A new classification allowing assessment of instrumental vaginal-birth practices

BACKGROUND

Instrumental vaginal birth, a very common intervention in obstetrics, concerns nearly one in eight women in France. Instrumentally assisted vaginal childbirth can be for maternal and/or fetal indications. Although it reduces recourse to caesarean section, it is subject to risks. Practices concerning instrumental birth are disparate, varying among different practitioners, maternity units and countries, and it is essential to be able to evaluate them. Our objective was to create a classification tool of women requiring instrumental birth to facilitate the analysis of practices within our maternity unit as well as to enable temporal and geographical comparisons.

MATERIALS AND METHODS

We propose a simple and robust classification based on the same principles as Robson's classification. It is made up of seven totally inclusive and mutually exclusive groups. Our classification was refined and validated using the Delphi method by a panel of 14 experts from throughout France, and tested in our maternity unit using data from throughout 2021.

RESULTS

The seven clinically relevant groups are based on five obstetric criteria (multiplicity, presentation, gestational age, previous type of birth, induction of labor). To classify each woman in a group, five successive questions are posed in a predefined order. The classification has been validated by the experts with highly satisfactory overall agreement.

CONCLUSION

In order to improve the quality of care, we propose a tool to standardize the evaluation of instrumental vaginal birth practice (called the "Isère classification", after the county where we work in south-eastern France). It will also facilitate the comparison the practices among different maternity units in a network, a country or even among different countries.

[Evolution of the rate of episiotomies and obstetric anal sphincter injuries since the last recommendations of 2018]

OBJECTIVES

There is a progressive reduction in the rate of episiotomies since the recommendations of the French college of gynaecologists. Our objective was to study the evolution of the rate of episiotomies and Obstetric Anus Sphincter Injury (OASI) since the restriction of episiotomies in our department.

METHODS

Observational monocentric retrospective study performed at the Rouen University Hospital. The inclusion criteria were monofetal pregnancies, delivery at a term greater than or equal to 37 weeks of amenorrhea of a living, viable child and by cephalic presentation. We compared two periods corresponding to before and after the 2018 recommendations. We used logistic regression modelling to identify factors associated with the risk of episiotomies and of obstetrical anal injuries, overall and in case of instrumental delivery.

RESULTS

We included 3329 patients for the 1st period and 3492 for the 2nd period, and the rate of instrumental deliveries were respectively of 16.4% (n=547) and 17.9% (n=626). Multivariate analysis showed a significant decrease in the rate of episiotomies in the 2nd period (OR 0.14, CI 95% [0.12; 0.16], P<0.0001). Main factors associated with the risk of OASI were primiparity (OR 6.21, CI 95% [3.19; 12.11]) and the use of forceps (OR 4.23, CI 95% [2.17; 8.27]) overall; and instrumental delivery using forceps (OR 3.25, CI 95% [1.69; 6.22]) and delivery during the 2nd period (OR 1.98, CI 95% [1.01; 3.88]) in case of instrumental delivery.

CONCLUSIONS

Our study confirms that the voluntary reduction in the episiotomy rate does not seem to be associated with an increased risk of OASI, overall and in case of instrumental delivery. However, we show an increase in the rate of OASI in case of instrumental delivery since the latest recommendations.

Determinants of fetomaternal complication of instrumental vaginal delivery among women who gave childbirth in Southern Ethiopia: a facility-based cross-sectional study

BACKGROUND

In Ethiopia, one in five instrumental deliveries among women giving birth resulted in an unfavourable outcome. This study aimed to assess the determinants of feto-maternal complications of instrumental delivery in selected public hospitals of Gamo and Gofa zones, Southern Ethiopia.

METHODS

An institution-based cross-sectional study was conducted among 399 women attending selected public hospitals in the Gamo and Gofa zones. Data were collected using data extraction tools using a systematic random sampling technique. The collected data was entered into Epi-data version 3.1 and then analyzed using SPSS version 25. Logistic regression analysis was conducted to determine an association.

RESULTS

One hundred eighty-three (45.9%, n = 183/399) instrumental deliveries were found to be complicated. Primigravida women (AOR: 95% CI: 2.21 (1.35, 3.63), infant birth weight (AOR: 95% CI: 2.56 (1.37, 4.77), post-term pregnancy (AOR: 95% CI: 12.77 (2.92, 55.78), and maternal age (AOR: 95% CI: 7.00 (2.16, 22.64) were associated with fetomaternal complications in instrumental delivery among women who gave birth.

CONCLUSIONS AND RECOMMENDATION

A high proportion of women developed fetomaternal complications when compared to local studies. Promotion of antenatal care services, increasing women's education and empowerment as well as working on capacity building of health care professionals through education and training is cost-effective to reduce the occurrence of fetomaternal complications.

Re-evaluation of modifiable risk factors for obstetric anal sphincter injury in a real-world setting

INTRODUCTION AND HYPOTHESIS

The objective was to identify modifiable risk factors for obstetric anal sphincter injury (OASI) in primiparous women.

METHODS

This was a retrospective cohort study of primiparous women with a singleton vaginal delivery. Main outcome measures were incidence of OASI and odds ratios for possible risk factors: maternal age, body mass index and height, fetal birthweight and head circumference, gestational age, epidural analgesia, mediolateral episiotomy, and instrumental deliveries. Univariate and multivariate logistic regressions were performed using forward methods for variable selection.

RESULTS

Of 19,786 primiparous women with a singleton vaginal delivery, 369 sustained an OASI (1.9%). Risk factors were identified: vacuum extraction (adjusted OR 2.06, 95% CI, 1.59-2.65, p < 0.001), increased fetal weight (aOR 1.06, 95% CI, 1.02-1.11, p = 0.002, per 100-g increments); head circumference (aOR 1.24, 95% CI, 1.13-1.35, p < 0.001, per 1-cm increments); gestational week (aOR 1.11, 95% CI, 1.02-1.2, p = 0.012, per week). Protective factors: mediolateral episiotomy (aOR 0.75, 95% CI, 0.59-0.94, p = 0.013) particularly in vacuum deliveries (aOR 0.50, 95% CI, 0.29-0.97, p = 0.040); epidural analgesia (aOR 0.64, 95% CI, 0.48-0.84, p = 0.001); maternal height ≥157 cm (aOR 0.97, 95% CI, 0.96-0.98, p = 0.006, risk decreases by 2.6% per 1 cm increase in height).

CONCLUSIONS

Mediolateral episiotomy was protective against OASI in both spontaneous and instrumental deliveries of primiparae. Increased fetal weight and large fetal head circumference, particularly in short women, were significant risk factors. These findings support the performance of ultrasound to acquire updated fetal measures before admission to the labor ward.

