The incidence o f assisted delivery also
placentae occurred in 11 cases (0.08%), which is rem ains high: OR 1.37 (1.11-1.68) [LE B ].23
not significantly different from a norm al term Possible explanations for this are an anom alous
population. m aternal pelvic shape (predisposing for breech pres
• Umbilical cord accidents: In several studies, umbili entation) or factors inherent to the fetus in breech
cal cord entwinement is reported as a complication presentation (other configuration o f the head, lower
o f ECV. But it appears from a large cohort study birthweight, lower fetoplacental ratio).22,23
C h a p te r 5: External C e p h a lic V ersio n
Table 5.1 Success rate o f ECV varies according to a num ber of

Measures for Preventing Complications variables
Based on the foregoing, several recom m endations can
D ecreases th e ch a n ce Increases th e ch a n ce
be m ade for keeping the chance o f com plications as
o f success o f success
small as possible:
• preceding ultrasound: to confirm position and Maternal
Term Preterm
rule out the existence o f hyperextension o f the Strong uterine tonicity Slight uterine tonicity
fetal head; Primigravida Multigravida
Obesity Bodyweight <65 kg
• preceding CTG : to discover already existing fetal
Tense abdom inal wall Relaxed abdom inal wall
heart arrhythmias; Caucasian African
• adm inistration o f anti-D im m unoglobulin to
ru
Fetal
rhesus D negative pregnant women; Incomplete breech Com plete breech
• quantification o f possible fetom aternal tran sfu Anterior placenta Posterior placenta
Com plete engagem ent No engagem ent
sion with the K leih au er-B etke test has not
Decreased am niotic fluid Normal am niotic fluid
been proven effective in preventing com plica >4000 g <3000 g
b.
tions; it is, however, inform ative on the ap p ro x i
m ately 4% o f the cases with fetom aternal
tran sfu sion .
• post-version cardiotocography and m onitoring com plication s. In 0.4% (95% C l 0.3 -0 .5 ) o f all
fetal m ovem ents during the first days. versions an em ergency cesarean section m ust be

Recommendations
-li perform ed due to alleged fetal distress. With
each EC V the follow ing m easures can be taken
to increase the chance o f success and to decrease
the chance o f com plications:
er
- preceding ultrasound;
• Breech presentation occurs in 3% to 4% o f term
- preceding CTG;
pregnancies, and even m ore in preterm.
- adm inistration o f betam im etics [LE A l];
• Owing to the increasing num ber o f cesarean sec
- ad m in istration o f anti-D gam m aglobulin in
tions for term breech presentations and the low
h
rhesus D negative w om en, in d oses dictated

com plication risk o f an ECV, an attem pt at ECV
by the result o f the K leih auer-B etke test.
m ust be proposed to every pregnant wom an with
In Flanders and the N etherlands they
a fetus in breech presentation in the absence o f
us
ad m in ister such a high dose o f anti-D that

absolute contraindications [LE A l].
you have to ask y ou rself if the system atic
• After a successful ECV, the chance o f a cesarean
q uantification o f fetom aternal tran sfu sion is
section and/or assisted delivery is still higher than
actually worthwhile.
for pregnancies with a fetus in “spontaneous
- post-version cardiotocography and m onitor
cephalic presentation” [LE B],
ak
ing fetal movem ents during the first days.

• For a trained practitioner, the success rate o f ECV
is around 50% [LE B], The success rate can be
individualized for the patient by taking into
account the variables in Table 5.1. References
• An ECV is effective in reducing the num ber 1 H annah M E, H annah W J, Hewson SA, et al; Term
Breech Trial Collaborative G roup. Planned cesarean
o f term breech presentations starting at 34 weeks
section versus planned vaginal birth for breech
o f gestation [LE A l]. Before 36 weeks there seems presentation at term: a random ised m ulticentre trial.
however a slightly higher risk o f preterm delivery Lancet. 2000;356:1375-83.
with no difference in cesarean deliveries com pared
2 H anssens M, Claerhout F, C orrem ans A, et al. Beleid en
to EC V after 36 weeks [LE A l]. techniek bij uitw endige kering. In: Slager E,
• EC V is a safe procedure, with few significant Fauser BCJM , D evroey P, et al. (ed). Infertiliteit,
com plication s [LE A l]. W om en m ust be gynaecologie en obstetrie anno 2001 (N ederland) -
in form ed of the (rare) p ossibility of C on gress Proceedings, 2001:300-7.
3 G rootscholten K, K ok M, Oei SG, et al. External 13 Percival R. O bstetric operations. In: Percival R (ed).
cephalic version-related risks: a m eta-analysis. Obstet H olland & Brew s’ m anual o f obstetrics. 14th edition.
Gynecol. 2008;112(5):1143-51. Edinburgh: Churchill Livingstone, 1980:614-740.
4 Feitsm a A H , M iddeldorp JM , Oepkes D. De uitwendige 14 C ollaris RJ, O ei SG . External cephalic version:
versie bij de aterm e stuit: een inventariserend a safe procedure? A system atic review o f
onderzoek. N ed Tijdschr O bstet Gynaecol. version -related risks. A cta O bstet G ynecol Scand.
2007;120:4-7. 20 0 4;83(6):511-18.
5 K ok M , van der Steeg JW, M ol BW , et al. W hich factors 15 W H O . The W H O R eproductive Health Library. 1997;8.
play a role in clinical decision-m aking in external h ttp://apps.w ho.int/rhl/archives/cd000083_leder_
cephalic version? Acta Obstet Gynecol Scand. com /en/
2 008;8 7 (l):3 1 -5 .
16 H ofm eyr GJ, Gyte GM L. Interventions to help external
6 R osm an A N , Guijt A, V lem m ix F, et al. cephalic version for breech presentation at term.
ru
C ontraindications for external cephalic version in Cochrane D atabase Syst Rev. 2004;1:CD 000184.
breech position at term: a system atic review. Acta 17 K ok M, B ais JM , van Lith JM , et al. N ifedipin e as
Obstet Gynecol Scand. 2013;92(2):137-42. uterine relaxant for external cephalic version:
7 Hutton EK, H ofm eyr GJ. External cephalic version for a ran dom ized con trolled trial. O bstet Gynecol.
breech presentation before term. Cochrane D atabase 2 0 0 8 ;1 1 2 (2 P tl):2 7 1 -6 .
b.
Syst Rev. 2006;1:CD 000084. 18 H utton EK, H annah M E, R oss SJ, et al. Early ECV 2
8 K ok M, C n ossen J, Gravendeel L, et al. Clinical Trial C ollaborative G roup. The Early External Cephalic
factors to predict the outcom e o f external cephalic V ersion (E C V ) 2 Trial: an international m ulticentre
version: a m eta-analysis. Am J O bstet Gynecol. ran dom ised controlled trial o f tim ing o f EC V for
9
2008;199(6):630.el-7.
-li
Briggs N D . Engagem ent o f the fetal head in the negro
prim igravida. Br J Obstet Gynaecol. 1981 ;S 8 (1 1):
1086-9.
19
20
breech pregnancies. BJO G . 2011;118(5):564-77.
Ferguson JE, D yson D C . Intrapartum external cephalic
version. A m J O bstet Gynecol. 1985;152:297-8.
Sheiner E, A bram ow icz JS, Levy A, et al. N uchal cord is
er
10 H aas D M , M agann EF. External cephalic version with not associated with adverse perinatal outcom e. Arch
an am niotic fluid index < or = 10: a system atic review. Gynecol Obstet. 2006;274(2):81-3.
J M atern Fetal N eonatal M ed. 2005;18(4):249-52. 21 C h apm an GP, W eller RO, N orm an d IC, et al. Spinal
11 K ok M, C nossen J, Gravendeel L, et al. U ltrasound cord transsection in utero. Br M ed J. 1978;2:398.
factors to predict the outcom e o f external cephalic 22 de H undt M , Velzel J, de G root C J, et al. M ode o f
h
version: a m eta-analysis. U ltrasoun d O bstet Gynecol. delivery after successful external cephalic version:
2009;33(1):76~84. a system atic review and m eta-analysis. O bstet Gynecol.
12 Rovinsky JJ. Abnormalities o f position, lie, presentation 2014;123:1327-34.
us
and rotation. In: Kaminetsky HA, Iffy L (eds). Principles 23 C orrem ans A, H an ssen s M, G abriels K. A rbeid en
and practice o f obstetrics and perinatology. 1st edition. bevalling na een geslaagde uitw endige kering a terme.
New Y o rk John Wiley & Sons, 1981: Chapter 49. Gunaekeia. 2004;9(2):47-50.
ak
106
Chapter
Vaginal Breech Delivery
6
A.T.M. Verhoeven, J.P. de Leeuw, H.W. Bruinse, H.C.J. Scheepers,
and B. Wibbens
ru
• fran k breech presentation: the legs lie alongside the
General information
body, flexed at the hips and extended at the knees:
the term incidence is 2.25%;
Introduction
b.
• complete breech presentation: the feet are next to
P o ss e s s in g a n d m a in t a in in g th e sk ills fo r v a g in a l
the breech, the legs are flexed at the hips and at the
b re e ch d e liv e ry is b e c o m in g in c r e a s in g ly m o r e i m p o r
knees: the term incidence is 0.75%;
tan t a s th e n u m b e r o f c e sa re a n s e c tio n s d u e to b re e c h
• footling presentation: one or both legs are extended
p r e se n ta tio n h a s in c r e a s e d d r a s tic a lly d u r in g re c e n t
-li
y e ars. T h e re a r e n o r a n d o m iz e d tria ls o n th e b e st
m a n e u v e r s u s e d in v a g in a l b re e c h b irth . T h e b e st
m a te ria ls w e h av e b e e n ab le to fin d w ith r e g a r d to
v a g in a l b re e c h d e liv e ry m a n e u v e r s a re th e fo llo w in g :
at the hips or knees and lie below the breech.
Incidence
The incidence o f term breech presentation is 3% to
er
• o r ig in a l d e s c r ip t io n s o f th e m a n e u v e r s b y th e ir 4%. At a gestational age o f approxim ately 32 weeks,
“ in v e n to r s ” ; the incidence is 10% to 15% [LE C ].7
• a u th o r ita tiv e te x tb o o k s p r o d u c e d d u r in g th e p a s t
c e n tu r y 1-6;
Causes
h
C auses o f breech presentation are:

• m a n ik in s im u la t io n in st r u c t io n s by D u tc h ,
B e lg ia n , a n d G e r m a n m e d ic a l s c h o o l fa c u ltie s; • prem ature birth;
• d is s e r ta tio n s in D u tc h ; • fetal growth restriction;
us
• e x p e r tis e o f th e a u th o rs. • congenital disorders (e.g., anencephaly, hydro

cephaly, and neurom uscular disorders);
T h e p r a c tic e o f e v i d e n c e - b a s e d m e d i c i n e im p lie s th e
in te g r a tio n o f th e b e st e v id e n c e to g e th e r w ith in d i
• multifetal pregnancy;
v id u a l e x p e rtise .
• um bilical cord problem s (short um bilical cord,
T h is c h a p te r d e a ls w ith te r m b re e c h d e liv e rie s, entwinement);
ak
e x c e p t w h e re s p e c ific a lly m e n tio n e d o th e rw ise . • oligo- or polyhydram nios;

• placenta previa;
• congenital uterine anom alies, m yomas;
Definition • pelvic tum ors;
A b re e c h p r e se n ta tio n is a lo n g itu d in a l lie w ith the
• contracted pelvis.
b u tto c k s a n d / o r fo o t (fe e t), a n d ra re ly th e k n e e s, a s th e
The cause for a breech presentation is usually not found.
p r e se n tin g p a rt.
Congenital disorders occur two to three times
m ore in children born in breech presentation than
Classification of Breech Presentations children born in cephalic presentation [LE B].8
T h e fo llo w in g b re e c h p r e s e n t a t io n s a re d iffe r e n tia te d Hyperextension o f the fetal neck can be a sign o f a
(F ig u r e 6 .1 ): congenital disorder [LE C ].9
O b ste tric In te r v e n tio n s , ed. P. Joep D orr, V incent M. Khouw , Frank A. Chervenak, A m os G runebaum , Yves Jacquem yn,
ru
b.
frank breech presentation complete breech presentation complete footling incomplete footling
presentation presentation
Figure 6.1 Types o f breech presentations.
Complications
-li needed. In a planned term vaginal delivery, the
er
chance o f m ostly short-term injury (cerebral, bra
In breech births there is a greater chance o f com plica
chial plexus injury, hem orrhaging, and ruptures o f
tions during the delivery than in cephalic presentation
internal organs) is 0.92%: 9 in 1000. These traum as
births. The following com plications can occur:
occur ju st as often in assisted vaginal deliveries in
• Prolapse o f the umbilical cord: In breech presenta cephalic presentation and rarely result in a perm a
h
tions there is a greater chance o f umbilical cord nent handicap.18

prolapse: 5% in a complete breech presentation,
• Perinatal mortality: The perinatal death rate of
15% in a footling presentation, and 0.5% in frank
breech presentations is 0.39% in planned vaginal
us
breech presentation.10 The risk o f an umbilical cord

deliveries and 0.17% in planned cesarean sections.
prolapse is 1% in all form s o f term breech births
That is a difference o f 0.22%: 2 in 1000 infants.18,19
and 0.4% in cephalic presentations.11
In a recent French/Belgian prospective study there
• Asphyxia can occur during the second stage o f
was no difference between perinatal m ortality and
labor in case o f a prolonged com pression o f the m orbidity [LE B ].20
um bilical cord between the head and the pelvis.
ak
Com pression o f the um bilical cord occurs from

the m om ent the anterior scapula point is visible.2'3
The Choice of Vaginal Delivery versus
In a breech presentation - in contrast with a Cesarean Section
cephalic presentation - the um bilical cord is The choice between a vaginal delivery and an elective
always com pressed during the second stage cesarean section m ust be m ade together with the
because o f its insertion below the head. The inci pregnant wom an in a conversation in which all of
dence o f an arterial umbilical cord pH o f <7.10 is the pros and cons o f both delivery m ethods are d is
from 4% to 10% in breech deliveries and ±1% in cussed. The decision m ust also take into account the
cephalic presentations [LE B ].12 "15 After adequate expertise o f the gynecologist and the logistics o f the
resuscitation, short-term asphyxia does not clinic. The considerations m ust not only contem plate
usually have long-term consequences.3,16,17 the perinatal and m aternal risks o f the current deliv
• M echanical lesions can occur in a non-progressive ery, but also those o f the previous and possible future
breech delivery, when (partial) extraction is deliveries (increased chance o f uterus rupture,
C h a p te r 6: V a g in a l Breech D elivery
placenta previa, placenta accreta). Bringing one extra deliveries and therefore o f the num ber o f cesarean
full term live birth into the world requires approxi sections (see Chapter 5 on external version).
mately 380 extra cesarean sections [LE C ].21
Individual desires are important: the situation o f a History
completed family or o f a first pregnancy at a higher age, In the description o f the different m aneuvers and
in which a future pregnancy is unlikely, differs substan m ethods we took the Dutch and Flemish obstetric
tially from that o f a young primigravida, who may have traditions as the point o f departure. For an adequate
the ability or the desire to become pregnant again.18'22 understanding, the history is im portant.
The m ode o f delivery o f preterm breech babies is Before 1936, the policy in breech deliveries was to
still up for debate.23 There are, however, som e specific wait until the first scapula point was born. If, despite
things to watch out for in m anaging the labor. A
ru
forceful pushing, the rest did not follow during a con
relatively large head increases the risk o f the head traction, the arm s were delivered according to the
being im pacted at the cervix. It should therefore be “classic” m ethod (posterior arm first) or according to
rem em bered that the use o f forceps would not be the Muller27 (anterior arm first) (1898), and then the head
first choice in this case, but that the procedure should according to M auriceau.28 The Bracht maneuver was
b.
proceed with a D iihrssen’s incision. A breech presen introduced in 1935.29' 33 Lovset published his m aneu
tation o f the second o f a set o f twins does not require ver during the sam e period.34”37 During the 1940s, the
special counseling. For this, a vaginal birth can be preference gradually moved to the Bracht maneuver in
pursued (see Chapter 4).24 Dutch obstetric training for infants with normal ton
Contraindications -li
The type o f breech presentation, the estimated birth-
weight, and the position o f the fetal head are determined
icity and a normal estimated birthweight. If this failed,
one o f the three methods was used to deliver the arms.
Delivery Methods in Breech

er
by means o f external and ultrasound examinations.
Contraindications for a vaginal breech birth are: Presentations
• contraindications for a vaginal delivery, such as
poor fetal condition, congenital abnorm alities that General Points of Interest in Breech
make a vaginal birth im possible (hydrocephaly), Presentation Births
h
placenta previa, presenting um bilical cord;

• The circumference o f the breech is irregular and
. footling or knee presentation, except when the
smaller than that o f the head. In a premature or
infant is ready to be born [LE D]. Note: a footling
us
dysmature infant there is a chance for the head to

presentation is rare in a norm al size fetus at term
get impacted at the cervix. Consequently, Diihrssen’s
with a closed cervix and unruptured m em branes,
incisions may be necessary (see Chapter 3). For the
but this can occur during the delivery after the
sake o f visibility, it may be decided to perform this
rupturing o f the m em branes;
only at the 12 o’clock position, which would mini
• suspected contracted pelvis, such as after a diffi
mize the chance of bladder lesions.38
ak
cult or failed assisted delivery, or during an inter

• The breech closes the pelvic inlet less effectively
nal pelvic exam ination [LE D];
than the head. This creates a greater chance of
• hyperextension o f the fetal head (thus, any p osi
umbilical cord prolapse.11
tion other than a neutral or flexed position con
• The ratio between the head and the pelvis cannot
stitutes a contraindication [LE D]);
be ascertained beforehand. If a disproportion
• m acrosom ia: estim ated weight >4000 g [LE D] and
becom es evident during the delivery o f a cephalic
intrauterine growth restriction: estim ated weight
presentation, a vaginal delivery can usually be
<2500 g [LE A ];17'19’25’26
cancelled on time; in a breech presentation there
• absence o f an experienced gynecologist [LE A 2].26
is usually no way back.39
• A thorough (internal) pelvic exam ination during
Prevention the pregnancy m ay provide early revelation o f the
External version at 36 weeks seem s to lead to a sig “pelvic factor” in case o f a disproportion between
nificant reduction (50%) in the incidence o f breech the head and the pelvis (see Chapter 1) [LE C].
Section 3: P a th o lo g y o f La b o r a n d L a b o r a n d D e live ry
• A pelvic exam ination with magnetic resonance response m ust be available to prevent asphyxia. In a
pelvimetry offers no added value in a term breech breech delivery everything has to be ready for a possible
presentation [LE A 2],40 partial breech extraction, a forceps extraction o f the
• In a complete breech presentation there are fewer aftercoming head, or an emergency cesarean section.
clear internal rotations (rotations around the C onditions for a breech delivery are as follows:
longitudinal axis) than with a frank breech pre • discussion o f the pros and cons o f a vaginal breech
sentation. For that reason, in a com plete breech delivery and an elective cesarean section;
presentation the back will rotate to the back (dor • explanation o f the procedure and clear instruc
sal side o f the m other) m ore often than in a frank tions to the wom an;
breech presentation. In that case, it is recom • properly instructed assistance;
m ended when using the Bracht m aneuver to
• birthing bed with the possibility o f a low bed
ru
turn - even before the um bilicus is visible - the
position;
back forward (ventral side o f the mother).
• em pty bladder;
• By perform ing an adequate episiotom y (at the
• open intravenous infusion port;
right m om ent), m ore room becom es available for
• readily available forceps;
the necessary procedures involved in a (partial)
b.
• emergency plan: if a spontaneous birth or Bracht
breech extraction. Furtherm ore, the head can be
m aneuver is not successful, know what the next
delivered m ore evenly and there is less chance o f a
step will be and m ake sure that step can be per
grade 3 or 4 sphincter rupture resulting from the
form ed rapidly;
rapid stretching o f the perineum [LE B ].41
•
-li
C TG monitoring is recommended: in case o f
unruptured membranes with external registration;
in case o f ruptured membranes with an electrode
on one buttock. In com parison with a birth in
•
•
availability o f operating room and surgical team;
availability o f a pediatrician and possibility for
neonatal resuscitation.
er
cephalic presentation, the heart rate is higher in a Steps to Follow in a Breech Birth
breech delivery, there are m ore decelerations due to The order o f the m aneuvers in a breech birth is as
umbilical cord com pression when the breech follows:
reaches the pelvic floor, the variability is decreased, 1 With the Bracht m aneuver, the arm s, shoulders,
and there are fewer accelerations [LE C] 42,43
h
and head are born in one m otion.

• M icro blood testing can be perform ed on the bu t 2 If the arm s do not follow, delivery is done with the
tocks on the sam e indication as in a cephalic pre M uller m aneuver, according to the “classic” m an
us
sentation. The validation o f this is limited: the euver or the one according to Lovset, after which
reliability o f the m easurem ents was good, but it the head is delivered as in Point 3 below. In prin
concerned only a sm all group o f patients.44 ciple, all three m ethods can be applied to deliver
• In a vaginal breech delivery, the progress o f the arm s: the choice is partially determ ined on the
the delivery m ust be assessed carefully. In a non basis o f the experience o f the gynecologist and
progressing engagement, dilation, or expulsion,
ak
partially on the pros and cons o f each maneuver.

a cesarean section m ust be perform ed despite ade 3 If the head does not follow, the procedure goes
quate contractions. over to M auriceau, D e Snoo, or forceps.
• From the m om ent the scapula point becom es
visible, the birth o f an infant that is in good con
dition and in a frank breech presentation m ay take Breech Delivery According to Bracht
approxim ately another 4 m inutes before an A pgar
score o f <7 appears after 5 m inutes [LE C ].10,45 A Conducting a Breech Delivery
hurried extraction contributes to the arm s being To conduct a breech delivery accord in g to the
outstretched beside the head [LE D], Bracht m ethod (see A n im a t io n 6 .1 ), g oo d tonicity
o f the infant is essential: g oo d m uscle tone is a
condition for the lord osis o f the back, which su p
Preparations for Breech Delivery p orts the rotation o f the fetus over the sym physis, as
If the breech delivery does not progress spontaneously or well as to m ain tain the m osaic o f the extrem ities and
smoothly according to the Bracht maneuver, rapid the chin on the chest. I f an asphyctic in fant is
expected, it is better to m ake a choice for a partial Bracht maneuver: he considered an episiotom y
breech extraction. “essentially unnecessary.”26 Presently there are clinics
The birth o f an infant in breech presentation has a where the m ethod is practiced in a m odified manner:
slow and a rapid phase. First o f all, a com plete dilation that m eans, pressure is applied only on indication of
and a gradual engagem ent o f the breech into the insufficient expulsion progress, but always with the
pelvic floor are aim ed for. The rapid phase takes application o f an episiotomy. (In 1928, Covjanov
place during the contraction after the breech has introduced a com parable m ethod in Russia47).
“crowned” and an episiotom y is perform ed. The
infant should be delivered during this contraction. Methodology of Breech Delivery According
The essence o f the m ethod is that the natural m ove
ment o f the fetal body is supported into the direction o f
to Bracht
ru
the extension o f the birth canal. Instead o f a downward • Instruct the m other not to push until there is
traction (caudally and dorsally) pressure is perform ed com plete dilatation and a clear urge to push.
from above through uterine contractions, supported by • Allow the breech to engage as far down as possible
fundus pressure. The helper perform s the m ost im por before starting active pushing by the mother.
b.
tant work by applying fundus pressure: the gynecolo • Perform an episiotom y at the end o f the contrac
gist, by m oving the infant toward the mother’s tion that precedes the contraction in which the
abdomen, essentially ensures that the infant does not birth is expected to take place. This is the case
fall to the ground! Furthermore, delivery is enhanced when the breech threatens to crown, i.e., when
since the maneuver o f encom passing the breech m ain both trochanters are visible. Prevent the breech
-li
tains the m osaic o f the “sm ooth fetal cylinder,” which
keeps this m osaic o f extremities and chin on the chest
from “disintegrating,” by which expulsion could be
further com plicated.31,33
from crowning at the end o f the contraction by
letting the mother breathe during part o f the
contraction.
er
• Instruct the m other to push forcefully during the
Applying pressure from the m om ent the um bili next contraction.
cus is born is im portant for the following reasons: it • T o support the contraction have a helper apply
prevents lifting o f the arm s, it strengthens the flexion pressure with both hands to the fundus o f the
o f the head, and enhances all form s o f partial uterus during that contraction (Figure 6.2).
h
extraction.2,4 A pplying pressure is inherent in the

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Figure 6.2 Fundus pressure according to Kristeller.1

Section 3: P a th o lo g y o f La bo r a n d La b o r a n d D elivery
• Make sure that when the torso is born the back • Support and guide the infant’s torso without
turns to the front (ventral) (Figure 6.3A). If this applying traction tow ard the m other’s abdom en
does not occur spontaneously, turn the back to until the arm s are born and the posterior hairline
ventral without applying traction. becom es visible. With the posterior hairline as
• Loosen the umbilical cord as soon as the um bilicus the point o f rotation, turn the infant over the
is born to prevent it from being under pressure. sym physis tow ard the abdom en o f the mother
• After the um bilicus is born, apply the Bracht m an (Figure 6.4). The wom an keeps pushing and the
euver (Figure 6.3B). That m eans that the fingers helper continues to apply pressure to the fundus,
will encom pass the breech, and the thum bs the possibly even with a fist if the fundus has becom e
upper legs (Figure 6.3C). too sm all to apply pressure with two hands
(Figure 6.5).
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Figure 6.3 Start o f the Bracht maneuver (A); then the hands guide the back forward (B).1
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Figure 6.3 (cont.)
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Figure 6.4 Rotation over th e symphysis; m eanw hile an assistant applies pressure to reinforce the abdom inal pushing and the contractions.1
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Figure 6.5 Pressure applied by the helper (from Bracht's article3133).
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If the Bracht maneuver fails - considered to be the
case if there is still no progress after 1 m inute o f
arm s. If pulling shallower, the arm s are m ore difficult
to reach. If pulling deeper, the head m ay obstruct the
er
applying the Bracht maneuver - then the delivery delivery o f the arm s.6
continues with the help o f a partial breech extraction.
Methodology
Partial Breech Extraction The breech is grasped with both hands so that the
h
If the infant is hypotonic, e.g., due to the m other’s thum bs are next to each other on the sacrum and the
(pain) m edication or asphyxia, entrapm ent o f the fetal index fingers reach over the iliac crest.
arm s behind the neck m ay occur. These nuchal arm s
1 The direction o f the traction is initially straight
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m ay im pact the pelvic inlet and prevent further des

upw ard (ventral side o f the m other) if the poster
cent o f the fetus. The arm s can then be delivered by
ior arm is to be delivered first according to the
applying one o f the following three appropriate
classical m ethod (Figure 6.6).
maneuvers:
2 The traction is initially directed straight dow n
• the “classical” maneuver to deliver the posterior ward (dorsal side o f the m other) if the anterior
arm first;
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arm is to be delivered first according to the Muller

• the Muller maneuver to deliver the anterior arm m ethod (see Figure 6.10).
first; 3 If the Lovset m ethod is applied, an attem pt is m ade
• the Lovset maneuver. to get the shoulders so low that the anterior
If the Bracht maneuver fails, the anterior scapula scapula point is visible. For this, the w om an has
point is usually already visible and the maneuver to lie slightly past the edge o f the bed.
stagnates at the shoulders. If, however, at the m om ent Each o f the three above-m ention ed m ethods h as its
o f the Bracht maneuver stagnation the scapula point is specific use and benefits. The M uller m aneuver is
not yet visible, the torso m ust first be further extracted ap p rop riate in a norm al size in fant and a norm al
(Figure 6.6). This m om ent at which the lower edge of pelvis, in which no p roblem s are expected .27,48 The
the anterior scapula becom es visible is the m ost favor follow ing benefits are listed again st the classical
able for the subsequent freeing o f the shoulders and m ethod: the speed and sim plicity o f the m aneuver,
114
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Figure 6.6 Extraction in ventral direction to deliver the posterior shoulder first.2
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the m in im u m risk o f clavicle and hum erus frac
tures, an d the low er incidence o f infection. The
classical m ethod is useful as a last resort in m ore
2 Bend the torso firmly in a ventral direction
(abdom inal side o f the mother) and to the groin
that coincides with the abdom inal side o f the
er
difficult cases, that is, in case the M uller or Lovset infant (Figure 6.7A).
m eth ods fail, and it is also ap p rop riate for a h y p o 3 Insert the index and m iddle fingers o f the other
tonic infant. The Lovset m aneuver is only a p p ro hand alongside the posterior shoulder and upper
priate in the case o f good m uscle tonicity and in a arm o f the infant, up to the crease in the elbow
large, rath er than dysm ature, infant. T h is is because (Figure 6.7B).
h
in h ypotonia, the 180° rotation o f the torso will be 4 U sing the two outstretched fingers like a splint,
follow ed less well by the pectoral girdle than in the m ove the fetal upper arm toward the abdom inal
case o f healthy tonicity. The m ethod is also a p p ro side o f the infant, sweeping it past the face.
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priate if the arm s are em bedded in the neck, i.e., Continue this until the arm is born (Figure 6.7C).
nuchal arm s [LE D ].37 5 Take the lower legs o f the infant in a forked grip
In principle, any o f the three m ethods can be with the hand that coincides with the dorsal side o f
applied. W hich m ethod to apply is, on the one hand, the infant (Figure 6.8).
determ ined by personal experience and, on the other 6 M ove the infant’s torso as far dorsally as possible
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hand, by the above-m entioned disadvantages and (dorsal side tow ard the m other) and d iam etri
benefits for the individual patient. In all three m eth cally opposite to the previous position (thus
ods, the application o f fundus pressure by a helper is from left anterior to right posterior or from
essential to the success. right anterior to left posterior), whereby the ante
rior arm is delivered with the other hand in the
Delivery of the Arms sam e way as the delivery o f the posterior arm
Posterior Arm First ("Classical" Method) (Figure 6 .8).
See A nim ation 6.2. The m ethod m entioned in Point 6 for delivering the
anterior arm is the French variant o f the classical
Methodology m ethod, which is usually taught in the Netherlands,
and is also called the “com bined arm delivery.”6
1 Take the lower legs o f the infant in a forked grip
If this does not resolve the delivery o f the anterior
with the hand that coincides with the abdom inal
arm , the original Germ an method can be applied by
side o f the infant.
Section 3: P a th o lo g y o f La bo r a n d La bo r a n d D elivery
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Figure 6.7 Delivery o f the posterior arm according to the "classical" method.2,46
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Figure 6.8 French variant o f the classical method.
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Figure 6.9 Stopfen: 180° rotation, the anterior arm becom es the posterior arm.2
having the anterior arm becom e the posterior arm, thus along the ventral side, and turned to the other
and then proceed as described above. side. The 180° rotation o f the torso then follows with
For this, the torso is grasped with both stretched “stop and g o ” m ovem ents: m eaning, the infant is not
out hands, which function as splints. The already turned in one single m aneuver, but with a series o f
delivered arm is included in this and pressed against short turning m otions, whereby the torso is pushed
the body. The rotation is done in such a way that the up each tim e tow ard the sacrum and then pulled
dorsum that is located laterally after the delivery o f the back again (stopfen = as in plugging a pipe)
posterior arm always passes under the symphysis, (Figure 6.9).
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Figure 6.10 Extraction on the buttocks until the anterior scapula becom es visible.1
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Anterior Arm First (Muller Maneuver) Methodology
See A nim ation 6.3.
1 G rasp the breech firmly with the thum bs parallel
If the anterior arm is delivered first, then in that on the buttocks and the index fingers over the iliac
case the right arm is also delivered with the right hand crest; the other fingers surround the thighs. First,
and the left arm with the left hand.
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apply continuous traction, slowly, constantly

H ere it is also the case that if at the m om ent o f down (dorsally) until the anterior shoulder and
stagn ation o f the Bracht m aneuver the anterior arm are out (Figure 6.11 A). I f the shoulder width
scapula is not yet visible, the torso m ust first be
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is not yet in the anteroposterior diam eter, the

further extracted (Figure 6.10). The breech is shoulder girdle m ust be turned in that direction
g rasp ed with both hands so that the thum bs are during the extraction.
next to each other and the index fingers reach over
2 Then pull straigh t in a ventral direction. Pull
the iliac crest. Then the infant is pulled firm ly and
the in fant firm ly again st the m oth er’s body
straight down, i.e., in the direction o f the gynecol
until the p o sterio r arm and sh ou lder appear
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o g ist’s feet, until the first shoulder follows. For

(Figure 6.11B). Som etim es, one o f the arm s
this, the w om an m u st lie slightly p ast the edge o f
does not ap p ear sp on tan eou sly and becom es
the bed.
trap p ed in the vulva. Then, sw eep the arm
The Muller maneuver is an im itation o f the nat
out with two fingers that splint the h um erus
ural, spontaneous breech birth, in which the anterior
(Figure 6.11C ).
shoulder and arm are the first to appear under the
symphysis.
118
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Figure 6.11 Delivery o f the anterior arm according to Muller, spontaneous dropping o f the anterior arm (A); posterior arm through traction to
dorsal and ventral, respectively (B); sw eeping o f th e anterior arm with two, humerus splinting, fingers (C).1,2
Lovset Maneuver rem aining fingers surround the upper legs from
See A nim ation 6.4. the back (Figure 6.12).
Initially, Lovset him self always began with the 2 At the same time, apply light traction with the 180°
Muller maneuver. Only after this maneuver failed, rotation mentioned in Point 3: the first 90° o f the
would he apply his own maneuver. Therefore, he rotation traction in a horizontal direction, followed
had already tried as best he could to bring the by traction in the direction o f the gynecologist’s feet.
shoulders as low as possible through extraction, but 3 Turn the posterior shoulder 180° forward, in such
without the lower edge o f the anterior scapula becom a way that the back always passes by the m other’s
ing visible in this way. symphysis. Som etim es the forw ard turned arm
The Lovset maneuver is not appropriate with falls out by itself (Figure 6.13).
hypotonia, as muscle tonicity is needed for this m an 4 If the arm does not fall out, take the index and
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euver to be successful. In a hypotonic and/or dysma- m iddle fingers o f the sam e-sided hand (thus the
ture infant, rotations o f the torso will lead less well to left hand for the left shoulder) over the shoulder
having the shoulder girdle follow. like a trough alongside the upper arm up to the
Therefore, it is better to apply the classic method elbow.
on a hypotonic infant. The Lovset m ethod has greater
b.
5 Apply pressure to the elbow and sweep the arm
success in a large child than in a dysm ature child. The past the face and the torso to the outside
method is also appropriate if the arm s are em bedded (Figure 6.14).
in the neck, i.e., nuchal arms. 6 G rasp the infant again as in Points 1 and 2.
7 Turn the infant 180° back again, in which the
Methodology
1
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G rasp the infant with the thum bs on the sacrum ,
and the index fingers over the iliac crests. The 8
back appears alongside the sym physis again
(Figure 6.15).
Repeat the procedures in Points 4 and 5.
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Figure 6.12 180° rotation o f the torso (arrow indicates direction o f the rotation): left posterior arm com es forward; L0 vset maneuver.49
120
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Figure 6.13 Torso is rotated 180° (arrow indicates the direction o f the turn): posterior arm is now under the symphysis.49
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Figure 6.15 180° reverse rotation o f the torso (arrow indicates direction o f the turn).4
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Figure 6.16 Delivery o f the nuchal arms according to Sellheim.
Sellheim Maneuver50 “h altin g” m ovem ents; i.e., the child is n ot turned

In the event o f em bedded arm s, the em bedded arm all at once, but by m eans o f a series o f short turns,
is prepared for being brought down by turning the in which the torso is repeatedly pu sh ed up sacrally
in fant’s torso 180° around its longitudinal axis and then pulled back dow n again (stopfen) (see
(Figure 6.16A ). The torso is turned 180° in stages Figure 6.9).
by m eans o f several rapid, short turn m otions. The direction o f the rotation is dictated by
Thus, the turning o f the torso by 180° is done in the direction in which the hand o f the
C h a p te r 6: V a g in a ! Breech D e live ry
corresp on din g em bedded arm o f the infant is in the m outh o f the fetus, the thum b against the
pointin g (Figure 6.16A ,B). In a sense, the infant lower jaw , and the index and ring fingers on the
indicates the direction. A fterw ards, the torso has to m axilla.
be turned back by 180°, otherw ise the spine will be 3 Let the infant “ride” with the belly and spread legs
turned to the b a ck !50 on the lower arm , i.e., with the legs hanging down
on each side.
Delivery of the Aftercoming Head 4 Maneuver (rotate) the head with the inserted fin
gers in such a way that the posterior fontanel
The aftercom in g head will have to be delivered as
com es to lie under the sym physis and is held in
in the Bracht m aneuver or if after the delivery o f
the arm s in a p artial breech extraction the head is flexion at the sam e time (Figure 6.17A).
5 Place two forked fingers o f the other hand from
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not born. In that case, the M auriceau and De Snoo
m aneuvers can be applied, as well as the forceps. the back around the neck and apply traction to the
For the delivery o f the head it is im portant that the shoulders o f the infant (Figure 6.17C). Avoid
occiput is under the sym physis and is (maximally) hooking the shoulders because o f the risk o f a
flexed. plexus injury.
b.
In all three m ethods, careful fundus pressure 6 Caution: traction m ay not be applied with the
rem ains im portant for success, finger that is placed inside the mouth!
7 The exterior hand pulls the infant down (dorsally),
i.e., in the direction o f the gynecologist’s feet, until
Mauriceau Maneuver: '
See Anim ations 6.5 and 6 .6.
Methodology
1
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G rasp the legs with a forked grip and lift up the
8
the posterior hairline is visible.
Have an assistant carefully apply fundus pressure
to the head above the symphysis, so that less trac
tion force is applied via the neck.
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9 W hen the posterior hairline becom es visible, m ove
torso. the torso gradually in a ventral and cranial direc
2 Place the m iddle finger o f the other hand (the tion, whereby the sym physis functions as the rota
right hand if the p osterior fontanel is in the right tion point and allow the head to be born gradually
h alf o f the pelvis; the left hand if on the left side) (Figure 6.17B).
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123
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The De Snoo Maneuver51,52 5 Lay the torso o f the infant on the left arm (“as in
riding”).
See A nim ations 6.7 and 6.8.
6 Place the right hand above the sym physis (Figure
Methodology 6.18A).
1 Grasp the legs with a forked grip and lift up the torso. 7 Pull with the left hand on the shoulder girdle and
2 Insert the index and m iddle fingers o f the left hand sim ultaneously apply pressure with the right hand
alongside the downturned chest and neck o f the to the head above the symphysis (Figure 6.18B).
infant. 8 With the left hand, pull in the direction o f the axis
3 Check by vaginal exam ination whether the chin is o f the birth canal, thus increasingly toward ventral
turned to the back (dorsal), which will usually be as the head gets deeper into the pelvis.
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the case in a ventrally turned back. If not, the chin
can be turned to the back with the fingers inserted Forceps on Aftercoming Head53-57
in the mouth. By using forceps on the aftercom ing head it is not so
4 From the front, grasp the neck o f the infant with the much the (ex)traction, but the enhancement o f the
left index and middle fingers over the shoulders. flexion o f the head through the action o f the forceps
b.
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Figure 6.18 The De Snoo maneuver.

