Traumatic intracranial haemorrhage in firstborn infants and delivery with obstetric forceps

Maternal and neonatal complications following Kielland's rotational forceps delivery: A systematic review and meta-analysis

BACKGROUND

There is conflicting evidence regarding the safety of Kielland's rotational forceps delivery (KRFD) in comparison with other modes of delivery for the management of persistent fetal malposition in the second stage of labour.

OBJECTIVES

To derive estimates of risks of maternal and neonatal complications following KRFD, compared with rotational ventouse delivery (RVD), non-rotational forceps delivery (NRFD) or a second-stage caesarean section (CS), from a systematic review and meta-analysis of the literature.

SEARCH STRATEGY

Standard search methodology, as recommended by the Cochrane Handbook for Systematic Reviews of Interventions.

SELECTION CRITERIA

Case series, prospective or retrospective cohort studies and population-based studies.

DATA COLLECTION AND ANALYSIS

A meta-analysis using a random-effects model was used to derive weighted pooled estimates of maternal and neonatal complications.

MAIN RESULTS

Thirteen studies were included. For postpartum haemorrhage there was no significant difference between Kielland's and ventouse delivery; the rate was lower in Kielland's delivery compared with non-rotational forceps (RR 0.79, 95% CI 0.65-0.95) and second-stage CS (RR 0.45, 95% CI 0.36-0.58). There were no differences in the rates of anal sphincter injuries or admission to neonatal intensive care. Rates of shoulder dystocia were higher with Kielland's delivery compared with ventouse delivery (RR 1.79, 95% CI 1.08-2.98), but rates of neonatal birth trauma were lower (RR 0.49, 95% CI 0.26-0.91). There were no differences seen in the rates of 5-min APGAR score < 7 between Kielland's delivery and other instrumental births, but they were lower when compared with second-stage CS (RR 0.47, 95% CI 0.23-0.97).

CONCLUSIONS

Kielland's rotational forceps delivery is a safe option for the management of fetal malposition in the second stage of labour.

Factors Associated with Nontraumatic Spontaneous Subdural Hematomas in Pediatric Patients

OBJECTIVE

 In our study, we aimed to summarize the etiology of subdural hematoma that was not traumatic and required operation in pediatric patients. The subdural hematoma characteristics, possible etiologies, and treatment, as well as the patient outcomes, were analyzed.

METHODS

 A retrospective examination was made of pediatric patients with subdural hematoma who were operated on at Ümraniye Training and Research Hospital. Patients with a history of trauma were excluded. Data on patient sex, age, bleeding location, type of hematoma based on computed tomography imaging, surgical treatment, presenting symptoms, presence of comorbidities, Glasgow Coma Scale, thrombocyte counts, and international normalized ratio values were recorded.

RESULTS

 Of the 19 patients included in the study, 4 were female and 15 were male. Their ages ranged between 0 and 15 (mean = 5.84) years. In 57.8% of the patients, comorbidities, including acute myeloid leukemia, a history of shunt operation, epilepsy, mucopolysaccharidosis, known subdural effusion, autism, coagulopathy, ventricular septal defect/tetralogy of Fallot, cerebrospinal fluid leakage after baclofen pump administration, Marfan's syndrome, and late neonatal sepsis were present, while 21% had arachnoid cysts and 21% had no reported comorbidities.

CONCLUSION

 This study suggests that, in pediatric patients with subdural hematoma with an amount of bleeding requiring surgical management, any underlying comorbidities should be investigated regardless of the presence of a history of trauma. While investigating systemic diseases, special attention should be paid to the presence of arachnoid cysts or disruption in cerebrospinal fluid dynamics along with a history of hematologic diseases.

