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PubMed1986

Complications associated with the macrosomic fetus.

A retrospective study was done on 525 infants who weighed more than 4,500 g. The rates of grand multiparity, diabetes mellitus, pregnancy-induced hypertension, deliveries in women over 35 years of age, placenta previa and weight gain of more than 15 kg were higher than in a control group weighing 2,500-4,000 g. The rates of delivery with instruments and cesarean section were also significantly higher. The main indication for cesarean section in the study group was cephalopelvic disproportion, while in the control group it was repeat cesarean section. Rates of postpartum hemorrhage, shoulder dystocia, oxytocin augmentation of labor and tears in the birth canal far exceeded those in the control group. Maternal and fetal morbidity and perinatal mortality were significantly higher than in the control group. The complications were due to a difficult second stage of labor. Delivery of the macrosomic fetus by cesarean section is highly recommended except for the subgroup of women who already delivered a macrosomic child.

Adult↗
PubMed1995

[Fetal macrosomia and mode of delivery].

During the period 1988-1993 the route of delivery in 482 infants with birth weight > or = 4000 grams was studied. Normal vaginal delivery occurred in 396 (82.1%) cases, vacuum extractor in 8 (1.6%) cases and caesarean section in 78 (16.1) cases. Elective induction of labor with oxytocin and/or amniotomy was carried out in 25 cases of macrosomia. Perinatal death and shoulder dystocia never occurred in these macrosomic babies, but clavicles abruption (27 cases), cephalohaematoma (2 cases), shoulder-bladehaematoma (1 case) and birth brachial palsy (1 case) were observed. Because, in our experience, elective induction of labor increased the operative delivery rate (caesarean section, vacuum extractor), we conclude that mothers with macrosomic fetuses can safely be managed expectantly unless there is a indication for induction or caesarean section.

Adult↗
PubMed1993

Does midline episiotomy increase the risk of third- and fourth-degree lacerations in operative vaginal deliveries?

OBJECTIVE: To explore the association between midline episiotomy and the risk of third- and fourth-degree lacerations during operative vaginal delivery with either vacuum extractor or forceps. METHODS: This retrospective cohort study analyzed all operative vaginal deliveries at a university hospital in 1989 and 1990. Univariate analysis of the relationships between perineal lacerations and obstetric variables was performed. Stratified analysis using the relevant variables was used to calculate relative risk (RR) estimates. RESULTS: Episiotomy, birth weight, and whether the index birth was the first vaginal birth were associated with third- and fourth-degree perineal lacerations. Stratified analysis demonstrated an RR of 2.4 with a 95% confidence interval of 1.7-3.5 for rectal injury with episiotomy, adjusting for parity and birth weight. CONCLUSION: Midline episiotomy is associated with an increased risk of third- and fourth-degree perineal lacerations in operative vaginal deliveries.

Birth Weight↗
PubMed1993

Obstetric correlates of neonatal retinal hemorrhage.

OBJECTIVE: To determine whether maternal or fetal factors, other than vacuum-assisted delivery, play a role in neonatal retinal hemorrhage, and whether correlates are similar in retinal hemorrhage after spontaneous vaginal delivery. METHODS: A cross-section of assisted deliveries at an urban hospital (n = 156) over 7 months were compared with contemporaneous spontaneous vaginal deliveries (n = 122). A subset of assisted deliveries (n = 87) was prospectively randomized to forceps or vacuum-assisted delivery by sealed envelope. Maternal and neonatal biometric data were collected, and Apgar scores, umbilical artery blood gas analysis, and neonatal ophthalmologic evaluations were performed. RESULTS: Moderate to severe retinal hemorrhage was found in 18% of spontaneous, 13% of forceps, 28% of vacuum-assisted, and 50% of sequential vacuum and forceps-assisted deliveries. Fetal distress (P < .008), vacuum-assisted delivery (P < .02), decreased birth weight for gestation (P < .004), umbilical artery pH less than 7.20 (P < .004), and second stage of labor less than 30 minutes (P < .05) were most closely associated with increased degrees of retinal hemorrhage. Maternal parity, preeclampsia, length of labor, and head circumference were not correlated with retinal hemorrhage. Vacuum-assisted delivery among low birth weight infants (P < .0001), short second stage of labor (P < .006), fetal acidosis (P < .045), and sequential use of vacuum and forceps for assisted delivery (P < .005) formed a logistic model that correctly predicted 81% of moderate to severe retinal hemorrhage cases. Logistic analysis of the randomized assisted deliveries gave similar results. CONCLUSIONS: Maternal and fetal factors other than vacuum-assisted delivery are significant correlates of moderate to severe retinal hemorrhage. Vacuum-assisted delivery among small for gestational age infants is closely correlated with moderate to severe retinal hemorrhage.

