Guidelines for Operative Vaginal Birth

Influence of the maternity unit and region of delivery on episiotomy practice in France: a nationwide population-based study

INTRODUCTION

Our objective was to identify factors associated with episiotomy practice in France, in particular, characteristics of the maternity units and regions of delivery.

MATERIAL AND METHODS

We performed a national cross-sectional population-based study in all French maternity units in 2016 including 9284 women with vaginal delivery. Our outcome was the performance of an episiotomy. After stratification for parity, associations of episiotomy practice with individual and organizational characteristics and the region of delivery were estimated with multilevel logistic regression models. The variability in maternity unit episiotomy rates explained by the characteristics studied was estimated by the proportional change in variance.

RESULTS

A total of 19.9% of the women had an episiotomy. The principal factors associated with episiotomy practice were maternal and obstetric and delivery in a maternity unit with <2000 annual deliveries. After adjusting for individual, obstetric and organizational characteristics, the practice of episiotomy was strongly associated with women's region of delivery. Additionally, women's individual characteristics did not explain the significant variability in episiotomy rates between maternity units (P < 0.001) but maternity unit characteristics partly did (proportion of variance explained: 7.2% for primiparas and 13.6% for multiparas) and regional differences still more (18% and 30.7%, respectively).

CONCLUSIONS

Episiotomy practices in France in 2016 varied strongly between maternity units, largely due to regional differences. Targeted actions by the regional perinatal care networks may reduce the national episiotomy rate and standardize practices.

Midline and Mediolateral Episiotomy: Risk Assessment Based on Clinical Anatomy

Episiotomy is the surgical incision of the vaginal orifice and perineum to ease the passage of an infant’s head while crowning during vaginal delivery. Although episiotomy remains one of the most frequently performed surgeries around the world, short- and long-term complications from the procedure are not uncommon. We performed midline and mediolateral episiotomies with the aim of correlating commonly diagnosed postepisiotomy complications with risk of injury to perineal neuromuscular and erectile structures. We performed 61 incisions on 47 female cadavers and dissected around the incision site. Dissections revealed that midline incisions did not bisect any major neuromuscular structures, although they did increase the risk of direct and indirect injury to the subcutaneous portion of the external anal sphincter. Mediolateral incisions posed greater risk of iatrogenic injury to ipsilateral nerve, muscle, erectile, and gland tissues. Clinician discretion is advised when weighing the potential risks to maternal perineal anatomy during vaginal delivery when episiotomy is indicated. If episiotomy is warranted, an understanding of perineal anatomy may benefit diagnosis of postsurgical complications.

Neonatal outcome of second-stage cesarean delivery versus vacuum extraction among neonates <34 weeks

OBJECTIVE

Among deliveries <34 weeks, there is inconclusive evidence regarding the preferred route of delivery when there is a need to expedite delivery during the second stage of labor. As it is unreasonable that future randomized controlled trials will be conducted to settle this query, every clinical data concerning this topic, may be helpful. We aim to compare neonatal outcomes among women undergoing emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) during the second stage of labor among singleton gestations <34 weeks.

METHODS

A retrospective cohort study including all women who underwent either ECD or VAD at the second stage of labor between 30°^/7 and 33^6/7weeks, during 2011-2019. The primary outcome was the rate of adverse neonatal outcomes, defined as intrapartum death, mechanical ventilation, asphyxia, respiratory distress syndrome, subgaleal hemorrhage, intraventricular hemorrhage, necrotizing enterocolitis, and phototherapy.

RESULTS

Of the 153,672 live singleton deliveries during the study period, 2871 (1.9%) delivered before 34°^/7. Of those 1674 (58.3%) delivered vaginally unassisted and 1137 (39.6%) delivered by a CD during the first stage of labor. A total of 60 deliveries were analyzed, with a median gestational age of 32 weeks, interquartile range (IQR) 31-33. Median birth weight at delivery was 1845 g, IQR 1574-2095. Overall 25 (42%) of women were delivered by VAD and 35 by CD (58%). Indications for expeditious delivery did not differ between the study groups. Neonates delivered by VAD had a higher median birth weight (1940 vs. 1620 g, p = .02). Second stage of labor was longer in the ECD group as compared to the VAD group (median 200 vs. 52 min, p = .01). The rate of Apgar score at 1 min <7 was higher among the CD group (10 (40%) vs. 5 (14%), OR [95% CI]: 4.0 (1.1-13.8), p = .03). Longer length of stay was evident in the CD group as compared to the VAD group (median 30 vs. 21 days, p = .001). The rate of composite neonatal adverse outcome was comparable between the study groups. Adverse outcomes were associated with lower body mass index (median 27.7 vs. 34.9, p = .04), higher rate of premature preterm rupture of membranes (40 (91%) vs. 5 (31%), OR [95% CI]: 22.0 (5.0-91.1), p < .001) and labor dystocia as the indication for expedited delivery (38 (86%) vs. 7 (44%), OR [95% CI]: 8.1 (2.1-30.1), p = .001).

CONCLUSIONS

Cesarean delivery during the second stage of labor of gestations <34 weeks was associated with a higher rate of lower Apgar scores and longer length of stay.

