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Management of normal labor and delivery

Authors:
Edmund F Funai, MD
Errol R Norwitz, MD, PhD, MBA
Section Editor:
Charles J Lockwood, MD, MHCM
Deputy Editor:
Vanessa A Barss, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Nov 04, 2016.

INTRODUCTION — The World Health Organization (WHO) defines normal birth as "spontaneous in onset, low-risk at the start of labor and
remaining so throughout labor and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of
pregnancy. After birth, mother and infant are in good condition" [1].

This topic will present a paradigm for intrapartum management of women who are expected to have a normal birth. Many of the options for
managing these women have not been studied in clinical trials or the data from clinical trials are insufficient for making strong
recommendations for a specific approach [2]. Therefore, much of our approach is based upon our clinical experience, data from
observational studies, and expert opinion.

Management of women with complicated labor and delivery is discussed in separate topic reviews (eg, malpresentation, protraction and
arrest disorders, preterm labor, operative vaginal delivery, maternal medical/obstetrical disorders, hemorrhage) (refer to individual topic
reviews on each subject).

PREPARATION — Four factors important in determining a woman's satisfaction with her childbirth experience are personal expectations, the
amount of support she receives, the quality of the caregiver-patient relationship, and her involvement in decision-making. Childbirth
education classes inform women and their partners about what to expect during labor and birth and provide a foundation for developing
personal plans for the birth experience. (See "Preparation for labor and childbirth".)

One-on-one support by a doula during the birthing process may lower intrapartum analgesia requirements, decrease the rate of operative
delivery, and increase satisfaction with the birth experience. (See "Continuous labor support by a doula".)

WHEN SHOULD LABORING WOMEN BE ADMITTED TO THE HOSPITAL — The appropriate time for hospital admission for women in
labor with uncomplicated pregnancies is unclear. There is consensus that women in active labor should be admitted; cervical dilation ≥4 cm
is one common threshold in research studies since most women enter the active phase of labor at 4 to 6 cm. Given that women cannot
check their cervical dilation, many women will present for a labor check before cervical dilation reaches 4 cm. If mother and fetus are well
and transport to the hospital is not a concern, should these patients be admitted to the Labor and Delivery Unit or sent home? Both
approaches are probably reasonable. Although women admitted before 4 cm cervical dilation are at higher risk for iatrogenic intervention, the
maternal and perinatal consequences of sending these patients home have not been studied adequately.

In Washington State, the Bree Collaborative Obstetrics Care Report attempted to influence clinical practice by recommending admission for
spontaneously laboring women at term with uncomplicated pregnancies only when cervical dilation was ≥4 cm [3]. The clinician determined
whether the pregnancy was low-risk, as well as appropriate counseling and reassessment of women not admitted. Adherence to the
recommendation was not mandatory. A retrospective cohort study of over 11,000 singleton, term deliveries in Washington State after this
report observed a 10 to 15 percent increase in hospital admission at cervical dilation ≥4 cm [4]. Women admitted with cervical dilation <4 cm
were more likely to have epidural anesthesia, oxytocin augmentation, and a cesarean delivery than women admitted with cervical dilation ≥4
cm. The authors were unable to identify women evaluated for labor, sent home because of cervical dilation <4 cm, and subsequently
admitted, thus the safety and efficacy of this approach could not be evaluated.

MANAGEMENT OF THE FIRST STAGE OF LABOR

Initial examination — The goals of the initial examination of the parturient are to review her prenatal record for medical or obstetrical
conditions that need to be addressed intrapartum, check for development of new disorders since the last prenatal visit, establish baseline
cervical status so that subsequent progress can be determined, and evaluate fetal status.
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On admission to the labor unit, vital signs include the woman's blood pressure; heart and respiratory rates; temperature; weight; frequency,
quality, and duration of uterine contractions; and fetal heart rate (FHR).

Determining whether a woman is in labor is sometimes difficult as painful uterine contractions alone are not sufficient to establish a diagnosis
of labor. Typically, the diagnosis is reserved for uterine contractions that result in cervical dilation and effacement over time. A recent history
of membrane rupture or bloody show (vaginal discharge of a small amount of blood and mucus [ie, mucus plug]) supports the diagnosis.

Physical examination is performed with particular emphasis on the cervical examination. Digital examination is performed after placenta
previa and preterm premature rupture of membranes (PPROM) have been excluded (by history and physical, laboratory, and ultrasound
examinations, as appropriate).

The purpose of the initial examination is to determine:

●Whether fetal membranes are intact or ruptured – (See "Management of premature rupture of the fetal membranes at term".)
If the membranes have ruptured, the presence of meconium is noted because of the possibility of meconium aspiration. (See "Clinical
features and diagnosis of meconium aspiration syndrome".)
●Whether uterine bleeding is present and excessive – Placenta previa, vasa previa, and abruptio placenta can cause bleeding,
and these disorders are potentially life-threatening to the mother and/or fetus. (See "Clinical features, diagnosis, and course of
placenta previa"and "Velamentous umbilical cord insertion and vasa previa" and "Placental abruption: Clinical features and
diagnosis".)
●Cervical dilation and effacement – In women with contractions, progressive cervical dilation and effacement on serial
examinations or advanced cervical dilation and effacement on an initial examination is evidence of labor. Cervical dilation is faster
after the cervix is completely effaced. [5]
●Fetal station – Fetal station is expressed as the number of centimeters of the leading bony edge of the presenting part above or
below the level of the ischial spines (figure 1); the maximum denominator is 5 (eg, 1 cm beyond the ischial spines corresponds
to +1/5 cm). Effacement and station are shown in the figures (figure 2A-B). An older system described fetal descent by dividing the
distance from the ischial spines to pelvic outlet into thirds. Using this system, station +1/3 corresponds to +2/5 cm in the centimeter
system. This assessment has largely been abandoned because it is even more subjective than the centimeter system and makes it
difficult to document small, but clinically significant, degrees of descent.
If a cervical examination is not performed because of ruptured membranes or vaginal bleeding, fetal descent can also be described in
terms of fifths of the fetal head palpable above the symphysis pubis [6]. This method is also useful if there is significant molding
(change in shape of the fetal skull) or caput (edema of the portion of the fetal scalp overlying the cervical opening) raising concerns
about cephalopelvic disproportion.
●Fetal lie, presentation, and position – Document fetal lie, presentation, and position. Lie refers to the long axis of the fetus relative
to the longitudinal axis of the uterus; it can be longitudinal, transverse, or oblique.
Presentation refers to the fetal part that directly overlies the pelvic inlet; it is usually vertex (head) or breech (butt), but can be a
shoulder, compound (eg, vertex and hand), or funic (umbilical cord).
Fetal position is the relationship of a nominated site of the presenting part to a denominating location on the maternal pelvis, eg, right
occiput anterior. The fontanelles and suture lines of the fetal skull and their orientation according to fetal position are illustrated in the
figures (figure 3 and figure 4A-C and figure 5 and figure 6). Ultrasound examination can be useful if digital assessment is unclear,
particularly for occiput posterior [7-9]. (See "Occiput posterior position", section on 'Diagnosis'.)
Asynclitism refers to an oblique position of the fetal head where the head is tilted toward the shoulder and the parietal bone is the
point of presentation.
●Fetal size and pelvic capacity – The clinician should make an attempt to determine whether the fetus is macrosomic, the pelvic
type (figure 1), and whether the pelvis is contracted; however, these assessments are poorly predictive of the course of labor.
(See "Shoulder dystocia: Risk factors and planning delivery of at risk pregnancies".)
Pelvimetry (ie, quantitative measurement of pelvic capacity) can be performed clinically or via imaging studies (radiography,
computed tomography, magnetic resonance imaging (figure 7A-B) [10-12]). Average and critical limit values for the various
parameters of the bony pelvis have been established but do not accurately predict women at risk for cephalopelvic disproportion [13].
Pelvimetry has been replaced, in large part, by clinical trial of the pelvis ("trial of labor").
●Fetal and maternal well-being – Fetal status is assessed by the FHR pattern (see "Intrapartum fetal heart rate assessment").
Maternal assessment is primarily directed toward identifying development of new pregnancy complications, such as preeclampsia or
infection.

Laboratory tests — Results from the following laboratory tests should be available at delivery, but intrapartum assessment is not always
necessary.
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●Hemoglobin/hematocrit – Although laboratory assessment of hemoglobin/hematocrit is commonly performed upon admission,

there is no evidence that this practice is necessary in uncomplicated pregnancies. Relying on a normal hemoglobin result obtained at
26 to 28 weeks (ie, at the time of screening for gestational diabetes) appears to be a safe and acceptable approach [14,15].
●Blood type and screen – Rhesus (Rh) typing with a negative antibody screen at the first prenatal visit is probably adequate for
women at low risk of postpartum hemorrhage [16-19]. A reasonable approach is to type and screen women at moderate risk of
needing a transfusion (eg, multiple gestation, trial of labor after cesarean, preeclampsia/HELLP [Hemolysis, Elevated Liver enzymes,
Low Platelet count] without coagulopathy, grand multiparity, intraamniotic infection, large fibroids) and type and crossmatch women at
high risk of needing a transfusion (eg, placenta previa or accreta, preeclampsia/HELLP with coagulopathy, severe anemia, congenital
or acquired bleeding diathesis) [20]. Holding a clot may be sufficient for women at low risk of hemorrhage.
●Human immunodeficiency virus (HIV) – Women who have not had HIV screening in pregnancy or whose HIV status is
undocumented should be offered rapid HIV testing in labor [21,22]. Some states require all women be screened at delivery. If the
rapid test is positive, then antiretroviral prophylaxis should be initiated while waiting for the results of confirmatory testing.
(See "Prenatal evaluation of the HIV-infected woman in resource-rich settings" and "Antiretroviral and intrapartum management of
pregnant HIV-infected women and their infants in resource-rich settings".)
●Hepatitis B – Women who were not screened for hepatitis B surface antigen prenatally, or engage in behaviors that put them at
high risk for infection (eg, having had more than one sex partner in the previous six months, evaluation or treatment for a sexually
transmitted infection, recent or current injection-drug use, a hepatitis B antigen-positive sex partner), or have clinical hepatitis should
be tested at hospital admission for delivery [21]. Some states require all women be screened at delivery. The infant should receive
immunoprophylaxis if the results are positive. (See "Hepatitis B virus immunization in infants, children, and adolescents", section on
'HBsAg-positive mother'.)
●Syphilis – Women who are at high risk for syphilis, live in areas of high syphilis morbidity, or are previously untested should be
screened at delivery [21]. Some states require all women be screened at delivery. (See "Syphilis in pregnancy".)
●Group B streptococcus – Women with unknown group B streptococcus (GBS) status can be tested with a nucleic acid
amplification tests (NAAT), such as polymerase chain reaction for GBS, where available. However, such testing is less reliable than
routine GBS screening at 35 to 37 weeks. Chemoprophylaxis is indicated if NAAT is positive, or if the GBS carrier status is unknown
but intrapartum risk factors for early-onset GBS infection develop (delivery at <37 weeks gestation, temperature ≥100.4ºF [≥38.0ºC] or
rupture of amniotic membranes ≥18 hours). (See "Neonatal group B streptococcal disease: Prevention", section on 'Rapid diagnostic
tests'.)

Patient preparation — Meta-analyses of randomized trials support avoidance of routine enemas and perineal shaving as these
interventions are not beneficial and have bothersome or harmful side effects [23,24]. Women can be encouraged to empty their bladder
regularly; a urinary catheter is unnecessary unless the woman is unable to void. Available data suggest that bladder distention does not
affect labor progress [25,26].

Fluids and oral intake — Historically, oral intake has been restricted during active labor because of the risk of aspiration pneumonitis, a
major cause of anesthetic-associated morbidity and mortality. However, this risk is very low in the current era and restriction of oral intake
can lead to dehydration and ketosis. We allow clear liquids to women at low risk of cesarean delivery, but restrict consumption of solid foods
in accord with guidelines by the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists Task
Force on Obstetric Anesthesia that recommend avoidance of solid foods in laboring women [27,28].

We provide maintenance intravenous fluids with 5 percent dextrose or 5 percent dextrose in 0.45 percent saline if oral intake is inadequate
[29,30]. Glucose requirements in labor are analogous to the requirement observed with sustained and vigorous exercise. Intrapartum
administration of glucose may also be important for optimal myometrial function [29], although a clear effect on progress of labor has not
been reported [29,31].

Dehydration adversely affects exercise performance and may be a factor contributing to longer duration of labor. Physiologists have shown
that hydration improves skeletal muscle performance during prolonged exercise; however, the effects of hydration on smooth muscle are less
clear [32,33]. Among nulliparous women not allowed oral intake during labor, a meta-analysis of two randomized trials found that the duration
of labor may be shortened by administration of intravenous fluids at a rate of 250 mL/hour rather than 125 mL/hour [31]. When oral intake is
not restricted, the benefit is less clear.

Although a 2013 systematic review of randomized trials found no benefits or harms associated with restricting access to fluids and foods
during labor for women at low risk of requiring a general anaesthetic (five trials, over 3100 women), a key outcome, aspiration rate, could not
be assessed because so few events occurred; another important outcome, maternal satisfaction, was not assessed [34]. In a 2016
systematic review, small quantities of oral carbohydrate intake during labor did not affect rates of oxytocin augmentation, cesarean or
instrumental vaginal delivery, vomiting, or length of labor, compared with placebo or standard care [35]. The effect of significant oral
carbohydrate intake on labor remains unclear as the mean difference between the intervention and control groups was only 195 kcal and the
overall quality of available data was low.
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Antacids — We do not routinely administer sodium citrate to our laboring patients, but give it to all patients before cesarean delivery. Some
authors have suggested administering a clear antacid (eg, 10 to 30 mL sodium citrate) to all laboring women since aspiration pneumonitis
results from the acidity of the aspirated gastric contents; however, the utility of this approach in laboring women has not been proven [36].

Medication management — Women can take their usual daily medications orally during labor; however, gastric absorption is unpredictable
if labor is advanced. If this is a clinically important concern, an alternate route of administration is preferable.

Women who have been taking glucocorticoids in a dose equivalent to prednisone 5 to 20 mg daily for more than three weeks may have
hypothalamic-pituitary-adrenal axis suppression and either should undergo testing or receive empiric glucocorticoid coverage. Perioperative
management of specific medications, including glucocorticoid coverage, is reviewed separately. (See "Perioperative medication
management".)

Infection prophylaxis

Systemic antibiotics — Intrapartum chemoprophylaxis to prevent early-onset neonatal GBS infection is indicated for patients who meet
standard criteria; the agent of choice is intravenous penicillin. A minimum of four hours of intrapartum therapy has been recommended prior
to delivery; however, bactericidal levels in cord blood are achieved within 30 minutes of administration to the mother so antibiotics should be
administered even if delivery seems imminent. (See "Neonatal group B streptococcal disease: Prevention".)

Vaginal delivery is not an indication for routine antibiotic prophylaxis, even in women with cardiac lesions, since the rate of bacteremia is low.
This issue is discussed in more detail separately. (See "Antimicrobial prophylaxis for bacterial endocarditis", section on 'Vaginal or cesarean
delivery'.)

Vaginal antiseptic antibacterial agents — Available data provide no convincing evidence to support the practice of
intrapartumchlorhexidine vaginal irrigation for reducing the risk of maternal and neonatal infection [37].

Maternal activity and position — Maternal preferences can guide maternal activity. In a randomized trial, walking during the first stage did
not enhance or impair active labor and had no harmful effects [38].

Laboring women should assume positions that are comfortable [39,40], unless specific positions are needed because of maternal-fetal status
and need for close monitoring. Data from randomized trials provide no strong evidence to discourage maternal preference for choosing
position during labor.

In a 2013 meta-analysis including 25 trials (5218 women), the duration of the first stage was more than one hour shorter in women randomly
assigned to upright positions (standing, sitting, kneeling, walking around) than in those randomly assigned to recumbent positions or bed
care (-1.36 hours, 95% CI -2.22 to -0.51 hours) and women in upright positions had a modest reduction in cesarean delivery (relative risk
[RR] 0.71, 95% CI 0.54-0.94), but there were no statistical differences in use of oxytocin augmentation (RR 0.89, 95% CI 0.76-1.05),
maternal pain requiring analgesia (RR 0.95, 95% CI 0.84-1.08), or duration of the second stage (-3.71 minutes, 95% CI -9.37-1.94 minutes)
[40]. Some limitations of these trials include risk of bias since blinding was not possible and wide variation in the patients' positions and time
spent in various positions.

A 2013 meta-analysis of five randomized trials on the effect of upright versus recumbent position in the second stage of labor in women with
epidural analgesia found no conclusive evidence that position affected the rate of operative delivery, duration of the second stage, or any
other maternal or fetal outcome [39].

Pain control — Multiple nonpharmacologic, pharmacologic, and anesthetic options are available to help women manage pain during labor.
These options are reviewed in detail separately. (See "Nonpharmacologic approaches to management of labor pain" and "Pharmacologic
management of pain during labor and delivery" and "Neuraxial analgesia for labor and delivery (including instrumented delivery)".)

Amniotomy — We do not perform amniotomy routinely as there is no convincing evidence of benefit in spontaneously laboring women.
Rupture of membranes increases the risk of ascending infection and cord prolapse. In a 2013 systematic review and meta-analysis of
randomized trials, routine amniotomy did not shorten the first or second stage of labor or reduce the rate of cesarean delivery compared with
planned preservation of intact membranes (15 randomized trials involving over 5500 women) [41]. A limitation of this analysis was the lack of
consistency in the timing of amniotomy with respect to cervical dilation and substantial crossover: 20 to 60 percent of women assigned to the
control group underwent amniotomy at some stage in their labor. Although amniotomy allows assessment of meconium passage, this
information alone has poor prognostic value and does not affect labor management [42,43].

