Vacuum Extraction Research Articles

Risk Factors for Intrapartum Anorectal Mucosal Lacerations and Rectovaginal Fistula: A Retrospective Comparative Study.

We examined the risk factors for fourth-degree perineal lacerations (intrapartum anorectal mucosal lacerations) and rectovaginal fistulas as one of the later complications. We reviewed the obstetric records of all singleton vaginal deliveries after 22 weeks of gestation at our institute between January 2006 and December 2018 (n = 19,370). Of the 19,370 deliveries, 61 had fourth-degree perineal lacerations (0.31%). Of the 61 women, 5 (8.2%) developed rectovaginal fistulas 2-3 weeks after their deliveries. Upon multivariate analysis, nulliparity (Adjusted odds ratios (OR) 3.58, 95% confidence interval (CI) 1.6-8.1, p < 0.01), midline episiotomy (Adjusted OR 2.10, 95% CI 1.0-4.2, p = 0.03), vacuum extraction (Adjusted OR 7.01, 95% CI 3.5-14, p < 0.01), and forceps delivery (Adjusted OR 22.0, 95% CI 7.8-61, p < 0.01) were independently associated with fourth-degree perineal lacerations, while mediolateral episiotomy (Adjusted OR infinity, 95% CI 2.1-infinity, p = 0.03) and forceps delivery (Adjusted OR infinity, 95% CI 14.5-infinity, p = 0.01) were independently associated with rectovaginal fistulas. In addition, in the women with fourth-degree perineal lacerations, mediolateral episiotomy was associated with rectovaginal fistulas (OR infinity, 95% CI 1.8-infinity, p = 0.04). Midline episiotomy and instrument-assisted delivery are independent risk factors for fourth-degree perineal lacerations after vaginal delivery. Mediolateral episiotomy and forceps delivery were independently associated with rectovaginal fistulas. Once fourth-degree perineal lacerations occurred, women with mediolateral episiotomies were more likely to develop rectovaginal fistulas.

Factors related to a positive childbirth experience – a cross-sectional study

ABSTRACT Background/aims Giving birth is a life-changing experience for women. Most previous studies have focused on risk factors for a negative childbirth experience. The primary aim of this study was to assess childbirth experience in a sample of postnatal Swedish women. The secondary aim was to analyse demographic and clinical determinants associated with a positive birth experience. Design/Methods A digital survey including the instrument Childbirth Experience Questionnaire 2 (CEQ2) was answered by 619 women six to 16 weeks postpartum. Regression analyses were made assessing the impact that different factors had on the overall childbirth experience and the four subscales of CEQ2: Own Capacity, Perceived Safety, Professional Support and Participation. Results Overall, women were satisified with their birthing experience. Several factors contributed to a positive childbirth experience. Having a vaginal mode of birth (without vacuum extraction) together with not having ongoing mental health problems were the factors with the most influence on the total childbirth experience. Not having maternal complications postpartum and receiving much support from a trusted birth companion were two other important factors. Conclusion Although Swedish women tend to express satisfaction with their childbirth experiences, there is a necessity to advocate for a childbirth approach that optimises the chance of giving birth vaginally rather than with vacuum extraction or acute caesarean section, and reduces the risk for complications whenever possible. During pregnancy, mental health problems should be appropriately addressed. Healthcare professionals could also more actively involve the birth companion in the birthing process and equip them with the necessary tools to effectively support birthing women.

Development and validation of an efficient approach for extracting essential oil, scutellarin, and rosmarinic acid from Perilla frutescens leaves using vacuum microwave-mediated rotary hydrodistillation and extraction in situ and a choline amino acid ionic liquid

