This guideline was prepared by the Laboring Program Science Board of the General Directorate of Family Planning and Maternal and Infant Department of Health of Turkish Health Ministry in close cooperation with Turkish Gynaecology and Obstetrics Society, Turkish Perinatology Society, Turkish Maternal Fetal Medicine and Perinatology Society to provide the unity in application and to be a guide in clinical practices of physicians. Practical Guideline for Labor is not a series of unchangeable rules and does not constitute the judicial standards of the services offered to patient. It admits that it is a basic principle to evaluate every single patient within his/her own special conditions.
Cesarean is generally applied in cases where it is not possible to complete vaginal delivery safely or when there is a certain increase in maternal and/or fetal morbidity and mortality together with vaginal delivery. According to the Turkish Population and Health Research (TNSA) in 2003, it is seen that cesarean rate which was 21.2% have reached 40% in recent delivery rates. It is known that the current rate is over the goal (5-15%) set by World Health Organization and the rates of developed countries. While large-scale retrospective and prospective studies have been planned by the General Directorate of Family Planning and Maternal and Infant Department of Health of Turkish Health Ministry of in order to reveal the reasons, it is considered that the factors such as the increase of discretionary and repeated cesareans and extending the indications are among the reasons increasing this rate. Today, risks such as infection, bleeding, transfusion need, thromboembolic risks, long hospital stayings, late recovery, having more pains continue while anesthesia, drugs and materials used, and developments in surgical and postoperative care have decreased mortality and morbidity due to cesareans. American Congress of Obstetricians and Gynecologists (ACOG) declared in their statement on May 9th, 2006 that cesareans should be performed not discretionally but due to medical reasons. The studies to follow deliveries and their outcomes in public and private health associations have been initiated by the ministry throughout the country to protect mother health. In this context, it is important to follow cesarean indications and outcomes. Obeying the medical reasons and indications suggested by modern obstetrics, keeping patient records in a certain form and within an application unity in detail and correctly, keeping statistics accurately and following ethic rules are the most important precautions to reach this goal.Application-Oriented Basic Priorities• Delivery by cesarean is a surgical intervention and it is essential to perform it for medical reasons, and it is an alternative to vaginal delivery. Advantages and risks peculiar to pregnant and pregnancy should be taken into consideration when planning cesarean delivery.
• While the request of mother is not a sufficient reason by itself for cesarean, psychological conditions of individual such as fear, anxiety, panic should be taken into consideration. Adequate and accurate consultancy should be given.
• Cesarean decision should be given by individualizing the diagnoses of each patient.
• As in all medical interventions, informed consent from should be taken from patient in also cesarean cases.Reducing the Cesarean Possibility• In all pregnancies where delivery is followed up, partograph should be used to follow up spontaneous delivery progress. • Beginning from the 36th gestational week, external cephalic version (ECV) can be suggested to pregnants who have single rectal baby without complication, excluding exceptional cases (pregnants whose deliveries have already begun and who have uterine scar and abnormality, fetal distress, membrane rupture and vaginal bleeding). The risks of intervention should be explained to mother-to-be by informed consent before the application.
• It is suggested to determine delivery type by individualizing treatment and deciding as to case for pregnants who exceed their 42nd gestational week and have single pregnancy without complication.
It should be kept in mind that there may be increase in cesarean rate and other complications by the induction of delivery. Mother should be informed about this matter.
• In appropriate cases, post-cesarean vaginal delivery can be suggested. The risks of intervention should be explained to mother-to-be by informed consent before the application.Cesarean IndicationsWhile delivery by cesarean is generally preferred in cases given below, these indications are not certain and they should be determined according to current conditions by individualizing delivery type as to case characteristics.1. Fetal Indications1.1. Fetal distress
1.2. Fetal presentation anomalies
1.2.a. Rectal presentation
1.2.b. Other presentation anomalies (transverse, forehead, face presentation etc.)
1.3. Multiple pregnancies
1.4. Fetal anomalies (hydrocephalia, sacrococcygeal teratoma etc.)2. Maternal Indications2.1. Performed uterus surgery (cesarean, other operations)
2.2. Systemic diseases (DM, HT, pregnancy induced hypertension etc.)
2.3. Vertical transitive maternal infections (HIV, HSV-2, HCV vb.)3. Labor or Natal Indications3.1. Cephalopelvic disproportion
3.2. Prolonged labor
3.3. Fetal Macrosomia4. Indications of Umbilical Cord and Placenta4.1. Cord prolapse
4.2. Placenta previa
4.3. Ablatio placentae
4.4. Vasa praeviaFetal Anomalies
Related Messages• Delivery by cesarean can be suggested in cases such as fetal myelomeningocele, sacrococcygeal teratoma, fetal abdominal anterior wall defects and non-immune hydrops.
