"To get the baby out off the hook": a prospective, longitudinal, multicenter, observational study about decision making in vacuum-assisted operative vaginal delivery.

BACKGROUND: Since operative vaginal delivery may be risky for women and might cause neonatal complications, the aim of this study is to assess appropriateness of the procedure. This is a prospective, longitudinal, multicenter, observational study and it was conducted in three Italian Obstetric Units (Pisa, Massa Carrara and Prato). All term pregnant women, either nulliparous and multiparous, with singleton pregnancy and a cephalic fetus, with spontaneous or induced labour, requiring vacuum-assisted delivery were enrolled. Indications to operative vaginal delivery were grouped as alterations of fetal cardiotocography (CTG) patterns, delay/arrest of second stage of labour or elective shortening of second stage of labour. A board consisting of five among authors evaluated appropriateness of the procedure. RESULTS: Overall, 466 women undergoing operative vaginal deliveries were included. Cardiotocography, classified as ACOG category 2 or 3 was the indication for vacuum assisted delivery in 253 patients (54.29%). Among these, 66 women (26.1%) had an operative vaginal delivery which was then considered to be inappropriate, while in 114 cases (45.1%) CTG traces resulted to be unreadable. CONCLUSION: Decision making process, which leads clinicians to go for operative vaginal delivery, is often influenced by shortness of time and complexity of the situation. Therefore, clinicians tend to intervene performing vacuum delivery without adopting critical analysis and without adequately considering the clinical situation. Operative vaginal delivery might be a risky procedure and should be performed only when clinically indicated and after adequate critical analysis.

Low use of vacuum extraction: Health care Professionals' Perspective in a University Hospital, Dar es Salaam.

BACKGROUND: Use of vacuum extraction (VE) has been declining in low and middle income countries. At the highest referral hospital Tanzania, 54% of deliveries are performed by caesarean section (CS) and only 0.8% by VE. Use of VE has the potential to reduce CS rates and improve maternal and neonatal outcomes but causes for its low use is not fully explored. METHOD: During November and December of 2017 participatory observations, semi-structured in-depth interviews (n = 29) and focus group discussions (n = 2) were held with midwives, residents and specialists working at the highest referral hospital in Tanzania. Thematic analysis was used to identify rationales for low VE use. FINDINGS: Unstructured and inconsistent clinical teaching structure, interdependent on a fear and blame culture, as well as financial incentives and a lack of structured, adhered to and updated guidelines were identified as rationales for CS instead of VE use. Although all informants showed positivity towards clinical teaching of VE, a subpar communication between clinics and academia was stated as resulting in absent clinical teachers and unaccountable students. CONCLUSION: This study draws connections between the low use of VE and the inconsistent and unstructured clinical training of VE expressed through the health care providers' points of view. However, clinical teaching in VE was highly welcomed by the informers which may serve as a good starting point for future interventions.

Birthing experience and quality of life after vacuum delivery and second-stage caesarean section: a prospective cohort study in Uganda.

OBJECTIVE: To assess perceptions of women undergoing vacuum extraction or second-stage caesarean section (SSCS) in a tertiary referral hospital in sub-Saharan Africa. METHODS: Prospective cohort study, with six-month follow-up, of women who gave birth to a term singleton in cephalic presentation by vacuum extraction (n = 289) or SSCS (n = 357) between 25 November 2014, to 8 July 2015, in Mulago Hospital, Uganda. Excluded were women who had failed vacuum extraction, severe birth complications and those whose babies had died. Outcome measures were birthing experience satisfaction, physical component summary (PCS) and mental component summary (MCS) of the SF-12 quality-of-life questionnaire, pain scores and dyspareunia. RESULTS: One day after vacuum extraction, 63.7% (181/284) of women were feeling well vs. 48.1% (167/347) after SSCS (OR 1.89; 95%CI 1.37-2.61) and mean pain sores were 2.70 vs. 3.87 (P < 0.001). In both groups, >90% of women were satisfied with their birthing experience. At six weeks, in vacuum extraction vs. SSCS, mean pain sores were 0.40 vs. 0.89 (P < 0.001); mean PCS was 48.67 vs. 44.03 (P < 0.001); mean MCS was 52.80 vs. 51.23 (P = 0.203); 40% (70/175) vs. 28.3% (70/247) of women had resumed sexual intercourse (OR 1.69; 95%CI 1.12-2.54) and 21.4% (15/70) vs. 28.6% (20/70) had dyspareunia (OR 0.68; 95%CI 0.32-1.47). No differences were found at six months after birth. CONCLUSION: One day and six weeks after birth, outcomes were better in women who had vacuum extraction. At six months, outcomes were similar. To promote quick recovery, vacuum extraction should be the first intervention considered in the second stage of labour.

Mode of birth and early postnatal psychological morbidity.

