A systematic review and a meta-analysis on the incidence of obstetric anal sphincter injuries during vaginal delivery.

AIM: The incidence of obstetric anal sphincter injuries (OASIS) has increased in the past two decades despite improved awareness of the risk factors. This study aimed to define the incidence of OASIS in women with different features (instrumental delivery or other variables). METHODS: A systematic review was conducted on articles reporting the incidence of OASIS. This review aims to examine the association of instrumentation and OASIS by performing a formal systematic review of the published literature. Databases used for the research were MEDLINE, Embase, CINAHL and 'Maternity and infant care' databases. RESULTS: Two independent reviewers screened the selected articles. 2326 duplicates were removed from the total of 4907 articles. The remaining 2581 articles were screened for title and abstract. 1913 articles were excluded due to irrelevance. The remaining 300 were screened as full text. Primiparity associated with the use of forceps were the features associated with the highest incidence of OASIS in the selected articles (19.4%). OASIS in all women had an overall incidence of 3.8%. The incidence of OASIS in all women by geographical region was the highest (6.5%) in North America. CONCLUSIONS: There are various factors that impact on the incidence of OASIS and the combination of some of these, such as the use of forceps in primiparas, resulted in the highest incidence of OASIS. The lack of international consensus is limiting the improvements that can be done to reduce OASIS rates and improve best clinical practice.

Vacuum-assisted delivery outcomes: is advanced maternal age a factor?

PURPOSE: This study evaluated age-related maternal outcomes of vacuum-assisted vaginal deliveries (VAD). METHODS: This retrospective cohort study included all nulliparous women with singleton VAD in one academic institution. Study group parturients were maternal age ≥ 35 years and controls < 35. Power analysis revealed that 225 women/group would be sufficient to detect a difference in the rate of third- and fourth-degree perineal tears (primary maternal outcome) and umbilical cord pH < 7.15 (primary neonatal outcome). Secondary outcomes were maternal blood loss, Apgar scores, cup detachment, and subgaleal hematoma. Outcomes were compared between groups. RESULTS: From 2014 to 2019, 13,967 nulliparas delivered at our institution. Overall, 8810 (63.1%) underwent normal vaginal delivery, 2432 (17.4%) instrumental, and 2725 (19.5%) cesarean. Among 11,242 vaginal deliveries, 10,116 (90%) involved women < 35, including 2067 (20.5%) successful VAD vs. 1126 (10%) women ≥ 35 years with 348 (30.9%) successful VAD (p < 0.001). Rates of third- and fourth-degree perineal lacerations were 6 (1.7%) with advanced maternal age and 57 (2.8%) among controls (p = 0.259). Cord pH < 7.15 was similar: 23 (6.6%) study group and 156 (7.5%) controls (p = 0.739). CONCLUSION: Advanced maternal age and VAD are not associated with higher risk for adverse outcomes. Older, nulliparous women are more likely to undergo vacuum delivery than younger parturients.

Angle of progression measured using transperineal ultrasound for prediction of uncomplicated operative vaginal delivery: systematic review and meta-analysis.

OBJECTIVE: To determine whether intrapartum transperineal ultrasound measurement of the angle of progression (AoP) during the second stage of labor can predict uncomplicated operative vaginal delivery (OVD) using vacuum or forceps extraction. METHODS: A systematic search in PubMed, EMBASE, Scopus, Web of Science and Google Scholar was performed from inception to February 2021. Studies assessing the predictive accuracy of AoP, measured using intrapartum transperineal ultrasound, for uncomplicated OVD, defined as successful vaginal delivery within three pulls using forceps or no more than two detachments of the vacuum extractor cup, were included. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Summary receiver-operating-characteristics (ROC) curves, pooled sensitivity and specificity, area under the ROC curve (AUC) and summary likelihood ratios (LRs) were calculated. RESULTS: Seven studies reporting on a total of 782 patients undergoing OVD were included in this systematic review and meta-analysis. Second-stage AoP measured during maternal rest had a pooled sensitivity of 80% (95% CI, 59-92%) and specificity of 89% (95% CI, 76-95%), with a LR+ of 7.3 (95% CI, 3.1-15.8) for uncomplicated OVD. AoP measured during active pushing had a sensitivity of 91% (95% CI, 85-94%) and specificity of 83% (95% CI, 69-92%), with a LR+ of 5.4 (95% CI, 2.7-10.6) for uncomplicated OVD. The performance of AoP measured at rest was particularly high in nulliparous women, with a sensitivity of 87% (95% CI, 75-94%) and specificity of 90% (95% CI, 82-94%) for uncomplicated OVD. CONCLUSION: AoP may be a reliable predictor for uncomplicated OVD when measured during the second stage of labor, especially in nulliparous women. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

What happens to brain outside the thermal ablation zones? An assessment of needle-based therapeutic ultrasound in survival swine.

