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- Page navigation anchor for A call for transparency and action regarding the safety of operative vaginal delivery in CanadaA call for transparency and action regarding the safety of operative vaginal delivery in Canada
We are pleased Walker and colleagues’(1) echo our sentiment regarding the need for a balanced perspective on delivery options. We welcome the opportunity to clarify our methods, to reiterate that our conclusions do not suggest that any mode of delivery is superior to another and to underscore that dismissing the high rates of injuries associated with operative vaginal delivery (OVD) is inconsistent with a balanced perspective and signals a disregard for pregnant peoples’ autonomy in making evidence-informed decisions regarding childbirth.
The quality of our data was questioned due to “small-scale, non-contemporaneous, province-specific” validation studies. However, we cited a 2016 national re-abstraction study that evaluated the accuracy of maternal trauma and found 97% agreement (95% CI 95–99) with medical charts in hospitals across Canada.(2) Further, the aggregation of 3rd/4th-degree perineal tears is the established definition of obstetric anal sphincter injury (OASI). There is no evidence that 3a vs 3c/4th degree tears predict qualitatively different long-term outcomes. While the paper cited by Walker et al. provides no insight into long-term outcomes, the NICHD Pelvic Floor Disorders Network(3) showed that anal incontinence rates at 24 weeks following 3a and 4th degree tears were 25% (95% CI 16-36) and 35% (95% CI 16-57), respectively.
The insistence that outcomes such as postpartum hemorrhage should have been included to capture “true maternal morbidit...
Show MoreCompeting Interests: None declared.References
- 1. Walker M, Tannenbaum E, Cohen N, Harris K, Hobson S. RE: A balanced perspective on intervention at full dilation. CMAJ 2022.
- 2. Canadian Institute of Health Information. Data quality study of the 2015–2016 Discharge Abstract Database: a focus on hospital harm. Ottawa: Canadian Institute of Health Information (CIHI); 2016. https://secure.cihi.ca/free_products/DAD_15_16_Reab_Repo
- 3. Richter HE, Nager CW, Burgio KL, et al. Incidence and predictors of anal incontinence after obstetric anal sphincter injury in primiparous women. Female Pelvic Med Reconstr Surg 2015;21:182-9.
- 4. Levy KS, Smith MK, Lacroix M, Yudin MH. Patient satisfaction with informed consent for cesarean and operative vaginal delivery. J Obstet Gynaecol Can 2022;44:785-90.
- 5. Sheinis M, Zhu J, Hobson S, Shah R, Shapiro J, Shirreff L. Documentation of consent practices for assisted vaginal births (AVB) at two tertiary care hospitals: a retrospective review of physician documentation. J Obstet Gynaecol Can 2022;44:627-8.
- Page navigation anchor for RE: A balanced perspective on intervention at full dilationRE: A balanced perspective on intervention at full dilation
The recently published article by Muraca et al (1) importantly highlights some key aspects of discussion and counselling around assisted vaginal birth (AVB). However, we have concerns regarding their methodology and conclusions, which lack clinical insight into the reality and complexities of intrapartum care.
Validation of their dataset includes only small-scale, non-contemporaneous, province-specific studies. The individual components included within the composite maternal trauma outcome are missing published objective indicators of maternal trauma, including postpartum hemorrhage, requirement for blood transfusion and intensive care admission (2), which reflect true maternal morbidity. The conclusions drawn by the authors stem from their findings of increased rates of third degree perineal lacerations. However, we reject the notion that the most common type of laceration, a 3a tear that involves disruption of the superficial fibres of the external anal sphincter should be aggregated along with the less common, but potentially-disabling, disruption of both the external and internal anal sphincters (3c tear), or the entire anal sphincter complex (fourth degree tear), with significantly different short- and long-term outcomes (3). Defining terms and using appropriate composite grouping are critically important when using large population-based retrospective methods to evaluate specialized and nuanced clinical scenarios.
The specific clinical situations opt...
Show MoreCompeting Interests: None declared.References
- 1. Muraca GM, Boutin A, Razaz N, Lisonkova S, John S, Ting JY, et al. Maternal and neonatal trauma following operative vaginal delivery. CMAJ. 2022;194(1):E1-E12.
- 2. Gachon B, Schmitz T, Artzner F, Parant O, De Tayrac R, Ducarme G, et al. A core outcome set development for a French national prospective study about the effect of mediolateral episiotomy on obstetric anal sphincter injury during operative vaginal deli
- 3. Roos AM, Thakar R, Sultan AH. Outcome of primary repair of obstetric anal sphincter injuries (OASIS): does the grade of tear matter? Ultrasound Obstet Gynecol. 2010;36(3):368-74.
- 4. Bloch C, Dore S, Hobson S. Committee Opinion No. 415: Impacted Fetal Head, Second-Stage Cesarean Delivery. J Obstet Gynaecol Can. 2021;43(3):406-13.
