Soft versus rigid vacuum extractor cups for assisted vaginal delivery

Precision of vacuum cup placement and its association with subgaleal hemorrhage and associated morbidity in term neonates

PURPOSE

To evaluate whether the precision of vacuum cup placement is associated with failed vacuum extraction(VE), neonatal subgaleal hemorrhage(SGH) and other VE-related birth trauma.

METHODS

All women with singleton term cephalic fetuses with attempted VE were recruited over a period of 30 months. Neonates were examined immediately after birth and the position of the chignon documented to decide whether the cup position was flexing median or suboptimal. Vigilant neonatal surveillance was performed to look for VE-related trauma, including subgaleal/subdural hemorrhages, skull fractures, scalp lacerations. CT scans of the brain were ordered liberally as clinically indicated.

RESULTS

The VE rate was 5.89% in the study period. There were 17(4.9%) failures among 345 attempted VEs. Thirty babies suffered from subgaleal/subdural hemorrhages, skull fractures, scalp lacerations or a combination of these, giving an incidence of VE-related birth trauma of 8.7%. Suboptimal cup positions occurred in 31.6%. Logistic regression analysis showed that failed VE was associated with a non-occipital anterior fetal head position (OR 3.5, 95% CI 1.22-10.2), suboptimal vacuum cup placement (OR 4.13, 95% CI 1.38-12.2) and a longer duration of traction (OR 8.79, 95% CI 2.13-36.2); while, VE-related birth trauma was associated with failed VE (OR 3.93, 95% CI 1.08-14.3) and more pulls (OR 4.07, 95% CI 1.98-8.36).

CONCLUSION

Suboptimal vacuum cup positions were related to failed VE but not to SGH and other vacuum-related birth trauma. While optimal flexed median cup positions should be most desirable mechanically to effect delivery, such a position does not guarantee prevention of SGH.

Analysis of suction-based gripping strategies in wildlife towards future evolutions of the obstetrical suction cup

The design of obstetrical suction cups used for vacuum assisted delivery has not substantially evolved through history despite of its inherent limitations. The associated challenges concern both the decrease of risk of soft tissue damage and failure of instrumental delivery due to detachment of the cup. The present study firstly details some of the suction-based strategies that have been developed in wildlife in order to create and maintain an adhesive contact with potentially rough and uneven substratum in dry or wet environments. Such strategies have permitted the emergence of bioinspired suction-based devices in the fields of robotics or biomedical patches that are briefly reviewed. The objective is then to extend the observations of such suction-based strategies toward the development of innovative medical suction cups. We firstly conclude that the overall design, shape and materials of the suction cups could be largely improved. We also highlight that the addition of a patterned surface combined with a viscous fluid at the interface between the suction cup and scalp could significantly limit the detachment rate and the differential pressure required to exert a traction force. In the future, the development of a computational model including a detailed description of scalp properties should allow to experiment various designs of bioinspired suction cups.

Cephalic marks and well-being in newborns after operative vaginal delivery

OBJECTIVES

To compare the incidence of cephalic marks in newborns exposed to operative vaginal delivery and those who are not. We examined the factors associated with alterations in neonatal well-being and with cephalic mark occurrence.

METHODS

Prospective study involving singleton term newborns delivered in a cephalic presentation. Newborns in the operative group were matched with newborns born on the same day without instruments required. A cephalic mark was defined as any mark or edema on the newborn's skin between 12 and 72 hours of life. Neonatal well-being was assessed by analgesic consumption, neonatal discomfort (EDIN score of 1 or more), and prolonged hospitalization (4 days or more). We compared the operative and spontaneous groups and determined the relative risk (RR) for cephalic marks. We investigated the factors associated with alterations in neonatal well-being and factors associated with cephalic mark occurrence in the case of operative delivery using multivariate logistic regression analysis.

RESULTS

A total of 135 newborns were included in each group. The incidence of cephalic marks was higher in the operative group (RR = 13.3 [6.0-29.5]). In case of operative delivery, cephalic marks were associated with neonatal discomfort (adjusted odds ratios [aOR] = 8.2 [2.2-30.6]) and analgesic consumption (aOR = 3.0 [1.2-7.1]). The number of cephalic marks was higher in cases with sequential use of vacuum and forceps (aOR = 3.5 [1.1-11.7]) and forceps only deliveries (aOR = 3.0 [1.1-8.1]) relative to vacuum only deliveries.

CONCLUSIONS

Operative delivery increases the risk of neonatal cephalic marks, which can negatively affect neonatal well-being.

Immediate unfavorable birth outcomes and determinants of operative vaginal delivery among mothers delivered in East Gojjam Zone Public Hospitals, North West Ethiopia: A cross-sectional study

Introduction

Operative vaginal delivery is the use of forceps or vacuum devices to assist the eligible laboring mother to avoid poor birth outcomes. It is associated with increased maternal, neonatal morbidity and perinatal complications if it is not used appropriately. Instrumental delivery use needs health care providers’ skills, knowledge, and decision-making ability for good maternal outcomes.

Objective

This study aimed to assess immediate unfavorable birth outcomes and associated factors of operative vaginal delivery among women delivered in East Gojjam Zone Public Hospitals, North West Ethiopia.

Method

The study design was institution based cross-sectional and consecutive sampling procedure was used to select 313 mothers in the study, from March 1, 2019, to April 30, 2019. We used Epi data version 3.1 for data entry and SPSS version 25 software for cleaning and analysis. A Bivariable logistic regression analysis was used to identify the association between each outcome variable and each factor. Again, a multivariable logistic regression analysis was employed to identify factors associated with each outcome variable, and variables with a p-value less than 0.05 were taken as significant variables.

Results

The overall unfavorable maternal outcomes of operative vaginal delivery were found to be 32.9% [95% CI: 27.8, 38.3]. No formal education (AOR = 8.36; 95% CI: 1.01, 69.2), rural residence (AOR: 11.77; 95% CI: 2.02, 68.41), male sex of the neonate (AOR: 2.87; 95% CI: 1.08, 7.61) and zero station during instrumental application (AOR: 6.93; 95% CI: 1.75, 27.5) were factors associated with unfavorable maternal outcomes. The study also showed that the magnitude of unfavorable neonatal outcomes was 34.8% (95% CI: 29.7, 40.3). Vaginal first-degree tear (AOR = 0.03, 95% CI: 0.001, 0.951) and blood transfusion (AOR = 7.38, 95% CI: 1.18–46.15) was statistically significant factors associated with unfavorable neonatal outcomes.

Conclusion

The overall unfavorable maternal and neonatal outcomes of operative vaginal delivery were high compared with some other studies done in Ethiopia.

