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Maternal and neonatal morbidity in instrumental deliveries with the Kobayashi vacuum extractor and low forceps

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FACULTE DE MEDECINE

H-/9S5"

M é /3U THESE PRESENTEE

A L’ECOLE DES GRADUES DE L’UNIVERSITE LAVAL

POUR L’OBTENTION

DU GRADE DE MAITRE ES SCIENCES (M.Sc.) PAR

LAURENCE MEYER DOCTEUR EN MEDECINE

DE L’UNIVERSITE PARIS-VII (FRANCE)

MATERNAL AND NEONATAL MORBIDITY IN INSTRUMENTAL DELIVERIES WITH THE KOBAYASHI VACUUM EXTRACTOR AND LOW FORCEPS

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RESUME

Maternal and neonatal morbidity in instrumental deliveries with the Kobayashi vacuum extractor and low forceps.

La ventouse obstétricale facilite 1'extraction du foetus dans les accouchements difficiles. Récemment une nouvelle ventouse en Silastic a été introduite en Amérique du Nord. L'objectif de cette recherche était de documenter les risques maternels et néonataux associés à l'utilisation, comme premier instrument, de la ventouse en Silastic de Kobayashi ou de forceps bas. L'étude concernait les femmes ayant accouché à l'Hôpital Saint-Sacrement de Québec entre juillet 1982 et novembre 1984. Les sujets éligibles devaient avoir eu une grossesse unique et un accouchement, à 37 semaines de gestation ou plus, ayant nécessité une instrumentation vaginale sur un vertex en station basse. Etaient exclues les instrumentations avec manoeuvres de rotation de 45 degrés ou plus. Deux cent quatre-vingt-treize accouchements par ventouse ont été comparés à 468 accouchements par forceps bas. Vingt-neuf instrumentations par ventouse avaient nécessité l'application de forceps bas pour compléter 1'accouchement. Ces 29 observations ont été incluses dans le groupe des ventouses, selon le premier instrument utilisé. Le groupe des forceps constituait le groupe de référence. Les risques relatifs ont été ajustés, Je cas échéant, par la méthode de Mante 1-Haensze1.

Les deux groupes étaient similaires pour la parité, l'âge maternel,l'âge gestationnel, et le poids de naissance. Par comparaison aux accouchements par forceps, les accouchements par ventouse étaient plus souvent effectués par des obstétriciens-gynécologues et plus souvent déclenchés médicalement. Dans le

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groupe des ventouses, ]1 anesthésie périduraJ e était moins fréquemment pratiquée et 3'existence d'une détresse foetale était deux fois moins souvent mentionnée.

Les déchirures périnéales du troisième ou du quatrième degré, les lacérations vaginales et cervicales, et la pose d'une sonde urinaire en post- partum ont été moins souvent observées dans le groupe des ventouses. Les risques relatifs correspondants étaient respectivement de 0,78 , 0,71 et 0,86. La fréquence de l'anémie post-partum, définie par une chute d'hémoglobine de 2 g/dl ou plus, était similaire dans les deux groupes. La morbidité maternelle était plus faible chez les multipares que chez les nullipares, dans les deux groupes. Mais quel que soit le niveau de parité, la morbidité chez les mères accouchées par ventouse était inférieure à celle chez les mères accouchées par forceps, en ce qui concerne les déchirures périnéales, les lacérations vaginales et la pose d'une sonde urinaire.

Les nouveau-nés accouchés par ventouse ou par forceps avaient un Apgar comparable. La fréquence des abrasions cutanées était la même dans les deux groupes. Leur localisation, sur le scalp ou sur la face, était fonction de l'instrument utilisé. Les bosses séro-sanguines et les céphalhématomes étaient plus souvent notés dans le groupe des ventouses ( risques relatifs respectifs de 3,32 et de 1,30). La survenue d'un ictère néonatal était également plus fréquente: les risques relatifs d'une hyperbilirubinémie de 12mg/100ml ou plus et d'une photothérapie étaient respectivement de 1,38 et de 1,56. Dans les deux groupes, les complications néonatales graves étaient rares et aucune différence n'a été mise en évidence.

