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PubMed2001

The management of the second stage of labor.

OBJECTIVE: To review obstetric practice in a single maternity hospital with respect to the assisted vaginal delivery rate. METHOD: A retrospective analysis of the hospital statistics, labor ward records, casenotes and management protocols with respect to the second stage of labor was performed in a single maternity unit in the UK; the study included 43352 women who delivered a baby between the years of 1987 and 1997. The study looked at the rate of assisted vaginal deliveries, cesarean section, epidural in labor, and as well as the perinatal mortality rate. RESULTS: In the 11-year period of the study, 43352 women delivered with a mean assisted vaginal delivery rate of 3.70%, cesarean section rate of 12.4% and an epidural rate of 31.5%. CONCLUSION: The management of the second stage of labor in this unit results in an assisted vaginal delivery rate significantly below the national average. The authors highlight the paucity of research in this important area of practice.

Anesthesia, Epidural↗
PubMed1990

[Neurologic complication following spinal anesthesia for manual detachment of the placenta].

Long-term paralysis of the lower extremities was observed in a 31-year-old fourth-gravida patient, undergoing a curettage under spinal anaesthesia because of placenta accreta. The patient recovered within three days from her neurological signs and symptoms, consisting of complete paresis of the hip and knee flectors and severe headache. Clinical investigations including a neurological examination, spinal puncture, x-ray pictures of the lumbosacral area and haemograms revealed no evidence for an infection, abscess or haematoma. With regard to the fact, that neurological deficiency disappeared completely within three days, it seems probable, that the symptoms were caused by the longer lasting gynaecological position (Steinschnitt-position) during the period of delivery and curettage thereafter.

Adult↗
PubMed1999

Vanishing forceps delivery.

This study evaluates the effect of decreasing cesarean rates and increasing regional anesthesia use on the frequency of forceps deliveries. Data of women who delivered at our community hospital from 1990 through 1997 are reviewed. In 1994, the members of our department adopted several strategies to decrease cesarean deliveries. The cesarean rate decreased whereas regional analgesia use increased. We studied the frequency and type of vaginal operative deliveries during this 8 year period. These data were evaluated by chi2 analysis. Data of women who delivered in the first 4 years (group 1) were compared with data of those who delivered in the second 4 years (group 2). A p < 0.05 was considered significant. The demographic and clinical characteristics of these women remained unchanged during the study period. The total cesarean rate decreased from 23.2% in group 1 to 17.9% in group 2 (p < 0.0001). The proportion of women who received regional anesthesia increased from 18.8 in group 1 to 25.7 in group 2 (p < 0.0001). Vaginal operative deliveries increased from 3.6 to 5.5 (p < 0.0001), whereas the proportion of forceps deliveries decreased from 2.2 to 1.5 (p = 0.001). Perinatal morbidity and mortality did not change. The decrease in cesarean rate and increase in regional anesthesia use were associated with an increase in operative deliveries; however, forceps deliveries continue to decrease in our community hospital.

Analgesia, Obstetrical↗
PubMed2005

Trends in the rate of shoulder dystocia over two decades.

OBJECTIVE: To describe the trend in the rate of shoulder dystocia over twenty-four years and identify the risk factors related to the occurrence of dystocia. METHODS: Data was obtained from Maryland State regarding all vaginal deliveries that occurred during six different time periods at five-year intervals since 1979. Trends in the rate of shoulder dystocia, episiotomy, forceps and vacuum delivery were examined. RESULTS: There were a total of 277 974 vaginal deliveries. The overall rate of shoulder dystocia was 1.29% (n = 3590). Induction of labor (adjusted OR 1.2, 1.1-1.3), presence of diabetes (gestational (OR 1.9, 1.7-2.3) or pre-gestational (OR 3.8, 2.7-5.4)), fetal macrosomia (OR 5.1, 4.1-6.3) use of episiotomy (OR 1.6, 1.5-1.8), forceps (OR 1.3, 1.0-1.8) or vacuum (OR 2.3, 2.0-3.9) at delivery were associated with a higher rate of shoulder dystocia. TREND: There was an increase in the rate of shoulder dystocia from 0.2% in 1979 to 2.11% in 2003. In addition there was a drop in the overall episiotomy rate from 73.67% to 23.94% and increase in the use of vacuum from 0.1% to 8.36%. CONCLUSION: The rate of shoulder dystocia has increased by 10 fold during the study period. The use of episiotomy either at spontaneous delivery or instrumental delivery does not appear to decrease the occurrence of shoulder dystocia.

