Mode of Delivery and Neonatal Injury
abstract & commentary
Synopsis: The rate of intracranial hemorrhage is higher among infants delivered by vacuum extraction, forceps, or cesarean section performed during labor than among infants delivered spontaneously.
Source: Towner D, et al. N Engl J Med 1999;341: 1709-1714.
To determine whether the risk for neonatal injury, particularly intracranial hemorrhage, is increased in infants delivered by vacuum extraction, forceps, or cesarean section as compared to infants delivered spontaneously, Towner and colleagues used the California database to study nearly 600,000 live-born singleton infants weighing 2500-4000 g born to nulliparous women between 1992 and 1994. During the three years of the study, the rate for spontaneous vaginal delivery was 66.5%, for cesarean delivery 20.1%, for vacuum extraction 10.2%, for forceps delivery 2.7%, and for combined vacuum extraction and forceps 0.5%. Intracranial hemorrhage occurred in 1/1900 infants delivered spontaneously, 1/860 delivered by vacuum extraction, 1/664 delivered with forceps, 1/256 delivered by vacuum extraction with forceps, 1/907 delivered by cesarean section during labor, and 1/2750 delivered by cesarean section without labor. When compared to infants delivered spontaneously, those delivered by vacuum extraction had a significantly higher rate of subdural or cerebral hemorrhage (OR, 2.7). There was no difference in the rate of cerebral hemorrhage comparing infants delivered by vacuum extraction, forceps, or a cesarean section performed during labor. The likelihood of facial nerve palsy was highest in infants delivered by forceps.
Towner et al conclude that the rate of intracranial hemorrhage is higher among infants delivered by vacuum extraction, forceps, or cesarean section performed during labor than among infants delivered spontaneously. However, because the rate of intracranial hemorrhage in infants delivered by cesarean section before labor is not increased, they suggest that abnormal labor may be the common risk factor for hemorrhage.
Comment by Steven G. Gabbe, MD
While considerable attention has been paid to the increasing cesarean delivery rate in this country, other important changes have occurred in the techniques used for operative vaginal delivery. Between 1985-1992, vacuum extraction deliveries increased 37% while births with forceps fell 22%. The vacuum extractor is easily applied and causes less maternal injury than forceps. However, concern has arisen about the risks of neonatal injury associated with vacuum extraction, even though the more traumatic metal cups have been replaced by plastic devices. In 1998, the FDA issued a Public Health Advisory, reporting a quintupling of the rate of serious neonatal injuries associated with vacuum extraction in the past four years as compared with the previous 11 years. The most serious injuries cited were subgaleal hematoma and intracranial hemorrhage.
Using a database for California that links birth and death certificates with maternal and neonatal discharge records, Towner et al have evaluated data on nearly 600,000 infants with birthweights of 2500-4000 g born to nulliparous women. While the rates of neonatal intracranial hemorrhage were low overall, the risk was increased in infants delivered by vacuum extraction, forceps, and cesarean delivery during labor. The incidence in infants delivered with forceps did not differ significantly from those delivered by vacuum extraction. Of concern is the high rate of intracranial hemorrhage associated with the combined use of vacuum extraction and forceps, 7.4 times greater than spontaneous delivery and 3.4 times higher than vacuum extraction alone. Clearly, repeated attempts at vaginal delivery with both vacuum extraction and forceps are inadvisable. Successful vaginal delivery with vacuum extraction or forceps was associated with no greater risk of neonatal intracranial hemorrhage than a cesarean section performed during labor. In other words, if an operative delivery is required, regardless of the instrument used or the route of delivery, there is an increased risk of neonatal intracranial hemorrhage, suggesting this complication may be due to the process of labor.
Which of the following methods of delivery was associated with the lowest rate of neonatal intracranial hemorrhage in the study by Towner et al?
a. Spontaneous vaginal delivery
b. Forceps
c. Vacuum extraction
d. Cesarean section before labor
e. Cesarean section during labor
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