The use of bubble charts in analyzing second stage cesarean delivery rates.

BACKGROUND: The incidence of second stage cesarean delivery has been rising globally because of the failure or the anticipated difficulty of performing instrumental delivery. Yet, the best way to interpret the figure and its optimal rate remain to be determined. This is because it is strongly influenced by the practice of other 2 modes of birth, namely cesarean delivery performed before reaching the second stage and assisted vaginal birth during the second stage. In this regard, a bubble chart that can display 3-dimensional data through its x-axis, y-axis, and the size of each plot (presented as a bubble) may be a suitable method to evaluate the relationship between the rates of these 3 modes of births. OBJECTIVE: This study aimed to conduct an epidemiologic study on the incidence of second stage cesarean deliveries rates among >300,000 singleton term births in 10 years from 8 obstetrical units and to compare their second stage cesarean delivery rates in relation to their pre-second stage cesarean delivery rates and assisted vaginal birth rates using a bubble chart. STUDY DESIGN: The territory-wide birth data collected between 2009 and 2018 from all 8 public obstetrical units (labelled as A to H) were reviewed. The inclusion criteria were all singleton pregnancies with cephalic presentation that were delivered at term (≥37 weeks' gestation). Pre-second stage cesarean delivery rate was defined as all elective cesarean deliveries and those emergency cesarean deliveries that occurred before full cervical dilatation was achieved as a proportion of the total number of births. The second stage cesarean delivery rate and assisted vaginal birth rate were calculated according to the respective mode of delivery as a proportion of the number of cases that reached full cervical dilatation. The rates of these 3 modes of births were compared among the parity groups and among the 8 units. Using a bubble chart, each unit's second stage cesarean delivery rate (y-axis) was plotted against its pre-second stage cesarean delivery rate (x-axis) as a bubble. Each unit's second stage cesarean delivery to assisted vaginal birth ratio was represented by the size of the bubble. RESULTS: During the study period, a total of 353,434 singleton cephalic presenting term pregnancies were delivered in the 8 units, and 180,496 (51.1%) were from nulliparous mothers. When compared with the multiparous group, the nulliparous group had a significantly lower pre-second stage cesarean delivery rate (18.58% vs 21.26%; P<.001) but a higher second stage cesarean delivery rate (0.79% vs 0.22%; P<.001) and a higher assisted vaginal birth rate (17.61% vs 3.58%; P<.001). Using the bubble of their averages as a reference point in the bubble chart, the 8 units' bubbles were clustered into 5 regions indicating their differences in practice: unit B and unit H were close to the average in the center. Unit A and unit F were at the upper right corner with a higher pre-second stage cesarean delivery rate and second stage cesarean delivery rate. Unit D and unit E were at the opposite end. Unit C was at the upper left corner with a low pre-second stage cesarean delivery rate but a high second stage cesarean delivery rate, whereas unit G was at the opposite end. Unit C and unit G were also in the extremes in terms of pre-second stage cesarean delivery to assisted vaginal birth ratio (0.09 and 0.01, respectively). Although some units seemed to have very similar second stage cesarean delivery rates, their obstetrical practices were differentiated by the bubble chart. CONCLUSION: The second stage cesarean delivery rate must be evaluated in the context of the rates of pre-second stage cesarean delivery and assisted vaginal birth. A bubble chart is a useful method for analyzing the relationship among these 3 variables to differentiate the obstetrical practice between different units.

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.

A new classification allowing assessment of instrumental vaginal-birth practices.

BACKGROUND: Instrumental vaginal birth, a very common intervention in obstetrics, concerns nearly one in eight women in France. Instrumentally assisted vaginal childbirth can be for maternal and/or fetal indications. Although it reduces recourse to caesarean section, it is subject to risks. Practices concerning instrumental birth are disparate, varying among different practitioners, maternity units and countries, and it is essential to be able to evaluate them. Our objective was to create a classification tool of women requiring instrumental birth to facilitate the analysis of practices within our maternity unit as well as to enable temporal and geographical comparisons. MATERIALS AND METHODS: We propose a simple and robust classification based on the same principles as Robson's classification. It is made up of seven totally inclusive and mutually exclusive groups. Our classification was refined and validated using the Delphi method by a panel of 14 experts from throughout France, and tested in our maternity unit using data from throughout 2021. RESULTS: The seven clinically relevant groups are based on five obstetric criteria (multiplicity, presentation, gestational age, previous type of birth, induction of labor). To classify each woman in a group, five successive questions are posed in a predefined order. The classification has been validated by the experts with highly satisfactory overall agreement. CONCLUSION: In order to improve the quality of care, we propose a tool to standardize the evaluation of instrumental vaginal birth practice (called the "Isère classification", after the county where we work in south-eastern France). It will also facilitate the comparison the practices among different maternity units in a network, a country or even among different countries.

