43

FORCEPS DELIVERY (R.C.O.G. TABLE 30)

DR. ROSEMARY JORDAN

Summary :

(a) To ta l n u m b e r of cases . . . . . . . . .

Inc idence a g a i n s t t o t a l i n f a n t s born 28 weeks m a t u r i t y a nd over (5,010) ...

(b) Ma te rna l m o r t a l i t y . . . . . . . . .

(c) Gross foetal loss . . . . . . . . . . . .

P e r i n a t a l m o r t a l i t y r a t e . . . . . . . . .

(d) Mul t ip le p r e g n a n c y (both i n f a n t s de l ive red b y forceps) . . . . . . . . . . . .

^ , 6 B o o k e d = 645 ~ 1 7 6 = 56

14.1 pe r cent .

Ni l

[~ D e a d b o r n = 11 22 4 1st week N N D ' s = 1 0

L L a t e N N D ' s = 1 29.6

4 se ts of tw ins

INSTRUMENT

B a r n e s

Kiel land ' s

W r y l e y s

To ta l

597

127

1

Leve l in P e l v i c Cav i ft T

H i g h

23 (I NND)

25 (I NND)

Mid

234 (5 D / B & 3 NND)

91 (1 D / B & 1 NND)

Low

320 (5 D/B & 5 NND)

11 (No foe ta l loss)

1 (No foe ta l loss)

T A B L E "A"

Indications for forceps delivery : Second s t a g e de l ay . . . . . . . . . . . . . . . Foe t a l d is t ress . . . . . . . . . . . . . . . . . . Ma te rna l d is t ress . . . . . . . . . . . . . . .

Ma te rna l d i s t r e s s / foe ta l d i s t ress . . . . . . P r o p h y l a c t i c . . . . . . . . . . . . . . . . . .

T o x a e m i a . . . . . . . . . . . . . . . Cardiac d i sease . . . . . . . . . . . . . . .

A.P .H. in l abour . . . . . . . . . . . . . . . P ro l apsed cord . . . . . . . . . . . . . . . . . . Twins . . . . . . . . . . . . . . . . . . . . . D i sp ropor t ion . . . . . . . . . . . . . . . . . . Obs t ruc ted l abou r To comple te de l ive ry fo l lowing V a c u u m e x t r a c t i o n

Causes of foetal loss associated with forceps delivery :

DEADBORN -- 1 l

I n t r a p a r t u m a s p h y x i a . . . . . . . . . . . . Second t w i n . . . . . . . . . . . . . . . T o x a e m i a . . . . . . . . . . . . . . . D i sp ropor t ion . . . . . . . . . . . . . . .

Mace ra t ion ... . . . . . . . . . . . . . . . Second t w i n ... . . . . . . . . . . . . No a p p a r e n t cause . . . . . . . . . . . .

Acc iden ta l h a e m o r r h a g e du r ing l abou r . . . . . . Pos tma tu r i t y - - -43 weeks . . . . . . . . . . . . Cord s t r a n g u l a t i o n / r h e s u s i n c o m p a t i b i l i t y . . . . . . Meningocoele . . . . . . . . . . . . . . . . . .

. . ~

~ 1 7 6 1 7 6

e e @

~ 1 7 6

. . ~

~

~

~ 1 7 6

O r e

@ e @

. ~ 1 7 6

~

. ~

O~@ O

~

. . ~

@ g D

... 421

... 185 27 ~

11 29 ~ 1 7 6

4 2

. . . 8

. . ~ 3

... 10

. . ~ 2

~ l

... 19

3 i

1 1

3 ~ 1 7 6 1 7 6

1 2

~ 1 7 6 1 7 6 2

~ 1 7 6 1 7 6 1

~ 1 7 6 1 7 6 1

. ~ 1

44

]ST V~EEK NEONATAL DEATHS--10 P r e m a t u r i t y and hyal ine m e m b r a n e disease . . . . . . . . . 1 H y d r o p s foetalis . . . . . . . . . . . . . . . . . . . . . 1 Anencephalus . . . . . . . . . . . . . . . . . . . . . . . . 1 P r e m a t u r i t y . . . . . . . . . . . . . . . . . . . . . 1 Anencephalus ancl" sp ina bifida . . . . . . . . . . . . . . . 1 Asphyxia neona to rum . . . . . . . . . . . . . . . . . . 2 Encephaloce]e . . . . . . . . . . . . . . . . . . . . . . . . 1 Congenital hear t d isease/pers is tent cyanosis . . . . . . . . . 1 Hydrocephalus and sp ina bifida . . . . . . . . . . . . . . . 1

LATE NEONATAL DEATHS--1 Hydrocephalus and spina bifida . . . . . . . . . . . . . . . 1

COMMENT

The incidence of forceps deliveries has risen by I per cent. since the last report, in which it was suggested that the second stage should be terminated when advance ceased rather than waiting the statutory time for second stage delay to be established. The number of cases where foetal distress was the indication has decreased and is possibly due to this more hberal interpretation.

