Canine Cesarean Section: Emergency and Elective.

Canine Cesarean Section (CS) is primarily performed to increase survival of newborns and less commonly to save the life or reproductive future of the dam. Conducting proper ovulation timing to accurately predict the due date will allow a planned, elective CS as an excellent alternative to a high-risk natural whelping, and possible dystocia, for certain breeds and situations. Techniques for ovulation timing, anesthesia, and surgery tips are provided.

Successful Resuscitation of Neonatal Kittens Delivered by a Perimortem Cesarean Section Following Maternal Cardiopulmonary Arrest.

A 9 yr old, unknown weight, intact female domestic shorthair presented for evaluation of dystocia with dyspnea. En route to the hospital for treatment, the owners noted the queen stopped breathing. On presentation, cardiopulmonary arrest was confirmed. The exact cause was unknown but suspected to be secondary to acute fulminant congestive heart failure or acute respiratory distress syndrome due to a large volume of serosanguineous fluid within the mouth and nose. Cardiopulmonary resuscitation (CPR) was immediately started. After 2 min of CPR without return of spontaneous circulation, the owners consented to perimortem Cesarean section. Two kittens were removed via emergency hysterotomy within 3-4 min. Both kittens were successfully resuscitated. CPR efforts were continued on the queen for 2 min after delivery of the kittens, at which time the owners elected to stop further resuscitative efforts. Both kittens were discharged from the hospital and were alive at last follow-up, 2 yr and 4 mo after birth. There are no previous reports regarding the use of a perimortem Cesarean section to deliver neonates in small animal medicine. Therefore, this report represents a novel treatment approach that can be considered in the case of maternal arrest during dystocia.

Comparing forces on the fetal neck in breech delivery in lithotomy versus all-fours position: a simulation model.

PURPOSE: To measure forces applied to the fetal neck, in a simulation model for breech delivery, in both lithotomy versus all-fours position. METHODS: We used a Laerdal SimMom simulator and a Birthing Baby together with PROMPT Flex Software. The descent of the fetus was accomplished using the Automatic Delivery Module 2. The baby was always in breech position; the SimMom in either all-fours or lithotomy positions. Sensors were located inside the fetal neck region to simulate forces applied to the plexus. RESULTS: The lowest force on the fetal neck region was recorded for the delivery in all-fours position without further maneuvers (mean force 58.70 Newton, standard deviation 2.54 N). As weight was added to the baby, the force increased (i.e. + 500 g, mean force 71.8 N, SD 3.08 N, p < 0.001). Delivery in lithotomy position resulted in a mean force of 81.56 N (SD 19.55 N). The force significantly increased in case of delivery of the head without assistance from contractions (mean force 127.93 N, SD 23.10 N). In all-fours position, the delivery of the fetal head from pelvic floor level without contractions (Frank's Nudge maneuver) resulted in a mean force of 118.45 N (SD 15.48 N, p = 0.02). Maneuvers for shoulder dystocia (the inverted type that can occur during breech delivery) led to significantly higher mean forces independent from birthing positions. CONCLUSION: Breech delivery in all-fours position was associated with the lowest force acting on the fetal neck in our simulation model.

Surgical management of dystocia in a colobus monkey (Colobus guereza).

A 14-year-old female black and white colobus monkey (Colobus guereza) presented in labor with fetal arms visible protruding from the vulva. Manual manipulation for assisted delivery of the fetus was unsuccessful. Radiographs identified a large fetal skull and hysterotomy was required with ovariohysterectomy elected to follow. The fetus was confirmed to be deceased during hysterotomy, but the dam recovered from the procedure uneventfully. The detailed description of the anesthesia and surgical procedure in this case may aid other clinicians when presented with similar dystocia cases in this species.

Review on a cesarean section in the cow: Its incision approaches, relative advantage, and disadvantages.

