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Operative vaginal delivery: current trends in obstetrics.

After centuries of use in obstetrics, have forceps and vacuum deliveries become a dying art?
Contemporary trends in operative vaginal delivery show increasing numbers of vacuum
deliveries and decreasing numbers of forceps deliveries worldwide. Primary drivers of such
trends include concerns over neonatal and maternal safety as well as fewer clinicians skilled in
forcep use. Current literature reports a comparable efficacy rate for the two instruments, as
well as a decrease in maternal morbidity compared with cesarean section. It has also been
suggested that the neonatal morbidity once associated with operative vaginal delivery may
actually be a function of an abnormal labor process itself, rather than a consequence of an
operative vaginal intervention. Both the American College and the Royal College of
Obstetricians and Gynecologists continue to support the use of both vacuum and forceps and
strongly encourage residency programs to incorporate the teaching of these skills into their

Vacuum-assisted delivery.
The literature seems to allow certain general conclusions regarding the choice of instrument for
assisted vaginal delivery. Both forceps and vacuum extraction offer certain advantages and
drawbacks. Forceps are more difficult to apply, more prone to potentially significant facial
injuries, require generally better maternal analgesia, and are associated with increased
maternal soft tissue trauma. Vacuum extractors in general are easier to apply, are more likely
to result in scalp trauma, and may be associated with increased rates of intracranial trauma. It
seems likely that factors particular to each patient may play a significant role in the genesis of
delivery associated with maternal and neonatal morbidity. Because of the ease of application,
vacuum extractors may be used potentially in circumstances in which forceps assistance would
not be attempted, allowing an operator of average experience to perform rotational deliveries.
The use of vacuum extraction does appear to decrease the incidence of cesarean section in
delivery populations. Given the apparent association between difficult assisted deliveries and
increased neonatal morbidity, it is incumbent on the operator to attempt delivery only when
vaginal delivery seems to be a safe option. Furthermore, the operator in such circumstances
must be willing to reassess the attempt if initial attempts are not met with success. The minimal
rates of significant intracranial injury associated with vacuum extraction in randomized studies
of the method demonstrate the relative safety of the vacuum extraction when used judiciously.
The ultimate choice of the route of delivery and method of assisted delivery should reflect a
consideration of the fetal station, presentation, and maternal and fetal circumstances. It is
hoped that further investigations in this area may clarify some of the issues discussed in this

Cervical Ripening and Labor Induction

Labor is induced in more than 13 percent of deliveries in the United States. Postdate pregnancy
is the most common indication. Oxytocin is the drug of choice for labor induction when the
cervical examination shows that the cervix is favorable. The use of this agent requires
experience and vigilant observation for uterine hyperstimulation, hypertonus or maternal fluid
overload. In a patient whose cervix is unfavorable, the use of prostaglandin analogs for cervical
ripening markedly enhances the success of inductions. Misoprostol, a prostaglandin E1 analog
marketed as a gastrointestinal mucosal protective agent, is safe, efficacious and inexpensive for
use in cervical ripening and labor induction. Further studies will better delineate its optimal use.
Family physicians need to be familiar with the various methods of cervical ripening and labor

Oxytocin Labor Induction

Once the cervix is ripe, oxytocin is still the favored pharmacologic agent for inducing labor.
Typically, a patient with an unfavorable cervix is admitted to the hospital on the afternoon or
evening before induction. Misoprostol, 25 to 50 g, is administered intravaginally one to three
times during the night. Oxytocin induction can proceed the next morning if the patient has not
already gone into labor.
Oxytocin is prepared for use by placing 10 U in 1 L of isotonic intravenous solution to achieve a
concentration of 10 mU per mL. Because severe hypotension can occur, especially with rapid
intravenous administration, the drug is infused into the main intravenous line; a controlled
infusion device must be used to determine its rate. It can be administered as a continuous
infusion or in "pulsed" doses. Continuous infusions usually start with a dosage of 0.5 to 2.5 mU
per minute, which is increased at the same increment every 15 to 60 minutes. The effect is
noted within three to five minutes, and a steady state is achieved within 15 to 30 minutes.
Studies show a wide range of effective dosages and change intervals, and no regimen has been
shown to be clearly superior.2,7,11
Oxytocin has many advantages: it is potent and easy to titrate, has a short half-life (one to five
minutes) and is generally well tolerated. Dose-related adverse effects may occur, however.
Because oxytocin is close to vasopressin in structure, it has an antidiuretic effect when given in
high dosages (40 mU per minute); thus, water intoxication is a possibility in prolonged
inductions.2,3 Uterine hyperstimulation and uterine rupture can also occur. When the resting
uterine tone remains above 20 mm Hg, uteroplacental insufficiency and fetal hypoxia can
result. This outcome underscores the importance of continuous FHR monitoring.
If a worrisome FHR occurs during induction, the oxytocin dosage can usually be lowered rather
than stopped completely. This allows the fetus to recover without unnecessarily slowing the
entire labor. In emergency situations, the infusion can be stopped. Minor FHR abnormalities
such as variable decelerations or lack of accelerations can be corrected by changing the
mother's position, administering oxygen and increasing intravenous fluid administration.

Induction using oxytocin has side effects, but because the drug does not cross the placental
barrier, no direct fetal problems have been observed.

