Perinatal and Maternal Outcomes After Training Residents in Forceps Before Vacuum Instrumental Birth

Interventions to reintroduce or increase assisted vaginal births: a systematic review of the literature

OBJECTIVE

To synthesise the evidence from studies that implemented interventions to increase/reintroduce the use of assisted vaginal births (AVB).

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

We included experimental, semi-experimental and observational studies that reported any intervention to reintroduce/increase AVB use.

DATA SOURCES

We searched PubMed, EMBASE, CINAHL, LILACS, Scopus, Cochrane, WHO Library, Web of Science, ClinicalTrials.gov and WHO.int/ictrp through September 2021.

RISK OF BIAS

For trials, we used the Cochrane Effective Practice and Organisation of Care tool; for other designs we used Risk of Bias for Non-Randomised Studies of Interventions.

DATA EXTRACTION AND SYNTHESIS

Due to heterogeneity in interventions, we did not conduct meta-analyses. We present data descriptively, grouping studies according to settings: high-income countries (HICs) or low/middle-income countries (LMICs). We classified direction of intervention effects as (a) statistically significant increase or decrease, (b) no statistically significant change or (c) statistical significance not reported in primary study. We provide qualitative syntheses of the main barriers and enablers for success of the intervention.

RESULTS

We included 16 studies (10 from LMICs), mostly of low or moderate methodological quality, which described interventions with various components (eg, didactic sessions, simulation, hands-on training, guidelines, audit/feedback). All HICs studies described isolated initiatives to increase AVB use; 9/10 LMIC studies tested initiatives to increase AVB use as part of larger multicomponent interventions to improve maternal/perinatal healthcare. No study assessed women's views or designed interventions using behavioural theories. Overall, interventions were less successful in LMICs than in HICs. Increase in AVB use was not associated with significant increase in adverse maternal or perinatal outcomes. The main barriers to the successful implementation of the initiatives were related to staff and hospital environment.

CONCLUSIONS

There is insufficient evidence to indicate which intervention, or combination of interventions, is more effective to safely increase AVB use. More research is needed, especially in LMICs, including studies that design interventions taking into account theories of behaviour change.

PROSPERO REGISTRATION NUMBER

CRD42020215224.

Caesarean birth in public maternities in Argentina: a formative research study on the views of obstetricians, midwives and trainees

OBJECTIVES

To explore obstetricians', midwives' and trainees' perceptions of caesarean section (CS) determinants in the context of public obstetric care services provision in Argentina. Our hypothesis is that known determinants of CS use may differ in settings with limited access to essential obstetric services.

SETTING

We conducted a formative research study in 19 public maternity hospitals in Argentina. An institutional survey assessed the availability of essential obstetric services. Subsequently, we conducted online surveys and semistructured interviews to assess the opinions of providers on known CS determinants.

RESULTS

Obstetric services showed an adequate provision of emergency obstetric care but limited services to support women during birth. Midwives, with some exceptions, are not involved during labour. We received 680 surveys from obstetricians, residents and midwives (response rate of 63%) and interviewed 26 key informants. Six out of 10 providers (411, 61%) indicated that the use of CS is associated with the complexities of our caseload. Limited pain management access was deemed a potential contributing factor for CS in adolescents and first-time mothers. Providers have conflicting views on the adequacy of training to deal with complex or prolonged labour. Obstetricians with more than 10 years of clinical experience indicated that fear of litigation was also associated with CS. Overall, there is consensus on the need to implement interventions to reduce unnecessary CS.

CONCLUSIONS

Public maternity hospitals in Argentina have made significant improvements in the provision of emergency services. The environment of service provision does not seem to facilitate the physiological process of vaginal birth. Providers acknowledged some of these challenges.

A push for evidence: An effective training in operative birth

Effective training in operative birth should be the only type of operative birth that trains the junior obstetricians who are exposed to it. Although it remains difficult to fully characterise, effective training in operative birth is likely to include (i) realistic, local, integrated simulation training and (ii) hands-on senior support for an extended period of time. To further improve skills training in operative birth, an evaluation of the real-world effectiveness of current training should take place, a core outcome set for clinical trials should be developed, and real-time reporting and tracking of practitioner-specific outcome measures should be implemented.

How do pregnant women's perceptions of obstetric forceps change according to their demographic background: a cross sectional study

Background

Women’s attitudes towards obstetric forceps likely contribute to declining use and opportunities for residency training, but formal documentation of women’s attitudes towards obstetric forceps is currently limited. A clearer understanding should help guide our attempts to preserve its use in modern obstetrics and to improve residency training. Our objective is to document women’s attitudes towards obstetric forceps and the influence basic demographic variables have on those attitudes.