Knowledge and experience of midwives and gynecologists about manual rotation of persistent occiput posterior position

BACKGROUND

management of persistent occiput posterior position has always been controversial. Manual rotation by a delivery operator can reduce instrumental delivery and cesarean section.

AIM

This study aims to determine the knowledge and experience of midwives and gynecologists about manual rotation of persistent occiput posterior position.

METHODS

This descriptive cross-sectional study was performed in 2022. The questionnaire link was sent to 300 participating midwives and gynecologists via WhatsApp Messenger. Two hundred sixty-two participants completed the questionnaire. Data analysis was performed using SPSS22 statistical software and descriptive statistics.

RESULTS

189 people (73.3%) had limited information about this technique, and 240 (93%) had never performed it. If this technique is recognized as a safe intervention and is included in the national protocol, 239 people (92.6%) want to learn, and 212 (82.2%) are willing to do it.

CONCLUSION

According to the results, the knowledge and skills of midwives and gynecologists need to be trained and improved for manual rotation of persistent occiput posterior position.

An intrapartum cervical buttonhole tear: A case report and review of rare tear pathogenesis

Genital tract trauma and obstetric anal sphincter injuries are known complications of normal vaginal and assisted vaginal delivery. Cervical tears are an uncommon complication that can lead to significant postpartum haemorrhage and may have implications for future pregnancies. Careful evaluation of the genital tract, including the cervix, along with adequate resuscitation are essential to reduce maternal morbidity and mortality. This is a case report of a 36-year-old primigravida woman at 41 + 6 weeks of gestation with delay in the second stage requiring Neville Barnes forceps delivery. She then went on to have a major postpartum haemorrhage, initially thought to be a result of uterine atony. However, inadequate response to uterotonics led to identification of a cervical buttonhole tear with an intact external os. She required repair under general anaesthesia. A rigid sigmoidoscope was utilised to ensure cervical canal patency during the repair. Previous reports have described annular cervical tears, thought to occur from the extension of a cervical buttonhole tear, but to the best of our knowledge the latter has not previously been reported. The case demonstrates the importance of awareness of such tears and proposes a novel technique for repair with the use of a rigid sigmoidoscope.

A retrospective cohort study of the characteristics of unsuccessful operative vaginal deliveries

INTRODUCTION

Unsuccessful operative vaginal delivery (OVD) is associated with high rates of materno-fetal morbidity. We aimed to examine institutional rates of unsuccessful OVDs (uOVD) and compare them with successful OVD (sOVD) in order to identify factors to aid patient selection and education.

METHODS

A 6-month retrospective cohort study was performed on all unsuccessful and successful OVDs in a tertiary level maternity hospital in the Republic of Ireland. Maternal demographics and obstetric factors were assessed to evaluate potential underlying risk factors for unsuccessful operative vaginal delivery versus successful vaginal delivery.

RESULTS

There were 4,191 births during the study period with an OVD rate of 14.2% (n = 595) with 28 (4.7% of OVDs) being unsuccessful. Unsuccessful OVD were predominately nulliparous (25; 89.2%) with a mean maternal age of 30.1 years (range 20-42), with more than half (n = 15, 53.5%) being induced. The most common indication for induction was prolonged rupture of membranes (PROM) (n = 7, 25%) which was significantly different from the successful OVD group. A senior obstetrician was significantly more likely to be the primary operator in uOVD when compared to sOVD. (82.1 % V 54.1% p < 0.01). The majority of unsuccessful OVD were vacuum deliveries (n = 17; 60.7%), with a significantly higher mean birthweight when compared to successful OVD (3.695 kg V 3.483 kg; p < 0.01). Following an unsuccessful OVD, women were more likely to have a postpartum haemorrhage (64.2 % V 31.5% p < 0.01) and their infant was more likely to require admission to the neonatal intensive care unit (NICU) (32.1 % V 5.8% p < 0.01) when compared with successful OVD.

CONCLUSION

Risk factors for unsuccessful OVD were higher birth weight and induction of labour. There was a higher incidence of postpartum haemorrhage and NICU admission when compared with successful OVD.

Prevalence, indications and fetal outcomes of operative vaginal delivery in Sub-Saharan Africa, systematic review, and meta-analysis

PURPOSE

This systematic review and meta-analysis is intended to assess the prevalence, indications, and fetal outcome of operative vaginal delivery in sub-Saharan Africa.

METHOD

In this study, 17 studies with a total population of 190,900 were included in both systematic review and meta-analysis. Search for relevant articles was done by using international online databases (like Google Scholar, PubMed, HINARI, EMBASE, Web of Science, and African journals) and online repositories of Universities in Africa. The JOANNA Briggs Institute standard data extraction format was used to extract and appraise high-quality articles before being included in this study. The Cochran Q and I² statistical tests were used to test the heterogeneity of the studies. The publication bias was tested by a Funnel plot and Egger's test. The overall pooled prevalence, indications, and fetal outcome of operative vaginal delivery along a 95% CI using forest plots and tables.

RESULT

The overall pooled prevalence of operative vaginal delivery in sub-Saharan Africa was 7.98% (95% CI; 5.03-10.65; I2 = 99.9%, P < 0.001). The indications of operative vaginal delivery in sub-Saharan African countries include the prolonged second stage of labor 32.81%, non-reassuring fetal heart rate 37.35%, maternal exhaustion 24.81%, big baby 22.37%, maternal cardiac problems 8.75%, and preeclampsia/eclampsia 2.4%. Regarding the fetal outcome, favourable fetal outcomes were 55% (95% CI: 26.04, 84.44), p =  < 0.56, I2: 99.9%). From those births with unfavourable outcomes, the need for the resuscitation of new-born was highest 28.79% followed by poor 5th minute Apgar score, NICU admission, and fresh stillbirth, 19.92, 18.8, and 3.59% respectively.

CONCLUSION

The overall prevalence of operative vaginal delivery (OVD) in sub-Saharan Africa was slightly higher compared to other countries. To reduce the increased applications and adverse fetal outcomes of OVD, capacity building for obstetrics care providers and drafting guidelines are required.

Descriptive Study of Obstetric Brachial Plexus Palsy (OBPP) at a Tertiary Care Hospital

Objective

To study the incidence and risk factors for obstetric brachial plexus palsy and assess the functional outcome.

Material and Methods

Five-year data of infants with OBPP were reviewed. Case-control study was performed using matched controls to identify the risk factors. Infants with OBPP were followed up to assess functional outcome.

