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Operative Vaginal Birth

Operative vaginal birth or operative vaginal delivery – refers to the use of forceps, vacuum, or more than one instrument to extract the fetus from the vagina, with or without the assistance of maternal pushing. Operative vaginal births account for 10–15% of all deliveries in the United Kingdom, with an incidence of up to 30% in first time mothers.

In the USA in 1990 – 9% of livebirths resulted from either forceps delivery or vacuum extraction, by 2014 only 3.21% of livebirths resulted from operative vaginal delivery; in 2017 3.1 percent of all deliveries were accomplished via an operative vaginal approach. Forceps deliveries accounted for 0.5 percent of vaginal births, and vacuum deliveries accounted for 2.6 percent of vaginal births.

One of the reasons for the great reduction in operative procedures is the lack of experience and hence reduced confidence of the operator, who instead will do a Caesarean Section. As a Resident/Registrar, I did hundreds of forceps deliveries. These days Obstetricians in training, in some regions, see very few.

Operative vaginal birth should be performed by, an operator who has the knowledge, skills and experience necessary to assess the woman, complete the procedure and manage any complications that arise. The majority of operative vaginal births, when performed correctly by appropriately trained personnel, result in a safe outcome for the woman and baby. Women who achieve an assisted vaginal birth rather than have a caesarean birth with their first child are far more likely to have an uncomplicated vaginal birth in subsequent pregnancies.

Operative vaginal delivery is indicated for both maternal and fetal reasons.

Indications for assisted vaginal birth

Fetal – Suspected fetal compromise (cardiotocography showing abnormal fetal heart rate (FHR) tracings; abnormal fetal blood sampling result; thick meconium). The need to rotate the fetal head to effect vaginal delivery.

Maternal – Maternal exhaustion or distress and ineffectual pushing in the second stage of labor.  Prolonged second stage of labor, arrest of descent. Various medical factors requiring an expedited second stage, such as preexisting cardiovascular disease or deteriorating medical conditions

No indication is absolute and each case should be considered individually. 

Safety of Operative Vaginal Birth

When considering adverse neurologic outcome, forceps deliveries are associated with a reduced risk of such outcomes compared with both vacuum extraction and cesarean delivery.

Forceps rotations to effect delivery are not linked to excess neonatal neurological morbidity. Furthermore, because forceps rotation of a fetus in a persistent occiput posterior position to an occiput anterior position may reduce maternal perineal laceration, it seems reasonable to attempt rotation in such circumstances.

Vacuum extraction is discouraged at gestational age of less than 34 weeks.

Although the routine use of episiotomy with operative vaginal delivery has been questioned.  A large observational study from the Netherlands of 28,732 assisted vaginal births concluded that mediolateral episiotomy is protective against Obstetric Anal Sphincter Injury (OASI) in both vacuum extraction and forceps birth. 

The balance between the art and science of medicine has been shifting for years, unfortunately operative vaginal delivery is an increasingly lost art.

REFERENCES

1. Hamilton BE, Martin JA, Osterman MJ, Curtin SC, Matthews TJ. Births: Final Data for 2014. Natl Vital Stat Rep. 2015 Dec;64(12):1-64.

2. Operative vaginal delivery. Practice Bulletin No. 154. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015;126:e56–65.

3. Demissie K, Rhoads GG, Smulian JC, Balasubramanian BA, Gandhi K, Joseph KS, et al. Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis. BMJ 2004; 329: 24– 9.

4. Crane AK, Geller EJ, Bane H, Ju R, Myers E, Matthews CA. Evaluation of pelvic floor symptoms and sexual function in primiparous women who underwent operative vaginal delivery versus cesarean delivery for second-stage arrest. Female Pelvic Med Reconstr Surg. 2013 Jan-Feb;19(1):13-6.

5. Johanson RB, Heycock E, Carter J, Sultan AH, Walklate K, Jones PW. Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse. Br J Obstet Gynaecol. 1999 Jun;106(6):544-9.

6. Werner E F, Janevic TM, Illuzzi J, Funai EF, Savitz DA, Lipkind HS. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol. 2011 Dec;118(6):1239-46.

7. Walsh CA, Robson M, McAuliffe FM. Mode of delivery at term and adverse neonatal outcomes. Obstet Gynecol. 2013 Jan;121(1):122-8.

8. Wesley BD, van den Berg BJ, Reece EA. The effect of forceps delivery on cognitive development. Am J Obstet Gynecol. 1993 Nov;169(5):1091-5.

