Morbidity and Mortality Associated With Forceps and Vacuum Delivery at Outlet, Low, and Midpelvic Station

A national survey of clinicians' opinions of rotational vaginal births

INTRODUCTION

Malposition of the fetal head, defined as occiput transverse or posterior positions, occurs in approximately 5% of births. At full cervical dilatation, fetal malposition is associated with an increased risk of rotational vaginal birth. There are three different rotational methods: manual rotation, rotational ventouse or rotational (Kielland's) forceps. In the absence of robust evidence, it is not currently known which of the three methods is most efficacious, and safest for parents and babies.

OBJECTIVE

To gain greater insights into opinions and preferences of rotational birth to explore the acceptability and feasibility of performing a randomised trial comparing different rotational methods.

MATERIAL AND METHODS

A survey was sent via email to obstetricians from the British Maternal Fetal Medicine Society, as well as expert obstetricians and active academics in ongoing research in the UK. The questions focussed on perceived competence, preferred rotational method, location (theatre or labour room), willingness to recruit to an RCT, and its outcome measures. Closed questions were followed by the option of free text to allow further comments. The free text answers underwent thematic analysis.

RESULTS

252 consultant obstetricians responded. The majority stated they were competent in performing manual rotation (88.1%). Half felt proficient using Kielland's rotational forceps (54.4%). Most obstetricians felt skilled in rotational ventouse (76.2%). Manual rotation was the preferred first rotational method of choice in cases of both occiput transverse and posterior positions. The decision for which rotational method to attempt first was considered case-dependent by many. Two thirds of obstetricians would usually conduct rotational births in theatre (67.9%). Over half (52%) do not routinely use intrapartum ultrasound. Most (62.7%) would be willing to recruit to a randomised controlled trial comparing manual versus instrumental rotation. Over half (57.2%) would be willing to recruit to the same RCT if they were the most senior doctor competent in rotational vaginal birth supervising a junior.

CONCLUSION

There is a wide range of practice in conducting rotational vaginal births in the UK. An RCT to investigate the impact of different rotational methods on outcome would be both feasible and desirable, especially in research-active hospitals.

Obstetric factors and neonatal outcomes of depressed skull fractures in newborns

PURPOSE

To determine the obstetric factors affecting the development of depressed skull fracture in neonates.

MATERIALS AND METHODS

This was a retrospectively cohort study on neonates born between July 2016 and August 2021. Neonates diagnosed with depressed skull fractures within one week of birth through X-ray and/or brain ultrasonography were included, and their mothers' obstetric characteristics were reviewed.

RESULTS

There were 12 cases in 6791 live births. Five women were over 35 years old. All except two were nulliparous. Five cases were delivered from labor induction and others presented with spontaneous labor. Except for two cases, delivery occurred within an hour after full cervical dilatation. Two cases were assisted by vacuum. None displayed fetal distress signs such as low Apgar scores below 7, meconium staining, and umbilical cord pH under 7.2. All depressed fractures were found in the right parietal area. Three cases resulted in focal hyperechoic lesion in brain ultrasonography and two of them showed small hemorrhage-like lesion in magnetic resonance imaging. All depressed skull fractures improved within 6 months in followed X-rays or ultrasonography.

CONCLUSIONS

There was no definitely associated obstetric condition for depressed skull fracture of neonates although nulliparous women were majority of the affected cases.

The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth

BACKGROUND

An increased risk for preterm birth has been observed among individuals with a previous second stage cesarean delivery when compared with those with a previous vaginal delivery. One mechanism that may contribute to the increased risk for preterm birth following a second stage cesarean delivery is the increased risk for cervical injury because of extension of the uterine incision (hysterotomy) into the cervix. The contribution of hysterotomy extension to the rate of preterm birth in a subsequent pregnancy has not been investigated and may shed light on the mechanism underlying the observed relationship between the mode of delivery and subsequent preterm birth.

OBJECTIVE

We aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery.

