Operative Vaginal Delivery Rates Research Articles

Operative vaginal delivery: a review of four national guidelines.

There is a broad range in the rates of operative vaginal deliveries (OVD) worldwide, which reflects the variety of local practice patterns, the number of trained clinicians and the lack of international evidence-based guidelines. The aim of this study was to review and compare the recommendations from published guidelines on OVD. Thus, a descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the American College of Obstetricians and Gynecologists (ACOG) on instrumental vaginal birth was conducted. All the guidelines point out that the use of any instrument should be based on the clinical circumstances and the experience of the operator. The indications, the contraindications, the prerequisites and the classification for OVD are overall very similar in the reviewed guidelines. Further, they all agree that episiotomy should not be performed routinely. The RCOG, the RANZCOG and the SOGC describe some interventions which may promote spontaneous vaginal birth and therefore reduce the need for OVD. They also highlight the importance of adequate postnatal care and counseling. There is no consensus on the actual technique that should be used, including the type of forceps or vacuum cup, the force and duration of traction or the number of detachments allowed. Hence, there is need for international practice protocols, so as to encourage the clinicians to use OVD when indicated, minimize the complications and reduce rates of cesarean delivery.

61: Hospital-level cesarean and operative delivery rate and risk for adverse outcomes

Hospital-level cesarean rates are used as a quality indicator and operative vaginal delivery (OVD) with vacuum or forceps may represent an alternative to cesarean in some clinical scenarios. However, it is not known whether OVD is more common among vaginal deliveries at hospitals with low cesarean rates. It is also not known whether hospitals with higher OVD rates have higher risk for neonatal injury, 3rd/4th degree vaginal lacerations, and shoulder dystocia. The objective of this study was to address these knowledge gaps. The Nationwide Inpatient Sample from 1998-2011 was used for this serial cross sectional analysis. Singleton, liveborn delivery hospitalizations were identified. Hospitals were divided into five quintiles based cesarean deliveries rates; OVD among all vaginal deliveries was calculated. The analysis was then repeated excluding cesarean deliveries and ordering hospitals into quintiles based on OVD rates; risk for 3rd/4th degree lacerations and shoulder dystocia among all vaginal deliveries was then calculated. Finally, birth injury based on OVD quintiles was analyzed for the entire hospital newborn population. Of 10,318,573 deliveries, 6,695,987 were vaginal. Among vaginal deliveries, OVD was more common in the lowest vs. highest cesarean quintiles (10.6% vs 8.7%, p< 0.01) (Figure 1). Hospital mean OVD rates were 3.5%, 6.4%, 8.6%, 11.4%, and 17.6% of all vaginal deliveries by OVD quintile. Shoulder dystocia (Figure 2A) and 3rd and 4th degree vaginal lacerations (Figure 2B) for the entire vaginal delivery population increased significantly from lowest to highest OVD quintile (p< 0.01). Evaluating the entire hospital newborn populations, risk for birth injury was 30.5% (95% CI 28.7%-32.4%) greater in the highest vs. lowest OVD quintile hospitals. In this analysis, lower cesarean rates were associated with higher OVD rates. Higher OVD rates were in turn associated with hospital-level risk for shoulder dystocia, 3rd/4th degree laceration, and neonatal injury. In the setting of efforts to reduce cesarean it is also important to track these outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

327: Differences in rates of operative vaginal delivery by age and race

327: Differences in rates of operative vaginal delivery by age and race

Intrapartum interventions that affect maternal and neonatal outcomes for vaginal birth after cesarean section.

ObjectiveTo investigate maternal and neonatal outcomes after different intrapartum interventions for vaginal birth after cesarean section (VBAC) in mainland China.MethodsA retrospective study was performed on 143 VBAC cases from Beijing Obstetrics and Gynecology Hospital between January 2015 and November 2016. These cases were divided into two groups on the basis of different intrapartum interventions. Maternal and neonatal outcomes were compared.ResultsThe durations of the first stage and total labor after oxytocin were significantly longer than those before oxytocin use. The proportion of operative vaginal delivery with oxytocin was significantly higher than that without oxytocin (43.9% vs. 11.8%). The times of the first stage, second stage, and total labor with analgesia were significantly longer than those without analgesia (548.4±198.1 vs. 341.8±233.0 minutes, 52.0±38.9 vs. 36.0± 29.1 minutes, and 606.3±212.1 vs. 387.3±233.0 minutes, respectively). Postpartum hemorrhage and operative vaginal delivery occurred significantly more frequently in women with epidural analgesia than in those without epidural analgesia (29.7% vs. 12.3 and 35.1% vs. 16.0%, respectively).ConclusionsInduction can increase the rate of operative vaginal delivery in VBAC. Oxytocin and epidural analgesia may increase the risk of operative vaginal delivery, and may be associated with a prolonged duration of labor.