BACKGROUND: Postnatal depression affects the well-being of women and families. While several studies have shown an association between mode of birth and symptoms of postnatal depression, others have found no relationship. AIMS: To determine whether women who have instrumental or caesarean births report higher levels of poor coping, sleep or appetite disturbance, or relationship difficulties, than women who have vaginal births, at the time of Universal Postnatal Contact (7-10 days post-discharge). MATERIALS AND METHODS: Retrospective cohort study of term, singleton births from 1st January 2013 to 31st December 2013 at a tertiary obstetric facility. Outcomes were compared for 1816 women having vaginal births versus 1205 women having instrumental or caesarean births. RESULTS: When adjusted for confounders, no association could be demonstrated between mode of birth and reporting of any postnatal symptom of psychological morbidity. However, the model did demonstrate an association between reporting of symptoms and nulliparity (aOR 1.69 (1.08-2.63); P = 0.02), as well as having an unplanned pregnancy with a supportive partner (aOR 0.54 (0.29-0.97); P = 0.04). CONCLUSIONS: Mode of birth does not appear to be associated with the reporting of symptoms of psychological morbidity in the early postnatal period. However, these symptoms may be associated with nulliparity and in the context of an unplanned pregnancy, a lack of partner support. These findings highlight the ongoing need for antenatal screening with respect to pregnancy intention and the presence of a social support system, to facilitate the implementation of interventions for women at risk of postnatal depression.

Fathers' experiences of a vacuum extraction delivery - a qualitative study.

OBJECTIVE: To explore fathers' experiences of a birth by vacuum extraction (VE). METHOD: A qualitative interview study with 10 fathers analysed with qualitative content analysis. FINDINGS: The theme 'affected but helpless' refers to the father's role changing when childbirth terminates with a VE. From initially being involved in the delivery, his role switches to being merely an observer at the mercy of the professionals' knowledge and guidance. The VE procedure evoked concerns over the mother's and the child's safety and wellbeing, even if the fathers wanted the birth process to be over. The fathers considered the choice of conducting a VE as an adequate alternative, but they expressed concerns about consequences on future decisions. The theme encompasses all the main categories: wish to be involved, anxious observer, turbulent feelings and thoughts about consequences. CONCLUSIONS: VE delivery has a strong emotional impact on fathers and the procedure is often experienced as a dramatic way to end a birth and an ultimate way to terminate a long birth process. The results indicate that a lack of support and of a genuine opportunity to participate, as well as the mother's pain impair their experience, not the VE delivery, per se.

The efficacy, safety and acceptability of medical termination of pregnancy provided by standard care by doctors or by nurse-midwives: a randomised controlled equivalence trial.

OBJECTIVE: To assess nurse-midwife provision of early medical termination of pregnancy (TOP) in a high-resource setting where ultrasound examination for dating of pregnancy is part of the protocol. DESIGN: Randomised controlled equivalence trial. SETTING: Out-patient family planning unit at a university hospital. POPULATION: Women seeking early medical TOP. METHODS: A total of 1180 women were randomised, without any prior examination, to counselling, examination, and treatment by either nurse-midwife or gynaecologist. Ultrasound was performed in all cases by the allocated provider. MAIN OUTCOME MEASURES: The primary outcome was efficacy, defined as the successful completion of TOP without need for vacuum aspiration. Secondary outcomes were safety, defined as need for hospitalisation or blood transfusion, and acceptability, defined as preferred provider were the women to have a medical TOP in the future. RESULTS: A total of 481 women in the nurse-midwife group and 457 women in the doctor group were available for the final analysis. The effectiveness of provision of medical TOP by nurse-midwife providers was superior to that provided by doctors (risk difference 1.6%, 95% confidence interval 0.2-3.0%, which was within the set margin of equivalence). There were no significant differences in safety parameters. Women examined and counselled by a nurse-midwife were significantly more likely (P < 0.001, 95% confidence interval 0.308-0.394) to prefer seeing a nurse-midwife for the consultation were they to have another medical TOP in the future. CONCLUSIONS: These findings show that nurse-midwife provision of early medical TOP in a high-resource setting, where ultrasound is part of the protocol, is effective, and can be safely implemented with high acceptability among women.

Mode of delivery and the probability of subsequent childbearing: a population-based register study.

