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International Journal of Gynaecology... Aug 2023To examine temporal trends in operative vaginal deliveries as well as the ratio between vacuum and forceps deliveries over 15 years in a large tertiary hospital.
OBJECTIVE
To examine temporal trends in operative vaginal deliveries as well as the ratio between vacuum and forceps deliveries over 15 years in a large tertiary hospital.
METHODS
This retrospective study assessed prospectively collected data from 2008 to 2021. Women with greater than 37 weeks of gestation who underwent an operative vaginal delivery were included. The rate and ratio of instrumental deliveries and perineal trauma were recorded.
RESULTS
From 2008 to 2021 there was a total of 109 230 term deliveries, of which 20 151 were an operative vaginal delivery. The rate of operative vaginal delivery as a proportion of all term deliveries decreased from 21.9% (1547 of 7069) in 2008 to 17.1% in 2021 (1428 of 8338, P < 0.001). The ratio between vacuum and forceps-assisted deliveries decreased significantly over the study period, from 7.06 in 2008 to 2.39 in 2021 (P < 0.001). Perineal trauma remained unchanged during the study period.
CONCLUSION
Operative vaginal delivery rates declined over the 15-year study period. While vacuum-assisted vaginal deliveries remain the favored instrument, forceps-assisted deliveries are becoming more prevalent. The cause for this change in practice is unclear but is likely multifactorial.
Topics: Pregnancy; Female; Humans; Tertiary Care Centers; Vacuum Extraction, Obstetrical; Retrospective Studies; Obstetrical Forceps; Delivery, Obstetric
PubMed: 36815738
DOI: 10.1002/ijgo.14736 -
BJOG : An International Journal of... Jul 2023
Topics: Pregnancy; Female; Humans; Obstetrical Forceps; Parturition; Extraction, Obstetrical
PubMed: 36719176
DOI: 10.1111/1471-0528.17413 -
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 -
CMAJ : Canadian Medical Association... Jan 2023
Topics: Female; Pregnancy; Humans; Sweating, Gustatory; Delivery, Obstetric; Surgical Instruments; Obstetrical Forceps
PubMed: 36623856
DOI: 10.1503/cmaj.221178 -
NeoReviews Jan 2023
Topics: Pregnancy; Infant, Newborn; Female; Humans; Vacuum; Delivery, Obstetric; Vacuum Extraction, Obstetrical; Surgical Instruments
PubMed: 36587012
DOI: 10.1542/neo.24-1-e1 -
AJOG Global Reports Nov 2022Occiput posterior is the most common malposition in labor. Deliveries in occiput posterior position have been shown to have higher rates of adverse short-term maternal...
BACKGROUND
Occiput posterior is the most common malposition in labor. Deliveries in occiput posterior position have been shown to have higher rates of adverse short-term maternal and neonatal outcomes compared with deliveries in occiput anterior position. There are no guidelines providing recommendations nor summarizing risks of adverse outcomes by delivery method to inform the decision-making process in occiput posterior delivery management. Population-based studies examining the outcomes associated with various management processes of occiput posterior position at the time of labor or delivery are lacking.
OBJECTIVE
This study aimed to describe the current management of term singleton occiput posterior deliveries in British Columbia, Canada and to examine the association between different management strategies and adverse outcomes by describing the rates of: occiput posterior malposition; and spontaneous vaginal delivery, operative vaginal delivery, and cesarean delivery from occiput posterior malposition. We also analyzed the rates of adverse labor and delivery outcomes stratified by fetal position and delivery mode, and the interaction effect of occiput posterior position and delivery mode on the rates of adverse outcomes.
STUDY DESIGN
This was a retrospective cohort study of cephalic term singleton deliveries in British Columbia from 2004 to 2020, using the British Columbia Perinatal Data Registry. The obstetrical adverse outcome index (a composite of 10 adverse maternal or neonatal events), adverse outcome index subcomponent rates, and adverse outcome index-derived weighted scores were compared between deliveries stratified by fetal position at delivery (occiput posterior or occiput anterior) and occiput posterior deliveries stratified by delivery method. Multivariable log-binomial logistic regression was used to model the adverse outcome index score.
