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.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

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

INTRODUCTION: This study aimed to determine the decision-to-delivery intervals (DDIs), total duration of surgery and factors influencing these for Caesarean sections (CSs). METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Multiple pregnancy is the leading contributor to cesarean sections in in vitro fertilization pregnancies: An analysis using the Robson 10-group classification system.

AIM: In vitro fertilization (IVF) pregnancy is an important contributor to rising cesarean section (CS) rates. The profile of CS in this group is not well documented. This study sought to identify leading patient categories of the Robson 10-Group Classification System (TGCS) contributing to the high IVF CS rate. METHODS: We carried out a prospective study of IVF patients who delivered in the Singapore General Hospital from January 2010 to July 2012. Parity, singleton/multiple pregnancy, previous CS, mode of labor onset and gestational age at delivery were collected based on the TGCS. All other deliveries during the study period served as control. RESULTS: There were a total of 215 IVF deliveries, of which 114 (54.4%) were CS. Group 8 (all multiple pregnancies) was the greatest contributor to the overall CS rate (43.0%). Group 2 (term nulliparous singleton cephalic pregnancies with induction of labor or planned CS) was the second largest contributor to overall CS rate (12.3%). The third and fourth leading contributors were Group 10 (preterm singleton pregnancies) and Group 5 (pregnancies with previous CS), respectively. In contrast, these two groups were top contributors to the overall CS rate for the control group. CONCLUSION: Multiple pregnancy is the principal contributor to CS in our IVF population, and reducing its incidence may reduce its CS rate. Among singleton pregnancies, planned CS and failed induction for cephalic term pregnancies and preterm singleton pregnancies were the next largest contributors, suggesting a higher prevalence of maternal request and high-risk obstetric indications requiring interventions at preterm gestations.

Rational dissection of a high institutional cesarean section rate: an analysis using the Robson Ten Group Classification System.

AIM: Cesarean section (CS) rates have risen far in excess of the optimal 15% recommended by the World Health Organization. The Robson Ten Group Classification System (TGCS) allows meaningful analysis of a CS rate. The aim of this study is to identify the leading patient categories contributing to our institution's CS rate. METHODS: Prospective study of all women who delivered at the Singapore General Hospital from January 2008 to December 2011. The following data was recorded: parity, singleton/multiple pregnancy, previous CS, mode of labor onset and gestational age at delivery. CS rates were computed for each group, as well as their relative contribution to the overall CS rate. RESULTS: There were 6074 deliveries, in which 2011 (33.1%) women had CS delivery. Group 5 was the largest contributor to the overall CS rate (25.9%). Of the patients in this group, 18.8% had a successful vaginal birth after cesarean (VBAC). Group 2 was the second largest contributor to the overall CS rate at 18.0%. Group 10 had a high contribution of 16.1%. CONCLUSION: The TGCS allows easy identification of the leading contributing patient groups. The surprisingly high contribution of group 10 suggests that our institution, a tertiary multidisciplinary teaching hospital, manages a sizeable group of high-risk patients in its obstetric case mix accounting for the high CS rate. Almost one in five term pregnancies with one previous CS had a successful vaginal delivery, suggesting that the institutional attempted VBAC rate is higher than 20%.

Alterations in physiology and anatomy during pregnancy.

Pregnant women undergo profound anatomical and physiological changes so that they can cope with the increased physical and metabolic demands of their pregnancies. The cardiovascular, respiratory, haematological, renal, gastrointestinal and endocrine systems all undergo important physiological alterations and adaptations needed to allow development of the fetus and to allow the mother and fetus to survive the demands of childbirth. Such alterations in anatomy and physiology may cause difficulties in interpreting signs, symptoms, and biochemical investigations, making the clinical assessment of a pregnant woman inevitably confusing but challenging. Understanding these changes is important for every practicing obstetrician, as the pathological deviations from the normal physiological alterations may not be clear-cut until an adverse outcome has resulted. Only with a sound knowledge of the physiology and anatomy changes can the care of an obstetric parturient be safely optimized for a better maternal and fetal outcome.