• Generally, delivery type in fetal anomalies should be individualized according to case characteristics. This decreases perinatal morbidity and mortality expected in cesarean.Fetal Distress
Related Messages• Gestational week during delivery, existence of congenital anomaly and development disorders affect perinatal outcome seriously.
• The technology used by newborn experts and advancements in prenatal care (such as determining high-risk patients, increasing use of antenatal steroids by those with ultrasonography and early labor risk etc.) affect perinatal outcome positively.
• Fetal distress is diagnosed by applying one or more methods given below according to risk situation.
1) Monitoring partogram and fetal heat beat rate by fetoscope
2) Discontinuous or continuous electronic fetal monitorization
3) Fetal scalp blood sampling or palse oximeter
• If there is a situation where fetal heart beat does not get normal, cesarean is suggested to prevent perinatal morbidity and mortality.
• It is needed to do cesarean within 30 minutes at the latest when a patient is diagnosed as having fetal distress.Protocol
Reminder: 1 - Fetal Distress Diagnosis• Abnormal heart rate curve.
• Amnion fluid with dark-dense meconium.
• Determining fetal hypoxia by using fetal pulse oximeter and scalp blood sampling. Today, these methods can be applied by limited number of hospitals and they are not practical.Reminder: 2 - If Fetal Distress Diagnosis Exists• Pregnant should be laid down on its left side or be kept in sitting position.
• Oxytocin infusion (if given) or another induction should be stopped.Reminder: 3 - Heart Rate• Normal heart rate can slow down during contraction but it returns to normal as soon as uterus loosens up.
• Very slow heart rate when there is no contraction or slow heart rate after contraction may indicate fetal distress.
• Fast heart rate may develop as a response to high fever, drugs accelerating heart rate of mother (i.e. tocolytic drugs), chorioamnionitis, hyperthyroidism or high tension. In the light of this information, to research the maternal-oriented reasons is the first thing to do when fast heart rate is found.
• The existence of fast heart rate of fetus despite the normal heart rate of mother should be considered as a diagnosis of fetal distress.Reminder: 4 - Meconium• As fetus maturates, amnion fluid stained with meconium is seen frequently and it may not be an indication of fetal distress on its own. It must be paid attention in the existence of amnion fluid stained with meconium without any abnormality in heart rate.
• Dense-dark meconium presence shows the meconium transiton into decreased amnion fluid and it is required to hasten the delivery.If this diagnosis occurs on the early phase of delivery and if it is predicted that the delivery will take long (primigravida), then cesarean may be considered. Mouth-nose aspiration required during delivery should be performed rapidly in order to prevent meconium aspiration.
• Meconium transition occurs due to pressure on fetus abdomen during delivery through rectal presentation. It is not a diagnosis of fetal distress providing that the situation is not on the early phase of delivery.Reminder: 5 - Additional Clinical Diagnosis (Chart-1)• If there are infection diagnoses (fever, fetid vaginal discharge), antibiotics should be given as in chorioamnionitis.
• If the cord is below the incoming part or in vagina, it should be managed as cord prolapse.Reminder: 6 - Delivery• If abnormality in fetus heart rate continues or there are additional diagnoses for distress (amnion fluid with thick-dense meconium), delivery should be planned:
• In the presence of required conditions, vacuum extraction or forceps can be tried. Otherwise, delivery is performed by cesarean.
• If cervix is not fully open or fetus head is over 0 level, delivery should be performed by cesarean.Rectal Presentation
Related Messages• Approximately 4% of single pregnancies are rectal presentation. Prevalance decreases as gestational weeks increase (3% in term pregnancies).
• Delivery of all rectal presentations should be done in hospitals which are capable of performing operation.
• Plannned vaginal delivery can be suggested to multipara pregnants who have pure and full rectal presentation between 2500 gr and 3500 gr estimated fetal weight.
• It is important to specialize on vaginal rectal deliveries and it is not suggested to try delivery without having the experience of this practice.
