Correlative analysis of different treatments of persistent occipitotransverse position on the outcome for mother and infant.

OBJECTIVE: To explore the clinical feasibility of different treatment methods for persistent occipitotransverse position and the influence on maternal and infant complications. METHOD: During the trial of vaginal delivery from April 2020 to March 2023 in our hospital, the cervix was fully dilated and the presentation was located at +2 station. Ninety-six pregnant women with fetal presentation at +4 station, occipitotransverse fetal position, maternal complications, abnormalities in the second stage of labor, and or fetal distress were divided into two groups: 65 patients with Kielland forceps vaginal delivery and 31 patients underwent emergency cesarean section. The delivery time, vaginal laceration rate, postpartum blood loss volume, puerperal infection rate, neonatal birth injury rate, and neonatal 1 min Apgar scores were analyzed. RESULTS: The delivery outcomes and maternal and neonatal complications of 96 pregnant women were analyzed: the application of Kielland forceps delivery time was shorter, while the vaginal laceration rate, postpartum hemorrhage, puerperal infection rate were significantly lower than that of patients undergoing emergency cesarean section and the neonatal 1 min Apgar score was higher than that of emergency cesarean section group (p < 0.05). CONCLUSION: It was clinically appropriate to use Kielland forceps in vaginal delivery when the persistent occipitotransverse position was present and delivery needed to be expediated. Use of Kielland forceps can shorten the delivery time, improve the success rate of vaginal delivery and reduce the complications of mothers and infants.

Analysis of the obstetrician's posture and movements during a simulated forceps delivery.

BACKGROUND: The objective of this study was to identify and qualify, by means of a three-dimensional kinematic analysis, the postures and movements of obstetricians during a simulated forceps birth, and then to study the association of the obstetricians' experience with the technique adopted. METHOD: Fifty-seven volunteer obstetricians, 20 from the Limoges and 37 from the Poitiers University hospitals, were included in this multi-centric study. They were classified into 3 groups: beginners, intermediates, and experts, beginners having performed fewer than 10 forceps deliveries in real conditions, intermediates between 10 and 100, and experts more than 100. The posture and movements of the obstetricians were recorded between December 2020 and March 2021 using an optoelectronic motion capture system during simulated forceps births. Joint angles qualifying these postures and movements were analysed between the three phases of the foetal traction. These phases were defined by the passage of a virtual point associated with the forceps blade through two anatomical planes: the mid-pelvis and the pelvic outlet. Then, a consolidated ascending hierarchical classification (AHC) was applied to these data in order to objectify the existence of groups of similar behaviours. RESULTS: The AHC distinguished four different postures adopted when crossing the first plane and three different traction techniques. 48% of the beginners adopted one of the two raised posture, 22% being raised without trunk flexion and 26% raised with trunk flexion. Conversely, 58% of the experts positioned themselves in a "chevalier servant" posture (going down on one knee) and 25% in a "squatting" posture before initiating traction. The results also show that the joint movement amplitude tends to reduce with the level of expertise. CONCLUSION: Forceps delivery was performed in different ways, with the experienced obstetricians favouring postures that enabled observation at the level of the maternal perineum and techniques reducing movement amplitude. The first perspective of this work is to relate these different techniques to the traction force generated. The results of these studies have the potential to contribute to the training of obstetricians in forceps delivery, and to improve the safety of women and newborns.

Rapid cycle deliberate practice: application in forceps simulation training for gynecology and obstetrics residents.

