Babies in occiput posterior position are significantly more likely to require an emergency cesarean birth compared with babies in occiput transverse position in the second stage of labor: A prospective observational study

Correlative analysis of different treatments of persistent occipitotransverse position on the outcome for mother and infant

OBJECTIVE

To explore the clinical feasibility of different treatment methods for persistent occipitotransverse position and the influence on maternal and infant complications.

METHOD

During the trial of vaginal delivery from April 2020 to March 2023 in our hospital, the cervix was fully dilated and the presentation was located at +2 station. Ninety-six pregnant women with fetal presentation at +4 station, occipitotransverse fetal position, maternal complications, abnormalities in the second stage of labor, and or fetal distress were divided into two groups: 65 patients with Kielland forceps vaginal delivery and 31 patients underwent emergency cesarean section. The delivery time, vaginal laceration rate, postpartum blood loss volume, puerperal infection rate, neonatal birth injury rate, and neonatal 1 min Apgar scores were analyzed.

RESULTS

The delivery outcomes and maternal and neonatal complications of 96 pregnant women were analyzed: the application of Kielland forceps delivery time was shorter, while the vaginal laceration rate, postpartum hemorrhage, puerperal infection rate were significantly lower than that of patients undergoing emergency cesarean section and the neonatal 1 min Apgar score was higher than that of emergency cesarean section group (p < 0.05).

CONCLUSION

It was clinically appropriate to use Kielland forceps in vaginal delivery when the persistent occipitotransverse position was present and delivery needed to be expediated. Use of Kielland forceps can shorten the delivery time, improve the success rate of vaginal delivery and reduce the complications of mothers and infants.

A new course on assisted rotational birth and complex caesarean section - Mixed methods evaluation of Art & Craft

OBJECTIVES

To assess the utility of Art & Craft - a new, hands-on course on Advanced Rotational Techniques and safe Caesarean biRth at Advanced/Full dilation Training aimed at senior Obstetrics trainees. The aims were to assess whether it improved confidence and skills in rotational vaginal birth, impacted fetal head at caesarean, and ultrasound for fetal position.

STUDY DESIGN

With ethical approval, pre- and post- course questionnaires and post- course interviews of attendees were conducted. A pre course questionnaire was emailed 1 week before the course. Attendees were asked to rate their confidence levels in performing vaginal examination and ultrasound assessment of fetal position, rotational ventouse, manual rotation, Kielland's rotational forceps, and disimpaction of the fetal head during second stage caesarean on a scale of 1 to 5. 1 = not confident at all and 5 = very confident. A post-course questionnaire with the same questions was emailed 3 days after. p values for differences in scores were calculated using the Wilcoxon signed rank test using Stata/MP 18 software.

RESULTS

32 trainees attended the course. 28 questionnaires were available for analysis. The majority 39 % were middle grade (ST3-ST5) level. Initial confidence was very low for rotational forceps (median 1/5). After attending the course and practical stations, respondents' confidence levels increased significantly (p < 0.05) across all domains; vaginal examination from 4 to 5, ultrasound for fetal position, rotational ventouse, and manual rotation from 3 to 5, disimpaction from 4 to 4.5, and Kielland's rotational forceps from 1 to 4. Nine participated in post course interviews, which were thematically analysed. Participants expressed that the course gave them the opportunity to ask specific questions from experts to improve their confidence. A barrier to learning new methods was highlighted in that it is difficult to receive practical training in Kielland's, resulting in low confidence.

CONCLUSION

A practical, hands-on course on complex operative birth significantly increases trainee confidence levels in vaginal examination, ultrasound for fetal position, disimpaction, and techniques for rotational vaginal birth. The evaluation highlights that continued education and practise is required, even when trainees are senior. Evaluation of clinical outcomes after training is needed; and planned.

