2.

08 Vaginal, Breech and Operative Deliveries

Dr. Marth Louie Z. Tarroza | August 27, 2018

Delivery of the Shoulder

I. SPONTANEOUS VAGINAL DELIVERY  Done after the fetus has undergone restitution and external
A. Vaginal Delivery
1. Second Stage of Labor rotation to the transverse position and the shoulders appear at
2. Third Stage of Labor the vulva
3. Fourth Stage of Labor  A gentle downward traction to effect descent of the anterior
II. OPERATIVE VAGINAL DELIVERY shoulder and gentle upward traction to deliver the posterior
A. Operative Delivery
B. Forceps Delivery
shoulder
C. Vacuum Extraction  After delivery of the shoulder the rest of the fetal body follows
III. BREECH DELIVERY
IV. CESAREAN DELIVERY
V. PERIPARTUM HYSTERECTOMY
VI. VAGINAL BIRTH AFTER CESAREAN
VII. UTERINE RUPTURE
VIII. REFERENCES
IX. QUIZ

Legend:
Supplementary Book
Audio Recording Emphasized Notes
Information
  

I. SPONTANEOUS VAGINAL DELIVERY

A. Vaginal Delivery
 Preferred route of delivery for most fetuses.
 It poses the lowest risk for most maternal comorbidities.
NOTE: Doc played a short video on spontaneous vaginal delivery;
for reference: https://www.youtube.com/watch?v=ZRQdNlY8tHE
1. Second Stage of Labor
 Begins with a fully dilated cervix  until the delivery of the baby
 HALLMARKS:
o CROWNING
 The encirclement of the largest head diameter by the
pelvic ring Figure 1. Delivery of the shoulders. (A) Gentle downward traction.
o Fully dilated cervix, stronger uterine contractions, maternal (B) Gentle upward traction
bearing down with urge to defecate, dilatation of the anus
 The end of second stage labor is heralded as the perineum Cord Clamping
begins to distend, the overlying skin becomes stretched, and
 Umbilical cord is cut between 2 clamps located
the fetal scalp is seen through the separating labia.
o 6 – 8 cm from the fetal abdomen
o 2 – 3 cm from its insertion into the fetal abdomen
Preparation
 Delayed cord clamping (1-3 minutes)/(up to 60
 Positions may vary seconds) is recommended because it:
 Lithotomy position – most common and often the most o Increase in total iron source
satisfactory o Expand blood volume
 Bladder is emptied during delivery o Decrease incidence of anemia
 Fetal heart tones are continuously monitored
 Vulvar and perineal cleansing 2. Third Stage of Labor
 Begins immediately after birth and ends with placental delivery
Delivery of the Head
 Goals:
 Episiotomy – not routinely performed but the use should be o Delivery of intact placenta
individualized o Avoidance of uterine inversion or Post-partum hemorrhage
 To limit spontaneous vaginal lacerations:  Are grave intrapartum complications that constitute
o Antenatal massage of the perineal body to increase emergencies
perineal distensibility
o Intrapartum perineal massage to widen the introitus for Expectant Management
head passage.
 Involves waiting for placental separation signs and allowing the
o Modified Ritgen Maneuver - It is done by moderate upper
placenta to deliver either spontaneously or aided by nipple
pressure supplied to the fetal chin by the posterior hand
stimulation
covering a sterile towel, and the other hand applies
occipital pressure, promoting head extension.

