Trial Of Instrumental Delivery Research Articles

Caesarean Section During Second Stage of Labor in a Tertiary Centre.

There is an alarming rise in caesarean section leading to increased adverse outcomes for both the mother and fetus when compared with vaginal delivery. Within this increasing caesarean section rate, there is a concerning increase in the rate of second stage caesarean section. This study highlight the feto-maternal outcome of caesarean section in second stage of labour. This was a retrospective cohort review of all women with a singleton, cephalic fetus at term delivered by caesarean section in the second stage of labor between April 1, 2013 and March 30, 2017 at Patan Academy of Health Sciences. The main outcome measures were second stage caesarean section, indications and its maternal and fetal morbidity. During the study period, there were 40,860 deliveries. A total of 18,011 (44%) babies were born by caesarean section, 10484 emergency and 7527 elective. Out of the emergency caesarean section, 200 (1.9 %) were performed in second stage of labor. In this study, the most common indication was cephalopelvic disproportion. (92.4%) were delivered without a trial of instrumental delivery. In terms of maternal complications, atonic post partum haemorrhage uterine incision extension 18 (12.5%), postoperative fever 27(18.8%), wound infection 7 (4.8%) were observed. In perinatal complications, meconium stained amniotic fluid 49(34.2%), neonatal hyperbilirubinemia 14(9.7%) and increased nursery admission 2(15.3%) and 2(1.3%) perinatal mortality were seen. Cesarean sections done in second stage of labor are associated with several intra-operative maternal complications and neonatal morbidity.

Caesarean section at full cervical dilatation.

Caesarean section at full cervical dilatation has many implications for maternal and neonatal morbidity as well as subsequent pregnancy outcomes. However, increasing trends are reported internationally for second-stage caesarean delivery. To review the rate and indication for a caesarean section at full dilatation over a 5-year period at a tertiary referral obstetric centre in Sydney. Retrospective cohort review of all women with a singleton, cephalic presenting fetus at ≥37(0) weeks' gestation delivered by caesarean section in the second stage of labour between 1 January 2009 and 31 December 2013 at Royal Prince Alfred Hospital. Medical records were reviewed, and demographic, maternal and fetal outcome data were obtained. Consultant supervision and documentation standards were recorded. The main outcome measures were the rate of caesarean section at full cervical dilatation, maternal and fetal morbidity. During the study period, 8449/26063 (32.4%) babies were born by caesarean section. Of these surgical births, 476 (5.6%) were performed at full cervical dilatation at >37weeks' gestation. There was no observed trend over the 5years. The majority of women delivered by caesarean section at full dilatation were nulliparous and in spontaneous labour. More than half of these women were delivered without a trial of instrumental delivery. Consultant obstetricians were present for 7% of public second-stage caesarean deliveries. We report a 5-year experience with caesarean delivery at full dilatation at a tertiary unit. The rate was variable over the 5years. Secondary outcome measures suggest that consultant supervision is uncommon and documentation standards require improvement.

Intrapartum risk factors for neonatal encephalopathy leading to cerebral palsy in women without apparent sentinel events.

To determine intrapartum factors associated with neonatal encephalopathy leading to cerebral palsy (NE-CP). A total of 70 NE-CP patients who fulfilled study criteria (cephalic singleton pregnancy with attempted vaginal delivery [AVD] at gestational week [GW] ≥36; intrapartum occurrence of non-reassuring fetal status without apparent cause following reassuring fetal status on admission; and development of NE-CP) were compared with 210 AVD controls who had 1- and 5-min Apgar score ≥8 matched for GW, maternal parity, and use of uterotonics. Suboptimal care was defined as delayed reaction due to misinterpretation of fetal heart rate (FHR) tracing, or inappropriate trial of instrumental delivery (TOID). Successful and failed TOID were defined as vaginal and cesarean delivery after TOID, respectively. The 210 controls were assumed not to have had suboptimal care. The rates of successful (34% vs 12%) and failed TOID (11% vs 0.0%), cesarean section (34% vs 14%), suboptimal care (57% vs 0.0%), pregnancy-induced hypertension (11% vs 2.4%), birthweight ≥3800 g (8.6% vs 1.9%), subgaleal hemorrhage (16% vs 0.0%) were significantly higher in NE-CP patients than in controls. Selection with the stepwise method and logistic regression analysis identified four independent risk factors for NE-CP: suboptimal intrapartum care (OR, 2.21; 95%CI: 1.99-2.47), cesarean section (OR, 1.19; 95%CI: 1.08-1.31), successful TOID (OR, 1.14; 95%CI: 1.03-1.25), and hypertension (OR, 1.20; 95%CI: 1.01-1.42). Training programs for improved interpretation of FHR tracing and appropriate TOID are required to prevent NE-CP among healthy and mature fetuses in Japan.

