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AJP Reports Jul 2020Residency applicants often express concern that fellows negatively impact surgical opportunities, especially with less common procedures. We sought to describe the...
Residency applicants often express concern that fellows negatively impact surgical opportunities, especially with less common procedures. We sought to describe the impact of maternal-fetal medicine (MFM) fellows on resident surgical opportunities. Anonymous 27-question e-survey sent to obstetrics and gynecology (OBGYN) residents in the United States and Puerto Rico in March 2018. Questions included experience as primary surgeon, for fourth year residents only, comfort performing procedures postresidency, and demographics. Residents from programs with MFM fellows (pMFM) were compared with those without (nMFM). Descriptive statistics used as appropriate. Regression was performed, controlling for significant variables. A total of 417 residents completed the survey; 275 (66%) from nMFM and 142 (33%) from pMFM. PMFM residents were more likely to have >7 residents/year, be from an academic residency, and less likely to be planning to practice obstetrics postresidency (all, < 0.01). Plan to pursue MFM fellowship did not differ. NMFM residents were more likely to have been primary surgeon on a vacuum assisted delivery (77 vs. 63%, < 0.01). No difference in primary surgeon experience was seen for forceps delivery, breech deliveries, third- or fourth-degree repairs, cerclage, or cesarean hysterectomy. With regard to comfort performing procedures postresidency, vacuum-assisted vaginal delivery (VAVD) was more likely among nMFM trainees, no other differences seen. In regression models, no differences in likelihood of comfort performing procedures postresidency for any procedures based on the presence of MFM fellows were seen. Among pMFM residents, 94% stated fellows positively impacted their learning. MFM fellows do not appear to impact residents' perceived competency in obstetric procedures and the majority of trainees report that fellows positively impact their education.
PubMed: 33094022
DOI: 10.1055/s-0040-1715168 -
Anesthesiology Jan 2021Up to 84% of women who undergo operative vaginal delivery receive neuraxial analgesia. However, little is known about the association between neuraxial analgesia and...
BACKGROUND
Up to 84% of women who undergo operative vaginal delivery receive neuraxial analgesia. However, little is known about the association between neuraxial analgesia and neonatal morbidity in women who undergo operative vaginal delivery. The authors hypothesized that neuraxial analgesia is associated with a reduced risk of neonatal morbidity among women undergoing operative vaginal delivery.
METHODS
Using United States birth certificate data, the study identified women with singleton pregnancies who underwent operative vaginal (forceps- or vacuum-assisted delivery) in 2017. The authors examined the relationships between neuraxial labor analgesia and neonatal morbidity, the latter defined by any of the following: 5-min Apgar score less than 7, immediate assisted ventilation, assisted ventilation greater than 6 h, neonatal intensive care unit admission, neonatal transfer to a different facility within 24 h of delivery, and neonatal seizure or serious neurologic dysfunction. The authors accounted for sociodemographic and obstetric factors as potential confounders in their analysis.
RESULTS
The study cohort comprised 106,845 women who underwent operative vaginal delivery, of whom 92,518 (86.6%) received neuraxial analgesia. The proportion of neonates with morbidity was higher in the neuraxial analgesia group than the nonneuraxial group (10,409 of 92,518 [11.3%] vs. 1,271 of 14,327 [8.9%], respectively; P < 0.001). The unadjusted relative risk was 1.27 (95% CI, 1.20 to 1.34; P < 0.001); after accounting for confounders using a multivariable model, the adjusted relative risk was 1.19 (95% CI, 1.12 to 1.26; P < 0.001). In a post hoc analysis, after excluding neonatal intensive care unit admission and neonatal transfer from the composite outcome, the effect of neuraxial analgesia on neonatal morbidity was not statistically significant (adjusted relative risk, 1.07; 95% CI, 1.00 to 1.16; P = 0.054).
CONCLUSIONS
In this population-based cross-sectional study, a neonatal benefit of neuraxial analgesia for operative vaginal delivery was not observed. Confounding by indication may explain the observed association between neuraxial analgesia and neonatal morbidity, however this dataset was not designed to evaluate such considerations.
Topics: Adult; Analgesia, Obstetrical; Apgar Score; Cohort Studies; Cross-Sectional Studies; Delivery, Obstetric; Female; Humans; Infant, Newborn; Infant, Newborn, Diseases; Male; Obstetrical Forceps; Pregnancy; Respiration, Artificial; Retrospective Studies; Risk Assessment; United States; Vacuum Extraction, Obstetrical; Young Adult
PubMed: 33045040
DOI: 10.1097/ALN.0000000000003589 -
BMC Pregnancy and Childbirth Oct 2020Pre-pregnancy obesity and excessive gestational weight gain (GWG) are established risk factors for adverse pregnancy, delivery and birth outcomes. Pregnancy is an ideal...
