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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 -
American Journal of Obstetrics and... Apr 2022This study aimed to assess the efficacy of sonographic assessment of fetal occiput position before operative vaginal delivery to decrease the number of failed operative... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This study aimed to assess the efficacy of sonographic assessment of fetal occiput position before operative vaginal delivery to decrease the number of failed operative vaginal deliveries.
DATA SOURCES
The search was conducted in MEDLINE, Embase, Web of Science, Scopus, ClinicalTrial.gov, Ovid, and Cochrane Library as electronic databases from the inception of each database to April 2021. No restrictions for language or geographic location were applied.
STUDY ELIGIBILITY CRITERIA
Selection criteria included randomized controlled trails of pregnant women randomized to either sonographic or clinical digital diagnosis of fetal occiput position during the second stage of labor before operative vaginal delivery.
METHODS
The primary outcome was failed operative vaginal delivery, defined as a failed fetal operative vaginal delivery (vacuum or forceps) extraction requiring a cesarean delivery or forceps after failed vacuum. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals using the random effects model of DerSimonian and Laird. An I (Higgins I) >0% was used to identify heterogeneity.
RESULTS
A total of 4 randomized controlled trials including 1007 women with singleton, term, cephalic fetuses randomized to either the sonographic (n=484) or clinical digital (n=523) diagnosis of occiput position during the second stage of labor before operative vaginal delivery were included. Before operative vaginal delivery, fetal occiput position was diagnosed as anterior in 63.5% of the sonographic diagnosis group vs 69.5% in the clinical digital diagnosis group (P=.04). There was no significant difference in the rate of failed operative vaginal deliveries between the sonographic and clinical diagnosis of occiput position groups (9.9% vs 8.2%; relative risk, 1.14; 95% confidence interval, 0.77-1.68). Women randomized to sonographic diagnosis of occiput position had a significantly lower rate of occiput position discordance between the evaluation before operative vaginal delivery and the at birth evaluation when compared with those randomized to the clinical diagnosis group (2.3% vs 17.7%; relative risk, 0.16; 95% confidence interval, 0.04-0.74; P=.02). There were no significant differences in any of the other secondary obstetrical and perinatal outcomes assessed.
CONCLUSION
Sonographic knowledge of occiput position before operative vaginal delivery does not seem to have an effect on the incidence of failed operative vaginal deliveries despite better sonographic accuracy in the occiput position diagnosis when compared with clinical assessment. Future studies should evaluate how a more accurate sonographic diagnosis of occiput position or other parameters can lead to a safer and more effective operative vaginal delivery technique.
Topics: Delivery, Obstetric; Female; Humans; Infant, Newborn; Labor Presentation; Pregnancy; Randomized Controlled Trials as Topic; Ultrasonography; Ultrasonography, Prenatal
PubMed: 34492220
DOI: 10.1016/j.ajog.2021.08.057 -
Acta Obstetricia Et Gynecologica... Nov 2021The objective was to report the role of intrapartum ultrasound examination in affecting maternal and perinatal outcome in women undergoing instrumental vaginal delivery. (Meta-Analysis)
Meta-Analysis
INTRODUCTION
The objective was to report the role of intrapartum ultrasound examination in affecting maternal and perinatal outcome in women undergoing instrumental vaginal delivery.
MATERIAL AND METHODS
MEDLINE, Embase, CINAHL, Google Scholar and ClinicalTrial.gov databases were searched. Inclusion criteria were randomized controlled trials comparing ultrasound assessment of fetal head position vs routine standard care (digital examination) before instrumental vaginal delivery (either vacuum or forceps). The primary outcome was failed instrumental delivery extraction followed by cesarean section. Secondary outcomes were postpartum hemorrhage, 3rd or 4th degree perineal lacerations, episiotomy, prolonged hospital stay, Apgar score<7 at 5 min, umbilical artery pH <7.0 and base excess greater than -12 mEq, admission to neonatal intensive care unit (NICU), shoulder dystocia, birth trauma, a composite score of adverse maternal and neonatal outcome and incorrect diagnosis of fetal head position. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB-2). The quality of evidence and strength of recommendations were assessed using the Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. Head-to-head meta-analyses using a random-effect model were used to analyze the data and results are reported as relative risk with their 95% confidence intervals.