SYNOPSIS

Delivery by second stage CD of premature neonates <34 weeks is associated with a higher rate of lower Apgar score.

Operative vaginal delivery: a review of four national guidelines

There is a broad range in the rates of operative vaginal deliveries (OVD) worldwide, which reflects the variety of local practice patterns, the number of trained clinicians and the lack of international evidence-based guidelines. The aim of this study was to review and compare the recommendations from published guidelines on OVD. Thus, a descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the American College of Obstetricians and Gynecologists (ACOG) on instrumental vaginal birth was conducted. All the guidelines point out that the use of any instrument should be based on the clinical circumstances and the experience of the operator. The indications, the contraindications, the prerequisites and the classification for OVD are overall very similar in the reviewed guidelines. Further, they all agree that episiotomy should not be performed routinely. The RCOG, the RANZCOG and the SOGC describe some interventions which may promote spontaneous vaginal birth and therefore reduce the need for OVD. They also highlight the importance of adequate postnatal care and counseling. There is no consensus on the actual technique that should be used, including the type of forceps or vacuum cup, the force and duration of traction or the number of detachments allowed. Hence, there is need for international practice protocols, so as to encourage the clinicians to use OVD when indicated, minimize the complications and reduce rates of cesarean delivery.

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.

Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial

BACKGROUND

Risk factors for maternal infection are clearly recognised, including caesarean section and operative vaginal birth. Antibiotic prophylaxis at caesarean section is widely recommended because there is clear systematic review evidence that it reduces incidence of maternal infection. Current WHO guidelines do not recommend routine antibiotic prophylaxis for women undergoing operative vaginal birth because of insufficient evidence of effectiveness. We aimed to investigate whether antibiotic prophylaxis prevented maternal infection after operative vaginal birth.

METHODS

In a blinded, randomised controlled trial done at 27 UK obstetric units, women (aged ≥16 years) were allocated to receive a single dose of intravenous amoxicillin and clavulanic acid or placebo (saline) following operative vaginal birth at 36 weeks gestation or later. The primary outcome was confirmed or suspected maternal infection within 6 weeks of delivery defined by a new prescription of antibiotics for specific indications, confirmed systemic infection on culture, or endometritis. We did an intention-to-treat analysis. This trial is registered with ISRCTN, number 11166984, and is closed to accrual.

FINDINGS

Between March 13, 2016, and June 13, 2018, 3427 women were randomly assigned to treatment: 1719 to amoxicillin and clavulanic acid, and 1708 to placebo. Seven women withdrew, leaving 1715 in the amoxicillin and clavulanic acid group and 1705 in the placebo groups. Primary outcome data were missing for 195 (6%) women. Significantly fewer women allocated to amoxicillin and clavulanic acid had a confirmed or suspected infection (180 [11%] of 1619) than women allocated to placebo (306 [19%] of 1606; risk ratio 0·58, 95% CI 0·49-0·69; p<0·0001). One woman in the placebo group reported a skin rash and two women in the amoxicillin and clavulanic acid reported other allergic reactions, one of which was reported as a serious adverse event. Two other serious adverse events were reported, neither was considered causally related to the treatment.

INTERPRETATION

This trial shows benefit of a single dose of prophylactic antibiotic after operative vaginal birth and guidance from WHO and other national organisations should be changed to reflect this.

FUNDING

NIHR Health Technology Assessment programme.

"Strategies to increase the accuracy and safety of OVD" (Clinical assessment skills and role of ultrasound, simulation training and new technologies to enhance instrument application)

Operative vaginal delivery (OVD) is commonly performed in the UK and Ireland. With skillful practice, the risks to mothers and babies are low. Caesarean section at full dilatation, particularly after failed OVD, can be more hazardous for mothers and babies. It is important to maintain and develop skills in OVD in order to provide it as a safe delivery option when the benefits outweigh the risks. As ultrasound machines have become more readily available on the labour ward, ultrasound assessment has been used to help clinicians diagnose the fetal head position and station, and also to try predict the success of the delivery. Simulation training has successfully been used in the setting of obstetric emergencies and is being developed to teach both technical and communication skills in OVD in order to improve maternal and neonatal outcomes. In this chapter we will discuss strategies to improve the accuracy and safety of OVD in more details.

Medico-legal considerations and operative vaginal delivery

Women undergo operative vaginal delivery (OVD) as an alternative to caesarean section when complications arise in the second stage of labour. The perinatal mortality associated with OVD is very low, and most of the perinatal morbidity is minor. However, when serious adverse events occur, such as traumatic birth injury, shoulder dystocia, cerebral palsy and perinatal death, there are medico-legal implications. There is also the potential for litigation in relation to maternal pelvic floor injury, which is increased with OVD. Obstetricians performing and supervising OVDs need to be aware of the potential pitfalls and minimise the risk of adverse outcomes. Given that most obstetricians will be involved in adverse birth-related events, it is important that they are aware of the legal processes that may ensue. It is also important when reviewing adverse OVD-related outcomes that association is differentiated from causation. These issues are addressed in the current chapter with attention drawn to the Montgomery ruling, which redefines the legal standards expected in relation to informed consent.