Adolescent↗
PubMed1991

The effects of the addition of sufentanil to 0.125% bupivacaine on the quality of analgesia during labor and on the incidence of instrumental deliveries.

In a double-blinded, randomized, prospective multi-center study of 695 women, we investigated whether epidural injection of sufentanil added to 0.125% bupivacaine with epinephrine (1:800,000) reduces the total amount of local anesthetic required, resulting in less motor blockade and reduced incidence of instrumental deliveries, and improves the quality of analgesia provided by this low concentration of local anesthetic without jeopardizing the safety of the baby. In addition, other potential benefits of sufentanil (such as decrease in the incidence of shivering) and side effects were examined. It was found that adding incremental doses of 10 micrograms sufentanil up to a maximum of 30 micrograms reduced the incidence of instrumental deliveries from 36 to 24% (P less than 0.01) and significantly improved quality and duration of analgesia without depressing the neurobehavioral status of the baby. No other benefits from adding sufentanil were found. The only side effect that occurred more frequently after sufentanil was pruritus. We conclude that epidural injection of 10-30 micrograms sufentanil added to 0.125% bupivacaine with epinephrine (1:800,000) improved the quality of analgesia during labor and reduced the incidence of instrumental deliveries without jeopardizing the safety of the baby.

Adult↗
PubMed1994

Low dose bupivacaine/fentanyl epidural infusions in labour and mode of delivery.

The aim of this study was to determine the effect on the instrumental delivery rate of two different concentrations of bupivacaine combined with fentanyl in epidural infusions during labour. Only primiparous women in whom a spontaneous vaginal delivery was anticipated, were included in the study. Those women receiving a higher concentration of bupivacaine and therefore a greater amount of local anaesthetic agent during labour were significantly more likely to have an instrumental delivery with Kielland's rotational forceps (p < 0.01). Those women receiving a lower concentration and smaller amount of bupivacaine were significantly more likely to have an instrumental delivery with Neville-Barnes forceps (p < 0.05). This provides evidence to support the theory that epidural analgesia may contribute to inadequate rotation of the presenting fetal part due to weakened pelvic floor muscles and that this is more likely to occur when higher concentrations of bupivacaine are used and a greater degree of motor block occurs.

Anesthesia, Epidural↗
PubMed1990

Silastic cup vacuum extractor or forceps: a comparative study.

A retrospective analysis over a 2-year period was carried out to compare the limitations in the use of the Silastic Cup vacuum extractor and forceps as the preferred instrument for operative vaginal delivery. Whilst the use of the vacuum extractor was associated with less maternal morbidity (54.9% episiotomy rate; 20.9% nil analgesia) and comparable neonatal problems, an increased failure rate (6.5%) was demonstrated in comparison to forceps delivery (0.7% failed vaginal delivery rate). A comparison of their use for rotational vaginal delivery failed to reveal any significant difference in maternal or neonatal outcome apart from an increased failure rate (30%) to complete vaginal delivery after application of the vacuum extractor. It is concluded that the vacuum extractor is a comparable instrument for midcavity or lift-out instrumental delivery but Kielland's forceps may still be a more appropriate instrument for rotational vaginal delivery.

Delivery, Obstetric↗
PubMed2001

A randomised controlled trial of epidural compared with non-epidural analgesia in labour.

OBJECTIVES: To investigate possible short and long term side effects of epidural analgesia, compared with non-epidural analgesia for pain relief in labour. DESIGN: Randomised controlled study, with long term follow up by questionnaire. Analysis by intention-to-treat. SETTING: Busy maternity unit within a district general hospital in England. PARTICIPANTS: Three hundred and sixty nine primigravid women in labour were included (randomised allocation: epidural n = 184, non-epidural n = 185). MAIN OUTCOME MEASURES: Backache at three and twelve months after delivery, instrumental delivery rates and maternal opinion of pain relief in labour. RESULTS: No significant differences were found in the reported incidence of backache between the groups at three months: middle backache [22% vs 20%, chi2 = 0.057, P = 0.81; odds ratio (95% CI) 1.4(0.9-2.3)]; low backache [35% vs 34%, chi2 = 0.009, P = 0.92; odds ratio (95% CI) 1.0(0.6-1.6)]. Nor were there significant differences at 12 months: [middle backache 16% vs 16%, chi2 = 0.013, P = 0.91; odds ratio (95% CI) 1.0(0.5-1.8)]; or low backache [35% vs 27%, chi2 = 1.91, P = 0.17; odds ratio (95% CI) 1.4(0.9-2.3)]. The incidence of instrumental delivery was somewhat higher in the epidural group [30% vs 19%, odds ratio (95% CI) 1.77(1.09-2.86)]. Maternal satisfaction was not significantly different between the groups. CONCLUSIONS: This study provided no evidence to support the suggestion of a direct association between the use of epidural anaesthesia in labour and the incidence of long term backache. Despite a significant proportion of women in each group not receiving their allocated analgesia, a significant difference in terms of instrumental delivery rates remained. Satisfaction in both groups of women was high.