Results

Of the 14,184 live births over a period of 5 years from 2013 to 2017, 23 (11 males, 12 females) had OBPP. Incidence of OBPP was 1.6 per 1000 live births. Higher birth weight (p-value 0.002) and instrumental delivery (p-value 0.02) were independent risk factors for obstetric brachial plexus palsy by multivariate logistic regression analysis. No cases of obstetric brachial plexus palsy were seen in babies born by cesarean section. 95% of the infants with obstetric brachial plexus palsy had complete recovery by 4 months of age.

Conclusion

Higher birth weight and instrumental vaginal delivery are independent risk factors for obstetric brachial plexus palsy. Cesarean section may have a protective effect against OBPP. Most infants with obstetric brachial plexus palsy have complete recovery.

Impacted fetal head during second stage Caesarean birth: A prospective observational study

OBJECTIVE

To determine the incidence of, and complication rates from, impacted fetal head at full dilatation Caesarean birth in the UK, and record what techniques were used.

DESIGN

Prospective observational study using the UK Obstetric Surveillance System (UKOSS).

SETTING

159 (82%) of the 194 UK hospitals with obstetric units.

POPULATION

All women who underwent second stage Caesarean birth in the UK between 1st March and 31st August 2019. Further information was collected on cases where a dis-impaction technique was used, or the operating surgeon experienced 'difficulty' in delivering the head.

METHODS

Prospective observational study.

MAIN OUTCOME MEASURES

Technique(s) used, maternal and neonatal outcomes.

RESULTS

3,518 s stage Caesarean births reported. The surgeon used a dis-impaction technique or reported 'difficulty' in 564 (16%) of these. The most common dis-impaction techniques used were manual elevation of the head by an assistant through the vagina (n = 235) and a fetal "pillow" (n = 176). Thirteen babies (2%) died or sustained severe injury. Four babies died (two directly attributable to the impacted fetal head).

CONCLUSIONS

Difficulty with delivery of the fetal head and the use of dis-impaction techniques during second stage Caesarean sections are common but there is no consensus as to the best method to achieve delivery and in what order.

Classification and evaluation of episiotomy practices from 2004 to 2020 and association with OASIS

OBJECTIVE

To apply a new classification based on 7 clinically relevant subgroups to accurately describe episiotomy practices and evaluate the association between episiotomy and obstetrical anal sphincter injuries (OASIS) rates according to the classification's subgroups.

METHODS

Observational retrospective cohort study based on a population comprising 39487 women from 01/01/2004 to 31/12/2020 in a level III university maternity unit. The primary outcome was the overall episiotomy rate in the institution, its trend over the time as well as in each subgroup of obstetric population classification. Secondary outcome was the rate of OASIS third and fourth degree, its association with episiotomy practice.

RESULTS

The episiotomy rate decreased significantly from 43,2% to 20% in the total population. The overall OASIS rate was 0,34%, it remained significantly the same during the study period, although the association between OASIS and episiotomy was significant only in group 2 (Nulliparous with instrumental delivery) with a decrease of OASIS rate if using episiotomy (OR 0.5; 95% CI[0,3-0,8]).

CONCLUSION

The episiotomy rate can be decreased without exposing women to an increased risk of OASIS. It encourages restrictive practice of episiotomy, but episiotomy should be considered in case of nulliparous women with instrumental delivery.

Evaluation of Suzor forceps training by studying obstetric anal sphincter injuries: a retrospective study

BACKGROUND

Instrumental deliveries are an unavoidable part of obstetric practice. Dedicated training is needed for each instrument. To identify when a trainee resident can be entrusted with instrumental deliveries by Suzor forceps by studying obstetric anal sphincter injuries.

METHODS

A French retrospective observational study of obstetric anal sphincter injuries due to Suzor forceps deliveries performed by trainee residents was conducted from November 2008 to November 2016 at Limoges University Hospital. Perineal lesion risk factors were studied. Sequential use of a vacuum extractor and then forceps was also analyzed.

RESULTS

Twenty-one residents performed 1530 instrumental deliveries, which included 1164 (76.1%) using forceps and 89 (5.8%) with sequential use of a vacuum extractor and then forceps. Third and fourth degree perineal tears were diagnosed in 82 patients (6.5%). Residents caused fewer obstetric anal sphincter injuries after 23.82 (+/- 0.8) deliveries by forceps (p = 0.0041), or after 2.36 (+/- 0.7) semesters of obstetrical experience (p = 0.0007). No obese patient (body mass index> 30) presented obstetric anal sphincter injuries (p = 0.0013). There were significantly fewer obstetric anal sphincter injuries after performance of episiotomy (p <  0.0001), and more lesions in the case of the occipito-sacral position (p = 0.028). Analysis of sequential instrumentation did not find any additional associated risk.

CONCLUSION

Training in the use of Suzor forceps requires extended mentoring in order to reduce obstetric anal sphincter injuries. A stable level of competence was found after the execution of at least 24 forceps deliveries or after 3 semesters (18 months) of obstetrical experience.

Rationale and design of ePPOP-ID: a multicenter randomized controlled trial using an electronic-personalized program for obesity in pregnancy to improve delivery

Background

Pre-pregnancy obesity and excessive gestational weight gain (GWG) are established risk factors for adverse pregnancy, delivery and birth outcomes. Pregnancy is an ideal moment for nutritional interventions in order to establish healthier lifestyle behaviors in women at high risk of obstetric and neonatal complications.

Methods

Electronic-Personalized Program for Obesity during Pregnancy to Improve Delivery (ePPOP-ID) is an open multicenter randomized controlled trial which will assess the efficacy of an e-health web-based platform offering a personalized lifestyle program to obese pregnant women in order to reduce the rate of labor procedures and delivery interventions in comparison to standard care. A total of 860 eligible pregnant women will be recruited in 18 centers in France between 12 and 22 weeks of gestation, randomized into the intervention or the control arm and followed until 10 weeks of postpartum.

The intervention is based on nutrition, eating behavior, physical activity, motivation and well-being advices in which personalization is central, as well as the use of a mobile/tablet application. Inputs includes data from the medical record of participants (medical history, anthropometric data), from the web platform (questionnaires on dietary habits, eating behavior, physical activity and motivation in both groups), and adherence to the program (time of connection for the intervention group only). Data are collected at inclusion, 32 weeks, delivery and 10 weeks postpartum. As primary outcome, we will use a composite endpoint score of obstetrical interventions during labor and delivery, defined as caesarean section and instrumental delivery (forceps and vacuum extractor). Secondary outcomes will consist of data routinely collected as part of usual antenatal and perinatal care, such as GWG, hypertension, preeclampsia, as well as fetal and neonatal outcomes including premature birth, gestational age at birth, birth weight, macrosomia, Apgar score, arterial umbilical cord pH, neonatal traumatism, hyperbilirubinemia, respiratory distress syndrome, transfer in neonatal intensive care unit, and neonatal adiposity. Post-natal outcomes will be duration of breastfeeding, maternal weight retention and child weight at postnatal visit.