STUDY DESIGN

We performed a retrospective cohort study using electronic perinatal data collected from 2 university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks' gestation; secondary outcomes included subsequent preterm birth at <34, <32, and <28 weeks' gestation. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios and 95% confidence intervals. Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labor, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity.

RESULTS

A total 4797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labor, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses that controlled for several confounders showed that a history of hysterotomy extension was not associated with a higher risk for preterm birth <37 weeks' gestation (adjusted rate ratio, 1.55; 95% confidence interval, 0.98-2.47), but it was associated with preterm birth <34 weeks' gestation (adjusted rate ratio, 2.49; 95% confidence interval, 1.06-5.42).

CONCLUSION

Patients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks' gestation when compared with patients who did not have this injury. This association was not observed for preterm birth <37 weeks' gestation. Future research should aim to replicate our analyses with incorporation of additional data to minimize the potential for residual confounding.

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.

Developing the TeamOBS-vacuum-assisted delivery checklist to assess clinical performance in a vacuum-assisted delivery: a Delphi study with initial validation

Introduction

In Northern Europe, vacuum-assisted delivery (VAD) accounts for 6-15% of all deliveries; VAD is considered safe when conducted by adequately trained personnel. However, failed vacuum extraction can be harmful to both the mother and child. Therefore, the clinical performance in VAD must be assessed to guide learning, determine a performance benchmark, and evaluate the quality to achieve an overall high performance. We were unable to identify a pre-existing tool for evaluating the clinical performance in real-life vacuum-assisted births.

Objective

We aimed to develop and validate a checklist for assessing the clinical performance in VAD.

Methods

We conducted a Delphi process, described as an interactive process where experts answer questions until answers converge toward a "joint opinion" (consensus). We invited international experts as Delphi panelists and reached a consensus after four Delphi rounds, described as follows: (1) the panelists were asked to add, remove, or suggest corrections to the preliminary list of items essential for evaluating clinical performance in VAD; (2) the panelists applied weights of clinical importance on a Likert scale of 1-5 for each item; (3) each panelist revised their original scores after reviewing a summary of the other panelists' scores and arguments; and (4) the TeamOBS-VAD was tested using videos of real-life VADs, and the Delphi panel made final adjustments and approved the checklist.

Results

Twelve Delphi panelists from the UK (n = 3), Norway (n = 2), Sweden (n = 3), Denmark (n = 3), and Iceland (n = 1) were included. After four Delphi rounds, the Delphi panel reached a consensus on the checklist items and scores. The TeamOBS-VAD checklist was tested using 60 videos of real-life vacuum extractions. The inter-rater agreement had an intraclass correlation coefficient (ICC) of 0.73; 95% confidence interval (95% CI) of [0.58, 0.83], and that for the average of two raters was ICC 0.84 95% CI [0.73, 0.91]. The TeamOBS-VAD score was not associated with difficulties in delivery, such as the number of contractions during vacuum extraction delivery, cephalic level, rotation, and position. Failed vacuum extraction occurred in 6% of the video deliveries, but none were associated with the teams with low clinical performance scores.

Conclusion

The TeamOBS-VAD checklist provides a valid and reliable evaluation of the clinical performance of vaginal-assisted vacuum extraction.

Implementation of normal childbirth guidelines among midwives: Adherence and influencing factors

BACKGROUND

Clinical practice guidelines on normal childbirth were issued worldwide with a view to achieve evidence-based, cost-effective and universal intrapartum care. Effective implementation of guideline recommendations is impossible without a full evaluation and understanding of current practice and factors influencing adherence among midwives.

AIM

This study aimed to explore midwives' adherence to clinical practice guidelines on normal childbirth and factors influencing the implementation of guideline recommendations in mainland China.

DESIGN

We used a mixed-method sequential explanatory design.

METHODS

A national level cross-sectional survey was conducted among 718 midwives to investigate their adherence to guideline recommendations on normal childbirth. Based on the findings of quantitative study phase, we developed the interview outline and performed semi-structured interviews with thirteen midwives to explore potential factors influencing their implementation of normal childbirth guidelines. An inductive thematic analysis was undertaken to identify themes, which were then deductively mapped to the Theoretical Domains Framework (TDF).

