Lecture #4 (FINALS): VAGINAL DELIVERY

Instructor:
OBSTETRICS·April 2020

PREPARATION FOR DELIVERY ❖ With each contraction, vulvovaginal opening is

dilated by the fetal head to gradually form an ovoid
The end of 2nd stage labor is heralded as: and finally, an almost circular opening.
a. The perineum begins to distend
b. The overlying skin becomes stretched
c. The fetal scalp is seen through the separating
labia
❖ Increased perineal pressure from the fetal head
creates reflexive bearing down efforts, which are
encouraged when appropriate.
❖ Note: If the bladder is distended, catheterization
may be necessary. Continued attention is also given
to fetal heart monitoring. As one example, a nuchal
cord often tightens with descent and may lead to
deepening variable decelerations. Figure 1. Perineum is supported as the head crowns

❖ During 2nd stage labor, pushing positions may vary.

But for delivery, the dorsal lithotomy position is most
common and often the most satisfactory. For better
exposure, leg holders or stirrups are used. In one
study by Corton and associates in 2012, they found
no increased rates of perineal lacerations with or
without their use.
❖ With positioning, legs are not separated too widely
or placed one higher than the other. Within the leg
holder, the popliteal region should rest comfortably
in the proximal portion and the heel in the distal
portion.
❖ Legs are not strapped into the stirrups, thereby
allowing quick flexion of the thighs backward onto
the abdomen should shoulder dystocia develop.
Legs may cramp during 2nd stage pushing, and
cramping is relieved by repositioning the affected
leg or by brief massage.
❖ Preparation for delivery includes vulvar and perineal
cleansing.
o If desired, sterile drapes may be placed in such
a way that only the immediate area around the
vulva is exposed.
o Scrubbing, gowning, gloving, and donning
protective mask and eyewear protect both the
laboring woman and accoucheur from
infectious disease.
OCCIPUT ANTERIOR POSITION
A. DELIVERY OF THE HEAD
CROWNING:
This is the encirclement of the largest head diameter
by the vulvar ring. During crowning, the perineum
thins and may spontaneously lacerate, anus
becomes greatly stretched, and the anterior wall of
the rectum can easily be seen through it.
❖ Routine episiotomy is no longer recommended, and
selective use aims to enlarge the vaginal opening for
specific indications.
❖ To limit spontaneous vaginal lacerations, some
perform:
a. antenatal massage of the perineal body to
increase perineal distensibility or
b. intrapartum perineal massage to widen the
introitus for head passage.
❖ During massage with a lubricant, the perineum is
grasped in the midline by both hands using the
thumb and opposing fingers.
❖ Outward and lateral stretching to thin the perineum
is repeatedly performed.
❖ Antepartum use of Epi-No intravaginal pump balloon
has similar aim, but it also fails to prevent perineal
trauma or levator injury.
❖ When the head distends the vulva and perineum
enough to open the vaginal introitus to a diameter
of 5 cm or more, a gloved hand may be used to
support the perineum

By the time of perineal distention, the position of

the occiput is usually unknown. In some cases, however,
molding and caput formation may have precluded early
accurate identification.
❖ In most cases, position is directly occiput anterior
(OA) or is rotated slightly oblique. But in perhaps 5%,
occiput posterior (OP) positioning persists.