Impact of nuchal cord on antenatal and intrapartum foetal heart rate surveillance and perinatal outcome

Analysing antepartum and intrapartum computerised cardiotocographic (cCTG) parameters in physiological term pregnancies with nuchal (NC) or body cord (BC), in order to correlate them with labour events and neonatal outcome. We enrolled 808 pregnant women, composed of 264 with ‘one NC’, 121 with ‘multiple NCs’, 39 with BC and 384 with ‘no NC’, were monitored from the 37th week of gestation before labour, while 49 pregnant women with ‘one or more NCs’ and 47 with ‘no NCs’ were analysed during labour. No differences in maternal characteristics, foetal pH at birth and 5-min Apgar score were observed. The birth weight was significantly lower in the ‘multiple NCs’ group, while 1-minute Apgar score was lower in the BC group than the other groups, respectively. No relevant differences in cCTG parameters were observed, except for LTI, Delta and number of variable decelerations in antepartum period and only variable deceleration in intrapartum period.Impact statementWhat is already known on this subject? Ultrasound cannot predict which foetuses with NCs are likely to have problem during labour. The question arose if single or multiple NC could affects FHR monitoring prior and during labour.What do the results of this study add? Computerised cardiotocography (cCTG) is a standardised method developed to reduce inter- and intra-observer variability and the poor reproducibility of visual analysis. Few studies have investigated the influence of NCs on FHR variability and, to our knowledge, no one has evaluated its linear and nonlinear characteristics in antepartum and intrapartum period using a computerised analysis system. No differences in maternal characteristics, foetal pH at birth and 5-min Apgar score were observed. Birth weight was significantly lower in the ‘multiple NCs’ group, while 1-min Apgar score was lower in the BC group than the other groups, respectively. Foetuses with ‘one or more NCs’ evidenced a larger number of prolonged second stage and meconium-stained liquor cases, while the operative vaginal delivery and emergency caesarean section rates were unchanged. No relevant differences in cCTG parameters were observed, except for LTI, Delta and number of variable decelerations in antepartum period and only variable deceleration in intrapartum period.What are the implications of these findings for clinical practice and/or further research? cCTG monitoring results confirmed their usefulness for assessing the state of good oxygenation for all foetuses investigated.

Effect of delayed misoprostol dosing interval for induction of labor: a retrospective study

BackgroundInduction of labor occurs in greater than 22% of all pregnancies in the United States. Previous studies have shown that misoprostol is more effective for induction than oxytocin or dinoprostone alone. The World Health Organization recommends vaginal misoprostol 25mcg every 6 hours and the American Congress of Obstetricians and Gynecologists recommends 25mcg vaginal misoprostol every three to 6 hours. Although route of administration and dosage of misoprostol has been extensively studied, little is known about the optimal dosing interval of vaginal misoprostol.MethodsThe primary objective of this study is to determine the effect of delayed vaginal misoprostol dosing, defined as any interval longer than 4.5 h, on time to vaginal delivery. Our hypothesis is that the routine dosing interval of 4 hours shortens times to vaginal delivery compared to delayed dosing, even when adjusted for the time of delay. Secondary objectives include the effect of delayed vaginal misoprostol dosing on cesarean section rate, operative vaginal delivery rate, maternal outcomes, and neonatal outcomes.We conducted a retrospective chart review of 323 inductions of labor at one academic institution. The primary outcome was the proportion of patients who achieved a vaginal delivery within 24 h. The group who received all doses of misoprostol within a 4.5 h dosing window (Routine Dosing Interval Group) was compared with the group who had any dosing deviation (Delayed Dosing Interval Group).ResultsOf 133 included patients, 64 subjects received routine interval dosing and 69 subjects received delayed interval dosing. The vaginal delivery rates within 24 h were 56% (36/64) and 20% (14/69), respectively (P < 10− 4). Spontaneous vaginal delivery rates were 86% (55/64) vs. 75% (52/69), respectively (P = .13). Kaplan Meier curves demonstrated statistically significant difference in time to vaginal delivery between groups, with a Cox Proportional Hazard ratio for routine dosing interval of 1.73 (P < 10− 5) unadjusted and 1.34 (P = .01) when adjusted for dosing delay.ConclusionsThis retrospective study demonstrates a significant increase in delay-adjusted time to vaginal delivery when doses of vaginal misoprostol are delayed past 4.5 h.