BACKGROUND
Pre-pregnancy obesity and excessive gestational weight gain (GWG) are established risk factors for adverse pregnancy, delivery and birth outcomes. Pregnancy is an ideal moment for nutritional interventions in order to establish healthier lifestyle behaviors in women at high risk of obstetric and neonatal complications.
METHODS
Electronic-Personalized Program for Obesity during Pregnancy to Improve Delivery (ePPOP-ID) is an open multicenter randomized controlled trial which will assess the efficacy of an e-health web-based platform offering a personalized lifestyle program to obese pregnant women in order to reduce the rate of labor procedures and delivery interventions in comparison to standard care. A total of 860 eligible pregnant women will be recruited in 18 centers in France between 12 and 22 weeks of gestation, randomized into the intervention or the control arm and followed until 10 weeks of postpartum. The intervention is based on nutrition, eating behavior, physical activity, motivation and well-being advices in which personalization is central, as well as the use of a mobile/tablet application. Inputs includes data from the medical record of participants (medical history, anthropometric data), from the web platform (questionnaires on dietary habits, eating behavior, physical activity and motivation in both groups), and adherence to the program (time of connection for the intervention group only). Data are collected at inclusion, 32 weeks, delivery and 10 weeks postpartum. As primary outcome, we will use a composite endpoint score of obstetrical interventions during labor and delivery, defined as caesarean section and instrumental delivery (forceps and vacuum extractor). Secondary outcomes will consist of data routinely collected as part of usual antenatal and perinatal care, such as GWG, hypertension, preeclampsia, as well as fetal and neonatal outcomes including premature birth, gestational age at birth, birth weight, macrosomia, Apgar score, arterial umbilical cord pH, neonatal traumatism, hyperbilirubinemia, respiratory distress syndrome, transfer in neonatal intensive care unit, and neonatal adiposity. Post-natal outcomes will be duration of breastfeeding, maternal weight retention and child weight at postnatal visit.
DISCUSSION
The findings of the ePPOP-ID trial will help design e-health intervention program for obese women in pregnancy.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02924636 / October 5th 2016.
Topics: Adult; Apgar Score; Birth Weight; Cesarean Section; Extraction, Obstetrical; Female; Follow-Up Studies; Gestational Weight Gain; Healthy Lifestyle; Humans; Infant, Newborn; Internet-Based Intervention; Multicenter Studies as Topic; Obesity, Maternal; Obstetric Labor Complications; Patient Compliance; Postnatal Care; Postpartum Period; Pregnancy; Prenatal Care; Randomized Controlled Trials as Topic; Risk Factors; Risk Reduction Behavior; Treatment Outcome
PubMed: 33028261
DOI: 10.1186/s12884-020-03288-x -
American Family Physician Oct 2020
Review
Topics: Adult; Antibiotic Prophylaxis; Extraction, Obstetrical; Female; Humans; Obstetrical Forceps; Pregnancy; Prenatal Care; Puerperal Disorders; Randomized Controlled Trials as Topic; Surgical Wound Infection; Vacuum Extraction, Obstetrical
PubMed: 32996760
DOI: No ID Found -
Proceedings of the Institution of... Jan 2021Complications during childbirth result in the need for clinicians to use 'assisted delivery' in over 12% of cases (UK). After more than 50 years in clinical practice,... (Review)
Review
Complications during childbirth result in the need for clinicians to use 'assisted delivery' in over 12% of cases (UK). After more than 50 years in clinical practice, vacuum assisted delivery (VAD) devices remain a mainstay in physically assisting child delivery; sometimes preferred over forceps due to their ease of use and reduced maternal morbidity. Despite their popularity and enduring track-record, VAD devices have shown little evidence of innovation or design change since their inception. In addition, evidence on the safety and functionality of VAD devices remains limited but does present opportunities for improvements to reduce adverse clinical outcomes. Consequently in this review we examine the literature and patent landscape surrounding VAD biomechanics, design evolution and performance from an engineering perspective, aiming to collate the limited but valuable information from a disparate field and provide a series of recommendations to inform future research into improved, safer, VAD systems.
