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BMC Pregnancy and Childbirth Feb 2024The trends of increasing use of cesarean section (CS) with a decrease in assisted vaginal birth (vacuum extraction or forceps) is a major concern in health care systems...
INTRODUCTION
The trends of increasing use of cesarean section (CS) with a decrease in assisted vaginal birth (vacuum extraction or forceps) is a major concern in health care systems all over the world, particularly in low-resource settings. Studies show that a first birth by CS is associated with an increased risk of repeat CS in subsequent births. In addition, CS compared to assisted vaginal birth (AVB), attracts higher health service costs. Resource-constrained countries have low rates of AVB compared to high-income countries. The aim of this study was to compare mode of birth in the subsequent pregnancy among women who previously gave birth by vacuum extraction or second stage CS in their first pregnancy at Mulago National Referral Hospital, Uganda.
METHODS
This was a retrospective cohort study that involved interviews of 81 mothers who had a vacuum extraction or second stage CS in their first pregnancy at Mulago hospital between November 2014 to July 2015. Mode of birth in the subsequent pregnancy was compared using Chi-2 square test and a Fisher's exact test with a 0.05 level of statistical significance.
RESULTS
Higher rates of vaginal birth were achieved among women who had a vacuum extraction (78.4%) compared to those who had a second stage CS in their first pregnancy (38.6%), p < 0.001.
CONCLUSIONS AND RECOMMENDATIONS
Vacuum extraction increases a woman's chance of having a subsequent spontaneous vaginal birth compared to second stage CS. Health professionals need to continue to offer choice of vacuum extraction in the second stage of labor among laboring women that fulfill its indication. This will help curb the up-surging rates of CS.
Topics: Pregnancy; Female; Humans; Cesarean Section; Vacuum Extraction, Obstetrical; Tertiary Care Centers; Retrospective Studies; Birth Order; Uganda; Labor, Obstetric
PubMed: 38302920
DOI: 10.1186/s12884-024-06282-9 -
Gynecologie, Obstetrique, Fertilite &... Feb 2024There is a progressive reduction in the rate of episiotomies since the recommendations of the French college of gynaecologists. Our objective was to study the evolution... (Observational Study)
Observational Study
OBJECTIVES
There is a progressive reduction in the rate of episiotomies since the recommendations of the French college of gynaecologists. Our objective was to study the evolution of the rate of episiotomies and Obstetric Anus Sphincter Injury (OASI) since the restriction of episiotomies in our department.
METHODS
Observational monocentric retrospective study performed at the Rouen University Hospital. The inclusion criteria were monofetal pregnancies, delivery at a term greater than or equal to 37 weeks of amenorrhea of a living, viable child and by cephalic presentation. We compared two periods corresponding to before and after the 2018 recommendations. We used logistic regression modelling to identify factors associated with the risk of episiotomies and of obstetrical anal injuries, overall and in case of instrumental delivery.
RESULTS
We included 3329 patients for the 1st period and 3492 for the 2nd period, and the rate of instrumental deliveries were respectively of 16.4% (n=547) and 17.9% (n=626). Multivariate analysis showed a significant decrease in the rate of episiotomies in the 2nd period (OR 0.14, CI 95% [0.12; 0.16], P<0.0001). Main factors associated with the risk of OASI were primiparity (OR 6.21, CI 95% [3.19; 12.11]) and the use of forceps (OR 4.23, CI 95% [2.17; 8.27]) overall; and instrumental delivery using forceps (OR 3.25, CI 95% [1.69; 6.22]) and delivery during the 2nd period (OR 1.98, CI 95% [1.01; 3.88]) in case of instrumental delivery.
CONCLUSIONS
Our study confirms that the voluntary reduction in the episiotomy rate does not seem to be associated with an increased risk of OASI, overall and in case of instrumental delivery. However, we show an increase in the rate of OASI in case of instrumental delivery since the latest recommendations.
Topics: Female; Humans; Pregnancy; Anal Canal; Delivery, Obstetric; Episiotomy; Obstetric Labor Complications; Retrospective Studies; Risk Factors; Infant, Newborn
PubMed: 38219814
DOI: 10.1016/j.gofs.2024.01.003 -
Alternative Therapies in Health and... Apr 2024Exploring the perinatal outcomes of forceps delivery and the risk factors of postpartum hemorrhage, laying a certain foundation for early identification of indications...
OBJECTIVE
Exploring the perinatal outcomes of forceps delivery and the risk factors of postpartum hemorrhage, laying a certain foundation for early identification of indications for forceps assisted delivery and suppressing the risk of bleeding during forceps assisted delivery, and improving delivery quality.
