Indications et prérequis à la réalisation d’une extraction instrumentale : quand, comment et où ?

The OdonAssist inflatable device for assisted vaginal birth-the ASSIST II study (United Kingdom)

BACKGROUND

Decreasing rates of assisted vaginal birth have been paralleled with increasing rates of cesarean deliveries over the last 40 years. The OdonAssist is a novel device for assisted vaginal birth. Iterative changes to clinical parameters, device design, and technique have been made to improve device efficacy and usability.

OBJECTIVE

This study aimed to determine if the feasibility, safety, and efficacy of the OdonAssist device were sufficient to justify conducting a future randomized controlled trial.

STUDY DESIGN

An open-label nonrandomized study of 104 participants having a clinically indicated assisted vaginal birth using the OdonAssist was undertaken at Southmead Hospital, Bristol, United Kingdom. Data were also collected from participants who consented to participate in the study but for whom trained OdonAssist operators were not available, providing a nested cohort. The primary clinical outcome was the proportion of births successfully expedited with the OdonAssist. Secondary outcomes included clinical, patient-reported, operator-reported, device and health care utilization. Neonatal outcome data were reviewed at day 28, and maternal outcomes were investigated up to day 90. Given that the number of successful OdonAssist births was ≥61 out of 104, the hypothesis of a poor rate of 50% was rejected in favor of a good rate of ≥65%.

RESULTS

Between August 2019 and June 2021, 941 (64%) of the 1471 approached, eligible participants consented to participate. Of these, 104 received the OdonAssist intervention. Birth was assisted in all cephalic vertex fetal positions, at all stations ≥1 cm below the ischial spines (with or without regional analgesia). The OdonAssist was effective in 69 of the 104 (66%) cases, consistent with the hypothesis of a good efficacy rate. There were no serious device-related maternal or neonatal adverse reactions, and there were no serious adverse device effects. Only 4% of neonatal soft tissue bruising in the successful OdonAssist group was considered device-related, as opposed to 20% and 23% in the unsuccessful OdonAssist group and the nested cohort, respectively. Participants reported high birth perception scores. All practitioners found the device use to be straightforward.

CONCLUSION

Recruitment to an interventional study of a new device for assisted vaginal birth is feasible; 64% of eligible participants were willing to participate. The success rate of the OdonAssist was comparable to that of the Kiwi OmniCup when introduced in the same unit in 2002, meeting the threshold for a randomized controlled trial to compare the OdonAssist with current standard practice. There were no disadvantages of study participation in terms of maternal and neonatal outcomes. There were potential advantages of using the OdonAssist, particularly reduced neonatal soft tissue injury. The same application technique is used for all fetal positions, with all operators deeming the device straightforward to use. This study provides important data to inform future study design.

Closed- or open-glottis pushing for vaginal delivery: a planned secondary analysis of the TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery study

BACKGROUND

The effect on obstetrical outcomes of closed- or open-glottis pushing is uncertain among both nulliparous and parous women.

OBJECTIVE

This study aimed to assess the association between open- or closed-glottis pushing and mode of delivery after an attempted singleton vaginal birth at or near term.

STUDY DESIGN

This was an ancillary planned cohort study of the TRAAP (TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery) randomized controlled trial, conducted in 15 French maternity units from 2015 to 2016 that enrolled women with an attempted singleton vaginal delivery after 35 weeks' gestation. After randomization, characteristics of labor and delivery were prospectively collected, with special attention to active second-stage pushing and a specific planned questionnaire completed immediately after birth by the attending care provider. The exposure was the mode of pushing, classified into 2 groups: closed- or open-glottis. The main endpoint was operative vaginal delivery. Secondary endpoints were items of maternal morbidity, including severe perineal laceration, episiotomy, postpartum hemorrhage, duration of the second stage of labor, and a composite severe neonatal morbidity outcome. We also assessed immediate maternal satisfaction, experience of delivery, and psychological status 2 months after delivery. The associations between mode of pushing and outcome were analyzed by multivariate logistic regression to control for confounding bias, with multilevel mixed-effects analysis, and a random intercept for center.

