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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 35  |  Issue : 2  |  Page : 123-127

Instrumental vaginal delivery in Usmanu Danfodiyo University Teaching Hospital, Sokoto: A ten-year review


1 Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University, Sokoto, Nigeria

Date of Web Publication17-Aug-2018

Correspondence Address:
Dr. J A Garba
Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJOG.TJOG_13_18

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  Abstract 

Background: Instrumental vaginal delivery is one of the key elements of essential obstetric care that mimics spontaneous vaginal delivery in order to expedite delivery with minimal maternal and neonatal morbidity. The objectives of the study were to determine the rate of instrumental deliveries, the common indications, and compare outcome and complications between forceps and vacuum deliveries.
Materials and Methods: This was a retrospective cross-sectional study on instrumental vaginal deliveries carried out in UDUTH over 10 years from January 2007 to December 2016. The list of cases was obtained, the case files were retrieved and relevant information was obtained. Data analysis was done using SPSS version 21. Level of significance was set at P < 0.05.
Results: The instrumental vaginal delivery rate was 2.06%. Vacuum deliveries accounted for 83.3% (n = 524) but forceps deliveries accounted for 16.7% (n = 105). The most common indication for both was delayed second stage of labor due to malposition. There was no statistical difference in the mean APGAR scores at 1st and 5th min between babies delivered by vacuum and those delivered by forceps. Majority had no complication and there was no statistical association between the type of procedure and maternal or fetal complications observed during the procedure (χ2 = 3.18, P = 0.2).
Conclusion: The rate of instrumental vaginal delivery is much lower than that reported in some centers in Nigeria and globally. Majority of the cases had no complication and there was no significant difference in complications observed between vacuum and forceps deliveries.

Keywords: Complications; forceps delivery; rate; vacuum delivery.


How to cite this article:
Garba J A, Burodo A T, Saidu A D, Sulaiman B, Umar A G, Ibrahim R, Nasir A M. Instrumental vaginal delivery in Usmanu Danfodiyo University Teaching Hospital, Sokoto: A ten-year review. Trop J Obstet Gynaecol 2018;35:123-7

How to cite this URL:
Garba J A, Burodo A T, Saidu A D, Sulaiman B, Umar A G, Ibrahim R, Nasir A M. Instrumental vaginal delivery in Usmanu Danfodiyo University Teaching Hospital, Sokoto: A ten-year review. Trop J Obstet Gynaecol [serial online] 2018 [cited 2018 Dec 18];35:123-7. Available from: http://www.tjogonline.com/text.asp?2018/35/2/123/239153


  Introduction Top


Instrumental vaginal delivery is one of the common obstetric interventions to aid delivery of the fetus. It is the use of the vacuum extractor or obstetric forceps in order to increase the forces along the pelvic curve and expedite delivery.[1] The aim of instrumental vaginal delivery is to mimic spontaneous vaginal birth, in order to expedite delivery with a minimal maternal or neonatal morbidity.[2]

The prevalence of instrumental vaginal delivery varies from one country to another and also from facility to facility. However, the prevalence had remained fairly stable over the past three decades. Operative vaginal delivery rates have been between 10% and 13% in the United Kingdom [2],[3] and 5% in United States.[4],[5] A survey in nine Asian countries by the World Health Organization (WHO) found prevalence of 3.2%.[6] In Nigeria, instrumental vaginal delivery rate was found to be 4.9% in Lagos, 0.69% in Bauchi, 3.6% in Zaria, and as high as 28.7% in Kano.[7],[8],[9],[10]

Forceps can be classified based on ability to rotate the fetal head in the birth canal into those that can exert traction only and those that can be used to exert both traction and rotation.[11] Obstetric forceps can also be classified based on depth into which it can be applied into pelvic cavity as high, midcavity, or low/outlet forceps. Low cavity and outlet forceps are the most frequently performed in current obstetrics practice.[12]

The different types of vacuum extractors can be based on the type of suction mechanism; which can be electrical or manual and the type of cup; which can either be rigid or soft (Malmstrom, OmniCup or Bird.[12] The Malmstrom vacuum extractor with soft or rigid cups is the most common and widely available in resource poor settings.