Discussion

The findings of the ePPOP-ID trial will help design e-health intervention program for obese women in pregnancy.

Trial registration

ClinicalTrials.gov Identifier: NCT02924636 / October 5th 2016.

Obstetric anal sphicnter injury in a Spanish hospital

OBJECTIVE

Estimation of the prevalence of obstetric anal sphincter injury (OASIS) in our environment and study of the associated risk factors.

STUDY DESING

A retrospective observational study of cases and controls of assisted deliveries at the Severo Ochoa University Hospital of Leganés during the period from January 1, 2012, to December 31, 2017. A total of 88 OASIS diagnosed in the study period is compared with a randomly selected group of 181 controls of similar characteristics, vaginal births of cephalic of 36 weeks gestation or more, occurring during the same period.

RESULTS

During the study period, a total of 8160 deliveries were attended in our hospital, of which 6187 were vaginal and we diagnosed a total of 88 OASIS at the time of delivery. The prevalence of OASIS is 1.07 % for total births and 1.42 % for total vaginal deliveries. In the case-control study, the univariate analysis shows statistical significance for nulliparity (OR 3.84; 95 % CI 2.155-6.834; p < 0.001), instrumental delivery (OR 8.73; 95 % CI 4.706-16.2016; p < 0.001), occipital posterior position (OR 7.23; 95 % CI 2.535-20.633; p < 0.001), long duration of the second stage of labor (OR 1.99; IC95 % 1,159-3,438; p 0.01), episiotomy (OR 3.51; 95 % CI 1,956-6,309; p < 0.001) and OBGYN labor assistant (<0.001). When performing the multivariate analysis, forceps delivery (OR19.68), Thierry spatulas delivery (OR 8.15), vacuum delivery (OR 2.74), nulliparity (OR 2.56) and fetal weight in grams (OR 1.12) remain significant in the final model.

CONCLUSION

The main risk factors for the onset of OASIS are instrumental delivery, nulliparity and fetal birth weight.

Vacuum extraction in twin deliveries-maternal and neonatal consequences: a retrospective cohort study

PURPOSE

To establish the frequency of vacuum extraction among parturients with twin pregnancies, identify the risk factors and perinatal outcomes.

METHODS

A retrospective cohort database study was conducted between 2005-2018. Twin fetuses with vertex presentation >34 weeks gestation who achieved vaginal delivery were included. Outcomes were compared between neonates who were delivered by vacuum extraction and neonates delivered by spontaneous vaginal delivery (aORs; [95% CI]).

RESULTS

A total of 1751 neonates of 905 parturients with twin pregnancies met inclusion criteria, of which 163 (18%) parturients had vacuum extraction and 225 (12.8%) neonates were delivered by vacuum extraction. The most significant risk factors for vacuum extraction were primiparity (6.79 [4.77-9.66]), previous cesarean delivery (5.59 [3.13-9.97]), and epidural analgesia (4.34 [1.83-10.31]). Vacuum extractions were associated with a spectrum of adverse maternal outcomes (2.60 [1.61-4.19]), particularly postpartum hemorrhage and its associated morbidities. From the neonatal aspect, vacuum extraction deliveries were associated with a composite of birth trauma injuries (21.81 [6.43-73.91]).

CONCLUSION

Vacuum extractions among twin pregnancies were found to be associated with significantly higher rates of postpartum hemorrhage, blood transfusion, and perinatal birth trauma. These findings should be presented to women when counseling on mode of delivery and considered individually against cesarean delivery disadvantages.

Women's, partners' and healthcare providers' views and experiences of assisted vaginal birth: a systematic mixed methods review

BACKGROUND

When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use.

METHODS

Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix.

RESULTS

Forty-two studies (published 1985-2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies.

CONCLUSIONS

Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.

Effect of maternal country of birth on intrapartum epidural use - A population-based register study of 602 095 deliveries

OBJECTIVE

To assess intrapartum epidural use during vaginal delivery among immigrant women giving birth in Norway, compared with Norwegian born women, and to explore associations between epidural use and other maternal characteristics, fetal and obstetrical variables.

STUDY DESIGN

Population-based cohort study. Data were obtained from Norwegian Medical Birth Registry and Statistics Norway, including 602 095 deliveries in 1999-2014. Intrapartum epidural analgesia use was described in percentages. Multivariable logistic regression analysis was performed to investigate the association between maternal country of birth and intrapartum epidural use, adjusted with maternal and fetal comorbidity, age, stillbirth, birthweight, fetal presentation, delivery method and time period.

RESULTS

There were significant differences in epidural use between women born in different parts of the world. Among nulliparous women, increased odds for intrapartum epidural use was observed among women born in Latin America compared with Norwegian born women, even after adjustment for maternal, fetal and obstetrical factors (aOR 1.93, CI 1.79-2.09). Reduced odds for intrapartum epidural use was observed among nulliparous women born in Sub-Saharan Africa (aOR 0.83, CI 0.78-0.88), East Asia and Pacific area (aOR 0.83, CI 0.80-0.87), and women with unknown country of birth (aOR 0.79, CI 0.71-0.89) compared with Norwegian born women. Similar pattern was observed among parous women from Latin America (aOR 1.69, CI 1.54-1.87), Sub-Saharan Africa (aOR 0.62, CI 0.57-0.67), East-Asia and Pacific area (aOR 0.68, CI 0.64-0.73), unknown country of birth (aOR 0.97, CI 0.84-1.13). Maternal hypertensive disorders, high infant birthweight, stillbirth, breech presentation and operative vaginal delivery increased the odds for use of intrapartum epidural analgesia.

CONCLUSIONS

We found differences between immigrant women from different parts of the world and use of intrapartum epidural, possibly related to un-measurable issues like cultural differences, maternal expectations and knowledge of safety on pain relief during childbirth. Intrapartum epidural use was more frequent in conditions related to maternal co-morbidity and factors indicating complicated delivery.