In this study, an efficient vacuum microwave-mediated rotary hydrodistillation and extraction in situ (VMRHDE) device was used for extracting essential oil, scutellarin, and rosmarinic acid from Perilla frutescens leaves with choline amino acid ionic liquid solution. The extracted products were then analyzed through GC–MS and HPLC. The optimal parameters were determined through a Doehlert design matrix and desirability function, resulting in the use of 10 % choline glutamate ionic liquid ([Ch][Glu]), a liquid–solid ratio of 15 mL/g, a microwave irradiation time of 20 min, a microwave irradiation power of 540 W, and a rotary speed of 24 r/min. Under optimal operating conditions, the yields of essential oil, scutellarin, and rosmarinic acid were 0.41 % ± 0.02 %, 0.39 % ± 0.01 %, and 0.36 % ± 0.01 %, respectively. GC–MS analysis revealed that adding [Ch][Glu] significantly increased the content of perilla aldehyde and oxygenates in the essential oils. Methodological validation confirmed that the established method met the detection requirements, with recoveries of 99.20 % for scutellarin and 99.83 % for rosmarinic acid, demonstrating high accuracy. The linear relationship of scutellarin and rosmarinic acid was good in the concentration range, with R2 values of 0.9999 for both.

Prediction of the healing efficiency of episiotomy wounds using hydrogel dressings with lidocaine

The objective: to study the factors affecting the healing process of an episiotomy wound and the effectiveness of using hydrogel dressings with lidocaine for its healing.Materials and methods. The prospective randomized study includes the analysis of anamnestic data from the medical cards of 123 primiparous women with episiotomy wounds who gave birth in the Kyiv City Maternity Hospital No. 5 during 2021–2022. The women were divided into two groups: a comparison group – 63 patients who received standard treatment, and a research group – 60 patients who additionally used hydrogel dressings with lidocaine on the wound.The healing of episiotomy wounds was evaluated according to the REEDA scale. Factors that may influence episiotomy wound healing were studied in patients of both groups: anthropometric indicators (age, height, body mass index), interventions during childbirth, and indicators of obstetric and gynecological history (term of gestation, volume of blood loss during childbirth, body weight of the newborn, etc.). Statistical analysis was performed using the Fisher, Mann–Whitney, Student and chi-square tests of the statistical package EZR v. 1.54.Results. Age (p=0.689) and body mass index (p=0.974) of patients in both groups did not show statistically significant differences. The duration of the second period of labor on average was 72 min (57.6–86.4) in the comparison group versus 43.2 min (28.8–57.6) in the research group with a statistically significant difference (p&lt;0.001). No statistically significant differences were found between the two groups regarding the term of delivery, the volume of blood loss, the weight of the newborn, the risk of pregnancy loss, the frequency of labor induction, the weakness of labor activity, manual revision of the uterine cavity, and vacuum extraction of the fetus. The frequency of use of different types of anesthesia during childbirth also did not differ (p=0.396).REEDA scale assessment revealed a reduced risk of high sum scores in the research group (odds ratio (OR) = 0.16, 95% confidence interval (CI): 0.07–0.38), that supports the efficacy of hydrogel dressings with lidocaine. Analysis of the duration of the second labor period and gestational term also revealed an association with the risk of a high sum of points on the REEDA scale (OR = 1.22, 95% CI: 1.02–1.45 per 0.01 days; OR = 1.65, 95% CI: 1.16–2.35 per week of pregnancy).A multivariate model which included research group, body mass index, duration of the second labor period, gestational term confirmed a reduced risk according to the REEDA scale in this group (OR = 0.19, 95% CI: 0.08–0.47). The four-factor model had a high accuracy (AUC = 0.81, 95% CI: 0.73–0.88), indicating a strong relationship between the selected factors and the risk of complications after episiotomy.Conclusions. The use of hydrogel dressings with lidocaine and taking into account some aspects of childbirth, namely, the duration of childbirth and gestational period, can contribute to the improvement of the course of healing of episiotomy wounds. Such a comprehensive approach supports the effectiveness and significance of using hydrogel dressings with lidocaine in the practice of modern obstetrics to improve the results of treatment of patients with an episiotomy wound.In the future, studies on the effectiveness of using hydrogel dressings for the treatment of episiotomy wounds are necessary.

