Editorial

The Ritgen ManeuverAnother Sacred Cow Questioned

Ferdinand August Marie Franz von Ritgen (17871867) was a Germanphysician who is credited with the perineum-sparing maneuver thatbears his name.1 In the first edition of Williams Obstetrics,2 the maneuveris described as follows: . . . in an interval between the pains . . . twofingers are applied just behind the anus, and forward and upward pressureis made upon the brow through the perinaeum (Fig. 1). This modifiedmaneuver differed slightly from the original description, which instructedthat towel-covered fingers be placed into the rectum. With either, thehead is delivered before the next contraction, with the intent of prevent-ing perineal tearing. The modified method was described through the14th edition of Williams Obstetrics, but beginning with the 15th edition,3

and continuing through today, the Ritgen maneuver is described as beingapplied during a contraction. Regardless of whether it is applied betweenor during a contraction, the maneuver undoubtedly has been taught toliterally millions of accoucheurs since its description by Ritgen more than150 years ago.

In this issue of Obstetrics & Gynecology, Rubin Jnsson and colleagues4

describe the results of their randomized trial to evaluate the modifiedRitgen maneuver, ie, during a contraction, and compared it with simpleperineal support to prevent anal sphincter tears. In more than 1,400nulliparous Swedish women randomized at the beginning of second-stagelabor, the authors observed a nonsignificant difference of 5.5% comparedwith 4.4% sphincter tears with and without performance of the Ritgenmaneuver, respectively. These observations are important because theyadd to the ever-increasing evidence-based outcomes for the practice ofobstetrics. At the same time, we must feel some loss of another sacredcow, as most of us were taught the Ritgen maneuver because we havealways done it this way.

There is likely more to this story than the end of the Ritgen era. Asmany well-designed studies do, this one raises the specter of the need forfurther studies. For example, and as mentioned by the investigators, therewill be those who will defend use of the Ritgen maneuver as originallydescribed as performed between contractions. To them I would say, Gofor it. Do the randomized trial because the study by Rubin Jnsson et al4

indicates that there is still a clinical problem to be solvedanal sphincterlaceration suffered at delivery. In their study, about 5% of nulliparouswomen had such a complication and thus will endure some of theattendant long-term sequelae, which includes sexual dysfunction and analincontinence. These and other sequelae of routine childbirth have beenbrought to the fore along with the renaissance of the heavily evidence-based subspecialty of female urogynecology. This is exemplified bycreation by the National Institute of Child Health and Human Develop-ment of the Pelvic Floor Disorders Network5 as well as other initiatives tostudy these vexing complications.

See related article on page 212.

Dr. Cunningham is from the Department of Obstet-rics and Gynecology at the University of TexasSouthwestern Medical Center at Dallas, Dallas,Texas; e-mail: gary.cunningham@utsouthwestern.edu. Dr. Cunningham is also a co-editor of WilliamsObstetrics.

2008 by The American College of Obstetriciansand Gynecologists. Published by Lippincott Williams& Wilkins.ISSN: 0029-7844/08

F. Gary Cunningham, MD

210 VOL. 112, NO. 2, PART 1, AUGUST 2008 OBSTETRICS & GYNECOLOGY

Questions to be posed include: Why are theresuch relatively high rates of childbirth-related analtears? And why are the variations between popula-tions and institutions so varied, even after confound-ing factors are controlled? Importantly, what can bedone to decrease their incidence? The incidence citedfor sphincter lacerations was 5.8% in more than 2million women delivered in California,6 7.3% in morethan 250,000 women delivered in Philadelphia,7 and16% in more than 13,000 nulliparas delivered inPittsburgh.8 Even after the confounding factors knownto increase lacerations are considered, these variationsare nonsensical. Can we learn more to decrease their

incidence? And if forceps beget lacerations and epi-dural analgesia begets forceps, can we assume thatepidural analgesia begets lacerations? Put anotherway, will the provision of elegant pain relief for laborbecome an ironic reason for jumping on the band-wagon for cesarean delivery on maternal request?9

More studies such as the one by Rubin Jnsson andher colleagues4 need to be designed to find a newRitgen maneuver that prevents some of these adverseoutcomes.

REFERENCES1. Ritgen FAMFcR. Ueber ein Dammschutzverfahren. Monatss-

chr. f. Geburtsk. 1855;vi:32147.

2. Williams JW. Obstetricsa text-book for use of students andpractitioners. New York (NY): D. Appleton and Co.; 1903. p.288.

3. Hellman LM, Pritchard JA. Williams Obstetrics. 14th ed. NewYork (NY): Appleton-Century-Crofts; 1971. p. 4123.

4. Rubin Jnsson E, Elfaghi I, Rydhstrm H, Herbst A. ModifiedRitgens maneuver for anal sphincter injury at delivery: arandomized controlled trial. Obstet Gynecol 2008;112:2127.

5. Brubaker L, Handa VL, Bradley CS, Connolly A, Moalli P,Brown MB, et al. Sexual function 6 months after first delivery.Obstet Gynecol 2008;111:10404.

6. Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphinc-ter lacerations. Obstet Gynecol 2001;98:22530.

7. Dandolu V, Chatwani A, Harmanli O, Floro C, Gaughan JP,Hernandez E. Risk factors for obstetrical anal sphincter lacer-ations. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:3047.

8. Lowder JL, Burrows LJ, Krohn MA, Weber AM. Risk factorsfor primary and subsequent anal sphincter lacerations: acomparison of cohorts by parity and prior mode of delivery.Am J Obstet Gynecol 2007;196:344.e15.

9. National Institutes of Health state-of-the-science conferencestatement: cesarean delivery on maternal request March2729, 2006. Obstet Gynecol 2006;107:138697.

Fig. 1. Delivery by the modified Ritgen maneuver. Thearrow indicates the direction of moderate pressure appliedby the posterior hand. Hellman LM, Pritchard JA. Williamsobstetrics. 14th ed. New York (NY): Appleton-Century-Crofts; 1971. Reproduced with permission from TheMcGraw Hill Companies.Cunningham. Randomized Trial to Study the Ritgen Maneuver.Obstet Gynecol 2008.

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