Instrumental delivery: clinical practice guidelines from the French College of Gynaecologists and Obstetricians

The impact of selective episiotomy on maternal short-term morbidity: a retrospective study

BACKGROUND

The aim is to investigate the risk of short-term maternal morbidity caused by the selective clinical use of episiotomy (rate < 0.02), and to compare the risk of severe perineal tears with the statewide risk.

METHODS

In this retrospective cohort study, we investigated the effect of selective episiotomy on the risk of severe perineal tears and blood loss in singleton term deliveries, using propensity scores with inverse probability weighting.

RESULTS

This study included 10992 women who delivered vaginally between 2008-2018. Episiotomy was performed in 171 patients (1.55%), three of whom (1.75%) experienced severe perineal tears compared to 156 (1.44%) in the control cohort. The adjusted odds ratio of severe perineal tears was 2.06 (95% confidence interval [CI]: 0.51, 8.19 with 0.3 p value). Multivariate linear regression showed that episiotomy increased blood loss by 96.3 ml (95% CI: 6.4, 186.2 with 0.03 p value). Episiotomy was performed in 23% (95% CI: 0.228, 0.23) of vaginal deliveries in the state of Hessen, with a risk of severe perineal tears of 0.0143 (95% CI: 0.0139, 0.0147) compared to 0.0145 (95% CI: 0.0123, 0.0168) in our entire cohort.

CONCLUSIONS

Selective use of episiotomy does not increase the risk of higher-grade perineal tears. However, it may be associated with maternal morbidity in terms of increased blood loss.

Which type of forceps is better for nonrotational operative births? A simulation study comparing Thierry spatulas and Simpson-Braun and Kielland forceps

OBJECTIVE

Obstetric forceps play an important role in safe childbirth, yet there is a lack of distinction between various forceps types in clinical practice. This study aimed to evaluate and compare perineal pressure and forces on the baby during nonrotational forceps-assisted births using Simpson-Braun forceps, Kielland forceps, and Thierry spatulas on a simulation model.

METHODS

This experimental study involved six obstetricians conducting 108 forceps-assisted births on a simulation model. Instruments were assessed for their impact on perineal pressure, traction force, and operator-assessed difficulty.

RESULTS

Thierry's spatulas exerted the lowest force on the baby, while Kielland forceps exhibited the lowest perineal pressure, though not statistically significant. An experienced obstetrician demonstrated less perineal pressure with Simpson forceps. Notably, no significant differences in difficulty were observed between instruments.

CONCLUSION

This study highlights distinctions in forceps performance, with Thierry spatulas applying the least force on the fetal head, while an experienced obstetrician fared better with Simpson forceps in terms of perineal pressure. Kielland forceps remain a viable alternative for nonrotational forceps births, showing comparable outcomes.

Rotational Forceps: Which technique is superior for blade insertion? A simulation study comparing direct, first posterior, and wandering maneuvers

OBJECTIVE

The Kielland's forceps is the most used forceps for assisting rotational operative births. There are various maneuvers described for blade insertion. Among these, the most used ones are the direct, first posterior, and wandering maneuver. The objective of this study was to compare these three maneuvers using a simulator.

STUDY DESIGN

In this experimental study, 144 rotational forceps-assisted births were conducted using a simulation model, with 72 starting in a right occiput-transverse position and 72 in a left occiput-transverse position. Each of the three maneuvers (direct, first posterior, or wandering) for blade insertion was performed 48 times by a total of 6 operators, comprising 3 obstetricians with over 10 years of experience and 3 trainees. The assessment of forceps application included evaluating the placement of the blades in terms of asymmetry and the distance from the lock to the posterior fontanelle. Additionally, the study evaluated the number of reinsertions and relocations required, the perceived difficulty of the procedure, and the operator's level of experience.

RESULTS

There were no statistically significant differences in terms of asymmetry with the three maneuvers. Regarding the distance from the lock to the posterior fontanelle, the best results were obtained with the direct maneuver. There were no differences in the number of reinsertions, relocations, and the perceived difficulty by the operators among the three maneuvers. Experienced obstetricians had better outcomes in terms of the need for reinsertions.

CONCLUSION

The direct maneuver offer advantages in the insertion of blades for rotational forceps.

Effects of Water Immersion Versus Epidural as Analgesic Methods during Labor among Low-Risk Women: A 10-Year Retrospective Cohort Study

BACKGROUND

Adequate pain relief during childbirth is a very important issue for women and healthcare providers. This study investigates the effects on maternal and neonatal outcomes of two analgesic methods during labor: water immersion and epidural analgesia.

METHODS

In this retrospective observational cohort study at a first-level hospital, in Spain, from 2009 to 2019, 1134 women, low-risk singleton and at term pregnancy, were selected. Among them, 567 women used water immersion; 567 women used epidural analgesia for pain control. Maternal outcomes included mode of birth and perineum condition. Neonatal outcomes included 5 min Apgar score, umbilical cord arterial pH, and Neonatal Intensive Care Unit admissions. Chi-square tests and Mann-Whitney U tests, together with their effect sizes (Cramer's V, odds ratio, and Cohen's d) were used to test the main hypotheses.

RESULTS

Spontaneous vaginal birth was almost 17 times more likely in the water immersion group (OR = 16.866 [6.540, 43.480], p < 0.001), whereas the odds of having a cesarean birth were almost 40 times higher in the epidural group (OR = 39.346 [3.610, 429.120], p < 0.001). The odds of having an intact perineum were more than two times higher for the water immersion group (OR = 2.606 [1.290, 5.250], p = 0.007), whereas having an episiotomy was more than eight times more likely for the epidural group (OR = 8.307 [2.800, 24.610], p < 0.001). Newborns in the water immersion group showed a better 5 min Apgar score and umbilical cord arterial pH and lower rates in admissions at the Neonatal Intensive Care Unit.

CONCLUSIONS

Women choosing water immersion as an analgesic method were no more likely to experience adverse outcomes and presented better results than women choosing epidural analgesia.

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.

Obstetric Interventions Among Native and Migrant Women: The (Over)use of Episiotomy in Portugal

Objective: Episiotomy, defined as the incision of the perineum to enlarge the vaginal opening during childbirth, is one of the most commonly performed surgical interventions in the world. We aimed to determine if migrant status is associated with episiotomy, and if individual characteristics mediate this association. Methods: We analyzed data from the Bambino study, a national, prospective cohort of migrant and native women giving birth at a public hospital in mainland Portugal between 2017 and 2019. We included all women with vaginal delivery. The association between migrant status and episiotomy was assessed using multivariable multilevel random-effect logistic regression models. We used path analysis to quantify the direct, indirect and total effects of migrant status on episiotomy. Results: Among 3,583 women with spontaneous delivery, migrant parturients had decreased odds of episiotomy, especially those born in Africa, compared to native Portuguese women. Conversely, with instrumental delivery, migrant women had higher odds of episiotomy. Disparities in episiotomy were largely explained by maternity units' factors, and little by maternal and fetal characteristics. Conclusion: Our results suggest non-medically justified differential episiotomy use during childbirth and highlight the importance of developing evidence-based recommendations for episiotomy use in a country with a high frequency of medical interventions during delivery.

