st6 1 survey on the practice of forcep delivery in public hospitals … · 2006-05-23 · survey on...

Survey on the Practice of Forceps Delivery in Public

Hospitals in Hong Kong

Prepared by Dr K B CHEUNGChief of Service

Department of O&G,Tuen Mun Hospital

Introduction

• Q.A. Subcommittee meeting in 2004, forceps delivery rate was found low throughout the past years.

• The training of such skill impossible?

Introduction

• The purpose of the present survey is to see the pattern of forceps deliveries in public hospitals in Hong Kong.

• Whether the skill of forceps delivery is deteriorating.

• Whether there are more complications.

Fetal Complications

• Scalp injury• Cephalhaematoma• Intracranial haemorrhage• Facial nerve palsy• Asphyxia ( A.S. < 75)

Maternal Complications

• Third degree perineal tears • Vaginal lacerations• Cervical tears• Uterine rupture• Postpartum haemorrhage• Rectovaginal fistula

Classification of Forceps Delivery

(1) Low Forceps

(2) Mid Forceps

(3) High Forceps

Fetal head not engaged

Classification of Forceps Deliveries

Fetal head engaged ( at Level < S+2 )

Fetal head at Level S+2 or more

Method

• Retrospective survey on forceps delivery from 1.1.2002 to 31.12.2002 in all H.A. hospitals.

• All women with a viable singleton term pregnancy which is cephalic presented and delivered by forceps are included.

Survey on the use of forceps delivery in singleton cephalicpresenting fetus in HA Hospitals

Name of Hospital : QMH / PYNEH / QEH / KWH / PMH / UCH / TMH / PWHName : ___ ___ ___ID No. : X X X ___ ___ ___ ( )Age : ___________Parity :

PrimigravidaMultiparous ( previous vaginal delivery : Yes / No )

Main indication for forceps delivery : ( only one is allowed )Delay in second stagePoor maternal effortFetal distressShorten the second stage _________________ ( please specify indication )Failed V / EOthers : ______________________________ ( please specify )

Operator :FHKAMMRCOGPre-MRCOG traineePre-MRCOG trainee under direct supervision

Survey on the use of forceps delivery in singleton cephalicpresenting fetus in HA Hospitals

Examination Findings :Level of head S0

S+1

S+2

S+3 or below

Position of head DOADOPOthers : ____________________ ( please specify )

Type of forceps used :WrigleyAndersonBarnesSimpsonKiellandOthers : ______________________________ ( please specify )

Type of analgesia :NilLocal anaestheticPudenal blockEpidural analgesia

Spinal anaesthesia

Survey on the use of forceps delivery in singleton cephalicpresenting fetus in HA Hospitals

Application-delivery interval :< 5 minutes5 – 10 minutes> 10 minutes – 15 minutes> 15 minutes

Mode of delivery :Forceps delivery after 1 ( pull / pulls )

234> 4

Vacuum extractionCaesarean section

Maternal injury :NilFirst degree vaginal tearSecond degree vaginal tearThird degree vaginal tearOthers : _________________________________ ( please specify )

Survey on the use of forceps delivery in singleton cephalicpresenting fetus in HA Hospitals

Neonatal outcome :Birth weight < 2.5Kg / 2.5 – 4Kg / > 4Kg Apgar score at 5 minutes _________________________________

Admission to NICU Yes / No

Birth traumaSkull fracture Yes / NoFacial nerve injury Yes / NoIntracranial haemorrhage Yes / NoAbrasion / bruises to face or scalp Yes / NoOthers : _________________________________ ( please specify )

Results & Discussions

• A total of 345 forms were received ( from the 8 obstetric units ).

• Number of deliveries in the same year was 37,349.

• A forceps rate of 0.92%.

No. of forceps delivery in the 8 Obstetrics Units

14

117

328 4

163

0 6

020406080

100120140160180

A B C D E F G H

Parity273

72

0

50

100

150

200

250

300

Primigravida Multiparous

Main indication for forceps delivery172

2

139

7 19 6

020406080

100120140160180

Delay insecondstage

Poormaternal

effort

Fetaldistress

Shortenthe

secondstage

failed V/E Other

Operator

47

90

190

17

020406080

100120140160180200

FHKAM Post-MRCOGtrainee

Pre-MRCOGtrainee

Pre-MRCOGtrainee under

directsupervision

Examination findings : Level of head

7

110

185

33

0

20

40

60

80

100

120

140

160

180

200

S0 S+1 S+2 S+3 or below

Examination findings : Position of head

166

28

148

020406080

100120140160180

DOA DOP Others

Type of forceps used

312

245 2

0

50

100

150

200

250

300

350

Wrigley Anderson Barnes Simpson

Type of analgesia

93

148

35

66

3

0

20

40

60

80

100

120

140

160

Nil Localanaesthetic

Pudenal block Epiduralanalgesia

Spinalanaesthesia

Application-delivery interval

140

25

0 1

179

020406080

100120140160180

<5 5-10 >10-15 >15 N/ATime in Minutes

Mode of delivery200

95

21 5 3 1

020406080

100120140160180200

Forcepsdeliveryafter 1

Forcepsdeliveryafter 2

Forcepsdeliveryafter 3

Forcepsdeliveryafter 4

Forcepsdeliveryafter >4

Caesareansection

No. of pulls

Maternal injury289

35

14 1 5

0

50

100

150

200

250

300

Nil First degreetear

Seconddegree tear

Third degreetear

Others

Neonatal outcome : Birth weight

22

309

14

0

50

100

150

200

250

300

350

< 2.5 kg 2.5 - 4 kg > 4 kg

Neonatal outcome : Apgar score at 5 min

1 3 3 5 15

60

257

0

50

100

150

200

250

300

4 5 6 7 8 9 10

Admission to NICU

19

326

0

50

100

150

200

250

300

350

Yes No

Birth trauma – Skull fracture

0

345

0

50

100

150

200

250

300

350

Yes No

Birth trauma – Facial nerve injury

1

344

0

50

100

150

200

250

300

350

Yes No

Birth trauma – Intracranial haemorrhage

2

343

0

50

100

150

200

250

300

350

Yes No

Birth trauma –Abrasion / Bruises-face / Scalp

18

327

0

50

100

150

200

250

300

350

Yes No

Conclusions

(1) The forceps rate is very low in the public hospitals in Hong Kong and it varies significantly in these hospitals.

(2) Most of the forceps deliveries belong to the outlet type and were performed by trainees.

(3) The complication rate is very low too for these forceps deliveries.

(4) The level of the head in many of these deliveries is too high to account for the high percentage outlet forceps deliveries, low complications and low percentage of anaesthesia used.

Recommendations

(1) We can continue our current practice of forceps delivery as it is still a safe procedure.

(2) We should clarify with our trainees the definition and classification of forceps delivery.

(3) A re-audit exercise can be carried out a few years later to see if there is any improvement.

References(1) Geoffrey Chamberlain, Turnbull’s Obstetrics. 2nd

Edition, Churchill Livingstone. 1995 : 696.

(2) F. Gary Cunningham, Paul C. MacDonald, Norman F. Gant. Williams Obstetrics, 18th

Edition. 1989 : 425 – 426.

(3) American College of Obstetricians &Gynaecologists : Manual of standards in Obstetric-Gynaecologic Practice 2nd Edition, ACOG, Chicago, 1965.

Thank You