Rate Of Instrumental Vaginal Delivery Research Articles

Twin and Singleton Births in Ghana — A Case-control Study

AbstractAretrospective study involving 623 twin and 1246 singleton births was conducted to compare the two groups with regard to selected maternal, fetal and labor and delivery characteristics and outcomes. Maternal age and parity were significantly higher for twins. The risks of preterm delivery, arrival in the labor ward in second stage of labor, cesarean births and postpartum haemorrhage were significantly higher in twin than in singleton births. In vaginal deliveries twin mothers were significantly less likely to have had episiotomies or perineal lacerations. There was no difference in the duration of the third stage of labor or in the incidence of retained placentae. Antepartum haemorrhage was a less likely indication for cesarean delivery among twins, while there was no significant difference in the likelihood of severe pre-eclampsia/eclampsia being an indication. Singleton babies were significantly heavier than twins. The incidences of malpresentation, low birth weight, stillbirths and of admission of live births to the neonatal intensive care unit were significantly higher in twins. There was no difference in the rate of instrumental vaginal delivery, or in the route of delivery of fetuses presenting by the breech. There is the need for detailed study of the incidences of antepartum haemorrhage and hypertensive diseases in twin and singleton pregnancies and of the factors determining the mode of delivery when such complications arise. Labor and delivery should also be examined to determine any differences between the two groups, especially in the first and second stages.

Unintended effects of epidural analgesia during labor: a systematic review.

Epidural analgesia is used by more than half of laboring women, yet there is no consensus about what unintended effects it causes. To evaluate the state of our knowledge, we performed a systematic review of the literature examining the unintended maternal, fetal, and neonatal effects of epidural analgesia used for pain relief in labor by low-risk women. Our review included randomized and observational studies appearing in peer review journals since 1980. Much of the evidence is equivocal. Existing randomized trials are either small or do not allow clear interpretation of the data because of problems with protocol compliance. In addition, few observational studies control for the confounding factors that result because women who request epidural are different from women who do not. There is considerable variation in the association of epidural with some outcomes, particularly those that are heavily practice-based. Despite this variation, there is sufficient evidence to conclude that epidural is associated with a lower rate of spontaneous vaginal delivery, a higher rate of instrumental vaginal delivery and longer labors, particularly in nulliparous women. Women receiving epidural are also more likely to have intrapartum fever and their infants are more likely to be evaluated and treated for suspected sepsis. There is insufficient evidence to determine whether epidural does or does not tend to increase the risk of cesarean delivery or fetal malposition. Adverse effects on the fetus may occur in the subset of women who are febrile. Women should be informed of unintended effects of epidural clearly supported by the evidence, especially since epidural use is almost always an elective procedure. Further research is needed to advance our understanding of the unintended effects of epidural. Improved information would permit women to make truly informed decisions about the use of pain relief during labor.

Unintended effects of epidural analgesia during labor: A systematic review

Epidural analgesia is used by more than half of laboring women, yet there is no consensus about what unintended effects it causes. To evaluate the state of our knowledge, we performed a systematic review of the literature examining the unintended maternal, fetal, and neonatal effects of epidural analgesia used for pain relief in labor by low-risk women. Our review included randomized and observational studies appearing in peer review journals since 1980. Much of the evidence is equivocal. Existing randomized trials are either small or do not allow clear interpretation of the data because of problems with protocol compliance. In addition, few observational studies control for the confounding factors that result because women who request epidural are different from women who do not. There is considerable variation in the association of epidural with some outcomes, particularly those that are heavily practice-based. Despite this variation, there is sufficient evidence to conclude that epidural is associated with a lower rate of spontaneous vaginal delivery, a higher rate of instrumental vaginal delivery and longer labors, particularly in nulliparous women. Women receiving epidural are also more likely to have intrapartum fever and their infants are more likely to be evaluated and treated for suspected sepsis. There is insufficient evidence to determine whether epidural does or does not tend to increase the risk of cesarean delivery or fetal malposition. Adverse effects on the fetus may occur in the subset of women who are febrile. Women should be informed of unintended effects of epidural clearly supported by the evidence, especially since epidural use is almost always an elective procedure. Further research is needed to advance our understanding of the unintended effects of epidural. Improved information would permit women to make truly informed decisions about the use of pain relief during labor. (Am J Obstet Gynecol 2002;186:S31-68.)

