FIGURE 1 In trained hands, operative vaginal delivery can be an extremely effective intervention to expedite delivery when nonreassuring fetal testing is noted during the second stage of labor. ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT 38 OBG Management | June 2014 | Vol. 26 No. 6 obgmanagement.com UPDATE OPERATIVE VAGINAL DELIVERY New data confirm that the combination of forceps and vacuum extraction should be avoided and demonstrate that use of midcavity rotational forceps is safe and effective ›› Errol R. Norwitz, MD, PhD Dr. Norwitz is Louis E. Phaneuf Professor of Obstetrics and Gynecology, Tufts University School of Medicine, and Chairman of the Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, Massachusetts. Dr. Norwitz serves on the OBG Management Board of Editors. The author reports no financial relationships relevant to this article. he past year has seen the publica- delivery in the setting of transverse arrest, Ttion of four studies with relevance for namely manual rotation, vacuum rota- clinicians: tion, and rotational forceps • a retrospective cohort study that exam- • another retrospective cohort study that ined the maternal risks of operative vaginal compared maternal morbidity among IN THIS ARTICLE delivery using forceps, vacuum extraction operative vaginal deliveries performed by (FIGURE 1), or a combination of forceps midwives and physician providers in the Why you should learn and vacuum United Kingdom to perform midcavity • a prospective cohort study that investi- • a description of a new technique for instru- rotational deliveries gated the efficacy and safety of three dif- mental vaginal delivery that is low-cost, page 40 ferent techniques for midcavity rotational simple, and easy to perform. Should midwives perform operative Do not switch instruments vaginal deliveries? page 42 Fong A, Wu E, Pan D, Chung HJ, Ogunyemi DA. Tem- cesarean delivery. What to do then in a situa- poral trends and morbidities of vacuum, forceps, and tion where the vacuum extractor keeps pop- A new device to combined use of both [published online ahead of print ping off, the vertex is at +3/+5 station, and facilitate vaginal April 9, 2014]. J Matern Fetal Neonatal Med. doi:10.310 the fetal heart rate has been at 80 bpm for delivery 9/14767058.2014.904282. 8 minutes? It is extremely tempting to discard the ventouse and grab the forceps. But would page 43 that be the right decision? n trained hands, operative vaginal delivery Ican be an extremely effective intervention Details of the study to expedite delivery in the setting of non- Earlier studies suggested that the combina- reassuring fetal testing (“fetal distress”) in tion of vacuum and forceps is associated with the second stage of labor. It takes just a few an increased risk of fetal injury. Whether minutes to perform and can avert a frantic this is also true of injury to the mother was dash to the operating room for an emergent not known. To address this issue, Fong and obgmanagement.com Vol. 26 No. 6 | June 2014 | OBG Management 39 UPDATE operative vaginal delivery WHAT THIS EVIDENCE MEANS and 710 fetuses delivered using a combina- FOR PRACTICE tion of the two methods. Using multivariate analysis modeling, The message is clear: Avoid combined Fong and colleagues demonstrated that, vacuum/forceps deliveries. Choose your when compared with the vacuum alone, the initial instrument with care because a combined use of vacuum and forceps was failed operative vaginal delivery means a associated with significantly higher odds of: cesarean. You don’t get to choose again. • third- and fourth-degree perineal lacera- The American College of Obstetricians tions (adjusted odds ratio [aOR], 2.86; 95% and Gynecologists also recommends confidence interval [CI], 2.43–3.36) against using multiple instruments “un- • postpartum hemorrhage (aOR, 1.81; less there is a compelling and justifiable 95% CI, 1.33–2.46) reason.”1 • operative delivery failure (aOR, 2.81; 95% CI, 2.27–3.48). Fortunately, combined vacuum/forceps colleagues performed a retrospective cohort deliveries are uncommon, comprising only study of all successful operative vaginal deliv- 0.33% of operative deliveries in this cohort. eries identified using ICD-9 procedure codes Despite the large dataset used, the study in the California Health Discharge Dataset was underpowered to examine the effect of from 2001 through 2007. Maternal outcomes combined vacuum/forceps on the incidence were compared between the 202,439 fetuses of rare events, such as pelvic hematoma, delivered by vacuum extraction (reference cervical laceration, thromboembolism, and group), 13,555 fetuses delivered by forceps, maternal death. The most common indication for cesarean delivery Learn to perform midcavity during the