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TAMAYAO, CHRIS GERARD C.
Lecture #4 (FINALS): VAGINAL DELIVERY
Instructor:
OBSTETRICS·April 2020
Figure 2. Delivery of the head. The mouth appears over the
perineum
❖ Referring back to figure 2, the other hand is used to
guide and control the fetal head to deliver the
smallest head diameter through the introitus and to
avoid expulsive delivery.
❖ Slow delivery of the head may decrease lacerations.
Overall, bracing the perineum lowers rates of anal
sphincter injury compared with a “hands off”
approach to delivery.
❖ Alternatively, if expulsive efforts are inadequate or
expeditious deliver is needed, the modified Ritgen
maneuver may be employed or an episiotomy cut.
MODIFIED RITGEN MANEUVER:
In this, the gloved fingers beneath a draped towel
exert forward pressure on the fetal chin through the
perineum just in front of the coccyx. Concurrently, the
other hand presses against the occiput
Figure 3. Modified Ritgen Maneuver. Moderate upward pressure
is applied to the fetal chin by the posterior hand covered by a
sterile towel. The other hand applies occipital pressure.
❖ Originally described in 1855, the maneuver allows
controlled fetal head delivery. It also favors neck
extension so that the head passes though the
introitus and over the perineum with its smallest
diameters.
❖ Comparing the Ritgen maneuver with simple
perineal support, Jonsson and colleagues in 2008
TAMAYAO, CHRIS GERARD C.
found a similar incidence of third- and fourth-degree
tears.
THIRD- AND FOURTH- DEGREE TEARS
These lacerations are considered obstetrical anal
sphincter injuries (OASIS), and their combined
incidence varies from 0.5-5%. Risk factors for these
more complex lacerations include:
o Nulliparity
o Midline episiotomy
o Persistent OP position
o Operative vaginal delivery
o Asian race
o Short perineal length, and
o Increasing fetal birthweight
B. DELIVERY OF THE SHOULDERS
Following the delivery of the fetal head, a finger is
passed across the fetal neck to determine whether it is
encircled by one or more umbilical cord loops.
❖ The nuchal cord incidence increases with
gestational age and is found in nearly 25 of
deliveries at term.
o If an umbilical cord coil is felt, it is slipped over
the head if loose enough. If applied too tightly,
the loop is cut between two clumps.
o Tight nuchal cords complicate approximately
6% of all deliveries but are not associated with
worse neonatal outcome than those without a
cord loop.
❖ Following its delivery, the fetal head falls posteriorly,
bringing the face almost into contact with the
maternal anus.
o The occiput promptly turns toward one of the
maternal thighs, and the head assumes a
transverse position. This external rotation
indicates that the bisacromial diameter, which
is the distance between the shoulders, has
rotated into the anteroposterior diameter of the
pelvis.
❖ Most often, the shoulders appear at the vulva just
after external rotation and are born spontaneously. If
delayed, extraction aids control delivery.
o The sides of the head are grasped with two
hands, and gentle downward traction is
applied until the anterior shoulder appears
under the pubic arch.
o Next, by an upward movement, the posterior
shoulder is delivered. During delivery, abrupt or
powerful force is avoided to avert fetal brachial
plexus injury
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Lecture #4 (FINALS): VAGINAL DELIVERY
Instructor:
OBSTETRICS·April 2020
Figure 4. Delivery of the shoulders. A. Gentle downward traction to effect
descent of the anterior shoulder. B. Delivery of the anterior shoulder
completed. Gentle upward traction to deliver the posterior shoulder.
❖ The rest of the body almost always follows the
shoulders without difficulty. With prolonged delay,
however, its birth may be hastened by moderate
outward traction on the head and moderate
pressure on the uterine fundus.
❖ Hooking the fingers in the axillae is avoided. This can
injure upper extremity nerves and produce a
transient or possibly permanent paralysis.
Immediately after delivery of the newborn, a gush of
amnionic fluid that is often blood-tinged but not
grossly bloody usually follows.
❖ Previously, immediate nasopharyngeal bulb
suctioning of the newborn was routine to remove
secretions. It was found, however, that suctioning of
the nasopharynx may lead to neonatal bradycardia.
❖ The current American Heart Association neonatal
resuscitation recommendations eschew most
suctioning immediately following birth—even with
meconium present.
o And with meconium-stained fluid, routine
intubation for tracheal suction is not
recommended for vigorous or for nonvigorous
neonates.
❖ Suctioning is reserved for neonates who have
obvious obstruction to spontaneous breathing or
who require positive-pressure ventilation.
❖ For suctioning, options are bulb syringe or suction
catheter aspiration and may include intubation and
suctioning if the airway is obstructed.
C. CORD CLAMPING
The umbilical cord is cut between two clamps
placed 6-8 cm from the fetal abdomen, and later an
umbilical cord clamp is applied 2-3 cm from its insertion
into the fetal abdomen.
TAMAYAO, CHRIS GERARD C.
❖ For term neonates, the timing of umbilical cord
clamping remains debatable. Delayed umbilical
cord clamping transfers a greater volume of blood
to the newborn. A delay for up to 60 seconds may:
a. increase total body iron stores
b. expand blood volume
c. decrease anemia incidence in the neonate
❖ Conversely, a higher hemoglobin concentration
increases risks for hyperbilirubinemia and extended
hospitalization for neonatal phototherapy.
❖ Delayed cord clamping may also hinder timely and
needed neonatal resuscitation. Fortunately, in
general, delayed umbilical cord clamping
compared with early clamping does not worsen
APGAR scores, umbilical pH, or respiratory distress
caused by polycythemia.
❖ Regarding maternal outcomes, rates of postpartum
hemorrhage are similar between early and delayed
clamping groups.
CORD “MILKING”
A maneuver where the operator pushes blood
through the cord toward the newborn. This appears
safe and may be advantageous if rapid cord
clamping is clinically indicated.
❖ For the preterm neonate, delayed cord clamping
has several benefits:
o Higher red cell volume
o Decrease need for blood transfusion, and
o Lower rates of intraventricular hemorrhage and
or necrotizing enterocolitis
❖ For neonates who require expedited resuscitation,
cord milking may have benefits to quickly transfer
volume. Still, because of rapid volume changes, the
American Heart Association (AHA) currently suggests
against the routine use of cord milking for neonates
born <29 weeks’ gestation.
❖ The American College of Obstetrician and
Gynecologists in 2017 notes sufficient evidence to
support delayed umbilical cord clamping for term
and preterm neonates for at least 30-60 seconds
after birth -- an opinion also endorsed by the
American Academy of Pediatrics in 2017. AHA
guidelines advice that the practice may have
benefits for term or preterm neonates not needing
immediate resuscitation at birth.
D. OCCIPUT TRANSVERSE POSITION
In the absence of a pelvic architecture abnormality
or asynclitism, the occiput transverse (OT) position is
usually transitory. Thus, unless contractions are hypotonic,
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Lecture #4 (FINALS): VAGINAL DELIVERY
Instructor:
OBSTETRICS·April 2020
the head usually spontaneously rotates to an OA position.
If rotation ceases because of poor expulsive forces,
vaginal delivery usually can be accomplished readily in
several ways.
❖ The easiest is manual rotation of the occiput either
anteriorly to OA or less commonly, posteriorly to
occciput posterior.
❖ If either is successful, it was reported that 4%
cesarean delivery rate compared with a 60% rate in
women in whom manual rotation was not successful.
❖ Recommended rotation with Kielland forceps for the
persistent OT position is observed in the figure below:
Figure 5. Outlet forceps delivery from an OP position. The head
should be flexed after the bregma passes under the symphysis.
KIELLAND FORCEPS DELIVERY FROM OP POSITION:
In this, downward and outward traction is applied
until the base of the nose passes under the symphysis
(refer to Figure 5). The handles are then slowly
elevated until the occiput gradually emerges over
the upper margin of the perineum. The forceps are
directed downward again, and the nose, mouth,
and chin successively emerge from the vulva.
Figure 6. Kielland forceps
❖ Kielland forceps are used to rotate the occiput to
the anterior position, and delivery is accomplished
with the same forceps or by substitution with
Simpson, Tucker-McLane or similar forceps.
❖ In some cases, pelvic shape leads to a persistent OT
position that is not easily overcome. For example, a
TAMAYAO, CHRIS GERARD C.
platypelloid pelvis is flattened anteroposteriorly and
an android pelvis is heart shaped. With these, space
may be inadequate for occipital rotation to either
an anterior or posterior position.
Figure 7. The four parent pelvic types of the Caldwell-Moloy
classification. A line passing through the widest transverse
diameter divides the inlets into posterior (P) and anterior (A)
segment.
