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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 35  |  Issue : 2  |  Page : 133-136

Review of instrumental vaginal delivery at the Obafemi Awolowo University teaching hospitals complex


1 Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
2 Department of Obstetrics and Gynaecology, Obafemi Awolowo University/Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria

Date of Web Publication17-Aug-2018

Correspondence Address:
Dr. Oluwaseun Oludotun Sowemimo
Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJOG.TJOG_51_18

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  Abstract 

Background: Instrumental vaginal delivery (IVD) is one of the signal functions of the basic emergency obstetric and newborn care. Some recent reviews point towards a sustained fall in the performance of this lifesaving procedure. With increasing caesarean section rates, institutional reviews of the practice of IVD are important to improve and sustain this art which is on the path of extinction.
Objectives: To determine the IVD rate at the OAUTHC over a 5-year period from January 2013 to December 2017 and to review the maternal and newborn outcomes.
Methods: This was a retrospective review. Case records of parturients who had either forceps or vacuum delivery during the study period were retrieved and relevant information were extracted. Data analysis was done with IBM-SPSS version 20.
Results: There were 10,286 deliveries and 101 IVDs over the 5-year period giving an IVD rate of 0.98%, with 0.41% for forceps and 0.57% for vacuum delivery. Seventy-one case records were available for review. Mean maternal age was 27.21 ± 5.8 years and 31 (43.7%) of the parturients were primigravidae. Thirty-nine (54.9%) were booked and 66 (93%) of the procedures were performed as emergencies. Senior residents conducted most (94.4%) of the procedures and poor maternal efforts in the second stage of labor was the most common indication (43.8%). All resulted in vaginal delivery with the most common maternal complication being genital tract laceration, most notably first and second-degree perineal tears. Of the 66 livebirths, neonatal ward admission rate was 45.5%. There was an early neonatal death which followed a traumatic vacuum delivery.
Conclusion and Recommendations: The IVD rate at OAUTHC is low, with higher preference for vacuum delivery. Appropriate case selection is evident, and poor maternal effort in second stage of labor remained the leading indication. The neonatal admission rate is high. Training and retraining of resident doctors is necessary towards increasing the conduct and ensuring better outcome.

Keywords: Forceps delivery; instrumental vaginal delivery; maternal complications; neonatal outcomes; vacuum delivery.


How to cite this article:
Sowemimo OO, Abdur-Rahim ZF, Kolawole OO, Ayegbusi EO, Archibong MS, Igbodike EP, Fasubaa OB. Review of instrumental vaginal delivery at the Obafemi Awolowo University teaching hospitals complex. Trop J Obstet Gynaecol 2018;35:133-6

How to cite this URL:
Sowemimo OO, Abdur-Rahim ZF, Kolawole OO, Ayegbusi EO, Archibong MS, Igbodike EP, Fasubaa OB. Review of instrumental vaginal delivery at the Obafemi Awolowo University teaching hospitals complex. Trop J Obstet Gynaecol [serial online] 2018 [cited 2018 Dec 12];35:133-6. Available from: http://www.tjogonline.com/text.asp?2018/35/2/133/239166


  Introduction Top


Instrumental vaginal delivery is the delivery of a baby vaginally using an instrument for assistance.[1] The advent of obstetric forceps and use of ventouse devices have revolutionized obstetric practice. Despite the use of newer designs of ventouse cups which have greatly reduced the risk of injury to the baby, and forceps availability as against its rarity in the era of the Chamberlains, many authorities believe that these vital obstetric arts are moving towards extinction.[2],[3]

At a period when instrumental vaginal delivery has become one of the seven signal functions of basic emergency obstetric and newborn care (BEmONC) towards addressing the causes of maternal and newborn morbidity and mortality, it is imperative that institutional practices are reviewed.[4] The increasing rates of caesarean section globally, although majorly attributed to improvement in surgical techniques, antibiotic choices and better blood transfusion services, the highly litigation-prone field of obstetrics has a tremendous impact on this surge. A significant proportion of obstetricians now prefer caesarean section to instrumental delivery, thus making assisted vaginal delivery, especially forceps delivery, an art that is gradually being lost.[3],[5]

While approximately 12% of deliveries are by instrumental vaginal delivery in the United Kingdom and 4.5% in the USA, incidence ranging from 0.69% to 4.52% have been reported in Nigeria.[1],[6],[7],[8] A review conducted in our center about three decades earlier revealed an incidence of 1.6% for vacuum deliveries.[9]

Aim

This study aimed to determine the instrumental delivery rate and evaluating maternal and newborn outcome at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria.


