[Instrumental delivery with perineum-fetal head distance >55 MM on ultrasound]

OBJECTIVE

Compare the issue of an operative vaginal delivery associated to the fetal presentation diagnosed by transperineal ultrasound. Three groups were formed: ≥55 mm, between 45 and 55 mm, and <45 mm.

METHODS

A monocentric prospective study on 108 patients has been conducted between April 2011 and August 2014. The distance between perinea and skull has been analyzed to compare the success of operative vaginal delivery considering the level of the fetal presentation in the pelvic cavity.

RESULTS

The failed operative vaginal deliveries are more frequent while the fetal head is above 55 mm (16.7%) or while the fetal head is between 45 and 55 mm (9.1%) than while the fetal skull is under 45 mm (1.8%) (P=0.04). However there is no significant difference for the fetal shoulder dystocia (5.6% vs 3.0% vs 3.5%, P=0.5), nor for the newborn outcomes (16.7 vs 15.2 vs 14; P=0.9).

CONCLUSION

Despite the high rate of failed operative vaginal delivery above 55 mm, it should be considered not to prohibit but send free to the obstetrician appreciation.

[Predictive factors of 2-month postpartum anal incontinence among patients with an obstetrical anal sphincter injury]

OBJECTIVES

To determine prevalence of short-term postpartum anal incontinence after obstetrical anal sphincter injury and prognostic factors.

MATERIALS AND METHODS

Retrospective study including every patient with an obstetrical anal sphincter injury between January 2006 and December 2012 in one tertiary maternity unit. Patients were interviewed and examined at 2-month postpartum. Anal incontinence was defined by the presence of at least one of the following symptoms: flatus incontinence, faecal incontinence and faecal urgency.

RESULTS

Among 17,110 patients who delivered vaginally during period study, 134 (0.8%) presented an anal sphincter injury. Postpartum obstetrical data were available for 110 of them. Among those patients, 50 women (45.5%) had at least one symptom of anal incontinence at 2-month postpartum and 8 (7.3%) had faecal incontinence. Only maternal age and second stage duration were significantly associated with anal incontinence after obstetrical anal sphincter injury. The degree of sphincter damage at delivery (IIIa, b, c, IV) was not associated with the risk of anal incontinence at 2-month postpartum.

CONCLUSION

Maternal age and second stage duration were the only risk factor for anal incontinence after obstetrical anal sphincter injury in this study. High prevalence of anal incontinence at 2-month postpartum of obstetrical anal sphincter injury is observed no matter what is the degree of anal sphincter damage. Our results highlight the importance to diagnose all obstetrical anal sphincter injuries whatever the degree of damage.

[Forceps delivery: Professionals' knowledge of forceps application in the area of Lyon]

OBJECTIVES

The aim of this study is to describe knowledge on forceps delivery in the area of Lyon.

MATERIAL AND METHODS

It is a multicentric observational study carried between January 1, 2013 and June 9, 2013. A questionnaire was sent to obstetricians and residents of the area of Lyon. It related prerequisites for operative vaginal delivery, the method used to apply forceps, practices and preferences of operators.

RESULTS

Seventy-five responses were obtained (47 obstetricians, 28 residents). About prerequisites: 6.4% of the obstetricians and 14.3% of the residents never do urinary catheterization. Instrumental delivery is never performed when the fetal head is not engaged. Mid-pelvic operative vaginal delivery is performed by 51.1% of obstetricians. Trans-abdominal ultrasound assessment is conducted in cases of clinical doubts about the fetal head position. For occipital anterior and left anterior positions, the left blade is first applied. A flexion of the fetal head is applied for anterior positions but not in posterior positions. Most of operators do not perform instrumental rotation. Vacuum extractor is the privileged instrument for obstetricians and forceps is often used in second line.

CONCLUSION

This study shows that most of the recommendations for forceps delivery are followed. In front of the lake of statistical power of this study, it might be interesting to improve a largest study with a comparison between obstetricians and residents' practices.

