Parto operatorio fallido / Failed operative vaginal delivery

La tasa de parto vaginal instrumental está disminuyendo en todos los países desarrollados a costa de un aumento generalizado de la tasa de cesáreas. El parto operatorio vaginal fallido es una situación indeseada por los obstetras, que puede conllevar en algunas ocasiones un aumento de la morbilidad materno-fetal y en casos extremos un aumento de la mortalidad fetal. Estos riesgos pueden minimizarse o evitarse mediante una evaluación individualizada de cada gestante, feto y situación clínica, aplicando los protocolos recomendados por las sociedades científicas para la realización de un parto instrumental y abandonando la vía vaginal en el momento adecuado, sin prolongar el número de intentos o sin aumentar la intensidad de la tracción realizada. La experiencia en parto operatorio vaginal es imprescindible, debiéndose abandonar dicho procedimiento ante la inseguridad del obstetra (AU)

Globally, the rate of instrumental vaginal delivery is declining in all developed countries at the expense of a general increase in the rate of cesarean sections. Failed operative vaginal delivery is an undesirable situation for all obstetricians and can sometimes lead to increased maternal and fetal morbidity and, in extreme cases, to fetal mortality. These risks can be minimized or avoided through individualized assessment of each patient, fetus, and clinical situation by using the protocols recommended by scientific societies to perform instrumental delivery and abandoning the vaginal route at the appropriate moment without extending the number of attempts or increasing the intensity of the traction performed. Experience of vaginal surgery is essential, and the procedure should be abandoned whenever the obstetrician feels uncertain (AU)

[Obstetrical forceps: yesterday, today and tomorrow. Toward a new classification of obstetrical forceps]. / Les forceps hier, aujourd'hui et demain. Une nouvelle classification des forceps.

OBJECTIVE: Obstetrical forceps are used worldwide since more than 400 years. In 2003 forceps deliveries accounted for 6.3% of all deliveries of the AURORE Grand-Lyon perinatal network. Although more than 400 different forceps have been described, obstetrics handbooks neither describe experimental forceps nor provide any chapter dedicated to instrumental delivery training. Our aim was to provide junior obstetricians with information that will allow them to select the best instrument and to let them know about experimental as well as pedagogic forceps. PATIENTS AND METHODS: International literature review using the terms "forceps" and "delivery" and a four year experimental work involving a close collaboration between obstetricians and biomechanics of the INSA engineering school. RESULTS: Two instruments are presented as well as a new forceps classification. DISCUSSION AND CONCLUSION: This classification distinguishes between three types of forceps: operational forceps designed to delivers neonates, experimental forceps designed to study biomechanics and training forceps designed for resident training. For the first time the classic blind forceps procedure is transformed in a full screen real time procedure.

Utilización de vacuum extractor de copa blanda en la atención de partos vaginales / Vacuum extractor with a soft cup is used in vaginal birth deliveries

En Chile, el parto vaginal instrumentalizado está reducido al uso de fórceps y espátulas de Thierry. La tendencia mundial está dirigida al uso de vacuum extractor de copa blanda. El vacuum extractor presenta múltiples ventajas en comparación con el fórceps, tales como requerimientos analgésicos menores, técnica de fácil aprendizaje y menor incidencia de traumatismo neonatal. Presentamos nuestra experiencia con el uso de vacuum extractor de copa blanda, en casos de expulsivo detenido y sufrimiento fetal, como alternativa al fórceps. Se utilizó el vacuum en 3 pacientes, sin traumatismo materno y neonatal.

Espatulas de thierry versus forceps de kjelland

Presentamos la experiencia y evolución del parto instrumentado en nuestro Servicio de Obstetricia y Ginecología, en los últimos once años 1992-2002. La evidencia demostró que respecto de las lesiones maternas y fetales, las Espátulas (ET), o instrumento no articulado de la clasificación general de los fórceps (F), son significativamente menores cuando se las compara con el fórceps articulado y fenestrado de Kjelland o Kielland (FK), por lo que se sugiere su conocimiento y adiestramiento en los Servicios de la especialidad, y cambiar el concepto de la presa del cráneo-fetal o biparieto malar por la toma libre facio malar.