Umbilical cord blood transplantation

Since the first report of a successful umbilical cord blood transplantation in 1988, there has
been great interest in the use of cord blood as an alternative stem cell source to treat cancer
and genetic diseases. More than 4000 cord blood transplantations have been performed
worldwide. In this review, the scientific rationale for this therapy, as well as related preclinical
studies, cord blood banking issues, and ethical concerns, will be addressed. Results of studies in
both pediatric and adult transplantation will be discussed. Finally, new indications for cord
blood use and emerging technologies will be addressed.

Combination cord blood and haploidentical bone marrow

The Spanish group has pioneered this unique approach. There were 11 adults who received
single cord blood units and haploidentical CD34+ selected cells from a family
member.55 Neutrophil engraftment occurred at 12 days (range, 9-36 days). There were 4
patients who experienced grade II or higher acute GVHD. Of the 11 patients, 5 survive disease
free with complete cord blood chimerism at 6 to 43 months after transplantation.
There are now alternatives to single cord blood transplantation for adult patients. The
sequential cord blood results appear promising in terms of neutrophil recovery, and a low risk
of GVHD, but more work is needed in larger studies with diverse patient populations. A
suggested algorithm for choosing an optimal donor source for adults is presented in Figure 1.
Patients who do not have a matched sibling donor should search simultaneously for unrelated
bone marrow and unrelated cord blood. Patients without time to find an unrelated bone
marrow donor, or who do no not have a 10/10 or 9/10 unrelated adult volunteer donor should
be considered for cord blood transplantation. The goal should be to procure a safe donor
source, either bone marrow or cord blood, in a timely fashion so no appropriate patients are
denied transplantation.

Birth Networks
These organized, regional groups of pregnant women and birthing professionals meet regularly
to educate, empower and support each other and advocate for the improvement of maternity
care in their communities. What started as a grassroots movement has exploded across the

Evidence of a growing trend: Amy Romano of Lamaze International estimates that the number
of birth networks has doubled in the past year. Since 2004, the Lamaze Institute for Normal
Birth has awarded grants to form and expand birth networks.

Birth Stories
Expectant women are hungry for information on labor and birth, and the mainstream media is
responding with birth stories. These stories offer much more than entertainment; they provide
information on birth options, tools, classes and techniques. The impact of birth stories on
expectant parents is quickly coming to the attention of the birth professionals, and many are
actively discouraging patients from watching the highly-dramatized birth programs on cable
television. Because the level of fear in a laboring woman directly impacts the progression of her
labor, birthing professionals are directing patients to read only empowering, inspiring birth
Evidence of a growing trend: There are now 7 programs on cable television that highlight the
experience of labor and delivery. Most pregnancy magazines now feature birth stories on a
regular basis, and many birth networks and childbirth educators now sponsor birth-story nights.

Hypnosis for Childbirth

Since a 1999 segment on NBCs Dateline featured hypnosis for childbirth, interest has steadily
grown. The HypnoBirthing Method and Hypnobabies are two of the oldest and most popular
programs, but with the growing interest in this method, there are now several different
programs available, as well as supplemental products such as Journey into Childbirth: Hypnosis
for Empowered Birthing by Sheri Menelli. While no program promises a pain-free birth, this is a
frequent result.
Evidence of a growing trend: In the late 19990s there were only a few hundred educators, and
as of this year, there are over 3000.

Prenatal yoga
Prenatal yoga strengthens and stretches the muscles that are used in childbirth, and teaches
breathing and focusing techniques that help women through labor.
Evidence of a growing trend: In San Diego, California, prenatal yoga instructors are reporting an
increase in class attendance of approximately 50% over the last three years. Much of the
increase is attributed to growing support from doctors, midwives and childbirth educators who
send their clients to yoga classes to relieve back pain, reduce tension, and cope with high blood
pressure. A number of prenatal yoga videos are now available to women who prefer to practice
at home.

Water-assisted labor
Widely known as natures epidural, warm water can ease the discomfort of labor by helping a
woman relax. A birthing tub counters the effect of gravity on her contracting muscles, and
even a warm shower can provide soothing comfort to tired and tense women.

Evidence of a growing trend: In the last 10 years, water-assisted labor has grown exponentially.
In 1995 there were only three hospitals in the country that offered it. Now it is offered in more
than 260 hospitals 15% of all U.S. hospitals. In the last year alone there was a 4% increase,
and this number is expected to grow in the coming year.

A doula is a professional who is trained to provide emotional and tactical support a family
through pregnancy, labor, delivery, and newborn care. Studies show that the presence of a
doula reduces the need for medication, as well as the possibility of a Cesarean-section birth.
Evidence of a growing trend: Every doula organization reports phenomenal growth in
membership, and in the number of students in doula training classes. Doulas of North America
(DONA), just one of several doula organizations reported a 10-fold increase in the number of
certified doulas in the last 7 years.

Pregnancy Massage
A specialized form of bodywork, pregnancy massage addresses the specialized needs of a
rapidly changing body. It enhances the function and alignment of muscles and joints, improves
circulation and muscle tone, and relieves mental and physical fatigue. These benefits translate
to lower levels of stress hormones, as reported in a study by Dr. Tiffany Field at the University
of Miami School of Medicine.
Evidence of a growing trend: Instructor Elien Alexander from The School of Healing Arts in San
Diego, California, reported a 10-fold increase in the number of students becoming certified in
pregnancy massage in the last 5 years.


Submitted to: Maam Nerissa Restor

Submitted by: Edades, Shyrra L.
Group 3