Maternal Complication Related To Instrumental Delivery At Felege Hiwot Specialized Hospital, Northwest Ethiopia. A Retrospective Cross-Sectional Study

doi:10.21203/rs.2.10698/v3

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Maternal Complication Related To Instrumental Delivery At Felege Hiwot Specialized Hospital, Northwest Ethiopia. A Retrospective Cross-Sectional Study

https://doi.org/10.21203/rs.2.10698/v3

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published 05 Aug, 2019

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ABSTRACT Objective: The study aimed to determine proportion and risk factors for maternal complication related to forceps and vacuum delivery among mother who gave birth at Felege Hiwot Comprehensive Specialized Hospital (FHCSH). Results: Records of 406 mothers managed with instrumental vaginal delivery were reviewed and 97% of the reviewed card had complete documentation. The proportion of maternal complications related to instrumental delivery was 12.1%. A major complication of forceps assisted delivery was 2nd-degree perineal tear (7.4%), 3rd-degree perineal tear (1.5%), cervical tear (1.5%) and episiotomy extension (1%). However, the complication of vacuum-assisted vaginal delivery was only cervical tear (0.5%) and episiotomy extension (0.5%). Episiotomy during instrumental delivery reduce maternal complication by 86% [AOR=0.14, 95%CI=0.07-0.3]. Forceps assisted vaginal delivery had 3.4 times more risk for maternal complication compared to vacuum-assisted vaginal delivery [AOR=3.4, 95%CI=1.08-10.67] and the same is true for primiparity that primipara women who gave birth by the help of instrument had 3.5 times more risk for maternal complication compared to a multipara women [AOR=3.5, 95%CI=1.26-9.98]. Keywords: maternal complication, instrumental delivery, northwest, Ethiopia

Maternal & Fetal Medicine

Obstetrics & Gynecology

maternal complication

instrumental delivery

northwest

Ethiopia

Instrumental vaginal delivery is applying obstetric forceps or vacuum device to effect in vaginal delivery of the fetus. These instrument-assisted deliveries are performed for the indication of maternal or fetal related condition and any event that threatens the mother or fetus but likely relieved by second-stage intervention [1-3].

Use of forceps and vacuum is common obstetrics practice in case of fetal distress or prolonged second stage of labor however they also carried a significant number of maternal complications like anal sphincter injuries.

In developed countries, a complication related to instrumental delivery is not significant as a result of advancement in skill on the management of instrumental delivery and accessibility of resources. However, developing countries like Ethiopia, mother and their newborn develop different degree of morbidity and even mortality due to instrumental delivery. Mostly those problems are avoidable if early interventions are undertaken [4, 5].

Complication due to instrumental delivery can be minor complication like laceration of vagina and perineum and major complication associated with traumatic haemorrhage, bladder injury and pelvic muscle injury[6].

In country like Ethiopia, there is insufficient evidence which shows on the magnitude and factor related to maternal complication of instrumental delivery. Knowledge on the magnitude of the problem and identification of possible risk factors for maternal complication related to instrumental delivery may reduce the maternal complication. Hence this study was aimed to determine the proportion of maternal complications related to instrumental vaginal delivery and its associated factors among mothers who gave birth at felege Hiwot comprehensive specialized hospital.

Study design and setting

A Facility-based retrospective cross-sectional study was conducted at the maternity ward of Felege Hiwot Comprehensive Specialized Hospital. This hospital is located in Bahir dar city which found approximately 565 km northwest of Addis Ababa.

The hospital has obstetrics, gynecology, pediatrics, internal medicine, ophthalmology & orthopedic surgery services. The labor ward gives services to around 612 deliveries per month. Department of Obstetrics and Gynecology had labor ward with seven beds in the first stage room, two delivery couches in the second stage room, four beds in the recovery unit and sixty-nine beds in the maternity ward along with two operating rooms.

SOURCE POPULATION: mothers who gave birth in Felege Hiwot comprehensive specialized hospital from December 1, 2015 to November 30, 2017.

STUDY POPULATIONS: mothers who had an instrumental vaginal delivery in Felege Hiwot comprehensive specialized Hospital from December 1, 2015 to November 30, 2017.

