Experiencia de parto instrumental con vacuum en Hospital Público de Santiago de Chile / Experience of vacuum-assisted instrumental delivery in a Public Hospital in Santiago, Chile

Introducción: El vacuum es el instrumento de elección para asistir el parto instrumental en países desarrollados. Objetivo: El objetivo del estudio es exponer los resultados maternos y fetales del uso del vacuum en población chilena y promover su disponibilidad y uso en nuestro país y Latinoamérica. Método: El estudio se realizó entre octubre de 2017 y diciembre de 2021, incluyendo a pacientes que tuvieron parto instrumental con vacuum en el Hospital San Juan de Dios de Chile. Se compararon los partos exitosos con vacuum y los partos en los que se requirió el uso de otro instrumento o una cesárea posterior al uso del instrumento. Resultados: Se realizaron 153 vacuum, correspondientes al 28,59% del total de partos instrumentales. El 79,74% tuvo éxito. El 5,88% no recibió anestesia o se aplicó anestesia local. Solo el 3,27% presentó desgarro perineal con compromiso del esfínter anal. El 91,5% de los recién nacidos no tuvieron complicaciones fetales. Un 20,3% requirió reanimación neonatal. Conclusiones: El estudio muestra que el vacuum es una opción segura y efectiva de parto instrumental en nuestra población. La correcta capacitación y protocolos adecuados son necesarios para garantizar resultados exitosos.

Introduction: Vacuum extraction is the instrument of choice for assisting instrumental delivery in developed countries. Objective: The aim of the study is to present the maternal and fetal outcomes of vacuum use in the Chilean population and promote its availability and usage in our country and Latin America. Method: The study was performed between October 2017 and December 2021, including patients who underwent instrumental delivery with a vacuum extraction at the Hospital San Juan de Dios in Chile. Successful vacuum deliveries were compared with deliveries where another instrument was required, or a cesarean section was performed after instrument use. Results: A total of 153 vacuum deliveries were carried out, accounting for 28.59% of all instrumental deliveries. 79.74% were successful. 5.88% did not receive anesthesia or received local anesthesia. Only 3.27% experienced perineal tear with involvement of the anal sphincter. 91.5% of newborns had no fetal complications. 20.3% required neonatal resuscitation. Conclusions: The study demonstrates that the vacuum is a safe and effective option for instrumental delivery in our population. Proper training and appropriate protocols are necessary to ensure successful outcomes.

Predicting obstetrical anal sphincter injuries in patients who undergo vaginal birth after cesarean delivery.

BACKGROUND: Women with a history of previous cesarean delivery must weigh the numerous potential risks and benefits of elective repeat cesarean delivery or trial of labor after cesarean delivery. Notably, 1 important risk of vaginal delivery is obstetrical anal sphincter injuries. Furthermore, the rate of obstetrical anal sphincter injuries is high among women undergoing vaginal birth after cesarean delivery. However, the risk of obstetrical anal sphincter injuries is not routinely included in the trial of labor after cesarean delivery counseling, and there is no tool available to risk stratify obstetrical anal sphincter injuries among women undergoing vaginal birth after cesarean delivery. OBJECTIVE: This study aimed to develop and validate a predictive model to estimate the risk of obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery population to improve antenatal counseling of patients regarding risks of trial of labor after cesarean delivery. STUDY DESIGN: This study was a secondary subgroup analysis of the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery prospective cohort (1999-2002). We identified women within the Maternal-Fetal Medicine Units Network cohort with 1 previous cesarean delivery followed by a term vaginal birth after cesarean delivery. This Maternal-Fetal Medicine Units Network Vaginal Birth After Cesarean Delivery cohort was stratified into 2 groups based on the presence of obstetrical anal sphincter injuries, and baseline characteristics were compared with bivariate analysis. Significant covariates in bivariate testing were included in a backward stepwise logistic regression model to identify independent risk factors for obstetrical anal sphincter injuries and generate a predictive model for obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery. Internal validation was performed using bootstrapped bias-corrected estimates of model concordance indices, Brier scores, Hosmer-Lemeshow chi-squared values, and calibration plots. External validation was performed using data from a single-site retrospective cohort of women with a singleton vaginal birth after cesarean delivery from January 2011 to December 2016. RESULTS: In this study, 10,697 women in the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery cohort met the inclusion criteria, and 669 women (6.3%) experienced obstetrical anal sphincter injuries. In the model, factors independently associated with obstetrical anal sphincter injuries included use of forceps (adjusted odds ratio, 5.08; 95% confidence interval, 4.10-6.31) and vacuum assistance (adjusted odds ratio, 2.64; 95% confidence interval, 2.02-3.44), along with increasing maternal age (adjusted odds ratio, 1.05; 95% confidence interval, 1.04-1.07 per year), body mass index (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.00 per unit kg/m2), previous vaginal delivery (adjusted odds ratio, 0.19; 95% confidence interval, 0.15-0.23), and tobacco use during pregnancy (adjusted odds ratio, 0.59; 95% confidence interval, 0.43-0.82). Internal validation demonstrated appropriate discrimination (concordance index, 0.790; 95% confidence interval, 0.771-0.808) and calibration (Brier score, 0.047). External validation used data from 1266 women who delivered at a tertiary healthcare system, with appropriate model discrimination (concordance index, 0.791; 95% confidence interval, 0.735-0.846) and calibration (Brier score, 0.046). The model can be accessed at oasisriskscore.xyz. CONCLUSION: Our model provided a robust, validated estimate of the probability of obstetrical anal sphincter injuries during vaginal birth after cesarean delivery using known antenatal risk factors and 1 modifiable intrapartum risk factor and can be used to counsel patients regarding risks of trial of labor after cesarean delivery compared with risks of elective repeat cesarean delivery.

