Operative Vaginal Birth

Operative vaginal birth or operative vaginal delivery – refers to the use of forceps, vacuum, or more than one instrument to extract the fetus from the vagina, with or without the assistance of maternal pushing. Operative vaginal births account for 10–15% of all deliveries in the United Kingdom, with an incidence of up to 30% in first time mothers.

In the USA in 1990 – 9% of livebirths resulted from either forceps delivery or vacuum extraction, by 2014 only 3.21% of livebirths resulted from operative vaginal delivery; in 2017 3.1 percent of all deliveries were accomplished via an operative vaginal approach. Forceps deliveries accounted for 0.5 percent of vaginal births, and vacuum deliveries accounted for 2.6 percent of vaginal births.

One of the reasons for the great reduction in operative procedures is the lack of experience and hence reduced confidence of the operator, who instead will do a Caesarean Section. As a Resident/Registrar, I did hundreds of forceps deliveries. These days Obstetricians in training, in some regions, see very few.

Operative vaginal birth should be performed by, an operator who has the knowledge, skills and experience necessary to assess the woman, complete the procedure and manage any complications that arise. The majority of operative vaginal births, when performed correctly by appropriately trained personnel, result in a safe outcome for the woman and baby. Women who achieve an assisted vaginal birth rather than have a caesarean birth with their first child are far more likely to have an uncomplicated vaginal birth in subsequent pregnancies.

Operative vaginal delivery is indicated for both maternal and fetal reasons.

Indications for assisted vaginal birth

Fetal – Suspected fetal compromise (cardiotocography showing abnormal fetal heart rate (FHR) tracings; abnormal fetal blood sampling result; thick meconium). The need to rotate the fetal head to effect vaginal delivery.

Maternal – Maternal exhaustion or distress and ineffectual pushing in the second stage of labor.  Prolonged second stage of labor, arrest of descent. Various medical factors requiring an expedited second stage, such as preexisting cardiovascular disease or deteriorating medical conditions

No indication is absolute and each case should be considered individually. 

Safety of Operative Vaginal Birth

When considering adverse neurologic outcome, forceps deliveries are associated with a reduced risk of such outcomes compared with both vacuum extraction and cesarean delivery.

Forceps rotations to effect delivery are not linked to excess neonatal neurological morbidity. Furthermore, because forceps rotation of a fetus in a persistent occiput posterior position to an occiput anterior position may reduce maternal perineal laceration, it seems reasonable to attempt rotation in such circumstances.

Vacuum extraction is discouraged at gestational age of less than 34 weeks.

Although the routine use of episiotomy with operative vaginal delivery has been questioned.  A large observational study from the Netherlands of 28,732 assisted vaginal births concluded that mediolateral episiotomy is protective against Obstetric Anal Sphincter Injury (OASI) in both vacuum extraction and forceps birth. 

The balance between the art and science of medicine has been shifting for years, unfortunately operative vaginal delivery is an increasingly lost art.


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2. Operative vaginal delivery. Practice Bulletin No. 154. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015;126:e56–65.

3. Demissie K, Rhoads GG, Smulian JC, Balasubramanian BA, Gandhi K, Joseph KS, et al. Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis. BMJ 2004; 329: 24– 9.

4. Crane AK, Geller EJ, Bane H, Ju R, Myers E, Matthews CA. Evaluation of pelvic floor symptoms and sexual function in primiparous women who underwent operative vaginal delivery versus cesarean delivery for second-stage arrest. Female Pelvic Med Reconstr Surg. 2013 Jan-Feb;19(1):13-6.

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6. Werner E F, Janevic TM, Illuzzi J, Funai EF, Savitz DA, Lipkind HS. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol. 2011 Dec;118(6):1239-46.

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8. Wesley BD, van den Berg BJ, Reece EA. The effect of forceps delivery on cognitive development. Am J Obstet Gynecol. 1993 Nov;169(5):1091-5.

9. Bahl R, Strachan B, Murphy DJ. Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study. BMJ 2004; 328: 311.


Induction of labour is the planned treatment that stimulates childbirth and delivery prior to its spontaneous onset. Inducing labour can be accomplished with pharmaceutical or non-pharmaceutical methods. Every year, 1 in 5 labours are induced in the UK.
Most women go into labour naturally (spontaneously) by the time they’re 42 weeks pregnant.
Induction is offered to all women who don’t go into labour naturally by 42 weeks, as there’s a higher risk of stillbirth or problems for the baby if pregnancy exceeds 42 weeks.
Other indications for induction include circumstances when there is increased risk to mother or baby, for example high blood pressure, pre-eclampsia or the baby isn’t growing. Once active labour is established, maternal and foetal monitoring should be carried out
Spontaneous rupture of membranes more than 24 hours before labour starts, has an increased risk of infection and is an indication for induction.
There are a number of absolute contraindications to induction including placenta praevia and severe foetal compromise.
It is therefore usually a medical decision to deal with a specific problem. There is however an argument in favour of inducing all women at term or shortly after.
Induction of labour for improving birth outcomes for women at or beyond term Philippa Middleton, Emily Shepherd, Caroline A Crowther
First published: 9 May 2018 Editorial Group: Cochrane Pregnancy and Childbirth Group
To assess the effects of a policy of labour induction at or beyond term compared with a policy of awaiting spontaneous labour, or until an indication for birth induction of labour is identified, on pregnancy outcomes for infant and mother.
A policy of labour induction at or beyond term compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections; but more operative vaginal births. NICU admissions were lower and fewer babies had low Apgar scores with induction. No important differences were seen for most of the other maternal and infant outcomes.