Kielland's rotational forceps delivery: comparison of maternal and neonatal outcomes with pregnancies delivering by non-rotational forceps

We compared complications in pregnancies that had Kielland's rotational forceps delivery (KRFD) with non-rotational forceps delivery (NRFD). Maternal outcomes included post-partum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS); neonatal outcomes included admission to neonatal intensive care unit (NICU), 5-minute Apgar scores <7, hypoxic ischaemic encephalopathy (HIE), jaundice, shoulder dystocia and birth trauma. The study population included 491 (2.1%) requiring KRFD, 1,257 (5.3%) requiring NRFD and 22,111 (93.0%) that had SVD. In pregnancies with NRFD compared to KRFD, there was higher incidence of OASIS (8.5% vs. 4.7%; p = .006) and a non-significant increased trend for PPH (15.0% vs. 12.4%; p = .173). There was no significant difference in rates of admission to NICU (p = .628), 5-minute Apgar score <7 (p = .375), HIE (p = .532), jaundice (p = .809), severe shoulder dystocia (p = .507) or birth trauma (p = .514). Our study demonstrates that KRFD has lower rates of maternal complications compared to NRFD whilst the rates of neonatal complications are similar.IMPACT STATEMENTWhat is already known on this subject? Kielland's rotational forceps is used for achieving vaginal delivery in pregnancies with failure to progress in second stage of labour secondary to fetal malposition. The use of Kielland's forceps has significantly declined in the last few decades due to concerns about an increased risk of maternal and neonatal complications, despite the absence of any major studies demonstrating this increased risk.What do the results of this study add? There are some studies which compare the risks in pregnancies delivering by Kiellands forceps with rotational ventouse deliveries but there is limited evidence comparing the risks of rotational with non-rotational forceps deliveries. Our study compares the major maternal and neonatal complications in a large cohort of pregnancies undergoing rotational vs. non-rotational forceps deliveries.What are the implications of these findings for clinical practice and/or further research? The results of our study demonstrate that maternal and neonatal complications in pregnancies delivering by Kielland's rotational forceps undertaken by appropriately trained obstetricians are either lower or similar to those delivering by non-rotational forceps. Consideration should be given to ensure that there is appropriate training provided to obstetricians to acquire skills in using Kielland's forceps.

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.

Kielland's forceps: does it increase the risk of anal sphincter injuries? An observational study

INTRODUCTION AND HYPOTHESIS

Rotational instrumental deliveries are thought to carry additional risks compared with non-rotational instrumental deliveries, including trauma to maternal tissues, and require specific expertise and training. We conducted a retrospective study to investigate the association between the type of forceps delivery and maternal perineal trauma, and in particular to investigate if Kielland's rotational forceps delivery increases obstetric anal sphincter injuries (OASIS).

METHODS

This is a retrospective observational study of 1,515 women who attended a tertiary maternity unit over a period of 5 years and had operative vaginal deliveries primarily or completed by forceps. Data were obtained through the hospital's maternity reporting system. The severity of maternal perineal trauma, particularly third and fourth-degree tears in relation to the type of forceps delivery was explored. Multinomial logistic regression models were used to estimate the crude and the adjusted relative risks (RR) of sustaining third-degree tears compared with other types of vaginal tears. Univariate analyses explored the crude associations between relative risks and age, ethnicity, birth weight, type of instrumental delivery and operator's experience. A multivariate multinomial logistic regression model estimated the adjusted relative risks and included all the previous variables as independent covariates.

RESULTS

Of the 1,492 women included in the study, 150 women (77 %) had sustained category 1 tears, 63 women (4 %) had sustained category 2 tears and 279 women (19 %) had sustained third-degree tears. There was no statistically significant association between the severity of maternal perineal trauma and the type of forceps delivery (failed ventouse vs Kielland's forceps RR 1.52, p = 0.159 CI 0.84-2.72, Wrigleys vs Kielland's RR 0.59, p = 0.249, CI 0.24-1.43; Andersons vs Kielland's RR 1.16, p = 0.603, CI 0.65-2.05) after adjusting for age, birth weight, BMI, ethnicity and operator experience (full list of covariates not included).

CONCLUSIONS

The incidence of third- and fourth-degree tears following rotational Kielland's forceps delivery and other non-rotational forceps deliveries is comparable.

