Postpartum Death Research Articles

Is there an association between short interval from previous cesarean section and adverse obstetric and prinatal outcome?

Objective: To investigate whether a short interdelivery interval from cesarean section (CS) to a subsequent delivery is associated with adverse obstetric outcomes, and specifically uterine rupture.Study design: A retrospective study was conducted, comparing all patients who delivered following CS during the years 1988–2010. Time interval was defined as the time from the day of CS to the day of the subsequent delivery. Women with multiple gestations or more than one previous CS were excluded from the study.Results: Three-thousand one-hundred and seventy-six deliveries were included in the study. Of these, 176 patients had an interval <12 month, 728 had an interval of 13–18 months, 635 had an interval of 19–24 months and 1637 had an interval of more than 24 months. The rate of uterine rupture did not differ between the groups. Patients with short interval of less than 12 month had higher rates of preterm deliveries (11.9% versus 4.9–6.6% in the other groups; p < 0.001). The rate of post partum perinatal death was comparable between the groups.Conclusion: Short time interval is not a risk factor for major maternal and neonatal complications such as uterine rupture and post-partum death. However, in our population, it is a risk factor for preterm delivery.

Fatal postpartum air embolism due to uterine inversion and atonic hemorrhage

We report a case of a 19-year-old woman who developed a persistent uterine hemorrhage after spontaneous delivery of a healthy child. Emergency laparotomy was indicated and then begun under stable circulatory conditions. Cardiac arrest occurred during the course of massive manual compression and packing of the uterus. After successful resuscitation, a supracervical hysterectomy was performed. During the suturing of the remaining cervix, a second cardiac arrest followed. The procedure was completed under constant external heart massage. Resuscitation was terminated due to the persistence of widened pupils. An autopsy was ordered by the public prosecutor as the manner of death was declared to be unascertained. An X-ray and a CT scan prior to the autopsy showed extensive gas embolism in both arterial and venous vessels extending from the pelvic region to the head. During the autopsy, gas was collected by aspirometer from the right ventricle of the heart. The autopsy showed no additional relevant findings, and gas analysis confirmed the suspicion of air embolism. The histological examination of the excised uterus especially in the corpus/fundus revealed an edema of the local smooth muscle cells and dilated vessels showing no sign of thrombogenesis. Upon evaluation of the clinical records, it became evident that, in addition to uterine atony, there had been a complete uterine inversion. This inversion was manually repositioned. After this maneuver, manual compression was performed. The air embolism, thus, was a complication of the manual repositioning of the uterine inversion. There is no evidence for other possible entries of the detected gas. In order to perform an effective exploration, the availability of all clinical records should be mandatory for medico-legal investigations of unexpected postpartum deaths.

Can we reduce post-partum haemorrhage maternal deaths?

African Journal of Midwifery and Women's HealthVol. 7, No. 1 EditorialCan we reduce post-partum haemorrhage maternal deaths?Christina Mudokwenyu-RawdonChristina Mudokwenyu-RawdonSearch for more papers by this authorChristina Mudokwenyu-RawdonPublished Online:23 Sep 2013https://doi.org/10.12968/ajmw.2013.7.1.5AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Ashford L (2002) Hidden Suffering: Disabilities From Pregnancy and Childbirth in Less Developed Countries. http://www.prb.org/Publications/PolicyBriefs/HiddenSufferingDisabilitiesFromPregnancyandChildbirthinLDCs.aspx (accessed 20 December 2012) Google ScholarMaternity Worldwide (2012) The three delays model. http://www.maternityworldwide.org/what-we-do/three-delays-model/ (accessed 20 December 2012) Google Scholar FiguresReferencesRelatedDetails 1 January 2013Volume 7Issue 1ISSN (online): 2052-4293 Metrics History Published online 23 September 2013 Published in print 1 January 2013 Information© MA Healthcare LimitedPDF download

