Operative Vaginal Delivery Rates Research Articles

Impact of clinical audits on cesarean section rate

ObjectiveMany countries have noted a substantial increase in the cesarean section rate (CSR). Several methods for lowering the CSR have been described. Understanding the impact of clinical audits on the CSR may aid in lowering CSR. Thus, our aim is to elucidate the effect of clinical audits on the CSR. Materials and MethodsWe retrospectively analyzed 3781 pregnant women who gave birth in a medical center between January 2008 and January 2011. Pregnant women who delivered between January 2008 and July 2009 were enrolled as the pre-audit group (n = 1592). After August 2009, all cesarean section cases that were audited were enrolled in the audit group (n = 2189). The CSR was compared between groups. ResultsThe overall CSR (34.5% vs. 31.1%, adjusted odds ratio [OR] = 0.83, p = 0.008) and the cesarean section rate due to dystocia (9.6% vs. 6.2%, p < 0.001) were significantly lower in the audit group than the pre-audit group. However, there was no significant difference in the rate of operative vaginal delivery between groups. Consensus on the unnecessity for cesarean section was achieved in 16 (8.2%) of 195 audit cases in the monthly audit conference. In nulliparous pregnant women (n = 2148), multivariate analysis revealed that clinical audit (OR = 0.78), maternal age (OR = 1.10), gestational age at delivery (OR = 0.80), and fetal body weight at birth (OR = 1.0005) were independent predictors of cesarean section (all p < 0.05). Most variables of maternal and perinatal morbidity and mortality did not differ before and after audits were implemented. ConclusionClinical audits appear to be an effective strategy for reducing the CSR. Therefore, we recommend strict monitoring of the indications in dystocia for cesarean section to reduce the CSR.

Induction of Labor in Post-Term Nulliparous and Parous Women - Potential Advantages of Misoprostol over Dinoprostone.

We undertook a prospective cohort study to compare the effectiveness and safety of 50 µg misoprostol versus 3 mg dinoprostone in two vaginal doses 6 hours apart, followed if necessary by oxytocin for labor induction in low-risk post-term (> 40 weeks) pregnancies with unfavorable cervix (Bishop score ≤ 6). Labor induction and subsequent management were conducted using a standardized protocol. The primary outcome of the study was labor induction rate. Secondary outcomes included mode of delivery, time interval from induction to delivery, maternal complications and neonatal outcome. 107 patients received misoprostol (Group A) and 99 patients received dinoprostone (Group B). Compared with group A, more women in Group B needed a second vaginal dose of prostaglandin or oxytocin infusion in order to proceed to labor (21.5 vs. 43.4 %; p = 0.01). Misoprostol alone as a single or double vaginal dose was more effective than dinoprostone alone in inducing labor without oxytocin administration (85.0 vs. 50.4 %; p = 0.04). Overall, the rate of successful induction of labor did not differ between groups (91.6 vs. 85.8 %; p = 0.75). Vaginal delivery, operative vaginal delivery and Caesarean section rates were not significantly different. Time interval from induction to delivery however, was shorter for Group A (median 11 hours vs. 14.1 hours; p < 0.001). Though emergency Caesarean section due to fetal distress was more frequent in Group A (16.8 vs. 4.0 %; p = 0.007), low Apgar scores < 7 and NICU admissions did not differ significantly. Maternal complications, mostly not serious, were higher in Group A (31.8 vs. 2.0, p < 0.001). Misoprostol is a more effective agent than dinoprost in post-term pregnancy for labor induction with few maternal adverse effects.

Temporal and Regional Variations in Operative Vaginal Delivery in Canada by Pelvic Station, 2004-2012.