Women undergoing augmentation or induction of labor may benefit from the combination of oxytocin administration and amniotomy
(see"Induction of labor", section on 'Amniotomy'). If amniotomy is performed in women with polyhydramnios or an unengaged presenting
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part, we suggest using a small gauge needle (rather than a hook) to puncture the fetal membranes in one or more places and performing the
procedure in an operating room. "Controlled amniotomy" minimizes the risk of gushing amniotic fluid and permits emergency cesarean
delivery in the event of an umbilical cord prolapse. (See "Umbilical cord prolapse".)

Amniotomy should be avoided, if possible, in women with active hepatitis B, hepatitis C, or HIV infection to minimize exposing the fetus to
ascending infection. Positive GBS carrier status is not a contraindication to amniotomy, if indicated.

Monitoring — Frequent maternal-fetal assessment is important as intrapartum complications can arise rapidly even in low-risk women: 20 to
25 percent of all perinatal morbidity and mortality occurs in pregnancies with no underlying risk factors for adverse outcome [44] and a study
of 10 million birth certificates in the United States found that 29 percent of low-risk pregnancies had at least one unexpected complication
that would require non-routine obstetric or neonatal care [45].

Fetal heart rate — Although controversial, intrapartum electronic FHR monitoring has become the most common obstetric procedure for
women in the United States because patients and clinicians are reassured by normal results and believe there is some value in detecting
abnormal FHR patterns. In women with pregnancies at increased risk of fetal compromise during labor (eg, suspected fetal growth restriction,
preeclampsia, abruptio placenta, type 1 diabetes), we perform continuous electronic FHR monitoring, in agreement with clinical management
guidelines from the American College of Obstetricians and Gynecologists [46]. We also monitor low-risk pregnancies continuously because it
is more practical than intermittent monitoring in terms of nursing staff resources, but we are not rigid about this if the patient understands the
risks and benefits of intermittent monitoring and has an uncomplicated pregnancy, normal FHR tracing, and is not resting in bed. Intrapartum
FHR monitoring is reviewed in detail separately. (See "Intrapartum fetal heart rate assessment".)

Electronic FHR monitoring requires ongoing clinical assessment. At a minimum, the American College of Obstetricians and Gynecologists
suggests review of FHR tracings in low-risk pregnancies every 30 minutes in the first stage of labor and every 15 minutes in the second
stage [46]. For higher-risk pregnancies, they suggest reviewing the tracing every 15 minutes in the first stage and every five minutes in the
second stage. Closer assessment and intervention may be indicated when abnormalities are identified. (See "Management of intrapartum
category I, II, and III fetal heart rate tracings".)

The healthcare provider's interpretation of the tracing should be documented in the patient's medical record and should include a description
of the uterine contractions, baseline FHR rate, baseline FHR variability, presence or absence of accelerations, presence or absence of
periodic decelerations (ie, with contractions) or episodic decelerations (ie, unrelated to contractions), and changes in the FHR over time.

Uterine contractions — The frequency of contractions is documented as the number of contractions over a 30-minute period divided by
three to give the number of contractions per 10 minutes. If this number is not a whole number, it may be rounded. Tachysystole is defined as
>5 contractions per 10 minutes; any number greater than 5 (eg, 5.2) should be interpreted as tachysystole. Information about contraction
frequency, duration, and strength can help the clinician determine the cause of abnormal labor progression and interpret abnormal FHR
patterns. (See "Overview of normal labor and protraction and arrest disorders" and "Management of intrapartum category I, II, and III fetal
heart rate tracings" and "Induction of labor", section on 'Tachysystole'.)

External tocodynamometry is a noninvasive means for recording contraction frequency and duration, and provides adequate information for
most labors. If the tracing is inadequate, an internal pressure transducer can be placed to measure contraction frequency, duration, and
strength. (See "Use of intrauterine pressure catheters".)

Labor progress — Few randomized trials have evaluated the optimum frequency and timing of intrapartum vaginal examination of the
cervix, fetal position, and fetal descent [47]. In most women, we perform vaginal examinations:

●On admission
●At four-hour intervals in the first stage
●Prior to administering analgesia/anesthesia
●When the parturient feels the urge to push (to determine whether the cervix is fully dilated)
●At two-hour intervals in the second stage
●If FHR abnormalities occur (to evaluate for complications such as cord prolapse or uterine rupture)

The number of examinations is kept to a minimum for patient comfort and to minimize iatrogenically exposing the fetus to vaginal flora.
(See"Intra-amniotic infection (clinical chorioamnionitis or triple I)", section on 'Risk factors'.)

Assessing whether labor is progressing normally is a key component of intrapartum care; however, determining the onset of labor, measuring
its progress, and evaluating the factors (power, passenger, pelvis) that affect its course is an inexact science. Criteria for normal and
abnormal progress and management of protracted labor are discussed in detail separately. (See "Overview of normal labor and protraction
and arrest disorders".)
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Precipitate or precipitous labor and delivery refers to a rapid labor and delivery of the fetus, variously defined as expulsion of the fetus within
two to three hours of commencement of contractions [20,21]. It is rare and not well-studied.

MANAGEMENT OF THE SECOND STAGE OF LABOR

Persistent anterior cervical lip — In most women, the final centimeter of cervix anteriorly between the pelvic brim and the fetal head rapidly
disappears as the cervix fully dilates and the fetal head descends. Occasionally an anterior lip persists for >30 minutes and may indicate
malposition or a labor abnormality, especially if the lip becomes edematous.

We manage these patients expectantly and avoid manually reducing the anterior lip because of the risk of lacerating the cervix and
hemorrhage. However, with prolonged expectant management, cervical laceration, necrosis, or detachment of the lip may occur
spontaneously. If manual reduction is attempted, the cervical lip is pushed backwards during a contraction until it slips over the fetal head
and above the interior border of the symphysis pubis [48]. The cervix is gently held in this position until the fetal head descends with the next
contraction and maternal pushing.

Perineal care — Application of warm compresses and perineal massage with a lubricant have been proposed as means of softening and
stretching the perineum to reduce perineal trauma during birth. In a meta-analysis of randomized trials, applying warm compresses during
the second stage of labor reduced third- and fourth-degree tears compared with a hands off or no warm compress technique (RR 0.48, 95%
CI 0.28-0.84; two trials, n = 1525 women); performing massage also reduced third- and fourth-degree tears compared with
hands off/usual care (RR 0.52, 95% CI 0.29-0.94 (two trials, n = 2147 women) [49]. Antepartum perineal massage may also be helpful [50].

Although not harmful, we do not routinely advise antenatal perineal massage, perform second stage perineal massage, or apply warm
compresses as available trials suggesting a benefit have major methodologic limitations due to lack of blinding, differences in the provision of
usual care, and inability to address the importance of other factors related to perineal injury [49,50].

If used, warm compresses can be made from clean wash cloths or perineal pads immersed in warm tap water (up to 110 degrees Fahrenheit
[43 degrees Celsius]) and wrung to release excess water [51,52]. They are held against the mother’s perineum during and between pushes,
and changed as needed to maintain warmth and cleanliness. Perineal massage is performed during and between pushes with two fingers of
the lubricated gloved hand moving from side to side just inside the patient’s vagina and exerting mild, downward pressure.

Pushing — Most women begin pushing when the cervix is fully dilated. However, if the FHR tracing is normal and station is high, we often
ask women to delay pushing until the further descent has occurred to reduce the duration of time of maximal maternal exertion (ie, "laboring
down"). This decision is based on patient-specific factors, such as whether there is a need to expedite delivery, maternal fatigue, and
maternal preference. There are no strong data that one approach is better than another.

We have the patient push in the position she finds most comfortable. There is no convincing evidence of an optimal maternal position for
pushing [53,54]. Upright positions, including kneeling and sitting, have several theoretical benefits (eg, increase in pelvic dimensions, good
fetal alignment) and the supine position should be avoided because of aortocaval compression.

The optimum pushing technique is also unclear. We favor allowing the woman to bear down when she feels the need (ie, spontaneous
pushing or physiologic pushing), unless epidural anesthesia has inhibited the bearing down sensation. We advise against Valsalva pushing
(pushing with a closed glottis), as there is no clinically significant benefit to this technique [55]. Women are typically told to pull back their
knees, tuck in their chin, take a deep breath, bear down at the start of a contraction, and push for 10 seconds with the goal of three pushes
per contraction. However, there is no evidence that coaching women in this way has any benefit over allowing them to bear down and push
according to their own reflex needs in response to the pain of contractions and the pressure felt from descent of the fetal head [55].

A 2015 meta-analysis of pooled data from 20 randomized trials of different approaches to pushing reported the following major findings [56]:

●No difference in the length of the second stage when women follow their own instincts about breathing while pushing (spontaneous
pushing) versus asking them to take a deep breath at the beginning of a contraction and holding the breath as long as possible while
bearing down (directed pushing with Valsalva maneuver)
●In women with epidural analgesia, delayed pushing lengthened the second stage by about one hour and decreased pushing
duration by a mean of 20 minutes compared with immediate pushing. It also slightly increased the chance of a spontaneous vaginal
delivery (RR 1.07; 95% CI 1.03-1.11). Although the frequency of low umbilical cord blood pH increased (RR 2.24; 95% CI 1.37-3.68),
no differences were observed in rates of admission to the neonatal intensive care or five-minute Apgar score less than seven.
●Pushing technique (spontaneous, directed, immediate, delayed, posture) did not appear to have a major impact on the occurrence of
adverse maternal or neonatal outcomes.
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Duration — As long as the FHR pattern is normal and some degree of progress is observed, there is no strict upper limit to the duration of
the second stage (ie, time from full dilation to birth). There is no threshold at which maternal or neonatal outcomes abruptly worsen, but a
second stage lasting longer than four hours in nulliparas and two hours in multiparas appears to be associated with a small increase in
frequency of maternal and potentially serious neonatal complications, and this is concerning.

In a prospective study including over 53,000 women at term with singleton cephalic gestations, 78 percent of nulliparas and 82 percent of
multiparas who continued to push longer these times achieved a vaginal delivery [57]. In nulliparas, the frequency of the neonatal composite
adverse outcome at <60 minutes and ≥240 minutes was 1.3 and 2.4 percent, respectively. In parous women, the frequency of the neonatal
composite adverse outcome at <60 minutes and ≥120 minutes was 1.1 and 2.8 percent, respectively. Of possible concern, seizures or
hypoxia-ischemic encephalopathy accounted for almost all adverse neonatal outcomes at ≥240 minutes (10 newborns or 2.2 percent of the
population pushing ≥240 minutes versus 0.4 percent of the population pushing <60 minutes). An increase in neonatal seizures and hypoxia-
ischemic encephalopathy at ≥120 minutes was also noted in parous women (seven newborns or 1.5 percent of the population pushing ≥120
minutes versus 0.2 percent of the population pushing <60 minutes). (See "Overview of normal labor and protraction and arrest disorders".)

Maternal position for delivery — If no fetal manipulation or complications are anticipated, delivery can be accomplished with the mother in
almost any position that she finds comfortable [39,53]. Common positions include the lateral (Sims) position and the partial sitting position.
Stirrups are not mandatory [58]. The lithotomy position is advantageous if fetal manipulation or need for optimal surgical exposure is
anticipated.

The second stage appears to be shortened by a few minutes in women without epidural anesthesia who birth in the vertical position [53].
Maternal birth position does not appear to have a significant effect on risk of third and fourth degree lacerations [39,53].

Episiotomy — Routine use of episiotomy is not beneficial and should be avoided. Episiotomy is reserved for deliveries with a high risk of
severe perineal laceration, significant soft tissue dystocia, or need to facilitate delivery of a possibly compromised fetus. (See "Approach to
episiotomy".)

Delivery of the newborn — The procedure for spontaneous vaginal delivery is described below. Operative vaginal and abdominal delivery
are reviewed separately. (See "Operative vaginal delivery" and "Cesarean delivery: Technique".)

The responsibilities of the healthcare provider at delivery are to reduce the risks of maternal perineal trauma and fetal injury during delivery
and provide initial support of the newborn. There is no consensus regarding the best method for protecting the perineum at delivery
[51,52,59-66], other than avoiding routine episiotomy and fundal pressure [67]. Options include delivering the fetus between contractions
versus during a contraction, and various methods of using the accoucheur's hands to control delivery of the fetal head. The latter may involve
no touch (“hands-off”), passive perineal support, support of the fetal crown, and using fingers placed between the maternal anus and coccyx
to actively lift the fetal chin anteriorly (ie, Ritgen maneuver). Warm compresses and perineal massage may be helpful to reduce perineal
trauma. (See 'Perineal care'above.)

We use the following approach (called the “hands-on” technique) to prevent precipitous expulsion of the newborn, which can lacerate the
perineum and anal sphincter [59,66,68]. We ask the woman to pant or make only small expulsive efforts when the head is fully crowning and
delivery is imminent; this prevents the head from being propelled through the perineum. We use one hand to maintain the head in a flexed
position and control the speed of crowning and use the other hand to ease the perineum over the head. Some providers support the
perineum with a sponge, applying medial pressure [49]. Once the fetal head delivers, external rotation (restitution) occurs spontaneously
(figure 8). A meta-analysis of three trials that evaluated manual perineal support found that it did not significantly reduce obstetrical anal
sphincter injuries (OASIS) (RR, 1.03, 95% CI 0.32–3.36), although three nonrandomized studies suggested a benefit (RR 0.45, 95% CI
0.40–0.50). Since the techniques for perineal support were not well described, it is difficult to interpret these findings. The role of various
obstetric factors on anal sphincter injury and postpartum function are discussed separately. (See "Effect of pregnancy and childbirth on anal
sphincter function and fecal incontinence".)

If the cord is around the neck (nuchal cord), slipping the cord over the head usually successfully frees the fetus from the tether. If a single
nuchal cord is not reducible, we doubly clamp and transect it. Other options for a cord that is difficult to reduce but not tight include slipping it
over the shoulders and delivering the body through the loop, and delivering the body without reducing the cord (somersault maneuver).
(See "Nuchal cord", section on 'Delivery'.)

Mucus is gently wiped from the newborn's nose and mouth. Most newborns do not need to be suctioned. (See 'Oropharyngeal care' below.)

After delivering the head, a hand is placed on each side of the head and the anterior shoulder is delivered with the next contraction, using
gentle downward traction toward the mother's sacrum in concert with maternal expulsive efforts. In this way, the anterior shoulder is guided
under the symphysis pubis. The posterior shoulder is then delivered by upward traction. These movements should be performed with as little
 8

downward or upward force as possible to avoid perineal injury and/or traction injuries to the brachial plexus. The delivery is then completed,
either spontaneously or with a gentle maternal push.

Oropharyngeal care — There is no evidence that oro-nasopharyngeal suctioning by a bulb or catheter is beneficial in healthy term
newborns [69-73] and, in some studies, suctioning slightly reduced neonatal oxygen saturation in the first few minutes of life [69,72,73].
However, suctioning immediately after birth is appropriate for newborns with obvious obstruction to spontaneous breathing due to secretions
or who are likely to require positive-pressure ventilation. The mouth is suctioned first and then the nares to decrease the risk for aspiration
(newborns are obligate nose breathers). Suctioning of the posterior pharynx should be avoided, as it can stimulate a vagal response,
resulting in apnea and/orbradycardia. In a randomized equivalency trial, wiping the face, mouth, and nose with a towel was equivalent to
suction with a bulb syringe [74]. The trial's primary endpoint was mean respiratory rate within the first 24 hours after birth; neonates who were
non-vigorous or born with meconium stained amniotic fluid were excluded. (See "Overview of the routine management of the healthy
newborn infant", section on 'Delivery room care' and "Neonatal resuscitation in the delivery room", section on 'Airway'.)

Meconium — The American Heart Association, the American Academy of Pediatrics, and the American College of Obstetricians and
Gynecologists (ACOG) recommend against routine nasopharyngeal suctioning of meconium-stained newborns who are vigorous at birth
[75,76]. Randomized trials have demonstrated that this approach does not decrease meconium aspiration syndrome or improve perinatal
outcome [77]. (See "Prevention and management of meconium aspiration syndrome".)

Cord clamping — In term newborns, we agree with the ACOG committee opinion to individualize decisions about early versus delayed cord
clamping [78], as the overall clinical benefits of routine use of delayed cord clamping in all term deliveries has not been established. The
main advantage is higher infant iron stores at 6 months of age, which may be particularly advantageous when the mother has a low ferritin
level or plans to breastfeed without supplementing with iron or fortified formula. In preterm infants, we agree with the ACOG committee's
opinion that the significant reduction of intraventricular hemorrhage associated with delayed cord clamping is sufficiently compelling to adopt
this intervention. Preterm infants also benefit from the increased iron stores provided by delayed clamping. However, delaying cord clamping
should never compromise the safety of the mother or newborn. The risks and benefits of delayed cord clamping for newborns who need
resuscitation is unclear because these infants have been excluded from the majority of trials.

Traditionally, the timing of cord clamping in the absence of a maternal or fetal/neonatal medical emergency was dictated by convenience and
was usually performed within one minute of delivery; approximately 75 percent of blood available for placenta-to-fetus transfusion is
transfused in the first minute after birth [79]. Delaying cord clamping increases the volume of placental blood transfused to the fetus,
increases neonatal blood volume, decreases neonatal and infant anemia, and may facilitate the fetal to neonatal transition [80]. However,
increased transfusion comes at a cost of a higher rate of polycythemia and neonatal jaundice, as illustrated in the following meta-analyses:

●Term infants – A 2013 meta-analysis of 15 randomized trials including 3911 mothers and their infants evaluated early versus late
(two to three minutes after birth) cord clamping in term infants [81]. Compared with early cord clamping, late cord clamping resulted in
higher neonatal hemoglobin levels at 24 to 48 hours after birth (mean difference 1.49 g/dL), but not in subsequent assessments, and
a lower proportion of infants with iron deficiency at three to six months of age (14 percent of infants in the early clamping group versus
8 percent in the late clamping group). However, late cord clamping also resulted in a 40 percent increase in newborns needing
phototherapy for jaundice (2.74 percent of infants in the early clamping group versus 4.36 percent in the late clamping group).
In addition, the only randomized clinical trial that assessed the effects of delayed cord clamping compared with early cord clamping at
four years of age reported a possible benefit in some neurodevelopmental outcomes, particularly in boys, and no harmful effects [82].
●Preterm infants – A 2012 meta-analysis of 15 randomized trials evaluated late versus early cord clamping in 738 preterm infants
[83]. Compared with early cord clamping, late cord clamping resulted in fewer infants requiring transfusion for anemia (24 versus 36
percent; RR 0.61, 95% CI 0.46-0.81; seven trials, 392 infants), lower risk of necrotizing enterocolitis (21 versus 32 percent; RR 0.62,
95% CI 0.43-0.90; five trials, 241 infants), and fewer infants with any grade of intraventricular hemorrhage on ultrasound (14 versus
20 percent; RR 0.59, 95% CI 0.41-0.85; 10 trials, 539 infants). Peak bilirubin level was higher with delayed cord clamping, but the
need for treatment of jaundice was not significantly increased.
A 2014 meta-analysis restricted to randomized trials of interventions to promote placental transfusion (delayed cord clamping, cord
milking) in pregnancies <32 weeks of gestation also reported significant neonatal benefits (reduced mortality, reduced rate of
transfusion, reduced rate of intraventricular hemorrhage) [84]. There was also a strong trend toward higher peak bilirubin levels with
the intervention.

