Increasing rates of operative vaginal delivery across two decades: accompanying outcomes and instrument preferences

Objective

To examine rates and outcomes of operative vaginal delivery over a 20-year study period and the changing preference for various instruments during this period.

Study design

This retrospective analysis of prospectively gathered data was carried out at a large tertiary referral center from 1991 to 2010. All cases of operative vaginal delivery during the study period were recorded. The rates of instrumental delivery, as well as neonatal outcomes and instrument preference, were compared for individual 5-year epochs.

Results

During the study period there were 156,130 deliveries of which 17,841 were operative vaginal deliveries, an incidence of 11.4/100 deliveries and 13.6/100 vaginal deliveries. There was an increase in the rate of operative vaginal delivery across the 20-year period (P < 0.0001; R² = 0.85; Slope = 0.42). When individual 5-year epochs were compared, the incidence of instrumental delivery increased from 7.3% (2340/31,937) in the first five years, 1991–1995, to 13.7% (6179/45,177) in the final five years, 2006–2010 (P < 0.0001; OR 2.34, 95% CI = 2.23–2.47). The perinatal mortality rate in cases of instrumental delivery was decreased when these time periods were compared (7.3/1000 (17/2340) vs. 1.8/1000 (11/6179); P = 0.003, OR 0.24, 95% CI = 0.11–0.52). The choice of instrument also varied, with 68.2% (1596/2340) of instrumental deliveries in 1991–1995 being carried out with forceps compared to 32.9% (2033/6179) in 2006–2010 (P < 0.001).

Conclusion

Rates of operative vaginal delivery have increased over the 20-year study period. The rate of perinatal mortality in infants who had an assisted vaginal delivery was decreased in the 5-year epoch at the end of the study compared with the period at the beginning. The rate of forceps delivery has fallen significantly, with vacuum delivery now being the choice of the majority of clinicians.     

Qualitative analysis by interviews and video recordings to establish the components of a skilled rotational forceps delivery

Objective

To define the skills of a mid-cavity rotational forceps delivery to facilitate transfer of skills from expert obstetricians to trainee obstetricians.

Study design

Qualitative interviews and video analysis carried out at maternity units of two university teaching hospitals (St. Michael's Hospital, Bristol, and Ninewells Hospital, Dundee). Ten obstetricians were identified as experts in conducting operative vaginal deliveries. Semi-structured interviews were carried out to identify key technical skills. The experts were also video recorded conducting mid-cavity rotational deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were individually coded by the three researchers and then compared for consistency of interpretation. The experts reviewed the data for respondent validation. The themes that emerged following the coding were used to formulate a taxonomy of skills.

Results

Rotational forceps were preferred by eight experts and two experts preferred manual rotation followed by direct traction forceps. The final taxonomy included detailed technical skills for Kielland rotational forceps delivery and manual rotation followed by direct traction forceps delivery.

Conclusion

This explicitly defined skills taxonomy could aid trainees’ understanding of the technique of rotational forceps delivery. This is an important potential contributor to safely reducing the rate of second-stage caesarean section.     

Comparison of outcomes between operative vaginal deliveries and spontaneous vaginal deliveries in southeast Nigeria

Objective

To evaluate the incidence of, indications for, and outcome of operative vaginal deliveries compared with spontaneous vaginal deliveries in southeast Nigeria.

Methods

A retrospective cohort study was conducted involving cases of operative vaginal delivery performed at Ebonyi State University Teaching Hospital over a 10-year period. Data on the procedures were abstracted from the operation notes of the medical records of parturients.

Results

An incidence of 4.7% (n = 461) was recorded. The most common indications for vacuum and forceps delivery were prolonged second stage of labor (44.9%) and poor maternal effort (27.8%). The only indication for destructive operation was intrauterine fetal death (3.7%). The risk ratio (RR) for hemorrhage/vulvar hematoma was 1.14 (95% confidence interval [CI], 0.53–2.48) for vacuum-assisted delivery and 5.49 (95% CI, 0.82–36.64) for forceps delivery. The RR for genital laceration was 1.21 (95% CI, 0.44–3.30) for vacuum-assisted delivery and 9.41 (95% CI, 1.33–66.65) for forceps delivery. The risk of fetal scalp bruises and caput succedaneum was higher for operative vaginal delivery than for spontaneous vaginal delivery, with no significant difference in maternal morbidity. The perinatal mortality rate was 0.9 per 1000 live births.

