Chapter 27: Vaginal Delivery

The natural culmination of second-stage labor is controlled vaginal delivery of a

healthy neonate with minimal trauma to the mother.

Vaginal delivery is the preferred route of delivery for most fetuses, although
certain clinical settings may favor cesarean delivery.

Malpresenting fetus or multifetal gestation in many cases may be delivered

vaginally but requires special techniques

ROUTE OF DELIVERY

Spontaneous vaginal vertex delivery poses the lowest risk of most maternal and
fetal comorbidity.

Spontaneous vaginal delivery compared with cesarean delivery

Spontaneous vaginal delivery has lower associated rates of maternal
infection, hemorrhage, anesthesia complications, and peripartum
hysterectomy,
In spontaneous vaginal delivery pelvic floor disorders may be increased
initial pelvic floor protection advantages gained from cesarean delivery are
lost as women age
Stress urinary incontinence rates after elective cesarean delivery are
lower than those following vaginal delivery.
PREPARATION FOR DELIVERY

The end of second-stage labor is heralded as the perineum begins to distend,

the overlying skin becomes stretched, and the fetal scalp is seen through the
separating labia.
Increased perineal pressure from the fetal head creates reflexive bearingdown efforts

At this time, preparations are made for delivery

Bladder is palpated, and if it is distended, catheterization may be
necessary.
Continued attention is also given to fetal heart rate monitoring

Nuchal cord often tightens with descent and may lead to deepening
variable decelerations.

Antibiotic prophylaxis against infective endocarditis is not recommended for

vaginal delivery in most women with cardiac conditions.
Exceptions are in women with cyanotic heart disease or prosthetic valves
or both.

Prophylaxis is indicated 30 to 60 minutes before the anticipated

procedure

During second-stage labor, dorsal lithotomy position is the most widely used
and often the most satisfactory.
For better exposure, leg holders or stirrups are used

No increased rates of perineal lacerations with stirrup use

compared to without their use.
With positioning, legs are not separated too widely or placed one higher
than the other.
Within the leg holder, the popliteal region should rest comfortably in the
proximal portion and the heel in the distal portion.
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 the second stage, in part, because of pressure by
the fetal head on pelvic nerves.

Cramping may be relieved by repositioning the affected leg or by

brief massage.

Preparation for delivery includes

Vulvar and perineal cleansing
Sterile drapes may be placed in such a way that only the immediate area
around the vulva is exposed.
OCCIPUT ANTERIOR POSITION

By the time of perineal distention, the position of the presenting occiput is

usually known.
Molding and caput formation have precluded accurate identification.

In most cases, presentation is directly occiput anterior or is rotated slightly

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

Delivery of the Head

With each contraction, the vulvovaginal opening is dilated by the fetal head to
gradually form an ovoid and finally, an almost circular opening
Crowning

Encirclement of the largest head diameter by the vulvar ring

Perineum thins and especially in nulliparous women and may undergo

spontaneous laceration.

Anus becomes greatly stretched, and the anterior wall of the rectum may be
easily seen through it.

Episiotomy increases the risk of a tear into the external anal sphincter, the
rectum, or both.
Anterior tears involving the urethra and labia are more common in women
in whom an episiotomy is avoided.
Most do not routinely perform episiotomy.

To limit spontaneous vaginal laceration, some perform intrapartum perineal

massage to widen the introitus for head passage.
Perineum is grasped in the midline by both hands using the thumb and
opposing fingers.
Rem Alfelor

Chapter 27: Vaginal Delivery

Outward and lateral stretch against the perineum is then repeatedly

applied.
When the head distends the vulva and perineum enough to open the vaginal
introitus to a diameter of 5 cm or more, a gloved hand may be used to support
the perineum (fig. 27-2).
The other hand is used to guide and control the fetal head to avoid
expulsive delivery.

FIGURE 27-1 Delivery of the head.

The occiput is being kept close to the
symphysis by moderate pressure on
the fetal chin at the tip of the maternal
coccyx.

Slow delivery of the head may decrease lacerations

If expulsive efforts are inadequate or expeditious delivery is needed, the
Modified Ritgen Maneuver may be employed.
Gloved fingers beneath a draped towel exert forward pressure on the fetal
chin through the perineum just in front of the coccyx.
Other hand presses superiorly against the occiput
Ritgen Maneuver
Allows controlled fetal head delivery
Also favors neck extension so that the head passes through the introitus
and over the perineum with its smallest diameters.
Hands-Poised Method
Attendant does not touch the perineum during delivery of the head
FIGURE 27-2 Delivery of the head. The mouth
appears over the perineum.

FIGURE 27-3 Modified Ritgen maneuver.

Moderate upward pressure is applied to the fetal
chin by the posterior hand covered with a sterile
towel, while the suboccipital region of the fetal
head is held against the symphysis.

Delivery of the Shoulders

Following delivery of the fetal head, a finger should be passed across the fetal
neck to determine whether it is encircled by one or more umbilical cord loops
(Fig. 27-4).
Nuchal cord is found in approximately 25% of deliveries and ordinarily
causes no harm.

If an umbilical cord coil is felt, it should be slipped over the head if loose enough.
If applied too tightly, the loop should be cut between two clamps. Such
tight nuchal cords complicate approximately 6% of all deliveries but are
not associated with worse neonatal outcome than those without a cord
loop.
FIGURE 27-4 The umbilical cord, if
identified around the neck, is readily slipped
over the head.

Following its delivery, the fetal head falls posteriorly, bringing the face almost
into contact with the maternal anus.
Occiput promptly turns toward one of the maternal thighs, and the head
assumes a transverse position (Fig. 27-5).