TRANSCRIBERS Gaerlan, Galang, Galapon, Galigao, Galvan EDITOR Canoza (0916 906 5283) 1 of 8
 Signs of placental separation: Episiotomy
o Sudden gush of blood  Incision of the pudendum
o Globular and firmer fundus  Used synonymously with:
o Lengthening of the umbilical cord o Perineotomy intended incision of the perineum
o Elevation of the uterus into the abdomen  Not done routinely and performed only when appropriate
 Median time: 4 – 12 minutes indications are present
o Prolonged placental separation: 30 minutes  manual o Large baby
extraction of placenta o Shoulder dystocia
 To prevent uterine inversion, umbilical cord traction must not be o Breech deliveries
used to pull the placenta from the uterus o Operative vaginal deliveries
 TIMING:
Active Management o Head is visible during a contraction to a diameter of
 Early cord clamping approximately 4 cm (CROWNING)
 Controlled cord traction during placental delivery You only do episiotomy if the head is already visible at the
 Immediate administration of prophylactic oxytocin after the introitus
delivery of the anterior shoulder  TYPES OF EPISIOTOMY:
 The goal of the active management is to limit the postpartum o Midline – begins at the fourchette, incises the perineal
hemorrhage body in the midline, and ends well before the external anal
sphincter is reached
3. Fourth Stage of Labor o Mediolateral – begins at the midline of the fourchette and
 First hour after placental delivery is directed to the right or left at an angle 60°off the midline
 Placental and cord inspection Table 1. Comparison between Midline and Mediolateral Episiotomy.
 Vigilant monitoring for uterine atony and hemorrhage Characteristic Midline Mediolateral
 Perineum must be inspected for lacerations and hematoma Surgical repair Easy More difficult
Faulty healing Rare More common
Classification of Perineal Lacerations Postoperative pain Minimal Common
Anatomical results Excellent Occasionally faulty
Blood loss Less More
Dyspareunia Rare Occasional
Extensions Common Uncommon
The only advantage of the mediolateral episiotomy over
midline episiotomy: the extension to rectal mucosa is
uncommon. So mas maganda parin yung midline, except dun
sa extension sa 4th degree

II. OPERATIVE VAGINAL DELIVERY

A. Operative Delivery
 Vaginal deliveries accomplished with the use of forceps or a
vacuum device
 Most important function: TRACTION
 Outward traction generates forces that augment maternal
pushing to deliver the fetus vaginally

Figure 2. Classification of perineal lacerations. Table 2. Indications of Operative Delivery

 First-degree lacerations Maternal Fetal
o Includes the vaginal epithelium or the perineal skin  Heart disease  Non-reassuring Fetal Heart
 Second-degree lacerations  Pulmonary Compromise Rate pattern
o Involve the perineal muscles, bulbocarvernosus, and the  Intrapartum infection  Premature Placental
superficial transverse perineal muscles.  Neurologic Conditions Separation
 Involves the perineal muscles (bulbospongiosus and  Exhaustion and prolonged
superficial transverse perineal muscles but spares the anal second stage labor
sphincter complex
 Third-degree [New classification] 
o 3A – <50% involvement of the external anal sphincter
o 3B – >50% involvement of the external anal sphincter
o 3C – Internal anal sphincter is already affected
 Fourth-degree
o Rectal mucosa is involved

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B. Forceps Delivery Classification of Forceps
Types of Forceps  Table 3. Classification According to Station and Rotation
1. TUCKER-MCLANE FORCEPS - Best used for a rounded head Procedure Criteria
for multiparas. 1. Scalp is visible at the introitus without
separating the labia
2. Fetal skull has reached the pelvic floor
OUTLET 3. Sagittal suture is in anteroposterior
FORCEPS diameter or right or left occiput anterior
or posterior position
4. Fetal Head is at or perineum
5. Rotation does not exceed 45 degrees
Leading point of fetal skull is at station ≥
+2 cm, and not on the pelvic floor and:
LOW FORCEPS  Rotation is ≤45 degrees or
 Rotation is >45 degrees
MIDFORCEPS Station is 0 between and +2
HIGH FORCEPS Not included in the classification

Analgesia
Figure 3. Tucker‐McLane forceps. The blade is solid, and the
shank is narrow. [2019B]  Outlet forceps: Pudendal Block is already enough
 Low and Midforceps: Regional or general anesthesia can be
given
2. KIELLAND FORCEPS - Used for molded head but ideal for
rotation because of no pelvic curvature Pre-Requisites
 Engaged head  Adequate anesthesia
 Vertex presentation  Emptied maternal bladder
 Known fetal head position  No fetal coagulopathy
 CPD not suspected  No fetal demineralization
 Fetal weight estimated  Willingness to abandon
 Experienced operator OVD
 Ruptured membraned  Informed consent
 Completely dilated cervix completed