Methods of Induction
Methods of inducing labour include both pharmacological medication and mechanical or physical approaches.
• Prostaglandin E2 is the most studied compound and with most evidence behind it. A range of different dosage forms are available with a variety of routes possible. Vaginal PGE2 should not be used if there are specific clinical reasons for not using it (in particular the risk of uterine hyper-stimulation).
• Intravenous administration of synthetic oxytocin preparations.
• “Membrane sweep”, also known as membrane stripping, or “stretch and sweep” during an internal examination, the practitioner moves their finger within the cervix to stimulate and/or separate the membranes around the baby from the cervix. This causes a release of prostaglandins which can help to kick-start labour.
• Artificial rupture of the membranes (AROM or ARM) (“breaking the waters”) which is usually done immediately following a membrane sweep.
• Cervical balloons catheters and laminaria tents are not used routinely for induction of labour.

The most recent reviews on the subject of induction and its effect on Caesarean section indicate that there is no increase with induction and in fact there can be a reduction.
Ekaterina Mishanina et al., “Use of labour induction and risk of caesarean delivery: a systematic review and meta-analysis”, April 2014, Canadian Medical Association Journal
Our meta-analysis showed that the risk of caesarean delivery following labour induction was significantly lower than the risk associated with expectant management. This finding supports evidence from systematic reviews but is contrary to prevalent beliefs and information from consumer organizations, guidelines and textbooks. Labour induction was associated with benefits for the fetus and no increased risk of maternal death.

How effective is amniotomy as a means of induction of labour? 2010, 179 (3):381-3 Ir J Med Sci
In total, 26,670 women delivered in the National Maternity Hospital during the study period. Of these 4,928 women required induction of labour and 72.8% of these (n = 3,586) underwent amniotomy only for induction of labour. Spontaneous labour occurred in 90.1% of the women who underwent amniotomy within 24 h. Oxytocin as an induction agent was employed in 9.8% of cases. Overall, 80.5% of the women had a spontaneous delivery, 7.3% had a ventouse delivery, 4.3% had a forceps delivery, and 7.9% underwent a caesarean section. CONCLUSIONS: Amniotomy is a simple, safe and effective method of induction of labour.

If there is a medical indication to induce labour then the decision had been taken to deliver that patient within 24 hours. Induction is an active process and should not be dependent on suitability unless the alternative is immediate caesarean section.

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3. Li XM, Wan J, Xu CF, Zhang Y, Fang L, Shi ZJ, Li K (March 2004). “Misoprostol in labor induction of term pregnancy: a meta-analysis”. Chin Med J (Engl). 117 (3): 449–52.
4. Budden, A; Chen, LJ; Henry, A (Oct 9, 2014). “High-dose versus low-dose oxytocin infusion regimens for induction of labour at term”. The Cochrane Database of Systematic Reviews. 10: CD009701.
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6. Kelly AJ, Kavanagh J, Thomas J (2001). “Relaxin for cervical ripening and induction of labor”. Cochrane Database Syst Rev (2): CD003103.
7. Guinn, D. A.; Davies, J. K.; Jones, R. O.; Sullivan, L.; Wolf, D. (2004). “Labour induction in women with an unfavourable Bishop score: Randomized controlled trial of intrauterine Foley catheter with concurrent oxytocin infusion versus Foley catheter with extra-amniotic saline infusion with concurrent oxytocin infusion”. American Journal of Obstetrics and Gynecology. 191 (1): 225–229
8. ACOG Committee on Practice Bulletins (2009). “ACOG Practice Bulletin No. 107: Induction of Labor”. Obstetrics & Gynecology. 114 (2, Part 1): 386–397.
9. Ekaterina Mishanina et al., “Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis”, April 2014, Canadian Medical Association Journal,
10. Heinberg EM, Wood RA, Chambers RB. Elective induction of labor in multiparous women. Does it increase the risk of cesarean section? 2002. J Reprod Med. 47(5):399–403.
11. Tim A. Bruckner et al, Increased neonatal mortality among normal-weight births beyond 41 weeks of gestation in California, October 2008, American Journal of Obstetrics and Gynecology, [2]
12. Caughey, AB; Sundaram, V; Kaimal, AJ; Gienger, A; Cheng, YW; McDonald, KM; Shaffer, BL; Owens, DK; Bravata, DM (Aug 18, 2009). “Systematic review: elective induction of labor versus expectant management of pregnancy”. Annals of Internal Medicine. 151 (4): 252–63, W53–63.
13. Caughey, AB; Sundaram, V; Kaimal, AJ; Gienger, A; Cheng, YW; McDonald, KM; Shaffer, BL; Owens, DK; Bravata, DM (Aug 18, 2009). “Systematic review: elective induction of labor versus expectant management of pregnancy”. Annals of Internal Medicine. 151 (4): 252–63,
14. National Institute for Health and Clinical Excellence, “CG70 Induction of labour: NICE guideline”,
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17. Yeast John D (1999). “Induction of labor and the relationship to caesarean delivery: A review of 7001 consecutive inductions”. American Journal of Obstetrics and Gynecology
18. Simpson Kathleen R.; Thorman Kathleen E. (2005). “Obstetric ‘Conveniences’ Elective Induction of Labor, Cesarean Birth on Demand, and Other Potentially Unnecessary Interventions”. Journal of Perinatal and Neonatal Nursing. 19 (2): 134–44.
19. Caughey AB, Nicholson JM, Cheng YW, Lyell DJ, Washington E (2006). “Induction of labor and caesarean delivery by gestational age”. Am Journal of Obstetrics and Gynecology. 195: 700–5.
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21. The Institute for Safe Medication Practices Results Of ISMP Survey On High-Alert Medications: Differences Between Nursing, Pharmacy, And Risk/Quality/Safety Perspectives
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23. Wennerholm UB, Hagberg H, Brorsson B, et al Induction of labor versus expectant management for post-date pregnancy: Is there sufficient evidence for a change in clinical practice? Acta Obstet Gynecol Scand 2009;88:6–17.
24. Wood S, Cooper S, Ross S. Does induction of labour increase the risk of caesarean section? A systematic review and meta-analysis of trials in women with intact membranes. BJOG 2014;121:674–85.
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26. Caesarean section [clinical guideline 132]. London (UK): National Institute for Health and Clinical Excellence; 2004.
27. Warren R, Arulkumaran S Best practice in labour and delivery. Cambridge (UK): Cambridge University Press; 2009