An additional benefit of delaying cord clamping is that clamping before initiation of spontaneous respirations (mean onset of respiration is
10±15 seconds after expulsion [85]) appears to adversely affect cardiovascular hemodynamics during the fetal to neonatal transition, likely
due to removal of umbilical venous return before dilation of the pulmonary vascular bed [86-89]. Lung aeration triggers an increase in
pulmonary blood flow, which supplies most of the preload to the left ventricle; if cord clamping precedes onset of respiration, ventricular
preload falls because the loss of umbilical venous return is not balanced by an increase in pulmonary venous return [89]. This may partially
account for some of the non-hematologic benefits reported in trials of delayed cord clamping [90].
 9

Disadvantages of delayed cord clamping include an increase in hyperbilirubinemia in the immediate newborn period resulting in more
phototherapy and an increased risk of polycythemia in growth-restricted neonates. Delaying cord clamping also reduces the volume of
umbilical cord blood available for harvesting stem cells; thus the size and cell dose of collected cord blood units may not be adequate for a
future hematopoietic cell transplant if cord clamping is delayed. This should be considered when cord blood collection is planned for this
purpose. (See"Collection and storage of umbilical cord blood for hematopoietic cell transplantation".)

Although the optimal amount of time before cord clamping has not been studied extensively, we believe the minimum duration of delay
should be at least 30 seconds in preterm births and at least one minute in term births [91]. One group suggested waiting two to five minutes
in healthy term births before clamping the cord (or longer if the mother requests) and at least one minute in healthy preterm births (or longer
if the mother requests) [92]. Very preterm newborns not requiring immediate resuscitation can be dried and wrapped with the cord intact.

Cord milking — We do not milk or strip the umbilical cord; however, this practice is an alternative to delayed clamping for enhancing blood
transfusion. Depending on technique, cord milking may be more efficient than delayed cord clamping for improving neonatal blood volume. A
randomized trial in preterm infants found that milking the accessible length of the cord four times at a speed of 20 cm/2 seconds was
equivalent to delaying cord clamping for 30 seconds [93].

Cord milking, like delayed cord clamping, may help stabilize blood pressure and increase urinary output in premature infants [94-96], but a
theoretic concern is that a non-quantifiable amount of blood will be given to an immature infant in an uncontrolled fashion, which could be
harmful. In a 2015 meta-analysis of seven randomized trials (n = 501 infants) of umbilical cord milking versus usual care, umbilical cord
milking significantly increased hemoglobin levels without increasing the need for phototherapy for hyperbilirubinemia [97]. In the 277 infants
<33 weeks, however, the need for blood transfusion was not reduced and the intervention did not significantly reduce mortality, hypotension
requiring volume expanders or inotrope support, severe intraventricular hemorrhage, or necrotizing enterocolitis rates. These data do not
provide convincing evidence for or against umbilical cord milking.

Delivery should not be unnecessarily delayed to milk the cord in situations where immediate pediatric assistance is needed, such as thick
meconium or neonatal depression. Also, it should not be performed if cord blood collection is planned.

Cord blood — Cord blood collected for diagnostic purposes is usually obtained by allowing blood to drain from the cut end into a glass tube
prior to delivery of the placenta, if possible. Cord blood may be tested for blood and Rhesus type or for a variety of newborn conditions, as
indicated. Newborn screening programs typically use blood from a heel stick obtained as close to hospital discharge as possible to permit the
maximum accumulation of abnormal compounds in the infant's blood and the best chance of obtaining a positive result if disease is present.
(See "Newborn screening".)

When indicated because of neonatal depression, fetal blood for acid-base analysis is collected from an umbilical artery using a needle and
syringe to minimize exposure to air and avoid mixing of arterial and venous blood. (See "Umbilical cord blood acid-base analysis at
delivery".)

Collection of cord blood for banking can be performed with a needle and syringe before or after delivery of the placenta. The procedure for
collection of umbilical cord blood for banking is reviewed separately. (See "Collection and storage of umbilical cord blood for hematopoietic
cell transplantation".)

Maternal-newborn interaction — In the absence of maternal or neonatal complications, a healthy term infant can be dried to minimize heat
loss and given to the mother. Skin-to-skin contact may benefit early mother-infant attachment and breastfeeding outcomes [98]. The location
of the newborn (above or below the level of the placenta) before cord clamping did not appear to significantly affect the volume of placenta-
to-newborn transfusion in a randomized trial [99]. Therefore, concerns about transfusion volume should not influence the decision to place
the newborn on the mother's abdomen.

MANAGEMENT OF THE THIRD STAGE OF LABOR

Normal placental separation — Myometrial thickening after delivery of the infant leads to substantial reduction in uterine surface area,
resulting in shearing forces at the placental attachment site and placental separation. This process generally begins at the lower pole of the
placental margin and progresses along adjacent sites of placental attachment. A "wave of separation" spreads upward so that the uppermost
part of the placenta detaches last [100,101].

Signs of placental separation include a gush of blood, lengthening of the umbilical cord, and anterior-cephalad movement of the uterine
fundus, which becomes firmer and globular after the placenta detaches. Placental expulsion follows separation as a result of a combination
of events including spontaneous uterine contractions, downward pressure from the developing retroplacental hematoma, and an increase in
maternal intraabdominal pressure.
 10

There is no universally accepted criterion for the normal length of the third stage. In two large series of consecutive deliveries, the average
length was five to six minutes, 90 percent of placentas were delivered within 15 minutes, and 97 percent were delivered within 30 minutes of
birth [102,103]. Gestational age is the major factor influencing the length of the third stage: Preterm deliveries are associated with a longer
third stage than term deliveries [102-105].

Active management and delivery of the placenta — We actively manage the third stage because active management reduced the risk of
severe postpartum blood loss and blood transfusion compared with expectant management in randomized trials [106]. (See "Pharmacologic
management of the third stage of labor", section on 'Active management'.)

Active management generally consists of prophylactic administration of an uterotonic agent before delivery of the placenta plus controlled
traction of the umbilical cord after cord clamping and transection; uterine massage also may be performed. Randomized trials have
demonstrated that the uterotonic agent is the most important component of this regimen [107-109]; we use oxytocin. (See "Pharmacologic
management of the third stage of labor", section on 'Oxytocin'.)

We use controlled cord traction to facilitate separation and delivery of the placenta. In a 2014 meta-analysis of randomized trials comparing
controlled cord traction with a hands-off approach, controlled cord traction resulted in a reduced need for manual removal of the placenta
(relative risk [RR] 0.70, 95% CI 0.58-0.84), as well as small statistical reductions in the duration of the third stage (three minutes), mean
blood loss (10 mL), and incidence of postpartum hemorrhage (11.8 versus 12.7 percent; RR 0.93, 95% CI 0.87-0.99); the rates of severe
postpartum hemorrhage, need for additional uterotonics, and blood transfusion were not statistically different [110]. Others have reported
similar findings [111]. Although the benefits of controlled cord traction are small, there are no significant harms from the maneuver if
performed gently without excessive traction, which can result in cord avulsion or uterine inversion.

Two maneuvers for cord traction have been described: the Brandt-Andrews maneuver (an abdominal hand secures the uterine fundus to
prevent uterine inversion while the other hand exerts sustained downward traction on the umbilical cord) [112] and the Crede's maneuver
(the cord is fixed with the lower hand while the uterine fundus is secured and sustained upward traction is applied using the abdominal hand).
We prefer the Brandt-Andrews maneuver.

If the cord avulses before delivery of the placenta, we wait up to 30 minutes for spontaneous placental separation and expulsion with
maternal pushing. While waiting, preparations are initiated in case manual removal of the placenta is needed. We intervene promptly if
bleeding becomes heavy. (See "Retained placenta after vaginal birth", section on 'Management'.)

As the placenta emerges from the vagina, the membranes flow behind it. Slowly rotating the placenta in circles as it is delivered or grasping
the membranes with a clamp helps prevent them from tearing and possibly being retained in the uterine cavity.

The placenta, umbilical cord, and fetal membranes should be systematically examined. The fetal side is assessed for any evidence of
vessels coursing to the edge of the placenta and into the membranes, suggestive of a succenturiate placental lobe. The number of vessels in
the cord is recorded. (See "Gross examination of the placenta".)

Bleeding — Average blood loss at vaginally delivery is estimated to be <500 mL. Excessive bleeding may be related to atony, trauma,
coagulopathy, placental abnormalities, or uterine inversion. A visual aid depicting known volumes of blood on common obstetric materials
(eg, peri pad, bed pan, kidney basin, bed pad) can improve obstetric provider accuracy in blood loss estimation [113]. (See "Overview of
postpartum hemorrhage" and "Management of postpartum hemorrhage at vaginal delivery" and "Puerperal uterine inversion".)

Repair of lacerations — The cervix, vagina, and perineum should be examined for evidence of birth injury. The major risk factors for third
and fourth degree perineal lacerations are nulliparity, operative vaginal delivery, midline episiotomy, and delivery of a macrosomic newborn
[114]. If a laceration is identified, its length and position should be noted and repair initiated with adequate analgesia (see "Repair of
episiotomy and perineal lacerations associated with childbirth"). Failure to recognize and repair a rectal injury can lead to serious long-term
morbidity, most notably fecal incontinence. We perform a rectal examination after perineal repair to palpate sutures inadvertently placed
through the rectal mucosa into the rectal lumen. If identified, the authors take down the repair and resuture, although there is no clear
evidence that transmucosal stitches increase the risk of fistula formation. (See "Effect of pregnancy and childbirth on anal sphincter function
and fecal incontinence".)

POSTPARTUM ISSUES AND CARE — Postpartum issues and care, including care of the newborn, are reviewed separately.
(See "Overview of postpartum care" and "Overview of the routine management of the healthy newborn infant".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key
questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles
 11

are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You
can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topics (see "Patient education: Labor and delivery (childbirth) (The Basics)" and "Patient education: How to tell when labor
starts (The Basics)" and "Patient education: Managing pain during labor and delivery (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Childbirth education classes inform women and their partners about what to expect during labor and birth and provide a foundation
for developing personal plans for the birth experience. (See 'Preparation' above.)
●The goals of the initial examination of the parturient are to review her prenatal record for medical or obstetrical conditions that need
to be addressed intrapartum, check for development of new disorders since the last prenatal visit, establish baseline cervical status so
that subsequent progress can be determined, and evaluate fetal status. (See 'Initial examination' above.)
●Results from the following laboratory tests should be available at delivery, but intrapartum assessment is not always
necessary:hemoglobin/hematocrit, blood type and screen, human immunodeficiency virus (HIV), hepatitis B antigen, syphilis,
rectovaginal group B streptococcus. (See 'Laboratory tests' above.)
Women who have not had HIV screening or whose HIV status is undocumented should be offered rapid HIV testing in labor.
We recommend not performing routine enemas (Grade 1A) and we suggest not routinely shaving the perineum (Grade 2B).
(See 'Patient preparation' above.)
●There is no consensus on acceptable maternal oral intake or need for intravenous fluids during an uncomplicated labor. We allow
patients at low risk of cesarean delivery to have clear liquids and we place an intravenous line or heparin lock for all women in labor.
(See 'Fluids and oral intake' above.)
●Vaginal delivery is not an indication for routine antibiotic prophylaxis, even in women with cardiac lesions, since the rate of
bacteremia is low. Intrapartum chemoprophylaxis to prevent early-onset neonatal GBS infection is indicated for patients who meet
standard criteria; the agent of choice is intravenous penicillin. (See 'Systemic antibiotics' above and "Neonatal group B streptococcal
disease: Prevention".)
●Maternal preferences can guide maternal activity. Walking during the first stage does not appear to enhance or impair labor
progress. Laboring women should assume positions that are comfortable, unless specific positions are needed because of maternal-
fetal status and need for close monitoring. (See 'Maternal activity and position' above.)
●Multiple nonpharmacologic, pharmacologic, and anesthetic options are available to help women manage pain during labor.
(See"Nonpharmacologic approaches to management of labor pain" and "Pharmacologic management of pain during labor and
delivery" and"Neuraxial analgesia for labor and delivery (including instrumented delivery)".)
●We suggest not performing amniotomy routinely (Grade 2B). There is no convincing evidence of benefit in spontaneously laboring
women, and rupture of membranes increases the risk of ascending infection and cord prolapse. (See 'Amniotomy' above.)
●In women with pregnancies at increased risk of fetal compromise during labor, we perform continuous electronic fetal heart rate
(FHR) monitoring, in agreement with clinical management guidelines from the American College of Obstetricians and Gynecologists.
We also monitor low-risk pregnancies continuously because it is more practical than intermittent monitoring, but we are not rigid about
this if the patient understands the risks and benefits of intermittent monitoring and has an uncomplicated pregnancy, normal FHR
tracing, and is not resting in bed. Contractions and labor progress are also monitored. (See 'Monitoring' above.)
●The optimal pushing position technique, position, and duration are unclear. We suggest patients push in the position they find most
comfortable and with an open glottis (Grade 2C). However, if the FHR tracing is normal and station is high, we often ask women to
delay pushing until the further descent has occurred to reduce the duration of time of maximal maternal exertion.
(See 'Pushing' above.)
●We recommend not performing episiotomy routinely (Grade 1A). (See "Approach to episiotomy".)
●We suggest a “hands-on” technique (Grade 2C). Preventing precipitous expulsion of the newborn can reduce the risk of obstetrical
and anal sphincter injury. (See 'Delivery of the newborn' above.)
●Routine oro-nasopharyngeal suctioning by a bulb or catheter is not beneficial in healthy term newborns, including those with
meconium-stained amniotic fluid. Suctioning is appropriate for newborns with obvious obstruction to spontaneous breathing or who
are likely to require positive-pressure ventilation. (See 'Oropharyngeal care' above and 'Meconium' above.)
●In preterm births who do not require resuscitation, we recommend delayed cord clamping (Grade 1B). Benefits include reduced
rates of transfusion, intraventricular hemorrhage, necrotizing enterocolitis, and hypotension. For term infants who do not require
resuscitation, we individualize the decision for early versus delayed cord clamping based on the infant's risk of anemia, since a
disadvantage is an increase in hyperbilirubinemia and more need for phototherapy. We suggest a minimum delay of at least 30
seconds in preterm infants and at least one minute in term infants. (See 'Cord clamping' above.)
 12

●Cord milking is an alternative to cord clamping and results in more rapid blood transfusion when time is a factor. (See 'Cord
milking' above.)
●Delaying cord clamping reduces the volume of umbilical cord blood available for harvesting stem cells; therefore, the size and cell
dose of collected cord blood units may not be adequate for a future hematopoietic cell transplant if cord clamping is delayed.
(See 'Cord clamping'above.)
●Active management of the third stage reduces maternal blood loss and risk of postpartum hemorrhage compared with expectant
management. We administer oxytocin and apply controlled traction of the umbilical cord. The placenta should be examined to make
sure it is intact. (See 'Active management and delivery of the placenta' above.)
●Average blood loss at vaginal delivery is estimated to be <500 mL. Excessive bleeding may be related to atony, trauma,
coagulopathy, placental abnormalities, or uterine inversion. (See 'Bleeding' above.)
●Failure to recognize and repair a rectal injury can lead to serious long-term morbidity, most notably fecal incontinence. (See 'Repair
of lacerations' above.)
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 14

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Obstet Gynecol 2011; 117:627.

Topic 4445 Version 110.0

 16

Surgical female pelvic anatomy

Authors:
Matthew D Barber, MD, MHS
Amy J Park, MD
Section Editor:
Howard T Sharp, MD
Deputy Editor:
Kristen Eckler, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Mar 28, 2016.

INTRODUCTION — Pelvic surgery requires a comprehensive knowledge of the pelvic anatomy to safely attain access, maximize exposure,
ensure hemostasis, and avoid injury to viscera, blood vessels, and nerves.

The anatomy of the female genital tract and lower urinary and gastrointestinal tracts relevant to the surgeon performing laparotomy or
laparoscopy, with an emphasis on clinical relevance and avoiding potential complications, is reviewed here. Surgical pelvic anatomy from a
vaginal approach and the surgical anatomy of the anterior abdominal wall are discussed separately. (See "Surgical female urogenital
anatomy"and "Anatomy of the abdominal wall".)

SURGICAL PEARLS — Anatomic features that are clinically applicable to female pelvic surgery are indented and bulleted throughout the
text.

GENITAL TRACT VISCERA — The female upper genital tract consists of the cervix, uterine corpus, fallopian tubes, and ovaries. A sagittal
view of the female pelvis is shown in the figure (figure 1).

The anatomy of the lower genital tract, comprised of the vulva and vagina, is discussed separately. (See "Surgical female urogenital
anatomy", section on 'Lower genital tract'.)

Uterus — The uterus includes the uterine corpus and uterine cervix (figure 2). In reproductive age women, the corpus is much larger than
the cervix while, during the prepubertal and postmenopausal stages, they are of similar sizes. However, the size of the uterus can vary
considerably, depending upon hormonal levels, previous parturition, or the presence of uterine pathology (eg, fibroids, adenomyosis) (picture
1).