Section 3: P a th o lo g y o f La b o r a n d La bo r a n d D e live ry
that is the m ost im portant aspect o f the delivery. 1 An assistan t holds the child with a hollow
Naegele’s forceps (the large size), the forceps accord back and the arm s out o f the way. T h is can
ing to Kielland, and the Piper forceps are all ap p ro be done by:
priate. The m ost im portant part is that the neck is
- holding the infant from above with a warm
long enough and that the pulling is perform ed in the
towel under the torso; or
proper direction. It is crucial to always have the for
- taking the legs in a forked grip and holding
ceps ready that were used for practicing on the
the infant above the horizontal plane and at
dummy.
the sam e tim e h olding the hands on the back
A condition for using forceps on the aftercom ing
o f the infant with the other hand (the best
head is that the occiput is in anterior position and
place for the assistant to stand w ould be on
engaged.
the left side o f the w om an) (Figure 6.19A).
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The blades o f the forceps are inserted as
Methodology
described in C hapter 7 on vaginal assisted
See Anim ations 6.9 and 6.10. deliveries.
b.
A
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Figure 6.19 Piper forceps on the aftercom ing head.3

Complete Breech Extraction

The only still u ndispu ted in dication for a com plete
breech extraction is the necessity for assisted
delivery o f the second m em ber o f a set o f
twins as part o f the version and extraction in a
transverse presentation that cannot be corrected
[EL A 2 ],59-61
A lso if for the second twin in breech p resen ta
tion an in dication arises to term inate, a choice for a
breech extraction can be m ade if the estim ated
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weight o f this infant is not m uch greater than that
o f the first in fan t.62 A com bined vaginal delivery
(twin A) and cesarean section (twin B) carries with
it the greatest risk o f perinatal asphyxia (o f twin B),
defined as A pgar score o f <4 after 5 m inutes. T his is
b.
true in com parison with a vaginal delivery o f both
in fants and in com pariso n with a planned cesarean
Figure 6.20 Speculum m aneuver according to DeLee. section [LE C ].63'64
If there is an indication to terminate a breech
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Ensure that the blades are inserted from a plane
that lies below the horizontal line o f the obstetric
bed, thus from dorsal to ventral (Figure 6.19B).
delivery o f a singleton delivery even before the torso
is b o m , an emergency C-section is perform ed, since
the total breech extraction is susceptible to a high
m ortality (14%) and m orbidity rate. Breech extraction
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3 The blades will be lying around the infant’s head, then becom es only an alternative if a cesarean section
along the m ento-occipital circum ference (= in the is no longer possible.2’22,25'46 62
chin-occiput line) (Figure 6.19C).
4 First, m axim um flexion o f the head is realized with
the forceps, then traction is applied in the direc Complete Breech Presentation
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tion o f the pelvic axis. The rotation point is the See A nim ation 6.11.
infant’s neck.
Methodology
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If the head does not follow, a Doyen vaginal speculum

1 While the external hand supports the fundus of
(24 cm, 180 x 60 m m ) can be used according to DeLee,
the uterus, the hand that coincides with the
to suction the infant and to allow it to breathe and a
abdom inal side o f the infant is inserted.
sym physiotom y can be considered (Figure 6.20).58
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2 The anterior leg is brought down by grasping

the ankle with the forked grip and by placing the
thumb after traction on the posterior side o f the
lower leg, the calf (Figure 6.21). It is im portant that
the posterior side o f the leg points to the front or is
brought to the front by turning it, since that pre
vents the back from turning backwards. Bringing
down the anterior leg prevents the breech from
getting stuck on the symphysis, as is possible
when the posterior leg is brought down first.
3 After that, the other fingers surround the entire
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lower leg. Then the m ost im portant aspect is the
direction o f the traction: straight down (dorsally),
to the gynecologist’s feet (Figure 6.22). After that,
the other hand grasps the upper leg as high as
b.
possible and pulls it straight down until the hip
is delivered. The thum b o f this hand rests on the
buttock; the other fingers firmly surround the
upper leg (Figure 6.23).
4 After the anterior trochanter has been passed
-li (Figure 6.24), stand at the abdom inal side o f the
infant. Surround the upper leg as high as possible
with the entire hand (with the right hand if the
back is to the right; with the left hand if the back is
er
to the left). With the wrist o f the hand, which
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Figure 6.21 Bringing dow n the anterior foot.2

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Figure 6.22 Grasping the lower leg, traction dow nw ard.1
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Figure 6.23 Traction on the low er leg in dorsal direction.1
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Figure 6.24 Traction on th e anterior leg in dorsal direction until the anterior trochanter is visible49
surrounds the upper leg and rests on the sym phy 5 A s soon as possible, hook the index finger o f the
sis, rotate the posterior buttock over the perineum other hand into the posterior hip. D o not do this
by m oving the anterior leg into a vertical position with two fingers, as this could increase the p o s
(Figure 6.25). After the anterior trochanter has sibility o f fem ur fracture! The thum b will n atu
been passed, pull forw ard (ventrally) and finally rally rest on the buttock, so that both thum bs
com pletely upward to allow the posterior hip to be will be situated parallel on the sacrum
born (Figure 6.25). (Figure 6.26).
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Figure 6.25 Traction on the anterior leg in ventral direction until the posterior trochanter is visible.49
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Figure 6.26 Hooking the posterior hip w ith a finger.49
6 Then the breech is grasp ed firm ly with both This is followed by delivery o f the arm s and deliv
h ands and pulled first to the front (ventrally), if ery o f the head (see A nim ation 6.14), as in Section:
you w ant to deliver the posterior arm first Partial breech extraction.
accordin g to the classical m ethod (Figure 6.27), Advice: if upon the appearance o f the lower edge
or straight down (dorsally) until the low er edge o f the shoulder a posterior foot that is elevated against
o f the anterior scapu la point is visible and the abdom en does not fall out yet and becom es stuck
palpable, if you want to deliver the anterior in the vagina, that leg should never be pulled. By
arm first accordin g to the M uller m aneuver turning the torso in the direction o f the back o f the
(Figure 6.28). infant, the leg will fall out by itself!
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Figure 6.27 Traction in ventral direction.2
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Figure 6.28 Traction tow ard th e obstetrician's feet: thum bs on the sacrum; index fingers over the crests.2
Frank Breech Presentation som etim es be pushed above the pelvic inlet in order
to bring down the anterior foot with the Pinard m an
There are two possibilities: the not yet completely
euver (see A nim ation 6.12). The breech is pushed up
engaged breech and the deeply engaged breech.
above the pelvic inlet and placed on the iliac fossa,
which coincides with the dorsal side o f the infant.
Not Yet Completely Engaged Breech Insert the index and m iddle fingers o f the
In frank breech presentation, the anterior leg can only inserted full hand on the side o f the extrem ities
be brought down if the breech has not engaged very (thus, the left index finger if the back is to the left
far yet. In case o f an engaged breech, this can and vice versa) with stretched fingers until the finger
Section 3: P a th o lo g y o f La b o r and La b o r a n d D e live ry
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Figure 6.29 Pinard maneuver: bringing dow n the anterior foot.1
tips arrive at the back o f the knee o f the anterior leg: m eans o f the Pinard m aneuver (Figure 6.29). For this,
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this is abducted, which creates space to bend the a uterus relaxing inhalation anesthesia (sevoflurane)
lower leg and bring down the foot. First, grasp the is recom m ended. If the anesthetist has not yet arrived,
entire lower leg. If the lower leg is bent, take the ankle m idazolam (D orm icum ) is recom m ended.
between the index and m iddle fingers and place the The technique o f the extraction o f the unborn
thum b on the dorsum o f the foot, after which the breech is as follow s. A s in all assisted deliveries,
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entire foot is pulled out (Figure 6.29). insert the left hand into the right h alf o f the pelvis
and the right hand into the left h alf o f the pelvis.
Deeply Engaged Breech Point the palm o f the hand to the in fan t’s abdom en.
If the breech is already firmly on the pelvic floor, Then insert the index finger from the side into the
pushing it up to bring down a leg is som etim es no groin against the iliac crest, and the thum b on the
longer possible. Then you have to pull on the breech sacrum . Since it is difficult to pull hard with one
itself until it is outside the vulva. That is difficult finger, place the other hand arou n d the w rist o f the
and risky: therefore, extraction o f a deeply engaged inserted hand. Pull the an terior bu ttock dow n and
frank breech (see A nim ation 6.13) can best be accom under (Figure 6.30). W hen the anterior b u ttock is
plished by first pushing up the breech so far in a visible in the vulva, insert the index finger of
cranial direction that a leg can be brought down by the second hand into the posterior groin crease. By
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Figure 6.30 Extraction on the anterior groin in the direction o f the dorsum .1
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Figure 6.31 Extraction on both groins in ventral direction.1
pullin g the breech firmly upw ard, it is now always • traction direction insufficiently straight to dorsal
possible to m ake the p osterior buttock appear over or ventral;
the perin eum (Figure 6.31). M aintain ing fundus • two fingers instead o f one finger in the hip, which
pressu re rem ain s essential in this m aneuver! carries a greater risk o f hip fracture;
• starting too early with arm delivery: deliver the
Note arm s only after the anterior scapula point is visi
Frequent errors in breech extraction are: ble/palpable.
Sectio n 3: P a th o lo g y o f La b o r a n d L a b o r a n d D e live ry
w ell-trained assistan t (for applying fundus p res

sure!) and the im m ediate availability o f a p e d ia
Recommendations'7 trician and an anesth esiologist are required
[LE A l],
Before the Delivery
• If there is no contraindication to an external ver During the Delivery
sion or a vaginal breech delivery, recom m end an
• Perform an ultrasound and internal pelvic exam
external version. If an external version is not suc
ination if these exam inations were not perform ed
cessful or refused, the options are vaginal delivery
recently.
or an elective cesarean section.
• Insert an intravenous infusion.
ru
• D iscuss the pros and cons o f a vaginal breech
• Provide C T G m onitoring: external in case of
delivery versus an elective cesarean section and
unruptured m em branes and internal in case of
record the outcome o f the discussion in the file.
ruptured m em branes, and continuous C T G m on
• Perform an ultrasound exam ination before
itoring starting at com plete dilation [LE A l].
delivery.
b.
• Keep forceps at the ready in case the head does not
- Determ ine whether it is a com plete breech follow and a forceps delivery o f the aftercom ing
presentation, a frank presentation, or a foo head is required.
tling presentation. • Ensure that an operating room and a surgical team
- A cesarean section is recom m ended in case o f a and pediatrician are im m ediately available
-
unavoidable. -li
footling presentation, unless delivery is
Determ ine the position o f the head relative to

the torso.
•
•
[LE A l].
Avoid rupturing the m em branes prematurely,
unless there is an indication for this.
W hen the m em branes rupture spontaneously, do
er
- If the head is hyperextended a cesarean section a vaginal exam ination to detect a possible p ro
is recommended. lapsed um bilical cord [LE D],
- Perform a cesarean section in case o f a present • Oxytocin m ay be adm inistered in case o f prob
ing um bilical cord [LE A2]. lematic contraction activity during the first and
h
second stage [LE A2].

• Perform external and ultrasound exam inations to
• In case o f insufficient progress o f dilation decide
estimate the birthweight (the error m argin
to perform a cesarean section [LE A2].
between the estim ated weight and the actual birth
us
weight is 10- 20% in ultrasound or external • An experienced gynecologist pronounces the

exam ination). “com plete dilation” diagnosis [LE D].
• A vaginal breech delivery can be contemplated if the • Encourage the w om an to avoid active pushing (for
estimated birthweight is between 2500 and 4000 g. at least 90 m inutes with a good C T G ) if on com
plete dilation the breech is not close to or on the
• M acrosom ia and intrauterine growth restriction
ak
pelvic floor yet. That allows tim e for the breech to

are contraindications for vaginal breech birth
engage [LE A l].
[L E B ],
• Active pushing by the m other com m ences when
• Perform an internal pelvic exam ination.
the breech is on or near the pelvic floor. D ecide to
- Perform a cesarean section in case o f abnorm al perform a cesarean section if the infant has not yet
findings. been born (with a good C T G ) after 60 minutes
• The best evidence o f adequate fetopelvic relation [L E A 2],
ships is a good labor and delivery progression. • Avoid a com plete breech extraction in case o f a
• A mechanically difficult delivery in the m edical non-progressing expulsion [LE B],
history is a contraindication for vaginal breech • Perform an episiotom y ju st before the crowning of
birth [LE D]. the breech [LE B].
• For a vaginal breech delivery, the presence o f an • Ensure proper docum entation o f the breech
experienced and com petent gynecologist and delivery.
C h a p te r 6: V a g in a l B reech D e live ry
References 17. Society o f O bstetricians & Gynaecologists o f Canada.

V aginal delivery o f breech presentation. Guideline
1. H olm er A JM , Ten Berge BS, V an Bouw dijk Bastiaanse Society o f O bstetricians & Gynaecologists o f C anada
M A , et al (eds). Leerboek der V erloskunde. 3rd edition. (w w w .sogc.org). J Obstet Gynaecol Can.
A m sterdam : V an H olkem a W arendorf, 1963. 2009;31:557-66.
2. Dudenhausen JW, Pschyrembel W. Praktische 18. V erhoeven A TM , de Leeuw JP, Bruinse HW . Aterm e
Geburtshilfe. Berlin/New York: W alter de Gruyter, 2000. stuitligging: onterechte keus voor de electieve
3. C un n in gh am G, G ant N F, Leveno KJ, et al (eds). keizersnede als standaardbehandeling vanwege te hoge
W illiam s O bstetrics: T echniques for breech delivery. risico’s voor m oeder en h aar volgende kinderen. N ed
21st edition. Stanford, Connecticut: A ppleton & Lange, Tijdschr Geneeskd. 2005;149:2007-10.
2001, pp. 495-508. 19. Rietberg C. Term breech delivery in the Netherlands.
4. Stoeckel W. Lehrbuch der Geburtshilfe. 7th edition. U npublished Ph.D. thesis, University o f Utrecht, 2006.
ru
Jena: Fisher V erlag, 1943. 20. Goffinet F, Carayol M, Foidart JM , et al. Is planned
5. G im ovsky M L, M cllh argie CJ. M unro K err’s operative vaginal delivery for breech presentation still an option?
obstetrics. London: W illiam s & W ilkins, 1995. Results o f an observational prospective survey in
France and Belgium . A m J O bstet Gynecol.
6. M artius H. D ie geburtshilflichen O perationen. 8th
2006;194:1002-11.
b.
edition. Stuttgart: G eorg Thiem e V erlag, 1958.
21. Verhoeven A TM . Tien jaa r na de Term Breech Trial,
7. H ickock D E, G ordon D C , M ilberg JA, et al. The
een balans voor N ederland. N ed Tijdschr Obstet
frequency o f breech presentation by gestational age at
Gynaecol. 2011;124:143-7.
birth: a large population -based study A m J Obstet
Gynecol. 1992;166:605-18. 22. D utch Society O bstetrics & Gynecology. Guideline
8.
9.
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H sieh YY, T sai FJ, Lin C C , et al. Breech deform ation-
com plex in neonates. J R eprod M ed. 2000;45:933-5.
Sh ipp T D , Brom ley B, B en acerraf B. The prognostic
significance o f hyperextension o f the fetal head
23.
Breech Position, 2008. www.nvog.nl.
Bergenhenegouwen LA, M eertens LJE, Sch aaf J, et al.
V aginal delivery versus caesarean section in preterm
delivery: a system atic review. Eur J O bstet Gynecol
er
Reprod Biol. 2014;172:1-6.
detected antenatally with ultrasound. U ltrasound
O bstet Gynecol. 2000;15:391-6. 24. Barrett JFR, H annah M E, H utton EK, et al. A
random ized trial o f planned cesarean or vaginal
10. Collea JV , Rabin SC, W eghorst GR , et al. The
delivery for twin pregnancy. N Engl J Med.
random ized m anagem ent o f term frank breech
presentation. V aginal delivery vs cesarean section. A m 2013;369:295-305.
h
J O bstet Gynecol. 1978;131:186-95. 25. Royal College o f O bstetricians and Gynaecologists.

The m anagem ent o f breech presentation. Guideline N o
11. Krebs L, Langhoff-Roos J. Breech presentation at term:
20b, London: R CO G , 2006.
indications for secondary caesarean section. In: Kiinzel
us
W (ed). Breech delivery, European practice in 26. Su M, M cLeod L, R oss S, et al. Factors associated with
gynaecology and obstetrics. Paris: Editions Scientifiques adverse perinatal outcom e in the T erm Breech Trial.
et M edicales/Elsevier SAS, 2002, pp. 129-37. A m J O bstet Gynecol. 2003;189:740-5.
12. Fischl F, Janisch H , W agner G. pH -M essungen nach 27. M ulder M E. Het ontwikkelen der arm en en de extractie
G eburt aus Beckenendlage. Z G eburtshilfe Perinatol. volgens A. M uller. Ph.D. thesis, U niversity o f
1979;58:183-7. G roningen, 1908.
ak
13. Z im m erm an P, Z im m erm an M , D ehnhard F. N och 28. V erhoeven A TM . H andgreep van M auriceau
eine U ntersuchung zur Frage des optim alen (Levret-Sm ellie-Veit) - Eponiem en. N ed Tijdschr
E ntbindun gsm odus bei Beckenendlage. Z Geburtshilfe O bstet Gynaecol. 2010;123:86-92.
Perinatol. 1978;57:182-8. 29. Bracht E. V ortrag: Z ur M anualhilfe bei Beckenendlage.
14. K ubli F, B oo s W, Ruttgers H. C aesarean section in the Z G eburtsh Gynakol. 1936; 112:271.
m anagem ent o f singleton breech presentation. In: 30. Bracht E. Z ur Behandlung der Steisslage. Handelingen
R ooth G, Bratteby LE (eds). Perinatal m edicine. 5th Internationaal Congres voor V erloskunde en
E uropean C on gress o f Perinatal M edicine, U ppsala. Gynaecologie. Congresbericht II. A m sterdam : Brill,
U ppsala: A lm qvist & W iksell, 1976, pp. 69-75. 1938, pp. 93-4.
15. K ubli F. G eburtsleitung bei Beckenendlagen. 31. Bracht E. Z ur Beckenendlage-Behandlung. Geburtsh
G ynakologe. 1975;8:48-57. Frauenheilkd. 1965;25:635-7.
16. Flanagan TA , M ulchahey K M , K oren brot C C , et al. 32. V erhoeven A TM . M ethode van Bracht - 70
M an agem ent o f term breech presentation. A m J Obstet ja a r - Eponiem en. N ed Tijdschr O bstet Gynaecol.
Gynecol. 1987;156:1492-9. 2006;119:8-12.
Sectio n 3: P a th o lo g y o f L a b o r a n d L a b o r a n d D e live ry
33. V erhoeven A TM , de Leeuw JP. De theorie van de 48. V erhoeven A TM , De ontwikkeling van de arm pjes bii
m ethode van Bracht en de praktische gevolgen. N ed stuitgeboorte volgens M uller - 110 ja a r - Eponiem en.
Tijdschr Obstet Gynaecol. 2008;121:58-60. N ed Tijdschr O bstet Gynaecol. 2009;122:251-4.
34. Lovset J. Schulterentwicklung ohne A rm losun g bei 49. von M ickulicz-Radecki F. G eburtshilfe des praktischen
natiirlicher und kiinstlicher Beckenendlage, Arch Arztes. 3rd edition. Leipzig: Barth, 1943.
Gynakol. 1936;161:397-8.
50. Verhoeven A T M , M ethode volgens Sellheim. N ed
35. Lovset J. Shoulder delivery by breech presentation. T ijdsch r O bstet Gynaecol. 2008;121:64-6.
J Obstet Gynaecol Br Em p. 1937;44:696-704.
51. V erhoeven A TM . H andgreep van D e Sn oo -
36. Lovset J. V aginal operative delivery. Oslo: Eponiem en. N ed T ijdsch r O bstet Gynaecol.
Scandinavian University Books, 1968. 2003;116:101-2.
37. Verhoeven A TM . H andgreep van Lovset - 70 jaar 52. de Snoo K. Leerboek der verloskunde. 4th edition.
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Eponiem en. N ed Tijdschr O bstet Gynaecol. Groningen: W olters, 1943.
2007;120:21-3.
53. Piper EB, Backm an C. The prevention o f fetal injuries
38. Verhoeven A TM . D iihrssense incisies. N ed Tijdschr in breech delivery. JA M A . 1929;92:217-21.
O bstet Gynaecol. 2010;123:61-3.
54. G ordon D ou glas R, Strom m e W . O perative obstetrics.
39. Verhoeven ATM . De handgreep van W igand Martin- 3rd edition. N ew York: A ppleton C en tury C rofts,
b.
V on W inckel - Eponiem en, Geschiedkundige 1976.
ontwikkeling en betekenis voor de huidige praktijk.
N ed Tijdschr Obstet Gynaecol. 2008;121:345-50. 55. G rady JP, G im ovsky M. Instrum ental delivery: a lost
art? In: Studd J (ed). Progress in obstetrics and
40. van Loon AJ, M antingh A, Serlier EK, et al.
gynecology. V ol 10. Edinburgh: Churchill Livingstone,
Random ised controlled trial o f m agnetic resonance
41.
1997;350:1799-804. -li
pelvim etry in breech presentation at term. Lancet.
de Leeuw JW de, Struijk PC, V ierhout M E, et al. Risk

factors for third degree perineal ruptures during
56.
1993.
G abbe SG , Niebyl JR, Sim pson JL, et al. O bstetrics,
n orm al and problem pregnancies. 4th edition.
Edinburgh: Churchill Livingstone, 2002.
er
delivery. BJO G . 2001;108:383-7. 57. Verhoeven A TM . De Piperforceps - 80 ja a r -
Eponiem en. N ed T ijdsch r O bstet Gynaecol.
42. K urz CS, Kiinzel W. Fetale Herzfrequenz,
2009;122:180-5.
D ezelerationsflache und Saure-Basen-Status bei
Entbindung aus Beckenendlage-und Schadellage. 58. Verhoeven ATM . H andgreep van DeLee. In:
Z Geburtshilfe Perinat. 1977;181:9-16.R ef in: Kiinzel Eponiem en en geschiedenis van de stuitgeboorte.
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W (ed). Breech delivery, E uropean practice in H aarlem : D C H G , 2010, pp. 131-7.

gynaecology and obstetrics. Paris: Elsevier, 2002, 59. Crow ther CA. Caesarean delivery for the second twin.
p. 126. C ochrane D atabase Syst Rev. 2000;2:CD 000047.
us
43. de Leeuw JP. Breech presentation vaginal o r abdom inal 60. Ayres A, Johnson TR. M anagem ent o f multiple
delivery? A prospective longitudinal study. Ph.D. pregnancy: labor and delivery. O bstet Gynecol Surv.
thesis, U niversity o f M aastricht, 1989. 2005;60:550-6.
44. Brady K, D u ff P, Read JA, et al. Reliability o f fetal 61. Rabinovici J, Barkai G, Reichm an B, et al. R andom ized
buttock sam pling in assessing the acid-base balance o f m anagem ent o f the second nonvertex twin: vaginal
the breech fetus. O bstet Gynecol. 1989;74:886-8. delivery or caesarean section. A m J O bstet Gynecol.
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45. Collea JV, Chein C, Q uilligan EJ. The random ized 1987;156:52-6.
m anagem ent o f term frank breech presentation: a 62. H ofm eyr G J, K ulier R. E xpedited versus conservative
study o f 208 cases. A m J O bstet Gynecol. ap pro ach es for vagin al delivery in breech
1980;137:235-44. presentation. C och ran e D atab ase Syst Rev. 2000;2:
46. Kiinzel W, Kirschbaum M. M anagem ent o f vaginal CD 000082.
delivery in breech presentation at term. In: Kiinzel W 63. U sta IM , N assar A H , Awwad JT, et al. C om p arison o f
(ed). Breech delivery, European practice in the perinatal m orbidity and m ortality o f the presenting
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47. van G rinsven-D m itrieva N , Verhoeven ATM . 64. Caukwell S, M urphy D J. The effect o f m ode o f
Stuitgeboorte volgens Bracht (1935) o f Covjanov delivery and gestational age on neonatal outcom e o f
(1 9 2 8 )... wie had de prim eur? N ed Tijdschr Obstet the non-cephalic-presenting second twin. A m J Obstet
Gynaecol. 2013;126:245-50. Gynecol. 2002;187:1356-61.
Chapter
Operative Vaginal Delivery (Vacuum
7
and Forceps Extraction)
P.J. Dorr, G.G.M. Essed, and F.K. Lotgering
ru
General Inform ation Indications
Indications for term inating a pregnancy with the aid
Introduction o f vacuum or forceps extraction are ;
To perform vacuum or forceps extraction requires • inadequate progress (of the bony part o f the fetal
b.
knowledge o f the indication, the instrumentation, and skull) o f the second stage:
the procedure. Practitioners who perform assisted deliv - in nulliparous women after 2 hours (with
eries m ust be skilled in making the proper diagnosis and regional anesthesia after 3 hours);
in carrying out the operative delivery.1' 3 - in m ultiparous women after 1 hour (with
Definition -li
The operative vaginal deliveries discussed in this chap •
-
regional anesthesia after 2 hours);
m aternal fatigue/exhaustion;
fetal: presum ed fetal com prom ise (e.g., an abnor
er
ter relate to operative deliveries o f infants in vertex m al fetal heart rate pattern on the cardiotocogram);
presentation, for whom the second stage is accelerated • maternal: contraindications to pushing (e.g., cer
through the use o f vacuum or forceps extraction. tain cardiac and neurological disorders).
Incidence Contraindications
h
The com bined incidence o f vacuum and forceps Contraindications for assisted vaginal delivery are:
extraction varies all over the world and is between • fetal bleeding disorders, e.g., in fetal hem ophilia
3% and 13%.3,4 In m any countries, the percentage of (in a possibly m ale fetus) or throm bocytopenia:
us
forceps extractions has decreased and that o f vacuum in general, the goal should be a non-traum atic
extractions has increased.5 In the Netherlands, delivery; an outlet forceps by an experienced
between 1990 and 2012, the percentage o f forceps gynecologist is not necessarily contraindicated
extractions decreased from 5.0% to 0.4% and that of [LE B ]3'8;
vacuum extractions increased from 11.5% to 12.4%. • fetal dem ineralization (osteogenesis im perfecta)
ak
In the United States the incidence o f operative vaginal and connective tissue disease (M arfan and
delivery continues to decline. In 2010 the incidence of E h lers-D an los syndrom es): the way o f delivery
vacuum and forceps delivery was 3.6%. The use of and a possible contraindication for operative
forceps declined from 6.6% in 1990 to 1% in 2010.6 vaginal delivery depend on the kind o f disorder
and the accom panying risk factors for m other
Indications and Contraindications and child ';
• face presentation: vacuum extraction is absolutely
The indications for a vaginal term ination o f a delivery
contraindicated in a face presentation.
m ay be decided on either fetal or m aternal grounds;
not infrequently there are com binations o f factors There is a reported risk o f cephalic hem atom as and
that m ake intervention desirable. The following indi external bleeding in vacuum extraction following fetal
cations and contraindications are not absolute. scalp blood testing [LE C ]." 10
O b ste tric In te rv e n tio n s , ed. P. Joep D orr, V incent M. Khouw , Frank A. Chervenak, A m os G runebaum , Yves Jacquem yn,
Classification of Vacuum and Forceps • em pty bladder: rem ove any indwelling catheter;
• em ergency plan: set a lim it on the num ber o f
Deliveries' tractions and pop-offs beforehand, know what
V acuum and forceps deliveries can be divided into: the next step has to be, and m ake sure that this
• outlet vacuum or forceps: step can be perform ed rapidly;
- the fetal skull has reached the pelvic floor • anticipation o f com plications, such as shoulder
(fourth plane o f Hodge, H4, +5 station), dystocia and postpartum hem orrhage;
• availability o f operating room and surgical team;
the sagittal suture is positioned at less than • availability o f a pediatrician for neonatal
45° relative to the midline, with the p o s resuscitation.
terior fontanel anterior or posterior;
ru
• low vacuum or forceps: Important Points and
- the fetal skull is engaged at > + 2 station, which
Recommendations
is >2 cm below the interspinal line (past the
third plane o f Hodge, which is indicated by • Consent: wom en should be inform ed about opera
b.
H 3+), but not yet at the pelvic floor, with the tive vaginal deliveries during the antenatal period.
following subdivisions: This inform ation needs to be part o f the birth plan
o f the mother. D uring delivery obtaining verbal
rotation <45° (the sagittal suture is p osi consent is recom m ended.
tioned at less than 45° relative to the m id
or posterior);
-li
line, with the posterior fontanel anterior
rotation >45° (the sagittal suture is p osi

tioned at m ore than 45° relative to the
• Macrosomia: the operative delivery o f macrosomic
infants (birthweight >4000 g) has a greater chance o f
failure and birth trauma after an operative vaginal
delivery than after a natural delivery (relative risk
er
factor [RR] 2.6) or an elective cesarean section (RR
midline, with the posterior fontanel ante 4.2). An operative vaginal delivery, however, is not
rior or posterior); contraindicated, because it is hard to establish
• m idvacuum or m idforceps: m acrosom ia before delivery and the absolute risk
o f persistent damage is small (0.3%). If an indication
- the fetal skull is engaged (the largest skull cir
h
for operative vaginal delivery exists, between 50 and

cumference has passed the pelvic inlet), but not
99 cesarean sections are needed to prevent one
yet at 2 cm below the interspinal line);
infant from having permanent dam age [LE B ].12
us
• high vacuum or forceps: • Prematurity: various guidelines recom m end not

- the fetal skull has not yet engaged and is above to perform a vacuum extraction at a gestational
the interspinal line (above 0 station, the third age o f less than 34 weeks because o f increased risk
plane o f Hodge). o f cephalohem atom a, subgaleal and intracranial
hem orrhage [LE D ]3’11 Based on two cohort stu
ak
dies it appears that in prem aturely born infants

Criteria for Vacuum or Forceps Delivery11 with a birthweight between 1500 and 2500 g there
Criteria for performing a vacuum or forceps delivery are:
is no increased incidence o f intracranial hem or
• inform ation, explanation, and consent on the rhage after vacuum extraction [LE B] 3
procedure; • M idpelvic rotation procedures and high vacuum
• com plete dilation; extraction have higher failure rates than low pelvic
• ruptured m em branes; procedures. Those who perform these operative
• engaged head (the largest diam eter o f the fetal deliveries m ust be skilled and consider the p ossi
head has passed the pelvic inlet); in an infant in bility o f success to be high. In case o f failure, an
occiput presentation this generally m eans that the em ergency cesarean m ust be possible. H igh for
bony part o f the head is at or below the interspinal ceps are no longer perform ed [LE D ].15
line (0 station, H3); • U ltrasound exam ination m ay be considered to
• exact attitude and position o f the head can be establish the exact posture and position of
determined; the fetal head. A bdom inal and transvaginal
C h a p te r 7: O p e ra tiv e V a g in a l D e live ry (V acuu m a n d F orcep s Extraction)
ultrasound exam ination are superior to digital delayed for 1 or 2 hours or strong urge to
vaginal exam ination in establishing attitude and push develops [LE AL].24
position o f the fetal head [LE B ].16,17 • Discontinuing epidural analgesia late in labor does
In general, with an operative vaginal delivery, not reduce the incidence o f operative vaginal
traction is applied during a contraction and delivery [LE A l ].25
while the wom an is pushing [LE D]. • D uring the vacuum or forceps extraction the fetal
In the case o f both vacuum and forceps extraction, condition should be m onitored and documented.
the possibility o f fetom aternal disproportion m ust This can be done by m eans o f continuous or inter
be taken into account if there is no progression m ittent internal or external recording.
during successive tractions. There is an increased • Proper docum entation o f a vacuum or forceps
risk o f birth traum a with an increased num ber o f
ru
delivery is a requirem ent from a medical/legal
tractions (m ore than three pulls), the use o f point o f view,
additional instrum ents (vacuum and forceps),
and failure o f an operative vaginal delivery (see
Choice Between Vacuum and Forceps
Table 7.1) [LE B ].18 In this situation it should be
Delivery
b.
decided to end the procedure and to switch to
cesarean section [LE D]. In the choice between vacuum or forceps extraction
Therefore, operative vaginal delivery should be and the various types o f these instruments, specific
abandoned following three pulls o f a correctly indications, knowledge o f the com plications for
applied instrument by an experienced operator.3,10 m other and child, and the personal experience o f the
-li
If after three pulls delivery is clearly imminent,
proceeding with instrumental delivery m ay be
appropriate and less m orbid than a cesarean deliv
ery o f an infant with its head on the perineum.
person perform ing or supervising the operative deliv
ery all play a role.
It is generally true that a vacuum cup is easier to
apply than forceps, that with vacuum extraction the
er
When deciding to do a forceps extraction after adaptations o f the fetal head to the birth canal are more
failed vacuum extraction, the increased risk o f birth physiological (promoting synclitism and flexion) than
traum a in the infant m ust be weighed against the with forceps extraction, and that with vacuum extrac
increased risk o f a cesarean section in the mother. tion there is an intrinsic limitation o f the traction force,
h
An easy to perform outlet forceps can be better in because the cup releases automatically in case o f erro
this situation than a surgically complicated cesar neous pulling direction or excessive traction force.
ean section [LE D]. Forceps is the only instrument o f choice in case of
us
Conclusive evidence that the routine use o f epi indication for vaginal termination o f a pregnancy
siotom y in operative vaginal delivery reduces anal with face presentation or aftercoming head in breech
sphincter injuries is lacking. Prospective and ret presentation (see Chapter 6 on breech delivery).
rospective cohort studies show different results The results o f a Cochrane Review o f 10 RCTs
[LE B ].19-21 The only random ized controlled trial on the advantages and disadvantages o f vacuum and
o f routine versus restrictive use o f episiotom y at forceps extractions are shown in Table 7,2,26
ak
operative vaginal delivery did not show differences

in anal sphincter tears [LE A2]. ' Complications
It is recom m ended to perform a m ediolateral epi Although the neonatal and m aternal com plications
siotom y with vacuum and forceps delivery espe that m ay occur after an operative vaginal delivery
cially in prim iparous w om en [LE DJ. are often the sam e as those after spontaneous vaginal
Epidural analgesia in labor: delivery, the relative risks o f operative vaginal deliv
- results in an increased risk o f operative vagi eries are usually greater.
nal delivery com pared with non-epidural or
no analgesia (RR 1.42, 95% C l 1.28-1.57) Neonatal Complications
[LE A l ].23 Early neonatal com plications o f operative vaginal
- results in a significant reduction in rotational delivery generally occur within the first 10 hours
or m idcavity operative vaginal deliveries (RR after delivery [LE B ].27 The com plications that may
0.69, 95% C l 0.55-0.87) when pushing is occur after vacuum or forceps extraction are caused
Table 7.1 Neonatal m orbidity after different types o f deliveries (figures per 10 000 deliveries)28,29
S p o n ta n e o u s V a cu u m Forcep s V a cu u m S e co n d a ry cesarean
a n d forcep s section
Cephalic hem atom a3 167.7 1116.6b 634.6b 1360.5b
Subdural or intracerebral 2.9 8.0b 9.8b 21.3b 7.4

hemorrhage
Intraventricular hemorrhage 1.1 1.5 2.6 3.7b 2.5b
Subarachnoidal hemorrhage 1.3 2.2 3.3 10.7b 1.2
Facial nerve lesion 3.3 4.6 45.4b 28.5 b 3.1
ru
Plexus-brachial lesion 7.7 17.6b 25.0b 46.4b 1,8b
Convulsions 6.4 11.7b 9.8b 24.9b 21.3b
Cerebral depression 3.1 9.2b 5.2 21.3b 9.6b
b.
Feeding problems 68.5 72.1 74.6 60.7 117.2b
Artificial respiration 25.8 39.1b 45.4b 50.0b 103.2b
a From the study o f Demissie et al.2S; other data taken from the study o f Towner et al.29
b Significantly different from spontaneous childbirth.
-li
by com pression and/or traction to the face, the scalp,
and/or the skull, or traction in the wrong direction
Until now there is no p ro o f o f an increased chance
o f vertical transm ission o f (asym ptom atic) herpes
er
(i.e., against the pubic bone) and m ay consist of: sim plex infection after vacuum extraction or hepatitis
• lacerations and hem atom as o f the skin; B viral infection (in case o f im m unization) after
• lesions o f the facial nerves; vacuum or forceps extraction [LE B ].32,33 N o data
• hem orrhages (Figure 7.1) o f the retina, under the are available in the literature on vertical transm ission
periosteum (cephalic hem atom a), subgaleal and o f HIV and hepatitis C infections with operative
h
intracranial (subdural, subarachnoidal, intracere vaginal deliveries. The transm ission risk probably
bral, and intraventricular); depends prim arily on the degree o f viremia. In case
o f detectable virem ia it seem s prudent to avoid opera
us
• skull fractures.
tive vaginal deliveries because o f an increased chance
The incidences o f a num ber o f the above-nam ed
o f facial or scalp injuries [LE D],
com plications are listed in Table 7.1 and are based
on two extensive retrospective studies [LE B ],28,29 Maternal Complications
Late neonatal complications are rare and can usually
Operative vaginal deliveries are associated with
be considered to be late consequences o f early complica
ak
dam age to the pelvic floor with sym ptom s o f urinary

tions (neuromuscular damage, hemorrhages). There are
and fecal incontinence and prolapse.
no indications that the cognitive development o f chil
dren born after an operative vaginal delivery is different Urinary Incontinence
from that o f spontaneously born infants [LE B ],30,31
From patient-control studies it appears that:
Infections • the prevalence o f urinary incontinence 3 m onths
after vaginal delivery is 29% and the urinary
With operative vaginal deliveries there can be an
incontinence persists in three-quarters o f these
increased chance o f vertical transm ission o f various
women;
viral infections due to lacerations o f the fetal scalp,
which m ay occur with either vacuum or forceps • in the short term (<1 year) and the long term (IV2
extraction. Data are very limited on the risk o f vertical and 6 years), there are no differences in the occur
transm ission o f viral infections with operative vaginal rence o f urinary incontinence after spontaneous
deliveries. delivery, vacuum , or forceps delivery [LE B ].34-36
C h a p te r 7: O p e ra tiv e V a g in a l D e live ry (V acuum a n d F orcep s Extraction)
Table 7.2 Pros and cons o f vacuum extractions (VE) and forceps extractions (FE)2'
V a cu u m (%) F o rce p s (%) O d d s ratio, 95% re lia b ility interval
Advantages of vacuum
Vaginal and perineal ruptures 10 20 0.41 0.33-0.50
Pain during and after delivery 9 15 0.54 0.31-0.93
Advantages of forceps
Failures 12 7 1.69 1.31-2.19
Cephalic hem atom a 10 4 2.38 1.68-3.37
Retinal bleeding 49 33 1.99 1.35-2.96
Concern by the m other about her child 14 2.17 1.19-3.94
No difference between VE and FE
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C-section after VE or FE 2 3 0.56 0.31-1.02
Apgar score <7,1 min 16 15 1.13 0.76-1.68
Apgar score <7, 5 min 5 3 1.67 0.99-2.81
Skin lesion 17 17 0.89 0.70-1.13
Phototherapy 4 4 1.08 0.66-1.77
Perinatal death 0.3 0.4 0.80 0.18-3.52
b.
caput succedaneum Figure 7.1 Anatom ic
overview o f extra- and
epicranial aponeurosis intracranial hemorrhages.
cranial hematoma
periosteum
-li skin
subcranial hemorrhage
skull
er
subdural
sagittal suture
subarachnoidal
h
us
intracerebral
ak
ventricular layer
intraventricular
frontal cross-section
Table 7.3 Fecal incontinence after different types o f childbirth

Forceps
G ro u p 1: G ro u p 2: Over the years m ore than 700 types o f forceps have
o d d s ratio o d d s ratio been developed. There is no system atic study in which
(95% Cl) (95% Cl)
different types o f forceps are com pared with each
Spontaneous delivery other. There is no particular forceps that is the best
versus cesarean section 1.32 1.86 choice in all cases. It is recom m ended to develop and
(1.04-1,68)a (0.62-5.64)
m aintain the skills o f forceps extraction with a limited
FE versus spontaneous num ber o f different types o f forceps.
delivery 1.50 1.52
This chapter discusses several forceps with differ
(1.19—1.89)a (0.58-3.97)
ent characteristics, i.e., the forceps o f Naegele,
VE versus spontaneous
Kielland, DeLee, Luikart, and Piper. The benefits
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delivery 1.31 0.80
(0.97-1.77) (0.29-2.18)
and lim itations attributed to these forceps will be
discussed.40 This knowledge can be beneficial when
FE/VE versus
spontaneous delivery
choosing the right instrument.
1.47 1.91
(1.22-1.78)3 (1.00-3.67)
b.
FE versus VE Description
1.51 1.63 Forceps consist o f two parts, i.e., a left and a right
(1.07-2.13)a (0.23-10.02)
branch, which close in a lock. The branches are nam ed
a Significantly different. after the side o f the pelvis into which they are
-li
FE = forceps extractions; VE = vacuum extractions.
Group 1: incontinence o f loose stools, solid stools, or flatus;
Group 2: incontinence o f solid stools.
introduced.
•
•
The branches are com posed o f (Figure 7.2):
the blades;
the shank or the neck;
er
Fecal Incontinence
• the lock;
A systematic review o f patient-control studies shows
• the handle.
that the prevalence o f fecal incontinence, defined as
incontinence o f loose stools, solid stools, or flatus The Blades
(Group 1), varies greatly and occurs in 3.8% to
h
The blades o f the forceps can have two curves

