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Jan 14, 2023 254 likes •353 views

6/14/2019 Optimizing the Use of Operative Disclosures Vaginal Delivery in 2019 UCSF AIM Conference Consultant, Bloomlife Technology Deirdre Lyell, MD Professor, Maternal-Fetal Medicine Stanford Investor, ZenFlow Medical Director,

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Optimizing the Use of Operative Vaginal Delivery in 2019

UCSF AIM Conference

Deirdre Lyell, MD Professor, Maternal-Fetal Medicine Stanford Medical Director, Labor and Delivery Associate Division Director

Disclosures

  • Consultant, Bloomlife Technology
  • Investor, ZenFlow

Of all vaginal deliveries in U.S., what percent were operative in 2007?

  • A. 16.4%

B. 12.8% C. 9.1% D. 6.6%

1 6 . 4 % 1 2 . 8 % 9 . 1 % 6 . 6 %

12% 21% 35% 33%

Of all vaginal deliveries in U.S., what percent were operative in 2017?

  • A. 18.2%

B. 9.8% C. 3.1% D. 1.6%

1 8 . 2 % 9 . 8 % 3 . 1 % 1 . 6 %

7% 7% 43% 43%

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Objectives

  • Examine the rate of and reasons for cesarean

deliveries in the U.S.

  • Explore patterns of use of operative vaginal

delivery throughout the U.S. and over time

  • Explore indications and outcomes of operative

vaginal delivery

Perinatal/maternal outcomes not improved

Accreta: 1/2,510 Accreta: 1/333-1/500

Caughey AB, et al. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210:17-93

Primary CD VBAC Repeat CD

Cesarean rates by state, 2010

Caughey AB, et al. Safe prevention of the primary cesarean

  • delivery. Am J Obstet Gynecol 2014;210:17-93
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Hospital Variation in Cesarean Rate

  • 2009 data, 593 U.S. hospitals
  • Nationwide Inpatient Sample
  • Cesarean rates: 7.1% to 69.9%
  • Low-risk women: 2.4% to 36.5%
  • Speculate: variation in practice patterns drives

difference

Kozhimannil et al, Health Affairs, March 2013

Healthy People 2020 goals

  • 10% reduction in incidence of:
  • Primary cesareans: 26.5% to 23.9%
  • Repeat cesareans: 90.8% to 81.7%
  • Reductions are from 2007 cesarean rates

https://www.healthypeople.gov/2020/topics-

  • bjectives/topic/maternal-infant-and-child-health/objectives

Obstetric Care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery. Obstetrics &

  • Gynecology. 123(3):693-711, March 2014. . (Data from Barber EL, Lundsberg LS, Belanger K, Pettker CM,

Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011;118:29-38.)

Indications for primary cesarean

  • Labor arrest: 34%
  • Abnormal/indeterminate

FHT: 23%

  • Malpresentation: 17%
  • Multiple gestation: 7%
  • Suspected macrosomia:

4%

  • Maternal-fetal: 5%
  • Preeclampsia: 3%
  • Maternal request: 3%

Incidence operative vaginal delivery (OVD)

  • Decreasing:
  • 2007: 6.6% of vaginal deliveries
  • 2013: 4.9%
  • Merriam AA et al. Trends in operative vaginal delivery,

2005-2013. BJOG 2017;124(9):1365

  • 2017: 3.1%
  • Forceps 0.5%
  • Vacuum 2.6%
  • Martin et al., Births 2017, Natl Vital Stat Rep

2018;67(8):1

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Change over time, forceps 2005-2013

Merriam AA et al. Trends in operative vaginal delivery, 2005-2013. BJOG 2017;124(9):1365

2017: forceps 0.5%

Martin et al., Births 2017, Natl Vital Stat Rep 2018;67(8):1

Change over time, vacuum 2005-2013

Merriam AA et al. Trends in operative vaginal delivery, 2005-2013. BJOG 2017;124(9):1365

2017: vacuum 2.6%

Martin et al., Births 2017, Natl Vital Stat Rep 2018;67(8):1

Regional variation

  • Does this matter?
  • Fundamental principle of quality control and

assessment: unnecessary/unexplained variation in a process or product generally demonstrates poor quality

Clark et al. Variation in the rates of operative delivery in the United States. Am J Obstet Gynecol. 2007;196(6):526 e1

Forceps: use by region 2007-2013

Merriam AA et al. Trends in operative vaginal delivery, 2005-2013. BJOG 2017;124(9):1365

Midwest: highest forceps rates NE and West: lowest rates

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Vacuum: use by region 2007-2013

Merriam AA et al. Trends in operative vaginal delivery, 2005-2013. BJOG 2017;124(9):1365

Midwest: highest vacuum rates; South: lowest

Tremendous variability within regions

Clark et al. Variation in the rates of operative delivery in the United States. Am J Obstet Gynecol. 2007;196(6):526 e1

If you practice obstetrics: in the last month, have you performed, participated in, or supervised an operative vaginal delivery?

  • A. Yes
  • B. No

Y e s N

  • 43%

57%

If you practice obstetrics: in the last year, have you performed, participated in, or supervised an operative vaginal delivery?