Premature Rupture of Membranes

Premature rupture of membranes (PROM), is defined as rupture of membranes (breakage of the amniotic sac), commonly called breaking of the mother’s waters, more than 1 hour before the onset of labour. The sac (consisting of 2 membranes, the chorion and amnion) contains amniotic fluid, which surrounds and protects the fetus in the uterus (womb). After rupture, the amniotic fluid leaks out of the uterus, through the vagina. The foetal membranes serve as a barrier to ascending infection. Once the membranes rupture, both the mother and fetus are at risk of infection and of other complications.
Women with PROM usually experience a painless gush of fluid leaking out from the vagina, but sometimes a slow steady leakage occurs instead.
Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks’ gestation and has presented with rupture of membranes (ROM) prior to the onset of labour. Preterm premature rupture of membranes (PPROM) is ROM prior to 37 weeks’ gestation. Prolonged ROM is any ROM that persists for more than 24 hours prior to the onset of labour.
Eighty-five percent of neonatal morbidity and mortality is a result of prematurity. PPROM is associated with 30-40% of preterm deliveries and is the leading identifiable cause of preterm delivery. PPROM complicates 3% of all pregnancies and occurs in approximately 150,000 pregnancies yearly in the United States
Despite the common TV image of ROM occurring in every pregnancy, PROM occurs in approximately 10% of pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but they are not having contractions. Most patients (90%) enter spontaneous labour within 24 hours when they experience ROM at term. The major question regarding management of these patients is whether to allow them to enter labour spontaneously or to induce labour. The management of these patients depends on a number of factors including patient’s wishes, however, the major maternal risk at this stage is intrauterine infection. The risk of intrauterine infection increases with the duration of ROM. Evidence supports the idea that induction of labour, as opposed to expectant management, decreases the risks.
Premature preterm rupture of membranes (PPROM) occurring from 24-37 weeks’ gestation is far more difficult to manage than premature rupture of membranes (PROM) at term. Prematurity is the principal risk to the fetus, while infection morbidity and its complications are the primary maternal risks. The initial evaluation of premature preterm rupture of membranes (PPROM) should include a sterile speculum examination to document ROM. Cervical cultures including Chlamydia trachomatis and Neisseria gonorrhoeae should be obtained. ROM diagnosis needs to be confirmed. Digital vaginal examinations should be avoided. Ultrasonography should be performed to confirm gestational age,
Maternal vital signs should be documented as well as continuous foetal monitoring initially to establish foetal status. Once the decision to manage a patient expectantly has been made, the institution of broad-spectrum antibiotics should be considered. Multiple trials have examined the advantages and disadvantages of using antibiotics and the choice of antibiotics. In most studies, use of antibiotics has been associated with prolongation of pregnancy and reduction in infant and maternal morbidity. However, a few studies have reported increased neonatal morbidity.
The RCOG recommends
Antenatal prophylactic antibiotics for women with PPROM
Offer women with PPROM oral erythromycin 250 mg 4 times a day for a maximum of 10 days or until the woman is in established labour (whichever is sooner).
For women with PPROM who cannot tolerate erythromycin or in whom erythromycin is contraindicated, consider oral penicillin for a maximum of 10 days or until the woman is in established labour (whichever is sooner).
Do not offer women with PPROM co amoxiclav as prophylaxis for intrauterine infection.

The use of corticosteroids to accelerate lung maturity should be considered in all patients with PPROM with a risk of infant prematurity from 24-34 weeks’ gestation. A single course of corticosteroids is recommended for pregnant women 24-34 weeks’ gestation who are at risk of preterm delivery within 7 days.

Several techniques have been developed in an attempt to artificially reseal the foetal membranes and prevent leakage of amniotic fluid including, among others, intra-amniotic injection of platelets and cryoprecipitate (amnio-patch), sealing the cervical canal, and laser coagulation. However, there is as yet no effective and safe technique to achieve this goal.

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3. Schucker JL, Mercer BM. Midtrimester premature rupture of the membranes. Semin Perinatol. 1996;20:389–400.
4. American College of Obstetricians and Gynecologists. Premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists. ACOG practice bulletin no. 1. Int J Gynaecol Obstet. 1998;63:75–84.
5. Mercer BM. Preterm premature rupture of the membranes. Obstet Gynecol. 2003;101:178–93.
6. Smith CV, Greenspoon J, Phelan JP, Platt LD. Clinical utility of the nonstress test in the conservative management of women with preterm spontaneous premature rupture of the membranes. J Reprod Med. 1987;32:1–4.
7. Cox SM, Leveno KJ. Intentional delivery versus expectant management with preterm ruptured membranes at 30–34 weeks’ gestation. Obstet Gynecol. 1995;86:875–9.
8. ACOG Committee on Practice Bulletins-Obstetrics, authors. Clinical management guidelines for obstetrician-gynecologists. (ACOG Practice Bulletin No. 80: premature rupture of membranes).Obstet Gynecol. 2007;109:1007–1019.
9. Spinillo A, Montanari L, Sanpaolo P, et al. Fetal growth and infant neuro-developmental outcome after preterm premature rupture of membranes. Obstet Gynecol. 2004;103:1286–1293
10. Healy AJ, Veille JC, Sciscione A, et al. The timing of elective delivery in preterm premature rupture of the membranes: a survey of members of the Society of Maternal-Fetal Medicine. Am J Obstet Gynecol. 2004;190:1479–1481.
11. Lee SE, Park JS, Norwitz ER, et al. Measurement of placental alpha-microglobulin-1 in cervicovaginal discharge to diagnose rupture of membranes. Obstet Gynecol. 2007;109:634–640
12. Mercer BM. Preterm premature rupture of the membranes: current approaches to evaluation and management. Obstet Gynecol Clin North Am. 2005;32:411–428.
13. Gold RB, Goyert GL, Schwartz DB, et al. Conservative management of second-trimester postamniocentesis fluid leakage. Obstet Gynecol. 1989;74:745–747.
14. Lewi L, Van Schoubroeck D, Van Ranst M, et al. Successful patching of iatrogenic rupture of the fetal membranes. Placenta. 2004;25:352–356.
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16. Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of the membranes: a systematic review. Obstet Gynecol. 2004;104:1051–1057.