9. Bahl R, Strachan B, Murphy DJ. Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study. BMJ 2004; 328: 311.

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Episiotomy

Episiotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician during second stage of labour to quickly enlarge the opening for the baby to pass through.
The incision, which can be done at a 90 degree angle from the vulva towards the anus or at an angle from the posterior end of the vulva (medio-lateral episiotomy), is performed under local anaesthetic and is sutured after delivery.

The use of a surgical incision of the perineum during childbirth was first described in 1742. It was introduced into the USA in the mid-19th Century. In 1920, at a meeting of the American Gynaecological Society in Chicago, USA, Joseph DeLee first publicly advocated the routine adoption of Medio lateral episiotomy for all deliveries in nulliparous women.

They became common practice during the 20th century, the main reason being to reduce the risk of severe perineal tears. 85% of women who have a vaginal delivery, will have some degree of perineal trauma, the majority of which will require suturing. By 1979, episiotomy was performed in approximately 63% of all deliveries in the USA, with higher rates among nulliparous women. In the UK in the same era, episiotomy rates ranged from 14 to 96% among nulliparous women and 16–71% among multiparous women. In recent years opposition to the use of episiotomy as a standard procedure has reduced the rate and its routine use is no longer recommended. Despite this, it is one of the most common medical procedures performed on women, though there is now considerable variation between countries. A review was published in JAMA in 2005. By this time the practice had declined in the USA from of over 60% to 30–35% of vaginal deliveries though the rate was as high as 99% in Eastern Europe.

In 2009, a Cochrane meta-analysis based on studies with over 5,000 women concluded that: “Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy”.

Levine EM et al in 2015 noted – The average episiotomy rate steadily declined from 1996-1998, 2003-2005 and 2012-2014. The rate of advanced perineal lacerations coincidentally rose during these time period comparisons. Levine EM, Bannon K, Fernandez CM, Locher S (2015) Impact of Episiotomy at Vaginal Delivery. J Preg Child Health 2:181.

It has been suggested that perineal massage during the second stage of labour can reduce the need for episiotomy.
Infrared lamp therapy is an effective method of treatment on healing of episiotomy wound among post-natal mothers.
In a study by Sabzaligol M et al. Aloe Vera gel not only relieved the pain but also increased the rate of wound healing in episiotomy.

References
1. Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery”. Obstetrics and Gynecology. 128 (1): e1–e15. July 2016.
2. Chang,S-R; Chen,K-H; Lin,H-H; Chao,Y-M Y.; Lai,Y-H (April 2011). “Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: A prospective follow-up study”. International Journal of Nursing Studies. 48 (4): 409–418.
3. Graham,I.D.; Carroli,G.; Davies,C.; Medves,J.M. (August 2005). “Episiotomy Rates Around the World: An Update”. Birth. 32 (3): 219–223.
4. Carroli, G, Mignini, L. “Episiotomy for vaginal birth”. Cochrane Database Syst Rev. 2009 Jan 21; (1):
5. Jiang, Hong; Qian, Xu; Carroli, Guillermo; Garner, Paul; Jiang, Hong (2017). “Selective versus routine use of episiotomy for vaginal birth”.
6. American College of Obstetricians-Gynecologists (2006). “ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006” Obstetrics & Gynecology. 107 (4): 956–62
7. Levine EM, Bannon K, Fernandez CM, Locher S (2015) Impact of Episiotomy at Vaginal Delivery. J Preg Child Health 2:181.
8. Sabzaligol M, Safari N, Baghcjeghi N, Latifi M, Koohestani H R, Bekhradi R, et al . The effect of Aloevera gel on prineal pain & wound healing after episiotomy. cmja. 2014; 4 (2) :766-775

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Too Many Caesarian Sections.

Cesarean delivery is the most commonly performed surgical procedure in the United States. Cesarean delivery may be a safe alternative to vaginal delivery but its use in 1 of 3 women giving birth in the US seems too high.
American College of Obstetricians and Gynecologists (ACOG) 2017 Annual Meeting.
“About half the C-sections we do in the United States today are probably avoidable.” “According to our own guidelines, we shouldn’t be doing any C-sections on labor progress alone before 6 centimetres, if we just did that, it’s worth tens of thousands of C-sections per year.”

