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American Journal of Obstetrics and... Jun 2020Vaginal birth is a risk factor for pubovisceral muscle tear, decreased urethral closure pressure, and urinary incontinence. The relationship between these 3 factors is... (Observational Study)
Observational Study
BACKGROUND
Vaginal birth is a risk factor for pubovisceral muscle tear, decreased urethral closure pressure, and urinary incontinence. The relationship between these 3 factors is complicated. Urinary continence relies on maintaining urethral closure pressure, particularly when low urethral closure pressure can usefully be augmented by a volitional pelvic muscle (Kegel) contraction just before and during stress events like a cough. However, it is unknown whether a torn pubovisceral muscle decreases the ability to increase urethral closure during an attempted pelvic muscle contraction.
OBJECTIVE
We tested the null hypothesis that a pubovisceral muscle tear does not affect the ability to increase urethral closure pressure during a volitional pelvic muscle contraction in the Evaluating Maternal Recovery from Labor and Delivery (EMRLD) study.
STUDY DESIGN
We studied 56 women 8 months after their first vaginal birth. All had at least 1 risk factor for pubovisceral muscle tear (eg, forceps and long second stage). A tear was assessed bilaterally by magnetic resonance imaging. Urethral closure pressure was measured both at rest and during an attempted volitional pelvic muscle contraction. A Student t test was used to compare urethral closure pressures. Multiple linear regression was used to estimate the effect of a magnetic resonance imaging-confirmed pubovisceral muscle tear on volitionally contracted urethral closure pressure after adjusting for resting urethral closure pressure.
RESULTS
The mean age was just a little more than 30 years, with the majority being white. By magnetic resonance imaging measure, unadjusted for other factors, the 21 women with tear had significantly lower urethral closure pressure during an attempted contraction compared with the 35 women without tear (65.9 vs 86.8 cm HO, respectively, P = .004), leading us to reject the null hypothesis. No significant group difference was found in resting urethral closure pressure. After adjusting for resting urethral closure pressure, pubovisceral muscle tear was associated with lower urethral closure pressure (beta = -21.1, P = .001).
CONCLUSION
In the first postpartum year, the presence of a pubovisceral muscle tear did not influence resting urethral closure. However, women with a pubovisceral muscle tear achieved a 25% lower urethral closure pressure during an attempted pelvic muscle contraction than those without a pubovisceral muscle tear. These women with pubovisceral muscle tear may not respond to classic behavioral interventions, such as squeeze when you sneeze or strengthen through repetitive pelvic muscle exercises. When a rapid rise to maximum urethral pressure is used as a conscious volitional maneuver, it appears to be reliant on the ability to recruit the intact pubovisceral muscle to simultaneously contract the urethral striated muscle.
Topics: Adult; Cohort Studies; Delivery, Obstetric; Extraction, Obstetrical; Female; Humans; Labor Stage, Second; Longitudinal Studies; Magnetic Resonance Imaging; Muscle Contraction; Obstetric Labor Complications; Obstetrical Forceps; Pelvic Floor; Physical Therapy Modalities; Postpartum Period; Pregnancy; Pressure; Recovery of Function; Urethra; Urinary Incontinence, Stress; Urodynamics; Young Adult
PubMed: 31765643
DOI: 10.1016/j.ajog.2019.11.1257 -
Acta Obstetricia Et Gynecologica... Apr 2020Malposition complicates 2-13% of births at delivery, leading to increased obstetric interventions (cesarean section and instrumental delivery) and higher rates of... (Comparative Study)
Comparative Study Observational Study
Babies in occiput posterior position are significantly more likely to require an emergency cesarean birth compared with babies in occiput transverse position in the second stage of labor: A prospective observational study.
INTRODUCTION
Malposition complicates 2-13% of births at delivery, leading to increased obstetric interventions (cesarean section and instrumental delivery) and higher rates of adverse fetal and maternal outcomes. Limited data are available regarding the likely rates of obstetric intervention and subsequent neonatal and maternal outcomes of births with babies in persistent occiput posterior position vs those in persistent occiput transverse position. The UK Audit and Research trainee Collaborative in Obstetrics and Gynecology (UK-ARCOG) network set out to collect data prospectively at delivery on final mode of delivery and immediate outcomes.