Association between the number of pulls and adverse neonatal/maternal outcomes in vacuum-assisted delivery.

OBJECTIVES: To determine the association between the number of pulls during vacuum-assisted deliver and neonatal and maternal complications. METHODS: This was a single-center observational study using a cohort of pregnancies who underwent vacuum-assisted delivery from 2013 to 2020. We excluded pregnancies transitioning to cesarean section after a failed attempt at vacuum-assisted delivery. The number of pulls to deliver the neonate was categorized into 1, 2, 3, and ≥4 pulls. We used logistic regression models to investigate the association between the number of pulls and neonatal intensive care unit (NICU) admission and maternal composite outcome (severe perineal laceration, cervical laceration, transfusion, and postpartum hemorrhage ≥500 mL). RESULTS: We extracted 480 vacuum-assisted deliveries among 7,321 vaginal deliveries. The proportion of pregnancies receiving 1, 2, 3, or ≥4 pulls were 51.9, 28.3, 10.8, and 9.0%, respectively. The crude prevalence of NICU admission with 1, 2, 3, and ≥4 pulls were 10.8, 16.2, 15.4, and 27.9%, respectively. The prevalence of NICU admission, amount of postpartum hemorrhage, and postpartum hemorrhage ≥500 mL were significantly different between the four groups. Multivariable logistic regression analysis found the prevalence of NICU admission in the ≥4 pulls group was significantly higher compared with the 1 pull group (adjusted odds ratio, 3.3; 95% confidence interval, 1.4-7.8). In contrast, maternal complications were not significantly associated with the number of pulls. CONCLUSIONS: Vacuum-assisted delivery with four or more pulls was significantly associated with an increased risk of NICU admission. However, the number of pulls was not associated with maternal complications.

Adverse obstetric outcomes among female childhood and adolescent cancer survivors in Sweden: A population-based matched cohort study.

