Non-instrumental Vaginal Delivery Research Articles

Birth by vacuum extraction delivery and school performance at 16 years of age

The aim of the present study was to investigate cognitive competence, as indicated by school performance, at 16 years of age, in children delivered by vacuum extraction. This was a register study of a national cohort of 126,032 16 year olds born as singletons, with a vertex presentation, at a gestational age of 34 weeks or older, with Swedish-born parents, delivered between 1990 and 1993 without major congenital malformations. Linear regression was used to analyze mode of delivery in relation to mean scores from national tests in mathematics (40.2; scale, 10-75; SD, 14.9) and mean average grades (223.8; scale, 10-320; SD, 52.3), with adjustment for perinatal and sociodemographic confounders. Children delivered by vacuum extraction (-0.51; 95% confidence interval [CI], -0.76 to 0.26) as well as by nonplanned cesarean section (-0.51; 95% CI, -0.82 to -0.20) had slightly lower mean mathematics test scores than children born vaginally without instruments, after adjustment for major confounders. Mean average grades in children delivered by vacuum extraction were -1.05 (95% CI, -1.87 to -0.23) and -1.20 (95% CI,-2.24 to -0.16) in children delivered by nonplanned cesarean section compared with children born vaginally. Children delivered by vacuum extraction had slightly lower grades at age 16 years compared with those born by noninstrumental vaginal delivery but very similar to those delivered by nonplanned cesarean. This suggests that vacuum extraction and nonplanned cesarean are equivalent alternatives for terminating deliveries with respect to cognitive outcomes.

Influencia de la edad gestacional, el tipo de parto y la reanimación en el riesgo de neumotórax en neonatos mayores de 37 semanas

BackgroundElective caesarean section before 39weeks gestational age (GA) has been associated with a higher incidence of iatrogenic respiratory distress and pneumothorax in term newborn babies, probably because of a higher respiratory morbidity and the need for resuscitation. These factors have not been systematically evaluated in our patients. ObjectiveTo determine whether the gestational age, type of delivery, and intensity of resuscitation, are associated with an increase in the incidence of pneumothorax in term neonates. Patients and methodsFull term neonates (≥37weeks GA) born in our maternity unit from January 2006 to December 2010 were studied, along with the type of delivery (vaginal, forceps or caesarean section). Advanced cardiopulmonary resuscitation (CPR) was defined as the need of bag and mask intermittent ventilation, intubation, chest compression, and/or administration of medication. The diagnosis of pneumothorax was clinical and radiological in all cases. ResultsA total of 32,238 full term newborns were included. Type of delivery: vaginal 76.1%, C-section 12.4%, and forceps 11.5%. The incidence of pneumothorax was 0.316%. It was significantly higher in C-section (0.85%), than in forceps (0.59%), or non-instrumental vaginal deliveries (0.19%) (P<.001), and in infants ≥40weeks GA (0.37%) compared to ≤39weeks GA (0.24%) (P=.033), and in advanced CPR (4.29%) compared to basic CPR (0.18%) (P<.001). ConclusionsA GA≥40 weeks, C-section, or forceps delivery, and advanced CPR immediately after birth were significantly associated with a higher incidence of pneumothorax in full term newborn babies. In our population, we did not observe an increase in pneumothorax among neonates born by elective C-section before 39weeks of gestation.

Stereophotogrammetry of the perineum during vaginal delivery

ObjectiveTo analyze deformation of the perineum during normal vaginal delivery in order to identify clinical steps that might be beneficial when executing manual perineal protection. MethodsThe present prospective study at Charles University Hospital, Pilsen, Czech Republic, enrolled 10 primiparous women at term undergoing non-instrumental vaginal delivery assisted by the same obstetrician between September 2009 and September 2010. A modified hands-poised technique performed concurrently with stereophotogrammetry was used to analyze and quantify perineal deformation and strain at the final stage of delivery. ResultsThe highest tissue strain (mean, 177%; 95% confidence interval [CI], 106.3–248.5) was in a transverse direction and occurred at the level of the fourchette (i.e. 1cm was transversely stretched and deformed to 2.77cm during the final stage of vaginal delivery). This strain was more than 4 times higher than the maximum anteroposterior strain (mean, 43%; 95% CI, 28.6–57.4). ConclusionOn the basis of these stereophotogrammetry data, a technique of perineal protection executed by fingers of the posterior (right) hand can be proposed. Further experimental and clinical studies are needed to evaluate whether this technique might assist in reducing obstetric perineal trauma.

