Expert Commentary
Is it time to revive rotational forceps?
Contemporary data suggest that it is.
What this EVIDENCE means for practice
Before we prematurely adopt ultrasound evidence of LMA as a significant morbidity, we need to learn more about its true etiology, pathophysiology, and epidemiology. We don’t yet know enough to say that it’s such a bad injury, when imaged via ultrasound, that it warrants cesarean delivery to avoid it.
When deciding between cesarean and forceps, keep the risks of second-stage cesarean in mind
Pergialiotis V, Vlachos DG, Rodolakis A, Haidopoulos D, Thomakos N, Vlachos GD. First versus second stage C/S maternal and neonatal morbidity: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2014;175:15–24.
This expert systematic review and meta-analysis summarizes the morbidity of second-stage cesarean delivery. When an obstetrician has a patient who is arrested at persistent occiput posterior position, say, and is trying to decide on cesarean delivery versus Kielland’s rotation or other forceps delivery, it is necessary to balance the risks and benefits of the 2 options. And as all clinicians are aware, when cesarean delivery is performed late in labor and the patient has been pushing for a prolonged period of time in the second stage—cesarean can be a challenging procedure. Moreover, these late cesareans are associated with much greater risks than cesarean deliveries performed earlier in labor.
Details of the review
Pergialiotis and colleagues selected 10 studies comparing maternal and neonatal morbidity and mortality between cesarean delivery at full dilatation and cesarean delivery prior to full dilatation. These studies involved 23,104 women with a singleton fetus who underwent cesarean delivery in the first (n = 18,160) or second (n = 4,944) stage of labor.
They found that second-stage cesarean was associated with a higher rate of maternal death (OR, 7.96; 95% CI, 1.61–39.39), a higher rate of maternal admission to the intensive care unit (OR, 7.41; 95% CI, 2.47–22.5), and a higher maternal transfusion rate (OR, 2.60; 95% CI, 1.49–2.54).
The rate of neonatal death also was higher among second-stage cesareans (OR, 5.20; 95% CI, 2.49–10.85), as was admission to the neonatal intensive care unit (OR, 1.63; 95% CI, 0.91–2.91), and the 5-minute Apgar score was more likely to be less than 7 (OR, 2.77; 95% CI, 1.02–7.50).
According to the authors, this study is the “first systematic review and meta-analysis that investigates the impact of the stage of labor on maternal and neonatal outcomes among women delivering by cesarean section.” The findings demonstrate with authority that second-stage cesareans can be a risky undertaking.
What this EVIDENCE means for practice
Cesareans performed late in the second stage of labor are distinct from those performed in the first stage, carrying much higher risks, especially for the mother. When deciding whether to proceed with cesarean, vacuum, or forceps, the added risk of second-stage cesarean is an important aspect of both the consent conversation and clinical decision making.
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