BACKGROUND: Rapid Cycle Deliberate Practice (RCDP) has gained prominence in recent years as an innovative teaching method in simulation-based training for adult and pediatric emergency medical skills. However, its application in the training of forceps delivery skills among obstetrics and gynecology residents remains unexplored. This study aimed to assess the impact of RCDP in this domain. METHODS: Conducted in March 2021, this randomized controlled study involved 60 second-year obstetrics and gynecology residents undergoing standardized training. Participants were randomly assigned to the RCDP group or the traditional teaching method (TTM) group, each comprising 30 residents. The RCDP group followed the RCDP practice mode, while the TTM group adhered to conventional simulation teaching. Post-training assessment of operational proficiency was conducted immediately and after one year. Independent operational confidence and training satisfaction were evaluated through questionnaire surveys and the Satisfaction with Simulation Experience (SSE) scale. Data analysis utilized SPSS 23.0. RESULTS: The RCDP group displayed significantly higher immediate post-training forceps operation scores compared to the TTM group (92.00 [range: 90.00-94.00] vs. 88.00 [range: 86.75-92.00]; z = 3.79; p < .001). However, no significant difference emerged in forceps operation scores after one year (86.00 [range: 85.00-88.00] vs. 85.50 [range: 84.00-88.25]; z = 0.54; p = .59). The RCDP group exhibited notable performance improvement over the TTM group (z = 3.49; p < .001). Independent operation confidence showed no significant discrepancy (p > .05). Importantly, the RCDP group reported higher satisfaction scores, particularly in the Debriefing and Reflection subscale (44.00 [range: 43.00-45.00] vs. 41.00 [range: 41.50-43.00]; z = 5.24; p < .001), contributing to an overall superior SSE score (z = 4.74; p < .001). CONCLUSIONS: RCDP exhibits immediate efficacy in elevating forceps delivery skills among residents. However, sustained skill enhancement necessitates innovative approaches, while RCDP's value lies in tailored feedback and reflection for enriched medical education.

Rapid Cycle Deliberate Practice (RCDP) demonstrates immediate effectiveness in enhancing forceps delivery skills among obstetrics and gynecology residents, leading to improved immediate performance, which also increased their satisfaction with the teaching process and operational confidence.Long-term skill retention through RCDP appears limited, highlighting the importance of ongoing reinforcement to prevent skill decay and maintain proficiency.

Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it?

Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor.

A new approach to assessing the obstetrician's posture and movement during an instrumental forceps delivery.

INTRODUCTION: The number of deliveries by forceps decreases significantly in favour of the vacuum. Now, when the use of forceps is necessary, physicians less experimented with this procedure are likely to induce serious and preventable perineal or foetal injuries. Training therefore becomes essential. However, there are no clear recommendations on the technique to perform a delivery by forceps, namely the body posture and gesture to adopt. Our goal is then to provide a protocol that can help to determine if there is an optimal technique to perform a delivery by forceps. METHOD: We will include voluntary participants whose level of experience and type of practice differ. We will propose to record their postures and gestures using an optoelectronic motion analysis system during a forceps delivery simulated on a mannequin. We will also measure the traction force produced by the subject on the forceps using force platforms and technical markers placed on the forceps. We will then perform a principal component analysis to look for similar motion patterns. EXPECTED RESULTS: We plan to analyse about fifty participants (25 seniors and 25 juniors). Our hypothesis is that the realism of the simulation will be deemed satisfactory by the participants, that the experimental conditions will not modify their gestures, and that the degree of experience will result in different techniques. CONCLUSION: A better knowledge on the posture and gesture to adopt to realise a forceps delivery should improve the safety of women and new-borns. The results of this study could also be a valuable contribution for the training of obstetricians.

Predictive factors for obstetric anal sphincter injury in primiparous women: systematic review and meta-analysis.