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Les 29 échecs de ventouse sont tous survenus chez des nu] ] ipares. Le poids moyen des nouveau-nés dans ce sous-groupe était supérieur de 135 g à ce] ui des 264 enfants accouchés avec succès par ventouse. Dans ces 29 accouchements, ] a morbidité materne] ]e était p]us importante que dans ] es accouchements où un seul instrument avait été uti]isé, même après ajustement pour ]a parité.

La ventouse en Si]astic de Kobayashi apparaît comme une a]ternative aux forceps dans ]es instrumentations du vertex en station basse. Son uti]ité dans d'autres indications te]]es que ] es instrumentations moyennes reste à évaJuer.

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AVANT-PROPOS

Je remercie profondément SyJ vie Marcoux et François Meyer, qui ont dirigé cette thèse. Je Jeur dois en grande partie ]e plaisir que j'y ai pris, et le savoir que j'y ai acquis.

Beaucoup d'autres personnes m'ont apporté leur concours. Parmi elles, je voudrais remercier:

- Jacques Mailloux , résident en obstétrique-gynécologie à l'Hôpital Saint-Sacrement, qui a collaboré activement à ce travail.

- Les membres du service des Archives de l'Hôpital Saint-Sacrement, qui ont fait des efforts remarquables pour me faciliter la consultation des dossiers hospitaliers.

- Suzanne Bruneau, dont le concours m'a été précieux pour la collecte des données.

- Elizabeth Maunsel 1 et Peter Frood, pour leurs remarques pertinentes lors de la rédaction.

Je voudrais mentionner également les membres du Département de Médecine sociale et préventive qui, d'une manière ou d'une autre, ont pu m'encourager à poursuivre cette recherche. Je remercie particulièrement René Verreault, pour sa présence et ses conseils.

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Ce travail a bénéficié de l'appui financier delà faculté de Médecine dans le cadre du Budget Spécial à la Recherche.

Les résultats de cette recherche sont présentés sous la forme d'un article en anglais soumis pour publication au moment du dépôt du mémoire.

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TABLE DES MATIERES

Page

RESUME ... i

AVANT-PROPOS ... iv

TABLE DES MATIERES ... vi

LISTE DES TABLEAUX ... vii

ARTICLE ABSTRACT ... 1

INTRODUCTION ... 2

MATERIAL AND METHODS ... 4

RESULTS ... 6

COMMENT ... 9

REFERENCES ... 13

TABLES ... 15

ANNEXE: Instrument de recueil des données ... 19

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LISTE DES TABLEAUX

Page

Tab]eau 1 Characteristics of women and newborns according

to type of instrument ... 15

Tableau 2 Percentage of maternal complications according to

type of instrument, and related relative risk ... 16

Tableau 3 Percentage of minor neonatal complications according to type of instrument, and related

rel ative risk ... 17

Tableau 4 Number of newborns with severe complications

according to type of instrument ... 18

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ABSTRACT

Maternal and neonatal morbidity in instrumental deliveries with the Kobayashi

vacuum extractor and 1 ow forceps

Risks to the mother and newborn associated with the use of the Kobayashi Silastic vacuum extractor (VE) were compared to those associated with the use of low forceps (LF). Two hundred and ninety-three deliveries with the VE were compared to 468 with LF. Third or fourth degree perinea) tears, vaginal and cervical lacerations were all less frequently observed among women delivered with the VE. The need for post-partum bladder catheterization was also reduced for these women. Newborns delivered with the VE were at increased risk of cephalhematoma and neonatal jaundice. No difference in major neonatal morbidity was observed between the two groups. The Kobayashi cup appears to be a useful alternative to forceps in low vagina) instrumental deliveries.

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INTRODUCTION

The principle of a traction by suction in difficult deliveries has been applied since the 18th century, but use of the vacuum extractor (VE) spread only after the 1954 invention of the Halmstrôm VE, a metal cup connected to a hand-driven pump-*". Within a few minutes the negative pressure induced by the pump produces a caput succedaneum or "chignon" that anchors the vertex to the cup. A number of advantages have been said to result from the use of the VE as

O

opposed to forceps . First, the application of the cup requires no additional lateral pelvic space, which reduces the need for specific analgesia and the risk of maternal injury. Fewer tears, a reduced frequency of anemia, and a shorter hospital stay have been reported in women delivered with the VE as opposed to those delivered with forceps^. Second, fewer rotation maneuvers

are

attempted because traction in itself frequently allows the fetal head to follow the path of least resistance. Finally, the VE can be applied when the vertex position is uncertain. Neonatal morbidity related to the use of the VE

A

is a subject of continuing controversy . Severe cutaneous and hemorrhagic injuries were described after Maimstrom VE deliveries in the early 60's^’^. The VE has also been said to increase the risk of neonatal jaundice through resorption of subcutaneous hematoma and cephalhematoma^.