Topics: Child; Female; Humans; Obstetrics; Pregnancy; Vacuum Extraction, Obstetrical
PubMed: 32928047
DOI: 10.1177/0954411920956467 -
International Health Feb 2021To observe prevalence, characteristics and outcomes associated with operative vaginal birth (OVB).
BACKGROUND
To observe prevalence, characteristics and outcomes associated with operative vaginal birth (OVB).
METHODS
We compared spontaneous vaginal birth with OVB.
RESULTS
Of 993 women, 759 (76.4%) experienced vaginal birth; 716 were spontaneous (94.3%), 14 (1.8%) underwent forceps-assisted birth and 29 (3.8%) had vacuum assistance. In a multivariable model of OVB (forceps and vacuum), compared with a midwife, general practitioners (OR 5.6, p = 0.04) and integrated emergency surgical officers (OR 42.8, p = 0.001) were more likely to attend. Women experiencing OVB were more likely to receive local anesthesia (OR 3.0, p = 0.009).
CONCLUSION
OVB is used sparingly but safely at Mizan-Tepi University Teaching Hospital.
Topics: Delivery, Obstetric; Female; Hospitals, Teaching; Humans; Parturition; Pregnancy; Prevalence; Universities; Vacuum Extraction, Obstetrical
PubMed: 32478380
DOI: 10.1093/inthealth/ihaa024 -
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 -
Acta Obstetricia Et Gynecologica... Sep 2020The effects of levator ani muscle (LAM) avulsion after instrumental delivery on the sexual function of patients are currently unknown. Therefore, the objective of our...
INTRODUCTION
The effects of levator ani muscle (LAM) avulsion after instrumental delivery on the sexual function of patients are currently unknown. Therefore, the objective of our study was to use a validated questionnaire, namely, the Female Sexual Function Index (FSFI), to compare the sexual function in patients with and without LAM avulsion after instrumental vaginal delivery.
MATERIAL AND METHODS
This was a prospective observational study of 112 primiparous women after instrumental (vacuum or forceps) vaginal delivery. The obstetric and general characteristics of the population were studied. At 6 months postpartum, the contraceptive method used and the occurrence of LAM avulsion (using four-dimensional transperineal ultrasound) were determined, and the FSFI was administered.
RESULTS
A total of 100 patients (62 without avulsion and 38 with avulsion) completed the study. Thirty-eight (38%) were diagnosed with avulsion (42.1% after Kielland forceps delivery, 57.9% after Malmström vacuum delivery; P = .837). Women with LAM avulsion had significantly lower scores for desire (2.9 ± 1.2 vs 3.4 ± 1.1; P = .049), arousal (2.8 ± 1.7 vs 3.6 ± 1.4; P = .014), lubrication (2.3 ± 1.4 vs 3.0 ± 1.2; P = .011), orgasm (2.6 ± 1.6 vs 3.3 ± 1.2; P = .006) and satisfaction (3.1 ± 1.8 vs 3.9 ± 1.5; P = .051) than did women without LAM avulsion. The overall FSFI score was lower in patients with avulsion (16.7 ± 8.9 vs 20.7 ± 6.9, P = .033). These results were obtained after controlling for confounders (delivery mode, induced labor, birthweight, perineal tears, avulsion degree, contraceptive method and group assignment for the parent study) in the multivariate analysis (F = 4.974, P = .001).
CONCLUSIONS
Patients with LAM avulsion present a higher degree of sexual dysfunction compared wiith patients without avulsion at 6 months after instrumental vaginal delivery.
Topics: Adult; Delivery, Obstetric; Female; Humans; Obstetric Labor Complications; Obstetrical Forceps; Pelvic Floor; Postpartum Period; Pregnancy; Prospective Studies; Sexual Dysfunction, Physiological; Ultrasonography; Vacuum Extraction, Obstetrical
PubMed: 32198764
DOI: 10.1111/aogs.13852 -
CMAJ : Canadian Medical Association... Feb 2020
Topics: Anal Canal; Delivery, Obstetric; Episiotomy; Female; Humans; Obstetrical Forceps; Pregnancy; Retrospective Studies
PubMed: 32094271
DOI: 10.1503/cmaj.74565 -
CMAJ : Canadian Medical Association... Feb 2020
Topics: Anal Canal; Delivery, Obstetric; Episiotomy; Female; Humans; Obstetrical Forceps; Pregnancy; Retrospective Studies
PubMed: 32094270
DOI: 10.1503/cmaj.74132