PP045. Maternal mortality due to hypertension: A look at the puerperium

Maternal death is the death of a woman during pregnancy within 42days after delivery. It is one of the most serious violations of human rights of women, because it is a preventable tragedy in 92% of cases and occurs mainly in developing countries. Brazil, a country of continental dimensions has the challenge of reducing maternal deaths; one of the priority regions is Santos, a city in the state of São Paulo. It is felt that efforts are made to the adoption of care that can minimize risks during complicated pregnancy with hypertensive disorders, but not always this service is offered proportionally to postpartum. Perhaps the erroneous concept that the delivery is capable of quickly balancing the harm of maternal hypertensive disorders is implicated in reducing postpartum surveillance, exposing this group of women to undesirable outcomes. Analyze the percentage of postpartum maternal deaths until 42days after delivery for hypertensive disorders in Santos in the period of 1999-2009. Data were provided by the Ministry of Health of Brazil in www.datasus.gov.br (accessed February 2012). The number of maternal deaths was divided into maternal death in pregnancy, delivery and abortion and maternal death in puerperium up to 42, considering all causes of maternal death and identifying the proportion of deaths due to hypertensive syndromes. According to the general causes of death, more women die during pregnancy, delivery and abortion (69.7%) than postpartum (30.3%) and hypertensive disorders account for 20% of these outcomes. Analyzing the proportion of deaths due to hypertensive disorders in each period, we observed that during pregnancy the disorder accounts for 16.5% of all causes, however, the percentage reaches 30.3% in the puerperium. The increase of death in postpartum due to hypertensive syndromes, regarding all general causes, shows the necessary action to be done by the professional team to offer continuity care in and out of hospital in this period, considering that the challenges persist even after delivery.

Intrauterine fetal death of one twin of diamnionic twins is associated with adverse perinatal outcome of the co-twin

Objective: To determine whether intrauterine fetal death (IUFD) of one twin of diamnionic twins after 22 weeks of gestation is associated with adverse perinatal outcome to the co-twin. Method: A retrospective case-control study (n = 4070), including all twin births delivered between the years 1988 and 2010, was conducted. Perinatal outcome of the co-twin in diamnionic pregnancies complicated by IUFD were compared with the first twin from a pair of live-born diamnionic twins. A multiple logistic regression model was constructed to determine the association between IUFD of one twin and postpartum death (PPD) of the co-twin while controlling for confounders such as gestational age. Results: Pregnancies complicated with IUFD of a co-twin (n = 116) had higher rates of adverse perinatal outcomes such as PPD (9.5% vs. 2.3%, p < 0.001), low Apgar scores (<7) at 1 and 5 min (30.2% vs. 10.6%, p < 0.001 and 6.9% vs. 1.8%, p < 0.001, respectively), lower birth weight (1953 ± 746 g vs. 2299 ± 559 g), and higher rates of preterm birth before 34 weeks of gestation (38.8% vs. 16.4%, p < 0.001). Using a multivariate analysis with PPD as the outcome variable, mortality was attributed to gestational age (adjusted OR = 0.58; 95% CI 0.5–0.6, p < 0.001) and not to the IUFD per se (adjusted OR = 1.3, 95% CI 0.5–3.3, p = 0.552). Conclusion: Intrauterine fetal death of one twin (of diamnionic twins) is associated with adverse perinatal outcome of the co-twin mainly due to prematurity.

Clinical analysis of Eisenmenger syndrome during pregnancy

Objective To investigate the outcome and the management of pregnant women with Eisenmenger syndrome during perinatal period to reduce the maternal fatality rate.Methods The clinical data of 23 pregnant women with Eisenmenger syndrome admitted into Beijing Anzhen Hospital Capital Medical University from January 1st,2001 to December 31st,2009 were retrospectively analyzed.Gestational week,primary disease of the heart,pulmonary hypertension,oxygen saturation and heart function of the patients were compared with Chi-square test or Fisher's exact test.Results (1) The gestational week of 23 patients with Eisenmenger syndrome were between 15 to 38 weeks,among which 11 cases in the midterm pregnancy and 12 in the last term pregnancy.The severity of pulmonary hypertension,heart function and pregnant outcomes have no difference in patients with differeut gestational weeks (P＞0.05).(2) Ventricular septal defect (VSD) were the most common disease (65.2％,15/23) among the four primary heart diseases of the patients.The heart function of the patients with VSD decreased most severely after pregnancy,and the fatality rate of the heart function Ⅳ was up to 73.3％ (11/15).The incidence of severe pulmonary hypertension was 20.0％ (3/15).The decreasing of the heart function of the patients with different primary heart diseases were different (P＜0.05).(3) Among the pulmonary hypertension patients,there were 7 mild cases (30.4％),12 moderate cases (52.2％) and 4 severe cases (17.4％).The severity of the pulmonary hypertension of the patients correlated to the incidence of postpartum heart failure and death (P＜ 0.05).The outcomes of four patients with severe pulmonary hypertension were the worst and all were reported to be dead (4/4).(4) Oxygen saturation related to the mortality of perinatal infants,incidence of premature birth and spontaneous abortion (P＜0.05).As oxygen saturation decreased to the lowest level,the fatality rate of perinatal infants increased to the highest (5.3 ％,1/19),so did the incidence of the premature birth (84.2％,16/19) and spontaneous abortion ( 10.5％,2/19).Conclusions The key point to increase the safety of patients with Eisenmenger syndrome during perinatal period was to strengthen monitoring,decrease the pulmonary hypertension and terminate pregnancy timely. Key words: Pregnancy complications, cardiovascular; Eisenmenger complex

