 Session objectives

 Introduction
 Types
o Indication/contraindication, pre-requisite &
preparation, procedure & post-procedure tasks,
and possible complications for each type.

 Conclusion
After completing this chapter students will be able
to: -
 Define version and describe its types.
 Discuss indications for each type of version.
 Elaborate preparation, procedure and post-procedure tasks for each
type of version.
 Discuss possible complications following each type of version.
 Definition:
 It is physical manipulation of the fetus to change its
presentation or lie. WHY?

 Cephalic vs. Podalic version:

 Cephalic: if head becomes presenting part.
 Podalic: if breech becomes presenting part.

 Internal vs. External version:

 Internal: performed by entering to uterine cavity.
 External: done through the abdomen.
1. External version (usually cephalic)
2. Internal podalic version
3. Bi-polar podalic version
 Definition:
 changing presentation from breech, transverse or
oblique to vertex
 by applying pressure on the gravid uterus.

 Indication:
 malpresentations at or > 36 weeks.
 Contraindications:
 CIs to vaginal birth
 Multiple fetal gestation: but can be used to deliver
2nd twin.
 Severe oligohydramnious, non-reassuring FHB,
uterine or fetal anomaly, pre-eclampsia, hyper-
extended fetal head (relative CIs → reduced
success).
 Pre-requisites:
 single tone fetus at/ > 36 weeks gestation
 reassuring fetal status
 no CI to vaginal birth

 Preparation:
 Review indication.
 Don’t perform procedure before 36 weeks of gestation
or if access to emergency CS isn’t available.
 Preparation …
 If ultrasound is available assess: fetal malpresentation,
position of placenta and cord, amniotic fluid volume and
fetal & uterine anomaly.

 Allow woman to empty bladder.

 Position woman on supine with separated legs.

 Anesthesia isn’t necessary.

 Auscultate FHB. (don’t proceed with abnormality)

 Procedure:
 Confirm position of fetal head, back and hip.
 Apply ultrasonic gel or oil over the abdomen.
 Grasp fetal part above symphysis pubis and lift it up.
 Gently rotate the fetus in a forward roll.
 Check FHB between each attempt and withhold
procedure in abnormal condition and manage as fetal
distress.
 Procedure …
 Reassess after 15 minutes and if FHB doesn’t stabilize within 30
minutes – CS.
 If the procedure succeeds, allow the woman to lie down for 15
minutes.
 Discharge her if FHB is within normal range.
 Counsel her to return for antenatal check-up or if she notes:
o Pain or vaginal bleeding

o Sign of onset of labor

o Baby returns to its previous position.

 Procedure …
 Procedure unsuccessful – try backward roll.
 Procedure still unsuccessful + good FHB – version
with tocolytics.
 Procedure still unsuccessful – try after a week/ at
early labor.
 Conditions that increase success rate:
 adequate amniotic fluid volume
 transverse/oblique lie
 complete breech
 multiparity
 unengaged fetal part
 Conditions that reduce success rate:
 nulliparity, frank breech, posterior fetal back
 engaged fetal part
 reduced amniotic fluid volume, ruptured
membrane, advanced cervical dilation
 maternal obesity
 estimated fetal weight < 2500 gm.
 anterior, lateral and cornual placental presentation
 Possible complications:
 FHB abnormalities (most common)
 Rare complications (need CS):
o cord prolapse
o abruptio-placenta
o still birth
o vaginal bleeding
o feto-maternal bleeding
 Definition:
 It is manual intrauterine manipulation to change one
presentation to the other; usually transverse → breech.

 Indications:
 shoulder presentation with dilated cervix and relaxed
uterus.
 entrapped second twin in cephalic pres. or transverse
lie.
 Pre-requisites:
 empty bladder, adequate pelvis
 fully dilated cervix, adequate amniotic fluid
 general anesthesia, uterine & pelvic relaxants
 complete aseptic technique, relaxed uterus
 no previous uterine scar
 Procedure:
 Swab perineum with 10% povidone iodine solution and
wear sterile glove.

 Insert one hand through the dilated cervix to uterus.

 Grasp lower foot if fetal back is anterior and upper foot

if fetal back is posterior.

 Push fetal head upwards as foot is dragged down

 Pull other foot too and deliver as breech extraction.

  After the procedure explore birth canal thoroughly
and administer antibiotics.

