Ministry of Health , Labour and Social Protection of the Republic of Moldova [625015]

1
Ministry of Health , Labour and Social Protection of the Republic of Moldova
State University of Medicine and Pharmacy "Nicolae Testemițanu"

MEDIC AL FACULTY Nr. 2

Department of Obstetrics , Gynecology and Human Reproduction

DIPLOMA THESIS
LOWER GENITAL TRACT INJURIES IN RELATION TO MODE OF
VAGINAL DELIVERY

Student: [anonimizat] ____________________________________
Year, the group nr. ____________________________________

Scientific coordinator: Cardaniuc Corina,
MD, PhD, Associate Professor

Chisinau, 2019

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Summary

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Introduction
The importance of the theme . There is little doubt that some women suffer
significant genital lacerations and trauma to pelvic floor structures as a consequence of
vaginal childbirth1. It has been reported that approximate 85% of women suffer some form
of perineal trauma, with 60 –70% requi ring sutures or stitches2. Birth injuries to mothers
can be devastating and have long -term consequences. They can affect personal
relationships, social life, careers and women’s mental health. Kettle C. (2006) mentioned
that "Perineal trauma affects women’ s physical, psychological and social wellbeing in the
immediate postnatal period as well as in the long term. It can disrupt breastfeeding, family
life and sexual relations" [2].
Perineal trauma can occur spontaneously or result from a
surgical incision (episiotomy). The damage is described as first -, second -, third – and
fourth -degree tears , first-degree tears being the least damage and fourth -degree tears being
the most3. Trauma associated to vaginal childbirth may affect the pudendal nerve or its
branches , the anal sphincter, the puborectalis –pubococcygeus complex, or pelvic fascial
structures. It has recently been shown that inferior aspects of the levator ani and fascial
pelvic organ supports such as the rectovaginal septum can be disrupted in childbirth . Such
trauma is associated with pelvic organ prolapse, bowel dysfunction, and urinary
incontinence [1].
The more prolonged a delivery is and the longer is the duration of second stage , the
higher seems the likelihood of anatomic or functional injury. Geni tal trauma may also
occur because of precipitate labor. Vaginal operative delivery seems to be a higher risk

1 Hans Peter Dietz Pelvi c floor trauma following vaginal delivery Curr Opin Obstet Gynecol 18:528 –537. 2006 Lippincott
Williams & Wilkins
2 Kettle C. (2006) Perineal care. Clinical Evidence 15 (June), 1904 –1918
3 Perineal techniques during the second stage of labour for reducing perineal trauma (Review) Copyright © 2018 The Cochrane
Collaboration. Published by John Wiley & Sons, Ltd

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factor for all forms of injuries mentioned above, independently or due to its association
with prolonged second stage [1,4] .
There is no doubt that pelvic floor trauma after vaginal birth is a reality, not a myth
[1]. In addition, it is clear that the effects of perineal trauma can be lasting and, in some
cases, severe, leading to significant dysfunction and distress for the women involved4.
Recent years have seen a steady increase in the awareness regarding pelvic floor trauma
in childbirth. At the same time, less attention has been paid to lacerations in other locations
such as periurethral, vaginal, labial, or cervical lacerations and how the ris k factors vary
for different lacerations. Because these lacerations may be preventable, detailed
examination of the risk factors for all types of lacerations may help identify preventive
strategies and effective management that are very important.

The aim of the study
The aim of the present study was to assess the rate and the degree of maternal genital
tract injuries in relation to the mode of vaginal delivery.

The objectives of the study
1. To determine the clinic al characteristics and the evolution of lab or in primiparous
women with singleton term pregnancy and operative vaginal delivery compared with
non-instrumental vaginal deliveries .
2. To estimate the incidence, type and extent of genital tract injuries in primiparous
women with spontaneous or operative vaginal delivery , and to identify the risk factors
associated with genital tract lacerations.
3. To determine the neonatal outcome s following spontaneous or operative vaginal
deliveries in primiparous patients with singleton term pregnancies.

4 K. Brandie & A. MacKenzie. Perineal trauma following vaginal delivery. Journal of the Association of Chartered
Physiotherapists in Women’s Healt h, Autumn 2009, 105, 40 –55

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Theoretical imp ortance and practical value of the work
The innovative nature of the work consists in addressing a current problem in
obstetrics, highlighting the particularities of genital tract trauma in primiparous women
with singleton term pregnancy and operative vagi nal delivery compared with non –
instrumental vaginal deliveries . The present research, with investigation of particularities
of evolution of delivery in women with singleton term pregnancy and non-instrumental or
operative vaginal delivery , allowed the esta blishment of the risk groups for developing
complications and revealed the need of individual approach in each case in order to reduce
the maternal and foetal risk, toward reducing maternal morbidity and improving perinatal
outcomes.