The impact of active delivery of the anterior arm during vacuum-assisted vaginal delivery on perineal tears: a clinical practice evaluation

Objective: Our purpose was to evaluate the impact of active delivery of the anterior arm with Couder's Maneuver (CM) during vacuum-assisted vaginal delivery (VAVD) on perineal tears. This maneuver can be beneficial because it has the advantage of reducing fetal biacromial diameter.Methods: This monocentric retrospective study compared two non-concurrent cohorts of nulliparous women before and after implementation of a systematic CM during VAVD: Cohort 1 from 1 January to 31 December 2006 without CM and Cohort 2 from 1 January to 31 December 2016 with systematic CM. This study reviewed all births during these two periods. All live-born singleton pregnancies where VAVD occurred after 37 weeks of gestation were included. The principal endpoint was the type of perineal tear.Results: In total, there were 179 VAVD in the Cohort 1 and 267 VAVD in the Cohort 2. In the Cohort 2, 233 VAVD (87.3%) were performed with systematic CM. No episiotomy was performed in both cohorts. There was a significant decrease in the rate of second-degree perineal tears between the two cohorts (42.4 versus 15%, p < .001) and a significant increase in the rate of intact perineum (34.1 versus 54.7%, p < .001). There was no influence of CM on the rate of obstetrical anal sphincter injury (3.9 versus 2.6%, p = .44).Conclusions: Practicing this maneuver could improve the perineal prognosis during VAVD in nulliparous women.

Cannabis Abuse or Dependence During Pregnancy: A Population-Based Cohort Study on 12 Million Births

OBJECTIVE

Cannabis is the most commonly used recreational drug during pregnancy in the United States. This study aimed to describe the rate of cannabis dependence or abuse use during pregnancy and its effect on obstetrical and neonatal outcomes.

METHODS

A retrospective population-based cohort of births in the United States between 1999 and 2013 was created using data from the National Inpatient Sample. Births to mothers who reported cannabis dependence or abuse were identified using ICD-9 codes, and the effect on various obstetrical and neonatal outcomes was assessed using logistic regression, adjusting for relevant confounders (Canadian Task Force Classification II-2).

RESULTS

A total of 12 578 557 births were included in our analysis. The incidence of cannabis abuse or dependence rose from 3.22 in 1000 births in 1999 to 8.55 in 1000 births in 2013 (P < 0.0001). Women reporting cannabis dependence or abuse were more likely to have a preterm premature rupture of membranes (odds ratio [OR] 1.46; 95% confidence interval [CI] 1.35-1.58), a hospital stay of >7 days (OR 1.17; 95% CI 1.11-1.23), and an intrauterine fetal demise (OR 1.50; 95% CI 1.39-1.62). Neonates born to exposed mothers had a higher risk of prematurity (OR 1.40; 95% CI 1.36-1.43) and growth restriction (OR 1.35; 95% CI 1.30-1.41).

CONCLUSION

Cannabis use during pregnancy steadily increased over the study period. Users of cannabis during gestation were more likely to have adverse outcomes during delivery and require longer periods of hospitalization. Neonates born to exposed mothers were more likely to be born preterm and underweight.

How did episiotomy rates change from 2007 to 2014? Population-based study in France

BACKGROUND

Since the 2000s, selective episiotomy has been systematically recommended worldwide. In France, the recommended episiotomy rate in vaginal deliveries is less than 30%. The aims of this study were to describe the evolution of episiotomy rates between 2007 and 2014, especially for vaginal deliveries without instrumental assistance and to assess individual characteristics and birth environment factors associated with episiotomy.

METHODS

This population-based study included all hospital discharge abstracts for all deliveries in France from 2007 to 2014. The use of episiotomy in vaginal deliveries was identified by one code in the French Common Classification of Medical Procedures. The episiotomy rate per department and its evolution is described from 2007 to 2014. A mixed model was used to assess associations with episiotomy for non-operative vaginal deliveries and the risk factors related to the women's characteristics and the birth environment.

RESULTS

There were approximately 540,000 non-operative vaginal deliveries per year, in the study period. The national episiotomy rate for vaginal deliveries overall significantly decreased from 26.7% in 2007 to 19.9% in 2014. For non-operative deliveries, this rate fell from 21.1% to 14.1%. For the latter, the use of episiotomy was significantly associated with breech vaginal delivery (aOR = 1.27 [1.23-1.30]), epidural analgesia (aOR = 1.45 [1.43-1.47]), non-reassuring fetal heart rate (aOR = 1.47 [1.47-1.49]), and giving birth for the first time (aOR = 3.85 [3.84-4.00]).

CONCLUSIONS

The episiotomy rate decreased throughout France, for vaginal deliveries overall and for non-operative vaginal deliveries. This decrease is probably due to proactive changes in practices to restrict the number of episiotomies, which should be performed only if beneficial to the mother and the infant.

Pregnancy-Associated Pelvic Floor Health Knowledge and Reduction of Symptoms: The PREPARED Randomized Controlled Trial

OBJECTIVES

Pregnancy and childbirth can lead to pelvic floor disorders, yet this topic is not routine in antenatal education. We aimed to determine the impact of a pregnancy workshop on women's postpartum pelvic floor health knowledge, performance of pelvic floor muscle exercises (PFME), symptoms, condition-specific quality of life, mode of delivery, and satisfaction.