PA.36 Impact of Resident Consultants on call at night in York Teaching Hospital

The implementation of the European Working Time Directive, safer childbirth requirements and changes to the structure of training continue to impact upon maternity care provision. Consultant decision-making is crucial to...

Trial of instrumental delivery in theatre versus immediate caesarean section for anticipated difficult assisted births

The majority of women have spontaneous vaginal births, but some women need assistance in the second stage with delivery of the baby, using either the obstetric forceps or vacuum extraction. Rates of instrumental vaginal delivery range from 5% to 20% of all births in industrialised countries. The majority of instrumental vaginal deliveries are conducted in the delivery room, but in a small proportion (2% to 5%), a trial of instrumental vaginal delivery is conducted in theatre with preparations made for proceeding to caesarean section. To determine differences in maternal and neonatal morbidity between women who, due to anticipated difficulty, have trial of instrumental vaginal delivery in theatre and those who have immediate caesarean section for failure to progress in the second stage. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 June 2012). Randomised controlled trials comparing trial of instrumental vaginal delivery (vacuum extraction or forceps) in operating theatre to immediate caesarean section for women with failure to progress in the second stage (active second stage more than 60 minutes in primigravidae). We identified no studies meeting our inclusion criteria. No studies were included. There is no current evidence from randomised trials to influence practice.

Rising Rates of Caesarean Deliveries at Full Cervical Dilatation: A Concerning Trend

Abstract Objectives To audit caesarean sections performed at full cervical dilatation over a three year period in a tertiary referral centre in Ireland. To evaluate (i) the rate of caesarean deliveries in the second stage of labour, (ii) the indication for delivery and (iii) the associated fetal and maternal morbidity in this cohort of women. Study design This cohort study was carried out in the University Hospital Galway (UHG). Medical records of 136 consecutive women with singleton cephalic pregnancies at term, identified from the hospital database, who underwent a second stage caesarean section (CS) between 1 January 2006 and 31 December 2008, were reviewed retrospectively and demographic and outcome data were collected. Results During the study period 2801/10,202 (27.5%) babies were delivered by CS. One hundred and thirty six CS (4.8%) were performed at full dilatation. The rate of CS during the second stage increased from 0.9% in 2006 to 1.8% in 2008. The majority of women were nulliparous (76.5%) and in spontaneous labour (64%). 44.1% of women had a second stage CS without a trial of instrumental delivery. 41.3% of public deliveries were attended by a consultant. The majority of babies (54%) were delivered because of a prolonged second stage with a mean duration of 146 min from full dilatation to delivery. Twenty-four of 59 primiparous women (40.7%), who underwent CS because of a prolonged second stage, did not receive oxytocin. 13.2% of babies were admitted to the neonatal intensive care unit. Estimated blood loss was documented in 67% of cases (n = 91); 14.3% of women (n = 13) had a postpartum haemorrhage greater than or equal to 1000 mls. 23% of these women (n = 3) required a blood transfusion. The overall blood transfusion rate was 2.2%. 50% of women had a hospital stay of greater than four days. Conclusions There is a worrying rise in the overall rate of CS at full dilatation. Audit of the second stage CS rate is a useful measure of clinical standards. Strategies for improved care include increased consultant presence, meticulous documentation and ongoing training of junior obstetric staff to ensure safe intrapartum care. Condensation The increase of second stage caesarean sections requires urgent strategies for improved care including increased consultant presence, meticulous documentation and training of junior obstetric staff.

