Skip to main content Accessibility help
×
Hostname: page-component-7479d7b7d-wxhwt Total loading time: 0 Render date: 2024-07-14T04:09:33.101Z Has data issue: false hasContentIssue false

Chapter 61 - Dysfunctional Labor (Content last reviewed: 20th February 2020)

from Section 6 - Late Prenatal – Obstetric Problems

Published online by Cambridge University Press:  15 November 2017

David James
Affiliation:
University of Nottingham
Philip Steer
Affiliation:
Imperial College London
Carl Weiner
Affiliation:
University of Kansas
Bernard Gonik
Affiliation:
Wayne State University, Detroit
Stephen Robson
Affiliation:
University of Newcastle
Get access

Summary

The primary goal for all involved in the care of women in labor is a healthy mother and baby after delivery. For most pregnancies, which are low risk, delivery by cesarean section appears to pose greater risk of maternal morbidity and mortality than vaginal delivery and can have significant implications for future pregnancies.

Type
Chapter
Information
High-Risk Pregnancy
Management Options
, pp. 1749 - 1774
Publisher: Cambridge University Press
First published in: 2017

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Clark, SL, Belfort, MA, Dildy, GA, et al. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 2008; 199: 36.e1–5.CrossRefGoogle ScholarPubMed
Karaçam, Z, Walsh, D, Bugg, GJ. Evolving understanding and treatment of labour dystocia. Eur J Obstet Gynecol Reprod Biol 2014; 182: 123–7.Google Scholar
Tulchinsky, D, Hobel, CJ, Yeager, E, Marshall, JR. Plasma estrone, estradiol, estriol, progesterone, and 17-hydroxyprogesterone in human pregnancy. I. Normal pregnancy. Am J Obstet Gynecol 1972; 112: 1095–100.CrossRefGoogle ScholarPubMed
Boroditsky, RS, Reyes, FI, Winter, JS, Faiman, C. Maternal serum estrogen and progesterone concentrations preceding normal labor. Obstet Gynecol 1978; 51: 686–91.Google Scholar
Avrech, OM, Golan, A, Weinraub, Z, Bukovsky, I, Caspi, E. Mifepristone (RU486) alone or in combination with a prostaglandin analogue for termination of early pregnancy: a review. Fertil Steril 1991; 56: 385–93.CrossRefGoogle ScholarPubMed
Chwalisz, K, Stockemann, K, et al. Mechanism of action of antiprogestins in the pregnant uterus. Ann N Y Acad Sci 1995; 761: 202–3.CrossRefGoogle ScholarPubMed
Neilson, JP. Mifepristone for induction of labour. Cochrane Database Syst Rev 2000; (4): CD002865.Google Scholar
Thomson, A, Telfer, J, Young, A, et al. Leukocytes infiltrate the myometrium during human parturition: further evidence that labour is an inflammatory process. Hum Reprod 1999; 14: 229–36.Google Scholar
Young, A, Jordan, F, Ledingham, M, et al. Quantification of pro-inflammatory cytokines in myometrium, cervix and fetal membranes during human parturition. J Soc Gynecol Invest 2002, 9: 137A.Google Scholar
Osman, I, Young, A, Ledingham, M, et al. Leukocyte density and pro-inflammatory cytokine expression in human fetal membranes, decidua, cervix and myometrium before and during labour at term. Mol Hum Reprod 2003; 9: 41–5.Google Scholar
Yuan, M, Jordan, F, McInnes, IB, Harnett, MM, Norman, JE. Leukocytes are primed in peripheral blood for activation during term and preterm labour. Mol Hum Reprod 2009; 15: 713–24.Google Scholar
Slater, DM, Dennes, WJ, Campa, JS, Poston, L, Bennett, PR. Expression of cyclo-oxygenase types-1 and -2 in human myometrium throughout pregnancy. Mol Hum Reprod 1999; 5: 880–4.CrossRefGoogle ScholarPubMed