PERSISTENT OCCIPUT POSTERIOR POSITION
Approximately 2-10% of singleton term cephalic
fetuses deliver in an occiput posterior (OP) position. Many
fetuses delivering OP are OA in early labor and reflect
malrotation during labor.
❖ Predisposing risks include:
a. Epidural analgesia
b. Nulliparity
c. Greater fetal weight
d. Prior delivery with OP positioning
❖ Regarding pelvic shape, an anthropoid pelvis and
narrow subpubic angle can predispose.
A. MORBIDITY
❖ Women with persistent OP position have higher
associated rates of prolonged 2nd stage labor,
cesarean delivery, and operative vaginal delivery.
❖ With women who deliver vaginally, rates of blood
loss, and of third- and fourth-degree lacerations are
increased.
❖ Newborns delivered from an OP position have higher
complication rates than those born positioned OA.
❖ In a study comparing deliveries of newborn through
OP or OA, results showed that every possible delivery
complication was found more frequently with
persistent OP position.
o 46% of these women delivered spontaneously
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Lecture #4 (FINALS): VAGINAL DELIVERY
Instructor:
OBSTETRICS·April 2020
o 9% of these delivered via cesarean
The study also showed that an OP position at
delivery was associated with more adverse short-
term neonatal outcomes that included the following:
o Acidemic umbilical cord gases
o Birth trauma
o APGAR scores <7
o Intensive Care Nursery Admission
❖ Methods to prevent persistent OP position and its
associated morbidity:
o Digital examination for identification of fetal
head position can be inaccurate
o Transabdominal sonography can be used to
increase accuracy.
❖ Sonogram shows fetal orbits and nasal bridge lying
ventrally whereas the occiput opposes the lower
sacrum. This may provide an explanation for
prolonged 2nd stage labor or may identify suitable
candidates for rotation.
B. DELIVERY
❖ Fetus in an OP position may be delivered either
spontaneously or operative vaginal delivery.
❖ If bony pelvic outlet is roomy and the perineum is
somewhat relaxed from prior deliveries, rapid
spontaneous OP delivery will often take place.
❖ Conversely, if perineum is resistant to stretch, 2nd
stage labor may be appreciably prolonged.
❖ During each expulsive effort, the head is driven
against the perineum to a much greater degree
than when the head position is OA, leading to
greater rates of third- and fourth-degree lacerations.
❖ Spontaneous vaginal delivery from an OP position
does not appear feasible or expedited delivery is
needed. Manual rotation with spontaneous delivery
from an OA position may then be preferred.
o Successful rotation rates range from 47-90%
o Lower rates of cesarean delivery, vaginal
laceration, and maternal blood loss follow
rotation to OA position and vaginal delivery.
o Disadvantageously, manual rotation is linked
with higher cervical laceration rates. Thus,
careful inspection of the cervix following
rotation is mandatory.
❖ For exigent delivery, forceps or vacuum device can
be applied to a persistent OP position, which is often
performed in conjunction with an episiotomy.
o If the head is engaged, the cervix is fully dilated,
and the pelvis adequate, forceps rotation may
be attempted.
❖ Protrusion of fetal scalp through the introitus is the
consequence of marked elongation of fetal head
TAMAYAO, CHRIS GERARD C.
from molding combined with formation of a large
caput succedaneum.
o In some cases, head may not be engaged--
that is, biparietal diameter may not have
passed through the pelvic inlet. In these, labor is
characteristically long and descent of the head
is slow.
o Careful palpation above the symphysis may
disclose the fetal head to be above the pelvic
inlet. Hence, prompt cesarean delivery is
appropriate.
❖ At Parkland Hospital, spontaneous delivery or
manual rotation is preferred for management of
persistent OP position.
o Either manual rotation to OA position followed
by forceps delivery or forceps delivery from OP
position is used
o If neither of the two, cesarean delivery is
performed.
SHOULDER DYSTOCIA
❖ The remainder of the body may not rapidly follow
after complete emergence of the fetal head during
vaginal delivery.
o The anterior fetal shoulder can become wedged
behind the symphysis pubis and fail to deliver
using normally exerted downward traction and
maternal pushing.
o Umbilical cord compressed within the birth canal
❖ No specific definition of shoulder dystocia.
o Some investigators focus on whether maneuvers
to free the shoulder are needed.
o Others use the head-to-body delivery time
interval as defining
▪ 24 seconds: mean head-to-body delivery
time in normal births
▪ 79 seconds: with shoulder dystocia
• >60 seconds: used to define shoulder
dystocia.
❖ Diagnosis continues to rely on the clinical perception
that the normal downward traction needed for fetal
shoulder delivery is ineffective.
❖ There is evidence that the incidence has increased in
recent decades, likely due to increasing fetal
birthweight.
A. MATERNAL AND NEONATAL CONSEQUENCES
❖ Shoulder dystocia poses greater risk to the fetus than
the mother
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Lecture #4 (FINALS): VAGINAL DELIVERY
Instructor:
OBSTETRICS·April 2020
o Postpartum hemorrhage, usually from uterine
atony but also from vaginal lacerations, is the
main maternal risk
o Significant neonatal neuromusculoskeletal injury
and even mortality are concerns.
❖ 514 cases of shoulder dystocia: 11% were associated
with serious neonatal trauma.
o 8% was diagnosed with brachial plexus injury
o 2% suffered a clavicle, humeral, or rib fracture.
o 7% showed evidence of acidosis at delivery
o 1.5% required cardiac resuscitation or developed
hypoxic ischemic encephalopathy.
❖ Raise the neonatal injury risk with shoulder dystocia:
o Increasing fetal weight
o Maternal body mass index,
o Second-stage duration and a prior shoulder
dystocia
B. PREDICTION AND PREVENTION
❖ Most cases of shoulder dystocia cannot be
accurately predicted or prevented
❖ Elective induction of labor or elective cesarean
delivery for all women suspected of having a
macrosomic fetus is not appropriate.
❖ Planned cesarean delivery may be considered for
the non-diabetic woman with a fetus whose
estimated fetal weight is >5000 g or for the diabetic
woman whose fetus is estimated to weigh > 4500 g.
BIRTHWEIGHT
❖ Maternal characteristics associated with increased
fetal birthweight:
o Obesity
o Post-term pregnancy
o Multiparity diabetes
o Gestational diabetes
❖ In a study of nearly 2 million vaginal deliveries, 75% of
shoulder dystocia cases, newborns weighed >4000 g
o Cesarean delivery is indicated for large fetuses,
even those estimated to weigh 4500 g.
❖ The combination of fetal macrosomia and maternal
diabetes mellitus escalates the frequency of shoulder
dystocia
o Fetuses of diabetic women have larger shoulder
and extremity circumferences and greater
shoulder-to-head and chest-to-head size
differences relative to comparable-weight
fetuses of non-diabetic mothers
❖ A prophylactic cesarean delivery policy for
macrosomic fetuses would require more than 1000
TAMAYAO, CHRIS GERARD C.
cesarean deliveries with attendant morbidity to avert
a single permanent brachial plexus injury.
PRIOR SHOULDER DYSTOCIA
❖ The risk of recurrent shoulder dystocia ranges from 1
to 13%
o For many women with prior shoulder dystocia, a
trial of labor may be reasonable
❖ It is recommended that estimated fetal weight,
gestational age, maternal glucose intolerance, and
severity of prior neonatal injury be evaluated
o Risks and benefits of cesarean delivery should be
discussed with any woman with a history of
shoulder dystocia.
C. MANAGEMENT
❖ Shoulder dystocia cannot be accurately predicted.
❖ Because of ongoing cord compression with this
dystocia, one goal is to reduce the head-to-body
delivery time.
❖ The second goal is avoiding fetal and maternal injury
from aggressive manipulations.
o An initial gentle attempt at traction, assisted by
maternal expulsive efforts, is recommended
o Adequate analgesia is ideal
❖ Some clinicians advocate performing a large
episiotomy to provide room for manipulations
o Episiotomy itself does not lower brachial plexus
injury rates but raises third- and fourth-degree
laceration rates.
❖ After gentle traction, various techniques can be used
to free the anterior shoulder from its impacted
position behind the symphysis pubis.
❖ Moderate suprapubic pressure can be applied by an
assistant, while downward traction is applied to the
fetal head.
o Pressure is applied with the heel of the hand to
the anterior shoulder wedged above and behind
the symphysis.
o The anterior shoulder is thus either depressed or
rotated, or both, so the shoulders occupy the
oblique plane of the pelvis. Here, the anterior
shoulder can be freed.
❖ The McRoberts maneuver is selected next if
additional steps are needed.
o The maneuver consists of removing the legs from
the stirrups and sharply flexing them up toward
the abdomen. Suprapubic pressure is often
concurrently applied.
o The maneuver causes straightening of the
sacrum relative to the lumbar vertebrae, rotation
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Lecture #4 (FINALS): VAGINAL DELIVERY
Instructor:
OBSTETRICS·April 2020