Conclusion

Operative vaginal delivery by experienced healthcare providers is associated with good obstetric outcomes with minimal risk.     

Decision-making in operative vaginal delivery: when to intervene,where to deliver and which instrument to use? Qualitative analysis of expert clinical practice

Objective

To identify the decision-making process involved in determining when to intervene, where to deliver and the optimal choice of instrument for operative vaginal deliveries in the second stage of labour.

Study design

A qualitative study using interviews and video recordings took place at two university teaching hospitals (St. Michael's Hospital Bristol and Ninewells Hospital, Dundee). Ten obstetricians and eight midwives were identified as experts in conducting or supporting operative vaginal deliveries. Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low cavity vacuum and mid-cavity rotational forceps deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and then compared for consistency of interpretation. The experts reviewed the coded interview and video data for respondent validation and clarification. The themes that emerged following the final coding were used to identify the decision-making process when planning and conducting an operative vaginal delivery. Key decision points were reported in selecting when and where to conduct an operative vaginal delivery and which instrument to use.

Results

The final decision-making list highlights the various decision points to consider when performing an operative vaginal delivery. We identified clinical factors that experts take into consideration when selecting where the delivery should take place and the preferred choice of instrument.

Conclusion

This detailed illustration of the decision-making process could aid trainees’ understanding of the approach to safe operative vaginal delivery, aiming to minimise morbidity.     

Comparison of outcomes of perinatal care in Slovakia and the UK

Objective

To investigate whether there are differences in maternal and perinatal outcomes between Slovakia and the UK, and whether any observed variations can be attributed to differences in perinatal care.

Methods

Data on outcomes of perinatal care in Slovakia and the UK between 2006 and 2010 were compared. Perinatal mortality figures included stillbirths weighing 1000 g or more and early neonatal deaths.

Results

In Slovakia, the perinatal mortality rate was significantly higher than that in the UK (RR 1.12; 95% CI, 1.06–1.18). Cesarean delivery was significantly more frequent in Slovakia (RR 1.05; 95% CI, 1.05–1.06); instrumental vaginal delivery was less frequent (ventouse delivery, RR 0.20; 95% CI, 0.19–0.21; forceps delivery, RR 0.09; 95% CI, 0.09–0.10). Episiotomy and peripartum hysterectomy were performed more often in Slovakia (episiotomy, RR 4.10; 95% CI, 4.07–4.12; peripartum hysterectomy, RR 2.02; 95% CI 1.65–2.47). The incidence of eclampsia was significantly higher in Slovakia (RR 1.60; 95% CI, 1.26–2.04). There were no significant differences in the rates of maternal death.

Conclusion

Perinatal care outcomes and intervention rates differ between Slovakia and UK. This may be explained by differences in outcome definitions, perinatal care, and official encouragement of medical complaints.     

Non-technical skills for obstetricians conducting forceps and vacuum deliveries: qualitative analysis by interviews and video recordings

Objective

Non-technical skills are cognitive and social skills required in an operational task. These skills have been identified and taught in the surgical domain but are of particular relevance to obstetrics where the patient is awake, the partner is present and the clinical circumstances are acute and often stressful. The aim of this study was to define the non-technical skills of an operative vaginal delivery (forceps or vacuum) to facilitate transfer of skills from expert obstetricians to trainee obstetricians.

Study design

Qualitative study using interviews and video recordings. The study was conducted at two university teaching hospitals (St. Michael's Hospital, Bristol and Ninewells Hospital, Dundee). Participants included 10 obstetricians and eight midwives identified as experts in conducting or supporting operative vaginal deliveries. Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting forceps and vacuum deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by the three researchers and then compared for consistency of interpretation. The experts reviewed the coded data for respondent validation and clarification. The themes that emerged were used to identify the non-technical skills required for conducting an operative vaginal delivery.