Precision of vacuum cup placement and its association with subgaleal hemorrhage and associated morbidity in term neonates

PURPOSE

To evaluate whether the precision of vacuum cup placement is associated with failed vacuum extraction(VE), neonatal subgaleal hemorrhage(SGH) and other VE-related birth trauma.

METHODS

All women with singleton term cephalic fetuses with attempted VE were recruited over a period of 30 months. Neonates were examined immediately after birth and the position of the chignon documented to decide whether the cup position was flexing median or suboptimal. Vigilant neonatal surveillance was performed to look for VE-related trauma, including subgaleal/subdural hemorrhages, skull fractures, scalp lacerations. CT scans of the brain were ordered liberally as clinically indicated.

RESULTS

The VE rate was 5.89% in the study period. There were 17(4.9%) failures among 345 attempted VEs. Thirty babies suffered from subgaleal/subdural hemorrhages, skull fractures, scalp lacerations or a combination of these, giving an incidence of VE-related birth trauma of 8.7%. Suboptimal cup positions occurred in 31.6%. Logistic regression analysis showed that failed VE was associated with a non-occipital anterior fetal head position (OR 3.5, 95% CI 1.22-10.2), suboptimal vacuum cup placement (OR 4.13, 95% CI 1.38-12.2) and a longer duration of traction (OR 8.79, 95% CI 2.13-36.2); while, VE-related birth trauma was associated with failed VE (OR 3.93, 95% CI 1.08-14.3) and more pulls (OR 4.07, 95% CI 1.98-8.36).

CONCLUSION

Suboptimal vacuum cup positions were related to failed VE but not to SGH and other vacuum-related birth trauma. While optimal flexed median cup positions should be most desirable mechanically to effect delivery, such a position does not guarantee prevention of SGH.

Assisted vaginal birth in 21st century: current practice and new innovations

Assisted vaginal birth rates are falling globally with rising cesarean delivery rates. Cesarean delivery is not without consequence, particularly when carried out in the second stage of labor. Cesarean delivery in the second stage is not entirely protective against pelvic floor morbidity and can lead to serious complications in a subsequent pregnancy. It should be acknowledged that the likelihood of morbidity for mother and baby associated with cesarean delivery increases with advancing labor and is greater than spontaneous vaginal birth, irrespective of the method of operative birth in the second stage of labor. In this article, we argue that assisted vaginal birth is a skilled and safe option that should always be considered and be available as an option for women who need assistance in the second stage of labor. Selecting the most appropriate mode of birth at full dilatation requires accurate clinical assessment, supported decision-making, and personalized care with consideration for the woman's preferences. Achieving vaginal birth with the primary instrument is more likely with forceps than with vacuum extraction (risk ratio, 0.58; 95% confidence interval, 0.39-0.88). Midcavity forceps are associated with a greater incidence of obstetric anal sphincter injury (odds ratio, 1.83; 95% confidence interval, 1.32-2.55) but no difference in neonatal Apgar score or umbilical artery pH. The risk for adverse outcomes is minimized when the procedure is conducted by a skilled accoucheur who selects the most appropriate instrument likely to achieve vaginal birth with the primary instrument. Anticipation of potential complications and dynamic decision-making are just as important as the technique for safe instrument use. Good communication with the woman and the birthing partner is vital and there are various recommendations on how to achieve this. There have been recent developments (such as OdonAssist) in device innovation, training, and strategies for implementation at a scale that can provide opportunities for both improved outcomes and reinvigoration of an essential skill that can save mothers' and babies' lives across the world.