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I. Literature review
1.1. Description and Stages of Normal Labor
Vaginal delivery is the most common and safe type of delivery. Normal labor is a
physiological process that permit the fetus to pass from the uterus thought maternal birth
canal to the world. Labor is defined as the onset of regular contractions and cervical
change or as progressive c ervical effacement and dilation resulting from regular uterine
contrac tions that occur at least every 3 minutes and last 30 to 60 seconds each. The World
Health Org anization (WHO) defines normal birth as "spontaneous in onset, low -risk at
the start of labor and remaining so throughout labor and delivery. The infant is born
spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy.
After birt h, mother and infant are in good condition" (Edmund F Funai, 2018, p. 1) .
Normal d elivery consists of four stages; each stage has it s own significant role and
prepare maternal body for parturiencies .
First stage of labor entails cervical modifications such as effacement and dilation
that appear after sufficient uterine contractions that become strong or adequate enough in
order to initiate the change s. The stage lasts for about 6 -18 h in nulliparous and 2 -10 h in
multiparou s women, and consider to be the longest part of labor (Samantha M. Pfeifer,
2012, pp. 99 -100). It consists of 2 phases: latent phase and active phase. In latent phase
cervix opens slowly to 4 cm and the contractions get stronger as time progresses.
Contractions are mild in nature and begin at 15 to 20 minutes apart , last 60 to 90 seconds
(Jane Dimer, 2014) . During active phase cervix dilate from 4-8 cm in more quickly
manner. Contractions get stronger and are about 3 minutes apart, lasting around 45
seconds. Transition to second stage begins when the cervix reaches its maximum opening
of 10 cm.
The s econd stage of labor begins when the cervix is completely dilated (10cm), and
ends with the expulsion of the fetus. According to NMS Obstetrics and Gynecology, 7th
Edition , in a nulliparous patient, the second stage of labor should last less than 2 hours

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without regi onal anesthesia, and less than 3 hours if a woman has regional anesthesia. In
a multiparous patient, the second stage of labor should last less than 1 hour without
regional anesthesia, and less than 2 hours if a woman has regional anesthesia. The stage
include 6 cardinal movements of the fetus in order to be adopted and to pass thought
maternal pelvis. These positional changes occur sequentially in the following order:
engagement, descent, flexion, internal rotation, extension, external rotation, and
expul sion.
The t hird stage of labor involve s separation and shedding of the placenta from the
maternal uterus, lasts immediately after fetal delivery and ends with the expulsion of the
placenta (Samantha M. Pfeifer, 2012, pp. 100 -102).
The f ourth stage of labor lasts from delivery of the placenta until 6 hours
postpartum. Recommended close observation of the woman in order to prevent
postpartum hemorrhage (CALVIN J. HOBEL M. Z., 2016, pp. 96 -113).
Vaginal delivery is a natural process that usually does not require significant
medical intervention. A multitude of factors and structures are involved in a spontaneous
vaginal delivery: uterus, cervix, placenta and the fetus – all must act in concert to ensure
a successful delivery. Successful delivery also depends on pelvic shape and size as well
as fetal size5.
Gamble J.A. and Creedy D.K. (2001) suggest that the majority of women have a
preference for vaginal delivery and not for cesarea n delivery6. Implicated factors involve
a higher degree of maternal satisfaction, woman’s personal control over delivery and
improved maternal –infant interaction at the time of delivery7,8. Buhimschi C. and

5 CATALIN S. BUHIMSCHI, MD and IRINA A. BUHIMSCHI, MD. Advantages of Vaginal Delivery. CLINICAL OBSTETRICS AND
GYNECOLOGY Volume 49, Number 1, 167 –183 2006, Lippincott Williams & Wilkins
6 Gamble JA, Creedy DK. Women’s preferenc e for a cesarean section: incidence and associated factors. Birth.
2001;28:101 – 110
7 Goodman P, Mackey MC, Tavakoli AS. Factors related to childbirth satisfaction. J Adv Nurs. 2004;46:212 –219.
8 Grady PA. National Institute of Nursing Research Working Gro up on optimizing pregnancy outcomes in minority
populations. Am J Obstet Gynecol. 2005;192 (suppl):S1 –S2

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Buhimschi I. (2006) state that a successful vagin al delivery is tolerated psychologically
better than delivery by cesarean section and early breastfeeding may be easier to
implement [5].
Practice changes as knowledge progresses. Obstetrics is currently undergoing a
major change with greater attention on maternal and fetal outcomes and continuously
rising studies are aimed to improve clinical practice [1,9,10,11]. Infant injury during birth
represents a constant concern . It was suggested that the modality of delivery may impact
on the fetal response to stres s, which may be responsible for higher or lower postnatal
morbidity [ 1,12].
Various opinions exist about the best birth method, the published data on short and
long-term outcomes of spontaneous vaginal, instrumental or cesarean delivery being
insufficient and inadequate. Therefore, it makes sense to assume that we have to rely on
good -quality studies that can guide our decision -making and make obstetric practice safer
for short – and the long-term future [5].
1.2. Assisted Vaginal Delivery : indications and contraindication s
Assisted vaginal delivery , also called operative vaginal delivery, is defined as an
operative application of direct traction on the fetal head with forceps or a vacuum
(Samantha M. Pfeifer, NMS Obstetrics and Gynecology, 2012, p. 128) . Assisted vaginal
delivery using forceps or a vacuum extractor is an essential part of obstetric practice13.
The most important function of both devices is traction. Operative vaginal deliveries are
accomplished by applying direct traction on the fetal skull with forceps or applying