Results

The final skills list was classified into seven main categories. Four categories (situational awareness, decision making, task management, and team work and communication) were similar to the categories identified in surgery. Three further categories unique to obstetrics were also identified (professional relationship with the woman, maintaining professional behaviour and cross-monitoring of performance).

Conclusion

This explicitly defined skills taxonomy could aid trainees’ understanding of the non-technical skills to be considered when conducting an operative vaginal delivery and potentially reduce morbidity and improve the experience of delivery for the mother.     

Resultados perinatales en 492 presentaciones podálicas: cesárea vs. parto vaginal

Objective

To analyze the perinatal results in our hospital comparing vaginal delivery and cesarean section in breech presentation singleton pregnancies at term.

Material and Methods

All live ante-partum singleton fetuses in breech presentation, at 37 to 41+6 weeks and days who delivered between July 2006 and August 2010 were included in the study. We compared perinatal results between cesarean section and vaginal delivery.

Results

There were no differences in Apgar score at 5 minutes < 7, pH umbilical cord < 7, base deficits and lactate, neonatal intensive care unit admission or perinatal mortality.

Conclusions

With appropriate maternal and fetal conditions and a qualified medical team, a breech vaginal delivery could be propose obtaining good perinatal outcomes.     

Influence of mode of delivery on neonatal mortality and morbidity in spontaneous preterm breech delivery

Objective

To study the association between mode of delivery and neonatal outcome in singleton pregnancy with breech presentation and preterm birth, due to premature labour (PTL) and/or preterm premature rupture of the membranes (pPROM).

Design and methods

Information on preterm (gestational week 25–36) singleton births in breech presentation in Sweden during 1990–2002 was obtained from the Swedish Medical Birth Registry and the Swedish Hospital Discharge Registry. The study groups included 1975 caesarean and 699 vaginal deliveries with a diagnosis of PTL or pPROM, without pregnancy complications implying a high risk of fetal compromise. The rates of infant respiratory distress syndrome (IRDS), intraventricular haemorrhage (IVH), low Apgar scores, and neonatal deaths were compared between infants delivered vaginally and by caesarean section. Odds ratios were calculated with adjustment for gestational age, year of birth, maternal age and parity.

Results

The risk of neonatal death and the risk of an Apgar score below 5 min postnatally were both lower after caesarean delivery (OR 0.4; 95% CI 0.2–0.7, and OR 0.4; 95% CI 0.3–0.7, respectively), whereas the risk of IRDS was increased (OR 2.1; 95% CI 1.4–3.2). A diagnosis of IRDS was not associated with mortality (OR 0.8; 95% CI 0.5–1.5). IVH was not associated with mode of delivery (OR 1.2; 95% CI 0.5–2.8).

Conclusion

The lower neonatal mortality after CS supports a policy of caesarean delivery of the preterm breech.     

The higher the educational level of the first-time mother,the lower the fetal and post-neonatal but not the neonatal mortality in Belgium (Flanders)

Objective

To assess, in a homogenous population of primiparous women, how fetal and infant (=first year of life) mortality varied by the mothers’ level of education.

Study design

We conducted an observational study in Flanders (Northern Belgium) involving 170,948 primiparous women who delivered in Flanders during the period 1999–2006, and their 174,495 babies. We linked the maternal education (3 levels) with a series of obstetrical and perinatal events, with special emphasis on fetal and infant death. A logistic regression analysis was performed to adjust for confounders.

Results

The incidence of fetal (0.21% – high level of education; 0.35% – medium level; 0.84% – low level) and infant mortality (0.32%; 0.41%; 0.70%, respectively), followed an inverse maternal educational gradient: higher with a lower level of education. However, neonatal death (0–27 days) was independent of the educational level of the mother. The age of the woman at delivery, the use of assisted reproductive technology and the incidence of twin birth increased while the rates of preterm birth (7.7% – high level; 8.9% – medium level; 10% – low level) and low birth weight (7.2%; 9.5%; 11.8%, respectively) decreased with the mother's educational level.

Conclusion

Perinatal and obstetrical outcome differ according to the level of the education of the mother, which is a determinant of the incidence of fetal and post-neonatal death but not of early and late neonatal death (0–27 days).     