Failed Forceps
 Considered when blades cannot be applied properly and when
there is no descent of the head despite traction

Complications
Figure 4. Kielland Forceps. The characteristic features are minimal
pelvic curvature (A), sliding lock (B), and light weight [2019B]  Maternal: Postpartum urinary retention, bladder dysfunction,
urinary, fecal and flatus incontinence (secondary to injury to the
3. SIMPSON FORCEPS - Best used for the delivery of the anal sphincter)
molded head  Fetal: Facial nerve palsy, skull fracture, intracranial hemorrhage

C. Vacuum Extraction
 Suction is created within a cup placed on the fetal scalp and
that traction on the cup  fetal expulsion
 Contains a cup, shaft, handle and vacuum generator

Advantages compared to forceps delivery

 Avoidance of insertion into the vagina of space occupying
blades
 No requirements for head position
 Less maternal trauma

Indications, Contraindications & Pre-requisites

 Same as forceps EXCEPT THAT IT CAN NOT BE USED IN
Figure 5. Simpson Forceps. FACE PRESENTATION OR FETAL COAGULOPATHY 

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Technique (lifted from 2019B)  On Leopold’s Maneuver: 
 Important step is proper cup placement over flexion point  o L1: Hard, round fetal head occupies the fundus
o Use of a rigid or soft cup placed 3 cm in front of the o L2: Fetal back on one side, small parts on the other side
posterior fontanel centering in the sagittal sutures o L3: If not engaged, the softer breech is movable above the
o A vacuum is then generated from the machine slowly up to pelvic inlet
600 mmHg creating a chignon (artificial caput on fetal o L4: After engagement, shows the breech below the
head) symphysis
o Traction is then applied with each uterine contraction until o The accuracy of this varies, thus sonographic evaluation is
the baby’s jaw becomes visible at the introitus indicated 

Failed Vacuum Extraction

 Abandon procedure when there is NO descent of the head
despite adequate traction or if the cup dislodges 3 times

Complications (mostly fetal)

 Scalp laceration & bruising
 Subgleal hematomas
 Cephalhematomas
 Intracranial hemorrhage
Figure 8. Incomplete Breech Presentation
III. BREECH DELIVERY
A. Classifications B. Predisposing Factors:
1. Frank Breech  Early gestational age
 Type of breech wherein the lower extremities are flexed at the  Extremes of amniotic fluid (poly/oligo-hydramnios)
hips and extended at the knees, and thus the feet lie in close  Multifetal pregnancy
proximity to the head  Hydrocephalus – wherein the larger head will occupy the bigger
or wider area (fundus) 
 Anencephaly
 Structural uterine abnormalities
 Placenta previa
 Pelvic tumors
 Prior breech delivery

C. Methods of Vaginal Delivery

1. Spontaneous Delivery
 The fetus is expelled entirely needing only a support
Figure 6. Frank Breech presentation
 Fetus is expelled entirely spontaneously without any traction or
2. Complete Breech manipulation other than support of the newborn 

 Both hips are flexed and one or both knees are also flexed.
2. Partial Breech Extraction
 Spontaneous delivery up to the umbilicus and the rest of the
fetal body is delivered with assisted maneuvers and traction
 Fetus is delivered spontaneously as far as the umbilicus, but
the rest of the body is extracted or delivered with operator
traction and assisted maneuvers, with or without maternal
expulsive efforts 

3. Total Breech Extraction

 The entire body is extracted by the obstetrician
Figure 7. Complete Breech Presentation

3. Incomplete Breech
 One or both hips are extended and one or both feet/knees lie
below the breech, such that a foot or knee is lowermost in
the birth canal
 Footling breech:
o A type of incomplete breech in which one or both feet are
below the breech
o Increased risk of cord prolapse

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 A video was shown in class made by Dra. Tongco and
Dr.Tarroza demonstrating a breech delivery:
1. See the descent of the baby noting the lower extremities &
the sacrum
2. Lower extremities pulled out first and are covered with a
wet towel
3. Delivery of the anterior shoulder
4. Then rotating 180 degrees to deliver the posterior arm
5. For the delivery of the head Mauriceau Maneuver is done

What method of vaginal delivery was observed [in the video]?

