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Obstetrical & Gynecological Survey Nov 2015The aim of this study was to determine the risk factors, clinical and radiologic criteria for diagnosis, and management of this unusual complication of pregnancy. (Review)
Review
OBJECTIVE
The aim of this study was to determine the risk factors, clinical and radiologic criteria for diagnosis, and management of this unusual complication of pregnancy.
METHODS
A PubMed and Web of Science search was undertaken with no limitations on the number of years searched.
RESULTS
There were 36 publications identified, with 19 articles being the basis of this review. Multiple risk factors have been identified including multiparity, macrosomia, cephalopelvic disproportion, forceps deliveries, precipitous labor, malpresentation, prior pelvic trauma, and use of the McRoberts maneuver. The diagnosis is usually made clinically, confirmed by imaging, and considered pathological when the intrapubic gap is greater than 10 mm. Magnetic resonance imaging appears to be superior to pelvic x-ray and computed tomography scan in visualization of the bone separation. Conservative treatment remains the first choice for therapy, but women who do not respond to conservative therapy or women with large separations may need surgical stabilization with external or internal fixation.
CONCLUSIONS
Widening of the pubic symphysis greater than 10 mm is pathologic. The diagnosis is clinical and confirmed by imaging studies, with magnetic resonance imaging being the superior technique. Conservative treatment is the first line of therapy. Failure of conservative therapy is treated by surgical stabilization.
Topics: Cephalopelvic Disproportion; Delivery, Obstetric; Female; Fetal Macrosomia; Fracture Fixation; Humans; Obstetric Labor Complications; Obstetrical Forceps; Parity; Pelvis; Pregnancy; Pubic Symphysis; Pubic Symphysis Diastasis; Radiography; Risk Factors; Rupture
PubMed: 26584720
DOI: 10.1097/OGX.0000000000000247 -
BJOG : An International Journal of... Jul 2023There is conflicting evidence regarding the safety of Kielland's rotational forceps delivery (KRFD) in comparison with other modes of delivery for the management of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
There is conflicting evidence regarding the safety of Kielland's rotational forceps delivery (KRFD) in comparison with other modes of delivery for the management of persistent fetal malposition in the second stage of labour.
OBJECTIVES
To derive estimates of risks of maternal and neonatal complications following KRFD, compared with rotational ventouse delivery (RVD), non-rotational forceps delivery (NRFD) or a second-stage caesarean section (CS), from a systematic review and meta-analysis of the literature.
SEARCH STRATEGY
Standard search methodology, as recommended by the Cochrane Handbook for Systematic Reviews of Interventions.
SELECTION CRITERIA
Case series, prospective or retrospective cohort studies and population-based studies.
DATA COLLECTION AND ANALYSIS
A meta-analysis using a random-effects model was used to derive weighted pooled estimates of maternal and neonatal complications.
MAIN RESULTS
Thirteen studies were included. For postpartum haemorrhage there was no significant difference between Kielland's and ventouse delivery; the rate was lower in Kielland's delivery compared with non-rotational forceps (RR 0.79, 95% CI 0.65-0.95) and second-stage CS (RR 0.45, 95% CI 0.36-0.58). There were no differences in the rates of anal sphincter injuries or admission to neonatal intensive care. Rates of shoulder dystocia were higher with Kielland's delivery compared with ventouse delivery (RR 1.79, 95% CI 1.08-2.98), but rates of neonatal birth trauma were lower (RR 0.49, 95% CI 0.26-0.91). There were no differences seen in the rates of 5-min APGAR score < 7 between Kielland's delivery and other instrumental births, but they were lower when compared with second-stage CS (RR 0.47, 95% CI 0.23-0.97).
CONCLUSIONS
Kielland's rotational forceps delivery is a safe option for the management of fetal malposition in the second stage of labour.
Topics: Infant, Newborn; Pregnancy; Humans; Female; Extraction, Obstetrical; Obstetrical Forceps; Cesarean Section; Retrospective Studies; Prospective Studies; Obstetric Labor Complications; Infant, Newborn, Diseases
PubMed: 36694989
DOI: 10.1111/1471-0528.17402 -
Journal of Obstetrics and Gynaecology... Jun 2019To provide evidence-based guidelines for safe and effective assisted vaginal birth.
OBJECTIVES
To provide evidence-based guidelines for safe and effective assisted vaginal birth.
OUTCOMES
Prerequisites, indications, contraindications, along with maternal and neonatal morbidity associated with assisted vaginal birth.
