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Scientific Reports May 2024To investigate neonatal injuries, morbidities and risk factors related to vaginal deliveries. This retrospective, descriptive study identified 3500 patients who...
To investigate neonatal injuries, morbidities and risk factors related to vaginal deliveries. This retrospective, descriptive study identified 3500 patients who underwent vaginal delivery between 2020 and 2022. Demographic data, neonatal injuries, complications arising from vaginal delivery and pertinent risk factors were documented. Neonatal injuries and morbidities were prevalent in cases of assisted vacuum delivery, gestational diabetes mellitus class A2 (GDMA2) and pre-eclampsia with severe features. Caput succedaneum and petechiae were observed in 291/3500 cases (8.31%) and 108/3500 cases (3.09%), respectively. Caput succedaneum was associated with multiparity (adjusted odds ratio [AOR] 0.36, 95% confidence interval [CI] 0.22-0.57, P < 0.001) and assisted vacuum delivery (AOR 5.18, 95% CI 2.60-10.3, P < 0.001). Cephalohaematoma was linked to GDMA2 (AOR 11.3, 95% CI 2.96-43.2, P < 0.001) and assisted vacuum delivery (AOR 16.5, 95% CI 6.71-40.5, P < 0.001). Scalp lacerations correlated with assisted vacuum and forceps deliveries (AOR 6.94, 95% CI 1.85-26.1, P < 0.004; and AOR 10.5, 95% CI 1.08-102.2, P < 0.042, respectively). Neonatal morbidities were associated with preterm delivery (AOR 3.49, 95% CI 1.39-8.72, P = 0.008), night-time delivery (AOR 1.32, 95% CI 1.07-1.63, P = 0.009) and low birth weight (AOR 7.52, 95% CI 3.79-14.9, P < 0.001). Neonatal injuries and morbidities were common in assisted vacuum delivery, maternal GDMA2, pre-eclampsia with severe features, preterm delivery and low birth weight. Cephalohaematoma and scalp lacerations were prevalent in assisted vaginal deliveries. Most morbidities occurred at night.Clinical trial registration: Thai Clinical Trials Registry 20220126004.
Topics: Humans; Female; Pregnancy; Risk Factors; Infant, Newborn; Adult; Retrospective Studies; Vacuum Extraction, Obstetrical; Delivery, Obstetric; Birth Injuries; Infant, Newborn, Diseases; Diabetes, Gestational; Pre-Eclampsia
PubMed: 38796580
DOI: 10.1038/s41598-024-62703-x -
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 -
Acta Chirurgica Belgica May 2024History has paid little attention to the childbirth of Marie Louise, second wife to the Emperor Napoleon I. Most historians state that the obstetrician Antoine Dubois... (Review)
Review
BACKGROUND
History has paid little attention to the childbirth of Marie Louise, second wife to the Emperor Napoleon I. Most historians state that the obstetrician Antoine Dubois needed to use his forceps during a difficult breech delivery. As practicing obstetricians we aimed to reconstruct the likely course of events using a forensic approach.
METHODS
We have consulted historical documents and key witness accounts as primary sources. We have followed the clinical guidance of the 1807 edition of 'l'Art des Accouchemens'. We have tested a new hypothesis of the possible course of the childbirth through a simulation using the Assisted Vaginal Birth Module PROMPT Flex CDE® as an obstetrical model and an authentic Levret forceps.
DISCUSSION
A transverse lie with hip presentation is the most plausible diagnosis of the foetal malposition that complicated the delivery of Marie Louise by Antoine Dubois. The long duration of the delivery of the entrapped foetal head and the insistence on the presence of his colleague Corvisart by Antoine Dubois can be explained through our hypothesis that the occiput of the entrapped foetal head was very likely in a transverse position. The seemingly impossible application of a forceps in this position, had already been described in the nineteenth century both in France and outside.
CONCLUSION
Our simulation confirmed the practicability of the application of the forceps as assumed by our hypothesis. Definitive proof that this scenario actually happened, cannot be given because there are no written first-hand accounts by Dubois on the delivery.
PubMed: 38696140
DOI: 10.1080/00015458.2024.2350803 -
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 -
Journal of Obstetrics and Gynaecology... Mar 2024
Topics: Pregnancy; Female; Humans; Delivery, Obstetric; Extraction, Obstetrical; Surgical Instruments; Canada; Obstetrical Forceps; Vacuum Extraction, Obstetrical
PubMed: 38548448
DOI: 10.1016/j.jogc.2023.102325 -
American Journal of Obstetrics &... Apr 2024Poor outcomes from operative vaginal birth have been associated with failure to recognize malposition, breakdown in interdisciplinary communication, and deviation from...