External Rotation indicates that the bisacromial diameter, which is

the transverse diameter of the thorax, has rotated into the
anteroposterior diameter of the pelvis.
Page 1 of 8

Most often, the shoulders appear at the vulva just after external rotation and are
born spontaneously.
If delayed, extraction aids controlled delivery.
Sides of the head are grasped with two hands, and gentle downward
traction is applied until the anterior shoulder appears under the pubic
arch.
By an upward movement, the posterior shoulder is delivered.
During delivery, abrupt or powerful force is avoided to avert brachial plexus
injury.
The rest of the body almost always follows the shoulders without difficulty.
With prolonged delay, however, its birth may be hastened by moderate
traction on the head and moderate pressure on the uterine fundus.
Hooking the fingers in the axillae is avoided.
This can injure upper extremity nerves and produce a transient or possibly
permanent paralysis.
Traction should be exerted only in the direction of the long axis of the neonate.
If applied obliquely, it causes neck bending and excessive brachial plexus
stretching.
Immediately after delivery of the newborn, there is usually a gush of amnionic
fluid, often blood-tinged but not grossly bloody.
FIGURE 27-5 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.

Previously, immediate nasopharyngeal bulb suctioning of the newborn was

routine to remove secretions.
It was found, that suctioning of the nasopharynx may lead to neonatal
bradycardia
Recommendations currently eschew most suctioning immediately following birth
even with meconium present.
This includes bulb syringe aspiration.
Suctioning should be reserved for neonates who have obvious obstruction
to spontaneous breathing or who require positive-pressure ventilation
If meconium is present and the newborn is depressed, then intubation and
tracheal suctioning is recommended

Clamping the Cord

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.
Plastic clamp that is safe, efficient, and fairly inexpensive, such as the
double grip umbilical clamp (hollister) is used

A delay in umbilical cord clamping for up to 60 seconds may increase total body
iron stores, expand blood volume, and decrease anemia incidence in the
neonate
Higher hemoglobin concentration increases risks for hyperbilirubinemia
and extended hospitalization for neonatal phototherapy
May also hinder timely and needed neonatal resuscitation.

In general, delayed umbilical cord clamping compared with early clamping does
not worsen Apgar scores, umbilical cord pH, or respiratory distress caused by
polycythemia.
Regarding maternal outcomes, rates of postpartum hemorrhage are
similar between early and delayed clamping groups

Cord Milking
Operator pushes blood through the cord toward the newborn.
This maneuver appears safe and may be advantageous if rapid cord
clamping is clinically indicated

For the preterm neonate, delayed cord clamping has several benefits.
Higher red cell volume
Decreased need for blood transfusion
Better circulatory stability
Lower rates of intraventricular hemorrhage and of necrotizing enterocolitis

American College of Obstetricians and Gynecologists (2012c) has concluded

that there is insufficient evidence to support or refute benefits from delayed
umbilical cord clamping for term neonates in resource-rich settings.
For preterm newborns, evidence supports delaying umbilical cord
clamping to 30 to 60 seconds after birth.
Our policy is to clamp the cord after assessing the need to clear the
airway, all of which usually requires approximately 30 seconds.
Rem Alfelor

Chapter 27: Vaginal Delivery

Newborn is not elevated above the introitus at vaginal delivery or much above
the maternal abdominal wall at the time of cesarean delivery.

PERSISTENT OCCIPUT POSTERIOR POSITION

Approximately 2-10% of singleton term cephalic fetuses deliver in an occiput

posterior (OP) position

Many fetuses delivering OP were occiput anterior (OA) in early labor and reflect
malrotation during labor.
Predisposing risks include

Epidural analgesia

Nulliparity

Greater fetal weight

Prior OP position delivery

Morbidity

Women with a persistent OP position have higher associated rates of

Prolonged second-stage labor
Cesarean delivery
Operative vaginal delivery

For women who deliver vaginally, rates of blood loss and of third- and fourthdegree laceration, so-called Higher-Order Vaginal Lacerations, are increased

Infants delivered from an OP position have many more complications then those
born positioned

Virtually every possible delivery complication was found more frequently with
persistent OP position.
Only 46% of these women delivered spontaneously
Remainder accounted for 9% of cesarean deliveries performed.

OP position at delivery was associated with increased adverse short-term

neonatal outcomes that included acidemic umbilical cord gases, birth trauma,
Apgar scores < 7, and intensive care nursery admission.

Methods to prevent persistent OP position and its associated morbidity have

been investigated.
Digital examination for identification of fetal head position can be
inaccurate, and sonography can be used to increase accuracy
May provide an explanation for prolonged second-stage labor or may
identify suitable candidates for manual rotation.

Varying maternal position either before or during labor does not appear to lower
rates of persistent OP position
Delivery of Persistent Occiput Posterior Position

Delivery of a fetus with an OP position may be completed by spontaneous or

operative vaginal delivery.
If the pelvic outlet is roomy and the vaginal outlet and perineum are
somewhat relaxed from prior deliveries, rapid spontaneous OP delivery
will often take place.
If the vaginal outlet is resistant to stretch and the perineum is firm,
second-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.
This leads to greater rates of higher-order perineal lacerations
Manual rotation with spontaneous delivery from an OA position may be
preferred.
Successful rotation rates range from 47-90%.
Lower rates of cesarean delivery, vaginal laceration, and maternal blood
loss follow rotation to OA position and vaginal delivery

Manual rotation is linked with higher cervical laceration rates.

Careful inspection of the cervix following rotation is prudent.

For exigent delivery, forceps or vacuum device can be applied to a persistent

OP position.
This is often performed in conjunction with an episiotomy.
If the head is engaged, the cervix fully dilated, and the pelvis adequate,
forceps rotation may be attempted.

These circumstances most likely prevail when expulsive efforts of

the mother during the second stage are ineffective.

Protrusion of fetal scalp through the introitus is the consequence of marked

elongation of the fetal head from molding combined with formation of a large
caput succedaneum
Head may not even be engaged, that is the biparietal diameter may not
have passed through the pelvic inlet.
Labor is characteristically long and descent of the head is slow.
Careful palpation above the symphysis may disclose the fetal head to be
above the pelvic inlet.
Prompt cesarean delivery is appropriate.