Dystocia is an abnormal and difficult birth in which the first or the second stage of labour is markedly prolonged and subsequently found impossible for the dam to deliver without artificial aid. In cattle, it can be relieved by different obstetric methods, including the cesarean operation and fetotomy. Caesarean section is the extraction of the fetus or foeti from the dam, through a surgical opening in the abdominal wall and the uterus. This surgical method can be performed by about eight alternative surgical approaches in bovines with its advantages and disadvantages. However, the selection is dependent on many factors like the type of dystocia, the cows and environmental conditions, the availability of assistants, and the surgeon's preference. For cows, most surgeons use a standing left paralumbar celiotomy. However, the left oblique approach is also preferable under most circumstances because the uterus is readily exteriorized, limiting peritoneal cavity contamination. Besides, alternative approaches are also available that will further limit the potential for contamination but many junior surgeons perform the left paralumbar celiotomy using the same approach each time due to their comfort with one specific approach or lack of familiarity with other available options. Therefore, the objective of this review is to provide basic insights and highlight the cesarean section incision approaches with their relative advantages and disadvantages in cows.

Caesarean section rates: applying the modified ten-group Robson classification in an Australian tertiary hospital.

The aim of this study was to determine the main contributors to caesarean section (CS) rates at an Australian tertiary hospital. We conducted a retrospective review of women who delivered in an Australian tertiary hospital between 2014 and 2017. Women were allocated according to a modified Robson Ten-Group Classification System and CS indications were collected in nulliparous women and women with previous CS. The largest contributor to the 35.7% overall CS rate was women with a term cephalic infant and a previous CS (31.5% relative CS rate) and the most common indication was repeat CS. The group CS rate in nulliparous women with a cephalic term infant was higher when labour was induced compared to occurring spontaneously (36.6% and 18.1% respectively). The primary CS indication for these women was labour dystocia and maternal request was the most common CS indication for nulliparous women with a pre-labour CS.IMPACT STATEMENTWhat is already known on this subject? Significantly increasing caesarean section (CS) rates continue to prompt concern due to the associated neonatal and maternal risks. The World Health Organisation have endorsed the Robson Ten-Group Classification System to identify and analyse CS rate contributors.What do the results of this study add? We have used the modified Robson Ten-Group Classification System to identify that women with cephalic term infants who are nulliparous or who have had a previous CS are the largest contributors to overall CS rates. CS rates were higher in these nulliparous women if labour was induced compared to occurring spontaneously and the primary CS indication was labour dystocia. In nulliparous women with a CS prior to labour the most common CS indication was maternal request. Majority of women with a previous CS elected for a repeat CS.What are the implications of these findings for clinical practice? Future efforts should focus on minimising repeat CS in multiparous women and primary CS in nulliparous women. This may be achieved by redefining the definition of labour dystocia, exploring maternal request CS reasoning and critically evaluating induction timing and indication. Appropriately promoting a trial of labour in women with a previous CS in suitable candidates may reduce repeat CS incidence.

Surgical Management of Dystocia Due to Unilateral Uterine Torsion in a Domestic Shorthair Cat.

A 2-year-old pluriparous domestic shorthair queen was brought to the Madras Veterinary College Teaching hospital with a history of full-term pregnancy, straining for the past 24 hours and brown vaginal discharge. Radiography of the abdomen showed presence of 3 fetal skeletons, and ultrasonography revealed no fetal heartbeat. An emergency caesarean section was performed, and a 720° torsion of the right uterine horn was revealed. Three dead kittens were delivered, 2 from the right horn and 1 from the left horn. An ovariohysterectomy was also performed.

Caesarean section followed by ovariohysterectomy in a Bangladeshi domestic cat: A surgical intervention for management of dystocia due to partial primary uterine inertia.