OBJECTIVE: To investigate the relationship between mode of first delivery and probability of subsequent childbearing. DESIGN: Population-based study. SETTING: Nationwide study in Sweden. POPULATION: A cohort of 771 690 women who delivered their first singleton infant in Sweden between 1992 and 2010. METHODS: Using Cox's proportional-hazards regression models, risks of subsequent childbearing were compared across four modes of delivery. Hazard ratios (HRs) were calculated, using 95% confidence intervals (95% CIs). MAIN OUTCOME MEASURES: Probability of having a second and third child; interpregnancy interval. RESULTS: Compared with women who had a spontaneous vaginal first delivery, women who delivered by vacuum extraction were less likely to have a second pregnancy (HR 0.96, 95% CI 0.95-0.97), and the probabilities of a second childbirth were substantially lower among women with a previous emergency caesarean section (HR 0.85, 95% CI 0.84-0.86) or an elective caesarean section (HR 0.82, 95% CI 0.80-0.83). There were no clinically important differences in the median time between first and second pregnancy by mode of first delivery. Compared with women younger than 30 years of age, older women were more negatively affected by a vacuum extraction with respect to the probability of having a second child. A primary vacuum extraction decreased the probability of having a third child by 4%, but having two consecutive vacuum extraction deliveries did not further alter the probability. CONCLUSIONS: A first delivery by vacuum extraction does not reduce the probability of subsequent childbearing to the same extent as a first delivery by emergency or elective caesarean section.

Giving birth with rape in one's past: a qualitative study.

BACKGROUND: Rape is one of the most traumatizing violations a woman can be subjected to, and leads to extensive health problems, predominantly psychological ones. A large proportion of women develop a form of posttraumatic stress termed Rape Trauma Syndrome. A previous study by our research group has shown that women with a history of rape far more often had an operative delivery in their first birth and those who gave birth vaginally had second stages twice as long as women with no history of sexual assault. The aim of this study is to examine and illuminate how women previously subjected to rape experience giving birth for the first time and their advice on the kind of birth care they regard as good for women with a history of rape. METHODS: A semi-structured interview with 10 women, who had been exposed to rape before their first childbirth. Data on the birth experience were analyzed by qualitative content analysis. RESULTS: The main theme was "being back in the rape" with two categories: "reactivation of the rape during labor," with subcategories "struggle," "surrender," and "escape" and "re-traumatization after birth," with the subcategories "objectified," "dirtied," and "alienated body." CONCLUSION: A rape trauma can be reactivated during the first childbirth regardless of mode of delivery. After birth, the women found themselves re-traumatized with the feeling of being dirtied, alienated, and reduced to just a body that another body is to come out of. Birth attendants should acknowledge that the common measures and procedures used during normal birth or cesarean section can contribute to a reactivation of the rape trauma.

Vacuum-assisted vaginal delivery simulation--quantitation of subjective measures of traction and detachment forces.

OBJECTIVE: Excessive traction has been alleged as the cause of newborn complications associated with vacuum delivery. We sought to quantify subjective levels of physician vacuum traction in a simulated obstetric delivery model, dependent upon level of training. METHODS: Three groups of physicians, based on training level applied traction (minimal, average, maximal) on a pre-applied vacuum model and forces were continually recorded. Detachment force was recorded with traction in both the pelvic axis and at an oblique angle. RESULTS: Quantified traction force increased from subjective minimal to average to maximal pulls. Within each level, there were no differences between the groups in the average traction force. Detachment force was significantly less when traction was applied at an oblique angle as opposed to the pelvic axis (11.1 ± 0.3 vs 12.2 ± 0.3 kg). CONCLUSION: Providers appear to be good judges of the force being applied, as a clear escalation in force is noted with minimal, average and maximal force pulls. There appears to be a relatively short learning curve for use of the vacuum, as junior residents' applied force was not different from those of more experienced practitioners. Using the KIWI device, detachment force is lower when traction is applied at an oblique angle.

'Let the computer choose?': the experience of participants in a randomised preference trial of medical versus surgical termination of pregnancy.

The termination of pregnancy trial (Newcastle upon Tyne, UK), is the only randomised trial on termination of pregnancy methods incorporating a qualitative element that aimed to understand the experiences of women participating in the trial. Based on the results of this qualitative work, this article aims to provide insights into two strands of understanding; firstly, women's experience of participating in research about abortion and secondly, their experience of participating in a randomised preference trial. Semi-structured interviews were conducted of up to 90 minutes with 30 participants recruited at a single hospital site. A total of 20 women from the preference arm and 10 from the random arm were interviewed. The analysis and discussion of our findings use reflexive modernisation as a framework for understanding and interpreting some of the actions of social agents, that is, the participants and trial recruiters in the course of a clinical trial as an expert system. We found that the factors that shape women's experiences and decisions include trust in the expert system and reflexivity and agency on the part of both participants and trial recruiters.

[The impact of epidural analgesia on birth experience]. / Auswirkungen der Periduralanästhesie (PDA) auf das Geburtserlebnis.