Uterine corpus — The corpus, or body, of the uterus has an inverted triangular shape (figure 3). The most superior portion is called the
fundus and the most inferior portion that is continuous with the cervix is called the isthmus, or the lower uterine segment. There are no
anatomic landmarks that divide these portions from the rest of the uterine corpus. The uterus is made up of three layers:

●Endometrium – The endometrium is the lining of the uterine cavity, with a superficial layer that consists of glandular epithelium and
stroma. The thickness of the endometrium changes with the menstrual cycle or other hormonal stimulation. (See "Physiology of the
normal menstrual cycle".)
●Myometrium – The myometrium is the thickest layer of the uterus. It is composed of smooth muscle fibers that are oriented
diagonally and crisscross with fibers from the contralateral side of the uterus.
●Serosa – The serosa is the thin outer lining layer of the uterus, investing the body of the uterus, consisting of visceral peritoneum.

Congenital anomalies of the uterus are discussed in detail separately. (See "Clinical manifestations and diagnosis of congenital anomalies of
the uterus".)

Uterine cervix — The cervix is a tubular structure that serves as the conduit between the endometrial cavity and the vagina. The superior
portion is continuous with the uterus. During surgery, the junction between the uterine corpus and cervix can be located by palpating the area
to feel the superior border of the cervix, which is tubular and bulky compared with the uterus.

The inferior portion of the cervix protrudes into the vagina. In some women (eg, postmenopausal, following pelvic radiation), the cervix may
appear flush with the vagina on examination rather than protruding.
 17

The cervical canal opens into the endometrial cavity at the internal os and into the vagina at the external os. The ectocervix is the surface of
the cervix that protrudes into the vagina.

The cervix is composed of dense fibrous connective tissue with a minimal amount of smooth muscle located on the periphery that forms a
continuous layer between the myometrium and the muscle in the vaginal wall.

The endocervical canal is lined with glandular epithelium. This transforms into stratified squamous epithelium on the ectocervix due to
exposure to the acidic environment that is present in the vagina after menarche. The area where the epithelium changes from glandular to
squamous is known as the transformation zone and is the area of the cervix that is most susceptible to dysplasia and malignant
transformation [1].

The anterior cervix is apposed to the bladder, while the lateral aspects of the cervix are covered by the broad ligament. The posterior aspect
of the cervix forms part of the anterior boundary of the pelvic posterior cul-de-sac (pouch of Douglas).

Uterine support structures

Uterosacral and cardinal ligament complex — The uterosacral/cardinal ligament complex suspends the uterus and upper vagina in its
normal orientation [2]. It serves to maintain vaginal length and keep the vaginal axis nearly horizontal in a standing woman so that it can be
supported by the levator plate. Loss of this support contributes to prolapse of the uterus and/or vaginal apex.

The cardinal ligaments are condensations of connective tissue that are several centimeters in width and run from the cervix and upper vagina
to the pelvic sidewall. The uterine vessels run for much of their course within the cardinal ligaments.

The uterosacral ligaments are bands of connective tissue that are fused with the cardinal ligaments at their point of insertion in the cervix.
The uterosacral ligaments pass posteriorly and inferiorly to attach to the ischial spine and sacrum [3,4].

Round ligaments — The round ligaments are extensions of the uterine musculature. They begin at the uterine fundus anterior and inferior to
the fallopian tubes (picture 2 and figure 4), travel retroperitoneally through the layers of the broad ligament, then enter the inguinal canal, and
terminate in the labia majora. The male homolog of the round ligaments is the gubernaculum testis.

Broad ligament — The broad ligament covers the lateral uterine corpus and upper cervix. The boundaries of the broad ligament are:
superiorly, the round ligaments; posteriorly, the infundibulopelvic ligaments; and inferiorly, the cardinal and uterosacral ligaments. It consists
of anterior and posterior leaves that separate to enclose viscera and blood vessels. Structures within the broad ligament are considered
retroperitoneal. Dissection between these leaves is necessary to provide exposure of these structures.

Various portions of the broad ligament are named for nearby structures, ie, the mesosalpinx (located near the fallopian tubes) and the
mesovarium (located near the ovary).

The broad ligament is composed of visceral and parietal peritoneum that contains smooth muscle and connective tissue.

Endopelvic fascia — The pelvic viscera are covered by endopelvic fascia, a connective tissue layer that provides support to the pelvic
organs, yet allows for their mobility to permit storage of urine and stool, coitus, parturition, and defecation.

Histologically, endopelvic fascia is composed of collagen, elastin, adipose tissue, nerves, vessels, lymph channels, and smooth muscle.

Adnexa — The uterine adnexa consist of the ovaries and fallopian tubes.

Ovary — The ovaries are suspended lateral and/or posterior to the uterus, depending upon the position of the patient. The supporting
structures of the ovaries include the utero-ovarian ligament that attaches the ovary to the uterus; the infundibulopelvic ligament (also referred
to as the suspensory ligament of the ovary), through which the ovarian vessels travel, that attaches the ovary to the pelvic sidewall; and the
broad ligament, which condenses to form the mesovarium. It is also attached to the broad ligament through the mesovarium.

●During hysterectomy, if the ovaries are conserved, the utero-ovarian ligament is transected. If salpingo-oophorectomy is performed,
the infundibulopelvic ligaments (with the ovarian vessels) are ligated (figure 4). (See "Abdominal hysterectomy", section on 'Adnexal
conservation or removal'.)

The ovary consists of an outer cortex, where the ova and follicles are located, and medulla, where the blood vessels and connective tissue
compose a fibromuscular tissue layer (figure 5).
 18

Fallopian tube — The fallopian tubes arise from the uterine corpus posterior and superior to the round ligaments. The broad ligaments
support the tubes with a condensation of connective tissue called the mesosalpinx. Paratubal cysts may develop within the mesosalpinx;
these are often remnants of the mesonephric or paramesonephric ducts that form and then resorb during embryologic development. The
lumen of the fallopian tubes communicates with the uterine cavity and the intraabdominal cavity. (See "Differential diagnosis of the adnexal
mass", section on 'Paraovarian/paratubal cysts and tubal and broad ligament neoplasms'.)

Each tube is divided into four distinct portions: the interstitial portion, where the tube passes through the uterine cornu; the isthmus, with a
narrow lumen and thick muscular wall; the ampulla, with a larger lumen and mucosal folds; and the fimbria, located at the end of the tube
with frond-like projections that increase the surface area of the end of the tubes, thereby facilitating contact with ovulated ova (figure 2).

The fallopian tubes consist of an outer muscularis layer of the tube with longitudinal smooth muscle fibers and an inner layer with circular
fibers. The fallopian tube mucosa is composed of numerous delicate papillary folds (plica) consisting of three cell types: ciliated columnar
cells; nonciliated, columnar secretory cells; and intercalated cells, which may simply represent inactive secretory cells [5].

VASCULATURE — The aorta provides the blood supply to the pelvic structures. The aorta bifurcates at approximately vertebrae L4 to L5
into the right and left common iliac arteries.

The inferior vena cava, where the right and common iliac veins return their blood flow, is located to the right of the aortic bifurcation.
Compression of these veins while packing the bowels during abdominal surgery may cause the patient's blood pressure to drop because of
the decreased venous return.

Common and external iliac vessels — The common iliac arteries divide into the external iliac and internal iliac arteries; the internal iliac
artery is also referred to as the hypogastric artery. The left common iliac vein travels anterior to the sacrum and medial to the aortic
bifurcation and joins the right common iliac vein to form the vena cava posterior to the right common iliac artery.

The external iliac artery is located medial to the psoas muscle; it continues its course inferiorly to ultimately become the femoral artery. In the
pelvis, the external artery gives off several branches, including: inferior epigastric artery; recurrent obturator artery; and superior vesical
artery (figure 6) [6].

The external iliac vein is much larger and lies posterior and medial to the artery. The external iliac vein also covers the obturator fossa, where
the obturator neurovascular bundle and lymph nodes are located medial to the obturator internus muscle.

The umbilicus is the location on the abdominal wall with the shortest distance from skin to peritoneum. Therefore, it is commonly used as the
entry point for the first trocar insertion during laparoscopy. The bifurcation of the aorta can be located directly underneath the umbilicus with
those with a normal body mass index, to 3 to 4 cm caudal to the umbilicus in the obese patient.

●During laparoscopy, in the thin patient, placement of the initial umbilical trocar or Veress needle should be performed at a 30 to 45
degree angle to the anterior abdominal wall in order to avoid injury to the common iliac vessels or the aorta. (See "Complications of
laparoscopic surgery", section on 'Major vessels'.)

Inferior and superficial epigastric vessels — The inferior epigastric vessels perfuse the rectus abdominis muscles. The inferior epigastric
artery originates from the external iliac artery, travels through the transversalis fascia into a space between the rectus muscle and posterior
sheath (figure 7). In their course from the lateral position of the external iliac vessels, the inferior epigastric artery and vein run obliquely
toward a more medial location as they approach the umbilicus.

●When a muscle-splitting technique is used during laparotomy (eg, Maylard), care must be taken to ensure hemostasis of the inferior
epigastric vessels, which may retract quickly when the muscle is transected. (See "Incisions for open abdominal surgery", section on
'Maylard's incision'.)

The superficial epigastric vessels perfuse the anterior abdominal wall. These vessels run from the femoral vessels and branch extensively as
they approach the umbilicus.

●When lower abdominal lateral ports are placed during laparoscopy, the inferior and superficial epigastric vessels should be identified
to avoid vascular injury. The superficial epigastric vessels can be seen by transilluminating the anterior abdominal wall, with the
exception of some obese patients. The inferior epigastric vessels must be visualized intra-abdominally where they run lateral to the
medial umbilical ligaments (picture 2) [7-9]. (See "Complications of laparoscopic surgery", section on 'Minor vessels'.)

The anatomy of the anterior abdominal wall is discussed in detail separately. (See "Anatomy of the abdominal wall".)
 19

Anterior and posterior divisions of the internal iliac artery — The internal iliac artery (hypogastric artery) branches into the anterior and
posterior divisions.

The posterior division travels toward the ischial spine, branching into the lateral sacral, iliolumbar, and superior gluteal arteries. The anterior
division of the internal iliac artery branches into the obliterated umbilical, uterine, superior vesical, obturator, vaginal, and inferior gluteal and
internal pudendal arteries (figure 6). The internal iliac vein lies medial to the internal iliac artery, while the other veins travel with their
corresponding arteries.

The internal iliac artery is a retroperitoneal structure and to identify and access any of its branches of interior iliac artery, a retroperitoneal
dissection must be performed. In addition, the ureter runs retroperitoneally in this region, and should be identified prior to the vessel
desiccation or ligation of any vessel.

●Ligation of the hypogastric artery is a useful surgical technique to control massive pelvic hemorrhage (figure 8). Following
hypogastric artery ligation, collateral flow from the aortic branches (ie, lumbar and middle sacral artery) or through the inferior
mesenteric branches (ie, superior hemorrhoidal vessels) prevents ischemia of the pelvic organs. (See "Management of hemorrhage in
gynecologic surgery", section on 'Internal iliac artery ligation'.)

Blood supply to the uterus, tubes, and ovaries — The majority of the blood supply to the uterus, tubes, and ovaries derives from the
uterine arteries and the ovarian arteries.

The uterine arteries originate from the anterior division of the internal iliac arteries in the retroperitoneum (picture 3). They may share a
common origin with the obliterated umbilical artery, internal pudendal, or vaginal artery. In the fetus, the pattern of oxygen delivery through
the umbilical artery and vein is reversed from the usual pattern. The umbilical artery carries waste, carbon dioxide, and deoxygenated blood
away from the fetus; the umbilical vein delivers oxygenated blood [10].

●The obliterated umbilical arteries (also referred to as the medial umbilical ligaments) can serve as a useful landmark during
laparotomy or laparoscopy, since tugging on the obliterated umbilical artery can help identify the uterine artery in cases of distorted
pelvic anatomy.

The uterine artery travels through the cardinal ligament and passes over the ureter, which is located approximately 1.5 cm lateral to the
cervix. It then joins the uterus near the level of the internal cervical os and gives off branches that run superiorly towards the uterine corpus
and inferiorly towards the cervix (figure 9). The uterine corpus branches anastomose with vessels that derive from the ovarian arteries, thus
providing collateral blood flow.

The uterine artery also sends a branch to the cervicovaginal junction at the lateral aspect of the vagina. The vagina also receives its blood
supply from this uterine branch, as well as from a vaginal branch of the internal iliac artery, which anastomose along the vagina laterally at
the 3 o’clock and 9 o'clock positions.

The ovarian arteries arise from the abdominal aorta. The right ovarian vein returns to the inferior vena cava while the left ovarian vein returns
to the left renal vein. The ovarian vessels travel through the infundibulopelvic ligaments in close proximity to the ureter, along the medial
aspect of the psoas muscle (picture 4 and picture 5).

LYMPHATICS — The lymphatic drainage follows the pelvic vessels, with the nodes located anterior, posterior, or lateral to the vessels. The
pelvic lymphatic system is located retroperitoneally, like the pelvic vasculature. The pelvic lymphatics include the common iliac, external iliac,
internal iliac, medial sacral, and pararectal lymph nodes (figure 10 and figure 11).

The medial sacral lymph nodes run along the middle sacral artery in the presacral space, while the pararectal nodes drain the sigmoid colon;
these lymph node chains are usually not involved in gynecologic disease.

●For pelvic lymph node dissection, the anatomic boundaries are: the ureter medially; the body of the psoas muscle and genitofemoral
nerve laterally; the mid-portion of the common iliac artery (2 cm above the bifurcation) superiorly to the deep circumflex iliac vein
inferiorly; and posteriorly, the obturator nerve at the base of the obturator fossa. The nodal tissue from the distal one-half of each
common iliac artery should be removed. The nodal tissue from the anterior and medial aspect of the proximal half of the external iliac
artery and vein should be excised, as well as the distal portion of the obturator fat pad.

Obturator lymph nodes — The obturator lymph nodes are located in the obturator fossa, medial to the external iliac vessels and lateral to
the obliterated umbilical ligament. The obturator nodes can be located by identifying the obturator nerve, which is usually the most easily
visualized component of the obturator neurovascular bundle as it enters the obturator canal.
 20

Internal iliac lymph nodes — The internal iliac lymph nodes are located along the internal iliac vessels and are most numerous in the
lateral pelvic sidewalls. In addition to the lymphatic drainage from the pelvic viscera, these nodes drain the pelvic viscera, the lower urinary
tract, and some of the gluteal region drainage.

External iliac lymph nodes — The external iliac lymph nodes are located lateral to the external iliac artery and medial to the external iliac
vein. They receive their lymphatic flow from the legs via the inguinal nodes.

Superficial inguinal lymph nodes — Some of the uterine lymphatic flow also drains to the superficial inguinal lymph nodes along the round
ligament, as well as to the lateral sacral nodes along the uterosacral ligaments. Because of the anastomotic connections, metastasis of
uterine or cervical malignancies may occur to the superficial inguinal lymph nodes, as well as to the external and iliac nodes, and the lateral
sacral nodes [11].

Paraaortic lymph nodes — The paraortic nodes are located in the lumbar region near the bifurcation of the aorta and inferior vena cava.
These lymph nodes are found both anterior and posterior to the vessels.

●For paraaortic lymph node dissection, the uppermost boundary is to the origin of the inferior mesenteric artery, with the inferior
border the mid-portion of the common iliac artery, and the lateral borders the ureters. The nodal tissue on the inferior vena cava,
aorta, and upper common iliac arteries should be removed [12]. For higher grade or higher risk tumor histologies, some surgeons
elect to extend the superior border of the dissection up to the renal artery and vein.

Lymphatic drainage of the pelvic viscera

Uterus and proximal vagina — The lymphatic drainage of the uterus and the upper two-thirds of the vagina flows through the obturator and
internal and external iliac lymph nodes, and ultimately drains into the common iliac lymph nodes.

Ovary — The lymphatic drainage of the ovaries travels with the ovarian vessels to the paraaortic lymph nodes.

Distal vagina and vulva — The distal one-third of the vagina, urethra, and vulvar lymphatic drainage goes to the inguinal nodes, reflecting
their distinctly different embryologic origin (sinovaginal bulbs) compared with the upper genital tract (paramesonephric, or Müllerian, ducts).
(See"Diagnosis and management of congenital anomalies of the vagina", section on 'Vagina'.)

NERVES

Aortic plexus — The ovaries and fallopian tubes are innervated by a nerve plexus that originates in the renal plexus with fibers from T10
and parasympathetic fibers from the vagus nerve that run along the ovarian vessels (figure 12).

Superior and inferior hypogastric plexi — The nerve supply to the pelvis runs through the superior hypogastric plexus (figure 12), a
ganglionic plexus that lies over the bifurcation of the aorta in the presacral space. The superior hypogastric plexus receives sympathetic input
from the thoracic and lumbar splanchnic nerves and afferent pain input from the pelvic viscera. Parasympathetic input derives from S2 to 4
via the pelvic splanchnic nerves that travel to join the hypogastric plexi through the lateral pelvic wall.

From the superior hypogastric plexus, the nerves split into two hypogastric nerves that run along the internal iliac vessels. These nerves
connect to the inferior hypogastric plexus.

The inferior hypogastric plexus is located lateral to the pelvic viscera and consists of three areas: the vesical plexus, uterovaginal plexus, and
the middle rectal plexus. The uterovaginal plexus lies on the medial side of the uterine vessels, lateral to the attachment of the uterosacral
ligaments to the uterus, and continues cephalad along the uterus and caudally along the vagina. The caudal fibers innervate the vulvar
vestibule and clitoris, and travel in the parametrial tissue lateral to the uterine artery and uterosacral and cardinal ligaments, but within the
tissue that is taken during a radical hysterectomy. The uterovaginal plexus receives sympathetic input from T10 to L1 and parasympathetic
input from S2 to S4.

●The inferior hypogastric plexus may be involved during the dissection of the parametrial tissues during hysterectomy, resulting in
short-term postoperative voiding dysfunction and urinary retention.