Adult↗
PubMed1987

[Informing the patient about alternative surgical methods of delivery].

The article discusses a judgment passed by the Düsseldorf Supreme Court on 30 January 1986. An obstetrician had resorted to vacuum extraction during multiple birth (twins) because one twin was in imminent danger of hypoxia. It was found only later that during this procedure he had caused a fracture of the parietal bone with subsequent subdural hematoma. This damage inflicted on the infant had initially remained unnoticed and resulted in hemiplegia of the left side. The infant, legally represented by his parents, filed a suit for compensation against the Board of Governors of the hospital. The Düsseldorf Supreme Court ruled on 30 January 1986 that the respondent was liable to compensation. The Court was convinced that the consent obtained from the infant's mother to proceed with vacuum extraction had been invalid at that time because the physician had failed to draw her attention beforehand to the available alternative surgical method of delivery, namely, to Caesarean section. Hence, the Court argued, the procedure followed during birth was against the law so that the Board of Governors was directly liable independent of whether the responsible obstetrician had or had not been guilty of malpractice. In addition, the liability of the Board of Governors follows from the fact that the infant had not been examined by a paediatrician immediately after birth as would have been mandatory had delivery been conducted lege artis.(ABSTRACT TRUNCATED AT 250 WORDS)

Extraction, Obstetrical↗
PubMed1990

Tentorial hemorrhage associated with vacuum extraction.

The clinical and radiologic descriptions of three neonates with tentorial hemorrhage after vacuum extraction are reported. All patients were full term, with Apgar scores of 8 or more; one patient experienced fetal distress during delivery. Within 36 hours after birth, the neonates had multiple generalized seizures; computed tomography or magnetic resonance imaging outlined distinctive tentorial hemorrhages with extension over the superior surface of the cerebellum or inferior surface of the occipital lobe. One patient had diffuse hypoxic-ischemic injury, and another had bilateral temporal lobe infarcts. Treatment included medical control of seizures and intracranial hypertension; one patient had surgical evacuation of bilateral subdural hematomas. Follow-up from 1 to 5 years showed significant developmental delays in two patients. These cases demonstrate that the forces generated on the fetal cranium by vacuum extraction are similar to those produced by forceps and result in tentorial laceration, venous rupture, and subdural hemorrhage. Because these hemorrhages may be associated with significant ischemic injury, serial radiologic evaluation is recommended for the detection of persistent structural abnormalities.

Birth Injuries↗
PubMed1976

[Frequency of obstetrical operations and perinatal mortality before and after admission of continuous fetal monitoring (author's transl)].

Two groups of obstetrical patients were statistically analyzed with a computer. The first group A (2339 deliveries, January 1967-June 1968) was controlled by conservative obstetrical methods, the second group B (2512 deliveries, January 1973-June 1974) was controlled by continuous monitoring of fetal heart rate and by analysis of fetal blood during labour. The results of the statistical analysis can be summarized: 1. The frequency of obstetrical operations (vacuum, obstetrical forceps, Caesarean section) increases from 12.8% (group A) to 22.5% (group B). 2. The percentage of Caesarean sections decided on for the sake of the child rose from 45.7% (group A) to 54.7% (group B). 3. Vital indications fell due to increasingly preventive obstetrics from 54.3% to 45.3%. 4. The frequency of Caesarean sections rose due to increasing indication "absolute or relative pelvic disproportion" of the mediterranean patients. 5. However the analysis of fetal blood during labour and the continuous monitoring of fetal heart rate has prevented a further increase of Caesarean sections. 6. The increasing percentage of obstetric forceps was due to our intention of preventing prolonged labour. 7. Maternal mortality after operative delivery reached 0.04% in group A and 0% in group B. 8. Perinatal mortality of children, delivered by operation, has decreased from 3.0% (group A) to 0,7% (group B). 9. The Apgar scores after operative deliveries were much better in group B (continuous fetal monitoring) than in group A (without fetal monitoring).