Assisted vaginal birth in 21st century: current practice and new innovations

Assisted vaginal birth rates are falling globally with rising cesarean delivery rates. Cesarean delivery is not without consequence, particularly when carried out in the second stage of labor. Cesarean delivery in the second stage is not entirely protective against pelvic floor morbidity and can lead to serious complications in a subsequent pregnancy. It should be acknowledged that the likelihood of morbidity for mother and baby associated with cesarean delivery increases with advancing labor and is greater than spontaneous vaginal birth, irrespective of the method of operative birth in the second stage of labor. In this article, we argue that assisted vaginal birth is a skilled and safe option that should always be considered and be available as an option for women who need assistance in the second stage of labor. Selecting the most appropriate mode of birth at full dilatation requires accurate clinical assessment, supported decision-making, and personalized care with consideration for the woman's preferences. Achieving vaginal birth with the primary instrument is more likely with forceps than with vacuum extraction (risk ratio, 0.58; 95% confidence interval, 0.39-0.88). Midcavity forceps are associated with a greater incidence of obstetric anal sphincter injury (odds ratio, 1.83; 95% confidence interval, 1.32-2.55) but no difference in neonatal Apgar score or umbilical artery pH. The risk for adverse outcomes is minimized when the procedure is conducted by a skilled accoucheur who selects the most appropriate instrument likely to achieve vaginal birth with the primary instrument. Anticipation of potential complications and dynamic decision-making are just as important as the technique for safe instrument use. Good communication with the woman and the birthing partner is vital and there are various recommendations on how to achieve this. There have been recent developments (such as OdonAssist) in device innovation, training, and strategies for implementation at a scale that can provide opportunities for both improved outcomes and reinvigoration of an essential skill that can save mothers' and babies' lives across the world.

Persistent occiput posterior position: predictive factors of spontaneous rotation of the fetal head

OBJECTIVES

To assess factors associated with spontaneous rotation in the occiput anterior position for fetuses in persistent occiput posterior (OP) during the second stage of labor. To evaluate maternal and fetal outcomes after spontaneous rotation of persistent OP.

METHODS

This is a prospective cohort of 495 women with fetuses in persistent OP position, confirmed with ultrasonography during the second stage of labor. We performed simple logistic regressions, followed by multiple logistic regressions.

RESULTS

Among 495 women with fetuses in persistent OP position, 78 fetuses (16%) underwent a spontaneous rotation during the second stage of labor. The multivariate analysis found that a short duration of the first stage of labor (<7 h) was associated with a spontaneous rotation of the fetal head in the second stage of labor (OR 0.43 [0.23; 0.76. There were fewer episiotomies (25.6% vs 52.3%, p < .01), cesarean sections (0% v. 5.4%, p = .03), and instrumental deliveries (8.9% vs. 50%, p < .01) in the "spontaneous rotation" group, and the two groups were similar regarding post-partum hemorrhage.The newborns in the "spontaneous rotation" group had a higher Apgar score at 1 min (10 v. 9, p = .02). The two groups did not differ for other neonatal parameters, such as arterial pH value, Apgar score at 5 min, birth trauma, or transfer into the pediatric unit.

CONCLUSION

A shorter duration of the first stage of labor (< 7 h) is a predictive factor of spontaneous rotation in the occiput anterior position for fetuses in persistent OP position. A spontaneous rotation in case of an OP position is associated with better maternal and fetal outcomes.

Early childhood eye diseases and perinatal risk factors: potential of record linkage between current information flows

BACKGROUND

The aim of this study was to analyze the occurrence of specific maternal, obstetric or neonatal factors, by performing a comparison between children with refractive error, strabismus and/or amblyopia (cases) and unaffected children (controls) in the province of Trento (North-East Italy).

METHODS

In 2012-2014, 14,346 children attending the second year of nursery school were assessed through the preschool orthoptic screening scheme (covering 91% of the preschool population). Record linkage was performed between the orthoptic screening database and birth records (birth confirmation certificate database) for the corresponding birth cohorts (2008-2010), to examine specific maternal factors (age, smoking, nationality/race), obstetric factors (type of delivery) and neonatal factors (gestational age, weight at birth, Apgar Score, congenital birth defects, hospitalization at birth). The correlations were investigated using univariate and multivariate analysis in accordance with the logistic regression method.

RESULTS

During orthoptic screening, 6.4% of children were found to have at least one refractive error, with astigmatism being the most common condition (5.1%). 1.9% of children were found to have strabismus and 1.8% amblyopia. Multivariate logistic regression analysis showed that the risk of developing a refractive error is associated with: maternal age ≥45 years, foreign nationality, vacuum-assisted delivery and neonatal weight <1500 grams. An excessive risk of strabismus was observed in children whose mother had smoked during pregnancy (adjusted OR=1.64).

CONCLUSIONS

Preschool orthoptic screening is a well-consolidated practice in the province of Trento, with adhesion values consistently over 90%. Studies of this type show the potential of record linkage between current information flows.

Prevalence, indications and fetal outcomes of operative vaginal delivery in Sub-Saharan Africa, systematic review, and meta-analysis

PURPOSE

This systematic review and meta-analysis is intended to assess the prevalence, indications, and fetal outcome of operative vaginal delivery in sub-Saharan Africa.

METHOD

In this study, 17 studies with a total population of 190,900 were included in both systematic review and meta-analysis. Search for relevant articles was done by using international online databases (like Google Scholar, PubMed, HINARI, EMBASE, Web of Science, and African journals) and online repositories of Universities in Africa. The JOANNA Briggs Institute standard data extraction format was used to extract and appraise high-quality articles before being included in this study. The Cochran Q and I2 statistical tests were used to test the heterogeneity of the studies. The publication bias was tested by a Funnel plot and Egger's test. The overall pooled prevalence, indications, and fetal outcome of operative vaginal delivery along a 95% CI using forest plots and tables.

RESULT

The overall pooled prevalence of operative vaginal delivery in sub-Saharan Africa was 7.98% (95% CI; 5.03-10.65; I2 = 99.9%, P < 0.001). The indications of operative vaginal delivery in sub-Saharan African countries include the prolonged second stage of labor 32.81%, non-reassuring fetal heart rate 37.35%, maternal exhaustion 24.81%, big baby 22.37%, maternal cardiac problems 8.75%, and preeclampsia/eclampsia 2.4%. Regarding the fetal outcome, favourable fetal outcomes were 55% (95% CI: 26.04, 84.44), p =  < 0.56, I2: 99.9%). From those births with unfavourable outcomes, the need for the resuscitation of new-born was highest 28.79% followed by poor 5th minute Apgar score, NICU admission, and fresh stillbirth, 19.92, 18.8, and 3.59% respectively.

CONCLUSION

The overall prevalence of operative vaginal delivery (OVD) in sub-Saharan Africa was slightly higher compared to other countries. To reduce the increased applications and adverse fetal outcomes of OVD, capacity building for obstetrics care providers and drafting guidelines are required.

Predictors of shoulder dystocia at the time of operative vaginal delivery: a prospective cohort study

Our aim was to identify factors associated with shoulder dystocia following an attempted operative vaginal delivery (aOVD) in a prospective cohort study and to evaluate whether these factors can be used to accurately predict shoulder dystocia by building a score of shoulder dystocia risk. This was a planned secondary analysis of a prospective cohort study of deliveries with aOVD at term from 2008-2013. Cases were defined as women with shoulder dystocia following an aOVD defined as a delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders. Multivariate logistic regression analyses were performed to determine risk factors for shoulder dystocia. Shoulder dystocia occurred in 57 (2.7%) of the 2118 women included. In the whole cohort, women with shoulder dystocia more often had a history of shoulder dystocia (3.5% vs. 0.2%, p = 0.01), and there was a significant interaction between aOVD and gestational age and the duration of the second stage of labor: women with shoulder dystocia more often had a gestational age > 40 weeks and a second stage of labor longer than 3 h specifically for midpelvic aOVD. In multivariable analysis, a history of shoulder dystocia was the only factor independently associated with shoulder dystocia following aOVD (aOR 27.00, 95% CI 4.10-178.00). The AUC for the receiver operating characteristic curve generated using a multivariate model with term interaction with head station was 0.70 (95% CI 0.62-0.77). The model failed to accurately predict shoulder dystocia.

Head-to-perineum distance measured transperineally as a predictor of failed midcavity vacuum-assisted delivery

BACKGROUND

During the second stage of labor, in case of a need for a fetal extraction at midcavity, the choice of attempting the procedure between operative vaginal delivery and cesarean delivery is difficult. Moreover, guidelines on this subject are not clear.

OBJECTIVE

This study aimed to identify antenatal and intrapartum parameters associated with a failed midcavity vacuum-assisted delivery and its association with maternal and neonatal adverse outcomes.

