Kielland's forceps or ventouse—a comparison

Summary. A retrospective study over a 3-year period compared maternal and neonatal outcomes after birth by Kielland's forceps with those by ventouse when there was deep transverse arrest of head. Of the 259 women, 117 were delivered with Kielland's forceps and 142 were delivered with the ventouse. Of the Kielland's forceps deliveries, 15% were performed by a specialist, compared with 41% of the vacuum extractions. There were no differences in maternal morbidity overall, but when groups of operators were compared maternal complications were more frequent in the forceps group with the less experienced operators. There was little early neonatal morbidity (as judged by Apgar score, intubation, admission to the special care baby unit, jaundice and abnormal neurological behaviour) but cephalhaematoma occurred significantly more often in babies born by the ventouse than by Kielland's forceps. There were no perinatal deaths.     

Kielland's forceps or ventouse--a comparison

A retrospective study over a 3-year period compared maternal and neonatal outcomes after birth by Kielland's forceps with those by ventouse when there was deep transverse arrest of head. Of the 259 women, 117 were delivered with Kielland's forceps and 142 were delivered with the ventouse. Of the Kielland's forceps deliveries, 15% were performed by a specialist, compared with 41% of the vacuum extractions. There were no differences in maternal morbidity overall, but when groups of operators were compared maternal complications were more frequent in the forceps group with the less experienced operators. There was little early neonatal morbidity (as judged by Apgar score, intubation, admission to the special care baby unit, jaundice and abnormal neurological behaviour) but cephalhaematoma occurred significantly more often in babies born by the ventouse than by Kielland's forceps. There were no perinatal deaths.     

Decision to delivery intervals for assisted vaginal vertex delivery

Objective To describe the time interval between decision for assisted vaginal delivery and the birth of the baby in different clinical circumstances.
Design A prospective analysis of 225 consecutive women with a singleton fetal cephalic presentation in the second stage of labour requiring an operative vaginal delivery for various reasons.
Setting A maternity unit in a district general hospital delivering more than 6000 women annually.
Main outcome measures The decision to delivery interval and the immediate and short term maternal and neonatal outcomes according to indication for operative vaginal delivery.
Results The mean (SD) decision to delivery interval was 34.4 minutes (28.3) with a range of 5 to 101 minutes. For those delivered because of suspected fetal distress, the interval of 26.5 minutes (14.0) was significantly shorter than for those performed without fetal distress 39.5 minutes (19.0) (   P < 0.0001  ); for cases with fetal distress, forceps were significantly quicker at 23.3 minutes (14.3) than the ventouse 29.2 minutes (13.2) (   P = 0.04  ). The longer the interval in cases of fetal distress the less favourable the condition of the neonate at birth, although this trend did not reach statistical significance and was not seen for deliveries expedited for other reasons. Perineal repair was required following 96% forceps deliveries compared with 87% ventouse (   P = 0.015  ). Perineal trauma was not influenced by the interval between decision and delivery.
Conclusions If speed of delivery is important, use of forceps results in a quicker birth than use of the ventouse, without any compromise to the condition of the baby at delivery, and with similar rates of perineal trauma.     

Fetal and maternal effects of forceps and vacuum extraction

Summary. Between 1976 and 1984, 223 forceps deliveries were compared with the next vacuum extraction that occurred in the labour ward. The groups did not differ in gestational age, parity, presentation and station of fetal head at start of the delivery, infant birthweights, or the indication for the procedure. Of the forceps deliveries, 66% were performed by a specialist, compared with only 16% of the vacuum extractions. Maternal complications were equally common in both groups. Severe birth canal trauma occurred in 7% of each group. Low 1-min Apgar scores (<7) were found significantly (P<0.0l) more often in the vacuum extraction group (36 infants) than in the forceps group (17 infants).Cephalohaematomas and scalp lesions, neonatal jaundice and clavicular fracture were all significantly less common after forceps than after vacuum extraction. One infant in the vacuum group had a cranial fracture.     

Prevention of shoulder dystocia related birth injuries: Myths and facts

Traditionally, brachial plexus damage was attributed to excessive traction applied on the fetal head at delivery. Recently, it was proposed that most injuries occur spontaneously in utero. The author has studied the mechanism of neurological birth injuries based on 338 actual cases with special attention to (1) fetal macrosomia; (2) maternal diabetes; and (3) methods of delivery. There was a high coincidence between use of traction and brachial plexus injuries. Instrumental extractions increased the risk exponentially. Erb’s palsy following cesarean section was exceedingly rare. These facts imply that spontaneous neurological injury in utero is extremely rare phenomenon. Literary reports show that shoulder dystocia and its associated injuries increased in the United States several-fold since the introduction of active management of delivery in the 1970’s. Such a dramatic change in a stable population is unlikely to be caused by incidental spontaneous events unrelated to external factors. The cited investigations indicate that brachial plexus damage typically is traction related. The traditional technique which precludes traction is the optimal method for avoiding arrest of the shoulders and its associated neurological birth injuries. Effective prevention also requires meticulous prenatal care and elective abdominal delivery of macrosomic fetuses in carefully selected cases.     

Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery

Objective  To determine the risk factors for anal sphincter injuries during operative vaginal delivery.
Setting and design  A population-based observational study.
Population  All 21 254 women delivered with vacuum extraction and 7478 women delivered with forceps, derived from the previously validated Dutch National Obstetric Database from the years 1994 to 1995.
Methods  Anal sphincter injury was defined as any injury, partial or complete, of the anal sphincters. Risk factors were determined with multivariate logistic regression analysis.
Main outcome measures  Individual obstetric factors, e.g. fetal birthweights, duration of second stage, etc.
Results  Anal sphincter injury occurred in 3.0% of vacuum extractions and in 4.7% of forceps deliveries. Primiparity, occipitoposterior position and fetal birthweight were associated with an increased risk for anal sphincter injury in both types of operative vaginal delivery, whereas duration of second stage was associated with an increased risk only in vacuum extractions. Mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09–0.13) and forceps delivery (OR 0.08, 95% CI 0.07–0.11). The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries.
Conclusions  Primiparity and occipitoposterior presentation are strong risk factors for the occurrence of anal sphincter injury during operative vaginal delivery. The highly significant protective effect of mediolateral episiotomies in both types of operative vaginal delivery warrants the conclusions that this type of episiotomy should be used routinely during these interventions to protect the anal sphincters.     

Maternal and neonatal outcome after failed ventouse delivery: Comparison of forceps versus cesarean section

Objectives.?To compare the immediate maternal and neonatal morbidity in women delivered by forceps or cesarean section after failed ventouse delivery.

Methods.?Case notes of 400 consecutive successful ventouse deliveries compared with 342 failed ventouse deliveries, where delivery was subsequently achieved with either forceps (N = 247) or cesarean section (N = 95), which took place between October 1999 and May 2003, were reviewed.

Results.?Failed ventouse delivery was associated with an increased chance for fetal malposition (OR 3.7, 95% CI 2.6 – 5.3) and postpartum hemorrhage (OR 3.5, 95% CI 1.8 – 6.8). Compared to forceps after failed ventouse, cesarean section was associated with a higher prevalence of postpartum hemorrhage (OR 7.8, 95% CI 3.6 – 16.9) and fewer third degree perineal tears (p < 0.05). There were no significant differences between cesarean section and forceps delivery after failed ventouse for neonatal morbidity.

Conclusions.?Failure of ventouse delivery is 3 – 4 times more likely with a fetal malposition and is associated with an increased risk of postpartum hemorrhage. While cesarean section increases the postpartum hemorrhage rate, forceps delivery is associated with increased likelihood of third degree perineal tears. The neonatal morbidity was comparable regardless of whether forceps or cesarean was used after failed ventouse.     

Maternal and neonatal outcome after failed ventouse delivery: comparison of forceps versus cesarean section.

OBJECTIVES: To compare the immediate maternal and neonatal morbidity in women delivered by forceps or cesarean section after failed ventouse delivery. METHODS: Case notes of 400 consecutive successful ventouse deliveries compared with 342 failed ventouse deliveries, where delivery was subsequently achieved with either forceps (N = 247) or cesarean section (N = 95), which took place between October 1999 and May 2003, were reviewed. RESULTS: Failed ventouse delivery was associated with an increased chance for fetal malposition (OR 3.7, 95% CI 2.6 - 5.3) and postpartum hemorrhage (OR 3.5, 95% CI 1.8 - 6.8). Compared to forceps after failed ventouse, cesarean section was associated with a higher prevalence of postpartum hemorrhage (OR 7.8, 95% CI 3.6 - 16.9) and fewer third degree perineal tears (p < 0.05). There were no significant differences between cesarean section and forceps delivery after failed ventouse for neonatal morbidity. CONCLUSIONS: Failure of ventouse delivery is 3 - 4 times more likely with a fetal malposition and is associated with an increased risk of postpartum hemorrhage. While cesarean section increases the postpartum hemorrhage rate, forceps delivery is associated with increased likelihood of third degree perineal tears. The neonatal morbidity was comparable regardless of whether forceps or cesarean was used after failed ventouse.     