BACKGROUND: The incidence of dystocia in cats is relatively low compared to that in other pet and farm animals. However, when dystocia occurs in cats, manual, medicinal or surgical intervention is required. OBJECTIVES: Here, we report a caesarean section (C-section) in a Bangladeshi domestic cat that suffered from dystocia due to partial primary uterine inertia. METHODS: A Bangladeshi domestic queen cat was presented to the Veterinary Teaching Hospital (VTH) with signs of dystocia. The queen had given birth to one kitten 36 hr earlier; however, newborn died 30 min after birth. She was unable to deliver the remaining fetuses. The cat had gone off feed, appeared depressed, had a severely enlarged abdomen and showed no straining efforts. On palpation, bony-like structures were felt in both sides of the abdomen. Ultrasonographic (USG) examination was carried out, which confirmed the presence of two fetuses, one fetus in each uterine horn. No fetal movements could be detected. The cat was diagnosed with dystocia due to partial primary uterine inertia. RESULTS: A C-section was performed, and two emphysematous, putrefied and large dead kittens were removed. The uterus was found to be severely decomposed and foul smelling; therefore, an ovariohysterectomy was carried out to prevent development of maternal toxaemia and septicaemia. The queen recovered fully. CONCLUSION: To the best of our knowledge, we report here, for the first time, a successful C-section followed by an ovariohysterectomy in a Bangladeshi domestic cat, suffering from severe dystocia due to partial primary uterine inertia for >36 hr.

Prophylactic Administration of Uterotonics to Prevent Postpartum Hemorrhage in Women Undergoing Cesarean Delivery for Arrest of Labor: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether prophylactic administration of oxytocin plus ergonovine or oxytocin plus carboprost is more effective than oxytocin alone in reducing the need for additional uterotonics among women undergoing cesarean delivery for labor arrest. METHODS: In this double-blind, three-arm randomized controlled trial, participants were assigned to receive either oxytocin 5 units intravenous alone, or with ergonovine 0.25 mg intravenous or carboprost 0.25 mg intramuscular immediately after delivery, followed with maintenance infusion of oxytocin 40 milliunits/minute in all groups. Uterine tone was assessed at 3, 5, and 10 minutes after delivery, and additional uterotonics were administered if deemed necessary. The primary outcome was intraoperative need for additional uterotonics. Secondary outcomes included uterine tone, calculated blood loss, and side effects. A sample size of 34 per group (n=102), based on the null hypothesis that there is no association between treatment assignment and the need for additional uterotonics, permitted independent post hoc pairwise comparisons between oxytocin plus ergonovine, oxytocin plus carboprost, and oxytocin alone using an adjusted P-value of .025. The association between the need for additional uterotonics and treatment group was assessed using the χ2 test. RESULTS: From June 2013 through July 2019, 105 participants were randomized (35 per group) and data from 100 participants were analyzed: oxytocin (n=35), oxytocin plus ergonovine (n=33), and oxytocin plus carboprost (n=32). There was no difference in the requirement of additional intraoperative uterotonics across groups (oxytocin [37%] vs oxytocin plus ergonovine [33%] vs oxytocin plus carboprost [34%], P=.932). Uterine tone and calculated blood loss were similar across groups. Incidence of nausea or vomiting was higher in oxytocin plus ergonovine (85%; odds ratio [OR] 5.3, 95% CI 1.7-16.9, P=.003) and oxytocin plus carboprost (72%; OR 2.4, 95% CI 0.9-6.7, P=.086) compared with the oxytocin (51%) group. CONCLUSION: Compared with oxytocin alone, prophylactic use of a combination of uterotonic drugs did not reduce the need for additional uterotonics at cesarean delivery for labor arrest. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT01869556.

Factors associated with ewe and lamb survival, and subsequent reproductive performance of sheep undergoing emergency caesarean section.