Diabetes is associated with impairment of uterine contractility and high Caesarean section rate

Aims/hypothesisThe prevalence of births worldwide complicated by diabetes mellitus is increasing. In the UK, for example, <25% of diabetic women have a non-instrumental vaginal delivery. Strikingly, more than half the Caesarean sections (CS) in these patients are non-elective, but the reasons for this are not understood. We have tested the hypothesis that poor myometrial contractility as a consequence of the disease contributes to this high CS rate.MethodsWe compared spontaneous, high K depolarisation and oxytocin-induced contractions from diabetic and matched control patients having an elective CS. To investigate the mechanism of any differences we measured intracellular Ca, and performed western blotting and compared the tissues histologically.ResultsThere was significantly decreased contraction amplitude and duration in uteri from diabetic compared with control patients, even when possible confounders such as BMI were analysed. Reduced intracellular calcium signals and expression of calcium entry channels were found in uteruses from diabetic patients, which, along with a reduction in muscle content found on histological examination, could explain the reduced force. Myometrium from diabetic patients was responsive to oxytocin, but still did not reach the levels found in non-diabetic patients.Conclusions/interpretationsThese are the first data investigating myometrium in diabetic patients and they support the hypothesis that there is poorer contractility even in the presence of oxytocin. The underlying mechanism is related to reduced Ca channel expression and intracellular calcium signals and a decrease in muscle mass. We conclude that these factors significantly contribute to the increased emergency CS rate in diabetic patients.Electronic supplementary materialThe online version of this article (doi:10.1007/s00125-011-2371-6) contains peer-reviewed but unedited supplementary material, which is available to authorised users.

Anal sphincter disruption during instrumental and non-instrumental vaginal delivery

Introduction: Anal sphincter trauma during childbirth represents the most important risk factor for development of fecal incontinence in women. Overt anal sphincter injury may be identified by clinical examination in 1-3% of vaginal deliveries, but the incidence is much higher when abnormalities are specifically sought using endoanal ultrasound and anal manometry. Aim of work: The aim of this study is to assess risk factors for sphincter damage during vaginal delivery in primiparous patients, and to assess the relationship of anal manometry and endosonography to anorectal complaints in patients who had demonstrated anal sphincter injury during vaginal delivery. Patients & methods: This was a prospective, observational study conducted over 130 healthy primiparous females with intact anal sphincter without history of either anorectal complaints or previous anorectal surgery. The patients were divided into: Group I: 100 patients without clinically recognized third- to fourth-degree intrapartum perineal tears. Group II: 15 primiparous patients who delivered by normal vaginal delivery, with clinically recognized third-degree perineal tears, who were examined following surgical repair by the overlapping technique. Group III: 15 primiparous patients who delivered by instrumental delivery, with clinically recognized third-degree perineal tears, who were examined following surgical repair. All patients were followed up by combined endoanal ultrasonography and anal manometry. Results: The risk factors for the anal sphincter damage during vaginal delivery include the length of 2nd stage if •75 min, absence of episiotomy, presence of shoulder dystocia, and the mode of delivery. In patients with anal sphincter damage, the maximal anal resting pressure (MARP) was significantly lower (P 0.05). Instrumental delivery (P<0.001), a MARP •30 mmHg (P<0.047), and ultrasound evidence of combined ES + IS defect (P=0.002), were significantly related to anorectal complaints. MASP and ultrasound evidence of an isolated EAS defect were not found to be significantly related to anorectal complaints. Conclusion: Knowledge of possible risk factors for the occurrence of anal sphincter injuries may therefore reduce the likelihood of faecal incontinence. Anal endosonography after vaginal delivery allows the diagnosis of clinically undetected anal sphincter damage that may be associated with subsequent fecal incontinence. Anal monometry is useful in assessment of anal sphincter disruption following vaginal delivery especially when combined with an endoanal ultrasonography

Non-urgent caesarean delivery increases the need for ventilation at birth in term newborn infants

ObjectiveTo compare the need for positive pressure ventilation (PPV) by bag and mask and by bag and endotracheal tube in newly born term infants with vertex presentation delivered by non-urgent...