RESULTS

Midwives' adherence to the guideline recommendations was relatively low, with non-adherence to thirteen guideline recommendations (41.94%) being observed. Six domains on the TDF and one additional theme were found to be factors influencing midwives' implementation of guideline recommendations on normal childbirth, with behavioural regulation, beliefs about consequences, professional roles and responsibilities being identified as barriers for interventions recommended against use, knowledge, environmental context and resources being identified as enablers for interventions recommended for use, and skills and women's preference being identified as barriers/enabler for both.

CONCLUSION

Guideline adherence can be improved by multifaceted efforts at professional, organizational and maternal levels. The identification of barriers and enablers of guideline implementation provides a solid foundation for further reducing non-evidence-based intrapartum interventions.

Association of the Kiwi OmniCup system with maternal and neonatal morbidity: A retrospective cohort study

OBJECTIVE

To discuss the effect of the Kiwi OmniCup system on reducing adverse maternal and neonatal outcomes and provide a reference for assisted vaginal delivery methods.

METHODS

Women who gave birth to singleton term neonates in a cephalic presentation and underwent assisted vaginal delivery from 2017 to 2021 were eligible for inclusion in the study; they were divided into a Kiwi OmniCup system group and a forceps group. Binary logistic regression analysis was used to observe and compare maternal and neonatal outcomes. The primary outcomes were severe maternal and neonatal morbidity. Severe maternal morbidity was defined as the occurrence of at least one of the following outcomes: third- or fourth-degree perineal lacerations, refractory postpartum hemorrhage, thrombotic events, amniotic fluid embolism, admission to the intensive care unit, and maternal death. Severe neonatal morbidity was defined as the occurrence of at least one of the following outcomes: neonatal asphyxia requiring resuscitation or intubation, neonatal head and face injuries, neonatal fracture, and admission to the neonatal intensive care unit for longer than 24 h.

RESULTS

The rate of severe neonatal morbidity in the forceps group was significantly higher than that in the Kiwi OmniCup system group, the differences between the two groups were significant (27.2% vs. 42.3%, P < 0.001), and there was no significant difference in the rate of severe maternal morbidity between the two groups (30% vs. 30%, P > 0.05). Binary logistic regression analysis showed that Kiwi OmniCup system-assisted delivery reduced severe neonatal morbidity (adjusted odds ratio 0.49; 95% confidence interval 0.33-0.73) and did not increase severe maternal morbidity compared with forceps-assisted delivery.

CONCLUSION

The Kiwi OmniCup system, which can reduce the incidence of severe neonatal morbidity without increasing the incidence of serious adverse maternal outcomes, is worthy of clinical promotion.

Operative vaginal delivery as an independent risk factor for maternal postpartum infectious morbidity

BACKGROUND

A recent study from the United Kingdom suggested that a single dosage of adjunctive amoxicillin/clavulanic acid with operative vaginal delivery reduces maternal infectious morbidity by 40% (from 19% to 11%). However, 89% of their study population received an episiotomy.

OBJECTIVE

This study aimed to evaluate whether operative vaginal delivery is an independent risk factor for composite maternal postpartum infectious morbidity in a population with a low episiotomy rate.

STUDY DESIGN

This was a retrospective cohort study of patients with viable singleton vaginal deliveries after ≥34 weeks gestation at a single perinatal center (2013-2018). The patients were categorized by the mode of delivery: spontaneous vaginal delivery or operative vaginal delivery (forceps or vacuum-assisted). The primary outcome was a composite of maternal infectious morbidity up to 6 weeks after delivery, defined as (1) endometritis, (2) perineal wound morbidity (infection, breakdown, or dehiscence), or (3) culture-proven urinary tract infection. The patient characteristics and outcomes were compared between the groups using appropriate tests. Multivariable models were used to estimate the association between operative vaginal delivery and study outcomes compared with spontaneous vaginal delivery, with adjustment for selected confounders.