A Follow-up Study of Infants with Intracranial Hemorrhage at Full-Term

Objective:

To determine physical and cognitive outcomes of full-term infants who suffered intracranial hemorrhage (ICH) at birth.

Methods:

A retrospective hospital-based, follow-up study of infants treated in London, Ontario between 1985 and 1996. Follow-up was conducted by telephone interviews and clinic visits. Outcome was measured according to physical and cognitive scales. Perinatal risk factors and hemorrhage characteristics were correlated with final outcome.

Results:

For this study 66 infants with ICH were identified, of which seven died during the first week of life. We obtained follow-up in all but ten cases (median = 3-years; range 1.0 to 10.9 years). Overall, 57% of infants had no physical or cognitive deficits at follow-up. Death occurred most frequently among those with primarily subarachnoid hemorrhage (19%) and the most favorable outcomes occurred among those with subdural hemorrhage (80% had no disability). In univariate models, thrombocytopenia (platelet count ≤ 70 x 109/L), increasing overall hemorrhage severity, frontal location and spontaneous vaginal delivery as opposed to forceps-assisted delivery increased risk for poor outcome. In multivariate models, all these factors tended towards increased risk, but only thrombocytopenia remained significant for physical disability (OR = 7.6; 95% CI = 1.02 – 56.6); thrombocytopenia was borderline significant in similar models for cognitive disability (OR = 4.6; 95% CI = 0.9 – 23.9).

Conclusion:

Although forceps-assisted delivery may contribute to ICH occurrence, our study found better outcomes among these infants than those who had ICH following a spontaneous vaginal delivery. Hemorrhage in the frontal lobe was the most disabling hemorrhage location and if multiple compartments were involved, disability was also more likely to occur. However, in this report we found that the factor that was most likely to contribute to poor outcome was thrombocytopenia and this remained important in multivariate analysis.

Representation of cerebral bridging veins in infants by postmortem computed tomography

The postmortem diagnosis of shaken baby syndrome, a severe form of child abuse, may be difficult, especially when no other visible signs of significant trauma are obvious. An important finding in shaken baby syndrome is subdural haemorrhage, typically originating from ruptured cerebral bridging veins. Since these are difficult to detect at autopsy, we have developed a special postmortem computed tomographic (PMCT) method to demonstrate the intracranial vein system in infants. This method is minimally invasive and can be carried out conveniently and quickly on clinical computed tomography (CT) systems. Firstly, a precontrast CT is made of the infant's head, to document the original state. Secondly, contrast fluid is injected manually via fontanel puncture into the superior sagittal sinus, followed by a repeat CT scan. This allows the depiction of even very small vessels of the deep and superficial cerebral veins, especially the bridging veins, without damaging them. Ruptures appear as extravasation of contrast medium, which helps to locate them at autopsy and examine them histologically, whenever necessary.

Soft forceps

OBJECTIVE

The risk of maternal and fetal trauma and, chiefly, the fear of law suits, have contributed to a significant decline in rates of forceps-assisted deliveries and an increase in rates of cesarean sections, especially in the United States. Our experience with gas-sterilized forceps blades covered with a soft rubber coating--the "soft" forceps--is described.

METHOD

Ninety-six women who required a forceps-assisted delivery for standard indications were randomly allocated to 2 groups. There were 51 women in the regular forceps group and 45 women in the soft forceps group. Low forceps delivery with a Simpson instrument was used in all cases. The groups were compared for fetal injury.

RESULTS

The rates of severe facial abrasion and minimal marking were 4.1% and 61%, respectively, in the regular forceps group and 1.9% and 34% in the soft forceps group.

CONCLUSION

The soft forceps may reduce the rates of neonatal facial abrasion and skin bruises. The forceps should be further perfected, as well as vacuum extractors; they should both continue to be part of the obstetrician's armamentarium.

Risk factors for intracranial hemorrhage among full-term infants: a case-control study

OBJECTIVE

To investigate the cause of intracranial hemorrhage among full-term infants.