Predictors of obstetric intervention rates: case-mix, staffing levels and organisational factors of hospital of birth

We performed a cross-sectional study of all Thames maternity units, 1994-96, including 540 834 live and stillbirths. In contrast to recent media speculation, no association of caesarean section rates with midwifery staffing levels was found after adjustment for confounders. The only association with staffing was with levels of junior obstetric staffing, which could be a reflection of less experienced management of labour. Caesarean section rates were also associated positively with the levels of delivery beds, which could be a reflection of the closer monitoring of labour that may result from increased bed availability. Both caesarean section and instrumental vaginal delivery rates were associated with epidural rates, which was expected from the literature. Variations in epidural rates were mainly associated with variations in demographic case-mix, due possibly to patient demand. Demographic case-mix was also associated with instrumental vaginal deliveries but not the caesarean section rate.

Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial

Epidural analgesia is the most effective labour pain relief but is associated with increased rates of instrumental vaginal delivery and other effects, which might be related to the poor motor function associated with traditional epidural. New techniques that preserve motor function could reduce obstetric intervention. We did a randomised controlled trial to compare low-dose combined spinal epidural and low-dose infusion (mobile) techniques with traditional epidural technique. Between Feb 1, 1999, and April 30, 2000, we randomly assigned 1054 nulliparous women requesting epidural pain relief to traditional (n=353), low-dose combined spinal epidural (n=351), or low-dose infusion epidural (n=350). Primary outcome was mode of delivery, and secondary outcomes were progress of labour, efficacy of procedure, and effect on neonates. We obtained data during labour and interviewed women postnatally. The normal vaginal delivery rate was 35.1% in the traditional epidural group, 42.7% in the low-dose combined spinal group (odds ratio 1.38 [95% CI 1.01-1.89]; p=0.04); and 42.9% in the low-dose infusion group (1.39 [1.01-1.90]; p=0.04). These differences were accounted for by a reduction in instrumental vaginal delivery. Overall, 5 min APGAR scores of 7 or less were more frequent with low-dose technique. High-level resuscitation was more frequent in the low-dose infusion group. The use of low-dose epidural techniques for labour analgesia has benefits for delivery outcome. Continued routine use of traditional epidurals might not be justified.

Epidural analgesia need not increase operative delivery rates

Objective: We sought to examine the relationship between epidural analgesia and cesarean and instrumental vaginal delivery rates. Study Design: This is a retrospective analysis of the first 1000 nulliparous pregnancies in women with a cephalic presentation in spontaneous labor at term in each of 3 different years, over which the epidural rate increased from 10% to 57%. Results: Cesarean and instrumental vaginal delivery rates were similar in all 3 years. Demographic characteristics remained unchanged or altered in a manner that has previously been associated with an increase in intervention. Electronic fetal monitoring and first-stage oxytocin use remained unchanged, but oxytocin use in the second stage increased considerably. Conclusions: Increased use of epidural analgesia had no effect on cesarean delivery rates. Although randomized trials have suggested that it increases instrumental vaginal delivery rates, this might be overcome by active management of labor or judicious use of oxytocin in the second stage. (Am J Obstet Gynecol 2000;182:358-63.)

Outcomes of induced labour.

We report a review of maternal and neonatal outcomes of labour in 1,405 pregnancies managed during a 12-month period. This included all singleton pregnancies of greater than 20 weeks' gestation, excluding women antenatally assigned for Caesarean delivery. Labour was induced in 313 cases (22.3%), and records were available for review in 311 of these. We classified the indications for induction according to the Australian Council of Healthcare Standards (ACHS)/RACOG list of 'defined' indications in Obstetric Clinical Indicator number 1. In 165 cases (53.7%) labour was induced for defined indications. There was no significant difference in the rates of instrumental vaginal delivery, Caesarean delivery or adverse neonatal outcome (admission to neonatal nursery in the first 24 hours of life; 5 minute Apgar score of < 7) between women who laboured spontaneously and those induced for 'nondefined' indications. However, labours induced for 'defined' indications had a significantly increased rate of these outcomes.