Olson, DM. The role of prostaglandins in the initiation of parturition. Best Pract Res Clin Obstet Gynaecol 2003; 17: 717–30.Google Scholar
Khanjani, S, Kandola, MK, Lindstrom, TM, et al. NF-kB regulates a cassette of immune / inflammatory genes in human pregnant myometrium at term. J Cell Mol Med 2011; 15: 809–24.Google Scholar
Campbell, EA, Linton, EA, Wolfe, CD, et al. Plasma corticotropin-releasing hormone concentrations during pregnancy and parturition. J Clin Endocrinol Metab 1987; 64: 1054–9.CrossRefGoogle ScholarPubMed
Schafer, WR, Zahradnik, HP. Programmed escalation: models for the control of parturition. Geburtshilfe Frauenheilk 2001; 61: 157–66.Google Scholar
McLean, M, Bisits, A, Davies, J, et al. A placental clock controlling the length of human pregnancy. Nat Med 1995; 1: 460–3.CrossRefGoogle ScholarPubMed
Gee, H. The cervix in labour. Contemp Rev Obstet Gynaecol 1994; 6: 84–8.Google Scholar
Read, CP, Word, RA, Ruscheinsky, MA, Timmons, BC, Mahendroo, MS. Cervical remodeling during pregnancy and parturition: molecular characterization of the softening phase in mice. Reproduction 2007; 134: 327–40.CrossRefGoogle ScholarPubMed
Wary, S. Uterine contraction and physiological mechanisms of modulation. Am J Physiol 1993; 254: C1–18.Google Scholar
Parkington, HC, Tonta, MA, Brennecke, SP, Coleman, HA. Contractile activity, membrane potential, and cytoplasmic calcium in human uterine smooth muscle in the third trimester of pregnancy and during labor. Am J Obstet Gynecol 1999; 181: 1445–51.Google Scholar
Greenwood, IA, Tribe, RM. Kv7 and Kv11 channels in myometrial regulation. Exp Phsiol 2014; 99: 503–9.Google Scholar
Sperelakis, N, Inoue, Y, Ohya, Y. Fast Na+ channels and slow Ca2+ current in smooth muscle from pregnant rat uterus. Mol Cell Biochem 1992; 114; 7989.CrossRefGoogle ScholarPubMed
Arias, F. Pharmacology of oxytocin and prostaglandins. Clin Obstet Gynecol 2000; 43: 455–68.Google Scholar
Friedman, EA. The graphic analysis of labor. Am J Obstet Gynecol 1954; 68: 1568–75.Google Scholar
Friedman, EA. Primigravid labor. Obstet Gynecol 1955; 6: 567–89.Google Scholar
Friedman, EA. Labor in multiparas. Obstet Gynecol 1956; 8: 691703.CrossRefGoogle ScholarPubMed
National Institute for Health and Care Excellence. Intrapartum Care for Healthy Women and Babies. NICE Clinical Guideline CG190. London: NICE, 2017. https://www.nice.org.uk/guidance/CG190 (accessed September 2018).Google Scholar
American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine; Caughey, AB, Cahill, AG, Guise, JM, Rouse, DJ. Obstetric care consensus: safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210: 179–93.Google Scholar
Zhang, J, Troendle, JF, Yancey, MK. Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol 2002; 187: 824–8.CrossRefGoogle ScholarPubMed
Garfield, RE, Maner, WL. Physiology and electrical activity of uterine contractions. Semin Cell Dev Biol 2007; 18: 289–95.Google Scholar
Fele-Zorz, G, Kavsek, G, Novak-Antolic, Z, Jager, F. A comparison of various linear and non-linear signal processing techniques to separate uterine EMG records of term and pre-term delivery groups. Med Biol Eng Comput 2008; 46: 911–22.Google Scholar
Gough, GW, Randall, NJ, Genevier, ES, Sutherland, IA, Steer, PJ. Head-to-cervix forces and their relationship to the outcome of labor. Obstet Gynecol 1990; 75: 613–18.Google Scholar