To describe temporal and regional variations in Canada in the use of operative vaginal delivery (OVD) at term for singleton pregnancies by pelvic station between 2004 and2013. Rates of OVD among term singleton pregnancies in Canada (excluding Quebec) were estimated using information from the Discharge Abstract Database of the Canadian Institute for Health Information for the years 2004-2012 (n= 2 284 109). Deliveries were stratified by pelvic station. Temporal trends were assessed using the Cochran-Armitage test for linear trend in proportions byyear. Geographic variation was assessed by calculating the rateand 95% confidence interval of each mode of delivery from 2010-2012 for each province and territory. Among singleton pregnancies at term, the OVD rate decreased from 12.0% in 2004 to 10.7% in 2012 (P < 0.001), whereas Caesarean section rates (excluding those following failed OVDs) increased from 24.9% to 26.7%. Forceps deliveries decreased from 3.1% to 2.5%, primarily due to decreases in midpelvic forceps delivery. Vacuum-assisted delivery increased significantly at outlet and low stations (by 26.0% and 15.1%, respectively) and remained stable at midpelvic station. The failed OVD rate was 0.3% and decreased by 23.7% (P < 0.001). There were large variations in OVD rates by province. Temporal trends in OVD rates varied by pelvic station, with rates of outlet and low OVD increasing and rates of midpelvic and failed OVD decreasing. Vacuum extraction is increasingly replacing forceps deliveries at outlet and low stations, whereas Caesarean sections are replacing forceps deliveries at midpelvic stations. Variations in OVD rates across provinces suggest differences in instrument preference and/or an evolution in standards of practice.

An Analysis of Operative Delivery Practices Over 30 Years [11D

INTRODUCTION: The aim of this study was to determine delivery practice changes over the past 30 years for singleton pregnancies as a means to elucidate the underlying causes of the rising cesarean section (c/s) rate over the last several decades. METHODS: Delivery data was collected at a medium-sized teaching hospital in Colorado, averaging 4,690 singleton births/year, over 34 years. The numbers of forceps, vacuums, breeches and c/s were recorded for 79,723 singleton deliveries, from alternating years between 1978 and 2012 with complete records available. RESULTS: C/s done for breech presentation remained largely stable, averaging 3% of all deliveries (range 2.09–3.9%). The rate of operative vaginal delivery significantly decreased from a high of 14.7% in 1978 to 2% in 2010. Pooling the number of all operative deliveries (cesarean and forceps/vacuums combined) for non-breech presentation, the overall rate of deliveries requiring an operative approach remained stable at 27.7% in 1978 and 28% in 2012, (average 25.8%). CONCLUSION: Our data suggests that an even trade-off between operative vaginal deliveries and laboring c/s has occurred during the 2nd stage of labor over the past 30 years. The decrease in operative deliveries and not the decrease in breech vaginal deliveries, accounts for the increase in c/s rates. This decrease in operative deliveries is not surprising and has been demonstrated in other studies. This is presumably due to lack of training and comfort using operative vaginal techniques, as well as concerns for morbidity to both the newborn and the mother.

Impact of the Introduction of Neuraxial Labor Analgesia on Mode of Delivery at an Urban Maternity Hospital in China

(Int J Gynecol Obstet. 2015;129:17–21) Although neuraxial analgesia is the most effective method for pain relief during labor and has physiological benefits for both the mother and the fetus, its impact on the overall duration of labor and the rates of operative vaginal delivery and episiotomy is uncertain. In China, where there are approximately 164 million deliveries per year, the estimated rate of cesarean delivery in 2010 was >50%.

Extraction instrumentale sur une hauteur de présentation supérieur à 55 mm à l’échographie transpérinéale

ObjectiveCompare the issue of an operative vaginal delivery associated to the fetal presentation diagnosed by transperineal ultrasound. Three groups were formed: ≥55mm, between 45 and 55mm, and <45mm. MethodsA monocentric prospective study on 108 patients has been conducted between April 2011 and August 2014. The distance between perinea and skull has been analyzed to compare the success of operative vaginal delivery considering the level of the fetal presentation in the pelvic cavity. ResultsThe failed operative vaginal deliveries are more frequent while the fetal head is above 55mm (16.7%) or while the fetal head is between 45 and 55mm (9.1%) than while the fetal skull is under 45mm (1.8%) (P=0.04). However there is no significant difference for the fetal shoulder dystocia (5.6% vs 3.0% vs 3.5%, P=0.5), nor for the newborn outcomes (16.7 vs 15.2 vs 14; P=0.9). ConclusionDespite the high rate of failed operative vaginal delivery above 55mm, it should be considered not to prohibit but send free to the obstetrician appreciation.

Association of fetal biparietal diameter with mode of delivery and perinatal outcome.