Seven years experience with vacuum extractor in obstetric practice in Kashmir

In Kashmir, India a ruptured uterus following cesarean section is a common cause of maternal and fetal wastage. To evaluate the place of ventouse in obstetrics practice, 1501 vacuum extractions were performed out of 9743 normal deliveries during 1968-1975. Prolonged 1st and 2nd stages of labor with fetal distress accounted for 57.1% of the indications for ventouse. There were no instances of maternal death and maternal complications. These were comparable both with incidence and severity with those that may occur with normal delivery. Fetal injuries varied from scalp abrasion to chignon formation. Vacuum extractions are useful in obstetric practice in developing countries like India where a need exists to avoid cesarean section. Ventouse which accelerates both 1st and 2nd stage of labor in selected cases appears to be more logical and practical than cesarean section and is less traumatic when performed by less trained physicians.     

Forceps or vacuum extraction? A comparison of effects on the newborn infant

Sixteen women delivered by forceps and 20 women delivered by vacuum extraction (VE) owing to secondary uterine inertia were compared with a control group of 11 women who gave birth spontaneously. The cord arterial pH was lower in the VE group than in the forceps and control groups. Base deficit in both arterial and venous cord blood was greater in the VE group than in the forceps group, probably owing to the longer application and extraction times in VE than in forceps delivery. The incidence of retinal hemorrhage did not differ between the forceps and VE groups. The incidence of cephalhematomata was greater among VE infants than in the forceps and control groups. All infants were examined on the 1st and 5th day by standardized neurological and behavioural examination. There were no significant differences in neurological status between the forceps and VE groups. Thus, in low extraction with no signs of fetal asphyxia, either method can be used with safety if the obstetrician is familiar with both methods of operative vaginal delivery.     

Kjelland's forceps in the new millennium. Maternal and neonatal outcomes of attempted rotational forceps delivery

Background:  The use of Kjelland's forceps is now uncommon, and published maternal and neonatal outcome data are from deliveries conducted more than a decade ago. The role of Kjelland's rotational delivery in the 'modern era' of high caesarean section rates is unclear.
Aims:  To compare the results of attempted Kjelland's forceps rotational delivery with other methods of instrumental delivery in a tertiary hospital.
Methods:  Retrospective review of all instrumental deliveries for singleton pregnancies 34 or more weeks gestation in a four-year birth cohort, with reference to adverse maternal and neonatal outcomes.
Results:  The outcomes of 1067 attempted instrumental deliveries were analysed. Kjelland's forceps were successful in 95% of attempts. Kjelland's forceps deliveries had a rate of adverse maternal outcomes indistinguishable from non-rotational ventouse, and lower than all other forms of instrumental delivery. Kjelland's forceps also had a lower rate of adverse neonatal outcomes than all other forms of instrumental delivery.
Conclusions:  Prudent use of Kjelland's forceps by experienced operators is associated with a very low rate of adverse maternal and neonatal outcomes. Training in this important obstetric skill should be reconsidered urgently, before it is lost forever.     

Review of singleton fetal and neonatal deaths associated with cranial trauma and cephalic delivery during a national intrapartum-related confidential enquiry

OBJECTIVE: To review delivery details of intrapartum-related fetal and neonatal deaths with singleton cephalic presentation and birthweight of 2500 g or more in which traumatic cranial or cervical spine injury or substantial difficulty at delivery of the head was a dominant feature. DESIGN: Review of freestyle summary reports and standard questionnaire responses submitted to the national secretariat for the Confidential Enquiry into Stillbirths and Death in Infancy (CESDI) during the 1994/1995 intrapartum-related mortality enquiry following regional multidisciplinary panel review. SETTING: United Kingdom. SAMPLE: Of the 873 cases of intrapartum-related deaths reported in the 1994-1995 national enquiry, 709 weighed more than 2499 g. REPORTS: from 181 (89 from 1994 and 92 from 1995) with a chance of meeting criteria for cranial or cervical trauma as significant contributors to death were examined in detail. Thirty-seven were judged to meet the criteria stated in the objectives (23 from 1994 and 14 from 1995) and form the basis for this review. METHODS: Electronic and hand search of CESDI records relating to intrapartum-related deaths. MAIN OUTCOME MEASURES: Intrapartum events and features of care. RESULTS: There was evidence of fetal compromise present before birth in 33 of the 37 (89%) study group cases reviewed. One delivery was performed vaginally without instrumentation, and in one there was no attempt at vaginal delivery before caesarean section (CS) in the second stage of labour. Twenty-four cases (65%) were delivered vaginally and 11 (30%) by CS after failure to deliver vaginally with instruments. A single instrument was used in six cases of vaginal delivery (four ventouse and two Kjelland's forceps). At least two separate attempts with different instruments were made in 24 cases. Overall, the ventouse was used in 27 cases and forceps in 29 cases. In six cases, three separate attempts were made with at least two different instruments, all of which included use of ventouse. The grade of operator was recorded in 27 cases. Of these, a consultant obstetrician was present at only one delivery and no consultant was recorded to have made the first attempt to deliver a baby. In six cases, shoulder dystocia was also reported. CONCLUSIONS: This study suggests a lower incidence of death from difficult cephalic delivery and cranial trauma than previously reported. The CESDI studies were believed to have achieved high levels of ascertainment for all intrapartum-related deaths from which the cases reported here were selected. Strictly applied entry criteria used in this study could have restricted the number of cases considered as could limited in vivo or postmortem investigations and lack of detailed autopsy. When cranial traumatic injury was observed, it was almost always associated with physical difficulty at delivery and the use of instruments. The use of ventouse as the primary or only instrument did not prevent this outcome. Some injuries occurred apparently without evidence of unreasonable force, but poorly judged persistence with attempts at vaginal delivery in the presence of failure to progress or signs of fetal compromise were the main contributory factor regardless of which instruments were used.     