Lumbosacral plexus — The lumbar and sacral plexi are formed from the lumbar and sacral nerve roots, lateral to the intervertebral
foramina. The lumbar plexus lies within the psoas muscle. The femoral nerve is the major branch of the lumbar plexus, supplying sensory
and motor function to the thigh. Its genitofemoral branch (L1 to L2) lies on the surface of the psoas muscle.
 21

●The genitofemoral branch can be damaged from pressure from a retractor blade during laparotomy and lead to anesthesia in the
medial thigh and lateral labia.
●The femoral cutaneous nerve (L2 to L3) may be compressed from a retractor placed lateral to the psoas muscle or from hyperflexion
of the hip in lithotomy position, leading to numbness or altered sensation in the anterior thigh.

Nerve injury associated with pelvic surgery is discussed in detail separately. (See "Nerve injury associated with pelvic surgery".)

The sacral plexus lies on the piriformis muscle. The major branch of the sacral plexus, the sciatic nerve, exits the pelvis through the inferior
portion of the greater sciatic foramen to innervate the muscles of the hip, pelvic diaphragm, perineum and lower leg.

Nerves of the anterior abdominal wall — The anatomy of the anterior abdominal wall that is relevant to the incisions used for pelvic
surgery is discussed in detail separately. (See "Anatomy of the abdominal wall", section on 'Nerves'.)

LOWER URINARY TRACT — The lower urinary tract is in close proximity to the uterus, tubes, and ovaries, as well as their vascular supply.
Therefore, pelvic surgeons should have a comprehensive knowledge of lower urinary tract anatomy to avoid injury to these structures.

The lower urinary tract includes the urethra, bladder, and distal ureters. The anatomy of these structures is discussed in detail separately.
(See"Surgical female urogenital anatomy", section on 'Lower urinary tract'.)

SIGMOID COLON, RECTUM, AND ANUS — The sigmoid colon descends into the pelvis curving from the left (descending) colon slightly to
the left of the midline and sacrum and is extraperitoneal (located within the peritoneal cavity), unlike much of the colon, which is
retroperitoneal. Its blood supply derives from the sigmoid arteries, branches of the inferior mesenteric artery.

●The sigmoid colon is attached to a distinct mesentery in its mid-portion, which can be traumatized during packing of the bowel out of
the pelvis and cause bleeding.
●There are often physiologic attachments of the sigmoid colon epiploicae to the left pelvic sidewall that may need to be dissected in
order to adequately visualize the left infundibulopelvic ligament or left ureter at the time of left salpingo-oophorectomy. During this
dissection, care should be taken to avoid injury to the genitofemoral nerve, which runs on the surface of the psoas muscle.
(See 'Lumbosacral plexus'above.)

Once the sigmoid colon has descended into the pelvis, its course straightens and it enters the retroperitoneum at the pelvic posterior cul-de-
sac and becomes the rectum. It then expands into the rectal ampulla, an area of stool storage, then bends downwards to almost a 90-degree
angle to become the anus. The rectum and anus rest on the sacrum and levator ani muscles and the vagina lies anterior to the rectum.

The blood supply to the rectum and anus consists of an anastomotic arcade of vessels from the superior rectal (hemorrhoidal) branch of the
inferior mesenteric artery, and the middle and inferior rectal (hemorrhoidal) branches of the internal pudendal artery.

Anal continence is maintained by a series of anal valves. The anus is surrounded by the internal anal sphincter and external anal sphincter.
The internal anal sphincter consists of a thicker layer of the circular involuntary smooth muscle fibers, which provides 80 percent of the
resting tone of the sphincter, while the external anal sphincter consists of skeletal muscle fibers and is attached to the coccyx.

AVASCULAR PLANES — The pelvis contains several potential spaces and connective tissue planes that allow the urinary, reproductive,
and gastrointestinal systems to function independently of each other. They lack blood vessels and nerves and are filled with loose areolar
tissue, allowing blunt dissection without disruption of these structures. Within these spaces, connective tissue septa form compartments that
limit the spread of infection or hematomas.

Knowledge of these spaces is fundamental for most major pelvic surgery. Familiarity with these avascular spaces, as well as their
relationships to each other, helps to avoid injury to the viscera and vasculature, restore normal anatomic relationships in the case of distorted
anatomy, perform pelvic reconstruction, and resect pelvic pathology (eg, endometriosis, cancer).

The avascular spaces of the female pelvis include the vesicovaginal, paravesical, pararectal, rectovaginal, and presacral spaces (figure 13).
There are also potential spaces within the pelvis: the anterior and posterior cul-de-sacs, and the retropubic space (space of Retzius).

Anterior and posterior cul-de-sacs — The anterior and posterior pelvic cul-de-sacs separate the uterus from the bladder and rectum,
respectively. The anterior cul-de-sac is also known as the vesicouterine pouch (figure 1), and is the space between the dome of the bladder
and the anterior surface of the uterus. The peritoneum overlying the dome of the bladder is loose and allows the bladder to expand. This
loose peritoneal fold is called the vesicouterine fold.
 22

●During abdominal hysterectomy, the vesicouterine fold is dissected to create the bladder flap, access the vesicovaginal space, and
dissect the bladder off the lower uterine segment and anterior cervix.

The posterior cul-de-sac (also referred to as the rectouterine pouch or pouch of Douglas) is the space between the uterus and rectum. Its
borders are the vagina anteriorly, the rectosigmoid colon posteriorly, and the uterosacral ligaments laterally.

Vesicovaginal space — The vesicovaginal space is located in the midline. Its boundaries are the bladder anteriorly, the bladder pillars
laterally, and the vaginal adventitia laterally. The bladder pillars are composed of connective tissue and blood vessels, specifically the veins
from the vesical plexus and the ureter, some cervical branches of the uterine artery anteriorly into the sides of the bladder base, and some
extensions of the stronger connective tissue portions of the cardinal ligament.

●During abdominal hysterectomy, to dissect the bladder off the lower uterine segment and anterior cervix, sharp dissection in the
midline between the bladder pillars will reveal a loose areolar avascular layer when in the proper plane. Veering laterally can result in
bleeding from the bladder pillars and obscure visualization during this dissection.

Retropubic space — The retropubic space, also called the space of Retzius, is a potential space between the bladder and the pubic bone. It
is bounded by the pubic bone, the peritoneum and muscles of the anterior abdominal wall. Its lateral borders are the arcus tendineus fascia
pelvis and the ischial spines.

Within the retropubic space lie the dorsal clitoral neurovascular bundle, located in the midline, and the obturator neurovascular bundle,
located laterally as it enters the obturator canal. In some women, an accessory obturator artery arises from the external iliac artery and runs
along the pubic bone. The space lateral to the bladder neck and urethra contains nerves innervating the bladder and urethra, as well as a
venous plexus (venous plexus of Santorini) that can ooze with the placement of sutures (ie, while performing a Burch retropubic
colposuspension).

●The sutures for a Burch procedure are anchored into the iliopectineal line, or Cooper's ligament, which runs along the superior
border of the ischiopubic rami bilaterally.

Paravesical space — The paravesical spaces are paired spaces that lie anterior to the cardinal ligaments. Their boundaries are the bladder
pillars medially, the obturator internus and levator ani muscles and the pelvic sidewalls laterally, and the medial umbilical ligaments
superiorly. This space is located within the space of Retzius, or the retropubic space.

During laparotomy, entry into this space entails dissection close to the pubic bone, avoiding the midline dorsal clitoral neurovascular bundle.
During a laparoscopic procedure, retrograde filling the bladder and noting the location of the median and medial umbilical ligaments can aid
in identifying the borders of the bladder. The median umbilical ligament can then be grasped with downward traction and transected with
monopolar cautery in order to enter the retropubic space.

●The paravesical space is most commonly accessed during Burch retropubic colposuspension or a paravaginal defect repair.
However, endometriosis can also infiltrate the paravesical space and may need to be excised.
●The paravesical space is also accessed at the time of radical hysterectomy. For cervical cancer, the majority of cervical lymphatic
drainage to the pelvic lymph nodes travels through the parametria and adequate central dissection of the parametria with tumor-free
margins is essential. Once the round ligament is transected, the surgeon develops the anterior leaf of the broad ligament inferiorly,
then turning medially in order to create the bladder flap. The paravesical space can then be developed lateral to the medial umbilical
ligament until the levator ani muscle is reached. The anterior cardinal ligament can also be assessed at this point for gross tumor
invasion into the parametria. (See "Radical hysterectomy".)

Pararectal space — The pararectal spaces are located on either side of the cardinal ligaments. The borders of the pararectal space are
defined anteriorly by the cardinal ligament, medially by the rectum, posteriorly by the sacrum, and laterally by the internal iliac artery or pelvic
sidewall.

●During laparotomy or laparoscopy, the most likely scenario necessitating access to this space is an obliterated posterior cul-de-sac
from endometriosis, where the rectum is adhered to the posterior cervix. In that case, the surgeon must first perform a bilateral
ureterolysis of the pelvic ureter and dissect the pararectal space in order to safely dissect the rectovaginal space and the rectum off
the posterior cervix and vagina. (See "Endometriosis of bowel or rectovaginal space", section on 'Surgical treatment'.)
●The pararectal space is also developed at the time of radical hysterectomy. It is accessed by opening the posterior leaf of the broad
ligament cephalad posterolateral to the infundibulopelvic ligament. Retraction of the uterus medially helps expose the pararectal
space. The ureter must be identified and the space between the ureter and internal iliac artery developed with careful blunt dissection
in order to avoid the small veins in this area. (See "Radical hysterectomy".)
 23

●During sacrospinous ligament suspension, the pararectal space is accessed to identify the sacrospinous ligament. The posterior
vaginal epithelium is dissected off the underlying rectum then the pararectal space is entered lateral to the rectum using blunt
dissection until the ischial spine is palpated. (See "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or
vaginal vault prolapse)", section on 'Sacrospinous ligament suspension'.)

Rectovaginal space — The rectovaginal space starts caudally at the superior margin of the perineal body (2 to 3 cm above the hymenal
ring) and extends superiorly between the posterior vagina and the rectum through the posterior cul-de-sac. Its most cephalad border is the
posterior cul-de-sac just inferior to the cervix. It contains loose areolar tissue that can bluntly be dissected. Its lateral boundaries are the
rectal pillars, which are fibers from the cardinal-uterosacral ligament complex that connect to the lateral rectum then to the sacrum. They
divide the rectovaginal space from the pararectal spaces.

●Occasionally the surgeon may need to enter the rectovaginal space during a hysterectomy when the patient has altered anatomy
due to an obliterated cul-de-sac from endometriosis or due to the presence of a posterior lower uterine segment, broad ligament, or
cervical fibroid [13].

SUMMARY

●Pelvic surgery in women requires a comprehensive knowledge of the pelvic anatomy to safely attain access, maximize exposure,
ensure hemostasis, and avoid injury to viscera, blood vessels, and nerves. (See 'Introduction' above.)
●The uterus includes the uterine corpus and uterine cervix (figure 2). In reproductive age women, the corpus is much larger than the
cervix while, during the prepubertal and postmenopausal stages, they are of similar sizes. However, the size of the uterus can vary
considerably, depending upon hormonal levels, previous parturition, or the presence of uterine pathology (eg, fibroids, adenomyosis).
(See 'Uterus'above.)
●Support of the uterus is provided by the uterosacral/cardinal ligament complex, round ligament, and broad ligament. Loss of this
support contributes to prolapse of the uterus and/or vaginal apex. (See 'Uterine support structures' above.)
●The uterine arteries originate from the anterior division of the internal iliac arteries in the retroperitoneum and travel through the
cardinal ligament and pass over the ureter. They then join the uterus near the level of the internal cervical os and give off branches
that run superiorly towards the uterine corpus and inferiorly towards the cervix (figure 9). The uterine corpus branches anastomose
with vessels that derive from the ovarian arteries, thus providing collateral blood flow. (See 'Blood supply to the uterus, tubes, and
ovaries' above.)
●The ovarian arteries arise from the abdominal aorta. The right ovarian vein returns to the inferior vena cava while the left ovarian
vein returns to the left renal vein. The ovarian vessels travel through the infundibulopelvic ligaments in close proximity to the ureter,
along the medial aspect of the psoas muscle. (See 'Blood supply to the uterus, tubes, and ovaries' above.)
●The lymphatic drainage follows the pelvic vessels, with the nodes located anterior, posterior, or lateral to the vessels. The pelvic
lymphatic system is located retroperitoneally, like the pelvic vasculature. The pelvic lymphatics include the common iliac, external
iliac, internal iliac, medial sacral, and pararectal lymph nodes (figure 10 and figure 11). (See 'Lymphatics' above.)
●The ovaries and fallopian tubes are innervated by a nerve plexus that originates in the renal plexus with fibers from T10 and
parasympathetic fibers from the vagus nerve that run along the ovarian vessels (figure 12). The nerve supply to the pelvis runs
through the superior hypogastric plexus (figure 12), a ganglionic plexus that lies over the bifurcation of the aorta in the presacral
space. (See 'Nerves'above.)
●The pelvis contains several potential spaces and connective tissue planes that allow the urinary, reproductive, and gastrointestinal
systems to function independently of each other (figure 13). They lack blood vessels and nerves and are filled with loose areolar
tissue, allowing blunt dissection without disruption of these structures. (See 'Avascular planes' above.)
Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Lindeque BG. Management of cervical premalignant lesions. Best Pract Res Clin Obstet Gynaecol 2005; 19:545.
2. Ramanah R, Berger MB, Parratte BM, DeLancey JO. Anatomy and histology of apical support: a literature review concerning cardinal and
uterosacral ligaments. Int Urogynecol J 2012; 23:1483.
3. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992; 166:1717.
4. Baggish MS. Intra-abdominal pelvic anatomy. In: Atlas of Pelvic Anatomy and Gynecologic Surgery, 2nd ed, Baggish MS, Karram MM. (Eds),
Saunders Elsevier, Philadelphia 2006. p.117.
5. Kumar V, Abbas AK, Fausto N, et al. Robbins and Cotran Pathologic Basis of Disease, Professional Edition, 8th ed, Saunders, Philadelphia
2009.
6. Baggish MS. Introduction to pelvic anatomy. In: Atlas of Pelvic Anatomy and Gynecologic Surgery, 3rd ed, Baggish MS, Karram MM. (Eds),
Elsevier Saunders, St. Louis 2011. p.5.
 24

7. Hurd WW, Bude RO, DeLancey JO, Newman JS. The location of abdominal wall blood vessels in relationship to abdominal landmarks
apparent at laparoscopy. Am J Obstet Gynecol 1994; 171:642.
8. Balzer KM, Witte H, Recknagel S, et al. Anatomic guidelines for the prevention of abdominal wall hematoma induced by trocar placement.
Surg Radiol Anat 1999; 21:87.
9. Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol
1993; 36:976.
10. Wang Y, Zhao S. Placental blood circulation. In: Vascular biology of the placenta, Morgan & Claypool Life Sciences, San Rafael, CA 2010.
11. Rock JA, Jone HW. Te Linde's Operative Gynecology, 9th ed, Lippincott, Philadelphia 2003.
12. Gynecologic Oncology Group Surgical Procedures Manual, Revised January 2010.
13. Vaginal surgery, 4th, Nichols DH, Randall CL (Eds), Lippincott Williams & Wilkins, Philadelphia 1996.

Topic 14185 Version 8.0

 25

Delivery of the fetus in breech presentation

Author:
G Justus Hofmeyr, MD
Section Editor:
Charles J Lockwood, MD, MHCM
Deputy Editor:
Vanessa A Barss, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Jul 08, 2016.

INTRODUCTION — Vaginal breech deliveries occur, even in institutions with a policy of routine cesarean delivery for breech presentation,
because of situations such as precipitous delivery, out of hospital delivery, severe fetal anomaly or fetal death, and mother's preference for
vaginal birth. Therefore, it is essential for clinicians to maintain the skills of breech delivery.

This topic will review techniques for vaginal breech birth. Choosing the best route of delivery of the fetus in breech presentation is reviewed
separately. (See "Overview of issues related to breech presentation".)

VIDEO — In the absence of clinical experience, teaching aids such as videos and mannequins can be useful [1]. The following simulation
video illustrates one clinician's approach to vaginal breech delivery using Piper forceps to extract the aftercoming head (movie 1).

A free video demonstrating vaginal breech delivery is also available online at the World Health Organization’s (WHO) Reproductive Health
Library (RHL) [2].

VAGINAL BREECH DELIVERY

Criteria for an optimal situation — Various criteria have been developed to minimize the risk of vaginal breech delivery. These criteria for
patient selection are largely based upon clinical experience, and typically include [3-6]:

●No contraindication to vaginal birth (eg, placenta previa, contracted pelvis, cord presentation)
●No prior cesarean deliveries
●Absence of a fetal anomaly that may cause dystocia
●Estimated fetal weight at least 2000 g and not more than 4000 g
●Gestational age ≥36 weeks
●No hyperextension of the fetal head (ie, an extension angle of greater than 90 degrees)
●Frank or complete breech presentation (incomplete breech presentation is a contraindication)
●Spontaneous labor
●Staff skilled in breech delivery and immediate availability of facilities for safe emergency cesarean delivery (eg, anesthesia,
obstetrical, and pediatric personnel, surgical facilities and personnel).

In a prospective series of over 8000 women with breech presentation at term, only about 30 percent of women met these criteria [7].

An ultrasound examination should be performed before labor or in early labor to determine the type of breech and the attitude of the head,
estimate fetal weight, and exclude fetal anomalies (if not previously done).

With a complete breech at term, a combination of fetal lower legs, thighs, and trunk is the presenting part, whereas with a frank breech, a
combination of the thighs and trunk is the presenting part. If this large presenting part passes easily through the cervix/pelvis, then
subsequent head entrapment is unlikely. In footling presentations, however, the legs and trunk deliver sequentially. The presenting part is
smaller than the combination of thigh and trunk and can pass through an incompletely dilated cervix or small pelvis. In this setting, the
aftercoming head may become entrapped. Therefore, footling breech extraction is usually limited to delivery of a second twin.