OBJECTIVES: The primary objective was to perform a systematic review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the diagnosis made by ultrasound (US-OASI). The secondary objective was to report on incidence rates of sonographic anal sphincter (AS) trauma, including trauma that was not clinically reported at childbirth, among the studies providing data for our primary objective. METHODS: We conducted a systematic search of MEDLINE, EMBASE, Web of Science, CINAHL, The Cochrane Library and ClinicalTrials.gov databases. Both observational cohort studies and interventional trials were eligible for inclusion. Study eligibility was assessed independently by two authors. Random-effects meta-analyses were performed to pool effect estimates from studies reporting on similar predictive factors. Summary odds ratio (OR) or mean difference (MD) is reported with 95% CI. Heterogeneity was assessed using the I2 statistic. Methodological quality was assessed using the Quality in Prognosis Studies tool. RESULTS: A total of 2805 records were screened and 21 met the inclusion criteria (16 prospective cohort studies, three retrospective cohort studies and two interventional non-randomized trials). Increasing gestational age at delivery (MD, 0.34 (95% CI, 0.04-0.64) weeks), shorter antepartum perineal body length (MD, -0.60 (95% CI, -1.09 to -0.11) cm), labor augmentation (OR, 1.81 (95% CI, 1.21-2.71)), instrumental delivery (OR, 2.13 (95% CI, 1.13-4.01)), in particular forceps extraction (OR, 3.56 (95% CI, 1.31-9.67)), shoulder dystocia (OR, 12.07 (95% CI, 1.06-137.60)), episiotomy use (OR, 1.85 (95% CI, 1.11-3.06)) and shorter episiotomy length (MD, -0.40 (95% CI, -0.75 to -0.05) cm) were associated with US-OASI. When pooling incidence rates, 26% (95% CI, 20-32%) of women who had a first vaginal delivery had US-OASI (20 studies; I2 = 88%). In studies reporting on both clinical and US-OASI rates, 20% (95% CI, 14-28%) of women had AS trauma on ultrasound that was not reported clinically at childbirth (16 studies; I2 = 90%). No differences were found in maternal age, body mass index, weight, subpubic arch angle, induction of labor, epidural analgesia, episiotomy angle, duration of first/second/active-second stages of labor, vacuum extraction, neonatal birth weight or head circumference between cases with and those without US-OASI. Antenatal perineal massage and use of an intrapartum pelvic floor muscle dilator did not affect the odds of US-OASI. Most (81%) studies were judged to be at high risk of bias in at least one domain and only four (19%) studies had an overall low risk of bias. CONCLUSION: Given the ultrasound evidence of structural damage to the AS in 26% of women following a first vaginal delivery, clinicians should have a low threshold of suspicion for the condition. This systematic review identified several predictive factors for this. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Influence of Different Obstetric Factors on Early Postpartum Pelvic Floor Function in Primiparas After Vaginal Delivery.

Purpose: This study sought to explore the obstetric factors affecting early postpartum pelvic floor function of primiparas after vaginal delivery. Patients and Methods: We included 3362 primiparas who underwent postpartum re-examination in International Peace Maternity and Child Health Hospital at 42-60 days after delivery. The Glazer Protocol was used to evaluate their pelvic floor function, and univariate and multivariate logistic regression analyses were performed to identify obstetric factors that might affect it. Results: Forceps-assisted delivery significantly increased the risk of the decline in fast- and slow-twitch muscle strength in the early postpartum period when compared with natural vaginal delivery (P < 0.05). Women with a pre-pregnancy body mass index (BMI) of ≥18.5 kg/m2 had a decreased risk of decline in fast-twitch muscle strength than those with a pre-pregnancy BMI of <18.5 kg/m2 (P < 0.05). Women who had a pre-pregnancy BMI of 24.0 to <28.0 kg/m2 bore a decreased risk of decline in slow-twitch muscle strength than those with a pre-pregnancy BMI of <18.5 kg/m2 (P < 0.05). The risk of decline in fast-twitch muscle strength and slow-twitch muscle in women with anemia during pregnancy was significantly increased (P < 0.05); women with second-stage labors of >2 h had an increased risk of fast-twitch and slow-twitch muscle strength decline than those with <2 h (P < 0.05). Conclusion: Both pre-pregnancy underweight and obesity may cause impairment of early postpartum pelvic floor function. Forceps delivery, anemia during pregnancy, and the length of second stage of labor are independent factors leading to pelvic floor function impairment.

