Obstentrics_Williams

Obstentrics_Williams. • Manual Removal of Placenta In approximately 2 percent of singleton births, the placenta may not deliver promptly (Cheung, 2011). Three possibilities include pacenta adherens, in which uterine contractions are insu.cient to detach the placenta; lower uterine segment constriction and a detached but trapped placenta; or a morbidly adherent placenta. Consistent risks for retained placenta include stillbirth, prior cesarean delivery, prior retention, and preterm delivery (Belachew, 2014; Coviello, 2015; Endler, 2014; Nikolajsen, 2013). For the last, in one study with nearly 46,000 deliveries, analysis predicted that 90 percent of placentas would spontaneously deliver by 180 minutes for gestations at 20 weeks; 21 minutes at 30 weeks; and 14 minutes at 40 weeks (Dombrowski, 1995).


Obstentrics_Williams

Obstentrics_Williams. Postpartum hemorrhage can complicate a retained placenta, and bleeding risk accrues with third-stage length. Thus, in the absence of bleeding, some recommend expectant management for 30 minutes, whereas others use a 15-minute threshold (Cummings, 2016; Deneux-Tharaux, 2009; Shinar, 2016a). he World Health Organization (2012) cites a 60-minute threshold. Notably, if brisk bleeding ensues and the placenta cannot be delivered by standard technique, manual removal of the placenta is indicated (Fig. 27-12). When performed, some administer a single dose of intravenous antibiotics, however, one systematic review of observational studies found no beneits (Chibueze, 2015). Although the American College of Obstetricians and Gynecologists (2016c) concludes that data neither support nor refute this practice, the World Health Organization (2012) recommends prophylaxis. At our institution, we administer a single dose to women not already receiving antibiotics.


Obstentrics_Williams

Obstentrics_Williams. The hour immediately following delivery of the placenta is critical. During this time, lacerations are repaired. Although utero tonics are administered, postpartum hemorrhage as the result of uterine atony is most likely at this time. Hematomas may expand. Consequently, uterine tone and the perineum are frequently evaluated. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (20 17b) recommend that maternal blood pressure and pulse be recorded immediately after delivery and every 15 minutes for the first 2 hours. The placenta, membranes, and umbilical cord are examined for completeness and for anomalies, as described in Chapter 6 (p. 111).


Obstentrics_Williams

Obstentrics_Williams. Lower genital tract lacerations may involve the cervix, vagina, or perineum. Those of the cervix and vagina are described in Chapter 41 (p. 763). Those of the perineum oten follow vaginal delivery, and most are irst-and second-degree lacerations. Lacerations are classified by their depth, and complete deinitions and visual examples are given in Figure 27-13. Of these, third-degree lacerations relect anal sphincter injury and are now subcategorized as: (3c) EAS plus internal anal sphincter (lAS) tears. FIGURE 27-12 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.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 27-13 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 laceration: the perineal body, entire anal sphincter complex, and anorectal mucosa are lacerated. (Reproduced with permission from Kenton K, Mueller M: Episiotomy and obstetric anal sphincter lacerations. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds):


Obstentrics_Williams

Obstentrics_Williams. Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201o7.) hird-and fourth-degree lacerations are considered obstetrical anal sphincter injuries (OASIS), and their combined incidence varies from 0.5 to 5 percent (Blondel, 2016; Friedman, 2015). ity, midline episiotomy, persistent OP position, operative vaginal delivery, Asian race, short perineal length, and increasing fetal birthweight (Ampt, 2013; Dua, 2009; Gurol-Urganci, 2013; Landy, 2011). Mediolateral episiotomy is protective in most, but not all, studies Ganga, 2014; Raisanen, 2011; Shmueli, 2016).


Obstentrics_Williams

Obstentrics_Williams. Landy, 2011). Mediolateral episiotomy is protective in most, but not all, studies Ganga, 2014; Raisanen, 2011; Shmueli, 2016). Morbidity rates rise as laceration severity increases. Compared with simpler lacerations, anal sphincter injuries are associated with greater blood loss and puerperal pain. Wound disruption and infection rates are other risks (Goldaber, 1993; Lewicy-Gaupp, 2015). Stock and coworkers (2013) reported that approximately 7 percent of 909 OASIS lacerations had complications. Long term, anal sphincter injuries are linked with approximately doubled rates of fecal incontinence compared with vaginl delivery without OASIS (Evers, 2012; Gyhagen, 2014). Data on long-term dyspareunia are limited, and rates are increased in some but not all studies (MoS, 2008; Otero, 2006; Salim, 2014; Sundquist, 2012).


Obstentrics_Williams

Obstentrics_Williams. To ensure appropriate repair, identiication and correct categorization is essential. Diagnosis rates of OASIS improve with clinical experience (ndrews, 2006). Intrapartum endoanal ultrasound, performed in research studies, also boosts detection, and rates of clinically occult tears in primiparas range from 6 to 12 percent (Corton, 2013; Faltin, 2005; Ozyurt, 2015). hat said, few data currently support routine intrapartum endoanal sonography, and the American College of Obstetricians and Gynecologists (20 16b) does not recommended i t (Walsh, 2015).


Obstentrics_Williams

Obstentrics_Williams. Women with a prior OASIS have a higher recurrence rate compared with multiparas without prior OASIS (Baghestan, 2012; Edozien, 2014; Elfaghi, 2004). That said, the risk mirrors that of primiparas in the general population and is low (Basham, 2013; Boggs, 2014; Priddis, 2013). Fetal macrosomia and operative vaginal delivery are notable risks in this cohort of parturients and can influence counseling in future pregnancies. Speciically, patients may choose to deliver by cesarean to avoid repeat OASIS. his consideration may be most pertinent for those with prior postpartum anal incontinence, with OASIS complications requiring corrective surgery, or with psychological trauma (American College of Obstetricians and Gynecologists, 2016b). However, planned cesarean delivery is balanced against its associated operative risks discussed in Chapter 30 (p. 568).


Obstentrics_Williams

Obstentrics_Williams. In contrast to spontaneous lacerations, perineotomy is intended incision of the perineum. Episiotomy is incision of the pudendum-the external genital organs. In common parlance, however, the term episiotomy often is used synonymously with perineotomy, a practice that we follow here. Obstetrical textbooks and organizational guidelines difer considerably in their description of episiotomy techniques. Kalis and associates (2012) have presented a classification, and we agree with the need for terminology standardization.


Obstentrics_Williams

Obstentrics_Williams. Midline and mediolateral episiotomies are the two main types and vary by the angle of perineal incision. Involved structures mirror those found with second-degree laceration, and their repairs are analogous. The midline episiotomy begins at the fourchette, incises the perineal body in the midline, and ends well before the external anal sphincter is reached. he incision length varies from 2 to 3 cm depending on perineal length and degree of tissue thinning. The mediolateral episiotomy begins at the midline of the fourchette and is directed to the right or left at an angle 60 degrees of the midline (Fig. 27-14). This angle accounts for perineal anatomy distortion during crowning and ultimately yields an incision 45 degrees of the midline for suturing (El-Din, 2014; Kalis, 2011). The lateral episiotomy begins at point 1 to 2 cm lateral from the midline. It too is angled toward either the right or the left ischial tuberosity.


Obstentrics_Williams

Obstentrics_Williams. Before episiotomy, analgesia may be provided by existing labor regional analgesia, by bilateral pudendal nerve blockade, or by local infiltration of I-percent lidocaine. Some instead advocate 2.5-percent lidocaine-prilocaine cream (EMLA cream), but this requires application an hour before expected delivery, which may be logistically diicult (Franchi, 2009; Kargar, 2016). If episiotomy is performed unnecessarily early, incisional bleeding may be considerable before delivery. If it is performed too late, lacerations will not be prevented. Typically, episiotomy is completed when the head is visible during a contraction to a diameter of approximately 4 cm, that is, crowning. When used in conjunction with forceps delivery, most perform an episiotomy after application of the blades.