RESULTS

Among 3041 women included in our main analysis, 2463 (81.0%) used closed-glottis pushing and 578 (19.0%) open-glottis pushing; their respective operative vaginal delivery rates were 19.1% (n=471; 95% confidence interval, 17.6-20.7) and 12.5% (n=72; 95% confidence interval, 9.9-15.4; P<.001). In an analysis stratified according to parity and after controlling for available confounders, the rate of operative vaginal delivery did not differ between the groups among nulliparous women: 28.7% (n=399) for the closed-glottis and 27.5% (n=64) for the open-glottis group (adjusted odds ratio, 0.93; 95% confidence interval, 0.65-1.33; P=.7). The operative vaginal delivery rate was significantly lower for women using open- compared with closed-glottis pushing in the parous population: 2.3% (n=8) for the open- and 6.7% (n=72) for the closed-glottis groups (adjusted odds ratio, 0.43; 95% confidence interval, 0.19-0.90; P=.03). Other maternal and neonatal outcomes did not differ between the 2 modes of pushing among either the nulliparous or parous groups.

CONCLUSION

Among nulliparous women with singleton pregnancies at term, the risk of operative vaginal birth did not differ according to mode of pushing. These results will inform shared decision-making about the mode of pushing during the second stage of labor.

Safety and efficacy of the OdonAssist inflatable device for assisted vaginal birth: the BESANCON ASSIST study

BACKGROUND

The first feasibility study of the OdonAssist inflatable device for use in clinically indicated assisted vaginal birth reported a success rate of 48% with no significant safety concerns. Additional studies exploring the device performance in other clinical settings are warranted before definitive conclusions can be drawn about its safety and efficacy in current practice.

OBJECTIVE

This study aimed to investigate the safety and efficacy of the OdonAssist before conducting a randomized controlled trial.

STUDY DESIGN

This was an open-label, nonrandomized study of 104 women with a clinically indicated assisted vaginal birth using the OdonAssist at the Besancon University Hospital, France. Data, including those of a nested cohort group of women who had an assisted vaginal birth using vacuum or spatulas because a trained OdonAssist device operator was not available at the time of delivery, were collected. The primary outcome measure was the proportion of successful assisted vaginal births using the OdonAssist. Neonatal outcome data were reviewed at days 1 and 28, and maternal outcomes were investigated up to day 90.

RESULTS

Between December 2019 and May 2021, 2191 pregnant women were approached, and 83% (1636/1973) of them consented to participate in the study. Among them, 10.7% (176/1636) required an assisted vaginal birth owing to a vertex presentation at +1 and below. The OdonAssist was used in 59% of births (104/176), and 41.1% (72/176) of the participants were included in the nested cohort group. The rate of successful assisted vaginal births using the OdonAssist was 88.5% (92/104). No emergency cesarean deliveries were performed in the OdonAssist group. There were no serious adverse maternal or neonatal reactions related to the use of the device. The rate of third- and fourth-degree perineal tears with the OdonAssist was 3.8% (4/104). The maternal perception ratings of the birth experience with the OdonAssist (collected on days 1, 7, and 28 using a 15-point scale) were high. In addition, the operators reported a positive perception of the device, with ease of use across the different steps of the procedure. One single technique was used for all vertex fetal head positions.

CONCLUSION

The OdonAssist is a safe and effective alternative to other current devices for assisted vaginal births. The high acceptance rate (83%) among pregnant women and the high rate of successful assisted vaginal births using the OdonAssist confirm the feasibility of a future randomized controlled trial.

Predictive value of head-perineum distance measured at the initiation of the active second stage of labor on the mode of delivery: A prospective cohort study

OBJECTIVE

The objective was to assess the predictive value of head-perineum distance measured at the initiation of the active second stage of labor on the mode of delivery.

MATERIAL AND METHODS

It was a prospective cohort study in an academic Hospital of Rennes, France, from July 1, 2020 to April 4, 2021 including 286 full-term parturients who gave birth to a newborn in cephalic presentation. A double-blind ultrasound measurement of the head-perineum distance was performed during the second phase of labor within five minutes after the onset of pushing efforts. The primary outcome was the mode of delivery (spontaneous vaginal delivery versus instrumental vaginal delivery or cesarean section). We performed a multivariate analysis to determine the predictive value of the head-perineum distance by adjusting on potential confounders.