Maternal and neonatal complications following Kielland's rotational forceps delivery: A systematic review and meta-analysis.

BACKGROUND: There is conflicting evidence regarding the safety of Kielland's rotational forceps delivery (KRFD) in comparison with other modes of delivery for the management of persistent fetal malposition in the second stage of labour. OBJECTIVES: To derive estimates of risks of maternal and neonatal complications following KRFD, compared with rotational ventouse delivery (RVD), non-rotational forceps delivery (NRFD) or a second-stage caesarean section (CS), from a systematic review and meta-analysis of the literature. SEARCH STRATEGY: Standard search methodology, as recommended by the Cochrane Handbook for Systematic Reviews of Interventions. SELECTION CRITERIA: Case series, prospective or retrospective cohort studies and population-based studies. DATA COLLECTION AND ANALYSIS: A meta-analysis using a random-effects model was used to derive weighted pooled estimates of maternal and neonatal complications. MAIN RESULTS: Thirteen studies were included. For postpartum haemorrhage there was no significant difference between Kielland's and ventouse delivery; the rate was lower in Kielland's delivery compared with non-rotational forceps (RR 0.79, 95% CI 0.65-0.95) and second-stage CS (RR 0.45, 95% CI 0.36-0.58). There were no differences in the rates of anal sphincter injuries or admission to neonatal intensive care. Rates of shoulder dystocia were higher with Kielland's delivery compared with ventouse delivery (RR 1.79, 95% CI 1.08-2.98), but rates of neonatal birth trauma were lower (RR 0.49, 95% CI 0.26-0.91). There were no differences seen in the rates of 5-min APGAR score < 7 between Kielland's delivery and other instrumental births, but they were lower when compared with second-stage CS (RR 0.47, 95% CI 0.23-0.97). CONCLUSIONS: Kielland's rotational forceps delivery is a safe option for the management of fetal malposition in the second stage of labour.

Prognostic accuracy of ultrasound measures of fetal head descent to predict outcome of operative vaginal birth: a comparative systematic review and meta-analysis.

OBJECTIVE: This study aimed to compare the prognostic accuracy of intrapartum transperineal ultrasound measures of fetal descent before operative vaginal birth in predicting complicated or failed procedures. DATA SOURCES: We performed a predefined systematic search in Medline, Embase, CINAHL, and Scopus from inception to June 10, 2022. STUDY ELIGIBILITY CRITERIA: We included studies assessing the following intrapartum transperineal ultrasound measures before operative vaginal birth to predict procedure outcome: angle of progression, head direction, head-perineum distance, head-symphysis distance, midline angle, and/or progression distance. METHODS: Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate meta-analysis was used to pool sensitivities and specificities into summary receiver operating characteristic curves for each intrapartum transperineal ultrasound measure. Subgroup analyses were performed for measures taken at rest vs with pushing and prediction of failed vs complicated operative vaginal birth. RESULTS: Overall, 16 studies involving 2848 women undergoing attempted operative vaginal birth were included. The prognostic accuracy of intrapartum transperineal ultrasound measures taken at rest to predict failed or complicated operative vaginal birth was high for angle of progression (area under the receiver operating characteristic curve, 0.891; 9 studies) and progression distance (area under the receiver operating characteristic curve, 0.901; 3 studies), moderate for head direction (area under the receiver operating characteristic curve, 0.791; 6 studies) and head-perineum distance (area under the receiver operating characteristic curve, 0.747; 8 studies), and fair for midline angle (area under the receiver operating characteristic curve, 0.642; 4 studies). There was no study with sufficient data to assess head-symphysis distance. Subgroup analysis showed that measures taken with pushing tended to have a higher area under the receiver operating characteristic curve for angle of progression (0.927; 4 studies), progression distance (0.930; 2 studies), and midline angle (0.903; 3 studies), with a similar area under the receiver operating characteristic curve for head direction (0.802; 4 studies). The prediction of failed vs complicated operative vaginal birth tended to be less accurate for angle of progression (0.837 [4 studies] vs 0.907 [6 studies]) and head direction (0.745 [3 studies] vs 0.810 [5 studies]), predominantly because of lower specificity, and was more accurate for head-perineum distance (0.812 [6 studies] vs 0.687 [2 studies]). CONCLUSION: Angle of progression, progression distance, and midline angle measured with pushing demonstrated the highest prognostic accuracy in predicting complicated or failed operative vaginal birth. Overall, the measurements seem to perform better with pushing than at rest.