Defining the upper limit of the second stage of labor in nulliparous patients

Increased duration of the second stage of labor provides clinical challenges in decision-making regarding the optimal mode of delivery that minimizes maternal and neonatal morbidity. In a large cohort of uncomplicated nulliparous singleton cephalic labors, we sought to examine the effect of increasing duration of second stage on delivery and perinatal outcome. The GENESIS Study recruited 2336 nulliparous patients with vertex presentation in a prospective double-blinded study to examine prenatal and intrapartum predictors of delivery. Metrics included maternal demographics, duration of second stage, mode of delivery, and associated maternal and neonatal outcomes. Indicators of morbidity included third- or fourth-degree tear, postpartum hemorrhage, neonatal intensive care unit admission, low Apgar scores, cord pH <7.20 and a composite of birth injury that included cephalohematoma, fetal laceration, brachial plexus palsy, facial nerve palsy, and fetal fracture. Of 2336 recruited nulliparous participants, 1872 reached the second stage of labor and had complete data for analysis. Increased maternal age (P=.02) and birthweight (P<.001) were found to be associated with a longer second stage. Increasing second stage duration was found to impact on mode of delivery, such that at <1 hour duration the spontaneous vaginal delivery rate was 63% vs 24% at >3 hours (P<.001). Operative vaginal delivery increased from 35% at <1 hour to 65% at >3 hours (P<.001). The rate of cesarean delivery increased with duration of the second stage from 1.2% at <1 hour to 11% at >3 hours (P<.001). The rates of third- or fourth-degree tear increased with second stage duration (P=.003), as did postpartum hemorrhage (P<.001). The composite neonatal birth injury rate increased from 1.8% at <1 hour to 3.4% at >3 hours. The maximum rate of birth injury was 6.5% at 2-3 hours (P<.001). Multiple logistic regression analysis that controlled for maternal age and birthweight confirmed that operative vaginal delivery, perineal trauma, postpartum hemorrhage, and neonatal birth injury remained significantly more likely with increasing second stage duration. In a prospective cohort of nulliparous pregnancies, increasing duration of second stage of labor was associated with increased rates of operative vaginal and cesarean delivery. Although almost 90% of term nulliparous women with a second stage of labor >3 hours will succeed in achieving a vaginal birth, this success comes at a maternal morbidity cost, with a 10% risk of severe perineal injury and an increasing rate of significant neonatal injury.

Pushing the bounds of second stage in term nulliparas with a predictive model

Management of the second stage of labor continues to be a clinical challenge with unclear indications for abandoning attempts at spontaneous vaginal delivery. The conflict between diminishing chances of spontaneous vaginal delivery and increasing maternal and neonatal morbidity is difficult to quantify, leading to significant variation in management between providers, and variation in rates of operative vaginal delivery and cesarean birth. The objective of the study was to develop an hourly prediction model for spontaneous vaginal delivery during the second stage of labor in nulliparous women with epidural anesthesia. This was a secondary analysis of the Consortium for Safe Labor database. The Consortium for Safe Labor collected data from 228,652 patients at 19 hospitals in the United State from 2002 through 2008. Primary outcome was delivery type per hour of second stage: spontaneous vaginal delivery vs operative delivery (operative vaginal and cesarean delivery). Inclusion criteria were term nulliparas with singleton gestations, vertex presentation, and attainment of 10 cm cervical dilation with epidural anesthesia. Exclusion criteria were intrauterine fetal demise, planned cesarean delivery, and major congenital anomalies. An optimal decision tree was used to create a prediction model. A test set was withheld from the data set to perform validation. A risk calculator tool was developed for prediction of spontaneous vaginal birth as well as adverse perinatal outcomes per hour. Adverse maternal outcomes were a composite of postpartum hemorrhage, transfusion, endometritis and third-/fourth-degree laceration. Adverse neonatal outcomes were a composite of neonatal intensive care unit admission, hypoxic ischemic encephalopathy, respiratory distress, seizures, apnea, asphyxia, and shoulder dystocia. The study population included 228,438 deliveries; 26,796 patients met inclusion and exclusion criteria. After removing cases with incomplete data, the study population consisted of 22,299 women, of which 16,593 women had a spontaneous vaginal delivery (74.4%). The number of deliveries at a given hospital per year, fetal position, cervical dilation on admission, chorioamnionitis, augmentation of labor, maternal age, and length of second stage were associated with the odds of spontaneous vaginal delivery. Using the predictors identified, a risk predictor calculator was created, taking into consideration the length of time in the second stage. A receiver-operator characteristic curve was developed to assess the calculator; area under the curve was 0.73. This calculator is available at https://www.pushprescriber.com/. Spontaneous vaginal delivery for women with term, cephalic, singleton gestations with epidural anesthesia was associated with several variables. This calculator tool helps facilitate provider decision making and patient counseling about the value of continuing the second stage of labor based on changing rates of success and risks of maternal and neonatal morbidity with time.