Obstentrics_Williams

Obstentrics_Williams. Few data directly compare midline and mediolateral types. As noted, midline episiotomy has a greater likelihood of associated anal sphincter lacerations (Coats, 1980; de Leeuw, 2001). Shortterm rates of self-perceived pain and dyspareunia are similar or increased with mediolateral episiotomy (Fodstad, 2013, 2014; Sartore, 2004). 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 of the midline. (Reproduced with permission from Kenton K, Mueller M: Episiotomy and obstetric anal sphincter lacerations. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 2017.)


Obstentrics_Williams

Obstentrics_Williams. Even fewer studies compare lateral episiotomy to either mediolateral or midline. One randomized trial compared lateral and mediolateral tpes in nulliparas. Groups did not difer in pain scores, in sexual qulity of life, or in vaginal or perineal trauma, including OASIS (Karbanova, 2014a,b; Necesalova, 2016). The authors also reported that mediolateral episiotomies required less time and suture for the repair. Thus, among the three, mediolateral episiotomy may be the preferred incision to reduce OASIS rates. In the past, routine episiotomy was practiced to avoid a ragged laceration and to limit postoperative pain and anal sphincter injury rates. But, a Cochrane review of randomized trials showed lower rates of severe perineal/vaginal trauma in women managed with a restrictive, that is, selective use of episiotomy for spontaneous delivery rather than with routine episiotomy Qiang, 2017). Importantly, this review did not discern between midline and mediolateral episiotomies.


Obstentrics_Williams

Obstentrics_Williams. The American College of Obstetricians and Gynecologists (20 16b) has concluded that restricted use of episiotomy is preferred to routine use. We are of the view that the procedure should be applied selectively for appropriate indications. Thus, episiotomy can be considered for indications such as shoulder dystocia, breech delivery, fetal macrosomia, operative vaginal deliveries, persistent OP positions, markedly short perineal length, and other instances in which failure to perform an episiotomy will result in signiicant perineal rupture. The final rule is that there is no substitute for surgical judgment and common sense.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 27-15 Mediolateral episiotomy repair. A. The vaginal epithelium and deeper tissues are closed with a single, continuous, locking suture. The angle seems less acute now (approximately 45°) since the perineum is no longer distended. B. Ater the vaginal component of the laceration is repaired, deeper perineal tissues are reapproximated by a single, continuous, nonlocking suture. Small episiotomies may not require this deeper layer. C. With a similar continuous, non locking technique, the superficial transverse perineal and bulbospongiosus muscles are reapproximated. D. Last, the perineal skin is closed using a subcuticular stitch. (Reproduced with permission from Kenton K, Mueller M: Episiotomy and obstetric anal sphincter lacerations. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201•7.) With this new approach, epIsIotomy rates have dropped.


Obstentrics_Williams

Obstentrics_Williams. With this new approach, epIsIotomy rates have dropped. Oliphant and coworkers (2010) used the National Hospital Discharge Survey to analyze episiotomy rates between 1979 and 2006 in the United States. hey noted a 75-percent decline in the age-adjusted episiotomy rate. In the United States in 2012 episiotomy was performed in approximately 12 percent of vaginal births (Friedman, 2015). Typically, perineal repairs are deferred until the placenta has been delivered. his policy permits undivided attention to the signs of placental separation and delivery. A further advantage is that the repair is not interrupted or disrupted by placenta delivery. his is especially true if manual removal must be performed. The major disadvantage is continuing blood loss until the repair is completed. Direct pressure from an applied gauze sponge will help to limit this volume.


Obstentrics_Williams

Obstentrics_Williams. For suitable repair, an understanding of perineal support and anatomy is necessary and is discussed in Chapter 2 (p. 19). Adequate analgesia is imperative, and women without regional analgesia can experience high levels of pain during perineal suturing. Again, locally injected lidocaine can be used solely or asia supplement to bilateral pudendal nerve blockade. In those with epidural analgesia, additional dosing may be necessary. First-degree lacerations do not always require repair, and sutures are placed to control bleeding or restore anatomy. Here, few data guide suture selection, and ine-gauge absorbable or delayed-absorbable suture or adhesive glue is suitable.


Obstentrics_Williams

Obstentrics_Williams. Second-degree laceration correction as well as midline and mediolateral episiotomy repairs include similar steps. Namely, these close the vaginal epithelium and reapproximate the bulbospongiosus and supericial transverse perineal muscles during restoration of the perineal body (Figs. 27-15 and 27-16). For this, most studies support a continuous


Obstentrics_Williams

Obstentrics_Williams. FIGURE 27-16 Midline episiotomy repair. A. An anchor stitch is placed above the wound apex to begin a running, locking closure with 2-0 suture to close the vaginal epithelium and deeper tissues and reapproximate the hymeneal ring. B. A transition stitch redirects suturing from the vagina to the perineum. C. The superficial transverse perineal and bulbospongiosus muscles are reapproximated using a continuous, non locking technique with the same length of suture. This aids restoration of the perineal 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. (Reproduced with permission from Kenton K, Mueller M: Episiotomy and obstetric anal sphincter lacerations. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201•7.) suturing method, which is faster than placing interrupted sutures and, with


Obstentrics_Williams

Obstentrics_Williams. LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201•7.) suturing method, which is faster than placing interrupted sutures and, with few exceptions, yields less pain (Grant, 2001; Kettle, 2012; Kindberg, 2008; Valenzuela, 2009). Blunt needles are suitable and likely decrease the incidence of needle-stick injuries (El-Refaie, 2012; Mornar, 2008). Commonly used suture materials are 2-0 polyglactin 910 (Vicryl) or chromic catgut. With the former, a decrease in postsurgical pain and lower risk of wound dehiscence are cited as major advantages Qallad, 2016; Kettle, 2010). Closures with traditional polyglactin 910, however, occasionally require removal of residual suture from the repair site because of pain or dyspareunia. This disadvantage may be reduced by using a rapidly absorbed polyglactin 910 (Vicryl Rapide) (Bharathi, 2013; Kettle, 2002; Leroux, 2006).


Obstentrics_Williams

Obstentrics_Williams. For third-degree laceration repair, two methods are available to repair the external anal sphincter. The irst is an endto-end technique, which we prefer, and is shown in Figure 27-17. Initially, the cut ends of the external anal sphincter, which often retract, are isolated and brought to the midline. Importantly, the strength of this closure is derived from the connective tissue surrounding the sphincter-often called the capsule-and not the striated muscle. Thus, serial interrupted


Obstentrics_Williams

Obstentrics_Williams. FIGURE 27-17 In overview, with end-to-end approximation of the external anal sphincter (EAS), a suture is placed through the EAS muscle, and four to six 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. (Reproduced with permission from


Obstentrics_Williams

Obstentrics_Williams. Kenton K, Mueller M: Episiotomy and obstetric anal sphincter lacerations. In Yeomans ER, Hofman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative ObstetriCS, 3rd ed. New York, McGraw-Hili Education, 201o7.) sutures incorporate sphincter fibers and perisphincter connective tissue, to bring sphincter ends together. here are few evidence-based data to guide suture selection for sphincter repair, but delayed-absorbable material can provide sustained tensile strength during healing. This theory is supported by the above study by J all ad and coworkers (2016), which showed higher perineal breakdown rate following OASIS repair with chromic gut.


Obstentrics_Williams

Obstentrics_Williams. With the overlapping technique, the ends of the external anal sphincter are brought to the midline and lie atop one another. This method is 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. In comparing the two methods, neither yields superior long-term anatomical or functional results (Farrell, 2012; Fernando, 2013; Fitzpatrick, 2000). Also with type 3c lacerations, the lAS is repaired before the EAS and is described next.


Obstentrics_Williams

Obstentrics_Williams. With fourth-degree laceration repairs, the torn edges of the rectal mucosa are reapproximated (Fig. 27-18). 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 ano rectal lumen. Clinicians oten use 4-0 polyglactin 910 or chromic gut for this running suture line. Some recommend a second reinforcing layer above this (Hale, 2007). If this is not done, then the next layer to cover the anorectal mucosa is formed by reapproximation of the internal anal sphincter. his running, nonlocking closure is completed with 3-0 or 4-0 suture (see Fig. 27-18B). Following any repair, needle and sponge counts are reconciled and recorded in the delivery note.