39.5% o f women within 1 year after childbirth.
(Figure 7.2), i.e.:
When the definition o f fecal incontinence is limited
• a cephalic curve, which conform s to the shape of
to only loose and solid stools (G roup 2), the preva
us
the head;
lence lies between 0% and 4.9%. Table 7.3 shows fecal
incontinence data from the review after different • a pelvic curve, which follows the pelvic axis.
types o f delivery.37 M ost forceps have both a cephalic and a pelvic curve.
In one o f the studies o f this system atic review Kielland forceps have only a cephalic curve. The
a 5-year follow -up study show ed urinary in co n ti blades can be fenestrated (good grip on the head) or
ak
nence o f various severity in 47%, bowel urgency solid (easy to insert). The Luikart forceps has a solid
in 44%, and incidental or frequent loss o f bowel blade and a raised edge on the inside o f the blade.
control in 20%. There were no differences in urinary
The Shank or the Neck
or fecal incontinence between forceps or vacuum
deliveries.31 The shanks contain the lock. The left branch usually
contains the prom inent part; the neck o f the right
Prolapse
branch fits into the prom inent part. A m odification
The literature is neither unanim ous on the prevalence o f the shank form s the perineal curve.
o f prolapse during and after pregnancy, nor on the
influence o f operative vaginal delivery on that The Lock
prevalence.38 The Naegele forceps has a socket or English lock
One patient-control study suggests that vacuum (firm grip around the head). A sliding lock
or forceps extraction does not constitute a risk factor (Figure 7.3), such as in the Kielland and Luikart
for the occurrence o f prolapse sym ptom s.39 forceps (Figure 7.4), has the advantage in synclitism,
pelvic curve
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blade neck lock handle
b.
-li
Figure 7.2 Forceps com ponents. (A) Top view; (B) side view.
in that one branch can be inserted deeper than the

er
other branch and slid into the other branch.
The Handles
There is little difference between the handles o f the
different types o f forceps. U sually they are hollow to
h
reduce their weight.

us
Characteristics of Different Forceps

The Naegele forceps (1854) was specifically developed
as “m idforceps” for application with a severely
m olded and stuck head to resolve relative cephalic-
pelvic disproportion (Figure 7.4A). The specially
ak
developed socket lock m akes it possible to firmly

grasp the head and, if needed, adapt it to the pelvis.
Kielland left the pelvic curve out ®f the forceps
named after him (1915, Figure 7.4B) ai.d user1, the slid
ing lock developed by the Dutchman, Boerma (1907).
Owing to the lack o f the pelvic curve, this forceps
makes it possible to rotate more than 90° and by means
o f the sliding lock to use a forceps in case o f asynclitism. routine use as a protective cage around the (premature)
The Kielland is not, by principle, a “pulling instru head. In 1924, Piper introduced a special forceps
ment,” but was introduced as a “rotation instrument.” (Figure 7.4D) with an extra curvature in the shank
The m ost popular modification to the classical Simpson (perineal curve) to extract the aftercoming head in
forceps is the DeLee forceps (1920, Figure 7.4C). breech delivery. The idea o f the perineal curve is to
The difference with the prototype consists primarily o f create room between the forceps and the infant’s
the lighter design. DeLee prom oted his instrument for trunk. In 1937, Luikart designed a forceps
A B
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b.
-li
h er
us
Figure 7.4 (A) Naegele forceps; (B) Kielland forceps; (C) DeLee forceps; (D) Piper forceps; (E) Luikart forceps.
(Figure 7.4E) with solid blades and raised edges. m et and the proper instrum ent has been chosen, the
The degree o f curvature o f the Luikart forceps blades steps in perform ing an outlet forceps on an OA infant
is midway between the forceps with a curve for a highly are as follows:
ak
molded skull (Naegele forceps) and a forceps with

• Explain the procedure.
a rounder skull curve for application to an unmolded
• A sk and help the w om an to place her legs in the
skull (DeLee forceps) (Figure 7.5). The use o f the sliding
stirrups.
lock allows for adaptation to the position o f the fetal
• Perform vulvar cleaning.
skull.
• Catheterize if necessary and rem ove any indwell
Forceps Extraction Technique ing catheter.
• Perform infiltration o f the perineum or
Outlet or Low Forceps Extraction in Occiput a pudendal block with local anesthetic.
• Carefully determ ine the engagem ent, attitude, and
Anterior Presentation (OA)41 position o f the fetal head (vaginal exam ination,
See A nim ation 7.1. ultrasound).
After the indication has been made, the conditions for • Join the branches o f the forceps together and hold
perform ing an operative vaginal delivery have been out the forceps in the position to be used (Figure 7.6).
C h a p te r 7: O p e ra tiv e V a g in a l D e live ry (V acuum and F orcep s Extraction)
Lubricate the blades. left hand (as in holding a pen) to prevent

Insert the forceps (between contractions). unwanted force from being exerted on the
fetal and/or maternal tissues.
- First insert the left branch, which is held with
After the exam ining fingers o f the right hand
the thum b and index and m iddle fingers o f the
are inserted between the head and the vaginal
wall, the left branch is introduced while being
guided by the fingers and the thumb o f the
right hand in a sm ooth m otion from the con
tralateral (right) groin (Figure 7.7).
In the sam e m anner, the right branch is then
introduced with the right hand from the left
ru
groin while guided with the inserted fingers o f
the left hand.
The right branch is then further inserted over
the left branch, preferably while the left branch
b.
is held by an assistant (Figure 7.8).
The branches are locked together (Figure 7.9).
Check the proper position o f the blades by
holding the handles with one hand and check
-li with the fingers o f the other hand whether:
the sagittal suture runs from front to back

and equally far between the blades;
the lock now points at the flexion point (see
er
Figure 7.11).
Figure 7.5 Skull curves (from left to right) o f Naegele, Luikart, and
DeLee forceps blades.
h
us
flexion point
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Figure 7 .6 A -B Holding out the forceps.

ru
b.
-li
Figure 7.7 Introduction o f the left branch.
Figure 7.8 Introduction o f the right branch.
er
- The branches are now situated “ideally around
the head” (along the occipitomental circumfer
ence) and “ideally in the pelvis” (the left branch
to the left and the right branch to the right in the
pelvis);
h
• Traction is applied during a contraction and while

the w om an is pushing.
us
• Traction is applied with one hand (the pulling

hand), while the other hand grasps the shank of
the forceps to determ ine and adjust the - ever
changing - traction direction (Figure 7.10A).
• With the so-called Pajot’s maneuver, the direction of
the traction can be “steered” by the combined trac
ak
tion o f the “pulling hand” and downward pressure

on the shank o f the forceps by the other hand
(Figure 7.10B).
• Traction is applied in the direction o f the axis of
the birth canal, thus first downward and then
upward (Figure 7.10C).
• Make a m ediolateral episiotom y when the peri
neum tightens.
• M ove the handles further upward when the p os
terior hairline has passed under the sym physis and
(gradually) deliver the head.
Figure 7.9 Locking o f the branches. • After that, the branches m ay be disarticulated
146
(first the right branch, then the left branch).
ru
b.
-li
er
Figure 7.10A-C Traction w ith Pajot's maneuver.
posterior fontanel • The delivery o f the shoulders and trunk proceed as

in norm al delivery.
h
Comments
us
• The flexion point (Figure 7.11) refers to the part of

the skull that - also in spontaneous deliveries with
an occiput anterior position - is situated centrally in
the birth canal axis. In a normally molded head the
flexion point is situated in the midline on the sagittal
suture, approximately 3 cm in front of the posterior
ak
fontanel and 6 cm behind the anterior fontanel.

• I n general, the left branch is introduced first and then
the right branch is slid over the top. This will allow
the branches to be locked together without “crossing
the branches” (crossing the branches may cause
lacerations of the birth canal and the infant’s scalp).
. If the branches do not close well, it must first be
anterior fontanel determined which branch is not situated properly
and this branch must be repositioned while guided
Figure 7.11 Flexion point.
by the examining fingers.
• To prevent compression o f the head while pulling,
one finger o f the pulling hand can be placed between
the handles. 14i
Outlet or Low Forceps Extraction in Occiput

Presentation, Occiput Left Anterior (LOA)
or Right Anterior (ROA)
See Anim ation 7.2.
U pon introducing the forceps, the head is encom
passed biparietally, but the forceps will not lie ideally
in the pelvis.
• In the LOA position the left branch is introduced
in the left posterior pelvis from the m iddle
ru
between the right groin and the symphysis, while
guided by the right hand. After insertion, the
handle points to the left thigh (Figure 7.12).
• The right branch is crossed over into the right
posterior pelvis starting from the left groin, guided
b.
by the left hand (Figure 7.13). After that, the right
branch is m ade to “wander” to right anterior
(Figure 7.14). After closing the lock both handles
point to the left.
•
•
Traction and rotation
simultaneously. -li
m ust
The rotation m ust be com plete when the pelvic

floor is reached.
be perform ed
er
• In the ROA position the sam e basic procedure is
followed, but in that case you let the left branch
wander. Figure 7.12 Introduction o f the left branch with head in LOA.
h
us
ak
Figure 7.13 Introduction o f the right branch.
Figure 7.14 W andering with the right branch.

C h a p te r 7: O p e ra tiv e V a g in a l D e live ry (V acuum a n d Forcep s Extraction)
ru
b.
Figure 7.15 Positioning the forceps with head in M A presentation.
Figure 7.16 M ove forceps ventrally before closing the branches.
Technique
See Anim ations 7.3 and 7.4.
-li • In an M A position the forceps is placed ideally
around the head and in the pelvis (Figure 7.15).
The lock points to the chin. The branches lie along
er
the m ento-occipital circumference.
When closing the forceps, the handles o f the not
completely closed forceps are m oved ventrally, so
that the head is grasped alongside the aforementioned
circumference and not over the forehead with the
h
point o f the branches in the neck (risk o f plexus

lesion!) (Figure 7.16).
• After the forceps is closed and the head is firmly
us
grasped between the blades, traction is applied in

a forward and dorsal direction, whereby the larynx
can becom e a rotation point (hypomochlion)
under the symphysis. Then the handles are
Figure 7.17 Traction applied in ventral direction after the larynx is m oved in a ventral direction, whereby the fore
ak
exposed below th e symphysis.

head and then the occiput are born (Figure 7.17).
Forceps Extraction in Face Presentation Comment

A forceps extraction with face presentation is only With an indication to terminate the delivery vaginally
possible if the following conditions are met: with the occiput in left or right transverse, left or right
posterior, or posterior position, vacuum extraction is
• head on the pelvic floor: only when at the pelvic
preferred. Ultimately, this facilitates “spontaneous”
floor the largest dim ension o f the head has passed
adaptation o f the head to the birth canal and norm al
the pelvic inlet;
development o f rotations [LE D],
• m entum anterior (M A) position; if the chin does
not present right under the sym physis and the
branches are introduced obliquely, there is a Vacuum Extractor
great chance o f injuring the face. With the chin The first clinically applicable obstetric vacuum
in posterior position, vaginal birth is im possible. extractor was invented in 1849 by Jam es Y oung
Sim pson. But vacuum extraction only becam e p o p

ular with the introduction o f a m ushroom -shaped
cup designed by M alm strom in 1957. T his allowed
for the sam e am ount o f negative pressure to provide
greater traction than with the previously used clock
shaped cups. The advantage o f this m u sh room
shaped cup is lost, however, if the traction is not
directly perpendicular to the surface o f the cup,
which causes the cup to tip to one side and pop off.
Since the ideal direction o f the traction follow s the
pelvic axis, and is therefore not always perp en d icu
ru
lar to the cup, attem pts have been m ade to rem edy
this disadvantage by either changing the technique
(Dreifingergriff [three-finger g rip ]j or through ad ap
tations to the instrum ent, such as with the O ’Neil
cup and the New G eneration cup o f Bird.
b.
The Instrument Figure 7.18 Soft cup.
Different types o f vacuum cups are available with
differences in m aterial, shape, and size. 15.7 kg is possible and 22.6 kg with a 6 cm cup.
Material -li
Currently used vacuum cups are made o f metal or of
flexible or hard plastic. Extractions made with soft cups
The m ost effective and safest cup size is not known.
The sam e is true for tractive force.
Vacuum Pressure
er
fail more often than those made with metal cups (OR In general, a vacuum pressure o f 0.8 kg/cm 2
1.65, 95% RI 1.19-2.29), but soft cups have the advan (= 600 m m H g) is recom m ended. At a lower pressure
tage o f causing less injury to the fetal scalp (OR 0.45, the chance o f cup pop-offs increases and at a higher
95% RI 0.34-0.60) [LE A ].42 Therefore, soft cups are an pressure the chances o f fetal skin lacerations and
h
alternative for an outlet vacuum with O A position, while cephalhem atom as are increased.44
metal and hard plastic cups are preferred with other Creating continuous suction up to 0.8 kg/cm 2 is
attitudes and positions o f the fetal head (Figure 7.18).43 faster than and ju st as effective and safe as increasing
us
the vacuum pressure in steps [LE A l ].45

Shape
Metal cups usually have the shape o f a m ushroom , Characteristics of Different Vacuum Cups
while soft cups are shaped like a clock. The pulling V acuum cups in current usage are all inspired by the
power o f a m ushroom -shaped vacuum cup is greater M almstrom cup and have the above-described m ush
than that o f a clock-shaped cup. Poor perform ance o f
ak
room shape. The suction tube is connected to a valve

the soft cup is probably m ore due to the clock shape in the center o f the cup. On the inside o f the cup there
than the m aterial being employed. is a metal plate to which a chain is attached. The
The Kiwi Om niCup was introduced in 2001. This chain runs through the exhaust tube to a handle.
disposable ventouse is equipped with a plastic cup and, The M alm strom cup is available in different sizes.
in contrast with other plastic cups, is mushroom The m ost used cup has a diam eter o f 50 mm
shaped. The Kiwi Om niCup has a visual indicator, (Figure 7.19). W ith this cup a m axim um tractive
which allows the tractive force to be read. Little research force o f m ore than 15 kg is only possible if the pull
has been done into the efficacy and safety o f this cup. chain is directly perpendicular to the cup while trac
tion is applied. As described with the extraction tech
Size
nique, traction is applied in the direction o f the axis of
The size o f the cup also determ ines the tractive force. the birth canal. W hen the direction o f the traction is
With a vacuum pressure o f 0.8 kg/cm 2 and a 5 cm no longer perpendicular to the surface o f the cup, even
diam eter m ushroom -shaped cup, a traction force o f with a sm all deviation the tractive force will decrease
considerably as a result o f the tipping o f the cup, chain. The O ’Neil cup is available in diam eters o f
which increases the chance o f the cup popping off. 50 m m and 55 mm.
This drawback is rem edied by the O ’Neil cup In the Bird cup the chain is in the center, without
(Figure 7.20). In this cup the connection point o f the elevation, fastened to the surface o f the cup, making
pull chain is flexibly attached to the top o f the cup. the contact point o f the tractive force closer to the
This allows the connection point to follow the direc surface o f the fetal skull com pared to the M alm strom
tion o f the traction, with the result that no tipping or cup. This greatly decreases the tendency o f the cup to
decreased tractive force occurs up to a deviation o f 30° tip when the direction o f the traction is not perpen
o f the right angle (Figure 7.20). Thus, the cup m ain dicular to the plane o f the cup.
tains its tractive force also when, under traction, the The suction tube o f the regular OA cup - just as in
axis o f the birth canal is followed. The tube for supply the O ’Neil cup - is located eccentrically on the cup
ru
ing suction to the cup is located eccentrically on the (Figure 7.21A). The OA cup is recom m ended for use
top (anterior cup) or the side (posterior cup) o f the
cup and has therefore no relationship to the pull
b.
-li
h er
Figure 7.19 Malm strom cup. Figure 7.20 O'Neil cup
Figure 7.21 Bird cup: OA

us
cup (A) and OP cup (B).

ak
151
Sectio n 3: P a th o lo g y o f La bo r a n d La bo r a n d D elivery
Figure 7.22 Kiwi Om niCup.
ru
b.
-li
with OA position. In the occiput posterior (OP) cup
the suction tube is located on the side o f the cup
and the proper instrument has been chosen, the steps
er
in perform ing a vacuum extraction are as follows:
(Figure 7.21B). This OP cup can be used to insert • Explain the procedure.
the cup deep toward the sacrum in case o f an OP • A sk and help the wom an to place her legs in
position. Cleaning the Bird cup and m aking it ready stirrups.
for use is easier than with the M alm strom cup.
• Perform vulvar cleaning.
h
The Kiwi OmniCup is a plastic disposable cup

• Catheterize if necessary and remove any indwel
that is fixed to a m anual vacuum pum p
ling catheter.
(Figure 7.22). In this cup the contact point o f the
• Perform an infiltration o f the perineum or
us
pull cord lies considerably closer to the fetal skull

a pudendal block with local anesthesia.
surface than with the M alm strom cup. The pull
• Carefully determ ine the engagem ent, attitude, and
cord - as in the M alm strom cup - runs through the
position o f the fetal head (vaginal exam ination,
vacuum suction tube. The suction tube has a sm all
ultrasound).
diam eter (Figure 7.22).
• Connect the cup to the vacuum pum p.
ak
As a result, the tube m ay easily becom e clogged at

suction o f even sm all am ounts o f am niotic fluid or • Check whether the vacuum pum p is functioning
blood, resulting in loss o f vacuum. properly.
The cup has a diam eter o f 50 mm. • Lubricate the outside o f the cup.
The failure rate (not achieving a vaginal delivery) • Introduce the cup beyond a contraction
o f the Kiwi O m niCup versus conventional cups shows (Figure 7.23).
heterogeneity o f results. There are no differences in - A m etal or a hard plastic cup is inserted at an
m aternal or neonatal outcom es [LE A 2].45 angle after spreading the labia; when the pos
terior side o f the cup touches the fetal head the
anterior side o f the cup is pushed downwards
Vacuum Extraction Technique41,43 till it lies on the fetal head.
After the indication has been set, the conditions for - A soft cup can be doubled and inserted after
performing an assisted vaginal delivery have been met, spreading the labia.
posterior fontanel
flexion
cup^diame^r 5 cm
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sagittal suture
b.
anterior fontanel
Figure 7.24 Location o f cup on flexion point.
-li after correct placement o f the cup. Note: Placement

o f the cup on the flexion point prom otes synclitism
er
and flexion o f the head and passage through
the birth canal with the suboccipitofrontal
circumference.
After placing the cup, it m ust be carefully deter
m ined through palpation around the cup whether
h
any part o f the cervix or vaginal wall is stuck

between the cup and the fetal scalp. If everything
is clear, negative pressure is applied up to 0.1-
us
0.2 kg/cm 2 and another check is perform ed by

palpation for any possible entrapm ent o f the
cervix or vaginal wall (in case o f entrapm ent the
vacuum pressure is shut o ff and the cup is reposi
tioned). Then negative pressure is applied up to
ak
0.8 kg/cm 2.
D uring the following contractions - and m aternal
Figure 7.25 Traction w ith presenting head in OA. expulsive efforts - tractions are performed.
- The fingers o f the dom inant hand grasp the
• The center o f the cup is placed at the flexion point handle, while the fingers o f the non-dom inant
o f the fetal head (Figure 7.24); with a 5 or 6 cm hand are placed on the fetal head and on the
cup, the center o f the cup should be approxim ately cup (two fingers on the head and the thum b
3 cm in front o f the posterior fontanel, and the on the cup, the Dreifingergriff [three-finger
edge o f the cup should be on the border of grip], Figures 7.25 and 7.26) (see A nim ation
the posterior fontanel; the anterior fontanel 7.5), in order to determ ine the traction direc
form s the reference point after placing the cup, tion and to prevent prem ature pop o ff o f
since the posterior fontanel is not readily palpable the cup.
153
- The direction o f the pulling m ust always follow

the axis o f the birth canal to prevent the head
from getting stuck against the pubic sym phy
sis. For that reason, the traction cannot always
be perpendicular to the cup (Figure 7.27) (see
Anim ation 7.6).
- If during the traction the pull chain is not per
pendicular to the cup, a tilt m om ent occurs that
m ust be corrected by digital pressure to the
tilting side o f the cup to prevent the cup from
dislodging. Traction is gradually increased dur
ru
ing a contraction. Jerking m otions increase the
chance o f the cup popping off.
- During traction the head will rotate sponta
neously if necessary as it descends. It should
b.
be avoided to make turning m otions during
the tractions - in order to prom ote rotation -
Figure 7.26 Traction with presenting head in OA. as this increases the chance o f scalp lesions.
-li
h er
us
ak
Figure 7.27A-C Traction with presenting head in LOA.

C h a p te r 7: O p e ra tiv e V a g in a l D e live ry (V acuu m a n d F o rcep s Extraction)
• It is recom m ended, at least in prim iparous

women, to perform a m ediolateral episiotom y
References
1 E ssed GGM . C om plicaties blj kunstverlossingen. In:
when the head crowns.
H einem an M I (ed.). Com plicaties in obstetrie en
• W hen the head is born, the vacuum is shut o ff and gynaecologie. Bussum : M edicom Europe, 1994,
the cup is removed. pp. 19-30.
• The delivery o f the shoulders and trunk proceed as 2 N V O G . V aginale kunstverlossing (vacuiim extractie,
in norm al delivery. forcipale extractie). N V O G richtlijn, 2005.
3 Royal College o f O bstetricians and Gynaecologists.
Guideline N o 26, Operative V aginal Delivery, 2011.
Reasons for Failure of Vacuum 4 Lum biganon P, Laopaiboon M, G iilm ezoglu M, et al.
Extractions43
ru
M ethod o f delivery and pregnancy outcom es in Asia:
Failure o f a vacuum extraction can be for various the W H O global survey on m aternal and perinatal
health 2007-8. Lancet. 2010;375:490-9.
reasons, e.g.:
5 G oetzonger KR, M acones GA. Operative vaginal
• fetom aternal disproportion;
delivery: current trends in obstetrics. W om ens Health
• placement o f the cup at a location other than the
b.
(Lond Engl). 2008;4:281-90.
flexion point: this will result in a greater circumfer 6 Births: Final data for 2010. N atl Vital Stat Rep.
ence o f the head having to pass through the birth 2012;61:1-70.
canal; 7 A C O G . Operative vaginal delivery. A C O G Practice
• incorrect traction direction: the chance o f cup Bulletin N o 17, 2000.
-li
pop-offs increases when the pull chain does not
follow the axis o f the birth canal, such as when
traction is applied upward before the head crowns;
• a large caput succedaneum .46
8 M eijer K, B ou m an K, Sollie K M , et al. B egeleiding
van de zw angerschap en de p artu s bij d raag sters
van hem ofilie. N ed T ijd sch r G eneeskd. 2008;152:
1249-53.
er
9 Roberts IF, Stone M. Fetal hem orrhage: com plication o f
Im portant Points and vacuum extractor after fetal blood sam pling. Am
I O bstet Gynecol. 1978;132:109.
Recommendations 10 Thierry M. Fetal hem orrhage follow ing b lood sam pling
and use o f vacuum extractor. A m J Obstet Gynecol.
h
• Prior to the vacuum or forceps extraction, care

1979;134:251
fully determ ine the engagem ent, posture, and
11 W egner EK, Lockw ood CJ, Baras VA. Operative vaginal
position o f the fetal head, if necessary with the
delivery. U pT oD ate. 2013; April.
us
aid o f ultrasound [LE D].

12 K olderup LB, L aros R K Jr, M usci TJ. Incidence o f
• Establish an (emergency) plan when perform ing
persistent birth injury in m acrosom ic infant:
a vacuum or forceps extraction. association with m ode o f delivery. A m J Obstet
- D eterm ine the num ber o f tractions and m in Gynecol. 1997;177:37-41.
utes, generally three or four tractions and 20 13 M orales R A dair C D , Sanchez-Ram os L, et al. V acuum
ak
m inutes [LE D], extraction o f preterm infants with birth weights o f 1500
to 2499 gram s. J Reprod M ed. 1995;40:127-30.
- Know what the next step has to be and make sure
that this step can be carried out quickly [LE D], 14 C astro M A, H oey SD , Tow ner D. Controversies in the
use o f the vacuum extractor. Sem in Perinatal
- Anticipate com plications (shoulder dystocia,
2003;27:46-53.
postpartum hem orrhage) [LE D],
15 H ankins D V, Rowe TF. Operative vaginal delivery' -
• Ensure there is close observation o f the neonate Y ear 2000. A m J O bstet Gynecol. 1996;175:275-82.
after a vacuum or forceps extraction. Early neo 16 Z ah alka N, Sadan O, M alin ger G, et al. C o m p ariso n
natal com plications o f assisted vaginal delivery o f tran svagin al so n o grap h y w ith digital
generally occur within the first 10 hours after e xam in ation an d tran sab d o m in al son o grap h y for
delivery [LE B ].27 the d eterm in ation o f fetal h ead p o sitio n in
the secon d stage o f lab or. A m J O bstet G ynecol.
• M aintain the skills o f forceps extraction by practi
2 00 5 ;1 9 3 :3 8 1 -6 .
cing on a dum m y [LE D].
155
Se ctio n 3: P a th o lo g y o f La b o r a n d La b o r a n d D e live ry
17 Ram phul M, Kennelly M, M urphy D J. E stablishing the in tracran ial delivery. N E ngl J M ed. 1999;341:
accuracy and acceptability o f abdom inal ultrasound to 1709-14.
define the foetal head position in the second stage of 30 C arm o d y F, G ran t A, M u tch L, et al. Follow up o f
labour: a validation study. Eur J O bstet Gynecol Reprod b ab ies delivered in a ra n d o m ize d con trolled
Biol. 2012;164:35-9. co m p a riso n o f vacu u m extraction an d forceps
18 M urphey D J, Liebling RE, Patel R, et al. C oh ort study o f delivery. A cta O b stet G yn ecol Scan d . 1 9 8 6;65:763-6.
operative delivery in the second stage o f labour and 31 Johan son RB, H eycock E, C arter J, et al. M aternal and
standard o f obstetric care. Br J Obstet Gynaecol. child health after assisted vaginal delivery: five year
2003;110:610-15. follow o f a random ized controlled study com paring
19 de Leeuw JW , de W it C, Kuijken JPJA , et al. forceps and ventouse. B r J O bstet Gynaecol. 1999;106:
M ediolateral episiotom y reduces the risk for anal 544-9.
sphincter injury during operative vaginal delivery.
ru
32 Sedan O, D ishi M, Som ekh E, et al. V acuum extraction
Br J Obstet Gynaecol. 2008;115:104-8. and herpes sim plex virus infections. Int J Gynecol
20 Raisanen SH , Vehvilainen-Julkunen K, G issler M, et al. Obstet. 2005;89:242-6.
Lateral episiotom y protects prim ip arous w om en from 33 W ang J, Zhu O, Z hang X. Effect o f delivery m ode on
obstetric anal sphincter rupture. Acta Obstet Gynecol m aternal-infant transistor o f hepatitis B virus by
Scand. 2009;88:1365-72.
b.
im m unoprophylaxis. Chin M ed J. 2002;115:1510-12.
21 M acleo d M , Strach an B, Bahl R, et al. 34 M acA rthur C, G lazener CM , W ilson PD, et al.
A p rospective coh ort study o f m atern al an d Persistent urinary incontinence and delivery m ode
n eon atal m o rb id ity in relation to use o f history: a six-year longitudinal study. BJO G . 2006;113:
ep isio to m y at operative vagin al delivery. 218-24.
22 -li
Br J O b stet G ynaecol. 2008;115 :1 6 8 8 -9 4 .
M u rph ey D J, M acleo d M , Bahl R, et al. A ran d om ized
con trolled trial o f routine versu s restrictive use o f
episiotom y at operative v agin al delivery:
35 G lazener CM , H erbison GP, M acA rthur C, et al.
New postnatal urinary incontinence: obstetric and
other risk factors in prim iparae. BJO G . 2006;113:
208-17.
er
a m ulticen ter p ilo t study. B r J O b stet G ynaecol. 36 G artland D , D onath S, M acA rthur C, Brow n SJ.
2 0 0 8;115:1695-702. The onset, recurrence an d associated obstetric risk
23 A nim -Som uah M, Smyth RM , Jon es L. E pidural versus factors for urine incontinence in the first 18 m onths
non-epidural or no analgesia in labour. Cochrane after a first birth: an A ustralian n ulliparous cohort
D atabase Syst Rev. 2011;12:CD 000331. D O I: 10.1002/ study. BJO G . 2012;119:1361-9.
h
14651858.C D 000331,pub3. 37 Pretlove SJ, T h om p so n PJ, T o osz-H ob son PM , et al.

24 Roberts CL, Torvaldsen S, C am aron CA, et al. Delayed D oes the m ode o f delivery predispose w om en to anal
versus early pushing in w om en with epidural incontinence in the first year postpartu m ?
us
anesthesia: a system atic review and m eta-analysis. A com parative system atic review. BJO G . 2008;115:
BJO G . 2004;111:1333-40. 421-34.
25 Torvaldsen S, Roberts CL, Bell JC, et al. 38 H an da V L, Brubaker L, Flak S. Pelvic floor disorders
D iscontinuation o f epidural analgesia late in labour for associated with pregnancy. U pT oD ate. 2008;M ay.
reducing adverse delivery outcom es associated with 39 Tegerstedt G, M iedel A, M aehle-Schm idt M , et al.
epidural analgesia. Cochrane D atabase Syst Rev. O bstetric risk factors for sym ptom atic prolapse:
ak
2004;4:CD 004457. a population -based approach. A m J O bstet Gynecol.

26 Johanson RB, M enon V. V acuum extraction versus 2006;194:75-81.
forceps for assisted delivery. Cochrane D atabase Syst 40 E ssed G G M . G eschieden is van de vaginale
Rev. 1999;2:CD 000224. D O I: 10.1002/14651858. ku n stverlossin g. In: M erkus JM W M (ed.).
CD 000224. O bstetrische interventies. B u ssu m : M edicom Europe,
27 Sm it-W u M N , M oonen-D elarue D M , Benders M J, et al. 1991, pp. 3-15.
Onset o f vacuum -related com plaints in neonates. Eur 41 O ’G rady JP, M cllhargie CJ. Instrum ental delivery. In:
J Pediatr. 2006;165:374-9. O ’G rady JP, G om ovski M L, M cllh argie C J (eds).
28 D em issie K, R hoads G C, Sm ulian JC, et al. Operative O perative obstetrics. Baltim ore: W illiam s 8c W ilkins,
vaginal delivery and neonatal and infant adverse 1995.
outcom es: population based retrospective analyses 42 Johan son R, M enon V. Soft versus rigid vacuum
BM J. 2004;329:1-6. extractor cups for assisted vaginal delivery. Cochrane
29 Tow ner D , C astro M A, Eby-W ilkins BS, et al. Effect o f D atabase Syst Rev. 2000;2:CD 000446. D O I: 10.1002/
m ode o f delivery in n ulliparous w om en on neonatal 14651858.CD 000446.
C h a p te r 7: O p e ra tiv e V a g in a l D e liv e ry (V acuu m a n d F o rce p s Extraction)
43 G reenberg J, Lockw ood CJ, B arss V. Procedure for 45 O ’M ahony F, H ofm eyr GJ, M enon V. Choice o f
vacuum assisted operative vaginal delivery. U pToD ate. instrum ents for assisted vaginal delivery. Cochrane
2013, M arch. D atabase Syst Rev. 2010;11:CD 005455. D O I: 10.1002/
14651858.CD005455.pub2.
44 Suw annachat B, Lum bigan on P, Laopaiboon M. Rapid
versus stepw ise negative pressure application for 46 M uise KL, D uchon M A, Brow n RH. The effect o f
vacuum extraction assisted vaginal deliver}'. Cochrane artificial caput on perform ance o f vacuum extractors.
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14651858.CD 006636.pub3.
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h er
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157
Chapter
Shoulder Dystocia
8
P.P. van den Berg and S.G. Oei
ru
General Information height and ultrasound, fetal weight is difficult to esti
mate. The average m argin o f error between the esti
Introduction m ated fetal weight and the actual birthweight is
between 15% and 20%. Therefore, the predictive
Shoulder dystocia constitutes an obstetric emergency
b.
value o f this risk factor is low [LE C ].2’3
due to the risk o f m orbidity to the infant, i.e., asphyxia
The risk o f shoulder dystocia m ust be taken into
and/or traum a, such as a brachial plexus injury.
account in the delivery o f a fetus with a high estimated
birthweight, as well as slow progress in dilatation and
Definition
-li
Shoulder dystocia occurs during childbirth when the
infant’s anterior shoulder becomes impacted behind
the symphysis o f the mother after going through the
customary steps. Since the definition o f shoulder dysto
expulsion and operative vaginal delivery. Early sym p
tom s o f shoulder dystocia include the occurrence of
head bobbing and the turtle sign. W ith head bobbing,
the head shows in the perineum each time during
pushing, but disappears again between contractions.
er
cia is rather subjective, the literature also speaks of With the turtle sign, the head is born slowly and
a “head-to-trunk time interval” o f more than 60 sec pulled back against the perineum (Figure 8.1).
onds. Another criterion for shoulder dystocia is the need
for performing additional maneuvers to deliver the
Indications
h
shoulders [LE D j.!

Prevention o f the above-m entioned risk factors
Incidence should provide the obstetrician with incentive to exer
us
cise extra care. A case o f estim ated high fetal weight

Shoulder dystocia occurs in 0.2-3% o f vertex presen
and protracted dilatation or expulsion should trigger
tation deliveries.2
the notion o f a possible shoulder dystocia.
In case o f difficulty in delivering the anterior
Risk Factors shoulder, be sure to:
There are different risk factors involved in the occur
ak
• provide sufficient rest and room ;

rence o f shoulder dystocia:
• do no m ore pushing, pulling, or turning the head;
• a previous delivery with shoulder dystocia; • use a birthing bed with stirrups;
• diabetes mellitus or gestational diabetes; • have a plan o f action, i.e., a series o f m aneuvers in
• obesity, post-term pregnancy; a fixed order.
• multiparity; The indication to perform a certain maneuver in the
• high birthweight; event o f a shoulder dystocia should be in an order from
• pelvic disorders [LE C ].2’3 less to m ore stressful to the woman and the infant.
M any o f the risk factors are related to high birth The first maneuver to be performed should be the one
weight. But the problem is that with the current that causes the least damage. If this does not solve the
m ethods, such as palpation and m easuring the fundus problem, the next step should be attempted.
O b stetric In te rv e n tio n s , ed. P. Joep D orr, V incent M. Khouw , Frank A. Chervenak, A m os G runebaum , Yves Jacquem yn,
and Jan G. N ijhuis. Published by C am bridge U niversity Press. © C am bridge U niversity Press 2017,
C h a p te r 8: S h o u ld e r D ystocia
ru
b.
Figure 8.1 Turtle sign. (A) Side view; (B) perspective view.
Technique -li
The treatment o f shoulder dystocia requires a series o f
successive actions that must be performed quickly and
causes the symphysis to turn upward and the angle
between the lumbar and the sacral spinal column to
decrease (Figure 8.2) (see Animation 8.1). This allows
the posterior shoulder to come down further and cre
er
expertly by the obstetrics team. The order o f the actions
ates m ore room for the anterior shoulder.
goes from less to more complicated, but may differ
from clinic to clinic. It is important, however, that the
obstetrics team in each clinic maintains a certain fixed
Pressure Suprapubic
order. One o f the possibilities is the so-called HELPERR Through suprapubic pressure, applied laterally in the
h
acronym, which is explained below [LE D ]4'5 direction o f the side o f the fetal abdom en, an attempt
is m ade to bring the anterior shoulder into an adduc
tion position, so that it can slide under the symphysis
Help
us
(Figure 8.3) (see Anim ation 8.2). While applying

Call in extra help, from nursing to obstetrics personnel suprapubic pressure, sim ultaneous dorsal traction is
and a pediatrician. Start a time clock and record the applied to the head (beware o f brachial plexus injury).
actions performed. It is essential that each assistant is This m aneuver can also be applied in com bination
familiar with the protocol and his or her responsibility with the M cRoberts maneuver.
therein. This will prevent unnecessary time loss.
ak
Enter Maneuvers (Internal Rotation)

Episiotomy The enter maneuvers concerns a num ber o f rotation
Even though shoulder dystocia is a bony problem , an techniques, all leading to the goal o f having the ante
episiotom y should be contem plated when applying rior shoulder to pass obliquely under the symphysis.
rotation m aneuvers to create m ore room for the • In the Rubin m ethod, pressure is applied with two
assistant and to prevent tissue injuries. Since the fingers to the back o f the scapula o f the anterior
M cRoberts m aneuver together with suprapubic pres shoulder to decrease the shoulder-to-shoulder
sure provide a high success rate (40-50% ), an episiot distance through adduction (Figure 8.4) (see
om y could be perform ed at a later stage. Anim ation 8.3).
• W ith the W oods m aneuver, pressure is also
Legs (McRoberts Maneuver) applied to the front o f the posterior shoulder
Apply extreme flexion and abduction to the hips o f the tow ard the back o f the infant, thereby initiating
pregnant woman. This prom otes pelvic rotation, which a “corkscrew -like” m ovem ent with both hands
ru
R = sacroiliac joints (point of rotation)
P S = position posterior shoulder
A S = position anterior shoulder
b.
Figure 8.2 McRoberts maneuver.
scapula
-li
h er
us
Figure 8.3 Pressure suprapubic.

ak
(Figure 8.5) (see A nim ation 8.4). T his causes a

combination o f adduction o f the anterior shoulder
and abduction o f the posterior shoulder, which Figure 8.4 Rubin method.
should dislodge the anterior shoulder that was

wedged behind the symphysis. This m aneuver
could be continued for 180°, thereby m aking
with the hand that coincides with the abdom inal side
the posterior shoulder becom e the anterior
shoulder. o f the infant (thus, with the left hand if the abdom en
is to the right and vice versa). The fingers follow the
hum erus up to the elbow. By applying pressu re to the
Remove the Posterior Arm fold in the elbow the lower arm flexes, which allows
The posterior arm o f the fetus is extracted by reach it to be swept p ast the thorax and the face to the
ing along the back o f the curvature o f the sacrum outside.
ru
Figure 8.5 W oods method.
creates space
This m aneuver decreases the biacrom ial width, Figure 8.6 Remove the posterior arm.
b.
whereby the fetus descends further into the sacral
cavity and thereby resolves the im paction. • The Zavanelli maneuver: the head is replaced into
G rasping and pulling o f the fetal arm m ust be the pelvis. After tocolysis, the head is returned
avoided, as this can cause hum erus fracture. When to the original occiput anterior or occiput poster
-li
perform ing internal m aneuvers, it is preferable to use
the whole hand, including the thumb. Otherwise it is
virtually im possible to reach high into the birth canal
to dislodge the posterior arm (Figure 8.6) (see
•
ior position, flexed and pushed back into the
vagina, followed by cesarean section.
Sym physiotom y (Figure 8.8) (see Anim ation 8.7).
- Two assistants m ust support the legs to pre
er
A nim ation 8.5). vent sudden abduction o f the legs after the
sym physiotom y (the angle between the legs
Roll the Patient (All-fours Maneuver)6-8 m ay be no m ore than 60-80°).
Applying the all-fours maneuver: the patient rolls - Ensure infiltration o f the skin and symphysis
h
from a dorsal position to a knees and elbows position. with lidocaine 2%.
By turning, the anterior shoulder often dislodges - Insert a transurethral catheter and keep the
spontaneously. The posterior arm m oves also toward catheter away from the midline with the
us
the abdom en due to gravity, which produces extra index and middle fingers.
sacral space and facilitates internal rotation proce - Make an incision with a scalpel o f the skin
dures or sweeping o f the posterior arm (Figure 8.7) above the symphysis, followed by incision o f
(see A nim ation 8.6) [LE C /D ]. the sym physis fibers until the pressure o f the
It depends on the attending obstetric team scalpel is felt by the index and middle fingers.
w hether they will first attem pt to perform the R o f
ak
- Remove the catheter after transecting the sym

Remove (sw eeping the p osterior arm down while the physis and allow the birth to take place.9
pregnant w om an lies on her back) or whether the
R o f Roll (patient is placed in a knees and elbows
position , after which an attem pt is m ade to free the Complications
p osterior arm ) is applied first in the H ELPERR The occurrence o f shoulder dystocia can have serious
acronym . com plications for the neonate. The morbidity
I f the above-m entioned procedures did not lead to reported in the literature is 8-20% [LE C ].2’10’11
the infant’s birth even after repeated efforts, there are Excessive traction to the head m ay cause a brachial
still a num ber o f other options.4 However, you m ust plexus injury (C 5-T 1) due to avulsion or stretching of
always ask yourself whether a risky procedure would the corresponding nerve fibers. This leads to limited
be the best choice, especially if the team lacks the m otion o f the arm or hand. Moreover, the traum a
experience. The options are as follows: resulting from the m aneuvers can cause clavicular or
• The clavicle is broken on purpose. hum eral fracture.
extra sacral space
ru
b.
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h er
Figure 8.7 The all-fours maneuver and sw eeping o f the "posterior" arm. (A) Extrasacral space; (B and C) locating posterior arm;
(D) sweeping posterior arm.
us
Insufficient oxygenation o f the fetus due to poor

perfusion can lead to perm anent neurological dam age
and death. After the delivery o f the head, the fetal
pH can decrease by 0.04 for each m inute the birth o f
the trunk is delayed. Therefore, a head-to-trunk time
ak
interval o f less than 5 m inutes m ust be pursued.