Adult↗
PubMed1980

Duration of the second stage of labor.

The second stage of labor, defined as the time from full dilatation of the external os to delivery of the child, was recorded during a three-month period in 635 labors with vaginal delivery. The median duration in labors of spontaneous onset was 31.3 minutes in para 0 mothers, 14.3 minutes in para 1 mothers and 11.7 minutes in para 2 + mothers. In induced labors the second stage had approximately the same length as in labors with spontaneous onset. The time distribution showed that the second stage in para 0 mothers had a plateau in the 17.5--37.5 minute range, whereas para 1 + mothers had a sharper peak at 7.5 minutes. Forty and 45 minutes respectively seemed to be limits beyond which only very few second stages of labor lasted. Operative delivery terminated 18 per cent of para 0 labors and 6 per cent of the para 1 + labors entering the second stage. The operative interventions seemed to appear in two clusters for each parity group. It appeared that fetal asphyxia requiring intervention was discovered before 40 minutes of the second stage in para 0 and before 30 minutes in para 1 + mothers. Later operative termination was more often performed to relieve fatigued mothers.

Cesarean Section↗
PubMed1990

Trends in caesarean section in Western Australia, 1980-1987.

During the 1980s the incidence of both emergency and elective caesarean section in Western Australia increased, accompanied by a decrease in that of all other delivery methods. The proportion of emergency caesarean sections increased from 5.9%. of all deliveries in 1980 to 8.2% in 1987 and that of elective sections from 5.3% to 8.7%. For each year studied less than 50% of primiparous women delivering singletons had a normal vaginal delivery. Emergency caesarean sections were more common in primiparas and at the teaching hospital and elective sections in multiparas and at the metropolitan private hospitals. The proportion of primiparas having either emergency or elective caesarean sections rose with maternal age, but for multiparas the proportion having elective sections rose, but there were few differences in emergency sections with increasing age. Repeat caesarean sections, which made up 28.8% of the total in 1987, have contributed increasingly to the rising proportion of caesarean section deliveries. Unless the number of emergency sections in primiparous women falls and the challenge of vaginal birth after caesarean section is met, it is likely that the caesarean section rate in Western Australia will continue to increase over the next decade.

Adult↗
PubMed2000

[Comparative assessment of efficacy and safety of assisted vaginal delivery with forceps and with vacuum extractor].

UNLABELLED: We performed a prospective, controlled, randomized trial to compare de safety and efficacy between the vaginal assisted delivery with vacum extractor forceps. We included a control group of primigravidae. We use the ACOG application criteria for operative obstetrics. We measured the differences in regard to indication for operative delivery, obstetric trauma and the general characteristics of the patients. A total of 210 patients were included which were distributed in three groups. In the first group we included the patients of vacum extractor, the second group of forceps and the third the control group. In our results we found no statistically significant differences among three groups in regard to the general characteristics and obstetric trauma. In the vacum extractor group we found six cefalohematomas (8.5%), two newborns with skin laceration (2.8%) and four newborns with cerebral edema (5.7%). In the forceps group we had two newborns diagnosed with cefalohematomas (2.8%), seven newborns with cerebral edema (10%) and scalp laceration on four newborns (6%). In the control group we found one cefalohematoma (1.4%) and cerebral edema in four newborns (5.7%). We did not find statistically significant differences when we compared the group of the vacum and the forceps. CONCLUSION: With this information we concluded that both instruments are equal in regard to efficacy and safety when they are use by experimented hands and following the application criteria. Nevertheless, there is a high incidence of vaginal injuries and obstetric trauma in the newborn in the operative delivery compared with the control group without an important increase in the perinatal mortality.

Adult↗