Deep Transverse Arrest Research Articles

Fetomaternal Outcomes in Epidural Analgesia during Labour: A Double-Arm Randomised Control Study

Background: Childbirth is undoubtedly one of the most challenging experiences a woman will ever go through. The use of analgesia during labor that is effective and safe has always been a topic of debate, alongside misconceptions and discussions about labor pain management. The objective of this study was to assess the impact of Epidural Analgesia (EA) on both the woman and the fetus during labor, as well as to compare the fetomaternal outcomes between the control and epidural groups. Materials and Methods: This study was a two-year, double-arm, randomized controlled trial conducted at the Department of Obstetrics and Gynecology, VIMSAR, Burla, between November 2018 and October 2020. Prior to participating in the study, all participants provided written informed consent, and strict confidentiality was maintained for all patient-related data throughout the investigation. Results: The results indicated that epidural pain management had no effect on the duration of the second stage of labor, which was similar in both groups (p=0.1). Cesarean section was performed for 7.3% of the analgesia group. Prolonged labor was observed in 50% of the women, fetal distress in 25%, and deep transverse arrest in 25%. Due to fetal jeopardy, three out of 55 expectant women in the control group underwent emergency caesarean sections. Conclusion: In conclusion, lumbar epidural analgesia, when administered by a skilled practitioner, offers a safe analgesic technique. This study supports its use as a recommendation for all women undergoing normal labor.

ASSESSMENT OF INDICATIONS OF LOWER SEGMENT CESAREAN SECTION AT TERTIARY CARE CENTER: A RETROSPECTIVE STUDY

Background: Cesarean section (CS) is one of the most common and widely performed surgical procedures in obstetrics in India and Worldwide. It is mainly evolved as a lifesaving procedure for mother and fetus during the difficult delivery. To study, various indications for the lower segment CS at our tertiary care center were the objective of the present study. Methods: This is a descriptive, retrospective study of all the patients who were underwent CS in the Department of Obstetrics and Gynecology, Jhalawar Medical College, Jhalawar from January 1, 2021, to March 31, 2021 for the duration of 3 months. Data of patients who delivered by C-Section in our hospital during the defined study period were recorded and a statistical analysis was done for various indications of the lower segment CS (LSCS). Results: The total numbers of women delivered by CS over the study period were 806 among these 339 (42.05%) patients were primiparous and 467 (57.95%) were multiparous. 550 (68.23%) cases were from age group 20–25 years and 153 (18.98%) were had age group 26–30 years, 20 (2.48%) were from age group below 19 years, and 76 (10.29%) patients were above 31 years age. The previous LSCS was the leading indication to the LSCS (31.14%) followed fetal distress (13.88%), malpresentation 95 (11.78%) (including breech presentation in maximum women (86), transverse and oblique lie (9 each), and face presentation (3)) (11.78%), meconium stained liquor with fetal distress 60 (7.44%), severe oligohydramnios 48 (5.95%), non-progress of labor 32 (3.97%), cephalopelvic disproportion 23 (2.85%), pre-eclampsia 20 (2.48%), obstructed labor 19 (2.35%), big baby 19 (2.35%), pregnancy-induced hypertension 18 (2.23%), maternal request and post-dated pregnancy 15 (1.86%) each, gestational hypertension and eclampsia 11 (1.36%) each, placenta previa 10 (1.24%), induction failure 8 (0.99%), and intrauterine growth retardation and antepartum hemorrhage 7 (0.86%) and 14 (1.73%). Patients had other indications such as Abruptio placentae, gestational diabetes, twin pregnancy, uterine rupture, and deep transverse arrest. Conclusions: In this study, CS rate (40.68%) is found to be higher as compared to other studies and the WHO guidelines. CSs rate is high probably because Jhalawar Medical College, Jhalawar acts as a government tertiary care center. The previous LSCS was a common indication in 31.14% of mothers in present study. Besides, previous LSCS, fetal distress, malpresentation (Breech presentation/transverse lie, oblique lie, and face presentation) MSL with fetal distress, and severe oligohydramnios were the common indications for LSCS, which are seen in the present study.