Maternal complication related to instrumental delivery at Felege Hiwot Specialized Hospital, Northwest Ethiopia: a retrospective cross-sectional study

OBJECTIVE

The study aimed to determine proportion and risk factors for maternal complication related to forceps and vacuum delivery among mother who gave birth at Felege Hiwot Comprehensive Specialized Hospital (FHCSH).

RESULTS

Records of 406 mothers managed with instrumental vaginal delivery were reviewed and 97% of the reviewed card had complete documentation. The proportion of maternal complications related to instrumental delivery was 12.1%. A major complication of forceps assisted delivery was 2nd-degree perineal tear (7.4%), 3rd-degree perineal tear (1.5%), cervical tear (1.5%) and episiotomy extension (1%). However, the complication of vacuum-assisted vaginal delivery was only cervical tear (0.5%) and episiotomy extension (0.5%). Episiotomy during instrumental delivery reduce maternal complication by 86% [AOR = 0.14, 95% CI 0.07-0.3]. Forceps assisted vaginal delivery had 3.4 times more risk for maternal complication compared to vacuum-assisted vaginal delivery [AOR = 3.4, 95% CI 1.08-10.67] and the same is true for primiparity that primipara women who gave birth by the help of instrument had 3.5 times more risk for maternal complication compared to a multipara women [AOR = 3.5, 95% CI 1.26-9.98].

Impact of maternal antepartum depressive and anxiety symptoms on birth outcomes and mode of delivery: a prospective cohort study in east and west coasts of Malaysia

BACKGROUND

Antepartum depressive and anxiety symptoms (ADS and AAS) are prevalent in Malaysia. Prior evidence linking maternal ADS and AAS with adverse birth outcomes and caesarean section (CS) or instrumental delivery is conflicting. There is no research in Malaysia on the association between maternal mental disorders and adverse birth outcomes and mode of delivery. This study aims to investigate the independent effect of maternal ADS and AAS on low birth weight (LBW), preterm birth (PTB) and CS or instrumental delivery among women in east and west coasts of Malaysia.

METHODS

We used data from a prospective cohort study of 799 pregnant women from health clinics of two states in east and west coasts of Malaysia. Baseline data were measured at the third trimester of pregnancy on ADS, AAS, socioeconomic condition, anthropometric status, reproductive history and intimate partner violence. Birth outcomes and mode of delivery were determined at the time of delivery. Univariate and multiple Cox's regressions were applied to assess the association between ADS and AAS and LBW, PTB and CS or instrumental delivery.

RESULTS

ADS was significantly associated with an increased risk of giving birth to LBW babies in both east coast (RR = 3.64; 95% CI 1.79-7.40) and west coast (RR = 3.82; 95% CI 1.86-7.84), but not with PTB. AAS was associated with increased risk of both LBW (RR = 2.47; 95% CI 1.39-4.38) and PTB (RR = 2.49; 95% CI 1.16-5.36) in the east coast, but not in west coast. The risk of CS or instrumental delivery was evident among women with ADS (RR = 2.44; 95% CI 1.48-4.03) in west coast only.

CONCLUSION

ADS predicts LBW in both coasts, AAS predicts LBW and PTB in east coast, and ADS predicts CS or instrumental delivery in west coast. Policies aimed at detection and management of ADS and AAS during antenatal check-up in health clinics may help improve birth outcomes and reduce obstetric interventions.

Vacuum Extraction in Preterm Deliveries and Long-Term Neurological Outcome of the Offspring

BACKGROUND

Concern exists regarding a possible harmful impact of vacuum extraction on the preterm newborn. We aimed to evaluate the long-term pediatric neurodevelopmental outcomes of the preterm offspring after vacuum extraction.

METHODS

A population-based cohort analysis was performed comparing the risk for long-term neurological morbidity (up to age 18 years) in preterm (less than 37 completed weeks of gestation) children born via following three delivery modes: vacuum extraction, spontaneous delivery, and Caesarean delivery performed during the second stage of labor. A Kaplan-Meier survival curve was used to compare the cumulative neurological morbidity in all groups. A Cox proportional hazards model was used to control for confounders.

RESULTS

During the study period 11,662 preterm newborns met the inclusion criteria, 97.2% (n = 11,338) of which were born via spontaneous vaginal delivery, 2.3% (n = 267) underwent vacuum extraction, and 0.5% (n = 57) were delivered by Caesarean section during the second stage of labor. Gestational age at delivery median (range) was 36 (29 to 36) weeks for vacuum extractions, 36 (23 to 36) for spontaneous vaginal delivery, and 35 (29 to 36) for Caesarean delivery within second stage of labor. Total pediatric hospitalizations involving neurological diagnoses were comparable between the groups as were the cumulative incidences of total neurological morbidity in the survival curves (log rank P = 0.723). In the Cox regression model, vacuum delivery in preterm newborns was not found to be associated with later pediatric neurological hospitalizations.

CONCLUSIONS

Vacuum extraction performed on preterm newborns does not appear to be independently associated with severe long-term neurological morbidity, as reflected by later pediatric hospitalizations.

Measuring angle of progression by transperineal ultrasonography to predict successful instrumental and cesarean deliveries during prolonged second stage of labor

OBJECTIVE

To compare the angle of progression (AoP) measured by transperineal ultrasonography before indicating an instrumental delivery or cesarean delivery.

METHODS

A prospective observational study was conducted among women with singleton term pregnancies with prolonged second stage of labor at Kwong Wah Hospital, Hong Kong, China, between May 16, 2011, and May 25, 2016. Transabdominal and transperineal ultrasonography were performed to determine fetal head position and AoP, respectively, both at rest and during uterine contraction with pushing. Mode of delivery was decided after vaginal examination without relying on ultrasonography.

RESULTS

Of 143 women, 116 underwent successful instrumental delivery and 27 underwent cesarean delivery. Median AoP was 153.0° in the instrumental group versus 139.0° in the cesarean group at rest (P<0.001), and 182.5° in the instrumental group versus 156.5° in the cesarean group during contraction (P<0.001). The best predictive cutoff AoP for successful instrumental delivery was 138.7° at rest (sensitivity 86.2%, specificity 51.9%) and 160.9° during contraction (sensitivity 87.1%, specificity 74.1%). No between-group differences in AoP were found for ease of vacuum extraction at rest (P=0.457) or during contraction with pushing (P=0.095).

CONCLUSION

The AoP predicted approximately 80% of successful instrumental deliveries performed for prolonged second stage of labor.

Predictors of successful manual rotation for occiput posterior positions

OBJECTIVE

To identify predictors of the success of manual rotation of fetuses in an occiput posterior position.

