Evaluation of delivery options for second-stage events

Area of Science:

• Obstetrics and Gynecology
• Maternal-Fetal Medicine
• Surgical Outcomes

Background:

• Cesarean delivery is common in the second stage of labor, while operative vaginal delivery rates are declining.
• Limited data exist comparing outcomes of attempted operative vaginal delivery versus cesarean delivery when intervention is needed in the second stage of labor.
• Previous studies often compared operative vaginal delivery to spontaneous vaginal delivery, which is not a viable option when intervention is required.

Purpose of the Study:

• To compare maternal and neonatal outcomes based on the first attempted operative delivery (vacuum, forceps, or cesarean) in patients requiring second-stage assistance at a fetal station of +2 or below.
• To provide data for clinical decision-making when operative delivery is necessary in the second stage of labor.

Main Methods:

• Secondary analysis of an observational obstetric cohort from 25 US hospitals over 3 years.
• Included were women at ≥37 weeks gestation, singletons, nonanomalous, vertex presentation, no prior vaginal delivery, reaching a station of +2 or below, and undergoing attempted operative delivery.
• Primary outcomes included a composite neonatal outcome and individual maternal outcomes (postpartum hemorrhage, severe lacerations, postpartum infection). Adjusted odds ratios were calculated.

Main Results:

• No significant difference in the composite neonatal outcome was observed between attempted delivery modes.
• Vacuum and forceps attempts were associated with lower rates of postpartum infection and hemorrhage compared to cesarean.
• Attempted vacuum delivery had the lowest frequency of postpartum infection (0.2%) and hemorrhage (1.4%), but severe lacerations were highest in the forceps group (33.8%) compared to vacuum (19.1%) and cesarean (0%).
• Cesarean delivery occurred more frequently in attempted vacuum (6.4%) and forceps (4.4%) groups.

Conclusions:

• In patients requiring second-stage delivery assistance, attempted operative vaginal delivery (vacuum or forceps) is associated with a lower frequency of postpartum infection compared to cesarean delivery.
• However, attempted operative vaginal delivery is also linked to a higher frequency of severe lacerations, particularly with forceps use.