Associations between fetal position at delivery and duration of active phase of labor: A historical cohort study.

INTRODUCTION: In clinical experience, occiput posterior (OP) position is associated with longer labor duration than occiput anterior (OA) position, but few studies have investigated the association between labor duration and fetal position. We aimed to compare duration of the active phase of labor in OP deliveries with OA deliveries in a contemporary population using survival methods. Secondary aims were to compare the frequencies of operative interventions, obstetric anal sphincter injuries (OASIS), postpartum hemorrhage, and newborn outcomes in OP with OA deliveries. MATERIAL AND METHODS: We did a historical cohort study in three university hospitals in Norway from 2012 to 2022. Women with a single fetus in cephalic presentation, no previous cesarean section and gestational age ≥37 weeks were eligible and stratified into the first four groups of the Robson ten-group classification system (TGCS). We estimated the mean duration and calculated the hazard ratio (HR) for delivery using survival analyses. Cesarean sections and instrumental vaginal deliveries were censored. RESULTS: The study population comprised 112 019 women, 105 571 (94.2%) were delivered in OA and 6448 (5.8%) in OP position. The estimated mean duration of the active phase of labor was longer in women with the fetus in OP position in all four TGCS groups. The estimated duration was longer in the OP groups in analyses stratified with respect to epidural analgesia and oxytocin augmentation. The graphical abstract illustrates the probability of delivery in OP compared with OA position in merged TGCS groups 1 and 2a, as a function of time. The unadjusted HR was 0.33 (95% CI 0.31-0.36) for fetuses delivered in OP position compared with OA position in TGCS group 1, 0.25 (95% CI 0.21-0.27) in group 2a, 0.70 (95% CI 0.67-0.73) in group 3, and 0.61 (95% CI 0.55-0.67) in group 4a, respectively. Neither maternal age, gestational age, BMI nor birthweight had confounding effect. Operative delivery rates and OASIS rates were higher in OP position in all four groups. CONCLUSIONS: We found longer duration of the active phase of labor in women with the fetus delivered in OP position in all four TGCS groups.

The impact of selective episiotomy on maternal short-term morbidity: a retrospective study.

BACKGROUND: The aim is to investigate the risk of short-term maternal morbidity caused by the selective clinical use of episiotomy (rate < 0.02), and to compare the risk of severe perineal tears with the statewide risk. METHODS: In this retrospective cohort study, we investigated the effect of selective episiotomy on the risk of severe perineal tears and blood loss in singleton term deliveries, using propensity scores with inverse probability weighting. RESULTS: This study included 10992 women who delivered vaginally between 2008-2018. Episiotomy was performed in 171 patients (1.55%), three of whom (1.75%) experienced severe perineal tears compared to 156 (1.44%) in the control cohort. The adjusted odds ratio of severe perineal tears was 2.06 (95% confidence interval [CI]: 0.51, 8.19 with 0.3 p value). Multivariate linear regression showed that episiotomy increased blood loss by 96.3 ml (95% CI: 6.4, 186.2 with 0.03 p value). Episiotomy was performed in 23% (95% CI: 0.228, 0.23) of vaginal deliveries in the state of Hessen, with a risk of severe perineal tears of 0.0143 (95% CI: 0.0139, 0.0147) compared to 0.0145 (95% CI: 0.0123, 0.0168) in our entire cohort. CONCLUSIONS: Selective use of episiotomy does not increase the risk of higher-grade perineal tears. However, it may be associated with maternal morbidity in terms of increased blood loss.

An episiotomy is a cut between the vagina and the anus that may be performed by an obstetrician during childbirth and can result in increased blood loss or severe birth tears. In this study, we investigated the risks of both bleeding and severe tears caused by a highly selective local practice of episiotomies below 2% and compared the results with statewide data. The study included 10992 women who delivered between 2008­2018, 171 of whom underwent episiotomies according to the hospital's protocols. Having an episiotomy did not increase the likelihood of severe birthing tears but was associated with an increase in estimated blood loss. Therefore, although highly selective use of episiotomy is unlikely to cause more severe tears, it has the potential to worsen the mother's health by increasing blood loss.