BACKGROUND: The satisfaction of our patients with the intrapartum analgesia and differences between labour with and without epidural analgesia (EDA) were analysed retrospectively. PATIENTS AND METHODS: In March 2004 questionnaires were sent to all women who gave birth between 1 January 2003 and 30 June 2003 at the University Hospital of Zurich. RESULTS: 45.5% of the questionnaires were returned. The EDA-rate reached 47.3%. Women with EDA had a significant longer delivery and the vacuum was more often used (p < 0.001 each). There was no difference between births with or without EDA concerning Apgar- and pH-scores from the umbilical artery. Several factors had an impact on satisfaction: higher age (> 30 years) (p = 0.012), the feeling that this labour was less painful than the previous (p = 0.010), the ability to control labour pain (p = 0.002), to influence drug therapy of pain (p < 0.001). CONCLUSION: Our results show, that the individual care and involvement of women in the birth process and pain therapy had a greater influence on satisfaction with birth than the type of analgesia.

Randomised controlled trial of community debriefing following operative delivery.

OBJECTIVE: The aim of this study was to determine if two debriefing sessions following an operative delivery could reduce a woman's fear of future childbirth. DESIGN: Prospective randomised controlled trial (RCT) with two arms comparing debriefing, aimed to reduce fear of future childbirth, with standard care after birth. SETTING: District General Hospital with 2500 deliveries per year. SAMPLE: Three hundred and nineteen mothers who delivered a first child by operative delivery (i.e. forceps, vacuum or emergency caesarean section). The study took place at Huddersfield Royal Infirmary, from January 2002 to July 2003. METHODS: Debriefing by community midwives specifically trained in postpartum debriefing at 10 days and 10 weeks. MAIN OUTCOME MEASURE: Fear of childbirth was assessed using the Wijma Delivery Expectancy Scale (WDEQ). WDEQ scores were measured 10 days, 10 weeks and 20 weeks following delivery. RESULTS: Fear of childbirth as measured by the WDEQ was lower throughout the study for the debriefing group. However, it never reached statistical significance in the short term [10 days debriefing = 94.5, control = 97.5 (P= 0.295), 10 weeks debriefing = 92.0, control = 97.9 (P= 0.076), 20 weeks debriefing = 90.9, control = 97.4 (P= 0.057)]. CONCLUSION: This study shows in the short term there was no significant difference in the WDEQ fear of childbirth scores. The debriefing group were showing a tendency for lower scores. Long term follow up of these cases may be more relevant.

Medical abortion or vacuum aspiration? Two year follow up of a patient preference trial.

OBJECTIVE: To describe and compare health outcomes two years after medical abortion or vacuum aspiration in women recruited into a patient preference trial during 1990 to 1991. DESIGN: Women recruited to the original, partially randomised study were contacted for assessment using a structured interview. SETTING: Grampian region of Scotland, UK. PARTICIPANTS: One hundred and forty women who had participated in a partially randomised study of first trimester abortion two years previously. INTERVENTION: Vacuum aspiration or medical abortion using mifepristone and gemeprost. MAIN OUTCOME MEASURES: Long-term general, reproductive and psychological health; acceptability of procedure; perceived value of choice of method of termination. RESULTS: There were no significant differences between women who had undergone medical abortion or vacuum aspiration two years previously in general, reproductive or psychological health. Almost all women placed a high value on the provision of choice of method of termination. There was a significant difference in perception of long term procedure acceptability among women who had been randomised to a method of termination. CONCLUSIONS: Women should have the opportunity to choose the method of termination. This opportunity will result in high levels of acceptability, particularly at gestations under 50 days of amenorrhoea.

PIP: In a comparative study conducted during 1990-91, 363 Scottish women with pregnancies of less than 64 days of gestation were given the option of selecting medical abortion with mifepristone/gemeprost or surgical vacuum aspiration abortion; those without a preference were randomly assigned to a method. There were no differences between groups in efficacy or medical complications at the 21-day postabortion follow-up. Medical abortion was associated with significantly more pain during the procedure, but not following hospital discharge, and its efficacy decreased with advancing gestation. At a median time interval of 26 months after the abortion, 140 women from the original cohort were reinterviewed to assess long-term acceptability. There were no significant differences between the medical and surgical abortion groups at long-term follow-up in their assessment of their current health status, the nature and incidence of subsequent morbidity requiring a doctor's care, consultations for psychiatric problems, or menstrual disorders. 9% of women who opted for surgical abortion and 11% who chose medical abortion indicated they would select a different method in the future. Vacuum aspiration remained significantly more acceptable than medical abortion among women who were randomly allocated to an abortion group. 97 women (69%) rated the opportunity to choose an abortion method as highly important, and 86-90% indicated a willingness to pay for the provision of such choice.

Temperament in children delivered by vacuum extraction.

Thomas and Chess's temperament variables were studied via questionnaires in two samples of children delivered by vacuum extraction and in a standardization sample at six months and at one and two years of age. Temperament was not systematically related to vacuum extraction delivery per se or to its indications or to offspring neonatal somatic impairment.