Outcomes of subsequent pregnancies after conservative treatment for placenta accreta

Objective

To estimate the association between conservative treatment for placenta accreta and subsequent pregnancy outcomes.

Methods

In a retrospective study, data were analyzed on women who received conservative treatment for placenta accreta (removal of the placenta with uterine preservation) at a tertiary hospital in Jerusalem, Israel, between 1990 and 2000. Data were collected on subsequent pregnancies and neonatal outcomes until 2010, and compared with those from a matched control group of women who did not have placenta accreta.

Results

A total of 134 women were included in both groups. Placenta accreta occurred in 62 (22.8%) of 272 subsequent deliveries in the study group for which data were available and 5 (1.9%) of 266 in the control group (relative risk [RR] 12.13; 95% confidence interval [CI] 4.95–29.69; P < 0.001). Early postpartum hemorrhage occurred in 23 (8.6%) of 268 deliveries in the study group and 7 (2.6%) of 268 in the control group (RR 3.29; 95% CI 1.43–7.53; P < 0.001). The odds ratio for recurrent placenta accreta in subsequent deliveries in the study group was 15.41 (95% CI 6.09–39.03; P < 0.001).

Conclusion

Although subsequent pregnancies after conservative treatment for placenta accreta were mostly successful, the risk of recurrent placenta accreta and postpartum hemorrhage is high in future deliveries.     

Adnexal masses encountered during cesarean delivery

Objective

To outline and discuss the clinical features and outcomes of adnexal masses that were treated during cesarean delivery at a tertiary referral hospital located in Ankara, Turkey.

Methods

The operating room and pathology department databases for 2007–2012 were retrospectively reviewed for surgically managed adnexal masses during cesarean delivery. Clinicopathologic characteristics and maternal and neonatal outcomes were assessed.

Results

Adnexal masses occurred in 151 women (0.3% of all cesarean deliveries). Most (54.9%) masses were incidentally discovered during cesarean delivery. The mean mass size was 5.3 ± 3.7 cm (range, 3–30 cm). The majority (96.7%) of the women underwent excision of the mass and ovarian repair. Most masses were benign, with dermoid cysts constituting the most common diagnosis (23.8%). Rare tumors such as thecoma, hyperreactio luteinalis, hemangioma, and benign Brenner tumor were also encountered. Three (2.0%) women were postoperatively diagnosed with ovarian cancer. Preterm delivery and neonatal intensive care unit admission rates were 15.9% and 11.9%, respectively. There were no serious neonatal morbidities and no neonatal mortality.

Conclusion

Adnexal masses encountered during cesarean delivery generally have a favorable prognosis in terms of maternal and fetal outcome.     

Advanced maternal age and adverse perinatal outcomes in an Asian population

Objective

To investigate (1) whether there is an increasing trend in the mean maternal age at the birth of the first child and in the group of women giving birth at age 35 or older, and (2) the association between advanced maternal age and adverse perinatal outcomes in an Asian population.

Study design

We conducted a retrospective cohort study involving 39,763 Taiwanese women who delivered after 24 weeks of gestation between July 1990 and December 2003. Multivariable logistic regression was used to adjust for potential confounding variables.

Results

During the study period, the mean maternal age at the birth of the first child increased from 28.0 to 29.7 years, and the proportion of women giving birth at age 35 or older increased from 11.4% to 19.1%. Compared to women aged 20–34 years, women giving birth at age 35 or older carried a nearly 1.5-fold increased risk for pregnancy complications and a 1.6–2.6-fold increased risk for adverse perinatal outcomes. After adjusting for the confounding effects of maternal characteristics and coexisting pregnancy complications, women aged 35–39 years were at increased risk for operative vaginal delivery (adjusted odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2–1.7) and cesarean delivery (adjusted OR 1.6, 95% CI 1.5–1.7), while women aged 40 years and older were at increased risk for preterm delivery (before 37 weeks of gestation) (adjusted OR 1.7, 95% CI 1.3–2.2), operative vaginal delivery (adjusted OR 3.1, 95% CI 2.0–4.6), and cesarean delivery (adjusted OR 2.6, 95% CI 2.2–3.1). In those women who had a completely uncomplicated pregnancy and a normal vaginal delivery, advanced maternal age was still significantly associated with early preterm delivery (before 34 weeks of gestation), a birth weight <1500 g, low Apgar scores, fetal demise, and neonatal death.