of the symphysis pubis toward the maternal

head, and a decrease in the angle of pelvic
inclination.
o Although this does not increase pelvic
dimensions, pelvic rotation cephalad tends to
free the impacted anterior shoulder
o The maneuver reduces the forces needed to free
the fetal shoulder.
o If unsuccessful, most move next either to free the
posterior shoulder or to rotate the bisacromial
diameter into one of the oblique diameters of the
maternal pelvis.
o The maneuver consists of removing the legs from
the stirrups and sharply flexing the thighs up
toward the abdomen. The assistant is also
providing suprapubic pressure simultaneously.

Figure 8. The McRoberts maneuver. The maneuver consists of

removing the legs from the stirrups and sharply flexing the thighs
up toward the abdomen. The assistant is also providing
suprapubic pressure simultaneously (arrow).
❖ With delivery of the posterior shoulder, the
accoucheur carefully sweeps the posterior arm of the
fetus across its chest, followed by delivery of the arm.
o The operator’s fingers are aligned parallel to the
long axis of the fetal humerus to lower bone
fracture risks.
o The shoulder girdle is then rotated into one of the
oblique diameters of the pelvis with subsequent
delivery of the anterior shoulder.
Figure 9. Delivery of the posterior shoulder for relief of
shoulder dystocia.A.The operator’s hand is introduced into
the vagina along the fetal posterior humerus. B.The arm is
splinted and swept across the chest, keeping the arm flexed
at the elbow. C.The fetal hand is grasped and the arm
extended along the side of the face. The posterior arm is
delivered from the vagina.
❖ Woods reported that by progressively rotating the
posterior shoulder 180 degrees in a corkscrew fashion,
the impacted anterior shoulder could be released.
This is frequently referred to as the Woods corkscrew
maneuver. There are two maneuvers:
o First, the fetal shoulders are rocked from side to
side by applying force to the maternal
abdomen.
o Second, if the first maneuver is not successful, the
pelvic hand reaches the most easily accessible
fetal shoulder, which is then pushed toward the
anterior surface of the chest.