BACKGROUND: In stereotactic radiosurgery, isodose lines must be considered to determine how surrounding tissue is affected. In thermal ablative therapy, such as laser interstitial thermal therapy (LITT), transcranial MR-guided focused ultrasound (tcMRgFUS), and needle-based therapeutic ultrasound (NBTU), how the surrounding area is affected has not been well studied. OBJECTIVE: We aimed to quantify the transition zone surrounding the ablation core created by magnetic resonance-guided robotically-assisted (MRgRA) delivery of NBTU using multi-slice volumetric 2-D magnetic resonance thermal imaging (MRTI) and subsequent characterization of the resultant tissue damage using histopathologic analysis. METHODS: Four swine underwent MRgRA NBTU using varying duration and wattage for treatment delivery. Serial MRI images were obtained, and the most representative were overlaid with isodose lines and compared to brain tissue acquired postmortem which underwent histopathologic analysis. These results were also compared to predicted volumes using a finite element analysis model. Contralateral brain tissue was used for control data. RESULTS: Intraoperative MRTI thermal isodose contours were characterized and comprehensively mapped to post-operative MRI images and qualitatively compared with histological tissue sections postmortem. NBTU 360° ablations induced smaller lesion volumes (33.19 mm3; 120 s, 3 W; 30.05 mm3, 180 s, 4 W) versus 180° ablations (77.20 mm3, 120 s, 3 W; 109.29 mm3; 180 s; 4 W). MRTI/MRI overlay demonstrated the lesion within the proximal isodose lines. The ablation-zone was characterized by dense macrophage infiltration and glial/neuronal loss as demonstrated by glial fibrillary acidic protein (GFAP) and neurofilament (NF) absence and avid CD163 staining. The transition-zone between lesion and normal brain demonstrated decreased macrophage infiltration and measured ∼345 microns (n - 3). We did not detect overt hemorrhages or signs of edema in the adjacent spared tissue. CONCLUSION: We successfully performed MRgRA NBTU ablation in swine and demonstrated minimal histologic changes extended past the ablation-zone. The lesion was characterized by macrophage infiltration and glial/neuronal loss which decreased through the transition-zone.

Traction force profile in children with severe perinatal outcomes delivered with a digital vacuum extraction handle: A case-control study.

INTRODUCTION: During the second stage of labor, vacuum-assisted delivery is an alternative to forceps delivery and emergency cesarean section. Extensive research concerning perinatal outcomes has indicated that the risk of complications, although rare, is higher than with a spontaneous vaginal delivery. An important factor related to perinatal outcomes is the traction force applied. Our research group previously developed a digital extraction handle, the Vacuum Intelligent Handle-3 (VIH3), that measures and records traction force. The objective of this study was to compare traction force profiles in children with and without severe perinatal outcomes delivered with the digital handle. A secondary aim was to establish a safe force limit. MATERIAL AND METHODS: This was an observational case-control study at the delivery ward at Karolinska University Hospital, Sweden. In total, 573 children delivered with the digital handle between 2012 and 2018 were included. Cases were defined as a composite of severe perinatal outcomes, including subgaleal hematoma, intracranial hemorrhage, hypoxic ischemic encephalopathy 1-3, seizures or death. The cases in the cohort were matched 1:3 based on five matching variables. Traction profiles were analyzed using the MATLAB® software and conditional logistic regression. RESULTS: The incidence of severe perinatal outcomes was 2.3%. The 13 cases were matched with three controls each (n = 39). A statistically significant increased odds for higher total traction forces was seen in the case group (odds ratio [OR] 1.004; 95% confidence interval [CI] 1.001-1.007) and for the peak force (OR 1.022; 95% CI 1.004-1.041). Several procedure-related parameters were significantly increased in the case group. As expected, some neonatal characteristics also differed significantly. An upper force limit of 343 Newton minutes (Nmin) revealed an 86% reduction in severe perinatal outcomes (adjusted OR 0.14; 95% CI 0.04-0.5). CONCLUSIONS: Children with severe perinatal outcomes had traction force profiles with significantly higher forces. The odds for severe perinatal outcomes increased for every increase in Nmin and Newton used during the extraction procedure. A calculated total force level of 343 Nmin is suggested as an upper safety limit, but this must be tested prospectively to provide validity.