Perinatal risk factors for asphyxia and the occurrence of hypoxic-ischemic encephalopathy in newborns

Intranatal asphyxia and hypoxic-ischemic encephalopathy of newborns are caused by risk factors from both the mother and the fetus, which makes the pathophysiology of this condition extremely difficult. Data from the federal statistical observation form No. 32 for the Moscow region show minor changes in the number of chronic diseases, a burdened obstetric and gynecological history, as well as pathology during pregnancy and childbirth in pregnant women over 3 years Perinatal risk factors were significantly more common in newborns with severe intranatal asphyxia and HIE compared with a moderate degree who underwent a therapeutic hypothremia procedure. Complications during the birth process, surgical methods of rapid fetal extraction (vacuum extractor) were the causal factors of asphyxia. To a minor extent, the asphyxia of the newborn is affected by the untimely discharge of amniotic fluid.

Assessment of Women's Awareness of the Effects of Gestational Diabetes Mellitus on the Mother and Fetus in Saudi Arabia: A Cross-Sectional Study.

Introduction Gestational diabetes mellitus (GDM) is a form of glucose intolerance that arises during pregnancy, affecting a significant portion of women. It has immediate and long-term effects on both the mother and fetus, including complications like preeclampsia, premature delivery, and an increased risk of cesarean sections. A cross-sectional study among Saudi Arabia's general population, which included 979 women aged between 18 and 60, found varying levels of awareness of GDM, emphasizing the need for more research on awareness levels regarding GDM in Saudi Arabia and more educational campaigns to improve awareness. Objectives The study evaluates the knowledge of pregnant women about GDM and its implications for the mother and fetus. It investigates the relationship between knowledge levels and demographic factors like age, education, and socioeconomic status, aiming to identify knowledge gaps regarding this health issue and develop targeted educational initiatives. Methodology This was a cross-sectional study that included 979 women and was conducted using a Google Forms (Google Inc., Mountainview, CA) questionnaire. The questionnaire covered demographics and explored the knowledge level of women about the impact of GDM on the mother and fetus. Statistical analysis was implemented by IBM SPSS software version 27.0 (IBM Corp., Armonk, NY), with a 5% significance level. Ethical approval was sought, emphasizing anonymous data collection. We did not collect any identifying or private information from participants, and all responses were kept confidential. Results A study of 979 women revealed that their knowledge of GDM was significantly influenced by their age, gestational age, and the number of prior deliveries (p-value < 0.05). The total mean knowledge score for women's correct responses stood at 7.62 (±4.49). The study found that a majority of women, exceeding 60%, accurately answered certain questions about GDM, such as its association with heightened risks, neonatal intensive care unit (NICU) admissions, cesarean section likelihood, high birth weight, and preeclampsia. However, less than 30% could answer yes to questions that indicated that GDM could increase the risk of shoulder dystocia, hypoglycemia at birth, premature rupture of membranes, postpartum hemorrhage, and vacuum delivery. Conclusion There is a need for targeted educational initiatives, particularly focusing on knowledge gaps that women are lacking regarding GDM. Age and prior deliveries were identified as significant determinants of knowledge levels.

Neonatal birth trauma and associated factors in low and middle-income countries: A systematic review and meta-analysis.

Neonatal birth trauma, although it has steadily decreased in industrialized nations, constitutes a significant health burden in low-resource settings. Keeping with this, we sought to determine the pooled cumulative incidence (incidence proportion) of birth trauma and identify potential contributing factors in low and middle-income countries. Besides, we aimed to describe the temporal trend, clinical pattern, and immediate adverse neonatal outcomes of birth trauma. We searched articles published in the English language in the Excerpta Medica database, PubMed, Web of Science, Google, African Journals Online, Google Scholar, Scopus, and in the reference list of retrieved articles. Literature search strategies were developed using medical subject headings and text words related to the outcomes of the study. The Joana Briggs Institute quality assessment tool was employed and articles with appraisal scores of seven or more were deemed suitable to be included in the meta-analysis. Data were analyzed using the random-effect Dersimonian-Laird model. The full search identified a total of 827 articles about neonatal birth trauma. Of these, 37 articles involving 365,547 participants met the inclusion criteria. The weighted pooled cumulative incidence of birth trauma was estimated at 34 per 1,000 live births (95% confidence interval (CI) 30.5 to 38.5) with the highest incidence observed in Africa at 52.9 per 1,000 live births (95% CI 46.5 to 59.4). Being born to a mother from rural areas (odds ratio (OR), 1.61; 95% CI1.18 to 2.21); prolonged labor (OR, 5.45; 95% CI 2.30, 9.91); fetal malpresentation at delivery (OR, 4.70; 95% CI1.75 to 12.26); shoulder dystocia (OR, 6.11; 95% CI3.84 to 9.74); operative vaginal delivery (assisted vacuum or forceps extraction) (OR, 3.19; 95% CI 1.92 to 5.31); and macrosomia (OR, 5.06; 95% CI 2.76 to 9.29) were factors associated with neonatal birth trauma. In conclusion, we found a considerably high incidence proportion of neonatal birth trauma in low and middle-income countries. Therefore, early identification of risk factors and prompt decisions on the mode of delivery can potentially contribute to the decreased magnitude and impacts of neonatal birth trauma and promote the newborn's health.

