|Year : 2014 | Volume
| Issue : 2 | Page : 99-104
Disappearing art of forceps delivery and the trend of instrumental vaginal deliveries at Abakaliki, Nigeria
Robinson Chukwudi Onoh1, Paul Olisaemeka Ezeonu1, Okeudo Chijioke2, Tochi Petronilla Onoh3, AK Saidu4, Chinonyelum Thecla Ezeonu5
1 Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
2 Department of Obstetrics and Gynaecology, Imo State University Teaching Hospital, Orlu, Imo State, Nigeria
3 Department of Pathology, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
4 Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
5 Department of Paediatrics, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
|Date of Web Publication||13-Nov-2014|
Dr. Robinson Chukwudi Onoh
Department of Obstetrics and Gynaecology, Federal Teaching Hospital, PMB 102, Abakaliki - 480 001, Ebonyi State
Source of Support: None, Conflict of Interest: None
Background: Instrumental vaginal deliveries are conducted for either maternal or fetal indication in well-selected cases to optimize feto-maternal outcome. The trend is changing from forceps toward vacuum deliveries in many countries. Objectives: The aim was to determine the rate of instrumental deliveries, the trend and the feto-maternal outcome. Materials and Methods: This was a retrospective study of all women that had instrumental delivery over 10 year period (between January 1, 2003 and December, 2012) at Federal Teaching Hospital, Abakaliki. Ethical approval was obtained from the Research and Ethics Committee of our hospital. The retrieved information were coded, entered and analyzed using the 2008 Epi-Info™ version 3.5.1 Statistical Software (Centre for Disease Control, Atlanta GA, USA). Results: A total of 768 instrument deliveries was conducted during the study period giving an instrument delivery rate of 768/20977 (3.7%) of total deliveries and 4.4% (768/17627) of the total vaginal deliveries. Vacuum delivery accounted for 764/768 (99.5%) giving a delivery rate of 764/20977 (3.6%), while forceps was 4/768 (0.5%) with a delivery rate of 4/20977 (0.1%). Within the study period, the trend waned from the maximum of 16.3% in 2003 to 79 (10.3%) in 2005 after which it had an upward spike to 83 (10.8%) in 2006. Thereafter, it decreased in the subsequent years reaching the lowest rate of 37 (4.8%) in 2009 and rose progressively till 2012 to the third highest level of 94 (12.3%). This pattern of trend is similar to findings in vacuum deliveries while forceps deliveries was only conducted in 2004 and 2011 with a percentage of 2 (2%) each. The most common fetal complication was birth asphyxia. No maternal mortality was recorded. Conclusion: Vacuum delivery was a common obstetric practice and has almost replaced forceps deliveries in our setting.
Keywords: Forceps delivery, instrumental vaginal delivery, Nigeria, trend, vacuum extraction
|How to cite this article:|
Onoh RC, Ezeonu PO, Chijioke O, Onoh TP, Saidu A K, Ezeonu CT. Disappearing art of forceps delivery and the trend of instrumental vaginal deliveries at Abakaliki, Nigeria. Afr J Med Health Sci 2014;13:99-104
|How to cite this URL:|
Onoh RC, Ezeonu PO, Chijioke O, Onoh TP, Saidu A K, Ezeonu CT. Disappearing art of forceps delivery and the trend of instrumental vaginal deliveries at Abakaliki, Nigeria. Afr J Med Health Sci [serial online] 2014 [cited 2018 Apr 25];13:99-104. Available from: http://www.ajmhs.org/text.asp?2014/13/2/99/144577
| Introduction|| |
Globally, about 10-20% of all deliveries need some form of assistance or intervention at delivery and 6-12% of these interventions are by instrumental vaginal deliveries. , Instrumental vaginal deliveries are deliveries conducted with forceps or vacuum extraction for either maternal or fetal indication in well selected cases to optimize fetal and maternal outcome.
There have been reports of variations in the trend of the general rate of instrumental vaginal deliveries , in obstetric practice. The pattern of this trend is changing from forceps toward vacuum extraction in many countries especially in developing countries. 
Vacuum delivery has been reported as the primary means of achieving operative delivery in the United States of America. 
