Operative Vaginal Birth: ACOG Practice Bulletin Summary, Number 219.

Despite significant changes in management of labor and delivery over the past few decades, operative vaginal birth remains an important component of modern labor management, accounting for 3.3% of all deliveries in 2013 (1). Use of obstetric forceps or vacuum extractor requires that an obstetrician or other obstetric care provider be familiar with the proper use of the instruments and the risks involved. The purpose of this document is to provide a review of the current evidence regarding the benefits and risks of operative vaginal birth.

Operative Vaginal Birth: ACOG Practice Bulletin, Number 219.

Despite significant changes in management of labor and delivery over the past few decades, operative vaginal birth remains an important component of modern labor management, accounting for 3.3% of all deliveries in 2013 (). Use of obstetric forceps or vacuum extractor requires that an obstetrician or other obstetric care provider be familiar with the proper use of the instruments and the risks involved. The purpose of this document is to provide a review of the current evidence regarding the benefits and risks of operative vaginal birth.

Operative vaginal delivery: a review of four national guidelines.

There is a broad range in the rates of operative vaginal deliveries (OVD) worldwide, which reflects the variety of local practice patterns, the number of trained clinicians and the lack of international evidence-based guidelines. The aim of this study was to review and compare the recommendations from published guidelines on OVD. Thus, a descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the American College of Obstetricians and Gynecologists (ACOG) on instrumental vaginal birth was conducted. All the guidelines point out that the use of any instrument should be based on the clinical circumstances and the experience of the operator. The indications, the contraindications, the prerequisites and the classification for OVD are overall very similar in the reviewed guidelines. Further, they all agree that episiotomy should not be performed routinely. The RCOG, the RANZCOG and the SOGC describe some interventions which may promote spontaneous vaginal birth and therefore reduce the need for OVD. They also highlight the importance of adequate postnatal care and counseling. There is no consensus on the actual technique that should be used, including the type of forceps or vacuum cup, the force and duration of traction or the number of detachments allowed. Hence, there is need for international practice protocols, so as to encourage the clinicians to use OVD when indicated, minimize the complications and reduce rates of cesarean delivery.

Simulation Training for Operative Vaginal Delivery Among Obstetrics and Gynecology Residents: A Systematic Review.

OBJECTIVE: To perform a systematic review of the literature on the effect of simulation training of operative vaginal delivery on learner technique and knowledge, operator comfort, and patient-centered outcomes. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, ERIC, The Cochrane Library, and ClinicalTrials.gov were searched from inception through April 2017. The search criteria used MeSH terms ("simulation training," "high fidelity simulation training," "teaching," "obstetrical extraction," "obstetrical forceps," "vaginal delivery," "clinical competence," and "internship and residency"). METHODS OF STUDY SELECTION: A total of 30,813 articles were reviewed for inclusion. Studies detailing operative vaginal delivery simulation using forceps or vacuums and reporting health care provider or patient outcomes were eligible. TABULATION, INTEGRATION, AND RESULTS: All studies were independently reviewed by two investigators for inclusion. Only eight articles assessed the effect of simulation on trainee skill and comfort or patient outcomes and were included. Four were pretest-posttest studies, two were cross-sectional studies, one was a case-control study, and one was a cohort study. No randomized trials were identified. Simulation was associated with improved forceps placement accuracy and generated force during extraction, as well as increased operator knowledge and comfort with operative vaginal delivery. Additionally, simulation had no association with forceps failure rates, but there was an association with decreased rates of maternal lacerations and neonatal injury. The quality of the included studies was assessed with the Medical Education Research Study Quality Instrument, with a median score of 9.75 (range 9.0-13.5), indicating low-to-moderate quality. CONCLUSION: The available evidence suggests that improved technique, comfort, knowledge, and patient outcomes are associated with operative vaginal delivery simulation, but additional studies are required to further characterize such benefits for both forceps and vacuum. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42018087343.