STUDY DESIGN

This was a single-center, retrospective, cohort study conducted at a tertiary maternity hospital in France from January 2010 to December 2020. Women with singleton pregnancies under epidural analgesia with nonanomalous cephalic presenting fetuses and gestational ages at ≥37 weeks of gestation, who were submitted to midcavity vacuum-assisted delivery, were included. Following the American College of Obstetricians and Gynecologists definition, midcavity was defined as the presenting part of the fetus (ie, the fetal head) found at stations 0 and +1. For research purposes, all patients were submitted to transperineal ultrasound to evaluate the head-to-perineum distance, however, this measurement did not affect the decision to perform a midcavity vacuum-assisted delivery. The primary outcome of the study was failed midcavity vacuum-assisted delivery leading to cesarean delivery or the use of a different instrument to achieve vaginal delivery.

RESULTS

Overall, 951 cases of midcavity vacuum-assisted delivery were included in this study. Failed midcavity vacuum-assisted delivery occurred in 242 patients (25.4%). Factors independently associated with failed midcavity vacuum-assisted delivery included maternal height (adjusted odds ratio, 0.96; 95% confidence interval, 0.94-0.99; P=.002), duration of the active phase of the first stage of labor (adjusted odds ratio, 1.11; 95% confidence interval, 1.05-1.17; P<.001), nonocciput anterior fetal head position (adjusted odds ratio, 1.47; 95% confidence interval, 1.06-2.04; P=.02), z score of the head-to-perineum distance (adjusted odds ratio, 1.23; 95% confidence interval, 1.05-1.43; P=.01), and birthweight of >4000 g (adjusted odds ratio, 2.04; 95% confidence interval, 1.28-3.26; P=.003). Women submitted to a failed midcavity vacuum-assisted delivery were more likely to have a major postpartum hemorrhage (7.1% vs 2.0%; P<.001), whereas neonates were more likely to have an umbilical artery pH of <7.1 (30.5% vs 19.8%; P=.001), be admitted to the neonatal intensive care unit (9.6% vs 4.7%; P=.005), and have a severe caput succedaneum (14.9% vs 0.7%; P<.001). Subgroup analysis on all patients with a fetal head station of 0 found that the head-to-perineum distance was the only independent variable associated with failed midcavity vacuum-assisted delivery (adjusted odds ratio, 1.66; 95% confidence interval, 1.29-2.12; P<.001). The area under the receiving operating characteristic curve of the head-to-perineum distance in this subgroup population was 0.67 (95% confidence interval, 0.60-0.73; P<.001), and the optimal cutoff point of the head-to-perineum distance measurement discriminating between failed and successful midcavity vacuum-assisted deliveries was 55 mm. It was associated with a 0.90 (95% confidence interval, 0.83-0.95) sensitivity, 0.19 (95% confidence interval, 0.14-0.25) specificity, 0.36 (95% confidence interval, 0.30-0.42) positive predictive value, and 0.80 (95% confidence interval, 0.66-0.90) negative predictive value.

CONCLUSION

Study data showed that a high fetal head station, measured using the head-to-perineum distance, and a nonocciput anterior position of the fetal head are independently associated with failed midcavity vacuum-assisted delivery. The result supported the systematic assessment of the sonographic head station and position before performing a midcavity vacuum-assisted delivery.

Is There a Role for Cerebral Ultrasonography in Near-Term/Term Neonates Following Assisted Vaginal Delivery? A Prospective, Single-Center Study

AIM

 To evaluate the role of cerebral ultrasonography studies (CUSS) in detecting intracerebral and cranial pathologies (hemorrhages, ischemia, skull fractures) in near-term and term neonates following assisted vaginal delivery.

PATIENTS AND METHODS

 Prospective single-center study (11/2017-11/2018) at the University Children's Hospital of Saarland, Homburg, Germany including newborns with a gestational age ≥ 36 weeks born by assisted vaginal delivery. In all newborns, a standardized CUSS was performed within the first three days of life prior to discharge.

RESULTS

 200 neonates (43.0 % female, 57.0 % male; gestational age 39.6 ± 1.3 weeks) were included in this study (birth weight 3345.6 ± 450.6 g, body length 51.7 ± 2.5 cm, head circumference 35.0 ± 1.5 cm). 67 (33.5 %) neonates had minor external injuries of the scalp. 5 children showed clinical neurologic abnormalities: 4 (2.0 %) seizures and 1 facial palsy (0.5 %). In 34 (17.0 %) patients, minor incidental intracranial abnormalities unrelated to mode of delivery were detected on CUSS. No intracerebral, cranial pathologies or skull fractures were seen on routine CUSS.

CONCLUSION

 Routine CUSS in newborns after assisted vaginal delivery did not yield clinically relevant results in our cohort. Clinical observation and selective CUSS in symptomatic newborns might be more efficient than routine CUSS.

How I manage pregnancy in women with Glanzmann thrombasthenia

Glanzmann thrombasthenia (GT) is a rare inherited platelet function disorder caused by a quantitative and/or qualitative defect of the αIIbβ3 integrin. Pregnancy and delivery is a recognized risk period for bleeding in women with GT. The newborn may also be affected by fetal and neonatal immune thrombocytopenia induced by the transplacental passage of maternal anti-αIIbβ3 antibodies, which can lead to severe hemorrhage and fetal loss. Pregnancy in GT women thus requires a multidisciplinary approach, including prepregnancy counseling, and a treatment plan for delivery for both the mother and child. In this article, we summarize the current knowledge on pregnancy in women with GT and describe how we manage this severe platelet disorder in our clinical practice.

Mediolateral episiotomy and risk of obstetric anal sphincter injuries and adverse neonatal outcomes during operative vaginal delivery in nulliparous women: a propensity-score analysis

Background

The potential protective effect of mediolateral episiotomy for obstetrical anal sphincter injuries (OASIs) remains controversial during operative vaginal delivery because of the difficulties to take into account the risk factors and clinical conditions at delivery; in addition, little is known about the potential benefits of mediolateral episiotomy on neonatal outcomes.

The objectives were to investigate the associations between mediolateral episiotomy and both OASIs and neonatal outcomes, using propensity scores.

Methods

We performed a retrospective population-based observational study from a perinatal registry that includes all births in a French region between 2010 and 2017. All nulliparous women with singleton pregnancy delivering by operative vaginal deliveries at 37 weeks gestational age or later were included. Inverse-probability-of-treatment weighting with propensity scores was used to minimize indication bias. OASIs was defined as third and fourth-degree tears according to Royal College of Obstetricians and Gynecologists. Two neonatal outcomes were studied: condition at birth (5-min Apgar score less than 7 and/or umbilical artery pH less than 7.10), and admission to neonatal intensive care unit.

Results

The study population consisted of 7589 women; 2880 (38.0%) received mediolateral episiotomy. After applying propensity scores, episiotomy was associated with a lower rate of OASIs in forceps/spatula delivery (2.3 vs 6.8%, Risk Ratio (RR) 0.38, 95% Confidence Interval (CI) 0.28–0.52) and in vacuum delivery (1.3 vs 3.4%, RR 0.27, 95% CI 0.20–0.38) as compared with no episiotomy. Mediolateral episiotomy was associated with better condition at birth in case of forceps/spatula delivery (4.5 vs 8.8%, RR 0.56, 95% CI 0.39–0.81). In cases of fetal distress (40.7%), mediolateral episiotomy was associated with better condition of infant at birth in women who delivered by forceps/spatula (4.2 vs 13.5%, RR 0.52, 95% CI 0.31–0.89). No association was found with neonatal unit admission (RR 0.93, 95% CI 0.50–1.74).

Conclusions

Use of mediolateral episiotomy was associated with a lower rate of OASIs during operative vaginal delivery, and in infants it was associated with better condition at birth following forceps/spatula delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04396-6.