- Page navigation anchor for RE: Operative vaginal delivery (OVD) in all-fours position (AFP): might this be a revolution in obstetrics?RE: Operative vaginal delivery (OVD) in all-fours position (AFP): might this be a revolution in obstetrics?
We congratulate Muraca et al on their interesting paper(1). Operative vaginal delivery (OVD) rates during the 2nd stage of labor are reported in decrease(2), reflecting Clinicians’ worries about OVD-related morbidity, and subsequent loss of clinical skills for OVD. However,vacuum delivery–when successfully performed-gives women higher chances to deliver vaginally in future pregnancies(3), and requires less analgesia, less time to action when fetal compromise occurs, and lower risk of maternal/neonatal complications than emergency caesarean section(CS). Accordingly,major guidelines (RCOG, RANZCOG, SOGC, ACOG) endorse OVD as the best option in 2nd stage of labor. Vacuum cup is usually applied in the “traditional” gynecological position. Non-recumbent positions-such as the so-called “All-fours position” (AFP), or“hands-and-knees” are infrequently adopted, despite having high evidence of benefit(4). In this position the pregnant abdomen is suspended and hips at right angles to the floor or bed. This posture implies several potential advantages: increase of all posterior diameters of the pelvis, hence easier gravitational descent of fetal head; wider space for fetal head to rotate in case of occiput posterior position(4); enhanced posterior mobility of the sacrum, hence extra-widening of the outlet; reduction of sacral pain related to decreased bed contact. A recent, large RCT involving 1400 subjects showed lower incidences of second-degree perineal lacerations, episiotomy, per...
Show MoreCompeting Interests: None declared.References
- 1. Muraca GM, Boutin A, Razaz N, et al. Maternal and neonatal trauma following operative vaginal delivery. CMAJ 2022;194:E1-E12.
- 2. Merriam AA, Ananth CV, Wright JD, et al. Trends in operative vaginal delivery, 2005-2013: a population-based study. BJOG. 2017 Aug;124(9):1365-1372.
- 3. Guo C, Ma W, Fan D, et al. Non-spontaneous vaginal delivery was associated with lower probability of subsequent fertility. Eur J Obstet Gynecol Reprod Biol. 2020 May;248:30-36.
- 4. Stremler R, Hodnett E, Petryshen P, et al. Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth. 2005 Dec;32(4):243-51
- 5. A randomised controlled trial in comparing maternal and neonatal outcomes between hands-and-knees delivery position and supine position in China. Midwifery 2017;50:117-24.
- Page navigation anchor for Intrapartum ultrasound may improve operative vaginal delivery outcomes in CanadaIntrapartum ultrasound may improve operative vaginal delivery outcomes in Canada
I read the article with Muraca et al with interest and congratulate them on their work.(1) The authors state that their results “raise questions about the choice of instrument, obstetrician training in OVD (operative vaginal delivery) use and the potential ability to recognize patients who would benefit from a cesarean delivery earlier in labour”.(1) I propose that developments in intrapartum ultrasound may have the potential to improve training and practice of operative vaginal delivery in Canada. Intrapartum ultrasound allows a more objective assessment of fetal head position and station through parameters such as angle of progression, midline angle, head-perineum distance, and head direction.(2,3) The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) published guidelines on this subject in 2018 and state that assessment prior to operative vaginal birth is a possible indication for intrapartum ultrasound.(3) Further the Royal College of Obstetricians & Gynaecologists (RCOG) guideline now recommends ultrasound prior to operative vaginal delivery if there a doubt about fetal head position following digital examination.(4) There is admittedly an urgent need for further research in this area and randomized controlled trials have not shown a benefit to date, but there have been promising results from observational studies suggesting that intrapartum ultrasound may lead to improved decision making regarding best mode of delivery, including opera...
Show MoreCompeting Interests: None declared.References
- Giulia M. Muraca, Amélie Boutin, Neda Razaz, et al. Maternal and neonatal trauma following operative vaginal delivery. CMAJ 2022;194:E1-E12.
- Dupuis O, Ruimark S, Corinne D, Simone T, André D, René-Charles R. Fetal head position during the second stage of labor: comparison of digital vaginal examination and transabdominal ultrasonographic examination. Eur J Obstet Gynecol Reprod Biol. 2005 Dec
- Ghi T, Eggebø T, Lees C, Kalache K, Rozenberg P, Youssef A, Salomon LJ, Tutschek B. ISUOG Practice Guidelines: intrapartum ultrasound. Ultrasound Obstet Gynecol. 2018 Jul;52(1):128-139.
- Murphy DJ, Strachan BK, Bahl R; Royal College of Obstetricians and Gynaecologists. Assisted Vaginal Birth: Green-top Guideline No. 26. BJOG. 2020 Aug;127(9):e70-e112.
- Ghi, T. Intrapartum ultrasound and evidence-based medicine: a necessary but challenging marriage. Am J Obstet Gynecol MFM 2021; 3, 6: 100428