SAMPLE SIZE DETERMINATION:

The sample size was determined by using a single population proportion formula after considering the following assumptions:

The proportion of maternal complication related to instrumental vaginal delivery accounts for 59.8% from previous studies[7]. By taking 5% Marginal error and 95% Confidence interval, the required sample size was 369. After adding 10% for incomplete secondary data the final sample size was 406.

SAMPLING PROCEDURE

The total number of women who gave birth in the hospital from Dec1, 2015 to Nov 30, 2017 was 14688. We identified and reviewed 841chart, of which 21 charts were not available (lost) in the card room and through Systematic random sampling technique 406 charts were selected from 820 charts for this study (FIG S1(2)).

INCLUSION AND EXCLUSION CRITERIA

INCLUSION CRITERIA: Medical records of all instrumental deliveries in the hospital from December 1, 2015 to November 30, 2017 were included in the study.

EXCLUSION CRITERIA: incompletely documented chart (chart which does not include all variable) and C/S delivery after failed instrument are excluded.

Socio-demographic, obstetric, enabling and Instrumental delivery related variables

Socio-demographic, obstetric and other factors were examined as a potential predictor in this analysis. Socio-demographic factors include age and place of residence. Obstetric related factors include parity, number of pregnancy, gestational age, BW(birth weight), Fetal presentation/position, station, current pregnancy type, frequency of ANC visit, duration of labour and Obstetric indications for IVD( prolonged second stage, non-reassuring Fetal heart rate pattern, poor maternal effort, APH/abruption, after coming head of breech presentation, MSAF). Enabling factors are the type of hospital visit, instrument available and availability of electronic Fetal monitoring (CTG used). Instrumental delivery related variables include types of instrument, the presence of episiotomy and type of episiotomy.

OPERATIONAL DEFINITIONS

Maternal complication: maternal complication related to instrumental delivery are the presence of at least one of the following (perineal tear, cervical laceration, vaginal laceration, episiotomy extension, traumatic hemorrhage (primary PPH), urinary retention, uterine rupture)[7].

DATA COLLECTION INSTRUMENTS

Data collection checklist was adapted and modified from different studies[7, 8]

DATA PROCESSING AND ANALYSIS

Collected data were entered into EPI Info version 7 then exported to SPSS version 23 for analysis. Descriptive statistics used to describe the main features of the data. Bivariate analysis was done to identify candidate variable using p≤ 0.2. Multivariate logistic regression was used to control the effect of confounder and variable with p≤0.2 was included in multivariable logistic regression analysis. Finally, statistical significance declared at p-value<0.05.

Socio-demographic characteristics

From Four hundred six (406) mothers managed with instrumental vaginal delivery, three hundred ninety-seven (97%) of mother’s chart was completely documented. Two hundred forty-nine mothers (62.7%) were from urban areas. The mean age was 24.94 ± 4.7 years. Nearly half of the mothers were below 25 years 254(64%) (table1).

Obstetric related characteristics

Two hundred eighty (70.5%) mothers were primipara. three hundred eighty-five (97%) mothers had at least one ANC follow (table1).

Obstetric indication for instrumental delivery

Prolonged 2^nd stage was the commonest indication for both forceps and vacuum-assisted delivery which accounts 110(33%) and 29(43.9%) respectively (Table 2).

Proportion of Maternal Complication Related To Instrumental Delivery

The proportion of maternal complication related to instrumental delivery was 12.1% [95%CI= 9.3-15.3]. From the total complication, 91.7% was contributed by forceps-assisted delivery and only 8.3% of complications occur due to vacuum-assisted vaginal delivery. A major complication of forceps assisted delivery was 2nd-degree perineal tear (7.4%), 3rd-degree perineal tear (1.5%), cervical tear (1.5%), episiotomy extension (1%). complication of vacuum-assisted vaginal delivery was cervical tear (0.5%) and episiotomy extension (0.5%).

Factors associated with maternal complications related to instrumental vaginal delivery

Primiparity, episiotomy, absence of CTG, age of mother, hospital visit type, type of instrumental delivery, low instrumentation were variable identified in bivariate logistic regression analysis. However, after fitting those variables in multivariable logistic regression model; episiotomy, Primiparity and forceps-assisted instrumental vaginal delivery were a statistically significant association with maternal complication related to instrumental delivery.