Instruments for assisted vaginal birth

BACKGROUND

Assisted vaginal births are carried out to expedite birth for the benefit of mothers and babies but are sometimes associated with significant morbidity for both. Various instruments are available, broadly divided into forceps and vacuum cups, and choice may be influenced by clinical circumstances, operator preference, experience and availability.  OBJECTIVES: To evaluate the different instruments in terms of success in achieving a vaginal birth, and the risk of morbidity for mother and baby.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (14 May 2021), and reference lists of retrieved studies.

SELECTION CRITERIA

We selected randomised controlled trials of assisted vaginal birth using different instruments. The review did not include quasi-randomised trials, cluster-randomised trials or cross-over designs. The review included trials for which abstracts alone were available as long as there was sufficient information to assess eligibility.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. We used the GRADE approach to assess the certainty of evidence.  The main outcomes assessed included failed delivery with allocated instrument, any maternal trauma, third- and fourth-degree tears, postpartum haemorrhage, any neonatal trauma, low Apgar and low umbilical artery pH.  MAIN RESULTS: We included 31 studies involving a total of 5754 women.  Risk of bias criteria were largely assessed as 'unclear', due to a lack of detail in trial reports. Blinding would have been challenging for all trials due to their inability to conceal the type of instrument used from either the woman or the operator, which is reflected in the risk of bias assessment. Any type of forceps versus any type of vacuum cup (12 studies, 3129 women) Forceps may be less likely to fail in achieving vaginal birth: risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.88; 11 studies, 3080 women; low certainty. 'Any maternal trauma' may be slightly more likely with forceps: odds ratio (OR) 1.53, 95% CI 0.98 to 2.40; 5 studies, 1356 women; low certainty; and third- or fourth-degree tears may also be more likely with forceps: RR 1.83, 95% CI 1.32 to 2.55; 9 studies, 2493 women; low certainty. There is no evidence of a difference in the incidence of postpartum haemorrhage (PPH) between the two groups: RR 1.71, 95% CI 0.59 to 4.95; 2 studies, 523 women; low certainty, because the evidence is very imprecise due to a very wide CI.  More women in the forceps group reported requiring pain relief. There is probably no evidence of difference in rates of low Apgar: RR 0.83, 95% CI 0.46 to 1.51; 7 studies, 1644 women; moderate certainty; or low umbilical artery pH in the forceps group compared to any vacuum: RR 1.33, 95% CI 0.91 to 1.93; 2 studies, 789 women; low certainty; both of these outcomes are imprecise and have wide CIs that include both benefit and harm. There were also lower rates of fetal trauma with 'any forceps' (cephalhematoma, retinal haemorrhage and jaundice). The composite outcome of 'any neonatal trauma' was not reported. Low-cavity forceps versus any vacuum cup (2 studies, 218 women) We included two small studies with 218 participants in this comparison, but we judged most of the evidence as very low certainty, hence it was not feasible to make judgements on the difference in the rates of failed delivery, any maternal trauma or third- and fourth- degree tears. PPH and low umbilical artery pH were not reported. Soft vacuum cup versus any rigid cup (9 studies, 1148 women) Failed delivery may be more likely in the soft vacuum cup group: RR 1.62, 95% CI 1.21 to 2.17; 9 studies, 1148 women; low certainty. There may be no difference in the rates of 'any maternal trauma': OR 0.63, 95% CI 0.24 to 1.67; 2 studies, 348 women; low certainty, but the confidence interval is wide, indicating possible benefit or harm. There may be no difference in the rates of third- or fourth-degree tears: RR 0.93, 95% CI 0.35 to 2.44; 4 studies, 619 women; low certainty. There is probably no difference in the rates of PPH: RR 0.89, 95% CI 0.49 to 1.61; 5 studies, 737 women; moderate certainty between the soft and rigid cup groups.   There may be little or no difference in the incidence of low Apgar scores: RR 0.82, 95% CI 0.49 to 1.37; 9 studies, 1148; low certainty; or low umbilical artery pH: RR 0.80, 95% CI 0.47 to 1.36; 1 study, 100 women; low certainty. Handheld vacuum versus any vacuum cup (4 studies, 968 women) There may be no difference in the rates of failures with allocated instrument: RR 1.35, 95% CI 0.81 to 2.25; 4 studies, 962 women; low certainty, any maternal trauma: OR 1.16, 95% CI 0.71 to 1.88; 2 studies; 394 women; low certainty, PPH: RR 0.31, 95% CI 0.03 to 2.92; 1 study, 164 women; low certainty, low umbilical artery pH: RR 1.06, 95% CI 0.71 to 1.59; 1 study, 164 women; low certainty, or low Apgar scores: RR 1.25, 95% CI 0.34 to 4.61; 3 studies, 784 women; low certainty) between the two groups. There is probably no difference in the rates of third- or fourth-degree tears between the 'handheld vacuum' and 'any vacuum cup' groups: RR 1.15, 95% CI 0.62 to 2.12; 4 studies, 962 women; moderate certainty.

AUTHORS' CONCLUSIONS

This review provides low-certainty evidence that forceps may be more likely to achieve vaginal birth and have lower rates of fetal trauma, but at a greater risk of perineal trauma and higher pain relief requirements compared with vacuum cups. There was low-certainty evidence that rigid vacuum cups may be more likely to achieve a vaginal birth than soft cups but with more fetal trauma, whilst handheld vacuum cups had similar success rates compared to other cups. There was no evidence of a difference in the rates of third- or fourth-degree tears or postpartum haemorrhages between types of cups, but wide confidence intervals around the estimates indicate further research is needed in this area.

Skull fracture during instrumental delivery using spatulas: A case report with CT-scan imaging

Neonatal skull fracture is rare and instrumental delivery is one of the risk factors. We present a case of parietal bone fracture in a term newborn with Thierry's spatulas who benefited from a 3D brain scan. If many cases have been reported with the use of forceps whatever their type, our case is to our knowledge the first one described with spatulas.

Severe maternal and neonatal morbidity after attempted operative vaginal delivery

BACKGROUND

Operative vaginal delivery is a critical tool in reducing primary cesarean delivery, but declining operative vaginal delivery rates and concerns about provider skill necessitate a clear understanding of risks. These risks are ambiguous because most studies compare outcomes of operative vaginal delivery with that of spontaneous vaginal delivery rather than outcomes of cesarean delivery in the second stage of labor, which is usually the realistic alternative.

OBJECTIVE

This study aimed to compare severe maternal and neonatal morbidity by mode of delivery of patients with a prolonged second stage of labor who had a successful operative vaginal delivery, a cesarean delivery after failed operative vaginal delivery, or a cesarean delivery without an operative vaginal delivery attempt.