INTRODUCTION: Cancer treatment during childhood may lead to late adverse effects, such as reduced musculoskeletal development or vascular, endocrine and pulmonary dysfunction, which in turn may have an adverse effect on later pregnancy and childbirth. The aim of the present study was to investigate pregnancy and obstetric outcomes as well as the offspring's health among childhood and adolescent female cancer survivors. MATERIAL AND METHODS: This register-based study included all women born between 1973 and 1977 diagnosed with cancer in childhood or adolescence (age <21), as well as an age-matched comparison group. A total of 278 female cancer survivors with their first childbirth were included in the study, together with 829 age-matched individuals from the general population. Logistic regression and analysis of variance were used to investigate associations between having been treated for cancer and the outcome variables, adjusting for maternal age, nicotine use and comorbidity. RESULTS: Survivors were more likely to have preeclampsia (adjusted odds ratio [aOR] 3.46, 95% confidence interval [CI] 1.58 to 7.56), undergo induction of labor (aOR 1.66, 95% CI 1.05 to 2.62), suffer labor dystocia (primary labor dystocia aOR 3.54, 95% CI 1.51 to 8.34 and secondary labor dystocia aOR 2.43, 95% CI 1.37 to 4.31), malpresentation of fetus (aOR 2.02, 95% CI 1.12 to 3.65) and imminent fetal asphyxia (aOR 2.55, 95% CI 1.49 to 4.39). In addition, deliveries among survivors were more likely to end with vacuum extraction (aOR 2.53, 95% CI 1.44 to 4.47), with higher risk of clitoral lacerations (aOR 2.18, 95% CI 1.47 to 3.23) and anal sphincter injury (aOR 2.76, 95% CI 1.14 to 6.70) and emergency cesarean section (aOR 2.34 95% CI 1.39 to 3.95). Survivors used pain-reliving methods to a higher extent compared with the comparison group. There was no increased risk of neonate diagnoses and malformations. The results showed that survivors who had been diagnosed with cancer when they were younger than 14 had an increased risk of adverse obstetric outcomes. CONCLUSIONS: The study demonstrates increased risk of pregnancy and childbirth complications among childhood and adolescent cancer survivors. There is a need to optimize perinatal care, especially among survivors who were younger than 14 at time of diagnosis.

The Raine study had no evidence of significant perinatal selection bias after two decades of follow up: a longitudinal pregnancy cohort study.

BACKGROUND: Cohort studies may increase or decrease their selection bias as they progress through time. The Western Australian Pregnancy Cohort (Raine) Study has followed 2868 children for over two decades; from fetal into adult life. This paper analyses the cohort over time, assessing potential bias that may come and go with recruitment, retention and loss of participants. METHODS: Linked data from all births in Western Australian over the 3 years the Raine Cohort was recruited were obtained to compare perinatal characteristics and subsequent health outcomes between the Western Australian (WA) contemporaneous birth population and the Raine Cohort at five time points. Perinatal exposure-outcome comparisons were employed to assess bias due to non-participation in Raine Study subsets. RESULTS: There were demographic differences between the Raine Study cohort and its source population at recruitment with further changes across the period of follow up. Despite these differences, the pregnancy and infant data of those with continuing participation were not significantly different to the WA contemporaneous birth population. None of the exposure-outcome associations were significantly different to those in the WA general population at recruitment or at any cohort reviews suggesting no substantial recruitment or attrition bias. CONCLUSIONS: The Raine Study is valuable for association studies, even after 20 years of cohort reviews with increasing non-participation of cohort members. Non-participation has resulted in greater attrition of socially disadvantaged participants, however, exposure-outcome association analyses suggest that there is no apparent resulting selection bias.

How many procedures does it take? Success of a CVS training program for Maternal Fetal Medicine fellows.

OBJECTIVES: To quantify the learning curve for a training program for Maternal Fetal Medicine (MFM) fellows in obtaining successful transvaginal chorionic villus sampling (CVS) results in women with early pregnancy failure (EPF). METHODS: Retrospective observational cohort study of transvaginal CVS and subsequent manual vacuum aspiration (MVA) performed by MFM fellows. CVS samples were sent for karyotype, and products of conception (POC) were sent if CVS sample did not yield a result. Success was defined as karyotype result on CVS specimen. RESULTS: A total of 130 women with EPF up to 9 weeks of gestation underwent transvaginal CVS and MVA from December 2011 to April 2015. CVS samples were successful in 53 (40.8%) cases, POC were analyzed for karyotype in 68 (52.3%) cases, and maternal decidua was obtained in 9 (6.9%) cases. Nine MFM fellows performed the CVS and MVA procedures. The mean number of procedures per fellow was 14 (5-24). The average success rate of transvaginal CVS sample was 33.3% after the first procedure and 50% at the 14th procedure. One procedure was performed per patient. CONCLUSIONS: Success increased over time from 33.3% to 50.0%. Given the gestational age and failed pregnancy status, this is a reasonable success rate for CVS at time of EPF. © 2016 John Wiley & Sons, Ltd.

Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery According to Fetal Head Station.