METHODS

A retrospective, hospital-based, matched case-control study was conducted at London Health Sciences Center, in southwestern Ontario, for the period from January 1, 1985, to December 31, 1996. Cases were diagnosed with magnetic resonance imaging, computed tomography, or ultrasonography within 7 days after birth. Control subjects were matched with respect to year of birth, sex, and, for nontransferred case patients only, obstetrician.

RESULTS

Sixty-six full-term infants with intracranial hemorrhage were identified, and 104 control subjects were matched. Each factor was independently associated with increased risk of intracranial hemorrhage, as follows: forceps assistance (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.2-15.1), compared with spontaneous vaginal delivery; 1-minute Apgar scores of 1 through 4 (OR, 110; 95% CI, 5.0-2400) and 5 through 8 (OR, 4.9; 95% CI, 1.3-18.3), compared with scores of 9 or 10 (corresponding 5-min Apgar scores were also statistically significant); and requirements for resuscitation (OR, 5.1; 95% CI, 1.8-14.1), compared with no resuscitation requirements. Of the 52 case patients for whom platelet counts were recorded within 48 hours after birth, 30.8% (95% CI, 18.3-43.3%) exhibited counts of less than 70 x 10(9)/L. Platelet counts of less than 50 x 10(9)/L were specifically associated with intraparenchymal hemorrhage and a more severe radiological grade. Forceps-associated hemorrhage was more frequently subarachnoid and subdural and less frequently intraparenchymal. Such hemorrhage also tended to be more caudal in location.

CONCLUSION

Thrombocytopenia seems to be an important cause of intraparenchymal hemorrhage, and the use of forceps is more likely to be associated with subarachnoid and subdural hemorrhage.

Subdural hematoma in term infants

Subdural hematomas are uncommon in term infants. The study objectives were to evaluate risk factors for and clinical significance of small subdural hematomas observed on computerized tomography. During a 3-year period, 26 near-term and term nonasphyxiated infants were found to have a subdural hematoma on computed tomography. Clinical indications for computed tomography were respiratory symptoms in 15 infants and neurologic symptoms in 10 infants; one infant had a skull fracture. Subdural hematomas were less than 3-mm maximum transverse dimensions in all infants: location was infratentorial (n = 7), supratentorial (n = 7), and in both sites (n = 12). Four infants also had evidence of edema and hemorrhage within the anterior temporal lobe. Delivery was vaginal in 25 of 26 infants, and forceps were used in 13 (50%) infants. Twenty-five infants were managed expectantly; one infant underwent surgical elevation of a depressed skull fracture. No infant required surgical evacuation of the subdural hematoma. At discharge, nine infants with subdural hematoma exhibited an abnormal examination, i.e., mild hypotonia (n = 7) and Erb's palsy (n = 2). The clinical syndrome attributed to subdural hematoma was most often a subtle clinical problem. The presence of subdural hematoma documented by computed tomography is not necessarily always indicative of birth trauma and may occur as sequelae of an otherwise uncomplicated delivery.

Have Kielland forceps reached their 'use by' date?

Kielland forceps have long been used in Australian hospitals for rotation and delivery from occipitolateral and occipitoposterior positions. We have studied the pattern and use of these forceps in our hospital, and conducted a statewide survey of obstetric trainees about their experience with Kielland forceps. We conclude that current obstetric training programmes are unlikely to provide registrars with sufficient skill in their safe use.

Failed trial of vacuum or forceps--maternal and fetal outcome

OBJECTIVE

Our purpose was to compare the maternal and neonatal morbidity associated with a failed trial of instrumental delivery with that of proceeding directly to cesarean section during the second stage of labor.

STUDY DESIGN

All second-stage cesarean deliveries between January 1986 and December 1992 in a tertiary care teaching hospital were retrospectively reviewed. Specific maternal and neonatal outcome parameters were studied to compare the failed instrumental group with the direct-to-cesarean section group.