Until recently, this instrument has been used mostly in Europe and particularly in Scandinavia. In North America, it has never enjoyed much popularity. This has been attributed to apprehensions concerning fetal morbidity, fear of legal actions resulting from inesthetic neonatal injuries, or simply the well-established use of forceps®. A new type of instrument, the Silastic Kobayashi VE*, is now available. This soft silicone elastomer

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cup is said to be better than the meta] VE. It is easier to handle and the suction is created without delay. It is also considered safer because negative pressure is only applied during the tractions and because Silastic is presumed to be less harmful than metal. To our knowledge, only one report on the use of the Silastic cup has been published^. The authors concluded that this new instrument allowed safe and efficient delivery. However, no control group was used to quantify risks or benefits to mothers and newborns associated with Silastic VE instrumentation.

In duly 1982 the Kobayashi cup was introduced at Saint-Sacrement Hospital, in Quebec City. It is now used for almost half the vaginal instrumental deliveries performed in this university hospital. This provided the opportunity to assess the morbidity associated with the use of either the Kobayashi VE or forceps as the first instrument in low vertex presentations. More specifically, this study aimed to document any decrease in maternal morbidity associated with VE use, and to compare the neonatal morbidity in the two instrumental delivery groups.

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MATERIAL AND METHODS

Eligible subjects for this study were women who required an instrumental delivery at Saint-Sacrement Hospital between duly 1982 and November 1984. All patients had a singleton pregnancy with a fetal vertex presentation and were delivered at 37 weeks of gestation or more. Patients were excluded when the medical records indicated that the instrument was used at a station higher than 3 or if a rotation of 45 degrees or more was attempted. The study population consisted of 761 women. The first instrument used was the VE in 293 deliveries and LF in 468. Twenty-nine women required a LE instrumentation following an unsuccessful VE application. They were included in the VE group. The instruments were the Kobayashi VE, the Luikart forceps or the Tucker- McLean forceps, depending on practitioners' preferences. The Kobayashi cup was used according to the metal VE recommendations: no more than 5 tractions within a 30-minute period were applied, each traction during a maternal expul sive effort.

Mothers' and newborns' hospital records were reviewed. Information was collected on the major determinants of the delivery outcome: maternal and gestational age, parity, mode of onset of labor, type of anesthesia, presence of fetal distress and birthweight. Maternal morbidity was assessed by the occurrence of perineal, vaginal or cervical tears, bladder catheterization and post-partum fall in hemogl obinemia. Information on cutaneous or hemorrhagic lesions in newborns was collected. The extent of neonatal jaundice was appraised by maximum bilirubinemia and phototherapy prescription.

Delivery outcomes in the VE and LF groups were compared. Statistical

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significance was assessed by chi-square and t-tests^. Relative risk (RR), defined as the ratio of the frequency of complications in the VE group to that in the LE group, was used as measure of association-^. Its 95% confidence limits were computed, one-sided for maternal outcome and two-sided for newborn outcome in accordance with the research hypotheses. When needed, adjustment of relative risks was made using the Mantel-Haenszel method^.

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RESULTS

The 293 de]iveries with the VE as first instrument were compared to the 468 with LF for selected determinants of the delivery outcome (Table 1). Mean maternal age, gestational age and birthweight, as well as the proportion of nulliparae, were similar in the two groups. Medical induction of labor was more frequent in the VE group. Obstetrician-gynecologists were responsible for 78.5% of VE deliveries compared to 68% of LF deliveries. Epidural anesthesia was less frequently required in the VE group. Fetal distress was mentioned twice as frequently in LF (10%) as in VE instrumentations (4.4%).