This maneuver most often abducts both

shoulders, which in turn produces a smaller shoulder-
to-shoulder diameter. This permits displacement of
the anterior shoulder from behind the symphysis.
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TAMAYAO, CHRIS GERARD C.
Lecture #4 (FINALS): VAGINAL DELIVERY
Instructor:
OBSTETRICS·April 2020
Figure 10. Woods Maneuver. The hand is placed behind the
posterior shoulder of the fetus. The shoulder is then rotated in a
corkscrew manner so that the impacted anterior shoulder is
released.
❖ All-fours maneuver – also the Gaskin maneuver.
o In this maneuver, the parturient rolls onto her
knees and hands.
o Downward traction against the head and neck
attempts to free the posterior shoulder
❖ Posterior axilla sling traction
o Used to deliver the posterior arm in cases where
the posterior arm is inaccessible for delivery
o Suction catheter is threaded under the axilla and
both ends are brought together above the
shoulder.
o Upward and outward traction on the catheter
loop delivers the shoulder.
❖ Deliberate fracture of the anterior clavicle by using
the thumb to press it toward and against the pubic
ramus can be attempted to free the shoulder
impaction.
o Deliberate fracture of a large neonate clavicle is
difficult.
o The fracture will heal rapidly and is usually trivial
compared with brachial nerve injury, asphyxia, or
death.
❖ The Zavanelli maneuver involves replacement of the
fetal head into the pelvis followed by cesarean
delivery.
o Terbutaline, 0.25 mg, is given subcutaneously to
produce uterine relaxation.
o The first part of the maneuver consists of returning
the head to an OA or OP position.
▪ The operator flexes the head and slowly
pushes it back into the vagina. After
which, cesarean delivery is performed.
o It was successful in 91% of cephalic cases and in
all cases of breech head entrapments.
TAMAYAO, CHRIS GERARD C.
o Despite successful replacement, fetal injuries
were common but may have resulted from the
multiple manipulations used before the Zavanelli
maneuver.
❖ Symphysiotomy: the intervening symphyseal cartilage
and much of its ligamentous support is cut to widen
the symphysis pubis.
o Used successfully for shoulder dystocia
o Maternal morbidity can be significant due to
urinary tract injury.
o Cleidotomy consists of cutting the clavicle with
scissors or other sharp instruments and is usually
done for a dead fetus
❖ Shoulder Dystocia Drill: used to better organize
emergency management.
1. Call for help—mobilize assistants and anesthesia
and pediatric personnel. Initially, a gentle
attempt at traction is made. Drain the bladder if
it is distended.
2. A generous episiotomy may be desired at this
time to afford room posteriorly
3. Suprapubic pressure is used initially by most
practitioners because it has the advantage of
simplicity. One assistant is needed to provide
suprapubic pressure, while normal downward
traction is applied to the fetal head.
4. The McRoberts maneuver requires two assistants.
Each assistant grasps a leg and sharply flexes the
maternal thigh toward the abdomen
o These maneuvers will resolve most cases of
shoulder dystocia.
o If the above listed steps fail, the following
steps may be attempted, and any of
o the maneuvers may be repeated
5. Delivery of the posterior arm is attempted. With a
fully extended arm, however, this is usually
difficult to accomplish.
6. Woods screw maneuver is applied.
7. Rubin maneuver is attempted.
Figure 11. Rubin Maneuver. A. The bisacromial diameter is
aligned vertically. B. The more easily accessible fetal
shoulder (the anterior is shown here) is pushed toward the
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Lecture #4 (FINALS): VAGINAL DELIVERY
Instructor:
OBSTETRICS·April 2020
anterior chest wall of the fetus (arrow). Most often, this
results in abduction of both shoulders, which reduces the
bisacromial diameter and frees the impacted anterior
shoulder.
❖ Other techniques generally should be reserved for
cases in which all other maneuvers have failed. These
include
o Intentional fracture of the anterior clavicle
o Zavanelli maneuver
❖ The American College of Obstetricians and
Gynecologists has concluded that no one maneuver
is superior to another in releasing an impacted
shoulder or reducing the chance of injury.
o Performance of the McRoberts maneuver,
however, was deemed a reasonable initial
approach.
❖ Shoulder dystocia training and protocols using
simulation based education and drills has evidence-
based support.
SPECIAL POPULATIONS
A. HOME BIRTH
❖ Unplanned births: in a study in Norway, fetal or
neonatal death from this subgroup was attributable
to infection, prematurity, and placental abruption
o Risks include multiparity and distance from the
hospital
❖ Planned births: in the US, women under this subgroup
favor those who are white, nonsmoking, self-pay,
college-educated, and multiparous
❖ Overall, risks of home births in the US are small but
greater than those of hospital delivery
❖ Midwife-attended home births carry a fourfold
greater mortality rate compared with midwife-
attended hospital births
o Most common underlying causes of death are
those attributed to labor and delivery events, to
congenital anomalies, and infection
❖ Substantial risks and absolute contraindications are
noted for those with:
o Prior cesarean delivery
o Breech presentation
o Multifetal gestation
B. WATER BIRTH
As one option for pain relief, some women choose to
spend part of first-stage labor in a larger water tub. This
practice was found in a study to have lower rates of
anesthesia block use and no greater adverse neonatal or
maternal effects compared with traditional labor.
TAMAYAO, CHRIS GERARD C.
❖ Carries greater concern for neonatal harm and
without proven benefits
o Aspiration: leads to fresh-water drowning
o Cord avulsion: stems primary from abruptly
bringing the newborn out of the water
o Serious infections
❖ ACOG currently recommend that “birth occur on
land, not in water.”
C. FEMALE GENITAL MUTILATION
❖ Refers to medically unnecessary vulvar and perineal
modification
❖ Practiced in countries throughout Africa, the Middle
East, and Asia.
❖ In the US, it is a federal crime to perform unnecessary
genital surgery on a girl younger than 18 years
❖ WHO classified it into 4 types:
❖ Long-term complications:
o Infertility
o Genital pain