To determine the association between sonographic assessment of fetal biparietal diameter (BPD) and pregnancy outcome. This was a retrospective cohort study of pregnancies at 37-42 weeks of gestation which had antepartum sonographic measurement of BPD within 7 days before delivery. Eligibility was limited to singleton pregnancies with neither known structural or chromosomal abnormalities nor prelabor Cesarean delivery (CD). The association of BPD with outcome was analyzed using multivariate logistic regression, receiver-operating characteristics curves and stratification according to BPD quartiles. In total, 3229 women were eligible for analysis, of whom 2483 (76.9%) had a spontaneous vaginal delivery (SVD), 418 (12.9%) underwent operative vaginal delivery (OVD) and 328 (10.2%) underwent CD. The mean BPD in the obstetric intervention groups (OVD and CD) was significantly higher than that in the SVD group (P < 0.001). After adjusting for confounders, increased BPD was an independent risk factor such that higher values of BPD were associated with progressively higher risk of obstetric intervention (adjusted odds ratio, 1.05 for each 1-mm increase in BPD (95% CI, 1.02-1.09)), but no clear cut-off value for obstetric intervention was found. The fourth quartile group (BPD ≥ 97 mm) was associated with a significantly lower SVD rate (P < 0.001) and higher OVD rate (P = 0.04), relative to the first (BPD 88-90 mm) and second (BPD 91-93 mm) quartile groups, with no apparent adverse impact on immediate neonatal outcome. Increased BPD within the week prior to delivery is an independent risk factor such that higher values of BPD are associated with progressively higher risk of obstetric intervention; however, in our experience, no adverse neonatal outcome resulted from such intervention. Thus, increased BPD should not discourage a trial of vaginal delivery.

Resultados maternos y perinatales de la analgesia del parto

Objetivos: Determinar los resultados maternos y perinatales de la analgesia de parto. Diseño: Estudio observacional, descriptivo, de casos y controles. Institución: Servicio de Ginecología y Obstetricia, Hospital Docente Madre Niño San Bartolomé, Lima, Perú. Participantes: Gestantes en trabajo de parto. Métodos: Se revisó los datos de 400 gestantes (grupo I=controles; grupo II=casos), atendidas en el periodo septiembre a diciembre de 2013. Principales medidas de resultados: Resultados maternos y perinatales. Resultados: La media de edad en el grupo de casos fue 24,2+/-3,5 años, el peso fue 72,3+/-3,7 kg y la edad gestacional 38,6+/-1,2 semanas. A los 30 minutos, el nivel de dolor descendió significativamente (p &lt; 0,01) en el grupo de los casos, manteniéndose este descenso hasta el final de la dilatación. La dilatación completa para el grupo control se alcanzó a los 233 ± 28,7 minutos y a los 200,9 ± 29,5 minutos para el grupo de los casos, con una diferencia menor estadísticamente significativa. La duración del expulsivo para el grupo control fue 23,3 ± 5,3 minutos comparado con los casos de 27,5 ± 3,7, con una diferencia mayor estadísticamente significativa para el último grupo. Conclusiones: La analgesia de parto con bupivacaína–fentanil resultó un método eficaz para el alivio del dolor del parto cuando fue administrada en trabajo de parto bien establecido (dilatación 4 cm), acortando la duración de manera significativa y no interfiriendo con el reflejo de pujar. Aunque la duración del expulsivo fue significativamente mayor, no tuvo implicancia con la obtención de recién nacidos en buenas condiciones ni aumentó de manera significativa los partos instrumentados y las cesáreas.

Prelabour rupture of membranes at term prospective study of expectant management versus induction of labour