METHODS

This was a RCT. Pregnant primiparous women in a tertiary care centre received a pelvic floor health workshop intervention versus routine prenatal care. Thirty-six participants/group were needed to detect a significant knowledge difference (power = 0.80, α = 0.05). Participants completed questionnaires at recruitment and six weeks postpartum. Main outcome measures were: difference between groups in knowledge scores; PFME-specific knowledge and practice; pelvic symptoms and condition-specific quality of life; and mode of and satisfaction with delivery.

RESULTS

Fifty women were recruited per group; 40 attended the workshop. Women were Caucasian (72%), college educated (96%), mean age 33.2. Mean demographics did not differ. Postpartum data were available for 37 women per group. The intervention group scored higher on a pelvic floor knowledge questionnaire (mean score 31.2/39 vs. 29.3/39, P = 0.02, 95% CI 0.3, 3.6). 58.3% of intervention participants reported daily performance of PFME compared with 22.9% of controls (P = 0.002) and rated higher confidence in correct performance (P = 0.004). The intervention group reported fewer bowel symptoms (P = 0.046). There were no differences in urinary or prolapse symptoms, mode of delivery, complications, or satisfaction.

CONCLUSION

A pelvic floor health workshop improves postpartum knowledge, performance of PFME, and bowel-specific quality of life.

Selective versus routine use of episiotomy for vaginal birth

BACKGROUND

Some clinicians believe that routine episiotomy, a surgical cut of the vagina and perineum, will prevent serious tears during childbirth. On the other hand, an episiotomy guarantees perineal trauma and sutures.

OBJECTIVES

To assess the effects on mother and baby of a policy of selective episiotomy ('only if needed') compared with a policy of routine episiotomy ('part of routine management') for vaginal births.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (14 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing selective versus routine use of episiotomy, irrespective of parity, setting or surgical type of episiotomy. We included trials where either unassisted or assisted vaginal births were intended. Quasi-RCTs, trials using a cross-over design or those published in abstract form only were not eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies, extracted data, and assessed risk of bias. A third author mediated where there was no clear consensus. We observed good practice for data analysis and interpretation where trialists were review authors. We used fixed-effect models unless heterogeneity precluded this, expressed results as risk ratios (RR) and 95% confidence intervals (CI), and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

This updated review includes 12 studies (6177 women), 11 in women in labour for whom a vaginal birth was intended, and one in women where an assisted birth was anticipated. Two were trials each with more than 1000 women (Argentina and the UK), and the rest were smaller (from Canada, Germany, Spain, Ireland, Malaysia, Pakistan, Columbia and Saudi Arabia). Eight trials included primiparous women only, and four trials were in both primiparous and multiparous women. For risk of bias, allocation was adequately concealed and reported in nine trials; sequence generation random and adequately reported in three trials; blinding of outcomes adequate and reported in one trial, blinding of participants and personnel reported in one trial.For women where an unassisted vaginal birth was anticipated, a policy of selective episiotomy may result in 30% fewer women experiencing severe perineal/vaginal trauma (RR 0.70, 95% CI 0.52 to 0.94; 5375 women; eight RCTs; low-certainty evidence). We do not know if there is a difference for blood loss at delivery (an average of 27 mL less with selective episiotomy, 95% CI from 75 mL less to 20 mL more; two trials, 336 women, very low-certainty evidence). Both selective and routine episiotomy have little or no effect on infants with Apgar score less than seven at five minutes (four trials, no events; 3908 women, moderate-certainty evidence); and there may be little or no difference in perineal infection (RR 0.90, 95% CI 0.45 to 1.82, three trials, 1467 participants, low-certainty evidence).For pain, we do not know if selective episiotomy compared with routine results in fewer women with moderate or severe perineal pain (measured on a visual analogue scale) at three days postpartum (RR 0.71, 95% CI 0.48 to 1.05, one trial, 165 participants, very low-certainty evidence). There is probably little or no difference for long-term (six months or more) dyspareunia (RR1.14, 95% CI 0.84 to 1.53, three trials, 1107 participants, moderate-certainty evidence); and there may be little or no difference for long-term (six months or more) urinary incontinence (average RR 0.98, 95% CI 0.67 to 1.44, three trials, 1107 participants, low-certainty evidence). One trial reported genital prolapse at three years postpartum. There was no clear difference between the two groups (RR 0.30, 95% CI 0.06 to 1.41; 365 women; one trial, low certainty evidence). Other outcomes relating to long-term effects were not reported (urinary fistula, rectal fistula, and faecal incontinence). Subgroup analyses by parity (primiparae versus multiparae) and by surgical method (midline versus mediolateral episiotomy) did not identify any modifying effects. Pain was not well assessed, and women's preferences were not reported.One trial examined selective episiotomy compared with routine episiotomy in women where an operative vaginal delivery was intended in 175 women, and did not show clear difference on severe perineal trauma between the restrictive and routine use of episiotomy, but the analysis was underpowered.

AUTHORS' CONCLUSIONS

In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma. Other findings, both in the short or long term, provide no clear evidence that selective episiotomy policies results in harm to mother or baby.The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence. Further research in women where instrumental delivery is intended may help clarify if routine episiotomy is useful in this particular group. These trials should use better, standardised outcome assessment methods.

