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The Journal of Maternal-fetal &... Jan 2020To compare maternal and neonatal outcomes by forceps vaginal delivery versus cesarean delivery during the second stage of labor. We conducted a retrospective cohort... (Comparative Study)
Comparative Study
To compare maternal and neonatal outcomes by forceps vaginal delivery versus cesarean delivery during the second stage of labor. We conducted a retrospective cohort study in a large tertiary maternity center in Shanghai, China through 2007-2016. A total of 7046 women carrying a singleton term nonanomalous fetus with vertex presentation who underwent forceps vaginal delivery, or cesarean delivery from a low station in the second stage of labor were included. Of the 7046 women, 6265 underwent forceps and 781 underwent second stage cesarean delivery. Forceps were associated with lower frequency of maternal infection (2.2 versus 4.7%), but higher incidence of mild postpartum hemorrhage (PPH) (4.3 versus 0.6%). When the procedures were performed for fetal indication, forceps were associated with lower frequency of the composite of perinatal mortality and/or hypoxic ischemic encephalopathy (HIE) (0.5 versus 1.9%; adjusted odds ratio (aOR), 0.24; 95% CI: 0.08-0.75), and also shorter decision to delivery interval (12.3 ± 3.5 versus 19.1 ± 5.0 min). The neonatal infection rate was higher in the forceps group (3.9 versus 2.0%). There were no differences in other neonatal outcomes including birth trauma. In women who had a need for intervention during the second stage with a station of +2 or below, forceps were associated with a lower frequency of maternal infection but a higher rate of PPH. Deliveries performed for nonreassuring status were accomplished faster by forceps and were associated with a lower frequency of the composite of perinatal mortality and HIE.
Topics: Adult; Cesarean Section; China; Episiotomy; Extraction, Obstetrical; Female; Fetal Distress; Humans; Obstetrical Forceps; Postpartum Hemorrhage; Pregnancy; Pregnancy Outcome; Retrospective Studies
PubMed: 29909749
DOI: 10.1080/14767058.2018.1490720 -
AJOG Global Reports Nov 2023The risk of third- and fourth-degree perineal laceration after vaginal delivery in patients with obesity is relatively understudied and has mixed findings in existing...
BACKGROUND
The risk of third- and fourth-degree perineal laceration after vaginal delivery in patients with obesity is relatively understudied and has mixed findings in existing literature.
OBJECTIVE
This study aimed to examine the association of maternal obesity and obstetric anal sphincter injuries at vaginal delivery.
STUDY DESIGN
The Healthcare Cost and Utilization Project's National Inpatient Sample was retrospectively queried to examine 7,385,341 vaginal deliveries from January 2017 to December 2019. The exposure assignment was obesity status. The main outcomes were third- and fourth-degree perineal lacerations after vaginal delivery. Statistical analysis examining the exposure-outcome association included (1) inverse probability of treatment weighting with log-Poisson regression generalized linear model to account for prepregnant and pregnant confounders for the exposure and (2) multinomial regression model to account for delivery factors in the inverse probability of treatment weighting cohort. The secondary outcomes included (1) the temporal trends of fourth-degree laceration and its associated factors at cohort level and (2) risk factor patterns for fourth-degree laceration by constructing a classification tree model.
RESULTS
In the inverse probability of treatment weighting cohort, patients with obesity were less likely to have fourth-degree lacerations and third-degree lacerations than patients without obesity (fourth-degree laceration: 2.3 vs 3.9 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 0.62; 95% confidence interval, 0.56-0.69; third-degree laceration: 15.6 vs 20.1 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 0.79; 95% confidence interval, 0.76-0.82). In contrast, in patients with obesity vs those without obesity, forceps delivery (54.7 vs 3.3 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 17.73; 95% confidence interval, 16.17-19.44), vacuum-assisted delivery (19.8 vs 2.9 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 5.18; 95% confidence interval, 4.85-5.53), episiotomy (19.2 vs 2.8 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 3.95; 95% confidence interval, 3.71-4.20), and shoulder dystocia (17.8 vs 3.4 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 2.60; 95% confidence interval, 2.29-2.94) were associated with more than a 2-fold increased risk of fourth-degree perineal laceration. Among the group with obesity, patients who had forceps delivery and shoulder dystocia had the highest incidence of fourth-degree laceration (105.3 per 1000 vaginal deliveries). Among the group without obesity, patients who had forceps delivery, shoulder dystocia, and macrosomia had the highest incidence of fourth-degree laceration (294.1 per 1000 vaginal deliveries). The incidence of fourth-degree perineal laceration decreased by 11.9% over time ( trend=.004); moreover, forceps delivery, vacuum-assisted delivery, and episiotomy decreased by 3.8%, 7.6%, and 29.5%, respectively (all, trend<.05).