RESULTS

Of 14,647 deliveries meeting the inclusion criteria, 732 (5.0%) were operative vaginal deliveries: 354 (48%) forceps and 378 (52%) vacuums. Overall, 210 (1.4%) patients developed the morbidity composite. Patients having an operative vaginal delivery were more likely to be nulliparous, have labor inductions, develop intrapartum chorioamnionitis, receive an episiotomy, and sustain a third- or fourth-degree laceration. After adjusting for confounding factors, no significant association was observed between operative vaginal delivery and composite morbidity (adjusted odds ratio, 1.4 [0.8-2.4]) or any of its individual components. Administration of postpartum antibiotics and documented fever were also similar between groups. There was also no significant association between instrument (forceps vs vacuum) and the maternal infection composite.

CONCLUSION

In this single-center US cohort, operative vaginal delivery was not an independent risk factor for maternal composite postpartum infectious morbidity.

Can We Predict Feto-Maternal Adverse Outcomes of Vacuum Extraction?

Introduction Vacuum extraction (VE) is an important modality in modern obstetrics, yet sometimes results in maternal or neonatal adverse outcomes, which can cause a lifetime disability. We aimed to characterize potential risk factors for adverse outcomes that in retrospect would have led the physician to avoid the procedure. Materials and Methods Retrospective cohort of 3331 singleton pregnancies, ≥ 34 w delivered by VE. 263 deliveries (7.9%) incurred a VE-related feto-maternal adverse outcome, defined as one or more of the following: 3-4th-degree perineal laceration, subgaleal hematoma, intracranial hemorrhage, shoulder dystocia, clavicular fracture, Erb's palsy or fracture of humerus. 3068 deliveries (92.1%) did not have VE-related adverse outcomes. Both groups were compared to determine potential risk factors for VE adverse outcomes. Results Multivariable regression found seven independent risk factors for VE-related feto-maternal adverse outcomes: Nulliparity - with an odds ratio (OR) of 1.82 (95% CI = 1.11-2.98, p = 0.018), epidural anesthesia (OR 1.99, CI = 1.42-2.80, p < 0.001), Ventouse-Mityvac (VM) cup (OR 1.86, CI = 1.35-2.54, p < 0.001), prolonged second stage as indication for VE (OR 1.54, CI = 1.11-2.15, p = 0.010), cup detachment (OR 1.66, CI = 1.18-2.34, p = 0.004), increasing procedure duration (OR 1.07 for every additional minute, CI = 1.03-1.11, p < 0.001) and increasing neonatal birthweight (OR 3.42 for every additional kg, CI = 2.33-5.02, p < 0.001). Occiput anterior (OA) position was a protective factor (OR 0.62, CI = 0.43-0.89, p = 0.010). Conclusions VE-related adverse outcomes can be correlated to clinical characteristics, such as nulliparity, epidural anesthesia, VM cup, prolonged second stage as indication for VE, cup detachment, prolonged procedure duration and increasing neonatal weight. OA position was a protective factor. This information may assist medical staff to make an informed decision whether to choose VE or cesarean delivery (CD).

Traction force profile in children with severe perinatal outcomes delivered with a digital vacuum extraction handle: A case-control study

INTRODUCTION

During the second stage of labor, vacuum-assisted delivery is an alternative to forceps delivery and emergency cesarean section. Extensive research concerning perinatal outcomes has indicated that the risk of complications, although rare, is higher than with a spontaneous vaginal delivery. An important factor related to perinatal outcomes is the traction force applied. Our research group previously developed a digital extraction handle, the Vacuum Intelligent Handle-3 (VIH3), that measures and records traction force. The objective of this study was to compare traction force profiles in children with and without severe perinatal outcomes delivered with the digital handle. A secondary aim was to establish a safe force limit.