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.

[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.

Temporal and Regional Variations in Operative Vaginal Delivery in Canada by Pelvic Station, 2004-2012

OBJECTIVE

To describe temporal and regional variations in Canada in the use of operative vaginal delivery (OVD) at term for singleton pregnancies by pelvic station between 2004 and 2013.

METHODS

Rates of OVD among term singleton pregnancies in Canada (excluding Quebec) were estimated using information from the Discharge Abstract Database of the Canadian Institute for Health Information for the years 2004-2012 (n = 2 284 109). Deliveries were stratified by pelvic station. Temporal trends were assessed using the Cochran-Armitage test for linear trend in proportions by year. Geographic variation was assessed by calculating the rate and 95% confidence interval of each mode of delivery from 2010-2012 for each province and territory.

RESULTS

Among singleton pregnancies at term, the OVD rate decreased from 12.0% in 2004 to 10.7% in 2012 (P < 0.001), whereas Caesarean section rates (excluding those following failed OVDs) increased from 24.9% to 26.7%. Forceps deliveries decreased from 3.1% to 2.5%, primarily due to decreases in midpelvic forceps delivery. Vacuum-assisted delivery increased significantly at outlet and low stations (by 26.0% and 15.1%, respectively) and remained stable at midpelvic station. The failed OVD rate was 0.3% and decreased by 23.7% (P < 0.001). There were large variations in OVD rates by province.

CONCLUSION

Temporal trends in OVD rates varied by pelvic station, with rates of outlet and low OVD increasing and rates of midpelvic and failed OVD decreasing. Vacuum extraction is increasingly replacing forceps deliveries at outlet and low stations, whereas Caesarean sections are replacing forceps deliveries at midpelvic stations. Variations in OVD rates across provinces suggest differences in instrument preference and/or an evolution in standards of practice.

[The practice of episiotomy in France 10 years after the recommendations of CNGOF: What inventory?]

Since its creation, the practice of episiotomy has evolved, being influenced by several factors. Various stances on its use were stated, until the eventual reduction of this practice, as suggested by numerous practical guides. In 2005, the National College of Obstetricians and Gynecologists in France published its French Guidelines for Clinical practice in this area. Today, it seems appropriate to focus on the evolution of the use of episiotomy, ten years after the publication of these recommendations. The authors propose a literature review, browsing through all the available epidemiological data in France related to episiotomy, recording all national statistics and some local trends, as there are regional specificities. This review allows to follow the overall evolution of the practice of episiotomy in France between 1981 and 2014, and to identify territorial disparities. Finally, in the specific context of the practice of episiotomy in French gynecological and obstetrics field, the authors conclude it by considering the possible evolution of this surgical practice, as well as, the Clinical Practice Recommendations related to it.

[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.

Labour and delivery interventions in women with intellectual and developmental disabilities: a population-based cohort study

BACKGROUND

Our objectives were to: (1) examine the occurrence of labour induction, caesarean section, and operative vaginal delivery in women with intellectual and developmental disabilities compared to those without and (2) determine whether pre-pregnancy health conditions and pregnancy complications explain any elevated occurrence of these interventions.

METHODS

We conducted a population-based study using linked Ontario (Canada) administrative data. We identified deliveries to women with (N=3932) and without (N=382,774) intellectual and developmental disabilities (2002-2011). Modified Poisson regression was used to estimate adjusted relative risks (aRR) and 95% CIs for interventions, controlling for sociodemographic characteristics. We used generalised estimating equations to determine whether pre-pregnancy health conditions and pregnancy complications explained any statistically significantly elevated aRRs.

RESULTS

After controlling for socio-demographic characteristics, women with intellectual and developmental disabilities were more likely to have labour inductions (aRR, 1.13; 95% CI 1.06 to 1.20) and caesarean sections (aRR, 1.09; 95% CI 1.03 to 1.16) but not operative vaginal deliveries, compared to the referent group. Pre-pregnancy health conditions explained 12.9% of their elevated aRR for labour induction. Pre-pregnancy health conditions and maternal complications explained 27.8% and 13.3%, respectively, of their elevated aRR for caesarean section.

CONCLUSIONS

Women with intellectual and developmental disabilities are slightly more likely to have labour inductions and caesarean sections than women without intellectual and developmental disabilities. The elevated occurrence of these interventions is not fully explained by their pre-pregnancy health conditions or pregnancy complications. Non-medical issues should be evaluated for their influence on the timing of labour and delivery in this population.