Re-evaluation of modifiable risk factors for obstetric anal sphincter injury in a real-world setting.

INTRODUCTION AND HYPOTHESIS: The objective was to identify modifiable risk factors for obstetric anal sphincter injury (OASI) in primiparous women. METHODS: This was a retrospective cohort study of primiparous women with a singleton vaginal delivery. Main outcome measures were incidence of OASI and odds ratios for possible risk factors: maternal age, body mass index and height, fetal birthweight and head circumference, gestational age, epidural analgesia, mediolateral episiotomy, and instrumental deliveries. Univariate and multivariate logistic regressions were performed using forward methods for variable selection. RESULTS: Of 19,786 primiparous women with a singleton vaginal delivery, 369 sustained an OASI (1.9%). Risk factors were identified: vacuum extraction (adjusted OR 2.06, 95% CI, 1.59-2.65, p < 0.001), increased fetal weight (aOR 1.06, 95% CI, 1.02-1.11, p = 0.002, per 100-g increments); head circumference (aOR 1.24, 95% CI, 1.13-1.35, p < 0.001, per 1-cm increments); gestational week (aOR 1.11, 95% CI, 1.02-1.2, p = 0.012, per week). Protective factors: mediolateral episiotomy (aOR 0.75, 95% CI, 0.59-0.94, p = 0.013) particularly in vacuum deliveries (aOR 0.50, 95% CI, 0.29-0.97, p = 0.040); epidural analgesia (aOR 0.64, 95% CI, 0.48-0.84, p = 0.001); maternal height ≥157 cm (aOR 0.97, 95% CI, 0.96-0.98, p = 0.006, risk decreases by 2.6% per 1 cm increase in height). CONCLUSIONS: Mediolateral episiotomy was protective against OASI in both spontaneous and instrumental deliveries of primiparae. Increased fetal weight and large fetal head circumference, particularly in short women, were significant risk factors. These findings support the performance of ultrasound to acquire updated fetal measures before admission to the labor ward.

Knowledge and experience of midwives and gynecologists about manual rotation of persistent occiput posterior position.

BACKGROUND: management of persistent occiput posterior position has always been controversial. Manual rotation by a delivery operator can reduce instrumental delivery and cesarean section. AIM: This study aims to determine the knowledge and experience of midwives and gynecologists about manual rotation of persistent occiput posterior position. METHODS: This descriptive cross-sectional study was performed in 2022. The questionnaire link was sent to 300 participating midwives and gynecologists via WhatsApp Messenger. Two hundred sixty-two participants completed the questionnaire. Data analysis was performed using SPSS22 statistical software and descriptive statistics. RESULTS: 189 people (73.3%) had limited information about this technique, and 240 (93%) had never performed it. If this technique is recognized as a safe intervention and is included in the national protocol, 239 people (92.6%) want to learn, and 212 (82.2%) are willing to do it. CONCLUSION: According to the results, the knowledge and skills of midwives and gynecologists need to be trained and improved for manual rotation of persistent occiput posterior position.

Prevalence, indications and fetal outcomes of operative vaginal delivery in Sub-Saharan Africa, systematic review, and meta-analysis.

PURPOSE: This systematic review and meta-analysis is intended to assess the prevalence, indications, and fetal outcome of operative vaginal delivery in sub-Saharan Africa. METHOD: In this study, 17 studies with a total population of 190,900 were included in both systematic review and meta-analysis. Search for relevant articles was done by using international online databases (like Google Scholar, PubMed, HINARI, EMBASE, Web of Science, and African journals) and online repositories of Universities in Africa. The JOANNA Briggs Institute standard data extraction format was used to extract and appraise high-quality articles before being included in this study. The Cochran Q and I2 statistical tests were used to test the heterogeneity of the studies. The publication bias was tested by a Funnel plot and Egger's test. The overall pooled prevalence, indications, and fetal outcome of operative vaginal delivery along a 95% CI using forest plots and tables. RESULT: The overall pooled prevalence of operative vaginal delivery in sub-Saharan Africa was 7.98% (95% CI; 5.03-10.65; I2 = 99.9%, P < 0.001). The indications of operative vaginal delivery in sub-Saharan African countries include the prolonged second stage of labor 32.81%, non-reassuring fetal heart rate 37.35%, maternal exhaustion 24.81%, big baby 22.37%, maternal cardiac problems 8.75%, and preeclampsia/eclampsia 2.4%. Regarding the fetal outcome, favourable fetal outcomes were 55% (95% CI: 26.04, 84.44), p = < 0.56, I2: 99.9%). From those births with unfavourable outcomes, the need for the resuscitation of new-born was highest 28.79% followed by poor 5th minute Apgar score, NICU admission, and fresh stillbirth, 19.92, 18.8, and 3.59% respectively. CONCLUSION: The overall prevalence of operative vaginal delivery (OVD) in sub-Saharan Africa was slightly higher compared to other countries. To reduce the increased applications and adverse fetal outcomes of OVD, capacity building for obstetrics care providers and drafting guidelines are required.