CONCLUSION
This national-level analysis suggests that patients with obesity are less likely to have obstetric anal sphincter injuries at the time of vaginal delivery. Furthermore, this analysis confirms other known risk factors for fourth-degree laceration, such as forceps delivery, vacuum-assisted delivery, episiotomy, and shoulder dystocia. However, we noted a decreasing trend in fourth-degree lacerations, which may be due to evolving obstetrical practices.
PubMed: 37885968
DOI: 10.1016/j.xagr.2023.100272 -
BMC Pregnancy and Childbirth Nov 2020Instrumental deliveries are an unavoidable part of obstetric practice. Dedicated training is needed for each instrument. To identify when a trainee resident can be... (Observational Study)
Observational Study
BACKGROUND
Instrumental deliveries are an unavoidable part of obstetric practice. Dedicated training is needed for each instrument. To identify when a trainee resident can be entrusted with instrumental deliveries by Suzor forceps by studying obstetric anal sphincter injuries.
METHODS
A French retrospective observational study of obstetric anal sphincter injuries due to Suzor forceps deliveries performed by trainee residents was conducted from November 2008 to November 2016 at Limoges University Hospital. Perineal lesion risk factors were studied. Sequential use of a vacuum extractor and then forceps was also analyzed.
RESULTS
Twenty-one residents performed 1530 instrumental deliveries, which included 1164 (76.1%) using forceps and 89 (5.8%) with sequential use of a vacuum extractor and then forceps. Third and fourth degree perineal tears were diagnosed in 82 patients (6.5%). Residents caused fewer obstetric anal sphincter injuries after 23.82 (+/- 0.8) deliveries by forceps (p = 0.0041), or after 2.36 (+/- 0.7) semesters of obstetrical experience (p = 0.0007). No obese patient (body mass index> 30) presented obstetric anal sphincter injuries (p = 0.0013). There were significantly fewer obstetric anal sphincter injuries after performance of episiotomy (p < 0.0001), and more lesions in the case of the occipito-sacral position (p = 0.028). Analysis of sequential instrumentation did not find any additional associated risk.
CONCLUSION
Training in the use of Suzor forceps requires extended mentoring in order to reduce obstetric anal sphincter injuries. A stable level of competence was found after the execution of at least 24 forceps deliveries or after 3 semesters (18 months) of obstetrical experience.
Topics: Adult; Anal Canal; Clinical Competence; Episiotomy; Extraction, Obstetrical; Female; France; Humans; Internship and Residency; Lacerations; Obstetric Labor Complications; Obstetrical Forceps; Obstetrics; Perineum; Pregnancy; Retrospective Studies; Risk Factors; Young Adult
PubMed: 33167939
DOI: 10.1186/s12884-020-03358-0 -
Journal of Obstetrics and Gynaecology... Aug 2021The objective of this single-centre, action research study was to increase resident experience performing operative vaginal deliveries. The secondary objective was to...
The objective of this single-centre, action research study was to increase resident experience performing operative vaginal deliveries. The secondary objective was to assess the incidence of maternal and neonatal complications. The rate of forceps deliveries increased in the post-training period (1.8%-4.0%; P < 0.001) but the overall rate of operative vaginal delivery did not change. The composite maternal complications rate following forceps delivery was lower in the post- training period (P = 0.006). There were no significant differences in maternal or neonatal complications with vacuum delivery between the periods before and after the initiative. Experiential training of residents may be a viable alternative to simulation training as it does not require expensive state-of-the-art simulation technology.
Topics: Delivery, Obstetric; Female; Humans; Infant, Newborn; Obstetrical Forceps; Pregnancy; Vacuum Extraction, Obstetrical
PubMed: 33621680
DOI: 10.1016/j.jogc.2021.01.019 -
The Journal of Maternal-fetal &... Jan 2022To investigate the effect of unique skill of perineum protection in forceps delivery on the maternal and neonatal morbidity.
OBJECTIVE
To investigate the effect of unique skill of perineum protection in forceps delivery on the maternal and neonatal morbidity.
