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      Perinatal and maternal morbidity and mortality among term singletons following midcavity operative vaginal delivery versus caesarean delivery

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          Abstract

          Objective

          To quantify severe perinatal and maternal morbidity/mortality associated with midcavity operative vaginal delivery compared with caesarean delivery.

          Design

          Population‐based, retrospective cohort study.

          Setting

          British Columbia, Canada.

          Population

          Term, singleton deliveries (2004–2014) by attempted midcavity operative vaginal delivery or caesarean delivery in the second stage of labour, stratified by indication for operative delivery ( n = 10 901 deliveries; 5057 indicated for dystocia, 5844 for fetal distress).

          Methods

          Multinomial propensity scores and mulitvariable log‐binomial regression models were used to estimate adjusted rate ratios ( ARR) and 95% confidence intervals (95% CI).

          Main outcome measures

          Composite severe perinatal morbidity/mortality (e.g. convulsions, severe birth trauma and perinatal death) and severe maternal morbidity (e.g. severe postpartum haemorrhage, shock, sepsis and cardiac complications).

          Results

          Among deliveries with dystocia, attempted midcavity operative vaginal delivery was associated with higher rates of severe perinatal morbidity/mortality compared with caesarean delivery (forceps ARR 2.11, 95% CI 1.46–3.07; vacuum ARR 2.71, 95% CI 1.49–3.15; sequential ARR 4.68, 95% CI 3.33–6.58). Rates of severe maternal morbidity/mortality were also higher following midcavity operative vaginal delivery (forceps ARR 1.57, 95% CI 1.05–2.36; vacuum ARR 2.29, 95% CI 1.57–3.36). Among deliveries with fetal distress, there were significant increases in severe perinatal morbidity/mortality following attempted midcavity vacuum ( ARR 1.28, 95% CI 1.04–1.61) and in severe maternal morbidity following attempted midcavity forceps delivery ( ARR 2.34, 95% CI 1.54–3.56).

          Conclusion

          Attempted midcavity operative vaginal delivery is associated with higher rates of severe perinatal morbidity/mortality and severe maternal morbidity, though these effects differ by indication and instrument.

          Tweetable abstract

          Perinatal and maternal morbidity is increased following midcavity operative vaginal delivery.

          Abstract

          Tweetable abstract

          Perinatal and maternal morbidity is increased following midcavity operative vaginal delivery.

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          Most cited references28

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          Propensity score techniques and the assessment of measured covariate balance to test causal associations in psychological research.

          Daniel C. Anthony, S Harder, Philip Stuart (2010)
          There is considerable interest in using propensity score (PS) statistical techniques to address questions of causal inference in psychological research. Many PS techniques exist, yet few guidelines are available to aid applied researchers in their understanding, use, and evaluation. In this study, the authors give an overview of available techniques for PS estimation and PS application. They also provide a way to help compare PS techniques, using the resulting measured covariate balance as the criterion for selecting between techniques. The empirical example for this study involves the potential causal relationship linking early-onset cannabis problems and subsequent negative mental health outcomes and uses data from a prospective cohort study. PS techniques are described and evaluated on the basis of their ability to balance the distributions of measured potentially confounding covariates for individuals with and without early-onset cannabis problems. This article identifies the PS techniques that yield good statistical balance of the chosen measured covariates within the context of this particular research question and cohort.
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            Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group

            Marian Knight, William Callaghan, Cynthia Berg … (2009)
            Background Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Several recent publications have noted an increasing trend in incidence over time. The international PPH collaboration was convened to explore the observed trends and to set out actions to address the factors identified. Methods We reviewed available data sources on the incidence of PPH over time in Australia, Belgium, Canada, France, the United Kingdom and the USA. Where information was available, the incidence of PPH was stratified by cause. Results We observed an increasing trend in PPH, using heterogeneous definitions, in Australia, Canada, the UK and the USA. The observed increase in PPH in Australia, Canada and the USA was limited solely to immediate/atonic PPH. We noted increasing rates of severe adverse outcomes due to hemorrhage in Australia, Canada, the UK and the USA. Conclusion Key Recommendations 1. Future revisions of the International Classification of Diseases should include separate codes for atonic PPH and PPH immediately following childbirth that is due to other causes. Also, additional codes are required for placenta accreta/percreta/increta. 2. Definitions of PPH should be unified; further research is required to investigate how definitions are applied in practice to the coding of data. 3. Additional improvement in the collection of data concerning PPH is required, specifically including a measure of severity. 4. Further research is required to determine whether an increased rate of reported PPH is also observed in other countries, and to further investigate potential risk factors including increased duration of labor, obesity and changes in second and third stage management practice. 5. Training should be provided to all staff involved in maternity care concerning assessment of blood loss and the monitoring of women after childbirth. This is key to reducing the severity of PPH and preventing any adverse outcomes. 6. Clinicians should be more vigilant given the possibility that the frequency and severity of PPH has in fact increased. This applies particularly to small hospitals with relatively few deliveries where management protocols may not be defined adequately and drugs or equipment may not be on hand to deal with unexpected severe PPH.
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              Improving propensity score weighting using machine learning.

