R Bahl

Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study

Objective To evaluate the reproductive outcome and the mode of delivery in subsequent pregnancies after instrumental vaginal delivery in theatre or caesarean section at full dilatation. Design Prospective cohort study. Setting Two urban hospitals with a combined total of 10 000 deliveries a year. Participants A cohort of 393 women with term, singleton, cephalic pregnancies who needed operative delivery in theatre during the second stage of labour from February 1999 to February 2000. Postal questionnaires were received from 283 women (72%) at three years after the initial delivery. Main outcome measure Mode of delivery in the subsequent pregnancy. Results 140 women (49%) achieved a further pregnancy at three years. 91/283 (32%) women wished to avoid a further pregnancy. Women were more likely to aim for vaginal delivery (87% (47/54) v 33% (18/54); adjusted odds ratio 15.55 (95% confidence interval 5.25 to 46.04)) and more likely to have a vaginal delivery (78% (42/54) v 31% (17/54); 9.50 (3.48 to 25.97)) if they had had a previous instrumental vaginal delivery rather than a caesarean section. There was a high rate of vaginal delivery after caesarean section among women who attempted vaginal delivery 17/18 (94%). In both groups, fear of childbirth was a frequently reported reason for avoiding a further pregnancy (51% after instrumental vaginal delivery, 42% after caesarean section; 1.75 (0.58 to 5.25)). Conclusion Instrumental vaginal delivery offers advantages over caesarean section for future delivery outcomes. The psychological impact of operative delivery requires urgent attention.

A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study.

Objective  To compare the maternal and neonatal outcomes of operative vaginal delivery in relation to the use of episiotomy.

A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery

Objective  To evaluate the maternal and neonatal morbidity of operative vaginal delivery in relation to the use of episiotomy.

A cohort study of maternal and neonatal morbidity in relation to use of sequential instruments at operative vaginal delivery

OBJECTIVE To evaluate the risk factors and maternal and neonatal morbidity associated with sequential use of instruments (vacuum and forceps) at operative vaginal delivery. STUDY DESIGN A cohort study of 1360 nulliparous women delivered by a single instrument (vacuum or forceps) or by both instruments, within two university teaching hospitals in Scotland and England. Outcomes were compared for use of sequential instruments versus use of any single instrument. A sub-group analysis compared sequential instruments versus forceps alone. Outcomes of interest included anal sphincter tears, postpartum haemorrhage, urinary retention, urinary incontinence, prolonged hospital admission, neonatal trauma, low Apgar scores, abnormal cord bloods and admission to the neonatal intensive care unit (NICU). RESULTS Use of sequential instruments at operative vaginal delivery was associated with fetal malpositions, Odds Ratio (OR) 1.8 (95% Confidence Interval (CI) 1.3-2.6), and large neonatal head circumference (>37 cm) (OR 5.0, 95% CI 2.6-9.7) but not with maternal obesity or grade of operator. Sequential use of instruments was associated with greater maternal and neonatal morbidity than single instrument use (anal sphincter tear 17.4% versus 8.4%, adjusted OR 2.1, 95% CI 1.2-3.3; umbilical artery pH <7.10, 13.8% versus 5.0%, adjusted OR 3.3, 95% CI 1.7-6.2). Sequential instrument use had greater morbidity than single instrument use with forceps alone (anal sphincter tear OR 1.8, 95% CI 1.1-2.9; umbilical artery pH <7.10 OR 3.0, 95% CI 1.7-5.5). CONCLUSIONS The use of sequential instruments significantly increases maternal and neonatal morbidity. Obstetricians need training in the appropriate selection and use of instruments with the aim of completing delivery safely with one instrument.

Maternal and neonatal morbidity in relation to the instrument used for mid-cavity rotational operative vaginal delivery: a prospective cohort study.

To compare the maternal and neonatal morbidity associated with alternative instruments used to perform a mid‐cavity rotational delivery.