MATERIAL AND METHODS

This was an observational case-control study at the delivery ward at Karolinska University Hospital, Sweden. In total, 573 children delivered with the digital handle between 2012 and 2018 were included. Cases were defined as a composite of severe perinatal outcomes, including subgaleal hematoma, intracranial hemorrhage, hypoxic ischemic encephalopathy 1-3, seizures or death. The cases in the cohort were matched 1:3 based on five matching variables. Traction profiles were analyzed using the MATLAB® software and conditional logistic regression.

RESULTS

The incidence of severe perinatal outcomes was 2.3%. The 13 cases were matched with three controls each (n = 39). A statistically significant increased odds for higher total traction forces was seen in the case group (odds ratio [OR] 1.004; 95% confidence interval [CI] 1.001-1.007) and for the peak force (OR 1.022; 95% CI 1.004-1.041). Several procedure-related parameters were significantly increased in the case group. As expected, some neonatal characteristics also differed significantly. An upper force limit of 343 Newton minutes (Nmin) revealed an 86% reduction in severe perinatal outcomes (adjusted OR 0.14; 95% CI 0.04-0.5).

CONCLUSIONS

Children with severe perinatal outcomes had traction force profiles with significantly higher forces. The odds for severe perinatal outcomes increased for every increase in Nmin and Newton used during the extraction procedure. A calculated total force level of 343 Nmin is suggested as an upper safety limit, but this must be tested prospectively to provide validity.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Maternal and neonatal trauma following operative vaginal delivery

Background:

Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel. However, opportunities for training in OVD have declined and, given these shifts in practice, the safety of OVD is unknown. We estimated incidence rates of trauma following OVD in Canada, and quantified variation in trauma rates by instrument, region, level of obstetric care and institutional OVD volume.

Methods:

We conducted a cohort study of all singleton, term deliveries in Canada between April 2013 and March 2019, excluding Quebec. Our main outcome measures were maternal trauma (e.g., obstetric anal sphincter injury, high vaginal lacerations) and neonatal trauma (e.g., subgaleal hemorrhage, brachial plexus injury). We calculated adjusted and stabilized rates of trauma using mixed-effects logistic regression.

Results:

Of 1 326 191 deliveries, 38 500 (2.9%) were attempted forceps deliveries and 110 987 (8.4%) were attempted vacuum deliveries. The maternal trauma rate following forceps delivery was 25.3% (95% confidence interval [CI] 24.8%–25.7%) and the neonatal trauma rate was 9.6 (95% CI 8.6–10.6) per 1000 live births. Maternal and neonatal trauma rates following vacuum delivery were 13.2% (95% CI 13.0%–13.4%) and 9.6 (95% CI 9.0–10.2) per 1000 live births, respectively. Maternal trauma rates remained higher with forceps than with vacuum after adjustment for confounders (adjusted rate ratio 1.70, 95% CI 1.65–1.75) and varied by region, but not by level of obstetric care.

Interpretation:

In Canada, rates of trauma following OVD are higher than previously reported, irrespective of region, level of obstetric care and volume of OVD among hospitals. These results support a reassessment of OVD safety in Canada.

Prospective assessment of vacuum deliveries from midpelvic station in a tertiary care university hospital: Frequency, failure rates, labor characteristics and maternal and neonatal complications

BACKGROUND

Midpelvic vacuum extractions are controversial due to reports of increased risk of maternal and perinatal morbidity and high failure rates. Prospective studies of attempted midpelvic vacuum outcomes are scarce. Our main aims were to assess frequency, failure rates, labor characteristics, maternal and neonatal complications of attempted midpelvic vacuum deliveries, and to compare labor characteristics and complications between successful and failed midpelvic vacuum deliveries.

STUDY DESIGN

Clinical data were obtained prospectively from all attempted vacuum deliveries (n = 891) over a one-year period with a total of 6903 births (overall cesarean section rate 18.2% (n = 1258). Student's t-test, Mann-Whitney U-test or Chi-square test for group differences were used as appropriate. Odds ratios and 95% confidence intervals are given as indicated. The uni- and multivariable analysis were conducted both as a complete case analysis and with a multiple imputation approach. A p-value of <0.05 was considered statistically significant.