9 Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior
cesarean delivery. N Engl J Med. 2004;351:2581 – 2589
10 Minkoff H, Chervenak FA. Elective primary cesarean delivery. N Engl J Med. 2003;348:946 –950.
11 Simpson KR, Thorman KE. Obstetric conveniences: elective induction of labor, cesarean birth on demand, and other
potentially unnecessary in terventions. J Perinat Neonatal Nurs. 2005;19:134 – 144.
12 Falconer AD, Poyser LM. Fetal sympathoadrenal mediated metabolic responses to parturition. BJOG. 1986;93:747 –753.
13 Keriakos R1, Sugumar S , Hilal N .Instrumental vaginal delivery –back to basics. J Obstet Gynaecol. 2013 Nov;33(8):781 -6. doi:
10.3109/01443615.2013.813917.

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traction to the fetal scalp by means of a vacuum extractor14. Furthermore, forceps may
also be used for rotation, especially from occiput transverse and posterior positions (F.
Gary Cunningham, Williams Obstetrics (24th edition), 2014, p. 574) . Use of forceps or
vacuum is reasonable when an operative intervention to terminate labor is indicated and
operative vaginal delivery can be safely and readily accomplished, otherwise, cesarean
delivery is the better option.
Operative vaginal delivery is used to speed up vaginal delivery for clinical
indications that take into account maternal and fetal wellbeing [14,15]. The maternal
indications include maternal exhaustion an d an inability to push effectively following
prolonged labor; prolonged second stage of labor; medical conditions such as maternal
cardiac disease, pre -eclampsia with the need to avoid pushing . Fetal indications include
arrest of descent; placental abrupti on or non -reassuring fetal heart rate patterns in the
second stage of labor [14,15 ,16]. A benefit of operative vaginal delivery is the possibility
to avoid cesarean delivery and its associated morbidities. For the non-reassuring state of
the fetus, operativ e vaginal delivery can shorten the exposure to additional labor and
reduce or prevent the e ffect of intrapartum insults17.
Operative vaginal delivery can be performed from either a low or outlet station.
Besides, forceps or vacuum delivery shouldn’t be use d electively until the criteria for an
outlet delivery have been met. In these circumstances, operative vaginal delivery is a safe
operation, yet unfortunately with some risk of maternal lower reproductive tract injury (F.
Gary Cunningham, Williams Obstetrics (24th edition), 2014, p. 574) .
In order to apply the instruments the following criteria should be met:

14 American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 7th
ed. Elk Grove Village (IL): AAP; Washington, DC: American C ollege of Obstetricians and Gynecologists; 2012.
15 Choice of instruments for assisted vaginal delivery (Revie w) Copyright © 2010 The Cochrane Collaboration. Published
by John Wiley & Sons, Ltd.
16 Samantha M. Pfeifer, NMS Obstetrics and Gynecology, 2012, p. 128
17 American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Neonatal encephalopathy and
neurologic outcome. 2nd ed. Elk Grove Village (IL): Washington, DC:AAP; American College of Obstetricians and
Gynecologists; 2014.

10
 The cervix must be fully dilated ;
 The membranes must be ruptured;
 Engaged head (0 station) ;
 Known positions of f etal head;
 Vertex presentation;
 Not suspec ted cephalopelvic disproportion;
 The bladder should be empty;
 A skilled operator must be present (Neville F. Hacker, 2016, pp. 229 -230)
Factors that must be taken into account are the station and position of the presenting
part, molding of the fetal head, co -operation of the mother, the experience of the operator
and the availability of the necessary equip ment [15]. Woman’s choice and informed
consent should influence practice .
Before using the forceps or the vacuum extractor, the obstetrician should analyze
carefully the factors that contribute to success of delivery , including estimated fetal
weight, the fetal station and p osition, the clinical adequacy of the maternal pelvis, and the
adequacy of anesthesia18.
Operative vaginal delivery is contraindicated if the fetus is in abnormal presentation ,
such as brow presentation or face presentation, the fetal head is not engaged in the
maternal pelvis or if the position of the vertex cannot be determined , suspicion for fetal-
pelvic disproportion and fetal bone demineralization , such as osteogenesis imperfecta,
blood clotting disorder, and recent fetal scalp blood collection [18, Unzila A Ali, 2009 ]
Obstetrical indications such as placenta previa and primary cesarean delivery, labor arrest
in the first stage and nonreassuring fetal heart rate before complete dilation are also
contraindications for operative vaginal delivery. The Royal College of Obstetricians and
Gynaecologists guildlines state , that operative deliveries shouldn’t be offered if the

18 The American College of Obstetricians and Gynecologists. Operative Vaginal Delivery. PRACTICE BULLETIN. Number 154, November 2 015.