Angle of progression measurements of fetal head at term: a systematic comparison between open magnetic resonance imaging and transperineal ultrasound

Objectives: During labor, transperineal sonography is increasingly used to evaluate fetal head descent. The aim of the present study was to compare the angle of progression assessed by open magnetic resonance imaging (MRI) versus transperineal ultrasound. Methods: 31 pregnant women at term (>37 weeks), who were not in labor, underwent a MRI in an open 1.0 Tesla system. A midsagittal plane of the maternal pelvis was stored. Immediately after, without changing the supine position, a transperineal ultrasound was performed. The angle of progression was measured off-line by transperineal ultrasound and MRI. Results The angles of progression measured by transperineal ultrasound (mean 79.05°, SD 11.44) and MRI (mean 80.48°, SD 11.06) correlated significantly (p<0.001). The intraclass correlation coefficient between the two methods was 0.89 (95% CI: 0.78–0.94). Conclusion: The angle of progression measurements obtained by transperineal ultrasound and open MRI showed very good agreement. This ultrasound technique provides reliable reproducible information of the fetal head station and it can become a ueful easy bed side tool to help in the clinical decision making of a trial of instrumental delivery versus a C-section at full dilatation

Trial of instrumental delivery at leeds general infirmary

ObjectiveTo review the practice regarding trial of instrumental delivery (ID) in theatre.Study designAll trials of ID in theatre over a 4 month period were retrospectively reviewed. Maternal demographics, labour and...

Audit on trial of instrumental deliveries

BackgroundIt is estimated that instrumental vaginal deliveries account for 10–15% of births in the UK. To improve the safety of these deliveries, the RCOG has issued guidelines, which include recommendations...

Rising rates of caesarean deliveries at full cervical dilatation: a concerning trend

ObjectivesTo audit caesarean sections performed at full cervical dilatation over a three year period in a tertiary referral centre in Ireland. To evaluate (i) the rate of caesarean deliveries in the second stage of labour, (ii) the indication for delivery and (iii) the associated fetal and maternal morbidity in this cohort of women. Study designThis cohort study was carried out in the University Hospital Galway (UHG). Medical records of 136 consecutive women with singleton cephalic pregnancies at term, identified from the hospital database, who underwent a second stage caesarean section (CS) between 1 January 2006 and 31 December 2008, were reviewed retrospectively and demographic and outcome data were collected. ResultsDuring the study period 2801/10,202 (27.5%) babies were delivered by CS. One hundred and thirty six CS (4.8%) were performed at full dilatation. The rate of CS during the second stage increased from 0.9% in 2006 to 1.8% in 2008. The majority of women were nulliparous (76.5%) and in spontaneous labour (64%). 44.1% of women had a second stage CS without a trial of instrumental delivery. 41.3% of public deliveries were attended by a consultant. The majority of babies (54%) were delivered because of a prolonged second stage with a mean duration of 146min from full dilatation to delivery. Twenty-four of 59 primiparous women (40.7%), who underwent CS because of a prolonged second stage, did not receive oxytocin. 13.2% of babies were admitted to the neonatal intensive care unit. Estimated blood loss was documented in 67% of cases (n=91); 14.3% of women (n=13) had a postpartum haemorrhage greater than or equal to 1000mls. 23% of these women (n=3) required a blood transfusion. The overall blood transfusion rate was 2.2%. 50% of women had a hospital stay of greater than four days. ConclusionsThere is a worrying rise in the overall rate of CS at full dilatation. Audit of the second stage CS rate is a useful measure of clinical standards. Strategies for improved care include increased consultant presence, meticulous documentation and ongoing training of junior obstetric staff to ensure safe intrapartum care. CondensationThe increase of second stage caesarean sections requires urgent strategies for improved care including increased consultant presence, meticulous documentation and training of junior obstetric staff.

Trial of operative vaginal delivery in theatre

The majority of instrumental deliveries are conducted in the delivery suite. However, in a small proportion (2–5%) where delivery is anticipated to be difficult, a trial of instrumental delivery in...

Trial of forceps – legal aspects

Where an obstetrician attempts a forceps delivery on the labour ward, rather than as a ‘Trial of Instrumental Delivery’ in theatre with the mother fully prepared for Caesarean section, he will have the burden of justifying his actions where he fails to deliver the baby, precipitates an acute bradycardia and is unable to deliver by Caesarean section before permanent brain damage ensues. The Bolitho test will apply to experts judging the question: was the Obstetrician's decision defensible having regard to the comparative risks and benefits? See Kingsberry [2005] EWHC (QB) 2253. Even where an obstetrician correctly decides to carry out a Trial of Operative Delivery, in theatre, he must not delay unreasonably in converting to Caesarean section when an acute bradycardia is precipitated. He should bear in mind the ‘10-minute rule’: Purver v Winchester &amp; Eastleigh NHS Trust [2007] LS Law Med 193.