RESULTS

Attempted vacuum extractions from midpelvic station constituted 36.7% (n = 319) of all attempted vacuum extractions (12.9% (n = 891) of all births). Of these 319 midpelvic vacuum extractions, 11.3% (n = 36) failed and final delivery mode was cesarean section in 86.1% (n = 31) and forceps in the remaining 13.9% (n = 5). Successful completion of midpelvic vacuum by 3 pulls or fewer was achieved in 67.1%. There were 3.9% third-degree and no fourth-degree perineal tears. Cup detachments were associated with a significantly increased failure rate (adjusted OR 6.13, 95% CI 2.41-15.56, p< 0.001).

CONCLUSION

In our study, attempted midpelvic vacuum deliveries had relatively low failure rate, the majority was successfully completed within three pulls and they proved safe to perform as reflected by a low rate of third-degree perineal tears. We provide data for nuanced counseling of women on vacuum extraction as a second stage delivery option in comparable obstetric management settings with relatively high vacuum delivery rates and low cesarean section rates.

Adverse outcomes in vacuum-assisted delivery after detachment of non-metal cup: a retrospective cohort study

PURPOSE

To evaluate neonatal and maternal outcomes associated with detachment of non-metal vacuum cup during delivery and to identify risk factors for these detachments.

METHODS

This retrospective cohort study included women with singleton pregnancy, who underwent vacuum-assisted vaginal delivery with a non-metal vacuum cup in a single academic institution, January 2014-August 2019. Failed vacuum deliveries were excluded. Primary outcomes were defined as subgaleal hematoma (SGH) and cord blood pH < 7.15. Secondary outcome included other neonatal complications and adverse maternal outcomes. Outcomes were compared between vacuum-assisted deliveries with and without cup detachment during the procedure.

RESULTS

A total of 3246 women had successful VAD and met the inclusion criteria. During the procedure, the cup detached at least once in 665 (20.5%) deliveries and did not detach in 2581 (79.5%). The cup detachment group experienced higher rates of SGH (8.9% vs. 3.5%, p = 0.001) and cord blood pH < 7.15 (9.8% vs. 7.1%, p = 0.03). There were also more neonatal intensive care unit admissions (NICU) (4.4% vs. 2.7%, p = 0.03) and more fetuses with occiput posterior position (70.8% vs. 79.4%, p = 0.001), the vacuum duration was slightly longer (6 ± 3.7 vs. 5 ± 2.9 min) and more neonates had birth weights > 3700 g (14.1% vs, 10.3%, p = 0.006). Interestingly, there were more males in that group (60.6 vs. 54.6, p = 0.005). All these factors remained significant after controlling for potential confounders.

CONCLUSIONS

Vacuum cup detachment has several predictive characteristics and is associated with adverse neonatal outcomes that should be incorporated into decisions made during the procedure.

Clinical Effects of Form-Based Management of Forceps Delivery under Intelligent Medical Model

Background

Forceps delivery is one of the most important measures to facilitate vaginal delivery. It can reduce the rate of first cesarean delivery. Frustratingly, adverse maternal and neonatal outcomes associated with forceps delivery have been frequently reported in recent years. There are two major reasons: one is that the abilities of doctors and midwives in forceps delivery vary from hospital to hospital and the other one is lack of regulations in the management of forceps delivery. In order to improve the success rate of forceps delivery and reduce the incidence of maternal and neonatal complications, we applied form-based management to forceps delivery under an intelligent medical model. The aim of this work is to explore the clinical effects of form-based management of forceps delivery.

Methods

Patients with forceps delivery in Maternal and Child Health Hospital Affiliated to Nanchang University were divided into two groups: form-based patients from January 1, 2019, to December 31, 2020, were selected as the study group, while traditional protocol patients from January 1, 2017, to December 31, 2018, were chosen as the control group. Then, we compared the maternal and neonatal outcomes of these two groups.