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woman has less than 34+0 gestational weeks, owning to possibilities of intraventricular
hemorrhage, cephalohematoma, subgaleal hematoma or neonatal jaundice .The use of
vacuum extraction is contraindicated in fetuses <34+0 gestational weeks, and most
guidelines state that safety between 34 and 36 gestational weeks is still insufficient and
should therefore be used with caution (Delivery, 2011, p. 5) .
1.3. Frequency and t ypes of assisted vaginal deliveries
The frequency of operative vaginal deliveries vary from country from country and
is estimated to be less than 5% of all vaginal deliveries19,20. Most of these a re vacuum
deliveries with forceps deliveries comprising l ess than 1% of total deliveries [20].
Although in some countries the frequency of operative vaginal delivery is as low
as 1.5% of deliveries, it may be as high as 15% in other countries21. In the U K, the rates
of instrumental vaginal delivery range between 10% and 15%; remaining fairly constant
over the past 3 decades22,23. In the United States, the rate of operative vaginal delivery has
decreased over the past decades, partially because of the increa se in cesarean birth rates.
According to the birth certificate data from the National Vital Statistics Report, the
frequency of operative vaginal delivery in the US decreased from 9.01% of all deliveries
in 1992 to 3.6% of births in 2010, and to 3.30% of a ll deliveries in 2013 [21,24,25]. A World
Health Organization (WHO) survey analyzed the method of delivery and maternal

19 Sunday E. Adaji and Charles A. Ameh Operative Vaginal Deliveries in Contemporary Obstetric Practice. 2012, p 255 –
268.
20Mich ael G Ross, Marie Helen Beall. Forceps Delivery. https://emedicine.medscape.com/article/263603 -overview
21 Zenebe Hubena ,1 Ahadu Workneh ,2 and Yibeltal Siraneh3Prevalence and Outcome of Operative Vaginal Delivery among Mothers
Who Gave Birth at Jimma University Medical Center, Southwest Ethiopia Journal of Pregnancy Volume 2018, Article ID 7423475, 1 2
pages
22 Information and Statistics Division, Scottish Health Statistics. Births in Scotland report 2002. Births and babies (Births
1976 –2008) [http://www.isdscotland.org/isd/1612.html; accessed 11 November 2009].
23 Royal College of Obstetricians and Gynecologists ( RCOG), Operative Vaginal Delivery Guideline Number 26 —Jan 2011 , Clinical
Green Top Guidelines, RCOG Press, London, UK, 2011.
24 Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Matthews TJ. Births: final data for 2013. Natl Vital Stat Rep 2015;64:1 –65.
25 F. Williams, J. L. Gary Cunningham Kenneth, Y. Bloom Catherine et al., Operative Vaginal Delivery , 24th edition, 2014.

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outcomes in nine Asian countries (total of 107, 950 births ) and found that 3.2% of these
births, were by operative vaginal delivery procedu res26.
There are several procedural variations of assisted vaginal birth , which depend on
many factors : operator ’s choice , clinical scenario, local practice, geographical location,
and consumer preference [15].
Historically, the obstetric forceps preceded t he development of the ventouse and
was the earliest instrument used for operative delivery . Ancient Egyptian, Greek, Roman,
and Persian texts and pictures refer to forceps used for extraction in cases of intrauterine
fetal deaths , in order to save the moth er’s life. The invention of the precursor of the
modern forceps belongs to Peter Chamberlen of England who widely contributed to the
development of the obstetrical forceps [19,20] . Obstetrical forceps have undergone
modifications over time , being estimated that there may be over 700 different types and
shapes of obstetrical forceps in existence .
There are two basic designs of forceps: the straight forceps which may be used for
rotational births, and several designs of curved forceps which can effect tract ion only and
cannot be rotated. Forceps deliveries are classified according to the station of the head in
the birth canal and according to whether traction alone or rotation of the fetal head is
required [19].
In 1965, the American College of Obste trician s and Gynecologists (ACOG )
formulated a classification of low/outlet forceps, mid forceps, and high forceps. In that
classification, the term of mid forceps was very broad. It included many positions of the
fetal head, and stations from engagement at zero station to the perineum [20]. Because the
safety of midforceps deliveries became doubtful in the 1980s, the ACOG redefined the
classification of forceps deliveries27.

26 Lumbiganon, P., Laopaiboon, M., Gulmezoglu, A. M., et al. (2010) Methodof delivery and pregnancy outcomes in Asia: the WHO
global survey o n maternal and perinatal health 2007 -08. Lancet, 375, 490 -9.
27American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 17. Operative vaginal delivery. June 2000. Int J
Gynaecol Obstet . 2001 July. 74(1):69 -76.