Naegele Forceps Delivery and Association between Morbidity and the Number of Forceps Traction Applications: A Retrospective Study

Objective. To present the method of Naegele forceps delivery clinically practiced by the lead author, its success rate, and morbidity and to evaluate the relationship between morbidity and the number of forceps traction applications. Methods. Naegele forceps delivery was performed when the fetal head reached station +2 cm, the forceps were applied in the maternal pelvic application, and traction was slowly and gently performed. In the past two years, Naegele forceps delivery was attempted by the lead author in 87 cases, which were retrospectively reviewed. Results. The numbers of traction applications were one in 64.7% of cases, two in 24.7%, and three or more in 10.7%. The success rate was 100%. No severe morbidity was observed in mothers or neonates. Neonatal facial injury occurred most commonly in cases with fetal head malrotation, elevated numbers of traction applications, and maternal complications. Umbilical artery acidemia most commonly occurred in cases with nonreassuring fetal status. The significant crude odds ratio for three or more traction applications was 20 in cases with malrotation. Conclusion. Naegele forceps delivery has a high success rate, but multiple traction applications will sometimes be required, particularly in cases with malrotation. Malrotation and elevated numbers of traction applications may lead to neonatal head damage.

Learning From Experience: Qualitative Analysis to Develop a Cognitive Task List for Kielland Forceps Deliveries

OBJECTIVE

Fetal malposition is a common indication for Caesarean section in the second stage of labour. Rotational (Kielland) forceps are a valuable tool in select situations for successful vaginal delivery; however, learning opportunities are scarce. Our aim was to identify the verbal and non-verbal components of performing a safe Kielland forceps delivery through filmed demonstrations by expert practitioners on models to develop a task list for training purposes.

METHODS

Labour and delivery nurses at three university-affiliated hospitals identified clinicians whom they considered skilled in Kielland forceps deliveries. These physicians gave consent and were filmed performing Kielland forceps deliveries on a model, describing their assessment and technique and sharing clinical pearls based on their experience. Two clinicians reviewed the videos independently and recorded verbal and non-verbal components of the assessment; thematic analysis was performed and a core task list was developed. The algorithm was circulated to participants to ensure consensus.

RESULTS

Eleven clinicians were identified; eight participated. Common themes were prevention of persistent malposition where possible, a thorough assessment to determine suitability for forceps delivery, roles of the multidisciplinary team, description of the Kielland forceps and technical aspects related to their use, the importance of communication with the parents and the team (including consent, debriefing, and documentation), and "red flags" that indicate the need to stop when safety criteria cannot be met.

CONCLUSION

Development of a cognitive task list, derived from years of experience with Kielland forceps deliveries by expert clinicians, provides an inclusive algorithm that may facilitate standardized resident training to enhance education in rotational forceps deliveries.

Persistent occiput posterior

Persistent occiput posterior (OP) is associated with increased rates of maternal and newborn morbidity. Its diagnosis by physical examination is challenging but is improved with bedside ultrasonography. Occiput posterior discovered in the active phase or early second stage of labor usually resolves spontaneously. When it does not, prophylactic manual rotation may decrease persistent OP and its associated complications. When delivery is indicated for arrest of descent in the setting of persistent OP, a pragmatic approach is suggested. Suspected fetal macrosomia, a biparietal diameter above the pelvic inlet or a maternal pelvis with android features should prompt cesarean delivery. Nonrotational operative vaginal delivery is appropriate when the maternal pelvis has a narrow anterior segment but ample room posteriorly, like with anthropoid features. When all other conditions are met and the fetal head arrests in an OP position in a patient with gynecoid pelvic features and ample room anteriorly, options include cesarean delivery, nonrotational operative vaginal delivery, and rotational procedures, either manual or with the use of rotational forceps. Recent literature suggests that maternal and fetal outcomes with rotational forceps are better than those reported in older series. Although not without significant challenges, a role remains for teaching and practicing selected rotational forceps operations in contemporary obstetrics.

Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery

In 2011, one in three women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be life-saving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women's access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.

Safe prevention of the primary cesarean delivery

In 2011, 1 in 3 women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be lifesaving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 through 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women's access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.

Analgesia for forceps delivery

BACKGROUND

A forceps delivery may be indicated when a fetus fails to progress to delivery, or when delivery needs to be expedited in the second stage of labour. Effective analgesia is required to ensure that the woman is comfortable throughout the delivery, to allow the obstetrician to safely perform the procedure. It is currently unclear what the most effective and safe agent or method is to provide pain relief during forceps delivery.

OBJECTIVES

To assess the effectiveness and safety of different analgesic agents and methods available for forceps delivery for women and their babies.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013), reviewed published guidelines and searched the reference lists of review articles.

SELECTION CRITERIA

Randomised controlled trials comparing an analgesic agent or method used for forceps delivery with placebo/no treatment or an alternative agent or method.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies.

MAIN RESULTS

We included four trials involving 388 women that were judged to be at an unclear to high risk of bias overall. A variety of different agents for providing analgesia were assessed in the trials, and a number of different methods to measure pain relief were used, and thus results could not be combined in meta-analysis. Three trials compared diazepam with an alternative agent (ketamine; vinydan-ether; "other" anaesthesic agent) for the provision of general anaesthesia, and one trial compared spinal analgesia to pudendal nerve block (in both groups lignocaine was administered).With regard to the primary outcomes, women receiving diazepam for forceps delivery in one small trial were more likely to judge their pain relief as effective compared with women receiving vinydan-ether (risk ratio (RR) 1.13; 95% confidence interval (CI) 1.02 to 1.25; 101 women). In a further small trial, no significant difference was seen in the number of women judging their pain relief as effective when diazepam was compared with ketamine (RR 1.42; 95% CI 0.98 to 2.07; 26 women). In the trial that compared spinal analgesia to pudendal nerve block, women receiving spinal analgesia were significantly more likely to regard their analgesia as adequate (RR 3.36; 95% CI 2.46 to 4.60; 183 women) and were less likely to report severe pain during forceps delivery (RR 0.02; 95% CI 0.00 to 0.27; 183 women). No trials reported on the review's other two primary outcomes of serious maternal adverse effects or complications, and neonatal mortality or serious morbidity.In terms of secondary outcomes, women receiving diazepam compared with vinydan-ether, were significantly less likely to experience vomiting (RR 0.04; 95% CI 0.00 to 0.62; 101 women). No significant differences were seen for the few neonatal outcomes that were reported across any of the comparisons (including Agpar score of less than seven at five minutes and acidosis as defined by cord blood arterial pH less than 7.2).