RESULTS

Of 29,457 live births at > 37 weeks' gestation, 401 women had a cesarean section performed in the second stage of labor. There were 326 cases in which cesarean section was performed directly during the second stage of labor and 75 women who had a failed attempt of instrumental delivery (forceps 33, vacuum 25, both 17) before cesarean delivery was done. The three instrumental groups and the direct-to-cesarean section group did not differ in any of the outcome variables for either mother or newborn.

CONCLUSIONS

Failed instrumental delivery performed as a trial of forceps and/or vacuum in a setting where a cesarean section can follow promptly is not associated with increased morbidity of either mother or baby.

Benefits and risks of episiotomy: a review of the English-language literature since 1980. Part II

Mediolateral and, to a lesser degree, midline episiotomies substantially increase the amount of blood loss at delivery; in fact, simple avoidance of episiotomy may be the most powerful means the delivery attendant has to prevent excessive intrapartum hemorrhage. The long-term morbidity of the anal sphincter damage induced by episiotomy, particularly midline, has generally been underestimated in both its frequency and severity. Other potential fetal and maternal complications of episiotomies, although rare, are numerous and serious. The overall degree of risk that accompanies this procedure could only be justified by a clear and overriding benefit, which, as discussed under "Benefits" earlier in this review, does not appear to exist.

Benefits and risks of episiotomy: a review of the English-language literature since 1980. Part I

The professional literature on the benefits and risks of episiotomy was last reviewed critically in 1983, encompassing material published through 1980. This paper reviews the evidence accumulated since then. (Part II follows in this issue.) It is concluded that episiotomies prevent anterior perineal lacerations (which carry minimal morbidity), but fail to accomplish any of the other maternal or fetal benefits traditionally ascribed, including prevention of perineal damage and its sequelae, prevention of pelvic floor relaxation and its sequelae, and protection of the newborn from either intracranial hemorrhage or intrapartum asphyxia. In the process of affording this one small advantage, the incision substantially increases maternal blood loss, the average depth of posterior perineal injury, the risk of anal sphincter damage and its attendant long-term morbidity (at least for midline episiotomy), the risk of improper perineal wound healing, and the amount of pain in the first several postpartum days.

Mode of delivery in deep transverse arrest

OBJECTIVES

To determine the trends in the mode of delivery in deep transverse arrest (DTA) over two decades and their impact on maternal morbidity and neonatal outcome.

METHODS

Obstetric and neonatal records of women with DTA who delivered at Nehru Hospital, PGIMER, Chandigarh in the years 1970, 1980 and 1990 were analyzed.

RESULTS

Although Kielland's forceps was used very frequently in 1970 (44.4%) it had disappeared by 1990 because of increased morbidity associated with it. Instead, use of vacuum extractor and cesarean section has increased over the years. Manual rotation forceps extraction was the most commonly used vaginal method of delivery over two decades (49.5%). Perinatal outcome was better with manual rotation forceps extraction or vacuum extraction as compared to Kielland's forceps. Cesarean section was associated with a high incidence of birth asphyxia (30%).

CONCLUSIONS

Manual rotation forceps extraction and vacuum extraction are safe methods of delivery in DTA. Cesarean section as an alternative does not improve the perinatal outcome.

Kielland's forceps or ventouse--a comparison

A retrospective study over a 3-year period compared maternal and neonatal outcomes after birth by Kielland's forceps with those by ventouse when there was deep transverse arrest of head. Of the 259 women, 117 were delivered with Kielland's forceps and 142 were delivered with the ventouse. Of the Kielland's forceps deliveries, 15% were performed by a specialist, compared with 41% of the vacuum extractions. There were no differences in maternal morbidity overall, but when groups of operators were compared maternal complications were more frequent in the forceps group with the less experienced operators. There was little early neonatal morbidity (as judged by Apgar score, intubation, admission to the special care baby unit, jaundice and abnormal neurological behaviour) but cephalhaematoma occurred significantly more often in babies born by the ventouse than by Kielland's forceps. There were no perinatal deaths.