The risk of maternal complications was lower among women delivered with the VE than among those delivered with LF (Table 2). Third or fourth degree perineal tears, vaginal and cervical lacerations were all less frequently observed in the VE group. For the latter two, the decrease in relative risk reached statistical significance (p<0.05). The need for post-partum urinary catheterization was slightly reduced for women in the VE group even when adjusted for the presence of epidural anesthesia. After adjustment for the existence of perineal or vaginal tears, the two groups did not differ in the need for bladder catheterization. The frequency of post-partum anemia, defined as a fall in hemoglobinemia of 2 g/dl or more, was almost identical in the two groups. Adjustment for presence of fetal distress, birthweight and type of practitioner did not substantially change any of the relative risk estimates presented in Table 2.

In each group, maternal morbidity was markedly reduced in multiparae as compared to nulliparae. Third or fourth degree perinea] tears occurred in

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on j y 4.5% and 9.6% of the mu]tiparae delivered with the V E and LF respectively, as opposed to 25.5% and 31.2% of the nulliparae. The frequency of vagina] tears and bladder catheterization among multipares was half that of nui liparae. In each stratum of parity, risk for any of these three complications remained lower in women delivered with the VE as compared to those del ivered with LF.

Apgar scores were comparable in the two groups. Three and four babies, in the VE and LF groups respectively, were assigned a one-minute score below 4. By five minutes, a 1 1 babies scored more than 4 and 99% of newborns in each group scored 7 or more. Minor neonatal complications are presented in Table 3. Localization of cutaneous abrasions, on the scalp or face, depended mainly on the instrument used. Overall, the frequency of abrasion was similar in the two groups. Caput succedaneum was reported three times more frequently in the VE group. The two groups differed slightly for the risk of cephalhematoma (RR= 1.3). Neonatal jaundice, defined as a maximum bilirubinemia of 12mg/d1 or more, was more frequent in the VE group (RR= 1.4). Phototherapy was also more frequent 1 y prescribed (RR= 1.6). One baby in each group had a bil irubinemia above 20 mg/d 1. Relative risk for hyperbilirubinemia did not change perceptibly after adjustment for mode of onset of labor, birthweight, type of feeding, presence of fetal distress or of ABO incompatibility. In these data, no association was observed between jaundice and the presence of a "chignon" or of a cephalhematoma (p= 0.98 and 0.81 in the VE and LF groups respectively). More severe neonatal complications are shown in Table 4. They were rare in either group. Overal 1 , 14 (4.8%) and 23 (4.9%) newborns delivered with the VE and LF respectively, presented at least one of these severe complications.

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The percentage of unsuccessful] vacuum extractions was 9.9%. It decreased from 15.2% in the first year following the introduction of the Kobayashi cup to 7.5% in the second year. The 29 VE failures a 1 1 occurred in nui liparae. Mean birthweight was 135g higher than that of the newborns actually delivered with the VE. Failures and successes in VE use did not differ with respect to the percentage of women delivered by obstetrician-gynecologists or the frequency of fetal distress. Maternal morbidity in this subgroup of 29 deliveries was greater than in the total VE or LF group. Third or fourth degree perinea] tears were observed in 72.4% of those deliveries, vaginal tears in 37.9%, urinary catheterization in 51.7%, and post-partum anemia in 58.6%. This increased morbidity persisted when comparisons were restricted to nulliparae. Among the newborns delivered with both instruments, 37.9% developed an hyperbilirubinemia and 27.6% required phototherapy. One baby had a clavicular fracture and one presented neonatal seizure. Apgar scores were not lower in this subgroup than in the VE or LF groups.

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COMMENT

This study indicated that, compared to low forceps, extraction of the fetus with the Kobayashi Silastic VE was associated with a lower maternal risk of perineal , vaginal and cervical tears and of urinary catheterization. Risk of neonatal jaundice was increased in newborns delivered with the VE. No difference in major neonatal morbidity was observed between the two groups.

Results of this study could have been affected by certain biases. First, some VE complications may have been the result of physicians' 1 ack of experience in the use of the instrument at the beginning of the study. This is suggested by the marked decrease in the failure frequency observed over the study period. Second, some mid instrumentations, which are known to be more harmful than low ones, might have been included in the VE group. The International Classification of Diseases does not distinguish VE instrumentations into low, mid and high as it does for forceps. Hence, some "mid-VE" might have been classified as low if no other information concerning the station and position was available in the medical records. These biases would tend to overestimate maternal and neonatal complications associated with VE use. Despite this, risk of maternal morbidity in the VE group was lower than in LF group.