Deaths associated with acquired haemophilia in France from 2000 to 2009: multiple cause analysis for best care strategies

Deaths occurring in the context of acquired haemophilia (AH) may be related to inter-connected causes and mechanisms including bleeding, specific or older patient co-morbidities or iatrogenic complications. However, their magnitude remains unknown. This study aimed to determine the respective weight and frequency of the various causes of death in AH. Multiple-cause analysis based on death certificates data is used in this purpose. Over a 10-year period (2000-2009), 121 deaths with AH as a cause were registered in France. All the deaths were of adults (extremes: 47 and 99 years; mean age: 80.7 years). The average number of causes per death certificate was 4.7. AH was the underlying cause of death (UCD) in 69.4% of the cases, and was more frequent in the older subjects. In contrast, before age of 75 years, AH was more often a contributing cause of death. No postpartum or obvious thromboembolism-related deaths were registered. Haemorrhagic shock was the most frequent direct cause of death (DCD), followed by infectious events, cardiac dysfunction, metabolic and nutritional disorders with muscle wasting and decubitus complications, and cancers (52.9%, 26.4%, 7.5%, 5.8% and 4.1%, respectively). However, when AH was not reported as an UCD, infections become the first DCD (32.4%) followed by bleeding events (16.2%). Best prophylactic and curative strategies for infections are particularly required to improve the prognosis in AH. Moreover, as several of its DCD correspond also to steroids side effects, best tolerated immunosuppressant regimen with steroid-sparing agents adjoining are particularly awaited in AH population.

Risk factors for intrauterine fetal death (1988–2009)

Objective. To determine risk factors for intrauterine fetal death (IUFD).Study design. A retrospective population-based study, of all singleton deliveries between the years 1988–2009 was conducted. Intrapartum deaths, postpartum death, and multiple gestations were excluded. A multiple logistic regression model was used to determine independent risk factors.Results. During the study period, out of 228,239 singleton births, 1694 IUFD cases were recorded (7.4 per 1000 births). The following independent risk factors were identified in the logistic regression executed: Oligohydramnios (OR 2.6, 95% CI 2.1–3.2, p-value < 0.001), polyhydramnios (OR 1.8, 95% CI 1.4–2.2, p-value < 0.001), previous adverse perinatal outcome (OR 1.7, 95% CI 1.5–2.1, p-value < 0.001), congenital malformations (OR 2.0, 95% CI 1.8–2.3, p-value < 0.001), true knot of cord (OR 3.7, 95% CI 2.8–4.9, p-value < 0.001), meconium stained amniotic fluid (OR 2.7, 95% CI 2.3–3.0, p-value<0.001), placental abruption (OR 2.9, 95% CI 2.4–3.5, p-value < 0.001), advanced maternal age (OR 1.03, 95% CI 1.02–1.04, p-value < 0.001), and hypertensive disorders (OR 1.24, 95% CI 1.0–1.4, p-value = 0.026). Jewish ethnicity (versus Bedouin – OR 0.64, 95% CI 0.57–0.72, p-value < 0.001), gestational diabetes (OR 0.7, 95% CI 0.5–0.8, p-value = 0.001), previous cesarean section (OR 0.8, 95% CI 0.7–0.97, p-value = 0.019), and recurrent abortions (OR 0.8, 95% CI 0.6–0.9, p-value = 0.011) were negatively associated with IUFD.Conclusion. Several independent risk factors were identified, suggesting a possible cause of death. Other pathologic conditions that facilitate tighter pregnancy surveillance and active management were found protective, pointing the benefit of such management approaches in high-risk pregnancies.