MATERIAL AND METHODS
The UK-ARCOG network collected data on all births with malposition of the fetal head complicating the second stage of labor (n = 838) (occiput posterior/occiput transverse) requiring rotational vaginal operative birth or emergency cesarean to expedite delivery across 66 participating UK National Health Service maternity units over a 1-month period. The outcomes considered were the need for emergency cesarean section without a trial of instrumental delivery, success of the first method of delivery employed in achieving a vaginal delivery and neonatal/maternal outcomes.
RESULTS
Obstetricians regarded assistance with an operative vaginal delivery method to be unsafe in 15% of babies in occiput posterior position and 6.1% of babies in occiput transverse position, and they were delivered by primary emergency cesarean section. When vaginal delivery was deemed safe (defined as attempted assisted vaginal rotational delivery), the first instrument attempted was successful in 74.4% of occiput posterior babies and 79.3% of occiput transverse babies.
CONCLUSIONS
Our data facilitates decision making by obstetricians to increase safety of assisted rotational operative delivery of a malpositioned baby at initial assessment and in counseling women. Until data from a well-designed randomized controlled trial of instrumental delivery vs emergency cesarean section are available, this manuscript provides contemporaneous national data from a high resource setting within a structured training program, to assist the selection of an appropriate instrument/method for the delivery of a malpositioned baby.
Topics: Adult; Cesarean Section; Emergencies; Extraction, Obstetrical; Female; Humans; Labor Presentation; Labor Stage, Second; Obstetric Labor Complications; Pregnancy; Prospective Studies; Version, Fetal; Young Adult
PubMed: 31667835
DOI: 10.1111/aogs.13765 -
BMC Pregnancy and Childbirth Aug 2019Though the rate of episiotomy has decreased in France, the overall episiotomy rate was 20% in the 2016 national perinatal survey. We aimed to develop a classification to...
BACKGROUND
Though the rate of episiotomy has decreased in France, the overall episiotomy rate was 20% in the 2016 national perinatal survey. We aimed to develop a classification to facilitate the analysis of episiotomy practices and to evaluate whether episiotomy is associated with a reduction in the rate of obstetric anal sphincter injuries (OASIS) for each subgroup.
METHODS
This population-based study included all the deliveries that occurred in the Burgundy Perinatal Network from 2011 to 2016. The main outcome was episiotomy, which was identified thanks to the French Common Classification of Medical Procedures. An ascending hierarchical cluster analysis was performed to build the classification. A clinical audit using the classification was conducted yearly in all obstetric units. The episiotomy rates were described throughout the study period for each subgroup of the classification. The OASIS rates were evaluated by subgroup and the association between mediolateral episiotomy and OASIS was investigated for each subgroup.
RESULTS
Our analyses included 81,290 pregnant women. The classification comprised 7 subgroups: nulliparous single cephalic at term, nulliparous single cephalic at term with instrumental delivery, multiparous single cephalic at term, multiparous single cephalic at term with instrumental delivery, all preterm deliveries (< 37 weeks gestation), all breech deliveries, all multiple deliveries. Episiotomy rates ranged from 6.2% in Group 3 to 40.9% in Group 2. From 2011 to 2016, every group except breech deliveries experienced a significant decrease in episiotomy rates, ranging from - 28.1 to - 61.0%. The prevalence of OASIS was the highest in Groups 2 (3.0%) and 4 (2.2%). Overall OASIS rates did not significantly differ with episiotomy use (P = 0.25). However, we found that the use of episiotomy was associated with a reduction in OASIS rates in Groups 1 and 2 (odds ratio 0.6 [95% CI 0.4-0.9] and 0.4 [0.3-0.5], respectively). This reduction was only observed in Group 4 with forceps delivery (odds ratio 0.4 [0.1-0.9]).
CONCLUSION
We developed the first classification for the evaluation of episiotomy practices based on 7 clinically relevant subgroups. This easy-to-use tool can help obstetricians and midwives improve their practices through self-assessment.