STUDY DESIGN

We used a population-based database to evaluate nulliparous, term, singleton, vertex live births in California between 2007 and 2012 of patients with prolonged second stage of labor. Birth certificates and the International Classification of Diseases, Ninth Revision, Clinical Modification coded diagnoses and procedures were used for ascertainment of exposure, outcome, and demographics. Exposure was mode of delivery of patients who had any operative vaginal delivery attempt vs cesarean delivery without operative vaginal delivery attempt. The outcomes were severe maternal morbidity and severe unexpected newborn morbidity, defined using established indices. Anticipating that the code for prolonged second stage of labor would represent only a fraction of true operative vaginal delivery candidates, a secondary analysis was conducted removing this restriction to explore granular outcomes in a larger cohort with unsuccessful labor. Multivariable logistic regression was used to compare outcomes by mode of delivery adjusted for measured confounders. Sensitivity analyses were done excluding patients with combined vacuum-forceps-assisted delivery and birthweight of >4000 g.

RESULTS

A total of 9239 births after prolonged second stage of labor were included, where 6851 (74.1%) were successful operative vaginal deliveries, 301 (3.3%) were failed operative vaginal deliveries, and 2087 (22.6%) were cesarean deliveries without operative vaginal delivery attempts. Of successful operative vaginal deliveries, 6195 (90.4%) were vacuum assisted and 656 (10.6%) were forceps-assisted. Of failed operative vaginal deliveries where operative vaginal delivery type was specified, 83 (47.4%) were vacuum assisted, 38 (21.7%) were forceps-assisted, and 54 (30.9%) were combined vacuum-forceps-assisted. Of note, all 54 combined vacuum-forceps-assisted operative vaginal delivery attempts that we identified failed. The outcomes of patients with failed operative vaginal delivery differed from those with successful operative vaginal delivery, such as higher rates of comorbidities, use of combined operative vaginal delivery, and birthweight of >4000 g. Successful operative vaginal delivery was associated with reduced severe maternal morbidity (adjusted odds ratio, 0.55; 95% confidence interval, 0.39-0.78) without a difference in severe unexpected neonatal morbidity (adjusted odds ratio, 0.99; 95% confidence interval, 0.78-1.26). In contrast, failed operative vaginal delivery was associated with increased severe maternal morbidity (adjusted odds ratio, 2.14; 95% confidence interval, 1.20-3.82) and severe unexpected neonatal morbidity (adjusted odds ratio, 1.78; 95% confidence interval, 1.09-2.86). In addition, findings were similar in the secondary analysis of 260,585 patients with unsuccessful labor.

CONCLUSION

In this large cohort of nulliparous, term, singleton, vertex births, successful operative vaginal delivery was associated with a 45% reduction in severe maternal morbidity without differences in severe unexpected neonatal morbidity compared with cesarean delivery after prolonged second stage of labor. Operative vaginal delivery infrequently failed and was associated with a 214% increase in severe maternal morbidity and a 78% increase in severe unexpected neonatal morbidity; furthermore, combined operative vaginal deliveries were major contributors to this, as all combined operative vaginal deliveries failed. Optimization of operative vaginal delivery success rates through means such as improved patient selection, enhanced provider skill, and discussions against combined operative vaginal delivery could reduce maternal and neonatal complications.

Persistent occiput posterior position outcomes following manual rotation: a randomized controlled trial

BACKGROUND

Persistent occiput posterior position in labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation from the occiput posterior position to the occiput anterior position in the second stage of labor is considered a safe and easy to perform procedure that in observational studies has shown promise as a method for preventing operative deliveries.

OBJECTIVE

This study aimed to determine the efficacy of prophylactic manual rotation in the management of occiput posterior position for preventing operative delivery. The hypothesis was that among women who are at least 37 weeks pregnant and whose baby is in the occiput posterior position early in the second stage of labor, manual rotation will reduce the rate of operative delivery compared with the "sham" rotation.

STUDY DESIGN

A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 4 tertiary hospitals was conducted in Australia. A total of 254 nulliparous and parous women with a term pregnancy and a baby in the occiput posterior position in the second stage of labor were randomly assigned to receive either a prophylactic manual rotation (n=127) or a sham rotation (n=127). The primary outcome was operative delivery (cesarean, forceps, or vacuum delivery). Secondary outcomes were cesarean delivery, combined maternal mortality and serious morbidity, and combined perinatal mortality and serious morbidity. Analysis was by intention to treat. Proportions were compared using chi-square tests adjusted for stratification variables using the Mantel-Haenszel method or the Fisher exact test. Planned subgroup analyses by operator experience and by manual rotation technique (digital or whole-hand rotation) were performed.

RESULTS

Operative delivery occurred in 79 of 127 women (62%) assigned to prophylactic manual rotation and 90 of 127 women (71%) assigned to sham rotation (common risk difference, 12; 95% confidence interval, -1.7 to 26; P=.09). Among more experienced operators or investigators, operative delivery occurred in 46 of 74 women (62%) assigned to manual rotation and 52 of 71 women (73%) assigned to a sham rotation (common risk difference, 18; 95% confidence interval, -0.5 to 36; P=.07). Cesarean delivery occurred in 22 of 127 women (17%) in both groups. Instrumental delivery (forceps or vacuum) occurred in 57 of 127 women (45%) assigned to prophylactic manual rotation and 68 of 127 women (54%) assigned to sham rotation (common risk difference, 10; 95% confidence interval, -3.1 to 22; P=.14). There was no significant difference in the combined maternal and perinatal outcomes.

CONCLUSION

Prophylactic manual rotation did not result in a reduction in the rate of operative delivery. Given manual rotation was associated with a nonsignificant reduction in operative delivery, more randomized trials are needed, as our trial might have been underpowered. In addition, further research is required to further explore the potential impact of operator or investigator experience.

An engineering perspective of vacuum assisted delivery devices in obstetrics: A 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.

The Health Impact of Surgical Techniques and Assistive Methods Used in Cesarean Deliveries: A Systemic Review

Cesarean delivery is one of the most frequently performed surgeries in women throughout the world. However, the most optimal technique to minimize maternal and fetal morbidities is still being debated due to various clinical situations and surgeons' preferences. The contentious topics are the use of vacuum devices other than traditional fundal pressure to assist in the delivery of the fetal head and the techniques of uterine repair used during cesarean deliveries. There are two well-described techniques for suturing the uterus: The uterus can be repaired either temporarily exteriorized (out of abdominal cavity) or in situ (within the peritoneal cavity). Numerous studies have attempted to compare these two techniques in different aspects, including operative time, blood loss, and maternal and fetal outcomes. This review provides an overview of the assistive method of vacuum devices compared with fundal pressure, and the two surgical techniques for uterine repair following cesarean delivery. This descriptive literature review was performed to address important issues for clinical practitioners. It aims to compare the advantages and disadvantages of the assistive methods and surgical techniques used in cesarean deliveries. All of the articles were retrieved from the databases Medline and PubMed using the search terms cesarean delivery, vacuum, and exteriorization. The searching results revealed that after exclusion, there were 9 and 13 eligible articles for vacuum assisted cesarean delivery and uterine exteriorization, respectively. Although several studies have concluded vacuum assistance for fetal extraction as a simple, effective, and beneficial method during fetal head delivery during cesarean delivery, further research is still required to clarify the safety of vacuum assistance. In general, compared to the use of in situ uterine repairs during cesarean delivery, uterine exteriorization for repairs may have benefits of less blood loss and shorter operative time. However, it may also carry a higher risk of intraoperative complications such as nausea and vomiting, uterine atony, and a longer time to the return of bowel function. Clinicians should consider these factors during shared decision-making with their pregnant patients to determine the most suitable techniques for cesarean deliveries.

