Operative vaginal delivery: practice patterns and outcomes at a tertiary general hospital

INTRODUCTION@#There has been a global decrease in operative vaginal deliveries, with a marked shift towards the vacuum extractor. However, little is known about the trends in operative vaginal delivery in Singapore.@*METHODS@#A retrospective study was conducted on all operative vaginal deliveries performed from 2012 to 2017 at Singapore General Hospital (SGH). Maternal outcomes in terms of postpartum haemorrhage and obstetric anal sphincter injuries were compared between forceps- and vacuum-assisted deliveries. Neonatal outcomes in terms of neonatal intensive care unit (NICU) admission and clinically significant neonatal events were compared. The instrument preference of obstetricians was analysed.@*RESULTS@#A total of 906 consecutive operative vaginal deliveries were included in the study, comprising 461 forceps- and 445 vacuum-assisted deliveries. The rate of operative vaginal delivery was maintained at approximately 10% from 2012 to 2017. Neonatal cephalohematomas were more common after vacuum-assisted deliveries. Other maternal and neonatal outcomes did not differ significantly between the two groups. Clinically significant neonatal events were mostly due to shoulder dystocia, whereas all cases of NICU admissions were not directly related to the mode of delivery. Obstetricians' choice of instrument appeared to reflect personal preference and was not affected by the year of graduation.@*CONCLUSION@#The rates of neonatal and maternal morbidity were low at SGH. Overall instrument use of forceps and vacuum was balanced, and proficiency in both was demonstrated by all operators. Operative vaginal delivery remains an essential skill in facilitating safe vaginal delivery, which should be maintained to keep Caesarean section rates in check.

Comparison of Caesarean sections and instrumental deliveries at full cervical dilatation: a retrospective review

INTRODUCTION@#This study aimed to compare instrumental vaginal deliveries (IDs) and Caesarean sections (CSs) performed at full cervical dilatation, including factors influencing delivery and differences in maternal and neonatal outcomes.@*METHODS@#A retrospective review was conducted of patients who experienced a prolonged second stage of labour at Singapore General Hospital from 2010 to 2012. A comparison between CS and ID was made through analysis of maternal/neonatal characteristics and peripartum outcomes.@*RESULTS@#Of 253 patients who required intervention for a prolonged second stage of labour, 71 (28.1%) underwent CS and 182 (71.9%) underwent ID. 5 (2.0%) of the patients who underwent CS had failed ID. Of the maternal characteristics considered, ethnicity was significantly different. Induction of labour and intrapartum epidural did not influence delivery type. 70.4% of CSs occurred outside office hours, compared with 52.7% of IDs (p = 0.011). CS patients experienced a longer second stage of labour (p < 0.001). Babies born via CS were heavier (p < 0.001), while the ID group had a higher proportion of occipitoanterior presentations (p < 0.001). Estimated maternal blood loss was higher with CSs (p < 0.001), but neonatal outcomes were similar.@*CONCLUSION@#More than one in four parturients requiring intervention for a prolonged second stage of labour underwent emergency CS. Low failed instrumentation rates and larger babies in the CS group suggest accurate diagnoses of cephalopelvic disproportion. The higher incidence of CS after hours suggests trainee reluctance to attempt ID. There were no clinically significant differences in maternal and neonatal morbidity.

A review of Caesarean section techniques and postoperative thromboprophylaxis at a tertiary hospital

<p><b>INTRODUCTION</b>Although Caesarean sections (CSs) are among the most commonly undertaken procedures in the world, there are wide variations in the surgical techniques used. This study aimed to: (a) review the surgical techniques used for CS by obstetricians working in a tertiary hospital in Singapore; (b) compare the techniques with those recommended in evidence-based guidelines; and (c) examine the relationship between the technique used and the level of seniority of the surgeons.</p><p><b>METHODS</b>Data on 490 CSs performed in Singapore General Hospital (SGH) between 1 August 2013 and 30 June 2014 was collected from the Delivery Suite database and reviewed. The surgical techniques studied were closure of the pelvic and parietal peritoneum, closure of the uterine layer, use of surgical drains and use of postoperative thromboprophylaxis.</p><p><b>RESULTS</b>A total of 486 CSs were analysed after four cases were excluded due to missing data. Most fetal head deliveries were manual. The majority of surgeons did not close the peritoneum; most of those who did were senior surgeons. Double-layer uterine closures were done for all cases and drain usage was rare. 2.0% of the patients received grossly inadequate thromboprophylaxis.</p><p><b>CONCLUSION</b>The surgical techniques currently practised in SGH are closely aligned with those of the evidence-based guidelines. Peritoneal closure appears to be associated with the surgeon's early training, with a greater number of senior surgeons being less willing to abandon this step. Greater vigilance in implementing appropriate thromboprophylaxis is recommended.</p>

Decision-to-delivery intervals and total duration of surgery for Caesarean sections in a tertiary general hospital

<p><b>INTRODUCTION</b>This study aimed to determine the decision-to-delivery intervals (DDIs), total duration of surgery and factors influencing these for Caesarean sections (CSs).</p><p><b>METHODS</b>A retrospective study was conducted of all CSs performed from August 2013 to June 2014 at a single tertiary general hospital. Data collected included maternal demographics, indications for CS, category of urgency, DDI, total duration of surgery, grade of first surgeon and number of previous CSs.</p><p><b>RESULTS</b>In total, 488 CSs (Category 1: n = 28; Category 2: n = 137; Category 3: n = 184; Category 4: n = 139) were studied. Overall mean duration of surgery was 41.7 minutes. Mean DDI was 23.9 minutes and 64.5 minutes for Category 1 and Category 2 CSs, respectively. For Category 1 CSs, deliveries during office hours had a significantly shorter DDI than deliveries out of office hours (p < 0.05). For Category 2 CSs, deliveries during office hours had a significantly longer DDI (p < 0.05). Total duration of surgery for senior surgeons was significantly shorter than for trainee surgeons (p < 0.05). Women with no previous CSs had a significantly shorter duration of surgery than those who had one or more (p < 0.05).</p><p><b>CONCLUSION</b>The majority of the deliveries were within the recommended DDI corresponding to the degree of urgency of CS. The influence of time of day on DDI might be due to challenges of time taken to transfer patients to operating theatres. Total duration of surgery was influenced by surgical experience, history of previous CS and individual surgical styles and preferences.</p>