  Materials and Methods Top


This was a retrospective study involving the review of case records of women with singleton pregnancies who had either vacuum or forceps delivery at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife over a 5-year period (1st January 2013 to 31st December 2017). Using the labor ward registers and ICD-10 coding for forceps and vacuum delivery, the case records numbers were obtained and permission was sought to retrieve and review the patients' records from the health records department of the hospital. Information pertaining to sociodemography, parity, indication for instrumental delivery, and newborn and maternal outcomes were retrieved on a purpose-designed proforma, and for neonates admitted into the neonatal ward, the clinical condition and outcome of care were checked up. The delivery statistics over the period was obtained from the Statistics unit of the health records department. The data were entered into a prepared spreadsheet and analyzed using the IBM-SPSS version 20.


  Results Top


Over the study period, there were 101 instrumental vaginal deliveries and 10,286 total deliveries, giving an instrumental delivery rate of 0.98% out of which 59 (0.57%) were vacuum delivery and 42 (0.41%) were forceps delivery. Out of the 101 cases, 71 case records were available for review, giving a retrieval rate of 70.3%.

The mean age of the women was 27.21 ± 5.8 years with a range of 16–46 years. Of the 71 reviewed cases, 31 parturients (43.7%) were primigravidae, whereas the rest had 1 or more parous experiences with only 2 (2.8%) being grandmultipara. Pertinent obstetric characteristics of parturients are shown in [Table 1].
Table 1: Pertinent obstetric characteristics of parturients (total=71)

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All the reviewed cases were successful. Fifty-nine (83.1%) were performed on fetuses ≥37 weeks whereas 22 (31.0%) occurred in post-dated pregnancies. Important procedural considerations are shown in [Table 2].
Table 2: Important procedural considerations (total=71)

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First and second-degree perineal tears occurred in eight (11.2%), third / fourth-degree in one (1.4%), and cervical laceration in 4 (5.6%). Other maternal complications are as depicted in [Table 3].
Table 3: Maternal complications (total=71)

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There were 66 (93%) live births and 5 (7.0%) still births in which fetal demise was diagnosed prior to the second stage of labor. Of the 66 livebirths, an early neonatal death occurred in a neonate approximately 2 hours after birth. Birth weights ranged from 2.00 to 4.28 kg with a mean of 3.0 ± 0.48 kg. Forty-eight (72.7%) of the livebirths had Apgar score ≥7 at 1 min while 58 (89%) had a score of ≥7 at 5 min of life. [Table 4] summarises the neonatal complications.
Table 4: Neonatal morbidity and mortality (total=66)

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  Discussion Top


Over the 5-year period reviewed, there were 10,286 deliveries and 101 instrumental vaginal deliveries with an incidence of 0.98%. The vacuum delivery rate of 0.57% is lower than the previously reported rate of 1.6% from our center approximately three decades earlier.[9] Our instrumental delivery rate of 0.98% is lower than the 4.52%, 4.4%, 3.6%, and 1.95% reported from Lagos, Enugu, Zaria, and Jos, respectively.[10],[11],[12],[13] It is, however higher, than 0.69% reported from Bauchi, Northern Nigeria.[14] There was a higher preference for vacuum over forceps delivery (58.4% versus 41.6%). This is in tandem with recent trends of preference for vacuum devices which are known to cause fewer maternal complications and are easier to learn and use when compared with forceps.[1],[3],[5]

The falling incidence of IVD may not be unconnected to the easily available option of caesarean section in tertiary centers. Unfortunately, as fewer instrumental deliveries are performed, this important obstetric art may be on its way out of practice as doctors in training have fewer cases to observe and perform. Contrary to known trends, primigravidae constitute less than half of the parturients with even fewer teenagers. These groups of women are prone to dysfunctional labor and are presumably candidates for assisted vaginal delivery. However, the typical parturient in this review is that of a booked multiparous young woman.

The most common indication for IVD in this review was poor maternal effort, accounting for 43.8%. This correlates with findings from previous studies.[7],[9] Fetal distress in the second stage of labor and prolonged second stage of labor are also noteworthy. All but one of the procedures were performed by resident doctors. A similar finding was reported in a review of instrumental delivery in Sokoto, northern Nigeria.[7] The often emergent need for the procedure and availability of resident doctors round-the-clock in labor room may be responsible for this finding. The 100% success rate points to the adequacy of preprocedure evaluation and careful patient selection. The most common maternal complications were genital tract laceration most commonly the first and second-degree perineal tears, and primary postpartum hemorrhage. These were also reported by Yakasai et al. in northern Nigeria.[15]

Thirty of the 66 live births (45.5%) were admitted in the neonatal unit for indications including birth asphyxia, preterm low birth weight, presumed sepsis, respiratory distress of the newborn, and birth injuries. All but one were discharged in satisfactory condition. The early neonatal mortality recorded occurred following vacuum delivery with subgaleal hemorrhage in a term neonate.


