Effect of instrument preference for operative deliveries on obstetrical and neonatal outcomes.
ABSTRACT To examine the relationship between physicians' instrument preference and obstetrical and neonatal outcomes.
A retrospective cohort study comparing obstetrical and neonatal outcomes of second stage deliveries between obstetricians who prefer forceps (forceps >/=90%) with obstetricians with no preference to forceps (either instrument <90%) was completed using the McGill Obstetrical and Neonatal Database. Logistic regression analysis was used to obtain an adjusted odds ratio controlling for maternal, intrapartum and neonatal confounders.
Two thousand and three hundred thirteen infants were delivered by 5 obstetricians who preferred forceps, and 9261 infants were delivered by 15 obstetricians with no instrument preference. Baseline characteristics were similar between the two groups. As compared to obstetricians who preferred forceps, obstetricians with no instrument preference had a higher rate of operative vaginal deliveries 1.5 (1.1-2.0), a higher cesarean section rate 2.5 (1.3-4.9) and a higher episiotomy rate in non-operative vaginal deliveries 3.4 (2.7-4.3). Infants delivered by obstetricians with no instrument preference were less likely to have significant bruising 0.3 (0.2-0.6) but more likely to have a cephalohematoma 3.0 (1.1-8.3).
Physician instrument preference is an important determinant of outcomes that should be considered in studies evaluating instrumental deliveries.
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ABSTRACT: Objective To compare the percentage of operative vaginal delivery (OVD) among all publicly funded maternity hospitals in Ireland and to develop quality control performance tables to facilitate national benchmarking. Methods The analysis included deliveries of neonates weighing 500 g or more in publicly funded hospitals in Ireland in 2010. Information was obtained from the Irish National Perinatal Reporting System. Maternities delivering in 1 private hospital or at home, and those with unknown parity were excluded. Mean ± SD OVD rates were calculated per hospital. Quality control tables were devised. Results In 2010, there were 75 600 deliveries, of which 73 029 met the inclusion criteria. The number of deliveries per hospital ranged from 1284 to 9759. The OVD rate per hospital was 15.3 ± 2.6% (range, 11.7–20.4%). The OVD rate was 29.1% among primigravidas (n = 30 468) compared with 6.7% among multigravidas (n = 42 561) (P < 0.001). Using quality control tables, 52.6% (n = 10) and 31.6% (n = 6) of hospitals were more than 1 SD outside the national mean for forceps and ventouse delivery, respectively. Conclusion Wide variations were found in both the range of OVD and instrument choice among maternity hospitals in Ireland, raising questions about practice and training in contemporary obstetrics.International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 06/2014; · 1.41 Impact Factor
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ABSTRACT: Instrumental vaginal delivery is currently widely used among obstetrical practices and leads to significant decrease in fetal mortality and morbidity. However, these practices could be associated with several neonatal adverse effects. Very few of these complications are specific and most of them could be observed during normal vaginal delivery. Neonatal mortality is not changed by forceps or vacuum use if no other risk factors are associated. The main neonatal adverse outcomes described with both techniques are extra and intracranial haemorrhages. Usually, intra-cerebral haemorrhages have good neurological prognosis. However, few longitudinal studies are available in the literature on long term outcome of exposed newborns. Other traumatic complications observed when using forceps (facial nerve palsy, cranial skull) are not associated with long term functional consequences. Many of the most severe neonatal complications are observed when perinatal asphyxia has occurred. Extractor types and quality of use under defined criteria are closely associated with neonatal adverse outcomes in operative vaginal delivery. Forceps deliveries are as safe as vacuum deliveries to the neonate. In conclusion, operative vaginal delivery performed for maternal or fetal reasons are associated with several neonatal adverse events, usually non specific and with a short term good prognosis.La Revue Sage-Femme 06/2009; 8(3):187-195.
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ABSTRACT: To evaluate risk factors for unsuccessful instrumental delivery when variability between individual obstetricians is taken into account. We conducted a retrospective cohort study of attempted instrumental deliveries over a 5-year period (2008-2012 inclusive) in a tertiary United Kingdom center. To account for interobstetrician variability, we matched unsuccessful deliveries (case group) with successful deliveries (control group) by the same operators. Multivariate logistic regression was used to compare successful and unsuccessful instrumental deliveries. Three thousand seven hundred ninety-eight instrumental deliveries of vertex-presenting, single, term newborns were attempted, of which 246 were unsuccessful (6.5%). Increased birth weight (odds ratio [OR] 1.11; P<.001), second-stage labor duration (OR 1.01; P<.001), rotational delivery (OR 1.52; P<.05), and use of ventouse compared with forceps (OR 1.33; P<.05) were associated with unsuccessful outcome. When interobstetrician variability was controlled for, instrument selection and decision to rotate were no longer associated with instrumental delivery success. More senior obstetricians had higher rates of unsuccessful deliveries (12% compared with 5%; P<.05) but were used to undertake more complicated cases. Cesarean delivery during the second stage of labor without previous attempt at instrumental delivery was associated with higher birth weight (OR 1.07; P<.001), increased maternal age (OR 1.03; P<.01), and epidural analgesia (OR 1.46; P<.001). Results suggest that birth weight and head position are the most important factors in successful instrumental delivery, whereas the influence of instrument selection and rotational delivery appear to be operator-dependent. Risk factors for lack of instrumental delivery success are distinct from risk factors for requiring instrumental delivery, and these should not be conflated in clinical practice. LEVEL OF EVIDENCE:: II.Obstetrics and Gynecology 04/2014; 123(4):796-803. · 4.37 Impact Factor