A study to assess the efficacy of fractional carbon dioxide laser with topical platelet-rich plasma in the treatment of androgenetic alopecia.

Owing to the inadequate response to and limitations of the approved medications for androgenetic alopecia, novel therapies are warranted to enhance outcomes. The objective of this paper is to ascertain the effectiveness of fractional carbon dioxide laser followed by platelet-rich plasma application on hair regrowth and to compare the two laser settings. Seven participants were enrolled in this half-head pilot study based on different laser pulse energy and density values (12 mJ, 800 spots/cm2 and 22 mJ, 400 spots/cm2). Ten treatment sessions were performed every 2 weeks with 12-week follow-up. The evaluation methods were based on hair density from standardized phototrichograms, global photographic assessment, and patient satisfaction. Significantly increased total and terminal hair densities were observed during treatment in both groups as compared with baselines. The mean total hair density has weekly increased significantly with high pulse energy (1.42 hair/cm2) as compared to low pulse energy (1.04 hair/cm2) throughout the study period (p = 0.023; 4.89 hair/cm2). Global photographs and patient satisfaction scores demonstrated improvement, but only the latter showed statistical significance (p = 0.029). The average pain intensity scores were not different between the groups (p = 0.760) all over the procedure. The adverse events were minor and well tolerated. This synergistic treatment remarkably leads to hair restoration and high patient satisfaction. The parameters of 22-mJ beam energy with 400 spots/cm2 density are appropriate and superior to 12-mJ beam energy with 800 spots/cm2. Albeit higher energy, no more pain is indicated in the high pulse energy group. Trial registration number (TRN): TCTR20180619004, Thai Clinical Trials Registry (TCTR) since 2018-05-15 13:39:48.

Adverse outcomes in vacuum-assisted delivery after detachment of non-metal cup: a retrospective cohort study.

PURPOSE: To evaluate neonatal and maternal outcomes associated with detachment of non-metal vacuum cup during delivery and to identify risk factors for these detachments. METHODS: This retrospective cohort study included women with singleton pregnancy, who underwent vacuum-assisted vaginal delivery with a non-metal vacuum cup in a single academic institution, January 2014-August 2019. Failed vacuum deliveries were excluded. Primary outcomes were defined as subgaleal hematoma (SGH) and cord blood pH < 7.15. Secondary outcome included other neonatal complications and adverse maternal outcomes. Outcomes were compared between vacuum-assisted deliveries with and without cup detachment during the procedure. RESULTS: A total of 3246 women had successful VAD and met the inclusion criteria. During the procedure, the cup detached at least once in 665 (20.5%) deliveries and did not detach in 2581 (79.5%). The cup detachment group experienced higher rates of SGH (8.9% vs. 3.5%, p = 0.001) and cord blood pH < 7.15 (9.8% vs. 7.1%, p = 0.03). There were also more neonatal intensive care unit admissions (NICU) (4.4% vs. 2.7%, p = 0.03) and more fetuses with occiput posterior position (70.8% vs. 79.4%, p = 0.001), the vacuum duration was slightly longer (6 ± 3.7 vs. 5 ± 2.9 min) and more neonates had birth weights > 3700 g (14.1% vs, 10.3%, p = 0.006). Interestingly, there were more males in that group (60.6 vs. 54.6, p = 0.005). All these factors remained significant after controlling for potential confounders. CONCLUSIONS: Vacuum cup detachment has several predictive characteristics and is associated with adverse neonatal outcomes that should be incorporated into decisions made during the procedure.

Comparison of fractional erbium:YAG laser-assisted tranexamic acid delivery alone and in combination with oral tranexamic acid in melasma.