Methods

A cross sectional study was performed. We developed a one-time anonymous structured 5-question survey that was given to all women with low-risk pregnancies presenting to our medical center for prenatal care between October 2018–December 2018. The questionnaire asked for the woman’s self-reported age, race, education level and insurance type. The five questions were as follows: (1) Do you think forceps should be used to deliver babies, (2) Is forceps safe for the baby, (3) Is forceps safe for the mother, (4) Do you think forceps can help to lower the cesarean section rate, (5) Do you think physicians in training should learn to place forceps on a real patient. We calculated means and proportions for the responses according to the overall group and various subgroups. Statistical analysis included Kruskall-Wallis or Mann-Whitney tests as appropriate. Results were also adjusted by regression using a Generalized Linear Model. Power calculation showed sample size of 384 was required.

Results

A total of 499 women returned the questionnaire. Response rate was 56.8% (499/878). The findings suggest that women’s perceptions towards forceps are generally negative. Women with white ethnicity, college education or higher and private insurance did have more favorable views than their counterparts, but the majority still had unfavorable views. Age was not shown to have a significant effect on maternal attitude.

Conclusion

Women’s views towards forceps use in the University of Kansas Medical Center are negative and may be contributing to the decline of its use. Improving women’s perceptions of forceps would require multiple different strategies rather than a single focused easily-implemented message. If forceps training continues, such training will rely on a minority of women who will accept forceps use in childbirth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03854-x.

An Initiative to Increase Resident Performance of Operative Vaginal Deliveries

The objective of this single-centre, action research study was to increase resident experience performing operative vaginal deliveries. The secondary objective was to assess the incidence of maternal and neonatal complications. The rate of forceps deliveries increased in the post-training period (1.8%-4.0%; P < 0.001) but the overall rate of operative vaginal delivery did not change. The composite maternal complications rate following forceps delivery was lower in the post- training period (P = 0.006). There were no significant differences in maternal or neonatal complications with vacuum delivery between the periods before and after the initiative. Experiential training of residents may be a viable alternative to simulation training as it does not require expensive state-of-the-art simulation technology.

Differential effects of different delivery methods on progression to severe postpartum hemorrhage between Chinese nulliparous and multiparous women: a retrospective cohort study

BACKGROUND

Delivery methods are associated with postpartum hemorrhage (PPH) both in nulliparous and multiparous women. However, few studies have examined the difference in this association between nulliparous and multiparous women. This study aimed to explore the difference of maternal and neonatal characteristics and delivery methods between Chinese nulliparous and multiparous women, and then examine the differential effects of different delivery methods on PPH between these two-type women.

METHODS

Totally 151,333 medical records of women who gave birth between April 2013 to May 2016 were obtained from the electronic health records (EHR) in a northern province, China. The severity of PPH was estimated and classified into blood loss at the level of < 900 ml, 900-1500 ml, 1500-2100 ml, and > 2100 ml. Neonatal and maternal characteristics related to PPH were derived from the same database. Multiple ordinal logistic regression was used to estimate associations.

RESULTS

Medical comorbidities, placenta previa and accreta were higher in the nulliparous group and the episiotomy rate was higher in the multiparous group. Compared with spontaneous vaginal delivery (SVD), the adjusted odds (aOR) for progression to severe PPH due to the forceps-assisted delivery was much higher in multiparous women (aOR: 9.32; 95% CI: 3.66-23.71) than in nulliparous women (aOR: 1.70; 95% CI: 0.91-3.18). The (aOR) for progression to severe PPH due to cesarean section (CS) compared to SVD was twice as high in the multiparous women (aOR: 4.32; 95% CI: 3.03-6.14) as in the nulliparous women (aOR: 2.04; 95% CI: 1.40-2.97). However, the (aOR) for progression to severe PPH due to episiotomy compared to SVD between multiparous (aOR: 1.24; 95% CI: 0.96-1.62) and nulliparous women (aOR: 1.55; 95% CI: 0.92-2.60) was not significantly different. The (aOR) for progression to severe PPH due to vacuum-assisted delivery compared to SVD in multiparous women (aOR: 2.41; 95% CI: 0.36-16.29) was not significantly different from the nulliparous women (aOR: 1.05; 95% CI: 0.40-2.73).

CONCLUSIONS

Forceps-assisted delivery and CS methods were found to increase the risk of severity of the PPH. The adverse effects were even greater for multiparous women. Episiotomy and the vacuum-assisted delivery, and SVD were similar to the risk of progression to severe PPH in either nulliparous or multiparous women. Our findings have implications for the obstetric decision on the choice of delivery methods, maternal and neonatal health care, and obstetric quality control.

Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review

BACKGROUND

When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions.

METHODS

We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427).

RESULTS

Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time.

CONCLUSIONS

The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.