Review: Prevention of postpartum haemorrhage (PPH) and deaths from PPH

The occurrence of PPH can be minimised by addressing preventable factors that lead to haemorrhage and the appropriate management of the third stage of labour. The antenatal detection and treatment of anaemia plays a critical role in decreasing morbidity and mortality from PPH. Other factors placing women at risk of PPH include increased parity, increased maternal age, obesity, polyhydramnios, multiple pregnancy, known placenta praevia and abruptio placenta. Women identified with such factors should be delivered in hospitals with 24 hour caesarean section services. Their labours should have a skilled attendant, active management of the third stage and close observation in the first 4 hours after birth. All attempts must be made to prevent haemorrhage, detect it early and prevent it from becoming massive by aggressive use of uterotonic agents and early recourse to surgical measures to arrest haemorrhage.

The evolving management of the third stage of labour

The immediate postpartum period is a risky period because life-threatening events can occur unexpectedly, and lead to death if they are not managed promptly. Appropriate management of the third stage of labour can reduce severe postpartum haemorrhage and death. This commentary summarizes how various management techniques of third stage of labour evolved to date and the evidence base for current international recommendations.

Forensic aspects of post-mortem histological detection of amniotic fluid embolism

Amniotic fluid embolism (AFE) continues to be one of the most feared and devastating complications of pregnancy. A reliable diagnosis can be made only upon histological examination. A detection of AFE every now and then has a relevant implication on medico-legal aspects of intrapartum or post-partum maternal death. However, there are only isolated reports in the literature concerning the detection interval of amniotic fluid elements after their transfer into the lungs. The objective of this study was to determine how long after the onset of clinical symptoms the elements of amniotic fluid may be detectable in the pulmonary circulation. An autopsy, as well as a histological and toxicological examination of 29 women, who died intrapartum or post-partum were performed. AFE was diagnosed in seven women (25%). The maximum survival time of the women with AFE and also the detection interval of AF in the pulmonary vasculature was 36 h. In the lungs of the women who did not die of AFE, amniotic fluid components were not found. Thus, there is no evidence for a physiologic occurrence of AFE. In women who die some days or even weeks after delivery as a consequence of a haemorrhagic shock following post-partum genital bleeding ensuing from uterine atony, AFE should be considered as a cause of a coagulopathy.

Pregnancy outcome in women with lupus nephritis

Objective To study the outcome of pregnancy with lupus nephritis. Methods The clinical data of 9 pregnancies with lupus nephritis were retrospectively malyzed. Results Hypertension,proteinuria,injured renal function and abnormal serological marker were complicated with nine patients with lupus nephritis in pregnancy. The outcome of pregnancy was as following:abortion 2 cases,stillbirth 1 case,premature delivery 4 cases,term delivery 2 cases. All neonate survived without malformation. There was no postpartum hemorrhage or death. Patients with active SLE had very high fetal mortality( 100% ). And SLE got worsen in 50% of them. However,fetal mortality rate in pa-tients with controlled or quiescent SLE was 11.1% ,which was much lower than it in other patients(P<0.05). Con-clusion Lupus nephritis should be controlled before pregnancy. Pregnancy outcome could be improved by careful multidisciplinary monitoring and proper usage of adrenal cortical hormone. Key words: Pregnancy complications; Lupus nephritis; Pregnancy Outcome; Time management

Determinants of post-partum maternal mortality at Queen Elizabeth Central Hospital, Blantyre, Malawi: a case-control study 2001-2002.

The aim of this research is to identify the clinical, demographic and service-based determinants of postpartum maternal mortality within Queen Elizabeth Central Hospital, Blantyre, Malawi, during 2001 and 2002. The study uses a case-control design using all postpartum maternal deaths in 2001 and 2002 as cases, with analysis conducted using conditional logistic regression. The results indicate that the mothers' reason for admission into hospital and the outcome of the birth were significantly related to maternal death when analysing all potential explanatory variables in one model. A group of high-risk mothers can be identified using these factors. If these criteria were applied as a predictive tool in the clinical setting the resulting sensitivity and specificity would be over 85%. Identification within the hospital setting of a group of very high-risk mothers in whom serious complications are aggressively managed in a coordinated way across the medical specialties may reduce maternal mortality.