Active management of third stage of labor: evidence versus practice

To determine the correct use of active management of third stage of labor (AMTSL) (using the full complement of existing standard definitions) and compare the outcomes of third stage of labor in women who received AMTSL (according to these definitions) with those who did not. Observational, cross-sectional survey. Seven tertiary centers in southwest Nigeria. Women undergoing non-instrumental vaginal deliveries. Prospective direct observations of childbirth procedures. AMTSL was defined according to Cochrane review, ICM/FIGO (International Confederation of Midwives/International Federation of Gynecology and Obstetrics), and WHO (World Health Organization) recommendations. Main outcome measures. Use of AMTSL and its components and outcome of third stage of labor. There was a high rate of compliance with most of the individual components of AMTSL. The use of AMTSL varied widely with the definition applied and tended to decrease with increasing strictness of the criteria (Cochrane review: 88.9%; ICM/FIGO: 42%; WHO: 1.8%). The frequencies of adverse labor outcomes were generally low (postpartum hemorrhage (PPH): 4.9%; severe PPH: 0.8%; retained placenta: 1.9%; uterine inversion: 0.0%). Frequencies of PPH, postpartum anemia, and mean blood loss among women who received AMTSL according to the Cochrane review definition were significantly lower than for those who did not (p < 0.05). There was no significant difference between any of the outcomes for women who received AMTSL according to the ICM/FIGO definition and those who did not. The survey reveals substantial definition-dependent variation in the providers' adherence to recommended AMTSL practices. The clinical implications of the current practice in this population suggest the need for randomized comparison of various AMTSL packages to determine their comparative effectiveness in the prevention of PPH.

Doula Care, Early Breastfeeding Outcomes, and Breastfeeding Status at 6 Weeks Postpartum Among Low-Income Primiparae

To examine associations between doula care, early breastfeeding outcomes, and breastfeeding duration. Prospective cohort. Regional hospital in northern California. Low-income, full gestation primiparae receiving doula care (n=44) or standard care (n=97). Birth outcomes and newborn feeding data obtained from the hospital record. Follow-up interviews conducted at day 3 to record the timing of onset of lactogenesis and breastfeeding behavior and at 6 weeks to obtain current breastfeeding status. Adjusting for baseline differences, women receiving doula care were significantly more likely to have a short stage II labor, a noninstrumental vaginal delivery, and to experience onset of lactogenesis within 72 hours postpartum (timely onset of lactogenesis). Overall, 68% of women receiving doula care and 54% of women receiving standard care were breastfeeding at 6 weeks. In the subset with a prenatal stressor (n=63), the doula care group was more than twice as likely to be breastfeeding at 6 weeks (89% vs. standard care, 40%). Breastfeeding at 6 weeks was also significantly associated with timely onset of lactogenesis and maternal report that the infant "sucked well" at day 3. Doula care was associated with improved childbirth outcomes and timely onset of lactogenesis. Both directly and as mediated by timely onset of lactogenesis, doula care was also associated with higher breastfeeding prevalence at 6 weeks.

Shoulder Dystocia at Noninstrumental Vaginal Delivery

This study examines the relationship between episiotomy and the occurrence of shoulder dystocia among noninstrumental vaginal deliveries. Analysis of data from a retrospective database was used to study noninstrumental vaginal deliveries in New Jersey during the years 1996 to 2001. The episiotomy group and nonepisiotomy group were analyzed separately using univariate and multivariate analysis. Among 358,664 deliveries, rate of shoulder dystocia was 1.0% (n = 3596). Thirty-five percent of deliveries were assisted by episiotomy. Rate of dystocia was 1.42% with the use of episiotomy, and 0.81% when episiotomy was not used. This increased rate with episiotomy was noted across all of the racial groups, all birthweight categories, and all of the risk factor subgroups analyzed. There was a gradual decrease in the use of episiotomy from 37.30 to 26.03% without a corresponding increase in the rate of dystocia. Among noninstrumental deliveries, the rate of shoulder dystocia is higher in the episiotomy group. Decrease in the use of episiotomy has not resulted in an increase in the occurrence of dystocia.

Danish obstetricians' personal preference and general attitude to elective cesarean section on maternal request: A nation-wide postal survey

Objective. To assess Danish obstetricians' and gynecologists' personal preference and general attitude towards elective cesarean section on maternal request in uncomplicated single cephalic pregnancies at term. Design. Nation-wide anonymous postal questionnaire. Population. Four hundred and fifty-five obstetricians and gynecologists identified in the records of the Danish Society of Obstetrics and Gynecology from January 2000. Main outcome measures. Personal preference on the mode of delivery and general attitude towards elective cesarean section on maternal request in an uncomplicated single cephalic pregnancies at term. Results. Of Danish specialists in obstetrics and gynecology, 1.1% would prefer an elective cesarean section in an uncomplicated pregnancy at 37 weeks of gestation with fetal weight estimation of 3.0 kg. This rose to 22.5% when the fetal weight estimation was 4.5 kg at 37 weeks. The main reasons given for preferring abdominal deliveries was the risk to the fetus, risks of perineal injury, and urinary and anal incontinence. Of Danish specialists in obstetrics and gynecology, 37.6% agreed with a woman's right to have an elective cesarean section on maternal request without any medical indication. Obstetricians and gynecologists who had experienced a noninstrumental vaginal delivery themselves or practiced as a private gynecologist only, were less likely to agree with the woman's right to elective cesarean section on maternal request. Conclusion. The vast majority of Danish obstetricians and gynecologists would personally prefer vaginal delivery in uncomplicated pregnancies, but nearly 40% agree with the woman's right to request a cesarean section.