Successful versus unsuccessful instrumental deliveries-Predictors and obstetric outcomes

OBJECTIVE

The purpose of this study was to examine instrumental births in a multi-ethnic population to assess the factors associated with success and failure in instrumental births.

STUDY DESIGN

This was a large retrospective study of 7954 women that underwent either a successful or an unsuccessful instrumental delivery in a single centre over a 10 year period.

RESULTS

Logistic regression analysis showed that women with a BMI of more than 30, attempted Forceps delivery, having a prolonged second stage, Macrosomia (birth weight more than 4 kg) and a senior obstetrician performing the procedure increase the risk of a failed instrumental delivery. While age, ethnicity, type of anaesthesia, use of oxytocin or induction of labour did not provide a significant outcome. Results also showed that patients are likely to bleed more and neonates need admission in failed instrumental deliveries when compared to successful attempts.

CONCLUSION

This is one of a very few studies comparing a large cohort of successful instrumental births with unsuccessful attempts at an instrumental birth. The rate of failure has been difficult to reduce, and the analysis shows that many of the factors associated with failure are not modifiable in labour. We should consider studies with use of ultrasound assessment before application or consideration of instruments to facilitate birth. This will allow us to objectively come up with an algorithm to predict success or failure and consider if it is suitable to attempt an instrumental birth. Our data can be used to counsel women about the difficulty in predicting success and failure rate of instrumental births.

Vacuum-assisted cesarean section

There has been a dramatic rise in the frequency of cesarean sections, surpassing 30% of all deliveries in the US. This upsurge, coupled with a decreasing willingness to allow vaginal birth after cesarean section, has resulted in an expansion of the use of vacuum assistance to safely extract the fetal head. By avoiding the use of a delivering hand or forceps blade, the volume being delivered through the uterine incision can be decreased when the vacuum is used properly. Reducing uterine extensions with their associated complications (eg, excessive blood loss) in difficult cases is also a theoretical advantage of vacuum delivery. Maternal discomfort related to excessive fundal pressure may also be lessened. To minimize the risk of neonatal morbidity, proper cup placement over the “flexion point” remains essential to maintain vacuum integrity and reduce the chance of inadvertent detachment and uterine extensions. Based on the published literature and pragmatic clinical experience, utilization of the vacuum device is a safe and effective technique to assist delivery during cesarean section.

[Forceps delivery: Professionals' knowledge of forceps application in the area of Lyon]

OBJECTIVES

The aim of this study is to describe knowledge on forceps delivery in the area of Lyon.

MATERIAL AND METHODS

It is a multicentric observational study carried between January 1, 2013 and June 9, 2013. A questionnaire was sent to obstetricians and residents of the area of Lyon. It related prerequisites for operative vaginal delivery, the method used to apply forceps, practices and preferences of operators.

RESULTS

Seventy-five responses were obtained (47 obstetricians, 28 residents). About prerequisites: 6.4% of the obstetricians and 14.3% of the residents never do urinary catheterization. Instrumental delivery is never performed when the fetal head is not engaged. Mid-pelvic operative vaginal delivery is performed by 51.1% of obstetricians. Trans-abdominal ultrasound assessment is conducted in cases of clinical doubts about the fetal head position. For occipital anterior and left anterior positions, the left blade is first applied. A flexion of the fetal head is applied for anterior positions but not in posterior positions. Most of operators do not perform instrumental rotation. Vacuum extractor is the privileged instrument for obstetricians and forceps is often used in second line.

CONCLUSION

This study shows that most of the recommendations for forceps delivery are followed. In front of the lake of statistical power of this study, it might be interesting to improve a largest study with a comparison between obstetricians and residents' practices.

Symphysiotomy for feto-pelvic disproportion

BACKGROUND

Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus enlargement of the pelvic dimensions during childbirth. It is performed with local analgesia and does not require an operating theatre nor advanced surgical skills. It may be a lifesaving procedure for the mother or the baby, or both, in several clinical situations. These include: failure to progress in labour when caesarean section is unavailable, unsafe or declined by the mother; and obstructed birth of the aftercoming head of a breech presenting baby. Criticism of the operation because of complications, particularly pelvic instability, and as being a 'second best' option has resulted in its decline or disappearance from use in many countries. Several large observational studies have reported high rates of success, low rates of complications and very low mortality rates.

OBJECTIVES

To determine, from the best available evidence, the effectiveness and safety of symphysiotomy versus alternative options for obstructed labour in various clinical situations.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 July 2012).

SELECTION CRITERIA

Randomized trials comparing symphysiotomy with alternative management, or alternative techniques of symphysiotomy, for obstructed labour or obstructed aftercoming head during breech birth.

DATA COLLECTION AND ANALYSIS

Planned methods included evaluation of studies against objective quality criteria for inclusion, extraction of data, and analysis of data using risk ratios or mean differences with 95% confidence intervals. The primary outcomes were maternal death or severe morbidity, and perinatal death or severe morbidity.

MAIN RESULTS

We found no randomized trials of symphysiotomy.

AUTHORS' CONCLUSIONS

Because of controversy surrounding the use of symphysiotomy, and the possibility that it may be a life-saving procedure in certain circumstances, professional and global bodies should provide guidelines for the use (or non-use) of symphysiotomy based on the best available evidence (currently evidence from observational studies). Research is needed to provide robust evidence of the effectiveness and safety of symphysiotomy compared with no symphysiotomy or comparisons of alternative symphysiotomy techniques in clinical situations in which caesarean section is not available; and compared with caesarean section in clinical situations in which the relative risks and benefits are uncertain (for example in women at very high risk of complications from caesarean section).