AUTHORS' CONCLUSIONS

There is insufficient evidence to support any particular analgesic agent or method as most effective in providing pain relief for forceps delivery. Neonatal outcomes have largely not been evaluated.

Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting

A culture of safety is a growing movement in obstetrical healthcare quality and management. Patient-centered and safe care is a primary priority for all healthcare workers, with communication and teamwork central to achieving optimal maternal health outcomes. A mandatory educational program was developed and implemented by physicians and nurses to sustain awareness and compliance to current protocols within a large university-based hospital. A didactic portion reviewing shoulder dystocia, operative vaginal delivery, obstetric hemorrhage, and fetal monitoring escalation was combined with a simulation session. The simulation was a fetal bradycardia activating the decision to perform an operative vaginal delivery complicated by a shoulder dystocia. More than 370 members of the healthcare team participated including obstetricians, midwives, the anesthesia team, and nurses. Success of the program was measured by an evaluation tool and comparing results from a prior safety questionnaire. Ninety-seven percent rated the program as excellent, and the response to a question on perception of overall grade on patient safety measured by the Agency for Healthcare Research and Quality safety survey demonstrated a significant improvement in the score (P = .003) following the program.

Rapid versus stepwise negative pressure application for vacuum extraction assisted vaginal delivery

BACKGROUND

Vacuum extraction is a common technique of assisted vaginal delivery. Traditionally, it has been recommended that the pressure is increased slowly in a stepwise procedure; some have advocated rapid increases in pressure.

OBJECTIVES

To assess the efficacy and safety of rapid versus stepwise negative pressure application for assisted vaginal delivery by vacuum extraction.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (4 April 2012).

SELECTION CRITERIA

Randomized controlled trials and quasi-randomized controlled trials of rapid (within two minutes) versus stepwise (as defined by trialists) increases in negative pressure application for vacuum extraction assisted vaginal delivery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality. The same two review authors extracted data. We entered data into Review Manager software and checked for accuracy. Data extraction and 'Risk of bias' assessment of the contact person's own study were also carried out by three independent assessors who were not involved in the new study.

MAIN RESULTS

We included two trials involving 754 participants.One new trial of 660 participants showed the same success rate of vacuum procedure of 98.2% by both methods (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.98 to 1.02).The two included trials showed significant reductions in the time between applying the vacuum cup and delivery, (one trial (74 women): mean difference (MD) -6.10 minutes, 95% CI -8.83 to -3.37 and the other trial (660 women): with median difference -4.4 minutes, 95% CI -4.8 to -4.0). The two included trials showed no significant difference in detachment rate (RR 0.85, 95% CI 0.38 to 1.86, 2 studies, 754 women), no significant difference in Apgar score below seven at one minute (RR 1.04, 95% CI 0.51 to 2.09) and five minutes (RR 1.00, 95% CI 0.29 to 3.42), no significant differences in scalp abrasions or lacerations, cephalhematoma, subgaleal hemorrhage and hyperbilirubinemia. There were no significant differences between the two methods in all secondary outcomes.

AUTHORS' CONCLUSIONS

The rapid negative pressure application for vacuum assisted vaginal birth reduces duration of the procedure whilst there is no evidence of differences in maternal and neonatal outcomes. Rapid method of negative application should be recommended for vacuum extraction assisted vaginal delivery.

The effect of vacuum operator's experience on Apgar scores

OBJECTIVE

To determine the effect of a vacuum operator's experience on Apgar scores.

METHODS

A historical cohort study was conducted. All women who delivered by vacuum extraction between January 2003 and December 2007 at Songklanagarind Hospital were recruited. Vacuum operators were divided into two groups: staff doctors and residents. Comparisons of Apgar scores and rates of low Apgar scores (≤7) between the two groups were studied. A multivariate logistic regression analysis was used to control confounding variables for low Apgar scores.

RESULTS

The percentages for the procedure performed by the staff doctors and residents were 76.9 and 23.1%. At 1 min, the rates of low Apgar scores in the staff and resident groups were 6.7 and 24.1% (p<0.001), and at 5 min, the rates of low Apgar scores were 0.6 and 5.2% (p<0.001). Multivariate logistic regression analysis showed that the operator's experience was an independent risk factor for low Apgar scores. The residents had a 2.9-fold increased risk of low Apgar scores at 1 min compared with the staff doctors (adjusted odds ratio 2.9; 95% confidence interval 1.7-6.8). In the resident group, the third year residents had the lowest risk of low Apgar scores.