Allman, ACJ, Genevier, ESG, Johnson, MR, Steer, PJ. Head-to-cervix force: an important physiological variable in labour. 1. The temporal relationship between head-to-cervix force and intrauterine pressure during labour. Br J Obstet Gynaecol 1996; 103: 763–8.Google Scholar
Allman, ACJ, Genevier, ESG, Johnson, MR, Steer, PJ. Head-to-cervix force: an important physiological variable in labour. 2. Peak active force, peak active pressure and mode of delivery. Br J Obstet Gynaecol 1996; 103: 769–75.Google ScholarPubMed
Bakker, JJ, Janssen, PF, van Halem, K, et al. Internal versus external tocodynamometry during induced or augmented labour. Cochrane Database Syst Rev 2013; (8): CD006947.Google Scholar
Myles, MF. Myles’ Textbook for Midwives, 11th edn. Edinburgh: Churchill Livingstone, 1989.Google Scholar
Jeffcoate, JNA. Physiology and mechanism of labour. In Claye, A, Bourne, A (eds), British Obstetric and Gynaecological Practice. London: Heinemann, 1963, pp. 145–83.Google Scholar
Pontonnier, G, Puech, F, Grandjean, H, Rolland, M. Some physical and biochemical parameters during normal labour. Biol Neonate 1975; 26: 159–73.CrossRefGoogle ScholarPubMed
Caldyro-Barcia, R, Sica-Blanco, Y, Poseiro, JJ, et al. A quantitative study of the action of synthetic oxytocin on the pregnant human uterus. J Pharmacol Exp Ther 1957; 121: 1831.Google Scholar
Bugg, GJ, Siddiqui, F, Thornton, JG. Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour. Cochrane Database Syst Rev 2011; (7): CD007123.Google Scholar
Wei, S, Wo, BL, Qi, HP, et al. Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care. Cochrane Database Syst Rev 2013; (8): CD006794.CrossRefGoogle Scholar
Woolfson, J, Steer, PJ, Bashford, CC, Randall, NJ. The measurement of uterine activity in induced labour. Br J Obstet Gynaecol 1976; 83: 934–7.Google Scholar
Berglund, S, Grunewald, C, Pettersson, H, Cnattingius, S. Severe asphyxia due to delivery-related malpractice in Sweden 1990–2005. BJOG 2008; 115: 316–23.Google Scholar
Burke, MS, Porreco, RP, Day, D, et al. Intrauterine resuscitation with tocolysis: an alternate month clinical trial. J Perinatol 1989; 9: 296300.Google Scholar
Briozzo, L, Martinez, A, Nozar, M, et al. Tocolysis and delayed delivery versus emergency delivery in cases of non-reassuring fetal status during labor. J Obstet Gynaecol Res 2007; 33: 266–73.Google Scholar
Nordstrom, L, Chua, S, Persson, B, Naka, K, Arulkumaran, S. Intrapartum tocolysis has no effect on fetal lactate concentration. Eur J Obstet Gynecol Reprod Biol 2000; 89: 165–8.CrossRefGoogle ScholarPubMed
Pattinson, RC. Farrell, EE. Pelvimetry for fetal cephalic presentations at term. Cochrane Database Syst Rev 2000; (4): CD000161.Google Scholar
Impey, L, O’Herlihy, C. First delivery after cesarean delivery for strictly defined cephalopelvic disproportion. Obstet Gynecol 1998; 92: 799803.Google Scholar
Lurie, S, Levy, R, Ben-Arie, A, Hagay, Z. Shoulder dystocia: could it be deduced from the labor? Am J Perinatol 1995; 12: 61–2.Google Scholar
Irion, O, Boulvain, M. Induction of labour for suspected fetal macrosomia. Cochrane Database Syst Rev 2000; (2): CD000938.Google Scholar
Kramer, MS, Morein, I, Yang, , et al. Why are babies getting bigger? Temporal trends in fetal growth and its determinants. J Pediatr 2002; 141; 538–42.Google Scholar