Pathological post-obstructive diuresis following obstructive uropathy due to constipation in the post-partum period: a case report

BackgroundConstipation during pregnancy is not uncommon. Usually, this does not warrant extensive evaluation and settles with minor interventions or lifestyle modifications. Severe fecal impaction in chronically constipated patients can rarely lead to obstructive uropathy. Relief of obstruction can result in a diuretic phase which may be self-limiting or pathological. However, occurrence of pathological post-obstructive diuresis as a result of severe constipation is an extremely rare complication during pregnancy and puerperium which can even be fatal if not promptly diagnosed and adequately monitored and timely intervened. We describe the management of a pathological post-obstructive diuresis which occurred in the immediate postpartum period after treatment of severe constipation and obstructive uropathy.Case presentationA woman who had undergone an emergency caesarean section due to deep transverse arrest 1 week ago, presented with fecal impaction and anuria. On relief of urinary obstruction which had developed secondary to fecal impaction, she developed pathological post-obstructive diuresis. Careful and timely monitoring with exact fluid replacement, correction of electrolyte imbalances and multidisciplinary care ensured complete recovery of the patient.ConclusionsDespite obstructive uropathy being uncommon in obstetric practice, clinicians need to have a high index of suspicion to monitor and promptly manage the potentially life-threatening condition of post-obstructive diuresis in pregnant and puerperal women undergoing urinary tract decompression. Due to unreliability of laboratory cutoff values in pregnancy and puerperium, a more vigilant and multidisciplinary approach with lower threshold for intervention is more prudent in the management of these patients.

Prediction of significant hyperbilirubinemia in term neonates by early non-invasive bilirubin measurement.

Neonatal jaundice is a common problem. We evaluated the utility and best cut-off values of 24-and 48-hour transcutaneous bilirubin indices (TcBI) in predicting subsequent significant hyperbilirubinemia and evaluated various associated maternal and fetal risk factors. TcBI at 24 and 48 hours and serum bilirubin levels at 72 hours of age were obtained for healthy, term, appropriate for gestational age neonates. Neonates with prematurity, birth weight <2500 g, ABO or Rh incompatibility, onset of clinical jaundice <24 hours, clinical suspicion of septicemia, positive pressure ventilation at birth, admission in neonatal intensive care unit and contraindications for BiliChek were excluded. Twently-four and 48-hour TcB indices were assessed as predictors of subsequent hyperbilirubinemia, defined as serum bilirubin >17 mg/dL after 72 hours of life and various cut-offs, and were evaluated by calculating sensitivity, specificity and predictive values. Of 500 newborns, 4.6% had significant hyperbilirubinemia, 27% had TcBI (mg/dL) <5 at 24 hours, and 27.4% had TcBI <8 at 48 hours. None of them had subsequent hyperbilirubinemia (100% negative predictive value). The percentage of newborns with subsequent hyperbilirubinemia increased from 3.4% to 13.2% as their 24-hour TcBI increased from 6 to above 9 mg/dL and from 4.2% to 7.4% as their 48-hour TcBI increased from 8 to above 11 mg/dL. The best cut-off value was TcBI (mg/dL) 7 (odd ratio=4.86, 95% confidence interval: 1.66-15.22) at 24 hours and 10 (odd ratio=2.87, 95% confidence interval: 1.04-8.29) at 48 hours. Area under the receiver operating characteristic curve for 24- and 48-hour measurements was 0.750 and 0.715, respectively. Maternal premature rupture of membranes, deep transverse arrest, post-date pregnancy, and fetal distress were significant risk factors for hyperbilirubinemia. Twenty-four and 48-hour TcB indices are good predictors of subsequent hyperbilirubinemia. Twenty-four-hour TcBI had better predictive ability than 48-hour TcBI.