The possibility o f perm anent fetal brain dam age
increases progressively with a time interval o f 10
m inutes.9
In pregnant w om en, seriou s shoulder dystocia
and the corresp on din g m aneuvers can lead to
trau m a to the birth canal (sym ph ysiolysis) and
hem orrhage. These com plication s can also occu r if
the corresp on din g m aneuvers were perform ed
adequately.
The social and m edical/legal ram ifications o f the
com plications o f a shoulder dystocia during p arturi
tion should be borne in m ind. This is another reason
Figure 8.8 Symphysiotomy. why it is good to m aintain proper m edical reporting
[LE D ].12 The following checklist will be useful for this approach can provide support in this respect.
[LE D ]:8'12 In case o f sim ulation training, we recom m end that
all caregivers involved becom e fam iliar with the
• date and tim e o f delivery;
protocol [LE B /D ).
• caregivers present during the delivery;
• shoulder dystocia described as a com plication;
• indication o f the anterior shoulder; Important Points and
• time between the birth o f the head and that o f the Recommendations
trunk;
• The occurrence o f shoulder dystocia is usually not
• m aneuvers applied and the order thereof;
predictable [LE C].
• birthweight and A pgar scores;
ru
• A large time differential between the birth o f the
• blood analysis results o f the um bilical cord blood;
head and the trunk can result in serious hypoxia
• pediatric exam ination, prim arily for function
for the child, with a chance o f perm anent neuro
lim itations o f the upper extrem ities and fractures;
logical dam age [LE C |.
• blood loss;
• The risk, however, o f a hasty approach is that the
b.
• condition o f the perineum.
head will be pulled too much to be able to deliver the
In addition, good com m unication between the obste shoulders. Too much traction to the head can lead to
trician and the parents is essential in the event o f permanent damage o f the brachial plexus [LE C],
m orbidity in m other and/or child. Explain what hap • There are certain procedures that can be per
-li
pened and what was done to resolve the shoulder
dystocia. Provide adequate advice, a clear plan o f
action, and any necessary referrals. In cases where
a delivery was com plicated by a shoulder dystocia,
•
form ed as a team to safely resolve a shoulder dys
tocia [LE A 2 ].
A protocol approach with proper reporting and
good com m unication with the parents is essential
er
a subsequent prepregnancy consultation should d is
[LE D],
cuss the possibility o f an elective cesarean section for
• In cases where a delivery was com plicated by
the next pregnancy, regardless o f the occurrence of
a shoulder dystocia, the possibility o f an elective
any neonatal morbidity.
cesarean section in a subsequent pregnancy m ust
be discussed, regardless o f the occurrence o f any
h
Prevention neonatal m orbidity [LE D ].

For patients with a history o f risk factors, preventive
m easures could possibly lessen the occurrence o f
us
shoulder dystocia. The results o f older random ized

References
1 Resnik R. M anagem ent o f shoulder girdle dystocia. Clin
studies are disappointing [LE A l/ 2 ] ." ’ 14 However
O bstet Gynecol. 1980;23:559-64.
in a recent RCT, induction o f labor for suspected
2 D utch Society o f O bstetrics and Gynaecology. Guideline
large-for-date fetuses was associated with a reduced
Shoulder dystocia. Septem ber 2008.
risk o f shoulder dystocia com pared with expectant
ak
3 G eary M , M cFarlan d P, Johnson H, et al. Shoulder

m anagem ent [LE A 2].15 Stringent glucose control in
dystocia - is it predictable? Eur J O bstet Gynecol Reprod
pregestational diabetes m ellitus type I and II but also
Biol. 1995;62:15-18.
in gestational diabetes has been shown to be effective
4 G obbo R, Baxley EG. Shoulder dystocia. In: Leem an L
in prevention o f m acrosom ia and shoulder dystocia
(ed.). ALSO : advanced life support in obstetrics provider
[LE A 2],16,17 course syllabus. Leaw ood: Am erican A cadem y o f Fam ily
C onsidering the unpredictability o f the occur Physicians, 2000; p. 5.
rence o f shoulder dystocia, the em ergency nature o f 5 Baxley EG, G obbo RW. Shoulder dystocia. A m Fam
the event, and everyone’s lim ited experience due to Physician. 2004;69:1707-2014.
the low incidence, all personnel should be properly 6 G askin IM . For the first tim e in history an obstetrical
trained in resolving this com plication. Training on m aneuver is nam ed after a midwife. Birth Gaz.
a shoulder dystocia sim ulation m odel will im prove 1998;14:50.
the skills for resolving a case o f shoulder dystocia 7 Bruner JP, D rum m ond SB, M eenan AL, et al. All-fours
[LE A 2 /C ].18,19 This is not only true for the obstetri m aneuver for reducing shoulder dystocia during labor.
cian, but also for the entire delivery team. A protocol J R eprod M ed. 1998;43:439-43.
S e ctio n 3: P a th o io g y o f La b o r a n d La b o r a n d D e live ry
8 C op pus SFPI, Langeveld J, Oei SG. Een onderschatte 16 M etzger BE; H A PO Study C ooperative Research
techniek v oor het opheffen van schouderdystocie: Group. H yperglycem ia and adverse pregnancy
baren op handen en knieen (‘all-fours m anoeuvre’). outcom es. N Engl J M ed. 2008;358:1991-2002.
N ed Tijdschr Geneeskd. 2007;151:1493-7. 17
Landon M B, Spong GY, Thom E, et al. A m ulticenter,
9 G rady K, Howell C, C ox C (eds). Shoulder dystocia. In: random ized trial o f treatm ent for m ild gestational
The M O ET C ourse M anual, 2nd edition. London: diabetes. N Engl J M ed. 2009;361:1339-48.
R C O G Press, 2007; pp. 221-33. 18 D eering S, Poggi S, M acedon ia C, et al. Im proving
10 G herm an RB, O uzounian JG , G oodw in TM . O bstetric resident com petency in the m anagem ent o f shoulder
m aneuvers for shoulder dystocia and associated fetal dystocia with sim ulation. O bstet Gynecol. 2004;103:
m orbidity. A m J Obstet Gynecol. 1998;178:1126-30. 1224-8.
11 M cF arlan d M B, Langer O, Piper JM , et al. Perinatal 19 D eering S, Poggi S, H o dor J, et al. Evaluation o f
residents’ delivery notes after a sim ulated shoulder
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outcom e and the type and n um ber o f m aneuvers
in shoulder dystocia. Int J G ynaecol Obstet. dystocia. O bstet Gynecol. 2004;104:667-70.
1996;55:219-24. ' 20 D raycott T, Sibanda T, Owen L, et al. D oes training in
12 Borell U, Fem strom I. A pelvim etric m ethod for the obstetric em ergencies im prove neonatal outcom e?
assessm ent o f pelvic m ouldability. A cta Radiol. BJO G . 2006;113:177-82.
b.
1957;47:365-70. 21 D raycott T J, C rofts JF, Ash JP, et al. Im proving
13 Boulvain M, Stan C, Irion O. Elective delivery in neonatal outcom e through practical shoulder dystocia
diabetic pregnant wom en. Cochrane D atabase Syst Rev. training. O bstet Gynecol. 2008;112:14-20.
2001;2:CD 001997. 22 Fransen AF, van de V en J, M erien AE, et al. Effect o f
14 Irion O, Boulvain M. Induction o f labour for suspected obstetric team training on team perform ance and
15
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fetal m acrosom ia. Cochrane D atabase Syst Rev. 2000;2:
CD 000938.
Bou lvain M , Senat M V , P errotin F, et al. In du ction
o f lab o u r versu s expectan t m an agem en t for
m edical technical skills: a ran dom ised controlled trial.
BJO G . 2012;119(11): 1387-93.
^3 G robm an W A, M iller D, Burke C, et al. O utcom es

associated with introduction o f a shoulder dystocia
er
large-for-date fetuses: a ran d o m ise d con trolled trial. protocol. A m J O bstet Gynecol. 2011;205:513-17.
Lancet. 2 0 1 5 ;3 8 5 (9 9 8 7 ):2 6 0 0 -5 . D O I: 10.1016/ 24 G robm an W. Shoulder dystocia. O bstet Gynecol Clin
S0 1 4 0 -6 7 3 6 (14)61904-8. N orth Am . 2013;40:59-67.
h
us
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64
■ Retained Placenta
A H.J. van Beekhuizen and J.H. Schagen van Leeuwen
ru
General Inform ation 97% are delivered within 30 minutes.6 In preterm labor
the duration o f the third stage is usually longer.
Professional societies in different countries have
Introduction their own policies on when to perform MRP. Early
The third stage o f labor refers to the period between
b.
MRP possibly reduces blood loss at the cost o f too
the birth o f the infant and the detachm ent and many interventions, while late MRP may lead to more
expulsion o f the placenta and m em branes. The “3rd
blood loss. The timing o f when to perform MRP
stage o f lab or” m ay be m anaged either expectantly or
depends not only on clinical factors, but also on the
actively. The latter is recom m ended by the W H O ,1as logistical restraints o f the environment in which one is
-li
it lim its the average bloo d loss. Active m anagem ent
reduces the risk o f severe bleeding (postpartum
hem orrhage [PPH] >1000 m l) with a risk ratio o f
0.34 (95% C l 0.14-0.87) [LE A l] .2 It does not, how
working. It should be borne in mind that underestima
tion o f blood loss following delivery is a common
problem. The diagnosis is usually made subjectively
and many cases with clinically significant blood loss
er
ever, reduce the need for m anual rem oval o f the remain undetected. It is advisable to weigh or measure
placenta (M RP) as com pared to expectant m an age
the blood loss [LE D], A decision to perform MRP
m ent (RR 1.21,95% C l 0.82-1.78) [LE A l] .2 Recently
should not be unduly delayed.
a large R C T on m anagem ent o f the third stage o f
labor in 4000 w om en show ed a beneficial effect o f
h
controlled cord traction (C C T ) on the incidence o f

Definition
retained placenta (RP): the incidence o f RP was 4.2% A retained placenta is defined as a placenta that has
not been delivered within 30 to 60 minutes after the
us
in the C C T group versus 6.1% in the group that

received only oxytocin (RR 0.69, 95% C l 0.53-0.90) birth o f the infant [LE D ]1 and is a frequent cause of
[LE A 2 ].3 O f the three com ponents o f active m an age PPH (W HO definition mild PPH >500 ml vaginal
m ent oxytocin adm inistration is the m ost blood loss within 24 hours after the delivery; severe
im portant4 and recent recom m en dation s advise PPH >1000 ml/24 hours).
delaying clam ping o f the cord for at least 2 to 3 A (partially) retained placenta prevents norm al
ak
m inutes since delayed cord clam ping does not contraction and retraction activity o f the uterus and
increase the risk o f PPH , but can be advantageous can therefore cause blood loss.
for the infant by im proving iron status, which m ay
be o f clinical value particularly in infants where Incidence
access to good nutrition is poor [LE A l] .5 Retained placenta affects approxim ately 0.5-3.3% o f
Em ptying the bladder in case o f retained placenta deliveries worldwide 6-18 Review o f observational stu
m ay help to expel the placenta [LE D], dies showed that the m edian rate o f RP at 30 m inutes
The normal length o f the third stage o f labor is not was higher in developed countries than in low-
defined. The average duration o f the third stage o f labor resource countries (2.67% vs 1.46%, p < 0.02), as was
in term births is 5 to 6 minutes [LE B] ? ' Ninety percent the rate o f M RP (2.24% vs 0.45%, p < 0.001)18 [LE C].
o f term placentas are delivered within 15 minutes and This m ay be explained in part by differences in the
O b stetric In te rv e n tio n s , ed. P. Joep D orr, V incent M. Khouw , Frank A. Chervenak, A m os G runebaum , Yves Jacquem yn,
healthcare accessibility, i.e., high-risk women having

Prevention of Retained Placenta
a hospital delivery, (accuracy of) RP registration,
The effectiveness o f strategies to prevent RP with
reluctance to perform MRP in a low-resource setting,
interventions during the third stage o f labor has
and definition and tim ing o f MRP. In addition one
been studied extensively, as shown in Table 9.1.
may speculate that other factors, including ethnicity,
Only C C T was significantly effective.3 In prevention
parity, and previous cesarean section, m ay contribute
to the differences. o f MRP, ergom etrine is apparently contra-productive
(com pared to oxytocin).20
Risk Factors Treatment of Retained Placenta

Risk factors are: history o f retained placenta, cesarean MRP is the standard o f care in the treatment o f RP.
ru
section, and curettage as well as high m aternal age, MRP is generally performed under anesthesia (general
high parity, induction o f labor, and preterm delivery. or regional), after disinfection o f the vulva and vagina
Gestational age is a risk factor that influences the and application o f a single dose o f antibiotic. N o data
length o f the third stage o f labor and the chance are available on the efficacy o f antibiotics to prevent
o f a retained placenta. At less than 37 weeks, the endometritis26 or on the efficacy o f MRP itself. It is
b.
chance o f a prolonged third-stage labor as a result of known that MRP m ay be incomplete. Incomplete
a retained placenta is three tim es greater than in term MRP requires re-intervention.
birth [LE B].6 This is also the case in second trimester M edical drug treatment o f RP with respectively
pregnancy terminations. Recently a case-control nitroglycerin, intra-umbilical oxytocin, sulprostone,
-li
study was published in which augm entation o f
labor with oxytocin was a risk factor with an OR o f
2.00 (95% C l 1.20-3.34) for oxytocin augm entation
o f 195-415 m inutes [LE B ].19
and m isoprostol has been researched,4,27-30 with
MRP and excessive blood loss as endpoints. Only
one study shows beneficial outcom es: intravenous
250 |ag sulprostone (prostaglandin E2) adm inistered
er
Table 9.1 Review o f RCTs on the prevention o f MRP during the third stage o f labor
In te rv e n tio n V e rsu s P a tie n ts (n u m b e r) R e la tiv e ris k 95 % Cl

h
Active m anagem ent 3rd stage2 Expectant m anagem ent 4 829 1.78 0.57-5.56
Active m anagem ent 3rd stage4 Oxytocin 10 IU 18831 0.97 0.68-1.37

us
Oxytocin20 Placebo 2 243 1.17 0.79-1.75
Ergometrine21 Placebo 2429 3.75 0.14-99.7
Oral misoprostol 400 (jg22 Placebo 900 0.43 0.06-2.89
O xytocin20 Ergometrine 2 800 0.57 0.41-0.79

ak
Oxytocin 5 IU plus ergometrine Oxytocin 5 or 10 IU 9 932 1.03 (OR) 0.80-1.33

0.5 m g23
Oral misoprostol 600 ng22 Oxytocin/ergom etrine 21 806 0.97 0.81-1.16
Prostaglandin F2Ci22 Oxytocin/ergom etrine 231 1.09 0.31-3.81
Carbetocin 100 pig24 Oxytocin 5 IU plus ergom etrine 329 0.33 0.03-3.20
0.5 mg
Drainage o f umbilical cord plus Expectant managem ent 477 0.90 0.49-1.65
CCT25
Active m anagem ent with Active management w ithout CCT 4 000 0.69 0.53-0.90
controlled cord traction3
OR, odds ratio; CCT, controlled cord traction.

166
C h a p te r 9: R etained Placenta
when the placenta is retained 60 m inutes after delivery

o f the infant decreases the num ber o f m anual placenta
rem ovals by 50% [LE A 2].28 O f course, before adm in
istering the drug the contraindications o f sulprostone
m ust be considered.
Indications
Indications for M RP are:
. m ore than 500-1000 ml blood loss due to retained
placenta (depending on the national guidelines
ru
and the predelivery Hb level);
. retained placenta after 30 to 60 m inutes postbirth
o f the infant;
. (suspicion of) a retained placental fragment;
b.
• avulsion o f the um bilical cord on controlled
cord traction and lack o f (spontaneous) expulsion
Figure 9.1 External hand supports the fundus, internal hand fol
[L E D ].31 lows the um bilical cord.
Anesthesia
-li
A retained placenta is optimally removed in the oper
ating room under adequate anesthesia, which could be
regional when PPH is minimal and m ust be performed
dividing plane between the wall o f the uterus and
the placenta is located and the placenta is then
peeled o ff the wall o f the uterus. The cooperation
o f the internal hand (loosening o f the placenta)
er
according to local protocol and in coordination with
and the external hand (supporting the uterus) is
the anesthesiologist. A s a m inimum, the protocol must
crucial in this procedure (Figure 9.2).
state that the patient has to have a properly running
• After the placenta is completely separated, it is
intravenous drip, that a blood sam ple was taken to
guided to the outside by the internal hand that
determine the Hb count, as well as a cross-match for
h
rem ains in the uterus. Then the uterine cavity is

a possible blood transfusion, that the patient’s bladder
palpated by the hand that rem ained inside the
was emptied beforehand, and that before administering
uterus to ensure that the placenta has been
the anesthesia it was checked again whether the pla
us
rem oved completely and that the uterine cavity

centa dislodged by itself or through traction.
has a norm al shape (Figure 9.3).
• For women with a small area o f placenta accreta, we
Technique of Manual Removal of the suggest slow persistent finger dissection to create
Placenta a plane o f separation at the maternal-placental
ak
A n M RP is done under aseptic conditions and with interface [LE D].

gloves that reach to the elbows27,31 and a sterile gown. • Unexpected placenta accreta. Rarely, a placenta
The technique o f a m anual placenta rem oval is as accreta is first recognized at the time o f m anual
follows (see A nim ation 9.1). removal o f the placenta. In these cases, there is
• The external hand supports the fundus o f the no plane o f dissection between the uterus and
placenta and, alm ost invariably, attem pts at m an
uterus.
ual removal lead to life-threatening hemorrhage.
. The other hand follows the um bilical cord and
W e suggest the following m anagem ent in case the
reaches the uterine cavity via the vagina and the
placenta does not separate.32
cervix (Figure 9.1).
• It is im portant that the external hand continues to Adm inistration o f high-dose uterotonic drugs
provide counterpressure to prevent ruptures and and preparation for hysterectomy. Hysterectomy
traum a to the birth canal. is the definitive therapy o f placenta accreta in
• The m argin o f the placenta is then located and patients who do not wish to preserve their fertil
with the fingers pressed against each other the ity. It may be useful to perform a cystoscopy to
Section 3: P a th o lo g y o f La b o r a n d La bo r a n d D elivery
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Figure 9.3 Placenta is dislodged and is brought to the outside.
b.
Complications
Inversion o f the uterus is a rare com plication o f con
Figure 9.2 The margin o f the placenta is located. trolled cord traction and also o f a m anual rem oval o f
the placenta, in which the fundus o f the uterus is
catheters before hysterectomy.

-li
assess for bladder invasion and to insert ureter
When there is a strong wish to preserve fertil

pulled past the cervix and out o f the uterus. In that
case, im m ediate reposition is indicated after adm inis
tering tocolytics as described in Chapter 11.
M anual rem oval o f the placenta can lead to injury
er
ity in a patient who is willing to accept the risks (through laceration or perforation) o f the labia,
o f sudden bleeding, infection, and possible introitus, vagina, cervix, or uterine cavity. In case of
diffuse intravascular coagulation and when persistent blood loss after M RP these injuries should
obvious hem orrhage is absent: leave placenta be excluded.
in place and adm inister antibiotics. Observe
h
For diagnosis and treatment o f placenta accreta

for spontaneous resorption o f the placenta. and percreta we refer to Chapter 10.
If the placenta separates partially, deliver the In case of (suspected) retained placental fragments -
us
separate parts and leave the adherent portions either immediately after the delivery or later - it is
in place. This does not lead to postpartum not possible under certain circumstances to perform
hem orrhage as long as the uterus contracts a manual placenta removal due to insufficient access to
well and there is no area o f subinvolution at the uterus. In this situation curettage or hysteroscopic
the site o f the retained placental fragments. removal is indicated; the latter only if bleeding is not too
But one has to be careful: late postpartum profuse. Curettage can be done either with a vacuum
ak
hem orrhage m ay occur. instrument or with a blunt or sharp curette. It is recom

mended to perform postpartum curettage under ultra
• The value o f the prophylactic adm inistration
sound imaging to avoid perforation as much as possible
o f antibiotics around M RP has not been proven
and to ensure completeness o f the placenta removal.
[LE A I],26 but can be included in a local protocol
Hysteroscopic removal is associated with less adhesions
in consultation with the m icrobiologist.
and higher pregnancy rate afterwards [LE C ].5
U ltrasound scanning for com plete removal o f the
placenta (fragm ents) is a sim ple procedure that can Important Points and
be perform ed after the intervention and could be
useful, but its benefit has not been determ ined.33 Recommendations
After removal o f the placenta, uterotonics are • Active m anagem ent o f labor does not reduce the
normally adm inistered as a preventive m easure and risk for M RP [LE A l]; however it reduces the risk
possible treatment o f atonia o f the uterus. o f severe PPH.
C h a p te r 9: R etained Placenta
• A dm inistering oxytocin and C C T are the m ost clinical practice. Am J O bstet Gynecol.
im portant com ponents o f active m anagem ent o f 1995;172(4, Part l):1279-84,
labor in case o f RP [LE A l]. 8. A delusi B, Soltan M H , Chow dhury N , Kangave D. Risk
o f retained placenta: m ultivariate approach. Acta
• Early cord clam ping is no longer recom m ended by
O bstet Gynecol Scand. 1997;76(5):414-18.
the W HO [LE A l],
9. Bais JM , Eskes M, Pel M, Bonsel GJ, Bleker OP.
• U se the definition o f retained placenta if the
Postpartum haem orrhage in nulliparous women:
placenta is not expelled within 30 m inutes after incidence and risk factors in low and high risk
delivery o f the baby and start precautions to women. A D utch population-based cohort study on
prevent and treat possible PPH such as putting stan dard (> or = 500 ml) and severe (> or = 1000 ml)
up an IV drip and cross-m atch blood. If bleeding postpartum haem orrhage. Eur J Obstet Gynecol
Reprod Biol. 2004;115(2):166-72.
ru
is heavy perform a M RP immediately. If blood loss
is lim ited the M RP can be scheduled after 60 10. Chhabra S, D horey M. Retained placenta continues to
minutes. The 30 m inutes between diagnosis of be fatal but frequency can be reduced. J Obstet
RP and treatm ent by M RP leaves am ple time to Gynaecol. 2002;22(6):630-3.
study interventions that m ay help to expel the 11. Ow olabi A T, D are FO, Fasubaa OB, et al. R isk factors
b.
for retained placenta in southw estern N igeria.
placenta and avoid M RP [LE D ].
Singapore M ed J. 2008;49(7):532-7.
• In RP intravenous sulprostone 250 j-ig administra
12. Pan paprai P, Boriboonhirunsarn D. Risk factors o f
tion lessens the need for m anual placenta removal
retained placenta in Siriraj H ospital. J M ed A ssoc Thai.
[LE A2], 2007;90(7): 1293-7.
•
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M RP m ust be perform ed according to local
protocol and in coordination with the anesthesiol
ogist [LE D].
13.
14.
Soltan M H , Khashoggi T. Retained placenta and
associated risk factors. J Obstet Gynaecol.
1997;17(3):245-7.
Tan dberg A, Albrechtsen S, Iversen OE. M anual
er
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h er
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Placenta Accreta, Increta, and Percreta
W. Mingelen, F.M. van Dunne, and P.J. Dorr
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• placenta previa;
General Information
• previous cesarean section;
Introduction • procedures that can lead to damage to the endome
trium or myometrium, such as a m yoma enucle
b.
In placenta accreta, increta, or percreta, the decidua of
ation, curettage, endometrial ablation, embolization
the endometrium is lacking, causing the placenta to
o f the uterine artery, or a submucosal m yom a/ 9
partially or completely insert itself into the m yome
trium (placenta accreta; Figure 10.1A), invade the myo The risk is highest in women with a placenta previa
metrium (placenta increta; Figure 10.1B), or grow that lies partially on the anterior wall o f the uterus and
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through the myometrium into the surrounding struc
tures and organs (placenta percreta; Figure 10.1C) .'
The maternal mortality and morbidity are consid
erable and primarily the result o f massive blood loss
with a cesarean section in their prior m edical history.
This risk increases to 3%, 11%, 40%, 61%, and 67%
after one, two, three, four, and five cesarean sections
are perform ed, respectively, and whether or not the
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due to the abnorm al insertion o f the placenta, wherein placenta is located on the anterior wall over the old
scar.10 Both a cesarean section in the m edical history
the placenta does not release from the uterine wall after
the child’s birth.2 The incidence o f placenta accreta has (adjusted odds ratio [AOR] 5; 95% C l 3.4-7.7J and
a placenta previa (AO R 51; 95% C l 36-73) constitute
risen during the past decades and is expected to con
independent risk factors [LE B ].11 An elective cesar
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tinue to rise. This rise is related, am ong other things, to

ean section has a higher risk o f a placenta accreta in
the increased incidence o f cesarean sections.
a subsequent pregnancy than a secondary cesarean
section (O R 3.0; 95% C l 1.5-6.1) [LE B ].12
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Definition
A placenta accreta, increta, or percreta is a placenta
that com pletely or partially adheres abnorm ally to the Diagnosis
uterine wall. Prenatal diagnosis o f a placenta accreta is essential for
adequate treatment. Tim ely prenatal diagnosis allows
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Incidence a m ultidisciplinary plan o f action to be developed, by

m eans o f which m aternal and fetal mortality and
Before 1980, a placenta accreta was rare, with an
m orbidity can be prevented.
incidence o f 1 in 4000 pregnancies. Currently, the
The placenta location relative to the cervix and
incidence is 3 in 1000 to 1 in 530 pregnancies.3,4
any uterine scar m ust be exam ined by m eans of
This increase runs practically parallel to the rise in
a structural ultrasound scan. A transvaginal ultra
the num ber o f cesarean sections [LE B].5,6
sound is m ore accurate in a low-lying placenta than
an abdom inal ultrasound [LE B].
Risk Factors U pon suspecting a placenta previa or a placenta
Risk factors for a placenta accreta are: over a cesarean section scar, an ultrasound m ust be
• m aternal age above 35 years; repeated at the start o f the third trimester. This way
O b ste tric In te rv e n tio n s , ed. P. Joep D orr, V incent M. Khouw, Frank A. Chervenak, A m os G runebaum , Yves Jacquem yn,
Figure 10.1 Placenta accreta (A), placenta increta (B), placenta percreta (C).
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Figure 10.2 The absence o f the retroplacental echolucent zone. Figure 10.3 M ultiple irregular placental lacunae.
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there is sufficient time available to determ ine the

m ultidisciplinary policy for the third trim ester o f the diagnostic tools, but may, in combination with conven
pregnancy.13 tional ultrasound, contribute to the diagnosis. Patients
with a false-positive diagnosis are generally patients
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U ltrasound is a useful diagnostic tool (sensitivity:

91%; 95% C l 87-94; specificity: 97%; 95% C l 96-98; with one isolated ultrasound feature o f a placenta
LR+: 11; 95% C l 6-20; LR“ 0.2: 95% C l 0.1-0.2 with accreta.16
a diagnostic OR o f 99; 95% C l 49-199), but is never Color D oppler ultrasound can be used to visualize
entirely conclusive.14,15 The definitive diagnosis can a diffuse or focal lacunar flow, an increased am ount of
only be m ade during a surgical procedure (cesarean vascularization at the transition point from the uterus
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section or m anual placenta rem oval) [LE D ].13 to the bladder (Figure 10.4), and dilated blood vessels
The ultrasound characteristics o f a placenta insert in the peripheral subplacental zone as characteristics
ing itself into the uterine wall are: o f a placenta accreta.17,18
O f the above-mentioned isolated ultrasound
• the absence o f the retroplacental echolucent zone
characteristics, the color Doppler differences are the
(Figure 10.2);
m ost sensitive.15
• retroplacental m yom etrium thickness o f less
In com parison with conventional ultrasound,
than 1 mm;
MRI has produced com parable results.19,20 M RI offers
• multiple irregular placental lacunae (Figure 10.3);
diagnostic possibilities when the ultrasound findings
• focal exophytic growth o f the placenta invading are not conclusive. MRI also offers added value in
the bladder. determ ining the infiltration depth in surrounding
The use o f color Doppler ultrasound and three- structures (the param etrium ) and when suspecting
dimensional (3D) power Doppler ultrasound does not a placenta accreta o f the fundus and o f the posterior
increase the sensitivity or specificity as independent wall o f the uterus [LE B].20
C h a p te r 10: Placenta A ccreta, Increta, and Percreta
adm inistration o f corticosteroids for the fetal lung

m aturation [LE A2].24,25
To optimize the maternal and fetal outcomes,
a multidisciplinary consultation should take place in
the planning o f the cesarean section, not only including
an anesthesiologist, a perinatologist, a gynecologist
with extensive surgical skills, and a neonatologist,
but also with the intensivist, urologist, hematologist,
intervention radiologist, and a general surgeon. In case
o f a suspected placenta percreta with invasion into
the bladder, a preoperative cystoscopy should be
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performed.25
Treatment with Hysterectomy

Figure 10.4 An increased am ount o f vascularization at the point of
The opinions regarding the perform ance o f the
transition from the uterus to the bladder.
b.
procedure are as follows.
• U ltrasound testing im m ediately prior to the cesar
Policy ean section for precise localization o f the placenta.
W om en with a suspected placenta accreta should In case o f doubt about the location, an ultrasound
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be instructed concerning the risks and potential com
plications o f a placenta accreta. The m ain risks are
m assive blood loss and the need for a hysterectomy.
In view o f the blood loss, anem ia m ust be prevented
•
test can be perform ed during the operation.
Lithotom y position related to controlling vaginal
blood loss and a possible cystoscopy during the
operation.
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and treated prenatally, if necessary.21 • Consider pre- or perioperative placement o f ur
The preferred m ode o f delivery in case o f eteral catheters for easier localization o f the
a suspected placenta accreta is a planned cesarean ureters if a hysterectomy has to be performed.
section. If there is no desire for additional children, • Consider preoperative placem ent o f sheaths in
the first choice o f treatm ent in a placenta accreta is both uterine arteries by the intervention radiolo
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a hysterectomy following the cesarean section, while gist for a possible balloon occlusion.
leaving the placenta in place.22
• The location o f the placenta determ ines the place
A scheduled cesarean section is preferable to an
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o f the incision into the skin and the uterus.

em ergency cesarean section. An em ergency cesarean
A m edian incision provides a better overview
section generally leads to m ore com plications and
and m akes it possible, if necessary, to open the
blood loss than a planned cesarean section.
uterus in the fundus or (after lifting the uterus out
If the pregnancy progresses without com plica
o f the abdom en) in the posterior wall.
tions, it is advisable to plan the cesarean section at
• The uterus should be opened at a distance from
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37 weeks’ gestation [LE D]. The adm inistration o f

the placenta. An incision through the placenta
corticosteroids to prom ote fetal lung m aturation at
involves a lot o f blood loss and m ust therefore be
this stage is still under discussion. Prenatal cortico
avoided [LE B],
steroids in an elective cesarean section appear to lower
• After the child is born, it is checked whether the
the risk o f RDS (RR 0.46; 95% C l 0.23-0.93, p = 0.02)
placenta releases spontaneously since the positive
[LE B], but it is not clear whether the adm inistration
predictive value o f the prenatal diagnosis of
o f prenatal corticosteroids after a gestation period
a placenta accreta is not 100%.
o f 36 weeks does not have adverse effects on the
• If the placenta is not born spontaneously, it is left
neonate.23,24 In the event o f blood loss during
in place and a hysterectomy is perform ed im m e
the second half o f the pregnancy or in case o f an
diately after the cesarean section.
increased risk o f prem ature birth the perform ance o f
the cesarean section should be considered at 34 weeks’ • Attem pting to remove a placenta accreta m anually
gestation or earlier if necessary [LE D], after the is not recom m ended, as this is related to high
m aternal m orbidity and m ortality due to m assive the above-m entioned additional treatm ents is unclear
blood loss [LE B].22 due to the lim ited num ber o f patient groups in which
• W hen suspecting a placenta percreta with inva they are described. M ethotrexate is the m ost described
sion o f the bladder, that part o f the bladder m ust additional treatm ent option. There are indications
be removed together with the uterus.27 that m ethotrexate decreases the vascularization o f
• General anesthesia is recom m ended due to the the placenta and therefore leads to necrosis and
prolonged surgery time, but a com bination o f rapid involution o f the placenta.33 O n the other
spinal and general anesthesia allows the patient hand, m ethotrexate has been proven effective only in
to be awake for the birth o f her child, after which rapidly dividing cells, such as in trophoblast prolifera
a hysterectomy is perform ed under general tion, and it has a significant side-effect profile.34
anesthesia.'’’ There are insufficient data to m ake a reliable state
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• Standard prophylactic administration o f antibiotics ment about a successful pregnancy after conservative
is indicated, with a repeated dose after a surgery time treatm ent o f a placenta accreta. The results o f the
o f 2 to 3 hours and after a blood loss o f 1500 m l.1 largest study available appear to be positive. O f the
• The transfusion laboratory should be informed o f 96 patients treated conservatively with success, ulti
mately only 27 patients desired to have m ore children.
b.
this risky surgical procedure. The current Dutch
transfusion guidelines state that in case o f massive Twenty-four o f the 27 wom en becam e pregnant.35
blood loss multicomponent transfusions with fixed The risk o f renewed abnorm al placentation in
ratios between erythrocytes, plasma, and platelets a subsequent pregnancy is significant; num bers
(3:3:1) increase the survival by preventing or cor range from 29% to 100% o f the pregnancies.30,31,35,36
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recting a dilution coagulopathy. The optimal ratios
am ong the three components are still unclear.29
In case o f intensive vascularization o f the pelvis,
a hysterectomy m ay be considered at a later stage in
Recommendations
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a hem odynam ically stable patient. Vascularization • Prenatal discovery o f a placenta accreta, increta, or
usually decreases with time. A hysterectomy at percreta is essential to adequate m ultidisciplinary
a later stage m ay also be considered in case experi treatment.
enced surgeons and/or adequate operating room and • In a pregnant wom an with this m edical condition
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laboratory facilities are not available.25 a planned cesarean section m ust be considered,
wherein the placenta m ay be left in place and
followed im m ediately by a hysterectomy.
Treatment with Conservation
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• An attem pt to m anually rem ove (part of) the pla

of the Uterus centa is associated with a significant increase in
Conservative treatment o f women with a placenta m assive blood loss.
accreta, with the purpose o f preserving the uterus, is • In the event o f a significant future desire for m ore
possible. This treatment leaves the placenta in place children and after due counseling o f the patient
and closes the uterus after the child’s birth. This with respect to the risks, it m ay be decided after
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option should only be considered if there is a strong the birth o f the child by m eans o f a planned cesar
desire to have m ore children in the future and in ean section to close the uterus with the placenta
a hem odynam ically stable patient with a norm al co left in place.
agulation status. Risks o f this conservative treatment
are blood loss, infection, diffuse intravascular coagu References
lation, and the possibility o f still having to perform
1. A m erican College o f O bstetricians and G ynecologists.
a hysterectomy after the fact.
Placenta accreta. A C O G . 2012;529:207-11.
The available data in a group o f 253 patients treat
2. O ’Brien IM, Barton IR, D onaldson ES. The m anagement
ed conservatively show a success rate (with the pres
o f placenta percreta: conservative and operative strategies.
ervation o f the uterus) o f 80%.30-32 The m ajority o f A m J Obstet Gynecol. 1996;175:1632-8.
these conservatively treated patients were additionally
3. W u S, K ocherginsky M , H ibbard JU . A bnorm al
treated with arterial em bolization, bilateral ligation o f placentation: twenty-year analysis. A m J O bstet
the hypogastric vessels, or m ethotrexate. The value o f Gynecol. 2005; 192:1458-61.
C h a p te r 10: Placenta A ccre ta, Increta, a n d Percreta
4. M iller D A, Chollet JA, G oodw in TM . Clinical risk 18. W arshak CR, E skander R, Hull AD , et al. Accuracy o f
factors for placenta previa-placenta accreta. A m ultrasonography and m agnetic resonance im aging in
J O bstet Gynecol. 1997;177:210-14. the diagnosis o f placenta accreta. O bstet Gynecol.
5. H iggins M F, M onteith C, Foley M , O ’Herlihy C. Real 2006;108:573-81.
in creasing incidence o f hysterectom y for placenta 19. Dwyer BK, Belogolovin V, Tran L, et al. Prenatal
accreta follow ing previous caesarean section. Eur diagn osis o f placenta accreta: sonography or
J O bstet Gynecol R eprod Biol. 2013;171:54-6. m agnetic resonance im aging? J U ltrasoun d Med.
6. M orlando M, Sarno L, N ap olitan o R, et al. Placenta 2008;27:1275-81.
accreta: incidence an d risk factors in an area with 20. M asseli G, Brunelli R, C ascian i E, et al. M agnetic
a particularly high rate o f cesarean section. Acta Obstet resonance im aging in the evaluation o f placental
Gynecol Scand. 2013;92:457-60. adhesive disorders: correlation with color D oppler
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7. Al-Serehi A, M hoyan Q, Brow n M , et al. Placenta ultrasound. Eur Radiol. 2008;18:1292-9.
accreta: an association with fibroids and A sherm an 21. A m erican College o f O bstetricians and Gynecologists.
syndrom e. J U ltrasoun d M ed. 2008;27:1623-8. A C O G Practice Bulletin N o. 95: anem ia in pregnancy.
8. H am ar BD , W o lff EF, K odam an PH, et al. Prem ature O bstet Gynecol. 2008;112:201-7.
rupture o f m em branes, placenta increta and 22. Eller AG, Porter TF, Soisson P, et al. O ptim al
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hysterectom y in a pregnancy follow ing endom etrial m anagem ent strategies for placenta accreta. BJO G.
ablation. J Perinatol. 2006;26:135-7. 2009;116:648-54.
9. Pron G , M o carsk i E, Bennet J, et al. P regn an cy after 23. Stutchfield P, W hitaker R, Russell I; A ntenatal Steroids
uterin e artery em b o lizatio n for leiom y om ata: the for Term Elective C aesarean Section (A STECS)
O n tario m u lticen ter trial. O b stet G ynecol.
10.
2 0 0 5 ;2 6 :8 9 -9 6 .
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Silver RM , Lan don M B, Rouse D J, et al. M aternal
m orbidity associated with m ultiple repeat cesarean
deliveries. O bstet Gynecol. 2006;107:1226-32. 24.
Research Team . A ntenatal betam ethasone and
incidence o f neonatal respiratory distress after elective
caesarean section: pragm atic random ised trial. BMJ.
2005:331:662.
Royal College o f O bstetricians and Gynaecologists.
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11. Eshkoli T, W eintraub AY, Sergienko R, Sheiner E. Green-top Guideline N o. 7: Antenatal corticosteroids
Placenta accreta: risk factors, perinatal outcom es, and to reduce neonatal m orbidity and m ortality. London:
consequences for subsequent births. A m J Obstet RCO G , 2010.
Gynecol. 2013;208:219.el-7. 25. R ao KP, B elogolovk in V, Y ankow itz Y, et al.
12. K am ara M , H enderson JJ, D oherty D A, et al. The risk A b n orm al placen tatio n : eviden ce-based d iag n o sis
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o f placenta accreta follow ing prim ary elective an d m anagem en t o f placen ta previa, placenta
caesarean delivery: a case-control study. BJO G . accreta an d v a sa previa. O bstet G ynecol Surv.
2013;120:879-86. 2012;67:503-19.
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13. Royal College o f O bstetricians and G ynaecologists. 26. Eller AG, Bennett M A, Sharshiner M, et al. M aternal
R C O G G reen-top G uideline N o. 27: Placenta praevia, m orbidity in cases o f placenta accreta m anaged by
placenta praevia accreta an d vasa praevia: diagn osis a m ultidisciplinary care team com pared with standard
and m anagem ent. London: R C O G , 2011. obstetric care. O bstet Gynecol. 2011;117:331-7.
14. C ali G, G iam b an co L, P uccio G, F orlan i F. M orbidly 27. H offm an M S, Karlnoski RA, M angar D, et al.
ad heren t placenta: evalu ation o f u ltrasou n d M orbidity associated with nonem ergent hysterectom y
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d iag n ostic criteria an d d ifferen tiation o f placen ta for placenta accreta. A m J O bstet Gynecol.
accreta from percreta. U ltraso u n d O b stet G ynecol. 2010;202:628.el-5,
2 0 1 3 ;41:406-12. 28. Kato R, Terui K, Yokota K, et al. Anesthetic management
15. D ’A ntonio F, Iacovella C, Bhide A. Prenatal for cases o f placenta accreta presented for cesarean
identification o f invasive placentation using section: a 7-year single-center experience [article in
ultrasound: system atic review and m eta-analysis. Japanese; English abstract]. Masui. 2008;57:1421-6.
U ltrasoun d O bstet Gynecol. 2013;42:509-17. 29. D utch Blood T ransfusion Guideline, 2011. Core group:
16. Shih JC , Palacios Jaraquem ada JM , Su YN, et al. Role o f F.J.L.M . H aas, Prof. D.J. van Rhenen, Prof. R.R.P. de
three-dim ensional pow er D oppler in the antenatal V ries, M rs. M .A.M . Overbeeke, D r V .M .J. N ovotny, D r
diagn osis o f placenta accreta: com parison with Ch.P. Henny. http://w w w .sanquin.nl/repository/docu
gray-scale an d color D oppler techniques. U ltrasound m enten/en/prod-en-dienst/287294/blood-transfusion-
O bstet Gynecol. 2009;33:193-203. guideline.pdf
17. C om stock CH . Antenatal diagn osis o f placenta 30. T im m erm an s S, van H o f A C , D uvekot JJ. Conservative
accreta: a review. U ltrasoun d O bstet Gynecol. m anagem ent o f abnorm ally invasive placentation.
2005;26:89-96. O bstet Gynecol Surv. 2007;62:529-39.
31. Bretelle F, C ourbiere B, M azouni C, et al. M anagem ent 34. W inick M, C oscia A, N oble A. Cellular grow th in
o f placenta accreta: m orbidity and outcom e. Eur h um an placenta: n orm al placental growth. Pediatrics.
J Obstet Gynecol Reprod Biol. 2007;133:34-9. 1967;39:248-51.
32. Sentilhes L, A m broselli C, Kayem G, et al. M aternal 35. Sentilhes L, Kayem G, A m broselli C, et al. Fertility and
outcom e after conservative treatm ent o f placenta pregnancy outcom es follow ing conservative treatm ent
accreta. O bstet Gynecol. 2010;115:526-34. for placenta accreta. H um Reprod. 2010;25:2803-10.
33. A rulkum aran S, N g CS, Ingem arsson I, et al. M edical 36. K ayem G, C lem ent D , G offinet F. Recurrence follow ing
treatm ent o f placenta accreta with m ethotrexate. Acta conservative m anagem en t o f placenta accreta.
Obstet Gynecol Scand. 1986;65:285-6. Int J Gynecol Obstet. 2007;99:142-3.
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Chapter
Inversion of the Uterus
11
J.B. Derks and J. van Roosmalen
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General Inform ation • excessive traction on the um bilical cord when the
placenta is im planted in the fundus, possibly in
Introduction and Definition com bination with a relaxed uterus and fundal
pressure;
b.
Uterine inversion is a serious com plication, in
• placenta accreta, in which the placenta has
which - after delivery o f the infant - the uterus p ro
invaded the myometrium.
trudes com pletely or partially inside out through the
cervix to the outside.
Symptoms
Classifications
There are several classifications:
•
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based on duration (acute <24 hours postpartum ;
The sym ptom s are:
•
•
severe pain in the lower abdomen;
life-threatening bleeding and often deep shock;
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subacute diagnosis >24 hours, but <4 weeks; the shock is often disproportional to the am ount
chronic >4 weeks); o f blood loss due to a severe vagal reaction as
• based on severity (first degree: uterus in a result o f traction to the peritoneum.
cervix; second degree: uterus passed through cer All 15 Dutch patients presented with postpartum
vix; third degree: uterus reaches the perineum ; hem orrhage, for which they needed blood transfu
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total: the inverted uterus passes the perineum). sions. Five o f the 15 patients were in shock at the
All recent cases o f uterine inversion in the time o f diagnosis and 4 presented with placenta
accreta.3
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Netherlands were acute with different degrees o f ser