Planned vaginal delivery and cardiovascular morbidity in pregnant women with heart disease

Although consensus guidelines on the management of cardiovascular disease in pregnancy reserve cesarean delivery for obstetric indications, there is a paucity of data to support this approach. The objective of the study was to compare cardiovascular and obstetric morbidity in women with cardiovascular disease according to the plan for vaginal birth or cesarean delivery. We assembled a prospective cohort of women delivering at an academic tertiary care center with a protocolized multidisciplinary approach to management of cardiovascular disease between September 2011 and December 2016. Our practice is to encourage vaginal birth in women with cardiovascular disease unless there is an obstetric indication for cesarean delivery. We allow women attempting vaginal birth a trial of Valsalva in the second stage with the ability to provide operative vaginal delivery if pushing leads to changes in hemodynamics or symptoms. Women were classified according to planned mode of delivery: either vaginal birth or cesarean delivery. We then used univariate analysis to compare adverse outcomes according to planned mode of delivery. The primary composite cardiac outcome of interest included sustained arrhythmia, heart failure, cardiac arrest, cerebral vascular accident, need for cardiac surgery or intervention, or death. Secondary obstetric and neonatal outcomes were also considered. We included 276 consenting women with congenital heart disease (68.5%), arrhythmias (11.2%), connective tissue disease (9.1%), cardiomyopathy (8.0%), valvular disease (1.4%), or vascular heart disease (1.8%) at or beyond 24 weeks' gestation. Seventy-six percent (n= 210) planned vaginal birth and 24% (n= 66) planned cesarean delivery. Women planning vaginal birth had lower rates of left ventricular outflow tract obstruction, multiparity, and preterm delivery. All women attempting vaginal birth were allowed Valsalva. Among planned vaginal deliveries 86.2% (n= 181) were successful, with a 9.5% operative vaginal delivery rate. Five women underwent operative vaginal delivery for the indication of cardiovascular disease without another obstetric indication at the discretion of the delivering provider. Four of these patients tolerated trials of Valsalva ranging from 15 to 75 minutes prior to delivery. Adverse cardiac outcomes were similar between planned vaginal birth and cesarean delivery groups (4.3% vs 3.0%, P= 1.00). Rates of postpartum hemorrhage (1.9% vs 10.6%, P < .01) and transfusion (1.9% vs 9.1%, P= .01) were lower in the planned vaginal birth group. There were no differences in adverse cardiac, obstetric, or neonatal outcomes in the cohort overall or the subset of women with high-risk cardiovascular disease or a high burden of obstetric comorbidity. These findings suggest that cesarean delivery does not reduce adverse cardiovascular outcomes and lend support to a planned vaginal birth for the majority of women with cardiovascular disease including those with high-risk disease.

Adverse pregnancy outcomes and multiple nuchal cord loops.

To evaluate the effects of nuchal cord and the number of loops during labor and delivery on delivery outcomes among women with singleton pregnancy who delivered vaginally. This retrospective cohort study included 42,798 women with singleton, vertex, and vaginal deliveries at 24-43weeks of gestation. We analyzed delivery outcomes based on the number of nuchal cord loops. A total of 42,798 deliveries met the inclusion criteria, of which, 3809 (8.9%) had nuchal cord with 1 loop at delivery, 1035 (2.42%) had 2 loops, and 258 (0.6%) had 3 loops. Nuchal cord with 3 loops compared to no nuchal cord has been associated with higher incidence of intrauterine fetal death (1.9%), Apgar scores less than 7 at 1 and 5min (7.4%, 2.3%), and higher rate of operative vaginal deliveries (17.5%). Nuchal cord with 2 or 3 loops was associated with higher incidence of intrauterine growth restriction (10.2%, 11.6%). In a multiple logistic regression model, nuchal cord with 3 loops was an independent risk factor for operative vaginal delivery and Apgar score less than 7 in 1min. In the case of vaginal delivery in the presence of nuchal cord, as the number of nuchal cord loops increased, so did the number of adverse delivery outcomes. While 3 loops were associated with higher incidence of intrauterine fetal death, intrauterine growth restriction, increased operative vaginal deliveries, and low Apgar scores, 1 loop was not associated with adverse perinatal outcomes.