CONCLUSIONS

The vacuum operator's experience was an independent risk factor for low Apgar scores. Improvement of the residency training program is mandatory.

A comparative study of feto-maternal outcome in instrumental vaginal delivery

OBJECTIVE

To compare maternal and neonatal outcomes of vacuum versus forceps application in assisted vaginal delivery.

MATERIAL AND METHOD

Women in labor with vertex presentation were delivered by vacuum and forceps. A total of 120 cases were included in this prospective study. Maternal and neonatal morbidity were compared in terms of perineal lacerations, episiotomy extension, post-partum hemorrhage, Apgar score, instrumental injuries, NICU admissions PNM etc. χ(2) test was used to analyze the data.

OBSERVATIONS

Maternal morbidity viz. episiotomy extension as well as first and second degree perineal tear were significant in the forceps group (P = 0.0001 and P = 0.02, respectively). With regards to neonatal morbidity, no statistically significant difference was noted.

CONCLUSION

Vacuum and forceps should remain appropriate tools in the armamentarium of the modern obstetrician. However, ventouse may be chosen first (if there is no fetal distress) as it is significantly less likely to injure the mother.

Rapid versus stepwise application of negative pressure in vacuum extraction-assisted vaginal delivery: a multicentre randomised controlled non-inferiority trial

OBJECTIVE

To evaluate whether the application of rapid negative pressure for vacuum-assisted delivery is as effective and safe as the stepwise method.

DESIGN

Randomised controlled trial.

SETTING

Six centres, including university, secondary and tertiary hospitals, in Thailand.

SAMPLE

In total, 662 women were randomised to rapid and stepwise groups, with 331 women in each group.

METHODS

Vacuum extraction was performed by applying a metal cup (Malmstrom) connected to an electric pump to the fetal head. The stepwise method consisted of four incremental steps of 0.2 kg/cm² every 2 minutes to obtain a final negative pressure of 0.8 kg/cm². In the rapid method the negative pressure of 0.8 kg/cm² was applied in one step in < 2 minutes.

MAIN OUTCOME MEASURES

Success rate of vacuum extraction, vacuum cup detachment rate, duration of vacuum extraction, and maternal and neonatal complications.

RESULTS

There were no significant differences in detachment rates (RD 0.3%, 95% CI -3.1 to 2.4). The overall success rates were identical, at 98.2%. There were significant reductions in the time between applying the vacuum cup and attaining maximum negative pressure (MD -4.6 minutes; 95% CI -4.4 to -4.8 minutes), and in the time between applying the cup and delivery (MD -4.4 minutes; 95% CI -4.8 to -4.0 minutes). There was a significantly higher rate of perineal suture in the rapid method group (RD 4.5%; 95% CI 1.1-8.2). There were no significant differences in maternal and fetal morbidities.

CONCLUSIONS

Rapid negative pressure vacuum extraction could be performed as effectively and safely as the stepwise method, in a shorter period of time.

Choice of instruments for assisted vaginal delivery

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

Randomised controlled trials of assisted vaginal delivery using different instruments.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The fetal occiput posterior position: state of the science and a new perspective

BACKGROUND

The fetal occiput posterior position poses challenges in every aspect of intrapartum care-prevention, diagnosis, correction, supportive care, labor management, and delivery. Maternal and newborn outcomes are often worse and both physical and psychological traumas are more common than with fetal occiput anterior positions. The purpose of this paper is to describe nine prevailing concepts that guide labor and birth management with an occiput posterior fetus, and summarize evidence to clarify the state of the science.

METHODS

A search was conducted of the databases of PubMed and the Cochrane Library. Additional valuable information was obtained from obstetric and midwifery textbooks, books and websites for the public, conversations with maternity care professionals, and years of experience as a doula.

RESULTS

Nine prevailing concepts are as follows: (1) prenatal maneuvers rotate the occiput posterior fetus to occiput anterior; (2) it is possible to detect the occiput posterior fetus prenatally; (3) a fetus who is occiput anterior at the onset of labor will remain in that position throughout labor; (4) back pain in labor is a reliable sign of an occiput posterior fetus; (5) the occiput posterior fetus can be identified during labor by digital vaginal examination; (6) an ultrasound scan is a reliable way to detect fetal position; (7) maternal positions facilitate rotation of the occiput posterior fetus; (8) epidural analgesia facilitates rotation; (9) manual rotation of the fetal head to occiput anterior improves the rate of occiput anterior deliveries. Concepts 1, 2, 3, 4, 5, and 8 have little scientific support whereas concepts 6, 7, and 9 are supported by promising evidence.

CONCLUSIONS

Many current obstetric practices with respect to the occiput posterior position are unsatisfactory, resulting in failure to identify and correct the problem and thus contributing to high surgical delivery rates and traumatic births. The use of ultrasound examination to identify fetal position is a method that is far superior to other methods, and has the potential to improve outcomes. Research studies are needed to examine the efficacy of midwifery methods of identification, and the effect of promising methods to rotate the fetus (simple positional methods and digital or manual rotation). Based on the findings of this review, a practical approach to care is suggested.