Anal sphincter injury after vaginal delivery in primiparous females.

The purpose of this study was to determine the incidence of anal sphincter injury and fecal incontinence after vaginal delivery. This was a prospective, descriptive, observational study conducted over a three-year period in healthy primiparous females with previously intact anal sphincter and normal continence and without history of anorectal surgery. All patients completed a continence questionnaire and underwent endoanal ultrasound four to six weeks before and six weeks after delivery. Ninety-eight primiparous females had either instrumental (vacuum or forceps) vaginal delivery (n = 23) or noninstrumental vaginal delivery (n = 75). Twenty patients, 11 (48 percent) after instrumental delivery and 9 (12 percent) after noninstrumental vaginal delivery, had clinical sphincter tears that required primary repair. Twenty-eight patients (29 percent), 19 with previously repaired sphincter injury, had ultrasonographic defects that involved the external sphincter (n = 19) or both the internal and external sphincter (n = 9). Twenty-one patients (75 percent) with ultrasonographic sphincter defects had either major (n = 5) or minor (n = 16) fecal incontinence. Anal sphincter injuries, many of them undiagnosed at the time of delivery, are common in primiparous females after vaginal delivery, especially if vacuum or forceps are used. These injuries cause fecal incontinence in a significant proportion of the patients. Patients undergoing vaginal delivery should be aware of the risks of anal sphincter injury.

Conduct of labor and rupture of the sphincter ani.

To determine whether the conduct of the second stage of labor and delivery technique influences the incidence of rupture of the anal sphincter. A total of 1072 primipara delivered vaginally at term at Rigshospitalet in 1998. A questionnaire on prenatal risk factors, conduct of the second stage of labor, and delivery technique was completed by the attending midwife immediately after delivery in 90 cases with rupture of the sphincter and in two subsequent controls (n = 164), matched by use of vacuum extractor and episiotomy. Partial or total sphincter rupture was found in 8.4% of primipara who delivered vaginally, in 20.9% of those delivered by vacuum extraction, and in 6.4% of those with episiotomy only. The prenatal risk factors--maternal age, birth weight, shoulder dystocia, and edema of the perineum were found to have a statistically significant effect on the incidence of rupture of the sphincter ani. In non-instrumental vaginal deliveries easing of the perineum over the caput as it advanced helped prevent a rupture of the anal sphincter. Vacuum extraction performed with the woman in a semi-recumbant position was associated with an increased risk of rupture of the anal sphincter, whereas attention to the perineum during extraction decreased the risk. The significant effect of prenatal risk factors did not explain a correlation between delivery technique and rupture of the sphincter ani. The present study indicates that a reduction in the incidence of sphincter rupture may be accomplished by improved obstetric care: fewer vacuum extractions and improved delivery technique.

Conduct of labor and rupture of the sphincter ani

Objective. To determine whether the conduct of the second stage of labor and delivery technique influences the incidence of rupture of the anal sphincter. Material and method. A total of 1072 primipara delivered vaginally at term at Rigshospitalet in 1998. A questionnaire on prenatal risk factors, conduct of the second stage of labor, and delivery technique was completed by the attending midwife immediately after delivery in 90 cases with rupture of the sphincter and in two subsequent controls (n=164), matched by use of vacuum extractor and episiotomy. Results. Partial or total sphincter rupture was found in 8.4% of primipara who delivered vaginally, in 20.9% of those delivered by vacuum extraction, and in 6.4% of those with episiotomy only. The prenatal risk factors – maternal age, birth weight, shoulder dystocia, and edema of the perineum were found to have a statistically significant effect on the incidence of rupture of the sphincter ani. In non-instrumental vaginal deliveries easing of the perineum over the caput as it advanced helped prevent a rupture of the anal sphincter. Vacuum extraction performed with the woman in a semi-recumbant position was associated with an increased risk of rupture of the anal sphincter, whereas attention to the perineum during extraction decreased the risk. Conclusions. The significant effect of prenatal risk factors did not explain a correlation between delivery technique and rupture of the sphincter ani. The present study indicates that a reduction in the incidence of sphincter rupture may be accomplished by improved obstetric care: fewer vacuum extractions and improved delivery technique.