Topics: Adult; Anal Canal; Clinical Audit; Delivery, Obstetric; Episiotomy; Female; France; Humans; Obstetric Labor Complications; Obstetrics; Odds Ratio; Pregnancy; Young Adult
PubMed: 31419953
DOI: 10.1186/s12884-019-2424-2 -
BMC Research Notes Aug 2019The study aimed to determine proportion and risk factors for maternal complication related to forceps and vacuum delivery among mother who gave birth at Felege Hiwot...
OBJECTIVE
The study aimed to determine proportion and risk factors for maternal complication related to forceps and vacuum delivery among mother who gave birth at Felege Hiwot Comprehensive Specialized Hospital (FHCSH).
RESULTS
Records of 406 mothers managed with instrumental vaginal delivery were reviewed and 97% of the reviewed card had complete documentation. The proportion of maternal complications related to instrumental delivery was 12.1%. A major complication of forceps assisted delivery was 2nd-degree perineal tear (7.4%), 3rd-degree perineal tear (1.5%), cervical tear (1.5%) and episiotomy extension (1%). However, the complication of vacuum-assisted vaginal delivery was only cervical tear (0.5%) and episiotomy extension (0.5%). Episiotomy during instrumental delivery reduce maternal complication by 86% [AOR = 0.14, 95% CI 0.07-0.3]. Forceps assisted vaginal delivery had 3.4 times more risk for maternal complication compared to vacuum-assisted vaginal delivery [AOR = 3.4, 95% CI 1.08-10.67] and the same is true for primiparity that primipara women who gave birth by the help of instrument had 3.5 times more risk for maternal complication compared to a multipara women [AOR = 3.5, 95% CI 1.26-9.98].
Topics: Adult; Cross-Sectional Studies; Delivery, Obstetric; Ethiopia; Female; Hospitals, Special; Humans; Infant, Newborn; Obstetric Labor Complications; Parturition; Pregnancy; Retrospective Studies; Risk Factors; Vacuum Extraction, Obstetrical; Young Adult
PubMed: 31382987
DOI: 10.1186/s13104-019-4530-7 -
Ultrasound in Obstetrics & Gynecology :... Feb 2020To determine whether differences exist in the rate of levator ani muscle (LAM) avulsion between women who had undergone either Malmström vacuum delivery (MVD) or... (Observational Study)
Observational Study
OBJECTIVE
To determine whether differences exist in the rate of levator ani muscle (LAM) avulsion between women who had undergone either Malmström vacuum delivery (MVD) or Kielland forceps delivery (KFD), allowing for potential confounding factors.
METHODS
This was a prospective observational study of nulliparous women undergoing instrumental delivery using Malmström vacuum extractor or Kielland forceps, at two hospital centers in Spain. Fetal head position (anterior, posterior or transverse) and fetal head station (low or mid) were assessed by ultrasound and digital examination, respectively. Avulsion was defined on tomographic ultrasound imaging as an abnormal insertion of the LAM in the three central slices from the plane of minimal hiatal dimensions.
RESULTS
In total, 414 patients were included in the study (212 MVD and 202 KFD). We observed a higher rate of LAM avulsion in the KFD group (KFD 49.5% vs MVD 32.5%; P = 0.001). When the results were evaluated according to fetal head position and station, we observed no differences in LAM avulsion. The crude odds ratio (OR) for the difference in avulsion between women in the KFD and MVD groups was 2.03 (95% CI, 1.36-3.03). However, when adjusted for duration of second stage of labor, fetal head circumference and fetal head station, the OR was no longer statistically significant (OR, 2.14 (95% CI, 0.95-4.85); P = 0.068).
CONCLUSION
When potential confounding factors are taken into account, the rate of LAM avulsion does not differ between women according to whether they have undergone KFD or MVD. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Topics: Adult; Female; Fetus; Humans; Labor Presentation; Obstetric Labor Complications; Obstetrical Forceps; Odds Ratio; Pelvic Floor; Pregnancy; Prospective Studies; Spain; Ultrasonography, Prenatal; Vacuum Extraction, Obstetrical
PubMed: 31332857
DOI: 10.1002/uog.20404 -
Acta Obstetricia Et Gynecologica... Nov 2019Forceps use is the main risk factor for levator ani muscle (LAM) injuries. We believe that the disengagement of the forceps branches before delivery of the fetal head... (Comparative Study)
Comparative Study Observational Study
INTRODUCTION
Forceps use is the main risk factor for levator ani muscle (LAM) injuries. We believe that the disengagement of the forceps branches before delivery of the fetal head could influence LAM injuries, so we aimed to determine the influence of the disengagement of the forceps on the occurrence of LAM avulsion during forceps delivery.