OBJECTIVE: To compare severe short-term maternal and neonatal morbidity associated with midpelvic and low pelvic attempted operative vaginal delivery. METHODS: Prospective study of 2,138 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. We used multivariate logistic regression and propensity score methods to compare outcomes associated with midpelvic and low pelvic delivery. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesarean delivery, postpartum hemorrhage greater than 1,500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, and maternal death; severe neonatal morbidity was defined as 5-minute Apgar score less than 7, umbilical artery pH less than 7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, and neonatal death. RESULTS: From December 2008 through October 2013 there were 2,138 attempted operative vaginal deliveries; 18.3% (n=391) were midpelvic, 72.5% (n=1,550) low, and 9.2% (n=197) outlet. Severe maternal morbidity occurred in 10.2% (n=40) of midpelvic, 7.8% (n=121) of low, and 6.6% (n=13) of outlet attempts (P=.21); and severe neonatal morbidity in 15.1% (n=59), 10.2% (n=158), and 10.7% (n=21) (P=.02), respectively. Multivariable logistic regression analysis found no significant difference between midpelvic and low attempted operative vaginal delivery for either composite severe maternal (adjusted odds ratio [OR] 1.01, 95% confidence interval [CI] 0.66-1.55) or neonatal morbidity (adjusted OR 1.25, 95% CI 0.84-1.86). Similarly, propensity score matching found no significant difference between midpelvic and low operative vaginal delivery for either severe maternal (adjusted OR 0.69, 95% CI 0.39-1.22) or neonatal morbidity (adjusted OR 0.88, 95% CI 0.53-1.45). CONCLUSION: In singleton term pregnancies, midpelvic attempted operative vaginal delivery compared with low pelvic attempted operative vaginal delivery was not associated with an increase in severe short-term maternal or neonatal morbidity. LEVEL OF EVIDENCE: II.

Forceps delivery is associated with increased risk of pelvic organ prolapse and muscle trauma: a cross-sectional study 16-24 years after first delivery.

OBJECTIVES: To study possible associations between mode of delivery and pelvic organ prolapse (POP) and pelvic floor muscle trauma 16-24 years after first delivery and, in particular, to identify differences between forceps and vacuum delivery. METHODS: This was a cross-sectional study including 608 women who delivered their first child in 1990-1997 and were examined with POP quantification (POP-Q) and pelvic floor ultrasound in 2013-2014. Outcome measures were POP ≥ Stage 2 or previous prolapse surgery, levator avulsion and levator hiatal area on Valsalva. Univariable and multivariable logistic regression analyses and ANCOVA were applied to identify outcome variables associated with mode of delivery. RESULTS: Comparing forceps to vacuum delivery, the adjusted odds ratios (aOR) were 1.72 (95% CI, 1.06-2.79; P = 0.03) for POP ≥ Stage 2 or previous prolapse surgery and 4.16 (95% CI, 2.28-7.59; P < 0.01) for levator avulsion. Hiatal area on Valsalva was larger, with adjusted mean difference (aMD) of 4.75 cm(2) (95% CI, 2.46-7.03; P < 0.01). Comparing forceps with normal vaginal delivery, the adjusted odds ratio (aOR) was 1.74 (95% CI, 1.12-2.68; P = 0.01) for POP ≥ Stage 2 or surgery and 4.35 (95% CI, 2.56-7.40; P < 0.01) for levator avulsion; hiatal area on Valsalva was larger, with an aMD of 3.84 cm(2) (95% CI, 1.78-5.90; P < 0.01). Comparing Cesarean delivery with normal vaginal delivery, aOR was 0.06 (95% CI, 0.02-0.14; P < 0.01) for POP ≥ Stage 2 or surgery and crude OR was 0.00 (95% CI, 0.00-0.30; P < 0.01) for levator avulsion; hiatal area on Valsalva was smaller, with an aMD of -8.35 cm(2) (95% CI, -10.87 to -5.84; P < 0.01). No differences were found between vacuum and normal vaginal delivery. CONCLUSIONS: We found that mode of delivery was associated with POP and pelvic floor muscle trauma in women from a general population, 16-24 years after their first delivery. Forceps was associated with significantly more POP, levator avulsion and larger hiatal areas than were vacuum and normal vaginal deliveries. There were no statistically significant differences between vacuum and normal vaginal deliveries. Cesarean delivery was associated with significantly less POP and pelvic floor muscle trauma than were normal or operative vaginal delivery.

Crohn's disease and pregnancy: the impact of perianal disease on delivery methods and complications.

