Management of fetal malposition in the second stage of labor: a propensity score analysis
Aiken, Abigail R
Alberry, Medhat S
Brockelsby, Jeremy C
Scott, James G
American Journal of Obstetrics and Gynecology
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Aiken, A. R., Aiken, C., Alberry, M. S., Brockelsby, J. C., & Scott, J. G. (2014). Management of fetal malposition in the second stage of labor: a propensity score analysis. American Journal of Obstetrics and Gynecology, 212 355.e1-355.e7. https://doi.org/10.1016/j.ajog.2014.10.023
Objective: To determine the factors associated with selection of rotational instrumental versus cesarean delivery to manage persistent fetal malposition, and to assess differences in adverse neonatal and maternal outcomes following delivery by rotational instruments versus cesarean section. Study Design: We conducted a retrospective cohort study over a 5-year period in a tertiary UK obstetrics center. 868 women with vertex-presenting, single, live-born 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 section. Linear and logistic regression models were used to compare maternal and neonatal outcomes for delivery by rotational forceps or ventouse versus cesarean section, adjusting for propensity scores. Results: Increased likelihood of rotational instrumental delivery was associated with lower maternal age (OR= 0.95 p<0.01), lower BMI (OR=0.94 p<0.001), lower birth-weight (OR=0.95 p<0.01), no evidence of fetal compromise at the time of delivery (OR=0.31 p<0.001), delivery during the daytime (OR= 1.45, P<0.05), and delivery by a more experienced obstetrician (OR=7.21 p<0.001). 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± 48ml p<0.001). Conclusions: 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 section rates.
caesarean section, operative vaginal delivery, fetal malposition, delivery, intra-partum care
During data analysis, A.R.A. was supported by an NICHD Predoctoral Fellowship under grant number F31HD079182 and by grant R24HD042849, awarded to the Population Research Center at The University of Texas at Austin. She is currently supported by grant R24HD047879 for Population Research at Princeton University. J.G.S. is partially funded by a CAREER grant from the National Science Foundation (DMS-1255187).
External DOI: https://doi.org/10.1016/j.ajog.2014.10.023
This record's URL: https://www.repository.cam.ac.uk/handle/1810/246184