EVIDENCE
Medline database was searched for articles published from January 1, 1985, to February 28, 2018 using the key words "assisted vaginal birth," "instrumental vaginal birth," "operative vaginal delivery," "forceps delivery," "vacuum delivery," "ventouse delivery." The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventive Health Care.
VALIDATION
These guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada.
Topics: Analgesia, Epidural; Birth Injuries; Brachial Plexus; Canada; Cardiotocography; Clinical Competence; Episiotomy; Extraction, Obstetrical; Facial Injuries; Female; Humans; Labor Presentation; Labor Stage, Second; Lacerations; Obstetrical Forceps; Oxytocics; Oxytocin; Peripheral Nerve Injuries; Pregnancy; Puerperal Disorders; Scalp; Shoulder Dystocia; Soft Tissue Injuries; Stress Disorders, Post-Traumatic; Time Factors; Vacuum Extraction, Obstetrical; Version, Fetal
PubMed: 31126436
DOI: 10.1016/j.jogc.2018.10.020 -
CMAJ : Canadian Medical Association... Jan 2022Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel. However, opportunities for training in OVD have declined and, given these shifts...
BACKGROUND
Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel. However, opportunities for training in OVD have declined and, given these shifts in practice, the safety of OVD is unknown. We estimated incidence rates of trauma following OVD in Canada, and quantified variation in trauma rates by instrument, region, level of obstetric care and institutional OVD volume.
METHODS
We conducted a cohort study of all singleton, term deliveries in Canada between April 2013 and March 2019, excluding Quebec. Our main outcome measures were maternal trauma (e.g., obstetric anal sphincter injury, high vaginal lacerations) and neonatal trauma (e.g., subgaleal hemorrhage, brachial plexus injury). We calculated adjusted and stabilized rates of trauma using mixed-effects logistic regression.
RESULTS
Of 1 326 191 deliveries, 38 500 (2.9%) were attempted forceps deliveries and 110 987 (8.4%) were attempted vacuum deliveries. The maternal trauma rate following forceps delivery was 25.3% (95% confidence interval [CI] 24.8%-25.7%) and the neonatal trauma rate was 9.6 (95% CI 8.6-10.6) per 1000 live births. Maternal and neonatal trauma rates following vacuum delivery were 13.2% (95% CI 13.0%-13.4%) and 9.6 (95% CI 9.0-10.2) per 1000 live births, respectively. Maternal trauma rates remained higher with forceps than with vacuum after adjustment for confounders (adjusted rate ratio 1.70, 95% CI 1.65-1.75) and varied by region, but not by level of obstetric care.
INTERPRETATION
In Canada, rates of trauma following OVD are higher than previously reported, irrespective of region, level of obstetric care and volume of OVD among hospitals. These results support a reassessment of OVD safety in Canada.
Topics: Anal Canal; Birth Injuries; Canada; Female; Humans; Incidence; Intracranial Hemorrhages; Lacerations; Neonatal Brachial Plexus Palsy; Obstetric Labor Complications; Obstetrical Forceps; Pelvis; Pregnancy; Skull Fractures; Trauma, Nervous System; Urethra; Urinary Bladder; Vacuum Extraction, Obstetrical; Vagina
PubMed: 35012946
DOI: 10.1503/cmaj.210841 -
The Journal of Maternal-fetal &... Nov 2021To evaluate associations between operative vaginal delivery complications and provider experience (operative vaginal delivery volume and time since residency).
OBJECTIVE
To evaluate associations between operative vaginal delivery complications and provider experience (operative vaginal delivery volume and time since residency).
METHODS
We included all operative vaginal deliveries between 2008 and 2014 at a tertiary care teaching hospital, stratified into forceps-assisted and vacuum-assisted deliveries. Complications included severe perineal lacerations (3rd and 4th degree) and neonatal injuries (subgaleal/subdural/cerebral hemorrhage, facial nerve injury, and scalp injury), which were identified by International Classification Diagnosis-9 codes. Providers were categorized by operative vaginal delivery volume (mean annual forceps- or vacuum-assisted deliveries over the study interval) and time since residency. Regression analyses were used to compare complication rates by provider volume and time since residency, adjusting for potential confounders, using 0-1 deliveries per year and <5 years since residency as reference groups.
RESULTS
Nine hundred and thirty-four forceps and 1074 vacuums occurred. For forceps-assisted deliveries, severe perineal injury was decreased among providers with >10 forceps per year (aOR 0.50 [95%CI 0.30-0.81]) and at 15-19 years (aOR 0.45 [95% CI 0.22-0.94], and ≥25 years (aOR 0.45 [0.27-0.73]) since residency. There were no associations with neonatal injuries. Among vacuum-assisted deliveries, severe perineal injury decreased at ≥25 years since residency (aOR 0.35 [95%CI 0.17-0.74], with no association with provider volume. Neonatal injury decreased at 5-9 years (aOR 0.53 [95%CI 0.30-0.93]), and 15-19 years since residency (aOR 0.53 [95%CI 0.29-0.97]), due to differences in scalp injuries. Neonatal injuries other than scalp injury were rare.