Surkan, PJ, Hsieh, CC, Johansson, AL, et al. Reasons for increasing trends in large for gestational age births. Obstet Gynecol 2004; 104: 720–6.Google Scholar
Hadfield, RM, Lain, SJ, Simpson, JM, et al. Are babies getting bigger? An analysis of birthweight trends in New South Wales, 1990–2005. Med J Aust 2009; 190: 312–15.CrossRefGoogle ScholarPubMed
Zhang, J, Bricker, L, Wray, S, Quenby, S. Poor uterine contractility in obese women. BJOG 2007; 114: 343–8.Google Scholar
Dudley, NJ. A systematic review of the ultrasound estimation of fetal weight. Ultrasound Obstet Gynecol 2005; 24: 80–9.Google Scholar
Nahum, GG, Stanislaw, H. Ultrasonographic prediction of term birth weight: How accurate is it? Am J Obstet Gynecol 2003; 188: 566–74.Google Scholar
American College of Obstetricians and Gynecologists, Fetal Macrosomia. ACOG Practice Bulletin 22. Washington, DC: ACOG, 2000.Google Scholar
Rouse, DJ, Owen, J, Goldenberg, RL, Cliver, SP. The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound. JAMA 1996; 276: 1480–6.Google Scholar
Brown, HC, Paranjothy, S, Dowswell, T, Thomas, J. Package of care for active management in labour for reducing caesarean section rates in low-risk women. Cochrane Database Syst Rev 2013; (9): CD004907.Google Scholar
Philpott, RH. Graphic records in labour. Br Med J 1972; 4: 163–5.Google Scholar
Philpott, RH, Castle, WM. Cervicographs in the management of labour in primigravidae. J Obstet Gynaecol Br Commonw 1972; 79: 592602.Google Scholar
Lavender, T, Cuthbert, A, Smyth, RM. Effect of partograph use on outcomes for women in spontaneous labour at term and their babies. Cochrane Database Syst Rev 2018; (8): CD005461. doi: 10.1002/14651858.CD005461.pub5.Google ScholarPubMed
Souza, JP, Oladapo, OT, Fawole, B, et al. Cervical dilatation over time is a poor predictor of severe adverse birth outcomes: a diagnostic accuracy study. BJOG 2018; 125: 9911000. doi: 10.1111/1471-0528.15205.Google Scholar
Gherman, RB, Ouzounian, JG, Goodwin, TM. Brachial plexus palsy: an in utero injury? Am J Obstet Gynecol 1999; 180: 1303–7.Google Scholar
Zhang, J, Landy, HJ, Branch, DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010; 116: 1281–7.Google Scholar
Dujardin, B, De Schampheleire, I, Sene, H, Ndiaye, F. Value of the alert and action lines on the partogram. Lancet 1992; 339 1336–8.Google Scholar
Cheng, YW, Shaffer, BL, Bryant, A, et al. Length of the first stage of labor and associated perinatal outcomes in nulliparous women. Obstet Gynecol 2010; 116: 1127–35.Google Scholar
Saunders, NSG, Paterson, CM, Wadsworth, J. Neonatal and maternal morbidity in relation to the length of the second stage of labour. Br J Obstet Gynaecol 1992; 99: 381–5.Google Scholar
Stephansson, O, Sandström, A Petersson, G, Wikström, AK, Cnattingius, S. Prolonged second stage of labour, maternal infectious disease, urinary retention and other complications in the early postpartum period. BJOG 2015; 123: 608–16.Google Scholar
Rouse, DJ, Weiner, SJ, Bloom, SL, et al. Second-stage labor duration in nulliparous women: relationship to maternal and perinatal outcomes. Am J Obstet Gynecol 2009; 201: 357.e1–7.Google Scholar
Lemos, A, Amorim, MMR, Dornelas de Andrade, A, et al. Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev 2017; (3): CD009124. doi: 10.1002/14651858.CD009124.pub3.Google Scholar
