RESUMEN
Assisted vaginal birth rates are falling globally with rising cesarean delivery rates. Cesarean delivery is not without consequence, particularly when carried out in the second stage of labor. Cesarean delivery in the second stage is not entirely protective against pelvic floor morbidity and can lead to serious complications in a subsequent pregnancy. It should be acknowledged that the likelihood of morbidity for mother and baby associated with cesarean delivery increases with advancing labor and is greater than spontaneous vaginal birth, irrespective of the method of operative birth in the second stage of labor. In this article, we argue that assisted vaginal birth is a skilled and safe option that should always be considered and be available as an option for women who need assistance in the second stage of labor. Selecting the most appropriate mode of birth at full dilatation requires accurate clinical assessment, supported decision-making, and personalized care with consideration for the woman's preferences. Achieving vaginal birth with the primary instrument is more likely with forceps than with vacuum extraction (risk ratio, 0.58; 95% confidence interval, 0.39-0.88). Midcavity forceps are associated with a greater incidence of obstetric anal sphincter injury (odds ratio, 1.83; 95% confidence interval, 1.32-2.55) but no difference in neonatal Apgar score or umbilical artery pH. The risk for adverse outcomes is minimized when the procedure is conducted by a skilled accoucheur who selects the most appropriate instrument likely to achieve vaginal birth with the primary instrument. Anticipation of potential complications and dynamic decision-making are just as important as the technique for safe instrument use. Good communication with the woman and the birthing partner is vital and there are various recommendations on how to achieve this. There have been recent developments (such as OdonAssist) in device innovation, training, and strategies for implementation at a scale that can provide opportunities for both improved outcomes and reinvigoration of an essential skill that can save mothers' and babies' lives across the world.
Asunto(s)
Cesárea , Trabajo de Parto , Embarazo , Recién Nacido , Femenino , Humanos , Cesárea/efectos adversos , Extracción Obstétrica por Aspiración , Canal Anal , Madres , Parto Obstétrico/efectos adversos , Estudios RetrospectivosRESUMEN
INTRODUCTION: Malposition complicates 2-13% of births at delivery, leading to increased obstetric interventions (cesarean section and instrumental delivery) and higher rates of adverse fetal and maternal outcomes. Limited data are available regarding the likely rates of obstetric intervention and subsequent neonatal and maternal outcomes of births with babies in persistent occiput posterior position vs those in persistent occiput transverse position. The UK Audit and Research trainee Collaborative in Obstetrics and Gynecology (UK-ARCOG) network set out to collect data prospectively at delivery on final mode of delivery and immediate outcomes. MATERIAL AND METHODS: The UK-ARCOG network collected data on all births with malposition of the fetal head complicating the second stage of labor (n = 838) (occiput posterior/occiput transverse) requiring rotational vaginal operative birth or emergency cesarean to expedite delivery across 66 participating UK National Health Service maternity units over a 1-month period. The outcomes considered were the need for emergency cesarean section without a trial of instrumental delivery, success of the first method of delivery employed in achieving a vaginal delivery and neonatal/maternal outcomes. RESULTS: Obstetricians regarded assistance with an operative vaginal delivery method to be unsafe in 15% of babies in occiput posterior position and 6.1% of babies in occiput transverse position, and they were delivered by primary emergency cesarean section. When vaginal delivery was deemed safe (defined as attempted assisted vaginal rotational delivery), the first instrument attempted was successful in 74.4% of occiput posterior babies and 79.3% of occiput transverse babies. CONCLUSIONS: Our data facilitates decision making by obstetricians to increase safety of assisted rotational operative delivery of a malpositioned baby at initial assessment and in counseling women. Until data from a well-designed randomized controlled trial of instrumental delivery vs emergency cesarean section are available, this manuscript provides contemporaneous national data from a high resource setting within a structured training program, to assist the selection of an appropriate instrument/method for the delivery of a malpositioned baby.
Asunto(s)
Cesárea/estadística & datos numéricos , Extracción Obstétrica/estadística & datos numéricos , Presentación en Trabajo de Parto , Complicaciones del Trabajo de Parto/terapia , Adulto , Urgencias Médicas , Femenino , Humanos , Segundo Periodo del Trabajo de Parto , Embarazo , Estudios Prospectivos , Versión Fetal , Adulto JovenRESUMEN
Kielland's rotational forceps are designed to overcome malposition of the fetal head in the second stage of labor. After a decline in their use because of reported adverse outcomes and fear of litigation, recent evidence suggests that they may be safe and effective in trained hands and significantly more successful at achieving operative vaginal delivery than either rotational ventouse or manual rotation. This is important because of the increased short and long-term morbidity related to cesarean section compared with the reduced morbidity of subsequent pregnancy after operative vaginal delivery. Kielland's forceps are therefore re-emerging as a useful instrument in the armamentarium of modern obstetrics. Limitations to wider use of Kielland's forceps are the lack of training opportunities as well as that contemporary evidence remains underpowered to detect rare adverse outcomes.