MATERIAL AND METHODS
A prospective, observational, multicenter study was conducted with 261 women who underwent forceps delivery. The women were classified according to whether the branches of the forceps had been disengaged before delivery of the fetal head. LAM avulsion was defined using a multislice mode (3 central slices).
RESULTS
In all, 255 women completed the study (160 without disengagement and 95 with disengagement). LAM avulsions were observed in 37.9% of women in the group with disengagement and in 41.9% of women in the group without disengagement. The crude OR (without disengagement vs with disengagement) for avulsion was 0.90 (95% CI 0.49-1.67, P = 0.757) and an adjusted OR of 0.82 (95% CI 0.40-1.69, P = 0.603).
CONCLUSIONS
We did not observe a statistically significant reduction in the LAM avulsion rate with disengagement of the forceps branches before delivery of the fetal head.
Topics: Anal Canal; Delivery, Obstetric; Extraction, Obstetrical; Female; Follow-Up Studies; Humans; Logistic Models; Male; Maternal Age; Monte Carlo Method; Obstetric Labor Complications; Obstetrical Forceps; Odds Ratio; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Prospective Studies; Risk Assessment; Treatment Outcome; United States
PubMed: 31243757
DOI: 10.1111/aogs.13682 -
Anales de Pediatria Dec 2019The purpose of this study was to assess the neonatal morbidity and mortality associated with vacuum-assisted vaginal deliveries compared to all other vaginal deliveries,... (Comparative Study)
Comparative Study
INTRODUCTION
The purpose of this study was to assess the neonatal morbidity and mortality associated with vacuum-assisted vaginal deliveries compared to all other vaginal deliveries, and to identify the associated risk factors.
MATERIAL AND METHODS
We conducted a retrospective case-control study in a level iii maternity hospital between 2012 and 2016, including 1,802 vacuum-assisted vaginal deliveries and 2control groups: 1802 spontaneous deliveries and 909 forceps-assisted deliveries. We considered minor complications (soft tissue trauma, cephalohaematoma, jaundice, intensive phototherapy, transient brachial plexus injury) and major complications (hypoxic-ischaemic encephalopathy, intracranial and subgaleal haemorrhage, seizures, cranial fracture, permanent brachial plexus injury), admission to the neonatal intensive care unit and death.
RESULTS
The risk of soft tissue trauma (aOR, 2.4; P<.001), cephalohaematoma (aOR, 5.5; P<.001), jaundice (aOR, 4.4; P<.001), intensive phototherapy (aOR, 2.1; P<.001) and transient brachial plexus injury (aOR; 2.1, P=.006) was higher in vacuum deliveries compared to spontaneous deliveries. Admission to the neonatal intensive care unit was also higher in vacuum deliveries compared to spontaneous deliveries (OR, 1.9; P=.001). When we compared vacuum with forceps deliveries, we found a higher risk of soft tissue trauma (OR, 2.1; P=.004), cephalohaematoma (OR, 2.2, P=.046) and jaundice (OR, 1.4; P=.012). Major complications were more frequent in the vacuum group comparing with the control groups, but the difference was not significant. The 2deaths occurred in vacuum deliveries (1.1 per 1000).
CONCLUSION
The proportion of minor neonatal complications was higher in the vacuum-assisted delivery group. Although major complications and death were also more frequent, they were uncommon, with no significant differences compared to the other groups. There are obstetrical indications for vacuum delivery, but it should alert to the need to watch for potential neonatal complications.