Team performance during vacuum-assisted vaginal delivery: video review of obstetric multidisciplinary teams.

Vacuum extraction is generally considered an operator-dependent task, with most attention directed toward the obstetrician's technical abilities (1-3). Little is known about the effect of the team and non-technical skills on clinical outcomes in vacuum-assisted delivery. This study aimed to investigate whether the non-technical skills of obstetricians were correlated with their level of clinical performance via the analysis of video recordings of teams conducting actual vacuum extractions. We installed between two or three video cameras in each delivery room at Aarhus University Hospital and Horsens Regional Hospital and obtained 60 videos of teams managing vacuum extraction. Appropriate consent was obtained. Two raters carefully reviewed the videos and assessed the teams' non-technical skills using the Assessment of Obstetric Team Performance (AOTP) checklist, rating all items on a Likert scale score from 1 to 5 (1 = poor; 3 = average; and 5 = excellent). This resulted in a total score ranging from 18 to 90. Two different raters independently assessed the teams' clinical performance (adherence to clinical guidelines) using the TeamOBS-Vacuum-Assisted Delivery (VAD) checklist, rating each item (0 = not done, 1 = done incorrectly; and 2 = done correctly). This resulted in a total score with the following ranges (low clinical performance: 0-59; average: 60-84; and high: 85-100). Interrater agreement was analyzed using intraclass correlation (ICC), and the risk of high or low clinical performance was analyzed on a logit scale to meet the assumption of normality. Teams that received excellent non-technical scores had an 81% probability of achieving high clinical performance, whereas this probability was only 12% among teams with average non-technical scores (p < 0.001). Teams with a high clinical performance often had excellent behavior in the non-technical items of "team interaction," "anticipation," "avoidance fixation," and "focused communication." Teams with a low or average clinical performance often neglected to consider analgesia, had delayed abandonment of the attempted vaginal delivery and insufficient use of appropriate fetal monitoring. Interrater reliability was high for both rater-teams, with an ICC for the non-technical skills of 0.83 (95% confidence interval [CI]: 0.71-0.88) and 0.84 for the clinical performance (95% CI: 0.74-0.90). Although assisted vaginal delivery by vacuum extraction is generally considered to be an operator-dependent task, our findings suggest that teamwork and effective team interaction play crucial roles in achieving high clinical performance. Teamwork helped the consultant anticipate the next step, avoid fixation, ensure adequate analgesia, and maintain thorough fetal monitoring during delivery.

The Correlation Between Knowledge Level and Maternal Anxiety in Neonatal Asphyxia at Banyumas Regional Public Hospital