Prediction model for labour dystocia occurring in the active phase

To establish and verify a model for labour dystocia occurring in the active phase, this study retrospectively analysed the clinical data of primiparas with singleton cephalic full-term foetuses, who had delivered after a trial of labour. The Chi-square test, t-test, Mann-Whitney U test and multivariate logistic regression analysis were used for statistical analysis. Based on the model a nomogram was established using the R programming language. Multivariate logistic regression analysis showed that the foetal abdominal circumference, premature rupture of membranes (PROM), prolonged latent phase, foetal station and foetal position at the early stage of the active phase were independent factors influencing labour dystocia occurring in the active phase. The established model could effectively and accurately support clinicians in the early identification of labour dystocia to improve maternal and infant outcomes.Impact statementWhat is already known on this subject? Labour dystocia occurring during the active phase of the first stage, is the most commonly diagnosed as labour aberration. Previous studies have suggested that maternal age, body mass index, macrosomia and abnormal foetal position are the independent risk factors for labour dystocia. However, only the risk factors were reported, and few prediction models were established.What do the results of this study add? This study uses data in the real world to establish a prediction model of full-term singleton primipara with labour dystocia occurring in the active phase by logistic regression analysis. Foetal abdomen circumference, PROM, prolonged latent phase, the foetal station and foetal position at the early stage of the active phase are independent factors influencing labour dystocia that occurs in the active phase. In addition, a nomogram is established as a visual graph to predict the probability of it.What are the implications of these findings for clinical practice and/or further research? The nomogram based on the predictive model discarded complicated calculations and presented an easy visual graph-based method to predict the probability of labour dystocia occurring in the active phase. It helps to introduce interventions that could reduce the CS rate and occurrence of adverse maternal and foetal outcomes to ensure the safety of mothers and infants.

Crude and adjusted comparisons of cesarean delivery rates using the Robson classification: A population-based cohort study in Canada and Sweden, 2004 to 2016

BACKGROUND

The Robson classification has become a global standard for comparing and monitoring cesarean delivery (CD) rates across populations and over time; however, this classification does not account for differences in important maternal, fetal, and obstetric practice factors known to impact CD rates. The objectives of our study were to identify subgroups of women contributing to differences in the CD rate in Sweden and British Columbia (BC), Canada using the Robson classification and to estimate the contribution of maternal, fetal/infant, and obstetric practice factors to differences in CD rates between countries and over time.

METHODS AND FINDINGS

We conducted a population-based cohort study of deliveries in Sweden (January 1, 2004 to December 31, 2016; n = 1,392,779) and BC (March 1, 2004 to April 31, 2017; n = 559,205). Deliveries were stratified into Robson categories and the CD rate, relative size of each group and its contribution to the overall CD rate were compared between the Swedish and the Canadian cohorts. Poisson and log-binomial regression were used to assess the contribution of maternal, fetal, and obstetric practice factors to spatiotemporal differences in Robson group-specific CD rates between Sweden and BC. Nulliparous women comprised 44.8% of the study population, while women of advanced maternal age (≥35 years) and women with overweight/obesity (≥25 kg/m2) constituted 23.5% and 32.4% of the study population, respectively. The CD rate in Sweden was stable at approximately 17.0% from 2004 to 2016 (p for trend = 0.10), while the CD rate increased in BC from 29.4% to 33.9% (p for trend < 0.001). Differences in CD rates between Sweden and BC varied by Robson group, for example, in Group 1 (nullipara with a term, single, cephalic fetus with spontaneous labor), the CD rate was 8.1% in Sweden and 20.4% in BC (rate ratio [RR] for BC versus Sweden = 2.52, 95% confidence interval [CI] 2.49 to 2.56, p < 0.001) and in Group 2 (nullipara, single, cephalic fetus, term gestation with induction of labor or prelabor CD), the rate of CD was 37.3% in Sweden and 45.9% in BC (RR = 1.23, 95% CI 1.22 to 1.25, p < 0.001). The effect of adjustment for maternal characteristics (e.g., age, body mass index), maternal comorbidity (e.g., preeclampsia), fetal characteristics (e.g., head position), and obstetric practice factors (e.g., epidural) ranged from no effect (e.g., among breech deliveries; Groups 6 and 7) to explaining up to 5.2% of the absolute difference in the CD rate (Group 2: adjusted CD rate in BC 40.7%, adjusted RR = 1.09, 95% CI 1.08 to 1.12, p < 0.001). Adjustment also explained a substantial fraction of the temporal change in CD rates among some Robson groups in BC. Limitations of the study include a lack of information on intrapartum details, such as labor duration as well as maternal and perinatal outcomes associated with the observed differences in CD rates.