Obstentrics_Williams

Obstentrics_Williams. For reduction of infectious morbidity associated with anal sphincter lacerations, a single dose of antibiotic at the time of repair is recommended by the American College of Obstetricians and Gynecologists (20 16c). his practice is supported by evidence (Buppasiri, 2014; Duggal, 2008; Lewicky-Gaupp, 2015; Stock, 2013). A single dose of a secondgeneration 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. 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 Boor musculature (Roberts, 1990).


Obstentrics_Williams

Obstentrics_Williams. FIGURE 27-18 A. Suturing of the anorectal mucosa begins above the laceration apex using a continuous, non locking method with finegauge 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. (Reproduced with permission from Kenton K, Mueller M: Episiotomy and obstetric anal sphincter lacerations. In Yeomans ER, Hofman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201o7.)


Obstentrics_Williams

Obstentrics_Williams. Initially, locally applied ice packs help reduce swelling and allay discomfort (de Souza Bosco Paiva, 2016). In subsequent days, warm sitz baths aid comfort and hygiene. Additionally, a small squirt botde of warm water can cleanse the site after voiding or stooling. For pain, topical application of 5-percent lidocaine ointment was not efective in relieving episiotomy or perineal laceration discomfort in one randomized trial (Minassian, 2002). Oral analgesics containing codeine provide considerable relie. For lesser degree of discomfort, NSAID tablets can be given. Because pain may signal a large vulvar, paravaginal, or ischiorectal fossa hematoma or perineal cellulitis, these sites should be examined carefully if pain is severe or persistent. Management of these complications is discussed in Chapters 37 and 41 (pp. 674 and 764). In addition to pain, urinary retention may complicate episiotomy recovery (Mulder, 2012, 2016). Its management is described in Chapter 36 (p. 660).


Obstentrics_Williams

Obstentrics_Williams. For those with second-degree lacerations or anal sphincter tears, intercourse is usually proscribed until after the irst puerperal visit at 6 weeks. Compared with women with intact perineum, those with perineal trauma show higher rates of delayed intercourse at 3 and 6 months, but not at 1 year (McDonald, 2015; Rldestad, 2008; Signorello, 2001). Abdel-Aleem H, Singata M, Abdel-Aleem M, et al: Uterine massage to reduce postpartum hemorrhage after vaginal delivery. Int ] Gynaecol Obstet 111(1):32,r2010 Acker DB, Sachs BP, Friedman EA: Risk factors for shoulder dystocia. Obstet Gynecol 66(6):762, 1985 Almroth L, Elmusharaf S, El Hadi N, et al: Primary infertility ater genital mutilation in girlhood in Sudan: a case-control study. Lancet 366:385, 2005 Al-Wassia H, Shah PS: Eicacy and safety of umbilical cord milking at birth: a systematic review and meta-analysis.]AMA Pediatr 169(1):18, 2015 American Academy of Pediatrics: Delayed umbilical cord clamping after birth.


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Obstentrics_Williams. Delayed umbilical cord clamping after birth. Pediatrics 0957,r2017a American Academy of Pediatrics, American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, 8th ed. Elk Grove Village, AAP,r2017b American College of Obstetricians and Gynecologists: Documenting shoulder dystocia. Patient Safety Checklist No.r6, August 2012 American College of Obstetricians and Gynecologists: Guidelines for Women's Health Care, 4th ed. Washington, ACOG, 2014 American College of Obstetricians and Gynecologists: Immersion in water during labor and delivery. Committee Opinion No. 679, November 2016a American College of Obstetricians and Gynecologists: Prevention and management of obstetric lacerations at vaginal delivery. Practice Bulletin No. 165, July 2016b American College of Obstetricians and Gynecologists: Prophylactic antibiotics in labor and delivery. Practice Bulletin No. 120, June 2011, Reairmed 2016c


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists: Prophylactic antibiotics in labor and delivery. Practice Bulletin No. 120, June 2011, Reairmed 2016c American College of Obstetricians and Gynecologists: Delayed umbilical cord clamping after birth. Committee Opinion No. 684, January 2017a American College of Obstetricians and Gynecologists: Planned home birth. Committee Opinion No. 697, April American College of Obstetricians and Gynecologists: Shoulder dystocia. Practice Bulletin No. 178, November 2002, Reairmed May 2017c Ampt A], Ford ]B, Roberts CL, et al: Trends in obstetric anal sphincter injuries and associated risk factors for vaginal singleton term births in New South Wales 2001-2009. Aust N Z] Obstet Gynaecol 53(1):9, 2013 Andersson 0, Hellstrom-Westas L, Andersson D, et al: Efect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BM] 343:d7157, 2011


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Obstentrics_Williams. Andersson 0, Hellstrom-Westas L, Andersson D, et al: Efects of delayed compared with early umbilical cord clamping on maternal postpartum hemorrhage and cord blood gas sampling: a randomized trial. Acta Obstet Gynecol Scand 92(5):567, 2013 Andersson SH, Rymer ], Joyce OW, et al: Sexual quality of life in women who have undergone female genital mutilation: a case-control study. B]OG 119(13):1606,r2012 Andrews V, Sultan AH, Thakar R, et al: Occult anal sphincter injuriesBmyth or reality? B]OG 113:195,r2006 Anteby EY, Yagel S: Route of delivery of fetuses with structural anomalies. Eur ] Obstet Gynecol Reprod Bioi 106(1):5,2003 Attilakos G, Psaroudakis 0, Ash], et al: Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. B]OG 117(8):929,r2010


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Obstentrics_Williams. Backes CH, Rivera BK, Haque U, et al: Placental transfusion strategies in very preterm neonates: a systematic review and meta-analysis. Obstet Gynecol 124(1):4,r2014 Baghestan E, Irgens LM, Bordalll PE: Risk of recurrence and subsequent delivery after obstetric anal sphincter injuries. B]OG 119:62,r2012 Barth WH]r: Persistent occiput posterior. Obstet GynecoIr125(3):695, 2015 Basham E, Stock L, Lewicky-Gaupp C, et al: Subsequent pregnancy outcomes after obstetric anal sphincter injuries (OASIS). Female Pelvic Med Reconstr Surg 19(6):328,r2013 Beall MH, Spong C, McKay], et al: Objective definition of shoulder dystocia: a prospective evaluation. Am ] Obstet Gynecol 179:934, 1998 Beckmann MM, Stock OM: Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev 4:CD005123, 2013 Begley CM, Gyte GM, Devane 0, et al: Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 3:CD007412,r2015


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Obstentrics_Williams. Begley CM, Gyte GM, Devane 0, et al: Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 3:CD007412,r2015 Belachew ], Cnattingius S, Mulic-Lurvica A, et al: Risk of retained placenta in women previously delivered by caesarean section: a population-based cohort study. B]OG 121(2):224,2014 Berg RC, Odgaard-]ensen ], Fretheim A, et al: An updated systematic review and meta-analysis of the obstetric consequences of female genital mutilation/cutting. Obstet Gynecol Int 2014:542859,2014 Berggren V, Gottvall K, Isman E, et al: Infibulated women have an increased risk of anal sphincter tears at delivery: a population-based Swedish register study of250,000 births. Acta Obstet Gynecol Scand 92(1):101, 2013 Bharathi A, Reddy DB, Kote GS: A prospective randomized comparative study of Vicryl Rapide versus chromic catgut for episiotomy repair. ] Clin Diagn Res 7(2):326, 2013


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Obstentrics_Williams. Bharathi A, Reddy DB, Kote GS: A prospective randomized comparative study of Vicryl Rapide versus chromic catgut for episiotomy repair. ] Clin Diagn Res 7(2):326, 2013 Bingham], Chauhan SP, Hayes E, et al: Recurrent shoulder dystocia: a review. Obstet Gynecol Surv 65(3):183,r2010 Birthplace in England Collaborative Group, Brocklehurst P, Hardy P, et al: Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BM] 343:d7400, 201r1 Blondel B, Alexander S, Bjarnad6ttir RI, et al: Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project. Acta Obstet Gynecol Scand 95(7):746,r2016 Boggs EW, Berger H, Urquia M, et al: Recurrence of obstetric third-degree and fourth-degree anal sphincter injuries. Obstet Gynecol 124(6): 1128,2014