Fetal electrocardiography ST-segment analysis for intrapartum monitoring: a critical appraisal of conflicting evidence and a way forward

In the past century, some areas of obstetric including intrapartum care have been slow to benefit from the dramatic advances in technology and medical care. Although fetal heart rate monitoring (cardiotocography) became available a half century ago, its interpretation often differs between institutions and countries, its diagnostic accuracy needs improvement, and a technology to help reduce the unnecessary obstetric interventions that have accompanied the cardiotocography is urgently needed. During the second half of the 20th century, key findings in animal experiments captured the close relationship between myocardial glycogenolysis, myocardial workload, and ST changes, thus demonstrating that ST waveform analysis of the fetal electrocardiogram can provide information on oxygenation of the fetal myocardium and establishing the physiological basis for the use of electrocardiogram in intrapartum fetal surveillance. Six randomized controlled trials, 10 meta-analyses, and more than 20 observational studies have evaluated the technology developed based on this principle. Nonetheless, despite this intensive assessment, differences in study protocols, inclusion criteria, enrollment rates, clinical guidelines, use of fetal blood sampling, and definitions of key outcome parameters, as well as inconsistencies in randomized controlled trial data handling and statistical methodology, have made this voluminous evidence difficult to interpret. Enormous resources spent on randomized controlled trials have failed to guarantee the generalizability of their results to other settings or their ability to reflect everyday clinical practice. The latest meta-analysis used revised data from primary randomized controlled trials and data from the largest randomized controlled trials from the United States to demonstrate a significant reduction of metabolic acidosis rates by 36% (odds ratio, 0.64; 95% confidence interval, 0.46-0.88) and operative vaginal delivery rates by 8% (relative risk, 0.92; 95% confidence interval, 0.86-0.99), compared with cardiotocography alone.

Impact of Epidural Analgesia on Cesarean and Operative Vaginal Delivery Rates Classified by the Ten Groups Classification System

(Int J Obstet Anesth. 2018;34:37–41) Although epidural analgesia (EA) is widely used for pain relief during labor and delivery, there has been controversy over its impact on labor outcomes. The available evidence has not shown an increase in cesarean delivery rates associated with EA. However, some studies have found an association between EA rates and rates of assisted vaginal delivery. The Ten Group Classification System (TGCS) is used to assess all perinatal events and outcomes according to the obstetric characteristics of women in labor, such as singleton or multiple pregnancy; nulliparous, multiparous, or multiparous with a previous cesarean delivery; cephalic, breech presentation or other malpresentation; spontaneous or induced labor; and term or preterm births. This system has been endorsed by the World Health Organization and is used when analyzing various obstetric outcomes. It has not yet been used, though, to analyze the effects of EA on obstetric outcomes. The objective of this study was to use TGCS to evaluate potential associations between EA and cesarean and assisted vaginal delivery rates, according to the TGCS groups.

Electronic Fetal Monitoring and Neonatal Outcomes when a Nuchal Cord Is Present at Delivery.

This study aimed to determine the association between nuchal cord, electronic fetal monitoring parameters, and adverse neonatal outcomes. This was a prospective cohort study of 8,580 singleton pregnancies. Electronic fetal monitoring was interpreted, and patients with a nuchal cord at delivery were compared with those without. The primary outcome was a composite neonatal morbidity index. Logistic regression was used to adjust for confounders. Of 8,580 patients, 2,071 (24.14%) had a nuchal cord. There was no difference in the risk of neonatal composite morbidity in patients with or without a nuchal cord (8.69 vs. 8.86%; p = 0.81). Nuchal cord was associated with category II fetal heart tracing and operative vaginal delivery (OVD) (6.4 vs. 4.3%; p < 0.01). Nuchal cord is associated with category II electronic fetal monitoring parameters, which may drive increased rates of OVD. However, there is no significant association with neonatal morbidity.

