4th Degree Perineal Lacerations Research Articles

Forceps vs. vacuum: Which is associated with the greatest morbidity?

AARON B. CAUGHEY, PER SANDBERG, MARYA ZLATNIK, JULIAN T. PARER, MARIPAULE THIET, RUSSELL K. LAROS JR, University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, California Pacific Medical Center, Obstetrics and Gynecology, San Francisco, California 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 dystocia, but greater perineal lacerations. STUDY DESIGN: This is a retrospective cohort study of 4120 term, cephalic, singleton, operative vaginal deliveries at a single institution. Outcomes examined included rates of shoulder dystocia, perineal and cervical lacerations, and neonatal trauma. Potential confounders including maternal age, birthweight, ethnicity, parity, gestational age, station at delivery, episiotomy, attending physician, anesthesia, and lengths of 1st and 2nd stages of labor were controlled for using multivariate logistic regression. RESULTS: In the study population, there were 2045 (49.6%) forceps and 2075 (50.4%) vacuum assisted deliveries. Of note, the rate of shoulder dystocia was higher among women undergoing vacuum assisted delivery (3.5% vs. 1.5%, P! .001). Other differences are reported in the table below. These differences in perinatal complication rate persisted when controlling for the confounders listed above with adjusted odds ratio for shoulder dystocia being 3.05 (95% CI 1.85– 5.04), and 3rd or 4th degree lacerations being 0.65 (95% CI 0.55–0.75) when comparing vacuum to forceps. CONCLUSION: Vacuum assisted vaginal birth is more often associated with shoulder dystocia and cephalohematoma. Forceps delivery is more often associated with 3rd and 4th degree perineal lacerations as well as cervical lacerations. These differences in complications rates should be considered among other factors when determining the optimal mode of delivery.

How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes?

The purpose of this study was to examine maternal and neonatal outcomes in relation to lengthening intervals of the second stage of labor. This is a retrospective cohort study of 15,759 nulliparous, term, cephalic, singleton births at the University of California, San Francisco, between 1976 and 2001. The second stage of labor was divided into 1-hour intervals. Maternal and neonatal outcomes were compared with the use of chi-squared and Student t tests, and a probability value of < or =.05 was used to indicate statistical significance. Potential confounders were controlled for with multivariate logistic regression. Increasing rates of cesarean delivery, operative vaginal delivery, and perineal trauma were associated with the second stage beyond the first hour. In multivariate analysis, the >4-hour interval group had higher rates of cesarean delivery (odds ratio, 5.65; P < .001), operative vaginal deliveries (odds ratio, 2.83; P < .001), 3rd- or 4th-degree perineal lacerations (odds ratio, 1.33; P = .009), and chorioamnionitis (odds ratio, 1.79; P < .001). There were no differences in neonatal acid-base status associated with length of second stage. However, there were fewer neonates with a 5-minute Apgar score of <7 (odds ratio, 0.45; P = .01). Although the length of the second stage of labor is not associated with poor neonatal outcome, a prolonged second stage is associated with increased maternal morbidity and operative delivery rates.

Transverse arrest: a review of outcomes of rotational forceps and cesarean delivery at a single center

Objective: To assess whether Kielland forceps rotational delivery causes a significant increase in maternal or perinatal morbidity in comparison with cesarean delivery in the clinical situation of transverse arrest. Rotational forceps delivery has been reported to have unacceptably high maternal and neonatal complication rates when compared with either spontaneous vaginal delivery or non-rotational forceps delivery. Clinically, however, we considered the more relevant comparison between Kielland rotational forceps delivery and cesarean delivery as these are generally the two modes of delivery for the fetus in transverse arrest. Study Design: The charts of all the mothers delivered by Kielland forceps or cesarean delivery for the main indication of transverse arrest between July 1995 and June 1996 were reviewed. The following were evaluated: Apgar scores at 1 and 5 minutes, cord pH, birth weight, neonatal superficial facial laceration or bruising, bone or nerve injuries, maternal injuries, 3rd and 4th degree perineal or vaginal lacerations, post-partum fever. Statistical analysis was by χ 2 (for Apgar scores), two-tailed Fisher Exact test (for post-partum fever), and t test (for birth weight and cord pH). A P value < .05 was considered statistically significant. Results: Fifty-two Kielland forceps and 30 cesarean deliveries were performed. One-minute Apgar scores of less than or equal to 7 were noted in 11.5% and 6.7% of the forceps and cesarean section groups, respectively ( P = NS); mean arterial cord pH was 7.26 for both groups; no cases of post-partum fever were noted in the forceps versus 16% in the cesarean group ( P < .05); the mean weight was 3,316 and 3,569 g for the forceps and cesarean group, respectively ( P < .05). The Kielland group was also characterized by the following: 19 facial bruising and 2 temporary facial nerve injury (resolved by the time of discharge), 3 perineal lacerations, and 3 vaginal tears. No blood transfusions were required for either group. Conclusions: To our knowledge, this is the first study that compares rotational forceps delivery for transverse arrest with its true clinical alternative, cesarean delivery. No significant difference in cord pH and Apgar scores were noted between the two groups. The birth weight was greater and post-partum fever was more common in the cesarean section group. Neonatal facial bruising, temporary facial nerve palsy, and maternal perineal and vaginal lacerations were more common in the forceps groups. This study suggests that rotational forceps may be a reasonable alternative to cesarean delivery in the management of transverse arrest.

Is a prior 3RD or 4th degree perineal laceration a risk factor for subsequent extensive obstetrical lacerations

Is a prior 3RD or 4th degree perineal laceration a risk factor for subsequent extensive obstetrical lacerations

Episiotomy

The obstetric literature was reviewed to assess the risk of episiotomy dehiscence and rectovaginal fistula formation from routine episiotomy, with and without third- and fourth-degree laceration into the rectal sphincter or rectal mucosa, respectively. Strong evidence suggests that elective episiotomy predisposes to severe 3rd and 4th degree perineal lacerations and that episiotomy dehiscence with rectovaginal fistula formation is strongly related to 3rd and 4th degree perineal lacerations.