second stage of labor is rotational deliveries arrest of descent Bahl R, Van de Venne M, Macleod M, Strachan B, Mur- is arrest of descent due to malposition of the due to malposition phy DJ. Maternal and neonatal morbidity in relation fetal head, typically a transverse arrest. A of the fetal head, to the instrument used for midcavity rotational opera- number of alternatives to cesarean are avail- typically a transverse tive vaginal delivery: A prospective cohort study. BJOG. able, all of which involve assisted rotation of arrest 2013;120(12):1526–1532. the fetal head. Historical case series report- ing increased neonatal morbidity have led to a reduction in the use of rotational forceps esarean delivery during the second stage to facilitate this rotation. Attempted manual Cof labor used to be an uncommon event. rotation and “rotational vacuum extrac- It was said that if labor progressed adequately tion” are now preferred, particularly by less to achieve full cervical dilatation, a vaginal experienced providers. Which of these three delivery should be achieved. Over the past approaches is most effective is unknown. few decades, however, the rate of cesar- ean delivery at full cervical dilatation has Details of the study increased substantially, thereby contributing A prospective cohort study was carried out at to the well-documented cesarean epidemic. two university hospitals in Scotland and Eng- The most common indication for cesar- land to compare maternal and neonatal mor- ean delivery during the second stage of labor bidity associated with alternative techniques CONTINUED ON PAGE 42 40 OBG Management | June 2014 | Vol. 26 No. 6 obgmanagement.com UPDATE operative vaginal delivery CONTINUED FROM PAGE 40 WHAT THIS EVIDENCE MEANS vaginal delivery, 163 (42.8%) underwent FOR PRACTICE manual rotation followed by nonrotational forceps delivery, 73 (19.1%) had a rotational Midcavity rotational delivery can be vacuum delivery, and 145 (38.1%) delivered achieved with a high degree of success with the assistance of rotational (Kielland) and few adverse events in women who forceps. develop transverse arrest in the second Regardless of the instrument used, suc- stage of labor. Maternal and perinatal cessful rotation and vaginal delivery were outcomes are comparable with rotational achieved in more than 90% of cases, with forceps, vacuum extraction, and manual a cesarean rate of 4.2%, 6.8%, and 9.6% for rotation. With appropriate training, mid- manual rotation, vacuum, and rotational cavity rotational delivery can be prac- forceps, respectively (aOR, 0.39; 95% CI, ticed safely, including the use of Kielland forceps. 0.14–1.06). There were no significant differ- ences in maternal complications (postpar- tum hemorrhage, third- and fourth-degree for midcavity rotational delivery. The choice perineal lacerations) and neonatal mor- of instrument was left to the provider. bidity (low cord pH, neonatal trauma, and Of the 381 nulliparous women who had neonatal intensive care unit admission) an attempted midcavity rotational operative between the three instruments. Should midwives perform operative vaginal deliveries? Midwives were significantly less Black M, Mitchell E, Danielian P. Instrumental vagi- consecutive women who had a successful likely than nal deliveries; are midwives safer practitioners? A ret- nonrotational instrumental vaginal delivery physicians to use rospective cohort study. Acta Obstet Gynecol Scand. of a liveborn singleton infant outside of the forceps as the 2013;92(12):1383–1387. operating room between June 2005 and June instrument of choice 2010 at Aberdeen Maternity Hospital in the United Kingdom. for operative vaginal n the United States, instrumental vaginal Of the 2,540 women included in the final delivery Ideliveries are performed only by physicians. analysis, 330 (13%) were delivered by mid- In the United Kingdom, the opportunity to wives and the remaining 2,210 (87%) by phy- perform such deliveries has recently become sicians—1,049 (41%) by junior doctors and available to midwives as well. Because mid- 1,161 (46%) by more senior doctors. All mid- wives have less experience in performing sur- wives had undergone formal training at the gical procedures, the question has arisen as to University of Bradford. There were no differ- whether their complication rate is higher than ences between groups in demographic char- that of physicians. Alternatively, because mid- acteristics (maternal age, gestational age, wives typically are more patient than physi- parity, body mass index, or birth weight) or ON THE WEB cians and more reluctant to resort to obstetric in the indications for instrumental delivery. interventions, it is possible that their compli- Major findings were that midwives were Dr. Norwitz cation