RESULTS
Five studies were included (1463 women). There was no difference in the maternal, pregnancy or labor characteristics between the two groups. An ultrasound assessment prior to instrumental vaginal delivery did not affect the cesarean section rate compared with standard care (p = 0.805). Likewise, the risk of composite adverse maternal outcome (p = 0.428), perineal lacerations (p = 0.800), postpartum hemorrhage (p = 0.303), shoulder dystocia (p = 0.862) and prolonged stay in hospital (p = 0.059) were not different between the two groups. Composite adverse neonatal outcome was not different between the women undergoing and those not undergoing ultrasound assessment prior to instrumental delivery (p = 0.400). Likewise, there was no increased risk with abnormal Apgar score (p = 0.882), umbilical artery pH < 7.2 (p = 0.713), base excess greater than -12 (p = 0.742), admission to NICU (p = 0.879) or birth trauma (p = 0.968). The risk of having an incorrect diagnosis of fetal head position was lower when ultrasound was performed before instrumental delivery, with a relative risk of 0.16 (95% confidence interval 0.1-0.3; I :77%, p < 0.001).
CONCLUSIONS
Although ultrasound examination was associated with a lower rate of incorrect diagnoses of fetal head position and station, this did not translate to any improvement of maternal or neonatal outcomes.
Topics: Birth Injuries; Cesarean Section; Extraction, Obstetrical; Female; Humans; Postpartum Hemorrhage; Pregnancy; Pregnancy Outcome; Ultrasonography, Prenatal
PubMed: 34314520
DOI: 10.1111/aogs.14236 -
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 -
Journal of Obstetrics and Gynaecology :... Oct 2021The BD Odon Device™ was designed as an alternative to conventional methods for assisting vaginal delivery, especially in low-resource settings. This a systematic...
The BD Odon Device™ was designed as an alternative to conventional methods for assisting vaginal delivery, especially in low-resource settings. This a systematic review of published data concerning the BD Odon Device™ until March 2020 listed in Pubmed, Google Scholar, SCOPUS and Web of Science.Five studies testing the device were found, three in models and two in women with uncomplicated deliveries. According to their results, the device seems easy to use, safe, effective and requires simple and fast training, so it may become a good alternative to vacuum extractor or forceps, especially in places where there is less specialised staff, low-resources settings. The study protocol of the first study in complicated second stages has already been published. There is still few information about the BD Odon Device™ in scientific literature, however more research concerning the device is expected to take place in a near future.Impact Statement The Odon Device is a device under development that aims to be a useful tool to assist vaginal deliveries. This is a review of the current state of the development of the Odon Device. Further tests in humans are planned in the future in order to evaluate its safety and efficacy. The Odon Device may be a promising tool to assist vaginal deliveries, especially in low-resource countries and countries with high rates of C-section during second stage of labour, but further research is needed to evaluate its safety and efficacy.
Topics: Extraction, Obstetrical; Female; Health Resources; Humans; Pregnancy; Vagina
PubMed: 33459104
DOI: 10.1080/01443615.2020.1837756 -
The Cochrane Database of Systematic... Mar 2020Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear. This is an update of a review last published in 2017.
OBJECTIVES
To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps delivery, or both.
SEARCH METHODS
For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 July 2019), and reference lists of retrieved studies.
SELECTION CRITERIA
All randomised controlled trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium).
DATA COLLECTION AND ANALYSIS
Two review authors assessed trial eligibility and risk of bias. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. We assessed methodological quality of the two included studies using the GRADE approach.