BACKGROUND
Poor outcomes from operative vaginal birth have been associated with failure to recognize malposition, breakdown in interdisciplinary communication, and deviation from accepted guidelines. We recently implemented a safety bundle including routine intrapartum ultrasound and a structured time-out and procedural checklist aiming to reduce maternal and perinatal morbidity from operative vaginal birth.
OBJECTIVE
This study aimed to compare births where intrapartum ultrasound was used and those where it was not used during a safety bundle implementation period at Monash Health.
STUDY DESIGN
We performed a retrospective cohort study at Monash Health during the transitional phase of implementing an operative vaginal birth safety bundle. We studied all women with operative vaginal birth and fully dilated cesarean delivery with a singleton cephalic term fetus. We compared births for which intrapartum ultrasound was used and those for which it was not. The primary outcome was neonates delivered in an unexpected position. Neonatal and maternal morbidity were also assessed, including a neonatal composite of Apgar score <7 at 5 minutes, cord lactate >8 mmol/L, need for resuscitation, significant birth trauma, or neonatal intensive care unit admission. To control for confounding by indication, we estimated propensity scores for the probability of using intrapartum ultrasound for each case based on maternal and labor characteristics, and adjusted the effect estimates for the propensity scores using multivariable logistic regression models.
RESULTS
From August 2022 to July 2023, there were 1205 operative vaginal births or fully dilated cesarean deliveries at Monash Health, including 743 (61.7%) forceps, 346 (28.7%) vacuum, and 116 (9.6%) fully dilated cesarean deliveries. Over this time, we observed increased uptake of intrapartum ultrasound from 26% in August 2022 to 60% (P<.001) in July 2023, of the time-out from 21% to 58% (P<.001), and the checklist from 33% to 80% (P<.001) of operative second-stage births. Among the births where intrapartum ultrasound was used (n=509), compared with those where it was not (n=696), there were significantly more forceps births (67% vs 58%; adjusted odds ratio, 1.35; 95% confidence interval, 1.05-1.74; P=.021) and a reduction in vacuum births (24% vs 32%; adjusted odds ratio, 0.77; 95% confidence interval, 0.58-1.01; P=.059). There were no significant differences in fully dilated cesarean delivery or maternal morbidity. Intrapartum ultrasound use was associated with significantly fewer infants being delivered in an unexpected position (0.2% vs 2.2%; adjusted odds ratio, 0.08; 95% confidence interval, 0.00-0.44; P=.019) and a significant reduction in composite neonatal morbidity (22% vs 25%; adjusted odds ratio, 0.73; 95% confidence interval, 0.54-0.97; P=.031).
CONCLUSION
During the implementation of a safety bundle, the use of ultrasound before operative vaginal birth was associated with fewer infants delivered in an unexpected position and reduced neonatal morbidity.
Topics: Humans; Female; Retrospective Studies; Pregnancy; Adult; Infant, Newborn; Cesarean Section; Ultrasonography, Prenatal; Apgar Score; Extraction, Obstetrical; Cohort Studies; Propensity Score; Checklist; Vacuum Extraction, Obstetrical
PubMed: 38479490
DOI: 10.1016/j.ajogmf.2024.101345 -
American Journal of Obstetrics and... Mar 2024Decreasing rates of assisted vaginal birth have been paralleled with increasing rates of cesarean deliveries over the last 40 years. The OdonAssist is a novel device for... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Decreasing rates of assisted vaginal birth have been paralleled with increasing rates of cesarean deliveries over the last 40 years. The OdonAssist is a novel device for assisted vaginal birth. Iterative changes to clinical parameters, device design, and technique have been made to improve device efficacy and usability.
OBJECTIVE
This study aimed to determine if the feasibility, safety, and efficacy of the OdonAssist device were sufficient to justify conducting a future randomized controlled trial.