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The revised classification of the American College of Obste tricians and
Gynecologists uses the level of the leading bony point of the fetal head, in centimeters,
measured from the level of the maternal ischial spines, to define station ( -5 to 5 cm)
[18,20,28]:
1. Outlet forceps : the scalp is visible at the introitus without separating the l abia; fetal
skull has reached pelvic floor /fetal head is at or on perineum ; sagittal suture is in
anteroposterior diameter or right or left occiput anterior or posterior position ; and rotation
does not exceed 45 degrees.
2. Low forceps : the leading part of the fetal skull is at station +2 cm or more and not on
the pelvic floor. Low forceps have two subdivisions: rotation of 45 degrees or less and
rotation of more than 45 degrees.
3. Midforceps : the station is above + 2cm and the head is engaged.
High force ps procedures are no longer performed.
The forceps blades are inserted slowly into the vagina such that the sagittal suture
of the fetal head is directly between and perpendicular to the shanks. Damage to maternal
tissues may be avoided by placing one hand into the vagina to guide the toe of the blade
along the natural pelvic curve of the birth canal. With the next maternal pushing effort,
the forceps are locked and traction is applied. The direction of traction should be parallel
to the axis of the birth c anal at that level, such that typically there is downward traction
initially, followed by ever -increasing upward traction as delivery of the fetal head occurs.
With complete delivery of the head, the shanks are nearly perpendicular to the floor. If
progres s of the fetal head is not obtained with appropriate traction, the procedure should
be abandoned in favor of a cesarean delivery” (Neville F. Hacker, 2016, p. 230) .
In the past decades, the vacuum extractor has progressi vely replaced forceps as the
instrument of choice for many practitioners during vaginal delivery [29,30,31]. The vacuum

28 Neville F. Hacker, 201 6, pp. 229 -230
29 Kozak LJ, Weeks JD. U.S. trends in obstetric procedures, 1990 -2000. Birth . 2002 Sep. 29(3):157 -61.
30 Johanson RB, Menon V. Vacuum extraction versus forceps for assisted vaginal delivery. Cochrane Database Syst Rev . 2005. (2): CD00224:

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extractor (VE) is another type of device that can be used during operative vaginal delivery.
It is an instrument using a suction cup that is applied on the fetal head.
Vacuum extractor has a long a colorful history. It was described for the first time
in 1705 by Dr. James Yonge, an English surgeon31. Since the earliest stages of
development, the vacuum extractor has been considered an easier instrument to use than
obstetric forceps32. James Young Simpson of Scotland performed the first documented
series of successful vacuum deliveries and designed the obstetric forceps that bears his
name [32]. Swedish obstetrician Tage Malmström who introduce d a mushroom -shaped
metallic cup, called vacuum extractor, popularized the vacuum extraction33. By the 1970s,
the vacuum extractor had almost completely replaced forceps in most northern European
countries [31]. Later the utilization of vacuum for assisted vaginal delivery has suppressed
the forceps in the United States [32].
There are different types of vacuum extractors, depending o n the type of suction
mechanism: manual or electrical and type of cup : rigid or soft [35]. Vacuum cups varies
and may be meta l, hard plastic, or soft plastic and may also differ in their shape, size, and
reusability (F. Gary Cunningham, Williams Obstetrics (24th edition), 2014, p. 583) .
According to Johanson, R. B. and Menon, B. K. (2007) , metalic cups are more suitable
for 'occipito -posterior', transverse and difficult 'occipito -anterior' position deliveries
because they allow a greater traction force to be applied without cup slip offs. The soft
cups are appropriate for straightforward delive ries34. Mcquivey R. (2004) mentioned that
correct cup placement on the fetal head and knowing when to abandon the procedure
represent key components for a safe and successful vacuum delivery35.

31 Unzila A Ali , MD and Errol R Norwitz , MD, PhD Vacuum -Assisted Vaginal Delivery Rev Obstet Gynecol . 2009 Winter; 2(1): 5 –17
32 Danforth's Obstetrics and Gynecology
33 Malmström T. The vacuum extractor: an obstetrical i nstrument. Acta Obstet Gynecol Scand. 1957; 36:5–50.
34 Johanson, R. B. & Menon, B. K. (2007) Vacuum extraction versus forceps for assisted vaginal delivery (Review). The Cochrane
Collaboration. John Wiley & Sons, Ltd.
35 Mcquivey R. Vacuum -assisted delivery : A review . Journal of Maternal -Fetal and Neonatal Medicine 16(3):171 -80 · October 2004