Background: Neonatal asphyxia refers to condition newborn baby experiences lack of oxygen, leading to brain damage or even death. There are several factors that make asphyxia babies experience respiratory failure, labor factors which include prolonged labor, actions such as vacuum extraction, forceps extraction and sectiocaesarea. that can be also be caused by birth depression, infections and drugs used during labour. Based on the background above, the problem formulation in this research is :What is the relationship between the level of knowledge of mothers of babies born with Asphyxia Neonatorum? How do mothers worry about babies born with Asphyxia Neonatorum?It is hoped that it can educate pregnant women about the health of their unborn babies and carry out various positive activities to provide health services and health education to pregnant women about baby asphyxia, especially community health centers which play an active role in examining pregnant women. Method: This study quantitative research design with a questionnaire. The research design used analytical survey using cross-sectional. Data analysis univariate and bivariate analysis using the spearman correlation. The sample 30 mothers of infants with asphyxia at Banyumas Regional Hospital, selected through simple random sampling from june-july 2023. The research include knowledge level (Guttman Scale) and anxiety (Likkert Scale). The Cronbach’s reliability (0,6). The reliability knowledge level 0.829, indicating good reliability. Results:The correlation analysis of 0.575, with significant p-value of 0.001, indicating sginificant correlation between knowledge level and maternal anxiety in neonatal asphyxia. Conclusion:There is significant correlation between knowledge level and maternal anxiety in neonatal asphyxia.

The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth

BackgroundAn increased risk of preterm birth has been observed among individuals with a previous second stage cesarean delivery compared with a previous vaginal delivery. One mechanism that may contribute to the increased risk of preterm birth following second stage cesarean delivery is the increased risk of cervical injury due to extension of the uterine incision (hysterotomy) into the cervix. Investigating the contribution of hysterotomy extension to the rate of preterm birth has not been well-studied and may shed light on the mechanisms underlying the observed relationship between mode of delivery and subsequent preterm birth. ObjectiveWe aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery. Study designWe performed a retrospective cohort study using electronic perinatal data collected in two university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks; secondary outcomes included subsequent preterm birth <34, <32 and <28 weeks. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios (RRs) and 95% confidence intervals (CIs). Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labour, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity. ResultsA total 4,797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labour, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses controlling for several confounders showed that a history of hysterotomy extension is not associated with a higher risk of preterm birth <37 weeks gestation (adjusted RR 1.55, 95% CI 0.98-2.47), but is associated with preterm birth <34 weeks gestation (adjusted RR 2.49, 95% CI 1.06-5.42). ConclusionPatients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks compared with patients who do not sustain this injury. This association was not observed for preterm birth <37 weeks. Future research should aim to replicate our analyses while incorporating additional data to minimize the potential for residual confounding.

Obstetric and Neonatal Outcomes Following Hospital Transfers of Home Births and Births in Midwife-led Units in Austria.

Home births and births in midwife-led units and the associated potential risks are still being debated. An analysis of the quality of results of planned home births and births in midwife-led units which require intrapartum transfer of the mother to hospital provides important information on the quality of processes during births which occur outside hospital settings. The aim of this study was to analyze neonatal and maternal outcomes after the initial plan to deliver at home or in a midwife-led unit had to be abandoned and the mother transferred to hospital. The method used was an analysis of data obtained from the Austrian Birth Registry. The dataset consisted of singleton term pregnancies delivered in the period from 1 January 2017 to 31 December 2021 (n=286056). For the analysis, two groups were created for comparison (planned hospital births and hospital births recorded in the Registry as births originally planned as home births or births in midwife-led units but which required a transfer to hospital) and assessed with regard to previously defined variables. Data were analyzed using frequency description, bivariate analysis and regression models. In Austria, an average of 19% of planned home births have to be discontinued and the mother transferred to hospital. Home births and births in midwife-led units which require transfer of the mother to hospital are associated with higher intervention rates intrapartum, high rates of vacuum delivery, and higher emergency c-section rates compared to planned hospital births. Multifactorial regression analysis showed significantly higher risks of poorer scores for all neonatal outcome parameters (Apgar score, pH value, transfer rate). If a birth which was planned as a home delivery or as a delivery in a midwife-led unit fails to progress because of (possible) anomalies, the midwife must respond and transfer the mother to hospital. This leads to a higher percentage of clinical interventions occurring in hospital. From the perspective of clinical obstetrics, it is understandable, based on the existing data, that giving birth outside a clinical setting cannot be recommended.