Crude relative risk estimates did not change substantially when stratified analysis was used to control for potential confounding factors. It seems unlikely that the findings of this study could have been influenced by some other uncontrolled variables. The mode of anesthesia and the presence of fetal distress were the prominent factors distinguishing the two study groups.

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The reduced need for anesthesia associated with VE use is a we] ]-known advantage of the method^. The greater percentage of feta] distress in the LF group probab]y part]y ref]ected the fact that in emergency situations physicians tended to se]ect the instrument with which they were most fami]iar.

When compared to single instrument deliveries, the 29 deliveries which required both the VE and LF were associated with an increased risk of maternal adverse effects and neonatal jaundice. Vacuum extractor failures can occur from defects in the instrument, from faults in technique such as oblique traction, or from adverse obstetric factors such as cephalope! vie disproportion, very large caput succedaneum or malposition^. Unfortunately, little detailed information on circumstances surrounding these 29 failures was available in the records. It was therefore difficult to dissociate the effect of the use of both instruments from that of specific obstetric characteristics of these deliveries as explanations for this increased morbidity.

The risk of vaginal and cervical tears was significant 1 y lower with VE instrumentations. Third or fourth degree perineal tears and urinary catheterization were also less frequent in this group. Similar findings have been reported in studies comparing the metal VE and forceps^’Although

tears are sometimes considered of marginal clinical significance, they are responsible for undesirable post-partum pain and discomfort^. Moreover, they

can lead to a greater need for bladder catheterization and therefore to an increased risk of urinary tract infection-^.

In this study, as in most recent pub 1 ications^’^^’^, no increased risk

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of severe comp]restions was found among newborns delivered with the VE. Earlier papers reported severe neonatal injuries associated with Malmstrom VE instrumentations-’These studies, however, did not use appropriate control groups or included some whomen in whom instrument was applied during the first stage of labor. A larger population would be required to identify differences, if any, between the VE and LF with respect to rare severe complications among newborns. Our findings showed increased frequencies of hyperbilirubinemia and phototherapy in the VE group. In a trial comparing 152 metal VE to 152 forceps instrumentations, Vacca et alreported that clinical jaundice was more common in their VE group. However, there was no significant difference in the frequency of phototherapy, which they considered as an index of severity. In their study of the Kobayashi VE, Maryniak et al. reported a 15% frequency of jaundice^, which is lower than ours. Unfortunately they did not define their criteria for the presence of jaundice. In our study, caput succedaneum was noted in 18.4% of babies delivered with the VE. Greis et al. reported a 100% frequency of chignon with metal VE instrumentations^. This difference might indicate that, as presumed, Silastic is less harmful than metal . On the other hand, because of the transient nature of this injury, caput succedaneum could have been underreported depending on the moment when the newborns were examined. As for cephalhematoma, it might also have gone unnoted by physicians who often assumed it to be benign. There is no reason to believe that physicians reported these injuries differently for forceps than for VE deliveries. Therefore, such underreporting could explain why no relationship was found between neonatal jaundice and subcutaneous hematoma or cephalhematoma.

This study demonstrated substantia] benefits to the mother delivered with

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the Kobayashi Silastic VE, as compared to low forceps. Despite the increased risk of minor neonatal morbidity such as jaundice or cephalhematoma, the Kobayashi VE appears to be a useful alternative to forceps in low vertex instrumentations. Use of this VE in other situations such as mid- instrumentations needs to be assessed.

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REFERENCES

1. Ott WJ. Vacuum extraction. Obstet Gynecol Surv 1975; 30:643-9.

2. Chalmers JA. Five years' experience with the vacuum extractor. Br Med J 1964; 1:1216-20.

3. Hal me J, Ekbladch L. The vacuum extractor for obstetric delivery. Clin Obstet Gynaecol 1982; 25:167-75.

4. Editorial . Vacuum versus forceps. Lancet 1984; 1:144.

5. AgDero 0, Alvarez H. Fetal injury due to the vacuum extractor. Obstet Gynecol 1962; 19:212-7.

6. Ahuja GL, Willoughby MEN, Kerr MM, Hutchinson JH. Massive subaponeurotic haemorrhage in infants born by vacuum extraction. Br Med J 1969; 3:743-5.

