Risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery: observational study nested within the Instrumental Delivery & Ultrasound randomised controlled trial ISRCTN 72230496.

To identify risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery. Observational study, nested within a randomised controlled trial. Two university-affiliated maternity hospitals. A cohort of 478 nulliparous women at term (≥37 weeks of gestation) undergoing instrumental delivery. Univariable and multivariable logistic regression analyses were performed. Risk factors for suboptimal application of vacuum or forceps, maternal and neonatal morbidity, and the sequential use of instruments, second operator, and caesarean section following failed instrumental delivery. Instrument placement was suboptimal in 138 of 478 (28.8%) deliveries. Factors associated with suboptimal instrument placement included fetal malposition (OR 2.44, 95% CI 1.62-3.66), mid-cavity station (OR 1.68, 95% CI 1.02-2.78), and forceps as the primary instrument (OR 2.01, 95% CI 1.33-3.04). Compared with optimal instrument placement, suboptimal placement was associated with prolonged hospital stay (adjusted OR 2.28, 95% CI 1.30-4.02) and neonatal trauma (adjusted OR 4.25, 95% CI 1.85-9.72). Suboptimal placement was associated with a greater use of sequential instruments (adjusted OR 3.99, 95% CI 1.94-8.23) and caesarean section for failed instrumental delivery (adjusted OR 3.81, 95% CI 1.10-13.16). The mean decision to delivery interval (DDI) was 4 minutes longer in the suboptimal group (95% CI 2.1-5.9 minutes). Suboptimal instrument placement is associated with increased maternal and neonatal morbidity and procedural complications. Greater attention should be focused on instrument placement when training obstetricians for instrumental delivery.

Ramphul M ，Kennelly MM ，Burke G ，Murphy DJ ... -  《-》

Maternal and neonatal morbidity in relation to the instrument used for mid-cavity rotational operative vaginal delivery: a prospective cohort study.

To compare the maternal and neonatal morbidity associated with alternative instruments used to perform a mid-cavity rotational delivery. A prospective cohort study. Two university teaching hospitals in Scotland and England. Three hundred and eighty-one nulliparous women who had a mid-cavity rotational operative vaginal delivery. A data collection sheet was completed by the research team following delivery. Postpartum haemorrhage, third- and fourth-degree perineal tears, low cord pH, neonatal trauma, and failed or sequential operative vaginal delivery. One hundred and sixty-three women (42.8%) underwent manual rotation followed by non-rotational forceps delivery, 73 (19.1%) had a rotational vacuum delivery, and 145 (38.1%) delivered with the assistance of rotational (Kielland) forceps. The rates of postpartum haemorrhage were similar when comparing manual rotation with rotational vacuum (adjusted OR 1.42, 95% CI 0.66-3.98), and when comparing manual rotation with Kielland forceps (adjusted OR 1.22, 95% CI 0.71-2.88). The results were comparable for third- and fourth-degree perineal tears (adjusted OR 0.85, 95% CI 0.13-1.89; adjusted OR 0.94, 95% CI 0.39-1.82), low cord pH (adjusted OR 1.76, 95% CI 0.44-6.91; adjusted OR 1.12, 95% CI 0.44-2.83), neonatal trauma (adjusted OR 0.50, 95% CI 0.16-1.55; adjusted OR 3.25, 95% CI 0.65-16.17), and admission to the neonatal intensive care unit (adjusted OR 1.47, 95% CI 0.45-4.81; adjusted OR 1.04, 95% CI 0.49-2.19). The sequential use of instruments was less likely with manual rotation and forceps than with rotational vacuum delivery (0.6 versus 36.9%, OR 0.01, 95% CI 0.002-0.090). Maternal and perinatal outcomes are comparable with Kielland forceps, vacuum extraction, and manual rotation, with few serious adverse outcomes. With appropriate training mid-cavity rotational delivery can be practiced safely, including the use of Kielland forceps.

Bahl R ，Van de Venne M ，Macleod M ，Strachan B ，Murphy DJ ... -  《-》

Instrumental delivery: clinical practice guidelines from the French College of Gynaecologists and Obstetricians.