Linkages among reproductive health, maternal health, and perinatal outcomes

Some interventions in women before and during pregnancy may reduce perinatal and neonatal deaths, and recent research has established linkages of reproductive health with maternal, perinatal, and early neonatal health outcomes. In this review, we attempted to analyze the impact of biological, clinical, and epidemiologic aspects of reproductive and maternal health interventions on perinatal and neonatal outcomes through an elucidation of a biological framework for linking reproductive, maternal and newborn health (RHMNH); care strategies and interventions for improved perinatal and neonatal health outcomes; public health implications of these linkages and implementation strategies; and evidence gaps for scaling up such strategies. Approximately 1000 studies (up to June 15, 2010) were reviewed that have addressed an impact of reproductive and maternal health interventions on perinatal and neonatal outcomes. These include systematic reviews, meta-analyses, and stand-alone experimental and observational studies. Evidences were also drawn from recent work undertaken by the Child Health Epidemiology Reference Group (CHERG), the interconnections between maternal and newborn health reviews identified by the Global Alliance for Prevention of Prematurity and Stillbirth (GAPPS), as well as relevant work by the Partnership for Maternal, Newborn and Child Health. Our review amply demonstrates that opportunities for assessing outcomes for both mothers and newborns have been poorly realized and documented. Most of the interventions reviewed will require more greater-quality evidence before solid programmatic recommendations can be made. However, on the basis of our review, birth spacing, prevention of indoor air pollution, prevention of intimate partner violence before and during pregnancy, antenatal care during pregnancy, Doppler ultrasound monitoring during pregnancy, insecticide-treated mosquito nets, birth and newborn care preparedness via community-based intervention packages, emergency obstetrical care, elective induction for postterm delivery, Cesarean delivery for breech presentation, and prophylactic corticosteroids in preterm labor reduce perinatal mortality; and early initiation of breastfeeding and birth and newborn care preparedness through community-based intervention packages reduce neonatal mortality. This review demonstrates that RHMNH are inextricably linked, and that, therefore, health policies and programs should link them together. Such potential integration of strategies would not only help improve outcomes for millions of mothers and newborns but would also save scant resources. This would also allow for greater efficiency in training, monitoring, and supervision of health care workers and would also help families and communities to access and use services easily.

WITHDRAWN: Vacuum extraction versus forceps for assisted vaginal delivery

BACKGROUND

Proponents of vacuum delivery argue that it should be chosen first for assisted vaginal delivery, because it is less likely to injure the mother.

OBJECTIVES

The objective of this review was to assess the effects of vacuum extraction compared to forceps, on failure to achieve delivery and maternal and neonatal morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: February 1999.

SELECTION CRITERIA

Acceptably controlled comparisons of vacuum extraction and forceps delivery.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Ten trials were included. The trials were of reasonable quality. Use of the vacuum extractor for assisted vaginal delivery when compared to forceps delivery was associated with significantly less maternal trauma (odds ratio 0.41, 95% confidence interval 0.33 to 0.50) and with less general and regional anaesthesia. There were more deliveries with vacuum extraction (odds ratio 1.69, 95% confidence interval 1.31 to 2.19). Fewer caesarean sections were carried out in the vacuum extractor group. However the vacuum extractor was associated with an increase in neonatal cephalhaematomata and retinal haemorrhages. Serious neonatal injury was uncommon with either instrument.

AUTHORS' CONCLUSIONS

Use of the vacuum extractor rather than forceps for assisted delivery appears to reduce maternal morbidity. The reduction in cephalhaematoma and retinal haemorrhages seen with forceps may be a compensatory benefit.

Choice of instruments for assisted vaginal delivery

BACKGROUND

Instrumental or assisted vaginal birth is commonly used to expedite birth for the benefit of either mother or baby or both. It is sometimes associated with significant complications for both mother and baby. The choice of instrument may be influenced by clinical circumstances, operator choice and availability of specific instruments.

OBJECTIVES

To evaluate different instruments in terms of achieving a vaginal birth and avoiding significant morbidity for mother and baby.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2010).

SELECTION CRITERIA

Randomised controlled trials of assisted vaginal delivery using different instruments.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality, extracted the data, and checked them for accuracy.

MAIN RESULTS

We included 32 studies (6597 women) in this review. Forceps were less likely than the ventouse to fail to achieve a vaginal birth with the allocated instrument (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.45 to 0.94). However, with forceps there was a trend to more caesarean sections, and significantly more third- or fourth-degree tears (with or without episiotomy), vaginal trauma, use of general anaesthesia, and flatus incontinence or altered continence. Facial injury was more likely with forceps (RR 5.10, 95% CI 1.12 to 23.25). Using a random-effects model because of heterogeneity between studies, there was a trend towards fewer cases of cephalhaematoma with forceps (average RR 0.64, 95% CI 0.37 to 1.11).Among different types of ventouse, the metal cup was more likely to result in a successful vaginal birth than the soft cup, with more cases of scalp injury and cephalhaematoma. The hand-held ventouse was associated with more failures than the metal ventouse, and a trend to fewer than the soft ventouse.Overall forceps or the metal cup appear to be most effective at achieving a vaginal birth, but with increased risk of maternal trauma with forceps and neonatal trauma with the metal cup.

AUTHORS' CONCLUSIONS

There is a recognised place for forceps and all types of ventouse in clinical practice. The role of operator training with any choice of instrument must be emphasised. The increasing risks of failed delivery with the chosen instrument from forceps to metal cup to hand-held to soft cup vacuum, and trade-offs between risks of maternal and neonatal trauma identified in this review need to be considered when choosing an instrument.

Symphysiotomy for feto-pelvic disproportion

BACKGROUND

Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus enlargement of the pelvic dimensions during childbirth. It is performed with local analgesia and does not require an operating theatre nor advanced surgical skills. It may be a lifesaving procedure for the mother or the baby, or both, in several clinical situations. These include: failure to progress in labour when caesarean section is unavailable, unsafe or declined by the mother; and obstructed birth of the aftercoming head of a breech presenting baby. Criticism of the operation because of complications, particularly pelvic instability, and as being a 'second best' option has resulted in its decline or disappearance from use in many countries. Several large observational studies have reported high rates of success, low rates of complications and very low mortality rates.

OBJECTIVES

To determine, from the best available evidence, the effectiveness and safety of symphysiotomy versus alternative options for obstructed labour in various clinical situations.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3) and PubMed (1966 to 31 August 2010).

SELECTION CRITERIA

Randomized trials comparing symphysiotomy with alternative management, or alternative techniques of symphysiotomy, for obstructed labour or obstructed aftercoming head during breech birth.

DATA COLLECTION AND ANALYSIS

Planned methods included evaluation of studies against objective quality criteria for inclusion, extraction of data, and analysis of data using risk ratios or mean differences with 95% confidence intervals. The primary outcomes were maternal death or severe morbidity, and perinatal death or severe morbidity.

MAIN RESULTS

We found no randomized trials of symphysiotomy.

AUTHORS' CONCLUSIONS

Because of controversy surrounding the use of symphysiotomy, and the possibility that it may be a life-saving procedure in certain circumstances, professional and global bodies should provide guidelines for the use (or non-use) of symphysiotomy based on the best available evidence (currently evidence from observational studies). Research is needed to provide robust evidence of the effectiveness and safety of symphysiotomy compared with no symphysiotomy or comparisons of alternative symphysiotomy techniques in clinical situations in which caesarean section is not available; and compared with caesarean section in clinical situations in which the relative risks and benefits are uncertain (for example in women at very high risk of complications from caesarean section).