o Diminished sexual quality of life
o Propensity for urogenital infection
❖ Adverse maternal and neonatal complications:
o Increased perinatal morbidity rates
o Small increased risks for prolonged labor,
cesarean delivery, and postpartum hemorrhage
o Psychiatric consequences
❖ In general, women with significant symptoms
following type III procedures are candidates for
corrective surgery called:
Deinfibulation: division of midline scar tissue to reopen
the vulva
- can be performed either antepartum or
intrapartum to prevent obstetrical complications
- not undergoing the procedure increases anal
sphincter tear rates with vaginal delivery
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Figure 12. Deinfibulation. Although not shown here, lidocaine is
first infiltrated along the planned incision if regional analgesia is
not in place already. As protection, two fingers of one hand are
insinuated behind the shelf created by fused labia but in front of
the urethra and crowning head. The shelf is then incised in the
midline. After delivery, the raw edges are sutured with rapidly
absorbable material to secure hemostasis.
D. PRIOR PELVIC RECONSTRUCTIVE SURGERY
❖ Performed with increasing frequency in reproductive-
aged women
❖ Most women with prior corrective surgery for
incontinence can be delivered vaginally without
symptom recurrence; slightly greater protection
against postpartum incontinence is gained by
elective cesarean delivery
o Symptom recurrence and the need for additional
vaginal surgery should be weighed against the
surgical risk of cesarean delivery
E. ANOMALOUS FETUSES
❖ Mild hydrocephaly: if biparietal diameter is <10 cm or
if the head circumference is <36 cm, vaginal delivery
may be permitted
❖ Neonatal death: vaginal delivery may be
reasonable, but the head or abdomen must be
reduced in size for delivery
o Cephalocentesis or paracentesis with
sonographic guidance: performed intrapartum
to remove fluid
o For hydrocephalic fetuses that are breech,
cephalocentesis can be accomplished
suprapubically when the aftercoming head
enters the pelvis.
TAMAYAO, CHRIS GERARD C.
THIRD STAGE OF LABOR
A. DELIVERY OF THE PLACENTA
❖ Third-stage labor: begins immediately after fetal birth
and ends with placental delivery
Goals:
o Delivery of an intact placenta
o Avoidance of uterine inversion or postpartum
hemorrhage: considered as emergency
intrapartum complications
❖ Immediately after newborn birth: uterine fundal size
and consistency are examined
o Uterus is firm with no unusual bleeding: wait until
the placenta separates
o Fundus is frequently palpated to ensure that it
does not become atonic and filled with blood
from placental separation
o Neither massage nor downward fundal pressure
is employed
o To prevent uterine inversion, umbilical cord
traction must not be used to pull the placenta
from the uterus
Signs of Placental Separation:
-median time of appearance: 4 to 12 minutes
▪ sudden gush of blood into the vagina
▪ globular and firmer fundus
▪ lengthening of the umbilical cord as the
placenta descends into the vagina
▪ elevation of the uterus into the abdomen
❖ Once placenta has detached from the uterine wall,
mother may be asked to bear down, and the
intraabdominal pressure often expels the placenta
into the vagina (may or may not be possible due to
analgesia)
❖ After ensuring that the uterus has contracted firmly,
umbilical cord is kept slightly taut but is not pulled.
❖ Pressure is exerted by a hand wrapped around the
fundus to propel the detached placenta into the
vagina. Concurrently, the heel of the hand exerts
downward pressure between the symphysis pubis
and the uterine fundus.
❖ Once the placenta passes through the introitus,
pressure on the uterus is relieved.
❖ Placenta is then gently lifted away. Care is taken to
prevent placental membranes from being torn off
and left behind.
o If membranes begin to tear, they are grasped
with a clamp and removed by gentle teasing.
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High-Dose Oxytocin
❖ Oxytocin: recommended by the WHO as first-line
agent
❖ Synthetic oxytocin: identical to the one produced by
the posterior pituitary
o Action is noted at approximately 1 minute
o Has a mean half-life of 3 to 5 minutes
❖ Should be given as a dilute solution by continuous
intravenous infusion or as an intramuscular injection
❖ If given as bolus: may cause profound hypotension
o IV bolus of 10 units: caused a marked transient
fall in blood pressure with an abrupt increase in
cardiac output
❖ If given in a large volume of electrolyte-free
Figure 13. Expression of placenta. Note that the hand is not trying dextrose solution: can lead to water intoxication due
to push the fundus of the uterus through the birth canal! As the
to its antidiuretic action
placenta leaves the uterus and enters the vagina, the uterus is
o If it is to be administered in high doses for a
elevated by the hand on the abdomen while the cord is held in
position. The mother can aid in the delivery of the placenta by considerable period of time, its concentration
bearing down. As the placenta reaches the perineum, the cord must be increased rather than increasing the
is lifted, which in turn lifts the placenta out of the vagina. infusion rate.
❖ No standard prophylactic dose has been
B. MANAGEMENT OF THE THIRD STAGE
established
o 10 units (2 ml) of oxytocin per liter of infusate:
❖ Expectant Management: waiting for placental
done in practice
separation signs and allowing the placenta to deliver
▪ Administered after delivery of the placenta
either spontaneously or aided by nipple stimulation or at a rate of 10 to 20 mL/min (200 to 400
gravity
mU/min) for a few minutes until the uterus
❖ Active Management: consists of the following triad remains firmly contracted and bleeding is
which aims to limit postpartum hemorrhage
controlled
o early cord clamping ▪ Then, infusion rate is reduced to 1 to 2
o controlled cord traction during placental delivery
mL/min until the mother is ready for transfer
o immediate administration of prophylactic
from the recovery to postpartum unit
oxytocin
o For women without IV access, 10 units of IM
❖ Uterine massage after placental delivery:
oxytocin are injected
recommended by many to prevent postpartum ❖ Carbetocin:
hemorrhage
o Long-acting oxytocin analogue
o Effective for hemorrhage prevention during
UTEROTONICS
cesarean delivery