Middle-East OBGYN graduate education (MOGGE) foundation practice guidelines: use of labor charts in management of labor. Practice guideline no. 04-O-21

Since the 50 s of the last century, labor charts have been proposed and appraised as a tool to diagnose labor abnormalities and guide decision-making. The partogram, the most widely adopted form of labor charts, has been endorsed by the world health organization (WHO) since 1994. Nevertheless, recent studies and systematic reviews did not support clinical significance of application of the WHO partogram. These results have led to further studies that investigate modifications to the structure of the partogram, or more recently, to reconstruct new labor charts to improve their clinical efficacy. This guideline appraises current evidence on use of labor charts in management of labor specially in low-resource settings.

Prolongation of active second stage of labor: Associated factors and perinatal outcomes

BACKGROUND

Current data does not allow to define a reasonable threshold of duration of active second stage (ASS) of labor beyond which a medical intervention should be considered. Primary objective was to analyse perinatal outcomes associated with prolonged ASS beyond 45 min. Secondarily, we analysed associated maternal, gestational, labor and delivery characteristics associated with prolonged ASS.

METHODS

We performed a monocentric retrospective study among women with vaginal delivery, a term singleton cephalic fetus, without history of cesarean section. We compared women with active second stage of labor longer than 45 min (ASS ≥45 min, group A) and women with instrumental vaginal delivery (IVD) only for failure to progress (FtP) before 45 min of pushing (group B). Primary outcome was postpartum hemorrhage (PPH). Maternal and neonatal outcomes associated with ASS ≥ 45 min were assessed with multivariable logistic regression models.

RESULTS

Prolonged ASS ≥45 min (group A, N=177) was associated with lower rate of persistent occiput posterior position (1.7 vs 9.5%, p<0.01) and of non-engaged presentation when expulsive efforts started (10.7 vs 27.4%, p<0.01), compared to IVD for FtP <45 min (group B, N=84). In group A, 52% of women had instrumental delivery. Prolonged active second stage was independently associated with lower odds of episiotomy (38.4 vs 61.9%, AOR(95%CI)=0.43[0.24-0.78]) and was not associated with PPH (5.1 vs 5.9%, AOR=1.01[0.28-3.68]), pH<7.20, 5-min Apgar score < 7 (20.2 vs 15.9%, AOR=2.00[0.89-4.48]), lactates > 6 (23.0 vs 24.3, AOR=1.45[0.68-3.07]) or transfer to neonatal intensive care unit (6.2 vs 2.4%, AOR=4.71[0.76-29.08].

DISCUSSION

Extending the duration of active second stage of labor beyond 45 min seems reasonable under rigorous surveillance of maternal and fetal wellbeing.

Association between the number of pulls and adverse neonatal/maternal outcomes in vacuum-assisted delivery

OBJECTIVES

To determine the association between the number of pulls during vacuum-assisted deliver and neonatal and maternal complications.

METHODS

This was a single-center observational study using a cohort of pregnancies who underwent vacuum-assisted delivery from 2013 to 2020. We excluded pregnancies transitioning to cesarean section after a failed attempt at vacuum-assisted delivery. The number of pulls to deliver the neonate was categorized into 1, 2, 3, and ≥4 pulls. We used logistic regression models to investigate the association between the number of pulls and neonatal intensive care unit (NICU) admission and maternal composite outcome (severe perineal laceration, cervical laceration, transfusion, and postpartum hemorrhage ≥500 mL).

RESULTS

We extracted 480 vacuum-assisted deliveries among 7,321 vaginal deliveries. The proportion of pregnancies receiving 1, 2, 3, or ≥4 pulls were 51.9, 28.3, 10.8, and 9.0%, respectively. The crude prevalence of NICU admission with 1, 2, 3, and ≥4 pulls were 10.8, 16.2, 15.4, and 27.9%, respectively. The prevalence of NICU admission, amount of postpartum hemorrhage, and postpartum hemorrhage ≥500 mL were significantly different between the four groups. Multivariable logistic regression analysis found the prevalence of NICU admission in the ≥4 pulls group was significantly higher compared with the 1 pull group (adjusted odds ratio, 3.3; 95% confidence interval, 1.4-7.8). In contrast, maternal complications were not significantly associated with the number of pulls.

CONCLUSIONS

Vacuum-assisted delivery with four or more pulls was significantly associated with an increased risk of NICU admission. However, the number of pulls was not associated with maternal complications.

Simulation training program for vacuum application to improve technical skills in vacuum-assisted vaginal delivery

OBJECTIVE

evaluation of technical skills of the operators during the obstetrical device application for operative vaginal delivery, named kiwi-cup in a simulation training program.

METHODS

Thirty-five residents in obstetrics and gynecology of the University of Pisa, Italy were recruited and evaluated with an assessment scale on technical skills from 0 to 55 points. They performed various operative vaginal delivery simulations with kiwi-cup and were evaluated at time 0 by a tutor. After 8 weeks, simulation training was repeated and trainees were re-evaluated by the same tutor.

RESULTS

after 8 weeks from the first simulation session, trainees have been shown to increase technical skills (46.27 ± 4.6 with p-value < 0.0001), the successful application rate (85.71% with p-value 0.0161).) and to reduce the time to complete the procedure (86.2 ± 29.9 s with p-value < 0.0001).

CONCLUSION

simulation training on operational vaginal delivery significantly increases technical skills, improves successful rate, and reduces the time taken to complete the procedure.

CLINICAL TRIAL REGISTRATION

Not applicable.

Spatulas for operative vaginal birth: A systematic review and meta-analysis

BACKGROUND

Operative vaginal birth represents an alternative to address problems during the second stage of labor. Obstetricians have access to three different instruments forceps, vacuum, and spatulas.

OBJECTIVE

To evaluate the safety and effectiveness of the use of spatulas for operative vaginal birth.

SEARCH STRATEGY

MEDLINE/PubMed, Embase, CENTRAL, LILACS, SciELO, ClinicalTrials.gov, and OpenGrey.

SELECTION CRITERIA

Randomized controlled studies and non-randomized controlled studies (NRS) were included.

DATA COLLECTION AND ANALYSIS

Studies were independently assessed for inclusion, data extraction, and risk of bias.

MAIN RESULTS

Nine NRS (n = 16  497 women) compared the use of spatulas versus forceps. Low-certainty evidence suggests that spatulas were not different in terms of failed operative vaginal delivery rate (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.53-1.52), but may decrease the incidence of birth canal trauma (OR 0.70, 95% CI 0.54-0.91), birth canal laceration (OR 0.50, 95% CI 0.28-0.91), and neonatal soft-tissue injury (OR 0.19, 95% CI 0.13-0.29). Six NRS (n = 2992 women) compared the use of spatulas versus vacuum. Low-quality evidence suggests that spatulas may decrease failed operative vaginal delivery rate (OR 0.10, 95% CI 0.04-0.26). There were no apparent differences in other maternal and neonatal outcomes.

CONCLUSION

Low-certainty evidence suggests that, spatulas could be a safe and effective alternative for operative vaginal birth.

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.

Intrapartum ultrasound during rotational forceps delivery: a novel tool for safety, quality control, and teaching

BACKGROUND

Operative vaginal delivery and, in particular, rotational forceps delivery require extensive training, specific skills, and dexterity. Performed correctly, it can reduce the need for difficult late second-stage cesarean delivery and its associated complications. When rotation to occiput anterior position is achieved, pelvic trauma and anal sphincter injury commonly associated with direct delivery from occiput posterior positions may be avoided.

OBJECTIVE

We report the original and novel use of real-time intrapartum ultrasound simultaneously during Kielland's rotational forceps delivery to monitor correct execution and increase maternal safety.

STUDY DESIGN

This is a prospective observational study performed at the Charité University Hospital in Berlin between 2013 and 2018. Simultaneous, real-time, intrapartum suprapubic ultrasound during Kielland's rotational forceps deliveries were performed in a series of laboring women with normal fetuses and arrest of labor in the late second stage and with a fetal head malposition, requiring operative vaginal delivery. In addition to vaginal palpation for head station, rotation, and asynclitism, intrapartum ultrasound was also used to objectively determine head station, head direction, and midline angle. The operator was not blinded to the ultrasound findings. The delivering obstetrician examined the woman and performed the delivery. An assistant, trained in intrapartum ultrasound, placed a curved-array transducer transversely in the midline just above the pubic bone to display the forceps blades being applied and the rotation of the fetal head in occiput anterior position.