Spontaneous delivery or manual rotation is preferred for management of

persistent OP position.
Either manual rotation to OA position followed by forceps delivery or
forceps delivery from the OP position is used.
If neither can be completed with relative ease, cesarean delivery is
performed.
OCCIPUT TRANSVERSE POSITION

In the absence of a pelvic architecture abnormality or asynclitism, the occiput

transverse position is usually transitory.
Unless contractions are hypotonic, the head usually spontaneously
rotates to an OA position.
If hypotonic uterine contractions are suspected and cephalopelvic
disproportion is absent, then an oxytocin infusion can be used to stimulate
labor.
Page 2 of 8

If rotation ceases because of poor expulsive forces, vaginal delivery usually can
be accomplished readily in a number of ways.
Manual rotation of the occiput either anteriorly to OA or less commonly,
posteriorly to OP.
If either is successful, a 4% cesarean delivery rate compared with a 60% rate in
women in whom manual rotation was not successful.
Some recommend rotation with Kielland forceps for the persistent
occiput transverse position

These forceps are used to rotate the occiput to the anterior position,
and delivery is accomplished with the same forceps or by
substitution with either Simpson or TuckerMcLane forceps.
In some cases, there may be an underlying cause leading to the
persistent occiput transverse position that is not easily overcome.

Platypelloid pelvis is flattened anteroposteriorly

Android pelvis is heart shaped.

There may be inadequate space for occipital rotation to either an

OA or OP position

Undue force should be avoided if forceps delivery is attempted.

SHOULDER DYSTOCIA

Following complete emergence of the fetal head during vaginal delivery, the
remainder of the body may not rapidly follow.
Anterior fetal shoulder can become wedged behind the symphysis pubis
and fail to deliver using normally exerted downward traction and maternal
pushing.
Because the umbilical cord is compressed within the birth canal, such
dystocia is an emergency.

Several maneuvers, in addition to downward traction on the fetal head, may be

performed to free the shoulder.
This requires a team approach, in which effective communication and
leadership are critical.
Maneuvers to free the shoulder are needed
Others use the head-to-body delivery time interval as defining

Mean head-to-body delivery time in normal births was 24 seconds compared

with 79 seconds in those with shoulder dystocia.
Shoulder Dystocia: head-to-body delivery time > 60 seconds
Diagnosis continues to rely on the clinical perception that the normal
downward traction needed for fetal shoulder delivery is ineffective.

Incidence between 0.6-1.4%

Incidence has increased in recent decades, likely due to increasing fetal
birthweight
This increase may be due to more attention given to appropriate
documentation of dystocia
Maternal and Neonatal Consequences

Shoulder dystocia poses greater risk to the fetus than the mother.
Postpartum hemorrhage, usually from uterine atony but also from
vaginal lacerations, is the main maternal risk
Significant neonatal neuromusculoskeletal injury and even mortality

11% were associated with serious neonatal trauma.

8% brachial plexus injury

2% suffered a clavicle, humeral, or rib fracture.

7% showed evidence of acidosis at delivery

1.5% required cardiac resuscitation or developed hypoxic ischemic

encephalopathy.

Increasing fetal weight, maternal body mass index, and second-stage duration
and a prior shoulder dystocia appear to raise the neonatal injury risk with
shoulder dystocia

Prolonged second-stage labor

Operative vaginal delivery
Prior shoulder dystocia
Risk of recurrent shoulder dystocia ranges from 1-13%
Women with prior shoulder dystocia, a trial of labor may be reasonable
Estimated fetal weight, gestational age, maternal glucose intolerance, and
severity of prior neonatal injury be evaluated and risks and benefits of cesarean
delivery discussed with any woman with a history of shoulder dystocia.
Either mode of delivery is appropriate.

Management

Because shoulder dystocia cannot be accurately predicted, clinicians should be

well versed in its management principles.

Because of ongoing cord compression with this dystocia, one goal is to reduce
the head-to-body delivery time.
Balanced against the second goal, which is avoidance of fetal and
maternal injury from aggressive manipulations.

An initial gentle attempt at traction, assisted by maternal expulsive efforts, is

recommended.

Adequate analgesia is certainly ideal.

Some clinicians advocate performing a large episiotomy to provide room for

manipulations
No change in the brachial plexus injury rate for groups in which episiotomy
was not performed during shoulder dystocia management.

After gentle traction, various techniques can be used to free the anterior
shoulder from its impacted position behind the symphysis pubis.
Moderate suprapubic pressure can be applied by an assistant, while
downward traction is applied to the fetal head.
Pressure is applied with the heel of the hand to the anterior shoulder
wedged above and behind the symphysis.
Anterior shoulder is thus either depressed or rotated, or both, so the
shoulders occupy the oblique plane of the pelvis and the anterior shoulder
can be freed.

McRoberts Maneuver
Consists of removing the legs from the stirrups and sharply flexing them
up onto the abdomen (Fig. 27-7).
Procedure caused straightening of the sacrum relative to the lumbar
vertebrae, rotation of the symphysis pubis toward the maternal head, and
a decrease in the angle of pelvic inclination.
Although this does not increase pelvic dimensions, pelvic rotation
cephalad tends to free the impacted anterior shoulder
The maneuver reduced the forces needed to free the fetal shoulder.

Delivery of the posterior shoulder

Consists of carefully sweeping the posterior arm of the fetus across its
chest, followed by delivery of the arm.
Shoulder girdle is then rotated into one of the oblique diameters of the
pelvis with subsequent delivery of the anterior shoulder

FIGURE 27-7 The McRoberts maneuver.