Fetomaternal Outcome in Cesarean Sections Done in Second Stage of Labor

Objective: To study the fetomaternal outcome in cesarean sections done in second stage of labor. Method: It is a prospective observational study of 26 cases of cesarean sections done in second stage of labor in Adichunchanagiri institute of medical sciences from January to September 2014. Result: There were 1533 deliveries including 468 cesarean sections in the study period. The cesarean rate was 30%. Of 468 cases 26 were performed in second stage of labor contributing 1.6% of total deliveries and 5.5% of all cesarean sections. Most common indication for cesarean section in second stage of labor is deep transverse arrest. Second stage cesarean sections are associated with increased risk of atonic PPH requiring surgical management (7.69%), lower segment tears including angle extension and broad ligament hematoma(15.38%) along with other complications like extraction difficulty, post operative fever, wound sepsis, longer duration of hospital stay. Meconium stained amniotic fluid is present in 30.76% cases. Though timely second stage ceserean sections reduce perinatal mortality few complications like neonatal hyperbilirubinemia occur. Conclusion: Cesarean sections done in second stage of labor are associated with increased intra-operative maternal complications and neonatal morbidity. Theme: Healthy mother, healthy baby: Timely intervention to reduce fetomaternal complications. Key words: Cesarean section, Second stage of labor, Maternal morbidity, Complications

Factors predicting Success of Vaginal Birth after Cesarean Section

ABSTRACT Aim The aim of this article is to study the various factors that can predict the success of vaginal birth after cesarean (VBAC) section. Materials and methods A retrospective cohort study of deliveries was conducted from 1 January 2014 to 31 December 2014 by the Department of Obstetrics and Gynecology in our hospital. Patients with previous low transverse cesarean section who had undergone a trial of labor were identified. Maternal inpatient and prenatal records were reviewed in all eligible subjects. During labor, uterine activity and fetal heart rate were monitored. When indicated, oxytocin or prostaglandin E2 was used for induction of labor according to Bishop score. Emergency cesarean delivery was considered in cases with the appearance of scar tenderness, fetal distress, nonprogress of labor, and deep transverse arrest. Results A total of 200 women were eligible for VBAC, but after written informed consent, 131 (65.5%) subjects were given trial of labor at term after one prior cesarean delivery among 3,604 deliveries while 69 (34.5%) subjects opted for elective repeat cesarean section. The overall VBAC success rate was 63.3% (76 of 120) in our study. History of spontaneous labor (p = 0.042) and history of previous vaginal delivery (p = 0.038) were found to be significantly associated with increased chance of success of VBAC, and lesser interdelivery interval was not found to be associated with decreased success rate (p = 0.096). Neither indication of previous cesarean nor birth weight of newborn (&gt;3 kg) was found to be related to the success of VBAC. Conclusion Vaginal birth after cesarean section is a safe practice as long as it is offered with a proper selection of candidates with factors having a high success rate. Physicians need to be aware of factors having a good outcome before counseling mothers so that failure rates decrease and successful VBAC is increased. How to cite this article Verma ML, Nisha S, Singh U, Sankhwar PL, Qureshi S. Factors predicting Success of Vaginal Birth after Cesarean Section. J South Asian Feder Obst Gynae 2016;8(3):198-201.

Anaesthetic management of parturient with malaria and thrombocytopaenia.

Malarial infection during pregnancy is a significant public health problem with substantial risk for the pregnant woman and newborn child. Globally, 125 million women are at risk every year. In Sub-Saharan Africa, 23 million pregnant women are exposed to malarial infection annually and approximately 400,000 pregnant women develop moderate to severe anaemia.[1] We report successful perioperative management of case of Plasmodium vivax infection in full-term parturient who presented with thrombocytopaenia and deep transverse arrest and subsequently developed right occipito-parietal haematoma with mass effect.