iousness, whereby in som e cases the inversion was
only diagnosed upon internal exam ination prior to Physical Examination
m anual rem oval o f the placenta.1 D uring physical exam ination the uterine fundus is not
felt on abdom inal palpation and upon vaginal exam
Incidence ination the uterus m ay com e out o f the introitus
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U terine in version is a rare disorder. W illiams inside out or be palpable in the vagina. Som etim es
Obstetrics cites an incidence o f 1 in 6400 the inversion extends to the perineum. Often the
deliveries.2 D urin g the p erio d from A ugust 1, 2004 placenta is still present.
to A u gu st 1, 2006, 15 cases o f uterine inversion
were rep orted in the N etherlands out o f a total o f Therapy
358 874 deliveries, i.e., one uterine inversion in The therapy consists of:
23 925 deliveries.1 • call for extra help (nursing staff, obstetric assis
tants, anesthesiologist);
Causes • treatment o f shock (oxygen, two functioning I Vs,
C auses o f uterine inversion are: adm inistration o f crystalloids [0.9% N aCl], and if
O b ste tric In te rv e n tio n s , ed. P. foep D orr, V incent M. Khouw , Fran k A. Chervenak, A m os G runebaum , Yves lacquem yn,
and Ian G. N ijhuis. Published by C am bridge U niversity Press. © C am bridge U niversity Press 2017.
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Figure 11.1A-C Pushing the fundus back with the internal hand; external pressure with the other hand.
necessary, adm inistration o f plasm a expanders • Push the uterine fundus back through the cervix,
and blood products); while applying external pressure with the other
• repositioning o f the uterus as soon as possible; the hand (Johnson’s maneuver, Figure 11.1).3’4
sooner this is done, the greater the chance o f success. • Remove the placenta, if still present, only after
reposition.
• Keep the hand in the uterus until the uterus, after
Technique adm inistering an oxytocic agent, contracts to such
Repositioning is done as follows (see Anim ations 11.1 a degree that there is no further fear o f recurrence
and 11.2): o f the inversion (Figure 11.2).
C h a p te r 11: Inversion o f th e Uterus
If repositioning is still not possible because o f shrink

age o f the constriction ring, the uterus can be incised
posteriorly, after which repositioning should be p o s
sible. A careful inspection m ust be conducted o f the
internal organs after repositioning in order to treat
any lacerations. Uterotonic agents (oxytocin or sul-
prostone) m ust be adm inistered as soon as the uterus
has been repositioned, to prevent recurrent inversion.
If after reposition o f the uterus there is a case o f
placenta accreta, it is som etim es necessary to perform
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a hysterectomy.
Prevention
Uterine inversion can be prevented through con
b.
trolled cord traction during the third stage o f labor
only after the uterus has adequately contracted.
Figure 11.2 Internal hand stays inside until the uterus is properly
contracted. Important Points and
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For all 15 patients, except 1, this was sufficient to treat
the inversion.3 One o f the patients needed a Rusch
balloon in the uterus to stop the hem orrhage and to
Recommendations
• Uterine inversion is a rare, but potentially life-
threatening, acute situation in which the uterus
protrudes entirely or partially through the cervix
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prevent the inversion from recurring.5
to the outside. This is accom panied by severe
A nother possibility is to reposition the uterus with
abdom inal pain, profuse bleeding, and sym ptom s
the help o f hydrostatic pressure, by filling the vagina
o f shock. The placenta m ay still be present, espe
with warm saline solution and closing o ff the introitus
cially in the case o f placenta accreta. Treatm ent is
with one hand or with a silicone cup (O ’Sullivan’s
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focused on alleviating shock and repositioning the

technique).6
uterus as soon as possible. If it is not possible to do
If repositioning o f the uterus is not im m ediately
this directly in the delivery room, repositioning
possible in the delivery room , the patient m ust be
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should be done as soon as possible under general

taken urgently to the operating room , where the p ro
anesthesia [LE D],
cedure m ust be perform ed as soon as possible under
general anesthesia. This was the case for all 15
patients. Som etim es it m ay be necessary to adm inister References
tocolytic drugs for uterine relaxation, such as intrave 1 Zw art JJ, R ichters JM , O ry F, et al. Severe m aternal
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nous ritodrine or atosiban or sublingual nitroglycerin m o rb id ity d u rin g pregn ancy, delivery and
spray. p u erperiu m in the N eth erland s: a nationw ide
p o p u latio n -b ased stu d y o f 371000 pregn ancies.
W hen rep ositio n in g o f the uterus under
B JO G . 2 008;115:842-50.
anesth esia is not p ossible, lap aroto m y will be
2 Cunningham FG, G ant N F, Leveno KJ, et al. W illia m s
needed. T h is is rarely necessary when the inversion
obstetrics. NewYork: M cGraw -Hill, 2001.
is d iagn osed soon enough after delivery. Earlier
3 W itteveen T, van Stralen G, Zwart J, van R oosm alen J.
literature rep orts an incidence o f three lap arotom ies
Puerperal uterine inversion in the Netherlands:
on a total o f 102 uterine in version s.7 T h is procedure
a nationwide cohort study. A c ta O b ste t G ynecol Scand.
w as not needed in any o f the 15 recent cases in the 2013;92(3):334-7.
N eth erlan d s.3
4 K ochenour N K. D iagn osis and m anagem ent o f uterine
D uring laparotom y, the uterine fundus can inversion. In: H ankins G D V , C lark SL, Cunningham FG,
sim ultaneously be pulled from above, possibly with et al (eds). O p era tive obstetrics. Connecticut: Appleton &
a traction suture, under vaginal pressure from below. Lange, 1995: pp. 273-81.
5 Soleym ani M ajd H, Pilsniak A, Reginald PW. Recurrent manual. Uterine inversion. London: R C O G Press,
uterine inversion: a novel treatm ent approach using SO S 2007: pp. 239-42.
Bakri balloon. BJO G . 2009;116:999-1001. 7 Brar HS, G reenspoon JS, Platt LD , et al. Acute puerperal
6 G rady K, Howell C, C ox C. Managing obstetric uterine inversion: N ew approach es to m anagem ent.
emergencies and trauma: The MOET course J R eprod M ed. 1989;34:173-7.
ru
b.
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180
Technique for Cesarean Delivery
u S.A. Scherjon, J.G. Nijhuis, and W.J.A. Gyselaers
ru
General Inform ation experience in resolving specific, cesarean-related,
problem s.
Introduction
Incidence
b.
This chapter provides a description o f the technique
for perform ing cesarean sections. A s in any other Cesarean sections are the m ost practiced surgical pro
surgical procedure, the aim is a technique in which cedure around the world. Recently, there has been
tissue dam age is m inim al, ischem ia and infection are a sharp increase in the incidence o f cesarean sections.
prevented where feasible, and the form ation o f adhe- In 1977, the percentage was approximately 3-5%. For
;
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sions is as slight as possible. Additionally, the goals are
com plete hem ostasis with a precise approxim ation o f
the w ound planes, which are sutured rather loosely,
with the stitches at a reasonable distance and using the
the United States, cesarean section rates were 5.5% in
1970, rising to a rate o f 30.5% in 2007. Data from 119
countries between 1991 and 2003 on the median cesar
ean section rate showed a 100-fold difference in rate
er
sm allest am ount o f suturing m aterial possible. between countries o f 0.4-40%. If categorized by income
Present day cesarean sections are relatively safe (low-, medium-, high-income countries), the median
procedures with low maternal morbidity and m ortal cesarean section incidence is (with interquartile ranges
ity. In one study there were no differences in maternal in parentheses) 4.0% (2.3-9.6%), 16.1% (13.6-21.9%),
h
m orbidity between delivery after an intended cesarean and 17.0% (15.0-21.3%), respectively. Cesarean section
section and after an intended vaginal delivery: odds rates above 20% were found in respectively 3%, 36%,
| ratio (OR) 1.02 (95% Cl: 0.77-1.34) [LE A l/C ].1’2 and 31% o f these countries [LE C].'
us
Potential risks o f cesarean delivery included greater

com plications in subsequent pregnancies, such as Perioperative Phase
uterine rupture, placenta previa, placenta accreta, blad
der and bowel injuries, and the need for hysterectomy
[LE C ].3 A Canadian study o f prim iparous women
General
As in any other surgical procedure, it is important to
with singleton pregnancies showed an increased risk
ak
evaluate and document the patient’s medical history and

o f postpartum cardiac arrest, wound hematoma,
the current status. In that way, the standard cesarean
hysterectomy, m ajor puerperal infection, anesthetic
technique, as described in this chapter, can be indi
complications, venous thromboembolism, and hem or
vidualized and potential problems can be anticipated.
rhage that required hysterectomy in patients who had
a planned prim ary cesarean delivery [LE C |.
Developments outside the realm o f obstetrics, such Counseling
as the availability o f safe blood products and antibiotics, The decision to perform a cesarean section m ust
as well as improvements in anesthetics, have contribut always be based on appropriate indications and
ed to this [LE D ].5 If serious com plication s do arise, a balanced interaction between the physician in
they are usually related to a deficiency in basic su rgi charge and the pregnant w om an (and her partner).
cal skills, unexpected com plications, and insufficient A spects on counseling in general are described in
O b ste tric In te rv e n tio n s , ed. P. Joep D orr, V incent M. Khouw , Fran k A. Chervenak, A m os G runebaum , Yves Jacquem yn,
m ore detail in Chapter 14. The pregnant wom an and have been condu cted into the difference in efficacy
her partner m ust give their consent to the procedure. betw een different prophylactic sch em es, 11 Su pport
Even though an informed consent is not a universal for the use o f azithrom ycin as a second-line broad-
rule yet, it is still recom m ended to m ake a note in the spectrum antibiotic (active again st aerobes and
file that consent was obtained. anaerobes as well as U reaplasm a spp.) by preventing
neonatal sep sis and chronic lung disease w as su g
Preoperative Tests gested in several trials [LE C ].n A definitive R C T
h as still to be perform ed (broad-ran ge/p rein cisio n
Prior to perform ing a cesarean section it is good
versus n arrow -ran ge/postin cision ). The im portance
to know the recent hemoglobin (Hb) count, since in
o f other m easu res to prevent p ostoperative w ound
4-8% o f cesarean sections bleeding o f >1000 ml occurs
in fections, such as lim iting the opening o f the d oor
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[LE A l ].7 In clinical situations with a potentially
o f the operating roo m and keeping the p atien t’s
increased bleeding risk, such as placenta previa or
body tem perature at a p rop er level, are often still
abruption, it is recommended to perform the cesarean
overlooked.
section where a 24-hour blood transfusion is available or
to have cross-matched blood in stock before the surgery.
Thrombosis Prophylaxis
b.
This specific m easure is not indicated for
a prim ary cesarean section after an uncom plicated Throm bosis prophylaxis is recom m ended for
pregnancy. cesarean sections. Although the absolute risk is low,
an increased risk o f postoperative throm boem bolic
Antibiotics
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Prophylactic adm inistration o f antibiotics for cesar
ean section reduces postpartum endom etritis by m ore
than 60% in both prim ary (RR 0.4; 95% C l 0.2-0.6)
com plications does exist and is an infrequent but
potentially devastating contributor to m aternal m or
bidity and mortality. The prophylactic m ethod in all
cesarean sections (e.g., use o f com pression hose, early
er
mobilization, and short-term systematic adm inistra
and secondary cesarean sections (RR 0.4; 95% C l
tion o f low-molecular-weight heparins [LMW H]) can
0.3-0.4). Additionally, this reduces wound infections
be established by choice in local protocols, though
by approxim ately 25% in prim ary (RR 0.7; 95% C l
recently protocols have been developed for routine
0.5-0.99) and 65% in secondary cesarean sections
use o f low-dose heparin in all cesarean sections
h
(RR 0.4; 95% C l 0.3-0.5) [LE A l ].8 Also reductions

[LE C ].12 Com pression hose are described as an
in urinary tract infections are documented.
additive effect along with sim ultaneous use o f LMW H
The adm inistration o f antibiotics before the incision
[LE A l ].1 With short-term use o f LMW H in all cesar
us
com pared to after clam ping the um bilical cord

ean sections there is a negligibly sm all risk o f heparin-
decreases the risk o f endom etritis (RR 0.5; 95% C l
induced throm bopenia (HIT) and hemorrhage.
0.3-0.9) and infections in general (RR 0.5; 95% C l
0.3-0.8), with a tendency toward less wound infec
tions (RR 0.6; 95% C l 0.3-1.2). N o differences have Prevention of Continued Bleeding
been observed in im portant neonatal results, such as For the prevention o f uterine atony and postpartum
ak
suspected sepsis (RR 1.0; 95% Cl 0.7-1.4), proven bleeding in cesarean sections the sam e recom m enda
sepsis (RR 0.9; 95% C l 0.5-2.0), or adm ission to tions are given as for the third stage in a vaginal
intensive care (RR 1.1; 95% C l 0.5-2.2) [LE A I/D ].9’10 delivery: 5 IU o f oxytocin by slow IV, im m ediately
For cesarean section the use o f cefazolin (1 g, after the infant has been delivered. However, oxytocin
single intravenous dose) and m etronidazole m ay be adm inistered before clam ping the infant’s
(500 m g, single intravenous dose) as prophylaxis um bilical cord as this is beneficial for the autotransfu
especially in secondary cesarean sections is recom sion o f placental blood to the neonate.
m ended [LE C ] .11 C efazolin (a first generation For this indication - the prevention o f an atony
broad -spectru m cephalosporin ) is particularly after a cesarean section under spinal or epidural
effective against gram -positive cocci ( U reaplasm a anesthesia - carbetocin, a synthetic long-acting
and M ycoplasm a) and m etronidazole again st an aer oxytocin analogue, has been registered. Four trials in
obic bacteria. Besides this schem e, other antibiotics wom en undergoing a cesarean section showed
are also used for prophylaxis. Insufficient studies a decrease in the carbetocin-treated group (single
C h a p te r 12: T e c h n iq u e fo r C esa rea n D e live ry
dose o f 100 |ig by IV) versus oxytocin (different close to a prior uterine scar, or a placenta that lies over
dosage schemes: from 5 H U [Howell unit] bolus to a prior myomectomy. If this is the case (regardless o f
32.5 H U in 16 hours) o f the num ber o f patients need the question whether the placenta lies against the ante
ing therapeutic uterotonics (RR 0.62; 95% C l rior wall or the posterior wall) in a patient with
0.44-0.88), and the need for uterine m assage (RR a previous cesarean section, then the chance o f having
0.54; 95% C l 0.37-0.79). There were no differences a placenta accreta is more than 20% [LE B].19 This risk
in term s o f the risk for bleeding o f 500 m l or m ore (RR increases linearly up to 67% in the case o f four prior
0.66; 95% C l 0.42-1.06), 1000 m l or m ore (RR 0.91; cesarean sections [LE B /D ].20,21 The relative risk of
95% C l 0.39-2.15), or m ean blood loss (m ean differ placenta accreta, regardless o f placental localization, is
ence -29.00 m l; 95% C l -8 3 -2 5 m l). N o differences in 8.7 (95% C l 3.5-21.2) in two or more prior cesarean
adverse m aternal effects were reported [LE A l ].14-16 sections [LE B ].22
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In a high-risk population, the indication o f irre
gularly shaped lacunae in the placenta
Maternal Positioning a characteristic “cheese with holes im age,” with or
It is cu stom ary to place the pregnant w om an in
without turbulent flow - has a high positive predictive
a left-tilt p osition : a sem i-prone left side lie by
b.
value (PPV) o f 93%. The com bination o f smallest
m eans o f a w edge under the right flank or by tilting
sagittal m yom etrial thickness, lacunae, and bridging
the O R table. T his is an attem pt to prevent vena vessels, in addition to num ber o f cesarean deliveries
caval com p ression due to the large uterine volum e
and placental location, yielded an area under the
and thereby lessen the risk o f m aternal hypotension.
curve o f 0.87 (95% C l 0.80-0.95) [LE C ].23
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The neonatal benefits still ap p ear to be lim ited, with
a trend to fewer low A pgar scores com pared to
supine p osition , w ithout any difference in fetal pH
values [LE A l ] / At the m om en t there is no m eta
Other characteristic disorders are a thin m yom e
trium (<1 m m ) and growth o f the placenta into the
bladder in cases o f placenta percreta. The loss o f the
elongated clearing behind the placenta is less specific
er
analysis available. (PPV 6%) [LE D ].24 A high grade o f suspicion should
Also in other positions - standing, half-sitting, and suggest next steps for further diagnostic evaluations
also with a 15° tilt - there is probably som e aorta caval
such as im aging by m eans o f an MRI or CT
com pression, which can be reinforced through (regio
scan [LE D ].21 All patients with placenta previa and
nal) anesthesia [LE C ].17
h
prior cesarean deliveries should be assum ed to have

a placenta accreta unless proven otherwise.
Bladder Catheterization
us
Catheterization o f the bladder, whether just one time Anesthesia

or via an indwelling catheter, is custom ary in cesarean
sections to prevent bladder lesions. Regional Anesthesia
It has not been established whether one-time cathe Alm ost always, in m ore than 90% o f all cases, the safest
terization in cesarean sections is an advantage over an technique can be used: a form o f regional anesthesia.
indwelling catheter [LE A l ].7 To prevent a bladder
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• Efficacy: the spinal and the epidural technique are

infection, especially if in an emergency cesarean section
equally effective in term s o f relieving pain.
insufficient asepsis is (can be) observed, som e recom
• Contraindications are:
m end not to use catheterization [LE B ].18 It is also
recom mended after epidural anesthesia not to remove - coagulation disorders and (recent) anticoagu
the bladder catheter until at least 12 hours after the last lant use (coum arin derivatives and LMW H)
top-up and after the patient is mobile again [LE A l ].7 (relative contraindication);
- throm bocytopenia (com m only a marginal
Placental Localization value o f 50 x 109 throm bocytes/m l is used);
- brain tum or (increased intracranial pressure)
Placental localization may contribute to an increase in
(relative contraindication) [LE C ].25
blood loss, and therefore it is good practice to know
ahead o f time where the placenta is located and whether Platelet aggregation inhibitors (acetylsalicylic acid) do
you are dealing with an abnorm al placentation such as not constitute a contraindication for both epidural
a low-lying placenta, an anterior placenta that is located and spinal techniques o f regional anesthesia [LE C] .26
Local p rotocols vary in the precise con train d ica mean adaptive score between GA and epidural
tions, depending on the LM W H dose used (low anesthesia (EA) is not different (mean difference
versu s high prophylactic/therapeutic) and the [MD] 2.17; 95% C l -1.1-5.5) and also no differences
technique - single-shot spinal anesthesia versus in Apgar score after 5 minutes were found (M D 0.2;
epidural anesthesia. The interval between the last 95% C l -0.2-0.6) [LE A l ].30 Also arterial and venous
m om ent o f ad m in istration and the m om ent o f umbilical cord pH after GA is no different from that
regional anesthesia, preferably m ore than 10 in epidural and spinal anesthesia [LE A l ].29
hours, is an im portant factor [LE C ].26 • N o difference in m aternal death has been observed
am ong the different techniques.
Comparison of Epidural and Spinal Technique • It is doubtful whether GA, com pared to regional
• The advantage o f the epidural technique is that the techniques, leads to a faster operation in the case
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decrease in blood pressure (and thereby the nega o f an em ergency cesarean section. Yet, com pared
tive influence on the placenta perfusion) is less to non-em ergency cesarean sections, GA is used
than in the spinal technique. m ore often in em ergency cesarean sections than in
• The epidural pain relief can be continued success a control group in which there is no em ergency
fully during the postoperative period with patient- factor (O R 18.5; 95% C l 6.0-64.0) [LE B ].31
b.
controlled analgesia (PCA). • One system atic review showed that wom en who
• The spinal technique is som ewhat faster, but in had had a regional technique - com pared to the
order to prevent a blood pressure decrease the general anesthesia group - have a lower preference
patient m ust first have an intravenous infusion o f using the sam e technique again: epidural versus
with N aCl 0.9%.
Another m ethod that is used is a com bined
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spinal-epidural (SE) anesthesia technique [LE D ].2
In this m ethod both techniques are com bined and the
•
GA (RR 0.8; 95% C l 0.7-0.98) and spinal vs GA
(RR 0.8; 95% C l 0.7-0.99) [LE A l ].29
N o differences in adverse m aternal outcom e are
evident if GA and RA are com pared [LE A I ].'"1
er
dose needed for spinal analgesia can be decreased.
Local Anesthesia
General Anesthesia Very rarely it may be preferred, for example where an
General anesthesia is considered the anesthesia intracranial space-occupying tum or in the mother
h
o f choice only for a few patients who have a cesarean increases the intracranial pressure, to employ a comple
section including those with the inability to have tely local technique. In this procedure, the abdominal
spinal or epidural anesthesia, for exam ple because o f wall is locally anesthetized with approximately 12 times
us
prior back surgery or severe hem atologic anom alies, 1-2 ml lidocaine (0.5-1%), with possible additional
or occasionally for emergent situations. injections into the fascia and the peritoneum.
|
Comparison of General and Regional Anesthesia
• General anesthesia (GA ) is less safe (com plica
Obesity, Extra Risk Factor in Cesarean j
Sections? jj
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tion risk is increased [OR 1.5; 95% C l 1.1-2.1]),

because, am ong other things, o f the increased The cesarean section percentage in obese patients j
chance o f an aspiration and m ore blood loss has tripled (to 60%), in which the m aternal weight J
(O R 2.0; 95% C l 1.5-2.7) [LE C ].28 A lower has an independent association with the cesarean %
decrease in m ean difference pre-postoperative section percentage [LE B ].32-34 With obesity (BMI i
hem atocrit was found for regional anesthesia >30) there is a greater chance (42-74.4% ) o f a foiled
(RA) when com pared to GA, both for epidural initial placem ent o f an epidural catheter, com pared to j
anesthesia (1.7%; 95% C l 0.5-2.9% ) and spinal a population that is not overweight (6%) [LE Bj. f
anesthesia (3.1%; 95% C l 1.7-4.5% ). A lso esti General anesthesia presents greater problem s con- f
m ated m aternal blood loss is lower with epidural cerning intubation (in approxim ately 33%) and
anesthesia when com pared to GA; -0.32 ml; 95% aspiration [LE C ].36 M oreover, operative tim e is
C l -0.59 to -0.07 ml [LE A l ].29 longer, there is m ore blood loss [LE C ],36 and there
• With GA there is no evidence that the infant is are m ore wound infections [LE C ]37 and throm bo
on average more depressed after birth: the em bolic com plications.
C h a p te r 12: T e ch n iq u e fo r C esarean D elivery
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b.
-li
h er
Figure 12.1 Abdom inal incisions.
us
• To prevent the skin incision from adhering to the

Surgical Aspects
fascia, some surgeons open the fascia slightly higher
Opening the Abdominal Wall than the skin incision, which, after closing the skin,
makes the subcutis automatically position itself
Five techniques are described for opening the abdom
between the skin and the fascia and the scars are
inal wall in a cesarean section (Figure 12.1):
therefore not superimposed on each other.
ak
• the midline incision; • It is not necessary to use a separate “skin scalpel”

• the Pfannenstiel incision; for all skin incisions and then switch to an
• the Joel-Cohen method; “abdom inal scalpel” [LE B] ,39
• The surgeon can follow his or her own preference
- the M isgav-Ladach m ethod (M ichael Stark
for opening the abdom en, also o f the skin, with
Cesarean);
a scalpel or with electrocautery.
• the M aylard technique;
- Com pared to other operative procedures, cesar
• the supra or subum bilical transverse incision.
ean sections are prone to fluid spill. As such, the
General com m ents on abdom inal incisions: use of electrosurgery is theoretically at increased
risk for misconduct o f electrical current and
• T o obtain a straight, sym metrical skin incision, the subsequent burning wounds. Although this pro
place o f incision m ay be drawn on the skin before blem has not been investigated in randomized
disinfection. This m ethod is often applied in cos trials, surgeon’s knowledge o f safety measures
metic surgery [LE C ].38 for electrosurgery is highly recommended.40
Sectio n 3: P a th o lo g y o f La b o r a n d La b o r a n d D elivery
- The use o f a diathermal -m idline- skin incision D isadvantages o f m idline incisions are:
has clear advantages, such as a shorter operative • increased risk o f bladder lesion and/or intestinal
time, less blood loss, and lower pain scores, and lesion (corrected OR 3.9 [Cl 1.4-8.9] and 5.5, respec
no drawbacks with regard to wound healing or tively [insignificant due to small numbers]). The risk
infections [LE A 2].41 (in midline as well as transverse incisions) o f bladder
lesions is (also) related to the number o f cesarean
• If a scar from a previous operation is particularly
sections in the patient’s medical history [LE C ].42
unsightly, it is custom ary to suggest excision o f the
• greater risk (up to 3%) o f w ound dehiscence,
old scar.
which is alm ost 10 tim es higher than in
a transverse incision (0.37%) [LE A l ].7
Midline Incision
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Indications for a midline incision are: Closure of Midline Incisions
• if additional exploration o f the upper abdom en For midline incisions there are sufficient data in the
m ust also be perform ed; m edical literature to justify a so-called continuous
• in case o f specific obstetric com plications, such as mass-closure with long-lasting absorbable m aterial,
b.
a neglected transverse lie, because o f the longitu in which the rectus m uscle, fascia, and the parietal
dinal incision into the uterus in that case; peritoneum are included in one continuous layer
• if the patient had a previous midline lower abdom [LE A l ].7 This m ethod has less risk o f scar ruptures
inal laparotomy. and dehiscence than closures in individual layers.
was determ ined beforehand (in the event o f

-li
A m idline in cision is also preferred in em ergency
situ ation s and if the need to lim it bloo d loss
throm bocytopenia, a patient who refused a blood

Pfannenstiel Incision
The m ost frequently used transverse incision is the
“classical” Pfannenstiel m ethod. With this m ethod, all
o f the layers o f the abdom inal wall are incised sharply.
er
tran sfu sion [e.g., Jehovah’s witness] or an o p era
tion under anticoagulan t use). In both in dications The following structures are opened in succession:
the benefit is doubtful because o f w ider exp eri • The skin and the subcutaneous tissue are opened
ence with transverse in cisions (therefore faster) with a curvilinear incision o f approxim ately 12 cm
and the use o f blunt dissection techniques (less in length and two finger-widths above the pubis
h
blood loss). (Figure 12.2).

us
subcutis
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Figure 12.2 Skin incision (A) and situation after opening the skin (B).
C h a p te r 12: T e c h n iq u e for C esarean D elivery
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fascia
b.
Figure 12.3 Incision o f the subcutis.
Figure 12.4 Incision o f the fascia.
-li
er
S!<jn subcutis
h
us
rectus
fascia
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fascia
Figure 12.5 O pening o f the fascia.

Figure 12.6 Dissecting the fascia.
• The subcutis is incised sharply over the entire • The fascia is dissected sharply upward and down
length down to the fascia (Figure 12.3). ward o ff o f both rectus m uscles (Figure 12.6).
• The fascia is incised for 1-2 cm on each side next • The rectus m uscles are separated sharply from
to the m idline (Figure 12.4). each other in the midline (Figure 12.7) and then
• The fascia is opened sharply with surgical scissors, the rectus m uscles are further opened by traction
e.g., curved M ayo scissors (Figure 12.5). (Figure 12.8).
187
Section 3: P a th o lo g y o f La b o r and La b o r a n d D elivery
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fascia
rectus
b.
rectus
parietal peritoneum
fascia
Figure 12.7 Separating the rectus muscles. Figure 12.8 Separating the rectus muscles by digital traction.
-li
h er
us
bladder lower uterine segment

rectus peritoneum
umbilicus
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rectus parietal peritoneum
Figure 12.10 O pening the vesicouterine fold.

Figure 12.9 O pening the parietal peritoneum.
• The parietal peritoneum is opened sharply the m em branes (Figure 12.12), after which the
(Figure 12.9). incision is widened digitally in a transverse direc
• The visceral peritoneum (the vesicouterine fold) is tion (Figure 12.13). In this way the arterial
incised curvilinearly (Figure 12.10). branches are not severed by sharp cleavage, but
• The bladder is pushed caudally out o f the way with pushed aside and kept intact.
a dabber (Figure 12.11). • U pon opening the uterus, the m em branes may
• After placing a m arking incision, the lower uterine or m ay not be ruptured. If opening the uterus
segm ent is incised sharply in the center down to with ruptured m em branes or in case of
ru
marking uterus
b.
Figure 12.12 Marking incision and opening o f the lower uterine
segment.
Figure 12.11 Sliding bladder to the side.
-li In 70% o f the patients women experience the pain in

the lateral portions o f the scar. In half o f the patients
er
with moderate-to-severe pain the pain could be
related to nerve entrapm ent o f the iliohypogastric or
ilioinguinal nerve [LE B ].43
The Joel-Cohen Method

h
Joel-Cohen was particularly interested in shortening

the time duration, although there is a bit m ore blood
loss in the dissection o f the subcutis than in a midline
us
incision. In this “surgically m inim alistic” variation

o f the Pfannenstiel cesarean section, no wound
membranes
uterus retractors are used, only the skin is incised sharply,
and the subcutis is not separately “opened” sharply
[LE B /D ].44-46
ak
The following structures are then opened in

succession:
Figure 12.13 Digital w idening o f the incision.
• Joel-Cohen’s skin incision runs straight, approxi
mately 3 cm below the line between both antero-
oligohydram nios, it m ust be taken into account superior iliac spines (Figure 12.14).
that the infant can be easily nicked with a scalpel, • A sm all section o f the subcutis is incised sharply
which could have serious consequences. down to the fascia (Figure 12.15), after which it is
• A fter that, the in fant is rem oved from the opened further by blunt finger traction
uterus. (Figure 12.16).
After a Pfannenstiel incision moderate-to-severe • The fascia is opened via two sm all incisions on
chronic pain 2 years after the operation is reported each side o f the midline (Figure 12.17) and then
in 7% o f patients, while 9.8% o f the respondents opened bluntly through bilateral traction above
experience pain im pairing their daily activities. the rectus m uscles (Figure 12.18).
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b.
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er
subcutis
h
us
fascia fascia
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Figure 12.15 Incision o f the subcutis. Figure 12.16 Digital opening o f the subcutis.
• The rectus m uscles are not dissected from the and the abdom en is further opened by traction
fascia, but are opened bluntly in the midline (Figure 12.21).
(Figure 12.19). • The bladder peritoneu m is not opened, which is
• The parietal peritoneum is opened digitally a strategy that is also preferred accord in g to
(Figure 12.20). m ore recent stu d ies [LE A 2 /A 2 /C ],47-49
• The peritoneum , rectus muscle, and fascia are The om ission o f the b lad d er flap form ation is
grasped completely on both sides with four fingers associated with less fever and a significantly
C h a p te r 12: T e c h n iq u e fo r C esarean D elivery
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b.
Figure 12.17 Incision o f the fascia.
Figure 12.18 Digital opening o f the fascia.
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h er
us
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Figure 12.19 Separating the rectus muscles.
decreased operation tim e, less blood loss, and • The low er uterus segm ent is incised sharply
im proved patient outcom e [LE C ].48 Because dow n to the m em branes approxim ately 3 cm
the in cision is a little higher than in the above the vesicouterine fold, after which the
Pfannenstiel incision, it is assu m ed that less uterus is opened digitally (Figures 12.12 and
d am age occurs to the bladder. 12.13).
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b.
Misgav-Ladach Method (Michael Stark Cesarean)
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The m ethod according to M isgav-Ladach (Michael
Stark Cesarean), the m odification nam ed after
dilatation o f the cervix, no advantages and even d is
advantages have been reported. C losin g the uterus
er
outside the abdom en is p ossibly advantageous with
a hospital in Jerusalem described in 1983 by Stark
respect to blood loss, because o f a better view o f the
et al., does not differ in principle from the m odifica
incision in the uterus. Also, the locked technique of
tion according to Joel-Cohen [LE D ],50,51 In this
uterine closure described in the M isgav-Ladach ver
m ethod the subcutis is also barely opened (approxi
sion is now discouraged. The subcutis is not closed
h
m ately 2 cm down to the rectus sheath).

and the skin is closed after approxim ation - by
The following structures are then opened in
m eans o f clam ps - with only three sutures.
succession:
us
• The skin and subcutis are opened as in the m eth Maylard Method
ods according to Joel-Cohen.
In a M aylard incision both rectus m uscles are sev
• After an incision in the m idline o f 2 cm
ered crossw ise with the aid o f electrocoagulation.
(Figure 12.22A), the fascia is opened in W ith this approach there are no advantages with
a craniocaudal direction. This can be done with respect to the am ount o f room over a m idline inci
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scissors or digitally (Figure 12.22B). sion and in term s o f the m uscle function analysis
• The rectus muscles, the peritoneum , and the lower there m ay be disadvantages com pared to the
uterine segm ent are opened as in the method Pfannenstiel approach [LE A 2].53 Therefore, there
according to Joel-Cohen. seem s to be no justification for the M aylard m ethod
D issection o f the rectus sheath does not offer any in cesarean sections, except in the case o f extreme
advantages. D issection o f the (caudal) fascia seem s to obesity.
only result in negative consequences, such as
m ore postoperative pain and lower postoperative Supra or Subumbilicat Transverse Incision
Hb [LE A 2].52 By using a skin incision 2 cm above the projection of
O f three steps originally described by the the pubic sym physes, corresponding to a supra or
M isgav-Ladach m ethod, i.e., carefully pushing the subum bilical incision, in women with a volum inous
bladder out o f the way, the stan dard procedure o f panniculus a better approach to the lower uterine
a m anual placenta rem oval (M PR), and the digital segm ent is realized. In the U SA, 25% o f the pregnant
C h a p te r 12: T e ch n iq u e for C esarean D elivery
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b.
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population are obese. Obesity is defined as a BMI
>30 kg/m 2 and m orbid obesity as a BM I >40 kg/m 2.
Incision of the Lower Uterine Segment
er
Digital Opening
With this incision the panniculus is not m oved and To open the LU S, first a 2 cm sharp incision is m ade
stays in the apron position [LE D ].54 and then the uterus is further opened digitally. There
is less blood loss with digital w idening o f the opening
Uterine Incision (843 ml versus 886 ml with a sharp incision:
h
Corporeal Incision a difference o f 43 m l; 95% C l -2 0 to -6 6 m l) and

A corporeal vertical incision o f the uterus (a “classical on sharp opening there is less need for transfusions
cesarean section”) is needed only rarely [LE D ].55 (RR 0.22; 95% C l 0.1-1.01) [LE A l/ 2 ].56’57 Blunt
us
The following are (relative) indications for opening o f the uterus is not associated with m ore
endom etritis [LE A l ].55 Extensions of the uterine inci
a corporeal incision:
sion are reported less often with blunt extension (RR
• extremely short gestational age (barely form ing
0.41; 95% C l 0.31-0.54) [LE A l ].56 Due to the frequent
the lower uterine segm ent [LUS]);
dextroposition of the uterus, a hemorrhage o f the left
. transverse lie, especially in case o f preterm rupture
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parametric vessels or the left uterine artery may occur

o f the m em branes and with the back as presenting
because o f tearing o f the left parametrium. As was shown
part (“back down”), so that the sm all extremities
in a non-blinded study, the use o f an auto-suture tech
cannot be reached;
nique suggests a clinically but not statistically significant
• large cervical m yom a or serious adhesions in the
decrease in blood loss (median -87 ml; 95% C l -
true pelvis;
175-1.1 ml) [LE A l ].56
• placenta previa, in which large vessels run over the
LUS. However, despite a presenting placenta, in an
incision in the LUS, blood loss is still less than in Transverse Versus Midline Opening of the LUS
a corporeal incision; A prospective random ized study showed that the
• cervical carcinom a during the pregnancy, in which digital opening o f the uterus in both techniques
a cesarean section is perform ed prior to the radical (Pfannenstiel and Joel-Cohen) in the usual transverse
hysterectomy. direction com pared to a craniocaudal technique
results m ore frequently in lateral tearing (7.4% versus