METHODS

A prospective, observational, single-center study included all women with a singleton pregnancy at term with a fetus in an occiput posterior position for whom manual rotation was attempted from December 1, 2013, to April 30, 2015 at a tertiary care maternity unit in Nancy, France. Occiput posterior position was confirmed by ultrasonography, and success of manual rotation was defined by the occiput anterior position of the fetus after the attempt.

RESULTS

Occiput posterior position was diagnosed in 233 (9.2%) of the 2522 deliveries during the study period and the majority of cases were managed successfully by manual rotation (167 [71.7%]). Factors associated with successful rotation were fetal engagement (adjusted odds ratio [aOR] 2.20, 95% confidence interval [CI] 1.05-4.56), spontaneous labor (aOR 1.85, 95% CI 1.01-3.43), and no failure to progress (aOR 2.01, 95% CI 1.02-3.94). Successful manual rotation was associated with lower rates of cesarean (P<0.001) and instrumental (P<0.001) deliveries.

CONCLUSION

Study findings suggested that manual rotation, especially after fetal engagement, succeeded more often when performed systematically than when it was attempted after failure to progress.

[Fetal expulsion: Which interventions for perineal prevention? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The objective for all obstetricians and midwifes who intervene during the release of the fetal presentation is to prevent at best the perineal lesions. This work consisted in analyzing the literature, researching and evaluating interventions that reduce this perineal risk during the release.

METHODS

A keyword search for each medical intervention during the expulsion phase was conducted by selecting studies assessing perineal risk. Interventions during pregnancy and during delivery before the expulsion phase were specifically addressed in other sections of the recommendations.

RESULTS

Firstly, the degree of perineal stretching during the second stage of labour does not appear to be a risk factor for OASIS, postpartum incontinence, or sexual disorders (LE3) and that a substantial stretching of the perineum is not an indication of episiotomy (Professional consensus). Then, manual control of the expulsion of the fetus at the end of the second stage of labour and support of the posterior perineum during this time appear to reduce the rate of OASIS (LE3). The crowning of the baby's head should be manually controlled and the posterior perineum manually supported manually to reduce the risk of OASIS (GradeC). There is no recognised benefit to episiotomy in normal deliveries (LE1); the liberal practice of episiotomy results in fewer intact perineums than its restrictive practice, and the latter does not result in increasing the number of cases of OASIS. No evidence indicates that an episiotomy for women with a breech presentation, twin pregnancy, or posterior position prevents OASIS (LE3). Indication for episiotomy during delivery depends on individual risk factors and obstetric conditions (Professional consensus). It is recommended that the indication for episiotomy be explained and the woman's consent received before its performance. The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). The liberal practice of episiotomy to prevent OASIS is not recommended for women with a breech presentation, twin pregnancy, or posterior position (GradeC). Episiotomy during an instrumental delivery appears to be associated with a reduction of the risk of OASIS (LE3). The vacuum extractor appears to induce fewer cases of OASIS than other instruments (LE3). Episiotomy may be indicated in instrumental deliveries to avoid OASIS (GradeC). Training in perineal protection in obstetrics is recommended (Grade B). In operative vaginal deliveries when several instruments can be used, a vacuum extractor is preferentially recommended to reduce the risk of OASIS (GradeC). When forceps or spatulas are used, it is preferable that they be withdrawn just before cephalic deflexion so that the fetal head is not "capped" with these instruments at birth (Professional consensus). Couder's maneuver, which consists of lowering the forearm during the release of the fetal shoulders, appears to decrease the rate of second-degree perineal tears and increase the rate of intact perineum (LE3).

CONCLUSION

Manual control of the expulsion and perineal support reduce the risk of perineal injury. There is no benefit to episiotomy in normal delivery, nor in special cases such the breech presentation for example. On the other hand, in case of instrumental delivery, an episiotomy may be indicated to avoid OASIS (GradeC), and it is recommended if it is possible to use the ventouse preferentially. The Couder's maneuver seems to reduce the rate of 2^nd degree perineal lesions (LE3). Finally, training in perineal obstetric protection is recommended (Grade B).

Prospective cohort study comparing outcomes between vacuum extraction and second-stage cesarean delivery at a Ugandan tertiary referral hospital

OBJECTIVE

To compare maternal and perinatal outcomes between vacuum extraction and second-stage cesarean delivery (SSCD).

METHODS

The present observational cohort study was conducted among women with term vertex singleton pregnancies who underwent vacuum extraction or SSCD at Mulago National Referral Hospital, Kampala, Uganda, between November 25, 2014, and July 8, 2015. Severe maternal outcomes (mortality, uterine rupture, hysterectomy, re-laparotomy) and perinatal outcomes (mortality, trauma, low Apgar score, convulsions) were compared between initial delivery mode.

RESULTS

Among 13 152 deliveries, 358 women who underwent vacuum extraction and 425 women who underwent SSCD were enrolled in the study. No maternal deaths occurred after vacuum extraction versus five deaths from complications of SSCD. Vacuum extraction was associated with less severe maternal outcomes compared with SSCD (3 [0.8%] vs 18 [4.2%]; adjusted odds ratio [aOR] 0.24, 95% confidence interval [CI] 0.07-0.84). Fetal death during the decision-to-delivery interval was also less common in the vacuum extraction group (3 [0.9%] vs 18 [4.4%]; aOR 0.24, 95% CI 0.07-0.84); however, the perinatal mortality rate did not differ between the vacuum extraction and SSCD groups (29 [8.4%] vs 45 [11.0%], respectively; aOR 0.83, 95% CI 0.49-1.41). One infant in each group exhibited neurodevelopmental anomalies at 6 months.

CONCLUSION

Vacuum extraction had better maternal outcomes and equivalent perinatal outcomes compared with SSCD. These findings encourage re-introduction of vacuum extraction.

Mechanical birth-related trauma to the neonate: An imaging perspective

Mechanical birth-related injuries to the neonate are declining in incidence with advances in prenatal diagnosis and care. These injuries, however, continue to represent an important source of morbidity and mortality in the affected patient population. In the United States, these injuries are estimated to occur among 2.6% of births. Although more usual in context of existing feto-maternal risk factors, their occurrence can be unpredictable. While often superficial and temporary, functional and cosmetic sequelae, disability or even death can result as a consequence of birth-related injuries. The Agency for Healthcare research and quality (AHRQ) in the USA has developed, through expert consensus, patient safety indicators which include seven types of birth-related injuries including subdural and intracerebral hemorrhage, epicranial subaponeurotic hemorrhage, skeletal injuries, injuries to spine and spinal cord, peripheral and cranial nerve injuries and other types of specified and non-specified birth trauma. Understandably, birth-related injuries are a source of great concern for the parents and clinician. Many of these injuries have imaging manifestations. This article seeks to familiarize the reader with the clinical spectrum, significance and multimodality imaging appearances of neonatal multi-organ birth-related trauma and its sequelae, where applicable.