MAIN RESULTS
Two studies, involving 3813 women undergoing either vacuum or forceps deliveries, were included. One study involving 393 women compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. The other study involving 3420 women compared a single dose of intravenous amoxicillin and clavulanic acid with placebo using 20 mL of intravenous sterile 0.9% saline. The evidence suggests that prophylactic antibiotics reduce superficial perineal wound infection (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.40 to 0.69; women = 3420; 1 study; high-certainty evidence), deep perineal wound infection (RR 0.46, 95% CI 0.31 to 0.69; women = 3420; 1 study; high-certainty evidence) and probably reduce wound breakdown (RR 0.52, 95% CI 0.43 to 0.63; women = 2593; 1 study; moderate-certainty evidence). We are unclear about the effect on organ or space perineal wound infection (RR 0.11, 95% CI 0.01 to 2.05; women = 3420; 1 study) and endometritis (average RR 0.32, 95% CI 0.04 to 2.64; 15/1907 versus 30/1906; women = 3813; 2 studies) based on low-certainty evidence with wide CIs that include no effect. Prophylactic antibiotics probably lower serious infectious complications (RR 0.44, 95% CI 0.22 to 0.89; women = 3420; 1 study; high-certainty evidence). They also have an important effect on reduction of confirmed or suspected maternal infection. The two included studies did not report on fever or urinary tract infection. It is unclear, based on low-certainty evidence, whether prophylactic antibiotics have any impact on maternal adverse reactions (RR 2.00, 95% CI 0.18 to 22.05; women = 2593; 1 study) and maternal length of stay (MD 0.09 days, 95% CI -0.23 to 0.41; women = 393; 1 study) as the CIs were wide and included no effect. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain and probably reduce costs. Prophylactic antibiotics did not have an important effect on dyspareunia (difficult or painful sexual intercourse) or breastfeeding at six weeks. Antibiotic prophylaxis may slightly improve maternal hospital re-admission and maternal health-related quality of life. Neonatal adverse reactions were not reported in any included trials.
AUTHORS' CONCLUSIONS
Prophylactic intravenous antibiotics are effective in reducing infectious puerperal morbidities in terms of superficial and deep perineal wound infection or serious infectious complications in women undergoing operative vaginal deliveries without clinical indications for antibiotic administration after delivery. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain, probably reduce the costs, and may slightly reduce the maternal hospital re-admission and health-related quality of life. However, the effect on reduction of endometritis, organ or space perineal wound infection, maternal adverse reactions and maternal length of stay is unclear due to low-certainty evidence. As the evidence was mainly derived from a single multi-centre study conducted in a high-income setting, future well-designed randomised trials in other settings, particularly in low- and middle-income settings, are required to confirm the effect of antibiotic prophylaxis for operative vaginal delivery.
Topics: Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Antibiotic Prophylaxis; Cefotetan; Endometritis; Episiotomy; Extraction, Obstetrical; Female; Humans; Length of Stay; Obstetrical Forceps; Perineum; Pregnancy; Puerperal Infection; Randomized Controlled Trials as Topic; Surgical Wound Infection; Vacuum Extraction, Obstetrical; Vaginal Diseases
PubMed: 32215906
DOI: 10.1002/14651858.CD004455.pub5 -
Obstetrics and Gynecology Oct 2019To perform a systematic review of the literature on the effect of simulation training of operative vaginal delivery on learner technique and knowledge, operator comfort,...
OBJECTIVE
To perform a systematic review of the literature on the effect of simulation training of operative vaginal delivery on learner technique and knowledge, operator comfort, and patient-centered outcomes.
DATA SOURCES
MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, ERIC, The Cochrane Library, and ClinicalTrials.gov were searched from inception through April 2017. The search criteria used MeSH terms ("simulation training," "high fidelity simulation training," "teaching," "obstetrical extraction," "obstetrical forceps," "vaginal delivery," "clinical competence," and "internship and residency").
METHODS OF STUDY SELECTION
A total of 30,813 articles were reviewed for inclusion. Studies detailing operative vaginal delivery simulation using forceps or vacuums and reporting health care provider or patient outcomes were eligible.
TABULATION, INTEGRATION, AND RESULTS
All studies were independently reviewed by two investigators for inclusion. Only eight articles assessed the effect of simulation on trainee skill and comfort or patient outcomes and were included. Four were pretest-posttest studies, two were cross-sectional studies, one was a case-control study, and one was a cohort study. No randomized trials were identified. Simulation was associated with improved forceps placement accuracy and generated force during extraction, as well as increased operator knowledge and comfort with operative vaginal delivery. Additionally, simulation had no association with forceps failure rates, but there was an association with decreased rates of maternal lacerations and neonatal injury. The quality of the included studies was assessed with the Medical Education Research Study Quality Instrument, with a median score of 9.75 (range 9.0-13.5), indicating low-to-moderate quality.
CONCLUSION
The available evidence suggests that improved technique, comfort, knowledge, and patient outcomes are associated with operative vaginal delivery simulation, but additional studies are required to further characterize such benefits for both forceps and vacuum.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42018087343.
Topics: Clinical Competence; Delivery, Obstetric; Extraction, Obstetrical; Female; Humans; Obstetrics; Patient Outcome Assessment; Pregnancy; Simulation Training
PubMed: 31568036
DOI: 10.1097/AOG.0000000000003431