Transverse occiput position: Using manual Rotation to aid Normal birth and improve delivery OUTcomes (TURN-OUT): A study protocol for a randomised controlled trial.

BackgroundFetal occiput transverse position in the form of deep transverse arrest has long been associated with caesarean section and instrumental vaginal delivery. Occiput transverse position incidentally found in the second stage of labour is also associated with operative delivery in high risk cohorts. There is evidence from cohort studies that prophylactic manual rotation reduces the caesarean section rate. This is a protocol for a double blind, multicentre, randomised, controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate.Methods/DesignEligible participants will be ≥37 weeks pregnant, with a singleton pregnancy, and a cephalic presentation in the occiput transverse position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 49%, for a reduction to 35%, an alpha value of 0.05 and a beta value of 0.2, 416 participants will need to be enrolled. Participants will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery. Secondary outcomes will be caesarean section, significant maternal mortality and morbidity, and significant perinatal mortality and morbidity.Analysis will be on an intention-to-treat basis. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, (protocol number: X110410).DiscussionThis trial addresses an important clinical question concerning a commonly used procedure which has the potential to reduce operative delivery and its associated complications. Some issues discussed in the protocol include methods of assessing risk of bias due to inadequate masking of a procedural interventions, variations in intervention efficacy due to operator experience and the recruitment difficulties associated with intrapartum studies.Trial registrationThis trial was registered with the Australian New Zealand Clinical Trials Registry (identifier: ACTRN12613000005752) on 4 January 2013.

Kielland's forceps: demise before the 100th anniversary?

To the Editor: As the time for the centennial of the Kielland’s forceps approaches, one ponders: will this elegant instrument have its demise before its 100th anniversary? Introduced in 1915 by Dr Christian Kielland, a Norwegian obstetrician, for the “deep transverse arrest,” it evolved into the instrument of choice for arrest of descent with occipito-transverse or occipito-posterior position of a cephalic presentation.1.Patterson W.R. The Kielland forceps.Can Med Assoc J. 1928; 18: 177-180PubMed Google Scholar The malpresenting baby would often not be large, as opposed to a non-malpresenting baby that would usually be large to have arrested in the first place. With a high likelihood of failure with attempts at manual rotation or a rotational vacuum, the Kielland’s forceps became an ideal instrument for facilitating a vaginal birth for fetal malposition in cephalic presentation. The relatively straight handle with a gentle backward pelvic curve and a sliding lock were ingenious additions to the obstetric forceps design, allowing easy application to a severely asynclitic head. Further, this design, when combined with the Scanzoni manoeuvre, allowed rotation of up to 180 degrees within the tight constraints of the maternal pelvis due to a relatively small circle of rotation. Given the usual normal-sized baby being delivered, once the head could be successfully rotated, most skilled users would agree that the risk of a significant perineal laceration was small. However, the last decade has witnessed a rapid decline in the use of Kielland’s forceps.2.Ramin S.M. Little B.B. Gilstrap 3rd., L.C. Survey of forceps delivery in North America in 1990.Obstet Gynecol. 1993; 81: 307-311PubMed Google Scholar, 3.Vacca A. Current obstetric training programs are unlikely to provide registrars with sufficient skill in the safe use of Kielland forceps.Aust N Z J Obstet Gynaecol. 2000; 40: 226-227Crossref PubMed Google Scholar This can be attributed to concerns regarding poor neonatal outcomes that were associated with the use of Kielland’s forceps.4.Patel R.R. Murphy D.J. Forceps delivery in modern obstetric practice.BMJ. 2004; 328: 1302-1305Crossref PubMed Scopus (95) Google Scholar In the litigious field of obstetrics, it was tempting to give up a controversial practice for the easier option, the Caesarean section. Given the medico-legal climate, although North American centres were slow in adopting the use of Kielland’s forceps, they were quicker to let it go. However, more recent evidence suggests that the concerns regarding neonatal outcomes may have been misplaced. A retrospective review of deliveries at a tertiary care centre over a four-year period compared the use of Kielland’s forceps, rotational ventouse and emergency Caesarean section.5.Tempest N. Hart A. Walkinshaw S. Hapangama D.K. A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour.BJOG. 2013; 120: 1277-1284Crossref PubMed Scopus (72) Google Scholar With a 25% Caesarean section rate and a 13% operative vaginal delivery rate, a cohort of approximately 1300 cases that reached full cervical dilatation with fetal malposition was identified. With an intention-to-treat analysis, 80% had an attempted Kielland’s rotation, 8% had an attempted rotational ventouse, and 11% had an emergency Caesarean section. The likelihood of needing a Caesarean section was eight-fold higher if a ventouse was used as opposed to the Kielland’s forceps. Failure of delivery with Kielland’s occurred in 4% of cases. Other than a trend towards an increased rate of shoulder dystocia, no increase in adverse outcomes was noted.5.Tempest N. Hart A. Walkinshaw S. Hapangama D.K. A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour.BJOG. 2013; 120: 1277-1284Crossref PubMed Scopus (72) Google Scholar However, obstetric practice changed before the evidence relating to the long-term outcomes of babies could become available,6.Kotaska A. Menticoglou S. Gagnon R; SOGC Maternal Fetal Medicine Committee. Vaginal delivery of breech presentation. SOGC Clinical Practice Guideline no. 226, June 2009.J Obstet Gynaecol Can. 2009; 31 (567–78): 557-566Abstract Full Text PDF PubMed Scopus (72) Google Scholar leaving a generation of obstetricians who are untrained in the science and art of a rotational forceps delivery. With increasing Caesarean section rates and associated maternal morbidity and mortality, we need ongoing efforts to find viable alternatives to Caesarean section. This leads to the question: is it time to revive the Kielland’s forceps delivery before it is too late? Or should we helplessly watch this endangered species disappear and become a part of the annals of the history of medicine?