Results

There were significant differences in the maternal and neonatal adverse outcomes such as rate of postpartum hemorrhage, degree of perineal laceration, and incidence of neonatal facial skin abrasions between the two groups, whereas differences in the incidence of asphyxia and intracranial hemorrhage were not significant.

Conclusions

Form-based management could help us assess the security of forceps delivery comprehensively, as it could not only improve the success rate of the one-time forceps traction scheme but also reduce the incidence of maternal and neonatal adverse outcomes effectively.

Maternal and Neonatal Complications Resulting From Vacuum-Assisted and Normal Vaginal Deliveries

Background

Operative vaginal delivery is a procedure that is performed using forceps or vacuum to extract an infant from the birth canal. It has many indications, one of which is prolonged second stage of labor. Although rare, vacuum extraction (VE) can lead to various neonatal and maternal complications. The objective of this study was to compare the rates of different neonatal and maternal complications between vacuum-assisted deliveries and spontaneous vaginal deliveries.

Methods

This is a retrospective cohort study that was conducted in King Abdulaziz Medical City, Jeddah (KAMC-J), Saudi Arabia. The data were collected from the Labor and Delivery Unit at KAMC-J. A total of 745 samples was included (586 delivered spontaneously and 157 delivered by VE). Analysis was performed using the Statistical Package for Social Sciences (SPSS) Version 27.0.

Results

The median age was 30 years (IQR=36-34). Of all deliveries, vacuum was used in 21.1%. Perineal tear was the most frequent maternal complication (20.9%), while caput succedaneum was the commonest neonatal complication (11.8%). Post-partum hemorrhage was significantly higher among vacuum deliveries (RR=18.8; 95% CI: 5.5-64.15), as well as cephalohematoma (RR=28.9; 95% CI: 8.79-95.04) and caput succedaneum (RR=18.6; 95% CI: 10.99-31.49). The first-minute Apgar score was lower with VE (p < 0.001), and higher perineal tear degrees were reported with VE (p < 0.001).

Conclusion

The rates of maternal and neonatal complications were significantly higher among vacuum-assisted deliveries. The most serious neonatal complication was subgaleal hematoma, which is considered life-threatening. Further research is recommended to investigate subgaleal hematoma risk factors.

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.

Perinatal outcome after vacuum assisted delivery with digital feedback on traction force; a randomised controlled study

Background

Low and mid station vacuum assisted deliveries (VAD) are delicate manual procedures that entail a high degree of subjectivity from the operator and are associated with adverse neonatal outcome. Little has been done to improve the procedure, including the technical development, traction force and the possibility of objective documentation. We aimed to explore if a digital handle with instant haptic feedback on traction force would reduce the neonatal risk during low or mid station VAD.

Methods

A two centre, randomised superiority trial at Karolinska University Hospital, Sweden, 2016–2018. Cases were randomised bedside to either a conventional or a digital handle attached to a Bird metal cup (50 mm, 80 kPa). The digital handle measured applied force including an instant notification by vibration when high levels of traction force were predicted according to a predefined algorithm. Primary outcome was a composite of hypoxic ischaemic encephalopathy, intracranial haemorrhage, seizures, death and/or subgaleal hematoma. Three hundred eighty low and mid VAD in each group were estimated to decrease primary outcome from six to 2 %.

Results

After 2 years, an interim analyse was undertaken. Meeting the inclusion criteria, 567 vacuum extractions were randomized to the use of a digital handle (n = 296) or a conventional handle (n = 271). Primary outcome did not differ between the two groups: (2.7% digital handle vs 2.6% conventional handle). The incidence of primary outcome differed significantly between the two delivery wards (4% vs 0.9%, p < 0.05). A recalculation of power revealed that 800 cases would be needed in each group to show a decrease in primary outcome from three to 1 %. This was not feasible, and the study therefore closed.