Clinical records of all 212 ewes undergoing emergency caesarean surgery at a veterinary teaching hospital between January 2008 and December 2019 were evaluated retrospectively. Their age ranged from 1 to 10 years (median = 4 years), with German merino the predominant breed (48.1% of cases). The most frequently diagnosed indications were insufficient cervical dilatation (n = 94, 44.3%), uterine torsion (n = 50, 23.6%), foetopelvic disproportion (n = 31, 14.6%) and vaginal prolapse intra partum (n = 11, 5.2%). Fifty-four (25.5%) of the 212 ewes additionally suffered from one or more concurrent, pre-existing conditions. Overall ewe mortality until hospital discharge was 10.8% (23/212), and 3.8% (n = 6) for the 158 ewes without a history of concurrent disorders. Mortality during hospitalization increased to 31.5% (17/54) for those with pre-existing conditions. Total lamb mortality was 49.1% (173/352) until hospital discharge. Pre-existing conditions (p = .001) and the presence of post-surgical complications (p = .025) were identified as significant factors influencing dam mortality, while delayed presentation for veterinary attention with an observed duration of labour of >12 hr was identified as the most influential factor on total lamb mortality (p = .010). The presence of dead or emphysematous foetuses was not significant for ewe mortality. Follow-up information on further outcomes was available for 156 (82.5%) of the 189 discharged ewes. Eighty-nine animals (57.1%) were re-bred in the following season and achieved a 93.3% (83/89) pregnancy rate, while the remainder had either been slaughtered (n = 56, 35.9%), sold (n = 5, 3.2%) or had died of unknown causes (n = 3, 1.9%). The subsequent incidence of dystocia was 15.6% (n = 12) in the 77 ewes with available information on lambing ease. Adequate management of underlying conditions and timely intervention are important factors for best possible short-term outcomes. In the long term, the subsequent pregnancy rate was good and the incidence of subsequent dystocia was within the normal range.

Fetal Head Station at Second-Stage Dystocia and Subsequent Trial of Labor After Cesarean Delivery Success Rate.

OBJECTIVE: To investigate whether fetal head station at the index cesarean delivery is associated with a subsequent trial of labor success rate among primiparous women. METHODS: A retrospective cohort study conducted at two tertiary medical centers included all primiparous women with subsequent delivery after cesarean delivery for second-stage dystocia during 2009-2019, identified from the electronic medical record databases. Univariate and multivariate analyses were performed to assess the factors associated with successful trial of labor after cesarean (TOLAC) (primary outcome). Additionally, all women with failed TOLAC were matched one-to-one to women with successful TOLAC, according to factors identified in the univariate analysis. RESULTS: Of 481 primiparous women with prior cesarean delivery for second-stage dystocia, 64.4% (n=310) attempted TOLAC, and 222 (71.6%) successfully delivered vaginally. The rate of successful TOLAC was significantly higher in those with fetal head station below the ischial spines at the index cesarean delivery, as compared with those with higher head station (79.0% vs 60.5%, odds ratio [OR] 2.46, 95% CI 1.49-4.08). The proportion of neonates weighing more than 3,500 g in the subsequent delivery was lower in those with successful TOLAC compared with failed TOLAC (29.7% vs 43.2%, OR 0.56, 95% CI 0.33-0.93). In a multivariable analysis, lower fetal head station at the index cesarean delivery was the only independent factor associated with TOLAC success (adjusted OR 2.38, 95% CI 1.43-3.96). Matching all women with failed TOLAC one-to-one to women with successful TOLAC, according to birth weight and second-stage duration at the subsequent delivery, lower fetal head station at the index cesarean delivery remained the only factor associated with successful TOLAC. CONCLUSION: Lower fetal head station at the index cesarean delivery for second-stage dystocia was independently associated with a higher vaginal birth after cesarean rate, with an overall acceptable success rate. These findings should improve patient counseling and reassure those who wish to deliver vaginally after prior second-stage arrest.

Complications and outcomes of swine that underwent cesarean section for resolution of dystocia: 110 cases (2013-2018).