Partial Breech Extraction because we waited for the
umbilicus to be delivered before doing maneuvers and
traction.

D. Complications
1. Maternal Figure 9. (left/A) Delivery of the aftercoming fetal head using the
 Genital tract lacerations Mauriceau maneuver. Note that as the fetal head is being
 Uterine rupture due to maneuvers delivered, flexion of the head is maintained by suprapubic pressure
 Episiotomy extensions and tears provided by an assistant. (right/B) Pressure on the maxilla is applied
 Postpartum hemorrhage with uterine atony simultaneously by the operator as upward and outward traction is
 Postpartum infection exerted.

2. Fetal 2. Modified Prague Maneuver

 4x higher compared to NSD due to:  Used for persistent back-down fetuses (Rarely, the back of
o Associated conditions the fetus fails to rotate to the anterior )
o Preterm delivery  2 fingers of one hand grasping the fetal shoulders from below
o Congenital anomalies while the feet are drawn upwards towards the maternal
o Birth trauma (from manipulations) abdomen by the other hand
 Fractured femur or clavicle
 Brachial plexus palsy
 Specific causes of perinatal deaths include:
o Head entrapment
o Cerebral injury
o Intracranial hemorrhage
o Cord prolapse and asphyxia

E. Delivery of the aftercoming head

1. Mauriceau Maneuver
 2 fingers are placed on the maxillary prominence beside the
nose, 2 fingers on the fetal shoulders while an assistant is
applying gentle suprapubic pressure (this helps to keep the Figure 10. Modified Prague Maneuver. Indicated when the fetal
head flexed ) trunk fails to rotate anteriorly
 The index and middle finger of one hand are applied over the If the maneuvers fail, use Piper forceps
maxilla in order to flex the head, while the fetal body rests on
the palm of the hand and forearm. The operator’s forearm is F. Head Entrapment
straddled by fetal legs. Two fingers of the other hand are  It is an EMERGENCY!
hooked over the fetal neck, grasping the shoulders wherein  Reflects an incomplete dilated cervix, especially with a small
there is downward traction concurrently applied until the preterm fetus or cephalopelvic disproportion (CPD)
suboccipital region can be seen under the symphysis  Significant CORD COMPRESSION is noted thus time
 Downward traction is applied until the fetal suboccipital region is management is essential
delivered. This is followed by the elevation of the fetal body
towards the maternal abdomen and the mouth, nose, brows and 1. Maneuvers:
finally the occiput emerge over the perineum  Gentle traction on the fetal body, the cervix, at times, may be
manually slipped over the occiput. If this cannot be done
perform Duhrssen incisions.
 DUHRSSEN INCISION: Incision on the cervix at 2 o’clock, 10
o’clock positions (it may be necessary at times to add an
incision at 6 o’clock position)

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 o Incisions are so placed as to minimize bleeding from the
laterally located cervical branches of the uterine artery