[Czech Hospital in Uganda and quality of obstetric care]. / Ceská nemocnice v Ugande a kvalita porodnické péce.

OBJECTIVE: The target was to evaluate the present state of obstetric care in Czech Hospital in Buikwe in Uganda. We evaluated a professional level of hospital physicians, their obstetric expertise and technical equipment of delivery theatre and mobile surgery and we provided a short 4 months evaluation of deliveries in main view of obstetric pathologies, frequency of caesarean sections and maternal mortality. METHODS AND RESULTS: In period from October 2014 to January 2015 there was evaluated a group of 374 women, admited to labour at delivery theatre. We evaluated parity of women, number and indications of caesarean sections, age of women and obstetric finding by admission. The most of our patients were primiparas and secundiparas, the caesarean section was performed in 23,8% of cases and the most frequent indication of it was threatened rupture of the uterus, state after caesarean section, cephalopelvic disproportion and obstructed labour. Two women died. By evaluation of quality of obstetric care we have found some serious lacks. Ugandan doctors are not obstetricians, they have no experience with vaginal obstetric operations, the Hospital has no fetal-monitor and no possibility for a transport of emergency cases. CONCLUSIONS: The Hospital needs expert help from Czech Republic, as doctors-obstetricians so as some equipment for delivery theatre and above all suitable car for urgent transport and for use of mobile surgery.

[Management of shoulder dystocia]. / Conduite à tenir en cas de dystocie des épaules.

OBJECTIVE: The objective of this review is to propose recommendations on the management of shoulder dystocia. MATERIALS AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the foreign obstetrical societies or colleges have been consulted. RESULTS: In case of shoulder dystocia, if the obstetrician is not present at delivery, he should be systematically informed as quickly as possible (professional consensus). A third person should also be called for help in order to realize McRoberts maneuver (professional consensus). The patient has to be properly installed in gynecological position (professional consensus). It is recommended not to pull excessively on the fetal head (grade C), do not perform uterine expression (grade C) and do not realize inverse rotation of the fetal head (professional consensus). McRoberts maneuver, with or without a suprapubic pressure, is simple to perform, effective and associated with low morbidity, thus, it is recommended in the first line (grade C). Regarding the maneuvers of the second line, the available data do not suggest the superiority of one maneuver in relation to another (grade C). We proposed an algorithm; however, management should be adapted to the experience of the operator. If the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, delivery of the posterior arm should be performed preferentially (professional consensus). Routine episiotomy is not recommended in shoulder dystocia (professional consensus). Other second intention maneuvers are described. It seems necessary to know at least two maneuvers to perform in case of shoulder dystocia unresolved by the maneuver McRoberts (professional consensus). CONCLUSION: All physicians and midwives should know and perform obstetric maneuvers if needed quickly but without precipitation.

[Neonatal issues and duration of expulsive efforts: Observationnal data in 138 French maternity units]. / Etat néonatal et durée des efforts expulsifs chez les primipares à bas risque : données observationnelles dans 138 maternités françaises.

OBJECTIVES: In agreement with national guidelines published in 2007, limiting duration of expulsive efforts to 30 minutes is a common obstetrical practice in France. In many other countries, there is no fixed limit for pushing duration. The objective of our work is to analyze mode of delivery and neonatal issues according to duration of expulsive efforts. PATIENTS AND METHODS: It is a secondary analysis of an observational prospective study, among low-risk primiparous women, in 138 French maternity units. According to duration of expulsive efforts, we determined proportions of spontaneous and instrumental vaginal deliveries. Then, we analyzed the risk of neonatal asphyxia (defined by pH

Operative vaginal delivery.

Operative vaginal delivery remains a valid option when problems arise in the second stage of labor. The most common indications are fetal compromise and failure to deliver spontaneously with maximum maternal effort. There is a clear trend to choose vacuum extraction over forceps to assist delivery, but the evidence supporting that trend is unconvincing. Recent literature confirms some advantages for forceps (eg, a lower failure rate) and some disadvantages for vacuum extraction (eg, increased neonatal injury), depending on the clinical circumstances. To preserve the option of forceps delivery, residency training programs must incorporate detailed instruction in forceps techniques and related skills into their curricula. Simulation training can enhance residents' understanding of mechanical principles and should logically precede clinical work.