Cahill, AG, Srinivas, SK, Tita, ATN, et al. Effect of immediate vs delayed pushing on rates of spontaneous vaginal delivery among nulliparous women receiving neuraxial analgesia: a randomized clinical trial. JAMA 2018; 320: 1444–54. doi: 10.1001/jama.2018.13986.Google Scholar
American College of Obstetricians and GynecologistsOperative Vaginal Delivery: Use of Forceps and Vacuum Extractors for Operative Vaginal Delivery. ACOG Practice Bulletin No. 17. Washington DC: ACOG2000.Google Scholar
Royal College of Obstetricians and GynaecologistsOperative Vaginal Delivery. Green-top Guideline No. 26. London: RCOG, 2011. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg26/ (accessed March 2017).Google Scholar
Shere, DM, Miodovnik, M, Bradley, KS, Langer, O. Intrapartum fetal head position II: comparison between transvaginal digital examination and transabdominal ultrasound assessment during the second stage of labor. Ultasound Obstet Gynecol 2002; 19: 264–8.Google Scholar
Chelmow, D, Kilpatrick, SJ, Laros, RK. Maternal and neonatal outcomes after prolonged latent phase. Obstet Gynecol 1993; 81: 486–91.Google ScholarPubMed
Friedman, EA, Sachtleben, MR. Dysfunctional labor. Obstet Gynecol 1961; 17: 135–48.Google Scholar
Cardozo, LD, Gibb, DM, Studd, JW, Vasant, RV, Cooper, DJ. Predictive value of cervimetric labour patterns in primigravidae. Br J Obstet Gynaecol 1982; 89: 33–8.Google Scholar
O’Driscoll, K, Jackson, RJ, Gallagher, JT. Prevention of prolonged labour. Br Med J 1969; 2: 477–80.Google Scholar
Harrison, N, Larcombe-McDouall, JB, Earley, L, Wray, S. An in vivo study of the effects of ischaemia on uterine contraction, intracellular pH and metabolites in the rat. J Physiol 1994; 476: 349–54.Google Scholar
Quenby, S, Pierce, SJ, Brigham, S, Wray, S. Dysfunctional labor and myometrial lactic acidosis. Obstet Gynecol 2004; 103: 718–23.Google Scholar
Wiberg-Itzel, E, Pettersson, H, Cnattingius, S, Nordstrom, L. Association between lactate concentration in amniotic fluid and dysfunctional labor. Acta Obstet Gynecol Scand 2008; 87, 924–8.Google Scholar
Wiberg-Itzel, E, Pettersson, H, Andolf, E, et al. Lactate concentration in amniotic fluid: a good predictor of labor outcome. Eur J Obstet Gynecol Reprod Biol 2010; 152: 34–8.Google Scholar
Smyth, RM, Markham, C, Dowswell, T. Amniotomy for shortening spontaneous labour (Review). Cochrane Database Syst Rev 2013; (6): CD006167.Google Scholar
Kimura, T, Takemura, M, Nomura, S, et al. Expression of oxytocin receptor in human pregnant myometrium. Endocrinology 1996; 137: 780–5.Google Scholar
Chua, S, Kurup, A, Arulkumaran, S, Ratnam, SS. Augmentation of labour: does internal tocography result in better obstetric outcome. Obstet Gynecol 1990; 76: 164–7.Google Scholar
Phaneuf, S, Rodríguez Liñares, B, TambyRaja, RL, MacKenzie, IZ, López Bernal, A. Loss of myometrial oxytocin receptors during oxytocin-induced and oxytocin-augmented labor. J Reprod Fertil 2000; 120: 91–7.Google Scholar
Saccone, G, Ciardulli, A, Baxter, JK, et al. Discontinuing oxytocin infusion in the active phase of labor: a systematic review and meta-analysis. Obstet Gynecol 2017; 130: 1090–6. doi: 10.1097/AOG.0000000000002325.Google Scholar
Bor, P, Ledertoug, S, Boie, S, Knoblauch, NO, Stornes, I. Continuation versus discontinuation of oxytocin infusion during the active phase of labour: a randomised controlled trial. BJOG 2016; 123: 129–35.Google Scholar