Conclusions

The incidence of primary outcome was lower than estimated and the study was underpowered. However, the difference between the two delivery wards might reflect varying degree of experience of the technical equipment. An objective documentation of the extraction procedure is an attractive alternative in respect to safety and clinical training. To demonstrate improved safety, a multicentre study is required to reach an adequate cohort. This was beyond the scope of the study.

Trial registration

ClinicalTrials.gov NCT03071783, March 1, 2017, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03604-z.

A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance

Background

Current interest in using severe maternal morbidity (SMM) as a quality indicator for maternal healthcare will require the development of a standardized method for estimating hospital or regional SMM rates that includes adjustment and/or stratification for risk factors.

Objective

To perform a scoping review to identify methodological considerations and potential covariates for risk adjustment for delivery-associated SMM.

Search methods

Following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews, systematic searches were conducted with the entire PubMed and EMBASE electronic databases to identify publications using the key term “severe maternal morbidity.”

Selection criteria

Included studies required population-based cohort data and testing or adjustment of risk factors for SMM occurring during the delivery admission. Descriptive studies and those using surveillance-based data collection methods were excluded.

Data collection and analysis

Information was extracted into a pre-defined database. Study design and eligibility, overall quality and results, SMM definitions, and patient-, hospital-, and community-level risk factors and their definitions were assessed.

Main results

Eligibility criteria were met by 81 studies. Methodological approaches were heterogeneous and study results could not be combined quantitatively because of wide variability in data sources, study designs, eligibility criteria, definitions of SMM, and risk-factor selection and definitions. Of the 180 potential risk factors identified, 41 were categorized as pre-existing conditions (e.g., chronic hypertension), 22 as obstetrical conditions (e.g., multiple gestation), 22 as intrapartum conditions (e.g., delivery route), 15 as non-clinical variables (e.g., insurance type), 58 as hospital-level variables (e.g., delivery volume), and 22 as community-level variables (e.g., neighborhood poverty).

Conclusions

The development of a risk adjustment strategy that will allow for SMM comparisons across hospitals or regions will require harmonization regarding: a) the standardization of the SMM definition; b) the data sources and population used; and c) the selection and definition of risk factors of interest.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40748-020-00123-1.

The Real Maternal Risks in a Pregnancy: A Structured Review to Enhance Maternal Understanding and Education

This review sought to use high-level published data sources for system knowledge translation, collaborative enhanced maternal education and understanding, and prospective maternal quality and safety care planning. The goal was to answer the following question: What are the short- and long-term maternal risks ("near misses," adverse events, severe morbidity and mortality) associated with pregnancy and childbirth? A structured analysis of the literature (systematic review, meta-analysis, observational case-control cohort), focusing on publications between 2016 and April 2019, was undertaken using the following key word search strategy: maternal, morbidity, mortality, co-morbidities (BMI, fertility, hypertension, cardiac, chronic renal disease, diabetes, mental health, stroke), preconception, antepartum, intrapartum, postpartum, "near miss," and adverse events. Only large cohort database sources with control comparison studies were accepted for inclusion because maternal mortality events are rare. Systematic review and meta-analysis were not undertaken because of the wide clinical scope and the goal of creating an education algorithm tool. For this educational tool, the results were presented in a counselling format that included a control group of common maternal morbidity from a regional maternity cohort (2017) of 54 000 births and published risk estimates for pre-conception, pregnancy-associated comorbidity, pregnancy-onset conditions, long-term maternal health associations, and maternal mortality scenarios. Because issues related to maternal comorbidities are increasing in prevalence, personalized pre-conception education on maternal pregnancy risk estimates needs to be encouraged and available to promote greater understanding. This maternal morbidity and mortality evaluation tool allows for patient-provider review and recognition of the possible leading factors associated with an increased risk of maternal morbidity: pre-conception risks (maternal age >45 years; pre-existing cardiac or hypertensive conditions) and pregnancy-obstetrical risks (gestational hypertension, preeclampsia, eclampsia; caesarean delivery, whether preterm or term; operative vaginal delivery; maternal sepsis; placenta accreta spectrum; and antepartum or postpartum hemorrhage).