Protective effect of episiotomy was shown for maternal complication related to instrumental delivery. Women who had an episiotomy during instrumental delivery were 86% lower maternal complication compared to women who didn't have episiotomy [AOR= 0.14, 95%CI =0.07-0.3]. Furthermore, mother who had forceps delivery was 3.4 times more likely to develop maternal complication than mother who had vacuum delivery [AOR=3.4, 95%CI =1.08-10.67]. Similarly being a primipara mother was about 3.5 times more risk for a complication of instrumental delivery than being multipara mother. [AOR= 3.5, 95%CI =1.26-9.98] (Table 3)

Overall maternal complication related to instrumental delivery was12.1%. This finding was consistent with different other studies. Mothers who had the procedure developed complications like second and third-degree perineal tear as well as episiotomy extension [9-11].however, this finding was in contrast with other study finding like study in United States and England [12, 13]. This can be due to the population described in this study is highly different in wealth quintile and service quality provided.

There is a significant difference in maternal complications between women delivered by forceps as compared to those delivered by vacuum. Mothers who had forceps delivery were 3.4 times more likely to develop maternal complication than those mothers who had vacuum delivery. These findings are in accordance with the Cochrane database review study that maternal morbidity was less in vacuum extraction compared to forceps delivery. this is evidenced by vacuum extraction was associated with less pain at delivery and less likely to cause serious injury on the mother[14] [15]. Recently vacuum extraction is most commonly used when an instrument is needed to facilitate vaginal delivery, and also this is observed in different other studies. Forceps deliveries appear to have lost their favour. This shift in practice may have been influenced both by the evidence of dramatically reduced maternal trauma with vacuum extraction compared with forceps delivery. However, others showed that perineal damage like second and third-degree lacerations had no difference between the two methods [16, 17].

Mothers who had episiotomy were about 86% less risk for maternal complication of instrumental delivery than those who had no episiotomy. This is also true that mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction and forceps delivery. Mediolateral episiotomy in operative vaginal delivery strongly protects the occurrence of anal sphincter lesions [18, 19].

Primipara mother was about 3.5 times more likely risk for a complication of instrumental delivery than multipara mother. A possible explanation for this may be due to a higher tendency to second stage delays in primigravida mother. Even though the exact mechanism is not justified primipara women had a high risk for perineal injuries [18].

Maternal complication related to instrumental vaginal delivery is high in Felege Hiwot comprehensive specialized hospital. Forceps assisted vaginal delivery and primiparity were a significant risk factor associated with maternal complication related to instrumental delivery. However, episiotomy found to be strongly protective for maternal complication during instrumental delivery so liberal use of episiotomy during instrumental delivery is encouraged.

Limitation

This study shares the limitations of cross-sectional studies and hence may not be possible to establish a temporal relationship between maternal complication due to instrumental vaginal delivery and explanatory variables.
It was a retrospective study; important variables like socio-demographic status, body mass index of the mother and sequential use of instrument were not addressed in this study.
The study was conducted in a single hospital; the results might not be a representative of other institutions.

ANC: Antenatal Care, APH: Ante Partum Haemorrhage, CS: Caesarean Section, FHCSH: Felege Hiwot Comprehensive Specialized Hospital, IVD: Instrumental Vaginal Delivery, OVD: Operative Vaginal Delivery, PPH: Postpartum Haemorrhage

Ethical consideration

The data collection was carried out after getting approval for the project proposal from the ethical review board of Bahir Dar University College of medicine and health science. An official letter was obtained from the Amhara public health institute and permission from Felege Hiwot Referral Hospital director, obstetric ward case team coordinator and card room coordinator. Confidentiality of the information was assured from all the data collectors and investigators sides. The checklist was administered anonymously.

Consent for publication

Not applicable in this study

Availability of data and materials

The datasets used in this study are available from the corresponding author on reasonable request.

Competing interests

The authors declared that they have no competing interests.

Funding

We are grateful to Bahir Dar University College of medicine and health science for their financial support. However, beyond finical support, the founders did not have any role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Authors’ contributions

SB wrote the proposal, gives training on data collection, analyzed the data and drafted the paper. DA, SK, and SA approved the proposal with some revisions, participated in data analysis and manuscript writing. All authors read and approved the final manuscript.