Birth trauma and brain damage

Birth trauma is a rare primary cause of perinatal death, occurring at most only once in every 1000-2000 births. As a cause of brain damage and later handicap it is often difficult to dissociate injury at birth from the concomitant effects of asphyxia, growth retardation or preterm delivery. A continuum of reproductive casualty has been postulated, but for trauma is not proven. Among children with cerebral palsy and severe mental retardation trauma may be implicated in a few cases, possibly 1-2 of 1000 deliveries. Vaginal breech delivery has been related to a higher incidence of minimal brain damage syndromes and some of this damage probably has its origin in perinatal trauma. The pregnancies where there is particular risk of birth trauma include those where the infant is large for gestational age, has intrauterine growth retardation, is delivered preterm, is vaginally delivered in breech presentation or is from multiple gestation. Particular care must be given to diagnosis and preventive measures in these cases and competent handling is required if the disaster of brain damage caused by traumatic birth is to be minimized.

Rotational delivery with Kielland's forceps

A retrospective study over 15 months showed that 10.7% of primigravid women and 1.6% of multigravid women were delivered by Kielland's forceps: a total of 145 babies. The successful vaginal delivery rate for attempted Kielland's forceps was 96.7%. The neonatal outcome was good and there were no perinatal deaths. Traumatic injuries were present in 7.6% of babies and were minor. The data show that even in the presence of fetal distress, Kielland's forceps can be safely employed for rotational delivery from the mid-pelvic cavity. This approach can avoid some caesarean sections without undue risk to the baby, the caesarean rate being 9.5%. As 10.7% of primigravid women required rotational delivery with Kielland's forceps, it is desirable that primigravid women should be cared for by obstetricians who are skilled in the use of the instrument, in order to maintain a low caesarean section rate in this group, with a good neonatal outcome.

Intrapartum fetal monitoring

From the fetal viewpoint, labour is a prolonged contraction stress test which most pass without incident. Labour also represents the obstetrician's last opportunity to influence perinatal outcome and ensure that those fetuses who have suffered chronic hypoxia antenatally are recognized promptly, so that labour is supervised in a way that does not place them at increased risk of either death or birth asphyxia. In the case of the fetus who enters labour healthy, with normal reserves, labour is managed with the same aim in mind, but with the foreknowledge that visualization of a normal volume of clear amniotic fluid and reasonable duration of labour makes the development of hypoxia and asphyxia unlikely. Those at increased risk of hypoxia should be monitored electronically, but, for the remainder, intermittent auscultation is satisfactory until labour lasts in excess of 5 hours, or if the patient requires oxytocin, or if an epidural is placed. If EFM is used, then it is important to provide adequate education in trace interpretation, with particular emphasis on the importance of short-term variability. Widespread use of EFM has provided us with an immense amount of knowledge about fetal physiology, but it is critically important for the practising obstetrician to understand that, in the low-risk patient, EFM is not more effective than IA in preventing death from asphyxia, that EFM does protect against asphyxial seizures, but that widespread use of the technique has not been associated with a significant reduction in the population of permanently handicapped infants. This information is particularly relevant in developing nations where money spent on sophisticated monitoring equipment might be better spent in other areas. From the maternal point of view, intensive fetal monitoring has profound implications by virtue of its usual effect on incidence of Caesarean birth, although the Dublin trial results, with regard to incidence of Caesarean section, emphasize the importance of considering intrapartum fetal monitoring as just one part of the overall supervision of labour. Finally, it must be emphasized that the method of fetal monitoring chosen may be strongly influenced by factors other than scientific evidence, as in the United States where the medicolegal climate is such that failure to rigorously document absence of fetal distress/true birth asphyxia may result in a harrowing lawsuit. It is a position this author has developed considerable sympathy with in recent years.

The use of epidural bupivacaine for the relief of childbirth pain

Epidural anaesthesia is now a widely used method for pain relief in childbirth, particularly using the drug Bupivacaine. There are nevertheless differing opinions in the research literature about the advisability of its routine use. While it is clearly very effective in relieving labour pain, there are some consistent, troublesome patterns; for example, a strong association between epidural use and other interventions, such as instrumental delivery. Further, there are no clear answers from the research to date concerning the risks and benefits of epidural anaesthesia for infant and mother. Answers could be provided by randomized clinical trials, but meanwhile a conservative approach to its use is recommended for uncomplicated labours.