Common indications for instrumental vaginal deliveries are delay in the second stage of labor due to poor maternal effort, inadequate uterine activity, malposition, and fetal distress. It is also indicated in women with medical conditions like cardiac disease, respiratory, or intracranial pathology where bearing down may increase the preload.[13] Other indications include delivery of after coming head of a breech presentation, to deliver a “floating” fetal head during cesarean section using a Wrigley's forceps and delivery of an impacted fetal head using single forceps blade. However, the indications are not absolute and decision is made based on the individual case on ground.[12]

Instrumental vaginal delivery is one of the key elements of essential obstetric care. Advocating its use is likely to significantly reduce maternal and perinatal morbidity/mortality.[12] It would also likely reduce the rise in rate of cesarean section. Some studies have revealed underutilization of instrumental vaginal delivery in resource poor countries.[14],[15] There is need to assess its utilization and outcome of the procedures in order to ascertain its safety or otherwise. There is limited published data on instrumental vaginal delivery in the study area; hence the need to carry out the study. It is also important that obstetric care providers are aware of the maternal and neonatal complications associated with instrumental vaginal deliveries and suggest options to minimize such complications. The objectives of the study were to determine the rate of instrumental deliveries, the common indications, and compare outcome and complications between forceps and vacuum deliveries.


  Materials and Methods Top


This was a retrospective cross-sectional study on instrumental vaginal deliveries carried out in UDUTH over 10 years from January 2007 to December 2016. The list of cases of instrumental vaginal deliveries during the study period was obtained from medical record office and labor room register and the case files were retrieved. The total number of deliveries during the study period was also obtained. Relevant information on sociodemographic characteristics, booking status, parity, type of procedure, complications, indication, and fetal and maternal outcome was obtained.

The information obtained was analyzed using SPSS version 21. The instrumental delivery rate was obtained in percentage. Tables and figures were used to display the results. Independent sample t test was used to test for association between mean Apgar scores. Chi square was used to test for any significant association between the type of procedure and fetal or maternal outcome.


  Results Top


The total number of deliveries during the study period was 30,552. There were 629 instrumental vaginal deliveries and 518 files were retrieved, giving a retrieval rate of 82.4%. The mean age of the cases was 24 ± 5.6 and the range was 14–47 years. Majority of the cases (48.1%) were in the age group of 20–24 years and about 60% were primigravidae. Majority of the cases were Hausa and Muslims. The sociodemographic characteristics of the cases are shown in [Table 1].
Table 1: Sociodemographic characteristics of the cases (n=518)

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The overall instrumental vaginal delivery rate was 2.06%. Vacuum deliveries accounted for 83.3% (n = 524) whereas forceps delivery accounted for 16.7% (n = 105). The yearly incidence of instrumental vaginal delivery ranged from 1.36 to 3.01% during the 10 years study period. It was highest in 2007 and lowest in 2011 [Table 2].
Table 2: Instrumental vaginal delivery rates during the study period (n=629)

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The most common indication for both vacuum and forceps deliveries was delayed second stage of labor due to malposition, which was followed by eclampsia/severe preeclampsia. The distribution of the various indications for both vacuum and forceps is shown in [Table 3]. The mean gestational age at which instrumental vaginal deliveries were carried out in this study was 39 ± 1.5 weeks. The minimum gestational age was 34 weeks whereas the maximum was 41 weeks. However, majority were at gestational age of 40 weeks [Table 4].
Table 3: Indications for vacuum and forceps deliveries

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Table 4: Gestational ages for the instrumental vaginal deliveries

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The APGAR scores for vacuum and forceps deliveries are shown in [Figure 1] and [Figure 2]. The result showed that most of the babies (51.62%) had APGAR scores of 7 and above; which implied active and nonasphyxiated babies. Further analysis revealed that there was no statistical difference in the mean APGAR scores at 1 min between those babies delivered by vacuum (mean = 6.1 ± 2.3) and those delivered by forceps (mean = 5.3 ± 2.1) (t = 2.4, df = 516, P = 0.07). Similarly, there was no statistical difference in the mean APGAR scores at 5 min between those babies delivered by vacuum (mean = 7.4 ± 2.4) and those delivered by forceps (mean = 7.2 ± 2.2) (t = 0.86, df = 516, P = 0.38).
Figure 1: Apgar at 1st min for babies delivered by vacuum and forceps