691: Outcomes of elective induction of labor at 38 weeks versus expectant management until week 39

Recent evidence suggests that elective induction of labor may reduce cesarean deliveries and other obstetric outcomes. This study analyzes differences in maternal and neonatal outcomes from elective induction of labor (eIOL) at 38 weeks versus one additional week of expectant management in nulliparous women at community hospitals. We conducted a retrospective cohort study of singleton, vertex, nonanomalous deliveries in community hospitals in California between 2007 and 2011 using linked hospital discharge and vital statistics data (n=231,567). We compared outcomes from eIOL, defined by the Joint Commission, at 38 weeks against one additional week of expectant management and delivery at 39 weeks. Maternal outcomes of interest were cesarean delivery, operative vaginal delivery, perineal tear, chorioamnionitis, and endomyometritis. Neonatal outcomes of interest were intrauterine fetal death, 5 minute Apgar less than 7, NICU admission, respiratory distress syndrome (RDS), hypoglycemia, hypoxic ischemic encephalopathy (HIE) and jaundice. Results were compared using chi square analysis and examined using multivariate logistic regression. A p-value of less than 0.05 was used to indicate statistical significance. In our cohort of 231,567 deliveries, there were significant differences in the incidence of cesarean delivery, perineal tears, chorioamnionitis, and endomyometritis in women who were electively induced at 38 weeks compared to those who received expectant management and delivered at 39 weeks. However, the rate of operative vaginal delivery was not significantly different between the two groups. The rate of intrauterine fetal death was also significantly decreased when women were electively induced at 38 weeks. Logistic regression analysis indicated expectant management for one additional week, with delivery at 39 weeks, significantly increased cesarean deliveries (OR 1.45, 95% CI 1.37-1.54) but decreased RDS in neonates (OR 0.83, 95% CI 0.71- 0.98). There were no differences between the two groups for neonatal outcomes of hypoglycemia, HIE and jaundice. The maternal and neonatal outcomes following birth are associated with the timing and management prior to delivery. These findings can be used to counsel women regarding the risks of maternal and neonatal complications from elective induction of labor and expectant management for one additional week.

Is it Reasonable to Establish an Independently Managed Obstetric Unit in a Small Hospital and Does it Result in Measurable Changes in Quality of Maternity Care?

An independently managed, specialty obstetric unit in a small hospital setting resulted in measurable changes in quality of maternity care. We present obstetric data from a level I (basic care) hospital in Frankfurt, Germany. We compare data from the mandatory state register collected in 2013, when the obstetric unit was under single management with the gynaecology department, with data collected in 2016 after the establishment of independent obstetric unit and a specialised service. Between 2013 and 2016, the birth rate in our hospital increased by 46.4%, from 803 to 1176 births/year. CS rates decreased by 8.9%, from 34.9 to 26% (p<0.01). Operative vaginal delivery rates increased by 5.2 (p<0.01%). Transfer of neonates to NICU decreased from 5.6% to 3.1% (p<0.01). Other obstetric interventions also decreased, including induction of labour (10.1 to 9.4%, p=0.632) and rate of episiotomy (13.4 to 1.1%, p<0.01). Rates of severe fetal acidosis (p<0.05) increased from no events in 2013 to 2 events in 2016. There were non-significant reductions in planned caesarean section for primiparous women and repeat caesarean section. An independently managed, specialised obstetric unit separate from an Obstetric & Gynaecology Department previously under single management can lead to measurable changes and quality improvement in a short period of time.

The impact of extending the second stage of labor to prevent primary cesarean delivery on maternal and neonatal outcomes