Tranexamic acid (TA) emerged as a promising agent for melasma. However, due to its hydrophilic structure, topical TA should be combined with a penetration-enhancing strategy to augment efficacy. To evaluate the efficacy of fractional erbium:YAG laser-assisted delivery (LAD) of topical TA 5% either with or without oral TA treatment in recalcitrant melasma patients. The authors retrospectively assessed the treatment outcomes of melasma patients treated by fractional erbium:YAG LAD of topical TA 5%. Patients receiving a standard protocol including four biweekly laser sessions were eligible. The study included two groups: group 1 patients received oral TA and LAD of topical TA 5%, and group 2 patients received only LAD of topical TA 5%. Two blinded dermatologists reported pre-treatment and post-treatment modified MASI (mMASI) scores. Mean mMASI scores in both group 1 (n = 15) and group 2 (n = 19) were significantly lower at the end of the treatment than baseline values (p = 0.001; p = 0.022, respectively). The decrease of mMASI scores were higher in group 1 (median = 2.1) (64.7%) than in group 2 (median = 1.2) (41.8%) (p = 0.027). Fractional erbium:YAG LAD of topical TA 5% is an efficient treatment regimen for melasma patients recalcitrant to conventional treatment approaches. The implementation of oral TA to this regimen improves the therapeutic outcomes.

Comparison of a practice-based versus theory-based training program for conducting vacuum-assisted deliveries: a randomized-controlled trial.

PURPOSE: Vacuum-assisted deliveries (VAD) are complex procedures that require training and experience to be performed proficiently. We aimed to evaluate if a more resource intensive practice-based training program for conducting VAD is more efficient compared to a purely theory-based training program, with respect to immediate training effects and persistence of skills 4-8 weeks after the initial training. METHODS: In this randomized-controlled study conducted in maternity staff, participants performed a simulated low-cavity non-rotational vacuum delivery before (baseline test) and immediately after the training (first post-training test) as well as 4-8 weeks thereafter (second post-training test). The study's primary endpoint was to compare training effectiveness between the two study groups using a validated objective structured assessment of technical skills (OSATS) rating scale. RESULTS: Sixty-two participants were randomized to either the theory-based group (n = 31) or the practice-based group (n = 31). Total global and specific OSATS scores, as well as distance of cup application to the flexion point improved significantly from baseline test to the first post-training test in both groups (pall < 0.007). Skill deterioration after 4-8 weeks was only found in the theory-based group, whereas skills remained stable in the practice-based group. CONCLUSION: A practice-based training program for conducting VAD results in comparable immediate improvement of skills compared to a theory-based training program, but the retention of skills 4-8 weeks after training is superior in a practice-based program. Future studies need to evaluate, whether VAD simulation training improves maternal and neonatal outcome after VAD.

Individual and ecological analyses of antenatal care: Prospects for delivery assistance and use of modern family planning in Nigeria.

Despite the availability of healthcare centres for the provision of antenatal care (ANC) services in Nigeria, the services are still underutilized by pregnant women. ANC services not only reduce maternal mortality and birth defects, but also have a strong link to many causes of maternal deaths. This study explored the individual and ecological relationships between antenatal care, skilled birth assistance during delivery, and family planning use across states in Nigeria. This study was a secondary analysis of data from the 2018 National Nutrition and Health Survey (NNHS) carried out among 24,985 women aged 15-49 years in the 36 states and the Federal Capital Territory (FCT) in Nigeria. Analysis was carried out at the level of individual women and at the ecological level. Only 68.3% visited a health professional (doctors, nurses, midwives, community health extension workers, and community health officers) for ANC in the most recent pregnancy before the survey. At delivery, 44.9% were assisted by delivery attendants with about half (50.1%) assisted by non-professional (traditional birth attendants, relatives and friends) during delivery. There was a significant variation in use of modern family planning (FP) across types of ANC provider. There was a strong positive correlation between ANC utilisation and skilled birth attendance (SBA) (r=0.706, p <0.001), and between SBA and FP (r=0.730, p <0.001). These results have implications for the design of appropriate interventions for strengthening the role of healthcare providers to enhance ANC patronage, utilization of safe delivery services and sustained use of reproductive health services.

Predicting ablation zones with multislice volumetric 2-D magnetic resonance thermal imaging.

BACKGROUND: High-intensity focused ultrasound (HIFU) serves as a noninvasive stereotactic system for the ablation of brain metastases; however, treatments are limited to simple geometries and energy delivery is limited by the high acoustic attenuation of the calvarium. Minimally-invasive magnetic resonance-guided robotically-assisted (MRgRA) needle-based therapeutic ultrasound (NBTU) using multislice volumetric 2-D magnetic resonance thermal imaging (MRTI) overcomes these limitations and has potential to produce less collateral tissue damage than current methods. OBJECTIVE: To correlate multislice volumetric 2-D MRTI volumes with histologically confirmed regions of tissue damage in MRgRA NBTU. METHODS: Seven swine underwent a total of 8 frontal MRgRA NBTU lesions. MRTI ablation volumes were compared to histologic tissue damage on brain sections stained with 2,3,5-triphenyltetrazolium chloride (TTC). Bland-Altman analyses and correlation trends were used to compare MRTI and TTC ablation volumes. RESULTS: Data from the initial and third swine's ablations were excluded due to sub-optimal tissue staining. For the remaining ablations (n = 6), the limits of agreement between the MRTI and histologic volumes ranged from -0.149 cm3 to 0.252 cm3 with a mean difference of 0.052 ± 0.042 cm3 (11.1%). There was a high correlation between the MRTI and histology volumes (r2 = 0.831) with a strong linear relationship (r = 0.868). CONCLUSION: We used a volumetric MRTI technique to accurately track thermal changes during MRgRA NBTU in preparation for human trials. Improved volumetric coverage with MRTI enhanced our delivery of therapy and has far-reaching implications for focused ultrasound in the broader clinical setting.