Vacuum deliveries in proportion to forceps deliveries have increased over the last decade due to evidence suggesting less perineal trauma including third degree perineal tears.  Furthermore, vacuum delivery has been recommended as a better alternative for forceps delivery for similar indications in the second stage of labor.  It is believed that vacuum has an overall lower complication rate with regards to maternal complications. , The art of vacuum delivery is relatively easy to learn and use when compared with forceps and is easily performed by trained nurses and resident doctors.
We, therefore, aim to determine the rate of instrumental deliveries, the trend and the feto-maternal outcome over a decade at a tertiary hospital in Abakaliki, Ebonyi, Nigeria.
| Materials and Methods|| |
This was a cross-sectional descriptive study of retrospective data on cases of instrumental deliveries done at Federal Teaching Hospital Abakaliki (FETHA) (Formerly Federal Medical Centre [FMC] Abakaliki and Ebonyi State University Teaching Hospital [EBSUTH] Abakaliki) over a 10-year period (January 2002 to December 2011). FETHA was created in 2011 by upgrading the FMC and merging it with the EBSUTH, Abakaliki. Abakaliki is the Capital City of Ebonyi State and the only urban city out of the 13 Local Government Area of the State. About 75% of the inhabitants in the State are located in the rural areas and are mainly farmers.
These hospitals are located in the capital city and serve as major referral center for the state and other neighboring states. They are the tertiary hospitals which serve for training of both medical students and doctors. The hospital folders of patients who had instrumental deliveries were obtained from the postnatal ward, intensive care unit and newborn special Intensive Care Unit. The clinical case records of all these patients were retrieved from the hospital record's department. Instrumental deliveries done outside the hospital before presenting at these hospitals were excluded.
Information obtained from records included age of the women, parity, booking status, gestational age at deliveries, sex of babies, weights of babies, indications for instrumental deliveries and the fetal outcomes at delivery until the time of discharge from the hospital. Furthermore, information sought included type of instrumental deliveries, estimated blood loss, APGAR scores and total deliveries within the study period.
Ethical approval was obtained from the Research and Ethics Committee of our hospital. The data obtained were entered and analyzed using the 2008 Epi-Info™ version 3.5.1 Statistical Software (Center for Disease Control, Atlanta, GA, USA). Univalent analysis was done to obtain the sociodemographic variables, type of instrumental deliveries, indications for cesarean and fetal outcomes.
Bivalent analysis was performed using the annual distribution of instrumental deliveries to stratify the other variables giving the trend of the variables.
| Results|| |
During the study period, a total of 20,997 deliveries were conducted, of these 33 (16.05%) were caesarean deliveries and the remaining 17697 (83.95%) were vaginal deliveries. A total of 768 instrument deliveries were conducted during the study period giving an instrument delivery rate of 768/209977 (3.7%) of total deliveries and 4.4% (768/17627) of the total vaginal deliveries. Forceps delivery was conducted in 4 (0.5%) while vacuum delivery was conducted in 764 (99.5%) of the instrumental deliveries. There was no failed forceps delivery, but there were 11 (1.4%) failed vacuum deliveries. The mean age of the patients was 27.0 ± 5.3 years with a range of 14-45 years. Vacuum delivery was a common mode of delivery among parturient of all age group while forceps delivery was done among parturients within the age bracket <20-29 years in this study.
The mean gestational age in this study was 39.10 ± 1.5 weeks with a range of 34-45 weeks. Forceps delivery was only conducted among patients within the gestational age of 37-40 weeks. 4 (0.7%) vacuum delivery was the sole (100%) mode of delivery in the remaining gestational age brackets of 28 ≤ 34 weeks, 35-36 weeks, and ≥40 weeks.
The mean parity in the study was 1.6 ± 2.1 with a range of 0-9. Vacuum extraction when compared with forceps delivery was a common mode of delivery among all the parities (primigravida; 372 [99.5%]: 2 [0.5%], para 1-4; 290 [99.3%]: 2 [0.7%], grandmultipara; 100%: 0%) respectively.
