Comparison of outcomes – Forceps delivery v Caesarean Section
A study conducted in China has compared outcomes of forceps delivery with outcomes for caesarean section during the second stage of labour. The study of 7046 women found:
‘women who had a need for intervention with a station of + 2 or below, forceps were associated with a lower frequency of maternal infection but a higher rate of postpartum hemorrhage. Deliveries performed for nonreassuring status were accomplished faster by forceps and were associated with a lower frequency of the composite of perinatal mortality and HIE.’
The study can be found here.
Maternity eHandbook resource - management of breech and external cephalic version (ECV), and birth after caesarean.
Safer Care Victoria have released 2 new maternity ehandbooks in addition to the 5 they currently have. The new resources on management of breech and external cephalic version (ECV) and birth after caesarean complement the current resources that cover topics including decreased fetal movement, induction of labour & preterm labour. The handbooks provide clinical guidance for maternity clinicians caring for women during pregnancy, birth and the postpartum period. They provide an overview of the current evidence & information available on the topic, linking to further useful resources and providing key decision making and documentation points.
View all the handbooks here.
Study – ‘Is It the Time of Day/Week or Staffing Experience that Impacts Labor Floor Outcomes?’
A study by Reif et al. (BJOG, 2017) assessed whether time of birth, unit volume, and staff seniority affected neonatal outcomes among infants born ≥34w0d weeks. The study included 87,065 neonates and found:
5 years of cerebral palsy claims
In this lecture Dr Michael Margo reviews cerebral palsy claims from the UK over a 5 year period. He identifies problems with how serious incident investigations are conducted and considers key learnings. Recommendations are provided on how to conduct better investigations including:
Study – Increase in trauma to mums and babies from forceps deliveries
A study conducted in Canada of 2 million deliveries from 2004 – 2015 found an increase in injuries to women. The biggest increase in trauma involved forceps deliveries with a rate of 19.4 per cent in first-time mothers in 2004 that increased to 26.5 per cent in 2014. Not only that but rates of trauma to babies also increased among first-time mothers, from 4.5 to 6.8 per 1,0000 deliveries. This article suggests that skills and training in forceps use is declining resulting in the increased trauma.
I attended the first British Intrapartum Care Society meeting yesterday. It was a great success and congratulations to all the organisers.
Full dilation CS (FDCS) is a subject very close to my heart. The talk on this left us with more questions than answers and I feel that these need to be addressed.
One of the hardest tasks performed by an obstetrician is to have to tell parents that there was nothing wrong with their baby, but they just couldn’t get the baby out safely even at a CS after a long labour.
The idea of Fetal Pillow was conceived after such an incident many years back. Fetal Pillow has now gained mainstream status in UK and Australia (more than 40%) of all hospitals using it and the numbers are growing. It was cleared by FDA last year after all the available clinical data was presented to them along with stringent mechanical safety testing.
Q. Should we be reducing the second stage CS and not doing “any”?
A. A laudable aim and no doubt should be attempted and already being tried by many others. Using rotational forceps might help but we will always have full dilation CS.
Q. Use of forceps is much higher north of Birmingham. Does that mean there are no FDCS in that area?
A. In fact there are more users of FP north of Birmingham than south of it despite significantly higher use of rotational forceps in some of the hospitals.
Q. Can we push from below with the palm rather than fingers and also rotate the head at the same time?
A. No. For those of us who have had to do this will know that it is impossible to push using palm due to lack of space and awkward direction of push that is required. To be able to rotate the fetal head along with this is an impossible task.
Q. Can we teach rotational forceps in a 3 hr session every six months as suggested by the speaker?
A. No. Firstly there are not enough teachers to go around and the risks involved are high so this is unlikely to ever happen.