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

Prediction and Prevention

1.
Most cases of shoulder dystocia cannot be accurately predicted or prevented.
2.
Elective induction of labor or elective cesarean delivery for all women suspected
of having a macrosomic fetus is not appropriate.
3.
Planned cesarean delivery may be considered for the nondiabetic woman with a
fetus whose estimated fetal weight is > 5000 g or for the diabetic woman whose
fetus is estimated to weigh > 4500 g.
Birthweight

Commonly cited maternal characteristics associated with increased fetal

birthweight are
Obesity
Postterm pregnancy
Multiparity
Diabetes
Gestational diabetes.

Increasing birthweight is associated with an increasing incidence of shoulder

dystocia.

75% of shoulder dystocia cases, newborns weighed > 4000 g

Concept that cesarean delivery is indicated for large fetuses, even those
estimated to weigh 4500 g, should be tempered

Prophylactic cesarean delivery policy for macrosomic fetuses would require

more than 1000 cesarean deliveries with attendant morbidity as well as millions
of dollars to avert a single permanent brachial plexus injury.

FIGURE 27-8 Delivery of the

posterior shoulder for relief of
shoulder dystocia. A. The
operators 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.

Intrapartum Factors

Some labor characteristics have been associated with an increased shoulder

dystocia risk including
Rem Alfelor

Chapter 27: Vaginal Delivery

Page 3 of 8

Six stillbirths, eight neonatal deaths, and 10 neonates who suffered brain
damage were described.
Uterine rupture also was reported.
Symphysiotomy
Intervening symphyseal cartilage and much of its ligamentous support is
cut to widen the symphysis pubis
Used successfully for shoulder dystocia
Maternal morbidity was significant due to urinary tract injury.
Cleidotomy
Consists of cutting the clavicle with scissors or other sharp instruments
and is usually done for a dead fetus
Use of a shoulder dystocia drill to better organize emergency management:
1.
Call for help

Mobilize assistants and anesthesia and pediatric personnel.

Initially, a gentle attempt at traction is made.

Drain the bladder if it is distended.

2.
A generous episiotomy may be desired to afford room posteriorly.
3.
Suprapubic pressure is used initially by most practitioners because it has
the advantage of simplicity.

Only one assistant is needed to provide suprapubic pressure, while

normal downward traction is applied to the fetal head.
4.
The McRoberts maneuver requires two assistants.

Each assistant grasps a leg and sharply flexes the maternal thigh
against the abdomen.
These maneuvers will resolve most cases of shoulder dystocia.

If the above listed steps fail, the following steps may be attempted,
and any of the maneuvers may be repeated:
5.
Delivery of the posterior arm is attempted.

With a fully extended arm, however, this is usually difficult to

accomplish.
6.
Woods screw maneuver is applied.
7.
Rubin maneuver is attempted.
Other techniques generally should be reserved for cases in which all other
maneuvers have failed.
Intentional fracture of the anterior clavicle
Zavanelli maneuver
No one maneuver is superior to another in releasing an impacted shoulder or
reducing the chance of injury.
Performance of the McRoberts maneuver, however, was deemed a reasonable
initial approach.

Woods Corkscrew Maneuver

By progressively rotating the posterior shoulder 180 degrees in a
corkscrew fashion, the impacted anterior shoulder could be released.
Recommended two maneuvers.
Fetal shoulders are rocked from side to side by applying force to the
maternal abdomen.
If this is not
Successful, the pelvic hand reaches the most easily accessible fetal
shoulder, which is then pushed toward the anterior surface of the chest.
This maneuver most often abducts both shoulders, which in turn produces
a smaller shoulder-to-shoulder diameter.
This permits displacement of the anterior shoulder from behind the
symphysis (fig. 27-10).

FIGURE 27-9 Woods maneuver. The hand is

placed behind the posterior shoulder of the
fetus. The shoulder is then rotated
progressively 180 degrees in a corkscrew
manner so that the impacted anterior shoulder
is released.

FIGURE 27-10 The second

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

Importantly, progression from one maneuver to the next should be organized

and methodical.
Urgency to relieve the dystocia should be balanced against potentially
injurious traction forces and manipulations
All neonates without sequelae from shoulder dystocia were born by 4 minutes.
Most depressed neonates (57%) had head-to-body delivery intervals > 4
minutes.
Percentage of depressed neonates rose sharply after 3 minutes.
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.
If successful, the fracture will heal rapidly and is usually trivial compared
with brachial nerve injury, asphyxia, or death.
Pressure should be applied to the fetal jaw and neck in the direction of the
maternal rectum, with strong fundal pressure applied by an assistant as
the anterior shoulder is freed.

Strong fundal pressure applied at the wrong time may result in even
further impaction of the anterior shoulder
Fundal pressure in the absence of other maneuvers resulted in a 77%
complication rate
Strongly associated with (fetal) orthopedic and neurologic damage
Zavanelli Maneuver
Cephalic replacement into the pelvis followed by cesarean delivery.
First part consists of returning the head to the occiput anterior or posterior
position.
Terbutaline, 0.25 mg is given subcutaneously to produce uterine
relaxation.
Operator flexes the head and slowly pushes it back into the vagina.
Cesarean delivery is then performed.
Successful in 91% of cephalic cases and in all cases of breech head
entrapments.
Despite successful replacement, fetal injuries were common but may have
resulted from the multiple manipulations used before the Zavanelli
maneuver
Rem Alfelor

Chapter 27: Vaginal Delivery

SPECIAL POPULATIONS
Female Genital Mutilation

Inaccurately called Female Circumcision

Refers to medically unnecessary vulvar and perineal modification.

Forms of female genital mutilation are practiced in countries throughout Africa,

The Middle East, and Asia.

World health organization (1997) classifies genital mutilations into four types
(table 27-1).