Figure 12. Abdominal Incision Types

 Incidence rate significantly increasing due to the following

Figure 11. Duhrssen Incision. reasons:
o Women opting to have fewer children, thus most births are
“Because of the alarmingly high morbidity and mortality in nulliparas (greater CS risk)
breech vaginal delivery. ACOG states that EXCEPT FOR o More older women having their first pregnancies
CASES OF ADVANCED LABOR AND IMMINENT DELIVERY, o Widespread use of fetal monitoring and more non-
women with term breech should undergo a PLANNED reassuring FHR (lowered threshold for CS)
CESAREAN SECTION” o Most breech fetuses are delivered by CS
-ACOG #265 (2001) o Decrease in the incidence of forceps and vacuum
deliveries
IV. CESAREAN DELIVERY o Increased labor induction
o Prevalence of obesity
 Birth of a fetus via: laparotomy and then hysterectomy
o Increased rate of CS in preeclampsia
o Decrease in VBAC
Laparotomy (Abdominal Incision)
o Widening indications for elective CS
 Transverse Abdominal Entry
o Rise in malpractice litigations
o Pfannenstiel
 Suprapubic Transverse/ “Bikini cut”
Specific Indications for Cesarean Delivery
 Incision is low, transverse, slightly curvilinear
 Became popular in the past decade for cosmetic  Large fetus (> 4000 gms)  Healthy and viable
reasons  Any degree of pelvic preterm that needs to be
contraction or unfavorable delivered
 Discouraged if a large operating space is essential
shape of pelvis  Severe fetal growth
or access to the upper abdomen may be needed  Hyperextended head restriction
o Maylard Incision (stargazer fetus)  Previous perinatal death
 Bellies of the rectus abdominis muscles are  Indicated delivery in the or a child suffering from
transected horizontally to widen the operating space absence of labor birth trauma
 More difficult due to its required isolation and ligation  Uterine dysfunction  Request for sterilization
of the inferior epigastric arteries which lie lateral to  Incomplete or footling  Patient’s choice
these muscle bellies breech  Lack of experienced
operator
 Main disadvantage: more painful incision for the
patient during the 1st postoperative week
Table 4. Some Other Indications for Cesarean Delivery
 Midline Vertical Incision
MATERNAL
o Preferred during emergency cases because it is faster
Prior cesarean delivery
and easier to perform
Abnormal placentation
Maternal request
Hysterotomy (Uterine Incision)
Prior classical hysterotomy
 Low Transverse Incision
Unknown uterine scar type
o Preferred incision
Uterine incision dehiscence
o Easier to repair and causes less incision-site bleeding
Prior full-thickness myomectomy
o Promotes less bowel or omentum adherence to the
Genital tract obstructive mass
myometrial incision
Invasive cervical cancer
 Classical Cesarean Incision
Prior trachelectomy
o Prone to rupture in subsequent pregnancies
Permanent cerclage
o Indications:
Prior pelvic reconstructive surgery
 Densely adherent bladder from previous surgery
Pelvic deformity
 Myoma occupying lower uterine segment
HSV or HIV infection
 Placenta previa with anteriorly located placenta
Cardiac or pulmonary disease
 Transverse lie fetus (back-down)
Cerebral aneurysm or arteriovenous malformation

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 Pathology requiring concurrent intraabdominal surgery Some Factors for Consideration in Selection of Candidates for
Perimortem cesarean delivery Vaginal Birth after Cesarean Delivery (VBAC)
MATERNOFETAL  One previous prior low-transverse cesarean delivery
Cephalopelvic disproportion  Clinically adequate pelvis
Failed operative vaginal delivery  No other uterine scars or previous rupture
Placenta previa or placental abruption  Physician immediately available throughout active labor capable
FETAL of monitoring labor and performing an emergency cesarean
Nonreassuring fetal status delivery
Malpresentation  Availability of anesthesia and personnel for emergency
Macrosomia cesarean delivery
Congenital anomaly  If your patient had a history of classical CS, she cannot undergo
Abnormal umbilical cord Doppler study VBAC because it has higher risk of uterine rupture
Thrombocytopenia
Prior neonatal birth trauma Complications
 MATERNAL
But the most common indication for CS is still dystocia or  Uterine rupture
cephalopelvic disproportion  Hemorrhage
 Hysterectomy
Morbidity  Operative injury
Maternal  Transfusions
 Maternal morbidity increases 2-fold with CS relative to vaginal
delivery (2° to infection, hemorrhage, thromboembolism) FETAL
 Anesthetic complications, which rarely includes death  Hypoxic Ischemic Encephalopathy and perinatal death (11x
 Most likely to be delivered via repeat operation on subsequent greater that repeat CS)
pregnancies (entails greater maternal risk)
 ADVANTAGES: Lower rates of urinary incontinence and pelvic Precautions
organ prolapse  Careful selection of candidates
 Judicious use of oxytocin for augmentation of labor (risk of
Fetal uterine rupture)
 Lower rate of fetal trauma  Routine uterine scar exploration after delivery
 Cesarean following a failed operative delivery attempt had
highest injury rate, whereas lowest rate occurred in elective CS VII. UTERINE RUPTURE
delivery group (0.5%) Classification
 Higher asthma and allergy rates in those delivered by CS  Complete
o All uterine layers of myometrium separated
V. PERIPARTUM HYSTERECTOMY  Incomplete or dehiscence
 Indications – to arrest or prevent hemorrhage from: o Uterine muscle separate but viscera peritoneum is intact
o Intractable uterine atony or abnormal placentation
o Uterine rupture Diagnosis
o Large myomas  Non-reassuring fetal heart rate pattern (most common)
o Severe cervical dysplasia  Maternal hypovolemia
 Complications  Loss of station of presenting part
o Greater blood loss  Abdominal palpation will detect fetal parts alongside with
o Risk of urinary tract damage contracted uterus
 Techniques
o Supracervical Hysterectomy Management
 Amputation of uterus just above the uterine artery  Suture repair
ligation o Opted in incomplete rupture and existence of need for
 Easier and faster to do thus minimizing blood loss. uterine preservation
 Enough to control bleeding in most situations o Prone to recurrent uterine rupture
o Total Hysterectomy  Hysterectomy
 Mostly planned o Done in complete rupture
 More difficult and bloody
REFERENCES
VI. VAGINAL BIRTH AFTER CESAREAN SECTION 1. Dra. Tarroza’s Powerpoint and Lecture Notes
 The practice of VBAC has had its rise in 1996 when trail of labor 2. Recordings
was considered a big leap in the management of prior C section 3. 2019B trans
4. Williams Obstetrics, 25th Edition
delivery but suffered a sharp decline in popularity after a
decade due to patient preference and rising litigation.