CONCLUSIONS

In this study, we found that several factors not included in the Robson classification explain a significant proportion of the spatiotemporal difference in CD rates in some Robson groups. These findings suggest that incorporating these factors into explanatory models using the Robson classification may be useful for ensuring that public health initiatives regarding CD rates are evidence informed.

Manual rotation of occiput posterior or transverse positions: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The primary objective of this systematic review was to assess the association between spontaneous vaginal delivery and manual rotation during labor for occiput posterior or transverse positions. Our secondary objective was to assess maternal and neonatal outcomes.

DATA SOURCES

An electronic search of PubMed, EMBASE, ClinicalTrials.gov, and the Cochrane Register of Controlled Trials covered the period from January 2000 to September 2021, without language restrictions.

STUDY ELIGIBILITY CRITERIA

The eligibility criteria included all randomized trials with singleton pregnancies at ≥37 weeks of gestation comparing the manual rotation groups with the control groups. The primary outcome was the rate of spontaneous vaginal delivery. Additional secondary outcomes were rate of occiput posterior position at delivery, operative vaginal delivery, cesarean delivery, postpartum hemorrhage, obstetrical anal sphincter injury, prolonged second stage of labor, shoulder dystocia, neonatal acidosis, and phototherapy. Subgroup analyses were performed according to types of position (occiput posterior or occiput transverse), techniques used (whole-hand or digital rotation), and parity (nulliparous or parous).

METHODS

The quality of each study was evaluated with the revised Cochrane risk-of-bias tool for randomized trials, known as RoB 2. The meta-analysis used random-effects models depending on their heterogeneity, and risks ratios were calculated for dichotomous outcomes.

RESULTS

Here, 7 of 384 studies met the inclusion criteria and were selected. They included 1402 women: 704 in the manual rotation groups and 698 in the control groups. Manual rotation was associated with a higher rate of spontaneous vaginal delivery: 64.9% vs 59.5% (risk ratio, 1.09; 95% confidence interval, 1.03-1.16; P=.005; 95% prediction interval, 0.90-1.32). This association was no longer significant after stratification by parity or technique used. Manual rotation was associated with spontaneous vaginal delivery only for the occiput posterior position (risk ratio, 1.08; 95% confidence interval, 1.01-1.15). Furthermore, it was associated with a reduction in occiput posterior or transverse positions at delivery (risk ratio, 0.64; 95% confidence interval, 0.48-0.87) and episiotomies (risk ratio, 0.84; 95% confidence interval, 0.71-0.98). The groups did not differ significantly for cesarean deliveries, operative vaginal deliveries, or neonatal outcomes.

CONCLUSION

Manual rotation increased the rate of spontaneous vaginal delivery.

Single-centre survey of women reflecting on recent experiences and preferences of oral intake during labour

BACKGROUND

Consensus-based recommendations guiding oral intake during labour are lacking.

AIMS

We surveyed women at a tertiary women's hospital about preferences for and experiences of oral intake during labour, gastrointestinal symptoms during labour and recalled advice about oral intake.

MATERIALS AND METHODS

Women who experienced labour completed a postpartum survey with responses as free text, yes-no questions and five-point Likert scales. We identified demographic data and risk factors for surgical or anaesthetic intervention at delivery from medical records. We summarised free text comments using conventional content analysis.