Fetal weight should be estimated. Dystocia related to macrosomia is a major concern in breech presentation since, in contrast to the cephalic
presentation, the largest diameters of the fetus deliver last rather than first. Fetal growth restriction is also a concern because about half of
the perinatal deaths in the Term Breech Trial were in growth-restricted fetuses [6,8]. This may have been due to an increased risk of fetal
 26

acidosis related to chronic placental insufficiency compounded by the unavoidable cord compression that occurs during the second stage of
labor [6].

Hyperextension should be excluded by ultrasound, or radiograph if ultrasound is unavailable. An increased risk of neurodevelopmental
handicap has been observed in infants delivered vaginally in the breech position with hyperextension of the head [9-11]. In one large series,
an extended fetal head was reported in 33 of 445 (7.4 percent) breech presentations [10]. None of the seven fetuses delivered by cesarean
delivery had a neurologic abnormality, but 5 of the 26 fetuses delivered vaginally had neurological sequelae referable to spinal, supraspinal,
and cerebellar injuries.

There is no convincing evidence that information from pelvimetry (clinical, radiograph, magnetic resonance imaging, computed tomography)
for managing women with breech presentation leads to improved neonatal outcome [12]. However, there are few data from large or
randomized trials.

Labor management — Vaginal examination and/or ultrasound is performed to confirm whether the hips are flexed (frank or complete
breech) or extended (incomplete breech) and to monitor progress. The membranes are left intact because rupture of the membranes in
increases the risk of cord prolapse due to the irregular contour of the presenting part compared with the fetal head [13]. A vaginal
examination should be performed immediately following spontaneous rupture of membranes to exclude cord prolapse [6]. The risk is about 1
percent with a frank breech, but ≥10 percent with a footling breech [14].

Most experts recommend continuous electronic fetal heart rate monitoring, given the increased risk of cord compression [3,6,15]. After
membranes have ruptured, a scalp electrode may be attached to the buttocks if external monitoring is inadequate [16].

Labor progress is monitored and recorded, as with a cephalic presentation. Epidural analgesia is useful because it relieves pain, prevents the
mother from pushing involuntarily before full cervical dilatation, and provides anesthesia if obstetrical maneuvers are needed to facilitate
delivery. However, the mother should be able to push effectively when the breech descends to the pelvic floor [6].

Most experts recommend avoiding induction of labor [3,6,15]. However, two observational studies found no difference in maternal or
perinatal morbidity between women with induced versus spontaneous labors [17,18]. Oxytocin infusion may be used to treat hypocontractile
uterine activity in the latent phase of labor or after epidural anesthesia. By contrast, poor progress in the active phase may be an indicator of
fetopelvic disproportion; therefore, oxytocin augmentation is not recommended once active labor has begun

[6,19,20]. If labor progress is inadequate in the active phase, cesarean delivery is performed.

The normal progress of labor in the breech presentation has not been evaluated as extensively as cephalic presentation. Descent is
regarded as adequate if the breech reaches the level of the ischial spines when the cervix is 6 cm dilated and reaches the pelvic floor at full
dilation. A passive second stage (ie, delayed pushing) for up to 90 minutes is acceptable [6]. However, once the woman starts bearing down,
failure of the breech to descend and deliver within 30 to 60 minutes is managed by cesarean delivery rather than breech extraction.

The rationale for this guideline is based largely on good outcomes in observational studies of vaginal breech birth using strict selection
criteria, adherence to an intrapartum protocol with a low threshold for intervention, and with an experienced obstetrician in attendance. In one
large retrospective study from the National Maternity Hospital in Dublin, up to one hour was allowed for descent of the breech to the pelvic
floor in the second stage [20]. Delivery was expected within one hour of active pushing in nulliparas and 30 minutes in multiparas, and
resulted in neonatal outcomes comparable to cesarean delivery. The largest prospective series of planned vaginal breech birth included
2526 women who had 1796 vaginal breech deliveries [7]. Perinatal mortality and morbidity were very low (0.08 and 1.6 percent,
respectively), and the duration of the active second stage was less than one hour in 99.8 percent of patients. In the Term Breech Trial,
neonatal morbidity appeared to be increased in infants delivered after an active second stage longer than one hour [4]. In an observational
study in Finland, morbidity was increased when the active second stage of labor exceeded 40 minutes [21]. These data suggest that
cesarean delivery is preferable if birth is not imminent after 30 to 60 minutes of active maternal pushing or the second stage of labor exceeds
2.5 hours.

Delivery of the term fetus — Approaches to delivery of the term breech fetus are described below and illustrated by the figures (figure 1A-
E).

There is a general consensus that breech extraction should be avoided in singleton pregnancies [6]. Spontaneous or assisted breech
delivery is acceptable. A key point is to avoid assisting the delivery until maternal efforts have resulted in expulsion of the fetus to the
umbilicus or more, and then to apply suprapubic pressure to promote flexion and descent of the head. Rotation of the trunk and extraction of
limbs, when needed to assist this process, is acceptable. By contrast, traction on the trunk is thought to cause extension of the arms and
head and nuchal arms, which make delivery more difficult [22].
 27

Preparation — We place the mother in the lithotomy position with a wedge under one side of her buttocks. If she does not have epidural
analgesia, a pudendal block may be placed once the breech has descended onto the perineum. Episiotomy is performed if required to
facilitate delivery, and only after the fetal anus is visible at the vulva. Many clinicians perform routine episiotomy in breech delivery [23].
There are no data from randomized trials to guide practice.

Trunk and legs — Maternal expulsive efforts alone should be adequate to deliver the fetus' buttocks and lower limbs if not extended. The
mother is encouraged to bear down until the feet, legs, and trunk to the scapulae are visible. The body is supported in a plane at or below the
horizontal plane of the birth canal.

If the legs are extended after the umbilicus has delivered, the operator may use his/her fingers to exert pressure on the back of the knee
(Pinard maneuver) and guide the thigh away from the trunk as the trunk is rotated in the opposite direction. This causes the knee to flex and
allows extraction of the foot and the leg (figure 1B). The same procedure can be repeated, if needed, to deliver the other leg and foot.

Cord pulsation is checked and a small loop pulled down to prevent traction on the cord. Meconium passage is common.

Arms — After delivery of the trunk and legs, the mother is asked to push again and the shoulders should present in the anterior-posterior
plane and deliver spontaneously, one at a time, along with the arms, which are usually crossed in front of the chest.

Shoulder dystocia with breech presentation is usually due to extension of the arms or nuchal arms. This is typically caused by traction on the
fetus early in the delivery. If the trunk is pulled down, the arms can drag behind, whereas uterine contractions and maternal expulsive efforts
tend to push the entire fetus in its normal flexed attitude into the birth canal.

If the arms do not deliver spontaneously, intervention is required. The fetus is held by the hips or bony pelvis, never by the abdomen, as
injury to the kidneys/adrenals is possible. We wrap the legs/pelvis in a towel to provide a good grip and keep the back upwards. The fetus is
rotated through 180 degrees to deliver the first shoulder and arm, then in the opposite direction so the other shoulder and arm deliver under
the symphysis pubis (figure 2A-B). The second rotation may be assisted by gentle traction on the delivered arm in the direction of the
rotation.

Failure of the shoulders and arms to deliver with simple rotation of the trunk is managed by sliding an index finger along the fetal scapula,
over the shoulder, and into the antecubital fossa. The elbow is then swept in front of the face and downward to the chest, at which point the
arm can be delivered (figure 1C). This procedure is repeated for the other side. Gentle rotation of the fetal trunk at the same time, keeping
the back anterior (ie, toward the ceiling), will assist this maneuver.

If the arms remain trapped behind the neck, the fetus can be rotated so the chest is facing the symphysis pubis. This helps to dislodge the
nuchal arm(s) and allows the elbow to be swept down and extracted, as described above. Arm extraction can cause shoulder dislocation or
broken bones, but these complications are less morbid than prolonged dystocia resulting in asphyxia.

Head — At this stage, the fetal head may appear without any further effort on the operator's part. If the hairline is not visible after the
shoulders have delivered, the body is turned to face the floor and suprapubic pressure is applied by an assistant to flex the head and push it
down into the pelvis (Bracht maneuver) (figure 3). The combination of encouraging maternal expulsive effort, avoiding traction on the fetus by
the clinician, and applying suprapubic pressure to prevent a prolonged expulsion phase allowed Bracht to reduce perinatal mortality from a
baseline of 3.2 percent to 0 percent [6].

Once the hairline is visible, the head is delivered. We prefer to use forceps for delivery of the aftercoming head. If forceps delivery is not
possible or desired, the fetus's legs are swung upwards, keeping the vulva completely covered with the operator's other hand to keep the
head from "popping." This hand is then opened slowly to allow first the face and then the remainder of the head to deliver with maternal
expulsive efforts.

The Mauriceau-Smellie-Veit maneuver is favored by some obstetricians for routine delivery of the head. The fetal trunk lies along the
operator’s right forearm, with legs straddling the forearm. The middle finger of the right hand is placed on the maxilla, and the second and
fourth fingers on the malar eminences to promote flexion and descent while counter-pressure is applied to the occiput with the middle finger
of the left hand. Traction on the jaw should be avoided because of the possibility of temporomandibular joint injury [24].

With either forceps or spontaneous delivery, it is essential that the fetal legs are supported, but the trunk should be no more than 45 degrees
above horizontal; this avoids traction on the cervical spine during delivery of the head. If the body is bent backwards too far (eg, over the
mother's abdomen), hyperextension of the neck can occlude the vertebral arteries and can lead to necrosis of the cervical cord. Excess
weight on the cervical spine from downward traction can have the same effect or dislocate the fetus’s neck.
 28

Use of forceps — As mentioned above, we prefer to use forceps for delivery of the aftercoming head. The feet are grasped and, using as
much traction as required to keep the body straight and take weight off neck, the legs are swung upwards to no more than 45 degrees above
horizontal, where they are held by an assistant using a towel to make certain they do not slip. The operator then applies Piper's forceps
(picture 1A-B) and (movie 1). The assistant moves the fetal body to the mother's right so the operator, in a kneeling position, can apply the
left blade. Initially the handle of the forceps is held below the mother's thigh, almost at right angles to her body and to her right. Using two
fingers of the right hand as a guide, the toe of the blade is eased into the vagina and directed upward at an angle about 45 degrees below
the horizontal plane and over the infant’s right ear. The left hand gradually moves the handle along a curve, downward and toward midline,
while the fingers of the right hand guide the toe and protect the vaginal wall and side of the fetal head.

Unlike a cephalic delivery, a breech delivery means that the smallest part of the fetal skull appears at the vulva first with the large parietal
area at the back of the pelvis. Thus, if the forceps handle is brought to midline too soon after insertion of the blade, the distal part of the blade
will dig into the side of the head and it will not be possible to lock the handles. The tip must be kept directed at the maternal sacrum for as
long as possible, which means that the guiding hand has to be inserted well into the vagina until the tip has passed around the occiput.

The assistant then moves the fetus to the left and a similar procedure is performed for insertion of the right blade. The handles are locked
when both handles reach midline, and the fetal body straddles the shank.

Elevating the handles of the forceps and mild traction result in flexion and extraction of the head (figure 4A-B). The mouth can be cleared as
soon as it is seen.

Head entrapment — Head entrapment is a potentially serious complication of breech delivery. The preterm fetus is at high risk because its
fetal head-to-abdominal circumference ratio is larger than that of a mature fetus; therefore, the premature breech head may be caught in a
partially dilated cervix, resulting in acute asphyxia from compression of the umbilical cord. This can also happen with a larger fetus,
especially if the mother begins to push before full cervical dilatation occurs. In both premature and mature fetuses in breech presentation, the
skull may not have sufficient time to mold when passing through the bony pelvis. This may also play a role in head entrapment and can result
in damage to the occipital bone during delivery.

●Administer a uterine relaxant – If the head is entrapped, our preference is to administer a uterine relaxant, either a beta adrenergic
agonist (eg, terbutaline 0.25 mg subcutaneously or 2.5 to 10 mcg/minute intravenously) or nitroglycerin (50 to 200 mcg intravenously).
Uterine relaxation may allow the head to be delivered.

If uterine relaxation alone is unsuccessful, all other options pose significant risk to the fetus and mother.
●Symphysiotomy – Successful delivery of the obstructed aftercoming-head by symphysiotomy has been reported in observational
studies, primarily in Sub-Saharan Africa, where facilities for safe cesarean delivery may not be available and some clinicians have
experience with this procedure [25-30]. No randomized trials have been performed.

The Society of Obstetricians and Gynecologists of Canada recommend the use of symphysiotomy when needed to deliver an
obstructed aftercoming head of the breech fetus [6]. In this very rare situation, the symphysis pubis and overlying skin are infiltrated
with local anesthetic, and a firm plastic catheter is inserted into the urethra and used to displace the urethra laterally. Two assistants
support the mother's legs at no more than 90 degrees abduction. Using a scalpel, a small incision is made over the symphysis and
the anterior fibers of the pubic symphysis are divided. This allows the symphysis to separate just enough to allow delivery of the head.
The small skin incision may be left unsutured, or closed with a suture if needed for hemostasis. The mother rests in bed for about two
days, and then is mobilized on crutches until free weightbearing is comfortable. Rarely, pelvic instability has required delayed
orthopedic repair.
●Zavanelli maneuver with cesarean delivery – If surgical facilities are available, the provider can attempt to replace the body of the
fetus in the uterus (Zavanelli maneuver), and proceed to cesarean delivery [31,32]. Although a review of 11 cases of obstructed
aftercoming head of the breech managed with this maneuver reported successful outcomes, the safety of this approach is unclear
[33]. It has been used primarily in cephalic presentations with shoulder dystocia, and maternal and fetal injury and fetal death have
been reported in some of these cases [34].

Delivery of the preterm fetus — Delivery of the preterm fetus in breech presentation is similar to that described above for the term fetus,
except leaving the membranes intact may be particularly beneficial in the preterm population. Delay in rupturing the membranes until the
fetus has passed through the vagina reduces the risk of entrapment of the aftercoming head by an insufficiently dilated cervix, helps protect
the fetus from trauma, and impedes cord prolapse [35,36].

Dührssen incisions — If the fetus is preterm and the cervix is effaced, but incompletely dilated, the cervical os can be enlarged surgically.
One or two fingers are placed between the cervix and the presenting part to protect the fetus and allow the surgeon to palpate the
cervicovaginal junction. Bandage scissors are used to make one to three incisions (Dührssen incisions) extending the full length of the
remaining undilated cervix, typically at 2, 10, and 6 o'clock. A major disadvantage of this technique, which is rarely performed, is that the
 29

incisions may extend into the lower uterine segment and broad ligament, with potential injury to uterine vessels, ureter, and bladder, and
severe hemorrhage.

CESAREAN BREECH DELIVERY — The abdominal and uterine incisions should be sufficiently large to allow easy, atraumatic fetal
extraction.

Mature breech — We suggest planned cesarean delivery for breech presentation between 39 and 41 weeks of gestation or in early labor to
allow maximum time for spontaneous cephalic version and minimize the risk of respiratory problems in the neonate. The presentation should
be checked immediately prior to surgery in case spontaneous version has occurred.

A low transverse hysterotomy incision is adequate in most cases. The technique of fetal extraction through the hysterotomy incision is similar
to that described above for vaginal breech delivery and, likewise, forceps should be available for controlling delivery of the aftercoming head.

Care should be taken not to hyperextend or place too much traction on the cervical spine. Use of a uterine relaxant can be helpful when a
difficult delivery is anticipated or encountered [37].

Premature breech — The preterm lower uterine segment may be very narrow, making delivery through a transverse lower uterine incision
difficult. Several solutions have been suggested:

●Make a vertical uterine incision [38,39]

●Administer a uterine relaxant just before opening the uterus [40]
●Give halothane to relax the uterus [41]. The potential to cause hepatotoxicity has led to a decrease in its use.

A review of 416 breeches of various gestational ages delivered by low transverse or low vertical incisions found no advantages for the low
vertical incision [42]. Since this was an observational series and the patients delivered by low transverse incisions had different
characteristics than those delivered by low vertical incisions, we cannot conclude that the two incisions were similarly safe and effective.
Case by case clinical judgment should guide this decision.

Whichever incision is used, the fetus must be delivered gently and atraumatically. Forceps, if the appropriate size is available, are useful for
the aftercoming head.

SPECIAL SITUATIONS

Delivery of the hydrocephalic fetus in breech presentation — Breech presentation is more common when there are fetal anomalies,
particularly hydrocephaly. For this reason, it is important to exclude fetal anomalies before choosing the route of birth.

For a viable breech fetus with significant hydrocephaly, delivery should be by cesarean to avoid head entrapment. Both the uterine and the
abdominal incisions should be large enough to accommodate easy extraction of the head. A transverse incision in the lower segment may be
too small so it is preferable to use a vertical lower segment incision, which may have to be extended into the upper segment.

For a nonviable fetus with hydrocephaly, vaginal breech birth is preferable since vaginal birth is generally safer for the mother and perinatal
asphyxia is not a concern when congenital anomalies are lethal. If head entrapment occurs during spontaneous labor, the calvarium can be
decompressed and collapsed by cephalocentesis. The author uses a wide-bore spinal needle, but use of other similar instruments has been
described in case reports. The procedure is easier to perform when the head is fixed at the pelvic brim than when it is mobile in the upper
segment. It may be done transvaginally, but is usually more easily performed transabdominally. In the United States, a deliberate intentional
act that results in the death of a partially delivered fetus with a heart rate during an abortion may be unlawful (partial birth abortion). It is
prudent to consult a hospital attorney and review state and federal regulations before performing cephalocentesis.

Delivery in the absence of skilled assistance and appropriate facilities — The following synopsis describes management of women
during imminent delivery of a fetus in breech presentation not occurring on the Labor and Delivery Unit. It is intended for health care
providers who do not perform obstetrical deliveries as part of their usual practice.

