Maternal and neonatal morbidity in relation to the instrument used for mid‐cavity rotational operative vaginal delivery: a prospective cohort study

Abstract

Objective To compare the maternal and neonatal morbidity associated with alternative instruments used to perform a mid-cavity rotational delivery.Design A prospective cohort study.Setting Two university teaching hospitals in Scotland and England.Population Three hundred and eighty-one nulliparous women who had a mid-cavity rotational operative vaginal delivery.Methods A data collection sheet was completed by the research team following delivery.Main outcome measures Postpartum haemorrhage, thirdand fourth-degree perineal tears, low cord pH, neonatal trauma, and failed or sequential operative vaginal delivery.Results One hundred and sixty-three women (42.8%) underwent manual rotation followed by non-rotational forceps delivery, 73 (19.1%) had a rotational vacuum delivery, and 145 (38.1%) delivered with the assistance of rotational (Kielland) forceps. The rates of postpartum haemorrhage were similar when comparing manual rotation with rotational vacuum (adjusted OR 1.42, 95% CI 0.66-3.98), and when comparing manual rotation with Kielland forceps (adjusted OR 1.22, 95% CI 0.71-2.88). The results were comparable for third-and fourth-degree perineal tears (adjusted OR 0.85, 95% CI 0.13-1.89; adjusted OR 0.94, 95% CI 0.39-1.82), low cord pH (adjusted OR 1.76, 95% CI 0.44-6.91; adjusted OR 1.12, 95% CI 0.44-2.83), neonatal trauma (adjusted OR 0.50, 95% CI 0.16-1.55; adjusted OR 3.25, 95% CI 0.65-16.17), and admission to the neonatal intensive care unit (adjusted OR 1.47, 95% CI 0.45-4.81; adjusted OR 1.04, 95% CI 0.49-2.19). The sequential use of instruments was less likely with manual rotation and forceps than with rotational vacuum delivery (0.6 versus 36.9%, OR 0.01, 95% CI 0.002-0.090).Conclusions Maternal and perinatal outcomes are comparable with Kielland forceps, vacuum extraction, and manual rotation, with few serious adverse outcomes. With appropriate training mid-cavity rotational delivery can be practiced safely, including the use of Kielland forceps.Keywords Mid-cavity, morbidity, operative vaginal delivery, prospective cohort study, rotational.Please cite this paper as: Bahl R, Van de Venne M, Macleod M, Strachan B, Murphy DJ. Maternal and neonatal morbidity in relation to the instrument used for mid-cavity rotational operative vaginal delivery: a prospective cohort study . BJOG 2013;120:1526-1533

Kielland’s forceps: does it increase the risk of anal sphincter injuries? An observational study

“…Multinomial regression analysis was not a part of these studies to control for other potential confounders for third-/fourth-degree tears. Recent publications [24,25] have also confirmed comparable risks of third-/fourth-degree perineal trauma with Kielland's forceps vs other non-rotational forceps/rotational ventouse deliveries. In a recently published prospective cohort study on the use of alternative instruments to perform a mid-cavity rotational delivery, the different delivery groups have been adjusted for potential confounders such as age, BMI, birthweight, analgesia and operator grade [26].…”

Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery According to Fetal Head Station

“…The multivariate logistic regression allowed us to analyze together the effect of other risk factors and potential confounders (maternal age, parity, BMI before pregnancy, gestational age, induction of labor, epidural use, persistent occiput position, attempted operative vaginal delivery classification, delivery by attending obstetrician or registrar, instrument type, active phase of second stage longer than 30 minutes, indications for attempted operative vaginal delivery, birth weight, and episiotomy). [25][26][27][28] The propensity score analyses were performed as sensitivity analyses to confirm the results of the multivariate logistic regressions. The propensity score was based on a logistic regression model that included all the covariates that were significantly differently distributed according to whether the attempt was midpelvic or low pelvic.…”

Does advanced operative obstetrics still have a place in contemporary practice?

“…For fetuses in occipito-posterior or occiput-transverse positions at full dilatation, a strategy of MROT is associated with a reduction in the requirement for operative delivery [31 && ]. In addition, sequential instruments are less likely when MROT is combined with forceps over rotational ventouse [32]. Early data on the usefulness of MROT compared with rotational ventouse is encouraging but caution is required until robust morbidity data is available.…”