Vacuum Extraction or Cesarean Section in the Second Stage of Labor: A Systematic Review

(BJOG. 2023;130(6):586–598) Prolonged second-stage labor poses a significant risk for increased perinatal and maternal adverse outcomes. Two common interventions to expedite delivery during this stage are vacuum extraction (VE) and second-stage cesarean section (SSCS). The occurrence of each intervention procedure varies globally. This systematic review aimed to compare outcomes for both mother and baby associated with VE and SSCS.

Variation in Episiotomy Use Among Nulliparous Individuals by Maternity Care Provider and Associated Rates of Obstetric Anal Sphincter Injury

ObjectivesTo quantify variation in the association between episiotomy and obstetric anal sphincter injury (OASI) by maternity care provider in spontaneous and operative vaginal deliveries (SVDs and OVDs). MethodsPopulation-based retrospective cohort study of vaginal, term deliveries among nullipara in Canada (2004–2015). Adjusted rate ratios (ARRs) and 95% CIs were estimated using log-binomial regression to quantify the associations between episiotomy and OASI, stratified by care provider (obstetrician [OB], family physician [FP], or registered midwife [RM]) while adjusting for potential confounders. ResultsThe study included 631 642 deliveries. Episiotomy use varied by provider: among SVDs, the episiotomy rate was 19.6%, 14.4%, and 8.4% in the OB, FP, and RM groups, respectively. The rate of OASI was higher among SVDs with versus without episiotomy (5.8% vs 4.6%). Conversely, OASI occurred less frequently in operative vaginal deliveries with episiotomy (15.3%) compared with those without (16.7%). In all provider groups, the ARR for OASI was increased with episiotomy in SVD and decreased with episiotomy with forceps delivery. No differences in these associations were observed by provider except among vacuum delivery (ARR with episiotomy vs. without, OB: 0.88, 95% CI 0.84–0.92; FP: 0.89, 95% CI 0.83–0.96, RM: 1.22, 95% CI 1.02–1.48). ConclusionsIn nullipara, irrespective of maternity care provider, there is a positive association between episiotomy and OASI among SVDs and an inverse association between episiotomy and deliveries with forceps. The relationship between episiotomy and OASI is modified by maternity care providers among vacuum deliveries.

Pelvic floor dysfunction after intervention, compared with expectant management, in prolonged second stage of labour: A population-based questionnaire and cohort study.

To investigate the effect of vacuum extraction (VE) or caesarean section (CS), compared with expectant management, on pelvic floor dysfunction (PFD) 1-2 years postpartum in primiparous women with a prolonged second stage of labour. A population-based questionnaire and cohort study. Stockholm, Sweden. A cohort of 1302 primiparous women with a second stage duration of ≥3 h, delivering from December 2017 to November 2018. The 1-year follow-up questionnaire from the Swedish National Perineal Laceration Register was distributed 12-24 months postpartum. Exposure was VE or CS at 3-4 h or 4-5 h, compared with expectant management. Pelvic floor dysfunction was defined as at least weekly symptoms of urinary incontinence, pelvic organ prolapse or a Wexner score of ≥4. The risk of PFD was calculated using Poisson regression with robust variance estimation, presented as crude and adjusted relative risks (RRs and aRRs) with 95% confidence intervals (95% CIs). The implication of obstetric anal sphincter injury (OASI) on pelvic floor disorders was investigated through mediation analysis. In total, 35.1% of women reported PFD. Compared with expectant management, the risk of PFD was increased after VE at 3-4 h (aRR 1.33, 95% CI 1.06-1.65) and 4-5 h (aRR 1.34, 95% CI 1.05-1.70), but remained unchanged after CS. The increased risk after VE was not mediated by OASI. Pelvic floor dysfunction was common in primiparous women after a prolonged second stage, and the risk of PFD increased after VE but was unaffected by CS, compared with expectant management. If a spontaneous vaginal delivery eventually occurred, allowing an extended duration of labour did not increase the risk of PFD.

Developing the TeamOBS-vacuum-assisted delivery checklist to assess clinical performance in a vacuum-assisted delivery: a Delphi study with initial validation.