Teaching points

• Mechanical trauma related to birth usually occurs with pre-existing feto-maternal risk factors.

• Several organ systems can be affected; neurologic, musculoskeletal or visceral injuries can occur.

• Injuries can be mild and transient or disabling, even life-threatening.

• Imaging plays an important role in injury identification and triage of affected neonates.

A comparison of intrapartum interventions and adverse outcomes by parity in planned freestanding midwifery unit and alongside midwifery unit births: secondary analysis of 'low risk' births in the birthplace in England cohort

BACKGROUND

For low risk women, there is good evidence that planned birth in a midwifery unit is associated with a reduced risk of maternal interventions compared with planned birth in an obstetric unit. Findings from the Birthplace cohort study have been interpreted by some as suggesting a reduced risk of interventions in planned births in freestanding midwifery units (FMUs) compared with planned births in alongside midwifery units (AMUs). However, possible differences have not been robustly investigated using individual-level Birthplace data.

METHODS

This was a secondary analysis of data on 'low risk' women with singleton, term, 'booked' pregnancies collected in the Birthplace national prospective cohort study. We used logistic regression to compare interventions and outcomes by parity in 11,265 planned FMU births and 16,673 planned AMU births, adjusted for potential confounders, using planned AMU birth as the reference group. Outcomes considered included adverse perinatal outcomes (Birthplace primary outcome measure), instrumental delivery, intrapartum caesarean section, 'straightforward vaginal birth', third or fourth degree perineal trauma, blood transfusion and maternal admission for higher-level care. We used a significance level of 1% for all secondary outcomes.

RESULTS

There was no significant difference in adverse perinatal outcomes between planned AMU and FMU births. The odds of instrumental delivery were reduced in planned FMU births (nulliparous: aOR 0.63, 99% CI 0.46-0.86; multiparous: aOR 0.41, 99% CI 0.25-0.68) and the odds of having a 'straightforward vaginal birth' were increased in planned FMU births compared with planned AMU births (nulliparous: aOR 1.47, 99% CI 1.17-1.85; multiparous: 1.86, 99% CI 1.35-2.57). The odds of intrapartum caesarean section did not differ significantly between the two settings (nulliparous: p = 0.147; multiparous: p = 0.224). The overall pattern of findings suggested a trend towards lower intervention rates and fewer adverse maternal outcomes in planned FMU births compared with planned AMU births.

CONCLUSIONS

The findings support the recommendation that 'low risk' women can be informed that planned birth in an FMU is associated with a lower rate of instrumental delivery and a higher rate of 'straightforward vaginal birth' compared with planned birth in an AMU; and that outcomes for babies do not appear to differ between FMUs and AMUs.

Duration of second stage of labor and instrumental delivery as risk factors for severe perineal lacerations: population-based study

Background

We sought to investigate the impact of the duration of second stage of labor on risk of severe perineal lacerations (third and fourth degree).

Methods

This population based cohort study was conducted in the Stockholm/Gotland region, Sweden, 2008–2014. Study population included 52 211 primiparous women undergoing vaginal delivery with cephalic presentation at term. Unconditional logistic regression analysis was used to calculate crude and adjusted odds ratios (OR), using 95% confidence intervals (CI). Main exposure was duration of second stage of labor, and main outcome was risks of severe perineal lacerations (third and fourth degree).

Results

Risk of severe perineal lacerations increased with duration of second stage of labor. Compared with a second stage of labor of 1 h or less, women with a second stage of more than 2 h had an increased risk (aOR 1.42; 95% CI 1.28–1.58). Compared with non-instrumental vaginal deliveries, the risk was elevated among instrumental vaginal deliveries (aOR 2.24; 95% CI 2.07–2.42). The risk of perineal laceration increased with duration of second stage of labor until less than 3 h in both instrumental and non-instrumental vaginal deliveries, but after 3 h, the ORs did not further increase. After adjustments for potential confounders, macrosomia (birth weight > 4 500 g) and occiput posterior fetal position were risk factors of severe perineal lacerations.

Conclusions

The risk of severe perineal laceration increases with duration until the third hour of second stage of labor. Instrumental delivery is the most significant risk factor for severe lacerations, followed by duration of second stage of labor, fetal size and occiput posterior fetal position.

Quality of Labor Epidural Analgesia and Maternal Outcome With Levobupivacaine and Ropivacaine: A Double-Blinded Randomized Trial

Background:

Quality of labor analgesia plays a vital role in the maternal outcome. Very few literature are available analyzing the quality of epidural labor analgesia.

Aim:

The aim of this study was to compare the effectiveness of 0.1% levobupivacaine and 0.1% ropivacaine with fentanyl as an adjuvant for epidural labor analgesia in terms of onset, duration, quality of analgesia, and degree of motor blockade.

Methodology:

Sixty nulliparous parturients, with singleton uncomplicated pregnancy, were recruited by continuous sampling. Parturients were randomized to receive either levobupivacaine 0.1% or ropivacaine 0.1% with 2 μg/ml fentanyl as an intermittent epidural bolus. The epidural analgesia was initiated with 12 ml of study drug solution in the active stage of labor (cervix 3 cm dilated). Demand bolus was given whenever the visual analog scale (VAS) score >3. Onset, duration, and quality of analgesia and degree of motor blockade were analyzed. Maternal outcome was evaluated in terms of mode of delivery, duration of labor, and assisted vaginal delivery.

Statistical Analysis:

All the data were recorded in Microsoft Office Excel. Statistical analysis was carried out using SPSS version 19.0 (IBM SPSS, USA) software with Regression Modules installed. Descriptive analyses were reported as mean and standard deviation of continuous variables.

Results:

The mean onset of analgesia was shorter in ropivacaine (21.43 ± 2 min) than in levobupivacaine group (23.57 ± 1.71 min) (P = 0.000). Duration of analgesia was shorter in ropivacaine (60 ± 14 min) than levobupivacaine (68 ± 11 min) (P = 0.027). Levobupivacaine produced a better quality of analgesia in terms of not perceiving pain and uterine contraction during labor analgesia but was associated with 37% incidence of instrumental delivery. Duration of labor and rate of cesarean section were comparable between the groups.

