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Figures
- Figure 1:
Temporal trends in obstetric trauma stratified by parity and obstetric history (A), stratified by mode of delivery among nulliparous women (B), among parous women without a previous cesarean delivery (C), among women with a previous cesarean delivery (D), among term, singleton deliveries, Canada, 2004–2014. Using the Cochran-Armitage test for linear trend in proportions, p < 0.001 for overall obstetric trauma trend among nulliparous and parous women (with and without a previous cesarean delivery); p < 0.001 for obstetric trauma trend among operative vaginal delivery in all 3 groups; p < 0.0001, 0.03, and 0.01 for obstetric trauma trend among spontaneous vaginal delivery in nulliparous women, parous women without cesarean delivery, and women with a previous cesarean delivery, respectively; and p = 0.2, 0.07 and < 0.0001 for these trends in cesarean delivery among the same 3 groups, respectively. Note: CD = cesarean delivery, OVD = operative vaginal delivery, SVD = spontaneous vaginal delivery.
- Figure 2:
Temporal trends in severe birth trauma stratified by parity and obstetric history (A), stratified by mode of delivery among nulliparous women (B), among parous women without a previous cesarean delivery (C), among women with a previous cesarean delivery (D), among term, singleton deliveries, Canada, 2004–2014. Using the Cochran-Armitage test for linear trend in proportions, p = 0.0001 for the trend in severe birth trauma in operative vaginal delivery among nulliparous women. All other p values for severe birth trauma trend > 0.05. Note: CD = cesarean delivery, OVD = operative vaginal delivery, SVD = spontaneous vaginal delivery.
Tables
- Table 1:
Distribution of mode of delivery by maternal, obstetric and infant characteristics*
Maternal, obstetric or infant characteristic No. of spontaneous vaginal deliveries (%) No. of operative vaginal deliveries (%) Std. diff† operative vaginal delivery v. spontaneous vaginal delivery No. of cesarean deliveries (%) Std. diff† cesarean delivery v. spontaneous vaginal delivery Totals 1 234 877 (63.7) 207 675 (10.7) – 496 361 (25.6) – Nulliparous women 463 702 (37.6) 152 632 (73.5) – 223 438 (45.0) – Advanced maternal age (≥ 35 yr) 38 215 (8.2) 18 029 (11.8) 0.12 39 525 (17.7) 0.29 Hypertensive disorders 27 171 (5.9) 9785 (6.4) 0.02 22 852 (10.2) 0.16 Diabetes 16 097 (3.5) 6562 (4.3) 0.04 15 038 (6.7) 0.15 Induction of labour 118 773 (25.6) 44 658 (29.3) 0.08 73 761 (33.0) 0.16 Macrosomia (> 4000 g) 35 791 (7.7) 14 687 (9.6) 0.07 37 590 (16.8) 0.28 Parous women with no previous cesarean delivery 732 448 (59.3) 45 983 (22.1) – 56 185 (11.3) – Advanced maternal age (≥ 35 yr) 156 413 (21.4) 12 742 (27.7) 0.15 18 258 (32.5) 0.25 Hypertensive disorders 25 371 (3.5) 1955 (4.3) 0.04 3513 (6.3) 0.13 Diabetes 34 580 (4.7) 2783 (6.1) 0.06 5108 (9.1) 0.17 Induction of labour 173 213 (23.6) 13 081 (28.5) 0.11 10 908 (19.4) –0.10 Macrosomia (> 4000 g) 101 343 (13.8) 7247 (15.8) 0.06 10 318 (18.4) 0.13 Parous women with a previous cesarean delivery 38 727 (3.1) 9060 (4.4) – 216 738 (43.7) – Advanced maternal age (≥ 35 yr) 9611 (24.8) 2333 (25.8) 0.02 68 361 (31.5) 0.15 Hypertensive disorders 1111 (2.9) 232 (2.6) −0.02 8126 (3.8) 0.05 Diabetes 2021 (5.2) 441 (4.9) −0.01 16 933 (7.8) 0.11 Induction of labour 6595 (17.0) 1416 (15.6) −0.04 3692 (1.7) −0.54 Macrosomia (> 4000 g) 4699 (12.1) 1047 (11.6) −0.02 26 223 (12.1) 0.00 - Table 2:
Distribution of components of composite obstetric trauma outcome by mode of delivery*
Outcome All deliveries (%)
n = 1 938 913No. of operative vaginal deliveries (%)
n = 207 675No. of cesarean deliveries (%)
n = 496 361No. of spontaneous vaginal deliveries (%)
n = 1 234 877All obstetric trauma 85 842 (100) 33 095 (100) 8395 (100) 44 352 (100) Severe perineal lacerations (3rd and 4th degree) 60 970 (71.0) 28 550 (86.3) 39 (0.5) 32 381 (73.0) Injury to bladder or urethra 5774 (6.7) 341 (1.0) 3735 (44.5) 1698 (3.8) High vaginal laceration 5039 (5.8) 2015 (6.1) 205 (2.4) 2771 (6.2) Cervical laceration 4530 (5.3) 758 (2.3) 892 (10.6) 2857 (6.4) Other obstetric injury 3306 (3.9) 507 (1.5) 1105 (13.2) 1694 (3.8) Repair of uterine incision 2473 (2.9) 39 (0.1) 2296 (27.3) 138 (0.3) Delayed repair of episiotomy or repair of wound dehiscence after episiotomy or obstetrical laceration repair 2447 (2.9) 1056 (3.2) 47 (0.6) 1344 (3.0) Hematoma of the pelvis (perineum, vagina or vulva) 2180 (2.5) 487 (1.5) 262 (3.1) 1431 (3.2) Injury to the pelvic joints and ligaments 1186 (1.4) 154 (0.5) 447 (5.3) 585 (1.3) Laceration to the broad ligament of the uterus 492 (0.6) 9 (0.0) 439 (5.2) 44 (0.1) Repair of wound dehiscence after cesarean delivery 514 (0.6) 14 (0.0) 471 (5.6) 29 (0.1) ↵* The sum of individual trauma components may exceed the total because some deliveries had multiple trauma diagnoses.