RESULTS

In all 32 laboring women included in the study, the blades were applied correctly and the fetal heads successfully rotated to an occiput anterior position with direct ultrasound confirmation, and vaginal delivery was achieved. There were no cases of difficult application, repeat application, slippage of the blades, or rotation of the fetal head in the wrong direction. Maternal outcomes showed no vaginal tears, cervical tears, or postpartum hemorrhage >500 mL. There was 1 case of third-degree perineal tear (3a). Neonatal outcomes included mild hyperbilirubinemia (n=1), small cephalohematoma conservatively managed (n=1), and early-onset group B streptococcus sepsis secondary to maternal colonization (n=1). There were no neonatal deaths.

CONCLUSIONS

Ultrasound guidance during Kielland's rotational forceps delivery is an original and novel approach. We describe the use of intrapartum ultrasound in assessing fetal head station and position and also to simultaneously and objectively monitor performance of rotational forceps delivery. Intrapartum ultrasound enhances operator confidence and, possibly, patient safety. It is a valuable adjunct to obstetrical training and can improve learning efficiency. Real-time ultrasound guidance of fetal head rotation to occiput anterior position with Kielland's forceps may also protect the perineum and reduce anal sphincter injury. This novel approach can lead to a renaissance in the safe use of Kielland's forceps.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - - When and how to take medical action during labor?]

OBJECTIVE

The aim of this chapter is to provide recommendations for good practice regarding drug and technical interventions that may be considered during normal delivery.

METHODS

These recommendations were established by an expert consensus based on an analysis of the scientific literature and the French and international recommendations available on the subject.

RESULTS

Interventions during latent phase of the first stage of labor (up to 5-6cm) must be performed according to the fetal and maternal contraction tolerance (consensus agreement). In the active phase (from 5-6cm to full dilatation), dilation speed under 1cm/4h between 5 and 7cm or under 1cm/2h beyond 7cm is considered abnormal, it is then recommended to propose: an amniotomy if the membranes are intact and administration of oxytocin if membranes are already ruptured and uterine contractions are considered insufficient (consensus agreement). Intravenous (IV) antibiotic prophylaxis (at least four hours before birth) is recommended during labor in women at risk for group B streptococcal (GBS) maternofetal infection (GBS vaginal portage or GBS bacteriuria during pregnancy or history of maternofetal GBS infection) (grade B). In case of rupture of membranes after 37weeks of gestation without spontaneous labor, it is recommended: if the patient has GBS, to begin antibiotic prophylaxis immediately (consensus agreement); if delivery did not occur after 12hours, to start antibiotic prophylaxis (grade A), to set up dedicated patient monitoring (consensus agreement), to screen for an infection (at least a full blood count, a vaginal sample and a dipstick test) (consensus agreement). It is recommended not to start expulsive efforts as soon as a complete dilation is identified but to let the fetal presentation go down (grade A). The administration of oxytocin is recommended if the patient does not feel inclined to push and the presentation has not reached low-pelvic station after two hours of complete dilation in case of insufficient uterine activity (AE). There is no argument for recommending a push technique over another (grade B). It is recommended to inform the gynecologist-obstetrician in case of non-progression of the fetus after two hours of complete dilation with sufficient uterine activity (AE). Prophylactic administration of oxytocin at 5 or 10 IU is recommended to prevent postpartum hemorrhage after vaginal delivery (grade A). Administration could be performed intravenously (slow injection over about a minute) or intramuscularly (AE). In case of placental retention, manual removal of the placenta is recommended (grade A). In absence of bleeding, it must be performed after 30mins after birth, without exceeding 60mins (AE).

CONCLUSION

These recommendations define indications and methods for drug and technical interventions during a normal delivery to prevent poor obstetrical outcomes.

Is directed open-glottis pushing more effective than directed closed-glottis pushing during the second stage of labor? A pragmatic randomized trial - the EOLE study

OBJECTIVE

To compare the effectiveness of directed open-glottis and directed closed-glottis pushing.

DESIGN

Pragmatic, randomised, controlled, non-blinded superiority study.

SETTINGS

Four French hospitals between July 2015 and June 2017 (2 academic hospitals and 2 general hospitals).

PARTICIPANTS

250 women in labour who had undergone standardised training in the two types of pushing with a singleton fetus in cephalic presentation at term (≥37 weeks) were included by midwives and randomised; 125 were allocated to each group. The exclusion criteria were previous caesarean birth or fetal heart rate anomaly. Participants were randomised during labour, after a cervical dilation ≥ 7 cm.

INTERVENTIONS

In the intervention group, open-glottis pushing was defined as a prolonged exhalation contracting the abdominal muscles (pulling the stomach in) to help move the fetus down the birth canal. Closed-glottis pushing was defined as Valsalva pushing.

MEASUREMENTS

The principal outcome was "effectiveness of pushing" defined as a spontaneous birth without any episiotomy, second-, third-, or fourth-degree perineal lesion. The results in our intention-to-treat analysis are reported as crude relative risks (RR) with their 95% confidence intervals. A multivariable analysis was used to take the relevant prognostic and confounding factors into account and obtain an adjusted relative risk (aRR).

FINDINGS

In our intention-to-treat analysis, most characteristics were similar across groups including epidural analgesia (>95% in each group). The mean duration of the expulsion phase was longer among the open-glottis group (24.4 min ± 17.4 vs. 18.0 min ± 15.0, p=0.002). The two groups did not appear to differ in the effectiveness of their pushing (48.0% in the open-glottis group versus 55.2% in the closed-glottis group, for an adjusted relative risk (aRR) of 0.92, 95% confidence interval (CI) 0.74-1.14) or in their risk of instrumental birth (aRR 0.97, 95%CI 0.85-1.10).

KEY CONCLUSIONS

In maternity units with a high rate of epidural analgesia, the effectiveness of the type of directed pushing does not appear to differ between the open- and closed-glottis groups.

IMPLICATIONS FOR PRACTICE

If directed pushing is necessary, women should be able to choose the type of directed pushing they prefer to use during birth. Professionals must therefore be trained in both types so that they can adequately support women as they give birth.

Impact of clinical practice guidelines for vacuum-assisted delivery on maternal and neonatal outcomes in Japan: A single-center observational study

AIM

Practice guidelines for vacuum-assisted delivery in Japan were revised in 2014 to improve clinical safety. We aimed to determine the success rates of vacuum delivery before and after the release of the revised guidelines.

METHODS

This retrospective observational study included singleton deliveries at term gestation. Success rate of vacuum delivery, duration of extraction, number of tractions and maternal and neonatal injuries were compared between 2011-2014 and 2015-2019.

RESULTS

Vacuum extraction was attempted in 249 (15%) of 1657 deliveries. Duration of extraction was shorter in 2015-2019 (median, 3.0 min; interquartile range [IQR], 1.0-5.8 min) than in 2011-2014 (median, 4.0 min; IQR, 2.0-6.5 min; P = 0.0045). No significant differences were seen in success of vacuum extraction (98%), prolonged (>20 min) duration of extraction (1.5%) and repeated (>5 pulls) tractions (3.1%) in vacuum deliveries during 2011-2014, compared to success of vacuum extraction (94%), prolonged duration of extraction (1.6%) and repeated tractions (1.1%) in those during 2015-2019. Likewise, no significant differences were identified in maternal or neonatal injuries.

CONCLUSION

Successful vacuum-assisted deliveries and shortened duration of extraction were still confirmed after guideline revision. However, because of consistent safe practice with vacuum delivery from before the revision, improvements in maternal and neonatal injuries were not observed.