A simple tool to measure patient perceptions of operative birth.

OBJECTIVE: To assess the feasibility and validity of a maternal satisfaction measurement tool, the SaFE study Patient Perception Score (PPS), after operative delivery. DESIGN: Cross-sectional survey. SETTING: A large maternity unit in England. SAMPLE: 150 women who had had an operative birth. METHODS: We recruited women within 24 hours of birth and quantified their satisfaction with two questionnaires: PPS, and the Mackey Childbirth Satisfaction Rating Scale (CSRS; modified). MAIN OUTCOME MEASURES: Participation rate to determine feasibility; Cronbach's alpha as measure of internal consistency; PPS satisfaction scores for groups of accoucheurs of different seniority to assess construct validity; correlation coefficient of PPS scores with total scores from the CSRS questionnaire to establish criterion validity. RESULTS: Participation rate approached 85%. We observed high scores for most births except a few outliers. Internal consistency of the PPS was high (Cronbach's alpha=0.83). Total PPS scores correlated strongly with total CSRS scores (Spearman's r=0.64, P<0.001). CONCLUSIONS: The PPS is a simple and valid tool for patient-centred assessments. High scores were observed for most births but there were a small minority of accoucheurs who consistently scored poorly and these data could be used during appraisal and training.

Neonatal subgaleal hemorrhage.

Subgaleal hemorrhages, although infrequent in the past, are becoming more common with the increased use of vacuum extraction. Bleeding into the large subgaleal space can quickly lead to hypovolemic shock, which can be fatal. Understanding of anatomy, pathophysiology, risk factors, differential diagnosis, and management will assist in early recognition and care of the infant with a subgaleal hemorrhage.

Towards safe practice in instrumental vaginal delivery.

Approximately one in ten deliveries in the Western world is an instrumental vaginal delivery. Like other surgical operations, instrumental vaginal delivery has its complications, and the operator is obliged to critically appraise the indication for the procedure and the background risk factors, and communicate effectively with the woman. Also, it calls for team work. The safe approach to instrumental delivery should therefore be similar to that adopted for other surgical operations in terms of preoperative assessment, intraoperative precautions and postoperative care. Safe practice in instrumental delivery addresses the various types of error that may occur, and places a strong premium on operator skills, competence, and familiarity with the particular instrument. This chapter reviews good practice in the conduct of instrumental delivery, highlights what could go wrong, and outlines interventions that could reduce the incidence of harm. Issues relating to communication and consent as well as training and documentation are discussed. Indications for abandonment are outlined, and the importance of situational awareness is emphasized. Safe practice tips are amply provided.

Patient-requested neuraxial analgesia for labor: impact on rates of cesarean and instrumental vaginal delivery.

A systematic review, including a meta-analysis, on the timing effects of neuraxial analgesia (NA) on cesarean and instrumental vaginal deliveries in nulliparous women was conducted. Of 20 articles identified, 9 met the inclusion quality criteria (3,320 participants). Cesarean delivery (odds ratio, 1.00; 95% confidence interval, 0.82-1.23) and instrumental vaginal delivery (odds ratio, 1.00; 95% confidence interval, 0.83-1.21) rates were similar in the early NA and control groups. Neonates of women with early NA had a higher umbilical artery pH and received less naloxone. In the early NA group, fewer women were not compliant with assigned treatment and crossed over to the control group. Women receiving early NA for pain relief are not at increased risk of operative delivery, whereas those receiving early parenteral opioid and late epidural analgesia present a higher risk of instrumental vaginal delivery for nonreassuring fetal status, worse indices of neonatal wellness, and a lower quality of maternal analgesia.

[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.

How long does it take to perform an operative vaginal delivery?