OBJECTIVE: To report the surgical survival of dams and piglets and follow-up survival and future breeding potential of swine that underwent cesarean section for correction of dystocia. STUDY DESIGN: Retrospective study. ANIMALS: One hundred ten client-owned, female swine. All swine included in this study were breeding stock for market pigs to be used for exhibition purposes. METHODS: Medical records of swine that underwent cesarean section at The Ohio State University Hospital for Farm Animals for resolution of dystocia between January of 2013 and July of 2018 were reviewed. Signalment, history, number of piglets per litter, treatments, and surgical procedure were recorded. Follow-up information (survival, complications, and additional pregnancies) was obtained via telephone interview. RESULTS: A fetus was not palpable in 77 of 110 (70%) cases at presentation. The median litter size was eight piglets (range, 1-14), with medians of five (range, 0-13) live and one dead (range, 0-11) piglets per litter. Follow-up was available for 52 dams, of which 39 (75%) survived. Complications were recorded in 20 of 52 (38.46%) cases and included incisional seroma formation, lethargy, and anorexia. Twenty-three dams became pregnant and farrowed after the cesarean section, with no reported complication in 13 of these. CONCLUSION: Cesarean section in swine is associated with a good prognosis for recovery from the procedure and a fair to guarded prognosis for future breeding. CLINICAL SIGNIFICANCE: Cesarean section may be considered for resolution of dystocia in swine. However, owners should be advised that nearly half of sows require assistance in subsequent deliveries.

Association Between Time of Day and the Decision for an Intrapartum Cesarean Delivery.

OBJECTIVE: To examine whether the decision and indications for performing intrapartum cesarean delivery vary by time of day. METHODS: We conducted a secondary analysis of a multicenter observational cohort of 115,502 deliveries (2008-2011), including nulliparous women with term, singleton, nonanomalous live gestations in vertex presentation who were attempting labor. Those who attempted home birth, or underwent cesarean delivery scheduled or decided less than 30 minutes after admission were excluded. Time of day was defined as cesarean delivery decision time among those who delivered by cesarean and delivery time among those who delivered vaginally, categorized by each hour of a 24-hour day. Primary outcomes were decision to perform cesarean delivery and the indications for cesarean delivery (labor dystocia, nonreassuring fetal status, or other indications). Secondary outcomes included whether a dystocia indication adhered to standards promoted to reduce cesarean delivery rates. Bivariate analyses were performed using χ and Kruskal-Wallis tests for categorical and continuous outcomes, respectively, and generalized additive models with smoothing splines explored nonlinear associations without adjustment for other factors. RESULTS: Seven thousand nine hundred fifty-six (22.1%) of 36,014 eligible women underwent cesarean delivery. Decision for cesarean delivery (P<.001) decreased from midnight (21.2%) to morning, reaching a nadir at 10:00 (17.9%) and subsequently rising to peak at 21:00 (26.2%). The frequency of cesarean delivery for dystocia also was significantly associated with time of day (P<.001) in a pattern mirroring overall cesarean delivery. Among cesarean deliveries for dystocia (n=5,274), decision for cesarean delivery at less than 5 cm dilation (P<.001), median duration from 5 cm dilation to cesarean delivery decision (P=.003), and median duration from complete dilation to cesarean delivery decision (P=.014) all significantly differed with time of day. The frequency of nonreassuring fetal status and "other" indications were not significantly associated with time of day (P>.05). CONCLUSION: Among nulliparous women who were attempting labor at term, the decision to perform cesarean delivery, particularly for dystocia, varied with time of day. Some of these differences correlate with labor management differences, given the changing frequency of latent phase cesarean delivery and median time in active phase.

Decision-delivery intervals: Impact of a colour code protocol for emergency caesareans.