Does programmed intermittent epidural bolus improve childbirth conditions of nulliparous women compared with patient-controlled epidural analgesia?: A multicentre, randomised, controlled, triple-blind study

BACKGROUND

Epidural analgesia may change the mechanics of childbirth. These changes are related to the concentration of the local anaesthetic used epidurally but probably also to its mode of delivery into the epidural space.

OBJECTIVE

To determine whether the administration of programmed intermittent epidural boluses (PIEB) improves the mechanics of second-stage labour compared with patient-controlled epidural analgesia (PCEA) with a background infusion.

DESIGN

A randomised, controlled, triple-blind study.

SETTING

Multicentre study including four level III maternity units, January 2014 until June 2016.

PATIENTS

A total of 298 nulliparous patients in spontaneous labour were randomised to a PIEB or PCEA group.

INTERVENTION

After epidural initiation with 15 ml of 0.1% levobupivacaine containing 10 μg of sufentanil, patients received either an hourly bolus of 8 ml (PIEB) or a continuous rate infusion of 8 ml h (PCEA): the drug mixture used was levobupivacaine 0.1% and sufentanil 0.36 μg ml.

MAIN OUTCOME MEASURES

The primary outcome was a composite endpoint of objective labour events: a posterior occiput position in the second stage, an occiput position at birth, waiting time at full cervical dilatation before active maternal pushing more than 3 h, maternal active pushing duration more than 40 min, and foetal heart rate alterations. Vaginal instrumental delivery rates, analgesia and motor blockade scores were also recorded.

RESULTS

From the 298 patients randomised, data from 249 (124 PIEB, 125 PCEA) were analysed. No difference was found in the primary outcome: 48.0% (PIEB) and 45.5% (PCEA) of patients, P = 0.70. In addition, no difference was observed between the groups for each of the individual events of the composite endpoint, nor in the instrumental vaginal delivery rate, nor in the degree of motor blockade. Despite an equivalent volume of medication in the groups, a significantly higher analgesia score at full dilatation was observed in the PIEB group, odds-ratio = 1.9 (95% confidence interval, 1.0 to 3.5), P = 0.04.

CONCLUSION

The mechanics of the second stage did not differ whether PIEB or PCEA was used. Analgesic conditions appeared to be superior with PIEB, especially at full dilation.

TRIAL REGISTRATION

NCT01856166.

Complications of operative vaginal delivery and provider volume and experience

Objective: To evaluate associations between operative vaginal delivery complications and provider experience (operative vaginal delivery volume and time since residency).Methods: We included all operative vaginal deliveries between 2008 and 2014 at a tertiary care teaching hospital, stratified into forceps-assisted and vacuum-assisted deliveries. Complications included severe perineal lacerations (3rd and 4th degree) and neonatal injuries (subgaleal/subdural/cerebral hemorrhage, facial nerve injury, and scalp injury), which were identified by International Classification Diagnosis-9 codes. Providers were categorized by operative vaginal delivery volume (mean annual forceps- or vacuum-assisted deliveries over the study interval) and time since residency. Regression analyses were used to compare complication rates by provider volume and time since residency, adjusting for potential confounders, using 0-1 deliveries per year and <5 years since residency as reference groups.Results: Nine hundred and thirty-four forceps and 1074 vacuums occurred. For forceps-assisted deliveries, severe perineal injury was decreased among providers with >10 forceps per year (aOR 0.50 [95%CI 0.30-0.81]) and at 15-19 years (aOR 0.45 [95% CI 0.22-0.94], and ≥25 years (aOR 0.45 [0.27-0.73]) since residency. There were no associations with neonatal injuries. Among vacuum-assisted deliveries, severe perineal injury decreased at ≥25 years since residency (aOR 0.35 [95%CI 0.17-0.74], with no association with provider volume. Neonatal injury decreased at 5-9 years (aOR 0.53 [95%CI 0.30-0.93]), and 15-19 years since residency (aOR 0.53 [95%CI 0.29-0.97]), due to differences in scalp injuries. Neonatal injuries other than scalp injury were rare.Conclusion: Severe perineal lacerations decreased with increasing operative vaginal delivery experience, primarily among forceps-assisted vaginal delivery. Providers >5 years since residency may have lower scalp injury with vacuums, but this cohort was largely underpowered for neonatal injury.

Video-Based Teaching in Patient and Instrument Selection for Operative Vaginal Deliveries

OBJECTIVE

Worldwide, the rate of operative vaginal deliveries has decreased, and as a result trainees are lacking exposure and training. The aim of this study was to determine whether a video-based masterclass can improve trainees' confidence, comfort, and knowledge in performing second stage labour assessments and selecting appropriate patients and instruments for operative vaginal deliveries.

METHODS

Current University of Toronto obstetrics and gynaecology residents were invited to participate. The intervention included two videos on second stage assessment: (1) selecting the appropriate patient and (2) selecting the appropriate instrument for an operative vaginal delivery. Trainees' comfort and confidence were assessed pre- and post-intervention. A focus group was conducted that assessed trainees' knowledge acquisition. Descriptive thematic analysis was performed, and common themes were extracted.

RESULTS

On average, residents have performed more vacuum deliveries than forceps deliveries as primary operators (26.4 vs. 7.9). Following the video intervention, there was a statistically significant improvement (P ≤ 0.05) in trainees' comfort in the following areas: (1) understanding the maternal pelvis, (2) choosing instruments, (3) choosing forceps, (4) deciding the location of delivery, (5) identifying favourable clinical factors, and (6) identifying poor prognostic clinical factors. There was no difference in trainees' self-confidence. Major themes from focus group data included new knowledge gained on second stage assessment techniques, new approaches to existing knowledge, and the multiple challenges and barriers that exist to learning.

CONCLUSION

Video-based education on second stage labour assessment and operative vaginal delivery improves trainees' comfort and serves as a valuable complementary tool to clinical learning.

Risk factors associated with subgaleal hemorrhage in neonates exposed to vacuum extraction

INTRODUCTION

Subgaleal hemorrhage (SGH) is a life-threatening neonatal condition that is strongly associated with vacuum assisted delivery (VAD). The factors associated with the development of SGH following VAD are not well-established. We aimed to evaluate the factors associated with the development of SGH following attempted VAD.

MATERIAL AND METHODS

A retrospective case-control study of women who delivered at a tertiary university-affiliated medical center in Jerusalem, Israel, during 2009-2018. Cases comprised all parturients with singleton pregnancies for whom attempted VAD resulted in neonatal SGH. A control group of VAD attempts was established by matching one-to-one according to gestational age at delivery, parity and year of delivery. Fetal, intrapartum and vacuum procedure characteristics were compared between the groups.

RESULTS

In all, 313 (89.5%) of the 350 attempted VAD were nulliparous. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birthweight in the SGH group. In multivariate logistic regression analysis, only six independent risk factors were significantly associated with the development of SGH: second-stage duration (for each 30-minute increase, adjusted odds ratio [OR] 1.13; 95% confidence intervals [CI] 1.04-1.25; P = .006), presence of meconium-stained amniotic fluid (adjusted OR 2.61; 95% CI 1.52-4.48; P = .001), presence of caput succedaneum (adjusted OR 1.79; 95% CI 1.11-2.88; P = .01), duration of VAD (for each 3-minute increase, adjusted OR 2.04; 95% CI 1.72, 2.38; P < .001), number of dislodgments (adjusted OR 2.38; 95% CI 1.66-3.44; P < .001), and fetal head station (adjusted OR 3.57; 95% CI 1.42-8.33; P = .006). Receiver operating characteristic curves showed that VAD duration of ≥15 minutes had a 96.7% sensitivity and 75.0% specificity in predicting SGH formation, with an area under the curve equal to .849.

CONCLUSIONS

Vacuum duration, the number of dislodgments, the duration of second stage of delivery, fetal head station, the presence of caput succedaneum and the presence of meconium were found to be independently associated with SGH formation.

Outcomes of operative vaginal delivery managed by residents under supervision and attending obstetricians: a prospective cross-sectional study

BACKGROUND

To assess both severe maternal and neonatal mortality and morbidity after attempted operative vaginal deliveries by residents under supervision and by attending obstetricians.