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Obstentrics_Williams. Boggs EW, Berger H, Urquia M, et al: Recurrence of obstetric third-degree and fourth-degree anal sphincter injuries. Obstet Gynecol 124(6): 1128,2014 Bolten N, de ]onge A, Zwagerman E, et al: Efect of planned place of birth on obstetric interventions and maternal outcomes among low-risk women: a cohort study in the Netherlands. BMC Pregnancy Childbirth 16(1):329,2016 Boulvain M, Senat MV, Perrotin F, et al: Induction of labour versus expectant management for large-for-date fetuses: a randomised controlled trial. Lancet 385(9987):2600,r2015 Bovbjerg ML, Cheyney M, Everson C: Maternal and newborn outcomes following waterbirth: The Midwives Alliance of North America Statistics Project, 2004 to 2009 Cohort.] Midwifery Womens Health 61(1):11, 2016 Brito LG, Ferreira CH, Duarte G, et al: Antepartum use of Epi-No birth trainer for preventing perineal trauma: systematic review. Int Urogynecol ] (10):1429, 2015


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Obstentrics_Williams. MacKenzie IZ, Shah M, Lean K, et al: Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity. Obstet Gynecol 110:1059,r2007 Malin GL, Bugg G], Takwoingi Y, et al: Antenatal magnetic resonance imaging versus ultrasound for predicting neonatal macrosomia: a systematic review and meta-analysis. B]OG 123(1):77,r2016 McCandlish R, Bowler U; Van Asten H, et al: A randomised controlled trial of care of the perineum during second stage of normal labour. B]OG 105(12):1262, 1998 McDonald A, Gartland 0, Small R, et al: Dyspareunia and childbirth: a prospective cohort study. B]OG 122(5):672,2015 McDonald 5], Middleton P, Dowswell T, et al: Efect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev 7:CD004074, 2013 McFarland MB, Trylovich CG, Langer 0: Anthropometric diferences in macrosomic infants of diabetic and nondiabetic mothers. ] Maternal Fetal Med 7(6):292, 1998


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Obstentrics_Williams. McFarland MB, Trylovich CG, Langer 0: Anthropometric diferences in macrosomic infants of diabetic and nondiabetic mothers. ] Maternal Fetal Med 7(6):292, 1998 Mehta SH, Bujold E, Blackwell SC, et al: Is abnormal labor associated with shoulder dystocia in nulliparous women? Am] Obstet Gynecolr190( 6): 1604, 2004 Mei-dan E, Walfisch A, Raz I, et al: Perineal massage during pregnancy: a prospective controlled trial. Isr Med Assocr] 10(7):499, 2008 Melamed N, Gavish 0, Eisner M, et al: Third-and fourth-degree perineal tears-incidence and risk factors. ] Matern Fetal Neonatal Med 26(7):660, 2013 Minassian VA, ]azayeri A, Prien SO, et al: Randomized trial of lidocaine ointment versus placebo for the treatment of postpartum perineal pain. Obstet Gynecol 100: 1239, 2002


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Obstentrics_Williams. Minassian VA, ]azayeri A, Prien SO, et al: Randomized trial of lidocaine ointment versus placebo for the treatment of postpartum perineal pain. Obstet Gynecol 100: 1239, 2002 Mobeen N, Durocher ], Zuberi N, et al: Administration of misoprostol by trained traditional birth attendants ta prevent postpartum haemorrhage in homebirths in Pakistan: a randomised placebo-controlled trial. B]OG 118(3):353,r2011 Modanlou HD, Komatsu G, Dorchester W, et al: Large-for-gestational-age neonates: anthropometric reasons for shoulder dystocia. Obstet Gynecol 60:417,r1982 Moore HM, Reed SD, Batra M, et al: Risk factors for recurrent shoulder dystocia, Washington state, 1987-2004. Am] Obstet GynecoIr198:el6, 2008 Mornar S], Perlow JH: Blunt suture needle use in laceration and episiotomy repair at vaginal delivery. Am] Obstet Gynecol 198:e14, 2008


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Obstentrics_Williams. Mous M, Muller SA, de Leeuw]W: Long-term efects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints. B]OG 115(2):234,r2008 Mulder FE, Oude Rengerink K, van der Post ]A, et al: Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery. Int Urogynecol] 27(1):55, 2016 Mulder FE, Schofelmeer A, Hakvoort A, et al: Risk factors for POStpartum urinary retention: a systematic review and meta-analysis. B]OG 119(2):1440,r2012 Necesalova P, Karbanova], Rusavy Z, et al: Mediolateral versus lateral episiotomy and their efect on postpartum coital activity and dyspareunia rate 3 and 6 months postpartum. Sex Reprod Healthc 8:25, 2016 Nesbitt TS, Gilbert WM, Herrchen B: Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am ] Obstet Gynecol 179:476,r1998


Obstentrics_Williams

Obstentrics_Williams. Nesbitt TS, Gilbert WM, Herrchen B: Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am ] Obstet Gynecol 179:476,r1998 Nikolajsen S, L0kkegaard EC, Bergholt T: Reoccurrence of retained placenta at vaginal delivery: an observational study. Acta Obstet Gynecol Scand 92(4):421,r2013 Noumi G, Collado-Khoury F, Bombard A, et al: Clinical and sonographic estimation of fetal weight performed during labor by residents. Am] Obstet Gynecol 192(5):1407,2005 Nour NM. Female genital cutting: impact on women's health. Semin Reprod Med 330):41,r2015 Novartis: Methergine: prescribing information. 2012. Available at: http:// www.accessdata.fda.gov/drugsatfda_docs/labe1!20 12/00603 5s0781bl. pdf. Accessed October 26, 2016 Ogueh 0, I-Tarkait A, Vallerand D, et al: Obstetrical factors related to nuchal cord. Acta Obstet Gynecol Scand 85(7):810, 2006


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Obstentrics_Williams. Ogueh 0, I-Tarkait A, Vallerand D, et al: Obstetrical factors related to nuchal cord. Acta Obstet Gynecol Scand 85(7):810, 2006 Oliphant SS, Jones A, Wang L, et al: Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol 116(4):926,r2010 Otero M, Boulvain M, Bianchi-Demicheli F, et al: Women's health 18 years after rupture of the anal sphincter during child-birth: II. Urinary incontinence, sexual function, and physical and mental health. Amr] Obstet Gynecol 194(5):1260, 2006 Ouzounian ]G: Shoulder dystocia: incidence and risk factors. Clin Obstet Gynecol 59(4):791, 2016 Ouzounian ]G, Korst LM, Miller DA, et al: Brachial plexus palsy and shoulder dystocia: obstetric risk factors remain elusive. Am ] Perinatol 30(4):303, 2013


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Obstentrics_Williams. Ouzounian ]G, Korst LM, Miller DA, et al: Brachial plexus palsy and shoulder dystocia: obstetric risk factors remain elusive. Am ] Perinatol 30(4):303, 2013 Overland A, Spydslaug A, Nielsen CS, et al: Risk of shoulder dystocia in second delivery: does a history of shoulder dystocia matter? Am ] Obstet Gynecol 200(5):506.e1, 2009 0verland EA, Vatten L], Eskild A: Pregnancy week at delivery and the risk of shoulder dystocia: a population study of 2,014,956 deliveries. B]OG 1210):34,r2014 0verland EA, Vatten L], Eskild A: Risk of shoulder dystocia: associations with parity and ofspring birthweight. A population study of 1,914,544 deliveries. Acta Obstet Gynecol Scand 91(4):483, 2012 Ozyurt S, Aksoy H, Gedikbasi A, et al: Screening occult anal sphincter injuries in primigravid women after vaginal delivery with transperineal use of vaginal probe: a prospective, randomized controlled trial. Arch Gynecol Obstet 292(4):853, 2015


