Sub-aponeurotic haemorrhage: a rare but life-threatening neonatal complication associated with ventouse delivery

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.

Kiwi Omnicup versus Malmstrom metal cup in vacuum assisted delivery: a randomized comparative trial

AIM

To compare the success, clinical outcomes, and maternal and neonatal complications between the Kiwi Omnicup and the Malmstrom metal cup in vacuum assisted delivery.

METHODS

This was a prospective randomized comparative trial. Women who required vacuum assisted vaginal delivery were randomized into the Kiwi Omnicup (KO) group and the Malmstrom metal cup (MM) group. The vacuum assisted deliveries were conducted according to hospital protocol. Details of the procedure and delivery outcomes including success and complications were analyzed.

RESULTS

One hundred and sixty-four women were recruited - 85 were assigned to vacuum assisted delivery using the KO and 79 the MM. One hundred percent delivery success was achieved with no significant differences between the two instruments in terms of maternal morbidity (P = 0.66). Six women in the MM group sustained post delivery complications in comparison to five in the KO group. Three babies were diagnosed with birth asphyxia in each group. More babies in the MM group were admitted to the Neonatal Intensive Care Unit (NICU) (10 babies versus 5 babies) and suffered complications (14 versus 12 babies), compared to the KO group, although the difference was not statistically significant. There were no intrapartum or neonatal deaths and of those admitted to the NICU, all were discharged within a week without any serious consequences.

CONCLUSION

Kiwi Omnicup is an effective alternative to the currently available Malmstrom metal cup for vacuum assisted delivery with no increase in maternal or neonatal morbidity or mortality.

Neonatal subgaleal hemorrhage: clinical presentation, treatment, and predictors of poor prognosis

BACKGROUND

Neonatal subgaleal hemorrhage (SGH) is a rare but potentially lethal medical emergency. The objective of the present retrospective study was to clarify the clinical presentation, management, and factors associated with morbidity and mortality.

METHODS

The records of all newborns from January 1995 to December 2004 were reviewed for evidence of SGH, based on the presence of a fluctuating hemorrhagic mass that crossed suture lines and extended toward the neck. Characteristics were compared between those with a poor or a good outcome.

RESULTS

Forty-two newborns with SGH were identified, 77% having had an instrumental delivery. The incidence was 0.6/1000 deliveries and 4.6/1000 vacuum-assisted deliveries. Thirteen patients (31%) had a poor outcome (five died, four had epilepsy, three with severe auditory dysfunction, two with cerebral palsy, and one with renal vein thrombosis). The group with the poor outcome had significantly more patients who had been transferred from other hospitals (P < 0.001). Those with a poor outcome had significantly more hypotension (P < 0.001) and seizures (P < 0.05). Laboratory findings associated with a poor outcome included anemia, coagulopathy, metabolic acidosis, and renal impairment. Other predictors of a poor prognosis included skull bone fracture, the need for pressors, blood transfusion, ventilator support, intensive care unit admission, and a longer hospital stay.

CONCLUSIONS

SGH may be associated with serious complications and death. The condition must be recognized promptly and monitored closely. Those with poor prognostic factors should be referred for intensive care, treated aggressively, and followed in the long term.

Operative vaginal delivery: a cause of birth injury or is it?

Operative vaginal delivery has been maligned since the days of W.J. Little with the word "forceps" becoming nearly synonymous with "Birth Injury" and "Cerebral Palsy." However in his presentation to the Obstetrical Society of London in 1861, Little's emphasis was on difficult labors being the culprit in subsequent disabilities in the offspring. Instrumented deliveries in that era were the end result of a long, obstructed labor performed for maternal benefit and to avoid a destructive procedure to the fetus thus allowing a chance at life. If there had been a normal progress in labor, operative assistance for delivery would not have been needed. Thus, was it the instrument or the obstructed labor that led to fetal injury? In this article, we will review what injuries to the fetus and the mother can be directly attributable to the instrument. We will explore the processes of labor, conduct of labor management, and concurrent fetal factors that can modulate the occurrence of birth trauma. Evidence regarding inexperience and improper use as contributing to injury will also be explored.

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-assisted delivery

Unsuccessful vacuum extraction, cup detachment and failed anterior rotation in occipitoposterior positions are commonly associated with obstetric factors that are avoidable or correctable. These factors include the preferential use of soft vacuum cups, incorrect cup applications and attempts to deliver with the vacuum extractor before the cervix is completely dilated. Evidence from randomized trials demonstrates that soft cups cause fewer cosmetic effects and scalp lacerations than rigid cups. Soft cups do not reduce the incidence of cephalhaematomas nor have they been shown to provide any advantage over rigid cups for the prevention of subgaleal haemorrhage. Clinically significant subgaleal haemorrhage and intracranial injury are almost always preceded by difficult vacuum extraction. Although the vacuum extractor is less likely than forceps to injure the mother's genital tract and anal sphincters at delivery, no significant differences have been demonstrated between the instruments in terms of subsequent urinary or bowel disturbances.

Forceps delivery

This chapter reviews the role for instrumental delivery in current practice and gives a critical account of current techniques of operative vaginal delivery by forceps. Important issues, including case choice, documentation, forceps application, avoidance of complications, and training and education are included.

Obstetric vacuum extraction: state of the art in the new millennium

This article summarizes the current state of knowledge of obstetric vacuum extraction. The discussed topics include the history of vacuum extraction, indications and contraindications, technique of the procedure, currently marketed instruments, special uses of the vacuum extractor, comparison of vacuum extraction with forceps delivery, and maternal and fetal outcomes. Areas of controversy are identified and discussed. Vacuum extraction is replacing forceps as the preferred method of instrumental delivery.

Operative vaginal delivery: clinical appraisal of a new vacuum extraction device

The efficacy of a new vacuum extraction device, the Kiwi OmniCup, and its effects on mothers and infants were tested in a study of 18 non-rotational and 32 rotational vacuum assisted deliveries. Forty-nine (98%) of the extractions resulted in successful vaginal births. Autorotation of the fetal head when the occiput was transverse or posterior was achieved in 31 (97%) of the 32 vacuum procedures. The high success rates recorded for both vaginal delivery and autorotation of the fetal head were largely attributable to the fact that flexing cup applications were achieved in 90 % of the vacuum attempts. There were no cases of serious maternal trauma or clinically significant neonatal injuries. Two infants had cephalohaematomas and one infant developed a small subgaleal haemorrhage following a difficult delivery, which resolved rapidly without complications. It was concluded that the Kiwi OmniCup is an efficient and safe vacuum device for assisted vaginal delivery, provided it is used correctly and appropriately.

Vacuum extraction in modern obstetric practice: a review and critique

The practice of obstetric vacuum extraction is controversial. This article discusses several issues concerning vacuum extraction including maternal and fetal injury risks, failure rates, indications and technique. Recently published articles on these topics are presented and summarized. Throughout this review, vacuum extraction is evaluated against its principal alternatives, forceps and cesarean delivery.