Background: Premature rupture of membranes (PROM) complicates 5-10 % of pregnancies. Approximately 60-70 % of term PROM cases are followed by the onset of labor within 24 hours. Diagnosis and proper management is very important. In spite of many studies available in the literature, the clinical management is surprisingly controversial.Methods: Study conducted was prospective randomised controlled trial. Total 150 women were selected fulfilling the inclusion criteria, randomly allotted to the 3 groups. In group A, patients were observed for 24 hours. If labor didn’t supervene in 24 hours since admission, induction of labor was done depending on the bishop’s score. In the group B, labour was induced by vaginal misoprostol 25 micrograms given 4 hourly for 4 doses and in group C, labor was induced by instillation of 0.5mg PGE2 gel in the posterior fornix. The women were observed for onset and progress of labour. Failure of induction was considered if patient was not in established labour within 24 hours of instillation of first dose of cerviprime/misoprostol. Labour was monitored and managed as per hospital protocol. The analysis verified the following variables: duration of latent phase and active phase of labour, mode of delivery (spontaneous/vaccum/forceps/LSCS), third stage complications (PPH/fever/retained placenta), neonatal outcome.Results: Thirty percent women had onset of spontaneous labor during expectant management in group A. The durations of latent phase and active phase of labour were lower in group B and C than group A (9 and 10.4 versus 15 hours; p&lt;0.001) and (4 and 6 versus10 hours; p&lt;0.001), respectively. Immediate induction in group B and C resulted in significantly lower rate of caesarean section (17% and 19% versus 28.5%, P= 0.049) and operative vaginal delivery (5% and 3% versus 13%, P=0.007). Only a few maternal-neonatal infections occurred and no significant difference was noted (2.7% and 3% versus 3.5%, P= 0.71).Conclusions: Immediate induction with prostaglandin shortens the delivery interval and lowers the caesarean section rate as compared to expectant management; however the neonatal outcome is similar in the three groups.

250: Length of the second stage of labor and risk of preterm delivery in a subsequent pregnancy

250 Length of the second stage of labor and risk of preterm delivery in a subsequent pregnancy Joanne N. Quinones, Daniel Gomez, Matthew K. Hoffman, Cande V. Ananth, John C. Smulian, Lauren A. Plante, Daniel W. Skupski, Karin M. Fuchs, William E. Scorza Lehigh Valley Health Network, Allentown, PA, University of South Florida College of Medicine, Tampa, FL, Christiana Care Health System, Newark, DE, Columbia University College of Physicians and Surgeons, New York, NY, Drexel University College of Medicine, Philadelphia, PA, New YorkPresbyterian Hospital Queens, Flushing, NY, for the Perinatal Research Consortium, Allentown, PA OBJECTIVE: Cervical injury is considered a risk factor for preterm birth. Prolonged or obstructed labor at term may increase the risk for damage to cervical and related tissues. This study was designed to evaluate whether an increased duration of the second stage of labor in a term primiparous delivery increases the risk of spontaneous preterm birth in the subsequent pregnancy. STUDY DESIGN: This was a cohort study of women having their first term and subsequent birth at the same institution using prospectively collected obstetric data from January 2005 to January 2015. The duration of the second stage of labor from the first term pregnancy (index case) was obtained from information recorded at delivery. Demographic and other clinical data were obtained. The risk for spontaneous preterm birth (sPTB) in the subsequent delivery was estimated based on the duration of the second stage regardless of mode of delivery in the first birth. RESULTS: 6,715 women were identified as eligible for analysis. In the index pregnancy, the rate of second stage cesarean was 6.2% (n1⁄4416) and the rate of operative vaginal delivery was 19.8% (n1⁄41,264). Among the 6,342 women (94.4%) who delivered at term in the subsequent pregnancy, the median length of the second stage in the first delivery was 55.0 minutes (interquartile range 29-97). Among the 373 women (5.6%) who delivered preterm in the subsequent pregnancy, the median length of the second stage in the first term delivery was 42 minutes (interquartile range 24-93; p1⁄40.0004). After adjustment for maternal age, clinic or private patient, race/ ethnicity, smoking, and chronic hypertension, there was a 31% lower risk of sPTB in a subsequent delivery if the second stage of labor length was between 55-96 minutes in the first term delivery (Table). There were no differences in sPTB when stratified by mode of delivery. CONCLUSION: Second stage labor length in the index pregnancy was shorter for women who delivered preterm in a subsequent pregnancy. These data do not support the concept that cervical injury

Post-term pregnancy is an independent risk factor for neonatal morbidity even in low-risk singleton pregnancies

ObjectiveTo determine the independent association of post-term pregnancy with neonatal outcome in low-risk newborns.DesignRetrospective cohort.SettingTertiary university-affiliated medical centre.PatientsAll newborns of low-risk singleton pregnancies born at 39+0 to 44+0 weeks’ gestation...

