Obstetric trauma rates for forceps deliveries have increased in Canada

June 28, 2018, Canadian Medical Association Journal

Trauma to both mother and baby during vaginal deliveries, especially forceps deliveries, has increased in Canada in recent years, according to a large study published in CMAJ (Canadian Medical Association Journal).

Operative vaginal deliveries—using forceps or vacuum—have declined over the past few decades in the United States and Canada, while cesarean rates have increased. These trends have led to recommendations to increase operative vaginal delivery rates to counter high numbers of cesarean deliveries, although both types of births carry risks.

The study included information on almost 2 million singleton hospital deliveries in 4 Canadian provinces—Alberta, Manitoba, Ontario and Saskatchewan—from April 2004 to March 2015. Rates of operative vaginal delivery and cesarean delivery were 18.2% and 26.6% in who gave birth to their first child, 5.5% and 6.7% in women who had previously given birth vaginally, and 3.4% and 81.9% in women with a previous cesarean delivery.

Obstetric trauma among operative vaginal deliveries increased from 16.6% in 2004 to 19.4% in 2014 in first-time mothers and from 13.8% to 18.7% in women with a prior cesarean delivery. The largest increases in obstetric trauma occurred following forceps deliveries, with a rate of 19.4% in first time mothers in 2004 that increased to 26.5% in 2014. In women with a previous cesarean delivery, the obstetric trauma rate following forceps delivery increased from 16.6% to 25.5% over the same period. "Our population-level modelling showed that a 1% increase in the operative vaginal delivery rate in Canada may result in over 700 additional cases of obstetric trauma per year among first-time mothers alone," says lead author Dr. Giulia Muraca, Postdoctoral Fellow in the Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC.

Obstetric trauma includes a number of injuries to the mother during labour and delivery, including severe perineal tearing, and injuries to the bladder and urethra. "Severe perineal tearing accounted for 87% of the cases of obstetric trauma among operative vaginal deliveries in our study. Severe perineal tearing can cause significant long-term complications for women because such injuries can lead to impaired control of the bladder and bowel function as well as pelvic organ prolapse, one of the most common reasons for gynaecologic surgery" says Dr. Muraca.

The rate of severe birth trauma following operative vaginal delivery also increased in women delivering their first child, from 4.5 to 6.8 per 1000 deliveries from 2004 to 2014 and from 6.5 to 10.6 per 1000 deliveries in women with a previous vaginal delivery.

These increases in obstetric and severe birth trauma among women having an operative vaginal delivery occurred during a period when rates of operative vaginal delivery decreased in Canada by 11%. This contrasts with declining rates of trauma and operative vaginal delivery in the United States.

"Recommendations to reduce cesarean delivery rates by increasing rates of operative vaginal delivery should be tempered by the understanding that such actions may be associated with higher rates of obstetric trauma," according to Dr. Muraca and coauthors.

The findings provide population-level data that could inform efforts to increase operative vaginal delivery rates. "These results should make policy-makers cautious about recommending increased operative vaginal delivery without improving training, skill and oversight associated with operative vaginal delivery."

However, caution is advised in moving away completely from operative vaginal delivery, writes Dr. Christopher Ng, Department of Obstetrics & Gynaecology, University of British Columbia in a related commentary. "It is not easy to find the optimal balance of risks and benefits among operative vaginal delivery, trial of labour after cesarean, and cesarean delivery. Unfortunately, that discussion may be cut short as we run the real risk of having the skills for operative vaginal delivery wither because of the difficulty in training future providers."

"Ecological association between operative vaginal delivery and and birth " is published June 18, 2018.

Explore further: Midpelvic forceps, vacuum deliveries: Higher rates of trauma for mothers and babies

More information: Giulia M. Muraca et al. Ecological association between operative vaginal delivery and obstetric and birth trauma, Canadian Medical Association Journal (2018). DOI: 10.1503/cmaj.171076

Christopher Ng. Taking a stand for operative vaginal delivery, Canadian Medical Association Journal (2018). DOI: 10.1503/cmaj.180668

Related Stories

Midpelvic forceps, vacuum deliveries: Higher rates of trauma for mothers and babies

June 5, 2017
Compared with cesarean deliveries, midpelvic forceps and midpelvic vacuum deliveries lead to higher rates of maternal and infant trauma, according to a new study published in CMAJ (Canadian Medical Association Journal).

Operative vaginal delivery remains appropriate

October 23, 2015
(HealthDay)—Operative vaginal delivery remains an important component of modern labor management, but obstetric care providers need to be familiar with the proper use of the instruments and the risks involved, according ...

C-sections linked to long-term risks and benefits

January 23, 2018
Compared to vaginal deliveries, caesarean deliveries are associated with a decreased risk of urinary incontinence and pelvic prolapse, but an increased risk of miscarriage or placenta previa in future pregnancies. Those are ...

Overall incidence of obstetric anal sphincter injury 4.9 percent

January 18, 2018
(HealthDay)—The incidence of obstetric anal sphincter injury is 4.9 percent, and risk factors include vacuum-assisted vaginal delivery and prolonged duration of second stage of labor, according to a study published online ...

Higher risks associated with vaginal birth after cesarean, although absolute risk small

May 7, 2018
Attempted vaginal birth after cesarean (VBAC) is associated with higher rates of adverse effects or death for mothers and infants, although absolute rates were low in mothers who attempted this type of birth, according to ...

Low cost, easy to administer drug may be the key to preventing maternal deaths

January 29, 2018
Postpartum hemorrhage (major blood loss after labor and birth) is the leading cause of maternal mortality worldwide, accounting for approximately one-quarter of all maternal deaths. In a study to be presented at the Society ...

Recommended for you

Undiagnosed STIs can increase negative PMS symptoms

September 17, 2018
Women that have undiagnosed sexually transmitted infections may be at greater risk of experiencing negative premenstrual symptoms (PMS), according to new Oxford University research.

High dose folic acid does not prevent pre-eclampsia in high risk women

September 13, 2018
Taking high dose folic acid supplements in later pregnancy (beyond the first trimester) does not prevent pre-eclampsia in women at high risk for this condition, finds a randomised controlled trial published by The BMJ today.

Study finds air purifiers may benefit fetal growth

September 12, 2018
A new study led by SFU health sciences researchers Prabjit Barn and Ryan Allen reveals fetal growth may improve if pregnant women use portable air purifiers inside their homes.

Delayed childbearing is a growing source of multiple births, study shows

September 12, 2018
Starting in the 1980s, the number of multiple births—twins, triplets, quadruplets and quintuplets—steadily increased from about 20 sets per 1,000 live births to almost 35 sets per 1,000 live births in the 2010s.

Transforming pregnancy research with a smartphone app

September 5, 2018
For years, pregnant women have been underrepresented in biomedical research. Current treatments, interventions and guidelines do a poor job of taking into consideration the diverse characteristics of all pregnant women.

For women undergoing IVF, is fresh or frozen embryo transfer best?

August 21, 2018
The world's first baby born via in-vitro fertilization turned 40 years old this summer. Still, after four decades, IVF is a relatively new field with ongoing debate on how to get the best results for families who have placed ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.