METHODS
A case-control study was conducted. Singleton pregnancies with forceps-assisted and normal vaginal deliveries were recruited. The maternal and neonatal complications were compared between forceps and normal deliveries.
RESULTS
Five hundred forty participants were included. The prevalence of maternal anal sphincter injury, postpartum hemorrhage, vaginal hematoma, cervical laceration, perineal wound infection, perineal wound dehiscence, dyspareunia, urinary incontinence, and anal incontinence were not significantly different between forceps and normal deliveries ( > .05). However, the rate of neonatal facial injury was higher in the forceps group (2.9% versus 0, = .004).
CONCLUSIONS
Cooperation according to the tension of perineum and labor process between obstetrician and midwife is important for perineum protection. Forceps-assisted delivery concentrating on perineum protection is an effective alternative in decreasing maternal morbidity.
Topics: Case-Control Studies; Delivery, Obstetric; Female; Humans; Infant, Newborn; Lacerations; Obstetrical Forceps; Perineum; Pregnancy; Retrospective Studies
PubMed: 31928263
DOI: 10.1080/14767058.2020.1712699 -
BMC Pregnancy and Childbirth Apr 2024The objective of this study was to identify and qualify, by means of a three-dimensional kinematic analysis, the postures and movements of obstetricians during a...
BACKGROUND
The objective of this study was to identify and qualify, by means of a three-dimensional kinematic analysis, the postures and movements of obstetricians during a simulated forceps birth, and then to study the association of the obstetricians' experience with the technique adopted.
METHOD
Fifty-seven volunteer obstetricians, 20 from the Limoges and 37 from the Poitiers University hospitals, were included in this multi-centric study. They were classified into 3 groups: beginners, intermediates, and experts, beginners having performed fewer than 10 forceps deliveries in real conditions, intermediates between 10 and 100, and experts more than 100. The posture and movements of the obstetricians were recorded between December 2020 and March 2021 using an optoelectronic motion capture system during simulated forceps births. Joint angles qualifying these postures and movements were analysed between the three phases of the foetal traction. These phases were defined by the passage of a virtual point associated with the forceps blade through two anatomical planes: the mid-pelvis and the pelvic outlet. Then, a consolidated ascending hierarchical classification (AHC) was applied to these data in order to objectify the existence of groups of similar behaviours.
RESULTS
The AHC distinguished four different postures adopted when crossing the first plane and three different traction techniques. 48% of the beginners adopted one of the two raised posture, 22% being raised without trunk flexion and 26% raised with trunk flexion. Conversely, 58% of the experts positioned themselves in a "chevalier servant" posture (going down on one knee) and 25% in a "squatting" posture before initiating traction. The results also show that the joint movement amplitude tends to reduce with the level of expertise.
CONCLUSION
Forceps delivery was performed in different ways, with the experienced obstetricians favouring postures that enabled observation at the level of the maternal perineum and techniques reducing movement amplitude. The first perspective of this work is to relate these different techniques to the traction force generated. The results of these studies have the potential to contribute to the training of obstetricians in forceps delivery, and to improve the safety of women and newborns.
Topics: Pregnancy; Humans; Female; Infant, Newborn; Extraction, Obstetrical; Obstetricians; Delivery, Obstetric; Obstetrical Forceps; Posture
PubMed: 38589802
DOI: 10.1186/s12884-024-06457-4 -
International Journal of Gynaecology... May 2024Obstetric forceps play an important role in safe childbirth, yet there is a lack of distinction between various forceps types in clinical practice. This study aimed to...
OBJECTIVE
Obstetric forceps play an important role in safe childbirth, yet there is a lack of distinction between various forceps types in clinical practice. This study aimed to evaluate and compare perineal pressure and forces on the baby during nonrotational forceps-assisted births using Simpson-Braun forceps, Kielland forceps, and Thierry spatulas on a simulation model.
METHODS
This experimental study involved six obstetricians conducting 108 forceps-assisted births on a simulation model. Instruments were assessed for their impact on perineal pressure, traction force, and operator-assessed difficulty.
RESULTS
Thierry's spatulas exerted the lowest force on the baby, while Kielland forceps exhibited the lowest perineal pressure, though not statistically significant. An experienced obstetrician demonstrated less perineal pressure with Simpson forceps. Notably, no significant differences in difficulty were observed between instruments.