Neonatal outcome in preterm deliveries between 23 and 27 weeks’ gestation with and without preterm premature rupture of membranes

To characterize neonatal morbidity and mortality rates in extreme preterm deliveries (between 23 and 27 weeks' gestation) with and without PPROM, and to evaluate the association between PPROM and chorioamnionitis. A retrospective population-based study was conducted on preterm singleton pregnancies delivered between 23 and 27 weeks' gestation from 1988 to 2007. Immediate neonatal morbidity and mortality rates in pregnancies complicated by PPROM were compared to pregnancies with intact membranes. A multivariate analysis was conducted in order to determine the independent association between PPROM and chorioamnionitis. Out of 1,437 preterm deliveries, 236 (16.4%) were complicated with PPROM. There were more neonates with low 1 min (61.0 vs. 42.5%; P = 0.001) and low 5 min (30.1 vs. 23.8%; P = 0.042) Apgar scores (of less than 7) in pregnancies complicated by PPROM than in the comparison group. There were more cases of chorioamnionitis in the PPROM group born at 23-24 weeks' gestation (33.8 vs. 17.0%; P < 0.001), and in the PPROM group born at 25-27 weeks (42.0 vs. 15.5%; P < 0.001). In the group born at 23-24 weeks' gestation, there were more postpartum deaths (PPD) in the PPROM group (70.0 vs. 54.8%; P = 0.013); however, there was no significant difference in PPD in the groups born at 25-27 weeks. In the group born at 23-24 weeks, as well as at 25-27 weeks, there were fewer antepartum deaths (APD) in the PPROM group as compared to the control group (16.3 vs. 32.6%; P = 0.002, and 5.3 vs. 36.3%; P < 0.001; respectively). After adjusting for gestational age and gender, using a multivariate analysis, the association between PPROM and chorioamnionitis remained significant (OR = 3.32; 95% CI 2.43-4.51, P < 0.001). PPROM is associated with adverse perinatal outcome in deliveries between 23 and 27 weeks' gestation. Moreover, PPROM is an independent risk factor for chorioamnionitis.

The Safe Motherhood Initiative and beyond

In 2007 the Safe Motherhood Initiative is celebrating its 20th anniversary. Many countries have been able to improve the health and well-being of mothers and newborns over the last 20 years. However countries with the highest burdens of mortality and illness have made the least progress and inequalities between countries are increasing. In many places inequalities within countries are increasing too between those who live in better conditions and have access to care and those who for a variety of reasons are excluded. Globally the numbers remain staggering: each year there are at least 3.2 million stillborn babies 4 million neonatal deaths and more than half a million maternal deaths. The majority of these deaths are avoidable. HIV/ AIDS and malaria in pregnancy are having an impact on maternal mortality and could reverse the progress that has been made. A total of 11-17% of maternal deaths occur during childbirth itself; 50-71% occur in the post-partum period. The time spent in labour andgiving birth the critical moments when a joyful event can suddenly turn into an unforeseen crisis needs more attention as does the often-neglected post-partum period. These periods account not only for the high burden of post-partum maternal deaths but also for the associated large number of stillbirths and early newborn deaths. (excerpt)

Postpartum Maternal Mortality and Cesarean Delivery

A continuous rise in the rate of cesarean delivery has been reported in many countries during the past decades. This trend has prompted the emergence of a controversial debate on the risks and benefits associated with cesarean delivery. Our objective was to provide a valid estimate of the risk of postpartum maternal death directly associated with cesarean as compared with vaginal delivery. A population-based case-control study was designed, with subjects selected from recent nationwide surveys in France. To control for indication bias, maternal deaths due to antenatal morbidities were excluded. For the 5-year study period 1996-2000, 65 cases were included. The control group was selected from the 1998 French National Perinatal Survey and included 10,244 women. Multivariable logistic regression analysis was used to adjust for confounders. After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery (odds ratio 3.64 95% confidence interval 2.15-6.19). Both prepartum and intrapartum cesarean delivery were associated with a significantly increased risk. Cesarean delivery was associated with a significantly increased risk of maternal death from complications of anesthesia, puerperal infection, and venous thromboembolism. The risk of death from postpartum hemorrhage did not differ significantly between vaginal and cesarean deliveries. Cesarean delivery is associated with an increased risk of postpartum maternal death. Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request and should inform preventive strategies.