Postpartum haemorrhage--a continuing problem

The factors responsible for postpartum haemorrhage (PPH) in singleton vaginal deliveries, not complicated by a retained placenta, were identified by comparing labour characteristics in 86 women who had a PPH (blood loss greater than 500 ml) with 351 women whose blood loss at delivery was less than 350 ml. Primiparity, induction of labour by amniotomy/oxytocin, forceps delivery, long first and second stages, oxytocin compared with syntometrine (oxytocin plus ergometrine maleate), as a prophylactic oxytocic, were identified as significant risk factors. Epidural analgesia contributed indirectly to an increase in the risk of postpartum haemorrhage. The changes in labour ward practice over the last 20 years have resulted in the re-emergence of PPH as a significant problem.

Fear of failure: a place for the trial of instrumental delivery

The safety of performing potentially difficult midcavity forceps or vacuum extractions, as trials of instrumental delivery was assessed retrospectively. Successful vaginal delivery was achieved in 61% of 122 patients with delay in the second stage who had a trial of instrumental delivery performed in an operating theatre with full preparations to proceed to caesarean section. The outcome was compared with that in 42 patients who were delivered for the same indication, by primary caesarean section, without prior instrumentation. Transient fetal trauma occurred only in the trials of instrumental delivery, and there was no significant difference in immediate neonatal or maternal morbidity. In another group of 61 patients instrumental delivery was attempted without full preparations for possible caesarean section and when unexpected difficulty arose, the forceps or vacuum extractor were abandoned in favour of caesarean section. Within this group of unexpected failures of instrumentation there were significantly more babies with low Apgar scores, delayed onset of respirations or needing intubation. A carefully conducted trial of instrumental delivery is an acceptable alternative to caesarean section for delay in the second stage due to a potentially difficult midcavity arrest.

The influence of episiotomy on the neonatal survival and incidence of periventricular haemorrhage in very-low-birth-weight infants

The neonatal survival and incidence of periventricular haemorrhage (PVH) in very-low-birthweight (VLBW) infants who present by the vertex are not influenced by the use of episiotomy. This study does not support the routine use of episiotomy for pre-term vertex deliveries.

Experience with the Bamberg obstetrical forceps

The design and use of a divergent obstetrical forceps, which was developed at the Staatliche Frauenklinik und Hebammenschule in Bamberg by Sipli and Krone are presented. The major advantage associated with the use of this instrument is that it permits the exertion of a limited constant application force (max 300 g) on the fetal head. Thus, compression injuries are effectively prevented and slippage of the forceps with resultant trauma is precluded. The Bamberg forceps was evaluated at the Frauenklinik und Poliklinik der Technischen Universität München and at the Staatliche Frauenklinik und Hebammenschule Bamberg, Federal Republic of Germany. An evaluation of 483 cases where this forceps was used is presented. No serious complications directly attributable to the use of this instrument could be documented.

Uterine activity in the second stage of labour and the effect of epidural analgesia

Uterine activity was measured during the second stage of normal labour in 20 patients with and 31 patients without epidural analgesia. There was a significantly lower uterine activity integral (UAI) in patients having epidural analgesia, and it is suggested that this may contribute to the increased rate of instrumental delivery associated with epidural analgesia.

