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Operative vaginal birth in the 21st century: A global perspective
Abstract and Figures
The varied epidemiology of birthing around the world (and even the differences within one country) are attributable to both obstetric and midwifery practice styles and birthing agenda priorities The skills required for vacuum extraction and forceps do have some commonality Trainees who wish to gain additional operative obstetric experience in a developing country setting should choose training sites where the rate of operative vaginal birth (OVB) is more than 3%. Historical perspectives Obstetric forceps to assist birth of the baby date from the 16th century and were developed by three generations of the Chamberlen family. Between 1600 and 1920 over 700 types of forceps were designed; examples of about 100 of these can be viewed in the RCOG museum. Nowadays only four or five types of obstetric forceps are still in use. In most parts of the world, the proportion of assisted births performed by forceps is being overtaken by vacuum extraction procedures.
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... Much of this decline can be attributed to fears of complications, litigation and lack of skills [6] [7]. Vacuum and forceps extraction is still fairly common although vacuum extraction is by far the more common procedure performed in developing countries [7] [13]. One major reason for such high aversion for caesarean section there is failure to achieve vaginal delivery is often considered, albeit wrong, a reproductive failure of the parturient woman [14]. ...
In African countries, caesarean sections are usually performed to save mothers and babies' lives, sometimes in extremis and at considerable costs. Little is known about the health and lives of women once discharged after such surgery. We investigated the long-term effects of life-saving caesarean section on health, economic and social outcomes in Burkina Faso.
We conducted a 4 year prospective cohort study of women and their babies using mixed methods. The quantitative sample was selected in seven hospitals and included 950 women: 100 women with a caesarean section associated with near-miss complication (life-saving caesareans); 173 women with a vaginal birth associated with near-miss complication; and 677 women with uncomplicated vaginal childbirth. Structured interviews were conducted at 3 months, 6 months, 12 months and 3 and 4 years postpartum. These were supplemented by medical record data on delivery and physical examinations at 6 and 12 months postpartum. The lives and experiences of 21 women were documented ethnographically. Data were analysed with multivariable logistic regressions, using survival analysis and thematic analysis.
The physical effects of life-saving caesareans appeared to be similar to women who had an uncomplicated childbirth, although 55 % of women with life-saving caesareans had another caesarean in their next pregnancy. The negative effects were generally economic, social and reproductive when compared to vaginal births, including increased debts (AOR = 3.91 (1.46-10.48) and sexual violence (AOR = 4.71 (1.04-21.3)) and lower fertility (AOR = 0.44 (0.24-0.80)) 4 years after life-saving caesareans. In the short and medium term, women with life-saving caesareans appeared to suffer increased psychological distress compared to uncomplicated births. They were more likely to use contraceptives (AOR = 5.95 (1.53-23.06); 3 months). Mortality of the index child was increased in both near-miss groups, independent of delivery mode. Ethnographic data suggest that these consequences are significant for Burkinabe women, whose well-being and social standing are mostly determined by their fertility, marriage strength and family links.
Life-saving caesareans have broad consequences beyond clinical sequelae. The recent policy to subsidise emergency obstetric care costs implemented in Burkina Faso should help avoid the majority of catastrophic costs, shown to be problematic for women undergoing emergency caesarean section.
Objective. Assessment of the frequency of complications observed with various forceps and operative vaginal delivery (OVD) techniques performed at the ABC Medical Center (Mexico City) to evaluate their safety, bearing in mind the importance of decreasing our country’s high cesarean section incidence. Methods. We reviewed 5,375 deliveries performed between the years 2007 and 2012, only 146 were delivered by OVD. Results. Only 1.0% of the cases had a serious, life-threatening situation (uterine rupture). The Simpson forceps was the most favored instrument (46%) due to its simplicity of use, effectiveness, and familiarity. Prophylactic use was the most common indication (30.8%) and significant complications observed were vaginal lacerations (
p
=
0.016
), relative risk (RR) of 3.4 (95% confidence interval [CI]: 1.15–10.04), and fourth degree perineal tear (
p
=
0.016
), RR of 3.4 (95% CI: 1.15–10.04). Conclusions. Forceps use and other OVD techniques are a safe alternative to be considered, diminishing C-section incidence and its complications.
In 1985 when a group of experts convened by the World Health Organization in Fortaleza, Brazil, met to discuss the appropriate technology for birth, they echoed what at that moment was considered an unjustified and remarkable increase of caesarean section (CS) rates worldwide.1 Based on the evidence available at that time, the experts in Fortaleza concluded: ‘there is no justification for any region to have a caesarean section rate higher than 10–15%’.1 Over the years, this quote has become ubiquitous in scientific literature, being interpreted as the ideal CS rate. Although this reference range was intended for ‘populations’, which are defined by geopolitical boundaries, in many instances it has been mistakenly used as the measurement for healthcare facilities regardless of their complexity or other characteristics. In addition to the case mix of the obstetric population served, the use of CS at healthcare facilities is also affected by factors such as their capacity to handle cases, availability of resource and the clinical management protocols used locally.
Task shifting - moving tasks to healthcare workers with a shorter training - for emergency obstetric care (EmOC) can potentially improve access to lifesaving interventions and thereby contribute to reducing maternal and neonatal morbidity and mortality. The present paper reviews studies on task shifting for the provision of EmOC. Most studies were performed in Sub-Saharan Africa and South Asia and focused primarily on task shifting for the performance of cesarean deliveries. Cesarean delivery rates increased following EmOC training without significant increase in adverse outcomes. The paper discusses the advantages and disadvantages of task shifting in EmOC and the role of this approach in improving maternal and newborn health in the short and long term.
This article summarizes the current state of knowledge of obstetric vacuum extraction. The discussed topics include the history of vacuum extraction, indications and contraindications, technique of the procedure, currently marketed instruments, special uses of the vacuum extractor, comparison of vacuum extraction with forceps delivery, and maternal and fetal outcomes. Areas of controversy are identified and discussed. Vacuum extraction is replacing forceps as the preferred method of instrumental delivery. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to summarize the current state of knowledge of obstetric vacuum extraction, to list the indications and contraindications of obstetric vacuum extraction, and to compare vacuum extraction and forcep delivery of the fetus.