METHOD
Retrospective analysis was made on the clinical information of 1520 parturients delivered by vagina in hospitals from December 2019 to December 2021. They were divided into normal vaginal delivery group (sample size=1454) and forceps assisted delivery group (sample size 66) according to whether forceps-assisted delivery occurred during the second stage of labor. They were divided into a postpartum hemorrhage group (sample size 9) and non-postpartum hemorrhage group (sample size 47) according to whether forceps-assisted delivery occurred, the risk factors of postpartum hemorrhage were analyzed by logistic regression.
RESULT
The incidence of perinatal infants in the forceps assisted delivery group compared to those in the normal vaginal delivery group who were transferred to the neonatal intensive care unit (25.76% vs 9.97%), neonatal asphyxia (4.55% vs 1.03%), shoulder dystocia (1.52% vs 0.69%), and facial scratches (40.91% vs 0.14%) was statistically significant (P < .05), except for shoulder dystocia. Univariate analysis showed that abnormal coagulation function, fetal orientation during midwifery, soft birth canal laceration, perineum lateral incision, and neonatal birth weight were the single factors related to postpartum hemorrhage during forceps delivery (P < .05). Multivariate analysis showed that abnormal coagulation function, laceration of the soft birth canal, and lateral episiotomy were independent risk factors for postpartum hemorrhage during forceps-assisted delivery. The rate of postpartum hemorrhage under forceps-assisted delivery was relatively low when the fetal orientation was occipital transverse (P < .05).
CONCLUSION
The incidence of postpartum hemorrhage in the forceps assisted delivery group is higher, with occipital posterior position, abnormal coagulation function, soft birth canal tear, and lateral perineal incision being high-risk factors for postpartum hemorrhage in forceps assisted delivery. We need to strengthen prevention and control measures to improve the quality of the perinatal period. This study has guiding significance for early identification of high-risk factors for postpartum hemorrhage, strengthening pre pregnancy knowledge education, strengthening labor process monitoring, actively correcting fetal orientation, and improving midwifery techniques.
Topics: Humans; Female; Postpartum Hemorrhage; Pregnancy; Obstetrical Forceps; Risk Factors; Retrospective Studies; Adult; Delivery, Obstetric; Extraction, Obstetrical; Infant, Newborn
PubMed: 38064601
DOI: No ID Found -
Journal of Mother and Child Jun 2023Nowadays, we are witnessing a decrease of vaginal instrumental deliveries and continuous increase of caesarean section rate. However, proper identification of... (Review)
Review
BACKGROUND
Nowadays, we are witnessing a decrease of vaginal instrumental deliveries and continuous increase of caesarean section rate. However, proper identification of possibility of execution, indications for instrumental delivery and their skilful use may improve the broadly understood maternal and neonatal outcomes. The aim of this study is to present prevalence, risk factors, indications and outcomes of forceps deliveries among the patients at Department of Perinatology, Lodz.
MATERIAL AND METHODS
A retrospective study was conducted at the Department of Perinatology, Medical University of Lodz. The study included forceps deliveries carried out between January 2019 and December 2022. Total number of 147 cases were analysed in terms of indications for forceps delivery and maternal and neonatal outcomes such as vaginal - or cervical - laceration, postpartum haemorrhage, perineal tear, newborn injuries, Apgar score, umbilical cord blood gas analysis, NICU admission and cranial ultrasound scans.
RESULTS
The prevalence of forceps delivery was 2.2%. The most common indication for forceps delivery was foetal distress (81.6%). Among mothers, the most frequent complication was vaginal laceration (40.1%). Third-and fourth-degree perineal tears were not noted. Regarding neonatal outcomes, Apgar score ≥ 8 after 1st and 5th minute of life received accordingly 91.2% and 98% of newborns. Only 8.8% experienced severe birth injuries (subperiosteal haematoma, clavicle fracture).
CONCLUSIONS
Although foetal distress is the most common indication for forceps delivery, the vast majority of newborns were born in good condition and did not require admission to NICU. Taking into consideration high efficacy and low risk of neonatal and maternal complications, forceps should remain in modern obstetrics.