Prevalence of suicidality during pregnancy and the postpartum

This review examined the available prevalence estimates of suicidality (suicide deaths, attempts, and ideation including thoughts of self harm) in pregnancy and the postpartum. Studies that used defined community or clinic samples were identified through multiple electronic databases and contacts with primary authors. Definitions of and measurement of suicide deaths, intentional self-harming behavior, suicide attempts, and thoughts of death and self-harm were varied and are described with each study. While suicide deaths and attempts are lower during pregnancy and the postpartum than in the general population of women, when deaths do occur, suicides account for up to 20% of postpartum deaths. Self-harm ideation is more common than attempts or deaths, with thoughts of self-harm during pregnancy and the postpartum ranging from 5 to 14%. The risk for suicidality is significantly elevated among depressed women during the perinatal period, and suicide has been found to be the second or leading cause of death in this depressed population.

Postpartum “Psychosis” in Mild Argininosuccinate Synthetase Deficiency

Urea cycle disorders are relatively rare but well-established causes of postpartum coma and death. Such clinical presentations have been reported previously in ornithine transcarbamylase and carbamyl phosphate synthetase deficiencies. We describe a woman, without prior symptoms of metabolic disease, who presented with hyperammonemia and psychiatric symptoms in the postpartum period. Initial diagnoses included acute fatty liver of pregnancy and postpartum psychosis. She was later found to have argininosuccinate synthetase deficiency after further metabolic investigations. Rare heterozygous mutations in the argininosuccinate synthetase gene were identified. Urea cycle disorders may present initially with postpartum psychiatric symptoms and may represent an underrecognized cause of "postpartum psychosis." We recommend obtaining metabolic studies in women with neurologic or severe psychiatric symptoms in the postpartum period.

Postpartum death with maple syrup urine disease

International Journal of Gynecology & ObstetricsVolume 81, Issue 1 p. 57-58 Brief communications Postpartum death with maple syrup urine disease S. Yoshida, S. Yoshida seiyay@meijohosp.com Department of Obstetrics and Gynecology, Meijo Hospital, Naka-ku, Nagoya, JapanSearch for more papers by this authorT. Tanaka, T. Tanaka Department of Obstetrics and Gynecology, Kamo Hospital, Toyota, JapanSearch for more papers by this author S. Yoshida, S. Yoshida seiyay@meijohosp.com Department of Obstetrics and Gynecology, Meijo Hospital, Naka-ku, Nagoya, JapanSearch for more papers by this authorT. Tanaka, T. Tanaka Department of Obstetrics and Gynecology, Kamo Hospital, Toyota, JapanSearch for more papers by this author First published: 19 March 2003 https://doi.org/10.1016/S0020-7292(02)00446-0Citations: 12 Corresponding author. Tel.: +81-52-201-5311; fax: +81-52-201-5318 Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume81, Issue1April 2003Pages 57-58 RelatedInformation

Failed Vacuum Extraction: Maternal Risk Factors and Pregnancy Outcome

Vacuum extraction, more widely used than forceps for operative vaginal delivery in Europe, is said to have failed when it is unduly difficult or there are more than two cup disengagements. This retrospective study of singleton, vertex deliveries at more than 36 weeks' gestation sought to identify obstetrical risk factors for a failed trial of vacuum extraction. A total of 211 trials taking place in the years 1990-1998 were reviewed; 5.4% of attempts (113) failed, leading to cesarean delivery within 15 minutes. Extraction was done only when the cervix was completely dilated, the membranes had ruptured, and the fetal head was engaged. Traction was done slowly and was stopped if there was any loss of vacuum. Pressure was limited to 0.8 kg/cm 2 . Only two reapplications of the metal cup were permitted. Three instances of lost suction were construed as method failure. Failed vacuum extraction was significantly and linearly associated with high birth weights; these infants were likelier to be large for gestational age and to weigh more than 4000 g. A lack of prenatal care also correlated with a higher rate of failed extraction. On multiple logistic regression analysis, both deficient prenatal care and a birth weight greater than 4000 g were independent risk factors for failed vacuum extraction. Women in whom extraction failed had significantly more cervical and uterine tears than when the procedure succeeded, and the relationship with uterine rupture persisted after adjusting for previous cesarean delivery, Failed extraction correlated with postpartum anemia and also with higher rates of intrapartum and postpartum fetal death (odds ratios: 35.9 for intrapartum fetal death and 9.1 for postpartum death). Both maternal and neonatal outcomes are compromised by a failed trial of vacuum extraction. An estimated fetal weight exceeding 4000 g should be viewed as a relative contraindication, particularly for women who have not received adequate prenatal care.