Comparison of perinatal outcomes for all modes of second stage delivery in obstetric theatres: a retrospective observational study

Abstract

Objective To compare rates of vaginal delivery and adverse outcomes of instrumental delivery trials in obstetric theatre compared to primary emergency full dilation caesarean section. Design Retrospective cohort study. Setting University teaching hospital. Population Women with singleton, non‐anomalous, pregnancy undergoing instrumental delivery trial in obstetric theatre. Methods Data were collected from consecutive cases during 2014 until 2018 using clinical records. Multivariate regression analysis was used comparing outcomes per first delivery method. Main Outcome Measures Primary outcome was completion of vaginal delivery between all methods of instrumental delivery. Secondary outcome was a composite of immediate perinatal adverse outcomes for instrumental delivery modes and primary full dilation caesarean section. Results From 971 deliveries analysed: ventouse delivery was significantly less likely to achieve vaginal delivery compared with Keilland’s forceps delivery (odds ratio [OR] 0.42, 95% CI 0.22–0.79). Once confounding factors were adjusted for, adverse outcome rates were less frequent in the Keilland’s forceps group than with primary full dilation caesarean section (OR 0.37, 95% CI 0.16–0.81); however, the receiver operating characteristic curve produced from this model demonstrated a low predictive value (AUC 0.64). Conclusions Attempting instrumental delivery in delivery suite theatre, as an alternative to primary emergency full dilation caesarean section, is both reasonable and safe. In this study, ventouse delivery performed poorly in comparison with other modes of instrumental delivery. Further research in the form of randomised controlled trials to identify the optimal mode of second stage delivery is paramount. Tweetable abstract Instrumental delivery trials in theatre are safe but use of ventouse was associated with a higher rate of failure.

Vacuum extraction or caesarean section in the second stage of labour: A systematic review

“…Eight studies adjusted for confounding factors, and five studies specified for which confounding factors they adjusted, when comparing outcomes of SSCS with outcomes of VE. Gurney et al 32 adjusted for body mass index (BMI), birthweight, parity, mode of analgesia, operator experience, indication for trial, fetal position and fetal station in the birth canal. Halscott et al 33 controlled for maternal race, diabetes (pregestational and gestational), BMI, insurance status and hospital type.…”

“…Fifteen articles were included in the final analysis, which provided outcomes of 32 823 vacuum-assisted births and 20 051 births by SSCS (Table 1). [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42] During the critical appraisal, one study from Israel met the maximum score (Table 2). 41 Most studies (n = 12/15) did not describe the duration of follow-up for both women and neonates.…”

Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery

“…3 Infection was defined as at least one of the following: endometritis, episiotomy infection, or wound infection requiring surgery. 4 Severe maternal morbidity was defined as at least one of the following criteria: third or fourth-degree perineal lacerations, perineal hematomas, cervical laceration, extension of uterine incision in cesarean delivery, PPH greater than 1,500 mL, surgical hemostatic procedure, uterine artery embolization, blood transfusion, infections (endometritis, episiotomy infection, wound infection requiring surgery), thromboembolic event (deep vein thrombophlebitis or pulmonary embolism), admission to ICU, or maternal death. 5 All newborns hospitalized in the NICU had at least one of the composite criteria for severe neonatal morbidity.…”

“…They also were limited by methodologic flaws including small sample size, retrospective design, limited data quality and availability, and absence of propensity score analysis to limit the indication bias affecting choice of instrument. 4,[34][35][36][37][38] Any statistical approaches were limited to multivariable analyses controlling for some potential confounders. In these cases, results were consistent with our adjusted OR showing higher maternal morbidity with forceps-assisted delivery than with vacuum-assisted delivery.…”

“…O perative vaginal delivery, an alternative for avoiding cesarean birth in the late second stage, enables vaginal birth for maternal or fetal indications. [1][2][3][4][5] Operative vaginal delivery rates range from 3% to 15% worldwide, 1,[6][7][8][9] and its practice patterns vary widely, especially instrument choice among the vacuum, forceps, or spatulas (consisting of two independent solid blades not connected to each other, ie, without a fixed or sliding lock mechanism, and with a rounded cephalic curve). 10 When operative vaginal delivery is necessary, operators must choose their instrument rapidly, based on the characteristics of the woman and her labor, clinical circumstances such as fetal head station and occipital position, local practices, and their own experience and skills.…”