In Northern Europe, vacuum-assisted delivery (VAD) accounts for 6-15% of all deliveries; VAD is considered safe when conducted by adequately trained personnel. However, failed vacuum extraction can be harmful to both the mother and child. Therefore, the clinical performance in VAD must be assessed to guide learning, determine a performance benchmark, and evaluate the quality to achieve an overall high performance. We were unable to identify a pre-existing tool for evaluating the clinical performance in real-life vacuum-assisted births. We aimed to develop and validate a checklist for assessing the clinical performance in VAD. We conducted a Delphi process, described as an interactive process where experts answer questions until answers converge toward a "joint opinion" (consensus). We invited international experts as Delphi panelists and reached a consensus after four Delphi rounds, described as follows: (1) the panelists were asked to add, remove, or suggest corrections to the preliminary list of items essential for evaluating clinical performance in VAD; (2) the panelists applied weights of clinical importance on a Likert scale of 1-5 for each item; (3) each panelist revised their original scores after reviewing a summary of the other panelists' scores and arguments; and (4) the TeamOBS-VAD was tested using videos of real-life VADs, and the Delphi panel made final adjustments and approved the checklist. Twelve Delphi panelists from the UK (n = 3), Norway (n = 2), Sweden (n = 3), Denmark (n = 3), and Iceland (n = 1) were included. After four Delphi rounds, the Delphi panel reached a consensus on the checklist items and scores. The TeamOBS-VAD checklist was tested using 60 videos of real-life vacuum extractions. The inter-rater agreement had an intraclass correlation coefficient (ICC) of 0.73; 95% confidence interval (95% CI) of [0.58, 0.83], and that for the average of two raters was ICC 0.84 95% CI [0.73, 0.91]. The TeamOBS-VAD score was not associated with difficulties in delivery, such as the number of contractions during vacuum extraction delivery, cephalic level, rotation, and position. Failed vacuum extraction occurred in 6% of the video deliveries, but none were associated with the teams with low clinical performance scores. The TeamOBS-VAD checklist provides a valid and reliable evaluation of the clinical performance of vaginal-assisted vacuum extraction.

Mode of birth in subsequent pregnancy when first birth was vacuum extraction or second stage cesarean section at a tertiary referral hospital in Uganda

IntroductionThe trends of increasing use of cesarean section (CS) with a decrease in assisted vaginal birth (vacuum extraction or forceps) is a major concern in health care systems all over the world, particularly in low-resource settings. Studies show that a first birth by CS is associated with an increased risk of repeat CS in subsequent births. In addition, CS compared to assisted vaginal birth (AVB), attracts higher health service costs. Resource-constrained countries have low rates of AVB compared to high-income countries. The aim of this study was to compare mode of birth in the subsequent pregnancy among women who previously gave birth by vacuum extraction or second stage CS in their first pregnancy at Mulago National Referral Hospital, Uganda.MethodsThis was a retrospective cohort study that involved interviews of 81 mothers who had a vacuum extraction or second stage CS in their first pregnancy at Mulago hospital between November 2014 to July 2015. Mode of birth in the subsequent pregnancy was compared using Chi-2 square test and a Fisher’s exact test with a 0.05 level of statistical significance.ResultsHigher rates of vaginal birth were achieved among women who had a vacuum extraction (78.4%) compared to those who had a second stage CS in their first pregnancy (38.6%), p < 0.001.Conclusions and recommendationsVacuum extraction increases a woman’s chance of having a subsequent spontaneous vaginal birth compared to second stage CS. Health professionals need to continue to offer choice of vacuum extraction in the second stage of labor among laboring women that fulfill its indication. This will help curb the up-surging rates of CS.

Evidence for variations in cryogenic extraction deuterium biases of plant xylem water across foundational northeastern US trees

AbstractMeasurements of oxygen and hydrogen isotopes in plant xylem water (2H, 18O) have helped to redefine conceptual and numerical models of the hydrological cycle and understand how plants compete for subsurface water. Recent experiments have shown that Cryogenic Vacuum Extraction (CVE) of plant xylem water can result in a δ2H bias. We tested if CVE δ2H‐biases varied significantly across seven foundational northeastern US forest trees with a series of tree core rehydration experiments. Our analysis demonstrated that CVE δ2H‐biases were well predicted by sample gravimetric water content and varied significantly with tree species identity. We show that species‐level δ2H‐bias corrections can result in substantially different understandings of plant water uptake and transpiration versus uncorrected data or generic bias corrections. This research demonstrates an urgent need for the critical evaluation of CVE for plant water extraction. In the absence of a stronger understanding of CVE δ2H‐biases, we recommend that xylem water δ2H observations should not be used in plant water uptake studies.