Conclusion

In this population of Taiwanese women, there is an increasing trend in the mean maternal age at the birth of the first child. Furthermore, advanced maternal age is independently associated with specific adverse perinatal outcomes.     

National variations in operative vaginal deliveries in Ireland

Objective

To compare the percentage of operative vaginal delivery (OVD) among all publicly funded maternity hospitals in Ireland and to develop quality control performance tables to facilitate national benchmarking.

Methods

The analysis included deliveries of neonates weighing 500 g or more in publicly funded hospitals in Ireland in 2010. Information was obtained from the Irish National Perinatal Reporting System. Maternities delivering in 1 private hospital or at home, and those with unknown parity were excluded. Mean ± SD OVD rates were calculated per hospital. Quality control tables were devised.

Results

In 2010, there were 75 600 deliveries, of which 73 029 met the inclusion criteria. The number of deliveries per hospital ranged from 1284 to 9759. The OVD rate per hospital was 15.3 ± 2.6% (range, 11.7–20.4%). The OVD rate was 29.1% among primigravidas (n = 30 468) compared with 6.7% among multigravidas (n = 42 561) (P < 0.001). Using quality control tables, 52.6% (n = 10) and 31.6% (n = 6) of hospitals were more than 1 SD outside the national mean for forceps and ventouse delivery, respectively.

Conclusion

Wide variations were found in both the range of OVD and instrument choice among maternity hospitals in Ireland, raising questions about practice and training in contemporary obstetrics.     

Audit of cesarean delivery in Burkina Faso

Objective

To assess the level and determinants of unnecessary cesarean delivery.

Methods

In a retrospective study, the medical charts were reviewed for 300 low-risk women who underwent intrapartum cesarean delivery at 10 referral hospitals in Burkina Faso between May 2009 and April 2010. In this context, cesarean deliveries were delegated to clinical officers who have less training than doctors.

Results

Among the 300 study patients, 223 women (74.3%) were referred from primary healthcare facilities. The reason for referral was not medically justified for 35 women. Cesarean was performed by a gynecologist–obstetrician (46.0%), a trained doctor (35.0%), or a clinical officer (19.0%). Acute fetal distress and fetopelvic disproportion were the main indications recorded for intrapartum cesarean delivery. These diagnoses were not confirmed by an obstetrician–gynecologist in 12.0% of cases. Clinical officers were associated with a higher risk of unnecessary cesarean delivery compared with gynecologist–obstetricians by multivariate analysis (odds ratio, 4.46; 95% confidence interval, 1.44–13.77; P = 0.009).

Conclusion

Verification of cesarean indications by highly qualified personnel (i.e. second opinion), in-service training, and supervision of health workers in primary healthcare facilities might improve the performance of the referral system and help to reduce unnecessary cesarean deliveries in Burkina Faso.     

Maternal and neonatal outcomes following additional doses of vaginal prostaglandin E2 for induction of labour: a retrospective cohort study

Objective

To assess maternal and neonatal outcomes following the use of additional doses of vaginal prostaglandins (PGE2) above the recommended dose for induction of labour in post-dates pregnancies.

Study design

Retrospective cohort study set in Aberdeen Maternity Hospital, Aberdeen, UK. A total of 3514 nulliparous women with labour induced with vaginal PGE2 (3 mg tablet or 2 mg gel) for a post-dates singleton pregnancy from January 1994 to December 2009 were included. Women receiving ≤ 2 doses of PGE2 were compared with those receiving > 2 doses (maximum 5 doses). Binary logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Primary outcomes included mode of delivery, terbutaline use, indication for CS, postpartum haemorrhage, neonatal unit admission, and Apgar score < 7. A further analysis was conducted which stratified for number of doses of PGE2 given.