Acknowledgments

The authors are gland to thanks Bahir Dar University College of medicine and health science. Our gratitude also goes to Felege Hiwot referral hospital card room staffs and data collectors.

[1] Hubena, Z., A. Workneh, and Y. Siraneh, Prevalence and Outcome of Operative Vaginal Delivery among Mothers Who Gave Birth at Jimma University Medical Center, Southwest Ethiopia. Journal of pregnancy, 2018. 2018: p. 12.

[2] Ali, U.A. and E.R. Norwitz, Vacuum-assisted vaginal delivery. Reviews in Obstetrics and Gynecology, 2009. 2(1): p. 5.

[3] Aliyu, L., A. Kadas, and M. Hauwa, Instrumental vaginal delivery in bauchi, northeast Nigeria. Journal of the West African College of Surgeons, 2011. 1(4): p. 18.

[4] Iyoke, C.A. and H.E. Onah, Vacuum deliveries at the University of Nigeria Teaching Hospital, Enugu. Tropical Journal of Obstetrics and Gynaecology, 2006. 23(1): p. 23-26.

[5] Singh, A. and P. Rathore, A comparative study of feto-maternal outcome in instrumental vaginal delivery. The Journal of Obstetrics and Gynecology of India, 2011. 61(6): p. 663-666.

[6] Damron, D.P. and E.L. Capeless, Operative vaginal delivery: a comparison of forceps and vacuum for success rate and risk of rectal sphincter injury. Am J Obstet Gynecol, 2004. 191(3): p. 907-10.

[7] Gebre S, h.A., Complications of Instrumental Vaginal Deliveries and Associated Factors in Suhul General Hospital, Shire,North-West Tigray, Ethiopia. J Gen Pract (Los Angel) 5: 300. 2017. 1.

[8] Abegizer, A., G.T. Feyissa, and A. Gurmessa, Operative deliveries: indications and post operative complications at Mattu Karl Hospital, Oromia Regional State, south west Ethiopia. Journal of Health, Medicine and Nursing, 2015. 16: p. 42-46.

[9] de Leeuw, J.W., Struijk, PC,Vierhout, ME,Wallenburg, HCS ., Risk factors for third degree perineal ruptures during delivery. BJOG: An International Journal of Obstetrics & Gynaecology, 2001. 108(4): p. 383-387.

[10] Adaji, S., S. Shittu, and S. Sule, Operative vaginal deliveries in Zaria, Nigeria. Annals of African medicine, 2009. 8(2).

[11] Singh, A. and P. Rathore, A comparative study of feto-maternal outcome in instrumental vaginal delivery. J Obstet Gynaecol India, 2011. 61(6): p. 663-6.

[12] Kudish, B., Blackwell, S. McNeeley, S. G.Bujold, E.Kruger, M.Hendrix, S. L.Sokol, R.et al., Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. Am J Obstet Gynecol, 2006. 195(3): p. 749-54.

[13] Ekéus, C., U. Högberg, and M. Norman, Vacuum assisted birth and risk for cerebral complications in term newborn infants: a population-based cohort study. BMC pregnancy and childbirth, 2014. 14(1): p. 36.

[14] O'Mahony, F., G.J. Hofmeyr, and V. Menon, Choice of instruments for assisted vaginal delivery. Cochrane Database of Systematic Reviews, 2010(11).

[15] Royal College of Obstetrician and Gynaecologists, Operative Vaginal Delivery., Green–top Guideline No. 26. London: RCOG, 2011.

[16] Prapas, N., Kalogiannidis, I. Masoura, S. Diamanti, E. Makedos, A. Drossou, D. Makedos, G.., Operative vaginal delivery in singleton term pregnancies: short-term maternal and neonatal outcomes. Hippokratia, 2009. 13(1): p. 41-5.

[17] Lurie, S., M. Glezerman, and O. Sadan, Maternal and neonatal effects of forceps versus vacuum operative vaginal delivery. Int J Gynaecol Obstet, 2005. 89(3): p. 293-4.