Complications include
Infertility
Dysmenorrhea
Diminished sexual quality of life
Propensity for vulvovaginal infection
Women with significant symptoms following type III procedures are candidates
for corrective surgery.
Defibulation or Deinfibulation
Division of midline scar tissue to reopen the vulva
Associated with some adverse maternal and neonatal complications.
Increased perinatal morbidity rates by 10-20 per 1000.
Small increased risks for prolonged labor, cesarean delivery, postpartum
hemorrhage, and early neonatal death
Psychiatric consequences can be profound.
For those women who do not desire defibulation until they become pregnant, the
procedure can be done at midpregnancy using spinal analgesia
Another option is to wait until delivery.
In women not undergoing defibulation, anal sphincter tear rates with vaginal
delivery may be increased
Intrapartum defibulation in many cases allows successful vaginal delivery
without major complications.

Page 4 of 8

FIGURE 27-11 Process of defibulation. Although not

shown here, lidocaine is first infiltrated along the
planned incision. As protection, two fingers of one
hand are insinuated behind the shelf created by fused
labia but in front of the urethra and crowning head.
The shelf is then incised in the midline. After delivery,
the raw edges are sutured with rapidly absorbable
material to secure hemostasis.

FIGURE 27-12 Expression of placenta. Note that

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

Prior Pelvic Reconstructive Surgery

For women with prior stress urinary incontinence surgery, slightly greater
protection against postpartum incontinence is gained by elective cesarean
delivery
Most women with prior anti-incontinence surgery can be delivered
vaginally without symptom recurrence
Cesarean delivery is not always protective.
Symptom recurrence and the need for additional vaginal surgery should
be weighed against the surgical risk of cesarean delivery

In those with prior surgeries for anal incontinence or pelvic organ prolapse, only
scant information regarding outcomes is available. Such cases require
individualization.
Anomalous Fetuses

Rarely, delivery can be obstructed by extreme macrocephaly secondary to

hydrocephaly or by massive fetal abdomen enlargement from a greatly
distended bladder, ascites, or large kidneys or liver.

With milder forms of hydrocephaly, if the biparietal diameter is < 10 cm or if the

head circumference is < 36 cm, then vaginal delivery may be permitted

In which neonatal death has occurred or is certain due to associated anomalies,

vaginal delivery may be reasonable, but the head or abdomen must be reduced
in size for delivery.

Removal of fluid by Cephalocentesis or Paracentesis with sonographic

guidance can be performed intrapartum.
For hydrocephalic fetuses that are breech, Cephalocentesis can be
accomplished suprapubically when the aftercoming head enters the
pelvis.
For those that require cesarean delivery, fluid removal before hysterotomy
circumvents extending a low transverse or lengthening a vertical incision.

FIGURE 27-13 The placenta is removed from the

vagina by lifting the cord.

FIGURE 27-14 Membranes that were somewhat

adhered to the uterine lining are separated by
gentle traction with a ring forceps .

THIRD STAGE OF LABOR

Delivery of the Placenta

Third-stage labor begins immediately after fetal birth and ends with placental
delivery.

Goals include
Delivery of an intact placenta
Avoidance of uterine inversion or postpartum hemorrhage.
Latter two are grave intrapartum complications and constitute
emergencies

Immediately after newborn birth, uterine fundal size and consistency are
examined.

If the uterus remains firm and there is no unusual bleeding, watchful waiting until
the placenta separates is the usual practice.
Massage is not employed, but the fundus is frequently palpated to ensure
that it does not become atonic and filled with blood from placental
separation.

To prevent uterine inversion, umbilical cord traction must not be used to pull the
placenta from the uterus.
Placental expression is not forced before placental separation.

Signs of separation include

Sudden gush of blood into the vagina
Globular and firmer fundus
Lengthening of the umbilical cord as the placenta descends into the
vagina
Rise of the uterus into the abdomen.

With the last, the placenta, having separated, passes down into the
lower uterine segment and vagina.

Its bulk pushes the uterus upward.

These signs sometimes appear within 1 minute after newborn

delivery and usually within 5 minutes.

Once the placenta has detached from the uterine wall, it should be determined
that the uterus is firmly contracted.

Mother may be asked to bear down, and the intraabdominal pressure often
expels the placenta into the vagina.
Efforts may fail or may not be possible because of analgesia.

After ensuring that the uterus is contracted firmly, pressure is exerted by a hand
wrapped around the fundus to propel the detached placenta into the vagina
Umbilical cord is kept slightly taut but is not pulled.
Heel of the hand exerts downward pressure between the symphysis pubis
and the uterine fundus.

Aids inversion prevention.

Once the placenta passes through the introitus, pressure on the uterus is
relieved.
Rem Alfelor
Chapter 27: Vaginal Delivery

Placenta is then gently lifted away

Care is taken to prevent placental membranes from being torn off and left
behind.
If the membranes begin to tear, they are grasped with a clamp and
removed by gentle teasing.

Manual Removal of Placenta

Occasionally, the placenta will not separate promptly
Common with preterm delivery
If there is brisk bleeding and the placenta cannot be delivered by the above
technique, manual removal of the placenta is indicated
It is unclear how much time should elapse in the absence of bleeding before the
placenta is manually removed
If labor analgesia is still intact, some obstetricians practice routine manual
removal of any placenta that has not separated spontaneously by the time they
have completed delivery of the newborn and care of the cord.
Most obstetricians await spontaneous placental detachment unless
bleeding is excessive.
When manual removal is performed, some administer a single dose of
intravenous antibiotics similar to that used for cesarean infection prophylaxis
American college of obstetricians and gynecologists (2011) has concluded
that there are no data to either support or refute this practice.

Management of the Third Stage

Physiological or expectant management involves

Waiting for placental separation signs
Allowing the placenta to deliver either spontaneously or aided by nipple
stimulation or gravity

Active management of third-stage labor consists of

1.
Early cord clamping
2.
Controlled cord traction during placental delivery
3.
Immediate administration of prophylactic uterotonics
Uterine massage following placental delivery is recommended by many
but not all to prevent postpartum hemorrhage
Immediate cord clamping does not increase postpartum hemorrhage rates
and thus is a less important component
Cord traction may also be less critical

Uterotonics appear to be the most important factor to decrease postpartum

blood loss.
Choices include

Oxytocin (Pitocin)

Misoprostol (Cytotec)

Carboprost (Hemabate)

Ergots: ergonovine (Ergotrate) and methylergonovine (Methergine).