Does the timing of neuraxial analgesia initiation in elective induction of multiparous women prolong the duration of delivery?

AIM: To investigate whether the early initiation of neuraxial analgesia prolongs the duration of electively induced labor in Japanese multiparous women. METHODS: This retrospective study included multiparous term women who underwent elective induction of labor using combined spinal-epidural analgesia at the Showa University Hospital between October 2018 and March 2021. The participants were divided into two groups: early and late. If neuraxial analgesia was initiated when the cervical dilation was ≤3 cm, the patient was included in the early group. The remaining patients were included in the late group. The obstetric and neonatal outcomes were compared between the two groups. The primary outcome was the duration of delivery. The secondary outcomes were the rates of instrumental and cesarean deliveries. RESULTS: Two hundred and ninety-seven women (early group = 139, late group = 158) were included in the analysis. The duration of the first stage of labor did not differ significantly between the early and late groups (median: 232 vs. 260 min, p = 0.35). Similarly, there was no significant difference in the duration of the second stage (37 vs. 40 min, p = 0.20). Moreover, the rates of instrumental and cesarean deliveries did not differ significantly between the groups, and the neonatal outcomes were comparable. CONCLUSION: Early initiation of neuraxial analgesia in the elective induction of parous Japanese women did not prolong the duration of delivery. Our results suggest that neuraxial analgesia may be initiated whenever a parturient desires it.

Outcomes of attempted vaginal births after previous recurrent operative vaginal deliveries: An individual cumulative risk analysis.

BACKGROUND: Data about the risk of recurrence of vacuum extraction (VE) in multiple consecutive deliveries are scarce. We aimed to evaluate the pattern and individual cumulative risk of recurrence of VE in consecutive term deliveries. STUDY DESIGN: A retrospective cohort study based on a validated electronic database at a single center between 2005 and 2019. For the purpose of the study, we focused on consecutive term deliveries of all primiparas (P1) that had a record of at least one additional delivery during the study period. We identified P1 VE deliveries (reference group) and calculated the individual cumulative risk of repeated VE for three consecutive deliveries. Multivariate analysis was conducted adjusting for potential confounders. RESULTS: We identified 35 113 primiparas that met inclusion criteria. The overall VE rate for P1 was 17.9% (6969 parturient). The cumulative rates of repeated VEs at the 2nd, 3rd, and 4th deliveries were 8.6%, 26.8%, and 25.0%, respectively. The risk of recurrent VE for each of the consecutive deliveries was confirmed after adjustment for confounders (aOR [95% CI]: 5.8 [4.76-7.04], 34.2 [18.59-62.81], and 113.9 [9.77-1328.69] for the 2nd, 3rd, and 4th consecutive deliveries, respectively). CONCLUSION: Women with VE at the first and second deliveries have a substantially increased risk of VE in their following deliveries; this finding may influence woman's preference when choosing future mode of delivery.

Do doctors preferring forceps encounter more obstetric anal sphincter injuries: A retrospective analysis.

