Fetal rotation during vacuum extractions for prolonged labor: a prospective cohort study

Kahrs, B.H.; Usman, Sana; Ghi, T.; Youssef, A.; Torkildsen, E.; Lindtjørn, Elsa; Østborg, Tilde Broch; Benediktsdóttir, Sigurlaug; Brooks, Lis; Harmsen, Lotte; Salvesen, Kjell Å.; Lees, C.; Eggebø, Torbjørn Moe

doi:10.1111/aogs.13372

Cited by 27 publications

(10 citation statements)

References 34 publications

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“…Exact knowledge of position and station is of paramount importance before performing an operative vaginal delivery or manual rotation [14,[23][24][25]. We investigated results for fetal head station and position as these factors are most widely studied, however the clinical examination has other qualities that are difficult to reproduce with ultrasound [8].…”

Section: Discussionmentioning

confidence: 99%

Structured clinical examinations in labor: rekindling the craft of obstetrics

Iversen

Jacobsen

Mikkelsen

et al. 2019

The Journal of Maternal-Fetal & Neonatal Medicine

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Objectives: Exact knowledge of fetal station and position is of paramount importance for reliable surveillance of labor progress and a prerequisite for safe operative vaginal procedures. Detailed clinical assessments are thoroughly described in old textbooks, but almost forgotten in contemporary obstetrics. Ultrasound is suggested as an objective diagnostic tool in active labor. Several publications have demonstrated a low correlation between ultrasound and clinical assessment of fetal head station and position, but the methods of clinical assessment in these studies are poorly described. We wanted to explore if a quality clinical assessment could perform better than clinical assessment in previous publications, by analysing the correlation between a structured method of clinical assessment and intrapartum ultrasound.Methods: In all, 100 laboring women with cervical dilatation ≥7 cm were included in a prospective cohort study at Oslo University Hospital from October to December 2016. The study design was cross sectional. Clinical examinations were performed by one special educated consultant (JKI), and transabdominal and transperineal ultrasound clips were recorded and examined by a blinded expert in intrapartum ultrasound (TME). Fetal position was classified as a clock face with 12 units (hourly divisions) and thereafter categorized as occiput anterior (OA), left occiput transverse (LOT), occiput posterior (OP) and right occiput transverse (ROT) positions. Fetal station was categorized clinically from -5 to + 5 and measured with ultrasound as angle of progression (AoP) and head-perineum distance (HPD).AoP is the angle between a longitudinal line through the symphysis and a tangent to the head contour. HPD is the shortest distance between the fetal skull and the perineum.Results: Eight women were excluded due to strong contractions between clinical assessments and ultrasound measurements, fetal distress or incomplete examinations. Fetal position assessed by ultrasound and clinical examination agreed exactly in 48/92 (52%) cases, within one unit (hour) in 87/92 (95%) of cases and within two units in 90/92 (98%) of cases.It differed by three units in one case and by five units in one case. The agreement categorized into OA, LOT, OP and ROT was good (Cohen's kappa 0.72; 95% CI 0.61-0.84). For station, the agreement was very good for both head-perineum distance (Pearson correlation coefficient r=0.86; 95% CI 0.80-0.91) and angle of progression (r=0.77; 95% CI to 0.67-0.84). The correlation between HPD and AoP was good (r =0.76; 95% CI 0.65-0.84). Conclusion:We found very good correlations between structured clinical assessments and ultrasound examinations, suggesting that an objective quality in clinical examinations is possible to achieve. More focus on clinical skills training may improve accuracy for clinicians.

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Section: Discussionmentioning

confidence: 99%

Structured clinical examinations in labor: rekindling the craft of obstetrics

Iversen

Jacobsen

Mikkelsen

et al. 2019

The Journal of Maternal-Fetal & Neonatal Medicine

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“…This is a secondary analysis of a multicenter cohort study of nulliparous women with slow progress in the second stage of labor at term. Duration of vacuum extraction, according to fetal head station and rotation of the fetal head during vacuum extraction, has been reported previously. According to a power calculation, which was performed before the multicenter cohort study was undertaken, a study population of 220 women was needed.…”

Section: Methodsmentioning

confidence: 99%

Descent of fetal head during active pushing: secondary analysis of prospective cohort study investigating ultrasound examination before operative vaginal delivery

