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

Abstract

Background: Prolonged second stage of labour is an important cause of maternal and perinatal morbidity and mortality. Vacuum extraction (VE) and second-stage caesarean section (SSCS) are the most commonly performed obstetric interventions, but the procedure chosen varies widely globally. Objectives: To compare maternal and perinatal morbidity, mortality and other adverse outcomes after VE versus SSCS. Search Strategy: A systematic search was conducted in PubMed, Cochrane and EMBASE. Studies were critically appraised using the Newcastle-Ottawa scale. Selection Criteria: All artictles including women in second stage of labour, giving birth by vacuum extraction or cesarean section and registering at least one perinatal or maternal outcome were selected. Data Collection and Analysis:The chi-square test, Fisher exact's test and binary logistic regression were used and various adverse outcome scores were calculated to evaluate maternal and perinatal outcomes. Main Results: Fifteen articles were included, providing the outcomes for a total of 20 051 births by SSCS and 32 823 births by VE. All five maternal deaths resulted from complications of anaesthesia during SSCS. In total, 133 perinatal deaths occurred in all studies combined: 92/20 051 (0.45%) in the SSCS group and 41/32 823 (0.12%) in the VE group. In studies with more than one perinatal death, both conducted in low-resource settings, more perinatal deaths occurred during the decision-to-birth interval in the SSCS group than in the VE group (5.5% vs 1.4%, OR 4.00, 95% CI 1.17-13.70; 11% vs 8.4%, OR 1.39, 95% CI 0.85-2.26). All other adverse maternal and perinatal outcomes showed no statistically significant differences. Conclusions: Vacuum extraction should be the recommended mode of birth, both in high-income countries and in low-and middle-income countries, to prevent unnecessary SSCS and to reduce perinatal and maternal deaths when safe anaesthesia and surgery is not immediately available.

First and Second Stage Labor Management

“…In a retrospective cohort study of 990 women undergoing operative delivery in the second stage, comparing those undergoing vacuum or forceps delivery with those undergoing cesarean delivery, there was no difference in rates of fetal acidemia between the groups (105). A 2023 systematic review comparing cesarean delivery and vacuum delivery in the second stage of labor that included this retrospective cohort study and 14 other studies from high-resource and lower-resource settings concluded that vacuum delivery is associated with lower maternal and perinatal mortality (106).…”

FIGO opinion paper: Drivers and solutions to the cesarean delivery epidemic with emphasis on the increasing rates in Africa and Southeastern Europe

“…In many LMICs, but also in Southeastern Europe, instrumental vaginal deliveries have almost disappeared. They carry a much lower risk for mother and child than a second‐stage cesarean, 37 and reintroduction should therefore be considered readily accomplishable. The cost of a disposable ventouse is relatively high but much lower than that of a cesarean and its associated complications.…”

A research agenda to improve incidence and outcomes of assisted vaginal birth

“… 9 Because assisted vaginal birth can reduce maternal and perinatal mortality and morbidity, including obstetric fistula, perinatal hypoxia, infection and postpartum haemorrhage associated with prolonged labour, the World Health Organization (WHO) recognizes it as an integral part of basic emergency obstetric care. 1 , 7 , 9 , 12 , 13 Major and influential obstetric societies worldwide also recognize this practice as an important component of modern childbirth management. 2 – 4 , 14 , 15 …”

“… 16 For many women, an assisted vaginal birth can therefore be safer than an emergency second-stage caesarean birth. 7 , 9 , 13 , 17 , 18 The short- and long-term risks associated with a caesarean delivery (at any stage of labour) also need to be considered, including the risks of complications in future pregnancies and on the health of the child later in life. 19 – 22 …”