Prevalence and descriptive analysis of congenital heart disease in parturients: obstetric, neonatal, and anesthetic outcomes

Study objectiveThe study objectives are to (1) assess prevalence of congenital heart disease (CHD), (2) describe outcomes of pregnancies in women with CHD, (3) compare outcomes in women with and without CHD, and (4) characterize neonatal outcomes in pregnancies complicated by CHD. DesignThis was a retrospective cohort study of women who delivered at the University of Colorado Hospital. Diagnosis of CHD was identified based on history of cardiac disease, pulmonary disease, or subacute bacterial endocarditis prophylaxis during labor and confirmed with echocardiogram when available. Comprehensive retrospective review of anesthetic, obstetric, and neonatal outcomes was performed. SettingUniversity of Colorado Hospital. Patients18,226 women. InterventionsMedical record review. MeasurementsValvular abnormalities, New York Heart Failure Association classification scores, types of CHD, maternal age, race, gravidity, parity, maternal prepregnancy body mass index, cigarette use, type of delivery, type of analgesia used, early initiation of neuraxial analgesia, arrhythmias, need for peripartum diuretics, prolonged maternal hospital stay, preterm birth, small for gestational age, neonatal CHD, neonatal or maternal intensive care unit (ICU) admissions, and maternal or neonatal death. Main resultsWe identified 117 pregnancies in 110 women with CHD. Parturients with CHD were more likely to have operative vaginal delivery (P < .0001), neonatal ICU admissions (P = .003), and had prolonged hospital stays. Occurrence of CHD in neonates was 6%. Moderate-to-severe valvular disease was associated with increased rates of operative vaginal delivery, early initiation of neuraxial labor analgesia, cardiac complications (including arrhythmia and use of diuretics), prolonged hospital stay, and maternal ICU admission. However, most deliveries and births were uncomplicated; and there were one case each of maternal mortality and fetal death after birth. ConclusionOperative abdominal deliveries and neonatal ICU admissions are more common in women with CHD, but these pregnancies are generally well tolerated with low mortality rates.

Nulliparous Women in the Second Stage of Labor: Changes in Delivery Outcomes Between Two Cohorts From 2000 and 2011.

To evaluate changes over the past decade in the mode of delivery and second-stage duration in nulliparous women. We conducted a retrospective cohort study at a single institution of nulliparous women reaching complete cervical dilation with singleton gestations 36 weeks or greater from January 1, 2011, to December 31, 2012, and compared these with a prior cohort prospectively collected from July 28, 2000, to February 28, 2003. We excluded pregnancies with prenatally diagnosed fetal anomalies. The primary outcome was cesarean delivery. Secondary outcomes included second-stage duration, rates of operative vaginal delivery (forceps and vacuum collectively), and indications for cesarean delivery and operative vaginal delivery. There were 1,023 mother-neonate pairs in the prior cohort and 1,476 in the current cohort. In the prior and current cohorts, respectively, 2% compared with 6% underwent cesarean delivery, 21% compared with 10% underwent operative vaginal delivery, and 77% compared with 84% had spontaneous vaginal delivery (all P<.01). Compared with the prior cohort, the adjusted odds (OR) of cesarean delivery (compared with any vaginal birth) for current patients was 1.74 (95% confidence interval [CI] 1.04-2.91), and in a separate regression model, the adjusted OR of operative vaginal delivery (compared with spontaneous vaginal delivery or cesarean delivery) was 0.42 (95% CI 0.33-0.54). Median (25th, 75th percentile) second-stage duration significantly increased from 38 (20, 71) to 42 (22, 87) minutes (P<.01), but this difference was nullified after adjusting for confounders. Comparing cohorts from 2000 and 2011, although the second-stage duration has not changed appreciably, nulliparous women in the second stage of labor at our institution are twice as likely to undergo cesarean delivery and half as likely to undergo operative vaginal delivery. II.

Group Prenatal Care Outcomes in a Military Population: A Retrospective Cohort Study.