Intra-operative Maternal Complications of Emergency Cesarean Section Done in Advanced Labor

Abstract Background: Emergency cesarean section done in advanced labor is a big challenge in obstetrics due to increased risk of intraoperative complications. In the last decade, a rapid increase in cesarean section done in advanced labor has been observed. Difficult deli-very of the fetal head during cesarean section carries a high risk of intraoperative complications like cervical and uterine tears, intra operative hemorrhage and trau-ma to the baby. Objectives: The purpose of this study is to find out the frequency and risk factors for intra-operative com-plications in emergency cesarean section done in adva-nced labor, so that appropriate management protocols can be planned to reduce these complications. Study Design: Prospective cohort study. Materials and Methods: This prospective study was carried out in Obstetrics and Gynecology Unit - 2 of Services Institute of Medical Sciences, Services Hos-pital, Lahore; from 1 st January 2007 to 31 st December 2007. All patients undergoing emergency cesarean sections done on laboring mothers were included in the study. The sample was divided into two groups; emergency C-section done in advanced labor as the study group and emergency C-section in early labor as the control group. Data were collected regarding age, parity, booked or unbooked status, indications for ces-arean section, level of competence of operating sur-geon, intra-operative complications and the risk factors for these complications. Data were recorded on a stru-ctured proforma and compared between the two gro-ups. Statistical Analysis: Data were analyzed using com-puter programme SPSS Version 14 for windows appl-ying student t-test for quantitative and chai square test for qualitative parameters. A p-value < 0.05 was used as statistically significant. Results: Out of 2064 total deliveries in the year 2007, 1290 (62.5%) were vaginal deliveries and 774 (37.5%) were C-Sections. Out of 774 C-Section, 174 (23%) were elective and 600 (77%) were emergency. Out of 600 emergency C-sections, 402 (59%) were done on laboring mothers and 198 (41%) were done on non-laboring mothers for indications like placenta previa, eclampsia, etc. Out of 402 C-sections done on laboring mothers, 241 (60%) were done in advanced labor and 161 (40%) in early labpr. The intra-operative compli-cation rate was 19.8% versus 11% (p-value 0.001) in the study and control group respectively. The main indications for cesarean section in labor were prolonged labor, deep transverse arrest of fetal head and fetal distress. The main complications noticed were the cer-vico - uterine lacerations and intra-operative hemorr-hage. Factors associated with increased maternal com-plications were; un-booked cases (p-value 0.01), stat-ion of the fetal head (p-value 0.02), good size baby (p-value 0.01) and experience of surgeon (p-value 0.04). Conclusion: Emergency cesarean section done in advanced labor is a high risk operation with significant maternal morbidity in terms of cervico - uterine tears and intra-operative bleeding. Key Words: Emergency cesarean section, advanced labor, maternal complications, cervicouterinetears, intraoperativehemorrhage.

