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International Urogynecology Journal Sep 2021Damage to the pelvic floor during pregnancy and vaginal delivery is an inevitable consequence of the natural birthing process. As this damage is associated with...
Damage to the pelvic floor during pregnancy and vaginal delivery is an inevitable consequence of the natural birthing process. As this damage is associated with functional and anatomical problems in later life, minimizing pelvic floor damage during pregnancy and vaginal delivery may serve as an important factor in the prevention of these unwanted sequelae. Operative vaginal delivery using forceps or vacuum extractor is common practice to achieve or expedite vaginal birth for maternal or fetal indications such as maternal exhaustion or fetal distress. However, operative vaginal delivery is associated with more extensive damage to the pelvic floor and perineal structures with forceps carrying a stronger risk compared to vacuum. The evidence on this subject is discussed with possible suggestions to minimize pelvic floor damage as much as possible.
Topics: Delivery, Obstetric; Fecal Incontinence; Female; Goals; Humans; Obstetrical Forceps; Perineum; Pregnancy; Surgical Instruments
PubMed: 34076719
DOI: 10.1007/s00192-021-04866-z -
BJOG : An International Journal of... Mar 2022There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors.
BACKGROUND
There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors.
OBJECTIVE
To explore the incidence rate of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion.
SEARCH STRATEGY
We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019.
STUDY ELIGIBILITY CRITERIA
A study was included if LA was assessed by an imaging modality after the first vaginal birth or caesarean section. Case series and reports were not included.
DATA COLLECTION AND ANALYSIS
RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages were used for type and timing of imaging analyses.
RESULTS
We included 37 primary non-randomised studies from 17 countries and involving 5594 women. Incidence rates of LA were 1, 15, 21, 38.5 and 52% following caesarean, spontaneous, vacuum, spatula and forceps births, respectively, with no differences by imaging modality. Odds ratio of LA following spontaneous birth versus caesarean section was 10.69. The odds ratios for LA following vacuum and forceps compared with spontaneous birth were 1.66 and 6.32, respectively. LA was more likely to occur unilaterally than bilaterally following spontaneous (P < 0.0001) and vacuum-assisted (P = 0.0103) births but not forceps. Incidence was higher if assessment was performed in the first 4 weeks postpartum.
CONCLUSIONS
LA incidence rates following caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. Ultrasound and magnetic resonance imaging were comparable tools for LA diagnosis.
TWEETABLE ABSTRACT
Levator avulsion incidence rates after caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively.
Topics: Cesarean Section; Female; Humans; Incidence; Pelvic Floor Disorders; Pregnancy; Vacuum Extraction, Obstetrical
PubMed: 34245656
DOI: 10.1111/1471-0528.16837 -
European Journal of Obstetrics,... Jan 2021Obstetric forceps were invented in the 1600s to assist vaginal delivery of term babies following prolonged labour. This probably explains their design, with a narrow... (Review)
Review
Obstetric forceps were invented in the 1600s to assist vaginal delivery of term babies following prolonged labour. This probably explains their design, with a narrow interblade distance and long blade length, to fit a severely moulded fetal head. However, in modern obstetric practice protracted labour is avoided, yet our research has shown that over 400 years forceps dimensions have remained largely unchanged. We believe it is time to optimise these dimensions based on biometry of the term, newborn baby's head, with the head width (biparietal diameter) and head length (mentovertical diameter) correlating with interblade distance and blade length respectively. We hypothesise that doing so should reduce the incidence of neonatal complications associated with forceps assisted delivery and it is also possible that the amended shape might be associated with better outcomes for women. In this article we present our rationale for the optimisation of the forceps dimensions based on the findings of our previous systematic review and an original series of mentovertical and biparietal diameter measurements using laser scanning technology.
Topics: Biometry; Delivery, Obstetric; Female; Head; Humans; Infant, Newborn; Labor, Obstetric; Obstetrical Forceps; Pregnancy
PubMed: 33259995
DOI: 10.1016/j.ejogrb.2020.11.046 -
American Family Physician Oct 2020
Review
Topics: Adult; Antibiotic Prophylaxis; Extraction, Obstetrical; Female; Humans; Obstetrical Forceps; Pregnancy; Prenatal Care; Puerperal Disorders; Randomized Controlled Trials as Topic; Surgical Wound Infection; Vacuum Extraction, Obstetrical
PubMed: 32996760
DOI: No ID Found -
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 -
Journal of Obstetrics and Gynaecology... Mar 2024
Topics: Pregnancy; Female; Humans; Delivery, Obstetric; Extraction, Obstetrical; Surgical Instruments; Canada; Obstetrical Forceps; Vacuum Extraction, Obstetrical
PubMed: 38548448
DOI: 10.1016/j.jogc.2023.102325 -
Obstetrics and Gynecology Jun 2023To examine clinical and physician factors associated with failed operative vaginal delivery among individuals with nulliparous, term, singleton, vertex (NTSV) births.
OBJECTIVE
To examine clinical and physician factors associated with failed operative vaginal delivery among individuals with nulliparous, term, singleton, vertex (NTSV) births.
METHODS
This was a retrospective cohort study of individuals with NTSV live births with an attempted operative vaginal delivery by a physician between 2016 and 2020 in California. The primary outcome was cesarean birth after failed operative vaginal delivery, identified using linked diagnosis codes, birth certificates, and physician licensing board data stratified by device type (vacuum or forceps). Clinical and physician-level exposures were selected a priori, defined using validated indices, and compared between successful and failed operative vaginal delivery attempts. Physician experience with operative vaginal delivery was estimated by calculating the number of operative vaginal delivery attempts made per physician during the study period. Multivariable mixed effects Poisson regression models with robust standard errors were used to estimate risk ratios of failed operative vaginal delivery for each exposure, adjusted for potential confounders.