To evaluate pregnancy outcomes in Centering Pregnancy patients. This was an IRB-approved retrospective cohort study from November 2009 to January 2013 involving 202 Centering Pregnancy patients and 202 Certified Nurse Midwife patients. The primary outcome was mean gestational age at time of delivery. Secondary outcomes included cesarean and operative vaginal delivery rate, triage visit frequency, Neonatal Intensive Care Unit admission rate, 1 and 5 minute APGAR scores, birth weight, breastfeeding rate at discharge and 6 weeks postpartum, third and fourth degree laceration rate, weight gain in pregnancy, and excessive weight gain rate. There was no statistically significant difference in any obstetric outcome including preterm delivery rate. Centering Pregnancy patients were more likely to be active duty (52.0 vs. 35.6%, p = 0.001), younger (24.8 vs. 26.3 years old, p < 0.001), and nulliparous (75.2 vs. 56.9%, p < 0.001). There was a statistically significant increase in triage visit frequency ≥ 6 for Centering Pregnancy patients (11.9% vs. 8.9%, p = 0.011). There were no clinically significant differences in the primary or secondary outcomes. Significant cost savings could be realized by expanding Centering Pregnancy in the military health system.

Continuous cardiotocography during labour: Analysis, classification and management

The use of continuous intrapartum electronic fetal heart rate monitoring (EFM) using a cardiotocograph (CTG) was developed to enable obstetricians and midwives to analyse the changes of fetal heart rateduring labour so as to institute timely intervention to avoid intrapartum hypoxic-ischaemic injury. Although CTG was initially developed as a screening tool to predict fetal hypoxia, its positive predictive value for intrapartum fetal hypoxia is approximately only 30%. Even though different international classifications have been developed with the aim of defining combinations of features that help predict intrapartum fetal hypoxia, the false-positive rate of the CTG is high (60%). Moreover, there has not been a demonstrable improvement in the rate of cerebral palsy or perinatal deaths since the introduction of CTG into clinical practice approximately 45 years ago. However, there has been a significant increase in intrapartum caesarean section and operative vaginal delivery rates. Unfortunately, existing guidelines employ the visual interpretation of CTG based on 'pattern recognition', which is fraught with inter- and intra-observer variability. Therefore, clinicians need to understand the physiology behind fetal heart rate changes and to respond to them accordingly, instead of purely relying on guidelines for management. It is very likely that such a 'physiology-based' approach would reduce unnecessary operative interventions and improve perinatal outcomes whilst reducing the need for 'additional tests' of fetal well-being.

Impact of Epidural Analgesia on Labor: Length of Labor, Operative Vaginal Delivery Rate and Occiput Posterior

Summary Introduction.Epidural analgesia (EA) is widely used as labor analgesia. It has been reported that EA can slow down the course of labor and increase the risk of operative vaginal delivery. Slower course of labor can lead to an increased risk of abnormal fetal heart rate (FHR). Some studies have also demonstrated an increase in occiput posterior position of the fetal head at delivery if EA is used. It represents a mechanism that may contribute to the lower rate of spontaneous vaginal delivery. Aim of study. To evaluate the impact of EA on the length of labor and the rate of operative vaginal delivery, and to determine whether EA increases the rate of occiput posterior of the fetal head at delivery Material and methods. We carried out a retrospective case-control study based on clinical records from parturients admitted to Riga Maternity Hospital in 2013. Parturients were divided into two groups: case group comprised parturients who had EA, while parturients of control group did not have EA. Groups were further subdivided into primiparas and multiparas and comparisons were made according to parity. We excluded parturients who had obstructed labor, pathological labor, induction of the labor, history of C-section and significant anomaly of the fetus. Results. A total of 832 parturients were included in the study, 304 in EA group (220 primiparas and 84 multiparas) and 528 in control group (257 primiparas and 271 multiparas). Primiparas of EA group had longer latent phase of the first stage of labor in comparison to primiparas of control group (p=0.001), while multiparas of EA group had longer first stage (p=0.031) of labor and longer latent phase of labor (p&lt;0.001) than their respective controls. Vacuum extraction was used in 1.27% of all deliveries with EA. Moreover, vacuum extraction was used only in primiparas an there was no statistically significant difference between EA group primiparas and control group primiparas (1.7% vs. 1.2%, p=0.593). EA did not increase the rate of occiput posterior positon of fetal head. However, primiparas with EA and occiput posterior were more likely to have an abnormal FHR tracing in comparison to primiparas with EA and without occiput posterior position of fetal head (40% vs. 9.8%, p=0.029; RR=4.09, 95% CI 1.3-12.9). There was no statistically significant link between occiput posterior position and abnormal FHR tracing in control group primiparas. Conclusion. EA does not increase the likelihood of operative vaginal delivery. However, parturients with EA have longer latent phase of the first stage of labor. Risk for occiput posterior at delivery is not increased in labor with EA. However, the risk for abnormal FHR among primiparas who receive EA is increased in case of occiput posterior position of the fetal head.

