Maternal and neonatal trauma following operative vaginal delivery

Abstract

Background: Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel. However, opportunities for training in OVD have declined and, given these shifts in practice, the safety of OVD is unknown. We estimated incidence rates of trauma following OVD in Canada, and quantified variation in trauma rates by instrument, region, level of obstetric care and institutional OVD volume. Methods:We conducted a cohort study of all singleton, term deliveries in Canada between April 2013 and March 2019, excluding Quebec. Our main outcome measures were maternal trauma (e.g., obstetric anal sphincter injury, high vaginal lacerations) and neonatal trauma (e.g., subgaleal hemorrhage, brachial plexus injury). We calculated adjusted and stabilized rates of trauma using mixed-effects logistic regression.Results: Of 1 326 191 deliveries, 38 500 (2.9%) were attempted forceps deliveries and 110 987 (8.4%) were attempted vacuum deliveries. The maternal trauma rate following forceps delivery was 25.3% (95% confidence interval [CI] 24.8%-25.7%) and the neonatal trauma rate was 9.6 (95% CI 8.6-10.6) per 1000 live births. Maternal and neonatal trauma rates following vacuum delivery were 13.2% (95% CI 13.0%-13.4%) and 9.6 (95% CI 9.0-10.2) per 1000 live births, respectively. Maternal trauma rates remained higher with forceps than with vacuum after adjustment for confounders (adjusted rate ratio 1.70, 95% CI 1.65-1.75) and varied by region, but not by level of obstetric care.Interpretation: In Canada, rates of trauma following OVD are higher than previously reported, irrespective of region, level of obstetric care and volume of OVD among hospitals. These results support a reassessment of OVD safety in Canada.

The impact of severe perineal trauma on a woman's relationship with her child: a hidden consequence

“…As these injuries predominantly occur with a first birth, women may be reluctant to have more children [31]. Some injuries may be prevented by active perineal protection at birth [3] and avoiding assisted vaginal delivery when safe to do so [32]. Better detection of the injury at the time allows immediate repair by clinicians mentored and trained to repair third and fourth degree tears, with better outcomes for bowel function in the shorter-term [33].…”

A balanced perspective on intervention at full dilation

“…The recently published article by Muraca and colleagues 1 highlights some key aspects of discussion and counselling around assisted vaginal birth. However, we have concerns regarding the study methodology and conclusions, which do not align with the reality and complexities of clinical intrapartum care.…”

Labor and delivery outcomes by delivery method in term deliveries in occiput posterior position: a population-based retrospective cohort study

“…The association of OASIs with OP OVDs is especially important to note in the Canadian population, where higher rates of OVD have recently been described 20 : among term singleton deliveries without previous CD, 11.3% were attempted OVDs, including 2.9% attempted forceps and 8.4% attempted vacuum deliveries, with 6.1% of vacuum deliveries followed by attempted sequential forceps use. 20 In our study, persistent OP position was not associated with OASI, with similarly low rates in OP/OP and OP/OA deliveries (3.6% and 5.1%, respectively; adjusted RR, 1.01 [0.92–1.10]), which contrasts with literature showing that rotated OP to OA position has lower risk of OASI than nonrotated OP/OP (24.3% vs 43.4%, respectively). 15 This discrepancy is likely because of the high rate of CD in the OP/OP delivery group in our study.…”