Perinatal outcome after vacuum assisted delivery with digital feedback on traction force; a randomised controlled study.

BACKGROUND: Low and mid station vacuum assisted deliveries (VAD) are delicate manual procedures that entail a high degree of subjectivity from the operator and are associated with adverse neonatal outcome. Little has been done to improve the procedure, including the technical development, traction force and the possibility of objective documentation. We aimed to explore if a digital handle with instant haptic feedback on traction force would reduce the neonatal risk during low or mid station VAD. METHODS: A two centre, randomised superiority trial at Karolinska University Hospital, Sweden, 2016-2018. Cases were randomised bedside to either a conventional or a digital handle attached to a Bird metal cup (50 mm, 80 kPa). The digital handle measured applied force including an instant notification by vibration when high levels of traction force were predicted according to a predefined algorithm. Primary outcome was a composite of hypoxic ischaemic encephalopathy, intracranial haemorrhage, seizures, death and/or subgaleal hematoma. Three hundred eighty low and mid VAD in each group were estimated to decrease primary outcome from six to 2 %. RESULTS: After 2 years, an interim analyse was undertaken. Meeting the inclusion criteria, 567 vacuum extractions were randomized to the use of a digital handle (n = 296) or a conventional handle (n = 271). Primary outcome did not differ between the two groups: (2.7% digital handle vs 2.6% conventional handle). The incidence of primary outcome differed significantly between the two delivery wards (4% vs 0.9%, p < 0.05). A recalculation of power revealed that 800 cases would be needed in each group to show a decrease in primary outcome from three to 1 %. This was not feasible, and the study therefore closed. CONCLUSIONS: The incidence of primary outcome was lower than estimated and the study was underpowered. However, the difference between the two delivery wards might reflect varying degree of experience of the technical equipment. An objective documentation of the extraction procedure is an attractive alternative in respect to safety and clinical training. To demonstrate improved safety, a multicentre study is required to reach an adequate cohort. This was beyond the scope of the study. TRIAL REGISTRATION: ClinicalTrials.gov NCT03071783 , March 1, 2017, retrospectively registered.

Risk of anal sphincter injury in trial of labor post cesarean section.

INTRODUCTION: We wanted to evaluate whether secundiparas who achieved vaginal birth after cesarean (VBAC) were at an increased risk for obstetric anal sphincter injury (OASI) compared to primiparas who delivered vaginally, with a stratification by the mode of delivery-spontaneous or operative vaginal delivery. MATERIAL AND METHODS: We conducted a retrospective cohort study of primiparous women who delivered by vacuum-assisted delivery between March 2011 and June 2019. Primiparas delivering vaginally and secundiparas undergoing VBAC were compared. The cohort was further stratified into two categories: spontaneous vaginal delivery and operative vaginal delivery. RESULTS: Overall, 23 822 primiparas who delivered vaginally and 1596 secundiparas who underwent VBAC were analyzed. Operative vaginal delivery was performed in 4561 deliveries. OASI rate did not differ between the VBAC and primipara groups (1.3% vs 1.8%, P = .142). A total of 20 857 women delivered by spontaneous vaginal delivery, among them 1180 (5.7%) women were secundiparas and 19 677 (94.3%) were primiparas. OASI rate was comparable between the secundiparas undergoing VBAC and primiparas delivering vaginally (17 [1.4%] vs 338 [1.7%], P = .436). A total of 4561 women delivered by operative vaginal delivery, among them 416 (9.1%) were secundiparas and 4145 (90.9%) were primiparas. The rate of operative vaginal deliveries was higher among the VBAC group compared with the primipara group (6.1% vs 17.4%, P < .001). However, women undergoing successful VBAC had lower rates of OASI compared with primiparas (3 [0.7%] vs 96 [2.3%]; odds ratio [OR] 0.30, 95% CI 0.09-0.97, P = .032). After multivariate logistic regression including all statistically significant factors, OASI was not associated with VBAC in spontaneous or operative vaginal deliveries (adjusted OR 0.85, 95% CI 0.51-1.40 and 0.39, 95% CI 0.12-1.28, respectively). CONCLUSIONS: Secundiparas undergoing VBAC were not at a higher risk of OASI when compared with primiparas delivering vaginally, either in spontaneous or operative vaginal deliveries. This information might aid when counseling women contemplating a trial of labor after cesarean--to address their concerns regarding the risks and benefits of VBAC.