●Call for help. There are two patients in an obstetrical delivery, the mother and the infant; each needs at least one health care
provider. An obstetrician and pediatrician or family practitioners should be summoned, if available.
●If no part of the fetus has emerged from the vagina, encourage the mother not to bear down; “panting” may help her to avoid
pushing. This provides some time to get her to the labor and delivery unit and/or for the arrival of a skilled birth assistant.
●A beta sympathomimetic drug (eg, terbutaline by injection) may help to reduce the strength and frequency of uterine contractions;
however, once the fetus is partially born (the buttocks or a leg or legs are visible at or beyond the introitus), it is better to assist with
 30

completing the birth. The umbilical cord will usually be compressed during delivery so the fetus should be delivered ideally within 10
minutes.
●The most important principle is to avoid any traction on the fetus unless there is absolutely no progress over several minutes of
maternal bearing-down efforts. Pulling on the fetus tends to cause the head to extend, which makes birth of the head more difficult.
●When the fetal buttocks present at the introitus, support the mother in a semi-upright, crouching, or kneeling position (whichever
feels best to her) with her thighs flexed and apart, and encourage her to bear down as strongly as she is able during contractions. In
most cases, the entire fetus will deliver spontaneously, and only gentle support of the body is needed as the head is born.
●If there is delayed progress of the birth, try turning the mother to a kneeling position and have her bear down in this position.
Alternatively, apply gentle, steady pressure on the top of her uterus, towards her pelvis, during contractions. Avoid sharp pressure.
●If there is no further progress, attempt the maneuvers described in this topic. (See 'Delivery of the term fetus' above.)

NEWBORN EVALUATION — All newborns born after abnormal fetal presentations require a thorough pediatric examination. A pediatrician
should be present at delivery because of the possibility of injury during delivery and the possibility that the malpresentation was due to a fetal
abnormality. In addition, the risk of developmental dysplasia of the hip is increased with breech presentation [43].

Neonatal morbidity is common, but not necessarily related to mode of delivery or obstetrical mismanagement in labor [44].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key
questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles
are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You
can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient education: Breech pregnancy (The Basics)")

SUMMARY AND RECOMMENDATIONS

Vaginal delivery

●We suggest avoiding vaginal breech delivery in singleton gestations, or the presenting twin (Grade 2C). However, vaginal delivery is
an acceptable alternative to cesarean delivery for women who meet selection criteria for safe vaginal delivery and choose this option.
(See"Overview of issues related to breech presentation".)
●Criteria for selecting women at lower risk of morbidity from vaginal breech birth include (see 'Criteria for an optimal situation' above):
•No contraindication to vaginal birth
•No prior cesarean deliveries
•No fetal anomaly that may cause dystocia
•Estimated fetal weight at least 2000 to 2500 g and not more than 4000 g
•Gestational age ≥36 weeks
•No hyperextension of the fetal head (ie, an extension angle of greater than 90 degrees)
•Frank or complete breech presentation (incomplete breech presentation is a contraindication)
•Spontaneous labor
•Staff skilled in breech delivery and immediate availability of facilities for safe emergency cesarean delivery (eg, anesthesia,
obstetrical, and pediatric personnel, surgical facilities and personnel).
●We suggest use of epidural anesthesia rather than parenteral anesthesia (Grade 2C) and avoidance of oxytocin augmentation in the
active phase of labor (Grade 2C). (See 'Labor management' above.)
●We suggest leaving membranes intact (Grade 2C). A vaginal examination should be performed immediately upon rupture of
membranes to exclude cord prolapse. (See 'Labor management' above and 'Delivery of the preterm fetus' above.)
●Descent is adequate if the breech reaches the level of the ischial spines when the cervix is 6 cm dilated and reaches the pelvic floor
at full dilatation. If the fetus fails to deliver within 60 minutes of maternal pushing, we suggest cesarean delivery rather than breech
extraction (Grade 2C). (See 'Labor management' above.)
●We suggest not assisting the delivery until maternal efforts have resulted in expulsion of the fetus at least to the scapulae (Grade
2C). (See'Trunk and legs' above.)
 31

●Arm dystocia can usually be resolved by rotation of the trunk, or by sliding an index finger along the scapula, over the shoulder, and
into the antecubital fossa. The elbow is then swept in front of the face and downward to the chest, at which point the arm can be
delivered (figure 1C). (See 'Arms' above.)
●It is essential that the trunk not be raised more than 45 degrees above the horizontal plane of the birth canal; this avoids traction on
the cervical spine, which can lead to death or severe disability. (See 'Head' above.)
●Suprapubic pressure helps the head to flex and descend. The head can deliver spontaneously or with use of the Mauriceau-Smellie-
Veit maneuver or with use of Piper forceps. No method has been proven to be superior to the others. (See 'Head' above.)
●If the head is entrapped, we suggest administering a uterine relaxant (Grade 2C). Options include a beta adrenergic agonist
(eg, terbutaline0.25 mg subcutaneously or 2.5 to 10 mcg/minute intravenously) or nitroglycerin (50 to 200 mcg intravenously). The
mother should also push effectively.

If maternal pushing, suprapubic pressure, and uterine relaxation are unsuccessful, all other options pose significant risk to the fetus
and mother. (See 'Head entrapment' above.)

Cesarean delivery

●Planned cesarean delivery for breech presentation is performed between 39 and 41 weeks of gestation or in early labor to allow time
for spontaneous cephalic version and minimize the risk of respiratory problems in the neonate. The presentation should be checked
immediately prior to surgery in case spontaneous version has occurred.

The technique of fetal extraction through the hysterotomy incision is similar to that for vaginal breech delivery. (See 'Cesarean breech
delivery' above.)
●The preterm lower uterine segment may be narrow, making delivery through a transverse lower uterine incision difficult.
(See 'Premature breech' above.)
Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

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2. Vaginal breech delivery and symphysiotomy http://apps.who.int/rhl/videos/en/ (Accessed on September 14, 2012).
3. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 340. Mode of term singleton breech delivery. Obstet Gynecol 2006;
108:235.
4. Su M, McLeod L, Ross S, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol 2003;
189:740.
5. Bingham P, Lilford RJ. Management of the selected term breech presentation: assessment of the risks of selected vaginal delivery versus
cesarean section for all cases. Obstet Gynecol 1987; 69:965.
6. Kotaska A, Menticoglou S, Gagnon R, et al. Vaginal delivery of breech presentation. J Obstet Gynaecol Can 2009; 31:557.
7. Goffinet F, Carayol M, Foidart JM, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an
observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006; 194:1002.
8. Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a
randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000; 356:1375.
9. Svenningsen NW, Westgren M, Ingemarsson I. Modern strategy for the term breech delivery--a study with a 4-year follow-up of the infants. J
Perinat Med 1985; 13:117.
10. Westgren M, Grundsell H, Ingemarsson I, et al. Hyperextension of the fetal head in breech presentation. A study with long-term follow-up. Br
J Obstet Gynaecol 1981; 88:101.
11. Ballas S, Toaff R. Hyperextension of the fetal head in breech presentation: radiological evaluation and significance. Br J Obstet Gynaecol
1976; 83:201.
12. van Loon AJ, Mantingh A, Serlier EK, et al. Randomised controlled trial of magnetic-resonance pelvimetry in breech presentation at term.
Lancet 1997; 350:1799.
13. Uygur D, Kiş S, Tuncer R, et al. Risk factors and infant outcomes associated with umbilical cord prolapse. Int J Gynaecol Obstet 2002;
78:127.
14. Cheng M, Hannah M. Breech delivery at term: a critical review of the literature. Obstet Gynecol 1993; 82:605.
15. Royal College of Obstetricians and Gynaecologist (RCOG). The management of breech presentation. London (UK). RCOG. December 2006.
16. Kessler J, Moster D, Albrechtsen S. Intrapartum monitoring with cardiotocography and ST-waveform analysis in breech presentation: an
observational study. BJOG 2015; 122:528.
17. Bleu G, Demetz J, Michel S, et al. Effectiveness and safety of induction of labor for term breech presentations. J Gynecol Obstet Biol Reprod
(Paris) 2016.
18. Macharey G, Ulander VM, Heinonen S, et al. Induction of labor in breech presentations at term: a retrospective observational study. Arch
Gynecol Obstet 2016; 293:549.
 32

19. Beazley JM, Banovic I, Feld MS. Maintenance of labour. Br Med J 1975; 2:248.
20. Alarab M, Regan C, O'Connell MP, et al. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004; 103:407.
21. Bin YS, Roberts CL, Ford JB, Nicholl MC. Outcomes of breech birth by mode of delivery: a population linkage study. Aust N Z J Obstet
Gynaecol 2016; 56:453.
22. Jotkowitz MW, Picton FC. An appraisal of an anatomically and physiologically correct method of breech delivery: the Bracht manoeuvre. Aust
N Z J Obstet Gynaecol 1970; 10:151.
23. Heres MH, Pel M, Elferink-Stinkens PM, et al. The Dutch obstetric intervention study--variations in practice patterns. Int J Gynaecol Obstet
1995; 50:145.
24. Grosfeld O, Kretowicz J, Brokowski J. The temporomandibular joint in children after breech delivery. J Oral Rehabil 1980; 7:65.
25. Verkuyl DA. Think globally act locally: the case for symphysiotomy. PLoS Med 2007; 4:e71.
26. Menticoglou SM. Symphysiotomy for the trapped aftercoming parts of the breech: a review of the literature and a plea for its use. Aust N Z J
Obstet Gynaecol 1990; 30:1.
27. Björklund K. Minimally invasive surgery for obstructed labour: a review of symphysiotomy during the twentieth century (including 5000
cases). BJOG 2002; 109:236.
28. Sunday-Adeoye IM, Okonta P, Twomey D. Symphysiotomy at the Mater Misericordiae Hospital Afikpo, Ebonyi State of Nigeria (1982-1999):
a review of 1013 cases. J Obstet Gynaecol 2004; 24:525.
29. Onah HE, Ugona MC. Preferences for cesarean section or symphysiotomy for obstructed labor among Nigerian women. Int J Gynaecol
Obstet 2004; 84:79.
30. Verkuyl DA. Symphysiotomies are important option in developing world. BMJ 2001; 323:809.
31. Iffy L, Apuzzio JJ, Cohen-Addad N, et al. Abdominal rescue after entrapment of the aftercoming head. Am J Obstet Gynecol 1986; 154:623.
32. Steyn W, Pieper C. Favorable neonatal outcome after fetal entrapment and partially successful Zavanelli maneuver in a case of breech
presentation. Am J Perinatol 1994; 11:348.
33. Sandberg EC. The Zavanelli maneuver: 12 years of recorded experience. Obstet Gynecol 1999; 93:312.
34. Ross MG, Beall MH. Cervical neck dislocation associated with the Zavanelli maneuver. Obstet Gynecol 2006; 108:737.
35. Goldenberg RL, Nelson KG. The unanticipated breech presentation in labor. Clin Obstet Gynecol 1984; 27:95.
36. Richmond JR, Morin L, Benjamin A. Extremely preterm vaginal breech delivery en caul. Obstet Gynecol 2002; 99:1025.
37. Ezra Y, Wade C, Rolbin SH, Farine D. Uterine tocolysis at cesarean breech delivery with epidural anesthesia. J Reprod Med 2002; 47:555.
38. Haesslein HC, Goodlin RC. Delivery of the tiny newborn. Am J Obstet Gynecol 1979; 134:192.
39. Westgren LM, Songster G, Paul RH. Preterm breech delivery: another retrospective study. Obstet Gynecol 1985; 66:481.
40. Westgren M, Ingemarsson I, Ahlström H, et al. Delivery and long-term outcome of very low birth weight infants. Acta Obstet Gynecol Scand
1982; 61:25.
41. Hobel CJ, Oakes GK. Special considerations in the management of preterm labor. Clin Obstet Gynecol 1980; 23:147.
42. Schutterman EB, Grimes DA. Comparative safety of the low transverse versus the low vertical uterine incision for cesarean delivery of
breech infants. Obstet Gynecol 1983; 61:593.
43. de Hundt M, Vlemmix F, Bais JM, et al. Risk factors for developmental dysplasia of the hip: a meta-analysis. Eur J Obstet Gynecol Reprod
Biol 2012; 165:8.
44. Illingworth RS. A paediatrician asks--why is it called birth injury? Br J Obstet Gynaecol 1985; 92:122.

Topic 5384 Version 20.0

 33

Overview of issues related to breech presentation

Author:
G Justus Hofmeyr, MD
Section Editor:
Charles J Lockwood, MD, MHCM
Deputy Editor:
Vanessa A Barss, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Jul 08, 2016.

INTRODUCTION — Breech presentation describes the fetus whose buttocks are adjacent to the birth canal. This topic will provide an
overview of major issues related to breech presentation, including the best approach for delivery. Techniques for breech delivery are
discussed separately. (See "Delivery of the fetus in breech presentation".)

TYPES OF BREECH PRESENTATION — The main types of breech presentation are:

●Frank breech – In the frank breech position, both hips are flexed and both knees are extended so that the feet are adjacent to the
fetal head (figure 1). At term, 50 to 70 percent of breech fetuses are in this position.
●Complete breech – In the complete breech position, both hips and both knees are flexed (figure 2). At term, 5 to 10 percent of
breech fetuses are in this position.
●Incomplete breech – In the incomplete breech position, one or both hips are not completely flexed (figure 3). At term, 10 to 40
percent of breech fetuses are incomplete.

The presenting part may be the buttocks, one or both feet (ie, footling breech) (image 1), or, rarely, one or both knees (ie, kneeling breech).

Significance — Because the hips are flexed and the knees are extended or flexed in the frank and complete breech presentations, the
thighs and trunk pass through the birth canal simultaneously. If this large presenting part passes through the birth canal easily, then the
aftercoming shoulders and head are likely to pass through easily as well, but a difficult delivery is still possible.

In contrast, one or both hips are not flexed in an incomplete breech; therefore, one or both feet or knees may easily slip through an
incompletely dilated cervix or an inadequate pelvis leading to entrapment of the shoulders or head because of their much larger diameters.
This increases the risks of hypoxic injury and delivery-related trauma. In addition, a foot or knee presentation provides space for umbilical
cord prolapse.

PREVALENCE — The prevalence of breech presentation decreases with increasing gestational age. It is a common occurrence in early
pregnancy when the fetus is highly mobile within a relatively large volume of amniotic fluid. Twenty to 25 percent of fetuses under 28 weeks
are breech, but only 7 to 16 percent are breech at 32 weeks, and only 3 to 4 percent are breech at term [1,2].

PATHOGENESIS — In most pregnancies, breech presentation appears to be a chance occurrence. In up to 15 percent of cases, however, it
may be due to fetal, maternal, or placental abnormalities. It is hypothesized that a fetus with normal anatomy, activity, amniotic fluid volume,
and placental location adopts the cephalic presentation near term because this position is the best fit for the intrauterine space, but if any of
these variables is abnormal, then breech presentation is more likely.

RISK FACTORS — Risk factors for breech presentation include:

●Preterm gestation
●Previous breech presentation (see 'Risk of recurrence' below)
●Uterine abnormality (eg, bicornuate or septate uterus, fibroid) [3,4]
●Placental abnormality (eg, placenta previa, cornual placenta) [5,6]
●Multiparity resulting in a lax abdominal wall and more rounded intrauterine space
●Extremes of amniotic fluid volume (polyhydramnios, oligohydramnios)
●Contracted maternal pelvis [7]
●Fetal anomaly (eg, anencephaly, hydrocephaly, sacrococcygeal teratoma, neck mass) [8]
 34

●Extended fetal legs [9]

●Crowding from multiple gestation
●Fetal neurologic impairment
●Short umbilical cord [10]
●Fetal asphyxia [11]
●Primiparity [9,12]
●Female sex [12,13]
●Maternal anticonvulsant therapy [14]
●Older maternal age [12]
●Fetal growth restriction [12]

Risk of recurrence — In population-based registries, the frequency of breech presentation in a second pregnancy was about 2 percent if the
first pregnancy was not a breech presentation and about 9 percent if the first pregnancy was a breech presentation [15]. After two
consecutive pregnancies with breech presentation at delivery, the risk of another breech presentation was about 25 percent [15,16], and after
three consecutive breech deliveries, the risk was almost 40 percent [15].

In addition, parents who themselves were delivered at term from breech presentation were twice as likely to have firstborn offspring in breech
presentation as parents who were delivered in cephalic presentation [17]. This suggests a possible heritable component to fetal presentation
that can be transmitted from either parent.

CLINICAL FINDINGS AND COURSE — Signs and symptoms of breech presentation are best appreciated in the third trimester. Clinical
assessment for fetal presentation should be a routine part of prenatal examination in late pregnancy since breech presentation affects
delivery management. (See 'Choosing the route of delivery at term' below.)

Symptoms — Women carrying a fetus in breech presentation often report subcostal discomfort due to the fetal head in the fundus [18]. They
may also perceive kicking in the lower abdomen when the breech is complete or incomplete.

Physical examination — On transabdominal examination, breech presentation is characterized by the presence of a soft mass (ie,
buttocks) and the absence of a hard fetal skull in the lower uterine segment. In addition, a hollow (fetal neck) next to the presenting part is
absent in a breech presentation and palpable in a cephalic presentation.

In breech presentation, the fetal head in the upper part of the uterus is readily balloted since it pivots on the neck and moves independently
from the trunk. By comparison, in cephalic presentation, ballottement of the breech in the upper part of the uterus is characteristically
sluggish because it is accompanied by movement of the entire trunk.

On transvaginal examination, the soft buttocks, anal orifice, or feet may be identified when the cervix is dilated, but can be difficult to palpate
when the cervix is closed.

Imaging — Ultrasound clearly identifies the fetal head in the fundus, buttocks in the lower uterine segment, extension or flexion of each hip
and knee, and location of each foot.

Hyperextension of the fetal head (defined by an extension angle greater than 90 degrees) is an important finding as it is a contraindication to
vaginal delivery. (See "Delivery of the fetus in breech presentation", section on 'Criteria for an optimal situation'.)