Kahrs

Usman

Ghi

et al. 2019

Ultrasound in Obstet & Gyne

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Objectives To investigate if descent of the fetal head during active pushing is associated with duration of operative vaginal delivery, mode of delivery and neonatal outcome in nulliparous women with prolonged second stage of labor. Methods This was a prospective cohort study of nulliparous women with prolonged second stage of labor, conducted between November 2013 and July 2016 in five European countries. Fetal head descent was measured using transperineal ultrasound. Head–perineum distance (HPD) was measured between contractions and on maximum contraction during active pushing, and the difference between these values (ΔHPD) was calculated. The main outcome was duration of operative vaginal delivery, estimated using survival analysis to calculate hazard ratios (HRs) for vaginal delivery, with values > 1 indicating a shorter duration. HR was adjusted for prepregnancy body mass index, maternal age, induction of labor, augmentation with oxytocin and use of epidural analgesia. Pregnancies were grouped according to ΔHPD quartile, and delivery mode and neonatal outcome were compared between groups. Results The study population comprised 204 women. Duration of vacuum extraction was shorter with increasing ΔHPD. Estimated mean duration was 10.0, 9.0, 8.8 and 7.5 min in pregnancies with ΔHPD in the first to fourth quartiles, respectively, and the adjusted HR for vaginal delivery, using increasing ΔHPD as a continuous variable, was 1.04 (95% CI, 1.01–1.08). Mean ΔHPD was 7 mm (range, −10 to 37 mm). ΔHPD was either negative or ≤ 2 mm in the lowest quartile. In this group, 7/50 (14%) pregnancies were delivered by Cesarean section, compared with 8/154 (5%) of those with ΔHPD > 2 mm (P < 0.05). There was no significant association between umbilical artery pH < 7.10 or 5‐min Apgar score < 7 and ΔHPD quartile. Conclusion Minimal or no fetal head descent during active pushing was associated with longer duration of operative vaginal delivery and higher frequency of Cesarean section in nulliparous women with prolonged second stage of labor. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

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“…Third, the criteria by which the women underwent one or another type of instrumentation (vacuum or forceps) was based on the obstetricians' experience and skill [50][51][52] (only five obstetricians participated in our study). First, only Malmström vacuum and Kielland forceps were used for the deliveries; therefore, the results obtained should not be generalized to all types of instrumental deliveries.…”

Section: Malmström Vacuum and Kielland Forceps Deliveriesmentioning

confidence: 99%

“…Second, the characteristics of the instrumentation included in our study, such as the station and fetal head position, were limited, and other factors, such as rotation or no rotation of the fetal head, should be evaluated in future studies. Third, the criteria by which the women underwent one or another type of instrumentation (vacuum or forceps) was based on the obstetricians' experience and skill [50][51][52] (only five obstetricians participated in our study). The experience of our obstetricians could have influenced our final results.…”

Section: Ta B L E 3 Levator Ani Muscle Injury and General Levator Hiamentioning

confidence: 99%

A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation

García‐Mejido

Fernández‐Palacín

Barby

et al. 2019

Acta Obstet Gynecol Scand

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Abbreviations: CI, confidence interval; LAM, levator ani muscle; OR, odds ratio. AbstractIntroduction: Forceps delivery is associated with a high rate of levator ani muscle (LAM) trauma (avulsion) at 35%-65% whereas data on avulsion rates after vacuum delivery vary greatly. Nevertheless, a common characteristic of all previous studies carried out to evaluate the association between instrumental deliveries (forceps and vacuum) and LAM avulsion, is the fact that characteristics of the instrumentation have not been described or evaluated. The objective of this study is to compare the rate of LAM avulsion between forceps and vacuum deliveries according to the characteristics of the instrumentation. Material and methods: Prospective, observational study, including 263 nulliparous women, who underwent an instrumental delivery with either Malmström vacuum or Kielland forceps. The characteristics of the instrumentation, position (anterior position and other position) and height of the fetal head at the moment of instrumentation (low instrumentation [vertex at +2 station] and mid-instrumentation [head isinvolved but leading part above +2 station]) were assessed. Evaluation of LAM avulsion was performed at 6 months postpartum by three-/four-dimensional transperineal ultrasound. Using the multi-view mode, a complete avulsion was diagnosed when the abnormal muscle insertion was identified in all three central slices, that is, in the plane of minimal hiatal dimensions and the 2.5-mm and 5.0-mm slices cranial to this one. To detect a 30% or 15% difference in the LAM injury rate, with 80% power and 5% α-error, we needed, respectively 42 and 99 women per study group.Results: In all, 263 nulliparous individuals have been evaluated (162 vacuum deliveries, 101 forceps deliveries). Instrumentation in an occipito-anterior position was more frequent in vacuum deliveries (75.3% vs 56.4%, P = .002), whereas other positions were more frequent in the forceps deliveries group (24.7% vs 43.6%). No statistically significant differences were noted regarding the height of the fetal head at the moment of instrumentation. No statistically significant differences were found in the presence of LAM avulsion (41.4% vs 38.6%) between vacuum and forceps deliveries.The univariate analysis of the crude odds ratio was 1.17, 95% CI 0.67-1.98, P = .70 for

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Fetal rotation during vacuum extractions for prolonged labor: a prospective cohort study

Abstract: Most fetuses in OP or OT positions rotated to OA position during vacuum extraction, but the proportion of failed vacuum extractions remained high.

Cited by 27 publications

References 34 publications

Structured clinical examinations in labor: rekindling the craft of obstetrics

Structured clinical examinations in labor: rekindling the craft of obstetrics

Descent of fetal head during active pushing: secondary analysis of prospective cohort study investigating ultrasound examination before operative vaginal delivery

A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation

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