Vacuum assisted delivery in Ecuador for prolonged second stage of labor: Maternal–neonatal outcome

Background. In South America, and particularly Ecuador, cesarean section rates have risen markedly over the past five years. The associated increases in maternal morbidity and healthcare costs indicate the need for alternative strategies. Operative vaginal delivery is minimally utilized in Ecuador, as neither vacuum nor forceps have been available.

Objective. As vacuum delivery was recently introduced to our clinical service, we sought to examine our initial experiences (i.e., maternal and neonatal outcome) with operative vaginal delivery for prolonged second stage of labor.

Methods. Following an initial educational program at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador, vacuum extraction cups (Mityvac®, Cooper Surgical) were offered to laboring women with term singleton gestations and cephalic presentations no higher than +3 station. Maternal and neonatal data were analyzed.

Results. During the study period, 100 vacuum applications were performed on laboring women complicated with prolonged second stage of labor. Mean maternal age was 23.8 ± 6.4 years (range14–41 years) with 57% of patients nulliparous. Left anterior and right posterior fetal positions were the most frequent (85% and 11%, respectively). Maternal complications included need for blood transfusion (1%), shoulder dystocia (1%) and perineal tears (first degree 6%, second degree 5%). Vaginal delivery was successful in 97% of cases. Among neonates, the average weight was 3149 ± 410 g, with 10% neonates small for gestational age and 5% large for gestational age. Only 1% of infants presented an Apgar score <7 at 5 min. There were no scalp lacerations, cephalohematomas, or subgaleal bleeds.

Conclusions. In this initial observational study, vacuum extraction for prolonged second stage was safe and effective. We propose that the introduction of operative vaginal delivery to developing countries will mitigate rising cesarean section rates.     

Should we allow a trial of labor after a previous cesarean for dystocia in the second stage of labor?

OBJECTIVE: To estimate the rate of successful vaginal birth including operative vaginal delivery in patients with a previous cesarean for cephalopelvic disproportion in the second stage of labor. METHODS: Data from all patients who underwent trial of labor after a previous cesarean between 1990 and 2000 at our tertiary care institution were analyzed. Medical records were reviewed and data collected for the following variables: indication for the previous cesarean, birth weight and cervical dilatation at previous cesarean delivery, as well as the mode of delivery (spontaneous, vacuum, forceps, cesarean) and the birth weight for the subsequent pregnancy. Pearson's chi(2) test and one-way analysis of variance were used for statistical analyses. RESULTS: There were 2002 patients included in the study. Two hundred fourteen (11%) had their previous cesarean for dystocia in the second stage of labor, 654 (33%) for dystocia in the first stage of labor, and 1134 (57%) for other indications. The vaginal birth after cesarean success rate was 75.2% (P = .015 vs other indications), 65.6% (P < .001 vs other indications), and 82.5%, respectively. The rate of operative vaginal delivery was 15%, 12%, and 10% (P = .109). CONCLUSION: A trial of labor is reasonable in women whose previous cesarean was for dystocia in the second stage of labor. In this series, patients who underwent a trial of labor after a previous cesarean for dystocia in the second stage had 75.2% (95% confidence interval 69.5, 81.0) chance of achieving vaginal delivery.     

Parity and route of delivery: does cesarean delivery reduce bladder symptoms later in life?

OBJECTIVE: This study was undertaken to investigate the impact of reproductive factors on the prevalence of urinary symptoms. STUDY DESIGN: Participants were women scheduled for hysterectomy (n=1299). Before surgery, urinary symptoms were assessed by questionnaire. Multiple logistic regression analysis was used to investigate the association between bladder symptoms and parity, route of delivery, and other characteristics. RESULTS: Stress incontinence and urinary urgency were more prevalent among parous than nulliparous women (P <.01). Controlling for parity and other characteristics, women who had a history of cesarean delivery were significantly less likely to report stress incontinence than women with a history of vaginal delivery (odds ratio 0.60; 95% CI 0.39-0.93). CONCLUSION: Women who have undergone vaginal delivery are more likely to report stress incontinence than women who have delivered by cesarean section. Although this suggests that cesarean delivery might reduce incontinence later in life, further research is needed to clarify the long-term risks, benefits, and costs of cesarean delivery.     

How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes?