- Table 3:
Distribution of components of composite severe birth trauma outcome by mode of delivery*
Outcome All deliveries (%)
n = 1 938 913No. of operative vaginal deliveries (%)
n = 207 675No. of cesarean deliveries (%)
n = 496 361No. of spontaneous vaginal deliveries (%)
n = 1 234 877All severe birth trauma 3366 (100) 1356 (100) 326 (100) 1684 (100) Severe peripheral nervous system injury (brachial plexus injury) 2352 (69.9) 880 (64.9) 99 (30.4) 1373 (81.5) Femur or humerus injury 443 (13.2) 139 (10.3) 74 (22.7) 230 (13.7) Subaponeurotic hemorrhage 244 (7.2) 191 (14.1) 37 (11.3) 16 (1.0) Intracranial hemorrhage or laceration 226 (6.7) 123 (9.1) 57 (17.5) 123 (7.3) Skull fracture 104 (3.1) 47 (3.5) 48 (14.7) 9 (0.5) Severe central nervous system injury (brain damage or spinal cord injury) 101 (3.0) 34 (2.5) 31 (9.5) 36 (2.1) Injury to the liver or spleen† < 5 (< 0.1) < 5 (< 0.4) < 5 (< 16.9) < 5 (< 0.3) - Table 4:
Change in obstetric trauma and severe birth trauma rates per 1% absolute increase in operative vaginal delivery rates and associated number of excess cases per year*
Outcome Nulliparous Parous No previous cesarean With a previous cesarean ARR (95% CI) No. of excess cases/yr† ARR (95% CI) No. of excess cases/yr† ARR (95% CI) No. of excess cases/yr† Obstetric trauma All OVD 1.06 (1.05–1.06) 708 1.10 (1.08–1.13) 360 1.11 (1.07–1.16) 158 Operative instrument Forceps 1.09 (1.08–1.10) 1061 1.26 (1.10–1.43) 937 1.11 (1.00–1.25) 158 Vacuum 1.06 (1.05–1.07) 708 1.05 (1.03–1.08) 180 1.16 (1.11–1.22) 230 Sequential 1.44 (1.35–1.55) 5189 1.19 (0.84–1.67) – 0.95 (0.83–1.09) – Pelvic station Outlet 1.07 (1.06–1.09) 825 1.22 (1.14–1.30) 793 1.17 (1.04–1.31) 245 Low 1.04 (1.03–1.05) 472 0.98 (0.93–1.03) – 1.02 (0.94–1.11) – Midpelvic 1.07 (1.07–1.08) 825 1.14 (1.12–1.17) 504 1.25 (1.20–1.30) 360 Severe birth trauma All OVD 1.05 (1.03–1.07) 18 0.98 (0.94–1.04) – 1.02 (0.85–1.22) – Operative instrument Forceps 1.01 (0.95–1.08) – 1.09 (0.68–1.76) – 0.86 (0.37–2.00) – Vacuum 0.97 (0.90–1.04) – 0.96 (0.89–1.04) – 1.25 (0.91–1.72) – Sequential 1.53 (1.03–2.27) 191 2.00 (0.58–6.86) – 0.47 (0.17–1.27) – Pelvic station Outlet 1.03 (0.96–1.10) – 0.91 (0.71–1.15) – 1.27 (0.58–2.80) – Low 1.06 (1.01–1.12) 22 1.18 (0.98–1.43) – 0.87 (0.49–1.55) – Midpelvic 1.04 (1.01–1.07) 14 0.94 (0.87–1.02) – 1.12 (0.82–1.53) – Note: ARR = adjusted rate ratio, CI = confidence interval, OVD = operative vaginal delivery.
↵* ARRs and 95% CIs expressing the change in obstetric trauma and severe birth trauma rates per 1% absolute increase in OVD rates and associated number of excess cases per year, term singleton deliveries, Canada, 2004–2014; includes data from Alberta, Manitoba, Ontario, and Saskatchewan. Crude and adjusted rate ratios were obtained from ecological random-intercept Poisson regression models. Adjusted for rates of older maternal age (≥ 35 years of age), hypertension, diabetes, labour induction, macrosomia (> 4000 g), and year of delivery.
↵† Number of excess cases of obstetric trauma and severe birth trauma in Canada annually, based on the number of births in Canada in 2015/16.13
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