FIGO good clinical practice paper: management of the second stage of labor

Episiotomy: Are Indian Obstetricians Getting the Angle Right?

Background

A mediolateral episiotomy is recommended when indicated at a 60° angle at crowning, to avoid obstetric anal sphincter injuries (OASIs) by episiotomies angled too close or distant to the anus. This study surveyed obstetricians in India regarding the recommended episiotomy angle and their ability to correctly draw the angle.

Methods

Workshops were conducted in India to share knowledge in the prevention and repair of OASIs. A questionnaire was distributed prior to the workshop. Participants were asked to describe the recommended episiotomy angle and to draw this on a paper replica of the perineum. The intra-class correlation coefficient (ICC) was calculated to assess the inter-rater reliability between the angle stated and drawn. A 2° difference was deemed acceptable. Standard errors of measurement (SEM) were calculated to measure the range of error of each measurement.

Results

One hundred and forty doctors participated. 47.9% described the angle of an episiotomy to be 60°. Only 2.2% drew an angle of 60°, but 8.7% (n = 12) drew between 58 and 62°. Only 5.8% (n = 6) of doctors correctly drew the episiotomy angle they described. There was poor agreement ICC = 0.18 (- 0.01 to 0.36) with a SEM of ± 12.2°.

Conclusions

Knowledge surrounding the recommended episiotomy angle is lacking. Doctors are failing to estimate their desired episiotomy angle. This highlights the need for national guidelines, the creation and validation of structured training programmes to improve accuracy, or using fixed-angle devices such as the EPISCISSORS-60 or other proven measurement aids to minimise preventable harm due to human error.

Engaging women to set the research agenda for assisted vaginal birth

INTRODUCTION

Public and patient involvement can provide crucial insights to optimise research by enhancing relevance and appropriateness of studies. The World Health Organization (WHO) engaged in an inclusive process to ensure that both technical experts and women had a voice in defining the research gaps and needs to increase or reintroduce the use of assisted vaginal birth (AVB) in settings where this intervention is needed but unavailable or underused.

METHODS

We describe the methods and outcomes of online workshops led by WHO to obtain women representatives' perspectives about AVB research gaps and needs.

RESULTS

After technical experts created a list of research questions based on various evidence syntheses, WHO organised four online workshops with 31 women's representatives from 27 mostly low- and middle-income (LMIC) countries. Women rated the importance and priority of the research questions proposed by the technical experts, improving and broadening some of them, added new questions, and voiced their main concerns and views about AVB. Women helped to put the research questions into context in their communities, highlighted neglected factors/dimensions that influence practices and affect women's experience during labour and childbirth, underscored less salient consequences of AVB, and highlighted the main concerns of women about research on AVB. The consolidated vision of technical experts and women's representatives resulted in a technical brief published by WHO. The technical brief is expected to stimulate global research and action closely aligned with women's priorities.

CONCLUSIONS

We describe a successful experience of engaging women, mostly from LMICs, in the identification of research gaps and needs to reintroduce AVB use. This process contributed to better aligning research questions with women's views, concerns, and priorities. Given the scarcity of reports about engaging women from LMICs to optimise research, this successful experience can serve as an inspiration for future work.

PATIENT OR PUBLIC CONTRIBUTION

Women representatives were involved at every stage of the workshops described in full in this manuscript.

Women's experiences of being assisted by two midwives during the active second stage of labour: Secondary outcomes from the Oneplus trial

BACKGROUND

'Collegial Midwifery Assistance' (CMA) is a clinical practice aiming to reduce severe perineal trauma (SPT) during childbirth. This practice involves two midwives being present during the active second stage of labour rather than one, which is the case in standard care. The effectiveness of CMA was evaluated in the Oneplus trial and a 30% reduction in SPT was shown.

AIM

The aim was to investigate the experience of women who received the CMA intervention in the trial and to explore factors influencing their experiences.

METHODS

A cohort study using data from the Oneplus trial and a one-month postpartum follow-up questionnaire. Descriptive statistics, univariable and multivariable logistic regression analyses were performed.

RESULTS

A total of 1050 women who received the CMA intervention responded to the questionnaire. Of these, 35.8% reported that they strongly agreed with feeling safe during the second stage of labour and 42.6% were inclined to have an additional midwife present at a subsequent birth. The intervention was favourably received by women who experienced fear of birth, who were non-native Swedish speakers, and had lower educational attainment. Furthermore, women were more positive towards CMA the longer the intervention lasted.

CONCLUSIONS

The results of this study suggest that the CMA intervention is accepted well by women and can be safely implemented into standard care. The duration of the CMA intervention was an important factor that influenced women's experiences and should be used to guide future practice.