The pliable obstetrical vacuum cup: application and opinions in The Netherlands.

A questionnaire was sent to all hospital obstetric units in The Netherlands to obtain information about the use of soft cups for vacuum extraction. Over 90% of the 156 units responded. Vacuum extraction was used twice as often as forceps for instrumental vaginal delivery. In 12 units the flexible cup was applied in the majority of vacuum extractions and without specific restrictions. In 47 units a minority of vacuum extractions was performed with a flexible cup: its use was generally restricted to anticipated easy low outlet extractions. It is concluded that in The Netherlands the flexible cup is an accepted instrument used in about 13% of vacuum extraction deliveries.     

Characteristics and outcome of deliveries by forceps after failed ventouse.

With the increasing use of the ventouse, it is becoming common for deliveries to be completed by the application of forceps. We present 48 cases delivered by forceps after a failed ventouse and compare these with 63 cases delivered by forceps only. There was significantly higher incidence of caesarean sections and cephalhaematoma in the group where forceps delivery was attempted after a failed ventouse compared to those delivered with forceps only.     

Is it Time to Rejuvenate the Forceps?

The obstetric forceps was designed to assist extraction of the foetal head and thereby accomplish delivery of the foetus in the second stage of labour. More than 700 types of obstetric forceps have been described. An understanding of the anatomy of the birth canal and the foetal head is a prerequisite to becoming a skilled and safe user of forceps. Operative vaginal delivery rates have remained stable at between 10 and 13 %. The last few decades has seen a rise in caesarean section, along with the introduction and safe use of the vacuum extractor. This has resulted in a decline both in the use of the obstetric forceps as well as in the training for the same. The forceps is less likely to fail when used as the primary instrument thereby reducing the need for the sequential use of two instruments which increase the morbidity of the neonate. Perineal trauma is more likely to occur with the use of the forceps but the evidence is that the maternal concern is less when compared to the ventouse. Simulation training is an important part of obstetric training. Application of forceps blades in the simulation setting can improve the skill level of obstetricians. The use of the forceps should not be decreasing and more senior involvement in training is necessary so that juniors develop the proper skills to perform forceps delivery in a competent and safe manner. It is vital that the art of the forceps is not lost to future generations of obstetricians and the women they care for.     

General Practitioner Obstetric Practice in Rural and Remote Western Australia

Summary: The objective of this study was to examine the practice of obstetrics by general practitioners in rural and remote areas of Western Australia (WA). A questionnaire was mailed to all rural and remote GPs in June, 1994. The response rate was 67%. Questionnaires asked GPs to self-report how many deliveries they had performed in the previous year and how many of those deliveries were by Caesarean section or assisted by forceps or ventouse. Comparisons were made with perinatal statistics for the entire State of WA. GPs reported an average of 28 deliveries per year. The Caesarean section rate of 8% was lower than the rate of 21% for all WA in 1993. Ventouse was used more often than forceps to assist the delivery of a baby. Intervention rates for ventouse, forceps and Caesarean section were lower in rural and remote areas of WA than the State as a whole; there was also less use of epidural analgesia. More than half of these GPs currently practising obstetrics hold the Dip RACOG or DRCOG. Medical indemnity is an increasing issue for many GPs. For 6 of the 7 country health regions, close to 80% of women deliver within the health region in which they reside.     

