pOBJECTIVE:br /
We sought to determine the factors associated with selection of rotational instrumental vs cesarean delivery to manage persistent fetal malposition, and to assess differences in adverse neonatal and maternal outcomes following delivery by rotational instruments vs cesarean delivery.br /
STUDY DESIGN:br /
We conducted a retrospective cohort study over a 5-year period in a tertiary United Kingdom obstetrics center. In all, 868 women with vertex-presenting, single, liveborn infants at term with persistent malposition in the second stage of labor were included. Propensity score stratification was used to control for selection bias: the possibility that obstetricians may systematically select more difficult cases for cesarean delivery. Linear and logistic regression models were used to compare maternal and neonatal outcomes for delivery by rotational forceps or ventouse vs cesarean delivery, adjusting for propensity scores.br /
RESULTS:br /
Increased likelihood of rotational instrumental delivery was associated with lower maternal age (odds ratio [OR], 0.95; P .01), lower body mass index (OR, 0.94; P .001), lower birthweight (OR, 0.95; P .01), no evidence of fetal compromise at the time of delivery (OR, 0.31; P .001), delivery during the daytime (OR, 1.45; P .05), and delivery by a more experienced obstetrician (OR, 7.21; P .001). Following propensity score stratification, there was no difference by delivery method in the rates of delayed neonatal respiration, reported critical incidents, or low fetal arterial pH. Maternal blood loss was higher in the cesarean group (295.8 plusmn; 48 mL, P .001).br /
CONCLUSION:br /
Rotational instrumental delivery is often regarded as unsafe. However, we find that neonatal outcomes are no worse once selection bias is accounted for, and that the likelihood of severe obstetric hemorrhage is reduced. More widespread training of obstetricians in rotational instrumental delivery should be considered, particularly in light of rising cesarean delivery rates./p
pOBJECTIVE: To evaluate risk factors for unsuccessfulnbsp;instrumental delivery when variability between individualnbsp;obstetricians is taken into account.br /
METHODS: We conducted a retrospective cohort studynbsp;of attempted instrumental deliveries over a 5-year periodnbsp;(2008ndash;2012 inclusive) in a tertiary United Kingdom center.nbsp;To account for interobstetrician variability, we matchednbsp;unsuccessful deliveries (case group) with successful deliveriesnbsp;(control group) by the same operators.nbsp;Multivariatenbsp;logistic regression was used to compare successful andnbsp;unsuccessful instrumental deliveries.br /
RESULTS: Three thousand seven hundred ninety-eightnbsp;instrumental deliveries of vertex-presenting, single, termnbsp;newborns were attempted, of which 246 were unsuccessfulbr /
(6.5%). Increased birth weight (odds ratio [OR]nbsp;1.11; P,.001), second-stage labor duration (OR 1.01;nbsp;P,.001), rotational delivery (OR 1.52; P,.05), and usenbsp;of ventouse compared with forceps (OR 1.33; P,.05)nbsp;were associated with unsuccessful outcome. When interobstetriciannbsp;variability was controlled for, instrumentnbsp;selection and decision to rotate were no longer associatednbsp;with instrumental delivery success. More seniornbsp;obstetricians had higher rates of unsuccessful deliveriesnbsp;(12% compared with 5%; P,.05) but were used to undertakenbsp;more complicated cases. Cesarean delivery duringnbsp;the second stage of labor without previous attempt atnbsp;instrumental delivery was associated with higher birthnbsp;weight (OR 1.07; P,.001), increased maternal age (ORnbsp;1.03; P,.01), and epidural analgesia (OR 1.46; P,.001).br /
CONCLUSION: Results suggest that birth weight andnbsp;head position are the most important factors in successfulnbsp;instrumental delivery, whereas the influence ofnbsp;instrument selection and rotational delivery appear tonbsp;be operator-dependent. Risk factors for lack of instrumentalnbsp;delivery success are distinct from risk factors fornbsp;requiring instrumental delivery, and these should not benbsp;conflated in clinical practice./p
pFocusing on intrauterine contraceptives (IUC), contraceptive implants, and emergency contraceptives,nbsp;we review recent advances in contraceptive development and discuss progress in policies to improvenbsp;access to the most effective methods. We report on the shift in practice towards routinely providingnbsp;IUCs and implants to young and nulliparous women, prompted in part by the reduced diameter of thenbsp;insertion tube for the Mirena IUC and the development of a smaller IUC called Skyla. Additionally, wenbsp;describe the new SCu300A intrauterine ball and the development of an implant called Nexplanon, whichnbsp;comes with a preloaded inserter.We also discuss the efficacy of ulipristal acetate versus levonorgestrelnbsp;for emergency contraception, especially for women who weigh more than 75 kg. Finally, in light of thenbsp;increasing interest in providing IUCs and implants to women in the immediate postpartum and postabortionnbsp;periods, we consider the rationale for this change in practice and review the progress that hasnbsp;been made so far in the United States./p