❖ Drugs that increase the uterine tone and

Other Uterotonics
contractions. They intensify uterine muscle ❖ Ergot alkaloid agents:
contractions at the beginning, during labor, and
Ergonovine & Methylergonovine
during postpartum period.
o Second-line for the prevention of postpartum
❖ Play an essential role to decrease postpartum blood
hemorrhage
loss.
o Less safe and tolerable compared with oxytocin
❖ May be given before or after placental expulsion o Only methylergonovine is currently manufactured
without affecting rates of postpartum hemorrhage,
in the US
placental retention, or third-stage labor strength Administration: 0.2 mg is slowly given
o Administration before delivery: may entrap an
intravenously in a period not less than 60
undiagnosed, undelivered second twin. Thus, seconds to avoid sudden hypertension
abdominal palpation should confirm no
(contraindicated in hypertensive women)
additional fetuses
❖ Misoprostol:
o Prostaglandin E1 analogue

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o Inferior to oxytocin for postpartum hemorrhage
prevention
o Suitable as hemorrhage prophylaxis in resource-
poor settings that lack oxytocin
o Given as a single oral 600-microgram dose
❖ Although oxytocin is preferred for prevention of
hemorrhage, ergot alkaloids and prostaglandins
play a greater role in postpartum hemorrhage
treatment
C. MANUAL REMOVAL OF PLACENTA
❖ Three possibilities why placenta may not deliver
promptly:
o Placenta adherens: uterine contractions are
insufficient to detach the placenta
o Lower uterine segment constriction and a
detached but trapped placenta
o Morbidly adherent placenta
❖ Risks for retained placenta:
o stillbirth
o prior cesarean delivery
o prior retention
o preterm delivery
❖ Postpartum hemorrhage can complicate retained
placenta, and bleeding risk accrues with third-stage
length
o Absence of bleeding:
▪ Some recommend expectant management
for 30 minutes
▪ Others use a 15-minute threshold
▪ WHO: cites 60-minute threshold
o Brisk bleeding with failure to deliver placenta by
standard technique:
▪ Manual removal of the placenta is indicated.
When performed, WHO recommends
administration of a single dose of IV
antibiotics as a prophylaxis
Figure 14. Manual removal of placenta. A.One hand grasps the
fundus and the other hand is inserted into the uterine cavity and
the fingers are swept from side to side as they are advanced. B.
When the placenta detaches, it is grasped and removed.
TAMAYAO, CHRIS GERARD C.
IMMEDIATE POSTPARTUM CARE
❖ Critical hour immediately after delivery of placenta.
❖ Time for repair of lacerations.
❖ Things to note:
o Postpartum hemorrhage due to uterine atony
most likely occurs although uterotonics are
administered.
o Hematomas may expand.
o Uterine tone and perineum are frequently
evaluated.
o Maternal blood pressure and pulse are recorded
immediately after delivery every 15 minutes for
the first 2 hours.
o The placenta, membranes, and umbilical cord
are examined for completeness and anomalies.
A. BIRTH CANAL LACERATION
❖ Lower genital tract laceration location:
o Cervix
o Vagina
o Perineum- often follows vaginal delivery mostly 1st
and 2nd degree laceration
❖ Lacerations are classified by:
o Depth
o Complete definitions
Figure 15. 1. First-degree perineal laceration: injury to only the
vaginal epithelium or perineal skin. 2. Second-degree laceration:
injury to perineum that spares the anal sphincter complex but
involves the perineal muscles, which are the bulbospongiosus
and superficial transverse perineal muscles. 3a. Third-degree
laceration: <50 percent of the external anal sphincter (EAS) is
torn. 3b. Third-degree laceration: >50 percent of the EAS is torn,
but the internal anal sphincter (lAS) remains intact. 3c. Third-
degree laceration: EAS and lAS are torn. 4. Fourth-degree
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laceration: the perineal body, entire anal sphincter complex,
and anorectal mucosa are lacerated.
❖ 3rd degree lacerations reflect anal sphincter injury
subcategorized as:
o (3a) <50 percent external anal sphincter (EAS)
tear.
o (3b) >50 percent EAS tear; and
o (3c) EAS plus internal anal sphincter (IAS) tears.
❖ 3rd and 4th degree lacerations are considered
obstetrical anal sphincter injuries (OASIS) with
combined incidence of 0.5 to 5%.
❖ Risk factors of complex lacerations:
o Nulliparity
o Midline episiotomy
o Persistent OP position
o Operative vaginal delivery
o Asian race
o Short perineal length
o Increasing fetal birthweight
❖ Mediolateral episiotomy is shown to be protective in
most studies.
❖ Morbidity rates rises with laceration severity.
❖ Anal sphincter injuries are associated with greater
blood loss and puerperal pain.
❖ Wound disruption and infection are other risks.
❖ Long term anal sphincter injuries are linked with
double rates of fecal incontinence compared with
vaginal delivery without OASIS.
❖ To ensure appropriate repair, identification and
correct categorization is essential.
❖ Diagnosis rates of OASIS improve with clinical
experience.
❖ Intrapartum endoanal ultrasound boosts detection.
❖ Clinically occult tears in primiparas ranges 6 to 12 %.
❖ Women with a prior OASIS have a higher recurrence
rate compared with multiparas without prior OASIS
❖ Fetal macrosomia and operative vaginal delivery are
risks and can influence counseling in future
pregnancies.
❖ Patients may choose cesarean delivery to avoid
repeat OASIS.
o Cesarean may be most pertinent for those with:
▪ prior postpartum anal incontinence
▪ OASIS complications requiring corrective
surgery
▪ psychological trauma
o Planned cesarean delivery is balanced against its
associated operative risks.
B. EPISIOTOMY
❖ Perineotomy: intended incision of the perineum.
TAMAYAO, CHRIS GERARD C.
❖ Episiotomy: incision of the pudendum (external
genital organs) often used synonymously with
perineotomy.
❖ Episiotomy is done when head is visible during
contraction to a diameter of approx. 4 cm(crowning)
❖ When used with forceps delivery, most perform an
episiotomy after application of the blades.
❖ 2 main types are midline and mediolateral
episiotomy.
❖ Regional analgesia by bilateral pudendal nerve
blockade or by 1% lidocaine may be provided
before episiotomy.
❖ 2.5% lidocaine-prilocaine cream (EMLA cream) may
be applied an hour before expected delivery.
❖ Too early episiotomy: incisional bleeding
❖ Too late episiotomy: lacerations
INDICATIONS:
o Shoulder dystocia
o Breech delivery
o Fetal macrosomia
o Operative vaginal deliveries
o Persistent OP positions
o Markedly short perineal length
o Instances in which failure to perform an
episiotomy will result in significant perineal rupture
❖ There is lower rate of severe perineal/vaginal trauma
in women managed with restrictive or selective use of
episiotomy for spontaneous delivery rather than with
routine episiotomy.
❖ TYPES BY ANGLE OF PERINEAL INCISION:
o Midline Episiotomy
▪ Begins at the fourchette, incises the perineal
body in the midline, and ends before the
external anal sphincter.
▪ Incision length varies from 2 to 3 cm
depending on perineal length and degree of
tissue thinning.
▪ Greater likelihood of anal sphincter
laceration
o Mediolateral Episiotomy
▪ Begins at the midline of the fourchette and is
directed to the right or left at an angle 60
degrees off the midline.
▪ This angle accounts for perineal anatomy
distortion during crowning and ultimately
yields an incision 45degrees off the midline
for suturing
▪ Short term self-perceived pain and
dyspareunia may be increased.
▪ Require less time and suture for repair.
▪ Preferred incision to reduce OASIS rate.
o Lateral Episiotomy
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▪ Begins at point 1 to 2 cm lateral from the transverse perineal muscles during restoration of the
midline. perineal body
▪ It is angled toward either the right or the left
ischial tuberosity.

Figure 16. A mediolateral episiotomy is cut as the baby’s head

crowns. Fingers are insinuated between the perineum and head.
The incision begins in the midline and is directed toward the
ipsilateral ischial tuberosity at an angle 60 degrees off the
midline.

Figure 17. Mediolateral Episiotomy Repair. A.The vaginal

C. LACERATION AND EPISIOTOMY REPAIRS
epithelium and deeper tissues are closed with a single,
continuous, locking suture. The angle seems less acute now (45o)
❖ Perineal repairs are deferred until placenta is since the perineum is no longer distended. B.After the vaginal
delivered component of the laceration is repaired, deeper perineal tissues
Advantages: (especially if manual removal is are reapproximated by a single, continuous, nonlocking suture.
performed) Small episiotomies may not require this deeper layer. C.With a
o Permits undivided attention to the signs of similar continuous, nonlocking technique, the superficial
transverse perineal and bulbospongiosus muscles are
placental separation and delivery.
reapproximated. D. Last, the perineal skin is closed using a
o Repair is not interrupted or disrupted by placenta
subcuticular stitch.
delivery.
Disadvantage:
o Continuous blood loss until repair is completed.
▪ Direct pressure with applied gauze helps limit
volume loss.
❖ Adequate analgesia is imperative and women
without regional analgesia can experience high
levels of pain during perineal suturing.
❖ Locally injected lidocaine can be used solely or as a
supplement to bilateral pudendal nerve blockade.
o Additional dosing may be necessary for those
with epidural analgesia.
❖ First-degree lacerations do not always require repair,
and sutures are placed to control bleeding or restore
anatomy.
o Fine-gauge absorbable or delayed-absorbable
suture or adhesive glue are suitable.
❖ Second-degree laceration correction as well as
Figure 18. Midline Episiotomy Repair. A.An anchor stitch is placed
midline and mediolateral episiotomy repairs include
above the wound apex to begin a running, locking closure with
similar steps that close the vaginal epithelium and 2-0 suture to close the vaginal epithelium and deeper tissues and
reapproximate the bulbospongiosus and superficial reapproximate the hymeneal ring. B.A transition stitch redirects
suturing from the vagina to the perineum. C.The superficial
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transverse perineal and bulbospongiosus muscles are