Rates in American hospitals for low-risk patients range from 2.4% to 36.5% (Health Aff [Millwood]. 2013;32:527-535)
In 2014, 1.3 million women in the United States delivered via cesarean, placing the rate at 32.2%, down just 0.7% from the peak in 2009.
In 2013-14, in the UK; 386,937 (60.9 per cent) of deliveries in NHS hospitals were spontaneous deliveries, while 166,081 (26.2 per cent) were caesarean deliveries.
In the 1950s, 3% of births in England were by CS. By the early 1980s this had risen to 10% and in the 1990s rates started to climb rapidly, from 12% in 1990 to 21% in 2001.
The cesarean rate has risen without improving maternal or neonatal outcomes.
One reason for increasing cesarean rates may be a rise in elective cesarean delivery, also known as cesarean delivery by maternal request (CDMR). estimated at 4% in the United States.
Physicians in one study reported that they were more likely to perform a cesarean if they had been sued recently or if they thought about being sued frequently. (Cheng YW, Snowden JM, Handler SJ, et al. Litigation in obstetrics: does defensive medicine contribute to increases in cesarean delivery? J Matern Fetal Neonatal Med. 2014;27:1668–1675.)
Delayed admission to an active delivery unit in the latent phase of labor may reduce cesarean deliveries. (Tilden EL, Lee VR, Allen AJ, et al. Cost-effectiveness analysis of latent versus active labor hospital admission for medically low-risk, term women. Birth. 2015;42:219–226.)
The effect of cesarean delivery on future pregnancies should be considered when the first cesarean is being performed. Infants born to mothers who have had prior cesareans are at increased risk of stillbirth, and in cases of trial of labor after Caesarian, uterine rupture carries a risk to the neonate. For pregnancies complicated by abnormal placentation, delivery before term may be required.
Solheim KN, Esakoff TF, Little SE, et al. The effect of current cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med. 2011;24:1341–1346.
Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003;362:1779–1784.
Malpresentation
Fetal malpresentation, most commonly breech presentation at term, is seen in approximately 4% of pregnancies. Currently, the vast majority of such pregnancies are delivered via cesarean. When I first went to Canada I was amazed that a consultant obstetrician could not conduct a breech vaginal delivery, which had been common practice in England. Of course morbidity in untrained hands will be higher. The current primary approach to reducing cesareans in breech presentation is the use of external cephalic version (ECV). In general, ECV will be effective in approximately 70% of attempts and the majority of women with a successful ECV will go on to deliver vaginally. Finally, moxibustion (a Chinese medicine approach) has been shown to reduce breech presentation ( Cardini F, Weixin H. Moxibustion for correction of breech presentation: a randomized controlled trial. JAMA. 1998;280:1580–1584.)
Malposition
A major management issue for patients in the second stage of labor is fetal malposition. Persistent fetal malposition particularly occiput transverse or occiput posterior position occurs in approximately 5% of fetuses and is associated with an increased risk of cesarean delivery and both maternal and neonatal complications. In such cases, rotation of the fetal head is useful. Historically, this was accomplished with forceps, particularly Kielland forceps but fewer Obstetricians are being trained to perform forceps rotations. I always found Kiellands to be a useful instrument but certainly not one for untrained hands, when used correctly and with gentleness they can achieve a controlled, atraumatic delivery.
Kielland’s forceps help to minimise the following risks that can occur with manual rotation:
• the baby rotating back to a malposition following manual rotation
• cord prolapse following disimpaction of the head
• complete disimpaction of the head out of the pelvis – too high for a safe forceps delivery.
(USA) In 1990 slightly more than 9% of livebirths resulted from either forceps delivery (5.11%) or vacuum extraction (3.9%), by 2014 only 3.21% of livebirths resulted from operative vaginal delivery and forceps accounted for less than 20% of these births (0.57% of all live births).
Hamilton BE, Martin JA, Osterman MJ, Curtin SC, Matthews TJ. Births: Final Data for 2014. Natl Vital Stat Rep. 2015 Dec;64(12):1-64.
Twin gestations
Supportive evidence exists for intended vaginal delivery in a twin gestation if the presenting twin is cephalic. A randomized trial found no improvement in neonatal outcomes in planned cesarean for a twin gestation. (Barrett JF, Hannah ME, Hutton EK, et al; Twin Birth Study Collaborative Group. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med. 2013;369:1295–1305.)
If the second twin is breech it is obvious that the obstetrician needs to be trained in vaginal breech delivery.

Practices that have become standard over decades should be carefully questioned and replaced by standardized, evidence-based practices. This may safely decrease the cesarean rate. Obstetrics is an art as well as a science. Unfortunately much of the art has been lost and abandoned practices should possibly be revisited.