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Obstentrics_Williams. Paris E, Greenberg ]A, Ecker ]L, et al: Is an episiotomy necessary with a shoulder dystocia? Am] Obstet GynecoI205(3):217.e1, 2011 Patel S, Clark A, Rodriguez CE, et al: Efect of umbilical cord milking on morbidity and survival in extremely low gestational age neonates. Am ] Obstet GynecoIr211(5):519.el, 2014 Pinette MG, Wax ], Wilson E: he risks of underwater birth. Am ] Obstet Gynecol 190(5):1211,2004 Pollard ME, Morrisroe S, Anger ]T: Outcomes of pregnancy following surgery for stress urinary incontinence: a systematic review. ] Urol 187(6): 1966, 2012 Ponkey SE, Cohen AP, Hefner L], et al: Persistent fetal occiput posterior position: obstetric outcomes. Obstet Gynecol101(5 Pt 1):915,r2003 Pradhan A, Tincello DG, Kearney R: Childbirth after pelvic floor surgery: analysis of Hospital Episode Statistics in England, 2002-2008. B]OG 120(2):200,r2013


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Obstentrics_Williams. Pradhan A, Tincello DG, Kearney R: Childbirth after pelvic floor surgery: analysis of Hospital Episode Statistics in England, 2002-2008. B]OG 120(2):200,r2013 Priddis H, Dahlen HG, Schmied V, et al: Risk of recurrence, sub-sequent mode of birth and morbidity for women who experienced severe perineal trauma in a first birth in New South Wales between 2000-2008: a population based data linkage study. BMC Pregnancy Childbirth 13:89, 2013 Rabe H, Diaz-Rossello ]L, Duley L, et al: Efect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev 8:CD003248,r2012 Radestad I, Olsson A, Nissen E, et al: Tears in the vagina, perineum, sphincter ani, and rectum and first sexual intercourse ater childbirth: a nationwide follow-up. Birth 35:98, 2008 Rahmanr], Bhattee G, Rahman MS: Shoulder dystocia in a 16-year experience in a teaching hospital. ] Reprod Med 54(6):378, 2009


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Obstentrics_Williams. Rahmanr], Bhattee G, Rahman MS: Shoulder dystocia in a 16-year experience in a teaching hospital. ] Reprod Med 54(6):378, 2009 Raisanen S, Vehvilainen-]ulkunen K, Gissler M, et al: High episiotomy rate protects from obstetric anal sphincter ruptures: a birth register-study on delivery intervention policies in Finland. Scand ] Public Health 39(5):457, 2011 Roberts PL, Coller ]A, Schoetz D], et al: Manometric assessment of patients with obstetric injuries and fecal incontinence. Dis Colon Rectum 33: 16, 1990 Rodriguez MI, Seuc A, Say L, et al: Episiotomy and obstetric outcomes among women living with type 3 female genital mutilation: a secondary analysis. Reprod Health 130):131,2016 Rouse D], Owen ]: Prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography-a Faustian bargain? Am J Obstet Gynecol 181 :332, 1999 Rubin A: Management of shoulder dystocia.]AMA 189:835, 1964


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Obstentrics_Williams. Rubin A: Management of shoulder dystocia.]AMA 189:835, 1964 Sagi-Dain L, Sagi S: he role of episiotomy in prevention and management of shoulder dystocia: a systematic review. Obstet Gynecol Surv 70(5):354, 2015 Salim R, Peretz H, Molnar R, et al: Long-term outcome of obstetric anal sphincter injury repaired by experienced obstetricians. Int ] Gynaecol Obstet 126(2):130,r2014 Sandberg EC: Shoulder dystocia: associated with versus caused by the Zavanelli maneuver. Am] Obstet Gynecol 1970): 115, 2007 Sandberg EC: The Zavanelli maneuver: 12 years of recorded experience. Obstet Gynecol 93:312, 1999 Sandberg EC: The Zavanelli maneuver: a potentially revolutionary method for the resolution of shoulder dystocia. Am ] Obstet Gynecol 152:479, 1985 Sartore A, De Seta F, Maso G, et al: The efects of mediolateral episiotomy on pelvic loor function after vaginal delivery. Obstet Gynecol 103(4):669, 2004 Schafer R: Umbilical cord avulsion in waterbirth.] Midwifery Womens Health 590):91,r2014


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Obstentrics_Williams. Schafer R: Umbilical cord avulsion in waterbirth.] Midwifery Womens Health 590):91,r2014 Schramm M: Impacted shoulders-a personal experience. Aust N Z ] Obstet Gynaecol 23:28, 1983 Schummers L, Hutcheon ]A, Bodnar LM, et al: Risk of adverse pregnancy outcomes by prep regnancy body mass index: a population-based study to inform prepregnancy weight loss counseling. Obstet Gynecol 125(1):133, 2015 Secher N], Arnso P, Wallin L: Haemodynamic efects of oxytocin (Syntocinon) and methylergometrine (Methergin) on the systemic and pulmonary circulations of pregnant anaesthetized women. Acta Obstet Gynecol Scand 57:97, 1978 Sen K, Sakamoto H, Nakabayashi Y, et al: Management of the occiput posterior presentation: a single institute experience. ] Obstet Gynaecol Res 39(1):160,r2013 Senecal ], Xiong X, Fraser WD, et al: Efect of fetal position on second-stage duration and labor outcome. Obstet Gynecol 105(4):763,r2005


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Obstentrics_Williams. Senecal ], Xiong X, Fraser WD, et al: Efect of fetal position on second-stage duration and labor outcome. Obstet Gynecol 105(4):763,r2005 Shafer BL, Cheng W, Vargas ]E, et al: Manual rotation of the fetal occiput: predictors of success and delivery. Am J Obstet Gynecol 194(5):e7, 2006 Shafer BL, Cheng W, Vargas ]E, et al: Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. ] Matern Fetal Neonatal Med 240):65,r201r1 Shinar S, Schwartz A, Maslovitz S, et al: How long is safe? Setting the cutof for uncomplicated third stage length: a retrospective case-control study. Birth 430):36,r2016a Shinar S, Shenhav M, Maslovitz S, et al: Distribution of third-stage length and risk factors for its prolongation. Am] PerinatoI33(0):1023, 2016b Shmueli A, Gabbay Benziv R, Hiersch L, et al: Episiotomy-risk factors and outcomes. ] Matern Fetal Neonatal Med 19: 1, 2016


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Obstentrics_Williams. Shmueli A, Gabbay Benziv R, Hiersch L, et al: Episiotomy-risk factors and outcomes. ] Matern Fetal Neonatal Med 19: 1, 2016 Signorello LB, Harlow BL, Chekos AK, et al: Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am] Obstet Gynecol 184:881,2001 Sikka P, Chopra S, Kalpdev A, et al: Destructive operations-a vanishing art in modern obstetrics: 25 year experience at a tertiary care center in India. Arch Gynecol Obstet 283(5):929,r201r1 Snowden JM, Tilden EL, Snyder J, et al: Planned out-of-hospital birth and birth outcomes. N Engl J vIed 373(27):2642,2015 Soltani H, Hutchon DR, Pouiose TA: Timing of prophylactic uterotonics for the third stage of labour after vaginal birth. Cochrane Database Syst Rev 8:CD006173,r2010 Spain JE, Frey HA, Tuuli MG, et al: Neonatal morbidity associated with shoulder dystocia maneuvers. m J Obstet Gynecol 212(3):353.e1, 2015


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Obstentrics_Williams. Spain JE, Frey HA, Tuuli MG, et al: Neonatal morbidity associated with shoulder dystocia maneuvers. m J Obstet Gynecol 212(3):353.e1, 2015 Spong CY, Beall M, Rodrigues D, et al: An objective definition of shoulder dystocia: prolonged head-to-body delivery intervals and/or the use of ancillary obstetric maneuvers. Obstet Gynecol 86:433, 1995 Stamp G, Kruzins G, Crowther C: Perineal massage in labour and prevention of perineal trauma: randomised controlled trial. BMJ 322(7297):1277, 2001 Stock L, Basham E, Gossett DR, et a1: Factors associated with wound complications in women with obstetric anal sphincter injuries (OASIS). m J Obstet Gynecol 208(4):32 .e1,2013 Stotland NE, Caughey AB, Breed EM, et al: Risk factors and obstetric complications associated with macrosomia. Int J Gynaecol Obstet 87(3):220, 2004 Su LL, Chong YS, Samuel M: Carbetocin for preventing postpartum haemor rhage. Cochrane Database Syst Rev 4:CD005457, 2012