Results

Of the 3514 women who met inclusion criteria, 605 (17%) received PGE2 that exceeded the licensed dose. They were more likely to deliver by caesarean section (53.4% vs. 31.8%, OR 2.2, 95% CI 1.8–2.6), have a caesarean section for ‘failed’ induction of labour (11.4% vs. 1.9%, OR 4.1, 95% CI 1.3–13.2) or lack of progress in labour (37% vs. 17%, OR 2.8, 95% CI 2.3–3.4), but not for fetal concerns (8.2% vs. 8.8% OR 0.9, 95% CI 0.7–1.3). Terbutaline use and postpartum haemorrhage was no more likely (0.7% vs. 0.9% OR 0.6 95% CI 0.3–1.5 and 19.8% vs. 18.9% OR1.01, 95% CI 0.97–1.06 respectively). Apgar score < 7 (1.1% vs. 1.3% OR 0.9 95% CI 0.8–1.1) and neonatal unit admission (13.7% vs. 10.7% OR 1.2 95% CI 0.8–1.6) were similar in both groups.

Conclusion

The use of additional doses of vaginal PGE2 above the recommended dose for induction of labour was not associated with increased maternal or neonatal morbidity and almost half of these women achieved a vaginal delivery.     

Induction of labor for term small-for-gestational-age fetuses: what are the consequences?

Objective

To evaluate whether early term labor induction for suspected intrauterine growth restriction (weeks 37–39) improves neonatal outcome for small-for-gestational-age (SGA) neonates.

Study design

Delivery room data for 2004–2008 from a single tertiary medical center were linked to neonatal discharge data from the same institution. Data were limited to all singleton, liveborn SGA neonates born at 37–42 weeks of gestation and their mothers. Births with known congenital anomalies were excluded. Women undergoing induction of labor for suspected growth restriction between 37 and 39 weeks’ gestation (early induction SGA) were compared with women who gave birth to term SGA neonates without early induction. SGA (<10th percentile for gestational age and gender) was used as a surrogate for intrauterine growth restriction. Associations between early term labor induction and neonatal morbidities were estimated using logistic regression.

Results

A total of 2378 SGA neonates meeting study criteria were identified. Of these, 445 underwent early term induction and 1933 were in the non-early induction SGA group. Intrauterine demise among term (37–42 weeks) SGAs occurred in one case at 37 weeks. Early term induction for SGA was associated with an increased risk of cesarean delivery. Several neonatal complications, including hyperbilirubinemia, hypoglycemia and respiratory complications were more prevalent in the early induction SGA group. The increased odds for neonatal complications persisted after controlling for possible confounders.

Conclusions

Early term induction for SGA fetuses results in an increased risk of cesarean deliveries as well as neonatal metabolic and respiratory complications, with no apparent neonatal benefit.     

Does young maternal age increase the risk of adverse obstetric,fetal and neonatal outcomes: A cohort study

Objective

To determine whether young maternal age is associated with increased risks of adverse obstetric, fetal and perinatal outcomes.

Study design

Register-based study using the data from a computerized database of a University Hospital for the years 1994–2001. The study population included 8514 primiparous women aged less than 31 who delivered a singleton infant. Using maternal age as a continuous variable, crude and adjusted relative risks (RRs) were estimated for each maternal and perinatal outcome.

Results

Crude and adjusted RRs of anaemia during pregnancy and fetal death consistently increased with younger maternal age. After adjustment for confounding factors, RRs (95% confidence interval) of fetal death and anaemia were respectively 1.37 (1.09–1.70) and 1.27 (1.15–1.40) for a 16-year-old compared to a 20-year-old mother. Younger mothers had significantly decreased risks of obstetric complications (preeclampsia, caesarean section, operative vaginal delivery and post-partum haemorrhage). Higher prevalence of prematurity and low birth weight in infants born to teenagers were not attributable to young maternal age after adjustment for confounding factors.

Conclusion

In our population, younger maternal age was significantly and consistently associated to greater risks of fetal death and anaemia and to lower risks of adverse obstetric outcomes.     

A cohort study of maternal and neonatal morbidity in relation to use of sequential instruments at operative vaginal delivery

Objective

To evaluate the risk factors and maternal and neonatal morbidity associated with sequential use of instruments (vacuum and forceps) at operative vaginal delivery.