Spontaneous intra-partum pneumothorax and subcutaneous emphysema

A 26-year-old primigravida was admitted at 42 weeks in spontaneous labour to a low risk birthing unit. Her first stage of labour lasted for 6 h and 45 min. After pushing for 90 min, she was not delivered and was then transferred to the delivery suite for further assessment. When examined in the delivery suite, she had massive swelling of her face and neck with her eyes barely visible because of facial swelling. Her haemodynamic condition was stable and she had no signs or symptoms of reduced cardiac output, such as dyspnoea, chest pain or raised JVP. The fetal heart rate was reassuring. Syntocinon augmentation was started and the patient was transferred to theatre for trial of instrumental delivery. By forceps, a live female infant of 3,740 g was delivered. Total duration of the second stage was 125 min. Postnatally, the patient was reviewed by the anaesthetist and physicians and a diagnosis of spontaneous pneumothorax with subcutaneous emphysema was made clinically and confirmed by chest X-ray (Figure 1). As it was a very small pneumothorax and the patient was haemodynamically stable, conservative management was appropriate. Her condition subsequently improved and she was discharged home on the second postnatal day, with follow-up appointments. She was reviewed in the clinic postnatally and was not found to have any underlying lung disease predisposing to pneumothorax and subcutaneous emphysema.

Trials and tribulations of operative vaginal delivery

The notion that operative vaginal delivery has declined in the wake of escalating caesarean section rates is not evidence based. In England, despite a progressive increase in caesarean deliveries over the past 20 years, reaching 23% of births in 2004, the instrumental delivery rate has remained relatively stable at 10–11% of all births.1 Similar trends are evident throughout the UK and North America.2 In Australia, in 2004, more than 29% of women across the nation had their babies delivered by caesarean section; yet, the instrumental delivery rate has remained steady at 11% for the past 10 years.3 The increase in caesarean deliveries, therefore, cannot be explained by a shift from instrumental-assisted births. During the same period, operative vaginal delivery has undergone a dramatic change in practice manifested by a decline in the number of forceps deliveries and a concomitant increase in vacuum extractions. In most reports, the vacuum extractor has now become the preferred instrument for assisted delivery.1,3 The Royal College of Obstetricians and Gynaecologists (RCOG) has issued evidence-based guidelines to increase safety of operative vaginal delivery for mothers and babies and to reduce the likelihood of litigation for medical practitioners and health institutions.4 One of the key recommendations of the guideline (section 5.2) is that ‘operative vaginal births that have a higher rate of failure should be considered a trial and conducted in the operating theatre where immediate recourse to caesarean section can be undertaken’. The rationale behind this recommendation is that fetal injuries have been attributed to the time delay between failed operative vaginal delivery and caesarean section. The benefits should be obvious yet, as the guideline admits, evidence to support this practice is limited. Olagundoye and MacKenzie in this issue of the journal (pages 603–8) report the findings of their evaluation of the impact of a trial of instrumental delivery in the operating theatre in terms of the decision-to-delivery intervals (DDI), mode of delivery and neonatal condition at birth.5 They concluded that on average, the DDI for instrumental procedures in the operating theatre were some two to three times longer than for deliveries undertaken in the labour ward room. Either way, their data showed no significant differences in short-term neonatal or maternal outcomes and do not provide support for the recommendation in the RCOG guideline. The DDI have been studied extensively in relation to emergency caesarean section, where delivery within 30 minutes has generally been accepted as the benchmark. Nevertheless, this recommendation is not achieved in up to 50% of emergency caesarean sections and is therefore an unrealistic target for clinical practice.6 Furthermore, large national and multicentre studies have reported no differences in neonatal or maternal outcomes for emergency caesarean sections when the delivery interval was less than 30 minutes compared with the intervals of longer than 30 minutes and up to 75 minutes.7,8 For forceps delivery and vacuum extraction, the DDI and its effects on neonatal outcome are less clear. A prospective analysis of 90 forceps and 135 vacuum deliveries reported that in cases of fetal distress, the mean DDI for forceps delivery (23 minutes) was significantly shorter than that for vacuum extraction (29 minutes).9 In the Portsmouth study, the mean interval from time of application of the forceps to delivery was shorter than that for vacuum extraction, but the interval from the decision to delivery was the same for both instruments.10 This is plausible when considering the number of steps involved in performing an operative vaginal delivery prior to application of the device.11 The preoccupation with DDI has diverted the focus from problems related to instrumental delivery that need urgent attention. Of particular importance are the high failure rates reported for vacuum extraction and the potential for injury associated with a failed instrumental delivery.12 In the analysis by Olagundoye and MacKenzie, 30 (22%) of the vacuum extractions were unsuccessful at the initial attempt, whereas

Unexpected reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period: was this the Hawthorne effect?

