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PubMed2005

Occiput posterior fetal head position increases the risk of anal sphincter injury in vacuum-assisted deliveries.

OBJECTIVE: The purpose of this study was to determine whether an occiput posterior (OP) fetal head position increases the risk for anal sphincter injury when compared with an occiput anterior (OA) position in vacuum-assisted deliveries. STUDY DESIGN: We conducted a retrospective cohort study of 393 vacuum-assisted singleton vaginal deliveries. Maternal demographics and obstetric and neonatal data were collected from an obstetric database and chart review. RESULTS: Within the OP group, 41.7% developed a third- or fourth-degree laceration compared with 22.0% in the OA group (OR 2.5, 95% CI 1.4-4.7). In a logistic regression model that controlled for BMI, race, nulliparity, length of second stage, episiotomy, birth weight, head circumference, and fetal head position, OP position was 4.0 times (95% CI 1.7-9.6) more likely to be associated with an anal sphincter injury than OA position. CONCLUSION: Among vacuum deliveries, an OP head position confers an incrementally increased risk for anal sphincter injury over an OA position.

Anal Canal↗
PubMed2006

Effect of instrument preference for operative deliveries on obstetrical and neonatal outcomes.

OBJECTIVES: To examine the relationship between physicians' instrument preference and obstetrical and neonatal outcomes. STUDY DESIGN: A retrospective cohort study comparing obstetrical and neonatal outcomes of second stage deliveries between obstetricians who prefer forceps (forceps >/=90%) with obstetricians with no preference to forceps (either instrument <90%) was completed using the McGill Obstetrical and Neonatal Database. Logistic regression analysis was used to obtain an adjusted odds ratio controlling for maternal, intrapartum and neonatal confounders. RESULTS: Two thousand and three hundred thirteen infants were delivered by 5 obstetricians who preferred forceps, and 9261 infants were delivered by 15 obstetricians with no instrument preference. Baseline characteristics were similar between the two groups. As compared to obstetricians who preferred forceps, obstetricians with no instrument preference had a higher rate of operative vaginal deliveries 1.5 (1.1-2.0), a higher cesarean section rate 2.5 (1.3-4.9) and a higher episiotomy rate in non-operative vaginal deliveries 3.4 (2.7-4.3). Infants delivered by obstetricians with no instrument preference were less likely to have significant bruising 0.3 (0.2-0.6) but more likely to have a cephalohematoma 3.0 (1.1-8.3). CONCLUSION: Physician instrument preference is an important determinant of outcomes that should be considered in studies evaluating instrumental deliveries.

Adult↗
PubMed2004

Immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries.

OBJECTIVE: To estimate the differences in immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries. METHODS: We conducted a medical record review of all forceps and vacuum-assisted deliveries that occurred from January 1, 1998, to August 30, 1999, at Winthrop-University Hospital. Maternal demographics and delivery characteristics were recorded. Maternal outcomes, such as use of episiotomy and presence of lacerations, were studied. Neonatal outcomes evaluated were Apgar scores, neonatal intensive care unit admissions, cephalohematomas, instrument marks and bruising, and caput and molding. RESULTS: Of 508 operative vaginal deliveries, 200 were forceps and 308 were vacuum assisted. Forceps were used more often than vacuum for prolonged second stage of labor (P =.001). There was a higher rate of epidural (P =.02) and pudendal (P <.001) anesthesia, episiotomies (P =.01), maternal third- and fourth-degree perineal (P <.001) and vaginal lacerations (P =.004) with the use of forceps, whereas periurethral lacerations were more common in vacuum-assisted (P =.026) deliveries. More instrument marks and bruising (P <.001) were found in the neonates delivered by forceps, whereas there was a greater incidence of cephalohematomas (P =.03) and caput and molding (P <.001) in the neonates delivered with vacuum. Multivariable logistic regression analysis showed that forceps use was associated with an increase in major perineal and vaginal tears (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.27, 2.69; P =.001), an increase in instrument marks and bruising (OR 4.63; 95% CI 2.90, 7.41; P <.001) and a decrease in cephalohematomas (OR 0.49; 95% CI 0.29, 0.83; P =.007) compared with the vacuum. CONCLUSIONS: Maternal injuries are more common with the use of forceps. Neonates delivered with forceps have more facial injuries, whereas neonates delivered with vacuum have more cephalohematomas. LEVEL OF EVIDENCE: II-3

Adult↗
PubMed2005

Forceps compared with vacuum: rates of neonatal and maternal morbidity.