RESULTS
Of 306,237 term births, 19% had occiput posterior position during labor, 37% of which persisted in occiput posterior position at delivery. Among occiput posterior deliveries, 27% were spontaneous vaginal deliveries, 8% vacuum, 5% forceps, 1% mixed vacuum-forceps, and 59% were cesarean delivery; this distribution differed from that of occiput anterior deliveries (<.0001). Overall, adverse outcome index scores were significantly higher in persistent occiput posterior deliveries (8.8% had ≥1 adverse outcomes; adjusted rate ratio, 1.07 [1.01-1.14]) than in occiput posterior labors that rotated to occiput anterior deliveries; the most frequent adverse outcome was third- or fourth-degree lacerations. Neonatal adverse outcomes were also more frequent in occiput posterior delivery (4.3% vs 3.3%; adjusted rate ratio, 1.21 [1.10-1.35]), whereas maternal outcomes were similar between groups (4.8% vs 6.0%; adjusted rate ratio, 1.04 [0.96-1.13]). Among persistent occiput posterior deliveries, spontaneous vaginal delivery and cesarean delivery had the lowest proportion of deliveries with ≥1 adverse outcomes (6.1% and 6.2%), whereas forceps deliveries had the highest (38.1%); the largest contributor to the adverse outcomes were third- or fourth-degree lacerations. Among occiput posterior deliveries with any adverse outcome, cesarean delivery had the highest Severity Index score, due in part to the inclusion of third- or fourth-degree tears (which are assigned a comparatively low score) as the most common adverse event in the other vaginal delivery modes, and because of outcomes with a higher severity score being associated with cesarean delivery, such as uterine rupture (a reason for cesarean delivery) and intensive care unit admission (an outcome following cesarean delivery). Overall, in a multivariable regression model, delivery mode and the interaction between delivery mode and occiput posterior position were significant predictors of a delivery with ≥1 adverse outcomes, whereas occiput posterior position itself was not.
CONCLUSION
One in five singleton deliveries at term gestation had occiput posterior position in labor; most of these rotated to occiput anterior by delivery, which had better outcomes than persistent occiput posterior deliveries. Among the latter, spontaneous vaginal delivery and cesarean delivery had the lowest frequency of adverse outcomes, whereas forceps deliveries had the highest. This study provides a robust updated analysis of birth outcomes following different occiput posterior management strategies, which can inform provider decision-making and counseling. Its observational design may limit its use for direct recommendations for management of occiput posterior malposition, yet the study helps to define the risks associated with different modes of delivery in the setting of occiput posterior malposition. With additional studies examining success rates of intermediate occiput posterior-occiput anterior rotation, other delivery management steps, and long-term outcomes, this study helps to define safe management of occiput posterior delivery.
PubMed: 36536849
DOI: 10.1016/j.xagr.2022.100080 -
Gynecologie, Obstetrique, Fertilite &... Feb 2023The idea of using an instrument to assist natural childbirth is not new and it was in the 18th and 19th centuries that the forceps was developed. It is only after the... (Review)
Review
The idea of using an instrument to assist natural childbirth is not new and it was in the 18th and 19th centuries that the forceps was developed. It is only after the Second World War that the suction cup provides an alternative to instrumental childbirth, but still based on prehension and traction. In 1950, Emile Thierry, in France, presented his spatulas based on the then original principle of propulsion. The diffusion of spatulas is almost non-existent in the Anglo-Saxon world but is not limited to France since its use was real by the Iberians and Latin Americans. There are currently three types of spatula, two of which are French and one Colombian. This review takes up the saga of this instrument for more than 70 years, develops its particularities and describes the present literature.
Topics: Pregnancy; Female; Humans; Extraction, Obstetrical; Obstetrical Forceps; Colombia; Delivery, Obstetric; Surgical Instruments
PubMed: 36436820
DOI: 10.1016/j.gofs.2022.11.009 -
European Journal of Obstetrics,... Jan 2023Instruments used in assisted vaginal birth have seen little innovation for decades. Due to the risk of trauma and technical difficulty incurred during forceps delivery,... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
Instruments used in assisted vaginal birth have seen little innovation for decades. Due to the risk of trauma and technical difficulty incurred during forceps delivery, instrumental deliveries are on a decline, and the global rate of primary cesarean birth is rising. The novel Paily Obstetric Forceps (POF) features a compact, lighter design with thinner blades, designed to increase operator comfort and minimize maternal and neonatal injuries. We aim to determine the feasibility and safety of POF in achieving vaginal birth compared to a ventouse device with a 50 mm silastic cup.
STUDY DESIGN
We conducted a single-blinded, parallel arm, randomized clinical trial of the novel POF vs a ventouse device, in patients undergoing indicated assisted vaginal birth, at a tertiary care obstetric unit. We randomized 100 patients to be allocated on a 1:1 ratio to both intervention arms. Primary outcome was the proportion of successful instrumental deliveries. Secondary outcomes were the number of pulls required during traction and any maternal or neonatal adverse events.
RESULTS
The POF was significantly more successful in achieving vaginal birth than the ventouse device (n = 50/50, 100 % vs n = 42/50, 84 %, p = 0.006). Operators reported requiring significantly fewer pulls during POF traction than ventouse. POF demonstrated a higher risk for maternal trauma (RR = 3.2, 95 % CI = 1.5 to 6.9, NNH = 2.7) but a lower risk for neonatal injury (RR = 0.6, 95 % CI = 0.3 to 1, NNH = 5.7). Maternal and neonatal recovery durations were comparable. There were no incidences of maternal or neonatal mortality.
