Editorial

The Ritgen Maneuver

Another Sacred Cow Questioned

F. Gary Cunningham, MD

See related article on page 212.

Dr. Cunningham is from the Department of Obstetrics and Gynecology at the University of Texas Southwestern Medical Center at Dallas, Dallas, Texas; e-mail: gary.cunningham@utsouthwestern. edu. Dr. Cunningham is also a co-editor of Williams Obstetrics. 2008 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/08

erdinand August Marie Franz von Ritgen (17871867) was a German physician who is credited with the perineum-sparing maneuver that bears his name.1 In the first edition of Williams Obstetrics,2 the maneuver is described as follows: . . . in an interval between the pains . . . two fingers are applied just behind the anus, and forward and upward pressure is made upon the brow through the perinaeum (Fig. 1). This modified maneuver differed slightly from the original description, which instructed that towel-covered fingers be placed into the rectum. With either, the head is delivered before the next contraction, with the intent of preventing perineal tearing. The modified method was described through the 14th edition of Williams Obstetrics, but beginning with the 15th edition,3 and continuing through today, the Ritgen maneuver is described as being applied during a contraction. Regardless of whether it is applied between or during a contraction, the maneuver undoubtedly has been taught to literally millions of accoucheurs since its description by Ritgen more than 150 years ago. In this issue of Obstetrics & Gynecology, Rubin Jnsson and colleagues4 describe the results of their randomized trial to evaluate the modified Ritgen maneuver, ie, during a contraction, and compared it with simple perineal support to prevent anal sphincter tears. In more than 1,400 nulliparous Swedish women randomized at the beginning of second-stage labor, the authors observed a nonsignificant difference of 5.5% compared with 4.4% sphincter tears with and without performance of the Ritgen maneuver, respectively. These observations are important because they add to the ever-increasing evidence-based outcomes for the practice of obstetrics. At the same time, we must feel some loss of another sacred cow, as most of us were taught the Ritgen maneuver because we have always done it this way. There is likely more to this story than the end of the Ritgen era. As many well-designed studies do, this one raises the specter of the need for further studies. For example, and as mentioned by the investigators, there will be those who will defend use of the Ritgen maneuver as originally described as performed between contractions. To them I would say, Go for it. Do the randomized trial because the study by Rubin Jnsson et al4 indicates that there is still a clinical problem to be solvedanal sphincter laceration suffered at delivery. In their study, about 5% of nulliparous women had such a complication and thus will endure some of the attendant long-term sequelae, which includes sexual dysfunction and anal incontinence. These and other sequelae of routine childbirth have been brought to the fore along with the renaissance of the heavily evidencebased subspecialty of female urogynecology. This is exemplified by creation by the National Institute of Child Health and Human Development of the Pelvic Floor Disorders Network5 as well as other initiatives to study these vexing complications.

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incidence? And if forceps beget lacerations and epidural analgesia begets forceps, can we assume that epidural analgesia begets lacerations? Put another way, will the provision of elegant pain relief for labor become an ironic reason for jumping on the bandwagon for cesarean delivery on maternal request?9 More studies such as the one by Rubin Jnsson and her colleagues4 need to be designed to find a new Ritgen maneuver that prevents some of these adverse outcomes. REFERENCES
Fig. 1. Delivery by the modified Ritgen maneuver. The arrow indicates the direction of moderate pressure applied by the posterior hand. Hellman LM, Pritchard JA. Williams obstetrics. 14th ed. New York (NY): Appleton-CenturyCrofts; 1971. Reproduced with permission from The McGraw Hill Companies.
Cunningham. Randomized Trial to Study the Ritgen Maneuver. Obstet Gynecol 2008. 1. Ritgen FAMFcR. Ueber ein Dammschutzverfahren. Monatsschr. f. Geburtsk. 1855;vi:32147. 2. Williams JW. Obstetricsa text-book for use of students and practitioners. New York (NY): D. Appleton and Co.; 1903. p. 288. 3. Hellman LM, Pritchard JA. Williams Obstetrics. 14th ed. New York (NY): Appleton-Century-Crofts; 1971. p. 4123. 4. Rubin Jnsson E, Elfaghi I, Rydhstrm H, Herbst A. Modified Ritgens maneuver for anal sphincter injury at delivery: a randomized controlled trial. Obstet Gynecol 2008;112:2127. 5. Brubaker L, Handa VL, Bradley CS, Connolly A, Moalli P, Brown MB, et al. Sexual function 6 months after first delivery. Obstet Gynecol 2008;111:10404. 6. Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol 2001;98:22530. 7. Dandolu V, Chatwani A, Harmanli O, Floro C, Gaughan JP, Hernandez E. Risk factors for obstetrical anal sphincter lacerations. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:3047. 8. Lowder JL, Burrows LJ, Krohn MA, Weber AM. Risk factors for primary and subsequent anal sphincter lacerations: a comparison of cohorts by parity and prior mode of delivery. Am J Obstet Gynecol 2007;196:344.e15. 9. National Institutes of Health state-of-the-science conference statement: cesarean delivery on maternal request March 2729, 2006. Obstet Gynecol 2006;107:138697.

Questions to be posed include: Why are there such relatively high rates of childbirth-related anal tears? And why are the variations between populations and institutions so varied, even after confounding factors are controlled? Importantly, what can be done to decrease their incidence? The incidence cited for sphincter lacerations was 5.8% in more than 2 million women delivered in California,6 7.3% in more than 250,000 women delivered in Philadelphia,7 and 16% in more than 13,000 nulliparas delivered in Pittsburgh.8 Even after the confounding factors known to increase lacerations are considered, these variations are nonsensical. Can we learn more to decrease their

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