STUDY DESIGN
An open-label nonrandomized study of 104 participants having a clinically indicated assisted vaginal birth using the OdonAssist was undertaken at Southmead Hospital, Bristol, United Kingdom. Data were also collected from participants who consented to participate in the study but for whom trained OdonAssist operators were not available, providing a nested cohort. The primary clinical outcome was the proportion of births successfully expedited with the OdonAssist. Secondary outcomes included clinical, patient-reported, operator-reported, device and health care utilization. Neonatal outcome data were reviewed at day 28, and maternal outcomes were investigated up to day 90. Given that the number of successful OdonAssist births was ≥61 out of 104, the hypothesis of a poor rate of 50% was rejected in favor of a good rate of ≥65%.
RESULTS
Between August 2019 and June 2021, 941 (64%) of the 1471 approached, eligible participants consented to participate. Of these, 104 received the OdonAssist intervention. Birth was assisted in all cephalic vertex fetal positions, at all stations ≥1 cm below the ischial spines (with or without regional analgesia). The OdonAssist was effective in 69 of the 104 (66%) cases, consistent with the hypothesis of a good efficacy rate. There were no serious device-related maternal or neonatal adverse reactions, and there were no serious adverse device effects. Only 4% of neonatal soft tissue bruising in the successful OdonAssist group was considered device-related, as opposed to 20% and 23% in the unsuccessful OdonAssist group and the nested cohort, respectively. Participants reported high birth perception scores. All practitioners found the device use to be straightforward.
CONCLUSION
Recruitment to an interventional study of a new device for assisted vaginal birth is feasible; 64% of eligible participants were willing to participate. The success rate of the OdonAssist was comparable to that of the Kiwi OmniCup when introduced in the same unit in 2002, meeting the threshold for a randomized controlled trial to compare the OdonAssist with current standard practice. There were no disadvantages of study participation in terms of maternal and neonatal outcomes. There were potential advantages of using the OdonAssist, particularly reduced neonatal soft tissue injury. The same application technique is used for all fetal positions, with all operators deeming the device straightforward to use. This study provides important data to inform future study design.
Topics: Female; Infant, Newborn; Pregnancy; Humans; Cesarean Section; Head; United Kingdom; Vagina
PubMed: 38462264
DOI: 10.1016/j.ajog.2023.05.018 -
American Journal of Obstetrics and... Mar 2024Assisted vaginal birth rates are falling globally with rising cesarean delivery rates. Cesarean delivery is not without consequence, particularly when carried out in the... (Review)
Review
Assisted vaginal birth rates are falling globally with rising cesarean delivery rates. Cesarean delivery is not without consequence, particularly when carried out in the second stage of labor. Cesarean delivery in the second stage is not entirely protective against pelvic floor morbidity and can lead to serious complications in a subsequent pregnancy. It should be acknowledged that the likelihood of morbidity for mother and baby associated with cesarean delivery increases with advancing labor and is greater than spontaneous vaginal birth, irrespective of the method of operative birth in the second stage of labor. In this article, we argue that assisted vaginal birth is a skilled and safe option that should always be considered and be available as an option for women who need assistance in the second stage of labor. Selecting the most appropriate mode of birth at full dilatation requires accurate clinical assessment, supported decision-making, and personalized care with consideration for the woman's preferences. Achieving vaginal birth with the primary instrument is more likely with forceps than with vacuum extraction (risk ratio, 0.58; 95% confidence interval, 0.39-0.88). Midcavity forceps are associated with a greater incidence of obstetric anal sphincter injury (odds ratio, 1.83; 95% confidence interval, 1.32-2.55) but no difference in neonatal Apgar score or umbilical artery pH. The risk for adverse outcomes is minimized when the procedure is conducted by a skilled accoucheur who selects the most appropriate instrument likely to achieve vaginal birth with the primary instrument. Anticipation of potential complications and dynamic decision-making are just as important as the technique for safe instrument use. Good communication with the woman and the birthing partner is vital and there are various recommendations on how to achieve this. There have been recent developments (such as OdonAssist) in device innovation, training, and strategies for implementation at a scale that can provide opportunities for both improved outcomes and reinvigoration of an essential skill that can save mothers' and babies' lives across the world.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Cesarean Section; Vacuum Extraction, Obstetrical; Labor, Obstetric; Anal Canal; Mothers; Delivery, Obstetric; Retrospective Studies
PubMed: 38462263
DOI: 10.1016/j.ajog.2022.12.305 -
European Journal of Obstetrics,... May 2024To assess the utility of Art & Craft - a new, hands-on course on Advanced Rotational Techniques and safe Caesarean biRth at Advanced/Full dilation Training aimed at...