CONCLUSION
The POF can be used in indicated assisted vaginal birth with superior success rates and better neonatal outcomes than ventouse. Other obstetric forceps must be standardized to conduct larger superiority trials of forceps designs.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Obstetrical Forceps; Vacuum Extraction, Obstetrical; Delivery, Obstetric; Surgical Instruments; Vagina; Birth Injuries
PubMed: 36399919
DOI: 10.1016/j.ejogrb.2022.10.028 -
Journal of Gynecology Obstetrics and... Dec 2022The presence of locum obstetricians in the delivery room raises concerns of increased maternal or perinatal morbidities.
BACKGROUND
The presence of locum obstetricians in the delivery room raises concerns of increased maternal or perinatal morbidities.
OBJECTIVES
To examine the method of delivery, maternal and perinatal morbidities depending on whether the delivery doctor is a member of hospital staff or a locum doctor.
MATERIALS AND METHODS
The study took place in a type 2 maternity ward marked by the departure of all hospital staff obstetricians in 2018. We compared the characteristics of the deliveries carried out in 2017 by a team of hospital staff obstetricians to those carried out by locums in 2019. The same was done for severe maternal and perinatal morbidities. The only exclusion criteria were medical terminations of pregnancy and births before 22 weeks of gestation.
RESULTS
A total of 1,323 deliveries in 2017, and 1,463 in 2019 were included. We found no significant difference in the overall rate of Caesarean sections between 2017 (19.6%) and 2019 (20.5%). However, we noted a significant increase in forceps-assisted deliveries (8.5% in 2017 versus 21.4% in 2019) (p<0.001). Regarding severe maternal morbidity, we found no significant difference in 2019 (3.2%) compared to 2017 (2.7%). Severe perinatal morbidity was not significantly different (4.3% morbidity in 2017 versus 5.1% in 2019).
CONCLUSION
The presence of locum obstetricians does not appear to impact either the method of delivery or maternal and perinatal morbidities.
Topics: Female; Pregnancy; Humans; Cesarean Section; Personnel, Hospital
PubMed: 36220541
DOI: 10.1016/j.jogoh.2022.102483 -
Acta Obstetricia Et Gynecologica... Nov 2022During the second stage of labor, vacuum-assisted delivery is an alternative to forceps delivery and emergency cesarean section. Extensive research concerning perinatal... (Observational Study)
Observational Study
INTRODUCTION
During the second stage of labor, vacuum-assisted delivery is an alternative to forceps delivery and emergency cesarean section. Extensive research concerning perinatal outcomes has indicated that the risk of complications, although rare, is higher than with a spontaneous vaginal delivery. An important factor related to perinatal outcomes is the traction force applied. Our research group previously developed a digital extraction handle, the Vacuum Intelligent Handle-3 (VIH3), that measures and records traction force. The objective of this study was to compare traction force profiles in children with and without severe perinatal outcomes delivered with the digital handle. A secondary aim was to establish a safe force limit.
MATERIAL AND METHODS
This was an observational case-control study at the delivery ward at Karolinska University Hospital, Sweden. In total, 573 children delivered with the digital handle between 2012 and 2018 were included. Cases were defined as a composite of severe perinatal outcomes, including subgaleal hematoma, intracranial hemorrhage, hypoxic ischemic encephalopathy 1-3, seizures or death. The cases in the cohort were matched 1:3 based on five matching variables. Traction profiles were analyzed using the MATLAB® software and conditional logistic regression.
RESULTS
The incidence of severe perinatal outcomes was 2.3%. The 13 cases were matched with three controls each (n = 39). A statistically significant increased odds for higher total traction forces was seen in the case group (odds ratio [OR] 1.004; 95% confidence interval [CI] 1.001-1.007) and for the peak force (OR 1.022; 95% CI 1.004-1.041). Several procedure-related parameters were significantly increased in the case group. As expected, some neonatal characteristics also differed significantly. An upper force limit of 343 Newton minutes (Nmin) revealed an 86% reduction in severe perinatal outcomes (adjusted OR 0.14; 95% CI 0.04-0.5).
CONCLUSIONS
Children with severe perinatal outcomes had traction force profiles with significantly higher forces. The odds for severe perinatal outcomes increased for every increase in Nmin and Newton used during the extraction procedure. A calculated total force level of 343 Nmin is suggested as an upper safety limit, but this must be tested prospectively to provide validity.
Topics: Infant, Newborn; Child; Pregnancy; Humans; Female; Vacuum Extraction, Obstetrical; Cesarean Section; Case-Control Studies; Traction; Delivery, Obstetric; Retrospective Studies
PubMed: 36030477
DOI: 10.1111/aogs.14444