Two common pitfalls in the analysis of water-stable isotopologues with cryogenic vacuum extraction and cavity ring-down spectroscopy.

Water stable isotopologue analysis is widely used to disentangle ecohydrological processes. Yet, there are increasing reports of measurement uncertainties for established and emerging methods, such as cryogenic vacuum extraction (CVE) or cavity ring-down spectroscopy (CRDS). With this study, we investigate two pitfalls, that potentially contribute to uncertainties in water-stable isotopologue research. To investigate fractionation sources in CVE, we extracted pure water of known isotopic composition with cotton, glass wool or without cover and compared the isotopologue results with non-extracted reference samples. To characterise the dependency of δ2H and δ18O on the water mixing ratio in CRDS, which is of high importance for in-situ applications with large natural variations in mixing ratios, we chose samples with a large range of isotopic compositions and determined δ2H and δ18O for different water mixing ratios with two CRDS analysers (Picarro, Inc.). Cotton wool had a strong fractionation effect on δ2H values, which increased with more 2H-enriched samples. δ2H and δ18O values showed a strong dependency on the water mixing ratio analysed with CRDS with differences of up to 34.5‰ (δ2H) and 3.9‰ (δ18O) for the same sample at different mixing ratios. CVE and CRDS, now routinely applied in water stable isotopologue research, come with pitfalls, namely fractionation effects of cover materials and water mixing ratio dependencies of δ2H and δ18O, which can lead to erroneous isotopologue results and thus, invalid conclusions about (ecohydrological) processes. These practical issues identified here should be reported and addressed adequately in water-stable isotopologue research.

Does delayed vacuum-assisted delivery harbor greater maternal or neonatal complications?

To compare maternal and fetal outcomes between early (<2 h) and delayed (>2 h) vacuum extraction (VE) deliveries. We performed a retrospective cohort study in a single, university-affiliated medical center (2014-2021). We included term singleton pregnancies delivered by VE, allocated into one of two groups according to second stage duration: <2 h or >2 h. Primary outcome was maternal composite adverse outcome (included chorioamnionitis, 3-4 degree lacerations, and postpartum hemorrhage [PPH]). We included 2521 deliveries: 2261 (89.6%) with early VE and 260 (10.4%) with delayed VE. Study groups' characteristics were not different, except of parity. Maternal composite outcome almost reached a significance (P = 0.054) comparing between the groups. Comparing second stage length up to 2 h versus more, there was similar rate of advance maternal lacerations. However, extending the second stage to more than 3 h was associated with third degree lacerations compared to 2-3 h (9.8% vs 3%, P = 0.011). There were significantly more PPH events in the later VE group (P = 0.004), but the need for blood transfusions was similar. The rates of 5 min Apgar score ≤7 (P = 0.001) and umbilical artery pH <7.0 were significantly higher in group 2 compared with group 1. The effect was much more pronounced when second stage was >3 h. After conducting multiregression analysis, the results became insignificant. Our study suggests that VE performed in the late second stage of labor, up to 3 h, is safe as VE performed in the early stages regarding maternal and neonatal outcomes. Extra caution is needed with extended second stage to more than 3 h.

Simplifying the use of the Kiwi vacuum.

A simplified and easily teachable method of performing Kiwi vacuums is described. The Kiwi Omnicup has several features which make it the ideal instrument for correcting malposition. Once the correct position of the fetus is ascertained using ultrasound, it is always possible to maneuver the cup over the flexion point. A retrospective study was undertaken of 239 consecutive patients in the author's private practice requiring assisted delivery from 2010 until 2016. No case was declined. Successful Kiwi vacuum delivery was achieved in 233 cases (98%) and complication rates were low.