Teen Pregnancy

The rate of teenage pregnancy in the United Kingdom is relatively high, when compared with other developed countries; the only other Western countries with higher teenage pregnancy rates are the United States and New Zealand. The rate of teenage pregnancy is higher in more economically deprived areas. In 2008 the number of births to girls under 20 in England & Wales was 44,690, a provisional rate of 26.2 per thousand teenage women in the population.
The UK government tracks teenage pregnancy rate using the age of the girl at conception, unlike pregnancy statistics in other countries. Which use the age of girl at the outcome of her pregnancy. In reporting teenage pregnancy rates, the number of pregnancies per 1,000 females aged 15 to 19 when the pregnancy ends is generally used. The teen pregnancy rate is the sum all live births, abortions, and miscarriages (or foetal losses) per 1,000 adolescent females ages 15-19 in a given year. Worldwide, teenage pregnancy rates range from 143 per 1000 in some sub-Saharan African countries to 2.9 per 1000 in South Korea.
Approximately 16 million girls aged 15 to 19 years and 2.5 million girls under 16 years give birth each year in developing regions. Complications during pregnancy and childbirth are the leading cause of death for 15 to 19 year-old girls globally. Every year, some 3.9 million girls aged 15 to 19 years undergo unsafe abortions

In the USA in 2016, there were 20.3 births for every 1,000 adolescent females ages 15-19, or 209,809 babies born to females in this age group. Births to teens ages 15-19 accounted for 5.3 percent of all births in 2016. Although the teen birth rate has declined the teen birth rate in the United States remains higher than that in many other developed countries, including Canada and the United Kingdom. Teen birth rates differ substantially by age, racial and ethnic group, and region of the country. Most adolescents who give birth are 18 or older; in 2016, 74 percent of all teen births occurred to 18- to 19-year-olds.1 Birth rates are also higher among Hispanic and black adolescents than among their white counterparts. In 2016, Hispanic adolescent females ages 15-19 had a higher birth rate (31.9 births per 1,000 adolescent females) than black adolescent females (29.3) and white adolescent females (14.3).
Not all teen births are first births. In 2016, one in six (17 percent) births to 15- to 19-year-olds were to females who already had one or more births.

There are a number of specific problems with adolescent pregnancy, social as well as medical. Education is a particular concern, in the UK a pregnant teenager is expected to stay at school and continue education until the end of Year 11, with a maximum 16-week break immediately before and after the birth.
Pregnancy in women less than 18 years old is associated with increased risk of preterm labour before 32 weeks’ gestation, maternal anaemia, chest infection and urinary tract infection. Rates of ectopic pregnancy, pre-eclampsia, eclampsia, preterm labour, premature rupture of membrane and caesarean section are significantly higher among adolescents less than 15 years of age; the risk then decreases steadily with age.
The high risk of adverse pregnancy outcome in the adolescent has been attributed to gynaecological immaturity and the growth and nutritional status of the mother. Gynaecological immaturity undoubtedly predisposes adolescent girls to poor pregnancy outcome in that the rates of spontaneous miscarriage and of very preterm birth (<32 weeks of gestation) are highest in girls aged 13–15 years. Adolescent pregnant women not only face pregnancy related problem but also they are prone to have obstructed labour due to their developing pelvic bones. Obstructed labour is one of the most common and preventable causes of maternal and perinatal deaths and disabilities.
Maternal and prenatal health is of particular concern among teens who are pregnant or parenting. The worldwide incidence of premature birth and low birth weight is higher among adolescent mothers.
Research indicates that pregnant teens are less likely to receive prenatal care, often seeking it in the third trimester, if at all. Studies show that one-third of pregnant teens receive insufficient prenatal care and that their children are more likely to have health issues in childhood or be hospitalized than those born to older women.
Young mothers who are given high-quality maternity care have significantly healthier babies than those who do not. Many of the health-issues associated with teenage mothers appear to result from lack of access to adequate medical care.
Many pregnant teens are at risk of nutritional deficiencies from poor eating habits common in adolescence, including attempts to lose weight through dieting, and food faddism.
Inadequate nutrition during pregnancy is an even more marked problem among teenagers in developing countries. Complications of pregnancy result in the deaths of an estimated 70,000 teen girls in developing countries each year. Young mothers and their babies are also at greater risk of contracting The World Health Organization estimates that the risk of death following pregnancy is twice as high for women aged 15–19 than for those aged 20–24. The maternal mortality rate can be up to five times higher for girls aged 10–14 than for women aged 20–24. Illegal abortion also holds many risks for teenage girls in areas such as sub-Saharan Africa.
Risks for medical complications are greater for girls aged under 15, as an underdeveloped pelvis can lead to difficulties in childbirth. Obstructed labour is normally dealt with by Caesarean section in industrialized nations; however, in developing regions where medical services might be unavailable, it can lead to eclampsia, obstetric fistula, infant mortality, or maternal death. Complications from pregnancy and childbirth are the leading cause of death in young women aged 15 to 19 in developing countries. A pelvis that is less than fully developed in adolescents, as assessed by pelvic size, may also contribute to lower birth weight in adolescent mothers. For mothers who are older than fifteen, age in itself is not a risk factor, and poor outcomes are associated more with socioeconomic factors rather than with biology.
During labour and delivery where age is the only risk factor, management is usually the same as for other labouring women. However, in very young adolescents there is an increased likelihood of obstructed labour because of a small, immature pelvis.
Teenage pregnancy today represents one of the most important public health problems. There is no doubt that the obstetrical problems can be managed by modern medicine and so the risk of teenage pregnancy can be diminished. The health care provider should consider teenage pregnancy as a ‘high risk’ pregnancy and should educate pregnant teenagers to have more antenatal visits so that the signs and symptoms of various complications of teenage pregnancy could be recognized at the earliest opportunity.