BACKGROUND: Obstetric anal sphincter injuries (OASIS) is a hospital-acquired injury and can affect a woman's quality of life with problems such as anal incontinence, perineal pain, dyspareunia, mental health, psychosexual issues, and concerns about future childbirth choices. AIMS: The aim of this study was to determine whether there is a correlation between a doctor's preference for instruments, their individual OASIS rate and whether factors such as their fully dilated caesarean section rate, rate of double instrumental and seniority, influences their individual rate of OASIS. MATERIALS AND METHODS: A population-based retrospective cohort study was performed on 1340 term nulliparous women with singleton pregnancies who underwent an instrumental delivery or fully dilated caesarean section. A survey of doctors involved in these deliveries was performed. The risk of OASIS was analysed for maternal age, ethnicity, birth position, level of training and doctor's instrument preference using a generalised linear mixed model. Doctors' instrument preferences were established in two ways: a self-reported survey and data-inferred preference based on the most used instrument per doctor. The OASIS rate for individual doctors was calculated. RESULTS: The overall risk of OASIS is higher for forceps compared to vacuum deliveries. Doctors with a preference for forceps compared to vacuum, correlated with both a lower OASIS rate and a higher fully dilated caesarean section rate. CONCLUSIONS: Doctors preferring forceps report a lower OASIS and higher fully dilated caesarean section rate. Doctors preferring vacuum must consider carefully whether forceps should follow if a vacuum fails as OASIS is more likely to occur.

Prophylactic manual rotation of occiput posterior and transverse positions to decrease operative delivery: the PROPOP randomized clinical trial.

BACKGROUND: Persistent occiput posterior and occiput transverse positions are the most common malpositions of the fetal head during labor and are associated with prolonged second stage of labor, cesarean deliveries, instrumental deliveries, severe perineal tears, postpartum hemorrhage, and chorioamnionitis. Manual rotation is one of several strategies described to deal with these malpositions. OBJECTIVE: This study aimed to determine if the trial of prophylactic manual rotation at the early second stage of labor is associated with a decrease in operative deliveries (instrumental and/or cesarean deliveries). STUDY DESIGN: We conducted a multicenter, open-label, randomized controlled trial in 4 French hospitals. Women with singleton term pregnancy and occiput posterior or occiput transverse position confirmed by ultrasound at the early second stage of labor and with epidural analgesia were eligible. Women were randomly assigned (1:1) to either undergo a trial of prophylactic manual rotation of occiput posterior or occiput transverse position (intervention group) or no trial of prophylactic manual rotation (standard group). The primary outcome was operative delivery (instrumental and/or cesarean deliveries). The secondary outcomes were length of the second stage of labor, maternal complications (postpartum hemorrhage, operative complications during cesarean delivery, episiotomy and perineal tears), and neonatal complications (Apgar score of <5 at 10 minutes, arterial umbilical pH of <7.10, neonatal injuries, neonatal intensive care unit admission). The main analysis was focused on intention-to-treat analysis. RESULTS: From December 2015 to December 2019, a total of 257 women (mean age, 30.4 years; mean gestational age, 40.1 weeks) were randomized: 126 were assigned to the intervention group and 131 were assigned to the standard group. Operative delivery was significantly less frequent in the intervention group compared with the standard group (29.4% [37 of 126] vs 41.2% [54 of 131]; P=.047; differential [intervention-standard] [95% confidence interval] = -11.8 [-15.7 to -7.9]; unadjusted odds ratio [95% confidence interval] = 0.593 [0.353-0.995]). Women in the intervention group were more likely to have a significantly shorter second stage of labor. CONCLUSION: Trial of prophylactic manual rotation of occiput posterior or occiput transverse positions during the early second stage of labor was statistically associated with a reduced risk of operative delivery. This maneuver could be a safe strategy to prevention operative delivery.

Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study.