reapproximated using a continuous, nonlocking technique with
the same length of suture. This aids restoration of the pereineal
body for long-term support. D.The continuous suture is then
carried upward as a subcuticular stitch. The final knot is tied
proximal to the hymeneal ring.

❖ Continuous suturing method

o Faster than interrupted sutures
o Yields less pain
❖ Blunt needles
o Suitable
o Decrease the incidence of needle-stick injuries
❖ Commonly used suture materials:
o 2–0 polyglactin 910 (Vicryl): decrease in
postsurgical pain and lower risk of wound
dehiscence are cited as major advantages
o Chromic catgut
❖ Closures with traditional polyglactin 910 occasionally
require removal of residual suture from the repair site
because of pain or dyspareunia.
o May be reduced by using a rapidly absorbed
polyglactin 910 (Vicryl Rapide)
❖ Third-degree laceration repair includes 2 methods to
repair the external anal sphincter:
o End-to-end Technique
▪ Preferred over other techniques
▪ Initially, the cut ends of the external anal
sphincter, which often retract, are isolated
and brought to the midline.
▪ Strength of this closure is derived from the
connective tissue surrounding the sphincter—
often called the capsule—and not the
striated muscle.
▪ Serial interrupted sutures incorporate
sphincter fibers and perisphincter connective
tissue, to bring sphincter ends together.
▪ Delayed-absorbable material can provide
sustained tensile strength during healing.
▪ There is higher perineal breakdown rate
following OASIS repair with chromic gut.
Figure 19. In overview, with end-to-end approximation of the
external anal sphincter(EAS), a suture is placed through the EAS
muscle, and 4to 6 simple interrupted 2-0 or 3-0 sutures of
polyglactin 910 are placed at the 3, 6, 9, and 12 o’clock
positions through the perisphincter connective tissue. To begin,
disrupted ends of the striated EAS muscle and capsule are
identified and grasped. The first suture is placed posteriorly to
maintain clear exposure. Another suture is then placed inferiorly
at the 6 o'clock position. The sphincter muscle fibers are next
reapposed by a figure-of-eight stitch. Last, the remainder of the
fascia is closed with a stitch placed anterior to the sphincter
cylinder and again with once placed superior to it.
o Overlapping Technique (Figure xx)
▪ Ends of the external anal sphincter are
brought to the midline and lie atop one
another.
▪ Only suitable for type 3c lacerations—those
involving the external and internal anal
sphincter.
▪ Two rows of mattress sutures travel through
both sphincter ends to recreate the anal ring.
▪ With type 3c lacerations, the IAS is repaired
before the EAS and is described next.
▪ With fourth-degree laceration repairs, the
torn edges of the rectal mucosa are
reapproximated.
▪ At a point 1 cm proximal to the wound apex,
sutures are placed approximately 0.5 cm
apart in the rectal muscularis and do not
enter the anorectal lumen.
▪ 4–0 polyglactin 910 or chromic gut for
running suture line are often used.
- Some recommend a second reinforcing
layer above this.
▪ If this is not done, the next layer to cover the
anorectal mucosa is formed by

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reapproximation of the internal anal ❖ Codeine provide considerable relief in oral

sphincter.
▪ This running, nonlocking closure is completed
with 3–0 or 4–0 suture.
▪ Following any repair, needle and sponge
counts are reconciled and recorded in the
delivery note.
analgesics.
❖ NSAID tablets can be given for lesser degree of
discomfort
❖ Because pain may signal a large vulvar, paravaginal,
or ischiorectal fossa hematoma or perineal cellulitis,
these sites should be examined carefully if pain is
severe or persistent.
❖ Urinary retention may complicate episiotomy
recovery.
❖ For those with second-degree lacerations or anal
sphincter tears, intercourse is usually proscribed until
after the first puerperal visit at 6 weeks.
❖ Compared with women with intact perineum, those
with perineal trauma show higher rates of delayed
intercourse at 3 and 6 months.

Figure 20. A.Suturing of the anorectal mucosa begins above the

laceration apex using a continuous, nonlocking method with fine
gauge absorbable suture such as 3-0 or 4-0 chromic gut or
polyglactin 910. Sutures are placed through the anorectal
submucosa approximately 0.5 cm apart down to the anal verge.
B. A second reinforcing layer uses 3-0 delayed-absorbable suture
in a continuous, nonlocking fashion. This incorporate the torn
ends of the internal anal sphincter (lAS), which can be identified
as the glistening white fibrous structure lying between the anal
canal submucosa and the fibers of the external anal sphincter. In
many cases, the lAS retracts laterally and must be sought and
retrieved for repair.

❖ For reduction of infectious morbidity associated with

anal sphincter lacerations, a single dose of antibiotic
at the time of repair is recommended.
❖ A single dose of a second-generation cephalosporin
is suitable, or clindamycin for penicillin-allergic
women.
❖ With OASIS, postoperatively, stool softeners are
prescribed for a week, and enemas and suppositories
are avoided.
❖ Normal function is not always ensured even with
correct and complete surgical repair.
❖ Some women may experience continuing fecal
incontinence caused by injury to the innervation of
the pelvic floor musculature.

D. PERINEAL LACERATION CARE

❖ Initially, locally applied ice packs help reduce

swelling and allay discomfort.
❖ In subsequent days, warm sitz baths aid comfort and
hygiene.
❖ Warm water can cleanse the site after voiding or
stooling.

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