Combination agent of oxytocin and ergonovine (Syntometrine) is used outside

the United States.

Carbetocin (Duratocin)
Long-acting oxytocin analogue
Effective for hemorrhage prevention during cesarean delivery

World Health Organization (2012) recommends oxytocin as a first-line agent.

Ergot-based drugs and misoprostol are alternatives in settings that lack

oxytocin.
Page 5 of 8

Uterotonics may be given before or after placental expulsion without increasing

rates of postpartum hemorrhage, placental retention, or third-stage labor length
If they are given before delivery of the placenta, they may entrap an
undiagnosed, undelivered second twin.

Abdominal palpation should confirm no additional fetuses.

High-Dose Oxytocin
Synthetic oxytocin is identical to that produced by the posterior pituitary.
Action is noted at approximately 1 minute, and it has a mean half-life of 3
to 5 minutes.
When given as a bolus, oxytocin can cause profound hypotension.
An intravenous bolus of 10 units of oxytocin caused a marked transient
fall in blood pressure with an abrupt increase in cardiac output.

Mean pulse rate increased 28 bpm, mean arterial pressure

decreased 33 mm Hg, and electrocardiogram changes of
myocardial ischemia as well as chest pain and subjective discomfort
were noted.

Hemodynamic changes could be dangerous for women

hypovolemic from hemorrhage or those with cardiac disease.
Oxytocin should not be given intravenously as a large bolus.
It should be given as a dilute solution by continuous
intravenous infusion or as an intramuscular injection.
Water intoxication can result from the antidiuretic action of high-dose
oxytocin if administered in a large volume of electrolyte-free dextrose
solution
Convulsions in both a mother and her newborn following administration of
6.5 liters of 5% dextrose solution and 36 units of oxytocin before delivery.

Cord plasma sodium concentration was 114 meq/l.

If oxytocin is to be administered in high doses for a considerable period of
time, its concentration should be increased rather than increasing the
infusion flow rate
Despite the routine use of oxytocin, no standard prophylactic dose has
been established for its use following either vaginal or cesarean delivery.
Higher infusion doses to be more effective than lower doses or protracted
fixed-dose administration

If an intravenous infusion is established, is to add 20 units (2 ml) of

oxytocin per liter of infusate.
This solution is administered after delivery of the placenta at a
rate of 10 to 20 mL/min (200-400 mU/min) for a few minutes
until the uterus remains firmly contracted and bleeding is
controlled.
The infusion rate then is reduced to 1 to 2 mL/min until the
mother is ready for transfer from the recovery suite to the
postpartum unit.
The infusion is usually then discontinued.
For women without intravenous access, 10 units of intramuscular oxytocin
are provided.
Ergonovine and Methylergonovine
These ergot alkaloids have similar activity levels in myometrium
Only Methylergonovine is currently manufactured in the United States.
Require very specific storage conditions, as they deteriorate rapidly with
exposure to light, heat, and humidity.
Whether given intramuscularly or orally, both are powerful stimulants of
myometrial contraction, exerting an effect that may persist for hours.
In pregnant women, an intramuscular or oral dose of 0.2 mg results in
tetanic uterine contractions.

Effects develop within a few minutes after intramuscular or oral

administration.

The response is sustained with little tendency toward relaxation.

Ergots are dangerous for the fetus and mother when given before delivery.

Serious injury and death have been reported when

methylergonovine was administered accidentally to newborns in the
labor and delivery room instead of vitamin K, hepatitis B vaccine, or
naloxone

Recommending a 12-hour delay between the last methylergonovine

dose and breast feeding.

No adverse effects attributable to this drug in breast milk have been

reported
Parenteral administration of ergot alkaloids, especially by the intravenous
route, may induce transient maternal hypertension.
Other reported side effects: nausea, vomiting, tinnitus, headache, and
painful uterine contractions.

Hypertension is more likely to be severe in women with gestational

hypertension.
Contraindicated in patients with hypertension, cardiac disease or
occlusive vascular disorders, severe hepatic or renal disease, and sepsis

This drug is not routinely given intravenously to avoid inducing

sudden hypertensive and cerebrovascular accidents.
If considered a lifesaving measure, intravenous methylergonovine should
be given slowly during no less than 60 seconds with careful monitoring of
blood pressure
Do not provide superior protection against postpartum hemorrhage
compared with oxytocin.
Safety and tolerability are greater with oxytocin
Ergot alkaloid agents are considered second-line for third-stage labor
prevention of hemorrhage.
Misoprostol
Prostaglandin E1 Analogue
Rem Alfelor

Chapter 27: Vaginal Delivery

Proved inferior to oxytocin for postpartum hemorrhage prevention

Although oxytocin is preferred, in resource-poor settings that lack
oxytocin, misoprostol is suitable for hemorrhage prophylaxis
Given as a single oral 600-g dose
Side effects include: shivering (30%) and fever (5%)

Nausea or diarrhea is infrequent

FOURTH STAGE OF LABOR

Hour immediately following delivery of the placenta is critical

Designated by some as the fourth stage of labor.

During this time, lacerations are repaired.

Although uterotonics are administered, postpartum hemorrhage as the result of

uterine atony is most likely at this time.

Hematomas may expand.

Uterine tone and the perineum should be frequently evaluated.

Maternal blood pressure and pulse be recorded immediately after delivery and
every 15 minutes for the first 2 hours.

Placenta, membranes, and umbilical cord should be examined for completeness

and for anomalies

Birth canal lacerations

Lower genital tract lacerations may involve the cervix, vagina, or perineum.

Perineal tears may follow any vaginal delivery and are classified by their depth.
Third- and fourth-degree lacerations are considered higher-order
lacerations.

Short-term, these are associated with greater blood loss, puerperal pain, and
wound disruption or infection risk.

