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PubMed1997

Choice of instrument for vaginal delivery.

This review covers a selection of the important recently published papers that show enormous variations in obstetric intervention rates. It includes references to the forceps versus vacuum extractor controversy, discussing the controlled trial data as well as selected observational studies. Papers on new equipment and techniques of delivery are reviewed, although in the recent literature these are principally related to the vacuum extractor and not to forceps. Final discussion is made of methods of ensuring adequate training.

Contraindications↗
PubMed2005

Risk factors associated with subaponeurotic haemorrhage in full-term infants exposed to vacuum extraction.

OBJECTIVES: To determine obstetric and neonatal risk factors associated with subaponeurotic haemorrhage (SAH) in infants exposed to vacuum extraction. DESIGN: A prospective observational study. SETTING: In the labour room, operation theatre, postnatal wards and neonatal intensive care unit (NICU) of a tertiary teaching hospital. POPULATION: All infants born in the hospital with a history of exposure to vacuum extraction. METHODS: A prospective observational study carried out over a 26-month period. All eligible infants were examined at birth and during the first 24 hours of life. MAIN OUTCOME MEASURES: A diagnosis of SAH was based on detection of a tender fluctuant scalp swelling that crossed the skull suture lines of infants. RESULTS: Of 10,066 infants born in the hospital during the study period, 338 (3.4%) had exposure to vacuum extraction. SAH was detected in 71 (21.0%) of them. Forward multivariate logistic regression analysis showed that five factors were significantly associated with development of SAH: maternal nulliparity (adjusted odds ratio [OR]: 4.0; 95% confidence intervals [CI]: 1.6, 10.0), failed vacuum extraction (adjusted OR: 16.4; 95% CI: 2.0, 135.6), Apgar score of less than 8 at 5 minutes of life (adjusted OR: 5.0; 95% CI: 1.7, 15.2), marks of vacuum cup over the sagittal suture (adjusted OR: 4.4; 95% CI: 1.9, 10.2) and marks of leading edge of vacuum cup at <3 cm away from the anterior fontanel of infants' heads (adjusted OR: 6.0; 95% CI: 1.7, 21.0). CONCLUSION: Maternal nulliparity, placement of vacuum extraction cup over the sagittal suture at a distance too close to infant's anterior fontanel and failed vacuum extraction predisposed infants to develop SAH.

Adult↗
PubMed2005

Use of epidural analgesia and its relation to caesarean and instrumental deliveries-a population--based study of 94,217 primiparae.

OBJECTIVES: To investigate the association between epidural analgesia for labour-pain relief and mode of delivery. STUDY DESIGN: The Swedish medical birth register covers 99% of all births and contains prospectively collected information from all delivery units in Sweden. The present population-based cohort study includes singleton births among nulliparae during 1998-2000, excluding deliveries with elective caesarean section, giving study population of n=94,217. The frequencies of epidural block in this population were estimated for each delivery unit. The outcomes studied were non-elective caesarean section and instrumental delivery. RESULTS: There was no clear association between frequency of epidural block and caesarean section and instrumental delivery, respectively. Delivery units with the lowest (20-29%) and the highest (60-64%) relative frequencies of epidural block had the lowest proportion of caesarean section (9.1%). For the other groups the proportion varied between 10.3 and 10.6%. Instrumental deliveries were most common, 18.8%, in delivery units with 50-59% frequency of epidural block use. The lowest incidence (14.1%) was in units using epidurals in 30-39% of cases. In the other groups (20-29, 40-49 and 60-64%) the proportion varied between 15.3 and 15.7%. CONCLUSIONS: This investigation shows no clear association between epidural use and caesarean section or instrumental delivery, indicating that there is no reason to restrict the epidural rate to improve obstetric outcome.

Analgesia, Epidural↗
PubMed1999

Sequential use of instruments at operative vaginal delivery: is it safe?

OBJECTIVE: Our purpose was to examine maternal and neonatal outcomes in a cohort of women who underwent delivery with the sequential use of instruments. STUDY DESIGN: This retrospective case-control study included deliveries from May 1996 through March 1998. Charts of women who underwent delivery with the sequential use of instruments (vacuum first, then forceps, or vice versa) were identified. Two control groups (1 forceps group, 1 vacuum group) were randomly selected and matched for each case. Maternal and neonatal outcomes were abstracted and compared. RESULTS: There were 34 patients in each group. There were no significant demographic differences. The vacuum group had lower rates of episiotomy (P =.01) and deep perineal lacerations (P =.014), whereas these outcomes were similar in the sequential and forceps groups. All other maternal outcomes were equivalent. There were no differences in any neonatal parameter except for superficial scalp trauma, which was more common in the vacuum group (P =.002). CONCLUSION: We conclude that the prudent use of sequential instruments at operative vaginal delivery did not engender higher rates of maternal or neonatal morbidity.

Adult↗
PubMed1982

[Amniotic fluid embolism with coagulation disorder--a case report (author's transl)].