There were 11 deadbom infants, of which 6 were possibly preventable. The Ist case was one of undiagnosed twin pregnancy. The 1st twin was delivered normally and intra-venous ergometrine given at delivery (which is our routine). The 2nd foetal heart was never heard and the uterus went into intense spasm not reheved despite general anaesthesia. The 2nd infant was delivered by vacuum extraction and forceps 1�88 hours after the ist infant. Another 2nd twin was lost after an uncomplicated antenatal career, the mother fell into labour spontaneously 5 days over term and was delivered normally of her Ist twin. The 2nd twin was delivered by forceps and found to show signs of early maceration. It is of course debatable whether induction at 39 or 40 weeks would have saved this infant. A 3rd set of twins was admitted from district having had an antepartum haemorrhage at 38 weeks. The patient was examined in theatre and no placenta praevia found, the membranes were ruptured, but foetal hearts subsequently failed. These infants could only have been saved by abdominal delivery, a course which requires especially careful consideration in this community of high parity.

Case No. 61807, a patient of 23 years, was examined under anaesthesia at 40 weeks because the head was not engaged. She was found to have a small pelvis with a flattened brim, but it was decided to allow her to fall into labour with a close watch on her progress. She was readmitted at 42 weeks in spontaneous labour. The head was free at the onset of labour which was inert. After 40 hours the head had descended into the mid cavity and the cervix was almost tully dilated when foetal heart failed and a dead- born infant of 7 lb. 4 oz. was delivered after manual rotation and heavy traction with Barnes forceps. The foetal head showed gross caput and moulding indicating that the degree of cephalo-pelvic disproportion had been underestimated. One primipara attending the clinic was allowed to go 20 days past term before admission in spontaneous labour. The infant showed signs of early maceration. A particularly disappointing case was that of a 35 year old primipara with 7 years infertility who was grossly overweight and developed superadded foxaemia. Labour began spontaneously at 39 weeks but the foetal heart failed late in the Ist stage.

Six of the 10 neonatal deaths were associated with severe abnormalities. The 4 potentially preventable deaths were associated with foetal distress, in 3 cases in the second stage of labour. One of these infants was premature 4 lb. 14 oz. ; another small baby 5 lb. 3 oz. succumbed to the combined effects of asphyxia, hyaline membrane disease and postmaturity. A primigravida, uncertain of her dates, could have been 4 weeks postmature.

45

The infant appeared postmature. In the 4th case foetal distress developed in a primigravida during the 1st stage of labour. Full dilatation of the cervix was achieved using the vacuum extractor and the delivery completed by rotation and traction with Kielland's forceps. The infant's head was well-moulded so it is probable that there was a greater degree of dis- proportion than expected.

VACUUM EXTRACTOR (R.C.O.G. TABLE 30A)

MASTER

Summary :

82 f Booked (a) To ta l n u m b e r of cases . . . . . . . . . ~ Unbooked

Inc idence a g a i n s t t o t a l i n f a n t s born 28 weeks m a t u r i t y a n d over (5,010) ... 1.6 pe r cent .

(b) Ma te rna l m o r t a l i t y . . . . . . . . . Ni l

=69 =13

(c) Gross foeta l loss . . . . . . . . . . . . 2 (Both 1st week NND's ) P e r i n a t a l m o r t a l i t y r a t e . . . . . . . . . 24.4

(d) Mul t ip le p regnanc ie s . . . . . . . . . N i l

Foetal loss associated with Vacuum extractor delivery :

I S T WEEK NEONATAL DEATHS--2 (I) Gravida 15. Unbooked. Grade 2 placenta praevia. Foetal distress. Easy

delivery--7 lb. Lived l0 hours. Cause--Atelectasis.

(2) Gravida 5. Brow presentation. Flexed with difficulty---easy delivery. 6 lb. 2 oz. Infant's condition " fair " at birth. Lived 3 days. Cause-- Mongolism. Congenital heart disease.

T A B L E " B "

'o ta l cases . . . . . . . . . . . . ' e r ina ta l loss . . . . . . . . . . . .

ndications : Pro longed l abour ( l s t s t age V.E.) Fa i l u r e to advanc e in 2nd s t a g e ... F o e t a l d is t ress ( l s t s t age V.E.) ... Foe t a l d is t ress (2nd s t age V.E.) ... P r o p h y l a c t i c - - " t o x a e m i a " ... M a n a g e m e n t of b row p r e s e n t a t i o n Ass i s t ance in ca rd i ac /d i abe t e s ... M a n a g e m e n t of breech . . . . . . U n s t a b l e lie . . . . . . . . . ... M a n a g e m e n t of tw ins . . . . . . Cord compl ica t ion . . . . . . M a t e r n a l d is t ress ... ::: ... P l a c e n t a p r a e v i a - - g r a d e s 1 a n d 2 A c c i d e n t a l haemor r ha ge

(unclassified) . . . . . . . . . C o m p o u n d p r e s e n t a t i o n . . . . . . K n o w n I .U .D . . . . P rophy lac t i c - - -p rev ious L.S.S . . . .

TOTALS . . . . . . . . .

1960

51 2

(1 D / B a n d

1 NND)

22 6

14 2 2 1 1 1 1 0 0 0 0

51

1961

47 5

(2 D]B and

3 NND)

7 3

11 3 2 2 1 0 3 7 1 0 1

47

1962

102 5

(3 D]B and

2 NND)

21 6

22 14

3 0 1 1 4

16 2 2 2

102

1963

82 2

(Both NND 1

11 4

43 1 3 2 I 0 0 3 1 9 I

82