Long-term, they are linked with higher rates of anal incontinence and
dyspareunia.

Incidence of higher order lacerations varies from 0.25-6 %

Risk factors for these more complex lacerations include

Midline episiotomy
Nulliparity
Longer second-stage labor
Precipitous delivery
Persistent occiput posterior position
Operative vaginal delivery
Asian race
Increasing fetal birthweight

Epidural analgesia was found to be protective

Morbidity rates rise as laceration severity increases.

Approximately 7% of 909 higher-order lacerations had complications.

Mediolateral episiotomy was the most powerful predictor of wound disruption.

5.4% of women with fourth-degree lacerations experienced significant morbidity.

1.8 % dehiscences, 2.8% infections plus a dehiscence, and 0.8% with
isolated infections.

Repair of perineal lacerations is virtually the same as that of episiotomy

incisions, albeit sometimes less satisfactory because of tear irregularities.

FIGURE 27-15 Classification of perineal lacerations. A. First-degree lacerations involve the

fourchette, perineal skin, and vaginal mucous membrane but not the underlying fascia and muscle.
These included periurethral lacerations, which may bleed profusely. B. Second degree
lacerations involve, in addition, the fascia and muscles of the perineal body but not the anal
sphincter. These tears may be midline, but often extend upward on one or both sides of the vagina,
forming an irregular triangle. C. Third-degree lacerations extend farther to involve the external
anal sphincter. D. Fourth-degree lacerations extend completely through the rectal mucosa to
expose its lumen and thus involve disruption of both the external and internal anal sphincters .

Episiotomy
Derives from the Greek episton: pubic region + tomy:to cut
Incision of the pudendum, external genital organs.
Perineotomy: incision of the perineum
Used Synonymously With Perineotomy
Incision
Page 6 of 8

May be made in the midline, creating a Median or Midline

Episiotomy
May also begin off the midline and directed laterally and downward
away from the rectum, termed a Mediolateral Episiotomy.

If episiotomy is required during operative vaginal

delivery, a protective effect from mediolateral
episiotomy against higher-order perineal
lacerations

TABLE 27-2. Midline versus Mediolateral Episiotomy

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

Episiotomy Indications and Consequences

Through the 1970s, however, it was common practice to cut an episiotomy for
almost all women having their first delivery
Substitution of a straight surgical incision, which was easier to repair, for
the ragged laceration that otherwise might result.
Postoperative pain is less and healing improved with an episiotomy
compared with a tear, however, appeared to be incorrect
It prevented pelvic floor disorders.

Routine episiotomy is associated with an increased incidence of anal sphincter

and rectal tears

Lower rates of posterior perineal trauma, surgical repair, and healing

complications in women managed with a restrictive use of episiotomy.

Incidence of anterior perineal trauma was lower in the group managed with
routine use of episiotomy.

Episiotomy did not protect the perineal body but contributed to anal sphincter
incontinence by increasing the risk of higher-order lacerations.

Fecal and flatal incontinence was increased four- to six fold in women with an
episiotomy compared with a group of women delivered with an intact perineum.

Episiotomy tripled the risk of fecal incontinence and doubled it for flatal
incontinence.
Episiotomy without extension did not lower this risk.
Despite repair of a third-degree extension, 30-40% of women have longterm anal incontinence

Episiotomy performed for the first delivery conferred a fivefold risk for seconddegree or higher order laceration with the second delivery.

Restricted use of episiotomy is preferred to routine use.

Procedure should be applied selectively for appropriate indications.

Episiotomy should be considered for indications such as

Shoulder dystocia

Breech Delivery

Macrosomic Fetuses

Operative Vaginal Deliveries

Persistent Occiput Posterior Positions

Failure to perform an episiotomy will result in significant perineal rupture

Final rule is that there is no substitute for surgical judgment and common sense.

Repair of Episiotomy or Perineal Laceration

Episiotomy repair is deferred until the placenta has been delivered.

This policy permits undivided attention to the signs of placental separation
and delivery.
Episiotomy repair is not interrupted or disrupted by the obvious necessity
of delivering the placenta, especially if manual removal must be performed
that may disrupt a newly repaired episiotomy.
Major disadvantage is continuing blood loss until
the repair is completed.

Direct pressure from an applied gauze

sponge will help to limit this loss.

Adequate analgesia is imperative, women without

regional analgesia can experience high levels of pain
during perineal suturing
Local lidocaine can be used solely or as a
supplement to bilateral pudendal nerve blockade.
In those with epidural analgesia, additional dosing
may be necessary.

There are many ways to repair an episiotomy incision,

but hemostasis and anatomical restoration without
excessive suturing are essential.
Similar postoperative pain scores using either continuous or interrupted
closure
Less pain with continuous suturing
Continuous suturing is faster and uses less
suture material.
Blunt needles are suitable and likely decrease
the incidence of needle stick injuries.

Suture

Episiotomy Type and Timing

Before episiotomy, analgesia may be provided by

Existing labor epidural analgesia
Bilateral pudendal nerve blockade
Infiltration of 1% lidocaine.

If performed unnecessarily early, bleeding from the episiotomy may be

considerable during the interval between incision and delivery.

If it is performed too late, lacerations will not be prevented.

Episiotomy is completed when the head is visible during a contraction to a

diameter of approximately 4 cm (crowning)

When used in conjunction with forceps delivery, most perform an episiotomy

after application of the blades

Technique

For midline episiotomy, fingers are insinuated between the crowning head and
the perineum

Scissors are positioned at 6 oclock on the vaginal opening and directed

posteriorly

Incision length varies from 2 to 3 cm depending on perineal length and degree of

tissue thinning.
Incision is customized for specific delivery needs but should stop well
before reaching the external anal sphincter.

Mediolateral Episiotomy: scissors are positioned at 7 oclock or at 5 oclock

Incision is extended 3 to 4 cm toward the ipsilateral ischial tuberosity.