3.4%: corrected OR 2.2; 95% C l 1.1-4.2) and also in
Delivery
Delivery of the Head
m ore blood loss (>1500 ml: 0.2% versus 2.0%; cor
rected OR 8.4; 95% C l 4.2-18.5) [LE A 2].58 The goal o f the delivery is to have the infant’s head
flexed. This can usually be done with a flat hand. In an
Lengthening of the Transverse Incision in the LUS occiput or sinciput posterior presentation it is best to
Som etim es, for exam ple in extrem e growth restric first turn the occiput to anterior.
tion during the prem ature period, the space
obtained by opening the LU S is insufficient and it
Difficult Delivery of the Head
is decided to “lengthen” the incision. In this case it The standard use o f instruments to deliver the head has
is generally accepted that a “T -sh ap ed ” incision not proven to be an advantage over the open hand.
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will lead to a uterine rupture faster in pregnancy In this respect - in case o f a non-engaged head -
than a “ J-sh aped ” incision. Before carrying out this a (manual) vacuum cup (Kiwi) can be used if necessary.
procedure, it is im p ortan t to evaluate whether the D uring a secondary cesarean after an unsuccessful
lack o f space in the uterus is due to a uterine vaginal attempt the fetal head can be deeply engaged -
“im pacted.” Two techniques can then be used: the
b.
contraction or contracture: sim ply w aiting until
the uterus relaxes again or adm inisterin g a tocoly “push” technique, whereby the fetal head is displaced
tic agent (see Section: T ocolysis) m ay prevent any to the uterine cavity with m anual pressure via the
u nnecessary iatrogenic traum a to the m other and vagina and the reverse breech “pull” technique whereby
the infant. there is a prim ary attempt to deliver first the breech
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The “T-shaped” incision denotes a corporeal
incision and the need for a prim ary cesarean section
in a possible subsequent pregnancy. In a “J-shaped”
incision this m ay not be the case, but it is som ething
(Figure 12.23). In small, non-randomized studies some
advantages have been described for the “pull” techni
que. Less extension o f the uterine incision is seen and
also a “J-incision” is needed less frequently. Also less
er
that needs to be considered. The indication for maternal fever and less urinary tract infections are
a prim ary cesarean section in a subsequent pregnancy reported, while neonatal outcomes are not different
m ust be indicated clearly by the surgeon, in both the [L E C ].61’62
surgical report and the discharge letter.
Fundus Pressure
h
An extreme form o f a surprise lie o f the uterus

is a uterine rotation o f m ore than 180°, possibly It has been hypothesized that the application o f fun
resulting from a fixed retroflexion, in which an inci dus pressure to assist extraction o f the baby increases
fetom aternal transfusion, and w arrants careful
us
sion was m ade in the posterior wall o f the uterus;

which was only acknowledged after the delivery preventive m anagem ent o f rhesus im m unization in
o f the infant [LE D ].59 In inadequate progress o f rhesus negative women. However, one random ized
the second stage o f delivery, the Bandl ring may trial did not find any difference in transplacental
have presented itself so high that the bladder is located m icrotransfusion between cesarean births with or
much higher than expected. The bladder is then m ore without fundus pressure [LE A 2].63
ak
easily dam aged and is not infrequently opened

Tocolysis
iatrogenically.
In general and in order to prevent a skin lesion in In a difficult delivery o f the infant some clinics use
the infant it is prudent to open the m yom etrium up to glyceryl trinitrate (= nitroglycerin). In a randomized
the chorion, in which the rem aining fibers are pushed study, a routine use o f intravenous nitroglycerin (0.25
aside by blunt traction. and 0.50 mg) or placebo showed no difference in the
A random ized study has borne out the observa ease o f the fetal extraction or in a decrease in uterine
tion that the use o f stapling during opening results in tone [LE A l ].64 A higher IV dose (100-250 (ig) has been
a (m inim al) decrease in blood loss (-4 4 ml; 95% clinically applied, but not enough clinical trials have
C l -6 6 to -2 0 ml) [LE A l ]57 or no difference in been done [LE A l/C ].65-66 Alternative forms o f adm in
blood loss [LE B ],60 in surgery o f total equal duration istration, such as sublingual (800 |ig), have been
[LE A l ].57 described [LE D ].67 Until m ore evidence becomes
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b.
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h er
us
Figure 12.23 Reverse breech pull technique. (A) Introduction o f the hand; (B) grasping o f one o f the feet; (C) delivery o f the buttocks first,
follow ed by th e b ody and head.
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available, as stated before, it is important that an opera The perform ance o f an M RP is associated with
tor demonstrates patience in allowing a contracting an increased risk o f low Ht: - 1.6 (95% C l -3.1-0.01)
uterus to relax to prevent unnecessary surgical or m ed [LE A l] 68;
ical harm to mother and child. • alm ost 40% lower risk o f significant blood loss
[LE A 2].71 The perform ance o f an M PR is asso
Delivery of the Placenta
ciated with an increased risk o f blood loss o f more
A random ized study showed that a spontaneous pla
than 11: 1.8 (95% C l 1.4-2.3) [LE A l ].68
cental delivery or with a lightly controlled cord traction
has clear advantages over a m anual rem oval o f the M RPs are also associated with a higher infection risk
placenta (M RP), i.e.: (endometritis) (OR 1.6; 95% C l 1.4-1.9), a tendency
• less blood loss, estim ated 94 ml (95% C l 17- toward increased fetomaternal transfusion (OR 1.6;
172 ml) [LE A l] 68; 95% C l 0.8-3.2) [LE A l/2 ],68,69 and a longer hospital
• higher H t [LE A 2]69 and Hb [LE A 2].70 stay: 0.4 (95% C l 0.2-0.6) [LE A l ].68
The adm inistration o f 5 IU o f oxytocin (intrave Removal of the Placenta during the Cesarean
nous) [LE A l ]7 or carbetocin 100 |ig IV [LE A 2]15 Section in Case of a (Complete) Placenta Previa and/or
decreases the blood loss. The anesthesiologist adm in
Placenta Accreta (Cesarean Hysterectomy)
isters the oxytocin by IV (and not in the uterus).
Placenta accreta is a m orbid adherence o f the placenta to
Delaying cord clam ping even for 3 m inutes favors
the myometrium. The incidence was rare before 1950,
child outcome, even in the long term, and has no
m aternal drawbacks [LE D, A l ].72-74 but has increased to possibly 3/1000 deliveries; this is
related to the increase in number o f cesarean sections.
A lthough this has not been dem onstrated, it
M ost o f the placenta accreta are inserted at the scar
seem s sensible to check m anually whether the uter
o f a previous cesarean section [LE C ].75 Whether
ine cavity is really em pty and whether there are any
a uterine dehiscence (niche) should be repaired after
abnorm alities in the shape o f the uterus. W iping out
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a cesarean, and whether such a finding is related to
the uterus after delivery o f the placenta with a sponge
closure of the uterus with one versus two layers are
is not worthwhile, and digitally opening the cervix to
two o f the many questions that remain unanswered.
enhance the drainage from the uterus has no support
It therefore must be realized that if any part o f the
in study data. Blood loss after the delivery o f the
placenta is located near a previous cesarean section
b.
infant can be dim inished by applying pressure to
scar, a placenta accreta should be considered. Both
the w ound area with an abdom inal gauze pad. This
can also be consciously used to include a pause in the ultrasound and MRI are considered to be useful
modalities in its diagnosis, although it can never be
operation. The placem ent o f (atraum atic) uterine
completely conclusive and the definitive diagnosis
clam ps and the insertion o f two hem ostatic sutures
blood loss. -li

at the corners o f the incision m ay also decrease the
can only be made at surgery [LE D ].76 3D power
Doppler and MRI possibly have the same good
test characteristics (sensitivity: 100%; specificity 85%;
h er
us
ak
Figure 12.24 Bakri balloon tam ponade. (A) Tip o f Bakri balloon - the tw o “canals' fixed together w ith a suture thread - inserted via the
uterine incision through the cervix; (B) the inflated Bakri balloon after closure o f the uterine incision.
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uterus
b.
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h er
us
Figure 12.25 B-Lynch procedure. (A) Frontal view: introduction o f the suture starting below and leaving just above the uterine incision.
(B) Sagittal view: the suture is introduced and leaves at the dorsal side o f the uterus, just above the cervix. (C) Sagital schematic view: the suture
is tied at the frontal side o f the uterus just above the cervix.
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PPV 88%; risk 100%). Both placenta accreta and pla hysterectomy. The lower uterine segm ent full
centa previa increase the risk o f severe postpartum thickness com pression sutures, which are applied
hemorrrhage (PPH). As pharmacological treatment after an terior-p osterior decom pression o f the LUS,
fails in general in these cases, massive hemorrhage have been shown to be successful in reducing blood
occurring after removal o f a placenta previa due to the loss. It consists o f two fast absorbable sutures that are
poor contractility o f the lower uterine segment is treated passed on both sides o f the uterus, 2 cm from the
with different m odalities by packing o f the lower edge o f the uterus from anterior to posterior and
uterine segm ent with gauze, balloon tam ponade then back, and then knotted (Figure 12.26) [LE
(Figure 12.24) [LE C /D ],77’78 a stepwise ligation o f D /C ].79,80 T his seem s a m ore rational choice for
the uterine vessels or o f the internal iliac arteries, this com plication than craniocaudal com pression
uterus com pression with a (m odified) B-Lynch p ro sutures (H aym an), which are prim arily intended
cedure (Figure 12.25) [LE D ],79 and em bolization or for treatm ent o f uterine atony (Figure 12.27).
tie both ends
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uterus
Figure 12.26 Full-thickness com pression sutures. (A) An absorbable suture is introduced from the anterior side and then to the posterior
b.
side and back again. Both ends are 1 cm distant from each other and are tied in the frontal aspect o f the uterus, above the cervix.
(B) The compression sutures are introduced at the tw o sides: 3 cm under the uterine incision and 2 cm from the lateral uterine wall.
B
tie both
-li uterus ends

h er
us
cervix uterus
Figure 12.27 Hayman compression sutures. (A) Two separate sutures are introduced just below the uterine incision; (B) the sutures
are tied at the fundal site o f the uterus.
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Extra-abdominal or Intra-abdominal is less [LE A 2],83,84 but aside from that there is also an
increase in perioperative nausea and tachycardia
Uterine Closure with spinal anesth esia [LE A 2 ]85 and an increase in
It m ay be useful to lift the uterus out o f the abdomen, pain sym ptom s after 6 h ours [LEA 2]82 and during
as this improves the view o f the uterine incision. the first 2 p ostp artu m days [LE A 2].86 It has also
C om pared to the intra-abdom inal closure o f the been reported that the intestinal function resum es
uterus, this procedure is associated with a decrease in m ore slowly after extra-abdominal closure [LE A2]79
febrile periods o f m ore than 3 days (RR 0.4; 95% C l and there is uncertainty on an increase (0.24 days; 95%
0.2-0.97), without a clear difference in other m orbid C l 0.08-0.39) [LE A l ]81 or decrease in the hospital stay
ity variables [LE A l ].81 M ore recent randomized (0.8 days) [LE A 2].87 However, a recent RCT does
studies indicate that the extra-abdom inal closure o f not confirm all these findings, suggesting that both
the uterus is done faster than the intra-abdom inal methods can be valid options during surgery with
closure [LE A 2]82 and that intraoperative blood loss a minor decrease in surgery time (3 minutes) and
a minor difference (0.2 days) in hospital stay after (O R 5.0; 95% C l 2 .6 -9 .5 ) and not after an unlocked
intra-abdominal repair [LE A 2].87 A meta-analysis - single-layer closer (O R 0.5; 95% C l 0 .2 -1 .2 ) [LE
including 11 RCTs published before 2008 - shows no C ].94 The ever-continuing d iscu ssion led to setting
differences in all these findings. There are no data up the previously mentioned randomized study
on adhesion formation as a result of extra-abdominal (“CAESAR”) into the different surgical techniques
closure o f the uterus [LE C ].88 o f a cesarean section (National Perinatal Epidemiology
Unit: www.npeu.ox.ac.uk/caesar).89 In addition to one-
Uterine Closure layer or two-layer closings, this study also looked
into the effects o f whether or not to close the parietal
The uterine incision is usually closed with a one- or
peritoneum. Long-term outcomes, especially on uterine
two-layer, continuous, atraum atic (non-locking)
rupture in a next pregnancy, await elucidation.
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stitch, using m ultifilam ent thread (e.g., with polyglac-
The thickness o f the uterine wall for suturing has
tin 910-1). This produces a better tension distribution
not been studied sufficiently, just as whether or not to
o f the suture (com pared to a locked technique and the
include the serosa and/or the decidua in the suturing
knotted technique), which can spiral through the
(inverted “endom etrium -sparing” suturing). At this
w ound area in a shorter operative time: 7.4 minutes
b.
time, no valuable recom m endations can be form u
(95% C l - 8.4-6.5) [LE A l ],57 with less blood loss:
lated on these aspects [LE A l ].95 The use o f a large
70 ml (95% C l -102 to -3 9 ml) and less postoperative
abdom inal sponge after the infant’s birth for applying
pain (RR 0.7; 95% C l 0.5-0.9) [LE A l/B ].57'60
pressure to the wound area results in a shorter opera
In the C A ESA R trial no difference in maternal
tive time.
95% C l 0.9-1.2) [LE A 2].89

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infectious m orbidity was found after single- versus
double-layer closure o f the uterine incision (RR 1.0;
U ltrasound testing perform ed regularly up to 6

Inspection of the Adnexa and Sterilization
It is good practice to inspect (and possibly palpate) the
er
weeks postpartum shows no difference between adnexa after closing the uterus in order to rule out any
one-layer and two-layer closures in the decrease in adnexal pathology. N o studies have been done on the
thickness o f the uterine scar [LE A 2].90 usefulness o f this procedure.
There are no serious arguments against closing If the partners m ade a request for sterilization
in two layers, although a minor study found that during the weeks prior to the cesarean section, this
h
after closing the uterus in one layer there were radio- can be done during this phase o f the intervention.
logically fewer scar defects [LE B ].91 In patients who The m ost frequently used method is the Pomeroy
were randomized for one-layer or for two-layer closure, technique, in which a bilateral 2 -3 cm portion o f
us
no difference was found in negative outcomes in fallopian tube is resected at the isthm us level after
a subsequent pregnancy for either the mother or the prior distal and proxim al ligation. Traditionally, for
child (interpregnancy interval, vaginal delivery, preterm reasons o f a greater inflam m atory response, catgut
delivery, placental abruption, uterine dehiscence). was used for this procedure. By analogy with tubal
However, the groups were small, including only 18% ligation in general, the lifetime risk o f a failing tubal
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o f the original cohort [LE B ].92 A retrospective study ligation during a cesarean section is estimated at
found more uterine ruptures after one-layer closure 1:200, but specific studies on this have not been pub
(OR 4.0; 95% C l 1.4-11.5). In this study, the uterus lished [LE A l ].7 Sterilizations are also done with
was closed in one layer with chromic catgut suture and a Falope Ring or a Filshie clip. It is assum ed that by
a locked closure, two factors which contribute to addi using one o f these two techniques the chance o f preg
tional necrosis o f the uterine scar and therefore a poorer nancy is m ore successful after a possible refertiliza
healing o f the scar [LE B ].93 In a recent meta-analysis of tion. An observational study (2-15 years) showed no
eight observational studies and an RCT (n = 5810 preg differences in pregnancy rate between a Pomeroy
nancies) the risk o f uterine rupture and uterine dehis technique (0/203) and Filshie clips application (1/85)
cence in a trial o f labor in the next pregnancy was not [LE C] ,96 The Filshie clip application is quicker and is
different between single- versus double-layer closure simpler. Intraoperative sterilization during a cesarean
(OR 1.7; 95% C l 0.7-4.4). Interestingly, confirming the is a practical and safe method and has as a second
former study, this risk is com pared to double-layer advantage that less negative effects were found on
closure, in creased after a locked single-layer closure ovarian reserve [LE C ].97 Also the placem ent o f an
intrauterine device (IUD) through the incision at the • A random ized study showed that there is less
time o f cesarean birth is a possibility [LE D] ,98 chance o f ileus when the peritoneum is left open.
N ot closing both peritoneal layers is not linked to
Peritoneal Closure more wound dehiscence and it also shortens the
surgical duration (7.3 m inutes; 95% C l 8.4-6.4
Despite the fact that since the 1926 article by Kerr it
m inutes) [LE A 1/2/B ].99,104-106
has been standard practice to close the visceral and
• Fewer infections occur and there is a decrease
parietal peritoneum to prevent adhesions, this
in febrile duration (O R 0.62; 95% C l 0.41-0.94)
method has been losing popularity in recent years.
[LE A l/ 2 ].99'104 This finding was confirm ed in the
It appeared that when suturing the peritoneum there
was a slower postoperative recovery. C A ESA R trial where no difference in m aternal
infectious m orbidity was found after closure ver
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The advantages o f not closing the peritoneum
sus non-closure o f the pelvic peritoneum (RR 0.9;
com pared to closing it are as follows:
95% C l 0.8-1.1) [LE A 2].89
• Owing to a possible diminished ischemia because
• The need for pain medication is lessened [LE A 2].105
o f suturing and a decreased fibrinolysis shown in
All o f this results in a decrease in hospitalization
animal experiments it is now generally believed
b.
stay by less than 1 day (-0.4; 95% C l -0 .5 to -0.3)
that closing the peritoneum actually causes more
[LE A l ] 104 m aking the cesarean section less
adhesion formation [LE A 2/B].45,99 The percentage
expensive.
o f serious adhesions increases with each cesarean
section. The percentage is 0.2% for the first cesarean The problem with these data is that they are prim arily
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section, while 11.5% o f serious adhesions are
encountered in the second cesarean, and this
increases to 44.5% in the fourth cesarean [LE C ].1
In one follow-up study o f an RCT comparing the
based on short-term results. In contrast to the Stark
study [LE B ],46 two recent prospective studies found
that the num ber o f adhesions increases in the long
term [LE B ],106,107 In a group o f patients who under
went a prim ary cesarean section after a prior cesarean
er
Pfannenstiel cesarean with a modified (Joel-Cohen)
cesarean technique (with without bladder formation in which the peritoneal layers were closed, there were
and with non-closure o f the peritoneum; 62 patients clearly less adhesions (O R 0.20; 95% C l 0.08-0.49)
in each group), the number of adhesions seen at com pared to a group in which the peritoneal layers
repeat cesarean (the primary outcome) was higher were not closed [LE B ].107 This was confirm ed in
h
with a Pfannenstiel cesarean (RR 3.1; 95% C l 1. a random ized study in which closure or non-closure
5-6.8). In the classic Pfannenstiel technique there o f the peritoneal layers was observed in a second
was also more fibrosis o f the anterior abdominal cesarean. M ore adhesions were observed in the non
us
wall and the bladder was found adherent to the closure group (RR 3.2; 95% C l 1.0-10.2) [LE B ].106
uterus more often [LE A2].101 With the repeat cesar Although the evidence points in the direction o f not
ean, operation time, blood loss, time to mobiliza closing the peritoneum , the results o f the CAESAR
tion, and postoperative hospital stay all favored the trial should shed m ore light on this m atter (National
modified technique. In an RCT where closure and Perinatal Epidem iology Unit; www.npeu.ox.ac.uk/cae
sar).89
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non-closure o f both the visceral and parietal perito

neum were compared, the proportion o f patients
with adhesions at repeat cesarean was the same in Fascia Closure
both groups (60% in the closure and 51% in the non N o study data are available on the short- and long-term
closure group; p = 0.31), with comparable mean results of methods and materials for closing the fascia
adhesion scores [LE A2].102 [LE A l ].94 In most cases one continuous (non-locked)
• This debate is still ongoing as a m eta-analysis (33 suture is used [LE A l ],108 either with a monofilament
observational studies) provided strong evidence suture, e.g., polydioxanone (PDS) 0, or absorbable,
for closure o f the peritoneum . Two groups - twisted synthetic suture, such as polyglactin 910-1.
with and without closure o f the peritoneum - For this, the 10-10 rule or the 20-10 rule can be used:
were com pared using the Stark technique. M ore the distance between the sutures, 10 or 20 mm, and the
adhesions were found when the peritoneum was distance to the fascial edge, 10 mm. The advantage of
left open com pared to when it was closed (O R 4.7; a continuous suture is that the spiraling closure o f fascia
95% C l 3.3-6.6) [LE A l ].103 results in a more even pressure distribution on the
fascial edges. This continuous suture may be fixed on restricted use o f a subrectus sheath drain (RR 0.9;
both sides to separately placed corner stitches. 95% C l 0.8-1.1) [LE A 2].89
There are no study results on the benefits or
adverse effects o f approxim ating the rectus m uscles Skin Closure
over the midline. There is a general consensus that There is no general consensus on the m ethod for
this intervention has potentially m ore disadvantages closing the skin after a cesarean section.
than advantages [LE A l ].94 The skin can be closed with a continuous, intracu-
taneous absorbable suture that does not have to be
Subcutis Closure removed (e.g., Rapide polyglactin 910 or polyglactin
The theoretical advantages and disadvantages o f clos 910 4-0). U sing staples is a faster method (5-10 m in
ru
ing the subcutaneous fat layer are interpreted differ utes) [LE A l ],110,111 but in one study m ore pain sym p
ently, depending on the thickness o f the subcutis [LE tom s were reported [LE A l ] 110; however, a more recent
A l ].108 As a theoretical advantage, closing the subcu RCT shows significantly less pain 6 weeks post-
taneous layer has better w ound healing because o f operatively [LE A1/A 2],110,112 The results for incision
a lesser chance o f hem atom as and serom as. appearance are comparable ([LE B ]109 and [LE A 2]112),
b.
The value o f the study is doubtful due to the subjec especially where the neat wound edges are not lost as
tivity in the assessm ent o f the endpoints o f the study. a result o f the (unnecessary) gain in speed. A meta
In a random ized, non-blinded study no advantage analysis, however, showed more wound separation (OR
was found in subcutis closure after 4 m onths, with 4.0; 95% C l 2.1-8.0) and more wound complications
-li
respect to w ound healing and patient satisfaction [LE
B ]109 Furtherm ore, the conclusion o f m ost studies
advise against subcutis closure. The m eta-analysis o f
the whole group did not dem onstrate any advantages
(OR 2.1; 95% C l 1.3-3.5) [LE A l ],111 suggesting
a possible benefit in using subcuticular stitches for
closure o f a cesarean section.
Conclusions
er
in term s o f wound infections, operational duration,
and average blood loss. Nevertheless, there are indica
In summary, there appears to be an advantage to re
tions that less hem atom a and serom a form ation
placing several sharp incision steps in the cesarean sec
occurs when the subcutis has been closed (RR 0.5;
tion technique with digital steps [LE A1/2/C].113-115 Two
95% C l 0 .3 -0 .8) [LE A l ].108
modifications, the Misgav-Ladach or the Joel-Cohen
h
Thin Subcutis modification, have shown a number o f advantages

com pared to the Pfannenstiel technique, whereby
In case o f a very thin subcutis, it seem s prudent to close
us
a reduction o f 65% has been found in reported post

it in order to prevent skin adhesions to the fascia. Also,
operative m orbidity in general (RR 0.4; 95% C l
the subcutis contains a very fine connective tissue net
0.1-0.9). M ore specifically this concerns (except for
that, if approxim ated, decreases traction on the skin.
adhesions) only the following short-term results:
Thick Subcutis • a shorter operation time: 11 m inutes (95% C l -6
to -1 7 m inutes);
ak
I f the subcutis is thicker (> 2 -3 cm ), it is a good idea to

close it, e.g., with polyglycolic acid 3.0 or Rapide • less blood loss: 58 ml (95% C l -8 to -109 ml);
polyglactin 910. This has a favorable effect on decreas • less fever (RR 0.35; 95% C l 0.1-0.9), and decreased
ing the am ount o f hem atom as and serom as (RR 0.42; antibiotics use (RR 0.5; 95% C l 0.3-0.8);
95% C l 0.24-0.75) and infections [LE A l ].95 • less suturing m aterial [LE C ];113
It is recom m ended to close or drain a subcuta • shorter duration o f postoperative pain: 14.2 hours
neous layer with a thickness o f at least 2 -3 cm. If, (95% C l -10.0 to -18.3 hours), less use o f injections
however, a subcutis o f 2-3 cm or m ore is not closed, for pain relief: -0.9 injections (95% C l -0.6 to -1.2),
again fewer w ound com plications are reported with and less use of analgesics (RR 0.6; 95% C l 0.4-0.8);
the placem ent o f a 24-hour wound drain [LE A l ].95 • shorter hospitalization time: 1.5 days (95% C l -0.8
There are no com parative studies on suturing versus to - 2.2 days);
draining, or on a com bination o f both. • tendency for a 6.7-hour (95% C l -15.3-1.8 hours)
In the C A ESA R trial no difference in m aternal [LE A l ]115 faster recovery o f intestinal function
infectious m orbidity was found after liberal versus [L E C ];113
Table 12.1 Comparison between com plication rates after cesarean and vaginal deliveries
A b s o lu te risk (%) Relative risk (RR) Evidence (LE)
C esarean section V a g in a l C esa rea n section 95% Cl D e g re e

versus va g in a l
Maternal effects
Peripartum
Perineal pain 2 5 0.3 0.2-0.6 A2
Abdom inal pain 9 5 1.9 1.3-2.8 A2
Bladder or intestinal lesion 0.1 0.001 25.2-36.6 2.6-243.5 C
Re-intervention 0.5 0.03 17.58 9.4-32.1 B
ru
Hysterectomy 0.7-0.8 0.01-0.02 44.0-95.5 22.5-136.9 B
Intensive care admission 0.9 0.1 9 7.2-11.2 C
Throm boem bolism General = 0.04-0.16 3.8 2.0-4.9 B
Hospitalization stay extension 3 -4 days 1-2 days A2
Readmission after discharge 5.3 2.2 3.8 2.0-4.9 B
Maternal death 0.008 0.002 4.9 3.0-8.0 C
b.
Hemorrhage >1000 ml 0.5 0.7 0.8 0.4-4.4 A1
Infection 6.4 4.9 1.3 1.0-1.7 Al
Trauma o f the genital tract 0.6 0.8 1.2 0.4-3.4 Al
Long term
Urinary incontinence (3 months) 4.5 7.3 0.6 0.4-0.9 A2
Urethrocystocele
Fecal incontinence
Back pain
Postnatal depression
Dyspareunia
-li
General = 5
0.8
11.3
10.1
17
1.5
12.2
10.8
18.7
0.6
0.5
0.9
0.9
0.9
0.5-0.9
0.2-1.6
0.7-1.2
0.7-1.2
0.7-1.1
C
A2
A2
A2
A2
er
Effect on next pregnancy
No next pregnancy 42 29 1.5 1.1-2.0 B
Placenta previa 0.4-0.8 0.2-0.5 1.3-1.6 1.0-2.0 B
Scar rupture 0.4 0.01 42.2 31.5-57.2 B
Neonatal effects
h
Intrauterine death 0.4 0.2 1.6 1.2-2.3 B

Respiratory m orbidity after elective 3.5 0.5 6.8 5.2-8.9 C
cesarean section
us
Neonatal death (excluding breech) 0.1 0.1 1.1 0.1-8.4 B

Intracranial bleeding 0.008-0.04 0.01-0.03 0.6 0.1 -2.5 B
Brachial plexus lesion General = 0.05 0.5 0.1—1.9 C
Cerebral palsy General = 0.2 C
Source: NICE guidelines, 2004, pages 22-3.7

ak
less time before oral intake can begin: 3.9 hours Complications
(95% C l -0.7 to -7.1 hours);
fewer adhesions in a second cesarean section
[LE B ];45'107’116
Maternal Complications
C om plications in cesarean sections are not that rare
no difference in the num ber o f wound infections
and they m ust always be weighed against the possible
(RR 1.4; 95% C l 0.5-3.9);
com plications o f a vaginal delivery. A com parison
no difference in wound dehiscences (RR 0.9; 95%
between m aternal and neonatal com plications in
C l 0.4-2.1);
a cesarean versus a vaginal delivery is shown in
no difference in A pgar scores <7 (RR 0.2; 95% Table 12.1 [LE A l ].7 It is im portant to identify these
C l 0.01-3.7 hours). com plications correctly and com m unicate them to the
pregnant w om an during the inform ational discussion Neonatal Complications

prior to the procedure. From a recent Norwegian
In a cesarean section respiratory com plications, such
study it appears that one or m ore apparent m aternal
as tachypnea (wet lung syndrome and respiratory
com plications occur in 21% o f all cesarean sections,
distress syndrome [RDS] type II), RDS, and pulm onary
and have been coded as such by the surgeon [LE C ].28
hypertension, becom e elevated, possibly because in
In the following circum stances the chance o f
a cesarean section less am niotic fluid is removed
m aternal com plications is increased:
from the lungs [LE C ].118 The literature describes
• In an advanced (>9 cm or more) dilatation the risk greatly divergent ORs in this respect: for tachypnea
o f com plication is 33%, com pared to 17% in the (OR 1.2-2.8); RDS (OR 1.3-7.1); persistent pulm on
case o f no dilatation (OR 2.4; 95% C l 1.8-3.2). ary hypertension (OR 4.6; 95% C l 1.9-11).
ru
A s the dilatation advances, a higher num ber o f The risk o f neonatal com plications is influenced
em ergency cesarean sections take place and the by the following factors.
percentage o f GA - which carries a higher m ater
• Contraction activity: a protective effect is found in
nal risk - also increases drastically [LE C ].28
having had contractions (OR 1.9; 95% Cl 1.2-2.9).
In em ergency cesarean sections no increase has
b.
Without contraction activity the OR is 2.6 (95% Cl 1.
been found in blood loss and bladder or intestinal
3-2.8) [LE B ].119 In a cesarean section between 34
lesions [LE B ].31
and 37 weeks (without prior contraction activity)
• U nplanned cesarean sections carry a higher risk o f
there is an occurrence o f neonatal intensive care
com plications (24%) than planned ones (16%; OR
hospitalization due to serious RDS in 28% o f neo
•
1.6; 95% C l 1.3-2.0) [LE B ].28
-li
The risks are greater in case o f insufficient super
vision and insufficient experience. Experience can
be im proved by practicing in a s k ills la b .
•
nates; in 30%, admission is needed due to mild RDS.
Gestational age: this is the most important risk factor
(a cesarean section before 36 weeks has an OR o f 2.1;
95% C l 1.0-4.4 o f serious RDS). In addition, single
er
• There is a greater risk with cesarean sections in the
ton pregnancies (OR 3.2; 95% C l 1.5-6.7) and a fetal
preterm period (<30 weeks): RR 1.0 (95% Cl
indication of a cesarean section (OR 2.7; 95% C l 1.
1.1-3.1). 2-5.7) have a risk elevation effect, while early rup
• There is a greater risk with ruptured m em branes. turing o f the membranes has a protective action (OR
h
• There is a greater risk with a fully engaged head. 0.2; 95% C l 0.1-0.8) against contracting serious RDS
• A m acrosom ic infant increases the risk for the [LE C ].120 In a group of children born after an
mother. elective cesarean section from the 37th week it
us
• “H aste” appears to be an independent risk factor appeared that between 5.1% and 6.2% o f the
(RR 1.7) [LE C ].28 children had contracted respiratory complications
• M aternal obesity (BM I >30 kg/m 2) is an indepen [LE B/C],121,122 Prevention is highly dependent on
dent risk factor in the occurrence o f com plications the gestational age: at 37 weeks the incidence is 73.8/
after cesarean sections. A s a result o f obesity, 1000 and it decreases to 17.8 at 39 weeks [LE B ].118
surgeons not only find m ore technical difficulties See Table 12.2 [LE b /D ].120’123,124
ak
that can lengthen the operational duration, but

also there is m ore blood loss, as well as a greater
Table 12.2 Neonatal com plications related to gestational age
chance o f postoperative wound infections and
throm boem bolic com plications [LE C ].37 G esta tio n a l N eonatal OR to respiratory
• Prior pelvic surgery also increases the chance of a g e in respiratory m orbidity
com plications. w eeks com p lications [LE B]124
Re-closing o f a dehiscent cesarean scar o f the skin is after elective

cesarean section
associated with faster healing o f the wound and fewer
(range in %)
postoperative visits to the outpatient clinic than with
secondary w ound healing [LE A l ].117 N ot enough 37 0/7-37 6/7 7.4-11 3.9 (95% Cl2.4-6.5J
study data are available regarding the m om ent and
38 0/7-38 6/7 4.2-8.4 3.0 (95% Cl2.1 -4.3)
the technique o f the re-intervention and the benefit o f
39 0/7-40 0/7 0.8-2.1 1.9 (95% Cl 1.2-3.0)
antibiotics [LE A l ].95
In the entire group o f term pregnancies, after in the history already has an increased risk of
a planned cesarean section the num ber o f pulm onary placenta previa (O R 1.4; 95% C l 1.1-1.8). This
com plications is low at 1.6% (but twice as much, risk increases even m ore with the parity and the
however, com pared to a planned vaginal delivery: num ber o f cesarean sections: para 3 with three
RR 2.1; 95% C l 1.2-3.7) and there are also nearly prior cesarean sections (O R 4.1; 95% Cl
twice the am ount o f adm issions to the neonatal 1.5-11.0) [LE B ].130
intensive care unit at 10% (RR 1.7; 95% C l 1.4-2.2) • Placenta accreta is found especially in a patient
[LE B ].125 with a placenta previa and prior cesarean section.
For infants born at a gestational age o f >39 weeks, In a second cesarean section this percentage is
no difference is encountered in pulm onary com plica 11%; in a third cesarean section it is as m uch as
tions [LE B /D ],121,125 This is the decisive argum ent for 40% [LE B ].130 In the absence o f placenta previa,
ru
planning an elective cesarean section as early as week the O R for a placenta accreta is 2.4 (95% C l
39 0/7 or to wait for spontaneous contraction activity 1.3-4.3) in a third cesarean section. After
and then perform a cesarean section [LE A 2].126 a fourth cesarean section, the O R for
To decrease the num ber o f emergency cesarean a hysterectomy is 3.8 (2.4-6.0) [LE B ].130
b.
sections it can locally be agreed, in principle, to only • There is an increased risk o f a uterine rupture
perform prim ary cesarean sections from week 38 0/7. in a subsequent vaginal delivery o f 3.9 per 1000
deliveries com pared to 1.6 per 1000 in an elective
subsequent cesarean section (O R 2.1; 95% C l
Follow-up Care after Cesarean Sections 1.5-3.1) [LE A l ].131
-li
The following can be noted with regard to after-care
for cesarean sections [LE A l ].7 Just as after a vaginal
delivery, early direct skin contact between m other and
child has a positive influence on the m other/child
• Prenatal death beyond 39 weeks o f a subsequent
pregnancy is slightly increased: 1.1/1000 com
pared to 0.5/1000 in a pregnancy without cesarean
er
section, in which the relative risk after 34 weeks
relationship, as well as the success rate o f breastfeed
is already increased: RR 2.7 (95% C l 1.7-4.3)
ing. It is therefore recom m ended to stim ulate the
[LE B ].132 This association is only found in the
mother/child contact as early as possible after the
African A m erican population (O R 1.4; 95%
cesarean section [LE D ].127
C l 1.1-1.7) [ L E B ].133
Besides continuing the epidural analgesic, opiates
h
• There is m ore perinatal death in attem pted vaginal

are indicated for perioperative and im m ediate p ost
delivery than in elective cesarean sections: RR 11.6
operative pain relief, while in the later postpartum
(95% C l 1.6-86.7) [LE B ].134
us
period preference is given to non-steroidal anti

• M aternal death rem ains rare, although many
inflamm atory medication. During an uncom plicated
other form s o f surgical m orbidity, such as bladder
postpartum development after a cesarean section, the
and intestinal lesions, necessity o f a blood transfu
w om an m ay com mence eating and drinking on
sion, artificial respiration, and intensive care
request and an early discharge is not contraindicated.
hospitalization, increase with the num ber o f cesar
ak
ean sections in the m edical history.