7. Arad I, Fainmesser P, Birkenfeld A, Gulaiev B, Sadovsky E. Vacuum extractor and neonatal jaundice. J Perinat Med 1982; 10:273-7.

8. Plauché WC. Fetal cranial injuries related to delivery with the Malmstrom vacuum extractor. Obstet Gynecol 1979; 53:750-7.

9. Maryniak GM, Frank JB. Clinical assessment of the Kobayashi vacuum extractor. Obstet Gynecol 1984; 64:431-5.

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10. Armitage P. Statistical methods in medical research. Blackwell scientific publications. Oxford, 1971.

11. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research.Lifetime learning publications. Belmont, CA, 1982.

12. Bird GO. The use of the vacuum extractor. Clin Obstet Gynaecol 1982; 9:641-61.

13. Vacca A, Grant A, Wyatt G, Chalmers I. Portsmouth operative delivery trial : a comparison vacuum extraction and forceps delivery. Br 0 Obstet Gynaecol 1983; 90:1107-12.

14. Greis OB, Bienarz 0, Scommegna A. Comparison of maternal and fetal effects of vacuum extraction with forceps or cesarean deliveries. Obstet Gynecol 1981; 37:371-7.

15. Thacker SB, Banta HD. Benefits and risks of episiotomy. Obstet Gynecol Sur v 1983; 38:322-38.

16. Garibaldi RA, Burke OP, Britt MR, Miller WA, Smith CB. Meata 1 colonization and catheter-associated bacteriura. N Engl 0 Med 1980; 303:316-8.

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TABLE 1: Characteristics of women and newborns according to type of instrument

Characteristics Vacuum extractor (n = 293)

Low forceps (n = 468)

Mean materna] age (yrs) 27.4 27.3

% NuJ]iparae 69.3 66.5

Mean gestational age (wks) 39.6 39.6

% Obstetrician-gynecologists 78.5 68.0* % Induced labor 23.6 15.6* % Epidural anesthesia 87.0 97.4* % Fetal distress 4.4 10.0* Mean birthweight (g) 3413 3354 * p < 0.01 15

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TABLE 2: Percentage of materna] complications according to type of instrument, and related relative risk

Maternal comp]ications Vacuum extractor (n = 293) % Low forceps* (n = 468) % Relative risk Upper 95% confidence 1 imit Perinea] tear (3rd or 4th degree) 18.8 23.9 0.78 1.06 Vaginal tear 16.7 23.7 0.71 0.96 Cervical tear 1.4 3.4 0.40 0.98 Bladder catheterization 17.4 20.3 0.86 1.17 Fall in hemoglobin > 2 g/dl 22.5 23.1 0.98 1.30 ^reference group

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TABLE 3: Percentage of minor neonatal complications according to type of instrument, and related relative risk

Minor comp!ications Vacuum extractor (n = 293) % Low forceps* (n = 468) % Relative risk 95% confidence 1imits Scalp abrasion 15.1 6.4 2.34 1.46-3.77 Face abrasion 4.8 14.3 0.33 0.19-0.59 Caput succedaneum 18.4 5.6 3.32 2.08-5.30 Cephalhematoma 14.7 11.3 1.30 0.85-1.99 Bilirubin > 12mg/dl 24.2 17.5 1.38 0.98-1.96 Phototherapy 15.1 9.6 1.56 1.00-2.42 ■^reference group 17

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TABLE 4: Number of newborns with severe complications according to type of instrument

Severe complications Vacuum extractor (n = 293) Low forceps (n = 468) Facial palsy 4 9 Brachial palsy 2 3 Clavicular fracture 3 * 8 Torticol1 is - 3 Skull fracture 1 1 Seizure 3 * 2 Intracranial hemorrhage 1

-* Includes one newborn delivered with both instruments.

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ANNEXE

INSTRUMENT DE RECUEIL DES DONNEES

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1. 2. 3. 4. 5. 6. 1. 8. 9. 10

.

11

.

12. 13. 14. 13. 16.

ETUDE SUR LA MORBIDITE ASSOCIEE A LA VENTOUSE ET AUX FORCEPS

NUMERO DANS L'ETUDE ET CODE CARTE

NUMERO DE DOSSIER DU BEBE

NUMERO DE DOSSIER DE LA MERE

DATE DE NAISSANCE DE LA MERE (A/M/O)

AGE GESTATIONNEL (SEMAINES COMPLETES)

DATE DE L'ACCOUCHEMENT (A/M/3)

parité

(nombre d'accouchements antérieurs)

8 8 et plus 9 S.R.

