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PubMed1971

Breech delivery.

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Anesthesia, Obstetrical↗
PubMed2005

Guidelines for operative vaginal birth. Number 148, May 2004.

OBJECTIVE: To provide guidelines for operative vaginal birth in the management of the second state of labour. OPTIONS: Nonoperative techniques, episiotomy, and Caesarean section are compared to operative vaginal birth. OUTCOME: Reduced fetal and maternal morbidity and mortality. EVIDENCE: MEDLINE and Cochrane databases were searched using the key words "vacuum" and "birth" as well as "forceps" and "birth" for literature published in English from january 1970 to June 2004. The level of evidence and quality of recommendations made are described using the Evaluation of Evidence from the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS: (1) Nonoperative interventions such as one-to-one support, partogram use, oxytocin use, and delayed pushing in women using epidurals will decrease need for operative birth (I-A). (2) Manual rotation may be used alone or in conjunction with instrumental birth with little or no increased risk to the pregnant women or the fetus (III-B). (3) Routine episiotomy is not necessary for an assisted vaginal birth (II-1E). (4) When operative intervention in the second stage of labour is required, the options, risks, and benefits of vacuum, forceps, and Caesarean section much be considered. The choice of intervention needs to be individualized, as one is not clearly safer or more effective than the other (II-B). (5) Failure of the chosen method, vacuum and/or forceps, to achieve delivery of the fetus in a reasonable time should be considered an indication for abandonment of the method (III-C). (6) Adequate clinical experience and appropriate training of the operator are essential to the safe performance of operative deliveries. Hospital credentialing boards should grant privileges for performing these techniques only to an appropriately trained individual who demonstrates adequate skills (III-C). VALIDATION: The Clinical Practice Obstetrics Committee and Executive and Council of the Society of Obstetricians and Gynaecologists of Canada approved these guidelines.

Cesarean Section↗
PubMed1987

Fetal heart rate monitoring during labour--too frequent intervention, too little benefit?

For many obstetricians and midwives continuous electronic fetal heart rate monitoring during labour has replaced the traditional method of intermittent auscultation. Of the eight prospective randomised controlled trials designed to assess its value in obstetric care, four were concerned with mothers defined as being at high-risk, three with normal or low-risk patients, and the eighth with the total population of a maternity hospital over several months. None suggested any major advantage of continuous fetal heart rate monitoring over intermittent surveillance in terms of neonatal mortality, morbidity, cord blood pH values, or the five minute Apgar score. The rates of caesarean section and forceps delivery were higher in the continuously monitored group. For low-risk mothers there is a good case for a return to the traditional method of intermittent auscultation with its lower false-positive rate, lesser incidence of intervention, and opportunity for greater contact between the maternity care staff and the mother.

Cesarean Section↗
PubMed2006

Effect of availability of a parturient-elective regional labor pain relief service on the mode of delivery.

BACKGROUND/PURPOSE: Regional analgesia for labor pain relief is effective and widely used. This study evaluated the controversial association between mode of operative delivery and patient-elective labor regional analgesia. METHODS: We retrospectively compared the rates of instrumental vaginal and cesarean deliveries in parturients before the introduction, in the first 15 months after, and in the subsequent 36 months after the implementation of an elective labor regional analgesia service. A total of 9779 low-risk singleton cephalic pregnancies above 36 weeks of gestation were included. The maternal and fetal outcomes for parturients before the service was implemented and in those with or without pain relief service in the two postimplementation periods were analyzed. Multivariate logistic regression analyses were used to investigate the effects of maternal age, gestational weeks and newborn weight, in addition to regional analgesia, on the mode of delivery in nulliparous women. RESULTS: After adjusting for maternal age, gestational weeks, and newborn weight, no significant association was found between regional analgesia and cesarean delivery in nulliparas. Further, this lack of association was not affected by the receipt of regional analgesia in the early period of program implementation or in the period after staff had become familiar with the service. A higher rate of instrumental vaginal delivery was noted in nulliparas given regional analgesia. CONCLUSION: Regional analgesia for pain relief increased the likelihood of instrumental vaginal delivery, but did not increase the likelihood of cesarean delivery.

Adult↗
PubMed2005

Obstetric outcome of extreme macrosomia.