Diven, LC, Rochon, ML, Gogle, J, et al. Oxytocin discontinuation during active labor in women who undergo labor induction. Am J Obstet Gynecol 2012; 207: 471.e1–8.Google Scholar
Girard, B, Vardon, D, Creveuil, C, Herlicoviez, M, Dreyfus, M. Discontinuation of oxytocin in the active phase of labor. Acta Obstet Gynecol Scand 2009; 88: 172–7.CrossRefGoogle ScholarPubMed
Öztürk, FH, Yilmaz, SS, Yalvac, S, Kandemir, Ö. Effect of oxytocin discontinuation during the active phase of labor. J Matern Fetal Neonatal Med 2015; 28: 196–8.Google Scholar
Vlachos, DE, Pergialiotis, V, Papantoniou, N, Trompoukis, S, Vlachos, GD. Oxytocin discontinuation after the active phase of labor is established. J Matern Fetal Neonatal Med 2015; 28: 1421–7.Google Scholar
Gaudernack, LC, Frøslie, KF, Michelsen, TM, Voldner, N, Lukasse, M. De-medicalization of birth by reducing the use of oxytocin for augmentation among first-time mothers – a prospective intervention study. BMC Pregnancy Childbirth 2018; 18: 76. doi: 10.1186/s12884-018-1706-4.Google Scholar
Isidore, J, Rousseau, A. Administration of oxytocin during spontaneous labour: a national vignette-based study among midwives. Midwifery 2018; 62: 214–19. doi: 10.1016/j.midw.2018.04.017.Google Scholar
Liston, WA, Campbell, AJ. Dangers of oxytocin induced labour to fetuses. BMJ 1974; iii: 606–7.Google Scholar
Miller, LA. Oxytocin, excessive uterine activity, and patient safety: time for a collaborative approach. J Perinat Neonatal Nurs 2009; 23: 52–8.Google Scholar
NHS Litigation Authority. Ten Years of Maternity Claims: An Analysis of NHS Litigation Authority Data. London: NHS, 2012. http://www.nhsla.com/Pages/Publications.aspx?library=safety%7clearningfromclaims%7cmaternityclaimsdataproject (accessed March 2017).Google Scholar
Anim-Somuah, M, Smyth, R, Howell, C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev 2005; (4): CD000331.Google Scholar
Costley, PL, East, CE. Oxytocin augmentation of labour in women with epidural analgesia for reducing operative deliveries. Cochrane Database Syst Rev 2013; (7): CD009241.Google Scholar
Bloom, SL, Casey, BM, Schaffer, JI, et al. A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. Am J Obstet Gynecol 2006; 194: 1013.Google Scholar
Gupta, JK, Hofmeyr, GJ Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 2012; (5): CD002006.Google Scholar
Stremler, R, Hodnett, E, Petryshen, O, et al. Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth 2005; 32: 243–51.Google Scholar
Walker, KF, Kibuka, M, Thornton, JG, Jones, NW. Maternal position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev 2018; (11): CD008070. doi: 10.1002/14651858.CD008070.pub4.)Google Scholar
Johanson, RB, Menon, BK. Vacuum extraction versus forceps for assisted vaginal delivery. Cochrane Database Syst Rev 2000; (2): CD000224.Google Scholar
O’Mahony, F, Hofmeyr, GJ, Menon, V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev 2010; (11): CD005455.Google Scholar
World Health Organization Odon Device Research Group. Feasibility and safety study of a new device (Odón device) for assisted vaginal deliveries: study protocol. Reprod Health 2013; 10: 33.Google Scholar
Carroli, G, Belizan, J. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2000; (4): CD000081.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×