Preferences and comfort of maternal fetal medicine fellows in the United States with operative vaginal deliveries

OBJECTIVE

The objective of this study was to determine the current landscape of vacuum and forceps-assisted vaginal delivery (FAVD) preferences and comfort across maternal fetal medicine (MFM) fellows in the United States (U.S.).

METHODS

A survey was sent to MFM fellowship program directors for distribution to current MFM fellows across U.S. Geographic regions, as determined using Census Bureau-designated regions. The survey looked at comfort and experience with FAVDs and vacuum-assisted vaginal deliveries (VAVD) throughout their post-graduate training. Descriptive statistics were used to analyze survey responses. Respondents were compared by post-graduate year (PGY) and region.

RESULTS

One hundred six MFM fellows (32%) completed the survey. 22.6% of MFM fellows had performed greater than 30 FAVDs, with 33% having performed ≤10 FAVDs. In comparison, 35.8% of fellows had performed more than 30 VAVDs. While 95.2% of fellows feel prepared to perform a VAVD independently, only 59.4% feel prepared to do FAVDs independently. Never the less, 53% of MFM fellows favor performing a FAVD. While some regional differences were seen, there was no significant difference in the percent of fellows by geographic region who have performed >30 FAVD (p = .87). MFM fellows in the West are most likely to have performed >30 FAVD at 57.8%, compared to 42.3, 35, and 11.4% in the Midwest, South, and Northeast, respectively.

CONCLUSION

MFM fellows are more confident with VAVD compared to FAVD. Despite feeling less confident performing FAVD (versus VAVD), the majority of MFM fellows feel comfortable performing FAVDs independently. Region of training fellowship training does not significantly affect one's confidence in FAVDs. A coordinated nationwide effort to increase exposure to and confidence for FAVDs should be considered.

The effect of replacing vacuum with forceps in operative vaginal delivery: an observational study

INTRODUCTION AND HYPOTHESIS

An increase in vaginal delivery with forceps may increase rates of pelvic floor trauma. This study was designed to predict trauma rates resulting from policies preferencing forceps.

METHODS

This is an observational cohort study utilizing data from 660 primiparae enrolled in an RCT in two tertiary obstetric units in Sydney, Australia. Participants were assessed clinically and with 4D translabial ultrasound in the late third trimester and again at 3-6 months postpartum. Incidence of trauma associated with mode of delivery was adjusted to reflect change associated with a conversion of vacuum to forceps delivery. Primary outcome measures were third-/fourth-degree tear, levator avulsion (LA) and external anal sphincter (EAS) trauma diagnosed sonographically.

RESULTS

Five hundred four women were seen at a mean of 5.1 (2.3-24.3) months postpartum. After exclusion of 21 because of missing data, 483 women were analysed: 112 (23%) had a CS, 268 (55%) a normal vaginal delivery (NVD), 69 (14%) a vacuum (VD) and 34 (7%) a forceps (FD). One hundred fifty-two women had EAS trauma and/or LA; 17 sustained both. After VD, 32/69 (46%) women suffered LA and/or EAS trauma; after FD, it was 33/34 (97%). Converting VD to FD was estimated to result in an increase in trauma from 152/483 (31%) to 187/483 (39%). A formula can be generated based on local obstetric and ultrasound data to estimate trauma incidence.

CONCLUSIONS

A change in obstetric practice resulting in the conversion of primary VD to primary FD would be expected to substantially increase the likelihood of pelvic floor trauma.

Lithuania's experience in reducing caesarean sections among nulliparas: the impact of the quality improvement course

Background

To evaluate the role of the quality improvement course (QIC) to reduce the caesarean section (CS) rate among nulliparas (Robson groups 1 and 2) and to find out which group of women have reduced the CS rate following attendance at the course.

Methods

The QIC was organized in 2015. For the evaluation of the CS rate after the OIC, deliveries from the selected hospitals in 2014 and 2016 were compared using MS EXCEL and SPSS 23.0.

Results

Nulliparas accounted for 44.6% (3585/8046) and 42.9% (3628/8460) of all the deliveries in 2014 and 2016 years, respectively. The CS rate among nulliparas decreased from 19.0% (665/3502) in 2014 to 16.8% (593/3526) in 2016 (p = 0.018). The greatest decrease in absolute contribution to the overall CS rate was recorded in group 1 (p = 0.08). Perinatal mortality was 3.1 in 2014 and 3.9 in 2016 per 1000 deliveries (p = 0.569).

Conclusion

The QIC has helped to reduce the CS rate among nulliparas without a negative influence on perinatal mortality. The greatest decrease in the overall CS rate was recorded among nulliparous women who were treated with oxytocin and managed to reach a full cervical dilatation.

Changing rates of the modes of delivery over the decades (1976, 1986, 1996, 2006, and 2016) based on the Robson-10 group classification system in a single tertiary health care center

AIM

To identify the underlying factors that may affect the changing rates of modes of delivery over the decades based on Robson-10 group classification system (TGCS) in a single tertiary health care center.