1. Sedgh, Gilda (2015). “Adolescent Pregnancy, Birth, and Abortion Rates Across Countries: Levels and Recent Trends”. Journal of Adolescent Health.
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11. UNESCO. Early and Unintended Pregnancy & the Education Sector: Evidence Review and Recommendations. Paris: UNESCO; 2017.
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Do you need an enema in labour?

An enema is the injection of fluid into the lower bowel by way of the rectum. The most frequent use of an enema is to relieve constipation or for bowel cleansing before a medical examination or procedure.

Giving women enemas during labour has been routine practice in delivery wards of many countries and settings. Occasionally women leak from their back passage whilst giving birth and it was thought an enema in early labour would reduce this soiling and the consequent embarrassment for women. It was also thought that emptying the back passage would give more room for the baby to be born, would reduce the length of labour and would reduce the chance of infection for both the mother and the baby. It was also suggested it would reduce bowel movements after birth which often cause women concern.

A study in 1981 suggested that when preparing for normal labour the enema should be reserved for women who have not had their bowels open in the past 24 hours and have an obviously loaded rectum on initial pelvic examination.

In a Cochrane Database Review in 2013, the Selection criteria being randomised controlled trials (RCTs) in which an enema was administered during the first stage of labour and which included assessment of possible neonatal or puerperal morbidity or mortality were reviewed. Following meta‐analysis of two trials the authors’ conclusion was – “These findings speak against the routine use of enemas during labour, therefore, such practice should be discouraged”.

Enema versus no-enema in pregnant women on admission in labour: A randomized controlled trial Journal of the Medical Association of Thailand = 88(12):1763-7 · December 2005 

To compare the maternal and neonatal outcomes between enema and no-enema in pregnant women on admission in labour. One thousand and one hundred term pregnant women with labour pain were selected randomly on admission to be assigned into two groups at Rajavithi Hospital from 1 February 2002 to 15 June 2002. Five -hundred and thirty-nine cases received enema and five-hundred and sixty one cases received no enema. Seventy three women (39 and 34 cases from the enema and no-enema groups, respectively) were excluded because of caesarean section due to obstetric indications. Five hundred cases received enema and five-hundred and twenty -seven cases received no-enema. All cases were delivered vaginally. There was no statistical significant difference between the two groups with regards to maternal age, gestational age, gravidity, parity, mode of delivery, type of episiotomy and degree of perineal tear. Faecal contamination rate during the second stage of labour was significantly higher in the women who received no-enema (34.9%) in comparison with those receiving enema (22.8% (p < 0.001). No neonatal infection occurred in both groups. Duration of labour was significantly longer in the women who received no-enema (459.8 min) compared with those who received enema (409.4 min) (p < 0.001). No-enema methods on admission in labour had significantly more increase in faecal contamination in the second stage of labour and longer duration of labour than the enema method but there was no difference in perineal wound infection and neonatal infection between both groups.

There continues to be advocates both for and against, particularly amongst midwives and nurses involved in daily deliveries but also with women themselves. There are also marked regional differences.

A survey of maternity practices in Croatia in 2015 found that 78 % of women were given an enema in labour.

Reveiz L, Gaitán HG, Cuervo LG. Enemas during labour. Cochrane Database of Systematic Reviews 2013, Issue 7.
Clarke NT, Jenkins TR. Randomized prospective trial of the effects of an enema during labor [abstract]. Obstetrics & Gynecology 2007;109(4 Suppl):7S.
Cuervo LG, Bernal MP, Mendoza N. Effects of high volume saline enemas vs no enema during labour – the N-Ma randomised controlled trial. BMC Pregnancy and Childbirth 2006;6:8.
Br Med J (Clin Res Ed) 1981;282:1269
Kovavisarach E, Sringamvong W. Enema versus no-enema in pregnant women on admission in labor: a randomized controlled trial. Journal of the Medical Association of Thailand 2005;88(12):1763-7.
Lurie S, Baider C, Glickman H, Golan A, Sadan O. Are enemas given before cesarean section useful? A prospective randomized controlled study. European Journal of Obstetrics & Gynecology and Reproductive Biology 2012;163(11):27-9.
Romney ML, Gordon H. Is your enema really necessary?. British Medical Journal 1981;282(6272):1269-71.


Episiotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician during second stage of labour to quickly enlarge the opening for the baby to pass through.
The incision, which can be done at a 90 degree angle from the vulva towards the anus or at an angle from the posterior end of the vulva (medio-lateral episiotomy), is performed under local anaesthetic and is sutured after delivery.

The use of a surgical incision of the perineum during childbirth was first described in 1742. It was introduced into the USA in the mid-19th Century. In 1920, at a meeting of the American Gynaecological Society in Chicago, USA, Joseph DeLee first publicly advocated the routine adoption of Medio lateral episiotomy for all deliveries in nulliparous women.