A case of amniotic fluid embolism during the delivery of a twin pregnancy is reported. After immediate resuscitation with artificial ventilation the mother and the neonates survived the acute episode. As a result of hyperfibrinolysis with premature separation of the placenta a dramatic postpartum haemorrhage occurred, which could be controlled by Fritsch' manoeuvre. Meanwhile it was possible to restore the coagulation disorder with fresh whole blood, fibrinogen and an antifibrinolytic agent (Aprotinin).

Aprotinin↗
PubMed2002

Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery.

OBJECTIVE: This study was undertaken to determine the incidence of clinically overt postpartum urinary retention after vaginal delivery and to examine what maternal, fetal, and obstetric factors are associated with this problem. STUDY DESIGN: This was a retrospective case-controlled study of women who had overt postpartum urinary retention after vaginal delivery from August 1992 through April 2000. RESULTS: Fifty-one of 11,332 (0.45%) vaginal deliveries were complicated by clinically overt postpartum urinary retention. In most cases (80.4%), the problem had resolved before hospital dismissal. Persons with urinary retention were more likely than control subjects to be primiparous (66.7% vs 40.0%; P <.001), to have had an instrument-assisted delivery (47.1% vs 12.4%; P <.001), to have received regional analgesia (98.0% vs 68.8%; P <.001), and to have had a mediolateral episiotomy (39.2% vs 12.5%; P <.001). On multivariate logistic regression analysis, of these 4 variables, only instrument-assisted delivery and regional analgesia were significant independent risk factors. CONCLUSION: Clinically overt postpartum urinary retention complicates approximately 1 in 200 vaginal deliveries, with most resolving before hospital dismissal. Factors that are independently associated with its occurrence include instrument-assisted delivery and regional analgesia.

Adult↗
PubMed2000

Decision to delivery intervals for assisted vaginal vertex delivery.

OBJECTIVE: To describe the time interval between decision for assisted vaginal delivery and the birth of the baby in different clinical circumstances. DESIGN: A prospective analysis of 225 consecutive women with a singleton fetal cephalic presentation in the second stage of labour requiring an operative vaginal delivery for various reasons. SETTING: A maternity unit in a district general hospital delivering more than 6,000 women annually. MAIN OUTCOME MEASURES: The decision to delivery interval and the immediate and short term maternal and neonatal outcomes according to indication for operative vaginal delivery. RESULTS: The mean (SD) decision to delivery interval was 34.4 minutes (28.3) with a range of 5 to 101 minutes. For those delivered because of suspected fetal distress, the interval of 26.5 minutes (14.0) was significantly shorter than for those performed without fetal distress 39.5 minutes (19.0) (P < 0.0001); for cases with fetal distress, forceps were significantly quicker at 23.3 minutes (14.3) than the ventouse 29.2 minutes (13.2) (P = 0.04). The longer the interval in cases of fetal distress the less favourable the condition of the neonate at birth, although this trend did not reach statistical significance and was not seen for deliveries expedited for other reasons. Perineal repair was required following 96% forceps deliveries compared with 87% ventouse (P = 0.015). Perineal trauma was not influenced by the interval between decision and delivery. CONCLUSIONS: If speed of delivery is important, use of forceps results in a quicker birth than use of the ventouse, without any compromise to the condition of the baby at delivery, and with similar rates of perineal trauma.

Adult↗
PubMed2003

Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery.

OBJECTIVE: To compare, in a prospective, randomised controlled trial, differences in anal sphincter function following forceps or vacuum assisted vaginal delivery in an institution practising standardised management of labour. DESIGN: Prospective, randomised controlled trial. SETTING: Tertiary-referral maternity teaching hospital. POPULATION: One hundred and thirty women. METHODS: Primiparous women were recruited antenatally and if an instrumental delivery was indicated, were randomised to either a vacuum or low-cavity, non-rotational forceps assisted delivery. Follow up consisted of a symptom questionnaire, anal manometry and endoanal ultrasound at three months postpartum. MAIN OUTCOME MEASURES: Faecal continence scores, anal manometry, endoanal ultrasound. RESULTS: Sixty-one women delivered with forceps assistance (40 for failure to progress in the second stage) and 69 with vacuum assistance (33 for failure to progress); 16/69 vacuum deliveries proceeded to a forceps assisted delivery (23%). There were no statistical differences in the antecedent antenatal factors between the two groups. A third degree perineal tear followed 10 (16%) forceps and 5 (7%) vacuum deliveries. Based on intention-to-treat analysis, 36 (59%) women complained of altered faecal continence after forceps delivery compared with 23 (33%) following vacuum delivery three months postpartum (RR 2.88, 95% CI 1.41-5.88). Endoanal ultrasound was reported as abnormal following 34 (56%) forceps deliveries and 34 (49%) vacuum deliveries (RR 1.3, 95% CI 0.65-258). After exclusion of 'failed vacuum', median anal canal resting pressure was significantly lower following forceps delivery compared with vacuum delivery alone (P = 0.004). There were no significant differences in degree of ultrasound abnormality between the two groups. CONCLUSIONS: Symptoms of altered faecal continence are significantly more common following forceps assisted vaginal delivery. Based on continence outcome, when circumstances allow, vacuum should be the instrument of first choice in assisted delivery.

Adult↗