OBJECTIVE: The purpose of this study was to examine maternal and neonatal outcomes in relation to lengthening intervals of the second stage of labor. STUDY DESIGN: This is a retrospective cohort study of 15,759 nulliparous, term, cephalic, singleton births at the University of California, San Francisco, between 1976 and 2001. The second stage of labor was divided into 1-hour intervals. Maternal and neonatal outcomes were compared with the use of chi-squared and Student t tests, and a probability value of < or =.05 was used to indicate statistical significance. Potential confounders were controlled for with multivariate logistic regression. RESULTS: Increasing rates of cesarean delivery, operative vaginal delivery, and perineal trauma were associated with the second stage beyond the first hour. In multivariate analysis, the >4-hour interval group had higher rates of cesarean delivery (odds ratio, 5.65; P < .001), operative vaginal deliveries (odds ratio, 2.83; P < .001), 3rd- or 4th-degree perineal lacerations (odds ratio, 1.33; P = .009), and chorioamnionitis (odds ratio, 1.79; P < .001). There were no differences in neonatal acid-base status associated with length of second stage. However, there were fewer neonates with a 5-minute Apgar score of <7 (odds ratio, 0.45; P = .01). CONCLUSION: Although the length of the second stage of labor is not associated with poor neonatal outcome, a prolonged second stage is associated with increased maternal morbidity and operative delivery rates.     

Epidural anaesthesia for labour: does it influence the mode of delivery?

Background Epidural anaesthesia (EDA) is an effective method to lower labour pain. EDA might have an impact on instrumental delivery rates and on caesarean section rates. The present study compares the mode of delivery in women who were either receiving EDA or not. The indication for EDA was pain relief only in order to switch off a selection bias. Methods During a 1-year duration, we included a total of 1,452 cases. Exclusion criteria were factors that could influence the mode of delivery, independent from EDA, as well as obstetrical indications for administering EDA. 530 women remained in the analysis. The primary outcome variable was the mode of delivery. Results We detected in both nullipara and multipara a statistically significant accumulatin in patients with EDA and caesarean section combined. Most importantly, the majority of the women without EDA (57% of nullipara and 60% of multipara) delivered within the median timeframe from admission until administration of EDA. Conclusions It seems to be obvious to conclude that EDA as performed in our study results in a higher rate of caesarean sections. It is important though to take into consideration that between the period from admission to the delivery ward and administration of EDA most of the parturients without EDA had already delivered. Our results make evident, that the administration of EDA exclusively used for reducing labour pain is a result of a complex collaboration of temporal conditions of labour as well as psychological conditions and also of the mother’s wish.     

Choosing between bad,worse and worst: what is the preferred mode of delivery for failure of the second stage of labor?*

Objective: To determine the preferred mode of delivery (vacuum, forceps or cesarean delivery) for second-stage dystocia.

Methods: Retrospective cohort study of women delivered by forceps, vacuum or cesarean delivery due to abnormalities of the second stage of labor. Primary outcome included neonatal and maternal composite adverse effects.

Results: A total of 547 women were included: 150 (27.4%) had forceps delivery, 200 (36.5%) had vacuum extraction, and 197 (36.1%) had cesarean section. The rate of neonatal composite outcome was significantly increased in vacuum extraction (27%) compared to forceps delivery (14.7%) or cesarean section (9.7%) (p?p?=?0.004).

Conclusion: Operative vaginal delivery was associated with reduced postpartum infection compared to cesarean section. Forceps delivery was associated with reduced risk for adverse neonatal outcome compared to vacuum extraction, with no increase in the risk of composite maternal complications.     

Ultrasound assessment of bladder volume: is it valid after delivery?

AIM: To assess the validity of a commercially available bladder volume scanner in the puerperium. METHODS: A prospective blinded comparison of bladder volume measurement after vaginal delivery using the BladderScan bladder volume instrument (BVI) 3000 and Foley catheter; comparison using the intraclass correlation coefficient. RESULTS: The mean difference between the two measurements was a 130-mL over-measurement by the bladder scanner (range: -156 mL to +422 mL). The intraclass correlation coefficient was 0.23 (95% confidence interval 0.00, 0.59). CONCLUSIONS: The BladderScan BVI 3000 is not an accurate instrument to assess bladder volume the day after vaginal delivery. Some of the discrepancy might relate to use of the Foley catheter as the reference standard. Further comparison between the BladderScan and a short female catheter or real time ultrasound is indicated.     

“Can the intrapartum ultrasonography reduce the legal liability in distocic labor and delivery?”