Morbidity experienced by women before and after operative vaginal delivery: prospective cohort study nested within a two‐centre randomised controlled trial of restrictive versus routine use of episiotomy

To explore: (1) the antenatal and postnatal morbidity experienced by women in relation to operative vaginal delivery (OVD); and (2) the impact of restrictive versus routine use of episiotomy.

Qualitative analysis by interviews and video recordings to establish the components of a skilled low-cavity non-rotational vacuum delivery.

Objectives  The objectives of this study were to define the components of a skilled low‐cavity non‐rotational vacuum delivery (occiput anterior, vertex at station +2 or below and less than 45‐degree rotation from midline) and to facilitate the transfer of skills from expert to trainee obstetricians.

Operative vaginal delivery and episiotomy

Sir, We read with interest de Leeuw et al.’s large retrospective study evaluating the relationship between episiotomy and anal sphincter tears during forceps and vacuum deliveries.1 The results were surprising and very different from other previously published studies. First, the rate of anal sphincter injuries raises concerns about underascertainment or underreporting. The majority of deliveries were performed with the use of mediolateral episiotomy, which is similar to the practice in the UK, particularly for forceps delivery. de Leeuw et al.’s study reported an anal sphincter tear rate of 1.4% for vacuum deliveries and 2.6% for forceps deliveries. These are substantially lower than most reported rates and conflict with the well-recognised association between operative vaginal delivery and an increased risk of anal sphincter tears.2,3 Second, the magnitude of association between operative vaginal delivery without episiotomy and anal sphincter injury is extremely high. We question why obstetricians in the Netherlands continue to perform forceps delivery without episiotomy if anal sphincter tearing occurs once in every five cases (especially in the context of a very low background rate). Our findings in a Scottish study were very different for both vacuum and forceps.4 The database we used contained records completed by both the midwife and the obstetrician. In some parts of the database, only the most serious morbidity was recorded, i.e. thirdor fourth-degree tear rather than all morbidities, including use of an episiotomy. We cross-referenced all recorded variables on perineal trauma to identify inconsistencies and where necessary reverted to the handwritten records. This gave us an accurate database of the procedures used and the outcomes. The findings of the Dutch study suggest that there has been incomplete recording of all types of perineal morbidity at operative vaginal delivery, with a default to record only the most serious morbidity. We would welcome clarification on these issues and would urge caution with regards to the authors’ forceful conclusion, given the known limitations of retrospective studies.

PLD.18 Recurrence rate of Manual Removal of Placenta and associated Postpartum Haemorrhage

Introduction Recurrence rate of retained placenta requiring manual removal of placenta (MROP) varies in the reported literature. NICE guidance suggests birth at an obstetric unit for women who have previously had MROP. However, some women do give birth at home or at midwife-led units and may require emergency transfer to obstetric units for recurrent retained placenta. Aim To investigate the recurrence rate of MROP and associated postpartum haemorrhage (PPH). Method Women who had MROP and subsequent pregnancies at St. Michael’s Hospital over a ten year period (2002–2012) were identified using maternity databases. Caesarean births were excluded as the threshold for performing MROP is lower and any future deliveries would be managed in an obstetric-led unit. Results Of the 46,697 births during this period, 282 women had MROP and a subsequent pregnancy. 17.7% (50 women) had recurrent MROP. Incidence of PPH (>500 ml) was 11.7% and of major haemorrhage (>1000 ml) was 4.2%. The incidence of major haemorrhage was lower (2.7%) in women who did not have a major haemorrhage in the index pregnancy and was much lower (0.7%) in women who lost less than 500ml in the index pregnancy. Conclusions The recurrence rate of retained placenta leading to MROP is high but the incidence of associated major haemorrhage is lower, especially in women who did not have PPH in the index pregnancy. This data should help inform patients and healthcare professionals when selecting optimal place of birth in subsequent pregnancies.

A rapid cycle method for local adaptation of an obstetric emergencies training program

To describe the adaptation of an obstetric emergencies training program to align with local clinical practice.