Comparison of teaching effect of hands-on instruction versus video demonstration in forceps delivery for training residents / 中华全科医师杂志

Objective:To evaluate the effectiveness of hands-on training and video demonstration in training of forceps delivery for residents.Methods:Forty nine residents who were rotating in the obstetrics department of Peking Union Medical College Hospital from 2019 to 2021 were enrolled. The residents were randomly divided into two groups: the instructor group ( n=24) was taught by hands-on training of forceps delivery and the video group ( n=25) was instructed by watching video demonstration. All the trainees completed the self-confidence questionnaire survey, and were evaluated by written tests and objective structured assessment of technical skills scoring system. Results:The scores of self-confidence in each item after the simulation training were higher than those before training in both groups; and there were no significant differences between two groups in the increment of scores(mastering knowledge: 1.54±0.98 vs. 1.40±0.71, U=266.68, P=0.480;mastering operation skills: 1.42±0.93 vs.1.80±0.87, U=233.47, P=0.161; mastering forceps structure: 1.63±1.10 vs. 1.88±0.93, U=261.63, P=0.416; confidence in independent operation: 1.13±0.90 vs. 1.00±1.08, U=287.74, P=0.799; evaluation of simulation training: 0.21±0.51 vs. 0.16±0.55, U=288.27, P=0.776). In the written tests, the scores of the instructor group were significantly higher than those of the video group (83.00±7.18 vs.70.56±10.37; t=4.86, P<0.001). In the practical operation, the instructor group significantly outperformed the video group in items of “right blade placement” (0.71±0.46 vs. 0.20±0.41, U=147.54, P<0.001), “objective total score” (6.17±1.46 vs. 4.72±1.65, U=155.49, P=0.003) and “correct traction” (0.85±0.31 vs. 0.56±0.51, U=213.86, P=0.036). Conclusion:Training delivered via hands-on instruction and demonstration was generally more effective than that delivered via video, although both groups show a increased self-confidence in learning and performing forceps delivery.

Caesarean section, vaginal instrumental delivery and perineal morbidity in the Slovak Republic in the years 2007-2018.

OBJECTIVE: Analysis of caesarean section, vaginal instrumental deliveries and severe perineal morbidity in the Slovak Republic in the years 2007-2018. METHODS: The analysis of prospectively collected caesarean section and vaginal instrumental delivery data in the years 2007-2018, and episiotomies and severe perineal morbidity data in the years 2008-2018 from obstetrics hospitals in the Slovak Republic. RESULTS: Caesarean section rate progressively increased from 24.1% in 2007 up to 30.8% in 2013 and decreased to 29.6% in 2018. Vacuum-extraction frequency was 1.3% in 2007 and increased up to 2.0% till 2018. Forceps frequency decreased since 2008-2018 from 0.56% to 0.43%. In the years 2008-2018, frequency of perineal tears of the 3rd and 4th degree increased from 0.4% to 0.8%. Frequency of episiotomies decreased in the years 2008-2018 from 74.7% to 47.7%. CONCLUSION: The highest caesarean section rate in the Slovak Republic - 30.8% occurred in 2013, but slowly decreased in the following years. The frequency of vacuum extraction increased and forceps decreased. Frequency of episiotomies had decreased and severe perineal tears held an increasing trend.