 Possible complications:
 Shock (in light anesthesia), sepsis

 PPH, uterine rupture

 Abruptio-placenta, fetal asphyxia

 Cervical laceration
 It is outdated.
 It was done in partially dilated cervix to:
o modify transverse lie in dead or premature fetus
o compress placenta previa
 Procedure:
 Put mother under general anesthesia
 Insert one hand through partially dilated
cervix
 Grasp fetal foot, pull and deliver it through
cervix
 Other hand support version externally
through the abdomen.
 Possible complications:
 Similar to internal podalic version but with
increased incidence.
 Version is physical manipulation of fetus to change its
presentation or lie.
 External vs. internal & cephalic vs. podalic
 External cephalic version (ECV)
 Definition
 Indication/Contrandication
 Pre-requisite & preparation
 Procedure
 Conditions raising and reducing success
 Possible complications
 Internal podalic version
 Definition
 Indication
 Pre-requisites
 Procedure
 Possible complications
 Bipolar podalic versions
Procedure

 Complication
 Session objectives
 Introduction
 Indications for episiotomy
 Types of episiotomy
 Procedure and post-procedure care
 Possible complications
 Conclusion
After completing this chapter students will be
able to:
 Define perineal tear and describe its types.
 Define episiotomy and identify its types.
 List indications for episiotomy.
 Discuss procedure of episiotomy and its post-procedure care.
 Elaborate possible complications following episiotomy.
 Perineal tear is a tear/injury to skin and or muscles
between vaginal introitus and anal opening.
 Types: classification is based on extent and
severity
A. First degree: involves perineal skin only. Heal by
itself without suturing it.
B. Second degree: involves skin, and perineal
muscles. Requires suturing.
c. Third degree: involves perineal skin,

muscles and anal sphincter.

D. Fourth degree: involves perineal skin,
muscles, anal sphincter and rectal mucosa.
 Third and fourth degree tears requires suturing in
operation room.
 Risk factors:
 Previous episiotomy
 Lack of perineal support as head extends
 Big fetal size
 Augmentation
 Primiparity
 Rigid or scarred perineum
 Operative vaginal deliveries
 Definition:
 incision on the perineum
 to widen vaginal opening and facilitate delivery
 It is intentional second degree tear.
 Indications: shouldn’t be routine but may be
considered in the f/f conditions
 Instrumental delivery
 Previous third or fourth degree tear
 Excision
 Malpresentations and shoulder dystocia
 Edematous & scarred perineum
 Prolonged second stage of labor due to tight
perineum and fetal distress.
 Advantage:
 Prevents perineal tear
 Shorten second stage in fetal & maternal
compromise
 Reduce fetal hypoxia and acidosis
 Minimize pushing effort
 Prevent pelvic relaxation
 Avoids urethral bruise
  Types:
A. Median/medial:
 Start – at the center of fourchette
 For 2.5 cm at center of perineum towards anus

Advantage: reduced blood loss, comfortable during

healing, easy to suture.
Disadvantage: possibility of expansion to anal
sphincter and rectum.
 Types …
B. Medio-lateral:
 Start – at the center of fourchette
 For 3 cm diagonally (posterio-laterally) in straight line.

Advantage: prevent involvement of anal sphincter

and rectum, provide more space.
Disadvantage: difficult to repair, uncomfortable
during healing, more blood loss.
 Types …
C. J – shaped:
 Start – at center of fourchette
 Continues for 2 cm → shift to 7 or 5 in the clock to
avoid rectum.

Disadvantage: difficult to appose wound edges and

repair, wound puckering.
- Done rarely.
 Types …
D. Lateral:
 Start – 1cm away from center of fourchette
 Continues laterally

Disadvantage: damage to Bartholin’s gland, difficult

to repair, more blood loss, uncomfortable while
healing.
- Not being done.
 Preparation:
 Revise indication
 Clean perineum with antiseptic solution
 Reassure mother
 Confirm mother isn’t allergic to lidocaine or related
drug.
 Local anesthesia infiltration:
 Infuse 0.5% lignocaine beneath vaginal mucosa, perineal
skin and deep into the muscles
o after checking needle isn’t in vein.
 Wait for 2 minutes and pinch with forceps.
 Timing of incision:
o perineum distends (thins out)
o 3 – 4 cm of the head is visible during contraction.
 Avoid early incision. WHY?
 Making incision:
 Wear sterile glove
 Insert two fingers between fetal head and perineum.
 Make incision and extend it for 3 – 4 cm in medio-
lateral direction.
 Incise center of posterior vaginal wall for 2 - 3 cm.
 Protect delivery of head and shoulder.
 Examine tear for expansion and repair.
 Repairing incision:
 clean incision site using antiseptic solution.
 start repair 1cm above apex
 suture vaginal mucosa using 2 – 0 continuous
suture until the edge of vaginal opening.
 Bring together cut edges of vaginal opening.
 Pass needle under vaginal opening through
incision and tie.
 Repairing episiotomy …
 Close perineal muscle using 2 – 0 interrupted suture.
 Close skin using 2 – 0 interrupted (subcuticular) suture.

Polyglygolic sutures (like vicryl) are preferred over

chromic catgut because:
 Increased tensile strength
 Reduced allergenic reaction
 Reduced incidence of infection & wound debride.
 Post-procedure care:
 Cleanse vulva and perineum.
 Inspect area and prevent contamination and
infection.
 Minimize pain, tenderness and edema following
procedure.
 Possible complications:
 Hematoma
 Pain
 Tenderness
 Infection
 Wound dehiscence
 Dyspareunia
 Perineal tear is damage to skin and or muscles between vaginal
introitus and anal opening.
 Types of perineal tear
 Risk factors
 Episiotomy
 Definition
 Indication
 Types
 Procedure
 Possible complications