Apgar Score↗
PubMed1981

Dilation and evacuation: a preferred method of midtrimester abortion.

A comparison between two methods of therapeutic termination of midtrimester pregnancies was performed. Twenty-nine patients at 13 to 16 weeks' gestation underwent dilation and evacuation (D and E). A second group, of 29 patients at 16 to 19 weeks' gestation underwent therapeutic abortion by prostaglandin F2 alpha instillation. There was a significantly lower complication rate (6.9% versus 55%) and a shorter hospital stay of 1 full day in the D and E group. Also, the blood loss was not significantly greater in the D and E group.

Abortion, Therapeutic↗
PubMed2005

A randomised controlled trial of a new handheld vacuum extraction device.

OBJECTIVE: To evaluate the effectiveness of a new handheld vacuum delivery device. DESIGN: Randomised controlled trial. SETTING: Southmead Hospital, Bristol, UK. POPULATION: One hundred and ninety-four women requiring delivery with vacuum extraction. METHODS: Women were recruited into the study while still in early labour. If during delivery, vacuum extraction was indicated they were then randomly allocated to either a new handheld vacuum device, the Kiwi Omnicup, or to a 'standard' vacuum cup selected by the obstetrician. The 'standard group' consisted of the silastic (66/98, 67%) or the metal cups (32/98, 33%). Study data were recorded at completion of the delivery and at 24-48 hours. An additional brief symptom questionnaire was completed by the mother at 10 days postnatally. Statistical analyses were done on an 'intention-to-treat' basis. MAIN OUTCOME MEASURES: The primary outcome was the successful completion of delivery with the allocated instrument. Secondary outcomes were substantial fetal scalp trauma and substantial maternal trauma. RESULTS: The Omnicup was associated with a significantly higher failure rate than the standard cup [34%vs 21%, odds ratio (OR) = 1.9 (1.01-3.6)]. This difference persisted after adjusting for confounding factors [adjusted OR = 2.25 (1.01-5.0)] and resulted in significantly more forceps deliveries in the Kiwi Omnicup group [22%vs 10%, unadjusted OR = 2.5 (1.1-5.5)]. The caesarean section rates were similar in both groups [9.4%vs 8.2%, OR = 1.2 (0.4-3.2)]. Rates of substantial scalp trauma and maternal trauma were similar in both groups. However, there were more cases of jaundice in the standard cup group [2.3%vs 12.0%, unadjusted OR = 0.18 (0.04-0.82) and adjusted OR = 0.10 (0.01-0.88)]. CONCLUSIONS: The Omnicup is not as successful at achieving a vaginal delivery as the combination of the currently used vacuum cups.

Female↗
PubMed2001

Umbilical cortisol levels as an indicator of the fetal stress response to assisted vaginal delivery.

OBJECTIVES: While it is well established that delivery by elective caesarean section is less stressful for the fetus than normal vaginal delivery, little attention has been paid to the effect on the baby of an assisted delivery. STUDY DESIGN: We examined cortisol levels in venous cord blood from seven babies born by forceps, 10 by ventouse extraction, 28 by unassisted normal vaginal delivery, and 12 born by elective caesarean. Paired maternal bloods were taken immediately after delivery. RESULTS: Cord blood cortisol values were significantly different in the different groups (one-way ANOVA, P < 0.0001). The forceps group had the highest values and the caesarean group the lowest; both were different from the normal vaginal delivery group (P=0.019 and P=0.046, respectively). There was no effect of length of labour, or method of pain relief on cortisol levels. Maternal values were similar in the different groups, confirming that the differences observed derived from the fetus. CONCLUSIONS: There is increasing evidence that the stress experienced by the fetus or neonate can have long-term effects on the function of the hypothalamic-pituitary-adrenal axis in later life. We speculate that the stress caused by some assisted deliveries may contribute to this.

Cesarean Section↗