• ECV performed on 36th gestational week and over can turn the position in pregnants with noncomplicated (full and pure rectal presentation) rectal presentation from rectal presentation to cephalic presentation. However, ECV is not a method used frequently by obstetrics in Turkey. It can be offered as an alternative if physician is experienced on the subject matter.
• If ECV succeeds, normal action follow-up is performed. If ECV fails, vaginal rectal delivery is followed or delivery is performed by cesarean.
• Pregnant should be examined regularly and delivery progress should be marked on delivery monitorization graph.
• Elongated action in rectal presentation is a cesarean indication.
• Membranes should not be opened; when they are opened, pregnant should be examined immediately in terms of cord prolapse.
• If the cord prolapsed and the delivery is not soon, then the delivery should be performed by cesarean.
• If gestational week of fetus is less than 34th gestational week in early rectal delivery, then the cesarean appropriate.
• In rectal presentation, delivery by cesarean is frequently suggested in cases given below;
1. Big fetus,
2. Inappropriate pelvis,
3. Cord entanglement on neck,
4. Hyperextension of head,
5. Being unable to initiate spontaneous labor in presence of membrane rupture developed 12 hours or long ago,
6. Uterus dysfunction,
7. Foot presentation,
8. In pregnancies at 34th gestational week or below, being on active delivery action of mother when preterm fetus is apparently healthy,
9. Serious fetal growth retardation,
10. Perinatal death undergone or childhood background with birth trauma,
11. Sterilization requestProtocol
Reminder: 1 - Evaluation in Antenatal PeriodConsultation of pregnant with an obstetrician before 36th week:
The definition of noncomplicated single rectal presentation:
• Pregnancy of 37th-42nd week,
• Full (with flexion) or pure (with extension) rectum,
• No feto-pelvic disproportion,
• Fetal head is at full flexion or does not have hyperextension (Leopold 3, 4),
• No fetal anomaly,
• No mechanical obstacle,
• Clinically calculating fetus under 3500 gr, Reminder: 2 - Progress of Delivery• Cervical dilatation:
❖ Proceeding by opening at least 0.5 cm per hour after 3 cm for multiparas.
❖ Proceeding by opening at least 0.5 cm within 1.5 hour after 3 cm for nulliparas.
❖ Rectum going down to perineum within 2 hours after full dilatation.Reminder: 3 - Suggestions for the Action (Chart-2 and Chart-3)• Pregnant should not be made to do active pushing move until rectum goes down to perineum.
• Delivery is close after one hour of active pushing.
• Pregnant is given active delivery position.
• If delivery of thorax gets slow, “Lovsett” maneuver should be done. Then, head should be delivered in a controlled and gentle way.
• When needed, forceps can be applied to head coming from back by obstetrician who is sufficiently qualified and experienced for such cases. Obstetrician should be informed beginning from first moments of active delivery action. Hospital conditions required for a planned vaginal rectal delivery are: Experienced midwife, expert pediatrician, obstetrician who is qualified to follow delivery, operating room for emergency cesarean and existence of emergency conditions.Transverse Presentation
Related MessagesIt can be tried to rotate fetus from outside (external version) if it is early period of the action and membranes are not open. It should be discussed with mother scientifically that this procedure may cause early labor and ablatio placentae and cesarean should be arranged under elective conditions by the consent of mother to be if needed. After 36th gestational week, pregnant should reside in a place close to hospital where she will deliver at. If the attempt of rotating from outside becomes successful, normal action follow-up is performed. If this attempt is fails or it is not safe to do, cesarean should be applied. Obstetrician should be aware of cord prolapse and perform the followup carefully. If cord prolapse happens when delivery is not soon, cesarean should be applied. Transverse presentation is the most dangerous one among malpresentations and elective cesarean can be arranged without considering the exceptional examples (ECV etc.) since it has a risk of high morbidity. If case is neglected, uterus rupture may develop. Obstetrician should discuss with mother to be about the risk of maternal-fetal mortality and suggest cesarean.Forehead Presentation
Related Messages• If fetus is alive, then it is delivered by cesarean. If it is dead, vaginal delivery should be considered as the first option.Facial Presentation
Related MessagesIt is delivered by mento-posterior cesarean. If fetus is dead, vaginal delivery should be considered as the first option. For mentum anterior, vaginal delivery can be provided by close follow-up.Multiple PregnanciesRelated Messages
• Multiple pregnancies are observed among pregnancies with a frequency of 15/1000, which are mostly twin pregnancies (twin pregnancies: 14.4/1000; triplet pregnancies: 4/1000). Since perinatal morbidity and mortality (cerebral palsy, stillbirth, neonatal death etc.) rates increase significantly in multiple pregnancies, it is an important process to determine the delivery type.MULTIPLE PREGNANCIES SHOULD BE PLANNED FOR DELIVERING IN CENTERS WHICH HAVE SUFFICIENT EXPERIENCE AND EQUIPMENT.❖ If first baby is vertex, second baby is vertex presentation;
• Vaginal delivery is preferred.