RESULTS

Overall, 199 patients delivered by spontaneous vaginal delivery, 80 by instrumental vaginal delivery, and seven by cesarean section. The head-perineum distance measured at the beginning of pushing efforts was predictive of the mode of delivery with a threshold at 44 mm (crude: sensitivity = 56.8 % and specificity = 79.3 %; adjusted: sensitivity = 79.4 % and specificity = 87.4 %). The risk of medical intervention was higher when the head-perineum distance is>44 mm with an adjusted OR of 2.78 [1.38; 5.76].

CONCLUSION

The head-perineum distance measured at the initiation of the active second stage of labor is predictive of the mode of delivery. Head-perineum distance below 44 mm predicts a vaginal delivery with the best diagnostic performance, and optimizes the time to start pushing efforts.

Effect of patient-controlled epidural analgesia with and without automatic intermittent bolus on levobupivacaine consumption during labour: A single-centre prospective double-blinded randomised controlled study

BACKGROUND

During labour, the effects of adding a programmed intermittent epidural bolus (PIEB) baseline analgesic regimen to patient-controlled epidural analgesia (PCEA) remain uncertain.

METHODS

This single centre prospective double-blinded controlled study randomised nulliparous women over 35 weeks of gestational age in a PCEA + PIEB or PCEA only group. After an epidural analgesia catheter was inserted, a specific pump administered a solution of levobupivacaine 0.625 mg mL^-1, sufentanil 0.25 µg mL^-1, and clonidine 0.375 µg mL^-1. In both groups the PCEA mode delivered an 8 mL bolus with a lockout period of 8 min. In the PCEA + PIEB group, women also received a programmed 8 mL bolus every 60 min. Additional bolus were allowed if required. The primary outcome was the hourly consumption of levobupivacaine from epidural catheter placement to new-born delivery. Secondary outcome were motor block, oxytocin use, sufentanil consumption, additional bolus required, instrumental vaginal delivery, unplanned caesarean section, pain during labour and women's satisfaction.

RESULTS

Analysis included 162 and 155 women in the PCEA and PCEA + PIEB groups, respectively. The median [IQR] hourly consumption of levobupivacaine was significantly lower in the PCEA group (9.9 (7.8-12.4] mg h^-1) as compared to the PCEA + PIEB group (11.2 [7.9-14.3] mg h^-1; p = 0.046). The difference between medians was 1.3 mg h^-1 95 % CI (0.1-2.9). There was no difference between groups for secondary outcomes.

CONCLUSIONS

PCEA only modestly decreased the hourly consumption of local anaesthetic as compared to PCEA + PIEB but the difference was not clinically relevant.

Intra pelvic spontaneous rotation of persistent occiput posterior position in case of operative vaginal delivery with spatulas

OBJECTIVES

In 5 % of vaginal deliveries in case of cephalic presentation there is a persistent occipital posterior position known to be associated with a higher maternal and neonatal morbidity. In these situations, vacuum extractor seems to be the best choice for assisted delivery but it also has limits and contraindications, for example an important caput succadenum or premature birth. The aim of our study was to evaluate the rate of intra-pelvic rotation of persistent occipital posterior position without instrumental rotation in case of operative delivery with spatulas.

METHODS

This is a retrospective, monocentric and descriptive study evaluating the rate of spontaneous intra-pelvic rotation of persistent occipital posterior position in case of assisted delivery with spatulas among all live births at the Besançon University Medical Center between 2010 and 2017.

RESULTS

There were 20 205 births during the study and 81(0,4 %) operative deliveries by spatulas in case of persistent occipital posterior position. Delivery in occiput anterior (OA) position was obtained in 36 cases (44.4 %). There was no significant difference in maternal or neonatal morbidity between both groups and perineum injuries were less severe in case of OA delivery.

CONCLUSION

Operative deliveries by spatulas without instrumental rotation in case of persistent occipital-posterior position seem to be a relevant alternative to vacuum extractor, especially in case of premature birth or important caput succedaneum without altering the maternal or neonatal prognostic.

Effect of Oral Carbohydrate Intake During Labor on the Rate of Instrumental Vaginal Delivery: A Multicenter, Randomized Controlled Trial

BACKGROUND

Carbohydrate intake during physical exercise improves muscle performance and decreases fatigue. We hypothesized that carbohydrate intake during labor, which is a period of significant physical activity, can decrease the instrumental vaginal delivery rate.