A low rate of primary cesarean delivery is expected to reduce some of the major complications that are associated with a repeat cesarean delivery, such as uterine rupture, adhesive placental disorders, hysterectomy, and even maternal death. Since 2014, and in alignment with the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, we changed our approach to labor dystocia, defined as abnormal progression of labor, by allowing a longer duration of the second stage of labor. To examine the effect of prolonging the second stage of labor on the rate of cesarean delivery, and maternal and neonatal outcomes. In a historical control group, we compared maternal and neonatal outcomes over 2 periods. Period I (9300 patients): from May 2011 until April 2014, when a prolonged second stage in nulliparous women was considered after 3 hours with regional anesthesia or 2 hours if no such anesthesia was provided. Second-stage arrest was defined in multiparous women after 2 hours with regional anesthesia or 1 hour without it. Period II (10,531 patients): from May 2014 until April 2017, allowed nulliparous and multiparous women continuing the second stage of labor an additional 1 hour before diagnosing second-stage arrest. Singleton deliveries at or beyond 37 weeks' gestation were initially considered for eligibility. We excluded women with high-risk pregnancies and known fetal anomalies. For comparing means, we used the t test. If variables were not normally distributed, we used the Mann-Whitney test instead. For comparing proportions, we used the χ2 test with continuity correction. The primary cesarean delivery was decreased in nulliparous women from 23.3% (819 of 3515) in period I to 15.7% (596 of 3796) in period II (relative risk [RR], 0.67; 95% CI, 0.61-0.74), a trend that was also significant in multiparous women (10.9%, 623 of 5785, in period I vs 8.1%, 544 of 6735, in period II; RR, 0.75; 95% CI, 0.67-0.84). The rate of operative vaginal deliveries in nulliparous women was higher in period II than in period I (19.2%, 732 of 3515, vs 17.7%, 622 of 3796, P < .0001). Rates of third- and fourth-degree laceration and of shoulder dystocia were also higher in period II. The rate of arterial cord pH < 7.0 and the rate of admission to the neonatal intensive care unit were higher in period II, but the early neurological outcome was not different when comparing the 2 periods. The new policy of labor management successfully decreased primary cesarean deliveries, with a small rise in instrumental deliveries. However, it also increased the other immediate maternal and neonatal complications. A higher rate of lower umbilical artery cord pH was the most significant finding; however, the early neurological outcome did not change. It is possible that the ongoing adjustment to the new labor protocol will avoid, in the future, maternal and neonatal complications. The long-term maternal and neonatal consequences of our new approach will be evaluated in future studies.

Safely lowering the emergency Cesarean and operative vaginal delivery rates using the Fetal Reserve Index

Objective: The cardiotocograph (CTG) or electronic fetal monitoring (EFM) was developed to prevent fetal asphyxia and subsequent neurological injury. From a public health perspective, it has failed these objectives while increasing emergency operative deliveries (emergency operative deliveries (EODs) – emergency cesarean delivery or operative vaginal delivery) for newborns, who in retrospect, actually did not require the assistance. EODs increase the risks of complications and stress for patients, families, and medical personnel. A safe reduction in the need for EOD will likely reduce both the overall Cesarean section rate as well as the risk of fetal neurological injury during labor to which it is related. We have developed the fetal reserve index (FRI), which is more comprehensive than CTG as a new screening method for early identification of the fetus at-risk of both neurological harm and the need to “rescue” by means of an EOD. Here, we compare prospectively the need for EOD in two groups of parturients undergoing a trial of labor at term. One group was managed conventionally, the other by the principles of the FRI.Study design: We compared the need for EOD of 800 parturients with singleton cases undergoing a trial of labor at term entering with normal CTG patterns (ACOG category 1). Patients were either treated routinely (400 – “early cases”) or in a second group seen later actively managed using the principles of the FRI (400 – “late cases”). The FRI includes measurements of five components of the CTG: rate, variability, decelerations, accelerations, and abnormal uterine activity combined with the presence of medical, obstetrical, and fetal risk factors. The 8-point metric categorizes cases as “green”, “yellow”, and “red” with the latter being at risk.Results: All 800 patients delivered babies, who were discharged in the usual time course with no untoward outcomes noted. The incidence of red zone scores was comparable in the two groups (≈25%), but the use of intrauterine resuscitation (IR) when reaching the red zone in the late group (47%) was more than double the incidence in the early group (20%) (p < .001). Despite (or because of) this, EODs were significantly reduced in the late group, from 17.3 to 4.0% (p < .001). Further, the late group spent less time in the red zone without increasing overall time in labor. Overall, EOD cases averaged >1 h in the red zone versus 0.5 h for non-EODs.Conclusions: The FRI may provide a metric to reduce EODs and by extension also reduce the risks of both cesarean delivery and adverse fetal/neonatal outcomes. The safe avoidance of EOD would seem to be an important metric to assess the quality of intrapartum management. This study represents the first attempt to apply the principles of the FRI “live” for the concurrent management of patients during labor. These promising results, if confirmed, in larger sample sizes, set the stage for our computerization of the FRI for widespread study. Benefits appear to come from identification and early, conservative management of fetal deterioration before the need to “rescue” the fetus by EOD.

