Abstract
Introduction and hypothesis
Levator avulsion occurs in 10−35% of women after a first vaginal delivery, with forceps being the main risk factor. Three mechanisms have been proposed to account for the high risk of trauma: the additional space requirement, increased speed of distension, and/ or greater force. This study examines the additional space requirements associated with forceps to determine any associated increase in avulsion risk.
Methods
This was an in vitro simulation study of spatial requirements for delivery of a fetal head by forceps, with mathematical modelling of spatial requirements using data from a local observational study. A balloon device was used to model head circumferences through the range of expected measurements at term, with measurements taken after application of three different types of forceps. Each measurement was performed in triplicate.
Results
On average, forceps increased the circumference of the fetal head by 1.01 cm for Wrigley’s, 1.04 cm for Kielland’s, and 1.64 cm for Neville-Barnes forceps, resulting in an estimated increase in the diameter of the fetal head by 0.32 cm, 0.33 cm, and 0.52 cm, respectively. This increase was linear throughout the tested range. In 534 singleton pregnancies at term, we determined an odds ratio (OR) of 1.11 per centimeter head circumference for avulsion. Hence, the additional space requirement due to forceps explains ORs of 1.11, 1.12, and 1.19 for avulsion, depending on forceps type.
Conclusions
The effect of forceps on avulsion risk is not fully explained by the increase in space requirement alone. Other factors, such as shortened time to maximum distension and/or increased peak force applied may contribute to the excess risk.
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References
Dietz HP. Pelvic floor trauma in childbirth. Aust N Z J Obstet Gynaecol. 2013;53(3):220–30.
NSW Mothers and Babies 2015 [Internet]. 2016 [cited 2017 Sep 14]. Available from: http://www.health.nsw.gov.au/hsnsw/Publications/mothers-and-babies-2015.pdf
Ashton-Miller JA, DeLancey JOL. On the biomechanics of vaginal birth and common sequelae. Annu Rev Biomed Eng. 2009;11:163–76.
Sultan AH, Kamm MA, Hudson CN. Pudendal nerve damage during labour: prospective study before and after childbirth. BJOG An Int J Obstet Gynaecol. 1994;101:22–8.
Dietz HP. Pelvic floor ultrasound: a review. Am J Obstet Gynecol Elsevier Inc. 2010;202:321–34.
Friedman T, Eslick GD, Dietz HP. Risk factors for prolapse recurrence: systematic review and meta-analysis. Int Urogynecol J. 2018;29:13–21.
Caudwell-Hall J, Kamisan Atan I, Martin A, Guzman Rojas R, Langer S, Shek K, et al. Intrapartum predictors of maternal levator ani injury. Acta Obstet Gynecol Scand. 2017;96:426–31.
Skinner EM, Dietz HP. Psychological and somatic sequelae of traumatic vaginal delivery: a literature review. Aust N Z J Obstet Gynaecol. 2015;55:309–14.
Lurie S, Glezerman M, Baider C, Sadan O. Decision-to-delivery interval for instrumental vaginal deliveries: vacuum extraction versus forceps. Arch Gynecol Obstet. 2006;274:34–6.
Caudwell-Hall J, Kamisan Atan I, Brown C, Guzman Rojas R, Langer S, Shek KL, et al. Can pelvic floor trauma be predicted antenatally? Acta Obstet Gynecol Scand. 2018;97:751–7.
Dietz HP, Bernardo MJ, Kirby A, Shek KL. Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J Pelvic Floor Dysfunct. 2011;22:699–704.
Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ. Forceps delivery is associated with increased risk of pelvic organ prolapse and muscle trauma: a cross-sectional study 16-24 years after first delivery. Ultrasound Obstet Gynecol. 2015;46:487–95.
Cassadó Garriga J, Pessarrodona Isern A, Espuña Pons M, Duran Retamal M, Felgueroso Fabrega A, Rodriguez Carballeira M, et al. Four-dimensional sonographic evaluation of avulsion of the levator ani according to delivery mode. Ultrasound Obstet Gynecol. 2011;38:701–6.
Nash Z, Nathan B, Mascarenhas L. Kielland’s forceps. From controversy to consensus? Acta Obstet Gynecol Scand. 2015;94:8–12.
Dildy GA, Belfort MA, Clark SL. Obstetric forceps: a species on the brink of extinction. Obstet Gynecol. 2016;128:436–9.
Rather H, Muglu J, Veluthar L, Sivanesan K. The art of performing a safe forceps delivery: a skill to revitalise. Eur J Obstet Gynecol Reprod Biol Elsevier Ireland Ltd. 2016;199:49–54.
Dietz HP. Obstetric forceps: a species on the brink of extinction simulation training for forceps-assisted vaginal delivery and rates of maternal perineal trauma copyright a by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer H. 2016;128(6):1447–8.
Dietz HP, Shek KL, Callaghan S. Letter to the editor re: perinatal and maternal outcomes after training residents in forceps before vacuum instrumental birth. Obstet Gynecol. 2017;130(4):910.
Dietz HP, Wilson PD, Milsom I. Maternal birth trauma: why should it matter to urogynaecologists? Curr Opin Obstet Gynecol. 2016;28:441–8.
Friedman T, Eslick G, Dietz H. Instrumental delivery and the risk of obstetrical anal sphincter injury (OASI): a meta-analysis. Int Urogynecol J. 2016;27(S1):S30–1.
Friedman T, Eslick G, Dietz H. Instrumental delivery and the risk of avulsion: a meta-analysis. Int Urogynecol J. 2017;28(S1):S26–7.
Valsky DV, Lipschuetz M, Bord A, Eldar I, Messing B, Hochner-Celnikier D, et al. Fetal head circumference and length of second stage of labor are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women. Am J Obstet Gynecol Mosby, Inc. 2009;201:91 e1-91.e7.
Requejo JH, Belizán JM. Odon device: a promising tool to facilitate vaginal delivery and increase access to emergency care. Reprod Health. 2013;10(1):2008–9.
Perone N. The electronically-controlled axis-traction handle: preliminary report. J Obstet Gynaecol Res. 2010;36(5):1080–6.
Skinner S, Davies-Tuck M, Wallace E, Hodges R. Perinatal and maternal outcomes after training residents in forceps before vacuum instrumental birth. Obstet Gynecol. 2017;130:151–8.
Dupuis O, Decullier E, Clerc J, Moreau R, Pham MT, Bin-Dorel S, et al. Does forceps training on a birth simulator allow obstetricians to improve forceps blade placement? Eur J Obstet Gynecol Reprod Biol. 2011;159(2):305–9.
Shek KL, Green K, Hall J, Guzman-Rojas R, Dietz HP. Perineal and vaginal tears are clinical markers for occult levator ani trauma: a retrospective observational study. Ultrasound Obstet Gynecol. 2016;47:224–7.
Hoyte L, Damaser MS, Warfield SK, Chukkapalli G, Majumdar A, Choi DJ, et al. Quantity and distribution of levator ani stretch during simulated vaginal childbirth. Am J Obstet Gynecol. 2008;199(2).
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Professor Hans Peter Dietz has received unrestricted educational grants from GE Medical. The other authors have no potential conflict of interest to declare.
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Caudwell-Hall, J., Weishaupt, J. & Dietz, H.P. Contributing factors in forceps associated pelvic floor trauma. Int Urogynecol J 31, 167–171 (2020). https://doi.org/10.1007/s00192-019-03869-1
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DOI: https://doi.org/10.1007/s00192-019-03869-1