They became common practice during the 20th century, the main reason being to reduce the risk of severe perineal tears. 85% of women who have a vaginal delivery, will have some degree of perineal trauma, the majority of which will require suturing. By 1979, episiotomy was performed in approximately 63% of all deliveries in the USA, with higher rates among nulliparous women. In the UK in the same era, episiotomy rates ranged from 14 to 96% among nulliparous women and 16–71% among multiparous women. In recent years opposition to the use of episiotomy as a standard procedure has reduced the rate and its routine use is no longer recommended. Despite this, it is one of the most common medical procedures performed on women, though there is now considerable variation between countries. A review was published in JAMA in 2005. By this time the practice had declined in the USA from of over 60% to 30–35% of vaginal deliveries though the rate was as high as 99% in Eastern Europe.

In 2009, a Cochrane meta-analysis based on studies with over 5,000 women concluded that: “Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy”.

Levine EM et al in 2015 noted – The average episiotomy rate steadily declined from 1996-1998, 2003-2005 and 2012-2014. The rate of advanced perineal lacerations coincidentally rose during these time period comparisons. Levine EM, Bannon K, Fernandez CM, Locher S (2015) Impact of Episiotomy at Vaginal Delivery. J Preg Child Health 2:181.

It has been suggested that perineal massage during the second stage of labour can reduce the need for episiotomy.
Infrared lamp therapy is an effective method of treatment on healing of episiotomy wound among post-natal mothers.
In a study by Sabzaligol M et al. Aloe Vera gel not only relieved the pain but also increased the rate of wound healing in episiotomy.

1. Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery”. Obstetrics and Gynecology. 128 (1): e1–e15. July 2016.
2. Chang,S-R; Chen,K-H; Lin,H-H; Chao,Y-M Y.; Lai,Y-H (April 2011). “Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: A prospective follow-up study”. International Journal of Nursing Studies. 48 (4): 409–418.
3. Graham,I.D.; Carroli,G.; Davies,C.; Medves,J.M. (August 2005). “Episiotomy Rates Around the World: An Update”. Birth. 32 (3): 219–223.
4. Carroli, G, Mignini, L. “Episiotomy for vaginal birth”. Cochrane Database Syst Rev. 2009 Jan 21; (1):
5. Jiang, Hong; Qian, Xu; Carroli, Guillermo; Garner, Paul; Jiang, Hong (2017). “Selective versus routine use of episiotomy for vaginal birth”.
6. American College of Obstetricians-Gynecologists (2006). “ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006” Obstetrics & Gynecology. 107 (4): 956–62
7. Levine EM, Bannon K, Fernandez CM, Locher S (2015) Impact of Episiotomy at Vaginal Delivery. J Preg Child Health 2:181.
8. Sabzaligol M, Safari N, Baghcjeghi N, Latifi M, Koohestani H R, Bekhradi R, et al . The effect of Aloevera gel on prineal pain & wound healing after episiotomy. cmja. 2014; 4 (2) :766-775

Water Birth

Water birth is childbirth that occurs in water. During the 1970s Michel Odent in France and Igor Tcharkovsky in Russia pioneered the use of water in labour. Proponents believe water birth results in a more relaxed, less painful experience. It is best to enter the pool after the cervix has dilated to 5cm. Before this the relaxing effect of water may reduce the power of contractions. Critics argue that the safety of water birth has not been scientifically proven and that a wide range of adverse neonatal outcomes have been documented, including increased mother or child infections and the possibility of infant drowning. A 2009 Cochrane Review of water immersion during the first stage of labour found that it reduces the use of epidural/spinal analgesia and duration of the first stage of labour. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no specific evidence of increased adverse effects to the baby or woman from labouring in water or water birth. (Elizabeth R Cluett, and Ethel Burns Cochrane Pregnancy and Childbirth Group 2009).

Baby doesn’t usually draw breath until there is contact with the cooler air above the water – the dive reflex. There is a small risk of inhaling water where there is foetal distress, so it is important for normal foetal monitoring of heart rate during labour.

It has been suggested that neonatal infection may occur due to cross-contamination from the water and pool, and from the woman. However, several comparative studies, report no increased risk of infection for the baby (Zanetti-Daellenbach RA, Tschudin S, Zhong XZ, Holzgreve W, Lapaire O, Hösli I. Maternal and neonatal infection and obstetrical outcome in water birth. European Journal of Obstetrics & Gynecology and Reproductive Biology 2007;134(1):37-43.). As with all maternity care it is necessary to adhere to cleaning protocols for labour and birthing pools, and employ usual precautions.

As with any labouring woman, it is important to avoid her becoming pyrexial. Therefore, the water temperature of a pool should not exceed the maternal body temperature, as immersing a woman in water above her natural core temperature will result in foetal hyperthermia and associated cardiovascular and metabolic disturbances. High temperatures have been identified as a safety issue by several authors as being associated with foetal mortality and morbidity, based on individual case studies. (Deans AC, Steer PH. Temperature of pool is important. BMJ 1995;311:390-1.).


Reid-Campion M. Hydrotherapy: Principles and Practice. 2nd Edition. Oxford: Butterworth Heineman, 1997.

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2011, Issue 7

Mammas IN, Thiagarajan P. Water aspiration syndrome at birth – report of two cases. Journal of Maternal-Fetal and Neonatal Medicine 2009;22(4):365-7.

Department of Health. Changing Childbirth. HMSO, 1993.

Thoeni A, Zech N, Moroder L, Ploner F. Review of 600 water births. Does water birth increase the risk of neonatal infection?. Journal of Maternal-Fetal and Neonatal Medicine 2005;17(5):357-61.