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An important step in proper us e of vacuum extractor is to confir m that no maternal
tissue is trapped between the cup and the fetal head. The cup should be placed over the
flexion point, placing the posterior edge of the suction cup 3 cm from the anterior fontanel
straight forwardly over the sagittal suture . This application point augments traction,
minimizes cup detachment, flexes but prev ents twisting of the fetal head. (F. Gary Cunningham,
Williams Obstetrics (24th edition), 2014, pp. 583 -584). By using the same principles as in forceps
delivery, parallel to the axis of the birth canal, with the aid of mater nal pushing efforts,
traction is applied. Detachment of the suction cup from the fetal head during traction is
termed a “pop -off.” In case the fetal head progress is not obtained with appropriate
traction, or if two “pop -offs” occur, the procedure should be discontinued in favor of a
cesarean delivery (Neville F. Hacker, 2016 , pp. 230 -231).
The indications for use of the vacuum extractor are the same as for forceps delivery .
The American Congress of Obstetricians and Gynecologists settled the indications for
vacuum assisted delivery in the practice bulletin "Operative vagin al delivery" in 200036.
However, vacuum extractor is contra indicated in preterm delivery (<34 weeks) due to the
fact that preterm fetal head and scalp are more prone to injury from the suction cup. “The
vacuum extractor is suitable for all vertex presenta tions, but unlike forceps, it must never
be used for delivery of fetuses presenting by the face or breech” (Neville F. Hacker, 2016, p. 231 ).
Controverses exist aboout the best operative vaginal deliveries that should be
conducted and which instrument is the best to use in specific clinical settings. Use of the
vacuum is reasonable when an indication is present, and when the vacuum delivery can
be rapidly and safely done. Otherwise, cesarean delivery is the better option37.
1.4. Types and causes of maternal birth injuries
Injury can occur during any vaginal delivery , even if the mother has no risk factors
and the birth is supposed to be normal . Vaginal births are often associated with some

36 American College of Obstetrics and Gynecology. Operativ e vaginal delivery. Practice Bulletin # 17. June 2000
37 Anne Garrison Vacuum Extraction. https://emedicine.medscape.com/article/271175 -overview

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form /degree of trauma to the gen ital tract . Vaginal delivery may be accompanied by
different kinds of lower genital track injuries that can involve the cervix, vagina, perineum
and even other genital organs , ranging from mild and superficial laceration s to severe and
deep lesions. These traumas of the birth canal can be associated with high maternal
morbidity or mortality in case of poor manage ment or delayed repair.
Clinically significant obstetric intrapartum cervical laceration, which are associated
with bleeding or require cervical su turing, are uncommon complication of vaginal
delivery38,39. Parikh R. et al (2007) noted an incidence of 0.2% of 16,832 deliveries for
development of a cervical laceration40.
Intrapartum cervical lacerations occur due to the delivery of the fetus through the
cervix at the time of vaginal birth41. Usually they are less than 0.5 cm in length and rarely
require repair. Some risk factors have been associated with cervical lacerations including
gestational diabetes, precipitous labor, nulliparity, induction of labor , birth weight > 4,000
g, shoulder dystocia, delivery with forceps/vacuum, history of cerclage or cervical
conization42,43,44.
Cervical tears most often develop in the lateral cervical sides. Three degrees of
cervical lacerations have been described :
 First-degree laceration is up to 2 cm. Such tears heal rapidly and are rarely the source
of any difficulty.

38 Shunji Suzuki Risk of Intrapartum Cervi cal Lacerations in Vaginal Singleton Deliveries in Women With Cerclage J Clin Med
Res. 2015;7(9):714 -716
39 Seravalli V, Potti S, Berghella V. Risk of intrapartum cervical lacerations in women with cerclage. J Matern Fetal Neonatal
Med. 2013;26(3):294 -298.
40 Reshma Parikh, MD; Susan Brotzman; James N. Anasti, MD. Cervical lacerations: some surprising facts. MAY 2007
American Journal of Obstetrics & Gynecology, e17 -e18
41 Luchin F. Wong , MD,1,2 Jacob Wilkes , BS,3,4 Kent Korgenski , MS,3,4 Michael W. Varner , MD,1,2 andTracy A. Manuck Intrapartum Cervical
Laceration and Subsequent Pregnancy Outcomes AJP Rep . 2016 Jul; 6(3): e318 –e323.
42 Melamed Nir, Ben -Haroush A, Chen Rony, Kaplan Boris, Yogev Y. (2009). Intrapartum cervical lacerations:
characteristics, risk factors, and effects on subsequent pregnancies . Am J Ob Gyn , 200( 4): 388.e381 –.e384.
43 Malihe TABARRAI ,1,* Tahere EFTEKHAR ,2 and Esmaeel NAZEM Etiology of the Vaginal, Cervical, and Uterine Laceration on Avicenna
Viewpoints Iran J Public Health . 2013 Aug; 42(8): 927 –928.
44 Parikh R, Brotzman S, Anasti JN. Cervical lacerations: some surprising facts. Am J Obstet Gynecol. 2007;196(5):e17 -18.