STUDY DESIGN

Secondary analysis of a 5-year prospective study with cross-sectional analysis including 2192 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. Obstetricians who attempted or performed an operative vaginal delivery were classified into 2 groups according to their level of experience: attending obstetricians (who had 5 years or more of experience) and obstetric residents (who had less than 5 years of experience) under the supervision of an attending obstetrician. We used multivariate logistic regression and propensity score methods to compare outcomes associated with attending obstetricians and obstetric residents. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesareans, postpartum hemorrhage >1500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, or maternal death; severe neonatal morbidity was defined as a 5-minute Apgar score <7, umbilical artery pH <7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, or neonatal death.

RESULTS

High prepregnancy body mass index, high dose of oxytocin, manual rotation, persistent occiput posterior or transverse positions, operating room delivery, midpelvic delivery, forceps, and spatulas were significantly more frequent in deliveries managed by attending obstetricians than residents whereas a second-stage pushing phase longer than 30 minutes was significantly more frequent in deliveries managed by residents. The rate of severe maternal morbidity was 7.8% (115/1475) for residents vs 9.9% (48/484) for attending obstetricians; for severe neonatal morbidity, the rates were 8.3% (123/1475) vs 15.1% (73/484), respectively. In the univariate, multivariable, and sensitivity analyses, attempted operative vaginal delivery managed by a resident was significantly and inversely associated with severe neonatal but not maternal morbidity. After propensity score matching, delivery managed by a resident was not significantly associated with severe maternal morbidity (adjusted odds ratio, 0.74; 95% confidence interval, 0.39-1.38) and was no longer associated with neonatal morbidity (adjusted odds ratio, 0.51; 95% confidence interval, 0.25-1.04).

CONCLUSION

Management of attempted operative vaginal deliveries by residents under the supervision of attending obstetricians, compared with by the attending obstetricians themselves, does not appear to be associated with either maternal or neonatal morbidity. These reassuring results support the continued use of residency programs for training in operative vaginal deliveries under the supervision of attending obstetricians.

[Manual rotation in occiput posterior position: A systematic review in 2019]

OBJECTIVE

The aim of our study was to evaluate the safety and the benefits of manual rotation in the management of Occiput-posterior positions in 2019.

METHODS

A systematic review of literature was performed using the MEDLINE and COCHRANE LIBRARY databases, in order to identify articles concerning maternal and neonatal outcomes after a manual rotation, through January 2019. Information on study characteristics (review, author, year of publication), population, objectives and main neonatal and maternal outcomes were extracted.

RESULTS

A total of 51 articles were identified and 12 articles were selected for the systematic review. The rate of successful manual rotation were about 47 to 90%. There were more success if systematic manual rotation, multiparity, engagement, spontaneous labour and maternal age<35. The 2nd stage of labour was shorter after an attempt of manual rotation. The randomised controlled trials did not find any statistical difference concerning operative deliveries or neonatal and maternal outcomes.

CONCLUSION

The manual rotation is an obstetrical manoeuvre which must be regulated and only practiced by trained operators. Currently, the state of science is not sufficient to recommend the manual rotation as a systematic practice in 2019.

Design and development of the BD Odon DeviceTM : a human factors evaluation process

OBJECTIVE

To (1) determine how intended users interact with and use the BD Odon Device in simulation, (2) use these findings to alter progressively the design of the BD Odon Device and (3) validate that these changes have improved the ability of practitioners to use the BD Odon Device.

DESIGN

Human factors evaluation study.

SETTING

Simulation suite designed to mimic delivery room.

POPULATION OR SAMPLE

Three hundred and ninety simulated operative births, performed by 100 practising clinicians.

METHODS

Simulated operative vaginal births performed using the BD Odon Device and the device Instructions for use were subjected to three formative human factors evaluations and one human factors validation test. Following each evaluation, findings were reviewed and the design of the BD Odon Device and Instructions for use were modified.

MAIN OUTCOME MEASURES

Successful performance of an operative vaginal birth using the BD Odon Device in accordance with provided training and Instructions for use.

RESULTS

Using version two of the BD Odon Device, and following exposure to face-to-face training and written instructions, 25% of accouchers were able successfully to perform a simulated operative vaginal birth. In the final evaluation, following device design and training material alterations, all accouchers were able successfully to perform a simulated operative vaginal birth using version four of the BD Odon Device.

CONCLUSIONS

Human factors evaluations have enabled a multi-professional device and training materials design team to alter the design of the BD Odon Device and the Instructions for use in an evidence-based fashion. This process has resulted in a device which has a predictable and likely safe pattern of use.

TWEETABLE ABSTRACT

Human Factors evaluations help make the BD Odon Device safe and usable for clinical practice.

The role of manual rotation in avoiding and managing OVD

Manual rotation (MR) is the most common technique used by accoucheurs who wish to correct malposition of the foetal head to either avoid or facilitate an operative vaginal delivery (OVD). MR can be performed using either a whole-hand or a digital approach. MR should be formally taught and trainees should be assessed for competence, and later, performance should ideally be tracked with statistical control charts. There is paucity of robust evidence evaluating MR relative to the other methods of rotational OVD: rotational forceps (RF) and rotational ventouse (RV). Furthermore, there is little evidence concerning long-term maternal outcomes of rotational OVD. A prospective randomised trial of MR versus either RF or RV is clearly needed, along with a core outcome set for OVD to facilitate comprehensive evaluation programmes that focus on aspects pertaining to women.

Is episiotomy worthwile to prevent obstetric anal sphincter injury during operative vaginal delivery in nulliparous women?

OBJECTIVES

Episiotomy is a marker of Obstetric Anal Sphincter Injury (OASIS) condition, therefore, unmeasured factors could have biased the strength of the association between episiotomy and reduced OASIS during Operative Vaginal Delivery (OVD). The aim of this study was to compare the OASIS rate during OVD according to episiotomy practice.

STUDY DESIGN

Retrospective cohort study of all nulliparous pregnant women attempting an OVD between 2014-2017. To avoid unmeasured bias, all maternal and delivery data were prospectively captured after the birth. The strong relationship between parity and episiotomy practice (indication bias) lead to analyze only nulliparous women. Association between mediolateral episiotomy and OASIS following OVD was performing by using multivariate logistic regression analysis including significant variable in univariate analysis and relevant factors known to be associated both with OASIS and/or OVD.

RESULTS

Over the study period, 1709 (17.1%) women had an OVD, among them 40 (2.3%) had OASIS. In the 1342 (78.5%) nulliparous women, OASIS rate were 2% and 5.1% with and without episiotomy (p < 0.01). In multivariate analysis a lower incidence of OASIS with the use of episiotomy (OR 0.267 IC 0.132-0.541) were observed. The persistent occiput posterior position was associated with an increase risk of OASIS (OR 6.742 IC 2.376-19.124). Spatula/forceps, as compared to vacuum operative vaginal delivery increased the risk OASIS (OR 2.847 IC 1.311-7.168). Area under the curve of the model was 0.745.

CONCLUSION

Episiotomy is a modifiable risk factors which can contribute to reduce the risk of OASIS in nulliparous women with operative vaginal delivery. This intervention should be included in a global management of the second stage of labor.

[Which interventions during labour to decrease the risk of perineal tears? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The objective of this review was to evaluate whether interventions performed during labour could influence the risk of perineal tears.

METHODS

A separate keyword search for each medical intervention during labor was performed by selecting only studies evaluating perineal consequences, particularly the risk of obstetrical anal sphincter injury (LOSA). Interventions during pregnancy and during fetal expulsion have been specifically addressed in other chapters of the recommendations.