Except for the important issue of third-and fourth-degree extensions, midline

episiotomy is superior

More than fourfold decrease in severe perineal lacerations following

mediolateral episiotomy compared with rates after midline incision.

Rem Alfelor

Chapter 27: Vaginal Delivery

material commonly used

20 chromic catgut.

Polyglycolic
acid
derivatives

Decrease in
postsurgical pain is
cited as the major
advantage of
synthetic materials.
Closures
with these
materials,
however,
occasionally require suture removal from the repair site because of pain or
dyspareunia.
This disadvantage may be reduced using a rapidly absorbed Polyglactin
910 (Vicryl Rapide).
Repair of a mediolateral episiotomy is similar to a midline repair.

Page 7 of 8

FIGURE 27-17 Repair of midline episiotomy. A. Disruption of the hymenal ring and
bulbocavernosus and superficial transverse perineal muscles are seen within the diamond-shaped
episiotomy incision. B. An anchor stitch is placed above the wound apex to begin a running
closure. Absorbable 20 or 30 suture is used for continuous closure of the vaginal mucosa and
submucosa with interlocking stitches. C. After closing the vaginal incision and reapproximating the
cut margins of the hymenal ring, the needle and suture are positioned to close the perineal incision.
D. A continuous closure with absorbable 20 or 30 suture is used to close the fascia and
muscles of the incised perineum. This aids restoration of the perineal body for long-term support.
E. The continuous suture is then carried upward as a subcuticular stitch. The final knot is tied
proximal to the hymenal ring.

and the sutures are placed through the submucosa of the anorectum approximately 0.5 cm apart
down to the anal verge. B. A second layer is placed through the rectal muscularis using 30 Vicryl
suture in a running or interrupted fashion. This reinforcing layer should incorporate the torn ends
of the internal anal sphincter, which is identified as the thickening of the circular smooth muscle
layer at the distal 2 to 3 cm of the anal canal. It can be identified as the glistening white fibrous
structure lying between the anal canal submucosa and the fibers of the external anal sphincter
(EAS). In many cases, the internal sphincter retracts laterally and must be sought and retrieved for
repair. C. In overview, with traditional end-to-end approximation of the EAS, a suture is placed
through the EAS muscle, and four to six simple interrupted 20 or 30 Vicryl sutures are placed
at the 3, 6, 9, and 12 oclock positions through the connective tissue capsule of the sphincter. The
sutures through the inferior and posterior portions of the sphincter should be placed first to aid this
part of the repair. To begin this portion of the closure, the disrupted ends of the striated EAS
muscle and capsule are identified and grasped with Allis clamps. Suture is placed through the
posterior wall of the EAS capsule. D. Sutures through the EAS (blue suture) and inferior capsule
wall. E. Sutures to reapproximate the anterior and superior walls of the EAS capsule. The
remainder of the repair is similar to that described for a midline episiotomy in Figure 27-17 .

FIGURE 27-18 Mediolateral episiotomy repair. The vaginal mucosa is shown as already closed
using 20 absorbable suture in a running interlocking stitch similar to that for midline repair. As
illustrated, perineal reapproximation begins with reunion of bulbocavernosus and transverse
perineal muscles. These will assist reestablishment of perineal body support. Distal to these
muscles, abundant fat in the ischiorectal fossa is incorporated in the same running closure. A
second layer atop this first perineal layer may be required to adequately close dead space. The
skin is then closed with a subcuticular stitch as used for midline closure.

Fourth-Degree Laceration Repair

Two methods are used to repair a laceration involving the anal sphincter and
rectal mucosa
1.
End-To-End Technique which we prefer
2.
Overlapping Technique

End-To-End Technique
In all techniques that have been described, it is essential to approximate
the torn edges of the rectal mucosa with sutures placed in the rectal
muscularis approximately 0.5 cm apart.

One suitable choice is 20 or 30 chromic gut.

This muscular layer then is covered by reapproximation of the internal
anal sphincter.
Finally, the cut ends of the external anal sphincter are isolated,
approximated, and sutured together end-to-end with three or four
interrupted stitches.
The remainder of the repair is the same as for a midline episiotomy.

FIGURE 27-19 Layered repair of a

fourth-degree perineal laceration. A.
Approximation of the anorectal mucosa
and submucosa in a running or
interrupted fashion using fine
absorbable suture such as 30 or 40
chromic or Vicryl. During this
suturing, the superior extent of the
anterior anal laceration is identified,

Rem Alfelor

Chapter 27: Vaginal Delivery

Overlapping Technique
Alternative method to approximate the external anal sphincter.
Data based on randomized controlled trials do not support that this
method yields superior anatomical or functional results compared with
those of the traditional end-to-end method
Recommend perioperative antimicrobial prophylaxis for the reduction of
infectious morbidity associated with higher-order perineal injury repair
Single dose of a second-generation cephalosporin is suitable, or
clindamycin for penicillin allergic women.
Postoperatively, stool softeners should be prescribed for a week, and enemas
and suppositories should be avoided.
Unfortunately, normal function is not always ensured even with correct and
complete surgical repair.
Some women may experience continuing fecal incontinence caused by
injury to the innervation of the pelvic floor musculature

Post episiotomy Pain

Pudendal Nerve Blockade can aid relief of perineal pain postoperatively

Locally applied ice packs help reduce swelling and allay discomfort.

Analgesics such as Codeine give considerable relief.

Because pain may be a signal of a large vulvar, paravaginal, or Ischiorectal

fossa hematoma or perineal cellulitis, these sites should be examined carefully if
pain is severe or persistent.

Urinary retention may complicate episiotomy recovery

For those with second-degree or greater lacerations, intercourse is usually

proscribed until after the first puerperal visit at 4-6 weeks.
Those delivered with an intact perineum reported better sexual function
compared with those who had perineal trauma
Delayed intercourse at 3 and 6 months, but not at 1 year, in women with
and without perineal trauma.

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