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Figure 2: Apgar at 5th min for babies delivered by vacuum and forceps

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The maternal and fetal complications observed during vacuum and forceps deliveries are shown in [Table 5]. Both vacuum and forceps deliveries were associated with neonatal and maternal complications but majority had no complication. The percentage of those that had genital laceration following vacuum and forceps deliveries was 5.8% and 4.9%, respectively. There was no statistical significant association between the type of procedure and maternal complications observed during the procedure (χ2 = 3.18, P = 0.2).
Table 5: Complications of vacuum and forceps deliveries

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In terms of neonatal complications, 9.7% of the neonates that had vacuum delivery were asphyxiated whereas 7.0% of those that had forceps delivery were asphyxiated. Among those that had forceps delivery, 7.0% died during early neonatal period whereas 5.1% of those that had vacuum delivery died during the neonatal period. However, there was no statistical association between the type of procedure and neonatal complication encountered during the procedure (χ2 = 2.9, P = 0.56).


  Discussion Top


The prevalence of instrumental vaginal delivery found in this study is much lower than that reported in some developed countries in United Kingdom and United States.[2],[3],[4],[5] It is also lower than that reported in some states in Nigeria like Lagos, Zaria, and Kano.[7],[9],[10] This may be because of underutilization of the procedures by the doctors or underutilization of hospital services by the pregnant women in the study area. Underutilization of instrumental vaginal deliveries has been reported in some resource poor countries.[14],[15] Lower prevalence of 0.69% was reported in Bauchi, Nigeria.[8]

The result showed that vacuum delivery was carried out more than forceps delivery which may be due to lack of expertise to conduct forceps delivery by young residents and the fear that it is more associated with complications and fear of litigation. This finding contradicts previous study in northern part of Nigeria that revealed forceps delivery was carried out more than vacuum.[9]

Primigravidae are more likely to have delayed second stage that explains why instrumental vaginal deliveries were carried out more on them. This may also explain why it was more in the younger age group who were mostly primigravidae. Similar finding was also reported in some centers in northern Nigeria.[9] The predominant population in the study area is Hausa/Muslim that may explain why most of the cases of instrumental vaginal deliveries were Hausa and Muslims.

The finding that most of the instrumental vaginal deliveries had no complication indicates that the goal of performing the procedure has been achieved. It has been well documented that instrumental vaginal delivery is indicated both for fetal and maternal conditions with the aim of shortening the second stage of labor.[2] The indications for instrumental vaginal deliveries in this study do not differ from those documented in previous studies.[2],[7],[9],[10] Prolonged second stage was found to be the most common indication for both vacuum and forceps deliveries and this may be because it has been demonstrated that there is increased maternal morbidity after 3 h of the second stage of labor which is further increased after 4 h.[16]

Cases of abruptio placentae in the second stage of labor benefitted from instrumental vaginal delivery in order to shorten the second stage and avoid fetal compromise. Cases of fetal distress that occurred in second stage of labor also had instrumental vaginal delivery. Instrumental vaginal deliveries were carried out in cases with medical comorbidities in order to shorten second stage of labor. Some of these medical conditions were sickle cell disease and cardiac diseases in pregnancy. Women with some medical conditions may benefit from instrumental vaginal delivery to avoid bearing down that may not be conducive to their health.[13]

This study did not find any significant difference in complications observed in either vacuum or forceps. Similar finding was also reported in a 5-year follow-up of women enrolled in a randomized controlled trial where there was no significant difference in the long-term outcome between vacuum and forceps deliveries for both the mother and the child.[2] It has also been documented that vacuum is not significantly associated with low 5-min Apgar scores.[2] The two cases of macerated stillbirth have occurred even before the procedures.