MATERIALS AND METHODS

This study included data from 10,458 deliveries in 1976, 1986, 1996, 2006, and 2016 with fetuses more than or equal to 500 g at the Department of Obstetrics and Gynecology at Hacettepe University Hospital. Patient characteristics and the mode of delivery were evaluated according to the TGCS.

RESULTS

The cesarean section (CS) rates were 11.4% (304/2668), 19.2% (459/2393), 44.7% (783/1751), 69.3% (1213/1751), and 77.9% (1477/1895) in 1976, 1986, 1996, 2006, and 2016, respectively. CS has become the preferred method of delivery for multiple pregnancies and breech presentations over the years. TGCS Group 5 was the greatest contributor to increased CS ratios. Relative contributions of TGCS Groups 1 and 3 were decreased and relative contributions of Groups 2 and 4 were increased. Operative vaginal deliveries decreased over the years.

CONCLUSION

In conclusion, effective management of labor induction, choosing vaginal delivery for appropriate breech presentations and multifetal pregnancies, proper education of obstetricians for operative vaginal delivery and objective evaluation of labor dystocia might be key points in CS rate debates.

Simulation TRaining for Operative vaginal Birth Evaluation: study protocol for an observational stepped-wedge interrupted time-series study (STROBE)

BACKGROUND

Operative vaginal birth is a common procedure used to expedite birth after full cervical dilatation where there is a clinical need to do so (15% of births in the UK in 2016). The acquisition of skills for operative vaginal birth is dependent on the exposure of junior obstetricians to situations in which they can undertake directly supervised learning from senior accouchers. The Royal College of Obstetricians and Gynaecologists has recently introduced the first structured course in operative vaginal birth. To date, there have been no attempts to determine the clinical impact of a structured training package for operative vaginal birth.

METHODS

The STROBE study is a quasi-experimental before-after interrupted time-series study of the effect of simulation training in operative vaginal birth for obstetricians on clinical outcomes of women and babies following operative vaginal birth. Similar to a stepped-wedge design, the intervention will be gradually implemented in all participating units but at different time periods. The primary outcome is failed operative vaginal birth with the first intended instrument. Secondary maternal outcomes are; use of second instrument to achieve operative vaginal birth, caesarean section, episiotomy, perineal trauma (1st, 2nd, 3rd, 4th degree tear), cervical tear requiring suturing, general anaesthesia and estimated blood loss. Secondary neonatal outcomes are; Apgar score at one, five, and ten minutes, Umbilical artery pH, shoulder dystocia, admission to Neonatal Intensive Care Unit and death within 28 days of birth. The analysis will be intention-to-treat (per unit) on the primary and secondary outcomes. The STROBE study received approval from the Health Research Authority and is sponsored by North Bristol NHS Trust. Results will be published in an open-access peer-reviewed medical journal within one year of completion of data gathering.

DISCUSSION

The STROBE study will help establish our understanding of the effectiveness of locally-delivered simulation training for operative vaginal birth. Robust evidence supporting the effectiveness of such an approach would add weight to the argument supporting regular, local training for junior obstetricians in operative vaginal birth.

TRIAL REGISTRATION

ISRCTN11760611 05/03/2018 (retrospectively registered).

Contributing factors in forceps associated pelvic floor trauma

INTRODUCTION AND HYPOTHESIS

Levator avulsion occurs in 10-35% of women after a first vaginal delivery, with forceps being the main risk factor. Three mechanisms have been proposed to account for the high risk of trauma: the additional space requirement, increased speed of distension, and/ or greater force. This study examines the additional space requirements associated with forceps to determine any associated increase in avulsion risk.

METHODS

This was an in vitro simulation study of spatial requirements for delivery of a fetal head by forceps, with mathematical modelling of spatial requirements using data from a local observational study. A balloon device was used to model head circumferences through the range of expected measurements at term, with measurements taken after application of three different types of forceps. Each measurement was performed in triplicate.

RESULTS

On average, forceps increased the circumference of the fetal head by 1.01 cm for Wrigley's, 1.04 cm for Kielland's, and 1.64 cm for Neville-Barnes forceps, resulting in an estimated increase in the diameter of the fetal head by 0.32 cm, 0.33 cm, and 0.52 cm, respectively. This increase was linear throughout the tested range. In 534 singleton pregnancies at term, we determined an odds ratio (OR) of 1.11 per centimeter head circumference for avulsion. Hence, the additional space requirement due to forceps explains ORs of 1.11, 1.12, and 1.19 for avulsion, depending on forceps type.

CONCLUSIONS

The effect of forceps on avulsion risk is not fully explained by the increase in space requirement alone. Other factors, such as shortened time to maximum distension and/or increased peak force applied may contribute to the excess risk.