Effect of perineum protection cooperated by two operators in the forceps-assisted vaginal delivery: a case-control study.

OBJECTIVE: To investigate the effect of unique skill of perineum protection in forceps delivery on the maternal and neonatal morbidity. METHODS: A case-control study was conducted. Singleton pregnancies with forceps-assisted and normal vaginal deliveries were recruited. The maternal and neonatal complications were compared between forceps and normal deliveries. RESULTS: Five hundred forty participants were included. The prevalence of maternal anal sphincter injury, postpartum hemorrhage, vaginal hematoma, cervical laceration, perineal wound infection, perineal wound dehiscence, dyspareunia, urinary incontinence, and anal incontinence were not significantly different between forceps and normal deliveries (p > .05). However, the rate of neonatal facial injury was higher in the forceps group (2.9% versus 0, p = .004). CONCLUSIONS: Cooperation according to the tension of perineum and labor process between obstetrician and midwife is important for perineum protection. Forceps-assisted delivery concentrating on perineum protection is an effective alternative in decreasing maternal morbidity.

Kielland's rotational forceps delivery: comparison of maternal and neonatal outcomes with pregnancies delivering by non-rotational forceps.

We compared complications in pregnancies that had Kielland's rotational forceps delivery (KRFD) with non-rotational forceps delivery (NRFD). Maternal outcomes included post-partum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS); neonatal outcomes included admission to neonatal intensive care unit (NICU), 5-minute Apgar scores <7, hypoxic ischaemic encephalopathy (HIE), jaundice, shoulder dystocia and birth trauma. The study population included 491 (2.1%) requiring KRFD, 1,257 (5.3%) requiring NRFD and 22,111 (93.0%) that had SVD. In pregnancies with NRFD compared to KRFD, there was higher incidence of OASIS (8.5% vs. 4.7%; p = .006) and a non-significant increased trend for PPH (15.0% vs. 12.4%; p = .173). There was no significant difference in rates of admission to NICU (p = .628), 5-minute Apgar score <7 (p = .375), HIE (p = .532), jaundice (p = .809), severe shoulder dystocia (p = .507) or birth trauma (p = .514). Our study demonstrates that KRFD has lower rates of maternal complications compared to NRFD whilst the rates of neonatal complications are similar.IMPACT STATEMENTWhat is already known on this subject? Kielland's rotational forceps is used for achieving vaginal delivery in pregnancies with failure to progress in second stage of labour secondary to fetal malposition. The use of Kielland's forceps has significantly declined in the last few decades due to concerns about an increased risk of maternal and neonatal complications, despite the absence of any major studies demonstrating this increased risk.What do the results of this study add? There are some studies which compare the risks in pregnancies delivering by Kiellands forceps with rotational ventouse deliveries but there is limited evidence comparing the risks of rotational with non-rotational forceps deliveries. Our study compares the major maternal and neonatal complications in a large cohort of pregnancies undergoing rotational vs. non-rotational forceps deliveries.What are the implications of these findings for clinical practice and/or further research? The results of our study demonstrate that maternal and neonatal complications in pregnancies delivering by Kielland's rotational forceps undertaken by appropriately trained obstetricians are either lower or similar to those delivering by non-rotational forceps. Consideration should be given to ensure that there is appropriate training provided to obstetricians to acquire skills in using Kielland's forceps.