CONCLUSION
Severe perineal lacerations decreased with increasing operative vaginal delivery experience, primarily among forceps-assisted vaginal delivery. Providers >5 years since residency may have lower scalp injury with vacuums, but this cohort was largely underpowered for neonatal injury.
Topics: Cohort Studies; Delivery, Obstetric; Female; Humans; Infant, Newborn; Lacerations; Obstetrical Forceps; Perineum; Pregnancy; Vacuum Extraction, Obstetrical
PubMed: 31744361
DOI: 10.1080/14767058.2019.1688293 -
Journal of Perinatal Medicine Mar 2020There is a broad range in the rates of operative vaginal deliveries (OVD) worldwide, which reflects the variety of local practice patterns, the number of trained... (Review)
Review
There is a broad range in the rates of operative vaginal deliveries (OVD) worldwide, which reflects the variety of local practice patterns, the number of trained clinicians and the lack of international evidence-based guidelines. The aim of this study was to review and compare the recommendations from published guidelines on OVD. Thus, a descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the American College of Obstetricians and Gynecologists (ACOG) on instrumental vaginal birth was conducted. All the guidelines point out that the use of any instrument should be based on the clinical circumstances and the experience of the operator. The indications, the contraindications, the prerequisites and the classification for OVD are overall very similar in the reviewed guidelines. Further, they all agree that episiotomy should not be performed routinely. The RCOG, the RANZCOG and the SOGC describe some interventions which may promote spontaneous vaginal birth and therefore reduce the need for OVD. They also highlight the importance of adequate postnatal care and counseling. There is no consensus on the actual technique that should be used, including the type of forceps or vacuum cup, the force and duration of traction or the number of detachments allowed. Hence, there is need for international practice protocols, so as to encourage the clinicians to use OVD when indicated, minimize the complications and reduce rates of cesarean delivery.
Topics: Extraction, Obstetrical; Female; Humans; Postnatal Care; Practice Guidelines as Topic; Pregnancy
PubMed: 31926101
DOI: 10.1515/jpm-2019-0433 -
European Journal of Obstetrics,... Apr 2016The number of forceps deliveries is globally falling possibly due to Obstetricians gaining more experience and competence in the use of Ventouse deliveries. The... (Review)
Review
The number of forceps deliveries is globally falling possibly due to Obstetricians gaining more experience and competence in the use of Ventouse deliveries. The declining use of traction forceps can increase the rate of second stage caesarean sections, which may have a long-term impact on the overall rate of vaginal births, despite the efforts of improving uptake of vaginal births after caesarean sections. The failures in forceps deliveries are commonly related to inaccurate assessment of the foetal position and station, which can be addressed by gaining sound clinical experience and applying intra-partum scanning to determine the fetal head position in the second stage, and should be part of the core curriculum in obstetric training. The alternate techniques of rotation, like digital and manual rotation, should be taught and encouraged in cases where rotation is required, which will significantly increase the success rate of instrumental deliveries.
Topics: Clinical Competence; Extraction, Obstetrical; Female; Humans; Labor Presentation; Obstetrical Forceps; Pregnancy
PubMed: 26897398
DOI: 10.1016/j.ejogrb.2016.01.045 -
American Journal of Obstetrics and... Oct 2016The rate of cesarean delivery has become an important health care issue, and has attracted the attention of governments, professional organizations, health care...
The rate of cesarean delivery has become an important health care issue, and has attracted the attention of governments, professional organizations, health care administrators, clinicians, and patients. This has resulted in the generation of guidelines, clinical recommendations, and other documents aimed at increasing the likelihood of vaginal delivery. Sometimes, these recommendations are formulated with limited input from clinicians. In some countries, such as the United Kingdom, external pressure exerted on clinicians to reduce the rate of cesarean delivery has been the subject of public debate, and has led to unintended consequences, including an increase in medicolegal tensions. In the United States and Australia, recent recommendations generated by professional bodies have advocated that clinicians should change practice to reduce the rate of cesarean delivery. We do not summarize the risks and benefits of cesarean birth in different clinical situations, which have been the subject of numerous reviews. Rather, we try to examine the potential implications of such policies in light of recent observations made in maternity units, judicial decisions, and clinical research. The emphasis is on maternal morbidity and patient autonomy. This may include the negative consequences of increasingly risky attempts at vaginal birth after cesarean delivery such as uterine rupture, higher rates of pelvic floor and anal sphincter trauma due to rising forceps rates, and a bias against elective cesarean delivery on maternal request.
