Erica Wu

Temporal trends and morbidities of vacuum, forceps, and combined use of both

Abstract Objective: To assess trends over time of operative vaginal delivery and compare delivery-related morbidity between vacuum delivery, forceps delivery, or combined use of both in California. Methods: California ICD-9 discharge data from 2001 to 2007 were used to identify cases of forceps and vacuum delivery. Results: There was a decline in all operative delivery types (9.0% in 2001 to 7.6% in 2007), with the decline in the use of forceps most pronounced (7.26/1000 deliveries in 2001 to 3.85/1000 in 2007). Higher rates of third/fourth degree lacerations, postpartum hemorrhage, manual extraction of placenta, pelvic hematoma requiring evacuation, cervical laceration repair, and thromboembolic events were noted in forceps compared to vacuum deliveries. When both instruments were used, rates of third/fourth degree lacerations and postpartum hemorrhage were increased. Operative delivery failure was highest in combined use compared to forceps or vacuum alone. Conclusion: The incidence of operative vaginal delivery in California is declining, with decreasing use of forceps most notable. Several maternal morbidities are increased in forceps and combined deliveries compared to vacuum deliveries. There is a significantly higher risk of failure when two operative delivery methods are employed. These findings may be contributing to the declining willingness of providers to perform operative vaginal delivery.

Implementation of an obstetric hemorrhage risk assessment: validation and evaluation of its impact on pretransfusion testing and hemorrhage outcomes

Abstract Objective: To evaluate the impact of an obstetric hemorrhage risk assessment on pretransfusion testing and hemorrhage outcomes at a tertiary care, academic medical center. Methods: A retrospective cohort study was performed among women delivering neonates ≥24 weeks from 2009 to 2011. Demographics, pretransfusion testing rates and hemorrhage outcomes were compared between those delivering before and after implementation of the risk assessment. Multivariable analyses were used to determine predictors of postpartum hemorrhage and transfusion. Results: There were 1388 women delivering before and 2121 women delivering after implementation of the risk assessment. More pretransfusion testing occurred after the assessment was initiated (22.8% versus 15.0%). Those who were considered high-risk were more likely to experience hemorrhage outcomes. In multivariable analyses, physician ordering practice in the pre-risk assessment period was a better prognosticator of both postpartum hemorrhage (aOR 9.98, 95% CI 5.02–19.82) and transfusion (aOR 31.14, 95% CI 14.97–64.82) than completion of a cross-match after implementation of the risk assessment (postpartum hemorrhage: aOR 2.10, 95% CI 1.20–3.66, transfusion: aOR 6.31, 95% CI 3.34–11.94). Conclusions: Pre-risk assessment practice may be better at identifying those in need of blood transfusion, strictly due to the necessity for pretransfusion orders for transfusion to occur. In contrast, the obstetric hemorrhage risk assessment accurately predicted those who were more likely to experience hemorrhage outcomes. Optimal utilization of the risk assessment has yet to be determined.

Declining VBAC Rates Despite Improved Delivery Outcomes Compared to Repeat Cesarean Delivery [20Q]

INTRODUCTION: To describe the incidence and sociodemographic features of vaginal birth after cesarean (VBAC) and to compare delivery-related outcomes of patients undergoing VBAC when compared to repeat cesarean delivery (RCD). METHODS: A retrospective cohort study was performed using California discharge data. All deliveries from 2001–2009 were analyzed. VBAC cases as well as other delivery-related morbidities were identified via ICD-9-CM code. Logistic regression was performed to adjust for potential confounders. RESULTS: Out of 663,700 women with prior cesarean delivery, 14.2% underwent VBAC. VBAC incidence decreased considerably during the time period, from a peak of 23.7% down to about 10.9%. Caucasians, those with government-funded insurance, and extremes of age had the lowest VBAC rates. VBAC rates were significantly lower in subjects with gestational diabetes, preeclampsia, eclampsia, multiple gestations, preterm delivery, and obesity. There were 234 total cases of uterine rupture identified in the cohort, comprising a uterine rupture rate of 3.5 in 10,000. VBAC, when compared to RCD, was associated with increase in some vaginal delivery related morbidity, such as manual placental extraction, third/fourth degree laceration, and postpartum hemorrhage. RCD, however, was associated with increased rates of postpartum endometritis and anesthesia-related complications, as well as severe morbidities such coagulopathy and hysterectomy. CONCLUSION: VBAC levels overall declined during the study period. Subjects with certain co-morbid conditions are less likely to undergo VBAC. Given the overall low uterine rupture rate of VBAC, and evidence of increased serious morbidity of repeat CD, initiatives should be undertaken to encourage providers to offer VBAC to their patients.