Most of the booked instrumental deliveries 526 (99.4%) were conducted by vacuum extraction while the remaining 3 (0.6%) were by forceps delivery. Among the instrumental deliveries in unbooked parturients; 238 (99.6%) of the deliveries were by vacuum while 1 (0.4%) was by forceps delivery. All instrumental deliveries at FETHA after the merging of FMC and EBSUTH were by vacuum extraction. A total of 582 (99.5%) delivery were by vacuum, while 3 (0.5%) were by forceps at EBSUTH. A total of 88 (98.9%) of vacuum delivery and 1 (1.1%) of forceps delivery were conducted at FMC before the merging. Most fetal outcome were male 448 (58.8%) and they were all delivered by vacuum extraction whereas among the total female deliveries 316 (98.8%) were delivered by vacuum while 4 (1.2%) were delivered by forceps. Birth asphyxia occurred in 230 (69%) at 1 st min but was reduced to 69 (7.0%) at the 5 th min. Most of the babies delivered had a normal birth weight while low-birth weight and fetal macrosomia accounted for 56 (7.3%) and 50 (6.5%) respectively. All babies delivered with forceps (4 or 0.6%) were of normal weight [Table 1].
|Table 1: Sociodemographic variables and fetal outcome of instrumental deliveries|
Click here to view
The overall yearly trend ranged from a minimum of 37 (4.8%) in 2009 to a maximum of 125 (16.3%) in 2003. Within the study period, the annual trend had a downward trend from 127 (16.3%) in 2003 to 79 (10.3%) in 2005 from where it had an upwards spike to 83 (10.8%) in 2006. Thereafter, the trend decreased in subsequent years reaching the lowest rate of 37 (4.8%) in 2009 and then rose progressively until 2012 reaching the third highest level of 94 (12.3%). This overall trend has a waning and waxing pattern in four successions which are similar to yearly trend of vacuum delivery in this study. Forceps delivery was only conducted in 2004 and 2011 within the study period and this accounted for 2 (1.8%) and 2 (2.7%), respectively. Vacuum delivery accounted for all (100%) of the yearly instrumental deliveries except in 2004 and 2011 when it accounted for 111 (98.2%) and 71 (97.3%) respectively [Table 2], [Figure 1] and [Figure 2].
|Figure 1: Overall annual trend of instrumental deliveries over the study period|
Click here to view
|Figure 2: Comparism of annual trend of vacuum extraction and forceps delivery|
Click here to view
|Table 2: Annual distribution of instrumental deliveries over the study period|
Click here to view
The overall trend of instrumental delivery at FMC had a tangential drop from 2003 2 (2.2%) to reach the lowest instrumental delivery rate of zero in 2007 thereafter had an upward trend till it reached the maximum instrumental delivery 38 (42.7%) in 2011. The trend in EBSUTH had two upward spikes in 2006, 82 (14%) and 2011, 35 (6.0%) otherwise it maintained a downward trend from the maximum of 125 (21.4%) to the minimum of 12 (2.1%) in 2010 [Figure 3].
|Figure 3: Trend of instrumental deliveries over the three tertiary institutions|
Click here to view
[Figure 4] shows the monthly trend of instrumental delivery at FETHA after the merging. All the deliveries were by vacuum extraction 94 (100%). The trend had a waxing and waning pattern in seven successions with a minimum vacuum delivery of 5 (5.3%) in January, May, August, and a maximum vacuum delivery rate of 12 (12.8%) in December 2012. Instrumental delivery rate of 8 (8.5%) were recorded in the months of February, July, September, November while a rate of 10 (10.6%) was recorded in the month of March and June 2012. In the month of April and October 2012 the instrumental delivery rate were 9 (9.6%) and 6 (6.4%), respectively.
|Figure 4: Monthly trend of instrumental deliveries (all vacuum) at Federal Teaching Hospital, Abakaliki|
Click here to view
The most common complication in this study was severe caput succedaneum 263 (26.4%) and this constituted the most common fetal complication 263 (33%). A total of 101 (10.2%) had still the birth and 231 (23.1%) had birth asphyxia within the 1 st min of delivery. At 5 th min assessment, birth asphyxia was reduced to 69 (6.9%). Early neonatal death was 6 (0.6%). Other fetal complications include neonatal jaundice 57 (5.7%), scalp/facial bruising 32 (3.2%), neonatal sepsis 18 (1.8%), cephalo hematoma 13 (1.3%), convulsion 4 (0.4%), and intracranial hemorrhage 3 (0.3%). Vaginal lacerations (first-degree perineal tear) was the most common maternal complication 75 (37.9%) and this accounted for 75 (7.5%) of all complication in this study. Other maternal complication include postpartum hemorrhage 73 (7.3%), second degree perineal tear 25 (2.5%), third degree perineal tear 11 (1.1%), puerperal sepsis 7 (0.7%) and cervical laceration 4 (0.4%). There was no record of maternal mortality relating to instrumental delivery within the study period [Table 3].