BACKGROUND: The optimal delivery method in patients with Crohn's disease is unknown, and there is no large-scale evidence on which to base decisions. OBJECTIVE: The aim of this study was to compare delivery methods and outcomes in patients with and without Crohn's disease. DESIGN AND PATIENTS: The Nationwide Inpatient Sample and International Classification of Diseases, Ninth Revision codes were used to identify childbirth deliveries. Patients were stratified by the presence or absence of Crohn's disease and perianal disease (anorectal fistula or abscess, rectovaginal fistula, anal fissure, and anal stenosis). SETTINGS: A large population-cohort database was used for the analysis. MAIN OUTCOME MEASURES: The primary outcomes measured were cesarean delivery and perineal lacerations. RESULTS: Of 6,794,787 pregnant women who delivered, 2882 had a diagnosis of Crohn's disease. Rates of cesarean delivery were higher in patients who had Crohn's disease with (83.1%) and without (42.8%) perianal disease in comparison with patients who did not have Crohn's disease with (38.9%) and without (25.6%) perianal disease (p < 0.001). Rates of 4th degree perineal lacerations were similar between patients who had or did not have Crohn's disease without perianal disease (1.4% vs 1.3%), but these rates increased significantly in patients with perianal disease (12.3%, p < 0.001). On multivariate analysis, perianal disease (OR, 10.9; 95% CI, 8.3-4.1; p < 0.001) and smoking (OR, 1.6; 95% CI, 1.5-1.7; p < 0.001) were independently associated with higher rates of 4th degree laceration. Crohn's disease was not independently associated with 4th degree laceration. LIMITATIONS: This was a retrospective study with the inherent limitations of large databases. CONCLUSIONS: Patients with Crohn's disease have higher rates of cesarean delivery. Perianal disease predicts severe perineal laceration independent of the presence of Crohn's disease. In the absence of perianal disease, the method of delivery in women with Crohn's disease should be predicated on obstetric indication.

Gestational trophoblastic disease.

BACKGROUND: Molar pregnancy represents a significant burden of disease on the spectrum of Gestational Trophoblastic Disease (GTD). The incidence appears to be quite high in South Asia. The objective of this study was to determine the frequency of GTD, and clinical presentation, management and outcome of patients with molar pregnancy. METHODS: This retrospective, descriptive study was conducted at Nuclear Institute of Medicine and Radiotherapy (NIMRA), Jamshoro from 1st Jan to 31st Dec 2009. All patients diagnosed and registered as GTD were included in the study. The clinical records of all molar patients were reviewed regarding presentation, treatment, and follow-up. RESULTS: There were a total of 167 patients presenting with different female genital tract neoplasia at NIMRA during the study period, including 39 (29.35%) cases of GTD. Hydatidiform mole was seen in 33 (84.61%) patients. Complete mole in 31 (79.48%), partial mole in 2 (5.12%) patients, invasive mole in 1 (2.56%) patient, and choriocarcinoma in 5 (12.82%) patients. The mean age of the patients was 27 +/- 9.8 years. The highest incidence was found in nulliparous and para 1. Thirty-two patients had suction evacuation and 1 patient underwent hysterectomy. Patients received chemotherapy, 17 (54.54%) patients followed protocol for 3-6 months. CONCLUSION: Frequency of molar pregnancy was high, more common in low-parous, poor socioeconomic class women, and usually presented late.

U.S. trends in obstetric procedures, 1990-2000.

BACKGROUND: During the 1980s the rate of obstetric procedures performed during delivery rose precipitously. This study follows the use of obstetric procedures through the 1990s to explore whether the patterns witnessed in the previous decade continued through the next. METHODS: Data on total obstetric procedures and eight specific procedures (cesarean section, medical and surgical induction of labor, other artificial rupture of membranes, episiotomy, repair of current obstetric laceration, vacuum extraction, forceps delivery) were obtained from the National Hospital Discharge Survey, a nationally representative survey of discharges from short-stay non-Federal hospitals. Approximately 32,000 records for women with deliveries were included in the survey each year. RESULTS: The total rate of all obstetric procedures did not change significantly from 1990 through 2000. However, as during the 1980s, rates increased for induction of labor, vacuum extraction, and repair of current obstetric laceration. Rates decreased for forceps delivery and episiotomy, also continuing 1980s trends. After a long period of increase, the rate of cesarean section declined from 1988 to 1995 but increased again from 1995 to 2000. CONCLUSIONS: Unlike the 1980s, the overall rate of obstetric procedures did not increase from 1990 to 2000, but the mix of obstetric procedures performed continued to change during this period.