Long-term Complications • Subfertility is slightly increased after a term
After a previous cesarean section, the risk o f serious prim ary cesarean section (RR 1.2; 95% Cl
com plications is increased in a subsequent pregnancy. 1.1-1.2) [LE C ].135
• There is a greater chance o f a cesarean section in
a subsequent pregnancy. It is assum ed that
Pregnancy and Delivery after
approxim ately 50% o f cesarean sections concern
a previous cesarean section in the m edical history. Cesarean Section
• The OR o f a placenta previa is 1.9 (95% C l 1.7-2.2) After a cesarean section for a non-repetitive indica
to 2.7 (95% C l 2.3-3.2) [LE A l ].128 The risk o f tion, and in the absence o f contraindications during
a placenta previa (or other serious m aternal m or the next pregnancy, a vaginal delivery can be pursued.
bidity) increases with the num ber o f cesarean It is not known whether this advice is also true after
sections in the m edical history and the parity (two or) three cesarean sections in the m edical his
[LE B],128,129 A para 2 with one cesarean section tory. The literature reports a variable chance of
successful vaginal delivery after a cesarean section, • It is advisable not to routinely slide the bladder out
varying between 21% and 86% [LE A l ].7 The choice o f the way and open the lower uterine segment
o f a delivery m ethod after prior cesarean section is above the vesicouterine fold [LE A l],
once again a joint decision between the physician and • O pening the lower uterine segm ent by digital
the pregnant wom an and her partner, who m ust be extension o f the scar reduces the blood loss
sufficiently inform ed. The potential pros and cons o f and the need for p ostp artu m tran sfu sion
both delivery m ethods m ust be considered in this [LE A l].
decision, as well as the potential risks o f scar rupture • A single R C T shows that digitally opening the
and perinatal m ortality/m orbidity. lower uterine segm ent in a craniocaudal direction
The chance o f a vaginal delivery after a prior is preferred [LE A2].
cesarean section increases if a vaginal delivery was
ru
• The one-time adm inistration o f antibiotics before
already perform ed before that, and decreases if the m aking the skin incision reduces the chance o f
w om an has already had m ore than one cesarean postpartum endom etritis and wound infections
section [LE A l ].7 Pregnant w om en with a cesarean [LE A l].
scar are recom m ended to give birth in a setting • The adm inistration o f oxytocin agonists (oxytocin
b.
with an availability o f continuous electronic fetal or carbetocin) is desirable to prevent significant
m onitoring and a possibility for em ergency cesar blood loss after a cesarean section [LE D ].137
ean section under safe circum stances. • W aiting for spontaneous expulsion o f the
placenta, with or without slight um bilical cord
Perimortem Cesarean
-li
After a m aternal cardiac arrest and a non-im m ediate
successful resuscitation, it is recom m ended to per
form a cesarean section within 4 m inutes, in order
•
traction, reduces the risk o f postpartum endom e
tritis and blood loss [LE A l].
Extra-abdom inal placem ent o f the uterus before
closing the uterine incision reduces postpartum
er
to increase the chance o f survival o f the infant as well fever and blood loss [LE A l].
as a chance o f a successful cardiopulm onary resusci • N ot suturing the peritoneum (both visceral and
tation. Although the data are far from optim al, the parietal) reduces the risk o f postoperative fever,
neonatal results do not appear unfavorable, and there the total operational time, and hospitalization
is a clear im provem ent o f the cardiac output after the duration [LE A l].
h
cesarean section [LE C ].136 • The closing o f a midline abdominal wall incision
with a continuous mass closure with slowly absorb
Important Points and able suture material reduces the risk of scar rupture
us
[LE A l].
Recommendations • N ot closing a subcutis o f less than 2 -3 cm in
thickness reduces the risk o f wound infection or
Preoperative Aspects bleeding [LE A l].
• Regional anesthesia for cesarean section is safer • Closing a subcutis o f greater than 2 -3 cm in
ak
than GA [LE A l]. thickness reduces the risk o f wound infection or

• Positioning o f the m other in a sem i-prone side bleeding [LEA1],
ways lie on the left side reduces the chance of • The routine use o f subcutaneous drains has no
m aternal hypotension [LE D]. advantages [LE D].
• Placing a wound drain in a non-sutured subcutis
Operative Aspects between 2 and 3 cm in thickness reduces the risk o f
w ound com plications [LE A l],
• To prevent neonatal respiratory morbidity, it is best
to plan an elective cesarean section during the last
week o f the pregnancy (>39 weeks) [LE A l].
Postoperative Aspects
• Opening the abdom inal wall according to the • Im m ediate skin contact between m other and
Joel-Cohen technique reduces the total opera child as soon as possible after the cesarean sec
tional tim e and the postoperative febrile m orbidity tion stim u lates the m other/child bon din g and
[LE A l]. increases breastfeeding success [LE A l].
• Opiates are the analgesics o f choice during the early 13 Q uinones JN , Jam es D N , Stam ilio D M , et al.
postpartum period after cesarean section, while T h rom boproph ylaxis after cesarean delivery: a decision
during the late postpartum period non-steroidal analysis. O bstet Gynecol. 2005;106:733-40.
anti-inflammatory agents are preferred [LE A l]. 14 Su LL, C h ong YS, Sam uel M. C arbetocin for preventing
p ostpartu m haem orrhage. C ochrane D atabase Syst Rev.
• During the uncom plicated postpartum period
2012;4:CD 005457.
after cesarean section the patient m ay com mence
15 Borruto F, Treiser A, C om paretto C. U tilization o f
eating and drinking as desired [LE A l],
carbetocin for prevention o f postpartu m hem orrhage
after caesarean section: a random ized clinical trial.
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36
37
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39 H asselgren PO, H agberg E, M aim er H , et al. One subum bilical transverse incision? Acta Obstet Gynecol
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72 van Rheenen P. Delayed cord clam ping and im proved
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96 O ligbo N , Revicky V, U deh R. Pom eroy technique or Eur J Obstet Gynecol Reprod Biol. 2008;138:29-33.
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210
Chapter
Sphincter Injury
13 M. Weemhoff, C. Willekes, and M.E. Vierhout
ru
General Inform ation Anatomy and Function
Anatomy
Introduction The anal sphincter complex consists o f the external anal
b.
It is very im portant to properly diagnose and repair sphincter (EAS) and the internal anal sphincter (IAS)
sphincter injuries, as there is a significant chance of (Figure 13.1). These two sphincter components are sepa
long-term morbidity. After a sphincter injury, women rated from each other by a thin fibromuscular longi
often suffer from emotional, physical, and/or sexual tudinal layer, which is an extension o f the longitudinal
problems. Even after optimal (peri)operative care there smooth muscle o f the rectum and the internal transverse
-li
are still m any residual sym ptom s and complications.
The care for this patient group is therefore o f great
importance, not only immediately after the childbirth,
but also in the long term and when counseling towards
muscle fibers o f the anal levator muscle. The internal
anal sphincter is a widened extension o f the circular
smooth muscle layer of the intestine. Macroscopically,
the internal anal sphincter has a pale aspect and can be
er
a new pregnancy. The goal o f this chapter is to provide distinguished from the red external anal sphincter.
the inform ation that is essential to achieve this care. The difference in color can be described as the color of
chicken meat versus the color o f red beefsteak
Definition A longside the sphincter there is ischioanal fat,
h
which can serve as a m arker to confirm that the

Sphincter injury (synonyms: third- or fourth-degree
structure is part o f the sphincter. The external anal
tears, com plete tear) is defined as a tear involving the
sphincter has a length o f approxim ately 2 cm.
anal sphincters.
us
In women, the external anal sphincter is thinner on

the ventral side than on the dorsal side. On the ante
Prevalence rior side, the m uscle fibers o f the anal sphincter are
The prevalence o f sphincter injuries was 2% in a connected to the m uscle fibers o f the bulbospongiosus
Dutch study analyzing 284 783 deliveries in muscle and to the coccyx on the posterior side.
a national database [LE B ].1 However, recent studies Besides the anal sphincter complex, the puborectal
ak
show a m uch higher percentage. In a 2006 study, muscle is also important in maintaining continence
251 postpartum prim iparas were exam ined by the (see Figure 13.3). The puborectal muscle is the most
person who supervised the delivery and by an expert. caudal part o f the anal levator muscle. The puborectal
In 24.5% o f the deliveries a sphincter injury was d iag fibers run from the rear o f the pubic bone and from the
nosed. There was a large difference between the phys tendinous arch in a loop around the rectum and are
ical exam ination perform ed by the person who had responsible for the formation o f the anorectal angle.
supervised the delivery (11%), and the expert (24.5%)
[LE B ].2 This study shows the im portance o f good Innervation
training in diagnosing sphincter injuries. Sphincter Since the involuntary internal anal sphincter is
injuries will only heal properly if the injury is recog a continuation o f the circular m uscle fibers o f the
nized and acknowledged in a timely manner. rectum, it has the sam e innervation from the cranial
O b ste tric In te rv e n tio n s , ed. P. Joep D orr, V incent M. Khouw , Frank A. Chervenak, A m os G runebaum , Yves lacquem yn,
rectum
fibromuscular longitudinal
intersphincteric space ischioanal fat
ru
anal levator muscle
b.
puborectal sling
Internal anal
sphincter (IAS)
external anal
sphincter (EAS)
-li
er
anal mucosa
h
R L
Figure 13.1 Cross-section o f the anal sphincter complex.

us
direction through sympathetic nerves o f the pelvic anal sphincter is associated with incontinence for
plexus and parasym pathetically from level S2 -S 4 via flatus and soiling (unexpected leakage o f sm all quan
the splanchnic pelvic nerves. The voluntary external tities o f liquid stools). The external anal sphincter is
anal sphincter (striated m uscle tissue) is innervated also in a continuous state o f tonic contraction.
from the lateral side through rectal and sacral The external anal sphincter contributes 30% o f the
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branches o f the pudendal nerve, which com es from instinctive resting tonus through a reflex arch at the
S2-S4. The puborectal muscle has a dual innervation level o f the cauda equina. Injury o f the pudendal
through the anal levator nerve (S3-S4) on the inside nerve can lead directly to incontinence problem s.
and the pudendal nerve from the outside o f the pelvic The puborectal sling form s the anorectal angle of
floor (Figure 13.2). alm ost 90°, which through contraction form s a type
o f functional valve action and consequently plays
Continence a role in the continence m echanism (Figure 13.3).
Stool continence takes m ore than a properly function
ing sphincter complex. M any structures play a role in Risk Factors and Sphincter Injury
the continence m echanism . Incontinence can be
a consequence o f myogenic and neurogenic factors. Prevention
The internal anal sphincter is in a continuous tonic The m ost im portant risk factors for the occurrence of
contraction and determ ines 50-85% o f the resting third- or fourth-degree tears are instrum ental vaginal
tonus o f the anal sphincter. Injury to the internal delivery, the first vaginal delivery, a large infant,
C h a p te r 13: S p h in cte r Injury
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b.
D
E
F
G
H
-li
er
J
K
L
h
A. aorta 1. plexus hypogastricus superior

8. a. iliaca communis 2. n. hypogastricus
C. S2 3. truncus sympathicus
us
D. S3 4. plexus pelvinus = plexus

E. a. iliaca interna hypogastricus inferior
F. S4 5. n. levator ani
G. anal levator muscle 6. nn. splanchnici pelvici
H. a. iliaca externa 7. n. pudendus
I. rectum 8. nn. rectalis inferiores
J. sphincter ani internus
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K. sphincter ani externus

L. ischioanal fat
Figure 13.2 Innervation o f the rectum, sphincter, and anal levator muscle.
shoulder dystocia, persistent occipitoposterior p o si risk o f sphincter injury [LE B]. Table 13.1 shows the
tion, and a perineal length less than 2.5 cm. risk factors for assisted deliveries as they were identi
In addition, induction o f labor, prolonged labor and fied in an analysis o f a 284 783 deliveries in a national
delivery, and a second stage longer than 1 hour are obstetric database registry (Landelijke Verloskunde
associated with third- and fourth-degree tears Registratie, LVR).
[LE A l/ B ].3'4 All form s o f operational deliveries are In contrast with a m ediolateral episiotomy,
associated with an increased risk o f sphincter injury, a midline episiotom y is associated with an increased
but forceps extraction clearly indicates the greatest risk o f sphincter injury [LE A l ].5 A m ediolateral
Table 13.1 Risk o f operational deliveries for the occurrence o f Table 13.2 Classification o f tears according to Sultan
sphincter injury [LE B]1
Grade 1 Skin tear only
P e rform ed in n u m b e r OR
Grade 2 Skin and perineal tear w ith intact
o f p a tients w ith (95% Cl)
sphincter
sp h in cter injury/
p e rfo rm e d in total Grade 3 Tear to perineum and anal sphincter
n u m b e r o f w o m en Grade 3a Tear <50% o f EAS
Grade 3b Tear >50% o f EAS
Forceps 348/7478 3.53 (3.11-4.02) Grade 3c Tear in both the
IAS and the EAS
Vacuum 646/21 254 1.68(1.52-1.86)
Grade 4 Tear in perineum, anal sphincter, and anal
Fundus 191/9176 1.83 (1.57-2.14) mucosa
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pressure (FP)
Forceps with FP 27/522 4.62 (3.09-6.89)
Vacuum with FP 74/2661 1.78 (1.40-2.28)
b.
1. symphysis
2. puborectal sling
3. axis of the rectal ampulla
4. axis of the anal canal
5. external anal sphincter
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h er
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Figure 13.4 Classification o f third- and fourth-degree tears.
Classification of Tears
In 2002, Sultan introduced a classification for perineal
and sphincter tears. This classification has been
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adopted globally by international organizations as

the standard classification (Table 13.2, Figure 13.4).7
Figure 13.3 During defecation the anorectal angle changes In case o f doubt o f the classification o f a third-
through relaxation o f the puborectal sling. degree tear, it is advised to choose the highest degree
to avoid the risk o f undertreatment.
A defect up to the anal m ucosa behind the level o f
episiotom y can decrease the risk o f sphincter injury the sphincter, thus with an intact internal and external
(O R 0.21; 95% C l 0.19-0.23), but cannot prevent anal sphincter, is not classified as a fourth-degree tear,
a sphincter injury in all cases [LE B ].5 The angle o f but m ust be described.
the mediolateral episiotom y is im portant, because A rectal exam ination is essential for proper classi
a greater angle o f the episiotom y with respect to the fication o f the sphincter injury, not only to examine
midline is linked to a lower risk o f sphincter injury the anal m ucosa, but also frequently stretching o f the
(see also Figures 2.65-67) [LE B ].6 m uscular fibers is needed to assess the sphincters
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b.
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Figure 13.5 Rectal examination (A) and cross-section (B).
er
(Figure 13.5). In the anal examination, the index finger that is the m ost fam iliar to the surgeon. The disad
is in the anus and the thumb rests on the sphincter. vantage o f the overlapping technique is that it cannot
The sphincter is palpated between the thumb and the be used in grade 3a sphincter tears when the external
index finger. In case o f doubt, the patient m ay be asked sphincter is still largely intact. Surgeons using the
to contract the anus. A defect can then be felt more overlapping technique in a grade 3b or higher sphin-
h
clearly. A rectal examination m ust therefore precede ter tear m ust be trained and have practice in both
any suturing. methods, since in a grade 3a sphincter defect an end-
to-end technique m ust always be used.
us
Then, after the suturing, another rectal examination

is performed to verify that there is good continuity again The internal and external anal sphincters each
and to check whether the suturing caused any uninten have their own function and m ust both be approxi
tional perforation in the m ucous membrane. Reluctance m ated in the suturing. It is therefore o f utm ost
to do a post-suturing rectal examination out o f fear of im portance to identify the internal and external anal
dam aging the sutures is not prudent. Obviously, this sphincters when closing the sphincter and to ensure
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m ust be done with the necessary caution. the proper closure o f both sphincters.
Some authors recommend closing the internal and
external sphincters separately12,14; however, there is no
Technique supporting convincing evidence in the literature for this.
To close the internal anal sphincter separately, both
Background sphincter halves must be dissected. This can be techni
There are two techniques to repair a sphincter defect: cally difficult, with additional chances o f complications
the end-to-end approxim ation o f the sphincter and and, in case o f insufficient experience, even a risk of
the overlapping technique, in which both sphincter additional damage to the thin and delicate internal
halves are sutured on top o f each other. In the litera sphincter.
ture there is no convincing evidence that one tech It is recom m ended to perform a sphincter repair
nique has a better outcom e for the patient than the under optim al conditions; this m eans, with good
other technique [LE A l/2 ].7-13 The m ost im portant lighting and adequate pain managem ent. These con
aspect in the choice o f technique is to choose the one ditions are usually optim al in an operating room.
Until now, studies have not shown a difference in bodies in the tissue will be lim ited as much as possible
the outcom e o f fecal incontinence when a complete and thereby provide the least chance o f infection.
tear is repaired im m ediately after the delivery, com The m ucosa can also be sutured continuously.
pared to a repair done 8 to 12 hours after the Locked sutures are preferred to prevent retraction of
delivery.15 In such cases the disadvantage o f waiting the m ucous membrane.
to repair the com plete tear m ay be weighed against the
advantage o f asking a m ore experienced gynecologist Internal Anal Sphincter
to perform or supervise the operation. The internal anal sphincter is sutured with side-by-
side m attress sutures (Figure 13.7). The im portance
Suturing Procedure o f using m attress sutures lies in the transverse
traction orientation in a longitudinal m uscle to pre
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A grade 3a tear, in which the external anal sphincter is
vent tearing.
damaged by <50%, is closed with the end-to-end
method. In a grade 3b tear or higher, either the end-to-
External Anal Sphincter
end method or the overlapping technique may be used.
It is im portant to view and approxim ate the entire
In cases where the overlapping technique is chosen, the
length o f the anal sphincter. This determ ines the
b.
remaining fibers o f the external sphincter that are still
length o f the anal canal, which influences its resting
intact must be cut in order to be able to perform an
tone and the risk o f fecal incontinence [LF C ].16 If the
overlap.
entire length o f the m uscle is not approxim ated, the
In higher stage sphincter defects, one half o f the
functional result will be inferior.
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sphincter is often retracted into the m uscle’s fibrous
capsule. On both sides, the internal and external anal
sphincters are identified and grasped with Allis
clamps. Besides Allis clam ps, other atraum atic clam ps
End-to-End Technique
The end-to-end technique for suturing the external
anal sphincter is accom plished with figure-of-eight
er
can be used, such as Duval clamps.
sutures or m attress sutures. With m attress sutures
Anal Mucosa there is nevertheless a short overlap o f the approxi
m ated m uscle halves. Figure-of-eight sutures consti
The anal m ucosa is loosely sutured with the knots
tute real end-to-end suturing. Both m ethods have
placed intraluminally (Figure 13.6). The m ost im por
their pros and cons and the surgeon is free to decide
h
tant argum ent for this is that the am ount o f foreign

on the m ethod with which he or she is m ost fam iliar
(Figure 13.8).
us
Detailed Description of End-to-End Technique: Figure-of-Eight

In the end-to-end technique, the figure-of-eight
sutures are placed as follows (Figure 13.9):
• First, both sphincter halves are identified and
atraum atic clam ps are placed (Figure 13.9A).
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• Suturing starts with the left h alf o f the sphincter.

The suture enters the top 1 cm from the edge and
com es out at the bottom (Figure 13.9B). Then
a switch is m ade to the right sphincter half.
The suture enters the bottom 1 cm from the edge
and com es out the top (Figure 13.9C). Next,
another switch is m ade to the left sphincter half
and there, 1 cm next to the previous stitch, again
1 cm from the edge, in at the top and out at the
bottom (Figure 13.9D). Again a switch to the right
sphincter h alf and the suture 1 cm next to the
other stitch, 1 cm from the edge, in from the
bottom and out the top (Figure 13.9E). This results
Figure 13.6 Anal mucosa.
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b.
Figure 1 3.7A -B Internal anal sphincter. -li
h er
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Figure 13.8 External anal sphincter in the end-to-end technique. (A) Figure-of-eight sutures. (B) Mattress sutures.
in sutures with two parallel lines at the bottom and • After the sutures are placed, the clam ps can be
a figure-of-eight at the top (Figure 13.9F). rem oved and the sutures can be tied.
Two or three sutures are placed next to each other • An overview o f the situation after placing all o f the
with a distance o f 0.5 cm between them. sutures is illustrated in Figure 13.9G.
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b.
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Detailed Description of End-to-End Technique: Mattress Sutures
In the end-to-end technique, m attress sutures are
be placed in the correct location. It is preferable to
place three overlapping sutures next to each other
er
placed as follows (Figure 13.10): (Figure 13.11).
• First, both sphincter halves are identified and
atraum atic clam ps are placed (Figure 13.10A).
Detailed Description of the Overlapping Technique
• Suturing starts with the left half o f the sphincter.
h
In the overlapping technique the sutures are placed as

The suture enters the top 1 cm from the edge and
follows (Figure 13.12A-F and A nim ation 13.1):
comes out at the bottom (Figure 13.10B). Then
a switch is made to the right sphincter half. • First, both sphincter halves are identified and
us
The suture enters the bottom 1 cm from the edge atraum atic clam ps are attached (Figure 13.12A).
and comes out the top (Figure 13.10C). Next, the • Suturing starts with the left half o f the sphincter.
suture is inserted into the right sphincter half 0.5 cm The suture enters the top, 2 cm from the edge and
next to the other stitch, 1 cm from the edge, in at the comes out the bottom. Then a switch is m ade to the
top and out at the bottom (Figure 13.10D). Again right sphincter half. The suture enters the top, 1 cm
from the edge and com es out the bottom . After that,
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a switch to the left sphincter half and there 0.5 cm

next to the previous stitch, again 1 cm from the edge, the suture enters the bottom o f the right sphincter
in from the bottom and out the top (Figure 13.10E). h alf and com es out the top in order to finish again
• Two or three sutures are placed next to each other in the left sphincter half, entering from the bottom
with a distance o f 0.5 cm between them. and com ing out the top (Figure 13.12B).
• After the sutures are placed, the clam ps can be • Preferably, three stitches are m ade next to each
rem oved and the sutures can be tied. other with a distance o f 0.5 cm between them
• An overview o f the situation after placing all o f the (Figure 13.12C).
sutures is illustrated in Figure 13.10F. • After the three sutures are placed, the clam ps can
be rem oved and the sutures can be tightened and
The Overlapping Technique tied, so that the two sphincter halves are pulled on
In the overlapping technique, the m uscle halves top o f each other (Figure 13.12D).
that are grasp ed by the A llis clam ps are placed • Then, a second row is placed with support stitches.
over the top o f each other, so that the sutures can These go into the top 1 cm from the edge o f the left
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b.
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h er
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Figure 13.11 (A) O verview o f the external anal sphincter in a grade 3b tear. (B) Overview o f the location o f the sutures after an overlap
repair o f a grade 3b tear.
Figure 13.12 A -F Detail o f suturing

with the overlapping technique.
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b.
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h er
sphincter half and com e out the bottom . Then, Suturing Material
2 cm from the edge a firm transverse bite is taken The anal m ucosa is sutured with atraum atic polyglac-
into the right sphincter half, com ing out the top. tin 910, polyglycolic acid, or a com parably absorbable
us
Then, the suture is finished in the left sphincter material with a thickness o f 3-0. The internal and the
half, entering from below and com ing out on top external anal sphincters are sutured with polydioxa-
(Figure 13.12E). none (PDS) 3 -0 or other com parable m onofilam ent,
• An overview o f the situation after placing all o f the slowly dissolvable material. An atraum atic and m on o
sutures is illustrated in Figure 13.12F. filament suture is preferred in view o f infections.
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The sphincter m ust be sutured with dissolvable m ate

Perineum
rial since non-dissolvable sutures can lead to abscess
W hen suturing the perineum it is im portant to build form ation. The tensile strength and reabsorption time
up the perineal body with loose or continuous m ust be sufficiently long for proper healing o f the
sutures. The chance o f a new sphincter injury is sphincter. Sharp ends o f sutures can cause irritation
partially determ ined by the quality o f the perineal and m ust therefore be cut short and m ust be covered
body and the length o f the perineum . T o build up with a good protective layer. The perineum and the
the perineal body, it is recom m ended, after suturing skin m ust be sutured with polyglactin 910, polyglyco
the sphincter, to place som e additional sup port lic acid, or com parable rapidly absorbable material
sutures in the bottom o f the tear before ap p ro xim at with a thickness o f 2 -0 or 3-0.
ing the bu lb osp on giosu s m uscle, the urethrovaginal
m uscle, and the transverse perineal m uscle, as Antibiotics
in a second-degree tear. The skin is sutured According to the surgical wound classification (accord
intracutaneously. ing to Mayhall), a third-degree tear is considered to be
a “contaminated wound” and a fourth-degree tear is Complications: Postpartum and Late Consequences
a “dirty wound” because o f the contamination with Recent studies show that after 12 m onths o f follow-
fecal m atter.17 Treatment with antibiotics is advised in up, 60-80% o f the patients are asym ptom atic
both cases. An infection causes a risk o f wound prob [LE A 2 ].12
lems and a chance o f developing incontinence or fistula Frequent com plaints after a sphincter injury are:
form ation; therefore, it is not prudent to withhold perineal pain, dyspareunia, wound dehiscence, recto
treatment with antibiotics [LE A l ].17 If the total tear vaginal fistulas, and m ost importantly, incontinence
is repaired immediately after childbirth, a single pre for flatulence and feces and fecal urgency.12’18’19 There
operative dose o f antibiotics will be sufficient. are m any women suffering from a persistent sphincter
If the repair time o f the tear is more than 3 hours, defect despite prim ary recovery, who initially do not
a repeated dose o f antibiotics should be considered. have any sym ptom s [LE C ].20-22 Young women can
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Prophylaxis for m ore than 24 hours is not advisable com pensate quite well with the residual sphincter
and causes unnecessary disturbance o f the microbial fibers and the puborectal sling. Nevertheless, these
flora [LE A l ].17 Antibiotics m ust be administered women have an insecure future since the anal sphinc
immediately after the sphincter injury is diagnosed. ter function deteriorates with age due to prolonged
b.
Therefore, the antibiotics m ust be administered in conduction tim es o f the pudendal nerve and fibrosis
the delivery room and not wait until getting to the ring o f the internal and external anal sphincter.
operating room. A large section o f women with a sphincter defect
only develop sym ptom s at a later age.
Postoperative Phase
Postoperative Management
•
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Laxatives: it is advised to prescribe laxatives for
Management of Subsequent Pregnancies
The literature provides little data for providing
evidence-based guidelines for m anaging subsequent
pregnancies after prior sphincter injury.12'13
er
several weeks [LE D ].12 Lactulose can lead to
Ninety-five percent o f the women with a sphincter
intestinal gas form ation, which m ay cause flatu
injury do not experience a new sphincter injury d u r
lence and false defecation pressure. In that case,
ing a subsequent pregnancy [LE C ].23 The risk of
m acrogol/electrolytes or m agnesium hydroxide is
having a (transitory) deterioration o f fecal sym ptom s
preferred. If defecation does not occur, there is
h
after a subsequent pregnancy varies in the studies

a risk o f bolus form ation, with the possible result
from 17% to 24% [LE C ].12,13 This risk is not only
o f severe anal dilatation. Where defecation does
caused by further dam age o f the sphincter, but can
not occur, enem as are recom m ended.
us
also arise due to further neurogenic com prom ise

• Pain relief: paracetam ol and N SA ID s are the m ed
because o f engagem ent o f the fetal head during preg
icines o f first choice when pain relief is needed.
nancy and delivery. Especially women who after their
Preparations with codeine m ust be avoided, as
first childbirth had a transitory period o f fecal incon
they m ay cause constipation.
tinence run an increased risk o f worsening sym ptom s
• Pelvic floor exercises: the advice is to start pelvic
ak
after a subsequent childbirth [LE C ].24

floor physiotherapy or pelvic floor exercises after
A num ber o f recom m endations can be form ulated
a few weeks [LE D ].13
for a subsequent pregnancy [LE D ]12,13:
Follow-Up and Consequences of Sphincter • In patients without residual symptoms there are
insufficient reasons for advising against a vaginal
Injuries delivery after a sphincter injury. Counseling on the
Follow-Up risk o f developing sym ptoms should be offered.
The follow-up m ust be longer than only one p ostp ar If an episiotomy is indicated, a mediolateral episiot
tum check-up. If a patient has residual sym ptom s o f om y with a sufficiently large angle o f 45° to 60°
fecal incontinence, it is im portant to refer her to from the vertical midline must be made. There is
a pelvic floor physiotherapist, provide dietary m ea insufficient evidence that a routine episiotomy can
sures, perform additional diagnostic testing by m eans prevent a recurrence o f sphincter injury and there
o f ultrasound im aging and ultim ately refer the patient fore should only be performed on the indication of
to a colorectal surgeon or urogynecologist. risk factors.
Section 3: P a th o lo g y o f La b o r and La b o r a n d D elivery
• W om en who continue to have (temporary) resid - residual symptoms (temporary): counseling on

ual symptoms after a sphincter injury and women the risk o f a com promised sphincter function
with m ild residual sym ptom s should be counseled after a subsequent delivery, consultation
that a subsequent vaginal delivery has a risk o f between the woman and the gynecologist about
com prom ised sphincter function. U pon proper vaginal delivery versus elective cesarean section;
counseling a choice should be m ade for a vaginal - serious residual symptoms: if an indication for
delivery or an elective cesarean section. reconstructive surgery, first vaginal delivery,
• In serious persistent symptoms o f fecal inconti then reconstruction;
nence and a dem onstrable sphincter defect there - after reconstructive surgery: elective cesarean
is an indication o f secondary reconstructive section.
surgery. If women still have a clear desire to have
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children, it m ay be contem plated to avoid the risk
o f a cesarean section by first delivering vaginally References
and only then do a reconstruction. The risk 1 Leeuw JW de, Struijk PC, V ierhout M E, et al. Risk
that further dam age in a subsequent delivery will factors for third degree perineal ruptures during
influence the result after a secondary sphincter delivery. BJO G . 2001;108(4):383-7.
b.
reconstruction appears to be m inim al on theor 2 Andrew s V, Sultan AH , T h akar R, et al. O ccult anal
etical grounds. sphincter injuries - myth or reality? BJO G .
2006;113:195-200.
• After reconstructive surgery o f a sphincter, a cesar
ean section is indicated. 3 E ason E, Labrecque M, W ells G, et al. Preventing

Recommendations
-li 4
perineal trau m a during childbirth: a system atic review.
O bstet Gynecol. 2000;95(3):464-71.
Sultan A H , K am m M A, H udson C N , et al. Th ird degree
obstetric anal sphincter tears: risk factors and clinical
er
outcom e o f prim ary repair. BM J. 1994;308:887-91.
• Training in diagnosing, classifying, and repairing
5 C arroli G, Belizan J. E pisiotom y for vaginal birth
sphincter injuries is o f great importance. Repairing (C ochrane Review). The C ochrane Library Issue 3,
an injury is only done after precise diagnosis [LE B ]. 2004. Chichester, U K: John W iley & Sons, Ltd.
• All form s o f operative deliveries are associated 6 Eogan M, D aly L, O ’Connell PR, et al. D oes the angle o f
h
with an increased risk o f sphincter injury, in episiotom y affect the incidence o f anal sphincter injury?
which forceps extraction clearly indicates the BJO G . 2006;113:190-4.
greatest risk o f sphincter injury. Considering the 7 Fernando R, Sultan A H , Kettle C, et al. M ethods o f
us
m ajor avoidable risk o f a sphincter injury, forceps repair for obstetric anal sphincter injury. Cochrane
extraction should be perform ed with reservation D atabase Syst Rev. 2008;3:CD 002866.
[LE B], 8 W illiam s A, A d am s EJ, Tincello D G , et al. H ow to
• The overlapping technique is just as effective as repair an anal sphincter injury after vaginal delivery:
results o f a random ized controlled trial. BJO G .
the end-to-end technique. It is therefore recom
2006;113(2):201-7.
mended to choose the technique which is the m ost
ak
9 Farrell SA, G ilm our D, Turnbull G K , et al. O verlapping

fam iliar to the surgeon.
com pared with end-to-end repair o f third- and
• O f all patients with a sphincter injury, 60-80% are fourth-degree obstetric anal sphincter tears:
asym ptom atic after 12 m onths [LE A2]. O f all a random ized controlled trial. O bstet Gynecol.
patients with a sphincter injury, 95% have no 2010;116( 1):16—24.
recurrent sphincter injury during the next child 10 Fernando R, Sultan A H , Kettle C, Th akar R, Radley S.
birth [LE C], M ethods o f repair for obstetric anal sphincter injury.
• Recom m endations for the next pregnancy are Cochrane D atabase Syst Rev. 2013;12:CD 002866.
[L E D ]: D O I: 10.1002/14651858.CD 002866.pub3.
11 Rygh A B, K orner H. The overlap technique versus
- no residual symptoms: no contraindication for
end-to-end approxim ation technique for prim ary
vaginal delivery, counseling regarding the risk repair o f obstetric anal sphincter rupture: a random ized
o f recurrent sym ptom s, episiotom y on indica controlled study. A cta O bstet Gynecol Scand.
tion o f risk factors; 2 0 10;89( 10): 1256-62.
12 Fernando RJ, W illiam s AA, A d am s EJ. 18 Fernando R, Sultan AH , Kettle C, et al. Repair
The m anagem ent o f third- and fourth-degree perineal techniques for obstetric anal sphincter injuries:
tears. R C O G G reen-top G uideline 2007;29. a random ized controlled trial. Obstet Gynecol.
13 Richdijn N V O G . Totaal Ruptuur. 2013. http://richtlij 2006;107:1261-8.
nendatabase.nl/richtlijn/totaalruptuur/risicofactoren_ 19 Sultan AH , Thakar R, Fenner DE. Perineal and anal
en_preventie_van_totaalruptuur.htm l sphincter traum a. London: Springer, 2007.
14 Lindqvist PG, Jernetz M. A m odified surgical approach to 20 Pinta TM , Kylanpaa M L, Salm i T K , et al. Prim ary
women with obstetric anal sphincter tears by separate sphincter repair: are the results o f the operation good
suturing o f external and internal anal sphincter. enough? D is C olon Rectum. 2004;47( 1): 18—23.
A modified approach to obstetric anal sphincter injury. 21 M ackenzie N , Parry L, T asker M, et al. Anal
BM C Pregnancy Childbirth. 2010;10:51. function follow ing third degree tears. Colorectal Dis.
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15 N orden stam J, M ellgren A, A ltm an D , Lopez A, 2004;6(2):92-6.
Zetterstrom J. Im m ediate or delayed repair o f obstetric 22 G offeng AR, A ndersch B, A ndersson M, et al. Objective
anal sphincter tears - a random ized controlled trial. m ethods cannot predict anal incontinence after
BIO G . 2008;115:857-65. prim ary repair o f extensive anal tears. Acta Obstet
16 H o oi GR, Lieber M L, C hurch JM . Postoperative anal Gynecol Scand. 1998;77(4):439-43.
b.
canal length predicts outcom e in patients having 23 H arkin R, Fitzpatrick M, O ’Connell PR, et al. Anal
sphincter repair for fecal incontinence. D is Colon sphincter disruption at vaginal delivery: is recurrence
Rectum . 1999;42(3):313-18. predictable? Eur J Obstet Gynecol Reprod Biol.
17 van K asteren M EE, G ijssens IC, Kullberg BJ, et al. 2003;109(2): 149-52.
O ptim aliseren van het antibioticabeleid in N ederland. 24 Bek KM , Laurberg S. R isk o f anal incontinence from
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V. SW AB-richtlijnen voor perioperatieve antibiotische
profylaxe. N ed T ijdsch r Geneeskd. 2000;144(43):
2049-55.
subsequent vaginal deliveries after a com plete obstetric
anal sphincter tear. Br J Obstet Gynaecol. 1992;99:
724-6.
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Chapter
Ethical Dimensions of Obstetrical
14 Interventions
F.A. Chervenak, A. Grunebaum, and L.B. McCullough
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since the eighteenth century European and American
Introduction
Enlightenments has been secular.5 It makes no refer
Ethics is an essential dimension o f obstetrical
ence to God or revealed tradition, but to results of
intervention.1-3 In this chapter, we therefore develop
argument-based reasoning. At the same time, secular
b.
a framework for clinical judgm ent and decision
medical ethics is not intrinsically hostile to religious
making about the ethical dim ensions o f obstetrical
beliefs. Therefore, ethical principles and virtues should
interventions. We emphasize a preventive ethics
be understood to apply to all physicians, regardless o f
approach that appreciates the potential for ethical con
their personal religious and spiritual beliefs.6 Secular
flict and adopts ethically justified strategies to prevent
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those conflicts from occurring by use o f the informed
consent process. Preventive ethics helps to build and
sustain a strong physician-patient relationship.
We begin by defining ethics, medical ethics, and the
medical ethics has the distinct advantage o f being
transcultural and transnational.
The traditions and practices o f medicine consti
tute an obvious source o f morality for physicians.
er
These provide an im portant reference point for m ed
fundamental ethical principles o f medical ethics, ben
ical ethics because they are based on the obligation to
eficence, and respect for autonomy. The central ethical
protect and prom ote the health-related interests o f the
challenge for obstetrical interventions is an adequate
patient. This obligation tells physicians what m orality
informed consent process. We therefore show how
in medicine ought to be, but in very general, abstract
h
these two ethical principles should shape the informed

terms. Providing a practical, clinically applicable
consent process between the obstetrician and the preg
account o f this general ethical obligation is the central
nant woman, identifying the appropriate roles for each.
task o f m edical ethics, using ethical principles.4
us
Key Concepts The Ethical Principle of Beneficence

The ethical principle o f beneficence in its general
Medical Ethics m eaning and application requires one to act in a way
Ethics is the disciplined study o f morality that aim s to that is expected reliably to produce the greater balance
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provide practical guidance in our lives. Medical ethics o f benefits over harm s in the lives o f others.6 To put
is the disciplined study o f morality in medicine and this principle into clinical practice requires a reliable
provides practical guidance to physicians by identify account o f the benefits and harm s relevant to the care
ing their obligations to patients as well as the obliga o f the patient, and o f how those goods and harm s
tions o f patients.4 It is im portant not to confuse should be reasonably balanced against each other
medical ethics with the many sources o f morality in when not all o f them can be achieved in a particular
modern pluralistic societies. These include, but are not clinical situation, such as a request for an elective
limited to, law, history, the world’s religions, ethnic cesarean delivery.7 In medicine, the principle o f
and cultural traditions, families, the traditions and beneficence requires the physician to act in a way
practices o f medicine (including medical education that is reliably expected to produce the greater balance
and training), and personal experience. Medical ethics o f clinical benefits over harm s for the patient.4
O b ste tric In te rv e n tio n s , ed. P. loep D orr, V incent M. Khouw, Frank A. Chervenak, A m os Grunebaum , Yves Jacquem yn,
Section 4: Ethics o f O bstetrical Interventions
Beneficence-based clinical judgm ent has an m aking role o f the pregnant wom an about the m an
ancient pedigree, with its first expression found in agem ent o f her pregnancy.
the H ippocratic Oath and accom panying texts.8
It m akes an im portant claim : to interpret reliably
the health-related interests o f the patient from m ed Beneficence and Respect for
icine’s perspective. T his perspective is provided by Autonomy in the informed Consent
the com m itm ent to evidence-based reasoning in the
deliberative practice o f m edicine. A s rigorously Process for Obstetrical Interventions
evidence-based,9 beneficence-based judgm ent is not The ethical principles o f beneficence and respect for
the function o f the individual clinical perspective o f autonom y both shape the inform ed consent process.
any particular physician and therefore should not be As to beneficence, it is im portant to note that there is
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based m erely on the clinical im pression or intuition an inherent risk o f paternalism in beneficence-based
o f an individual physician. On the basis o f this clinical judgm ent. By this we m ean that beneficence-
rigorous clinical perspective, focused on the best based clinical judgm ent, if it is mistakenly considered
available evidence, beneficence-based clinical ju d g to be the sole source o f m oral responsibility and there
b.
m ent identifies the clinical benefits that can be fore m oral authority in m edical care, invites the un
achieved for the patient in clinical practice based wary physician to conclude that beneficence-based
on the com petencies o f m edicine. The benefits that judgm ents can be im posed on the pregnant wom an
m edicine is com petent to seek for patients are the in violation o f her autonom y. Paternalism can be
prevention and m anagem ent o f disease, injury, d is experienced as a dehum anizing response to the
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ability, and unnecessary pain and suffering, and the
prevention o f prem ature or unnecessary death. Pain
and suffering becom e unnecessary when they do not
result in achieving the other goods o f m edical care,
patient and, therefore, should be avoided in the prac
tice o f obstetrics.
The preventive ethics response to this inherent
paternalism is for the physician to explain the d iag
er
e.g., allowing a w om an to labor without effective nostic, therapeutic, and prognostic reasoning that
analgesia.4 leads to his or her clinical judgm ent about what is in
Nonmaleficence means that the physician should the interest o f the patient so that the patient can assess
prevent causing harm and expresses the limits o f ben that judgm ent for herself and provide consent.
h
eficence. Nonmaleficence is better known as “primum The practical steps for doing so are the following:
non nocere” or “first do no harm.” This commonly The physician should disclose and explain to the
invoked dogm a is really a Latinized misinterpretation patient the m ajor factors o f this reasoning process,
us
o f the Hippocratic texts, which emphasized beneficence including m atters o f uncertainty. In neither medical
while avoiding harm when approaching the limits of law nor m edical ethics does this require that the
medicine.4 Nonmaleficence should be incorporated patient be provided with a com plete m edical
into beneficence-based clinical judgment: when the education.1" The physician should then explain how
physician approaches the limits o f beneficence-based and why other clinicians m ight reasonably differ from
clinical judgment, i.e., when the evidence for expected his or her clinical judgm ent. The physician should
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benefit diminishes and the risks o f clinical harm then present a well-reasoned response to this critique.
increase, then the physician should proceed with great The outcom e o f this process is that beneficence-based
caution. The physician should be especially concerned clinical judgm ents take on a rigor that they som etim es
to prevent serious, far-reaching, and irreversible clinical lack, and the process o f their form ulation includes
harm to the patient. explaining them to the patient. It should be apparent
that beneficence-based clinical judgm ent can result in
The Ethical Principle of Respect the identification o f a continuum o f obstetrical inter
ventions that protect and prom ote the patient’s
for Autonomy health-related interests, when these alternatives are
In contrast to the principle o f beneficence, there has supported in evidence-based clinical judgm ent.
been increasing em phasis in m edical ethics on the Beneficence-based clinical judgm ent provides an
principle o f respect for autonom y.6 This principle im portant preventive ethics antidote to paternalism
requires the physicians to empower the decision by increasing the likelihood that one or m ore o f these
C h a p te r 14: Ethical D im e n sio n s o f O b stetrical Interventions
m edically reasonable, evidence-based alternatives will established the concept o f sim ple consent, i.e.,
be acceptable to the patient. All beneficence-based whether the patient says “yes” or “no” to surgical
alternatives m ust be identified and explained to all m anagem ent o f a “fibroid tum or.” 10,12 This decision
patients, regardless o f how the physician is paid, espe is frequently quoted: “Every hum an being o f adult
cially those that are well established in evidence-based years and sound m ind has the right to determine
obstetrical interventions. what shall be done with his body, and a surgeon
This inform ed consent process is also a response who perform s an operation without his patient’s
to the reality that pregnant women increasingly bring consent com m its an assault for which he is liable in
to their m edical care their own perspectives on what is dam ages.” 12 The legal requirement o f consent
in their interest. The principle o f respect for auton further evolved to include disclosure o f inform ation
sufficient to enable patients to make inform ed
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om y translates this fact into autonom y-based clinical
judgm ent. Because each patient’s perspective on her decisions about whether to say “yes” or “no” to m ed
interests is a function o f her values and beliefs, it ical intervention.10 These legal developments should
is im possible to specify the benefits and harm s o f be interpreted as giving the force o f law to best ethical
autonom y-based clinical judgm ent in advance. practices. There is an im portant lesson to be learned
b.
Indeed, it would be inappropriate for the physician from this history: best ethical practices in obstetrics
to do so, because the definition o f her benefits and should be fostered by obstetricians, to lead and appro
harm s and their balancing are the prerogative o f the priately shape the development o f law and health
patient. N ot surprisingly, autonom y-based clinical policy.
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judgm ent is strongly antipaternalistic in nature.4
The practical steps that the pregnant wom an needs
to com plete in the inform ed consent process are the
following: pay attention to inform ation that she is
How should the obstetrician decide on the scope
o f inform ation to be provided to the pregnant woman,
to ensure giving her enough inform ation without
overwhelming her with inform ation? The reasonable
person standard provides guidance, with its clinical
er
provided with about the progress o f her labor and
beneficence-based intrapartum m anagem ent; absorb ethical concept o f “m aterial” inform ation: what any
and retain this inform ation; appreciate that this patient in the patient’s condition needs to know and
inform ation does indeed apply to her; evaluate the lay person o f average sophistication should not be
beneficence-based alternatives on the basis o f her expected to know. Patients need to know what the
h
own values and beliefs; and express a value-based physician thinks is clinically salient, i.e., the physi
preference. The obstetrician needs to complete cian’s beneficence-based clinical judgm ent about
com plem entary steps: recognize the capacity o f each obstetrical interventions such as the use o f forceps
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pregnant w om an to deal with clinical inform ation versus cesarean delivery. This reasonable person
(and not to underestim ate that capacity); provide should be adopted in obstetric practice. On this
information (disclose and explain all medically reason standard, the obstetrician should disclose to the
able alternatives, i.e., those supported in beneficence- pregnant w om an inform ation about her current
based clinical judgm ent); recognize the validity o f the condition and the m edically reasonable alternatives
to diagnose and m anage the patient’s condition,
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values and beliefs o f the patient; not interfere with and,

when necessary, assist the patient in her evaluation and along with the clinical benefits and risks o f each
ranking o f diagnostic and therapeutic alternatives for such alternative. W hen evidence-based reasoning
managing her condition; and elicit and implement the identifies only one such alternative or when such
patient’s value-based preference.4’11 reasoning identifies an alternative as clinically
The ethical obligations o f physicians in the superior, it should be recom m ended. M aking
inform ed consent process and the practical steps for beneficence-based recom m endations enhances, and
fulfilling these obligations were developed first in does not interfere with, patient autonom y.
m edical ethics and practice. These ethical obligations
were subsequently codified into law. In the United
States this process occurred in the com m on law, i.e., Conclusion
the law written by courts in deciding civil litigation, While this book em phasizes techniques o f obstetrical
starting early in the twentieth century. In 1914, interventions, it is apparent that the clinical applica
Schloendorjf v. The Society o f The New York Hospital tion o f these techniques should incorporate the ethical
Section 4: Ethics o f O bstetrical Interventions
dim ensions that we have discussed in this chapter. 6 Beaucham p TL, Childress JF. Principles o f Biom edical
Specifically, obstetricians should routinely engage Ethics. 5th edn. New York, NY: O xford U niversity
their pregnant patients in a decision-making process, Press; 2001.
starting with evidence-based reasoning and then 7 Chervenak FA, M cC ullough LB. An ethically justified
shaped by both beneficence and respect for autonomy algorithm for offering, recom m ending, and p erform in g
cesarean delivery and its application in m anaged care
in the practical steps that we have described. In the
practice. O bstet Gynecol. 1996;87:302-5.
United States and other countries throughout the
8 H ippocrates. O ath o f H ippocrates. In: Tem kin O,
world the professional liability crisis has, unfortunately,
Tem kin CL, eds. Ancient M edicine: Selected Papers o f
influenced physicians’ behaviors in decision-making Ludw ig Edelstein. Baltim ore, M D : Johns H opkins
with patients.13 While risk-reduction strategies to U niversity Press; 1976:6.
improve patient safety and thereby reduce professional
ru
9 M cC ullough LB, Coverdale JH, C hervenak FA.
liability are fully ethically justified,14 the performance A rgum ent-based m edical ethics: a form al tool for
o f unnecessary cesarean deliveries through distortion critically appraisin g the norm ative m edical ethics
o f the informed consent process is unethical and literature. A m J O bstet Gynecol. 2004;191:1097-1102.
should be eschewed, as a matter o f professional integ 10 Faden RR, Beaucham p TL. A H istory and Theory o f
b.
rity, by obstetricians throughout the world.13,15'16 Inform ed Consent. N ew York, N Y: O xford U niversity
Press; 1986.
11 W ear S. In form ed Consent: Patient A uton om y and
References Clinician Beneficence within Health Care. 2nd edn.
1 A m erican College o f O bstetricians and Gynecologists. W ashington, D C : G eorgetow n U niversity Press; 1998.
2
Gynecologists; 2004.
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Ethics in O bstetrics and Gynecology. 2nd edn.
W ashington, D C: A m erican College o f O bstetricians and
A ssociation o f Professors o f Gynecology and Obstetrics.