OBJECTIVE: To compare perinatal outcomes between forceps- and vacuum-assisted deliveries. Our hypothesis was that the force vectors achieved in forceps delivery will lead to fewer shoulder dystocias, but greater perineal lacerations. METHODS: This was a retrospective cohort study of 4,120 term, cephalic, singleton, nonrotational operative vaginal deliveries at a single institution. Outcomes examined included rates of neonatal trauma, shoulder dystocia, and perineal lacerations. Potential confounders, including maternal age, birthweight, ethnicity, parity, station at delivery, episiotomy, attending physician, anesthesia, and length of labor, were controlled for using multivariate logistic regression. RESULTS: Among the 2,075 (50.4%) forceps- and 2,045 (49.6%) vacuum-assisted deliveries, the rate of shoulder dystocia was lower among women undergoing forceps delivery (1.5% compared with 3.5%, P < .001), as was the rate of cephalohematoma (4.5% compared with 14.8%, P < .001), whereas the rate of third- or fourth-degree perineal laceration was higher (36.9% compared with 26.8%, P < .001). These differences in perinatal complications persisted when controlling for the confounders listed above. The adjusted odds ratio for shoulder dystocia was 0.34 (95% confidence interval [CI] 0.20-0.57), for cephalohematoma was 0.25 (95% CI 0.19-0.33), and for third- or fourth-degree lacerations was 1.79 (95% CI 1.52-2.10) when comparing forceps to vacuum. CONCLUSION: Vacuum-assisted vaginal birth is more often associated with shoulder dystocia and cephalohematoma. Forceps delivery is more often associated with third- and fourth-degree perineal lacerations. These differences in complications rates should be considered among other factors when determining the optimal mode of delivery. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed1977

Ketamine and diazepam as anaesthesia for forceps delivery. A comparative study.

In a clinically controlled trial in forceps delivery, a comparison was made between the general anaesthesia induced by ketamine and that by a combination of diazepam and N2O. Local anaesthesia was added in the diazepam group for episiotomy and suturation. The indication for operative delivery was in all cases a prolonged second stage of labour. In the katamine group, awareness was noted in four cases out of 13, even if the analgesic effect was found to be good. Four patients showed marked, short-lasting elevation of blood pressure and seven had unpleasant dreams. All thirteen mothers in the diazepam group found the anesthesia effective and the recovery pleasant. The blood pressure was stable. One mother in each group required ventilation with oxygen due to respiratory depression of short duration. Three of the children in the ketamine group and two in the diazepam group had subnormal Apgar score with slight acidosis. This was probably not attributable to the anaesthesia.

Adult↗
PubMed1975

Continuous pethidine/diazepam infunsion during labour and its effects on the newborn.

This paper presents a study comparing the effects on the mother and baby of a continuous intravenous infusion of pethidine and diazepam and of intramuscular pethidine and promazine. It is concluded that the administration of intravenous pethidine and diazepam is safe in labour provided that diazepam has not been given during the previous week.

Anesthesia, Obstetrical↗
PubMed1993

A randomised prospective study comparing the new vacuum extractor policy with forceps delivery.

OBJECTIVE: To compare assisted vaginal delivery by forceps with delivery by vacuum extractor, where a new vacuum extractor policy was employed which dictated the cup to be used in specific situations. DESIGN: Multicentre randomised controlled trial. SETTING: Four district general hospitals in the West Midlands. SUBJECTS: Six hundred-seven women requiring assisted vaginal delivery, of whom 296 were allocated to vacuum extractor delivery and 311 to forceps. MAIN OUTCOME MEASURES: Delivery success rate, maternal perineal and vaginal injuries, maternal anaesthetic requirements, neonatal scalp and facial injuries. RESULTS: Of the vacuum extractor group, 85% were delivered by the allocated instrument compared to 90% in the forceps group (odds ratio (OR) 0.64; 95% confidence intervals (CI) 0.4-1.04). However, more women in the vacuum extractor group were delivered vaginally (98%) than in the forceps group (96%). There were significantly fewer women with anal sphincter damage or upper vaginal extensions in the vacuum extractor group (11% vs 17%, OR 0.6; 95% CI, 0.38-0.97). There were significantly fewer women in the vacuum extractor group requiring epidural or spinal anaesthetics (25.4% vs 32.7%, OR 0.69; 95% CI 0.49-0.99) or general anaesthetics (1% vs 4%, OR 0.17; 95% CI 0.04-0.76). Although there were significantly more babies in the vacuum extractor group with cephalhaematomata (9% vs 3%, OR 3.3; 95% CI 1.4-7.4) there were fewer babies in the vacuum extractor group with other facial injuries. There were three babies in the forceps group with unexplained neonatal convulsions. CONCLUSIONS: Assisted vaginal delivery using the new vacuum extractor policy is associated with significantly less maternal trauma than with forceps. Further studies are required to assess neonatal morbidity adequately.