Laser-Assisted Hyaluronic Acid Delivery by Fractional Carbon Dioxide Laser in Facial Skin Remodeling: A Prospective Randomized Split-Face Study in France.

BACKGROUND AND OBJECTIVES: Combining the efficacy of ablative fractional carbon dioxide lasers (AFXL) to laser-assisted hyaluronic acid delivery (LAHAD) has not yet been studied. The objective of our study was to evaluate the safety and the efficacy of laser-assisted hyaluronic acid (HA) delivery with AFXL in facial skin remodeling. STUDY DESIGN/MATERIALS AND METHODS: We conducted a prospective, double-blinded, randomized split-face study on 20 patients from 30 to 70 years old, with a skin phototype from I to IV. Each patient received full-face treatment with AFXL, immediately followed by the application in droplets into the fractional ablative tunnels of 1 ml of HA gel on one hemiface and 1 ml of physiological saline on the other hemiface. To evaluate postlaser aftermath, the intensity of erythema, edema, and crusts was graded. To assess facial skin remodeling, we scored the improvement of skin texture, firmness, fine lines, and skin radiance from baseline. Patients were evaluated on the 3rd and 7th day, 1st and 3rd month using clinical evaluations, photographs, and patient questionnaires. RESULTS: We showed equivalence in postlaser aftermath between HA-treated and nontreated hemiface. Trend data analyses at the 3rd month suggested that immediate application of HA after AFXL resulted in a greater improvement in facial skin remodeling, especially for skin texture (mean score of 2.60 vs. 2.45) and skin firmness (mean score of 2.55 vs. 2.40). Skin radiance showed the best improvement, reaching almost a score of 5/10. CONCLUSIONS: LAHAD with AFXL is a safe treatment showing promising results in facial skin remodeling. These findings need to be confirmed by a larger study to evaluate the value of LAHAD in daily clinical practice. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

Risk factors for obstetric anal sphincter injury among parous women.

PURPOSE: Nulliparity and operative vaginal delivery are established risk factor for obstetric anal sphincter injury (OASI). However, risk factors for OASIS occurrence among parous women delivering vaginally are not well-established. We aimed to study the risk factors for OASI occurrence among parous women. METHODS: A retrospective study including all parous women who delivered vaginally at term during 2011-2019 at a university hospital. Deliveries of parous women with OASI were compared to deliveries without OASI. The risk factors associated with OASI were investigated. RESULTS: Overall, 35,397 women were included in the study with an OASI rate of 0.4% (n = 144). A higher rate of only one previous vaginal delivery was noted in the OASI group (78.5% vs. 46.4%, OR [95% CI] 4.20, 2.82-6.25, p < 0.001). The rate of vacuum-assisted deliveries was comparable between the study groups. The median birth weight was higher among the OASI group (3566 vs. 3300 g, p < 0.001), as was the rate of macrosomic neonates (19.4% vs. 5.5%, OR [95% CI] 4.15, 2.74-6.29, p < 0.001). On multivariate logistic regression analysis, only two factors were independently positively associated with the occurrence of OASI: a history of only one previous vaginal delivery (adjusted OR [95% CI] 4.34, 2.90-6.49, p = 0.001), and neonatal birth-weight (for each 500 g increment) (adjusted OR [95% CI] 2.51, 1.84-3.44, p < 0.001). CONCLUSIONS: Among parous women, the only factors found to be independently positively associated with OASI were the order of parity and neonatal birth-weight. Vacuum-assisted delivery was not associated with an increased risk of OASI among parous women.

Vacuum extraction delivery at first vaginal birth following cesarean: maternal and neonatal outcome.

