Maternal and neonatal morbidity in relation to the instrument used for mid-cavity rotational operative vaginal delivery: a prospective cohort study

ObjectiveTo compare the maternal and neonatal morbidity associated with alternative instruments used to perform a mid-cavity rotational delivery. DesignA prospective cohort study. SettingTwo university teaching hospitals in Scotland and England. PopulationThree hundred and eighty-one nulliparous women who had a mid-cavity rotational operative vaginal delivery. MethodsA data collection sheet was completed by the research team following delivery. Main outcome measuresPostpartum haemorrhage, third- and fourth-degree perineal tears, low cord pH, neonatal trauma, and failed or sequential operative vaginal delivery. ResultsOne hundred and sixty-three women (42.8%) underwent manual rotation followed by non-rotational forceps delivery, 73 (19.1%) had a rotational vacuum delivery, and 145 (38.1%) delivered with the assistance of rotational (Kielland) forceps. The rates of postpartum haemorrhage were similar when comparing manual rotation with rotational vacuum (adjusted OR1.42, 95%CI 0.66-3.98), and when comparing manual rotation with Kielland forceps (adjusted OR1.22, 95%CI 0.71-2.88). The results were comparable for third- and fourth-degree perineal tears (adjusted OR0.85, 95%CI 0.13-1.89; adjusted OR0.94, 95%CI 0.39-1.82), low cord pH (adjusted OR1.76, 95%CI 0.44-6.91; adjusted OR1.12, 95%CI 0.44-2.83), neonatal trauma (adjusted OR0.50, 95%CI 0.16-1.55; adjusted OR3.25, 95%CI 0.65-16.17), and admission to the neonatal intensive care unit (adjusted OR1.47, 95%CI 0.45-4.81; adjusted OR1.04, 95%CI 0.49-2.19). The sequential use of instruments was less likely with manual rotation and forceps than with rotational vacuum delivery (0.6 versus 36.9%, OR0.01, 95%CI 0.002-0.090). ConclusionsMaternal and perinatal outcomes are comparable with Kielland forceps, vacuum extraction, and manual rotation, with few serious adverse outcomes. With appropriate training mid-cavity rotational delivery can be practiced safely, including the use of Kielland forceps.