Ultrasonographic Evaluation of the Second Stage of Labor according to the Mode of Delivery: A Prospective Study in Greece

BACKGROUND AND OBJECTIVES

Accurate diagnosis of labor progress is crucial for making well-informed decisions regarding timely and appropriate interventions to optimize outcomes for both the mother and the fetus. The aim of this study was to assess the progress of the second stage of labor using intrapartum ultrasound.

MATERIAL AND METHODS

This was a prospective study (December 2022-December 2023) conducted at the Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece. Maternal-fetal and labor characteristics were recorded, and two ultrasound parameters were measured: the angle of progression (AoP) and the head-perineum distance (HPD). The correlation between the two ultrasonographic values and the maternal-fetal characteristics was investigated. Multinomial regression analysis was also conducted to investigate any potential predictors of the mode of delivery.

RESULTS

A total of 82 women at the second stage of labor were clinically and sonographically assessed. The mean duration of the second stage of labor differed between vaginal and cesarean deliveries (65.3 vs. 160 min; p-value < 0.001) and between cesarean and operative vaginal deliveries (160 vs. 88.6 min; p-value = 0.015). The occiput anterior position was associated with an increased likelihood of vaginal delivery (OR: 24.167; 95% CI: 3.8-152.5; p-value < 0.001). No significant differences were identified in the AoP among the three different modes of delivery (vaginal: 145.7° vs. operative vaginal: 139.9° vs. cesarean: 132.1°; p-value = 0.289). The mean HPD differed significantly between vaginal and cesarean deliveries (28.6 vs. 41.4 mm; p-value < 0.001) and between cesarean and operative vaginal deliveries (41.4 vs. 26.9 mm; p-value = 0.002); it was correlated significantly with maternal BMI (r = 0.268; p-value = 0.024) and the duration of the second stage of labor (r = 0.256; p-value = 0.031). Low parity (OR: 12.024; 95% CI: 6.320-22.876; p-value < 0.001) and high HPD (OR: 1.23; 95% CI: 1.05-1.43; p-value = 0.007) were found to be significant predictors of cesarean delivery.

CONCLUSIONS

The use of intrapartum ultrasound as an adjunctive technique to the standard clinical evaluation may enhance the diagnostic approach to an abnormal labor progress and predict the need for operative vaginal or cesarean delivery.

Primary midwives' experiences of collegial midwifery assistance during the active second stage of labor: Data from the Oneplus trial

BACKGROUND

Collegial midwifery assistance during the active second stage of labor that involves a second midwife being present has been shown to reduce severe perineal trauma (SPT) by 30%. The aim of this study was to investigate primary midwives' experiences of collegial midwifery assistance with the purpose of preventing SPT during the active second stage of labor.

METHODS

This study uses an observational design with data from a multicenter randomized controlled trial (Oneplus). Data consist of clinical registration forms completed by the midwives after birth. Descriptive statistics as well as univariable and multivariable logistic regression were used to analyze the data.

RESULTS

The majority of the primary midwives felt confident (61%) and were positive (56%) toward the practice. Midwives with less than 2 years' work experience were more likely to completely agree they felt confident (aOR 9.18, 95% CI: 6.28-13.41) and experience the intervention as positive (aOR 4.04, 95% CI: 2.83-5.78) than those with over 20 years' work experience. Factors such as duration of time spent in the birthing room by the second midwife, opportunity for planning and if the second midwife provided support were further associated with the primary midwife's experience of the practice as being positive.

CONCLUSIONS

Our findings indicate that having a second midwife present during the active second stage of labor was an accepted practice, with the majority of primary midwives feeling confident and positive toward the intervention. This was especially pronounced among midwives with less than 2 years' work experience.

FIGO best practice guidance in surgical consent

Obtaining medical consent preoperatively is one of the key steps in preparing for surgery, and is an important step in informed decision making with the patient. According to good medical practice guidelines, doctors are required to have the knowledge and skills to treat patients as well as inform them, respect their wishes, and establish trust between themselves and their patients. Valid consent includes elements of competence, disclosure, understanding, and voluntariness. Documentation of these elements is also very important. The International Federation of Gynecology and Obstetrics (FIGO) Education Communication and Advocacy Consortium (ECAC) has realized that the quality of consent varies considerably across the world and has developed simple guidelines regarding consent and procedure-specific checklists for the most common obstetric and gynecological procedures.

Vacuum-assisted birth in maternal lateral posture versus lithotomy. A simulation study

OBJECTIVE

Maternal lateral postures provide advantages during childbirth. This study aims to investigate the feasibility of assisting vacuum births in maternal lateral postures in a simulation model.