Conclusion:

Quality of analgesia in labor epidural was superior to levobupivacaine but was associated with higher incidence of instrumental vaginal delivery.

Predictive factors for the success of McRoberts' manoeuvre and suprapubic pressure in relieving shoulder dystocia: a cross-sectional study

BACKGROUND

McRoberts' and suprapubic pressure are often recommended as the initial choices of manoeuvres to manage shoulder dystocia, as they are believed to be less invasive compared to other manoeuvres. However, their success rates range from 23 to 40 %. This study aims to investigate the predictive factors for the success of McRoberts' manoeuvre with or without suprapubic pressure (M+/-S).

METHODS

All cases of shoulder dystocia in a tertiary hospital in South East Asia were recruited from 1995 to 2009. Subjects were analysed according to either 'success' or 'failure' of M+/-S. Maternal and fetal antenatal and intrapartum factors were compared by univariate and multivariate analysis.

RESULTS

Among 198 cases of shoulder dystocia, M+/-S as the primary manoeuvre was successful in 25.8 %. The other 74.2 % needed either rotational or posterior arm manoeuvres or combination of manoeuvres. Instrumental delivery was the single most significant factor associated with an increased risk of failed M+/-S on logistic regression (p < 0.001, OR 4.88, 95 % CI 2.05-11.60). The success rate of M+/-S was only 15.0 % if shoulder dystocia occurred after instrumental delivery but was 47.7 % after spontaneous vaginal delivery.

CONCLUSIONS

When shoulder dystocia occurs after instrumental vaginal delivery, the chance of failure of M+/-S is 85 %, which is 4.7 times higher than that after spontaneous vaginal delivery. Hence all operators performing instrumental delivery should be proficient in performing all manoeuvres to relieve shoulder dystocia when M+/-S cannot do so.

Long-term Impact of Mode of Delivery on Stress Urinary Incontinence and Urgency Urinary Incontinence: A Systematic Review and Meta-analysis

Context

Stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) are associated with physical and psychological morbidity, and large societal costs. The long-term effects of delivery modes on each kind of incontinence remain uncertain.

Objective

To investigate the long-term impact of delivery mode on SUI and UUI.

Evidence acquisition

We searched Medline, Scopus, CINAHL, and relevant major conference abstracts up to October 31, 2014, including any observational study with adjusted analyses or any randomized trial addressing the association between delivery mode and SUI or UUI ≥1 yr after delivery. Two reviewers extracted data, including incidence/prevalence of SUI and UUI by delivery modes, and assessed risk of bias.

Evidence synthesis

Pooled estimates from 15 eligible studies demonstrated an increased risk of SUI after vaginal delivery versus cesarean section (adjusted odds ratio [aOR]: 1.85; 95% confidence interval [CI], 1.56–2.19; I² = 57%; risk difference: 8.2%). Metaregression demonstrated a larger effect of vaginal delivery among younger women (p = 0.005). Four studies suggested no difference in the risk of SUI between spontaneous vaginal and instrumental delivery (aOR: 1.11; 95% CI, 0.84–1.45; I² = 50%). Eight studies suggested an elevated risk of UUI after vaginal delivery versus cesarean section (aOR: 1.30; 95% CI, 1.02–1.65; I² = 37%; risk difference: 2.6%).

Conclusions

Compared with cesarean section, vaginal delivery is associated with an almost twofold increase in the risk of long-term SUI, with an absolute increase of 8%, and an effect that is largest in younger women. There is also an increased risk of UUI, with an absolute increase of approximately 3%.

Patient summary

In this systematic review we looked for the long-term effects of childbirth on urinary leakage. We found that vaginal delivery is associated with an almost twofold increase in the risk of developing leakage with exertion, compared with cesarean section, with a smaller effect on leakage in association with urgency.

[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.

Unscarred Uterine Rupture: A Retrospective Analysis

INTRODUCTION

Uterine rupture is a catastrophic obstetrical emergency associated with a significant feto-maternal morbidity and mortality. Many risk factors for uterine rupture, as well as a wide range of clinical presentations, have been identified.

OBJECTIVES

To analyze the frequency, predisposing factors, and maternal and fetal outcomes of uterine rupture.

METHODS

A retrospective analysis of cases of unscarred uterine rupture was conducted at the Department of Obstetrics and Gynecology, RIMS, Imphal from June 1, 2010 to June 30, 2012.

RESULTS

Our analysis comprised 13 cases. Of these, 30.8 % were booked cases. Most of the cases (46.2 %) were Para 2. Uterine rupture occurred at term in 10 cases. The rupture occurred due to mismanaged labor (30.8 %), the use of oxytocin (23 %), instrumental delivery (15.4 %), obstructed labor (15.4 %), induction by prostaglandin gel (7.7 %), and placenta percreta (7.7 %). Maternal deaths and perinatal deaths were 30.8 and 53.8 %, respectively. Sub-total hysterectomy was done in 8 cases and in 1 patient laparotomy with repair was performed.

CONCLUSION

Ruptured uterus causes a high risk in patients. An unscarred uterus can undergo rupture even without etiological or risk factors. The patients with mismanaged labor, grand multiparas, and obstructed prolonged labor must be managed by properly trained personnel at a tertiary care center in order to avoid the morbidity or mortality.

Influence of obesity on route of delivery in a population of African descent in Martinique

OBJECTIVE

To determine whether obesity is an independent risk factor for cesarean delivery in Martinique.

METHODS

A retrospective study was performed using data for deliveries that occurred at the University Hospital of Fort de France between January and September 2010. Women were divided into four groups on the basis of body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters; < 25 [group 1], 25-29 [group 2], 30-39 [group 3], and ≥ 40 [group 4]). Independent risk factors for cesarean delivery were identified through multivariate analysis.

RESULTS

Overall, 1286 women were included. Mean weight gain was lower in groups 2 (9.9 kg, 95% CI 9.2-10.7), 3 (5.7 kg, 4.7-6.7), and 4 (1.0 kg,-1.5 to 3.5), than in group 1 (12.3 kg, 11.9-12.7; P < 0.001 for all). In univariate analysis, cesarean deliveries were more frequent among nulliparous women in group 2 (P = 0.007) and group 3 (P = 0.053) than among those in group 1. In multivariate analysis, BMI was not associated with cesarean delivery (BMI 25-29: adjusted odds ratio 0.64, 95% CI 0.33-1.25; BMI ≥ 30: 0.61, 0.29-1.39).

CONCLUSION

Obesity was not an independent risk factor for cesarean delivery. Weight control and a positive attitude towards trial of labor in obese women could have led to the findings.

[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.