METHODS

In a multicenter, prospective, randomized, controlled trial, healthy adult pregnant women presenting with spontaneous labor were assigned to a "Carbohydrate" group (advised to drink 200 mL of apple or grape juice without pulp every 3 hours) or a "Fasting" group (water only). The primary outcome was the instrumental vaginal delivery rate. Secondary outcomes included duration of labor, rate of cesarean delivery, evaluation of maternal hunger, thirst, stress, fatigue, and overall feeling during labor by numeric rating scale (0 worst rating to 10 best rating), rate of vomiting, and hospital length of stay. Statistical analysis was performed on an intention-to-treat basis. The primary outcome was tested with the "Fasting" group as the reference group. The P values for secondary outcomes were adjusted for multiple comparisons. The differences between groups are reported with 99% confidence interval (CI).

RESULTS

A total of 3984 women were analyzed (2014 in the Carbohydrate group and 1970 in the Fasting group). There was no difference in the rate of instrumental delivery between the Carbohydrate (21.0%) and the Fasting (22.4%) groups (difference, -1.4%; 99% CI, -4.9 to 2.2). No differences were found between the Carbohydrate and the Fasting groups for the duration of labor (difference, -7 minutes; 99% CI, -25 to 11), the rate of cesarean delivery (difference, -0.3%; 99% CI, -2.4 to 3.0), the rate of vomiting (difference, 2.8%; 99% CI, 0.2-5.7), the degree of self-reported fatigue (difference, 1; 99% CI, 0-2), self-reported hunger (difference, 0; 99% CI, -1 to 1), thirst (difference, 0; 99% CI, -1 to 1), stress (difference, 0; 99% CI, -1 to 1), overall feeling (difference, 0; 99% CI, 0-0), and the length of hospitalization (difference, 0; 99% CI, -1 to 0).

CONCLUSIONS

Carbohydrate intake during labor did not modify the rate of instrumental vaginal delivery.

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.

[Pathophysiology, diagnosis and management of occiput posterior presentation during labor]

Persistant occiput posterior (OP) positions are the commonest malpresentations of the fetal head during labor and their diagnosis remains challenging. They are associated to prolonged second stage of labor, prolonged expulsive efforts, labor augmentation, cesarean sections and instrumental deliveries. On the maternal side, severe perineal tears, post-partum hemorrhage or chorioamnionitis are more frequent. Currently, prevention of persistent OP positions is based on the maintain of precise maternal positions. Several positions have been evaluated but only lateral position on the same side of the fetal spine has proved its effectiveness. Fetal head rotation can also be achieved with extraction instruments though none has ever been evaluated by a randomized controlled trial. Obstetrical forceps seem more efficient than vacuum but are associated with severe perineal tears. Evaluation of rotation with Thierry's spatulas is scarce. Last, manual rotation is of routine use in many wards. This management is associated with a twofold reduction of operative delivery rate and rare adverse outcomes but has never been evaluated through randomized control trial.

[Caesarean section at full dilatation: What are the risks to fear for the mother and child?]

OBJECTIVES

Caesarean section is associated with increased maternal morbidity compared to a vaginal delivery, especially if it occurs during labour. Little data on caesarean section performed at full dilatation is available.

METHODS

This was a retrospective study done in University Hospital of type 3 over a period of ten years, including future primiparous patients who had a caesarean section performed at full dilatation, compared to a control group of patients whose caesarean section was conducted in first part of the labour. We collected different maternal data per- and postoperative and neonatal.

RESULTS

In total, 824 patients were enrolled including 412 in each group. For caesarean section at full dilatation, foetal extraction required more manoeuvres (RR=3.05; 95% CI: 2.1; 4.39; P<0.001); we noted more extension of hysterotomy (RR=1.79; 95% CI: 1.30; 2.46; P<0.001). Postoperative and neonatal maternal morbidity was not different, except more frequent neonatal trauma for caesarean section at full dilatation.

CONCLUSION

A caesarean section at full dilatation has an excess intraoperative risk and requires great caution. Nevertheless, no significant increase of postoperative and neonatal complications can be proved.

[Risks factors of cesarean delivery after 3hours of delayed pushing]

OBJECTIVES

Identify the factors associated with caesarean delivery for unengaged fetal head beyond 3hours of passive second stage of labor, among primiparous patients.

METHODS

A case-control study conducted in level III universitary center between October 2012 and September 2015. Only primiparous at term, with a singleton, cephalic fetus and a passive second stage of labor prolonged over 3hours before pushing were included. During the second stage of labor, patients who had caesarean for abnormal fetal heart rate were excluded. Risk factors of cesarean were analyzed with univariate analysis and after statistical adjustment using multivariate logistic regression.