OBJECTIVE: To determine the effect of extreme macrosomia on perinatal outcome. METHODS: We conducted a retrospective review of all deliveries with birth weight > or = 5000 g in a tertiary centre from 1986 to 2000 and analyzed the method of delivery and perinatal outcome. RESULTS: Extreme macrosomia (birth weight > or = 5000 g) was coded in 111 deliveries. There were 62 deliveries by Caesarean section (CS) (25 in labour and 37 elective). The 49 vaginal deliveries were complicated by 10 (20%) cases of shoulder dystocia and 3 (6%) of Erb's palsy. Permanent Erb's palsy was noted in only 1 of these 3 cases. Shoulder dystocia was associated with use of oxytocin and instrumental deliveries. CONCLUSION: Implementing the 2002 guidelines from the American College of Obstetricians and Gynecologists (that is, recommending Caesarean delivery of fetuses with an estimated weight of at least 5000 g) would have a negligible effect on the CS rate while eliminating 10 cases of shoulder dystocia in 49 births. A policy eliminating the use of oxytocin and instrumental deliveries would have prevented most birth traumas in this group. Unfortunately, this high-risk group is difficult to identify in the antepartum period, complicating the implementation of these guidelines and probably leading to higher rates of CS. In addition, the effect of endorsing such a policy on overall neonatal and maternal morbidity is minimal, because most morbidity occurs in newborns weighing less than 4000 g.

Birth Injuries↗
PubMed1992

Birth trauma in insulin-dependent diabetic pregnancies.

Infants of insulin-dependent diabetic mothers are considered to be at high risk for birth trauma, presumably due to macrosomia. With current management of diabetes in pregnancy, including strict glycemic control, the rate and the severity of macrosomia should be decreased. The frequent use of ultrasound to assess fetal growth and weight and the use of cesarean delivery in case of fetal macrosomia should further decrease the risk for birth trauma in these infants. We therefore undertook this study to test the null hypothesis that with current management, insulin-dependent diabetic mothers have a rate of birth trauma similar to that of infants of nondiabetic mothers (normal glucose challenge test at 28 weeks' gestation) matched for gestational age at birth, presence or absence of labor, delivery method (vaginal versus cesarean), and race. We studied 118 insulin-dependent diabetic mothers (White classes B-RT) and 354 control subjects (three matches for each insulin-dependent diabetic mother). The rate of birth trauma was 3.4% in insulin-dependent diabetic mothers, not significantly different from controls (2.5%). Logistic regression analysis in which birth trauma was the dependent variable and diabetes, race, presence or absence of labor, mode of delivery (vaginal versus cesarean), infant weight, and infant head circumference were independent variables revealed that only vaginal delivery was a significant risk factor for birth trauma in infants in both groups (p = 0.01). Most frequently observed birth traumas were brachial plexus injury, facial nerve injury, and cephalohematoma. Of the three infants with brachial plexus injury (insulin-dependent diabetic mothers, two; controls, one), two were delivered with use of midforceps.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Continuous subarachnoid infusion of 0.125% bupivacaine for analgesia during labour.

We have studied 20 primiparous women requesting pain relief for labour, to determine the feasibility of subarachnoid infusions of bupivacaine for analgesia. A 28-gauge catheter was inserted into the subarachnoid space through a modified 22-gauge Sprotte needle. After a bolus dose of up to 1.5 ml of 0.25% bupivacaine, a continuous infusion of 0.125% bupivacaine was commenced. If analgesia became inadequate, additional 0.5-ml boluses of 0.25% bupivacaine were given (mean number of top-ups 2.8; range 0-6). Persistent perineal pain occurred in four women and this was relieved by 0.5% hyperbaric bupivacaine. Analgesia was good or excellent in 15 of 20 mothers within 10 min and in 19 of 20 within 30 min, and it remained good or excellent throughout labour and delivery. Motor block was complete in three of the women who needed hyperbaric 0.5% bupivacaine. There were no difficulties with insertion of the catheter, no episodes of significant hypotension (systolic arterial pressure less than 100 mm Hg) or postdural puncture headache. Seven mothers delivered their babies vaginally, eight required assistance with forceps and five needed a Caesarean section.

Adolescent↗