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Obstentrics_Williams. Sundquist JC: Long-term outcome after obstetric injury: a retrospective study. Acta Obstet Gynecol Scand 91(6):715,r2012 Svanstrom Me, Biber B, Hanes M, et al: Signs of myocardial ischaemia after injection of oxytocin: a randomized double-blind comparison of oxytocin and methylergometrine during caesarean section. Br J Anaesth 100:683, 2008 Taylor H, Kleine I, Bewley 5, et 1: Neonatal outcomes of waterbirth: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 101(4):F357, 2016 Thoeni A, Zech N, Moroder L, et al: Review of 1600 water births. Does water birth increase the risk of neonatal infection? J Matern Fetal Neonatal Med 17(5):357,r2005 Tun;alp 0, Hofmeyr GJ, Gulmezoglu M: Prostaglandins for preventing postpartum haemorrhage. Cochrane Database Syst Rev 8:CD000494, 2012 UNICEF: Female genital mutilation and cutting. 20r16. Available at: http:// data.unicef.org/topiclchild-protection/female-genital-mutilation-and-cutting.! Accessed October 24, 2016


Obstentrics_Williams

Obstentrics_Williams. UNICEF: Female genital mutilation and cutting. 20r16. Available at: http:// data.unicef.org/topiclchild-protection/female-genital-mutilation-and-cutting.! Accessed October 24, 2016 Upadhyay A, Gothwal 5, Parihar R, et al: Efect of umbilical cord milking in term and near term infants: randomized control trial. Am J Obstet Gynecol 208(2):120.el, 2013 Valenzuela P, Saiz Puente MS, Valero JL, et al: Continuous versus interrupted sutures for repair of episiotomy or second-degree perineal tears: a randomised controlled trial. B]OG 11r6(3):436,r2009 Walsh JM, Kandamany N, Ni Shuibhne N, et al: Neonatal brachial plexus injury: comparison of incidence and antecedents between 2 decades. Am J Obstet GynecoIr204(4):324.e1, 2011 Walsh A, Grivell RM: Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth. Cochrane Database Syst Rev 1 O:CDO 1 0826, 2015


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Obstentrics_Williams. Walsh A, Grivell RM: Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth. Cochrane Database Syst Rev 1 O:CDO 1 0826, 2015 Wasden SW, Chasen ST, Perlman JM, et al: Planned home birth and the association with neonatal hypoxic ischemic encephalopathy. J Perinat Med November 19,r2016 [Epub ahead of print] Westhof G, Cotter M1, Tolosa JE: Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Database Syst Rev 10:CD001808,r2013 Whalley PJ, Pritchard JA: Oxytocin and water intoxication. JM1A 186:601, 1963 Winter J, Kattwinkel ], Chisholm e, et 1: ventilation of preterm infants during delayed cord clamping (VentFirst): a pilot study of feasibility nd safety. m ] PerinatoI34(2):1l1,r2017 Woods CE: A principle of physics is applicable to shoulder delivery. Am ] Obstet Gynecol 96, 1943


Obstentrics_Williams

Obstentrics_Williams. Woods CE: A principle of physics is applicable to shoulder delivery. Am ] Obstet Gynecol 96, 1943 World Health Organization: Eliminating female genital mutilation. Geneva, World Health Organization, 2008 World Health Organization: Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 367: 1835, 2006 World Health Organization: Guideline: delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes. Geneva, World Health Organization, 2014 World Health Organization: WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva, World Health Organization, 2012 Wuest 5, Raio L, Wyssmueller D, et al: Efects of female genital mutilation on birth outcomes in Switzerland. B]OG 116(9):1204,r2009


Obstentrics_Williams

Obstentrics_Williams. Wuest 5, Raio L, Wyssmueller D, et al: Efects of female genital mutilation on birth outcomes in Switzerland. B]OG 116(9):1204,r2009 Wyckof MH, Aziz K, Escobedo MB, et al: Part 13: Neonatal resuscitation: 2015 American Heart Association guidelines update for cardiopulmonaIY resuscitation and emergency cardiovascular care. Circulation 132(18 Suppl 2):5543,r2015 Yao AC, Lind J: Placental transfusion. Am] Dis Child :128, 1974 Zahalka N, Sadan 0, Malinger G, et al: Comparison of transvaginal sonography with digital examination and transabdominal sonography for the determination of fetal head position in the second stage of labor. Am ] Obstet Gynecol 193:381,r2005 CLASSIFICATION OF BREECH PRESENTATIONS ....... 539 DIAGNOSIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540 ROUTE OF DELIVERYe. . . . . . . . . . . . . . . . . . . . . . . . . . . . 540 LABOR AND DELIVERY MANAGEMENTe. . . . . . . . . . . . . 543 PARTIAL BREECH EXTRACTION ................... 544


Obstentrics_Williams

Obstentrics_Williams. LABOR AND DELIVERY MANAGEMENTe. . . . . . . . . . . . . 543 PARTIAL BREECH EXTRACTION ................... 544 TOTAL BREECH EXTRACTIONe. . . . . . . . . . . . . . . . . . . . . 548 EXTERNAL CEPHALIC VERSION. . . . . . . . . . . . . . . . . . . . 549 extremities and buttocks. With a frank breech, lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to the head With a complete breech, both hips are lexed, and one or both knees are also lexed (Fig. 28-2). With an incomplete breech, one or both hips are extended. As a result, one or both feet or knees lie below the breech, such that a foot or knee is lowermost in the birth canal (Fig. 28-3). A footling breech is an incomplete breech with one or both feet below the breech. FIGURE 28-1 Frank breech presentation.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 28-1 Frank breech presentation. The essential prerequisite or the successful peormance of breech extraction lies in the complete dilatation of the cervix and the absence of any serious mechanical obstacle. It is true that in a certain number of cases extraction through an impeecty dilated cervix is possible, but this is usualy fected ony at the cost of deep cervical tears. -J. Whitridge Williams (1903) Near term, the fetus typically has spontaneously assumed a cephalic presentation. Conversely, if the fetal buttocks or legs enter the pelvis before the head, the presentation is breech. This fetal lie is more common remote from term, as earlier in pregnancy each fetal pole has similar bulk. At term, breech presentation persists in approximately 3 to 5 percent of singleton deliveries (Cammu, 2014; Lyons, 2015; Macharey, 2017). he categories of frank, complete, and incomplete breech presentations difer in their varying relations between the lower


Obstentrics_Williams

Obstentrics_Williams. he categories of frank, complete, and incomplete breech presentations difer in their varying relations between the lower FIGURE 28-2 Complete breech presentation. FIGURE 28-3 Incomplete breech presentation. Of term breech fetuses, the neck may be extremely hyperextended in perhaps 5 percent, and the term stargazing etus is used (Cimmino, 1975). With these, fetal or uterine anomalies may be more prevalent and are sought if not previously identified (Phelan, 1983). With this hyperextension, vaginal delivery can result in injury to the cervical spinal cord. hus, if identified at term, this is an indication for cesarean delivery (Westgren, 1981). hat said, flexion itself may be implicated, s cses of spinal cord injury have been reported following uneventul cesarean delivery of such fetuses (Hernandez-Marti, 1984). With transverse lie and similar hyperextension of the fetal neck, the term iyingetus is applied.