RESULTS

The mean passive second stage duration was significantly longer among patients who had a caesarean (3h37±21min vs 3h13±19min [P=0,0001]). After multivariate logistic regression, factors associated with a risk of caesarean were body mass index higher than 30kg/m² (OR=25.9 [3.1-215.9]). fetal macrosomia suspected by 3rd trimester ultrasound (OR=4.4 [1.2-16.4]), induction by prostaglandins (OR=5.7 [2.1-15.5]), a stagnation of cervical dilatation during the 1st stage (OR=[1.3-6.8]), and fetal occiput posterior position beyond 3hours (OR=30.7 [3.3-280.9]).

CONCLUSIONS

Risk of caesarean delivery for unengaged fetal head beyond 3hours of passive second stage of labor is associated with maternal, fetal and obstetrical factors. Those factors might be taken into account before accept or not a 3rd hour at full cervical dilation.

[Mode of delivery in spontaneous preterm birth]

OBJECTIVE

To evaluate the benefit/risk balance of way of birth according to fetal presentation, to assess monitoring during preterm labor, to discuss method of delivery and practice of delayed cord clamping in case of spontaneous preterm birth.

METHODS

Bibliographic research from the Pubmed database and recommendations issued by the main scientific societies, and assignment of a level of evidence and a recommendation grade.

RESULTS

In case of vertex presentation, no studies suggest that cesarean section improve neonatal outcome during spontaneous preterm birth (LE4). Nevertheless, cesarean is associated with higher maternal morbidity than vaginal delivery. Thus, routine cesarean is not recommended simply because of a spontaneous preterm labor (professional consensus). The available data do not allow specific recommendations about the choice of mode of delivery for preterm breech presentation in view of the low levels of proof (Professional consensus). Fetal rate monitoring is necessary during preterm labor (Professional consensus). Current data about second lines method for fetal surveillance (fetal scalp blood for pH or lactates) are insufficient to recommend their use before 34 WG (Professional consensus). Systematic assisted vaginal delivery is not recommended during preterm birth (Professional consensus). Use of vacuum is possible after 34 WG when cranial vertex ossification is considered satisfactory (Professional consensus). Systematic use of episiotomy in case of preterm birth is not recommended (Professional consensus). A delayed cord clamping is possible if the neonatal or maternal state so permits (Professional consensus). The available data are insufficient to recommend a systematic use of this procedure (LE3).

CONCLUSION

In case of preterm delivery, the available data do not allow specific recommendations about the choice of mode of delivery regardless of fetal presentation.

[Instrumental delivery with perineum-fetal head distance >55 MM on ultrasound]

OBJECTIVE

Compare the issue of an operative vaginal delivery associated to the fetal presentation diagnosed by transperineal ultrasound. Three groups were formed: ≥55 mm, between 45 and 55 mm, and <45 mm.

METHODS

A monocentric prospective study on 108 patients has been conducted between April 2011 and August 2014. The distance between perinea and skull has been analyzed to compare the success of operative vaginal delivery considering the level of the fetal presentation in the pelvic cavity.

RESULTS

The failed operative vaginal deliveries are more frequent while the fetal head is above 55 mm (16.7%) or while the fetal head is between 45 and 55 mm (9.1%) than while the fetal skull is under 45 mm (1.8%) (P=0.04). However there is no significant difference for the fetal shoulder dystocia (5.6% vs 3.0% vs 3.5%, P=0.5), nor for the newborn outcomes (16.7 vs 15.2 vs 14; P=0.9).

CONCLUSION

Despite the high rate of failed operative vaginal delivery above 55 mm, it should be considered not to prohibit but send free to the obstetrician appreciation.

Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery According to Fetal Head Station

OBJECTIVE

To compare severe short-term maternal and neonatal morbidity associated with midpelvic and low pelvic attempted operative vaginal delivery.

METHODS

Prospective study of 2,138 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. We used multivariate logistic regression and propensity score methods to compare outcomes associated with midpelvic and low pelvic delivery. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesarean delivery, postpartum hemorrhage greater than 1,500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, and maternal death; severe neonatal morbidity was defined as 5-minute Apgar score less than 7, umbilical artery pH less than 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, and neonatal death.