OBJECTIVES
To assess the utility of Art & Craft - a new, hands-on course on Advanced Rotational Techniques and safe Caesarean biRth at Advanced/Full dilation Training aimed at senior Obstetrics trainees. The aims were to assess whether it improved confidence and skills in rotational vaginal birth, impacted fetal head at caesarean, and ultrasound for fetal position.
STUDY DESIGN
With ethical approval, pre- and post- course questionnaires and post- course interviews of attendees were conducted. A pre course questionnaire was emailed 1 week before the course. Attendees were asked to rate their confidence levels in performing vaginal examination and ultrasound assessment of fetal position, rotational ventouse, manual rotation, Kielland's rotational forceps, and disimpaction of the fetal head during second stage caesarean on a scale of 1 to 5. 1 = not confident at all and 5 = very confident. A post-course questionnaire with the same questions was emailed 3 days after. p values for differences in scores were calculated using the Wilcoxon signed rank test using Stata/MP 18 software.
RESULTS
32 trainees attended the course. 28 questionnaires were available for analysis. The majority 39 % were middle grade (ST3-ST5) level. Initial confidence was very low for rotational forceps (median 1/5). After attending the course and practical stations, respondents' confidence levels increased significantly (p < 0.05) across all domains; vaginal examination from 4 to 5, ultrasound for fetal position, rotational ventouse, and manual rotation from 3 to 5, disimpaction from 4 to 4.5, and Kielland's rotational forceps from 1 to 4. Nine participated in post course interviews, which were thematically analysed. Participants expressed that the course gave them the opportunity to ask specific questions from experts to improve their confidence. A barrier to learning new methods was highlighted in that it is difficult to receive practical training in Kielland's, resulting in low confidence.
CONCLUSION
A practical, hands-on course on complex operative birth significantly increases trainee confidence levels in vaginal examination, ultrasound for fetal position, disimpaction, and techniques for rotational vaginal birth. The evaluation highlights that continued education and practise is required, even when trainees are senior. Evaluation of clinical outcomes after training is needed; and planned.
Topics: Pregnancy; Humans; Female; Cesarean Section; Extraction, Obstetrical; Obstetrical Forceps; Obstetrics
PubMed: 38432018
DOI: 10.1016/j.ejogrb.2024.02.046 -
Journal of Obstetrics and Gynaecology... May 2024To quantify variation in the association between episiotomy and obstetric anal sphincter injury (OASI) by maternity care provider in spontaneous and operative vaginal...
OBJECTIVES
To quantify variation in the association between episiotomy and obstetric anal sphincter injury (OASI) by maternity care provider in spontaneous and operative vaginal deliveries (SVDs and OVDs).
METHODS
Population-based retrospective cohort study of vaginal, term deliveries among nullipara in Canada (2004-2015). Adjusted rate ratios (ARRs) and 95% CIs were estimated using log-binomial regression to quantify the associations between episiotomy and OASI, stratified by care provider (obstetrician [OB], family physician [FP], or registered midwife [RM]) while adjusting for potential confounders.
RESULTS
The study included 631 642 deliveries. Episiotomy use varied by provider: among SVDs, the episiotomy rate was 19.6%, 14.4%, and 8.4% in the OB, FP, and RM groups, respectively. The rate of OASI was higher among SVDs with versus without episiotomy (5.8% vs 4.6%). Conversely, OASI occurred less frequently in operative vaginal deliveries with episiotomy (15.3%) compared with those without (16.7%). In all provider groups, the ARR for OASI was increased with episiotomy in SVD and decreased with episiotomy with forceps delivery. No differences in these associations were observed by provider except among vacuum delivery (ARR with episiotomy vs. without, OB: 0.88, 95% CI 0.84-0.92; FP: 0.89, 95% CI 0.83-0.96, RM: 1.22, 95% CI 1.02-1.48).
CONCLUSIONS
In nullipara, irrespective of maternity care provider, there is a positive association between episiotomy and OASI among SVDs and an inverse association between episiotomy and deliveries with forceps. The relationship between episiotomy and OASI is modified by maternity care providers among vacuum deliveries.
Topics: Humans; Episiotomy; Female; Anal Canal; Pregnancy; Retrospective Studies; Adult; Parity; Canada; Obstetrics; Obstetric Labor Complications; Young Adult; Midwifery; Physicians, Family; Delivery, Obstetric
PubMed: 38387834
DOI: 10.1016/j.jogc.2024.102415