Direct hyperbilirubinemia caused by severe subgaleal hemorrhage with ischemic liver injury

1,2 The prognosis of neonates born with asphyxia can be poor if it is associated with underlying anemia, coagulopathy, metabolic acidosis, or renal impairment. Hemolytic indirect hyperbilirubinemia is one of the minor complications of SGH. 3 We report on a patient who presented with severe direct hyperbilirubinemia after receiving acute intensive therapy such as massive transfusion and continuous hemodiafiltration. Typically, indirect bilirubin levels increase in hemolysis alone, but underlying ischemic liver injury resulting from systemic hypoperfusion was considered to be the likely cause of direct hyperbilirubinemia in the present patient. The pathogenetic mechanism of this condition and the management are discussed. Case report A girl was born at 41 weeks 4 days gestation, weighing 3656 g, by spontaneous vaginal delivery. The mother was 45 years old with a history of five pregnancies and five live births, of which the first delivery was by cesarean section and four were vaginal. The third boy had acute subdural hematoma of unknown cause at 1 week of age and died of aspiration pneumonia during the chronic stage. He had no definite bleeding diathesis. The mother’s blood type was O positive and she had experienced rubella. Hepatitis B surface antigen and a serologic test for syphilis and rubella were negative. No abnormality was noted during the course of the pregnancy, but her second delivery stage was delayed due to persistent deep transverse arrest, and fetal heart rate began to decrease just before birth. Because the fetal head did not come down after several attempts of vacuum extractions, forceps were used to achieve vaginal delivery.

The use of Kielland's forceps and obstetricians' anxiety trait

SummaryThere is very limited literature available on the use of Kielland's forceps in the management of deep transverse arrest, and currently no studies looking at the correlation between obstetricians' personality traits and Kielland's forceps use. This study, therefore, aims to explore this relationship. All practicing consultant obstetricians in Wales received a postal invitation, including a psychometric questionnaire. The results showed that 32.7% currently use Kielland's compared with 36.7% who have never used Kielland's forceps. The remainder (30.6%) have used Kielland's in the past, but have since abandoned their use. Anxiety levels were actually lowest in those consultants who have never used Kielland's and highest in those who have abandoned their use. This could reflect the fact that Kielland's users tend to be the more senior consultants, who have perhaps become discouraged by recent changes in practice.