Postdate antenatal testing

Objective: To test the effect on pregnancy outcome of a policy of very early commencement of postdate surveillance testing, and induction of labor at 42 weeks. Methods: Retrospective analysis of 2776 consecutive cephalic deliveries at 38–42 weeks of gestation. Management of the postdate pregnancies included twice-weekly antenatal testing beginning at 40 completed weeks and elective induction of labor at 42 completed weeks. Pregnancy outcome parameters were compared between the groups delivered at 38–40 weeks and at 41–42 weeks. Results: There were 2138 pregnancies delivered at 38–40 weeks and 638 at 41–42 weeks. The latter group had a statistically significant increase in the rate of cesarean section, mainly accounted for by an increased rate of fetal distress and failure to progress in labor. Similarly the rate of instrumental vaginal delivery, meconium in labor and macrosomia had a statistically significantly higher incidence in the postdate group. These differences in outcome were already apparent at 41 weeks of gestation. Conclusion: Despite early initiation of fetal surveillance, starting at 40 completed weeks, postdate pregnancies are associated with an increased rate of emergency cesarean section, macrosomia and meconium in labor.

Patterns of use of obstetrical interventions in 12 countries

Recent obstetrical practice trends in 12 countries were surveyed. There was a 3-fold difference in caesarean section rates and a 10-fold difference in instrumental vaginal delivery rates among countries. There was a net increase in the caesarean section rate of all countries over the study period and a net decrease in the instrumental vaginal delivery rate of some countries. There was a decrease in the caesarean section rate during the last year of observation in Australia, Denmark and Finland. In general, countries with high caesarean rates also had high instrumental vaginal delivery rates. There was no consistent relationship between use of caesarean section and use of instrumental vaginal delivery, although in several countries increasing use of caesarean section was accompanied by decreasing use of instrumental vaginal delivery. Oxytocin use rates were associated positively with instrumental delivery but not with caesarean section rates. While it was not possible to determine the proportions of women who received appropriate obstetrical care, we can infer that a significant proportion of interventions were unnecessary or only marginally beneficial. Continued increases in rates of obstetrical intervention are unlikely to result in improvements in birth outcome overall and may pose a risk to mothers and their newborns.

Benefits of Continuous Infusion Epidural Analgesia Throughout Vaginal Delivery

Two groups of nulliparous women with fetuses in singleton vertex presentation received continuous infusion epidural analgesia (EDA) with bupivacaine: group A (90 parturients) without infusion analgesia in the second stage of labor and group B (90 parturients) with infusion analgesia throughout delivery. The groups were compared regarding pain relief, duration of the second stage, persistent malrotation of the fetal head, and rate of instrumental vaginal delivery. The continuous infusion EDA gave satisfactory pain relief in 93.3% of the parturients in group A and 97.8% in group B. The duration of second stage was the same in both groups. There were more persistent mal-rotations of the fetal head in group A, but the malrotation did not affect the mode of deli: very. The rate of instrumental vaginal delivery was 25.5% in both groups. The main cause of operative intervention was delay in the second stage. When the continuous infusion technique is used, it seems unreasonable to discontinue the EDA and thereby deprive the parturient of analgesia during the second stage.

Benefits of Continuous Infusion Epidural Analgesia Throughout Vaginal Delivery

Two groups of nulliparous women with fetuses in singleton vertex presentation received continuous infusion epidural analgesia (EDA) with bupivacaine: group A (90 parturients) without infusion analgesia in the second stage of labor and group B (90 parturients) with infusion analgesia throughout delivery. The groups were compared regarding pain relief, duration of the second stage, persistent malrotation of the fetal head, and rate of instrumental vaginal delivery. The continuous infusion EDA gave satisfactory pain relief in 93.3% of the parturients in group A and 97.8% in group B. The duration of second stage was the same in both groups. There were more persistent malrotations of the fetal head in group A, but the malrotation did not affect the mode of delivery. The rate of instrumental vaginal delivery was 25.5% in both groups. The main cause of operative intervention was delay in the second stage. When the continuous infusion technique is used, it seems unreasonable to discontinue the EDA and thereby deprive the parturient of analgesia during the second stage.