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 QUIZ
1. What is the degree of perineal laceration where there are tears 9. What is the most appropriate anesthesia in a cardiac patient in
involving the perineal skin, mucosa, fascia, and muscles with the 2nd stage of labor and in whom the plan of delivery is either
injury to the external anal sphincter? outlet forceps or vacuum extraction?
a. 1st a. Epidural
b. 2nd b. Local infiltration of the vulva
c. 3rd c. Low spinal block
d. 4th d. Pudendal block

2. What is the mechanism involved in the technique of Mauriceau 10. Which condition will qualify for trial of labor for vaginal birth after
maneuver in the facilitation of the delivery of the aftercoming cesarean section?
head of the breech? a. Not more than 2 previous CS
a. Keep the head flexed in a back up position b. Previous Classical cesarean delivery
b. Keep the head extended in a back up position c. Previous CS for fetal distress
c. Keep the head flexed in a back down position d. Previous CS for dystocia
d. Keep the head extended in a back down position

3. What is the management for difficult delivery of the aftercoming

head of a baby in breech due to an incompletely dilated cervix?
a. Duhrssen’s incision on the cervix
b. Extraction of the fetal head by Pipers forceps
c. Replace the fetus into the uterus and emergency cesarean
d. Slipping the lips of the cervix over the occiput

4. Which of the following is a prerequisite for safe vaginal delivery

of baby in breech presentation?
a. Incomplete breech
b. Multiparity
c. Preterm fetus
d. Previous VBA

5. A 29 year old G1P0, term, is on the second stage of labor. IE =

fully dilated, cephalic, St+4/5, LOA, ruptured bag of waters. She
is tired and dehydrated. What type of forceps delivery will be
performed at this time?
a. High
b. Mid
c. Low
d. Outlet

6. What is the sole advantage of a mediolateral episiotomy over

midline incision?
a. Easy Repair
b. Faster healing
c. Less bleeding
d. Less extension

7. During the delivery of the placenta, fundal pressure and

excessive cord traction were applied by the midwife prior to
signs of placental separation. What is the most serious
complication that can happen?
a. Cord avulsion
b. Retention of placental fragments
c. Uterine inversion
d. Uterine rupture

8. A 22 year old, term primigravid was admitted with a large for

gestational age fetus in neglected transverse lie. What is the
most appropriate abdominal incision for a cesarean delivery?
a. Joel-Cohen, Mislav-Ladach incision
b. Midline vertical
c. Paramedian vertical
d. Suprapubic transverse (Pfannenstiel)

Answer key: 1C, 2A, 3A, 4B, 5D, 6D, 7C, 8B, 9D, 10C

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