RESULTS

From December 2008 through October 2013 there were 2,138 attempted operative vaginal deliveries; 18.3% (n=391) were midpelvic, 72.5% (n=1,550) low, and 9.2% (n=197) outlet. Severe maternal morbidity occurred in 10.2% (n=40) of midpelvic, 7.8% (n=121) of low, and 6.6% (n=13) of outlet attempts (P=.21); and severe neonatal morbidity in 15.1% (n=59), 10.2% (n=158), and 10.7% (n=21) (P=.02), respectively. Multivariable logistic regression analysis found no significant difference between midpelvic and low attempted operative vaginal delivery for either composite severe maternal (adjusted odds ratio [OR] 1.01, 95% confidence interval [CI] 0.66-1.55) or neonatal morbidity (adjusted OR 1.25, 95% CI 0.84-1.86). Similarly, propensity score matching found no significant difference between midpelvic and low operative vaginal delivery for either severe maternal (adjusted OR 0.69, 95% CI 0.39-1.22) or neonatal morbidity (adjusted OR 0.88, 95% CI 0.53-1.45).

CONCLUSION

In singleton term pregnancies, midpelvic attempted operative vaginal delivery compared with low pelvic attempted operative vaginal delivery was not associated with an increase in severe short-term maternal or neonatal morbidity.

LEVEL OF EVIDENCE

II.

[Delivery of premature infants]

Prematurity is a frequent event and clearly raises an issue concerning how these fetuses with multiple weaknesses should be delivered. Although, a systematic abdominal approach has no scientific basis, there are cases where the caesarean is chosen because of other factors associated to prematurity such as any maternal or fetal indication to terminate the pregnancy while labour induction remains impossible. However, in case of breech presentation, which is often delivered by caesarean, the literature does recommend neither the vaginal nor the abdominal approach. Caesarean in case of prematurity is more difficult because of the absence of any inferior segment and implies making a large incision so as to easily extract these weak fetuses. Increased maternal morbidity related to preterm caesarean sections has been reported through out literature. The viability gestational age limit represents a confounding factor in most studies since caesarean is rarely chosen for these fetuses because of a very low expected survival rate, while it is probably in this situation that the abdominal approach could provide a real benefit. Larger studies are required to show potential advantages. Systematic use of episiotomies or instrumental deliveries in case of vaginal births is not recommended in case of prematurity. Protecting the fetal head with spatulas still requires further evaluations.

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

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Operative vaginal deliveries: practical aspects

Forceps, vacuum, and cesarean sections are relatively recent additions to the obstetrician's armamentarium. The art of modern obstetrics is one that mandates from obstetricians the attentive vigilance of the development of natural processes and an active intervention when such processes fall outside normally accepted standards. What constitutes the "normal process" and the "accepted standard" is subject to discussion, and international variations in obstetric practice are in part the reflection of such controversies. This article presents a practical approach to the contemporary issue of instrumental deliveries, outlining supporting evidence (when available) and the most current position of professional colleges in obstetrics and gynecology.

[Learning use of spatulas: risks of perineal injuries and newborns morbidity]

OBJECTIVES

To examine the acute neonatal and maternal perineal morbidity due to resident training on spatulas assisted deliveries.

MATERIAL AND METHODS

We conducted a retrospective observational study of succesful spatulas-assisted deliveries at Nice University Hospital between January2003 and December2006. We performed univariate analysis and logistic regression to assess risk of severe perineal injuries, vaginal laceration and newborn hospitalization according to operator status, controlling for confounders.

RESULTS

Among 1004 deliveries, 86.4% were performed by residents. No significant difference was found on incidence of severe perineal tears between the 872 extractions performed by residents and the 132 performed by an attending physician (6.9% versus 7.9% p=0.706; OR=0.86 IC95% [0.41-1.81]), but extraction performed by young residents were associated to more severe perineal tears than those performed by senior residents (8.0% versus 4.5% p=0.035; OR=2.10 IC95% [1.16-3.77]). There was no difference between groups concerning newborn morbidity and hospitalisation in special care units (6.4% versus 9.8% p=0.149; OR=1.49 IC95% [0.73-304]).

CONCLUSION

According to our data, training of resident do not increase the incidence of severe perineal injuries, neonatal complications and hospitalisation linked to spatulas assisted delivery.