Topics: Adult; Birth Injuries; Case-Control Studies; Delivery, Obstetric; Female; Humans; Infant, Newborn; Male; Pregnancy; Retrospective Studies; Risk Factors; Vacuum Extraction, Obstetrical
PubMed: 30981643
DOI: 10.1016/j.anpedi.2018.11.016 -
American Journal of Perinatology Apr 2020This study aimed to evaluate whether the number of vacuum pop-offs, the number of forceps pulls, or the duration of operative vaginal delivery (OVD) is associated with... (Observational Study)
Observational Study
OBJECTIVE
This study aimed to evaluate whether the number of vacuum pop-offs, the number of forceps pulls, or the duration of operative vaginal delivery (OVD) is associated with adverse maternal and perinatal outcomes.
STUDY DESIGN
This is a secondary analysis of a multicenter observational cohort of women who underwent an attempted OVD. Women were stratified by the duration of OVD and the number of pop-offs (vacuum) or pulls (forceps) attempted. Severe perineal lacerations, failed OVD, and a composite adverse neonatal outcome were compared by the duration of OVD and number of pop-offs or pulls.
RESULTS
Of the 115,502 women in the primary cohort, 5,325 (4.6%) underwent an attempt at OVD: 3,594 (67.5%) with vacuum and 1,731 (32.5%) with forceps. After adjusting for potential confounders, an increasing number of pop-offs was associated with an increased odds of the composite adverse neonatal outcome. However, an increasing duration of vacuum exhibited a stronger association with the composite adverse neonatal outcome. Similarly, the number of forceps pulls was less strongly associated with the composite adverse neonatal outcome compared with the duration of forceps application.
CONCLUSION
The duration of OVD may be more associated with adverse neonatal outcomes than the number of pop-offs or pulls.
Topics: Adult; Extraction, Obstetrical; Female; Humans; Infant, Newborn; Infant, Newborn, Diseases; Lacerations; Obstetric Labor Complications; Obstetrical Forceps; Operative Time; Pregnancy; Treatment Failure; Vacuum Extraction, Obstetrical
PubMed: 30895577
DOI: 10.1055/s-0039-1683439 -
Female Pelvic Medicine & Reconstructive... 2020Obstetric levator avulsion may be an important risk factor for prolapse. This study compares the size of the levator hiatus, the width of the genital hiatus, and pelvic...
OBJECTIVES
Obstetric levator avulsion may be an important risk factor for prolapse. This study compares the size of the levator hiatus, the width of the genital hiatus, and pelvic muscle strength between vaginally parous women with or without levator avulsion, 5 to 15 years after delivery.
METHODS
Parous women were assessed for levator ani avulsion, using 3-dimensional transperineal ultrasound. Women with and without levator ani avulsion were compared with respect to levator hiatus areas (measured on ultrasound), genital hiatus (measured on examination), and pelvic muscle strength (measured with perineometry). Further analysis also considered the association of forceps-assisted birth.
RESULTS
At a median interval of 11 years from first delivery, levator avulsion was identified in 15% (66/453). A history of forceps-assisted delivery was strongly associated with levator avulsion (45% vs 8%; P < 0.001). Levator avulsion was also associated with a larger levator hiatus area (+7.3 cm; 95% confidence interval [CI], 4.1-10.4, with Valsalva), wider genital hiatus (+0.6 cm; 95% CI, 0.3-0.9, with Valsalva), and poorer muscle strength (-14.5 cm H2O; 95% CI, -20.4 to -8.7, peak pressure). Among those with levator avulsion, forceps-assisted birth was associated with a marginal increase in levator hiatus size but not genital hiatus size or muscle strength.
CONCLUSIONS
Obstetric levator avulsion is associated with a larger levator hiatus, wider genital hiatus, and poorer pelvic muscle strength. Forceps-assisted birth is an important marker for levator avulsion but may not be an independent risk factor for the development of pelvic muscle weakness or changes in hiatus size in the absence of levator avulsion.
Topics: Adult; Anal Canal; Case-Control Studies; Extraction, Obstetrical; Female; Humans; Imaging, Three-Dimensional; Longitudinal Studies; Middle Aged; Muscle Strength; Pelvic Floor; Pelvic Organ Prolapse; Pregnancy; Risk Factors; Ultrasonography
PubMed: 30272594
DOI: 10.1097/SPV.0000000000000641