External Cephalic Version

External Cephalic Version involves applying pressure to a woman’s abdomen to manipulate the fetus and turn it from breech to vertex presentation, which increases the likelihood of a vaginal delivery. Interest in the technique has increased in light of medicine’s movement to decrease caesarean deliveries, which particularly in North America has been standard procedure for breech presentations.
The American College of Obstetricians and Gynecologists (ACOG) now recommends that all eligible women with breech presentations who are near term should be offered external cephalic version (ECV) to cut down on the number of caesarean deliveries. It is a valuable management technique and, in a properly selected population, poses little risk to either the woman or the fetus. If successful, ECV provides a clear benefit to the woman by allowing her an opportunity for a successful vertex vaginal delivery. Obstet Gynecol. 2016;127:412-413
Spontaneous version of a breech presentation usually occurs by 36 weeks and is less likely after that time.
How effective is ECV in preventing non-cephalic birth?
• The success rate of ECV is approximately 50%.
• A successful ECV reduces the chance of caesarean section.
• Few babies revert to breech after successful ECV.
• After an unsuccessful ECV attempt at 36 weeks of gestation or later, only a few babies presenting by the breech will spontaneously turn to cephalic presentation.

Potential complications
There is no general consensus on the eligibility for, or contraindications to, ECV.
ECV after one caesarean delivery appears to have no greater risk than with an unscarred uterus.
Although case reports of placental abruption and large feto-maternal haemorrhage exist, complications associated with ECV are very rare. In a 2015 Cochrane systematic review, Hofmeyr et al.reported no significant differences in Apgar scores, neonatal admission or perinatal death according to whether ECV had been performed or not. A number of large consecutive series have reported no fetal deaths attributable to the procedure.
The reported risk of emergency caesarean section within 24 hours is approximately 0.5%, with the indication in over 90% being vaginal bleeding or an abnormal CTG following the procedure
If, after ECV, the breech persists, the best mode of delivery should depend on expertise of the healthcare provider.
Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. Green-top Guideline No. 20b. London: RCOG; 2017.
• Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev 2015;(4):
• Tong Leung VK, Suen SS, Singh Sahota D, Lau TK, Yeung Leung T. External cephalic version does not increase the risk of intra-uterine death: a 17-year experience and literature review. J Matern Fetal Neonatal Med 2012;25:1774–8.
• Collins S, Ellaway P, Harrington D, Pandit M, Impey LW. The complications of external cephalic version: results from 805 consecutive attempts. BJOG 2007;114:636–8
• Leung TY, Lau TK. Prediction of outcome of external cephalic version for breech presentation at term. Fetal Matern Med Rev 2005;16:245–62.
• Burgos J, Cobos P, Rodrıguez L, Osuna C, Centeno MM, , et al. Is external cephalic version at term contraindicated in previous caesarean section? A prospective comparative cohort study BJOG 2014;121:230–5; discussion 235.
• Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev 2012;(5):

Exercise in Pregnancy

There is almost always a decline in physical activity during pregnancy in healthy pregnant women. A high proportion of pregnant women do not participate in any physical activity or exercise, putting them at increased risk of obesity, gestational diabetes mellitus (GDM), and other pregnancy-related diseases and complaints.
In pregnancy the expanding uterus displaces the centre of gravity, which results in the woman compensating to avoid falling forward. This may result in progressive lumbar lordosis and anterior rotation of the pelvis. Postural balance is affected after the first trimester of pregnancy. Subsequently, falling is a common cause of injury in the general pregnant population, and pregnant women are 2–3 times more likely to be injured by falling than are non-pregnant women. This should be taken into consideration when considering the type of exercise. Exercise training in pregnant women is influenced by the physiological changes however women with low-risk pregnancies can undertake the major types of training during pregnancy.
Physically active women are also less likely to develop pre-eclampsia
Appl Physiol Nutr Metab. 2006 Dec;31(6):661-74.
Weissgerber TL1, Wolfe LA, Davies GA, Mottola MF.
Compared with non-exercisers, women who exercised before and during pregnancy had a 36% reduction in pre-eclampsia.

In the general obstetric population, studies have shown inconsistent results with respect to relationships between exercise/physical activity and gestational weight gain.

The 2016 Evidence Summary From the IOC Expert Group Meeting, Lausanne encouraged elite women athletes to continue to participate in all Olympic sport disciplines, with specific guidelines for endurance and peak performance training.

Several studies on the benefits of prenatal yoga (maternity yoga) have been reported in recent years. The findings suggest that prenatal yoga may help reduce pelvic pain. It may also improve mental condition (stress, depression, anxiety, etc.), physical condition at the delivery and perinatal outcomes (obstetrical complications, delivery time, etc.). Overall, the evidence that yoga is well suited to pregnancy is positive.
Field T. Yoga clinical research review. Complementary Therapies in Clinical Practice. 2011;17(1):1–8.

The American College of Obstetrics and Gynaecology recommends 30 minutes or more of moderate exercise per day, unless there is a medical or pregnancy complication.
Exercise is not recommended if –
• There is history of vaginal bleeding or spotting
• Low-lying placenta (praevia)
• A history of miscarriage or preterm delivery
• Cervical incompetence
Women who were exercising regularly before pregnancy, and who are healthy during pregnancy, should be able to continue exercising as before, with slight changes depending on the trimester.
Women who have not been exercising before pregnancy will benefit from taking up a low-intensity program and gradually increasing to a higher activity level.
Exercise is recommended for 20 to 30 minutes each day. Most exercises are safe to perform during pregnancy if done with caution.