BACKGROUND: To date, no research has focused on the sonographic quantification of the degree of flexion of the fetal head in relation to the labor outcome in women with protracted active phase of labor. OBJECTIVE: This study aimed to assess the relationship between the transabdominal sonographic indices of fetal head flexion and the mode of delivery in women with protracted active phase of labor. STUDY DESIGN: Prospective evaluation of women with protracted active phase of labor recruited across 3 tertiary maternity units. Eligible cases were submitted to transabdominal ultrasound for the evaluation of the fetal head position and flexion, which was measured by means of the occiput-spine angle in fetuses in nonocciput posterior position and by means of the chin-to-chest angle in fetuses in occiput posterior position. The occiput-spine angle and the chin-to-chest angle were compared between women who had vaginal delivery and those who had cesarean delivery. Cases where obstetrical intervention was performed solely based on suspected fetal distress were excluded. RESULTS: A total of 129 women were included, of whom 43 (33.3%) had occiput posterior position. Spontaneous vaginal delivery, instrumental delivery, and cesarean delivery were recorded in 66 (51.2%), 17 (13.1%), and 46 (35.7%) cases, respectively. A wider occiput-spine angle was measured in women who had vaginal delivery compared with those submitted to cesarean delivery owing to labor dystocia (126±14 vs 115±24; P<.01). At the receiver operating characteristic curve, the area under the curve was 0.675 (95% confidence interval, 0.538-0.812; P<.01), and the optimal occiput-spine angle cutoff value discriminating between cases of vaginal delivery and those delivered by cesarean delivery was 109°. A narrower chin-to-chest angle was measured in cases who had vaginal delivery compared with those undergoing cesarean delivery (27±33 vs 56±28 degrees; P<.01). The area under the curve of the chin-to-chest angle in relation to the mode of delivery was 0.758 (95% confidence interval, 0.612-0.904; P<.01), and the optimal cutoff value discriminating between vaginal delivery and cesarean delivery was 33.0°. CONCLUSION: In women with protracted active phase of labor, the sonographic demonstration of fetal head deflexion in occiput posterior and in nonocciput posterior fetuses is associated with an increased incidence of cesarean delivery owing to labor dystocia. Such findings suggest that intrapartum ultrasound may contribute in the categorization of the etiology of labor dystocia.

Comparison of perinatal outcomes for all modes of second stage delivery in obstetric theatres: a retrospective observational study.

OBJECTIVE: To compare rates of vaginal delivery and adverse outcomes of instrumental delivery trials in obstetric theatre compared to primary emergency full dilation caesarean section. DESIGN: Retrospective cohort study. SETTING: University teaching hospital. POPULATION: Women with singleton, non-anomalous, pregnancy undergoing instrumental delivery trial in obstetric theatre. METHODS: Data were collected from consecutive cases during 2014 until 2018 using clinical records. Multivariate regression analysis was used comparing outcomes per first delivery method. MAIN OUTCOME MEASURES: Primary outcome was completion of vaginal delivery between all methods of instrumental delivery. Secondary outcome was a composite of immediate perinatal adverse outcomes for instrumental delivery modes and primary full dilation caesarean section. RESULTS: From 971 deliveries analysed: ventouse delivery was significantly less likely to achieve vaginal delivery compared with Keilland's forceps delivery (odds ratio [OR] 0.42, 95% CI 0.22-0.79). Once confounding factors were adjusted for, adverse outcome rates were less frequent in the Keilland's forceps group than with primary full dilation caesarean section (OR 0.37, 95% CI 0.16-0.81); however, the receiver operating characteristic curve produced from this model demonstrated a low predictive value (AUC 0.64). CONCLUSIONS: Attempting instrumental delivery in delivery suite theatre, as an alternative to primary emergency full dilation caesarean section, is both reasonable and safe. In this study, ventouse delivery performed poorly in comparison with other modes of instrumental delivery. Further research in the form of randomised controlled trials to identify the optimal mode of second stage delivery is paramount. TWEETABLE ABSTRACT: Instrumental delivery trials in theatre are safe but use of ventouse was associated with a higher rate of failure.

Postpartum urinary retention in women undergoing instrumental delivery: A cross-sectional analytical study.

INTRODUCTION: Women undergoing instrumental delivery are known to be at higher risk of urinary retention, which can lead to long-term complications such as voiding dysfunction. Nulliparous women undergo a pronounced and sudden change in the perineum due to stretching during delivery, which may add to the perineal trauma from an episiotomy, increasing the risk of urinary retention. We aim to study the incidence and risk factors associated with postpartum urinary retention in women undergoing instrumental delivery. MATERIAL AND METHODS: Pregnant women who had an instrumental delivery after 37 weeks of gestation at JIPMER, Puducherry, India, between January 2017 and June 2017 were included in the study. Postpartum urinary retention was defined as the inability to void spontaneously or ultrasonographic documentation of post-void residual volume of >150 mL, 6 hours after delivery. Demographic factors, clinical profile and follow-up of these patients were noted. Multivariate logistic regression analysis was performed to assess the risk factors associated with urinary retention and was presented as adjusted odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Postpartum urinary retention was noted in 124 (20.6%) women undergoing instrumental delivery. Overt and covert urinary retention occurred in 2.3% and 18.3%, respectively. After adjusting for other risk factors, nulliparity (adjusted OR = 4.05, 95% CI 2.02-8.12 compared with multiparity) and prolonged second stage (OR = 3.96, 95% CI 1.53-10.25) compared with suspected fetal compromise as an indication for instrumental delivery was associated with increased risk of postpartum urinary retention. Interaction was noted between parity and episiotomy on the occurrence of postpartum urinary retention (P = .010). Among nulliparous women, those with episiotomy (adjusted OR = 6.10, 95% CI 2.65-14.04) have higher odds of developing postpartum urinary retention compared with those without episiotomy. CONCLUSIONS: Approximately one of five (20.6%) women undergoing instrumental delivery developed postpartum urinary retention. Among women undergoing instrumental delivery, episiotomy increased the chances of developing postpartum retention in nulliparous but not multiparous women. Prolonged second stage as an indication for instrumental delivery also increased the chances of retention. Future studies are needed to define the cutoff for diagnosis and to evaluate the long-term effects of covert postpartum urinary retention, as well to study the effect of episiotomy on development of postpartum urinary retention in women undergoing instrumental delivery.