Obstentrics_Williams

Obstentrics_Williams. Understanding the clinical settings that predispose to breech presentation can aid early recognition. Other than early gestational age, risk factors include extremes of amnionic fluid volume, multifetal gestation, hydrocephaly, anencephaly, structural uterine abnormalities, placenta previa, pelvic tumors, and prior breech delivery. One study found that following one breech delivery, the recurrence rate for a second breech presentation was 10 percent, and for a subsequent third breech it was 28 percent (Ford, 2010). Leopold maneuvers to ascertain fetal presentation are discussed in Chapter 22 (p. 424). With the irst maneuver, the hard, round fetal head occupies the fundus. he second maneuver identifies the back to be on one side of the abdomen and the small parts on the other. With the third maneuver, if not engaged, the softer breech is movable above the pelvic inlet.


Obstentrics_Williams

Obstentrics_Williams. After engagement, the fourth maneuver shows the breech to be beneath the symphysis. he accuracy of this palpation varies (Lydon-Rochelle, 1993; Nassar, 2006). hus, with suspected breech presentation-or any presentation other than cephalic-sonographic evaluation is indicated.


Obstentrics_Williams

Obstentrics_Williams. During cervical examination with a frank breech, no feet are appreciated, but the fetal ischil tuberosities, sacrum, and anus are usually palpable. Ater urther fetal descent, the external genitalia may also be distinguished. When labor is prolonged, the fetal buttocks may become markedly swollen, rendering digital diferentiation of a face and breech diicult. In some cases, the anus may be mistaken for the mouth and the ischial tuberosities for the malar eminences. With careul examination, however, the inger encounters muscular resistance with the anus, whereas the hard, less yielding jaws are felt through the mouth. The finger, upon removal from the anus, may be stained with meconium. The mouth and malar eminences form a triangular shape, whereas the ischial tuberosities and anus lie in a straight line. With a complete breech, the feet may be felt alongside the buttocks. In footling presentations, one or both feet are inferior to the buttocks.


Obstentrics_Williams

Obstentrics_Williams. The fetal sacrum and its spinous processes are palpated to establish position. As with cephalic presentations, fetal position is designated to reflect the relations of the fetal sacrum to the maternal pelvis. Positions include left sacrum anterior (LSA) , right sacrum anterior (RSA), left sacrum posterior (LSP), right sacrum posterior (RSP), and sacrum transverse (ST). Multiple factors aid determination of the best delivery route for a given mother-fetus pair. These include fetal characteristics, maternal pelvic dimensions, coexistent pregnancy complications, provider experience, patient preference, hospital capabilities, and gestational age. Compared with their term counterparts, preterm breech fetuses have distinct complications related to their small size and immaturity. For example, rates of head entrapment, birth trauma, and perinatal mortality can be greater. Accordingly, separate dis cussions of term and preterm breech fetuses are more appropriate.


Obstentrics_Williams

Obstentrics_Williams. Current obstetrical thinking regarding vaginal delivery of the term breech fetus has been tremendously inluenced by results of the Term Breech Trial (Hannah, 2000). his trial included 1041 women randomly assigned to planned cesarean and 1042 to planned vaginal delivery. In the planned vaginal delivery group, 57 percent were actually delivered vaginally. Planned cesarean delivery was associated with a lower risk of perinatal mortality compared with planned vaginal delivery-3 per 1000 versus 13 per 1000. Cesarean delivery was also associated with a lower risk of "serious" neonatal morbidity-1.4 versus 3.8 percent. Short term maternal morbidity was similar between groups. Critics of the Term Breech Trial emphasize that fewer than 10 percent of candidates underwent radiological pelvimetry. Also, most of the outcomes included in the "serious" neonatal morbidity composite did not actually portend long-term infant disability (Whyte, 2004).


Obstentrics_Williams

Obstentrics_Williams. Since that trial, however, additional data favoring cesarean delivery has come from the World Health Organization (Lumbiganon, 2010). From their evaluation of more than 100,000 deliveries from nine participating Asian countries, they reported improved perinatal outcomes for the term breech fetus with planned cesarean compared with planned vaginal delivery. Other studies have evluated neonatal outcome with cesarean delivery and also found lowered neonatal morbidity and mortality rates (Hartnack Tharin, 2011; Lyons, 2015; Rietberg, 2005; Vistad, 2015). From their metaanalysis, Berhan and Haileamlak (2016) calculate absolute risk of perinatal mortality to be 0.3 percent and of fetal birth trauma or neurological morbidity to be 0.7 percent.


Obstentrics_Williams

Obstentrics_Williams. In contrast, other studies support vaginal delivery as a suitable option at term (Hofmeyr, 2015a). he Presentation et Mode dAccouchement-PEMODA study-which translates as presentation and mode of delivery-showed no diferences in corrected neonatal mortality rates and neonatal outcomes according to delivery mode (Goinet, 2006). his French prospective observational study involved more than 8000 women with term breech singletons. Strict criteria were used to select 2526 of these for planned vaginal delivery, and 71 percent of that group were delivered vaginally. Similarly, data from the Lille Breech Study Group in France showed no excessive morbidity in term breech singletons delivered vaginally provided strict fetal biometric and maternal pelvimetry parameters were applied (Michel, 2011). Other smaller studies support these findings as long as guidelines are part of the selection process (Alarab, 2004; Giuliani, 2002; Toivonen, 2012).


Obstentrics_Williams

Obstentrics_Williams. Long-term evidence in support of vaginal breech delivery comes from Eide and associates (2005). These investigators analyzed intelligence testing scores of more than 8000 men delivered breech and ing vaginal or cesarean delivery. Also, a 2-year follow up from the velopmental delay between delivery groups (Whyte, 2004). Despite evidence on both sides of the debate, at least in the United States, rates of planned vaginal delivery attempts con tinue to decline. And as predicted, the number of skilled pro viders able to safely select and vaginally deliver breech fetuses continues to dwindle (Chinnock, 2007). Moreover, obvious ies diicult. In response, some institutions have developed birth simulators to improve resident competence in vaginal breech delivery (Deering, 2006; Maslovitz, 2007).


Obstentrics_Williams

Obstentrics_Williams. In contrast to the term breech fetus, there are no randomized trials regarding delivery of the preterm breech fetus. Moreover, study comparisons are oten made diicult by lumping, splitting, or overlapping of preterm gestational age groups. All that said, it would appear that for the preterm breech fetus, planned cesar ean delivery confers a survival advantage compared with planned vaginal delivery. Reddy and associates (2012) reported data from deliveries between 24 and 32 weeks' gestation. For breech fetuses within these gestational ages, attempting vaginal delivery yielded a low success rate, and those completed were associated with higher neonatal mortality rates compared with planned cesar ean delivery. Other investigations have reported similar findings (Bergenhenegouwen, 2014; Demirci, 2012; Muhuri, 2006).


Obstentrics_Williams

Obstentrics_Williams. For preterm fetuses in younger subgroups-23 to 28 weeksthe data are more conflicting, and some studies describe no improved survival rate with planned cesarean delivery (Bergenhenegouwen, 2015; Kayem, 2015; Thomas, 2016). Forperiviable etuses, deined by them as 20 to 256/7 weeks, a consensus workshop of perinatal organizations concluded that "available data do not consistently support routine cesarean delivery to improve perinatal mortality or neurological outcomes for early preterm infants" (Raju, 2014). A subsequent joint statement by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (2017) suggested consideration for cesarean delivery for periviable fetuses beginning at 23°/7 weeks, with a recommendation for cesarean delivery at 25°1 weeks.


Obstentrics_Williams

Obstentrics_Williams. For more mature preterm breech fetuses, that is, between 32 and 37 weeks, again there are sparse data to guide delivery route selection. Bergenhenegouwen and coworkers (2015) studied more than 6800 breech deliveries in a subgroup between 32 and 37 weeks. With planned cesarean delivery, they found similar perinatal mortality rates but less composite mortality and severe morbidity. It appears in this subgroup that fetal weight rather than gestational age is likely more important. he Maternl-Fetal Nfedicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) states that vaginal breech delivery is reasonable when the estimated fetal weight is >2500 g (Kotaska, 2009). There are especial concerns for delivery of the second noncephalic-presenting twin fetus that are discussed in Chapter 45 (p. 888).


Obstentrics_Williams

Obstentrics_Williams. In the United States, all these findings shape practice, and cesarean delivery is almost uniformly favored for the preterm breech fetus for which resuscitation is planned.