  Conclusion Top


This study has identified that rate of instrumental vaginal delivery was 2.06% that is much lower than that reported in some centers in Nigeria and globally. The most common indication for both vacuum and forceps deliveries were delayed second stage of labor due to malposition. Majority of the cases had no complication and there was no statistical significant difference in complications observed between vacuum and forceps deliveries. The finding suggests that either of the two types of instrumental vaginal deliveries can be safely carried out when indicated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yvonne M, Cargill MD, Ottaw ON. Guideline for operative vaginal birth. J Obstet Gynaecol 2004;26:747-53.  Back to cited text no. 1
    
2.
Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. London: RCOG Press; 2001. Available from: http://www.rcog.org.uk/files/rcog-corp/uploaded- files/nscs_audit.pdf. [Last accessed on 2015 Jan 11].  Back to cited text no. 2
    
3.
Information and Statistics Division, Scottish Health Statistics. Births in Scotland report 2002. Births and babies (Births 1976–2008). Available from: http://www.isdscotland.org/isd/1612.html. [Last accessed on 2015 Feb 14].  Back to cited text no. 3
    
4.
Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. Natl Vital Stat Rep 2007;56:1-103.  Back to cited text no. 4
    
5.
Clark SL, Belfort MA, Hankins GD, Meyers JA, Houser FM. Variation in the rates of operative delivery in the United States. Am J Obstet Gynecol 2007;196:526.e1–526.e5.  Back to cited text no. 5
    
6.
Lumbiganon P, Laopaiboon M, Gulmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al. Method of delivery and pregnancy outcomes in Asia: The WHO global survey on maternal and perinatal health 2007-08. Lancet 2010;375:490-9.  Back to cited text no. 6
    
7.
Ogedengbe OK, Odeneye TO. Outcome of Instrumental Deliveries in Lagos Nigeria Implications for its use at the Second Tier Healthcare Level. Nig Med Pract 2004;45:106-10.  Back to cited text no. 7
    
8.
Aliyu LD, Kadas AS, Hauwa MA. Instrumental vaginal delivery in Bauchi, Northeast Nigeria. J West Afr Coll Surg 2011;1:18-27.  Back to cited text no. 8
    
9.
Adaji SE, Shittu SO, Sule ST. Operative vaginal deliveries in Zaria, Nigeria. Ann Afr Med 2009;8:95-9.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Yakasai IA, Abubakar IS, Abdullahi H. An audit of instrumental vaginal delivery in Aminu Kano Teaching Hospital, Kano. Trop J Obstet Gynaecol 2011;28.  Back to cited text no. 10
    
11.
Adaji SE, Ameh CA. Operative Vaginal Deliveries in Contemporary Obstetric Practice, From Preconception to Postpartum, Dr. Stavros Sifakis (Ed.), 2012. Available from: http://www.intechopen.com/books/from-preconception-to-postpartum/operative-vaginaldeliveries-in-contemporary-obstetric-practise. [Last accessed on 2015 Feb 10].  Back to cited text no. 11
    
12.
Ameh CA, Weeks AD. The role of instrumental vaginal delivery in low resource settings. Br J Obstet Gynaecol 2009;116(Suppl 1):22-5.  Back to cited text no. 12
    
13.
Arulkumaran S. Malpresentation, malposition, cephalopelvic disproportion and obstetric procedures; in Dewhurst's text book of obstetrics and gynaecology. 8th edition. Edited by DK Edmonds. Willy-Blackwell: UK; 2012. pp 311-25.  Back to cited text no. 13
    
14.
Kongnyuy EJ, Leigh B, Vandenbroek N. Effect of audit and feedback on the availability, utilisation and quality of emergency obstetric care in three districts in Malawi. Women Birth 2008;21:149-55.  Back to cited text no. 14
    
15.
Tsu VD, Coffe PS. New and underutilised technologies to reduce maternal mortality and morbidity: What progress have we made since Bellagio 2003? Br J Obstet Gynaec 2009;116:247-56.  Back to cited text no. 15
    
16.
Cheung YW, Hopkins LM, Caughey AB. How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal morbidity? Am J Obstet Gynecol 2004:191:933-8.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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