Surface electromyography of the pelvic floor at 6-8 weeks following delivery: a comparison of different modes of delivery.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to compare the impact of different modes of delivery, especially forceps delivery (FD), on pelvic floor muscles (PFMs) through vaginal surface electromyography (sEMG) in primiparous women at early (6-8 weeks) postpartum. METHODS: A total of 1259 primiparous women with full-term singleton births were included in this cross-sectional study. Of these, 98 were delivered by forceps, 865 underwent spontaneous vaginal delivery (SD) and 296 underwent elective cesarean delivery (CD). Clinical demographic characteristics and vaginal sEMG variables of parturients 6-8 weeks after birth were collected and analyzed using SPSS software. One-way ANOVA with Bonferroni correction, Chi-square test or Student's t-test was used according to the variable type. Spearman correlation and binary logistic regression analyses were also used. P/α ≤ 0.05 was considered statistically significant. RESULTS: Amplitude of fast and sustained contractions on sEMG in the FD group was significantly lower compared with the CD and SD groups. The sEMG amplitude of all contractions was significantly higher in the CD group compared with the FD and SD groups (P < 0.01). According to binary logistic regression analysis, mode of delivery was a major influencing factor in sEMG. CONCLUSIONS: An early postpartum sEMG test appears to be helpful for the assessment of PFM activity. Mode of delivery was a major influencing factor on sEMG. Forceps delivery significantly inversely influenced PFM activity.

Risk analysis of poor wound healing in forceps delivery.

AIM: This study aims to explore the risk factors leading to poor wound healing after forceps delivery. METHOD: In this retrospective study, 74 patients undergoing forceps delivery with poor wound healing were compared with contemporary randomly selected 74 patients undergoing forceps delivery but with normal wound healing. RESULTS: Compared to the normal healing group, the poor healing group had larger birthweight (p = 0.01), longer labor length (805.9 ± 356.4 min vs. 572.9 ± 306.3 min, p < 0.001), more virginal checks (4.0 ± 1.5 vs. 3.4 ± 1.7, p = 0.029), and more contaminated amniotic fluid (p = 0.043). More patients in poor healing group suffered from postpartum fever (52.7% vs. 21.6%, p < 0.001), postpartum hemorrhage (p < 0.001), and anemia after delivery (p < 0.001). Labor length (odds ratio (OR) 1.125, 95% confidence interval [CI] = 1.033-1.226), anemia after delivery (OR 3.621, 95% CI = 2.077-6.314), postpartum fever (OR 7.100, 95% CI = 2.505-20.124), and degree of laceration (OR 3.067, 95% CI = 1.258-7.479) were the risk factors of poor healing of perineal wound after forceps delivery, while postpartum antibiotics (OR 0.303, 95% CI = 0.098-0.937) and suture removal days (OR 0.272, 95% CI = 0.133-0.556) were the protective factors. CONCLUSION: To promote the wound healing from the forceps delivery, obstetricians may consider to control the patient's labor length and degree of laceration, increase patient's nutrition, apply prophylactic antibiotics, and prolong the suture removal days.

Training the skills of obstetric forceps delivery for resident doctors by using simulation teaching method / 中华医学教育探索杂志

In this study, 15 second-year resident doctors who had standardized training of OBGYN were taken as research subjects to discuss the effect of training resident doctors with obstetrics forceps by using simulation teaching method. The simulation teaching process includes theoretical study, theoretical examination, simulation teaching of forceps skills and Assessment of forceps skills. In theoretical study section: before learning to use forceps, the students acquired the theoretical knowledge by flipped teaching micro-video mode. In theoretical examination section: the mastery of basic clinical knowledge of using forceps was evaluated through online assessment. In simulation teaching of forceps skills: students who scored 8/10 points were admitted to enter the simulation teaching process, and they had practical training of scenario simulation skills in Clinical Skills Center. In assessment of forceps skills: the mastery of forceps skills was evaluated by standardized forceps delivery procedure items. The results showed that the students in the simulation teaching group had excellent teaching assessment results, and the resident doctors had more confidence in operating forceps independently, and the teaching effect was ideal, which could further promote the simulation teaching of obstetric clinical skills.

Kielland's rotational forceps delivery: A comparison of maternal and neonatal outcomes with rotational ventouse or second stage caesarean section deliveries.