DUREE DU PREMIER STADE (HEURES COMPLETES)

DUREE DU DEUXIEME STADE (MN)

ANESTHESIE AVANT LA NAISSANCE 0 Aucune 1 Epidurale simple 2 Epidurale continue 3 Locale 4 Générale 5 Paracervicale 6 Honteuse Autre: _ _ _ _ _

ANALGESIE PENDANT LE TRAVAIL 1 Oui 2 Non EPISIOTOMIE 1 Oui 2 Non DECHIRURE PERINEALE 1 Oui 2 Non SI NON, PASSER A 15 DEGRE DE LA DECHIRURE 12349 S.R. DECHIRURE VAGINALE 1 Oui 2 Non DECHIRURE CERVICALE 1 Oui 2 Non 1 5 6 1 I I-- ■--- ,--- I 12 1 7

I__ i__ 1 1__ ,__ 1 I__ ■ 1

18 2 3 2 4 2 5 1 -- 1__

I

I__ t__ I I__ I 2 6 3 1 32 I i I 3 3 3 4 . I---1__ ,__ I 35 3 7 38 L 3 9 40 41 42 L 43 ■ I___I 4 4 20

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17. DETRESSE FOETALE 1 Oui 2 Non

18. MECONIUM

1 Oui 2 Non

19. ANOMALILE DU RYTHME DU COEUR FOETAL (coeur < 120 ou > 160 ou irrégulier) 1 Oui 2 Non 20. MONITORAGE INTERNE 1 Oui 2 Non Ns-46 47 48

21. NOM DU MEDECIN RESPONSABLE DE L'ACCOUCHEMENT AYANT APPLIQUE LE PREMIER INSTRUMENT 1 Charles Bernard 2 Robert Blais 3 Pierre Blanchet A Céline Bouchard 5 Jean-Marie Bourbeau 6 Jean Charlebois 7 Prime Duchesne 10 Danielle Gauthier 11 Denis Lamende 12 Jules Leclerc 13 René Lesieur 14 Michel Morrissette 15 Jean-Jacques Pinault 16 Michel Sirois 8 Michel Fortier 9 Paul-Emile Fortin 17 Jean-Pierre Verreault Autre: | 1 49 5 0 22. STATUT VITAL 1 Vivant 2 Décédé 1____| 23. APGAR A 1 MN l 5 1 i 52 5 3 24. APGAR A 5 MN 1__ 1 5 4 5 5

25. HEMORRAGIE IMMEDIATE DES SUITES DE COUCHES

1 Oui 2 Non l. I

SI NON, PASSER A 27

5 6

26. SI OUI, CAUSE INDIQUEE 1 Inertie utérine 2 Rétention placentaire

3 Saignement vaginal ou pelvien

Autre: 1 1 5 7 27. TRAVAIL 1 Spontané 2 Déclenché 5 8 28. PREMIER INSTRUMENT 1 Ventouse 2 Forceps ( SI VENTOUSE, PASSER A 30 5 9 29. TYPE DE FORCEPS

1 Bas 2 Moyen 3 Haut

60 21

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30. INDICATION DE L'INSTRUMENTATION

1 Détresse foetale 4 HTA, toxémie, cardiopathie 2 Arrêt en transverse Autres _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3 Défaut d'effort expulsif

31. STATION 1 < 3 2 3 ou 4 9 S.R. 32. POSITION 7 OT 8 Mal sentie 9 S.R. 1 Oui 2 Non SI NON, PASSER A 42

35. CAUSE INDIQUEE DE L'ECHEC

1 OIGA 4 OIDA

2 OIGP 5 OP

3 OIDP 6 05

33. TENTATIVE DE ROTATION

1 Oui 2 Non 9 S.R.

34. ECHEC DU PREMIER INSTRUMENT

62 6 3 6 4 I___I 65 66 36. RECOURS 1 Ventouse 2 Forceps 3 Césarienne 4 Accouchement spontané PASSER A 38 PASSER A 37 PASSER A 42 PASSER A 42 37. TYPE

1 Bas 2 Moyen 3 Haut 9 S.R.

38. STATION 1 < 3 2 3 ou 4 9 S.R. 39. POSITION 1 OIGA 4 OIDA 2 OIGP 5 OP 3 OIDP 6 OS 7 OT 8 Mal sentie 9 S.R. 40. TENTATIVE DE ROTATION 1 Oui 2 Non 9 S.R.