[A comparison of maternal and fetal complications during operative vaginal delivery using Thierry's spatulas and the vacuum extractor]

OBJECTIVE

To compare short-term maternal and fetal morbidities between Thierry's spatules and the vacuum extractor.

MATERIAL AND METHODS

A retrospective study of all assisted vaginal deliveries using spatules or the vacuum extractor between January 1, 2005 and December 31, 2007 in a single, university hospital maternity.

RESULTS

There were 385 deliveries with the vacuum extractor and 332 with spatulas, among a total number of 6941 deliveries. The obstetrical conditions did not differ between the two groups (indication, level or type of presentation, duration of the second stage before extraction). The rate of episiotomy was higher in the spatules than in the vacuum extractor group (80.3 % vs 54.8 %, p < 0.0001), whereas there was a lower rate of first-to-second degree perineal lacerations (18.8 % vs 35.2 %, p < 0.0001). There was no statistically significant difference in the rate of third-to-fourth degree perineal lacerations (2.1 % vs 0.7 %, respectively, p = 0.31). Neonatal outcomes did not differ significantly between the two groups (5-minute Apgar score < 7 in 0.3 % vs 1.8 %, respectively, p = 0.75).

CONCLUSION

There were few differences in maternal and neonatal outcomes according to the type of instrument used, except for a lower episiotomy rate with vacuum extraction.

[Evaluating a policy of restrictive episiotomy before and after practice guidelines by the French College of Obstetricians and Gynecologists]

AIM

To evaluate our practice following Clinical Practice Guidelines (CPG) of the French College of Obstetricians and Gynecologists (CNGOF) in 2005 advocating a policy of restrictive episiotomy and to show that a significative decrease in the rate of episiotomy does not increase the number of third and fourth degree perineal tears.

MATERIAL AND METHODS

A retrospective study of episiotomies and third/fourth degree perineal tears of the year 2003 (before the CPG) was compared with the year 2007 (after the CPG). We analyzed the indications of episiotomies and compared the rate of episiotomies and severe perineal tears between the two periods.

RESULTS

In 2003, the rate of episiotomies was 18.8% (upon 1755 vaginal deliveries). We observed 16 (9 per thousand) third-degree perineal tears, five of which was associated with episiotomies; and two (1 per thousand) fourth-degree perineal tears. In 2007, the rate of episiotomies was 3.4% (upon 1940 vaginal deliveries). There were eight (4 per thousand) third-degree and four (2 per thousand) fourth-degree perineal tears. The two periods of study were similar in terms of age, parity, gestational age, birthweight, rate of spontaneous deliveries, breech and instrumental deliveries. There were a difference regarding deliveries in the occipitoposterior position (5.8% vs 13.8% ; p=0.02). No significant difference was found between the rates of third degree (9 per thousand vs 4 per thousand ; p=0.059) and fourth degree perineal tears (1 per thousand vs 2 per thousand ; p=0.487). However, there was a significant decrease in the rate of episiotomies between the two periods (18.8% vs 3.4% ; p<0.001).

CONCLUSION

An episiotomy rate of 3.4% is much lower than the threshold rate of 30% recommanded. A policy of restrictive episiotomy is possible without increasing the rate of severe perineal tears. Aknowledging the risks and benefits of each obstetrical procedure might decrease the number of episiotomies, whose practice should be evaluated in every labour ward.

Reducing stillbirths: interventions during labour

BACKGROUND

Approximately one million stillbirths occur annually during labour; most of these stillbirths occur in low and middle-income countries and are associated with absent, inadequate, or delayed obstetric care. The low proportion of intrapartum stillbirths in high-income countries suggests that intrapartum stillbirths are largely preventable with quality intrapartum care, including prompt recognition and management of intrapartum complications. The evidence for impact of intrapartum interventions on stillbirth and perinatal mortality outcomes has not yet been systematically examined.

METHODS

We undertook a systematic review of the published literature, searching PubMed and the Cochrane Library, of trials and reviews (N = 230) that reported stillbirth or perinatal mortality outcomes for eight interventions delivered during labour. Where eligible randomised controlled trials had been published after the most recent Cochrane review on any given intervention, we incorporated these new trial findings into a new meta-analysis with the Cochrane included studies.

RESULTS

We found a paucity of studies reporting statistically significant evidence of impact on perinatal mortality, especially on stillbirths. Available evidence suggests that operative delivery, especially Caesarean section, contributes to decreased stillbirth rates. Induction of labour rather than expectant management in post-term pregnancies showed strong evidence of impact, though there was not enough evidence to suggest superior safety for the fetus of any given drug or drugs for induction of labour. Planned Caesarean section for term breech presentation has been shown in a large randomised trial to reduce stillbirths, but the feasibility and consequences of implementing this intervention routinely in low-/middle-income countries add caveats to recommending its use. Magnesium sulphate for pre-eclampsia and eclampsia is effective in preventing eclamptic seizures, but studies have not demonstrated impact on perinatal mortality. There was limited evidence of impact for maternal hyperoxygenation, and concerns remain about maternal safety. Transcervical amnioinfusion for meconium staining appears promising for low/middle income-country application according to the findings of many small studies, but a large randomised trial of the intervention had no significant impact on perinatal mortality, suggesting that further studies are needed.

CONCLUSION

Although the global appeal to prioritise access to emergency obstetric care, especially vacuum extraction and Caesarean section, rests largely on observational and population-based data, these interventions are clearly life-saving in many cases of fetal compromise. Safe, comprehensive essential and emergency obstetric care is particularly needed, and can make the greatest impact on stillbirth rates, in low-resource settings. Other advanced interventions such as amnioinfusion and hyperoxygenation may reduce perinatal mortality, but concerns about safety and effectiveness require further study before they can be routinely included in programs.

[Obstetric anaesthesia for instrumental vaginal delivery]

The aim of the anaesthesia for instrumental delivery is to provide optimal operation conditions for the obstetrician, appropriate maternal comfort, altogether with safety for the mother and her foetus. The type and location for this intervention are chosen individually for each case according to the indication, the risk of caesarean section and the local specificities. The general safety recommendations for obstetric anaesthesia apply in every case. Since an epidural analgesia is often already working, this type of anaesthesia is the most frequently used for the extractions. A spinal anaesthesia is a logical choice where an epidural in sot yet working. The pudendal block is a second line choice and the general anaesthesia remains as the last alternative in acute emergencies, in cases of failed regional anaesthesia or when the mother refuses any other anaesthesia despite proper information or proves unable to cooperate.

Reducing high-order perineal laceration during operative vaginal delivery

OBJECTIVE

This study was undertaken to assess the impact of a focused intervention on reducing high-order (third and fourth degree) perineal lacerations during operative vaginal delivery.