Adult↗
PubMed1997

Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy.

OBJECTIVE: To determine risk factors for third degree obstetric perineal tears and to give recommendations for prevention. DESIGN: Retrospective case control study. SETTING: A teaching hospital in The Netherlands. PARTICIPANTS AND METHODS: One hundred and twenty cases of vaginal delivery complicated by third degree perineal tear and 702 uncomplicated vaginal deliveries were compared, with respect to possible risk factors. RESULTS: In a multivariate model high birthweight, forceps delivery, induced labour, epidural anaesthesia and parity were risk factors for anal sphincter tear. In addition, mediolateral episiotomy was associated with fewer sphincter injuries. Separate analysis of nulli- and multiparous women demonstrated that high birthweight and epidural anaesthesia (increased risk) and mediolateral episiotomy (decreased risk) were factors associated with anal sphincter tear only in nulliparous women. CONCLUSIONS: We found several risk factors for anal sphincter tear. Nulliparous women are at higher risk than multiparous women. Mediolateral episiotomy may be sphincter-saving especially in nulliparous women and therefore prevent them from chronic faecal incontinence.

Adult↗
PubMed2000

Outcome of the next labour in women who had a vaginal delivery in their first pregnancy.

This study reviews the outcome of the next labour in women who are delivered vaginally in their first pregnancy. The influence of the method of delivery in the first pregnancy and of factors in both the first and next labour on the type of delivery in the second pregnancy, are recorded in a group of 13,813 women. Those delivered spontaneously and by vacuum, low forceps and mid-forceps in their first pregnancy had a 96%, 91%, 88% and 82% chance, respectively, of spontaneous delivery in their next pregnancy. The type of labour (spontaneous, induced or augmented) in the first pregnancy had minimal influence on the method of delivery in the second pregnancy. Compared with spontaneous onset, induction and augmentation of labour in the second pregnancy reduced the chance of spontaneous delivery by 6% and 18%, respectively.

Cesarean Section↗
PubMed1996

Premature rupture of the membranes (PROM) at term in nulliparous women with a ripe cervix. A randomized trial of 12 or 24 hours of expectant management.

OBJECTIVE: To compare maternal and neonatal outcomes after 12 or 24 hours of expectant management in healthy nulliparous women with a ripe cervix and PROM at term. DESIGN: A prospective, randomized study. LOCATION: Karolinska Hospital, Stockholm, Sweden. SUBJECTS: Two hundred and five healthy nulliparous women with singleton pregnancies, cephalic presentation, gestational duration 36 to 42 weeks, randomized to 12 or 24 hours of expectant management after evaluation of the cervical score (> 5). If spontaneous labor did not occur, induction was performed with oxytocin after 12 or 24 hours, respectively. MAIN PARAMETERS: Maternal early morbidity and neonatal infections, obstetric intervention rate (cesarean section or instrumental delivery). RESULTS: The cesarean section rate was 4% in each group. The vacuum extraction rate was 21% in each group. Induction of labor was performed in 47% of the women allocated to 12 hours of expectant management vs 17% of the women allocated to 24 hours of expectant management (p < 0.05). The maternal morbidity rate was almost negligible. Only a few fetal infections occurred and no difference was noted between the groups. CONCLUSIONS: In healthy nulliparous women at term with a ripe cervix, expectant management over 24 hours vs 12 hours resulted in fewer inductions of labor and no increase in instrumental deliveries, without any increase in neonatal or maternal morbidity.

Adult↗
PubMed1975

[Critical evaluation of paracervical anaesthesia in obstetrics (personal observations in 8038 cases) (author's transl)].