Q. Can Fetal Pillow elevate a 3.5kg baby along with IU pressures of second stage labour?
A. Yes. This is a question that used to be asked 7yrs back so it is a bit of a surprise that after almost 15,000 FP uses and lots and lots of clinical data that this should even come up again. To elaborate on this, intra uterine pressures in second stage of labour along with maternal effort are around 140mmHg. For the FDA we carried out mechanical test on FP and subjected it to pressures of 3000mmHg (more than 20 times the IUPs) and could inflate the device easily and elevate a dummy fetal head successfully using a 60cc syringe.
Q. Is reverse breech a better way to deliver a deeply impacted head?
A. No. The best way to manage this problem is to PREVENT the difficulty arising from a deeply impacted head by using FP. Reverse breech is an extremely difficult procedure to perform and the rarity of this condition makes it difficult if not impossible to teach to the trainees and in any case most senior haven’t done it either.
Dr R Varma
Consultant Obstetrician & Gynaecologist
About the author
Dr Varma is a consultant Obstetrician & Gynaecologist with 35 years’ experience in the field of O&G. He is the inventor of fetal pillow and a part time Medical Director of Safe Obstetric Systems. He is still in active clinical practice in the field of Urogynaecology.
Reduced mortality rates in UK for 2013 – 2016 - 4th MBRRACE-UK Perinatal Mortality Surveillance Report
The 4th MBRRACE-UK Perinatal Mortality Surveillance report for births in 2016 has been released. The report highlights a reduction in mortality rates from 2013 to 2016 with 300 fewer baby deaths, 200 fewer still births and 100 fewer neonatal deaths. improvements in survival rates for twins was particularly significant. The report did highlight wide regional variation in neonatal mortality rates in England. Full report is available here.
Balance of long-term benefits and risks of caesarean delivery explained
The National Institute of Health research has published details of research into the benefits and risks of caesarean section. The findings suggest caesarean section birth reduced urinary incontinence and pelvic organ prolapse, but adversely impacted on women’s future fertility, pregnancy complications and long-term child health, including asthma and obesity. UK NICE guidelines recommend that healthcare professionals should discuss the risks and benefits of both caesarean and vaginal birth with women. This study can provided a overview of some of those risks and benefits. Full details available here.
How the cervix thins and dilates during labour – Video
This video from a childbirth educator uses a balloon and ping pong ball to help demonstrate how the cervix thins and dilates during labour.
Use of ‘Count the Kicks’ app helping to reduce still births
A mother from the US has said the app Count the Kicks combined with a little vigilance saved her daughters life.
She had been using the app to monitor her baby’s movements so when they were reduced she realised something was wrong. Upon arrival at hospital doctors discovered the umbilical cord was wrapped around the baby 3 times limiting her movement. The baby was safely delivered via an emergency caesarean section.
Since beginning a campaign in the US the founder of Count the Kicks says there has been a 26% decrease in still births. Read the full story here
PROMPT Vaginal Breech Training
PROMPT Maternity have released this video on how to manage a vaginal breech birth. The short video guides you through the manoeuvres that can be used to assist in the birth. It includes advice for when the head is both descended and when it isn’t descended enough.
Randomised study suggests increased resident/junior supervision does not significantly reduce the rate of medical errors
A randomised trial conducted in the US has investigated the impact that 2 different levels of supervision has on a resident/junior doctor. Individuals received either direct supervision with joined rounds for previously admitted patients or standard supervision with support available but not attending the round.
Findings show increased supervision did not significantly reduce the rate of medical errors but did result in interns speaking less and residents reporting a decreased level of autonomy.
Full study available here:
Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education. A Randomized Clinical Trial
Crazy Socks for Docs day
Today (1st June) is crazy socks for docs day. This campaign is aimed at raising awareness of mental health issues experienced by doctors. Statistics from Australia suggest:
Finding the words – Talking about baby loss
Everyday in the UK 15 babies die before, during or shortly after birth. Sands has launched a campaign to break the silence around stillbirth and neonatal death by encouraging conversations with someone who has lost a baby. The website provides advice about how to start the conversation.