A re‐evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour

Abstract

Objective To compare the outcomes of operative cephalic births by Kielland forceps (KF), rotational ventouse (RV), or primary emergency caesarean section (pEMCS) for malposition in the second stage of labour in modern practise.Design Retrospective observational study.Population Data were included from 1291 consecutive full-term, singleton cephalic births between 2 November 2006 and 30 November 2010 with malposition of the fetal head during the second stage of labour leading to an attempt to deliver by KF, RV or pEMCS.Methods Maternal and neonatal outcomes of all KF births were compared with other methods of operative birth for malposition in the second stage of labour (RV or pEMCS).Main outcome measures Achieving a vaginal birth was the primary outcome and fetal (admission to special care baby unit, low cord pH, low Apgar, shoulder dystocia, Erb's palsy) and maternal (massive obstetric haemorrhage-blood loss of >1500 ml, sphincter injury, length of stay in hospital) safety outcomes were also recorded.Results Women were more likely to need caesarean section if RV (22.4%) was selected to assist the birth rather than KF (3.7%; adjusted odds ratio 8.20; 95% confidence interval 4.54-14.79). Births by KF had a rate of adverse maternal and neonatal outcomes comparable to those by RV and pEMCS in the second stage for malposition.Conclusions Our results suggest that, in experienced hands, assisted vaginal birth by KF is likely to be the most effective and safe method to prevent the ever rising rate of caesarean sections when malposition complicates the second stage of labour.Keywords Emergency caesarean section, Kielland forceps, rotational vaginal birth, rotational ventouse.

The role of rotational forceps

“…We also note the high failure rate of rotational ventouse and feel that this cannot be tolerated given the worse neonatal outcomes associated with sequential instrument use and secondary cesarean section. 1 In summary these results reaffirm our clinical impression that Kielland forceps are the superior tool in the obstetricians' armamentarium.…”

“…Tempest et al 1 conclude that the results of their study 'should encourage clinicians to re-evaluate their choice of instrument for rotational birth and professional bodies to re-consider training opportunities for this type of birth', and that within the UK, 'there are sufficient practitioners to allow a safe phased re-introduction of rotational forceps'. Although we would like to believe this is so, and trainees seem keen to learn, our survey suggests that, at least in our region, the cohort of trainers has declined so much that it may already be too late.…”

“…Sir, We commend Tempest et al 1 for providing some of the strongest evidence to date on the management of malposition in the second stage of labour. We are heartened to see that their results strengthen the evidence for the safety of Kielland forceps and the role that they play in reducing the rate of caesarean section in the second stage of labour, alongside the benefit of shorter hospitalisation.…”

Factors influencing the likelihood of vacuum delivery success

“…Although previous studies have concluded, as we do here in the full cohort analysis, that overall forceps delivery is more likely to achieve successful vaginal delivery than ventouse there is also evidence that operator preference for a particular instrument can affect the delivery outcome. [13][14][15][16][17] However, rotation of the fetal head is considered a controversial procedure by many obstetricians, despite data showing low complication rates. [18][19][20] Although more experienced accoucheurs had the highest unadjusted rates of unsuccessful instrumental attempts, this is likely to be because more difficult deliveries are usually handled by more senior obstetricians.…”

Outcome of labor in vertex malposition in Cameroon

“…1,3,5,11 Although instrumental vaginal deliveries are commoner in cases of VM, vacuum extraction is associated with higher failure rate than (Kielland's) forceps. 12,13 Manual rotation may correct the malposition. 10,14 No recent study to our knowledge has evaluated the outcome of labor in cases of VM in sub-Saharan women.…”