RESULTS

One hundred and forty-nine women completed the survey (47% response rate). Their mean (SD) age was 31 (four) years, birthing at median gestation of 39 weeks (interquartile range: 38-40). One hundred and twenty-two (83%) and 44 (30%) women strongly agreed or agreed they felt like drinking and eating respectively during labour. Ninety women (61%) reported nausea and 47 women (32%) reported vomiting in labour. Forty-one women (28%) did not receive advice on oral intake during labour. Maternal risk factors for surgical intervention were identified in 72 (48%) women and fetal risk factors in 27 (18%) women. Thirty-one women (21%) delivered by emergency caesarean section.

CONCLUSION

Pregnant women received variable advice regarding oral intake during labour, from variable sources. Most women felt like drinking but not eating during labour. Guidelines on oral intake in labour may be beneficial to women, balancing the preferences of women with risks of surgical intervention.

Management of persistent occiput posterior position: The added value of manual rotation

OBJECTIVE

To evaluate the delivery rate in the occiput posterior position according to the result of manual rotation performed in the case of persistent occiput posterior position. Secondary objectives were perinatal outcomes.

METHODS

This was a prospective cohort study conducted in two French tertiary care units. All women with a singleton pregnancy after 37 weeks of gestation with a fetus in persistent occiput posterior position and an attempt of manual rotation were included. The main outcome was the occiput position at delivery. The secondary outcomes were duration of labor, mode of delivery, and perineal tears. Two groups were compared according to the result of manual rotation.

RESULTS

In total, 460 women were included, with a manual rotation success of 62.4%. The success was significantly associated with a decrease in occiput posterior position at vaginal delivery (1.4% vs 57.2%, P < 0.0001), cesarean (0.7% vs 17.9%, P < 0.0001), operative vaginal delivery (40.1% vs 78%, P < 0.0001), episiotomy (40.1% vs 54.9%, P < 0.0001), and obstetric anal sphincter injury (3.1% vs 8.7%, P = 0.008) compared with a failure.

CONCLUSION

An attempt of manual rotation in the case of persistent occiput posterior position is associated with decreased rates of occiput posterior position at delivery, operative delivery, and anal sphincter injuries.

Babies in occiput posterior position are significantly more likely to require an emergency cesarean birth compared with babies in occiput transverse position in the second stage of labor: A prospective observational study

Introduction

Malposition complicates 2‐13% of births at delivery, leading to increased obstetric interventions (cesarean section and instrumental delivery) and higher rates of adverse fetal and maternal outcomes. Limited data are available regarding the likely rates of obstetric intervention and subsequent neonatal and maternal outcomes of births with babies in persistent occiput posterior position vs those in persistent occiput transverse position. The UK Audit and Research trainee Collaborative in Obstetrics and Gynecology (UK‐ARCOG) network set out to collect data prospectively at delivery on final mode of delivery and immediate outcomes.

Material and methods

The UK‐ARCOG network collected data on all births with malposition of the fetal head complicating the second stage of labor (n = 838) (occiput posterior/occiput transverse) requiring rotational vaginal operative birth or emergency cesarean to expedite delivery across 66 participating UK National Health Service maternity units over a 1‐month period. The outcomes considered were the need for emergency cesarean section without a trial of instrumental delivery, success of the first method of delivery employed in achieving a vaginal delivery and neonatal/maternal outcomes.

Results

Obstetricians regarded assistance with an operative vaginal delivery method to be unsafe in 15% of babies in occiput posterior position and 6.1% of babies in occiput transverse position, and they were delivered by primary emergency cesarean section. When vaginal delivery was deemed safe (defined as attempted assisted vaginal rotational delivery), the first instrument attempted was successful in 74.4% of occiput posterior babies and 79.3% of occiput transverse babies.

Conclusions

Our data facilitates decision making by obstetricians to increase safety of assisted rotational operative delivery of a malpositioned baby at initial assessment and in counseling women. Until data from a well‐designed randomized controlled trial of instrumental delivery vs emergency cesarean section are available, this manuscript provides contemporaneous national data from a high resource setting within a structured training program, to assist the selection of an appropriate instrument/method for the delivery of a malpositioned baby.