Is mode of first birth a risk factor for subsequent preterm birth?

BACKGROUND: Previous preterm birth is a strong predictor of subsequent preterm birth, but less is known about the causes of preterm birth following a full-term first pregnancy. Recent research has highlighted previous caesarean section as a potential risk factor. AIM: To examine the relationship between mode of first birth and the risk of subsequent preterm birth in New South Wales (NSW), Australia. MATERIALS AND METHODS: A population-based record-linkage study of NSW women who had a live singleton first birth at ≥37 weeks gestation, followed by a singleton second birth between 2005 and 2017. Relative risk (RR) and 95% CI of preterm birth in the subsequent pregnancy was calculated using modified Poisson regression, with mode of first birth as the exposure. Spontaneous preterm birth and preterm prelabour caesarean were secondary outcomes. RESULTS: Women who had either an intrapartum (RR: 1.26, 95% CI 1.19-1.32) or prelabour caesarean (RR: 1.26, 95% CI 1.18-1.35) first birth had a higher risk of subsequent preterm birth (any birth <37 weeks gestation), than those who birthed vaginally. Women who had a previous instrumental birth (RR: 0.85, 95% CI 0.79-0.91) or prelabour caesarean (RR: 0.74, 95% CI 0.67-0.82) had lower risks of subsequent spontaneous preterm birth. However, prior prelabour caesarean also greatly increased risk of subsequent preterm prelabour caesarean (RR: 5.25, 95% CI 4.65-5.93). CONCLUSIONS: The mode of first birth has differing effects on the risk of subsequent spontaneous preterm birth and preterm prelabour caesarean. Awareness of the risk of subsequent preterm birth following caesarean section may help inform clinical decisions around mode of first birth.

New technique for automatic sonographic measurement of change in head-perineum distance and angle of progression during active phase of second stage of labor.

OBJECTIVE: To evaluate the performance of a new ultrasound technique for the automatic assessment of the change in head-perineum distance (delta-HPD) and angle of progression (delta-AoP) during the active phase of the second stage of labor. METHODS: This was a prospective observational cohort study including singleton term pregnancies with fetuses in cephalic presentation during the active phase of the second stage of labor. In each patient, two videoclips of 10 s each were acquired transperineally, one in the axial and one in the sagittal plane, between rest and the acme of an expulsive effort, in order to measure HPD and AoP, respectively. The videoclips were processed offline and the difference between the acme of the pushing effort and rest in HPD (delta-HPD) and AoP (delta-AoP) was calculated, first manually by an experienced sonographer and then using a new automatic technique. The reliability of the automatic algorithm was evaluated by comparing the automatic measurements with those obtained manually, which was considered as the reference gold standard. RESULTS: Overall, 27 women were included. A significant correlation was observed between the measurements obtained by the automatic and the manual methods for both delta-HPD (intraclass correlation coefficient (ICC) = 0.97) and delta-AoP (ICC = 0.99). The high accuracy provided by the automatic algorithm was confirmed by the high values of the coefficient of determination (r2 = 0.98 for both delta-HPD and delta-AoP) and the low residual errors (root mean square error = 1.2 mm for delta-HPD and 1.5° for delta-AoP). A Bland-Altman analysis showed a mean difference of 0.52 mm (limits of agreement, -1.58 to 2.62 mm) for delta-HPD (P = 0.034) and 0.35° (limits of agreement, -2.54 to 3.09°) for delta-AoP (P = 0.39) between the manual and automatic measurements. CONCLUSIONS: The automatic assessment of delta-AoP and delta-HPD during maternal pushing efforts is feasible. The automatic measurement of delta-AoP appears to be reliable when compared with the gold standard manual measurement by an experienced operator. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Rationale and design of ePPOP-ID: a multicenter randomized controlled trial using an electronic-personalized program for obesity in pregnancy to improve delivery.