              Richard K. C. Lee, Justin Lessler, Philip Stuart … (2010)
              Machine learning techniques such as classification and regression trees (CART) have been suggested as promising alternatives to logistic regression for the estimation of propensity scores. The authors examined the performance of various CART-based propensity score models using simulated data. Hypothetical studies of varying sample sizes (n=500, 1000, 2000) with a binary exposure, continuous outcome, and 10 covariates were simulated under seven scenarios differing by degree of non-linear and non-additive associations between covariates and the exposure. Propensity score weights were estimated using logistic regression (all main effects), CART, pruned CART, and the ensemble methods of bagged CART, random forests, and boosted CART. Performance metrics included covariate balance, standard error, per cent absolute bias, and 95 per cent confidence interval (CI) coverage. All methods displayed generally acceptable performance under conditions of either non-linearity or non-additivity alone. However, under conditions of both moderate non-additivity and moderate non-linearity, logistic regression had subpar performance, whereas ensemble methods provided substantially better bias reduction and more consistent 95 per cent CI coverage. The results suggest that ensemble methods, especially boosted CART, may be useful for propensity score weighting. (c) 2009 John Wiley & Sons, Ltd.
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                Author and article information

                Contributors
                GM Muraca: gmuraca@cfri.ca
                Journal
                Journal ID (nlm-ta): BJOG
                Journal ID (iso-abbrev): BJOG
                Journal ID (doi): 10.1111/(ISSN)1471-0528
                Journal ID (publisher-id): BJO
                Title: Bjog
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Print): 1470-0328
                ISSN (Electronic): 1471-0528
                Publication date (Electronic): 21 August 2017
                Publication date (Print): May 2018
                Volume: 125
                Issue: 6 ( doiID: 10.1111/bjo.2018.125.issue-6 )
                Pages: 693-702
                Affiliations
                [ 1 ] School of Population and Public Health University of British Columbia Vancouver BC Canada
                [ 2 ] Department of Obstetrics & Gynaecology University of British Columbia Vancouver BC Canada
                [ 3 ] BC Children's Hospital Research Institute Vancouver BC Canada
                [ 4 ] Department of Obstetrics and Gynaecology King Saud University King Khalid University Hospital Riyadh Saudi Arabia
                [ 5 ] Department of Statistics University of British Columbia Vancouver BC Canada
                Author notes
                [*] [* ] Correspondence: G Muraca, Children's and Women's Hospital and Health Centre of British Columbia, C403‐4500 Oak Street, Vancouver, British Columbia, Canada, V6H 3N1. Email gmuraca@ 123456cfri.ca
                Article
                Publisher ID: BJO14820
                DOI: 10.1111/1471-0528.14820
                PMC ID: 5947834
                PubMed ID: 28692173
                SO-VID: 29b1521a-97f4-42f6-b2c7-4568592715a6
                Copyright © © 2017 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                Date accepted : 05 July 2017
                Page count
                Figures: 0, Tables: 4, Pages: 10, Words: 8690
                Funding
                Funded by: Vanier Canada Graduate Scholarship
                Funded by: BC Children's Hospital Research Institute
                Funded by: Canadian Institutes of Health Research (CIHR)
                Award ID: APR‐126338
                Award ID: MAH‐15445
                Categories
                Subject: General Obstetrics
                Subject: General Obstetrics
                Custom metadata
                source-schema-version-number 2.0
                component-id bjo14820
                cover-date May 2018
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:version=5.3.8.2 mode:remove_FC converted:11.05.2018

                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: birth injury,caesarean delivery,forceps extraction,instrumental vaginal delivery,obstetric trauma,operative vaginal delivery,vacuum extraction
                Data availability:
                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: birth injury, caesarean delivery, forceps extraction, instrumental vaginal delivery, obstetric trauma, operative vaginal delivery, vacuum extraction

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