Objective The study was originally designed to identify the risk factors that could predict those difficult instrumental deliveries resulting in birth trauma and birth asphyxia. Design A prospective study on all singleton deliveries in cephalic presentation with an attempt of instrumental delivery over a 12-month period (13 March 2000 to 12 March 2001). Setting A local teaching hospital. Sample Six hundred and seventy deliveries. Methods A codesheet was designed to record the demographic data, characteristics of first and second stages of labour and neonatal outcome. In particular, the doctor had to enter the pelvic examination findings before the attempt of instrumental delivery. Main outcome measures Birth trauma and birth asphyxia. Results There was a significant reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period (0.6%) when compared with that (2.8%) in the pre-study period (1998 and 1999) (RR 0.27, 95% CI 0.11–0.70). There was more trial of instrumental deliveries in the operating theatre although this was not statistically significant (RR 1.19, 95% CI 0.88–1.60). The instrumental delivery rate decreased during the study period (RR 0.88, 95% CI 0.82–0.94). The caesarean section rate for no progress of labour, the incidence of direct second stage caesarean section and the incidence of failed instrumental delivery did not increase during the study period. Conclusions Apart from the merits of regular audit exercise and increasing experience of the staff, the Hawthorne effect might be the major contributing factor in the reduction of birth trauma and birth asphyxia related to instrumental deliveries during the study period.

Unexpected reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period: was this the Hawthorne effect?

Objective The study was originally designed to identify the risk factors that could predict those difficult instrumental deliveries resulting in birth trauma and birth asphyxia.Design A prospective study on all singleton deliveries in cephalic presentation with an attempt of instrumental delivery over a 12‐month period (13 March 2000 to 12 March 2001).Setting A local teaching hospital.Sample Six hundred and seventy deliveries.Methods A codesheet was designed to record the demographic data, characteristics of first and second stages of labour and neonatal outcome. In particular, the doctor had to enter the pelvic examination findings before the attempt of instrumental delivery.Main outcome measures Birth trauma and birth asphyxia.Results There was a significant reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period (0.6%) when compared with that (2.8%) in the pre‐study period (1998 and 1999) (RR 0.27, 95% CI 0.11–0.70). There was more trial of instrumental deliveries in the operating theatre although this was not statistically significant (RR 1.19, 95% CI 0.88–1.60). The instrumental delivery rate decreased during the study period (RR 0.88, 95% CI 0.82–0.94). The caesarean section rate for no progress of labour, the incidence of direct second stage caesarean section and the incidence of failed instrumental delivery did not increase during the study period.Conclusions Apart from the merits of regular audit exercise and increasing experience of the staff, the Hawthorne effect might be the major contributing factor in the reduction of birth trauma and birth asphyxia related to instrumental deliveries during the study period.

Vaginal Delivery After Previous Caesarean Section for Failure of Second Stage of Labour

Objective To determine the outcome of subsequent labour in primiparous women after a caesarean section for delay in descent in the second stage of labour in cephalic presentations with or without trial of instrumental vaginal delivery. Design Retrospective follow up study. Setting Medical Centre Leeuwarden, The Netherlands. Participants All primiparous parturients who delivered after prior caesarean section during the second stage of labour in the period 1986–1998. Methods Data concerning the outcome of the first subsequent delivery were gathered from delivery notes and patients charts. The group of women was subdivided into those with or without trial of instrumental vaginal delivery during the previous labour. Results Of 132 women, 29 (22%) underwent a planned repeat caesarean section. Of the 103 women who were allowed a trial of labour, 82 (80%) were successful in having a vaginal delivery, and 21 (20%) had a second caesarean section. Of the 74 women with a failed trial of instrumental delivery during the previous labour, 19 had a planned repeat caesarean section and 41 of the remaining 55 (75%) had a successful trial of labour. Conclusions In women with a cephalic presentation who had an arrest of descent in the second stage of labour during their first delivery, the chances of vaginal delivery in their next pregnancy are high, even after a failed instrumented vaginal delivery, and a trial of labour can usually be pursued.