Routine use of a partograph is associated with a reduction in the use of forceps, but is not associated with a reduction in the use of vacuum extraction (Level A). Early artificial rupture of the membranes, associated with oxytocin perfusion, does not reduce the number of operative vaginal deliveries (Level A), but does increase the rate of fetal heart rate abnormalities (Level B). Early correction of lack of progress in dilatation by oxytocin perfusion can reduce the number of operative vaginal deliveries (Level B). The use of low-concentration epidural infusions of bupivacaine potentiated by morphinomimetics reduces the number of operative interventions compared with larger doses (Level A). Placement of an epidural before 3-cm dilatation does not increase the number of operative vaginal deliveries (Level A). Posterior positions of the fetus result in more operative vaginal deliveries (Level B). Manual rotation of the fetus from a posterior position to an anterior position may reduce the number of operative deliveries (Level C). Walking during labour is not associated with a reduction in the number of operative vaginal deliveries (Level A). Continuous support of the parturient by a midwife or partner/family member during labour reduces the number of operative vaginal deliveries (Level A). Under epidural analgesia, delayed pushing (2h after full dilatation) reduces the number of difficult operative vaginal deliveries (Level A). Ultrasound is recommended if there is any clinical doubt about the presentation of the fetus (Level B). The available scientific data are insufficient to contra-indicate attempted midoperative delivery (professional consensus). The duration of the operative intervention is slightly shorter with forceps than with a vacuum extractor (Level C). Nonetheless, the urgency of operative delivery is not a reason to choose one instrument over another (professional consensus). The cup-shaped vacuum extractor seems to be the instrument of choice for operative deliveries of fetuses in a cephalic transverse position, and may also be preferred for fetuses in a posterior position (professional consensus). Vacuum extraction deliveries fail more often than forceps deliveries (Level B). Overall, immediate maternal complications are more common for forceps deliveries than vacuum extraction deliveries (Level B). Compared with forceps, operative vaginal delivery using a vacuum extractor appears to reduce the number of episiotomies (Level B), first- and second-degree perineal lesions, and damage to the anal sphincter (Level B). Among the long-term complications, the rate of urinary incontinence is similar following forceps, vacuum extraction and spontaneous vaginal deliveries (Level B). Anal incontinence is more common following forceps delivery (Level B). Persistent anal incontinence has a similar prevalence regardless of the mode of delivery (caesarean or vaginal, instrumental or non-instrumental), suggesting the involvement of other factors (Level B). Rates of immediate neonatal mortality and morbidity are similar for forceps and vacuum extraction deliveries (Level B). It appears that difficult instrumental delivery may lead to psychological sequelae that may result in a decision not to have more children (Level C). The rates of neonatal convulsions, intracranial haemorrhage and jaundice do not differ between forceps and vacuum extraction deliveries (Levels B and C). Rapid sequence induction with a Sellick manoeuvre (pressure to the cricoid cartilage) and tracheal intubation with a balloon catheter is recommended for any general anaesthesia (Level B). Training must ensure that obstetricians can identify indications and contra-indications, choose the appropriate instrument, use the instruments correctly, and know the principles of quality control applied to operative vaginal delivery. Nowadays, traditional training can be accompanied by simulations. Training should be individualized and extended for some students.

Vayssière C ，Beucher G ，Dupuis O ，Feraud O ，Simon-Toulza C ，Sentilhes L ，Meunier E ，Parant O ，Schmitz T ，Riethmuller D ，Baud O ，Galley-Raulin F ，Diemunsch P ，Pierre F ，Schaal JP ，Fournié A ，Oury JF ，French College of Gynaecologists and Obstetricians ... -  《-》

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

Leung WC ，Lam HS ，Lam KW ，To M ，Lee CP ... -  《BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY》

Forceps or vacuum extraction: a comparison of maternal and neonatal morbidity.

Shihadeh A ，Al-Najdawi W 《EASTERN MEDITERRANEAN HEALTH JOURNAL》