Assisted vaginal delivery in low and middle income countries: an overview

Abstract

This study, accomplished with the use of a variety of data sources from health care facilities in a number of developing countries, demonstrates quite clearly the overall relatively low use of assisted vaginal delivery (AVD, obstetrical forceps and the vacuum extractor) in most of the facilities. The information available to the investigators did not allow an assessment of the comparative risks and benefits of AVD in these settings. Not surprising was that factors responsible for the low use of AVD were low availability of equipment and scarcity of adequately trained personnel, which varied in degree among the facilities studied. Also not unexpected was that the use of forceps delivery was much less common than assisted delivery with a vacuum extractor. Even in facilities in developed countries the rate of forceps deliveries has declined over the past three decades, with a concomitant increase in the use of the vacuum extractor (Patel et al. BMJ 2004;328:1302-5). This has occurred despite the fact that forceps deliveries are associated with fewer failures than vacuum extraction and that in cases of fetal distress, delivery can be accomplished more rapidly with forceps than with vacuum extraction. Of course, part, if not all, of the explanation for the declining use of forceps for AVD is that teaching and learning the skillful and safe use of forceps is far more difficult than learning the safe use of the vacuum extractor. This difficulty is augmented by the rise of caesarean delivery as an alternative for an attempted AVD and the decline in the number of practitioners who have sufficient experience using obstetrics forceps to be efficient teachers of the necessary skills using these instruments. Also, safe forceps delivery relies on an adequate knowledge of pelvic anatomy and a familiarity with the pros and cons of several types of forceps, neither of which is a requisite with the vacuum extractor. Evidence of this conundrum is a recent study of 5 years of deliveries (n = 5375) in an obstetric service in Mexico City in which there were only 146 forceps deliveries (i.e. approximately 29 per year) (Ayala-Y a~ nez et al. J Pregnancy 2015:489 267). Although this institution was not described as a training centre for physicians or nurse midwives, it nevertheless shows how few opportunities are available to train young practitioners in the use of forceps. Although the vacuum extractor is a reliable choice for AVD in most cases, it is of no use in a vaginal breech delivery. If spontaneous delivery of the after-coming head does not occur, the only safe alternative is the use of forceps (in most cases the Piper forceps). One of the most important conclusions of the authors of this study is the need for more comprehensive and reliable data collection in obstet-ric facilities in underdeveloped countries. This would allow an assessment of benefits and risks of AVD in these settings and a better estimate of where resources could most efficiently be directed to meet the need for more and better equipment and more trained pers...

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

“…The vacuum equipment used at this center comprises Kiwi vacuum extractors (Clinical Innovations, South Murray, Utah, USA), Bird and silicone cups, with hand and foot pumps. Forceps are available, but rarely used, as is the case in many hospitals in LMICs . Spinal anesthesia during cesarean delivery is provided by anesthetic nurses or anesthesiologists.…”

“…Indications for this approach include fetal distress, prolonged second stage of labor, maternal exhaustion, or the need to avoid expulsive efforts among women with conditions such as heart failure or severe anemia . Although vacuum extraction can reduce maternal mortality from hemorrhage and sepsis—as well as perinatal mortality from birth asphyxia—use of this method has almost disappeared from obstetric practice in many LMICs . One study found that instrumental vaginal delivery was not used in almost half of 1728 Sub‐Saharan African hospitals, with usage rates below 1% in the remaining centers.…”

“…One study found that instrumental vaginal delivery was not used in almost half of 1728 Sub‐Saharan African hospitals, with usage rates below 1% in the remaining centers. Reasons for this deficit include lack of functioning equipment, lack of trained personnel, staff perceptions regarding trauma to the fetus, and fear of mother‐to‐child transmission of HIV . Consequently, many women in LMICs undergo avoidable cesarean delivery …”

Failure to perform assisted deliveries is resulting in an increased neonatal and maternal morbidity and mortality: An expert opinion

“…The majority of instrumental vaginal deliveries are conducted in the delivery room, but in a small proportion (2% to 5%), a trial of instrumental vaginal delivery is conducted in theatre with preparations made for proceeding to CD. ' A recent cross-sectional study on the use of assisted deliveries in 40 low-and middle-income countries in Latin America, sub-Saharan Africa and Asia [5] showed that only 1% of patients were delivered using AVD (either vacuum or forceps). The primary obstacle to performing an AVD was lack of healthcare workers trained in the procedure.…”

The role of operative vaginal birth in the 21st century and a way forward

“…8 OVB is underused precisely in countries where pregnant women continue to face hardships accessing emergency obstetric care and where Caesarean birth can be relatively unsafe. 9 OVB itself is not without risk. Furthermore, forceps and ventouse are associated with different risks and benefits, including long-term outcomes; there are different rates of perineal injury, and long-term possibilities of vaginal prolapse and incontinence associated with different modes of birth.…”