| Discussion|| |
The instrumental delivery rate of 3.7% of the total deliveries was noted in the study with vacuum extraction and forceps delivery accounting for 3.6% and 0.1% of the total instrumental delivery respectively. This rate of instrumental delivery of 3.7% is higher than 2.0% in Maiduguri, Nigeria,  2.1% in Abakaliki, Nigeria,  0.51% in Ilorin Nigeria,  3.5% reported by Ghairaibeh et al.,  2.3% Younde Cameroon.  Forceps delivery rate of 0.1% is abysmally low. It is lower than the reported rates of forceps delivery recorded in Nigeria, which ranged from 0.3% to 2.4%. ,,,,,,, Majority of the instrumental delivery was by vacuum extraction, and this is similar to other findings in Nigeria, but higher than the recorded rates of 1.7% in Maiduguri and Lagos, 1.6% in Ilorin, 3.1% in Benin city, and 3.5% in Enugu. ,,,
The rate of instrumental delivery is lower than findings in developed countries. The low incidence of instrumental delivery could be explained by the preference of caesarean delivery to instrumental delivery. This preference could be because of lack of skills for the instrumental deliveries especially forceps deliveries.
Obstetricians and international training programs appear to promote vacuum extraction over forceps given the evidence and considerable experience needed to use forceps correctly. Vacuum extraction is advantageous for its use in developing countries labor wards because it is easy to learn and apply. A Cochrane review has reported that the risk and benefits of vacuum extraction when compared with forceps delivery are comparable.  The preference of one over the other is based on skills, experience and proper training of the individual as well as the indication for the procedure. 
Instrumental delivery is a highly skilled art and has been described as a "lost art"  or a "dying art."  This could be attributed to the rising cases of litigation against birth injuries and poor development or intellectual abilities even in late childhood life, especially if there were a difficult instrumental delivery.  This has resulted in preference for cesarean section by most obstetricians, as a result, most residents are not trained on the art of instrumental delivery, especially forceps delivery.  In this study, there was declining rate of instrumental delivery in the first half of the study and with an upwards trends in the last half of the study with forceps delivery not performed in most of the years. Vacuum delivery almost replaced forceps delivery and accounted for the trend over the study period. The preference for vacuum may be because of the modification of the vacuum cup from the metal cup to plastic and silastic cups which results in a reduction of feto-maternal complication.  The introduction of the silastic cups and Omni cups into our tertiary hospital has resulted in improved skills, proper training of the resident doctors and improved awareness of the importance of vacuum extraction in contemporary obstetrics. This could account for the increase in the instrumental deliveries over the last half of the study period. The declining rate in the first half of the study could be because of the complications observed with the metallic cup.
There is possible postulation that vacuum delivery may completely replace forceps delivery in the near future as it has been reported a safe alternative for forceps delivery. This is because numerous studies and Cochrane reviews have concluded that vacuum extraction is associated with less maternal trauma, requires less general or regional anesthesia, and is associated with more successful vaginal deliveries and fewer caesarean sections for failed vacuum extraction. ,, However the vacuum is associated with more fetal complications than forceps but these injuries or complication generally disappear after hours or weeks.  Potential fetal complications like cephalohematoma and retinal detachment could also occur with vacuum, but the risk of fetal injury is related to the techniques, number of pulls and it is advised that the guideline of 30 min, three pulls or two pull out should be observed. , Complications of vacuum are also less with soft cup, and it is recommended that soft cups should be preferred when feasible because it is associated with less neonatal trauma. 
In our setting, metal cup was used solely in the first half of this study period for vacuum delivery, and this could account for some of the complications observed. Fetal complications are more frequent in cases of prematurity and when metal cups are used, when the pull is >3 or after 30 min or more of vacuum application. ,, The common complications were severe caput at discharge, low APGAR score at 1 st min, neonatal jaundice and scalp/facial bruising. The risk of maternal and fetal complications are increased if forceps delivery is attempted after a failed vacuum extraction ,, and no such attempt was done in this study as cesarean section is preferred. Furthermore, the art of forceps delivery is not confidently practiced by the residents and the young specialists.