OBJECTIVE: To evaluate the maternal and neonatal morbidity outcome associated with vacuum assisted (VA) vaginal delivery at first vaginal birth following a previous cesarean delivery (CD). STUDY DESIGN: This is a retrospective computerized study conducted at a single tertiary center, between 2005 and 2018. The study compared the morbidity outcome of VA vaginal delivery between two groups of parturients at their first vaginal birth; primigravid and those in second delivery with a prior cesarean. The primary outcome was the maternal adverse outcome: postpartum hemorrhage (PPH), anal sphincter injuries, retained placenta, shoulder dystocia, uterine rupture, and intensive care unit (ICU) admissions. Secondary outcome was the neonatal adverse outcome: Apgar score, NICU admission, meconium aspiration, jaundice, sepsis, birth trauma, and death. Univariate analysis was followed by a multiple logistic regression model controlling for potential confounders, adjusted odds ratios (95% confidence interval). RESULTS: During the study period, we identified 3695 parturients that engaged in Trial of labor after cesarean with no previous vaginal birth, among which 679 (18.4%) delivered by Vacuum (VA-VBAC). These were compared to 6544/43,083 (15.2%) primigravid delivered by Vacuum. The VA-VBAC group had higher risk of PPH (10.5% vs. 7.2%, p < 0.01), blood transfusions (5.6% vs. 3.5%, p < 0.01), retained placenta (10.2% vs. 4.7%, p < 0.01), and uterine rupture (0.4% vs. 0%, p < 0.01). The adverse neonatal outcomes were comparable among groups. CONCLUSION: The VA-VBAC has a higher risk of maternal postpartum hemorrhagic complications; preventive measures should be directed to this selected group of operative vaginal deliveries.

Does birthweight have a role in the effect of episiotomy on anal sphincter injury?

PURPOSE: Most professional guidelines advise against routine episiotomy during vaginal delivery, although mounting evidence supports its protective role regarding obstetric anal sphincter injury (OASI). We aimed to study the effect of lateral and mediolateral episiotomies on the rate of OASI in relation to birthweight among nulliparous women undergoing vaginal delivery. METHODS: A historical cohort study was conducted of all nulliparous women who delivered vaginally at term between 2011 and 2019 at a tertiary university hospital. Women were allocated into two groups: (1) with OASI and (2) without OASI. Episiotomy performance and birthweight groups were analyzed. RESULTS: Overall, 22,250 deliveries were analyzed for inclusion: 18,533 (83.3%) spontaneous vaginal deliveries (SVD), 3222 (14.5%) vacuum-assisted deliveries (VAD) and 495 (2.2%) forceps deliveries. Total episiotomy and OASI rate was 48.2% and 1.7%, respectively. Episiotomy rate was lower in the OASI group as compared to the no OASI group (158 (41.3%) vs. 10,568 (48.3%), OR 0.75, 0.61-0.92, p = 0.006). Median birthweight was higher for OASI group neonates (3355 vs. 3160, p < 0.001). In SVDs, episiotomy decreased the rate of OASI in neonatal birthweight groups of 3000-3499, 3500-3999 and > 4000 g (OR 0.56, 0.38-0.82, p = 0.003; 0.66, 0.45-0.99, p = 0.04 and 0.24, 0.07-0.78, p = 0.01, respectively). In VADs, episiotomy decreased the rate of OASI in the neonatal weight groups of 2500-2999 and 3000-3499 g (OR 0.36, 0.14-0.89, p = 0.02 and OR 0.38, 0.19-0.75, p = 0.004, respectively). CONCLUSIONS: Lateral and mediolateral episiotomies are independent modifiable predictors of OASI, protective against OASI in SVDs when neonates weigh > 3000 g and 2500-3499 g in VADs.

Vacuum extraction in twin deliveries-maternal and neonatal consequences: a retrospective cohort study.

PURPOSE: To establish the frequency of vacuum extraction among parturients with twin pregnancies, identify the risk factors and perinatal outcomes. METHODS: A retrospective cohort database study was conducted between 2005-2018. Twin fetuses with vertex presentation >34 weeks gestation who achieved vaginal delivery were included. Outcomes were compared between neonates who were delivered by vacuum extraction and neonates delivered by spontaneous vaginal delivery (aORs; [95% CI]). RESULTS: A total of 1751 neonates of 905 parturients with twin pregnancies met inclusion criteria, of which 163 (18%) parturients had vacuum extraction and 225 (12.8%) neonates were delivered by vacuum extraction. The most significant risk factors for vacuum extraction were primiparity (6.79 [4.77-9.66]), previous cesarean delivery (5.59 [3.13-9.97]), and epidural analgesia (4.34 [1.83-10.31]). Vacuum extractions were associated with a spectrum of adverse maternal outcomes (2.60 [1.61-4.19]), particularly postpartum hemorrhage and its associated morbidities. From the neonatal aspect, vacuum extraction deliveries were associated with a composite of birth trauma injuries (21.81 [6.43-73.91]). CONCLUSION: Vacuum extractions among twin pregnancies were found to be associated with significantly higher rates of postpartum hemorrhage, blood transfusion, and perinatal birth trauma. These findings should be presented to women when counseling on mode of delivery and considered individually against cesarean delivery disadvantages.