RESULTS
Of 47,973 eligible operative vaginal delivery attempts, 93.2% used vacuum and 6.8% used forceps. Of all operative vaginal delivery attempts, 1,820 (3.8%) failed; the success rate was 97.3% for vacuum attempts and 82.4% for forceps attempts. Failed operative vaginal deliveries were more likely with older patient age, higher body mass index, obstructed labor, and neonatal birth weight more than 4,000 g. Between 2016 and 2020, physicians who attempted more operative vaginal deliveries were less likely to fail. When vacuum attempts were successful, physicians who conducted them had a median of 45 vacuum attempts during the study period, compared with 27 attempts when vacuum attempts were unsuccessful (adjusted risk ratio [aRR] 0.95, 95% CI 0.93-0.96). When forceps attempts were successful, physicians who conducted them had a median of 19 forceps attempts, compared with 11 attempts when forceps attempts were unsuccessful (aRR 0.76, 95% CI 0.64-0.91).
CONCLUSION
In this large, contemporary cohort with NTSV births, several clinical factors were associated with operative vaginal delivery failure. Physician experience was associated with operative vaginal delivery success, more notably for forceps attempts. These results may provide guidance for physician training in maintenance of operative vaginal delivery skills.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Vacuum Extraction, Obstetrical; Retrospective Studies; Delivery, Obstetric; Cesarean Section; Dystocia; Obstetrical Forceps
PubMed: 37141591
DOI: 10.1097/AOG.0000000000005181 -
Journal of Obstetrics and Gynaecology... Sep 2022To identify determinants of cesarean delivery (CD) and examine associations between mode of delivery (MOD) and maternal and perinatal outcomes.
OBJECTIVE
To identify determinants of cesarean delivery (CD) and examine associations between mode of delivery (MOD) and maternal and perinatal outcomes.
METHODS
We conducted a retrospective analysis of a Canadian multicentre birth cohort derived from provincial data collected in 2008/2009. Maternal and perinatal characteristics and outcomes were compared between vaginal and cesarean birth and between the following MOD subgroups: spontaneous vaginal delivery (VD), assisted VD, planned cesarean delivery (CD), and intrapartum CD. Multivariate regression identified determinants of CD and the effects of MOD and previous CD on maternal and perinatal outcomes.
RESULTS
The cohort included 264 755 births (72.1% VD and 27.9% CD) from 91 participating institutions. Determinants of CD included maternal age, parity, previous CD, chronic hypertension, diabetes, urinary tract infection or pyelonephritis, gestational hypertension, vaginal bleeding, labour induction, pre-term gestational age, low birth weight, large for gestational age, malpresentation, and male sex. CD was associated with greater risk of maternal and perinatal morbidity and mortality. Subgroup analysis demonstrated higher risk of adverse pregnancy outcomes with assisted VD and intrapartum CD than spontaneous VD. Planned CD reduced the risk of obstetric wound hematoma and perinatal mortality but increased maternal and neonatal morbidity. Previous CD increased the risk of maternal and neonatal morbidity among multiparous women.
CONCLUSIONS
The CD rate in Canada is consistent with global trends reflecting demographic and obstetric intervention factors. The risk of adverse pregnancy outcomes with CD warrants evaluation of interventions to safely prevent nonessential cesarean birth.
Topics: Canada; Cesarean Section; Delivery, Obstetric; Female; Humans; Infant, Newborn; Male; Pregnancy; Pregnancy Outcome; Retrospective Studies
PubMed: 35595024
DOI: 10.1016/j.jogc.2022.04.017 -
European Journal of Obstetrics,... Apr 2022The aim of this study was to assess perinatal morbidity associated with spatulas or forceps assisted delivery in preterm birth.
OBJECTIVE
The aim of this study was to assess perinatal morbidity associated with spatulas or forceps assisted delivery in preterm birth.
STUDY DESIGN
This is a retrospective cohort study including all women with assisted deliveries on singleton pregnancy in cephalic presentation, before 37 weeks of gestation, in two tertiary care centers. We compared forceps-assisted deliveries with spatula-assisted deliveries. The main outcome was the rate of neonatal birth trauma. Secondary outcomes included other neonatal parameters, maternal outcomes and obstetric anal sphincter injuries.
RESULTS
Out of 37 002 deliveries, 59 (0.2 %) preterm assisted deliveries with forceps and 111 (0.3%) preterm spatulas deliveries were included. The rate of neonatal birth trauma was low for both devices, without significant difference (3.4% in Forceps group vs 0.9% in Spatulas group, p = 0.28). The rate of episiotomy was 79.7% after forceps-assisted delivery and 48.6% for spatulas (p < 0.001). The rate of obstetric anal sphincter injuries was 1.7% and 2.7% respectively (p = 0,9).
CONCLUSION
The rate of birth trauma was low in both forceps-assisted deliveries and spatula-assisted deliveries and was not significantly different between the two groups.
Topics: Anal Canal; Delivery, Obstetric; Episiotomy; Female; Humans; Infant, Newborn; Morbidity; Obstetrical Forceps; Pregnancy; Premature Birth; Retrospective Studies; Surgical Instruments
PubMed: 35183002
DOI: 10.1016/j.ejogrb.2022.02.007 -
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