The authors emphasize the importance of performing an intrapartum ultrasonography in order to prevent maternal and neonatal complications but also physician legal liability. The main advantages of using this technique are: improvement of fetal head’s malposition diagnosis; prevention of maternal and fetal complications of childbirth due to the use of forceps or vacuum extractor (VE); a more accurate planning of cesarean section; a proof of professional correctness.     

Sonographic assessment of fetal occiput position during the second stage of labor: how reliable is the transperineal approach?

Objective: To compare the accuracy of transperineal (TP) ultrasound with transabdominal (TA) approach in the sonographic assessment of fetal occiput position during the second stage of labour.

Methods: A series of low-risk women at term attending the labour ward of three university hospitals were prospectively recruited for the purpose of this study. During the second stage of labor patients were evaluated first by TP and than by TA ultrasound to determine the fetal position. The occiput position was labelled as DOA (direct occiput anterior), ROA (right occiput anterior), LOA (left occiput anterior), DOP (direct occiput posterior), ROP (right occiput posterior), LOP (left occiput posterior), ROT (right occuput transverse) and LOT (left occiput transverse). The agreement between the two techniques was assessed.

Results: Overall 80 patients were recruited in the study group. Ultrasound examination was performed at 21(±8) minutes from the beginning of the active pushing. The ultrasound findings of the fetal occiput position were recorded. In all cases TA ultrasound confirmed the fetal occiput position as determined at TP approach except in one case of ROA that had been recorded as ROT using TP ultrasound.

Conclusions: Ultrasound TP examination is accurate in the diagnosis of fetal occiput position during the second stage of labor.     

Sequential use of instruments at operative vaginal delivery: Is it safe?

Objective: Our purpose was to examine maternal and neonatal outcomes in a cohort of women who underwent delivery with the sequential use of instruments. Study Design: This retrospective case-control study included deliveries from May 1996 through March 1998. Charts of women who underwent delivery with the sequential use of instruments (vacuum first, then forceps, or vice versa) were identified. Two control groups (1 forceps group, 1 vacuum group) were randomly selected and matched for each case. Maternal and neonatal outcomes were abstracted and compared. Results: There were 34 patients in each group. There were no significant demographic differences. The vacuum group had lower rates of episiotomy (P = .01) and deep perineal lacerations (P = .014), whereas these outcomes were similar in the sequential and forceps groups. All other maternal outcomes were equivalent. There were no differences in any neonatal parameter except for superficial scalp trauma, which was more common in the vacuum group (P = .002). Conclusion: We conclude that the prudent use of sequential instruments at operative vaginal delivery did not engender higher rates of maternal or neonatal morbidity. (Am J Obstet Gynecol 1999;180:1446-9.)     

Effects of pushing techniques during the second stage of labor: A randomized controlled trial

Objective

Spontaneous pushing is a method that is used in the management of the second stage of labor and suggested to be more physiological for the mother and infant. The present study aims to evaluate the effects of pushing techniques on the mother and newborn.

Does gender of the fetus have any relation with fetal heart monitoring during the first and second stage of labor?

Objective: To investigate fetal gender and its influences on neonatal outcomes, taking into consideration the available tools for the assessment of fetal well-being.

Methods: We conducted a retrospective study comparing maternal, fetal and neonatal outcomes according to fetal gender, in women carrying a singleton gestation.

A multivariate analysis was performed for the prediction of adverse neonatal outcomes according to fetal gender, after adjustment for gestational age, maternal age and fetal weight.

Results: A total of 682 pregnancies were included in the study, of them 56% (n?=?383) were carrying a male fetus and 44% (n?=?299) a females fetus. Male gender was associated with a significant higher rate of abnormal fetal heart tracing patterns during the first (67.7% versus 55.1, p?=?0.001) and the second stage (77.6 versus 67.7, p?=?0.01) of labor. Male gender was also significantly associated with lower Apgar scores at 1' (19.1% versus 10.7%, p?p?2, PO₂) compared with female fetuses. In the multivariate analysis, male gender was found to be significantly associated with first (OR 1.76, 95% CI 1.28–2.43, p?=?0.001) and second stage (OR 1.73, 95% CI 1.20–2.50, p?Conclusions: The present study confirms the general trend of a lower clinical performance of male neonates compared with females. In addition, the relation between fetal heart rate patterns during all stages of labor and fetal gender showed an independent association between male fetal gender and abnormal fetal heart monitoring during labor.