41. ECHEC DU DEUXIEME INSTRUMENT

6 8 6 9 70 7 1 1 Oui 2 Non 72 22

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42. SONDE URINAIRE POST-PARTUM

1 Aucune 4 A demeure 24 h et plus

2 Intermittente 9 S.R.

3 A demeure moins de 24 h

43. HEMOGLOBINE A L'ENTREE (..,.g/l)

44. HEMOGLOBINE POST-PARTUM LA PLUS BASSE (..,.g/l)

NUMERO DANS L'ETUDE ET CODE CARTE

45. GROUPE ABO DE LA MERE

1 A 3 AB

2 B 4 0

46. TRANSFUSION

1 Oui 2 Non

47. AUTRE PROBLEME NOTE SUR LA FEUILLE DE SORTIE

48. POIDS DU BEBE (GRAMMES)

49. BILIRUBINE PRESCRITE 1 Oui 2 Non SI NON, PASSER A 53

50. BILIRUBINEMIE LA PLUS HAUTE (.. ,./dl)

51. PHOTOTHERAPIE 1 Oui 2 Non

52. CAUSE INDIQUEE D'HYPERBILIRUBINEMIE

I_ 7 4 7 S 4 I 76 I-- --- 1 I 77 79 1-- --- --- --- 1 L_2_| 1 5 6 7 8 9 12 I— ....,I 14 16 1 7

53. GROUPE ABO DU BEBE '1 A 3 AB 2 B 4 0 54. ALLAITEMENT MATERNEL 1 Oui 2 Non 55. BOSSE SERO-SANGUINE 1 Oui 2 Non 1 8 1 9 2 0 2 1 23

(32)

56 CEPHALHEMATOME 1 Oui 2 Non

57. ABRASION OU ECCHYMOSE

1 Aucune A Les deux

2 Scalp 9 Localisation inconnue 3 Face 58. FRACTURE DU CRANE 1 Oui 2 Non 59. FRACTURE DE LA CLAVICULE 1 Oui 2 Non 60. PARALYSIE FACIALE 1 Oui 2 Non 61. AUTRES DIAGNOSTICS A: _ _ _ _ _ _ _ _ _ _ _ _ _ _ B: _ _ _ _ _ _ _ _ _ _ _ _ _ _ 62. SORTIE 1 Vivant au domicile 2 Vivant transféré 3 Décédé 63. SI TRANSFERT, PRECISER A: l'hôpital: _ _ _ _ B: le motif: _ _ _ _

64. DATE DE SORTIE DE SAINT-SACREMENT OU DATE DE DECES (A/M/3) PASSER A 64 PASSER A 64 22 2 3 2 4 2 5 2 6 1 . I 2 7 2 8 I■.... I 2 9 3 0 3 1 I i 38 ^3 1---- ,----1 I---- ---- 1 |---- ,----1 3 4 39 24

(33)

RESUME

Materna] and neonatal morbidity in instrumenta] deliveries with the Kobayashi vacuum extractor and low forceps.

Cette étude documente la morbidité maternelle et néonatale liée à l'utilisation, comme premier instrument, d'une ventouse en Silastic de Kobayashi ou de forceps bas. Deux cent quatre-vingt-treize accouchements par ventouse ont été comparés à 468 accouchements par forceps. Les déchirures périnéales du troisième ou du quatrième degré, les lacérations vaginales et cervicales ont été moins fréquemment observées chez les mères accouchées par ventouse. La pose d'une sonde urinaire était également moins fréquente dans ce groupe. Les nouveau-nés accouchés par ventouse présentaient plus souvent un céphal hématome ou un ictère. La fréquence des complications néonatales sévères était faible et identique dans les deux groupes.

Figure

Tableau 2 Percentage of maternal complications according to
TABLE 3: Percentage of minor neonatal complications according to type  of instrument, and related relative risk
TABLE 4: Number of newborns with severe complications according to  type of instrument

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