RESULTS

Maternal mobilisation and postures during the first stage of labour have not been shown to reduce the risk of OASIS (LE3). No particular posture has demonstrated its superiority over any other during the second stage of labour for preventing obstetric perineal lesions including OASIS and postnatal incontinence (urinary or faecal) (LE2). There is no reason to recommend one maternal posture rather than another during the first and the second stages of labour for the purpose of reducing the risk of OASIS (Grade C). Women should be allowed to choose the position most comfortable for them during the first and second stages of labour (Professional consensus). Posterior cephalic positions present the greatest risks of perineal injury (LE2). Manual rotation of cephalic posterior positions to the anterior during the second stage of labour may make it possible to reduce the risk of operative vaginal delivery, although no reduction in the risk of perineal injuries or OASIS has been clearly demonstrated (LE3). For fetuses in posterior cephalic positions, no data justifies a preference for manual rotation at full dilation to diminish the risk of perineal injury (Professional consensus). Urinary catheterisation is recommended for women with epidural analgesia during labour when spontaneous micturition is not possible (Professional consensus). Although current data does not justify a preference for continuous or intermittent urinary catheterisation (LE2), intermittent catheterisation nonetheless appears preferable in this situation (Professional consensus). During the second stage phase, delayed pushing does not modify the risk of OASIS (LE1). It does, however, increase the chances of spontaneous delivery (LE1). It is thus recommended that, when maternal and fetal status allow it, the start of pushing should be delayed (Grade A). There is no evidence to support preferring one pushing technique rather than another to diminish the risk of OASIS (grade B). Performing an operative vaginal delivery for the sole purpose of reducing the duration of the second stage of labour may increase the risk of OASIS (LE3). Perineal massage or the application of warm compresses during the second stage of labour appear to reduce the risk of OASIS (LE2). However, we have not made a determination about their use in clinical practice.

Practices during the active second stage of labor: A survey of French midwives

OBJECTIVE

the principal objective of our study was to describe the practices reported by French midwives during the active second stage of labor (expulsion phase).

DESIGN

this cross-sectional Internet survey questioned French midwives who attended at least one childbirth in 2013.

SETTING

this open survey was posted on a website from June 15 through December 1, 2014.

PARTICIPANTS

1496 midwives from 377 maternity units participated in the study.

MEASUREMENTS AND FINDINGS

the midwives most often reported suggesting horizontal positions during the active second stage (supine with footholds, lithotomy, lithotomy with knees turned in, or lateral positions). Non-horizontal positions were more often proposed by midwives in level I units (p<0.0001). Almost half the midwives responding (46.4%), especially those working in level III units (51.1%, p = 0.006), advised Valsalva pushing. The mean maximum pushing time was 35.3 minutes±12.8 minutes. Nearly all the midwives favored the 'hands on' technique at childbirth (91.4%), and 24% reported using warm compresses on the perineum at childbirth.

KEY CONCLUSION

most midwives advised horizontal positions for childbirth. The practices of French midwives differed as a function of where they worked. The midwives, especially those in level III facilities, reported that they cannot always ensure 'physiological childbirth'.

IMPLICATIONS FOR PRACTICE

the practices of French midwives must become more evidence-based. The development of professional guidelines for midwives in France appears essential. This study also helps to prioritise national training for midwives.

Sonographic evaluation of the fetal spine position and success rate of manual rotation of the fetus in occiput posterior position: A randomized controlled trial

BACKGROUND

To evaluate whether sonographic (US) diagnosis of the fetal spine position could increase the success rate of manual rotation of the fetal occiput (MRFO) in second-stage arrest in persistent occiput posterior position (OPP).

METHODS

In this randomized controlled parallel single-center trial, 58 nulliparous in second-stage arrest of labor with fetus in cephalic presentation and OPP diagnosed by US were randomly assigned to group A where the fetal spine position was not known by the operator or to group B where the operator knew it. The main outcome was the success of MRFO in the two groups. Secondary outcomes were perineal injuries, blood loss, duration of expulsive period, and neonatal APGAR at 5 minutes.

RESULTS

A priori knowledge of the spine position improves the success of the MRFO (41.4% group A versus 82.8% group B, p value < 0.001), the percentage of spontaneous deliveries (27.6% group A versus 69% group B, p value = 0.01), and maternal outcome (intact perineum and blood loss). No differences were detected on the neonatal side.

CONCLUSIONS

MRFO is a safe and useful procedure that should be performed in second-stage arrest in OPP. A better performance was observed when supported by the US knowledge of the spine position. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:472-476, 2017.

Predicting the difficulty of operative vaginal delivery by ultrasound measurement of fetal head station

BACKGROUND

Clinical assessment of fetal head station is difficult and subjective; it is mandatory before attempting operative vaginal delivery.

OBJECTIVE

The principal objective of our study was to assess whether measurement of the perineum-to-skull ultrasound distance was predictive of a difficult operative vaginal delivery. Secondary objectives included evaluation of the interobserver reproducibility of perineum-to-skull ultrasound distance and comparison of this measurement and digital examination in predicting a difficult operative delivery.

STUDY DESIGN

This was a prospective cohort study including all cases of operative vaginal deliveries in singleton pregnancies in cephalic presentation >34 weeks' gestation, from 2012 through 2015. All data were entered prospectively in a medical record system specially devised to meet the requirements of this study.

RESULTS

Of the 659 patients in whom perineum-to-skull ultrasound distance was measured prior to operative vaginal delivery, 120 (18%) met the composite criterion for a difficult extraction. Perineum-to-skull ultrasound distance measurement of ≥40 mm was significantly associated with the occurrence of a difficult extraction based on the composite criterion, after adjustment for parity, presentation type, and fetal macrosomia (odds ratio, 2.38; 95% confidence interval, 1.51-3.74; P = .0002). The intraclass correlation coefficient between the perineum-to-skull ultrasound distance measured by the first operator and that measured by the second operator was 0.96 (95% confidence interval, 0.95-0.97; P < .0001). Based on the receiver operating characteristic curve analyses, perineum-to-skull ultrasound distance was a more accurate predictor of difficult operative delivery than digital vaginal examination (P = .036).

CONCLUSION

Measurement of the perineum-fetal skull ultrasound distance is a reproducible and predictive index of the difficulty of instrumental extraction. Ultrasound is a useful supplementary tool to the usual clinical findings.

DECIDE: a cluster randomized controlled trial to reduce non-medically indicated caesareans in Burkina Faso

BACKGROUND

Since 2006, Burkina Faso has subsidized the cost of caesarean sections to increase their accessibility. Caesareans are performed by obstetricians, general practitioners, and nurses trained in emergency surgery. While the national caesarean rate is still too low (only 2 % in 2010), 12 to 24 % of caesareans performed in hospital are, in fact, not medically indicated. The objective of this study is to evaluate the effectiveness and analyze the implementation of a multi-faceted intervention to lower the rate of non-medically indicated caesareans in Burkina Faso.

METHODS

This study combines a multicentre cluster randomized controlled trial with an implementation analysis in a mixed-methods approach. The evidence-based intervention will consist of three strategies to improve the competencies of maternity teams: 1) clinical audits based on objective criteria; 2) training of personnel; and 3) decision-support reminders of indications for caesareans via text messages. The unit of randomization and of intervention is the public hospital equipped with a functional operating room. Using stratified randomization on hospital type and staff qualifications, 11 hospitals have been assigned to the intervention group and 11 to the control group. The intervention will cover 1 year. Every patient who delivered by caesarean during a 6-month period in the year preceding the intervention and the 6 months following its end will be included in the trial. The change in the rate of non-medically indicated caesareans is the main criterion by which the intervention's impact will be assessed. To analyze the intervention process, a longitudinal qualitative study consisting of deliberative workshops and individual in-depth interviews will be conducted. The target outcome is a 50 % reduction in the rate of non-medically indicated caesareans.

DISCUSSION

This study will provide evidence regarding the effectiveness of a multi-faceted intervention for reducing non-medically indicated caesareans in a low-income country. By combining qualitative and quantitative methods, the study's findings will allow understanding the factors that could influence the intervention process and ultimately the intended outcomes.

TRIAL REGISTRATION

The DECIDE trial is registered on the Current Controlled Trials website under the number ISRCTN48510263 on January 28, 2014.