  Conclusion and Recommendation Top


Our institutional IVD rate is low and declining. There is a higher preference for the ventouse device. The neonatal admission rate is, however, significantly high with the initial indication for assisted delivery probably being a contributory factor. We recommend training and retraining of resident doctors in instrumental delivery to reduce the abysmally increasing caesarean section rates. There is a need to audit practices to improve outcomes, especially for the newborn. The health records management should be improved to increase record retrieval rate for more comprehensive reviews. Adequate documentation of procedure and outcomes is essential as this will afford quality audit of care in the near future. There is a need to have a second look at embracing IVD to reduce the presently high caesarean section rate. Caesarean section by itself is traumatic, costly, and could be associated with dangers to the fetus and/or the mother. IVD is surely an alternative option which is very safe in properly selected cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Baker PN. Operative intervention in Obstetrics. In: Baker PN, Kenny LC, editors. Obstetrics by Ten Teachers. 19th ed. London: Hodder Arnold; 2011. P. 224-40.  Back to cited text no. 1
    
2.
Johanson RB, Rice C, Doyle M, Arthur J, Anyanwu L, Ibrahim J, et al. A randomised prospective study comparing the new vacuum extractor policy with forceps delivery. Intern J Obstetr Gynaecol 1993;100:524-30.  Back to cited text no. 2
    
3.
Incerpi MH. Operative delivery. In: DeCherney AH, Nathan L, Laufer N, Roman AS, editors. Current Diagnosis and Treatment in Obstetrics and Gynecology. 11th ed. New York: McGraw-Hill; 2013. p. 334-48.  Back to cited text no. 3
    
4.
World Health Organization (WHO), United Nations Population Fund, UNICEF and Mailman School of Public Health. Averting Maternal Death and Disability. Monitoring emergency obstetric care: A handbook. Geneva: WHO; 2009. Available from: http://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/. [Last accessed on 2018 Apr 20].  Back to cited text no. 4
    
5.
Arulkumaran S. Malpresentation, Malposition, Cephalopelvic disproportion and Obstetric Procedures. In: Edmonds DK, editor. Dewhurst's textbook of Obstetrics and Gynaecology. 8th ed. Oxford: Willey Blackwell Publishing; 2012. p. 312-25.  Back to cited text no. 5
    
6.
National Vital Statistics Reports, Volume 57, Number 7. January 7, 2009. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf. [Last accessed on 2018 Apr 12].  Back to cited text no. 6
    
7.
Shehu CE, Omembelede JC. Instrumental Vaginal Delivery. Orient J Med 2016;28:22-7.  Back to cited text no. 7
    
8.
Anate M. Instrumental (operative) vaginal deliveries vacuum extraction compared with forceps delivery at Ilorin University Teaching Hospital, Nigeria. West Afr J Med 1991;10:127-36.  Back to cited text no. 8
    
9.
Ogunniyi SO, Sunusi YO. Instrumental vaginal delivery in Ile-Ife and Ilesha, Nigeria. Niger J Med 1988;7:105-8.  Back to cited text no. 9
    
10.
Adaji SE, Shittu SO, Sule ST. Operative Vaginal Deliveries in Zaria. Ann Afr Med 2009;8:95-9  Back to cited text no. 10
    
11.
Emuveyan EE, Agboghoroma OC. Instrumental vaginal deliveries in Lagos, Nigeria: A 7 year study (1989-1995). Niger Quart J Hosp Med 1997;7:195-8.  Back to cited text no. 11
    
12.
Chukudebelu WO. In: Agboola A, editor. Textbook of Obstetrics and Gynaecology for Medical students. 2nd ed. Ibadan: Heinemann Educational Books (Nig.) Plc; 2006. p. 41-53.  Back to cited text no. 12
    
13.
Ochejele S, Musa J, Eka PO, Attah DI, Ameh T, Daru PH, et al. Trends and operators of instrumental vaginal deliveries in Jos, Nigeria: A 7-year study (1997–2003). Trop J Obstet Gynaecol 2018;35:79-83.  Back to cited text no. 13
    
14.
Aliyu LD, Kadas AS, Hauwa MA. Instrumental vaginal delivery in Bauchi, Northeast Nigeria. J West Afr Coll Surg 2011;1:18.  Back to cited text no. 14
    
15.
Yakasai IA, Abubakar IS, Yunus EM. Vacuum Delivery in a Tertiary Institution, in Northern Nigeria: A 5-Year Review. Open J Obstet Gynaecol 2015;5:213-8.  Back to cited text no. 15
    



 
 
    Tables

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



 

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