BACKGROUND: Pre-pregnancy obesity and excessive gestational weight gain (GWG) are established risk factors for adverse pregnancy, delivery and birth outcomes. Pregnancy is an ideal moment for nutritional interventions in order to establish healthier lifestyle behaviors in women at high risk of obstetric and neonatal complications. METHODS: Electronic-Personalized Program for Obesity during Pregnancy to Improve Delivery (ePPOP-ID) is an open multicenter randomized controlled trial which will assess the efficacy of an e-health web-based platform offering a personalized lifestyle program to obese pregnant women in order to reduce the rate of labor procedures and delivery interventions in comparison to standard care. A total of 860 eligible pregnant women will be recruited in 18 centers in France between 12 and 22 weeks of gestation, randomized into the intervention or the control arm and followed until 10 weeks of postpartum. The intervention is based on nutrition, eating behavior, physical activity, motivation and well-being advices in which personalization is central, as well as the use of a mobile/tablet application. Inputs includes data from the medical record of participants (medical history, anthropometric data), from the web platform (questionnaires on dietary habits, eating behavior, physical activity and motivation in both groups), and adherence to the program (time of connection for the intervention group only). Data are collected at inclusion, 32 weeks, delivery and 10 weeks postpartum. As primary outcome, we will use a composite endpoint score of obstetrical interventions during labor and delivery, defined as caesarean section and instrumental delivery (forceps and vacuum extractor). Secondary outcomes will consist of data routinely collected as part of usual antenatal and perinatal care, such as GWG, hypertension, preeclampsia, as well as fetal and neonatal outcomes including premature birth, gestational age at birth, birth weight, macrosomia, Apgar score, arterial umbilical cord pH, neonatal traumatism, hyperbilirubinemia, respiratory distress syndrome, transfer in neonatal intensive care unit, and neonatal adiposity. Post-natal outcomes will be duration of breastfeeding, maternal weight retention and child weight at postnatal visit. DISCUSSION: The findings of the ePPOP-ID trial will help design e-health intervention program for obese women in pregnancy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02924636 / October 5th 2016.

Evaluation of Suzor forceps training by studying obstetric anal sphincter injuries: a retrospective study.

BACKGROUND: Instrumental deliveries are an unavoidable part of obstetric practice. Dedicated training is needed for each instrument. To identify when a trainee resident can be entrusted with instrumental deliveries by Suzor forceps by studying obstetric anal sphincter injuries. METHODS: A French retrospective observational study of obstetric anal sphincter injuries due to Suzor forceps deliveries performed by trainee residents was conducted from November 2008 to November 2016 at Limoges University Hospital. Perineal lesion risk factors were studied. Sequential use of a vacuum extractor and then forceps was also analyzed. RESULTS: Twenty-one residents performed 1530 instrumental deliveries, which included 1164 (76.1%) using forceps and 89 (5.8%) with sequential use of a vacuum extractor and then forceps. Third and fourth degree perineal tears were diagnosed in 82 patients (6.5%). Residents caused fewer obstetric anal sphincter injuries after 23.82 (+/- 0.8) deliveries by forceps (p = 0.0041), or after 2.36 (+/- 0.7) semesters of obstetrical experience (p = 0.0007). No obese patient (body mass index> 30) presented obstetric anal sphincter injuries (p = 0.0013). There were significantly fewer obstetric anal sphincter injuries after performance of episiotomy (p <  0.0001), and more lesions in the case of the occipito-sacral position (p = 0.028). Analysis of sequential instrumentation did not find any additional associated risk. CONCLUSION: Training in the use of Suzor forceps requires extended mentoring in order to reduce obstetric anal sphincter injuries. A stable level of competence was found after the execution of at least 24 forceps deliveries or after 3 semesters (18 months) of obstetrical experience.

Women's, partners' and healthcare providers' views and experiences of assisted vaginal birth: a systematic mixed methods review.

BACKGROUND: When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use. METHODS: Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix. RESULTS: Forty-two studies (published 1985-2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies. CONCLUSIONS: Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.