The Impact of a Trial of Instrumental Delivery in Theatre on Neonatal Outcome

Abstract

The impact of a trial of instrumental delivery in theater on maternal and infant outcomes was examined in a prospective observational study of 229 consecutive deliveries utilizing ventouse (n = 134) or forceps (n = 95) because of either fetal distress or dystocia. All participants underwent instrumental delivery of a viable singleton pregnancy. The major outcome measures were the decision-to-delivery interval (DDI), mode of delivery, and the infant’s condition at birth. Sixty deliveries, just over one-fourth of the total, were managed as a trial in theater, 46 of them because of a prolonged second stage of labor (malposition being a factor in 39 instances) and 14 because of fetal distress. The mean DDI for these 60 deliveries was 59 minutes, compared with 21 minutes for 169 deliveries taking place in the labor room (P < 0.0001). All but one of these 169 deliveries took place within 45 minutes. One cesarean section was performed at 60 minutes. Nine women in all underwent cesarean delivery, 8 after a trial in theater. Malposition was a factor in 7 instances. Cord blood gas values were slightly less favorable when delivery followed a trial. These observations indicate that a trial of instrumental delivery takes 2 to 3 times longer than delivery in the labor room. Fetal malposition was the major indication for a trial of instrumental delivery and also the major reason for failed delivery. Based on recent guidelines from the Royal College of Obstetricians and Gynaecologists, at least 47% of labors in this study should have been managed as a trial in theater. The additional delay in delivery could be harmful to a fetus that already is hypoxic. The decision on whether or not to conduct a trial of instrumental delivery should be individualized.