Postpartum obturator neuropathy

A previously well 34-year-old woman sought treatment postpartum for left leg weakness. Several hours after labor onset, pain was noticed in the left groin and medial thigh. Epidural anesthesia was commenced via the L3/L4 interspace. The pain resolved within 15 minutes. A deep transverse arrest occurred, and semi-urgent cesarean section was performed without complication. Difficulty in left leg adduction was apparent the following day with walking requiring assistance. Bladder, bowel, and contralateral leg function were normal. Examination revealed profound weakness of left thigh adduction only. Knee and ankle reflexes were normal bilaterally with flexor plantar responses. The left adductor reflex was significantly reduced, whereas the right was easily elicited. A small area of decreased pinprick sensation was present over the medial left thigh. MRI of the lumbosacral spine was performed 5 days postpartum with no evidence of lumbar nerve root compression. Three weeks later, significant weakness of left thigh adduction remained. The adductor reflex was more …

A matched controlled study of Kielland's forceps for transverse arrest of the fetal vertex

This study attempted to determine whether delivery with Kielland's forceps for deep transverse arrest is less favourable than other instruments. One hundred and forty-six women who underwent rotation and delivery with Kielland's forceps between 1994 and 1997 were matched by parity and birth weight to one of two control groups: delivery by non-rotational forceps or the vacuum extractor. No significant differences were found in maternal or neonatal outcome (vaginal lacerations, 3rd- or 4th-degree perineal tears, postpartum haemorrhage, fever, blood transfusion, duration of hospitalisation, Apgar score, asphyxia, scalp trauma, admission to the intensive care unit or neonatal hospitalisation). The incidence of heart rate abnormalities prior to instrumental delivery was similar. The 'failure to deliver' rate (8·9% after Kielland's forceps) was not different to the 7·5% and 6·8% found in each control group. These data indicate that the outcome after Kielland's forceps delivery is similar to other instrumental deliveries if performed by experienced obstetricians.

Operative vaginal delivery: A survey of fellows of ACOG

To document operative vaginal delivery rates of ACOG Fellows and to stratify practice patterns with regard to mid-pelvic delivery and deep transverse arrest by the time elapsed since residency. A survey was mailed to a random sample of 1600 ACOG Fellows. Of the 597 respondents (37%), 558 who still practice obstetrics formed the study group. Selection bias regarding recipients of the survey was reduced by randomization by an uninvolved third party. The length of time since residency was categorized as 10 years or fewer ("recent," 31%), 11-20 years ("intermediate," 43%), and more than 20 years ("remote," 26%). The majority of respondents (338 of 558, 61%) reported an operative vaginal delivery rate of 15% or less. One hundred forty-two (25%) use only forceps, whereas 78 (14%) use vacuum extraction exclusively. More than half have abandoned mid-pelvic operative vaginal deliveries, and of the 41% who still perform these operations, about half use forceps. In cases of deep transverse arrest, about 25% perform cesarean delivery, whereas 26% and 42% use forceps or vacuum, respectively. Resident training and practice in vacuum delivery were more common in the recently trained groups (recent > intermediate > remote; P < .001). There were no differences among the groups with respect to attempting mid-pelvic operative vaginal delivery (P = .29), but the remote group was more likely to use forceps, whereas the recent group was more likely to use vacuum (P = .039). A large disparity existed among the groups regarding the management of deep transverse arrest, with vacuum use associated with group assignment (P < .001). The majority of respondents have an operative vaginal delivery rate of no more than 15%. Most respondents have abandoned mid-pelvic operative vaginal delivery. Practice patterns reflect differences in residency training; the more recently trained Fellows more often were taught and use vacuum for delivery.

Forceps and vacuum delivery: A survey of North American residency programs

To document resident instruction in operative vaginal delivery by forceps and vacuum. A survey was sent to all 291 obstetrics-gynecology training programs in the United States and Canada. The overall response rate was 72% (210 of 291). Most programs (60%) have an operative vaginal delivery rate of 10% or less. Nearly all of the responding programs (199 of 209, 95%) teach operative vaginal delivery via the vacuum route; metallic cups are used in only 14% of centers. Forceps are the primary instrument in most programs (68%), but nearly one-third of responding centers use the vacuum method more often than forceps. Instruction in midpelvic operative vaginal delivery is offered in 64% of the programs, with forceps being more common by nearly a two-to-one ratio. Deep transverse arrest is handled initially by forceps by half of the respondents, whereas 28 and 22% would proceed with cesarean or attempt a vacuum extraction, respectively. Instruction in both types of operative vaginal delivery is found in most programs. The forceps are used more commonly, but vacuum is the preferred instrument in about one-third of training programs. Instruction in midpelvic delivery is offered in 64% of programs, but we noted a declining trend.