STUDY DESIGN

In a simulation model, four obstetricians and four medical students were randomly allocated to perform vacuum-assisted births first in maternal lateral posture or lithotomy. A modification of Aldo Vacca's 5-step technique was developed to assist vacuum-assisted births in lateral posture. The lateral distance, vertical distance, and distance from the cup center to the flexion point were measured for every placement of the cup.

RESULTS AND CONCLUSIONS

A total of 128 vacuum-assisted births were performed. The mean distance to the flexion point was 1.15 ± 0.71 cm for the lithotomy posture and 1.31 ± 0.82 cm for the lateral posture (P = 0.127). There were no statistically significant differences in vacuum extractor cup placement accuracy based on maternal posture. Performing vacuum-assisted births in maternal lateral posture is feasible in a simulation model. The technique is easy to learn, and the differences in cup placement between the lateral and lithotomy postures are small.

Prep-for-Labor: Overview of FIGO's labor and delivery triage bundles of care to optimize maternal and newborn outcomes

Childbirth is an intense event in which decisions may need to be made in seconds to guarantee the health of both mother and newborn. Despite health systems and care approaches varying widely according to real-life scenarios, availability of facilities, beliefs, resources, staff, and geography, among others, optimal outcomes should be ensured worldwide. Triaging low-risk pregnancies from high-risk pregnancies is the first step to ensure proper allocation of resources. From this need, we developed FIGO's Prep-For-Labor triage methods, a series of 2-minute labor and delivery bundles of care, with special regard given to low- and middle-income countries and rural settings. Around 80% of women, once properly triaged, can pursue vaginal delivery with minimal intervention, while those at risk can either be managed on site or transferred promptly to an advanced care site. FIGO's bundles of care and good practice recommendations for labor and delivery and immediate newborn triage cover four clinical scenarios: (1) preterm labor; (2) induced or spontaneous labor at term; (3) cesarean delivery; and (4) newborn care. From rapid triage of the mother (low vs high risk) to the list of required equipment, description of skilled staff, and coordination of resources, the recommendations for care are introduced across these four areas in this overview article. Implementing the proposed management steps described in each summary can improve maternal and neonatal outcomes.

Intrapartum ultrasound in maternal lateral versus semi-recumbent posture. A repeated measures study

OBJECTIVE

This study aimed to assess whether intrapartum ultrasound (ITU) measurements in maternal lateral posture are superimposable to ITU measurements in semi-recumbent position.

STUDY DESIGN

A single-center, repeated measures design was used. Women in the second stage of labor were randomized to ITU first in semi-recumbent followed by ITU in side-lying posture without and with contraction, or inversely. The angle of progression (AOP) and the head-perineum distance (HPD) between contractions (AOP1 and HPD1) and with contraction (AOP2 and HPD2) were measured in each maternal posture. The differences between AOP1 and AOP2 (dAOP), and between HPD1 and HPD2 (dHPD) were calculated.

RESULTS AND CONCLUSIONS

Forty-two women participated in the study. A generalized estimating equation model showed that AOP1 (-3.00°; 95 % CI -5.77 to -0.23; p = 0.03) and AOP2 (-4.14°; 95 % CI -7.20 to -1.08; p = 0.008) were lower in semi-recumbent compared to maternal lateral posture. HPD1 (+1.43 mm; 95 % CI 0.05-2.81; p = 0.042) and HPD2 (+1.53 mm; 95 % CI 0.17-2.89; p = 0.03) were higher in semi-recumbent position. Differences in the ITU measurements in maternal lateral posture compared to semi-recumbent position are small. Monitoring the second stage of labor with ITU in lateral maternal posture is possible.

Mode of delivery and birth outcomes in relation to the duration of the passive second stage of labour: A retrospective cohort study of nulliparous women

OBJECTIVE

To investigate the mode of delivery and birth outcomes in relation to the duration of the passive second stage of labour in nulliparous women.

METHODS AND FINDINGS

A retrospective cohort study of all nulliparous women (n = 1131) at two delivery units in Sweden. Maternal and obstetric data were obtained from electronic medical records during 2019. The passive second stage was defined as the complete dilation of the cervix until the start of the active second stage. The duration of the passive second stage was categorized into three groups: 0 to 119 min (0 to <2 h), 120-239 min (2- <4h) and ≥240 min (≥4h). Differences between the groups were examined using t-test and Chi2-tests and regression analyses were used to analyse adjusted odds ratio with 95% confidence intervals. The primary outcome was mode of delivery in relation to the duration of the passive second stage and the secondary outcomes covered a series of adverse maternal and neonatal birth outcomes. The rates of instrumental and caesarean deliveries increased as the duration of the passive second stage increased. A ≥4-hour duration of the passive second stage was associated with a nine-times increased risk of caesarean section, and a four-times risk of instrumental delivery compared to a duration of <2 hours in the adjusted analyses. No differences were found in the maternal birth outcomes. The risk of a 5-minute Apgar score <7 was increased in the 2-<4h group. A longer passive second stage was not associated with an increased risk of negative birth experience.