[Introducing a daily obstetric audit: A solution to reduce the cesarean section rate?]

OBJECTIVE

To evaluate the impact of a medical audit assessing the accuracy of caesarean indications on the final caesarean section rate of an obstetrics department.

MATERIAL AND METHOD

Comparative observational study conducted in a regional university teaching hospital on the two first quadrimester periods of 2013. During the first quadrimester, there was no cesarean section audit introduced for the daily reports meetings, while an audit was introduced during the second quadrimester. The caesarean rate and the instrumental delivery rate on both quadrimesters were compared.

RESULTS

In the first quadrimester period, there were 248 caesarean sections for 947 deliveries (26.2%), while in the second quadrimester period, there were 246 for 1033 deliveries (23.8%), P=0.014. The emergency caesarean rate decreased from 19.6 to 16.7%, P=0.02 in the second quadrimester period while the instrumental delivery rate increased from 14.4 to 17.2%, P=0.0004. Mothers and children's health was not modified between the two periods.

CONCLUSION

In our experience, the introduction of a daily obstetric audit of the caesarean indications is effective to decrease the emergency caesarean section rate and it encourages us to be active in the first like in the second part of the labor.

[Correlation between the perineal-to-skull measurement by tranperineal ultrasound, failure of vaginal operative delivery and maternal-fetal morbidity]

OBJECTIVES

To assess the influence of the perineal-to-skull measurement by tranperineal ultrasound (TPU) on the outcome of vaginal operative extraction together with maternal and fetal morbidity.

MATERIALS AND METHODS

Retrospective, monocentric and descriptive study was done on 272 patients, from 2009 January 1st to 2009 December 31st. It compares the failure rate of instrumental extraction, total caesarean section rate together with the maternal morbidity (type of perineal tears and post-partum hemorrhage rate) and fetal morbidity (5' Apgar score, arterial pH, transfer in neonatal intensive care unit) to the values obtained with TPU.

RESULTS

There is a correlation between the perineal-to-skull measurements higher or equal to 50mm at TPU and the instrumental failure rate (<50mm 0.8% vs. ≥50mm 11.9%; P<0.0001), caesarean (0.9% vs. 33.3%; P<0.0001), post-partum haemorrhage (3% vs. 11.9%; P=0.02), et paediatric intervention (16.7% vs. 31%; P=0.03).

CONCLUSION

Perineal-to-skull distance measured with TPU higher or equal to 50mm is at risk of instrumental failure and maternal morbidity. Associated with clinical examination and usual obstetrical risk factors, TPU could be useful to the decision between operative vaginal delivery and prophylactic caesarean section.

[Failure of vacuum extractions: risk factors, maternal and fetal issues]

OBJECTIVES

Determine cases which are at risk of vacuum extraction failure as well as maternal and foetal issues depending on the delivery outcome.

MATERIAL AND METHODS

It was a retrospective study comparing 147 vacuum failures, from January 2002 to December 2010, with a control group randomly composed of 526 successful vacuum extractions. The outcomes were high risk situations of vacuum failure, maternal and neonatal morbidity depending on the delivery method (caesarean section or other instrumental extraction).

RESULTS

The global vacuum failure rate was 3.3 %. During labour, we identified several situations at risk of vacuum extraction failure: cephalhematomas prior to extraction (P<0.001), deflexion attitude (P<0.001), posterior variety (P<0.001), entering above the inlet strait (P<0.001), occiput posterior delivery (P<0.001), fœtal weight greater than 3500g (P=0.023). Neonatals consequency were more Apgar score below 7 at five minutes life (P=0.007), fœtal acidosis (pH<7,20) (P=0.032), neonatal resuscitation (P<0.001), and craniofacial damages (P<0.001).

CONCLUSION

Many dystocic situations occurring during labour require intense care when practicing vacuum extraction since they more frequently result in failure. In case of vacuum extraction failure, immediate adaptation to extra-uterine life seems to be more difficult for new-born babies.