The Influence of Fetal Head Circumference and Fetal Weight Measurement Assessed By Intrapartum Ultrasound on Labor Outcome

Background: labor is a clinical diagnosis characterized by regular, painful uterine that increase in frequency and intensity is associated with progressive cervical effacement or dilatation. More specifically, it is associated with a change in the myometrial contractility pattern from irregular contractures (long-lasting, low-frequency activity) to regular contractions (high-intensity, high frequency activity). Aim of the work: it was to determine if fetal head circumference and fetal weight could predict the rate of caesarian section and operative vaginal deliveries in nulliparous women in labor. Patients and Methods: this study was carried out at Al Alamein Hospital from January 2017 to January 2018 on two hundred (200) primigravida women; their ages ranged from 20 to 30 years and the gestational ages ranged from 38-40 weeks with normal singleton pregnancy with cephalic presentation in labor. Results: there were highly statistically significant relations between mode of delivery and fetal head circumference and estimated fetal weight as p value (0.001).it was found that large fetal head circumference relative to maternal pelvic diameter is the main cause of prolonged labor and therefor increased risk of primary caesarian section. Conclusion: the numerical data have a significant relation between intra partum head circumference and fetal weight and the incidence of primary caesarian section, maternal and fetal complications. Recommendations: according to numerical results obtained from this study. The study recommends strict labor monitoring by partogram in cases where fetal head circumference is more than 35cm or fetal weight is more than 3950gms.

Video-Based Teaching in Patient and Instrument Selection for Operative Vaginal Deliveries

ObjectiveWorldwide, the rate of operative vaginal deliveries has decreased, and as a result trainees are lacking exposure and training. The aim of this study was to determine whether a video-based masterclass can improve trainees' confidence, comfort, and knowledge in performing second stage labour assessments and selecting appropriate patients and instruments for operative vaginal deliveries. MethodsCurrent University of Toronto obstetrics and gynaecology residents were invited to participate. The intervention included two videos on second stage assessment: (1) selecting the appropriate patient and (2) selecting the appropriate instrument for an operative vaginal delivery. Trainees' comfort and confidence were assessed pre- and post-intervention. A focus group was conducted that assessed trainees' knowledge acquisition. Descriptive thematic analysis was performed, and common themes were extracted. ResultsOn average, residents have performed more vacuum deliveries than forceps deliveries as primary operators (26.4 vs. 7.9). Following the video intervention, there was a statistically significant improvement (P ≤ 0.05) in trainees' comfort in the following areas: (1) understanding the maternal pelvis, (2) choosing instruments, (3) choosing forceps, (4) deciding the location of delivery, (5) identifying favourable clinical factors, and (6) identifying poor prognostic clinical factors. There was no difference in trainees' self-confidence. Major themes from focus group data included new knowledge gained on second stage assessment techniques, new approaches to existing knowledge, and the multiple challenges and barriers that exist to learning. ConclusionVideo-based education on second stage labour assessment and operative vaginal delivery improves trainees' comfort and serves as a valuable complementary tool to clinical learning.

Meconium-stained amniotic fluid: a risk factor for postpartum hemorrhage.

Background/aimClinical data with respect to the impact of meconium on the risk of maternal hemorrhage are scarce. Therefore, in this study, we aimed to determine whether meconium-stained amniotic fluid (MSAF) represents a risk factor for postpartum hemorrhage (PPH) after vaginal delivery in a large unselected population.Patients and methodsA retrospective cohort study evaluated 78,542 consecutive women who had a vaginal delivery between 24th and 44th weeks of gestation. The women who had undergone cesarean section were excluded to avoid possible bias. Postpartum blood loss was measured with graduated blood sack. Postpartum blood loss between 1,000 and 2,000 mL and >2,000 mL were classified as moderate and severe PPH, respectively.ResultsA total of 74,144 patients were available for analysis. According to the color of amniotic fluid (AF), two groups of patients were identified: MSAF (n=10,997) and clear AF (n=63,147). The rates of severe and massive PPH were found to be significantly higher in the MSAF group than that of clear AF group (OR=1.3, 95% CI: 1.2–1.5, p<0.001 and OR=2.5, 95% CI: 1.5–4.2, p<0.001). Operative vaginal delivery rate was found to be higher in the MSAF group than that of clear AF group, but the difference was only borderline significant (OR=1.5, 95% CI: 1.0–2.2, p=0.05). There were no significant differences between the MSAF and the clear AF groups with respect to episiotomies, second- or third-degree perineal tears, vaginal–perineal thrombus, cervical lacerations, vaginal births after cesarean section, twin deliveries, and placental retention rates.ConclusionTo the best of our knowledge, this is the first clinical study that has investigated the role of MSAF as a risk factor for PPH after vaginal delivery in an unselected population. Our results suggest that MSAF is significantly associated with higher risk of moderate and severe PPH than clear AF.