CONCLUSIONS

Our study demonstrates an increased risk of operative delivery for a longer duration (>2h) of the passive second stage in nulliparous women, although most of the women gave birth by spontaneous vaginal delivery even after ≥4 hours. There was no evidence of an increased risk of adverse maternal outcomes in a longer duration of the passive second stage but there were indications of increased adverse neonatal outcomes. Assessment of fetal well-being is important when the duration of the passive phase is prolonged.

"Assisted vaginal birth using the Paily obstetric forceps vs Ventouse - A randomized clinical trial"

OBJECTIVE

Instruments used in assisted vaginal birth have seen little innovation for decades. Due to the risk of trauma and technical difficulty incurred during forceps delivery, instrumental deliveries are on a decline, and the global rate of primary cesarean birth is rising. The novel Paily Obstetric Forceps (POF) features a compact, lighter design with thinner blades, designed to increase operator comfort and minimize maternal and neonatal injuries. We aim to determine the feasibility and safety of POF in achieving vaginal birth compared to a ventouse device with a 50 mm silastic cup.

STUDY DESIGN

We conducted a single-blinded, parallel arm, randomized clinical trial of the novel POF vs a ventouse device, in patients undergoing indicated assisted vaginal birth, at a tertiary care obstetric unit. We randomized 100 patients to be allocated on a 1:1 ratio to both intervention arms. Primary outcome was the proportion of successful instrumental deliveries. Secondary outcomes were the number of pulls required during traction and any maternal or neonatal adverse events.

RESULTS

The POF was significantly more successful in achieving vaginal birth than the ventouse device (n = 50/50, 100 % vs n = 42/50, 84 %, p = 0.006). Operators reported requiring significantly fewer pulls during POF traction than ventouse. POF demonstrated a higher risk for maternal trauma (RR = 3.2, 95 % CI = 1.5 to 6.9, NNH = 2.7) but a lower risk for neonatal injury (RR = 0.6, 95 % CI = 0.3 to 1, NNH = 5.7). Maternal and neonatal recovery durations were comparable. There were no incidences of maternal or neonatal mortality.

CONCLUSION

The POF can be used in indicated assisted vaginal birth with superior success rates and better neonatal outcomes than ventouse. Other obstetric forceps must be standardized to conduct larger superiority trials of forceps designs.

Attitudes and knowledge regarding episiotomy use and technique in vacuum extraction: A web-based survey among doctors in Sweden

OBJECTIVES

Correct episiotomy use and technique may prevent obstetric anal sphincter injuries. We aimed to explore the attitudes, use, and technique regarding episiotomy among doctors in Sweden, and their willingness to contribute to a randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction in nulliparous women.

STUDY DESIGN

A web-based survey was sent to members of the Swedish Society of Obstetrics and Gynecology (n = 2140). The survey included 31 questions addressing personal characteristics, use of episiotomy, a two-dimensional picture on which the respondents drew an episiotomy, and questions regarding attitudes towards episiotomy and participation in a randomized controlled trial. We calculated the proportion of supposedly protective episiotomies (fulfilling criteria of a lateral or mediolateral episiotomy and a length ≥ 30 mm). We compared the results between obstetricians, gynecologists, and residents using Chi-square and Kruskal-Wallis tests for differences between groups, and logistic regression to estimate the odds ratio (OR) of drawing a protective episiotomy.

RESULTS

We received 432 responses. Doctors without a vacuum delivery in the past year were excluded, leaving 384 respondents for further analyses. In all, 222 (57.8%) doctors reported use of episiotomy in<50% of vacuum extractions. We obtained 308 illustrated episiotomies with a median angle of 53°, incision point distance from the midline of 21 mm, and length of 36 mm, corresponding to a lateral episiotomy. Few doctors combined these parameters correctly resulting in 167 (54.2%) incorrectly drawn episiotomies. Residents drew shorter episiotomies than obstetricians and gynecologists. Doctors ranked episiotomy the least important intervention to prevent obstetric anal sphincter injuries in vacuum extraction. Doctors contributing to an ongoing randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction were more able to draw a protective episiotomy (OR 3.69, 95% confidence interval 1.94-7.02).

CONCLUSIONS

Doctors in Sweden reported restrictive use of episiotomy in vacuum extraction and depicted lateral type episiotomies, although the majority were incorrectly drawn. Preventive episiotomy was ranked of low importance. Our results imply a need for education, training, and guidelines to increase uptake of correct episiotomy technique, which could result in improved prevention of obstetric anal sphincter injuries.