STUDY DESIGN

The following recommendations for clinical management were promulgated by departmental lectures, distribution of pertinent articles and manuals, training of physicians, and prominent display of an instructional poster: (1) increased utilization of vacuum extraction over forceps delivery; (2) conversion of occiput posterior to anterior positions before delivery; (3) performance of mediolateral episiotomy if episiotomy was deemed necessary; (4) flexion of the fetal head and maintenance of axis traction; (5) early disarticulation of forceps; and (6) reduced maternal effort at expulsion. Peer comparison was encouraged by provision of individual and departmental statistics. Clinical data were extracted from the labor and delivery database and the medical record.

RESULTS

One hundred fifteen operative vaginal deliveries occurred in the 3 quarters preceding the intervention, compared with 100 afterward (P = .36). High-order laceration with operative vaginal delivery declined from 41% to 26% (P = .02), coincident with increased use of vacuum (16% vs 29% of operative vaginal deliveries, P = .02); fewer high-order lacerations after episiotomy (63% vs 22%, P = .003); a nonsignificant reduction in performance of episiotomy (30% vs 23%, P = .22); and a nonsignificant increase in mediolateral episiotomy (14% vs 30% of episiotomies, P = .19).

CONCLUSION

Introduction of formal practice recommendations and performance review was associated with diminished high-order perineal injury with operative vaginal delivery.

[What are the risk factors of anal incontinence after vaginal delivery?]

Fecal incontinence is one of the most feared complications of vaginal delivery. It may be the consequence of sphincter tears, of pudendal neuropathy, or of a combination of the two. Fecal incontinence occurs immediately following 13-54% of vaginal deliveries but its persistence in the mid and long term is poorly known. The incidence of perineal tear with anal sphincteric defect varies from 1-9% and the incidence of unrecognized sphincter injury may be as high as 18-35%. Half the women who undergo primary anal sphincter repair have short or long term continence problems. Pudendal neuropathy is caused by nerve stretch during pushing in the second stage of labor and descent of the fetal head; it may occur even with the first delivery. Risk factors for sphincter injury and pudendal neuropathy include forceps delivery, large neonatal size, and prolonged second stage of labor. The risk of fecal incontinence must be considered even during the first pregnancy. Routine episiotomy does not prevent sphincter injury and may even predispose to it. Pudendal neuropathy following delivery may lead to delayed fecal incontinence abetted by postmenopausal hormonal deficiency and tissue senescence. The possible benefit of early episiotomy for women at high risk of sphincter injury must be evaluated by prospective studies.

Head trauma after instrumental births

Instrumental vaginal delivery involves the use of the vacuum extractor or obstetric forceps to facilitate delivery of the fetus. It is associated with substantial risk of head injury, including hemorrhage, fractures, and, rarely, brain damage or fetal death. This review article describes the different types, etiology, pathophysiology, risk factors, and clinical features of head trauma after instrumental birth, along with their management and prevention strategies.

Operative vaginal delivery and the use of episiotomy—A survey of practice in the United Kingdom and Ireland

OBJECTIVE

To establish the views and current practice of obstetricians with regard to operative vaginal delivery and the use of episiotomy.

STUDY DESIGN

A national survey of consultant obstetricians and specialist registrars practising in the United Kingdom and Ireland registered with the Royal College of Obstetricians and Gynaecologists (RCOG), London. A postal questionnaire was sent to all obstetricians with two subsequent reminders to non-responders. The choice of procedure for specific circumstances, instrument preference, use of episiotomy and views on the relationship between episiotomy use and anal sphincter tears at operative vaginal delivery were explored.

RESULTS

The response rate was 80.4%. Instrument preference varied according to the fetal position and station and the grade of operator. Vacuum and forceps were both used for mid-cavity non-rotational deliveries (64% and 56% reported frequent use respectively). Rotational vacuum was preferred for a mid-cavity mal-position (69%) followed by equal numbers using rotational forceps or manual rotation and forceps (34% and 36%, respectively). Inexperienced operators were more likely to proceed directly to caesarean section (35%). A restrictive approach to use of episiotomy was preferred for vacuum delivery (72%) and a routine approach for forceps (73%). Obstetricians varied greatly in their perception of the relationship between episiotomy use and anal sphincter tears at operative vaginal delivery.

CONCLUSION

There is wide variation in the use of episiotomy at operative vaginal delivery with uncertainty about its role in preventing anal sphincter tears. A randomised controlled trial would address this important aspect of obstetric care.

Admission of term infants to neonatal intensive care: a population-based study

BACKGROUND

Neonatal intensive care and special care nurseries provide a level of care that is both high in cost and low in volume. The aim of our study was to determine the rate of admission of term babies to neonatal intensive care in association with each method of giving birth among low-risk women.

METHODS

We examined the records of 1,001,249 women who gave birth in Australia during 1999 to 2002 using data from the National Perinatal Data Collection. Among low-risk women, we calculated the adjusted odds of admission to neonatal intensive care at term separated for each week of gestational age between 37 and 41 completed weeks. We also calculated the odds of admission to neonatal intensive care in association with cesarean section before or after the onset of labor, and vacuum or instrumental birth compared with unassisted vaginal birth at 40 weeks' gestation.

RESULTS

The overall rate of admission to neonatal intensive care of term babies was 8.9 percent for primiparas and 6.3 percent for multiparas. After a cesarean section before the onset of labor, the adjusted odds of admission among low-risk primiparas at 37 weeks' gestation were 12.08 (99% CI 8.64-16.89); at 38 weeks, 7.49 (99% CI 5.54-10.11); and at 39 weeks, 2.80 (99% CI 2.02-3.88). At 41 weeks, the adjusted odds were not significantly higher than those at 40 weeks' gestation. Among low-risk multiparas who had a cesarean section before the onset of labor, the adjusted odds of admission to neonatal intensive care at 37 weeks' gestation were 15.40 (99% CI 12.87-18.43); at 38 weeks, 12.13 (99% CI 10.37-14.19); and at 39 weeks, 5.09 (99% CI 4.31-6.00). At 41 weeks' gestation, the adjusted odds of admission were significantly lower than those at 40 weeks (AOR 0.64, 99% CI 0.47-0.88). Babies born after any operative method of birth were at increased odds of being admitted to neonatal intensive care compared with those born after unassisted vaginal birth at 40 weeks' gestation.

CONCLUSIONS

The adjusted odds of admission to neonatal intensive care for babies of low-risk women were increased after birth at 37 weeks' gestation. In a climate of rising cesarean sections, this information is important to women who may be considering elective procedures.