Koshino T. Management of regular exercise in pregnant women. Journal of Nippon Medical School. 2003;70(2):124–128.
• Monk C, Fifer WP, Myers MM, et al. Effects of maternal breathing rate, psychiatric status, and cortisol on fetal heart rate. Developmental Psychobiology. 2011;53(3):221–233.
• Melzer K, Schutz Y, Soehnchen N, et al. Effects of recommended levels of physical activity on pregnancy outcomes. American Journal of Obstetrics and Gynecology. 2010;202(3):266.e1–266.e6.
• Davies GA, Wolfe LA, Mottola MF, et al. Exercise in pregnancy and the postpartum period. J Obstet Gynaecol Can 2003;25:516–29.
• Royal College of Obstetricians and Gynaecologists. Exercise in pregnancy 2006:1–7.
• Evenson KR, Barakat R, Brown WJ, et al. Guidelines for physical activity during pregnancy: comparisons from around the world. Am J Lifestyle Med 2014;8:102–21.
• Cakmak B, Ribeiro AP, Inanir A. Postural balance and the risk of falling during pregnancy. J Matern Fetal Neonatal Med 2016;29:1623–5.

Nausea and vomiting of pregnancy

Nausea and vomiting of pregnancy is a common condition that affects the health of the pregnant woman and her fetus. It can diminish the woman’s quality of life and also significantly contributes to health care costs and time lost from work. Because “morning sickness” is common in early pregnancy, the presence of nausea and vomiting of pregnancy may be minimized by obstetricians, other obstetric providers, and pregnant women and, thus, undertreated. Furthermore, some women do not seek treatment because of concerns about safety of medications. Once nausea and vomiting of pregnancy progresses, it can become more difficult to control symptoms; treatment in the early stages may prevent more serious complications, including hospitalization. Mild cases of nausea and vomiting of pregnancy may be resolved with lifestyle and dietary changes, and safe and effective treatments are available for more severe cases. The woman’s perception of the severity of her symptoms plays a critical role in the decision of whether, when, and how to treat nausea and vomiting of pregnancy.
American College of Obstet Gynecol 2015;126:e12-24.

Nausea and vomiting is an expectation for the majority of women during the first trimester of pregnancy. In fact, only 25% of pregnancies are unaffected by nausea with or without vomiting. Approximately 35% of all pregnant women are absent from work on at least one occasion through nausea and vomiting. Among affected woman, recurrence in subsequent pregnancies varies. Although the symptoms are often most pronounced in the first trimester, they are by no means confined to it. Despite the usage of the term “morning sickness” in only a minority of cases are symptoms confined to the morning. The severity of symptoms is variable from patient to patient and they typically peak by 9 weeks. With early treatment and dietary counseling, the severity of symptoms diminishes as gestation advances; for most women, symptoms abate or resolve by the end of the first trimester. The etiology is unknown but theories include psychologic predisposition, evolutionary adaptation to protect the woman and fetus from potentially dangerous foods, and the hormonal stimulus of high human chorionic gonadotropin (HCG) and estradiol levels in early pregnancy. Conditions with increased placental mass such as multiple gestations and molar pregnancy are associated with a higher risk for nausea and vomiting.

In some women, the condition is severe and progresses to hyperemesis gravidarum, which occurs in 0.3 to 3% of pregnancies. A high risk of recurrence is observed in women with hyperemesis in the first pregnancy. The risk was reduced by a change in paternity. For women with no previous hyperemesis, a long interval between births slightly increased the risk of hyperemesis in the second pregnancy.
Trogstad LI, Stoltenberg C, Magnus P, Skjaerven R, Irtens LM. Recurrence risk in hyperemesis gravidarum. BJOG 2005;112:1641-5

Treatment of nausea and vomiting depends on the perception of severity. Basic recommendations include avoidance of stimuli that provoke nausea and vomiting such as sensory stimuli to strong odors, and other sensory stimuli such as heat and noises that trigger the labyrinthine areas. Dietary counseling about frequent small meals and avoidance of spicy or fatty foods is appropriate even though the evidence for such recommendation is lacking.
A Cochrane Database review found that the use of ginger products may be helpful to women, but the evidence of effectiveness was limited and not consistent. There was only limited evidence from trials to support the use of pharmacological agents including vitamin B6, and anti-emetic drugs to relieve mild or moderate nausea and vomiting.
Matthews A, Haas DM, O’Mathuna DP, Dowswell T, Doyle M. Interventions for nausea and vomiting in early pregnancy. Cochrane Database of systematic Reviews 2014, Issue 3.

A single blind randomized controlled trial to determine whether acupuncture reduced nausea, dry retching, and vomiting, and improved the health status of women in pregnancy was undertaken at a maternity teaching hospital in Adelaide, Australia. 593 women less than 14 weeks’ pregnant with symptoms of nausea or vomiting were randomized into 4 groups: traditional acupuncture, pericardium 6 (p6) acupuncture, sham acupuncture, or no acupuncture (control). Treatment was administered weekly for 4 weeks. They found that acupuncture was an effective treatment for women who experience nausea and dry retching in early pregnancy.
Birth. 2002 Mar;29(1):1-9.
Acupuncture to treat nausea and vomiting in early pregnancy: a randomized controlled trial.
Smith C, Crowther C, Beilby J.

Simon, Eric & Schwartz, Jennifer. (1999). Medical Hypnosis for Hyperemesis Gravidarum. Birth. 26. 248 – 254. 10.1046/j.1523-536x.1999.00248.x. Hyperemesis gravidarum in pregnancy is a serious condition that is often resistant to conservative treatments. Medical hypnosis is a well-documented alternative treatment. This article reviews the empirical studies of medical hypnosis for treating hyperemesis gravidarum, explains basic concepts, and details the treatment mechanisms. It is suggested that medical hypnosis should be considered as an adjunctive treatment option for those women with hyperemesis gravidarum. It is also stressed that medical hypnosis can be used to treat common morning sickness that is experienced by up to 80 percent of pregnant women. Its use could allow a more comfortable pregnancy and healthier foetal development, and could prevent cases that might otherwise proceed to full-blown hyperemesis gravidarum.