Evaluation of delivery options for second-stage events

Abstract

Background Cesarean delivery in the second stage of labor is common, whereas the frequency of operative vaginal delivery has been declining. However, data comparing outcomes for attempted operative vaginal delivery in the second stage versus cesarean in the second stage are scant. Previous studies that examine operative vaginal delivery have compared it to a baseline risk of complications from a spontaneous vaginal delivery and cesarean delivery. However, when a woman has a need for intervention in the second stage, spontaneous vaginal delivery is not an option she or the provider can choose. Thus, the appropriate clinical comparison is cesarean versus operative vaginal delivery. Objective Our objective was to compare outcomes by the first attempted operative delivery (vacuum, forceps versus cesarean delivery) in patients needing second stage assistance at a fetal station of +2 or below. Study Design Secondary analysis of an observational obstetric cohort in 25 academically-affiliated U.S. hospitals over a three-year period. A subset of ≥37 weeks, non-anomalous, vertex, singletons, with no prior vaginal delivery who reached a station of +2 or below and underwent an attempt at an operative delivery were included. Indications included for operative delivery were: failure to descend, non-reassuring fetal status, labor dystocia or maternal exhaustion. The primary outcomes included a composite neonatal outcome (death, fracture, length of stay ≥3 days beyond mother’s, low Apgar, subgaleal hemorrhage, ventilator support, hypoxic encephalopathy, brachial plexus injury, facial nerve palsy) and individual maternal outcomes (postpartum hemorrhage, third and fourth degree tears [severe lacerations], and postpartum infection). Outcomes were examined by the three attempted modes of delivery. Odds ratios were calculated for primary outcomes adjusting for confounders. Final mode of delivery was quantified. Results 2531 women met inclusion criteria. Vacuum attempt was associated with the lowest frequency of the neonatal composite (4.2% vs. 6.1% vaginal forceps vs. 6.9% cesarean) and maternal complications (Postpartum infection 0.2% vs. 0.9% forceps vs. 5.3% cesarean, Postpartum hemmorhage 1.4% vs. 2.8% forceps vs. 3.8% cesarean), except for severe lacerations (19.1% vs. 33.8% forceps vs. 0% cesarean). When confounders were taken into account, both forceps (odds ratio 0.16, 95%CI 0.05-0.49) and vacuum (odds ratio 0.04, 95%CI 0.01-0.17) were associated with a significantly lower odds of Post partuminfection. The neonatal composite and Postpartum hemmorhage were not significantly different between modes of attempted delivery. Cesarean occurred in 6.4% and 4.4% of attempted vacuum and forceps groups (P=.04). Conclusion In patients needing second stage delivery assistance with a station of +2 or below, attempted operative vaginal delivery was associated with a lower frequency of Postpartum infection, but higher frequency of severe lacerations.

Perinatal and maternal morbidity and mortality among term singletons following midcavity operative vaginal delivery versus caesarean delivery

“…Higher rates of severe postpartum haemorrhage were also found in midcavity vacuum deliveries among women with dystocia. Increased rates of postpartum haemorrhage following vacuum delivery at low and outlet station has been reported previously, 34 although such reports were restricted to babies with birthweight ≥4000 g. Studies that have compared postpartum haemorrhage in midcavity operative vaginal deliveries and caesarean deliveries have yielded conflicting results 8,9,35,36 at least partly due to differences in definitions of postpartum haemorrhage. We defined severe postpartum haemorrhage as postpartum haemorrhage requiring transfusion to ensure a clinically meaningful and standardised outcome.…”

Prospective cohort study comparing outcomes between vacuum extraction and second‐stage cesarean delivery at a Ugandan tertiary referral hospital

“…Indications for this approach include fetal distress, prolonged second stage of labor, maternal exhaustion, or the need to avoid expulsive efforts among women with conditions such as heart failure or severe anemia . Although vacuum extraction can reduce maternal mortality from hemorrhage and sepsis—as well as perinatal mortality from birth asphyxia—use of this method has almost disappeared from obstetric practice in many LMICs . One study found that instrumental vaginal delivery was not used in almost half of 1728 Sub‐Saharan African hospitals, with usage rates below 1% in the remaining centers.…”

Perinatal and maternal morbidity and mortality after attempted operative vaginal delivery at midpelvic station

“…6 The literature on perinatal and maternal mortality and morbidity after operative vaginal delivery compared with cesarean delivery is inconsistent. [7][8][9][10][11][12][13][14][15][16] In addition, studies on the risks and benefits of these Increased use of operative vaginal delivery (i.e., forceps or vacuum application), of which 20% occurs at midpelvic station, has been advocated to reduce the rate of cesarean delivery. We aimed to quantify severe perinatal and maternal morbidity and mortality associated with attempted midpelvic operative vaginal delivery.…”