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 Second -degree laceration is more than 2 cm but it doesn’t extend to the vaginal forni xes.
 Third -degree laceration extend to the vaginal forni xes (Bahnij, Perineal lacerations) .
Rarely, the cervix can been entirely or partially avulsed from the vagina, with
colporrhexis in the anterior, posterior, or lateral forni xes. This kind of lesions usually
follow difficult forceps deliverie s performed through an incompletely dilated cervix with
the forceps blades applied over the cervix. The cervical tears may extend and involve the
lower uterine segment and uterine artery and its major branches and even through the
peritoneum. Fortunately, such extensive traumatic lesions are rare in modern obstetric
practice. (F. Gary Cunningham, Williams Obstetrics (24th edition), 2014, p. 789) .
Vaginal tears usually occur when baby’s head passes through the vaginal can al or fetal
shoulders are too large to pass through the vaginal opening. Vaginal lacerations may be
spontaneous or traumatic as a result of vacuum/forceps application . Spontaneous vaginal
lacerations may develop in fetal malpresentations.
Isolated vaginal lacerations , involving the middle or upper third of the vagina but
unassociated with lacerations of the perineum or cervix , are less common. Such
lacerations are usually longitudinal, frequently extend deep into the underlying tissues and
may give rise to heavy hemorrhage . (Bahnij, Perineal lacerations) . Lacerations of the
anterior vaginal wall in close proximity to the urethra are relatively common. (Bahnij,
Perineal lacerations) . Periurethral tea rs may lead to profound bleeding because of a rich
blood supply. The most frequent cause for a periurethral tear is a sudden extension of the
fetal head during the delivery. (Dr.M.D.Mazumdar, n.d.) . Long -term complications
assoc iated with vaginal tears include painful intercourse and fecal incontinence. Also ,
women may experience urinary incontinence.
Genital haematomas during vaginal birth are relatively uncommon but can be a cause
of serious morbidity and even maternal death. They can be difficult to diagnose, as
symptoms can be non -specific and bleeding is often concealed. Anatomically, puerperal

18
haematomas can be vulval, vulvovaginal, paravaginal or subperitoneal (affecting the
broad ligament) (F. Gary Cunningham, Williams Obstetrics (24th edition), 2014, p. 790) .
Pelvic floor trauma during childbirth is a reality, not a myth [1]. Perineal lacerations
during vaginal birth can occur spontaneously or as a result from an episiotomy. Most
perine al tears are quite minor, but more serious tears can also extend to the vulva and
muscles in the anus.
Perineal tears are classified according to their depth :
– First -degree perineal lacerations involve the fourchette, perineal skin, and vaginal
mucous a, though not the underlying fascia and muscle s.
– Second degree perineal lacerations extend deeper and include, in addition, the fascia
and muscles of the perineal body but not the anal sphincter. (F. Gary Cunningham,
Willi ams Obstetrics (24th edition), 2014, p. 549) .
– Third -degree perineal lacerations broadens farther to affect the external anal sphincter.
Third degree perineal tears may be further subdivided into three subcategories:
3a: partial tear of the external ana l sphincter involving less than 50% thickness
3b: greater than 50% tear of the external anal sphincter
3c: internal sphincter is torn (Medicine, 2018) .
– Fourth -degree perineal lacerations extend completely through the rectal muco sa and
involve disruption of both the external and internal anal sphincters (F. Gary
Cunningham, 2014, pp. 548 -549).
Kettle C. (2006). suggested that as many as 85% of women suffer some form of
perineal trauma, with 6 0–70% requiring stitches [2]. Similarly, Frohlich J. and Kettle C.
(2015) repoted that more than 85% of females who undergo a vaginal birth will suffer
from some degree of perineal tear [ Frohlich J, Kettle C. Perineal care. BMJ Clin Evid 2015;2015. ], while several
recent studies found that 0.6 –11% of all vaginal deliveries resulting in a third -degree or
fourth -degree tear [ Villot A, Deffieux X, Demoulin G, Rivain AL, Trichot C, Thubert T. Management of third and fourth degree perineal
tears: A systematic re view. J Gynecol Obstet Biol Reprod (Paris) 2015;44(9):802 –11.; Aigmueller T, Umek W, Elenskaia K, et al. Guidelines for the

19
management of third and fourth degree perineal tears after vaginal birth from the Austrian Urogynecology Working Group. Int U rogynec ol J 2013;24(4):553 –
58.]. Perineal trauma can be lasting and severe, can affect women’s psychological and
phisical wellbeing leading to significant dysfunction and distress for the individual
involved [4]. Fortunately, the incidence of perineal tears decrea ses with subsequent births,
from 90.4% in women who are nulliparous to 68.8% in women who are multiparous
undergoing vaginal deliveries [ Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma:
A prospective observationa l study. BMC Pregnancy Childbirth 2013;13:59.; Goh R., Goh D., Ellepola H. Perineal tears – A review . AJGP, Volume 47, No.
1-2, January –February 2018 ].
In the 1980s and 1990s it was established that vaginal childbirth may significantly
change pudendal ner ve conduction patterns [1,45] Literature data suggest that in addition
to pudendal nerve injury, inferior zones of the levator ani and fascial pelvic organ supports
such as the rectovaginal septum can be disrupted in childbirth. Such trauma may be
associate d with pelvic organ prolapse, bowel dysfunction, and urinary or fecal
incontinence [1]. Bergholt T et al (2003) reported an incidence of anal sphincter laceration
rate of 5.6% during spontaneous vaginal birth46.
Brandie K. and Mac Kenzie A. (2009) investiga ted the incidence of perineal trauma
at the Maternity Unit of Raigmore Hospital, UK, and showed that 92% of women who
had vaginal deliveries suffered from some degree of perineal trauma, and thus, would have
been at risk of both the short – and longer -term d ysfunctions associated with this condition
[4]. Albers L. et al reported an incidence of 2 to 19% of the third – and fourth -degree degree
perineal lacerations in vaginal deliveries in the United States, depending on the
management of delivery47.
Although per ineal lacerations can occur in different locations, the third – and fourth –
degree perineal lacerations involving an injury of the anal sphincter have the highest