We set out to see how long it takes to achieve an operative vaginal delivery in normal practice. This was a prospective survey, conducted in a major and well-staffed British maternity unit over 1 month. Sixty-two assisted vaginal deliveries occurred in the month of the study. Thirteen data collection sheets were spoiled or could not be confirmed and were discarded before analysis. Therefore the remaining data are based on 49 deliveries. The main outcome measure was the time interval between the decision to assist the vaginal delivery and the delivery. Fifty per cent of babies were delivered within 18 minutes once the decision to act had been made (range 6-85 minutes). If the primary indication for delivery was an abnormal CTG the median time was 16 minutes (mean 20 minutes). Any legal claim based on the assumption that a reasonably competent obstetrician should deliver a baby within 15 minutes cannot be supported by scientific data.

[Breech presentation in obstetrics in Germany--an assessment of current status]. / Beckenendlagengeburtshilfe in Deutschland--eine Bestandesaufnahme.

Nowadays, the CS seems to be the most favourite way of delivery in case of breech presentation. Our opinion is that the vaginal delivery has no disadvantage for the physical and mental development of the newborns [11, 12]. The outcome depends on the set-up and organisation of each department. The most important condition to reach a good outcome by breech presentation is a well-established practical training of the whole team, a careful risk selection and a well structured perinatal centre. In our opinion the CS is the second choice to deliver a pregnant woman with a breech presentation at term. High CS-rates as well as a increased perinatal morbidity at vaginal breech delivery are a sign for insufficient training of the staff and insufficient organisation in small departments not being perinatal centres. Not the breech presentation is the real risk factor, but the unqualified Obstetrician and the insufficient set-up in the most of OB/Gyn-departments. We have a very high ethic responsibility against young women resultating from our profession. It's our duty to decide and recommend the best way to save the wellbeing of the mother and the unborn child. It's also our duty to avoid surgical manoeuvers resulting from economic reasons. Therefore a complete, sufficient practical training concerning breech delivery technics is absolutely needed. In future the answer of the question: "Delivery of breech presentation--vaginally or through CS?" will depend on, if we will be able to change this politic and professional undesirable trend.

Forceps and vacuum delivery: expectations of residency and fellowship training program directors.

The objective of this study is to compare current forceps training practices in North American obstetrical residency training programs with that in maternal-fetal medicine fellowship programs. We sent a survey to all obstetrics and gynecology residency training programs and to all maternal-fetal medicine fellowship programs in North America. After sending out 354 questionnaires, 219 were returned for a response rate of 62%. The response rate for fellowship programs (52 of 59; 88%) was significantly greater than that of residency training programs (167 of 295; 56.6%) (p < 0.05). All fellowship training programs were using the 1988 ACOG forceps classification system, as were 98% of the residency training programs. Eighty-five percent of fellowship directors and 80% of residency directors felt the same system should be used for vacuum deliveries. All residency and fellowship directors expected proficiency with both instruments for outlet deliveries. For low deliveries requiring < or =45 degrees of rotation, at least 92% expected proficiency with both instruments. For low-forceps deliveries with >45 degrees of rotation, 82% of fellowship directors and 80% of residency directors expected proficiency. For low-vacuum deliveries with >45 degrees of rotation, 80% of fellowship directors and 76% of residency directors expected proficiency. Significantly more fellowship directors expected midforceps proficiency (47%) than did residency program directors (38%) (p < 0.05). Midvacuum proficiency was expected by 73% of fellowship directors and 69% of residency directors. The ACOG 1988 forceps classification system has now achieved wide acceptance and is taught by both residency and fellowship program directors. Most program directors favor using the same classification system for vacuum extraction deliveries. In general, the expectations of the residency program directors mirror those of maternal-fetal medicine fellowship directors. While outlet and low operations with < or =45 degrees of rotation are taught and proficiency is expected, most programs no longer expect proficiency in midforceps delivery, but do expect proficiency in midvacuum delivery. Proficiency in low operations with rotations < or =45 degrees is still expected.