[Increased birth weights in the Nordic countries. A growing proportion of neonates weigh more than four kilos]. / Okad födelsevikt i Norden. Allt större andel nyfödda väger över fyra kilo.

The proportion of children with high birthweights is increasing in Sweden, as in the other Nordic countries. According to the Swedish national birth registry (founded in 1973), the proportion of term (i.e. (37 gestational weeks) offspring of singelton pregnancies, and weighing four kg or more, increased from 16.9 per cent in 1973 to 20.3 per cent in 1995. The respective figures for the first-born subgroup were 12.9 and 15 per cent, the increase in mean birthweight being from 3400 to 3520 g. There was a corresponding increase in head circumference. The risk of delivery-related complications increases with birthweight over four kg, and a higher incidence of major perineal rupture (grade 3 or 4) has been reported, as well as a disturbing increase in the incidence of brachial plexus damage. Findings in recent studies suggest high birthweight to be associated with an increased risk of subsequent morbidity, both in childhood and in adulthood, specifically diabetes type 1, eczema and certain malignancies, particularly breast cancer and prostate cancer. Although the cause of the increasing proportion of large newborns is not known, it may be partly due to weight increase among gravidae. Another possible explanation is reduced maternal smoking, as smoking is less common now than in the 1970s.

Clinical experience with the Silc Cup Vacuum Extractor.

The relative merits of vacuum extraction have been extensively studied and its advantages analysed. These include its ease of application, encouragement of "autorotation" of the malpositioned foetal head and its safety for both foetus and especially the mother. One hundred and eighty-six vacuum extraction assisted deliveries were performed at the Department of Gynaecological Oncology & Urology, Kandang Kerbau Hospital, from 1988 to 1990 using the 50 mm Silicone Silc Cup Vacuum Extractor (Menox AB). Anaesthetic requirements were minimal with 97% of cases accomplished with local perineal anaesthesia. Maternal complications were very few and only 1.6% of cases had third degree lacerations. There was no maternal or foetal mortality. The most frequent foetal morbidity was neonatal jaundice (28%) with only 7% requiring phototherapy. Cephalohaematoma was found in 8% and 2% had minor scalp abrasions. There were 3 infants with subaponeurotic haematoma who subsequently recovered uneventfully. Vacuum deliveries that were attempted but completed by forceps deliveries ("failed" vacuum extraction) accounted for 10% of total cases. The Silc cup vacuum extractor although not a replacement for all forceps manoeuvres offers a safe and efficient method of assisted delivery under the appropriate clinical circumstances.

Perinatal audit of one hundred consecutive vacuum extractions in Maputo.

The extraordinary demands on obstetrical services that prevail in many developing countries necessitate critical reviews of existing norms for obstetrical management. Vacuum extractions were studied in this context as a part of the regular perinatal audit carried out at the Maputo Central Hospital, the only hospital in Maputo with emergency surgery catering to the 43,000 annual deliveries. Extractions performed with the fetal head above the ischiatic spines were associated with a high number of complications and an 81% risk of neonatal asphyxia and also with a number of severe neonatal traumas. The risk of intracranial hemorrhage tended to be higher with extractions of fetuses with the head at or above the ischiatic spines, particularly when there was concomitant intrapartum asphyxia. It is concluded that a frequent perinatal audit of selected risk deliveries is a useful monitoring tool for examining prevailing indications for various obstetric interventions.

Trends in caesarean section in Western Australia, 1980-1987.

During the 1980s the incidence of both emergency and elective caesarean section in Western Australia increased, accompanied by a decrease in that of all other delivery methods. The proportion of emergency caesarean sections increased from 5.9%. of all deliveries in 1980 to 8.2% in 1987 and that of elective sections from 5.3% to 8.7%. For each year studied less than 50% of primiparous women delivering singletons had a normal vaginal delivery. Emergency caesarean sections were more common in primiparas and at the teaching hospital and elective sections in multiparas and at the metropolitan private hospitals. The proportion of primiparas having either emergency or elective caesarean sections rose with maternal age, but for multiparas the proportion having elective sections rose, but there were few differences in emergency sections with increasing age. Repeat caesarean sections, which made up 28.8% of the total in 1987, have contributed increasingly to the rising proportion of caesarean section deliveries. Unless the number of emergency sections in primiparous women falls and the challenge of vaginal birth after caesarean section is met, it is likely that the caesarean section rate in Western Australia will continue to increase over the next decade.