Can Ultrasound Performed in Prolonged Second Stage of Labor Predict the Difficulty and Success Rates of Operative Vaginal Delivery?

To evaluate different sonographic methods for the prediction of the difficulty and the success of operative vaginal delivery (OPD). A prospective study was performed on 45 term singleton uncomplicated pregnancies with prolonged 2nd stage of delivery with cephalic presentation. Measurements of the fetal head, relations between the fetal head and maternal pelvic parameters during rest and during maternal pushing were taken using translabial ultrasound. 29 cases of OPD were successful and 4 cases failed ending in cesarean section. The passage of the biparietal diameter (BPD) of the infrapubic line (IPL) was statistically correlated with the success of OPD. Head station, passage of the BPD of the IPL, percentage of head after the IPL, circumference of head after IPL were all correlated with the difficulty of OPD. When the distance between the widest diameter of the head and the IPL is < 1.2 cm, there is a 90 % probability of success of OPD. When that distance is > 3.3 cm, there is 90 % probability of cesarean section. When the percentage of head beyond the IPL was > 54 %, there was 90 % probability of successful OPD. Translabial ultrasound is useful in the prediction of the difficulty and the success of OPD. The higher the extent of head that passed the IPL, the less difficult the OPD and the greater the success rate of the OPD.

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?

Doğum Eylemi Sırasında Epidural Analjezi Uygulanmış Hastalarda Epidural Analjezinin Doğum Eylemi, Doğum ve Neonatal Sonuçlara Etkisi

Amaç: Doğum eylemi sırasında epidural analjezi uygulanmış hastalarda, epidural analjezinin doğum eylemi, doğum ve neonatal sonuçlara etkilerinin değerlendirilmesi amaçlanmıştır. Gereç ve Yöntemler: Çukurova Üniversitesi Tıp Fakültesi Hastanesi Kadın Hastalıkları ve Doğum Kliniğine 1 Ocak 2013-31 Aralık 2013 tarihleri arasında başvuran, doğum eylemi spontan başlamış, çalışmanın katılım kriterlerini karşılayan 106 gebe çalışmaya dâhil edildi. Aynı özelliklere sahip epidural analjezi işlemini kabul etmeyen 251 gebe de kontrol grubu olarak alındı. Gruplar demografik özellikleri, obstetrik sonuçları ve neonatal sonuçları açısından karşılaştırıldı. Sonuçlar arasında istatistiksel önem düzeyi için p değeri <0,05 olarak alındı. Bulgular: Yaş, beden kitle indeksi, gebelik haftası ve doğumhaneye yatışları sırasındaki servikal dilatasyonları açısından gruplar arasında anlamlı fark izlenmedi. Epidural analjezi uygulanan hastaların doğumun birinci ve ikinci evresinin anlamlı oranda uzun (p=0,001), normal doğum oranının anlamlı oranda fazla, epizyotomi ihtiyacının anlamlı düzeyde fazla (p=0,000), operatif doğum oranının ise anlamlı düzeyde az olduğu saptandı (p=0,009). Plasenta retansiyonu görülmesi açısından gruplar arasında anlamlı fark izlenmedi (p=0,158). Neonatal sonuçlar açısından karşılaştırıldığında ise gruplar arasında doğum kiloları, 1. ve 5. dakika APGAR skorları açısından anlamlı fark saptanmaz iken, epidural analjezi uygulanmış annelerin bebeklerinde yenidoğan yoğun bakıma yatış oranları anlamlı düzeyde yüksek saptandı (p=0,001). Sonuç: Çalışmamızda doğum eylemi sırasında epidural analjezi kullanımının operatif doğum ve sezaryen oranlarını artırmadığı, yenidoğanlarda yenidoğan yoğun bakım ünitesine yatış oranlarında artış olduğu saptansa da 1. ve 5. dakika APGAR skorları arasında çalışma ve kontrol grubu arasında anlamlı fark olmadığı gösterilmiştir. Bu sonuçlar ışığında çalışmamız, epidural analjezi ile normal doğumun hasta konforu açısından avantajlı bir yöntem olması yanı sıra hem anne hem bebek açısından güvenli ve seçkin bir yöntem olduğunu ortaya koymuştur. Objective: In this study, it is aimed to evaluate the effects of epidural analgesia on labor, delivery and neonatal outcomes in patients performed epidural analgesia during labor. Material and Methods: All patients admitted to Çukurova University Medical Faculty Hospital, Obstetrics and Gynecology Clinic because of the onset of labor spontaneously between 1 January 2013-31 December 2013 were included in the study. A total of 106 pregnant women that meet the inclusion criteria were enrolled in the study group. 251 pregnant women with the same characteristics and refuse epidural analgesia during labor were included as a control group. Groups were compared in terms of demographic characteristics, obstetric outcomes and neonatal outcomes. The p-value was taken as <0.05 for the level of statistical significance among the results. Results: Age, body mass index, gestational age and cervical dilatation on admission in the study group compared with the control group and there were no significant differences between the groups. The duration of the stages of birth was significantly long (p=0.001), vaginal delivery rates was statistically more, episiotomy procedure was significantly more (p=0.000) and the operative delivery rate was found significantly less compared to control patients in the group performed epidural analgesia during labor (p=0.009). There were no significant differences between the two groups for postpartum placental retention (p=0.158). When neonatal outcomes compared between two groups, while the neonates in the study group statistically significant more admitted to neonatal intensive care unit (p=0.001), there were not significant differences for 1. and 5. minutes APGAR scores between the two groups. Conclusion: In our study, we found that epidural analgesia during labor does not increase operative vaginal delivery and cesarean rates. Although there was an increase in the neonatal intensive care unit admission rates in newborns, we demonstrated no statistically significant difference for 1. and 5. minute APGAR scores between two groups. In light of these results our study revealed that epidural analgesia performed during delivery not only advantageable method of delivery for its comfort, it is also being a safe and exclusive method for both mothers and their babies.