The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring

In a randomized controlled trial involving 12,964 women, a policy of continuous electronic intrapartum fetal heart monitoring was compared with an alternative policy of intermittent auscultation, both policies including an option to measure fetal scalp blood pH. Women allocated to electronic fetal heart monitoring had shorter labors and received less analgesia. The caesarean delivery rates were 2.4% for electronic fetal heart monitoring and 2.2% for intermittent auscultation but this small difference arose from the identification of nearly twice as many fetuses with low scalp pH (less than 7.20) in the electronic fetal heart monitoring group. The forceps delivery rate was 8.2% in the electronic fetal heart monitoring group compared with 6.3% in the intermittent auscultation group, and this excess was explained by more instrumental deliveries prompted by fetal heart rate abnormalities. There were 14 stillbirths and neonatal deaths in each group, with a similar distribution of causes. There were no apparent differences in the rates of low Apgar scores, need for resuscitation, or transfer to the special care nursery. Cases of neonatal seizures and persistent abnormal neurological signs followed by survival were twice as frequent in the intermittent auscultation group, and this differential effect was related to duration of labor. Follow-up at 1 year of babies who survived neonatal seizures revealed three clearly abnormal infants in each group. The implications of these findings for both theory and practice are discussed.

Long-term effects of labor and delivery on offspring: a matched-pair analysis

An investigation was undertaken in an effort to learn whether the type of delivery or the pattern of labor progression has any lasting effect on the infant. Paired-data design was chosen to ensure that the comparisons between homogeneous groups would be valid. Our objective was to reduce potential bias based on unequal distribution of patient characteristics that might be more or less commonly associated with abnormal labors or with difficult deliveries. Seven-year intelligence quotient data for matched pairs of cases showed significant long-range adverse impact from midforceps operations but not from low-forceps procedures. Comparable paired-data analysis for the effect of labor disorder on the infant verified a similar deleterious influence from both arrest and protraction patterns.

A continuing use for Kielland's forceps?

A retrospective study over a 5-year period compared neonatal outcomes after birth by Kielland's forceps with those after caesarean section in the second stage of labour. The 253 babies born by these two modes of delivery showed no difference in Apgar score, the need for active resuscitation, incidence of jaundice or abnormal neurological behaviour. The neonatal outcome was no worse in the small number of patients where Kielland's forceps delivery was attempted but failed. This study offers support for the continuing role of Kielland's forceps in modern obstetrical practice.

Spinal cord transection, cerebral ischaemic and brain-stem injury in a baby following a Kielland's forceps rotation

A full-term infant suffered a high cervical cord transection after a Kielland 's forceps rotation and extraction. Quadriplegia developed immediately and initial cerebral swelling was followed by atrophy with ventricular dilatation on CT examination. Death occurred at 60 days. At post-mortem complete necrosis of the cervical cord at C2-C3 with old haemorrhage in the meninges was found, with damage to the inferior corpora quadrigemina , the thalamus, striatum, cerebellar and cerebral cortex. The mechanism is discussed briefly.

Unexplained intracranial haemorrhage in utero: the battered fetus?

Twenty stillborn infants with unexplained intracranial haemorrhages were identified in a review of approximately 3,500 perinatal postmortems performed between 1966 and 1982. After apparently uneventful pregnancies, fetal death occurred before the onset of labour and was recognized at a mean of 10 days before delivery; 80% had subdural haemorrhages, others had intraventricular and/or intracerebral haemorrhages, and many had haemorrhages at more than one of these sites. These haemorrhages were of sufficient size to have caused death and no other causes were found at postmortem examinations. All 20 mothers were immigrants to New Zealand from the Pacific Islands and almost all were older, married, multi-gravidas with uneventful medical histories and in stable socio-economic circumstances. In the period studied the incidence of stillbirths with unexplained intracranial haemorrhages was 1.15 per 1,000 Pacific Islander births and, at one hospital, these haemorrhages were found in 14.6% of Pacific Islander stillbirths. There were no unexplained intracranial haemorrhages in other racial groups. Prenatal subdural haemorrhage without a history of maternal trauma is extremely rare. In the absence of supporting maternal histories and other fetal or maternal injuries the possibility that these are 'battered' fetuses remains circumstantial.

Fatal forceps

One of the problems that faces pathologists, is to rate the information obtained at a post mortem at its true value. Changing the facts, knowingly or unknowingly, often springs from the weakness of the human mind which needs to ignore or even deny unpleasant experiences, especially if these experiences are linked to medical work that can be considered questionable.

In this article such weakness is illustrated with some examples of forceps deliveries.