Traumatic injury in large-for-date infants

The risk of traumatic injury and low Apgar score was studied in 473 infants with a birth weight of 4500 g or more at term (LFD) and 473 infants with normal weight (NFD, birth weight +/- 1 SD of mean for the respective gestational age). The LFD group comprised 3.2% of all infants delivered during a 5-year period. Traumatic injuries were observed in 8.0% of the LFD versus 0.6% of the NFD group. The injuries in the LFD group were 28 fractured clavicles, four fractured humerus and 12 brachial plexus injuries. Six of the LFD infants had multiple injuries. The injuries in the NFD group were three fractured clavicles. All infants with traumatic injuries were delivered vaginally. Contributory obstetrical factors for traumatic injury were forceps, post-term pregnancy and vacuum extraction. High birth weight was correlated to a low Apgar score at one minute, as also was post-term pregnancy.     

Obstetrical vacuum: a modern instrument]

Contrary to the forceps, the vacuum extractor has clearly progressed in the last years. The use of the vacuum extractor increases in every developed countries, certainly because of an easier learning than forceps. Furthermore, maternal after-effects of the delivery like sphincters injuries and anal incontinence seem to be less frequent with vacuum extractor than with forceps. For these reasons the American College of Gynecologists and Obstetricians (ACOG) recommend a large use and a priority teaching of this fetal extraction instrument. The technical aspects of use of the vacuum extractor are developed in this article, and personnel results are added as commentaries.     

Failed individual and sequential instrumental vaginal delivery: contributing risk factors and maternal-neonatal complications

BACKGROUND: To identify the risk factors for failed instrumental vaginal delivery, and to compare maternal and neonatal morbidity associated with failed individual and sequential instruments used. DESIGN: A retrospective case-control study. METHODS: From January 1995 to June 2001, there were 39 508 live births at >37 weeks' gestation of which 2628 (6.7%) instrumental vaginal deliveries were performed, 1723 (4.4%) were vacuum extractions and 905 (2.3%) were forceps. A total of 155/2628 (5.9%) patients who had failed instrumental delivery were matched with 204 patients who had successful instrumental delivery. The patients were divided into five groups. Group I (n = 129) had failed vacuum extraction, group II (n = 13) failed forceps, group III (n = 13) failed both (i.e. failed attempt at both instruments sequentially), group IV (n = 138) had successful vacuum extraction and group V (n = 66) successful forceps. RESULTS: The failure rate for vacuum extractions 129/1723 (7.5%) was significantly higher than that for forceps 13/905 (1.4%) [odds ratio (OR) = 5.6, 95% CI 3-10.3]. There were no significant differences in all maternal complications (25.5% vs. 26.6%) between vacuum (groups I and IV) and forceps (groups II and V) assisted deliveries. There were more maternal complications in group III (46.2%) than in groups I (35.7%), II (23.1%) and V (27.3%) that did not reach statistical significance but were significantly higher than in group IV (15.9%, OR = 4.5, 95% CI 1.2-16.9). There was a significantly higher rate of all fetal complications in group III [11/13 (84.6%)] than in groups I [69/129 (53.5%)], II [7/13 (53.8%)], IV [35/138 (25.4%)] and V [22/66 (33.3%)] (OR = 4.8, 95% CI 0.9-19.9). CONCLUSIONS: Applying the instrument at < or =0 fetal station, nulliparous women, history of previous cesarean section and fetal head other than occipitoanterior position were risk factors for failed instrumental delivery. Sequential use of instrumental delivery carries a significantly higher neonatal morbidity than when a single instrument is used.     

Vacuum extraction failure is associated with a large head circumference

Objective: To determine whether large head circumference increases the risk of vacuum extraction failure.

Study design: This EMR-based study included all attempted vacuum extractions performed in a tertiary center between January 2010 and June 2015. All term singleton live births were eligible. Cases were divided into four groups: head circumference ≥90th percentile both with birth weight ≥90th percentile and <90th percentile and fetal head circumference <90th percentile with birth weight ≥90th and <90th percentile. Risk of failed vacuum extraction was compared among these groups. Other neonatal and maternal parameters were also evaluated as potential risk factors. Multinomial multivariable regression provided adjusted odds ratio for vacuum extraction failure while controlling for potential confounders.

Results: During the study period, 48,007 deliveries met inclusion criteria, of which 3835 had an attempt at vacuum extraction. We identified 215 (5.6%) cases of vacuum extraction failure. The adjusted odds ratios (aOR) for vacuum extraction failure in cases of large fetal head circumference was 2.31 (95%CI, 1.7–3.15, p?Comments: In this study, we found that large head circumference was associated with vacuum extraction failure rather than high birth weight.