CONCLUSION
This study highlights distinctions in forceps performance, with Thierry spatulas applying the least force on the fetal head, while an experienced obstetrician fared better with Simpson forceps in terms of perineal pressure. Kielland forceps remain a viable alternative for nonrotational forceps births, showing comparable outcomes.
PubMed: 38767218
DOI: 10.1002/ijgo.15613 -
American Journal of Obstetrics &... Jul 2021
Topics: Episiotomy; Extraction, Obstetrical; Female; Humans; Obstetrical Forceps; Pregnancy
PubMed: 33831590
DOI: 10.1016/j.ajogmf.2021.100370 -
Journal of Gynecology Obstetrics and... Nov 2023The number of deliveries by forceps decreases significantly in favour of the vacuum. Now, when the use of forceps is necessary, physicians less experimented with this...
INTRODUCTION
The number of deliveries by forceps decreases significantly in favour of the vacuum. Now, when the use of forceps is necessary, physicians less experimented with this procedure are likely to induce serious and preventable perineal or foetal injuries. Training therefore becomes essential. However, there are no clear recommendations on the technique to perform a delivery by forceps, namely the body posture and gesture to adopt. Our goal is then to provide a protocol that can help to determine if there is an optimal technique to perform a delivery by forceps.
METHOD
We will include voluntary participants whose level of experience and type of practice differ. We will propose to record their postures and gestures using an optoelectronic motion analysis system during a forceps delivery simulated on a mannequin. We will also measure the traction force produced by the subject on the forceps using force platforms and technical markers placed on the forceps. We will then perform a principal component analysis to look for similar motion patterns.
EXPECTED RESULTS
We plan to analyse about fifty participants (25 seniors and 25 juniors). Our hypothesis is that the realism of the simulation will be deemed satisfactory by the participants, that the experimental conditions will not modify their gestures, and that the degree of experience will result in different techniques.
CONCLUSION
A better knowledge on the posture and gesture to adopt to realise a forceps delivery should improve the safety of women and new-borns. The results of this study could also be a valuable contribution for the training of obstetricians.
Topics: Pregnancy; Female; Humans; Extraction, Obstetrical; Obstetrical Forceps; Obstetricians; Delivery, Obstetric; Posture
PubMed: 37643694
DOI: 10.1016/j.jogoh.2023.102654 -
Neurourology and Urodynamics Feb 2020Levator ani avulsion rates after assisted vaginal delivery have been reported in the literature. However, there are no definitive data regarding the association between...
INTRODUCTION
Levator ani avulsion rates after assisted vaginal delivery have been reported in the literature. However, there are no definitive data regarding the association between overdistention and assisted vaginal delivery. Therefore, our aim is to report overdistention rates after assisted vaginal delivery with a postpartum ultrasound examination.
MATERIALS AND METHODS
This multicenter study involved a retrospective analysis of data from primiparous women (n = 602) who had previously been recruited at three tertiary hospitals between January 2015 and January 2017. Overdistention was assessed at 6 months postpartum using three-/four-dimensional transperineal ultrasound. Patients with levator ani muscle avulsion were excluded. Overdistention was defined as a levator hiatal area ≥ 25 cm on Valsalva.
RESULTS
Of the 602 primiparous patients, 250 patients who satisfied the inclusion criteria (139 patients who underwent forceps delivery and 111 patients who underwent vacuum delivery) were evaluated. Overdistention occurred in 20% (50 of 250) of these patients. Overdistention was observed for 1% (1/111) of vacuum deliveries and 35.3% (49 of 139) of forceps deliveries. We found an increased risk of overdistention following forceps delivery compared to vacuum delivery, with a crude odds ratio (OR) of 59.9 (95% confidence interval [CI]: 8.1, 442.2) and an adjusted OR (adjusted for maternal age, second-stage duration, and head circumference) of 17.6 (95% CI: 2.3, 136.7).
CONCLUSIONS
Postpartum overdistention occurred for 20% of assisted vaginal deliveries, with an increased risk of overdistention following forceps delivery compared to vacuum delivery.
Topics: Adult; Extraction, Obstetrical; Female; Humans; Imaging, Three-Dimensional; Obstetrical Forceps; Organ Size; Pelvic Floor; Postpartum Period; Pregnancy; Prevalence; Retrospective Studies; Soft Tissue Injuries; Ultrasonography; Vacuum Extraction, Obstetrical; Valsalva Maneuver
PubMed: 31977114
DOI: 10.1002/nau.24294