Natural history — Spontaneous version may occur at any time before delivery, even after 40 weeks of gestation. A prospective longitudinal
study using serial ultrasound examination reported the likelihood of spontaneous version to cephalic presentation after 36 weeks was 25
percent [9]. Characteristics that lower the likelihood of spontaneous version include extended fetal legs, oligohydramnios, short umbilical
cord, primiparity, and fetal/uterine abnormalities.

DIAGNOSIS — Identification of breech presentation on transabdominal or transvaginal physical examination or ultrasound examination is
diagnostic.

DIAGNOSTIC EVALUATION — We perform ultrasound examination to confirm suspected breech presentation and type of breech when the
clinical diagnosis is uncertain and this information will affect management. For example, ultrasound confirmation of breech presentation at or
near term should prompt a discussion of external cephalic version. Antepartum clinical diagnosis of breech presentation is not infallible. In a
study in which an experienced clinician examined 138 women at 30 to 41 weeks of gestation immediately before an ultrasound examination,
the examiner identified only three of eight breech presentations, and falsely diagnosed six breeches [19]. Clinical examination is fallible
 35

because characteristic transabdominal breech findings may be obscured or distorted by maternal obesity, full bladder, leiomyoma,
polyhydramnios, anterior placenta, or multiple gestation.

In a laboring patient, confirmation of previously unsuspected breech presentation should prompt a discussion about cesarean versus vaginal
delivery. Intrapartum transvaginal examination through a dilated cervix is more accurate than transabdominal examination, but is also fallible
because a frank breech presentation has some findings similar to those found with an edematous face presentation. A useful distinguishing
characteristic is that the fetal greater trochanters and anal orifice form a straight line in the buttocks, whereas the malar bones and mouth
form a triangle in the face. (See "Face and brow presentations in labor", section on 'Face presentation'.)

CHOOSING THE ROUTE OF DELIVERY AT TERM — Four strategies for delivery of the term breech fetus have evolved:

●External cephalic rotation before labor, with a trial of labor if the version is successful and cesarean delivery if unsuccessful. This is
the most common approach in the United States and many other countries.
●External cephalic rotation before labor, with a trial of labor if the version is successful. If the version is unsuccessful, a trial of labor
and vaginal breech birth is offered to patients who have characteristics that are believed to place them at a low risk of labor and
delivery related complications. Cesarean delivery is offered to higher-risk patients and any patient who declines to attempt vaginal
breech birth. This is the author's approach.
●Scheduled cesarean delivery for breech presentation, without a trial of external cephalic version.
●A trial of labor and vaginal breech birth for patients who have characteristics that are believed to place them at a low risk of labor
and delivery related complications, without a trial of external cephalic version.

There is general agreement that the breech fetus is at higher risk for asphyxia and traumatic injury during vaginal delivery than the cephalic
presenting fetus (see 'Significance' above). To minimize the risk of these complications, the choice of delivery route for the term breech fetus
is guided by patient values and preferences and provider experience, values, and preferences, taking into account the risks and benefits of
the various approaches. The mother's choice of mode of birth should be informed by unbiased, noncohesive counseling [20]. The choice
should be made with due consideration of specific healthcare environments, individual women, and the limitations inherent in the data
described below [21-26].

External cephalic version with cesarean delivery of the persistent breech — External cephalic version at or near term, followed by a
trial of vaginal delivery if the version is successful and scheduled cesarean delivery if breech presentation persists is the preferred approach
to delivery of the term breech fetus in the United States, and many other countries. Patients are encouraged to undergo external cephalic
version to convert a breech presentation to cephalic presentation and thus increase the likelihood of vaginal cephalic birth. In a 2015 meta-
analysis of randomized trials, external cephalic version at term resulted in a 60 percent reduction in non-cephalic presentation at birth
(relative risk [RR] 0.42, 95% CI 0.29-0.61) and a 40 percent reduction in cesarean delivery (RR 0.57, 95% CI 0.40-0.82) [27]. Performing the
version at 34 to 35 weeks of gestation and using a tocolytic drug increase the likelihood of success. These data and the technique for
external cephalic version are discussed separately. (See "External cephalic version".)

Planned cesarean delivery for persistent term breech presentation is associated with a clinically significant decrease
in perinatal/neonatalmortality and neonatal morbidity, with only a modest increase in short-term maternal morbidity, compared with a policy of
planned vaginal delivery.

The evidence supporting planned cesarean delivery was provided by a systematic review of randomized trials of planned cesarean delivery
versus planned vaginal delivery for term breech presentation (three trials, 2396 participants) [28]. In two of the trials, which were from the
same unit, women with frank [29] or non-frank [30] breech presentation were randomly assigned to undergo scheduled cesarean delivery or
a protocol allowing vaginal delivery within prescribed limitations, including the absence of diminished pelvic dimensions on radiographic
pelvimetry. The third trial, the Term Breech Trial, was a large (n = 2088 participants) multicenter, international trial comparing planned
cesarean delivery with planned vaginal delivery by an experienced clinician following agreed upon clinical guidelines [31]. The participating
countries were classified as having low or high perinatal mortality rates (low = less than 20 per 1000 live births plus late fetal deaths, high =
20 or more). Cesarean delivery was performed in 550 of 1227 women (45 percent) allocated to the vaginal delivery protocol.

The key findings were as follows.

Compared with planned vaginal birth of breech presentation, planned cesarean delivery [28]:

●Reduced perinatal/neonatal death (RR 0.29, 95% CI 0.10-0.86). Risk ratios were similar for countries with low versus high national
perinatal mortality rates, but absolute mortality rates were higher in the latter.
●Reduced composite short-term outcome of perinatal/neonatal death or serious neonatal morbidity (RR 0.33, 95% CI 0.19-0.56). This
result was largely driven by data from countries with low national perinatal mortality rates, where the comparative risk of the
composite outcome was RR 0.07 (95% CI 0.02-0.29; 4/1000 for planned cesarean delivery versus 57/1000 for planned vaginal
 36

delivery). In countries with high national perinatal mortality rates, the comparative risk of the composite outcome was RR 0.66 (95%
CI 0.35-1.24; 29/1000 for planned cesarean delivery versus 44/1000 for planned vaginal delivery). The unexpectedly low absolute
composite mortality/morbidity rate with planned vaginal delivery in high perinatal mortality rate countries may have been due to less
macrosomia, more experience with vaginal breech delivery, and documentation issues in these countries.
The numbers in the meta-analysis were too small to show statistical reductions in birth trauma and brachial plexus injury with planned
cesarean delivery.

In addition:

●Route of planned delivery had no significant effect on long-term outcome in offspring, except that infant medical problems were
significantly increased following planned cesarean delivery. The combined risk of death/neurodevelopmental delay was similar for the
planned vaginal and planned cesarean groups at two years of age. Since there were few serious adverse events despite the large
number of study participants and 17 of 18 neonates with serious early morbidity were neurologically normal at two years of age, a
small difference between groups in long-term composite mortality/morbidity cannot be excluded.
●Route of planned delivery had no significant effect on long-term maternal outcome. In the short-term, planned cesarean resulted in a
small increase in some maternal morbidities (eg, hemorrhage, transfusion, infection), but less urinary incontinence and incontinence
of flatus. Complications in future pregnancies related to scarring of the uterus were not assessed.

It is estimated that 338 cesareans for breech presentation would need to be performed to prevent one perinatal death [32].

The Term Breech Trial impacted clinical practice worldwide: The rate of planned vaginal breech birth fell since publication of this trial [33-35],
and limited data suggest that this fall has been accompanied by a fall in the morbidity and mortality of breech delivery [32,33], especially if
performed before labor begins [36]. However, a policy of planned cesarean delivery may not be affordable or feasible in resource-poor
settings. On an individual-case basis, there may be clinical situations in which the maternal risks of cesarean or the mother's desire to avoid
cesarean delivery outweigh the newborn's short-term risks of vaginal birth. Both routes of delivery have similar long-term maternal and
childhood outcomes and some data suggest some long-term health benefits to being born vaginally [37-39]. In addition, cesarean delivery
has implications for women planning future pregnancies including repeat cesarean delivery and increased risks of placenta accreta and
uterine rupture [40]. Lastly, the randomized trials that were the basis of current policies for planned cesarean delivery included fewer than
3000 women. Increasing the magnitude of planned cesarean deliveries worldwide will increase the absolute number of women who develop
rare but life-threatening complications of this major operative procedure [41,42].

External cephalic version with vaginal breech delivery for selected patients with a persistent breech — The author's preference is to
offer external cephalic version followed by trial of vaginal birth if successful. If unsuccessful, he offers scheduled cesarean delivery and, for
women who meet criteria, he offers a trial of labor and vaginal breech birth (see "Delivery of the fetus in breech presentation", section on
'Criteria for an optimal situation') [21-26,37-42]. Closely monitoring the progress of labor is particularly important in women who attempt a
vaginal breech birth. The author has a low threshold for performing a cesarean delivery if labor progress is protracted in the first stage or the
breech fails to descend normally and deliver spontaneously in the second stage. He does not administer oxytocin to patients in the active
phase of labor with a breech presentation and labor protraction or arrest. (See "Delivery of the fetus in breech presentation", section on
'Labor management'.)

There is a general consensus that women who choose to undergo a trial of labor and vaginal breech birth should be at low risk of
complications from vaginal breech delivery and their labor and delivery should be supervised by a clinician with experience in vaginal breech
birth. Whether such pregnancies can be identified and how the fetal risks from vaginal delivery compare with maternal risks from cesarean
delivery have been debated for decades.

The PREsentation et MODe d'Accouchement (PREMODA) study is often cited as the best evidence to support vaginal breech birth in
selected women [43]. The results of this observational study are less robust than those of the Term Breech Trial discussed above, but
provide information illustrating the magnitude of morbidity/mortality of planned vaginal birth in patients managed using the authors' protocol.
Subsequent smaller prospective observational studies have also reported low rates of adverse outcome from planned vaginal breech
delivery that followed strict protocols [44-46].

The PREMODA study was a prospective observational multicenter study conducted in 174 centers in France and Belgium and including
8105 singleton breech fetuses at term [43]. The study evaluated the safety of vaginal breech birth using strict criteria (table 1) for selecting
patients for a trial of labor. Major findings were [43,47]:

●The composite outcome of fetal/neonatal mortality or serious neonatal morbidity was not significantly different for planned vaginal
versus planned cesarean delivery (1.60 percent versus 1.45 percent, odds ratio [OR] 1.10, 95% CI 0.75-1.61) after adjustment for
geographic origin, gestational age less than 39 weeks at birth, birth weight less than the 10th percentile, and an annual number of
maternity unit births of less than 1500.
 37

●Approximately 70 percent of the 2502 patients in the planned vaginal birth group delivered vaginally, and 165 (6.6 percent) of these
pregnancies had an adverse perinatal outcome, including but not limited to brachial plexus injury (five infants), skull fracture (one
infant), genital injury (two infants), intraventricular hemorrhage (one infant), seizure (four infants), and death (two infants). Factors
associated with adverse perinatal outcome were geographic origin, delivery at <39 weeks of gestation, birthweight <10 th percentile,
and annual number of maternity unit births <1500.

Cesarean delivery without an attempt at external cephalic version — Some women may choose to undergo scheduled cesarean
delivery without an attempt at external cephalic version. Women with a low likelihood of successful version or at increased risk of fetal harm
from the procedure may reasonably avoid the procedure. (See "External cephalic version", section on 'Indications and contraindications'.)

Vaginal delivery without an attempt at external cephalic version — Some women may choose to undergo a trial of labor and vaginal
breech delivery without an attempt at external cephalic version. Women with a low likelihood of successful version or at increased risk of fetal
harm from the procedure may reasonably avoid the procedure. (See "External cephalic version", section on 'Indications and
contraindications'.)

As discussed above, there is a general consensus that women who choose to undergo a trial of labor and vaginal breech birth should be at
low risk of complications from vaginal breech delivery and their labor and delivery should be supervised by a clinician with experience in
vaginal breech birth. (See "Delivery of the fetus in breech presentation", section on 'Criteria for an optimal situation'.)

Guidelines from selected organizations

●American College of Obstetricians and Gynecologists

●Society of Obstetricians and Gynecologists of Canada
●Royal College of Obstetricians and Gynaecologists

CHOOSING THE ROUTE OF PRETERM DELIVERY — In most cases, cesarean is preferred for delivery of the preterm breech fetus
because the fetal head circumference-to-abdominal circumference ratio is larger than that of a term fetus; thus the premature breech head is
more likely to be caught in a partially dilated cervix, resulting in birth trauma and/or acute asphyxia from compression of the umbilical cord
[48,49]. This opinion is supported primarily by data from observational studies, as data from randomized trials are sparse [50].

In a 2014 systematic review of seven observational studies (n = 3557 women) that evaluated cesarean versus vaginal delivery of the preterm
breech, the weighted risk of neonatal mortality was lower in the cesarean delivery group than in the vaginal birth group (3.8 versus 11.5
percent; pooled relative risk 0.63, 95% CI 0.48-0.81) [51]. In one of the included studies, a retrospective study of women delivering breech
infants at 26 to 29 weeks of gestation, the rate of head entrapment was twofold higher in the planned vaginal delivery group than in the
planned cesarean delivery group (11/84 [13 percent] versus 5/85 [6 percent]) [49]. Four neonatal deaths were attributed to head entrapment;
three of these infants were delivered vaginally and died within an hour of birth (neonatal death related to head entrapment 3/45 vaginal
deliveries versus 1/124cesarean deliveries). The single infant that died after cesarean delivery complicated by head entrapment died five
days later because of sepsis and grade 3 intraventricular hemorrhage. Of note, approximately 50 percent of planned vaginal deliveries ended
in cesarean birth, while 6 percent of planned cesareans ended in vaginal birth.

The authors of the systematic review subsequently published a cohort study including over 8300 women with a singleton preterm pregnancy
in breech presentation who delivered at 260/7 to 366/7 weeks of gestation in the Netherlands from 2000 to 2011 [52]. A strength of this study is
the large number of women who intended to deliver vaginally (n = 6421), although 2995 of these women delivered by emergency cesarean
during labor. Compared with intended vaginal delivery, intended cesarean delivery was not associated with a significant reduction in perinatal
mortality (1.3 versus 1.5 percent, adjusted OR 0.97, 95% CI 0.60-1.57) or the composite outcome perinatal mortality/severe morbidity (3.2
versus 4.1 percent, adjusted OR 0.76, 95% CI 0.56-1.03); however, when minor morbidities such as five-minute Apgar score less than 7
were also considered, intended cesarean delivery reduced the rate of the composite outcome perinatal mortality/morbidity (8.7 versus 10.4
percent, RR 0.77, 95% CI 0.63-0.93). A subgroup analysis based on gestational age found that perinatal mortality, morbidity, and severe
morbidity were significantly reduced at 28 to 32 weeks of gestation. These data add to the body of evidence that vaginal delivery of the very
preterm breech fetus is likely associated with a small but significant increase in adverse outcome that can be avoided by cesarean birth.

TECHNIQUE FOR BREECH DELIVERY — (See "Delivery of the fetus in breech presentation".)

NEONATAL OUTCOME — Neonates who were breech in utero are more at risk for mild deformations (eg, frontal bossing, prominent
occiput, upward slant and low-set ears), torticollis, and developmental dysplasia of the hip [53,54]. (See "Congenital muscular torticollis:
Clinical features and diagnosis" and "Developmental dysplasia of the hip: Epidemiology and pathogenesis".)

As discussed above (see 'Choosing the route of delivery at term' above), randomized trials have shown that neonatal morbidity and mortality
are higher in planned vaginal versus planned cesarean breech birth.
 38

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key
questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles
are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You
can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Breech pregnancy (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Breech presentation may be frank, complete, or incomplete (figure 1 and figure 2 and figure 3). (See 'Types of breech
presentation' above.)
●Breech presentation complicates 3 to 4 percent of pregnancies at term; the prevalence is inversely associated with gestational age.
(See'Prevalence' above.)
●In most pregnancies, breech presentation is a chance occurrence. In up to 15 percent of cases, it may be due to fetal, maternal, or
placental abnormalities. (See 'Pathogenesis' above.)
●The diagnosis of breech presentation is based on physical examination, with ultrasound confirmation if the diagnosis is uncertain.
(See'Clinical findings and course' above.)
●The management of breech presentation at term is guided by patient values and preferences and provider experience, values, and
preferences after review of the evidence of the risks and benefits of available interventions. (See 'Choosing the route of delivery at
term'above.)
●The choice of delivery route should be made with due consideration of specific healthcare environments, individual women, and the
limitations inherent in available evidence. A policy of planned cesarean delivery may not be affordable or feasible in resource-poor
settings. On an individual case basis, there may be clinical situations in which the risks of cesarean to the mother, or the mother's
desire to avoid cesarean delivery, may outweigh the newborn's short-term risks of vaginal birth. Both routes of delivery have similar
long-term maternal and childhood outcomes and some data suggest some long-term health benefits to being born vaginally. In
addition, cesarean delivery has implications for women planning future pregnancies, including repeat cesarean delivery and increased
risks of placenta accreta and uterine rupture. (See 'Choosing the route of delivery at term' above.)
●In the United States, clinician preference for women with breech presentation is to offer external cephalic version at or near term,
followed by a trial of vaginal delivery if the version is successful and scheduled cesarean delivery if breech presentation persists
because planned cesarean delivery of the breech fetus reduces perinatal death or severe morbidity. (See 'External cephalic version
with cesarean delivery of the persistent breech' above.)
●Some women may choose to undergo scheduled cesarean delivery if the breech persists without an attempt at external cephalic
version. Women with a low likelihood of successful version or at increased risk of fetal harm from the procedure may reasonably avoid
the procedure. (See 'Cesarean delivery without an attempt at external cephalic version' above.)
●Some women may choose to have a vaginal breech delivery. There is a general consensus that these women should be at low risk
of complications from vaginal breech delivery and their labor and delivery should be supervised by a clinician with experience in
vaginal breech birth. (See 'External cephalic version with vaginal breech delivery for selected patients with a persistent
breech' above.)
Use of UpToDate is subject to the Subscription and License Agreement.

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Topic 6776 Version 20.