Between 1966 and 1973 a total of 8038 paracervical blockades (PCB) were performed at the Rhine State Women's Hospital in Wuppertal. In recent years the preparation normally used has been Bupivacain (Carbostesin) with adrenalin, 5 ml being injected paracervically. This results in complete analgesia in over 90% of cases. The incidence of forceps deliveries in the PCB group (19%) was higher, while the number of cesarean sections did not increase. Typical PCB-related bradycardias were observed in 6.9% of cases. Taking other forms of bradycardia into account-mainly reduced Dip II-a change in fetal cardiac action was seen in 12% of cases altogether. In 1973 there may have been a causal connection between PCB and postpartum infant death in 2 cases. In cases of acute bradycardia following PCB, intra-uterine reanimation, e.g. with Th 1165 a (Partutisten) under circulation control is recommended. Considering perinatal risks, especially those recognizable cardiotokodynagraphically, paracervical anesthesia is judged to be a suitable method of facilitating birth.

Anesthesia, Obstetrical↗
PubMed2003

Effect of operative vaginal delivery on the outcome of permanent brachial plexus injury.

OBJECTIVE: To evaluate whether operative vaginal delivery worsens the extent and/or degree of permanent brachial plexus injury. STUDY DESIGN: We utilized a dataset (n = 104) of vaginal deliveries resulting in permanent brachial plexus injury that ultimately underwent litigation. We excluded patients on whom neonatal injury information was incomplete (n = 5). Patients who had an operative vaginal delivery (n = 33) were compared with those who did not (n = 66) in regard to neonatal outcome and the location and extent of neurologic injury. RESULTS: The 2 classes were similar in demographic and obstetric variables. There were no differences in rates of 5-minute Apgar scores < 7 (17.9%, or 5/28, vs. 5.2%, or 3/57, P = .1), complete neurologic injury to the brachial plexus (C5-T1) (39%, or 13/33, vs. 38%, or 25/66; P = 1.0) or avulsion of the nerve roots (44%, or 12/27, vs. 36%, or 18/50; P = .5) between those with operative or spontaneous vaginal delivery. CONCLUSION: Operative vaginal delivery did not increase the severity of impairment in a dataset of deliveries resulting in permanent brachial plexus injury.

Adult↗
PubMed2004

Perineal care.

Explore the source record for details and available documents.

Delivery, Obstetric↗
PubMed2006

Obstetric anal sphincter injury: how to avoid, how to repair: a literature review.

Avoiding obstetrical injury to the anal sphincter is the single biggest factor in preventing anal incontinence among women. Any form of instrument delivery has consistently been noted to increase the risk of obstetric anal sphincter injury and altered fecal continence by between 2- and 7-fold. Routine episiotomy is not recommended. Episiotomy use should be restricted to situations where it directly facilitates an urgent delivery. A mediolateral incision, instead of a midline, should be considered for persons at otherwise high risk of obstetric anal sphincter injury. The internal anal sphincter needs to be separately repaired if torn. Women with injuries to the internal anal sphincter or rectal mucosa have a worse prognosis for future continence problems. All women, particularly those with risk factors for injury, should be surveyed for symptoms of anal incontinence at postpartum follow-up.

Anal Canal↗
PubMedDate not supplied

Induced abortion as a risk factor for perinatal complications: a review.

Past and continuing studies of the influence of a prior induced abortion on subsequent perinatal complications are reviewed. Many definitive conclusions are precluded because of design problems in the extant studies and these methodological issues, therefore, form the focus for the current review. The available studies do suggest that abortion by vacuum aspiration is not a risk factor for complications of subsequent pregnancies, labor, delivery, or of newborns. Abortion by dilatation and curettage, however, may increase the risk of subsequent spontaneous abortion, low birth weight, and prematurity but these findings need to be confirmed. The impact of other abortion techniques or perinatal complications has not been studied. The more common design problems in the extant literature include: (1) failure to control for confounding maternal factors; (2) problems in reliability of reporting previous abortion; and (3) nonspecific measurement of abortion techniques. Since approximately three-quarters of all abortions performed annually in the United States are on young never-married women who may eventually wish to bear children, further rigorous research to define the risks of induced abortion is urgently required.

Abortion, Induced↗
PubMed1987

Paresthesias and motor dysfunction after labor and delivery.

The incidence of paresthesias and motor dysfunction associated with 23,827 deliveries at Winnipeg Women's Hospital during a 9-yr period (1975-1983) was 18.9/10,000 deliveries. All the symptoms resolved within 72 hr after supportive therapy only. The frequency of paresthesias and motor dysfunction was greater in primiparas, women who had forceps- or vacuum-assisted deliveries, and women who had epidural or general anesthesia. Significant neurologic deficits after labor and delivery with or without epidural anesthesia were rare. Epidural anesthesia is a safe technique in this regard.

Anesthesia, Epidural↗