Operative Delivery
Operative Delivery
Abstract & Commentary
By John C. Hobbins, MD, Professor of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, is Associate Editor for OB/GYN Clinical Alert.
Dr. Hobbins reports no financial relationships relevant to this field of study.
Synopsis: Data from a New York City Birth Registry involving deliveries between 1995-2003 show a surprisingly lower incidence of seizures, depressed Apgar scores, and combined neonatal morbidity with forceps delivery compared with vacuum extraction.
Source: Werner EF, et al. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol 2011;118:1239-1246.
Managing labor is an art, while the actual delivery process requires the addition of skill and experience. Yet, the decision of which route of delivery to employ may have the greatest impact on outcome. A recent article deals with neonatal morbidity, including an important contributor, intracranial injury, and its association with various forms of operative delivery.
Werner at al reviewed hospital discharge data from New York City between 1995 and 2003. The authors were interested in the relationship of a variety of neurological and cranial injuries to vacuum extraction, forceps delivery, and cesarean section. More than 1 million births occurred during this time in New York City, but they narrowed their investigation to the 120,541 patients who had operative deliveries.
In the study, 72.2% of the operative deliveries were done by cesarean section, 15% by vacuum, and 12.8% by forceps (The type of forceps application — outlet, low, or mid pelvis — was not defined). Only 1.5% had more than one method attempted, and were excluded. The dependent variables were various types of intracranial and facial injuries, seizures, fractures, brachial plexus injuries, and low Apgar scores.
The trends over time were not unexpected. For instance, while the cesarean section rate went from 20.4% in 1995 to 23.4% in 2003, the vacuum extraction rate rose from 4.0% to 5.8%, and the forceps rate went from down from 5.6% to 2.1%. Cesarean section was associated with higher rates of seizures and lower Apgar scores (5-minute score of < 7), and there was a trend toward an increased rate of intraventricular hemorrhage. Vacuum deliveries had higher rates of subdural hematomas (0.19%) than forceps (0.14%), while cesarean section had the lowest rate of this complication (0.09%). Not surprisingly, brachial plexus and facial injuries were greatest in the forceps group. When comparing vacuum and forceps with regard to combined neurological morbidity, forceps was the surprising winner (0.26% vs 0.45%, respectively), and the rate was even lower for forceps than cesarean section (0.44%).
Commentary
It may be unfair to compare combined neurological morbidity (and especially seizures) between cesarean section and operative vaginal delivery because the cesarean section group, who had the highest rate of these outcomes, undoubtedly contained more mothers whose fetuses were judged to be incapable of tolerating labor. However, the two operative vaginal delivery groups were probably roughly similar and some of the outcomes should have been expected: cephalo-hematomas with vacuum extraction and facial and brachial plexus injuries with forceps. However, I was somewhat surprised that the combined neonatal morbidity, Apgar scores, and the incidence of seizures were lower with forceps than with vacuum extraction.
It is interesting that the sample included delivery data that dated back to 1995 when operators were probably more skilled in the application of forceps. Currently, there seems to be less enthusiasm for forceps training in the face of trends in the medico-legal climate, since one rarely gets sued for doing an expeditious cesarean section instead of attempting an operative vaginal delivery. Perhaps the study will provide some incentive to reconsider operative vaginal delivery as an acceptable option to what must still be considered a major operation, cesarean section.
Managing labor is an art, while the actual delivery process requires the addition of skill and experience. Yet, the decision of which route of delivery to employ may have the greatest impact on outcome. A recent article deals with neonatal morbidity, including an important contributor, intracranial injury, and its association with various forms of operative delivery.Subscribe Now for Access
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