[Five questions about the Kiwi OmniCup vacuum extractor]

The vacuum extractor Kiwi OmniCup (Clinical Innovations, Muray, Utah, USA) has been developed to provide several advantages. This is a complete system with an integral hand-held vacuum operated by the obstetrician. This is also a single use instrument, which may reduce the risk of potential transmission of infections and the logistic of sterilization process. Further potential benefits of this system include the smaller overall equipment size and the ability to measure traction force. However, the data about its efficiency remain conflicting. The first works demonstrated very high successful rate of vaginal delivery, whereas two recent randomized studies showed that the Kiwi Omnicup was less efficient than currently used vacuum extractor. It appears to be as safe as conventional a device for both mother and newborn. However, further additional data remain necessary needed to complete its evaluation.

Postpartum Genitourinary Changes

Genitourinary changes following childbirth and pregnancy are common, and include urinary and anal incontinence, pelvic pain, sexual dysfunction, and pelvic organ prolapse. At present, it is unclear whether or not these changes are a result of the pregnancy itself or the mode of delivery (cesarean section or vaginal birth). In this article, the authors aim to describe genitourinary postpartum pelvic floor changes, and review the literature regarding the impact of pregnancy or childbirth on these changes. Data is needed that compare the effects of pregnancy alone, cesarean delivery (labored and unlabored), and vaginal birth, so that physicians can better advise patients about the postpartum genitourinary tract changes they might expect.

Operative vaginal delivery and midline episiotomy: a bad combination for the perineum

OBJECTIVE

The purpose of this study was to determine the impact of operative vaginal delivery (forceps or vacuum) and midline episiotomy on the risk of severe perineal trauma.

STUDY DESIGN

In this retrospective cohort study, we assessed the impact of maternal and obstetric factors on the risk of development of severe perineal trauma (third- and fourth-degree perineal lacerations) for all singleton, vertex vaginal live births (n = 33,842) between 1996 and 2003.

RESULTS

Among nulliparous women, 12.1% had operative vaginal delivery, 22.4% had midline episiotomy, and 8.1% experienced severe perineal trauma. Among multiparous women, 3.4% had operative vaginal delivery, 4.2% had midline episiotomy, and 1.2% experienced severe perineal trauma. Controlling for maternal age, ethnicity, birth weight and head circumference, evaluation of the interaction of episiotomy and delivery method revealed that forceps (nulliparous women: odds ratio [OR] 8.6, 95% CI 6.5-10.7; multiparous women: OR 26.3, 95% CI 18.1-34.5) and episiotomy (nulliparous women: OR 4.5, 95% CI 3.7-5.4; multiparous women: OR 14.6, 95% CI 10.4-20.5) were consistently associated with the increased risk of anal sphincter trauma. In fact, the magnitude of effect of the statistically significant synergistic interaction was evidenced by more than 3-fold excess of risk of using operative vaginal delivery alone.

CONCLUSION

The use of operative vaginal delivery, particularly in combination with midline episiotomy, was associated with a significant increase in the risk of anal sphincter trauma in both primigravid and multigravid women. Given the reported substantial long-term adverse consequences for anal function, this combination of operative modalities should be avoided if possible.

Head injuries after instrumental vaginal deliveries

PURPOSE OF REVIEW

The types, mechanisms and clinical manifestations of head injuries (extracranial, cranial and intracranial) after instrumental delivery are described along with current evidence of their prevention and management.

RECENT FINDINGS

Asymptomatic subdural hematomas can occur in up to 6.1% of uncomplicated vaginal deliveries. Maternal nulliparity, incorrect placement of vacuum extraction cup and failed vacuum extraction are predisposing factors to subgaleal hemorrhage. Injuries associated with the vacuum devices may be minimized if the recommended limits for a safe traction force are not exceeded. There is no difference in the incidence of scalp trauma between vacuum deliveries by a rigid plastic cup (Omnicup) and the standard, silastic cup. The use of a metal cup may increase the occurrence of head injuries. Protective covers over forceps reduce the rates of neonatal facial abrasions and skin bruises. There is no difference in the incidence of cephalhematoma comparing a sequential operative vaginal delivery and a caesarean section following a failed vacuum delivery.

SUMMARY

Instrumental vaginal deliveries carry substantial risks. Only practitioners who are adequately trained or are under supervision should undertake instrumental delivery. The mode of intervention needs to be individualized after consideration of the operator's skills and experience and the clinical circumstances.

Rapidité d’extraction respective des césariennes et des forceps réalisés en urgence

AIM

Comparison of the decision to delivery interval in cases of forceps delivery and in cases of cesarean sections.

MATERIAL AND METHOD

A retrospective analysis was performed on 137 cases of forceps deliver (n = 63) and cesarean section (n = 74) indicated for abnormal fetal heart rhythm. All cases were observed in a level 3 maternity unit between October 2003 and August 2004.

RESULTS

The mean decision-to-delivery interval was significantly shorter in the forceps group (14.84 min +/- 6.54 versus 29.31 min +/- 11.79 p < 0.0001). Maternal and neonatal morbidity were comparable.

CONCLUSION

This study suggest that once the fetal head is engaged, forceps delivery can significantly reduced the decision-to-delivery interval.

Posterior pelvic floor compartment disorders

Posterior pelvic floor compartment disorders generally refer to functional anorectal disturbances that by definition are symptom-based rather than anatomical defect-based and have a significant impact on quality of life. Symptoms attributed to the posterior compartment are often non-specific and associated with structural, neuromuscular and functional defects giving rise to symptoms of prolapse, pelvic pressure, faecal incontinence, stool trapping and constipation. They may range from mild to incapacitating and occur in varying combinations. While symptoms of constipation and incontinence may conceptually represent the opposing extremes of normal anorectal function, the dynamic interrelationships between the different pathophysiological mechanisms involved in the development of these disorders suggest a more complex explanation. Faecal continence and defecation are dependent on several neurological and anatomical factors that involve coordinated physiological processes, including intestinal transit and absorption, colonic transit, rectal compliance, anorectal sensation and continence mechanism. However, it is well recognized that pelvic floor symptoms originating from one compartment do not imply absent pathology in another compartment. Furthermore, symptoms associated with one disorder (such as constipation related to functional obstructed defecation) can be causative in the sequential development of other pelvic floor disorders, such as a urogenital prolapse syndrome, that may further exacerbate symptoms. In addition, it has been found that treatment that corrects one problem may improve, worsen or even predispose to other symptoms from another compartment. Consequently, while the concept of global pelvic floor dysfunction has emerged, the traditional single speciality referral and evaluation of pelvic floor problems continues to foster potentially segregated management strategies that can overlook the relevance of concomitant symptomatology. The evaluation and treatment of posterior pelvic compartment disorders needs to assume an individualized but multidisciplinary therapeutic approach. Given the variation in surgical approaches described to correct anatomical integrity of posterior pelvic compartment deficits, the consensus on optimal management has yet to be achieved. Therefore, it is critical that outcome measures following surgery are clearly defined. Treatment is to a great extent dictated to by functional severity and the impact that symptoms have on quality of life. Long-term follow-up should ensure that the potential for complications is minimized and satisfactory bowel, bladder and sexual function is maintained.