Instrumental delivery has an upward trend in the latter half of the study period but a downward trend in the first half. Vacuum delivery accounted for most of the changes that were observed in this study.
| References|| |
American College of Obstetricians and Gynaecologist. ACOG Practice Bulletin, No. 17, Washington DC: ACOG; 2000.
Arulkumaram S. Malpresentation, malposition, cephalopelvic disproportion and obstetric procedure. In: Edmond DK, editor. Dewhurst's Textbook of Obstetrics and Gynaecology, London: Blackwell Publishing; 2007. p. 213-26.
Iyoke CA, Onah HE. Vacuum deliveries at the University of Nigeria Teaching Hospital Enugu. Trop J Obstet Gynecol 2006;23:23-6.
Johanson RB, Menon BK. Soft versus rigid vacuum extractor cups for assisted vaginal delivery (Cochrane review). The Cochrane library issue 4, Oxford: Update software; 2002.
Mairiga AG, Kyari O, Audu BM. Instrumental vaginal delivery at University of Maiduguri Teaching Hospital. Trop J Obstet Gynaecol 2005;22:42-5.
Ibekwe PC, Dimejesi IB. Obstetric indices at the Ebonyi State University Teaching Hospital, Abakaliki, South East Nigeria. Niger J Med 2008;17:399-402.
Anate M. Instrumental (operative) vaginal deliveries: Vacuum extraction compared with forceps delivery at Ilorin University Teaching Hospital, Nigeria. West Afr J Med 1991;10:127-36.
Gharaibeh AM, Al-Bdour AE, Akasheh HF. The mounting rate of cesarean sections. Is it accompanied by a drop in instrumental births? Saudi Med J 2008;29:267-70.
Nkwabong E, Nana PN, Mbu R, Takang W, Ekono MR, Kouam L. Indications and maternofetal outcome of instrumental deliveries at the University Teaching Hospital of Yaounde, Cameroon. Trop Doct 2011;41:5-7.
Ogunniyi SO, Sanusi YO. Instrumental Vaginal Delivery in Ile-Ife and Ilesha, Nigeria. Niger J Med 1998;7:105-8.
Chukwudebelu WO. Instrumental delivery. In: Agboola A, editor. Textbook of Obstetrics and Gyneacology for Medical Students. Vol. 3. Lagos, Nigeria: University Educational, Services Publishers, Heinemann Educational Books Plc.; 2006. p. 489-94.
Emuveyan EE, Agboghoroma OL. Instrumental delivery in lagos, Nigeria A 7-year study (1989-1995). Niger Q J Hosp Med 1997;7:195-8.
Middle C, MacFarlane A. Labour and delivery of 'normal' primiparous women: Analysis of routinely collected data. Br J Obstet Gynaecol 1995;102:970-7.
Yakasai IA, Abubakar IS, Abdullahi H. An audit of instrumental vaginal delivery in Aminu Kano Teaching Hospital, Kano. Trop J Obstet Gynaecol 2011;28:14-7.
Aimaku CO, Olayemi O, Oladokun A, Iwe CA, Umoh AV. Current practice of forceps and vacuum deliveries by Nigerian Obstericians. Trop J Obstet Gynaecol 2004;21:40-3.
Demissie K, Rhoads GG, Smulian JC, Balasubramanian BA, Gandhi K, Joseph KS, et al.
Operative vaginal delivery and neonatal and infant adverse outcomes: Population based retrospective analysis. BMJ 2004;329:24-9.
O'Gradly JP, Gimousky M. Instrumental delivery: A lost art? In: Studd J, editor. Progress in Obstetrics and Gynaecology. Vol. 10, 11. UK: Churchill Livingstone Ltd.; 1993. p. 183-212.
Bailey PE. The disappearing art of instrumental delivery: Time to reverse the trend. Int J Gynaecol Obstet 2005;91:89-96.
Johanson RB, Menon BK. Vacuum extraction versus forceps for assisted vaginal delivery. Cochrane Database Syst Rev 2000;2:CD000224.
Johanson R, Menon V. Soft versus rigid vacuum extractor cups for assisted vaginal delivery. Cochrane Database Syst Rev 2000;2:CD000446.
WHO, UNFPA, UNICEF, World Bank. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO/RHR/00.7. Geneva, Switzerland: WHO; 2000.
Towner DR, Ciotti MC. Operative vaginal delivery: A cause of birth injury or is it? Clin Obstet Gynecol 2007;50:563-81.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]