Examination of data base in midforceps delivery study

Abstract

delivery study To the Editors: We would once again like to call the attention of your readers to the review article by Richardson et al. (Midforceps delivery: a critical review. AM J OBSTET GYNECOL 1983;145:621). We believe that their review thoroughly presented the problem with midforceps definitions, potential neonatal mortality and morbidity, as well as an objective evaluation of the data (or lack of data) in regard to continued judicious use of midforceps deliveries in the 1980s. They discussed the design deficiencies in the collaborative perinatal project as a whole, as well as in reports in which a small subgroup of project patients were analyzed for specific aspects of neonatal outcome in relation to only a few of the many potential variables, that is, arrest and descent disorders, and spontaneous versus lowor midforceps delivery. Perhaps more importantly, even if all of the potential variables listed by Richardson et al. were controlled for, the collaborative project patients did not have continuous electronic fetal monitoring. We would clearly anticipate a worse immediate neonatal outcome in terms of Apgar scores, neonatal acidosis, etc., when the indication for either midforceps or cesarean delivery is fetal distress as compared to an arrest of descent. Indeed, we reported significantly lower Apgar scores and umbilical cord pH’s (less than 7.2) in both midforcep and cesarean deliveries performed for fetal distress versus arrest of labor disorders.’ The recent condemnation of midforceps deliveries of Friedman et al.” must be carefully reconsidered before acceptance inasmuch as they presented no data regarding the predelivery status of these neonates as reflected by the intrapartum fetal heart rate, presence or absence of late or severe variable decelerations, and/ or variability. This is by far the most commonly used method for ascertaining intrapartum fetal well-being in the 198Os, a technology not used during the collection of the collaborative perinatal project data. Thus Friedman et al. provided us with no information regarding the status of these neonates before their delivery by either cesarean section or lowor midforceps. The analysis of neonatal outcome in regard to arrest or protraction disorders and type of operative delivery has many variables, as Richardson et al. reported. In our opinion one must ensure that all fetuses began the actual delivery process in a reasonably similar state of well-being before condemning a particular method of delivery. Today this is routinely and best accomplished by continuous electronic fetal heart rate and pattern monitoring. The data of the collaborative project did not address this most important variable and, in our opinion, their ability to be used for such purposes has been exhausted. One must seriously question whether the data base of the perinatal collaborative group, rather than the midforceps delivery, is not the real obstetric anachronism. John C. Hauth, M.D. Larry C. GiLstrap III, M.D. Gary D. V. Hankins, M.D. Department of Obstetrics and Gynecology Wilford Hall USAF Medical CenterlSGHPG Lackland Air Force Base, Texas 782365300