Risk factors associated with subgaleal hemorrhage in neonates exposed to vacuum extraction.

INTRODUCTION: Subgaleal hemorrhage (SGH) is a life-threatening neonatal condition that is strongly associated with vacuum assisted delivery (VAD). The factors associated with the development of SGH following VAD are not well-established. We aimed to evaluate the factors associated with the development of SGH following attempted VAD. MATERIAL AND METHODS: A retrospective case-control study of women who delivered at a tertiary university-affiliated medical center in Jerusalem, Israel, during 2009-2018. Cases comprised all parturients with singleton pregnancies for whom attempted VAD resulted in neonatal SGH. A control group of VAD attempts was established by matching one-to-one according to gestational age at delivery, parity and year of delivery. Fetal, intrapartum and vacuum procedure characteristics were compared between the groups. RESULTS: In all, 313 (89.5%) of the 350 attempted VAD were nulliparous. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birthweight in the SGH group. In multivariate logistic regression analysis, only six independent risk factors were significantly associated with the development of SGH: second-stage duration (for each 30-minute increase, adjusted odds ratio [OR] 1.13; 95% confidence intervals [CI] 1.04-1.25; P = .006), presence of meconium-stained amniotic fluid (adjusted OR 2.61; 95% CI 1.52-4.48; P = .001), presence of caput succedaneum (adjusted OR 1.79; 95% CI 1.11-2.88; P = .01), duration of VAD (for each 3-minute increase, adjusted OR 2.04; 95% CI 1.72, 2.38; P < .001), number of dislodgments (adjusted OR 2.38; 95% CI 1.66-3.44; P < .001), and fetal head station (adjusted OR 3.57; 95% CI 1.42-8.33; P = .006). Receiver operating characteristic curves showed that VAD duration of ≥15 minutes had a 96.7% sensitivity and 75.0% specificity in predicting SGH formation, with an area under the curve equal to .849. CONCLUSIONS: Vacuum duration, the number of dislodgments, the duration of second stage of delivery, fetal head station, the presence of caput succedaneum and the presence of meconium were found to be independently associated with SGH formation.

Operative vaginal deliveries and their impact on maternal and neonatal outcomes - prospective analysis.

OBJECTIVE: Evaluation of maternal and neonatal outcomes in operative vaginal deliveries in prospective study analysis. DESIGN: Prospective case-control study analysis. SETTING: Prospective analysis of 292 operative vaginal deliveries (VEX, forceps) for the period June 2016 - August 2017 from overall 6056 vaginal deliveries. Type and frequency of maternal and neonatal trauma occurence was observed in connection with using vacuum-assisted delivery and forceps delivery, mainly the cephalohematomas and their complications. Collected data were statistically analysed. RESULTS: In the reported period from overall 6056 deliveries there were 216 vacuumextractions (3.6%) and 72 forceps deliveries (1.2%) performed. Both methods were used in four patients (VEX and forceps). The most frequent trauma in newborns were cephalohematomas. Remarkable cephalohematoma, requiring further observation has occured in 40 newborns (18.5%) after vacuum-assisted delivery and in 5 newborns (6.9%), (p = 0,017) after forceps delivery. Consequential punction of cephalohematoma occured only after vacuumextraction delivery and in 6 newborns (15.0 %). The third degree perineal rupture occured after vacuumextraction in 20 patients (9.3%) and after forceps delivery in 12 patients (16.7%), (p = 0,091). The fourth degree perineal rupture occured only after vacuumextraction and in 1 case (0.5%). CONCLUSION: The vacuumextraction compared with forceps is more likely to be associated with the statistically significant incidence of cephalohematomas and their further treatment. Forceps deliveries compared with vacuumextraction are more likely to be associated with the maternal perineal trauma, but the diference was not statistically significant.