Topics: Humans; Infant, Newborn; Pregnancy; Female; Cesarean Section; Fetal Distress; Retrospective Studies; Lacerations; Vacuum Extraction, Obstetrical; Obstetrical Forceps
PubMed: 37920112
DOI: 10.34763/jmotherandchild.20232701.d-23-00057 -
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 -
BMJ (Clinical Research Ed.) Oct 2023argue that Canada’s high rates of maternal and neonatal trauma following operative vaginal delivery warrant urgent recognition, transparency, and action
argue that Canada’s high rates of maternal and neonatal trauma following operative vaginal delivery warrant urgent recognition, transparency, and action
Topics: Pregnancy; Infant, Newborn; Female; Humans; Vacuum Extraction, Obstetrical; Infant, Newborn, Diseases; Birth Injuries; Family; Surgical Instruments; Obstetrical Forceps; Delivery, Obstetric; Extraction, Obstetrical; Retrospective Studies
PubMed: 37857419
DOI: 10.1136/bmj-2022-073991 -
The Journal of Obstetrics and... Dec 2023To determine the association of successful and unsuccessful operative vaginal delivery attempts with risk of severe neonatal birth injury. (Observational Study)
Observational Study
AIM
To determine the association of successful and unsuccessful operative vaginal delivery attempts with risk of severe neonatal birth injury.
METHODS
We conducted a population-based observational study of 1 080 503 births between 2006 and 2019 in Quebec, Canada. The main exposure was operative vaginal delivery with forceps or vacuum, elective or emergency cesarean with or without an operative vaginal attempt, and spontaneous delivery. The outcome was severe birth injury, including intracranial hemorrhage, brain and spinal damage, Erb's paralysis and other brachial plexus injuries, epicranial subaponeurotic hemorrhage, skull and long bone fractures, and liver, spleen, and other neonatal body injuries. We determined the association of delivery mode with risk of severe birth injury using adjusted risk ratios (RR) and 95% confidence intervals (CI).
RESULTS
A total of 8194 infants (0.8%) had severe birth injuries. Compared with spontaneous delivery, vacuum (RR 2.98, 95% CI 2.80-3.16) and forceps (RR 3.35, 95% CI 3.07-3.66) were both associated with risk of severe injury. Forceps was associated with intracranial hemorrhage (RR 16.4, 95% CI 10.1-26.6) and brain and spinal damage (RR 13.5, 95% CI 5.72-32.0), while vacuum was associated with epicranial subaponeurotic hemorrhage (RR 27.5, 95% CI 20.8-36.4) and skull fractures (RR 2.04, 95% CI 1.86-2.25). Emergency cesarean after an unsuccessful operative attempt was associated with intracranial and epicranial subaponeurotic hemorrhage, but elective and other emergency cesareans were not associated with severe injury.
CONCLUSIONS
Operative vaginal delivery and unsuccessful operative attempts that result in an emergency cesarean are associated with elevated risks of severe birth injury.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Cesarean Section; Obstetrical Forceps; Delivery, Obstetric; Birth Injuries; Intracranial Hemorrhages; Hemorrhage; Vacuum Extraction, Obstetrical
PubMed: 37772655
DOI: 10.1111/jog.15801 -
Revista Espanola de Anestesiologia Y... 2024Iatrogenic extradural pneumorrhachis is a rare clinical entity, but anesthesiologists should be aware of this possibility when using the air technique for the... (Review)
Review
Iatrogenic extradural pneumorrhachis is a rare clinical entity, but anesthesiologists should be aware of this possibility when using the air technique for the identification of epidural space. Although in most published cases extradural pneumorrhachis is asymptomatic, relevant neurological consequences have been described, such as meningeal irritation, radicular pain, unilateral lower extremity weakness, cauda equina syndrome, paraplegia, and tetraplegia.We describe a very extensive extradural pneumorrachis (T9-S1), related to obstetric analgesia, in a patient with severe and atypical perineal pain after forceps-assisted delivery. Our aim is to synthesize and organize the available scientific evidence, analyzing preventive measures and summarizing the most appropriate diagnostic, follow-up and therapeutic techniques for symptomatic conditions, among which high concentrations of inspired oxygen, hyperbaric oxygen therapy and percutaneous or surgical decompression have been described.
Topics: Humans; Female; Pregnancy; Pneumorrhachis; Analgesia, Obstetrical; Adult; Obstetrical Forceps; Thoracic Vertebrae; Magnetic Resonance Imaging; Epidural Space
PubMed: 37683975
DOI: 10.1016/j.redare.2023.09.009 -
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 -
American Journal of Obstetrics and... Mar 2024Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous... (Review)
Review
Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.
Topics: Pregnancy; Female; Humans; Birth Weight; Episiotomy; Parity; Parturition; Lacerations; Anal Canal; Risk Factors; Perineum; Obstetric Labor Complications
PubMed: 37635056
DOI: 10.1016/j.ajog.2022.06.021