Study design

A cohort study of 1360 nulliparous women delivered by a single instrument (vacuum or forceps) or by both instruments, within two university teaching hospitals in Scotland and England. Outcomes were compared for use of sequential instruments versus use of any single instrument. A sub-group analysis compared sequential instruments versus forceps alone. Outcomes of interest included anal sphincter tears, postpartum haemorrhage, urinary retention, urinary incontinence, prolonged hospital admission, neonatal trauma, low Apgar scores, abnormal cord bloods and admission to the neonatal intensive care unit (NICU).

Results

Use of sequential instruments at operative vaginal delivery was associated with fetal malpositions, Odds Ratio (OR) 1.8 (95% Confidence Interval (CI) 1.3-2.6), and large neonatal head circumference (>37 cm) (OR 5.0, 95% CI 2.6-9.7) but not with maternal obesity or grade of operator. Sequential use of instruments was associated with greater maternal and neonatal morbidity than single instrument use (anal sphincter tear 17.4% versus 8.4%, adjusted OR 2.1, 95% CI 1.2-3.3; umbilical artery pH <7.10, 13.8% versus 5.0%, adjusted OR 3.3, 95% CI 1.7-6.2). Sequential instrument use had greater morbidity than single instrument use with forceps alone (anal sphincter tear OR 1.8, 95% CI 1.1-2.9; umbilical artery pH <7.10 OR 3.0, 95% CI 1.7-5.5).

Conclusions

The use of sequential instruments significantly increases maternal and neonatal morbidity. Obstetricians need training in the appropriate selection and use of instruments with the aim of completing delivery safely with one instrument.     

Meconium-stained amniotic fluid—Perinatal outcome and obstetrical management in a low-risk suburban population

Objective

To determine whether amniotic fluid (MSAF) affects obstetrical interventions and immediate perinatal outcome in a low-risk suburban population.

Study design

A retrospective cohort study examined 11,226 deliveries at Tübingen University Hospital (1998–2003). Thousand one hundred and twenty-three women (10%) had MSAF during labor. A control group of matched pairs was created, assigning to each patient the next woman that gave birth without MSAF. Exclusion criteria were: gestational age less than 37 + 0 weeks, primary Cesarean (C-)section, multiple gestation, severe maternal disease, preeclampsia and fetal malformations.

Results

Only small differences were noted between the meconium and non-meconium groups with regard to arterial pH and Apgar scores: mean arterial-pH was 7.26 (±0.7) for both. Five minutes Apgar scores <6 occurred in 0.9% versus 0.4%. Obstetrical interventions were more common in the meconium group: C-section rates were 17.4% versus 9.6%, vaginal operative delivery rates 13.9% versus 6.2% and scalp pH rates 9.5% versus 3.7%, respectively.

Conclusions

In a low-risk suburban population the effect of MSAF on the newborn during the immediate postpartum period was small. However, obstetrical management was significantly effected by the presence of MSAF, possibly reflecting a combination of more difficult labor and a lower threshold for obstetric intervention.     

One-year evaluation of the impact of an emergency obstetric and neonatal care training program in Western Kenya

Objective

To determine the impact of introducing an emergency obstetric and neonatal care training program on maternal and perinatal morbidity and mortality at Moi Teaching and Referral Hospital, Eldoret, Kenya.

Methods

A prospective chart review was conducted of all deliveries during the 3-month period (November 2009 to January 2010) before the introduction of the Advances in Labor and Risk Management International Program (AIP), and in the 3-month period (August–November 2011) 1 year after the introduction of the AIP. All women who were admitted and delivered after 28 weeks of pregnancy were included. The primary outcome was the direct obstetric case fatality rate.

Results

A total of 1741 deliveries occurred during the baseline period and 1812 in the postintervention period. Only one mother died in each period. However, postpartum hemorrhage rates decreased, affecting 59 (3.5%) of 1669 patients before implementation and 40 (2.3%) of 1751 afterwards (P = 0.029). The number of patients who received oxytocin increased from 829 (47.6%) to 1669 (92.1%; P < 0.001). Additionally, the number of neonates with 5-minute Apgar scores of less than 5 reduced from 133 (7.7%) of 1717 to 95 (5.4%) of 1745 (P = 0.006).

Conclusion

The introduction of the AIP improved maternal outcomes. There were significant differences related to use of oxytocin and postpartum hemorrhage.