ST6 1 Survey on the practice of forcep delivery in public hospitals … · 2006-05-23 · Survey on...
37
Survey on the Practice of Forceps Delivery in Public Hospitals in Hong Kong Prepared by Dr K B CHEUNG Chief of Service Department of O&G, Tuen Mun Hospital
Transcript of 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