OBJECTIVE: Assess the impact of implementation by simple distribution of a "colour code" protocol for emergency caesareans on the course over time of the "decision-delivery interval" (DDI) and neonatal outcome. DESIGN: Observational study in 26 maternity units of the AURORE perinatal network, conducted between October 1, 2017, and April 30, 2018. Each maternity ward́ was supposed to prospectively include 20 consecutive cases of caesareans performed either as an emergency, that is, as a code orange, or an extreme emergency, that is, code red. We compared the DDIs observed in 2017 to those in 2007 according to the degree of emergency, the maternity unit level of care, and their adherence to the protocol. Neonatal outcome in 2007 and 2017, assessed from laboratory and clinical indicators, was also compared, overall and according to the degree of emergency. RESULTS: The DDI was significantly lower in 2017 (n = 478) than in 2007 (n = 447), regardless of the degree of emergency and the level of care (p < 0.0001). In 2017, all code red caesareans were performed in less than 15 min in level 3 maternity units compared with 73 % (p = 0.039) in 2007. Fewer than 20 % of the caesareans in the 2007 study period were performed in less than 15 min in level 1 and 2 maternity units. Today, this is the case for 83 % of these caesareans in level 2 units (p < 0.001) and 36 % in level 1 (p = 0.01). In 2017, code orange caesareans were performed in less than 30 min in 96 % of cases in level 3 units, 67 % in level 2, and 33 % in level 1, compared respectively with 67 % (p = 0.015), 25 % (p < 0.0001) and 16 % (p = 0.0003) in 2007. We did not observe any difference in the neonatal outcome between 2007 and 2017 or as a function of the DDI expected based on the caesarean colour code. CONCLUSION: The implementation of the colour code protocols was associated with an improved DDI and better adherence to the recommendations in all 26 maternity units in this perinatal network.

Non-adherence to labor guidelines in cesarean sections done for failed induction and arrest of dilation.

OBJECTIVES: In 2014, the American College of Obstetrics and Gynecology published guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) to prevent cesarean delivery (CD). The objectives of this study were to determine the rate of adherence to these guidelines and to compare the association of guideline adherence with physician CD rates and obstetric/neonatal outcomes. METHODS: Retrospective cohort review of singleton primary cesarean deliveries for FIOL and AOD at a single academic institution from 2014 to 2016. Univariate and multivariate analyses were used to compare adherence to the guidelines with physician CD rates and obstetric/neonatal outcomes. RESULTS: Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003). CONCLUSIONS: Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.

Optimizing Care for Ugandans with Untreated Abdominal Surgical Conditions.

BACKGROUND: Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce. OBJECTIVE: In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda. METHODS: In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda). FINDINGS: Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated. CONCLUSIONS: Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor.

Morbidity and Mortality Associated With Forceps and Vacuum Delivery at Outlet, Low, and Midpelvic Station.

OBJECTIVE: This study sought to quantify perinatal and maternal morbidity and mortality associated with forceps and vacuum delivery compared with Caesarean delivery in the second stage of labour and to estimate whether these associations differed by pelvic station. METHODS: The investigators conducted a population-based, retrospective cohort study of term singleton deliveries by operative delivery with prolonged second stage of labour in Canada (2003-2013) using national hospitalization data. The primary study outcomes were severe perinatal morbidity and mortality (i.e., seizures, assisted ventilation, severe birth trauma, and perinatal death) and severe maternal morbidity and mortality (i.e., severe postpartum hemorrhage, cardiac complication, and maternal death). Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) after stratifying by indication (dystocia or fetal distress). The Breslow-Day chi-square test for heterogeneity in ORs was used to test effect modification by pelvic station (outlet, low, or midpelvic). RESULTS: There were 61 106 deliveries included in the study. Among women with dystocia, forceps and vacuum deliveries were associated with higher rates of perinatal morbidity and mortality compared with Caesarean delivery (forceps: aOR 1.56; 95% CI 1.13-2.17; vacuum: aOR 1.44; 95% CI 1.06-1.97). Vacuum delivery was associated with lower rates of maternal morbidity and mortality compared with Caesarean delivery (dystocia: aOR 0.64; 95% CI 0.51-0.81; fetal distress: aOR 0.43; 95% CI 0.32-0.57). Pelvic station did not significantly modify the associations between forceps or vacuum and perinatal or maternal morbidity and mortality. CONCLUSION: Forceps and vacuum delivery is associated with increased rates of severe perinatal morbidity and mortality compared with Caesarean delivery among women with dystocia, whereas vacuum delivery is associated with decreased rates of severe maternal morbidity and mortality.