However, it shows that on average the two types of delivery amounted to around 35.4% (Fig. 11.2).

The different types of delivery have undergone an interesting evolution over the past twenty years.

The inexorable increase of caesarean section is associated with a considerable reduction in the use of the obstetric vacuum and especially of the forceps (Fig. 11.3).

One reason for the increase in the caesarean section was the patient’s request, even in the absence of traditional indications. The reasons for these requests are the fear of perineum damages (urinary and fecal incontinence, genital prolapse), but also the reduction of fetal risks due to vaginal delivery.

Regarding the use of forceps and the obstetric vacuum, while the effectiveness of these instruments is still recognized, but considering the severity of maternal and fetal injuries resulting from their use, many practitioners prefer to limit their use without very clear indications.

The clinical risk management in relation to fetal distress due to hypoxia or asphyxia during birth remains a central point as a major cause of coroner’s action and increased costs for operators and health facilities.

The incidence of encephalopathy and cerebral palsy remains unchanged in industrialized countries than in developing countries despite the obstetricians’ progress, such as continuous cardiotocographic monitoring [21].

The ACOG (American College of Obstetricians and Gynaecologists) reports that the percentage of cerebral palsy associated with intrapartum events is around 10%. Acute fetal asphyxia is less associated with adverse neonatal outcomes compared to prolonged intrauterine hypoxia. The current opinion is that severe perinatal asphyxia has not poor prognosis because an adequate neonatal resuscitation can avoid most of the brain damage in babies and that most of the survived infants does not have adverse neurological outcomes.

In contrast, chronic asphyxia has greater incidence of permanent damages [22].

In order to quickly resolve the dystocial labors at risk of acute asphyxia is therefore crucial to the proper use of forceps or vacuum cup, especially in cases of dystocia.

The placement of the cup in case of application of the vacuum or the application of forceps, in cases of asynclitism are two situations in which the operator finds good help with intrapartum sonography (Fig. 11.4).

The application of the obstetric vacuum is closely related to the correct determination of the position of the fetal head because otherwise it causes a deflection of the fetal head with consequent probable detachment of the cup itself and increase in neonatal morbidity.

The application of the obstetric vacuum on deflected occiput increases by 4–5 times the probability of failure, while its application on posterior or lateral occiput increases two times the chances of failure [23].

If the fetal head is deflected at the time of the application of the obstetric vacuum, the probability of a low Apgar score (less than 6) increases by 3.2 times and the probability of severe trauma of the scalp of 5.2 times and increases 12 times the probability of admission to neonatal intensive care [24, 25].

Since the lateral and posterior positions of the most difficult to diagnose with an obstetric examination, and as reported in the literature these situations have a higher frequency with epidural analgesia, the use of ultrasound gets more important with operative delivery during labor analgesia [26].

In case of vaginal operating delivery, the intrapartum sonography can therefore allow a more precise application of the forceps and of the vacuum, in particular for the latest disposable cups (Kiwi), which, if not positioned properly, can easily detach especially in case of misapplication over caput succedaneum (Fig. 11.5).

The intrapartum sonography is particularly important in cases of dystocia delivery, as it provides an image that guides the application of the branches of the forceps.

In particular, in anterior or posterior asynclitism, if you decide to apply the forceps, intrapartum transabdominal ultrasound can guide the direct and symmetrical application on the parietal bones, avoiding improper application of the branches on the face. The trans-labial ultrasound instead allows assessing the level of the presenting part, letting you to decide if there are the conditions for the application of the forceps or not.

In particular, in anterior or posterior asynclitism, if you decide to apply the forceps, intrapartum transabdominal ultrasound, can guide the direct and symmetrical application on the parietal bones, avoiding improper application of the branches on the face. The trans-labial ultrasound instead allows to assess the level of the presenting part, letting you to decide if there are the conditions for the application of the forceps or not.

Similarly, the application of the cup can be performed under ultrasound guidance highlighting the position of the fetal head and the localization of the caput succedaneum, avoiding the positioning of the cup on the tumors and prevent failures, as reported in different studies by Molina and Nicolaides [26], Sentilhes et al. [27], and Lau et al. [28].

Even in the case of caesarean sections, intrapartum sonography is also useful to consider other important intra- and postoperative data. For example, in occiput-posterior presentations, with ruptured membranes and with fixed head in the pelvic cavity, we should consider the position of the fetal head in order to avoid fetal injuries by cuts on the face. Nevertheless, in case of greatly flexed head, a pre\operative ultrasound evaluation is useful in order to prevent incongruous maneuvers during the extraction of the head (Fig. 11.6).

The intrapartum use of ultrasound is very important in early diagnosis of dystocia, which avoids unnecessary prolonged labors that often end with emergency caesarean sections (with a higher percentage of intra- and postoperative complications).

In particular, significant intraoperative bleeding complications may be due to an excessive distension of the lower uterine segment [29–36]. Postoperative complications may also occur after an inadequate hemostasis, but also as a consequence of hypotension caused by spinal anesthesia (Fig. 11.7) which is followed by a normalization of blood pressure that could generate a bleeding site if eschars fall from the vessels treated with electrocoagulation. This phenomenon could mainly happen in hypertensive or preeclamptic patients [37, 38].

Recent studies have shown that prolonged dystocial labor is caused not only by mechanical fetus-pelvic causes but also by dysfunctions of the uterine contractility that are associated with dynamic dystocia. In particular, the dystocial labor is also associated with an alteration of neurotransmitters that modulate the activity of the upper and lower uterine segment.

Also, excessive distension of the lower uterine segment by the presented part of the fetus changes the neurotransmitters creating a vicious cycle that increases the degree of dystocia, causes pain, and increases blood circulation. This provokes a more vascularized uterine segment, with possible intraoperative difficulties, and a reduction of neurotransmitters that accentuate the dystocia. In the uterine scar that is ­created, we have a reduced function of neurotransmitters in a subsequent labor, especially if you program a vaginal birth after caesarean section (VBACS) [39].

Another aspect of bleeding complications in the course of CS, the postpartum and early ­puerperium are related to the surgical technique used.

In particular, the suturing of the visceral peritoneum in the case of bleeding causes the “bladder flap hematoma” but in case of bleeding without suturing, the bladder fold can cause a hemoperitoneum [29–32] (Fig. 11.8).

Similarly, in case of bleeding with suture of the parietal peritoneum, a subfascial hematoma can develop (Fig. 11.9), but without the suture of the peritoneum, leaving the Retzius space open, the hemoperitoneum can form [33, 40].