OBJECTIVES: The objective of our study was to derive accurate estimates of risks of maternal and neonatal complications associated with Kielland's rotational forceps delivery (KRFD) compared to rotational ventouse delivery (RVD) or 2nd stage caesarean section (CS). METHODS: This was a retrospective cohort study undertaken at a large tertiary maternity and neonatal unit in the United Kingdom between January 2010 and June 2018. Pregnancies with fetal demise, major fetal defects, those lost to follow-up, those delivering by elective or emergency CS in the first stage of labour and non-rotational instrumental deliveries were excluded. The study population included singleton pregnancies delivering by Kielland's forceps, rotational ventouse, 2nd stage CS or spontaneous unassisted cephalic vaginal delivery; the latter forming the control group. The maternal outcomes examined included post-partum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS). The neonatal outcomes included admission to neonatal intensive care unit (NICU), 5-minute Apgar scores <7, hypoxic ischaemic encephalopathy (HIE), jaundice, shoulder dystocia and birth trauma. Absolute risks with 95 % confidence intervals (CI) were calculated in the study groups. Univariate and multivariate logistic regression analysis was carried out to estimate crude and adjusted odds ratio (OR) with 95 % CI. RESULTS: The study population of 23,786 pregnancies included: 491 (2.1 %) requiring KRFD, 344 (1.4 %) requiring RVD, 840 (3.5 %) that had a 2nd stage CS and 22,111 (93.0 %) spontaneous cephalic vaginal deliveries. With regard to maternal adverse outcomes, in pregnancies that had a KRFD compared to RVD, there was no significant difference in the incidence of OASIS (p = 0.599) or PPH (p = 0.982). In contrast, the risk of PPH was significantly higher in those delivering by a 2nd stage CS compared to KRFD (27.5 % vs. 12.4 %; p < 0.0001). With regard to neonatal adverse outcomes, in those delivering by KRFD compared to RVD and 2nd stage CS, there was no significant difference in the incidence of admission to NICU (p = 0.912; p = 0.746, respectively), 5-minute Apgar score<7 (p = 0.335; p = 0.150, respectively), jaundice (p = 0.810; p = 0.332, respectively), mild shoulder dystocia (p = 0.077), severe shoulder dystocia (p = 0.603) or birth trauma (p = 0.265; p = 0.323, respectively). The risk of maternal composite adverse outcome was highest after 2nd stage CS (OR 7.68; 95 %CI: 6.52-9.04) and lowest after KRFD (OR 3.82; 95 %CI: 2.98-4.91). The risk of composite neonatal adverse outcome was higher in those delivering by RVD (OR 2.87; 95 %CI: 2.10-3.91), compared to KRFD (OR 2.23; 95 %CI: 1.67-2.97) or 2nd stage CS (OR 2.02; 95 %CI: 1.60-2.54). CONCLUSION: Our study demonstrates that KRFD is a safer management option when compared to RVD or 2nd stage CS for the management of persistent fetal malposition in labour.

Women's, partners' and healthcare providers' views and experiences of assisted vaginal birth: a systematic mixed methods review.

BACKGROUND: When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use. METHODS: Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix. RESULTS: Forty-two studies (published 1985-2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies. CONCLUSIONS: Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.

SMFM Special Statement: Operative vaginal delivery: checklists for performance and documentation.

The frequency of operative vaginal delivery has been declining, even though it can be an attractive alternative to cesarean delivery in selected cases. Performance of operative vaginal delivery required consideration of many indications, contraindications, and prerequisites. Optimal documentation of operative vaginal delivery requires the recording of several specific elements that are unique to forceps or vacuum delivery. A cognitive aid such as a checklist is well suited to this situation in which there are numerous elements to consider, a low frequency of performance, and teams with variable expertise. We propose 2 checklists to help ensure that all relevant elements are considered for every operative vaginal delivery: (1) a checklist for preparation and performance of the procedure and (2) a checklist for documentation. We suggest practical tips to help facilities adapt these checklists to their own circumstances and implement them on their units.