• Though second fetus has always high risk in terms of mortality and morbidity, most of this risk is caused by inappropriate growth in favor of first fetus.
❖ If second baby is vertex, second baby is not vertex presentation;
• In cases where where second fetus is not vertex, vaginal delivery can be provided after deliver of first one if presentation is rectal. In transverse position, second fetus can be delivered through vaginal way by means of internal podalic version (IPV). In both cases, cesarean can be preferred if sufficient experience and favorable conditions do not exist.
❖ First baby is not vertex presentation;
• Delivery by cesarean is a preferred method.
• In non-complicated twin pregnancies, the most ideal week for planned cesarean seems as 38th gestational week. However, most of twin pregnancies are delivered between 35th and 38th gestational weeks. The risk of respiratory problems increase in babies delivered before 35th gestational week.Twins with Low Birth Weight• If the presentation is vertex-vertex and it is considered that birth weights of fetus are under 1500 gram, literature supports vaginal delivery. Besides, it should not be overlooked that low birth weight can be a result of chronic hypoxy such as intrauterine growth retardation (IUGR) and fetal distress may be seen. In multiple pregnancies, it should be remembered that there may be an unbalance among twins according to chorionicity determination and thus Dopper USG may be needed for evaluating placental reserve. If any or both of fetuses have chronic hypoxy diagnoses, it is suitable to end pregnancy by cesarean.
• The case of second twin which does not have vertex presentation without low birth weight (under 1500 gram) is very controversial and it is hard to evaluate the profit-loss rate between mother and baby. Physician should plan delivery by taking conditions and his/her training into consideration in this case.Monoamniotic twins;• These twin pregnancies are related with the characteristics increasing perinatal mortality such as twins being locked up during delivery, cord entanglement and transfusion between twins. Diagnosis is possible by USG use. In such case, delivery preference should be cesarean.Triplet and above pregnancies;• Cesarean is applied since it decreases possibility of low Apgar score at delivery and perinatal death incidence.Protocol
Delivery at Multiple Pregnancies
Reminder: 1 - Diagnosis • Fetus count is determined by USG and abdominal examination.Reminder: 2 - First Baby• If it is vertex presentation, the action is allowed to proceed as vertex presentation and the progress of action is followed up by using partogram; vaginal delivery is applied if there is no extraordinary situation.Reminder: 3 - First Baby• If it is rectal presentation, cesarean is a performed method.
• If it is a transverse presentation, then delivery is done by cesarean.Reminder: 4 - Monoamniotic Twins
• These twin pregnancies are related with the characteristics which increase perinatal mortality such as twins being locked up during delivery, cord entanglement and transfusion between twins. Diagnosis is possible by USG use. In such case, delivery preference should be cesarean.
Reminder: 5 - Second Baby Vertex Presentation
• Vaginal delivery is performed.
• Fetal distress diagnoses are examined after delivery of first baby.
Reminder: 6 - Second Baby Rectal Presentation
• Vaginal delivery is planned.
• Fetus heart rate is checked between contractions.
• If there is any extraordinary situation and vaginal delivery is not possible, then delivery is doen by cesarean.
Reminder: 7 - Second Baby Transverse Presentation
• Vaginal delivery is planned by internal podolic version (IPV) (if physician has sufficient experience and technical conditions exist). IPV processes may progress together with high morbidity and mortality. Therefore, cesarean may be planned if malpresentations or malpositions of fetuses can be predicted beforehand (Chart-4)
Note: If there is scar in uterus, membranes are opened, amnion has run out of fluid and operator has no training, IPV initiative is not performed. It is not insisted if baby is not rotated easily.
• Abnormal bleeding,
• Cord prolapse,
• Second baby much bigger than first baby,
• Contraction of cervix and getting thicker after delivery of first baby, not being dilated of itself,
• Fetal heart beats decreasing under 100/min, increasing above 180/min,
In such cases, cesarean should be planned as an emergency delivery.
Labor, practical guideline