Operative delivery during labour: trends and predictive factors.

Monitoring operative delivery trends provides the opportunity to consider whether changes are in a direction that will achieve the best outcomes for mothers and their infants. The aims of this study were to identify trends in and predictors of operative delivery (forceps, vacuum or caesarean) among women who have labour; and to determine trends in the operative methods used. The study was based on 616 303 live, singleton, term births delivered between 1990 and 1997 in New South Wales, Australia. There was no change in the annual percentage of women who experienced labour and 20% had an operative birth during labour. The vacuum to forceps ratio declined from 1 : 6 in 1990 to 1 : 1 in 1997. Among women with labour, caesareans increased from 6.4% to 7.8%. For primiparae, the factors predictive of operative delivery (epidural analgesia, age > 34 years, induced or augmented labour and private care) did not change over time. A predictive model for multiparae did not have adequate fit, indicating the importance of data on prior birth history. Studies of trends in operative deliveries are most useful and consistent with decision making when interventions before the onset of labour and during labour are analysed separately. Furthermore, the vacuum:forceps ratio provides a useful tool for comparative analyses.

Tendencias en la vía de interrupción del embarazo en el Instituto Nacional de Perinatología 1985-97 / Trends in the way of delivery at the Instituto Nacional de Perinatología 1985-97

Objetivo. Presentar la casuística en cuanto la resolución del embarazo a través de operación cesárea y la tasa de utilización de fórceps a lo largo de 13 años en el Instituto Nacional de Perinatología. Material y método. Se revisaron retrospectivamente todos los expedientes clínicos de los eventos obstétricos registrados entre el 1 de enero de 1985 y el 31 de diciembre de 1997. Se estableció el número total de nacimientos indicando si se trató de partos o cesáreas. en el caso de los nacimientos vaginales se resgistró si fueron instrumentados con fórceps. Resultados. El porcentaje de nacimientos atendidos por vía abdominal fue de 44.09 por ciento con un incremento anual de 1.85 por ciento. Por su parte de los partos vaginales en el 30.74 por ciento se aplicaron fórceps, en este caso el incremento anual correspondió a 2.54 por ciento

Trends in obstetric operative procedures, 1980 to 1987.

OBJECTIVES: Increasing rates of cesarean deliveries have received widespread attention in recent years, as concern in the United States about unnecessary surgical procedures has increased. However, little information has been published on the national trends of other operative obstetric procedures occurring during deliveries. METHODS: We analyzed data from the National Hospital Discharge Survey to examine trends in the use of forceps, vacuum extraction, and cesarean section from 1980 through 1987. RESULTS: The rate of cesarean sections increased by 48%, while the rate of forceps procedures declined by 43%. Although the risk of cesarean section was significantly increased for older women, the risk of forceps and vacuum extraction procedures did not vary by age. Women with private insurance were significantly more likely to receive a cesarean section (rate ratio [RR] = 1.2), forceps procedure (RR = 1.7), and vacuum extraction procedure (RR = 1.8) than were women without private insurance. CONCLUSIONS: As pressure mounts to decrease the national cesarean section rate from 24% to 15% by the year 2000, attention should also be given to surveillance of other operative delivery procedures.

[Forceps at a university hospital. Critical study of the evolution of the procedure]. / Le forceps en hôpital universitaire. Etude critique de l'évolution de la pratique.

A retrospective study was carried out using the obstetric summaries in a computer between the years 1981 and 1986. The percentage of instrumental deliveries using forceps or spatula was significantly reduced whereas the caesarean section rate stayed the same: the majority of forceps deliveries during the year 1986 (14.5% of all deliveries) were carried out under epidural analgesia (70% of the deliveries) and the mean of these (75%) were carried out for delay. This is a definite change as compared with 1981 and it appears to be linked mainly to an increase in the number of epidural analgesics (70% for forceps deliveries in 1986) and a new appreciation of fetal distress. The maternal results were better because most episiotomies were lateral (60% of cases) which meant that only 1.5% of cases affected the sphincters. The immediate neonatal results were good, but do not seem to have been improved by the changes that have been observed, although the methodology for assessing the state of the neonate has improved.