Mode of delivery in deep transverse arrest

OBJECTIVES: To determine the trends in the mode of delivery in deep transverse arrest (DTA) over two decades and their impact on maternal morbidity and neonatal outcome. METHODS: Obstetric and neonatal records of women with DTA who delivered at Nehru Hospital, PGIMER, Chandigarh in the years 1970, 1980 and 1990 were analyzed. RESULTS: Although Kielland's forceps was used very frequently in 1970 (44.4%) it had disappeared by 1990 because of increased morbidity associated with it. Instead, use of vacuum extractor and cesarean section has increased over the years. Manual rotation forceps extraction was the most commonly used vaginal method of delivery over two decades (49.5%). Perinatal outcome was better with manual rotation forceps extraction or vacuum extraction as compared to Kielland's forceps. Cesarean section was associated with a high incidence of birth asphyxia (30%). CONCLUSIONS: Manual rotation forceps extraction and vacuum extraction are safe methods of delivery in DTA. Cesarean section as an alternative does not improve the perinatal outcome.

Assessment of motor blockade during epidural analgesia in labour

Increasing doses of local anaesthetics provided for prolonged epidural analgesia in labour cause progressive motor blockade. 1 There are four possible adverse consequences of significant motor block in labour, Weakness of the muscles involved in active pushing may lead to a rise in the instrumental delivery rate. :''a Moreover, relaxation of the pelvic floor may cause deep transverse arrest necessitating rotational delivery# Recently muscular relaxation in the back has been implicated in the aetiology of long-term backache following childbirth, s Poor posture during labour coupled with motor block and the abolition of pain by effective epidural analgesia, may cause back strain. Finally leg weakness and reduced mobility may be distressing for the mother. 6

Kielland's Forceps for Deep Transverse Arrest

AbstractThis is a retrospective analysis of 165 deliveries conducted for deep transverse arrest at the Postgraduate Institute of Medical Education and Research, Chandigarh over a period of five years from January, 1974 to December, 1978. The maternal and foetal outcome in 109 cases following a Kielland's forceps delivery were compared with 56 cases delivered by manual rotation and forceps. However, there was no significant difference in the maternal and foetal outcome in the two groups, except for a significantly higher incidence of cephalohaematoma with manual rotation and a forceps delivery as compared to a Kielland's forceps delivery (p &lt; 0.01).

Further Experience with Continuous Caudal Analgesia in Obstetrics

Abstract 1. 1. Continuous caudal analgesia was attempted in 1,639 obstetric patients. Complete relief from pain was obtained in 1,525 patients. Forty patients had only partial relief from pain while seventy-four had no relief. Anatomical malformation was the main reason for the partial and complete failures. 2. 2. Early correction of occiput-posterior position and deep transverse arrest account for the increase in major operative deliveries and not the analgesic method used. Such early correction prevents soft tissue trauma, prevents pelvic relaxations and displacements and intracranial damage in the fetus. 3. 3. There was a higher percentage of major operative deliveries when continuous caudal analgesia was used. The complications during and following delivery, however, were much fewer than those found in the cases in which the major operative procedures were done with other forms of anesthesia. 4. 4. There is no delay in initiation of fetal respiration. Fetal distress is very rare. Ten stillbirths occurred; six were suspected before the analgesia was started and were confirmed by presence of maceration. Four stillbirths were due to obstetrical trauma. 5. 5. Some of the minor complications to the mother have been noted and discussed. There was one maternal death which occurred after delivery and after six hours of uneventful continuous caudal analgesia. It is doubtful that this method of analgesia was the cause of this death.