19: Optimizing second stage outcomes: a randomized controled trial assessing the ability of precise maternal feedback to reduce adverse perinatal outcomes

19 Optimizing second stage outcomes: a randomized controled trial assessing the ability of precise maternal feedback to reduce adverse perinatal outcomes Merlin Fausett, P. Barrilleaux, Jonnie Buford Women’s and Childrens Hospital, OB/GYN, Lafayette, LA, Community Medical Center, OB/GYN, Missoula, MT OBJECTIVE: Regional anesthesia reduces biofeedback impeding pushing efficacy during second stage labor. Long second stage is associated with adverse outcomes. We assessed the clinical impact of providing laboring women real-time audiovisual feedback regarding fetal descent during second stage. STUDY DESIGN: Abiofeedback device detecting fetal decentwas attached to 69 primigravidas receiving epidural anesthesia. Fetal decent was measured & conveyed at sub-second and sub-millimeter intervals. After attachment of the feedback device, women were randomized 2:1 to Feedback (Study) and No Feedback (Control) groups. The 45 women in the Study groupwere provided audiovisual feedback. Second stage management was otherwise routine in both groups. The primary outcome of interest was length of second stage (LSS). Secondarily, we assessed individual adverse outcomes (AO) rates for operative vaginal delivery (OVD), cesarean delivery (CS), 3rd/4th degree laceration (LAC), intra-amniotic infection (IAI), perineal edema (E) and NICU admissions. Length of second stage regression models controlled for initial head station (HS) and birth weight (BW). RESULTS: For women delivering vaginally, the median pushing time was 58 vs. 77 minutes for Study and Control groups respectively. The lower 3 quartiles of the Study group had a 23 minute (26%) reduction in LSS (p1⁄40.016), see Figure 1. The AO rates of OVD, LAC, IAI, and E were all lower in the Study group (all p values < 0.02). The CS rate was not different but the composite AO rate was 73% lower in the Study group (p 1⁄4 0.011)-Table 1. Women with any AO, had a mean 2 hour increased hospital length of stay, p<0.01. CONCLUSION: A system providing precise measurement of fetal decent and maternal feedback during second stage labor substantially shortens second stage. In nulliparous women with epidural anesthesia, this feedback system decreases key individual and composite adverse maternal outcomes and decreases NICU admissions.