12
13
Sch loendorff v. The Society o f The New Y ork H ospital,
211 N.Y. 125, 126, 105 N .E. 92, 93; 1914.
Chervenak JL, M cC ullough LB, Chervenak FA. A new
approach to profession al liability reform : placing
er
Exploring M edical-legal Issues in Obstetrics and obligations o f stakeholders ahead o f their interests. A m
Gynecology. W ashington, D C: APG O M edical J O bstet Gynecol. 2010;203:203.el-7.
Education Foundation; 1994.
14 G runebaum A, Chervenak F, Skupski D. Effect o f
3 FIGO Committee for the Study o f Ethical Aspects of a com prehensive obstetric patient safety program on
Hum an Reproduction. Recommendations o f Ethical Issues com pensation paym ents and sentinel events. Am
h
in Obstetrics and Gynecology. London: International J O bstet Gynecol. 2011;204:97-105.

Federation o f Gynecology and Obstetrics; 1997.
15 Chervenak FA, M cCullough LB. N eglected ethical
4 M cCullough LB, Chervenak FA. Ethics in O bstetrics and dim ensions o f the profession al liability crisis. Am
us
Gynecology. New York, NY: O xford U niversity Press; J O bstet Gynecol. 2004;190:1198-200.
1994.
16 Chervenak FA, M cC ullough LB. Planned hom e birth:
5 Engelhardt H T Jr. The Foundations o f Bioethics, the profession al responsibility response. A m J Obstet
2nd edn. New York, NY: O xford U niversity Press; 1995. Gynecol. 2013;208:31-8.
ak
230
Index
Page n um bers in b old are definitions/m ain points.
m aternal m ortality 184 breech delivery, vaginal 107-34
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abdom inal pain, severe 177, 179
regional vs. general 184 aftercom ing head delivery
abdom in al wall
spinal 183-4, 184 1 2 3 -7 ,1 3 9
and E C V 100, 105
see also lidocaine arm delivery 115-23
opening 1 85-93
anterior asynclitism 21, 26, 37, 44 com plete breech extraction 107,
tonicity 46, 52, 101
anterior asynclitism, persistent 4 4 ,6 4 ,6 5 1 27-33
abn orm al pelvis 13, 134
b.
anthropoid pelvis 10 errors, breech extraction 133
abnorm al placenta 68, 183
antibiotics footling breech 107, 109
abn orm al uterus shape 196
anal sphincter injury 220-1 forceps 125-7
abnorm alities, fetal see congenital
cesarean section 182, 205 frank breech 101, 107, 131-3
disorders; C T G ; fetal entries
placenta accreta 174, 181 partial breech extraction 114-27
abruption see placental abruption
retained placenta 166, 168 preparations 110
accreta see placenta accreta
active m anagem ent, placenta delivery
6 8 -9 , 165
active vs. spon tan eous placenta
delivery 69
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arm , nuchal 114-22
arm prolapse see extrem ities prolapse
arm prolapse em ergency 85
asphyxia risks 95, 108, 110, 114
steps 110
twins extraction 94, 127
vs. cesarean 108-9
see also Bracht m aneuver
er
asynclitism 21, 23, 35 breech presentations
adjacent hand 85
anterior 21, 26, 37, 44 and E C V 100, 101
adnexa, inspection and sterilization
posterior 21, 23, 35 classification 107
1 99-200
asynclitism , persistent 6 3 -5 determ ining point 19
aftercom ing h ead delivery 123-7, 139
attitude (fetus orientation) 19 um bilical cord prolapse 86, 90
A hlfeld’s sign 66
autonom y, respect for 2 2 8 -9 brow presentation 19, 4 6 -7 , 52
h
all-fours m aneuver 161

bulbospongiosus muscle 13,72,2 1 1 ,2 2 0
am niotom y 94
back flip 102
anal m ucosa laceration 214, 216, 220
Baer’s m aneuver 67 caesarean section see cesarean section
anal sphincter injury 69, 2 1 1 -2 2
us
beneficence 2 2 7 -8 C aldw ell-M oloy pelvis

breech delivery, vaginal 110
Bird cup 151 classification 10
end-to-end repair 215, 2 1 6 -1 8 , 222
birth canal 5 -1 5 , 23 cardiotocography see C T G
episiotom y exam ination 72
birth canal rupture 167 catheterization, bladder 161, 183
figure-of-eight suturing 216, 2 1 6 -1 7
birth passage factors 23 catheterization, bladder filling 88
future pregnancies 2 2 1 -2
birthweight see fetal weight cephalhem atom a 150
m attress suturin g 216, 216, 218
bladder catheterization 161, 183 cephalic presentations 8, 19, 19
overlapping technique 215,
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bladder filling, cord prolapse 88 see also external cephalic version

2 1 8 -2 0 , 222
blood loss, continued 182-3 cervical carcinom a 193
postoperative ph ase 2 2 1 -2
b lood loss, severe cervical m yom a 193
prevention 70, 71
after M R P 168 cervix 5, 13
suturing procedure 2 1 6 -2 0
placenta accreta 171, 173 digital opening 192, 196
anal triangle 15
placenta previa 197 D iihrssen’s incisions 89, 109
analgesia see epidural analgesia
p ostpartu m 138, 165, 168, 177 injury 168
A ndrew s, V. et al. 72
uterus inversion 177 occult cord prolapse 87
an droid pelvis 10
body o f uterus 67 uterine inversion 177, 178, 179
anesthesia
bony birth canal 5 -1 3 vacuum extraction 153
cesarean 1 8 2 ,1 8 3 -4
brachial plexus injury 108, 140, 158, cesarean section 181-206
cesarean em ergency 184
159, 161, 202 anesthesia 182, 183-4
epidural 182, 183, 184
Bracht m aneuver 109, 110, 110-14 closing the abdom en/uterus 198-201
epidural vs. spinal 184
see also breech delivery, vaginal com plications 2 0 2 -4
general 96, 167, 174, 184
Bracht m aneuver failure 110, 114 delivery 194-6
gen eral-sp inal 174
breastfeeding 75, 204, 205 follow -up/care 204
local cesarean 184
Index
cesarean section (cont.) Cochrane Reviews 71, 103, 139 subcutis 191
future pregnancies 20 4 -5 com plete breech 107, 127-33 dilation stage see first stage o f labor;
long-term com plications 204 complete breech extraction 107,127-33 H odge planes; stations o f
opening abdom inal wall 185-93 com plete tear see anal sphincter injury presentation
opening uterus 193-4 com plications “ D irty D un can ” 65
perioperative phase 181-3 anal sphincter injury 221 disorders see congenital disorders
placenta accreta/previa 196-7 breech delivery, vaginal 108 divergent presentations 19
twins 92, 93, 94 cesarean section 2 0 2 -4 , 204 Doyen vaginal speculum 127
cesarean section, avoiding E C V 104-5 D uh rssen ’s incisions 89, 109
breech presentations 100, 105, 109 episiotom ies 7 4 -5 Duncan, placenta delivery 65
ECV 100, 104, 105, 109 forceps/vacuum delivery 139-42 dyspareunia 75, 76, 202
forceps delivery 139 presenting/prolapsed extrem ities 85 dystocia (difficult birth) see shoulder
sphincter defects 222 shoulder dystocia 161-3 dystocia
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cesarean section, em ergency um bilical cord prolapse 89
anesthesia 184 com pound presentation see extrem ities eccentric pole 21, 26, 2 7 -9 , 56
arm /hand prolapse 85 prolapse E C V (external cephalic version) 88,
breech delivery, vaginal 110 com pression, um bilical cord 87, 100-5
locked twin 96 109, 110 breech prevention 109, 134
m aternal com plications 203 congenital disorders 34, 46, 52, 88, com plications 104-5
b.
um bilical cord prolapse 88, 88, 107, 109 factors influencing 100-1, 105
89, 90 conjoined twins 92 technique 101-3
vs. scheduled 173 continuous suturing 72-4, 200-1 tim ing 10 3 -4
cesarean section indications controlled cord traction (C C T ) 68 um bilical cord accidents 104
anal sphincter injuries 222 cesarean section 195 E h lers-D an los syndrom e 137
breech presentations 108-9, 110,
127, 134
brow presentation 47
forceps delivery 139
occult um bilical cord prolapse 87
-li retained placenta 165, 166, 167
uterus inversion 168, 177, 179
see also um bilical cord entries
corporeal incision 193
counseling 181-2
elbow, distinguish ing 82
em ergency cesarean section
anesthesia 184
breech delivery, vaginal 110
locked twin 96
er
pelves, abnorm al 13 C ovjanov m ethod 111 m aternal com plication s 203
persistent occiput posterior 60 crow ning o f the head 30 um bilical cord prolapse 88, 88,
placenta accreta 171, 171, 173 C T G (cardiotocography) 89, 90
posterior asynclitism 65 breech deliveries 110, 134 vs. scheduled 173
prolapsed extrem ities 8 2 -3 , 83, 85 occult um bilical cord prolapse 87 end-to-end suturing 215, 2 1 6 -1 8 , 222
h
shoulder dystocia 163 term E C V cases 104, 105 engagem ent 8

twin, second 95 twins, vaginal birth 94 and E C V 101, 105
twins 92, 94, 96 curettage 166, 168, 171 frank breech 131-3
um bilical cord prolapse 84, 88, head 138
us
89, 90 D eLee forceps 143, 145 shoulders 31

cesarean section, secondary 140 De Snoo m aneuver 110, 123, enter m aneuvers 15 9 -6 0
cheekbones, as point o f rotation 47 125 entwinem ent, um bilical cord 34, 46,
chin, as eccentric pole 56 death see m ortality, m aternal; 52, 104, 107
classical cesarean section 193 mortality, perinatal epidural analgesia 103, 139, 184
classical forceps 143 delivery, norm al epidural anesthesia 182, 183, 184
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classical m aneuver, com plete breech head delivery 31 epidu ral-spin al technique 184
extraction 130 shoulders delivery 3 2 -3 epidural vs. spinal technique 184
classical maneuver, partial breech trunk delivery 33 episiotom y 7 0 -5 , 76
extraction 114, 115-17 see also second stage o f labor Bracht delivery 111
classical Pfannenstiel incision delivery position, effects o f 70 forceps/vacuum delivery 139
186-9, 200 D em issie, K. et al. 140 national tendencies 70, 71
classifications descent 23, 41, 47, 52-4, 62, 114 partial breech extraction 110
breech presentations 107 determ ining point 19 prim ary/secondary 70
evidence levels x diabetes 93, 158, 163 shoulder dystocia 159
operative delivery 138 diagonal conjugate 11 ergom etrine 166
pelvic shapes 10 dichorionic twins 91, 95, 97 errors, breech extraction 133
planes o f H odge 8 digital correction 62 ethics 227
tears/lacerations 70, 214-15 digital opening 201 ethnicity, and E C V 101
uterine inversion 177 fascia 191, 192 evidence-based m edicine (reasoning)
w ounds 220 lower uterine segm ent 193 107, 221, 228-30
coccyx 12, 211 parietal peritoneum 191 evidence levels x
examination, internal pelvic 11-13, 109 fetal dem ineralization 137 cesarean delivery 194
exam ination, vaginal fetal distress 100, 137 frank breech delivery 133
brow presentation 47 fetal evaluation 92, 109 Kristeller technique 111
episiotom y suturing 72 fetal factors, and E C V 101 sphincter injury risk 214
face presentation 52 fetal heart rhythm 87, 88, 90, 104 fundus support, placenta delivery 168
occiput anterior 23 see also C T G fundus, uterine inversion 168,178, 194
occiput posterior 41 fetal hem atom a see h em atom a, fetal
persistent asynclitism 64 fetal m ortality see m ortality, perinatal general anesthesia 96, 167, 174, 184
persistent occiput transverse fetal prolapse 8 1 -5 general-spinal anesthesia 174
position 62 fetal skull 3 - 4 general vs. regional anesthesia 184
sinciput presentation 34 fetal spinal cord, trau m a 104 gestational age
expulsion stage see head delivery; fetal weight breech presentations 107
secon d stage o f labor breech delivery, vaginal 134 cesarean com plications 2 0 3 -4
ru
extension o f the head 30 ECV 101 E C V procedure 104
see also face presentation; operative vaginal delivery 138 placenta accreta 173
hyperextension shoulder dystocia 158, 163 retained placenta 166
extension presentations 19 um bilical cord prolapse 88 twins 9 1-2
external anal sphincter fetom aternal disproportion 46, 82, vacuum extraction 138
b.
anatom y 13, 2 1 1 -1 2 139, 155 see also preterm deliveries
closing technique 215 fetom aternal transfusion 104 grand m ultiparity 62
continence 212 fetus orientation 19-23 G rootscholten, K. et al. 104
Sultan laceration classification figure-of-eight suturing 216, 2 1 6 -1 7 gynecoid pelvis 10
70, 214 Filshie clip 199
hand see extrem ities prolapse
suturing 215, 216, 219
suturing m aterial 220
external cephalic version see ECV
external rotation, lengthwise 23, 32
extraction
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first-degree lacerations, perineal 75
first-degree uterine inversion 177
first stage o f labor 23, 93, 94, 97, 134
see also H odge planes; labor
m echanism s, norm al; stations o f
h an ds-on /h an ds-off head
delivery 31
h an ds-on /h an ds-off perineum 70
head bobbing 158
er
adjacent hand 85 presentation head delivery 31
episiotom y 110 flexion presentations 19 aftercom ing 123-7, 139
face presentation 137, 139, 149 foetus see fetus cesarean section 194-6
gestational age 138 fontanels 3 - 4 see also second stage o f labor
internal version and 8 4 -5 footling breech 107, 109 head, engagem ent 138
see also extraction, breech delivery; forceps 142-4 H ELPERR (m em ory aid) 159-61,
h
forceps; forceps extraction; choosing vacuum or forceps 1 39-42 161

vacuum extraction delivery classification 138 hem atom a, fetal
extraction, breech delivery Kielland 126, 142, 143 extrem ities prolapse 85
us
com plete breech extraction 107, Kocher 6 7 -8 vacuum extraction 137, 138, 150
127-33 Luikart 143-4 vacuum /forceps delivery 139,
errors, breech extraction 133 N aegele 126, 142, 143, 144 140, 141
partial breech extraction 110, Piper 126-7, 143 hem atom a, m aternal 65, 72, 181, 201
114-27 Sim pson 143 hem orrhage
twins extraction 94, 127 see also forceps extraction; forceps, after M RP 168
extraction, preterm deliveries 138 placenta delivery; operative placenta accreta 171, 173
ak
extrem ities prolapse 8 1 -5 vaginal delivery placenta previa 197

forceps extraction 144-9 postpartum 138, 165, 168, 177
face presentation 19, 5 2 -9 breech 12 5 -7 uterus inversion 177
brow presentation 47 caution 222 high vacuum /forceps 138
forceps extraction 139, 149 cesarean section, avoiding 139 H odge planes 8 -9 , 19
vacuum extraction 137 face presentation 139, 149 H odge 1 23, 41, 47, 64
Falope Ring 199 occiput presentation 126, 144-8, H odge 2 25, 43, 47, 65
fecal incontinence, m aternal 149 H odge 3 2 6 -9 , 44
anal sphincter injury 216, 221, 222 forceps, placenta delivery 6 7 -8 H odge 4 29, 45
cesarean/vaginal delivery 202 forw ard roll 101 persistent transverse position 62
episiotom y 75 fourth degree tear see anal sphincter see also first stage o f labor; stations o f
forceps/vacuum delivery 140, 142 injury presentation
fetal abnorm alities see congenital frank breech 101, 107, 131-3 hyperextension 104, 105, 107, 109, 134
disorders; C T G ; fetal entries frontal axis, rotation round 21 see also extension o f the head; face
fetal bleeding 137 fun dus pressure presentation
fetal com prom ise 137 Bracht delivery 111, 112 hypom ochlion see point o f rotation
Index
hysterectom y lacerations, third/fourth degree see m orbidity, m aternal 202

cervical carcinom a 193 anal sphincter injury anal sphincter injury 211
“cesarean hysterectom y” 196-7 laparotom y 179, 186 cesarean section 181, 198, 199, 200,
during cesarean 181 larynx, as point o f rotation 58, 149 201, 202, 204, 205
placenta accreta 167-8, 173-4 levator ani m uscle 15 long-term 211
post-delivery risks 202 lidocaine 71, 72, 75, 161, 184 placenta accreta 171, 173
uterus inversion 179 lie (fetus orientation) 19 shoulder dystocia 163
hysteroscopic placenta rem oval 168 Litzm ann’s obliquity 63 throm bosis 182
local anesthesia, cesarean section 184 twin cesareans 93
incom plete breech 101, 105 locked twin 92, 96 m orbidity, neonatal 1 39-40, 202
incontinence see fecal incontinence, longitudinal axis, rotation cesarean section 202
m aternal; urinary incontinence, around 2 1 -3 respiratory 203, 205
m aternal longitudinal lies 19 shoulder dystocia 158, 161, 163
ru
increta see placenta increta Lovset m aneuver 109, 110, 114, twin cesareans 93
induction o f labor 91-2, 163, 166, 213 114-15, 120 m orbidity, perinatal 202
infections, forceps/vacuum low vacuum /forceps 138 cesarean section 205
delivery 140 lower uterine segm ent 5, 13, 64, com plete breech 127
inform ed consent 182, 22 8 -9 66-7, 92 twin cesareans 93
innom inate line 12
b.
lower uterine segm ent, incisions twin pregnancies 91
internal anal sphincter 211-12 1 93-4, 205 um bilical cord prolapse 89
closing technique 215 digital opening 193 m ortality, m aternal 202
continence 212 hem orrhage 197 anesthesia 184
innervation 211 M isgav-Ladach m ethod 192 cesarean section 181, 202, 204
Sultan laceration classification 214 obesity 192 placenta accreta 171, 173
suturing 216, 217
internal pelvic exam ination 11-13,
109
internal rotation, lengthwise 21
internal version 8 4 -5
-li Pfannenstiel incision 188
supra or subum bilical transverse
incision 192
Luikart forceps 143-4
throm bosis 182
m ortality, perinatal 202
and E C V 104
breech presentations 108
cesarean section 204, 205
er
intervention, (m ajor sections headed), m acrosom ia 109, 134, 138 com plete breech 127
retained placenta 166 m agnetic resonance im aging (M RI) 13, locked twin 92
introitus injury 168 172, 196 shoulder dystocia 162
ischial spines 12 M alm strom vacuum cup 150, 150-1 twins 91, 9 1 -2
ischial tuberosity 12 m anual rem oval o f the placenta (M RP) um bilical cord prolapse 89, 89
h
ischiocavernosus m uscle 13 165-8, 166 m other see m ultiparous w om an;

M arfan syndrom e 137 nulliparous w om an; prim iparous
Joel-Cohen m ethod 189-91, 201 m aternal com plications, cesarean w omen
section 2 0 2 -3 m oulage see m olding
us
K err (1926) 200 m aternal m ortality see mortality, M RI (m agnetic resonance im aging) 13,
Kielland forceps 126, 142, 143 m aternal 172, 196
Kiwi O m niC up 150, 152 m attress suturing 216, 216, 218 M RP (m anual rem oval o f the placenta)
knee, distinguishing 82 M auriceau m aneuver 109, 110, 123 165-8, 166
Kocher forceps 6 7 -8 M aylard m ethod 192 M uller m aneuver 110, 114-15,
Kristeller fundus technique 111 M cRoberts m aneuver 159 118-20, 130
ak
Kiistner’s m aneuver 6 6 -7 m edical ethics 227 m ultiparity 62, 88, 100, 158, 166
m ediolateral episiotom y 70, 71, m ultiparous w om an 46, 52, 82
labia injury 168 75, 139 m ultiple entw inem ent 34
labor m echanism s, norm al see brow m em brane see rupture, m em brane m yom a 82, 107, 171, 193
presentation; cephalic M ichael Stark C esarean 192
presentations; face presentation; m id vacuum /forceps 138 N aegele’s forceps 126, 142, 143, 144
first stage o f labor; occiput, m idline cesarean incision 186 N aegele’s obliquity 63
anterior; occiput, posterior; m idline episiotom y 70, 75, 213 necrosis, prolapsed arm 85
parietal bone presentation; m idpelvis 6 neonatal com plications 139-40, 2 0 3 -4
persistent asynclitism ; persistent M isgav-Ladach m ethod 192, 201 neonatal m orbidity see m orbidity,
occiput anterior/posterior; m isoprostol 166 neonatal
persistent occiput transverse m olding 4 N IC E guidelines 202
position; sinciput presentation; m onoam niotic twins 96 nonm aleficence 228
twins m onochorionic diam niotic twins non-steroidal anti-inflam m atory drug
lacerations, perineal 33, 6 9 -7 0 , 75, 141 91-2, 9 5 -6 (N SA ID ) 75
see also anal sphincter injury; Sultan m orbid obesity 193 n orm al delivery
laceration classification see also obesity head delivery 31
Index
shoulders delivery 3 2 -3 extrem ities prolapse 82, 166 com plications 168
trun k delivery 33 grand m ultiparity 62 m anual rem oval 165-8, 166
see also secon d stage o f labor m ultiparity 88, 100, 158, 166 prevention 166
nulliparous w om an 23, 7 0 -1 , 75, 137 m ultiparous w om an 46, 52, 82 placental abruption 92,100,103,104,199
nulliparous w om an 2 3 ,7 0 - 1 ,7 5 ,1 3 7 planes o f H odge see H odge planes
O A SIS (obstetric anal sphincter prim iparous women 82, 139 platypelloid pelvis 10, 34
injuries) see anal sphincter injury partial breech extraction 110, 114-27 point o f rotation (hypom ochlion) see
obesity 193 patient-controlled analgesia 184 rotation point
cesarean section 184, 192, pelvic axis 6, 27 -9 polyhydram nios 82
192-3, 203 pelvic exam ination 11-13, 109 Pom eroy technique 199
E C V 100 pelvic floor 5, 13, 13-15 position (fetus orientation) 19
m orbid 193 forceps/vacuum delivery 140 posterior asynclitism 21, 23, 35
shoulder dystocia 158 prolapse 140, 142 posterior asynclitism , persistent 64, 65
ru
oblique lie 100 suturing 72 postpartum hem orrhage 138, 165,
obstetric anal sphincter injuries pelvic inlet 5 - 6 168, 177
(O A SIS) see anal sphincter injury pelvic outlet 6 post-term pregnancy 158
occiput 4, 19-21 pelvic shapes 10 prem aturity see preterm deliveries
aftercom ing head delivery 123, 126 pelvis 5 -1 3 prenatal m assage 70
b.
anterior 2 3 -3 3 , 144-8 pelvis, abn orm al 13, 134 prenatal treatm ent, placenta accreta
anterior cup 15 1 -2 pelvis classification 10 173, 174
cesarean section 194 percreta see placenta percreta presenting part 19
engaged head 138 perinatal m orbidity see m orbidity, arm 83
forceps extraction 126, 144-8, perinatal extrem ities 81
149
posterior 35, 4 1 -5
posterior cup 151-2
occult hand 85
occult um bilical cord prolapse 86, 87
-li
perinatal m ortality see m ortality,
perinatal
perineal body 13, 220
perineal lacerations 33, 69-70, 75, 141
perineal m assage 70
hand 81, 83
um bilical cord 86, 87, 109
see also breech presentations
preterm deliveries
breech presentation 100, 105,
er
oligoh ydram nios 189 perineal m em brane 13-15 107, 109
O ’N eil cup 151 perineal space 13 cesarean section 193, 194, 203
operative delivery see cesarean section perineum 13 E C V 103-4, 105, 105
operative vaginal delivery 71, 137-55 perineum , suturing 220 extrem ities prolapse 82
choosing vacuum or forceps 139-42 peritoneal closure 200 forceps 143
com plications 139-42 persistent asynclitism 6 3 -5 placenta accreta 173
h
delivery classification 138 persistent occiput anterior/ retained placenta 165, 166
forceps 14 2 -4 posterior 60 twins 91, 92
forceps extraction 144-9 persistent occiput traverse um bilical cord prolapse 86, 87, 88
us
vacuum extraction 152-5 position 6 1 -2 vacuum extraction 138

vacuum extractors 149-52 Pfannenstiel incision 186-9, 200, 201 preventative m easures
orientation, fetus see fetus orientation P inard m aneuver 131-2, 132 anal sphincter injury 70, 71
orientation points, pelvic exam ination Piper forceps 126-7, 143 arm /h and prolapse 85
11-13 placenta, abnorm al 68, 183 breech deliveries 100, 109, 110
O ’Sullivan technique 179 placenta accreta 167-8, 171-4 cesarean section 182-3
outlet vacu um /forceps 138 cesarean section 183 E C V 105
ak
overlapping technique, anal sphincter cesarean section, long-term 204 perineal lacerations 75, 174
215, 2 1 8 -2 0 , 222 hysterectom y 173-4 postpartum continued bleeding 182-3
oxytocin prenatal treatm ent 173, 174 retained placenta 166
cesarean section 182-3 uterus conservation 174 shoulder dystocia 163
placenta delivery 68, 69, 69, 196 uterus inversion 177 sphincter injury 212-14
postpartu m bleeding 182-3 placenta delivery (labor third stage) um bilical cord prolapse 8 9 -9 0
retained placenta 165, 166, 169 6 5 -9 , 165 uterine inversion 179
twins 94, 97, 134 placenta increta 171, 174 see also asphyxia risks
uterus inversion 178, 179 placenta localization 173, 183 prim ary episiotom y, indications 70
placenta percreta 171, 173, 174, 174 prim iparous w om en 82, 139
Pajot’s m aneuver 146 placenta previa primum non nocere 228
palpability, an d E C V 101 breech presentation 107, 109 prolapse, fetal 8 1 -5
parietal bon e 3 - 4 cesarean section 92, 183, 193, 204 prolapse, pelvic floor 140, 142
parietal bone presentation 63, 6 4 -5 cesarean vs. vaginal delivery 202 prolapse, um bilical cord see um bilical
parity placenta accreta 171 cord prolapse
cesarean section, long-term 204 placenta, retained 165-9 prom ontory 11
Index
pubic sym physis 5, 6, 12, 39, 45, 154 second-degree perineal lacerations 75 suprapubic pressure 159, 159
see also sym physiotom y second-degree uterine inversion 177 suture m aterial 72-3, 205, 220
second stage o f labor 23 sutures (fetal skull) 3 - 4
regional anesthesia 183-4 acceleration 137 suturing
regional vs. general anesthesia 184 asphyxia risks 108 anal sphincter injury 2 1 6 -2 0
retained placenta see placenta, retained h an ds-on /h an ds-off perineum 70 cesarean section 198-201
rotation 2 1 -3 oxytocin 134 episiotom ies 7 1 - 4
brow presentation 46, 47 twins 93 perineum 220
enter m aneuvers 159-60 see also delivery, norm al; head skin 72, 201
face presentation 5 5 -9 delivery sym physiotom y 161
forceps/vacuum delivery 138, 139, secondary episiotom y 70 sym physis see pubic sym physis
143, 148 section see cesarean section synclitism 21
occiput anterior 27, 29, 31, 32 Sellheim m aneuver 122-3
ru
occiput posterior 43, 44, 45 “ Shiny Schultze” 65 tear classification 2 1 4 -1 5
persistent occiput 60 shock, deep 177, 177 see also anal sphincter injury;
persistent occiput transverse shoulder dystocia 71, 104, 138, perineal lacerations; rupture;
position 62 158-63, 212 traum a
placenta 68 com plications 161-3 T erm Breech Trial 92, 100
b.
shoulder dystocia 159-60 prevention 163 third-degree tear see anal sphincter
sinciput presentation 3 7 -8 , 39-40 technique 159-61 injury
rotation, breech presentations 110 shoulders delivery, norm al 3 1 -3 third-degree uterine inversion 177
after head delivery 127 Sim pson forceps 143 third stage o f labor 165, 179
Bracht m aneuver 112 Sim pson, Jam es Y oung 149 see also placenta delivery; retained
Lovset m aneuver 120 sinciput presentation 3 4 -4 0 , 47 placenta
posterior arm first 117
Sellheim m aneuver 122
rotation point 23
anterior hairline 35, 41, 45
-li
sinciput presentation, cesarean
section 194
skin incisions, abdom inal 185-6
skin suturing 72, 201
throm bosis prophylaxis 182
tim ing, twin delivery 91, 9 1 -2
tocolysis
cesarean section 88, 194-5
er
cheekbones 46, 47 skull, fetal 3 - 4 E C V 103
glabella 34, 35, 39 soft-tissue birth canal 13-15 shoulder dystocia 161
larynx 52, 58, 149 soiling 212 twin delivery 96
neck 127 speculum m aneuver 127 uterus inversion 179
posterior hairline 112 sphincter anatom y 2 1 1 -1 2 Towner, D. et al. 140
sym physis 123 sphincter injury see anal sphincter transverse perineal m uscle 13, 72,
h
Rubin m ethod 159 injury 220

rupture spinal analgesia, EC V 103 transverse presentation 19, 100
birth canal 167 spinal anesthesia 183-4, 184 traum a
cesarean section 194, 199, 204
us
vs. epidural anesthesia 184 assisted vaginal delivery 108

forceps delivery 138, 141 spinal cord traum a, fetal 104 birth 138, 139
scar rupture 186, 202, 205 spin al-epidural technique 184 birth canal 162, 167
uterine 64, 194, 199, 204 spinal-gen eral anesthesia 174 genital tract 202
vagina 141 spinal vs. epidural technique 184 iatrogenic, cesarean 194
see also anal sphincter injury; spontaneous placenta delivery 6 6 -8 , perineal 70, 71
episiotom y; perineal lacerations; 69, 165 shoulder dystocia 139, 161
ak
Sultan laceration classification stapling 194 spinal cord, fetal 104

rupture, m em brane Stark, M. et al. 192 vaginal 72
breech presentations 110, 134 stations o f presentation see also anal sphincter injury;
cesarean section 188, 193 - 5 23, 41, 47, 64 perineal lacerations; rupture
EC V 103 - 2 1 - 3 25, 43, 47, 65 Trendelenburg position 89
preterm 87, 193 0 2 6 -9 , 44 true conjugate 11
presenting h and/arm 83, 84, 85, 90 +5 29, 45 trunk delivery, norm al 33
twins 93, 94, 95 persistent transverse position 62 turtle sign 158
um bilical cord prolapse 81, 86, 87, see also first stage o f labor; Hodge twins 9 1 - 7
88, 90 planes breech extraction 127
subcutis closure 201 cesarean section 92
sacrum 12 Sultan, A. 69 intertwin tim e interval 94
sagittal axis, rotation around 21 Sultan laceration classification 70, pregnancy 9 1 - 2
S c h lo e n d o r ff v. T h e S o ciety o f 2 1 4 -1 5 presenting part/prolap se 82, 84-5
T h e N e w Y o rk H o sp ita l 229 supra or subum bilical transverse specific situations 9 5 -6
Schultze, placenta delivery 65 incision 192-3 tim ing 9 1 - 2
Index
vaginal delivery 9 2 -4 , 127 cesarean section 84 injury 72, 141, 168

vertex presen tations 92-3, 94, 9 4 -5 cord accidents 104 O ’Sullivan technique 179
em ergency 8 7 -9 vaginal delivery see breech delivery,
ultrasound occult cord prolapse 87 vaginal; norm al delivery;
birthw eight 158 vacuum extraction 94 operative vaginal delivery
breech presentations 109, 134 urethrovaginal m uscle 13, 13, vaginal exam ination
E C V 101, 105 72, 220 brow presentation 47
forceps/vacuum delivery 138, 155 urinary incontinence, m aternal 75, episiotom y suturing 72
M R P 168 140, 202 face presentation 52
placenta accreta 171-2, 173, urogenital triangle 13 occiput anterior 23
183, 196 uterine cavity injury 168 occiput posterior 41
placenta previa 196 uterine fundus see fundus pressure persistent asynclitism 64
presenting extrem ities 81 uterine inversion 158 persistent occiput transverse
ru
presenting um bilical cord 87 uterine segm ent, lower see lower position 62
twins 94, 95 uterine segm ent; lower uterine sinciput presentation 34
um bilical cord prolapse 88, 90 segm ent, incisions vaginal speculum m aneuver 127
um bilical cord uterine tonicity 100, 101, 105, 194 vaginal suturing 72
Bracht m aneuver 112 uterotonics 69, 167-8, 168, vertex presentations 19
b.
clam ping 69, 165, 169, 196 179, 183 vertex presentations, twins 92-3,
com pression 87, 108, 109, 110 uterus conservation, placenta 94, 9 4 -5
drainage 166 accreta 174 vulva 5, 13, 30, 39-40, 69-70
E C V 104 uterus, opening 193-4
entw inem ent 34, 46, 52, 104, 107 uterus shape, abnorm al 196 weight see fetal weight; obesity
lon g 88
presenting 86, 87, 109
short 107
see also controlled cord traction
um bilical cord prolapse 8 6 -9 0
-li
vacuum extraction 8 4 -5 , 94, 138,
152-5
see also operative vaginal delivery
vacuum extractor 149-52
W illia m s O bstetrics 177
w om an see m ultiparous woman;
nulliparous w om an; prim iparous
women
W oods m aneuver 159-60
er
and prolap sed extrem ities 81 vagina 5, 13
breech presen tations 108, 109, 134 cord prolapse 89 Zavanelli m aneuver 96, 161
h
us
ak
23 /

Obstetric Intervention

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Obstetric Intervention

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Obstetric

Jan G. Nijhuis -li

University Printing House, Cambridge CB2 8BS, United Kingdom

Cambridge University Press is part o f the University o f Cambridge.

It furthers the University's mission by disseminating knowledge in the pursuit of

This publication is in copyright. Subject to statutory exception

Printed in the United Kingdom by Clays, St Ives pic

A catalogue record fo r this p ublication is available fr o m the British Library

Library o f Congress Cataloguing in Publication data

LCC RG701 | NLM WQ 330 | DDC 618.5-dc23

ISBN 978-1-316-63258-1 Paperback

Additional resources for this publication at www.cambridge.org/9781316632567

10 Placenta Accreta, Increta, and Percreta 171

11 Inversion of the Uterus 177

and Delivery 13 Sphincter Injury 211

M. W eemhoff, C. Willekes, and M.E.

A.J. Schneider and J.J. Duvekot

4 Delivery of Tw ins 91 Section 4-Ethics of Obstetrical

E. Roets, M. H anssens, and M. Kok Interventions 227

7 Operative Vaginal Delivery (Vacuum and

A nim ation 6.11

view. Anim ation 7.3 Forceps extraction face

Anim ation 3.1 Prolapsed arm. side view.

feet. A nim ation 8.3 Rubin method.

H J . van Beekhuizen, MD, PhD J J . Duvekot, MD, PhD

D epartm ent o f Obstetrics and Gynecology, Weill

D epartm ent o f Obstetrics and Gynecology, University

Netherlands University H ospital, Edegem, Belgium

P J . Dorr, MD, PhD S. Keizer, midwife

F.M. van Dunne, MD, PhD M. Kok, MD, PhD

M. Laubach, MD J.H. Schagen van Leeuwen, MD, PhD

J.P. de Leeuw, MD, PhD H .C J. Scheepers, MD, PhD

F.K. Lotgering, MD, PhD S.A. Scherjon, MD, PhD

J.G. Nijhuis, MD, PhD

M.E. Vierhout, MD, PhD

M. W eemhoff, MD, PhD

H ospital Ghent, Ghent, Belgium

M.C. de Ruiter, MD, PhD D epartm ent o f Obstetrics and Gynecology,

book, by explicating the passage o f the child through

delivery room and operating room using text, 3D Amos Grunebaum

1 P.J. Dorr, S. Keizer, M. Weemhoff, M.C. de Ruiter, and V.M. Khouw

Table 1.1 Skull dimensions

D istan ce (d.) a n d circu m fe re n ce (c.) cm From - to Presen ta tio n

c. suboccipitobregm atic 32-33

d. fronto-occipital 12 Glabella - back o f head Sinciput presentation

d. subm entobregm atic

Lower jaw - m iddle anterior

c. subm entobregm atic 34

d. biparietal 9.5 Greatest transverse diameter

d. bitem poral 8-8.5

Smallest transverse diam eter

Figure 1.2 Fontanels and sagittal suture.

Figure 1.3A-C Distances (A, B) and circum ferences (C).

Pelvic inlet F: upper edge o f pubic FB: 10.5-11.5

Maxim um pelvic F: m iddle posterior FB: 12-13

Midpelvis F: lower edge o f pubic FB: 11-12

pubic symphysis pubic symphysis

pubic symphysis pubic symphysis

Figure 1.6 Pelvic planes.

biparietal distance Figure 1.9 Head is engaged past the H3/0

engaged past the third plane o f Hodge (“0 station”),

Figure 1.10 Firmly m olded head is

• The android or male-like pelvis: has a “triangular”

cylinder-shaped, the ischial spines are not p rom i