  • A. Yes
  • B. No

Y e s N

  • 9%

91%

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Forceps in California, 2008-2012

  • 1,557,039 vaginal births, 276 hospitals
  • Forceps: 0.3% of vaginal births
  • 21% (59 hospitals): no forceps
  • 80% hospitals: <5/year
  • Largest volume hospital (a teaching hospital):

almost 14% of state volume

  • 16 highest volume hospitals: 5.8% of all

hospitals, 50% of all forceps deliveries

  • Blumenfeld Y et al., unpublished data

Risks OVD vs. unplanned cesarean

  • Published incidence of risk varies widely
  • Dependent on indication, operator experience,

station, head position, instrument

  • OVD from mid-pelvic station (0 to +1), OT or OP

positions, vs. low (>+2) or outlet (scalp visible) OVD:

  • higher failure (increased cesarean)
  • higher complications (increased neonatal injury)
  • requires greater skill

OVD and birth injury

  • Forceps: 1.1%
  • Vacuum: 0.8%
  • Two data sets: 1989-93, 1995-98

Demissie K, et al. BMJ, 2004 Jul 3;329(7456):24-9

  • No significant change in birth injury over time
  • 2005 forceps: 2.0/1000. 2005 vacuum: 2.0/1000
  • 2013 forceps: 3.6/1000. 2013 vacuum: 2.9/1000
  • Limitations of a large dataset?

Merriam AA et al. Trends in operative vaginal delivery, 2005-2013. BJOG 2017;124(9):1365

Risks OVD vs. unplanned cesarean

  • Intracerebral hemorrhage (ICH): vacuum vs.:
  • Forceps: OR 1.2 (95% CI 0.7-2.2)
  • Cesarean during labor: OR 0.9 (95% CI 0.6-1.4)
  • Spontaneous delivery: lowest rate of IVH
  • Abnormal labor is likely the risk factor

Effects of Mode of Delivery in Nulliparous Women on Neonatal Intracranial

  • Hemorrhage. Towner D, Gilbert WM. Et al. N Engl J Med, 341 (1999), pp. 1709-1714
  • Seizure, IVH, subdural hemorrhage: forceps vs.:
  • Vacuum: OR 0.60 (95% CI 0.40-0.90)
  • Cesarean: OR 0.68 (95% CI 0.48-0.97)
  • FAVD associated with less adverse neonatal neurologic outcome
  • 1995-2003 dataset, NY

Werner EF et al. Obstet Gynecol, 118 (2011), pp. 1239-1246

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Forceps:

  • greater vaginal

birth success Vacuum:

  • less vaginal birth

success

  • cephalohematoma

Modified by

  • perator skill

Vacuum:

  • fewer perineal

tears Forceps:

  • more 3rd/4th degree

tears

  • vaginal trauma
  • birth injuries, seizures

Modified by

  • perator skill

“Operative vaginal delivery in the second stage of labor by experienced and well-trained physicians should be considered a safe, acceptable alternative to cesarean delivery. Training in, and

  • ngoing maintenance of, practical skills related to
  • perative vaginal delivery should be encouraged.”

Caughey AB, et al. Safe prevention of the primary cesarean

  • delivery. Am J Obstet Gynecol 2014;210:17-9

Indications Operative Vaginal Delivery

  • Prolonged second stage
  • Suspicion of immediate or potential fetal

compromise

  • Shortening the second stage for maternal benefit

ACOG Practice Bulletin No. 154 Summary: Operative Vaginal Delivery. Committee on Practice Bulletins—Obstetrics Obstet Gynecol. 2015;126(5):1118

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Prerequisites for Operative Vaginal Delivery

  • Complete dilation
  • Ruptured membranes
  • Engaged fetal head
  • Known head position
  • Estimated fetal weight performed
  • Adequate anesthesia
  • Maternal bladder emptied
  • Informed consent
  • Willingness to abandon procedure; back up plan in place

ACOG Practice Bulletin No. 154 Summary: Operative Vaginal Delivery. Committee

  • n Practice Bulletins—Obstetrics Obstet Gynecol. 2015;126(5):1118

Contraindications

  • Unengaged fetal head
  • Unknown position of the fetal head
  • Suspected bone mineralization disorder (e.g.
  • steogenesis imperfecta)
  • Bleeding disorder (e.g. alloimmune thrombocytopenia,

hemophilia or von Willebrand disease)

  • Lack of provider experience
  • Inability to perform emergency cesarean delivery

Cautions against

  • Routine episiotomy:
  • Midline: increased risk of rectal/anal sphincter injury
  • Mediolateral: poor healing and prolonged discomfort
  • Sequential use of forceps/vacuum
  • OVD if provider feels chance of success is low
  • Ongoing attempt if no appropriate descent
  • High forceps
  • Vacuum < 34 weeks
  • Vacuum “pop-offs”

Other care

  • Alert neonatal care providers: observation for potential

complications from OVD

  • Document station and position at time of

forceps/vacuum application (ACOG performance measure)

  • Document time of vacuum application, duration, pulls,

pop offs

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Optimizing the Use of Operative Vaginal Delivery in 2019

UCSF AIM Conference

Deirdre Lyell, MD Professor, Maternal-Fetal Medicine Stanford Medical Director, Labor and Delivery Associate Division Director