[18] de Leeuw, J.W., de Wit, C. Kuijken, J. P. Bruinse, H. W.., Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG, 2008. 115(1): p. 104-8.

[19] Bodner-Adler, Barbara,Bodner, Klaus,Kimberger, Oliver,Wagenbichler, Peter Mayerhofer, Klaus., Management of the perineum during forceps delivery. Association of episiotomy with the frequency and severity of perineal trauma in women undergoing forceps delivery. The Journal of reproductive medicine, 2003. 48(4): p. 239-242.

Table 1: socio-demographic and Obstetrics related characteristics of women who undergone instrumental deliveries at FCSH from December 1, 2015 to November 30, 2017.

Variables

Frequency

Percent %

Age

<25

25-35

>35

254

128

64.0

32.2

3.8

Place of residence

Urban

rural

249

148

62.7

37.3

Parity

Primipara

Multipara

280

117

70.5

29.5

ANC visit

Yes

385

Hospital visit type

Referral

Direct visit

141

256

35.5

64.5

Gestational age

Pre-term

Term

Post-term

368

1.8

92.7

5.5

Types of instrumental delivery

Forceps delivery

Vacuum delivery

332

83.6

16.4

Type of instrumentation

Mid

Low

Outlet

215

143

9.8

54.2

36.0

Birth weight

<2500

≥2500

337

15.1

84.9

Fetal position

334

84.2

10.8

Table 2: Obstetric indications for instrumental vaginal delivery at FHCSH from December 1, 2015 to November 30, 2017

Indication	Types of instrumental delivery

	Forceps	vacuum


Prolonged second stage	110(33%)	29(43.9%)
Fetal distress	100(30%)	22(33.3%)
Maternal exhaustion	99(29.7%)	11(16.7%)
PE/E	16(4.7%)	3(6.1%)
Other (GIIIMSAF, APH/abruption, prophylactic forceps).	7(2.6%)	-

Table 3: Factors associated with maternal complications related to instrumental vaginal deliveries in binary & multiple logistic regressions at FHCSH from December 1, 2015 to November 30, 2017

Variables

Maternal

COR(95%CI)

AOR(95%CI)

p-value

Complication

Yes

Is CTG available

Yes

198

151

0.55[.3-1.0]

0.68[0.34-1.33]

0.266

Types of instrumental delivery

Forceps

Vacuum

288

2.33[0.81-6.73]

3.4[1.08-10.67]

0.034^*

Does she had an episiotomy

Yes

296

0.27[0.14-0.52]

0.14[0.07-0.3]

0.000*

Does she Had HTN

Yes

327

0.26[0.15-2.84]

3.7(0.4-31.)

0.23

Birth weight

<2500

≥2500

299

0.64[0.29-1.35]

1.41[0.6-3.31]

0.43

Age of the mother

<25

25-35

>35

216

119

0.37[0.17-0.81

0.4[0.05-3.08]

2.5[0.26-23.38]

0.8[0.08-7.76]

0.44

0.85

Parity

Primipara

Multipara

238

111

3.3[1.34-7.9]

3.5[1.26-9.98]

0.017*

ANC follow up

yes

340

0.4[.104-1.52]

2.82[0.6-13.14]

0.186

Hospital visit type

Referral

Direct visit

117

232

1.98[1.1-3.64]

1.58[0.81-3.06]

0.17

Fetal station

Mid

Low

Outlet

188

124

0.35[.08-1.58]

0.94[0.5-1.76]

0.2[0.04-1.05]

1.02[0.5-2.06]

0.06

0.96

*p-value<0.05

FIGS1.pdf

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Journal Publication

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Submission checks completed at journal
06 Nov, 2019
Editorial decision: Accept
27 Jul, 2019

You are reading this latest preprint version

Maternal Complication Related To Instrumental Delivery At Felege Hiwot Specialized Hospital, Northwest Ethiopia. A Retrospective Cross-Sectional Study

Status:

Journal Publication

Version 3

Abstract

INTRODUCTION

METHODS

Result

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Table 1: socio-demographic and Obstetrics related characteristics of women who undergone instrumental deliveries at FCSH from December 1, 2015 to November 30, 2017.

Supplementary Files

Status:

Journal Publication

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