Topics: Cesarean Section; Extraction, Obstetrical; Female; Health Policy; Humans; Obstetric Labor Complications; Patient Preference; Practice Guidelines as Topic; Practice Patterns, Physicians'; Pregnancy; Vaginal Birth after Cesarean
PubMed: 27131590
DOI: 10.1016/j.ajog.2016.04.021 -
Journal of Healthcare Engineering 2021Forceps delivery is one of the most important measures to facilitate vaginal delivery. It can reduce the rate of first cesarean delivery. Frustratingly, adverse maternal...
BACKGROUND
Forceps delivery is one of the most important measures to facilitate vaginal delivery. It can reduce the rate of first cesarean delivery. Frustratingly, adverse maternal and neonatal outcomes associated with forceps delivery have been frequently reported in recent years. There are two major reasons: one is that the abilities of doctors and midwives in forceps delivery vary from hospital to hospital and the other one is lack of regulations in the management of forceps delivery. In order to improve the success rate of forceps delivery and reduce the incidence of maternal and neonatal complications, we applied form-based management to forceps delivery under an intelligent medical model. The aim of this work is to explore the clinical effects of form-based management of forceps delivery.
METHODS
Patients with forceps delivery in Maternal and Child Health Hospital Affiliated to Nanchang University were divided into two groups: form-based patients from January 1, 2019, to December 31, 2020, were selected as the study group, while traditional protocol patients from January 1, 2017, to December 31, 2018, were chosen as the control group. Then, we compared the maternal and neonatal outcomes of these two groups.
RESULTS
There were significant differences in the maternal and neonatal adverse outcomes such as rate of postpartum hemorrhage, degree of perineal laceration, and incidence of neonatal facial skin abrasions between the two groups, whereas differences in the incidence of asphyxia and intracranial hemorrhage were not significant.
CONCLUSIONS
Form-based management could help us assess the security of forceps delivery comprehensively, as it could not only improve the success rate of the one-time forceps traction scheme but also reduce the incidence of maternal and neonatal adverse outcomes effectively.
Topics: Cesarean Section; Child; Delivery, Obstetric; Female; Humans; Infant, Newborn; Obstetrical Forceps; Postpartum Hemorrhage; Pregnancy; Vacuum Extraction, Obstetrical
PubMed: 34194686
DOI: 10.1155/2021/9947255 -
Using Motion Tracking to Analyze Forceps Paths During Simulated Forceps-Assisted Vaginal Deliveries.Simulation in Healthcare : Journal of... Dec 2021The purpose of this study was to evaluate the ability of motion tracking to discern variation in forceps paths during standardized simulated forceps-assisted vaginal...
OBJECTIVE
The purpose of this study was to evaluate the ability of motion tracking to discern variation in forceps paths during standardized simulated forceps-assisted vaginal deliveries among experienced and inexperienced obstetric providers.
METHODS
This is a pilot study involving 24 obstetrics and gynecology residents and 6 faculty at a single institution. Each participant was filmed performing standardized simulated forceps-assisted vaginal deliveries on a high-fidelity model. Motion tracking software (Kinovea, Medoc, France) was used to track the path of the forceps shank. Data were analyzed for total path length, total x-plane displacement, total y-plane displacement, and final forceps angle. One-way analysis of variance was used to evaluate for statistically significant differences between groups based on education year, with Turkey HSD post hoc test to identify interactions.
RESULTS
Statistically significant differences were noted between groups in the total path length (F = 7.57, P < 0.001) and total y-plane displacement (F = 5.79, P < 0.001). On pairwise comparison, significant differences were noted between faculty and postgraduate year 1 as well as faculty and postgraduate year 2 for total y-plane displacement and total path length. Significant differences were not observed between groups for total x-plane displacement (F = 0.89, P = 0.475) and final forceps angle (F = 2.45, P = 0.052).
CONCLUSIONS
Motion tracking of standardized simulated forceps-assisted vaginal deliveries identifies statistically significant differences between experienced and inexperienced obstetric providers. Our findings suggest that motion tracking can be used to design an educational intervention to improve forceps technique among obstetrics and gynecology residents.
Topics: Delivery, Obstetric; Female; Humans; Obstetrical Forceps; Obstetrics; Pilot Projects; Pregnancy; Surgical Instruments
PubMed: 33600138
DOI: 10.1097/SIH.0000000000000552