Obstentrics_Williams

Obstentrics_Williams. Increased rates of maternal and perinatal morbidity can be anticipated with breech presentations. For the mother, with either cesarean or vaginal delivery, genital tract laceration can be problematic. With cesarean delivery, added stretching of the lower uterine segment by forceps or by a poorly molded fetal head can extend hysterotomy incisions. With vaginal delivery, especially with a thinned lower uterine segment, delivery of the atercoming head through an incompletely dilated cervix or application of forceps may cause vaginal wall or cervical lacerations, and even uterine rupture. Manipulations may also extend an episiotomy, create deep perineal tears, and increase infection risks. Anesthesia suicient to induce appreciable uterine relaxation during vaginal delivery may cause uterine atony and in turn postpartum hemorrhage. Maternal death is rare, but rates appear higher in those with planned cesarean delivery for breech presentation-a case fatality rate of 0.47 maternal deaths per


Obstentrics_Williams

Obstentrics_Williams. and in turn postpartum hemorrhage. Maternal death is rare, but rates appear higher in those with planned cesarean delivery for breech presentation-a case fatality rate of 0.47 maternal deaths per 1000 births (Schutte, 2007). Last, the risks associated with vaginal breech delivery are balanced against general cesarean delivery risks described in Chapter 30 (p. 568). Long-term, cesarean risks include those associated with repeated hysterotomy or with vaginal birth ater cesarean-VBAC-further described in Chapter 31 (p. 593).


Obstentrics_Williams

Obstentrics_Williams. For the fetus, prematurity and its complications are frequently comorbid with breech presentation. Rates of congenital anomalies are also greater (Cammu, 2014; Mostello, 2014). Compared with cephalic presentation, umbilical cord prolapse is more frequent with breech fetuses (Behbehani, 2016; Obeidat, 2010). Birth trauma can include fractures of the humerus, clavicle, and femur (Canpolat, 2010; Matsubara, 2008). In some cases, traction may separate scapular, humeral, or femoral epiphyses (Lamrani, 2011). Trauma is more common with vaginal births, but fetal trauma is also seen with cesarean deliveries.


Obstentrics_Williams

Obstentrics_Williams. Rare traumatic injuries may involve soft tissues. Brachial plexus injury and paralysis is one example (Foad, 2008). The spinal cord may be injured or even severed, or vertebrae fractured, especially if great force is employed (Vialle, 2007). Hematomas of the sternocleidomastoid muscles occasionally develop after delivery but usually disappear spontaneously. Last, genital injury may follow breech delivery (Saroha, 2015). Some perinatal outcomes may be inherent to the breech position rather than delivery. For example, development of hip dysplasia is more common in breech compared with cephalic presentation and is unafected by delivery mode (de Hundt, 2012; Fox, 2010; Ortiz-Neira, 2012).


Obstentrics_Williams

Obstentrics_Williams. In many fetuses-especially those that are preterm-the breech is smaller than the atercoming head. Moreover, unlike cephalic presentations, the head of a breech-presenting fetus does not undergo appreciable molding during labor. Thus, if vaginal delivery is considered, fetal size, type of breech, and degree of neck lexion or extension are evaluated. In addition, pelvic dimensions are assessed to avoid head entrapment from cephalopelvic disproportion. Sonography and fetal pelvimetry are options. Sonographic fetal evaluation will have been performed in most cases as part of prenatal care. If not, gross fetal abnormalities, such as hydrocephaly or anencephaly, can be rapidly ascertained with sonography. This will identiy many fetuses not suitable for vaginal delivery. It will also help to ensure that a cesarean delivery is not performed under emergency conditions for an anomalous fetus with no chance of survival.


Obstentrics_Williams

Obstentrics_Williams. Head flexion can usually also be determined sonographically, and for vaginal delivery, the fetal head should not be extended (Fontenot, 1997; Rojansky, 1994). If imaging is uncertain, then simple two-view radiography of the maternal abdomen is useful to define fetal head inclination. Sonographic identification of a nuchal arm may warrant cesarean delivery to avoid neonatal harm (Sherer, 1989). he accuracy of fetal weight estimation by sonography is not altered by breech presentation (McNamara, 2012). Although variable, many protocols use fetal weights >2500 g and <3800 to 4000 g or evidence of growth restriction as exclusion criteria for planned vaginal delivery (Azria, 2012; Kotaska, 2009). Similarly, a biparietal diameter (BPD) >90 to 100 mm is often considered exclusionary (Giuliani, 2002; Roman, 2008).


Obstentrics_Williams

Obstentrics_Williams. Pelvimetry assesses the maternal bony pelvis before vaginal delivery, and one-view computed tomography (CT) , magnetic resonance (MR) imaging, or plain film radiography is suitable. Comparative data among these modalities for pelvimetry are lacking, but CT is favored due to its accuracy, low radiation dose, and widespread availability (homas, 1998). At Parkland Hospital, we use CT pelvimetry when possible to assess the critical dimensions of the pelvis (Chap. 2, p. 30). Although variable, some suggest specific measurements to permit a planned vaginal delivery: inlet anteroposterior diameter : 10.5 cm; inlet transverse diameter : 12.0 cm; and midpelvic interspinous distance : 10.0 cm (Azria, 2012; Vendittelli, 2006). Some have recommended maternalfetal biometry correlation. Appropriate values include: the sum of the inlet obstetrical conjugate minus the fetal BPD is : 15 mm; the inlet transverse diameter minus the BPD is :25 mm; and the midpelvis interspinous distance minus the BPD is


Obstentrics_Williams

Obstentrics_Williams. include: the sum of the inlet obstetrical conjugate minus the fetal BPD is : 15 mm; the inlet transverse diameter minus the BPD is :25 mm; and the midpelvis interspinous distance minus the BPD is :0 mm (Michel, 2011). With MR imaging, Hofmann and colleagues (2016) found vaginal delivery success rates of 79 percent in selected candidates if the interspinous distance exceeded 11 cm.


Obstentrics_Williams

Obstentrics_Williams. Currently, the American College of Obstetricians and Gynecologists (2016b) recommends that "the decision regarding the mode of delivery should depend on the experience of the health-care provider" and that "planned vaginal delivery of a term singleton breech fetus may be reasonable under hospitalspecific protocol guidelines." These guidelines have been echoed by other obstetrical organizations (Kotaska, 2009; Royal College of Obstetricians and Gynaecologists, 2006). Risks versus beneits are weighed and discussed with the patient. If possible, this is preferably done before admission. A diligent search is made for other complications, actual or anticipated, that might warrant cesarean delivery. Common circumstances are listed in Table


Obstentrics_Williams

Obstentrics_Williams. For a favorable outcome with any breech delivery, at the very minimum, the birth canal must be suiciently large to allow passage of the fetus without trauma. he cervix must be fully dilated, and if not, then a cesarean delivery nearly always is the more appropriate method of delivery if suspected fetal compromise develops. TABLE 28-1 . Factors Favoring Cesarean Delivery of the Breech Fetus Lack of operator experience Patient request for cesarean delivery Large fetus: >3800 to 4000 g Apparently healthy and viable fetus either with active labor or with indicated delivery Severe fetal-growth restriction Fetal anomaly incompatible with vaginal delivery Prior perinatal death or neonatal birth trauma Incomplete or footling breech presentation Hyperextended head Pelvic contraction or unfavorable pelvic shape determined clinically or with pelvimetry Prior cesarean delivery


Obstentrics_Williams

Obstentrics_Williams. The conduct of both labor and delivery difer between cephalic and breech presentations. First, breech labor in general proceeds more slowly, but steady cervical progress is a positive indicator of adequate pelvic proportions (Lennox, 1998). Vaginal breech delivery is accomplished by one of three methods. With spontaneous breech delivery, the fetus is expelled entirely without any traction or manipulation other than support of the newborn. With partial breech extraction, the fetus is delivered spontaneously as far as the umbilicus, but the remainder of the body is delivered by provider traction and assisted maneuvers, with or without maternal expulsive eforts. With total breech extraction, the entire fetal body is extracted by the provider.