45 Snooks SJ, Swash M, Mathers SE, Henry MM. Effect of vaginal delivery on the pel vic floor: a 5 -year follow -up. Br J Surg
1990; 77: 1358 -1360.
46 Bergholt T, Stenderup JK, Vedsted -Jakobsen A, et al. Intraoperative surgical complication during cesarean section: an
observational study of the incidence and risk factors. Acta Obstet Gynecol Scand. 2003;82:251 –256.
47 Albers LL, Migliaccio L, Bedrick EJ, Teaf D, Peralta P. Does epidural analgesia affect the rate of spontaneous obstetric
lacerations in normal births? J Midwifery Womens Health. 2007;52:31 –36.

20
clinical imp act because injury of the anal sphincter is related to short -term and long -term
fecal incontinence48,49. Anal sphincter injuries during vaginal birth determine an increased
risk for pelvic organ prolapse, urinary and fecal incontinence, and sexual
dysfunction50,51,52.
Risk factors for perineal severe lacerations include primiparity, fetal mac rosomia ,
operative vaginal delivery, occip ital posterior position, prolonged second stage of labor,
a shortened perineal body and horizontal position of the mother during delivery
[50,53,54,55,56,57,58].
Mikolajczyk R. et al (2008) analyzed the risk factors for genital lacerations in 1009
primiparous women with singleton pregnancies and vaginal deliveries and found that
Large fetal size (≥ 3500 g) substantially increased the risk of perineal and periurethral
lacerations but not other types of lacerations [48]. Episiotomy had no impact on perineal
lacerations, and Prolonged second stage of labor (>120 minutes) increased the risk of
perineal and vaginal lacerations but reduced the risk for periurethral lacerations. Also, the
authors cited that higher maternal age in creases the risk of third – and fourth -degree
perineal lacerations [48]. Similarly, Lane T.L. et al (2017) reported that perineal body
length, duration of second stage of labor, type of delivery, and patient age were associated

48 Rafael T. Mikolajczyk , Jun Zhang , James Troendle , Linda Chan . Risk Factors for Bi rth Canal Lacerations in Primiparous Women. Am J
Perinatol. 2008 May; 25(5): 259 –264.
49 Borello -France D, Burgio KL, Richter HE, et al. Fecal and urinary incontinence in primiparous
women. Obstet Gynecol. 2006;108:863 –872.
50 T. Lance Lane, Christopher P. C hung, Paul M. Yandell, Thomas J. Kuehl, Wilma I. Larsen. Perineal body length and perineal lacerations during delivery in pri migravid patients. Proc
(Bayl Univ Med Cent) 2017;30(2):151 –153.
51 Safarinejad MR, Kolahi AA, Hosseini L. The effect of the mode of delivery on the quality of life, sexual function, and sexual satisfaction in primiparous
women and their husbands. J Sex Med 2009;6(6):1645 –1667.
52 Borello -France D, Burgio KL, Richter HE, Zy czynski H, Fitzgerald MP, Whitehead W, Fine P, Nygaard I, Handa VL, Visco AG, Weber AM, Brown
MB; Pelvic Floor Disorders Network. Fecal and urinary incontinence in primiparous women. Obstet Gynecol 2006;108(4):863 –872.
53 Groves JW Jr, Foster RT, Kuehl TJ, Yandell PM. Risk and outcome of obstetrical anal sphincter injury. J Pelvic Med Surg 2007;13(4):171 –176.
54 Dua A, Whitworth M, Dugdale A, Hill S. Perineal length: norms in gravid women in the fi rst stage of labour. Int Urogynecol J Pelvic Floor Dysfunct
2009;20(11):1361 –1364.
55 Altman D, Ragnar I, Ekstrom A, Tyden T, Olsson SE. Anal sphincter lacerations and u pright delivery postures —a risk analysis from a randomized
controlled trial. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:141 –146.
56 Altman MR, Lydon -Rochelle MT. Prolonged second stage of labor and risk of adverse maternal and perinatal outcomes: a sys tematic
review. Birth. 2006;33:315 –322.
57 Baumann P, Hammoud AO, McNeeley SG, Derose E, Kudish B, Hendrix S. Factors associated with anal sphincter laceration in 40,92 3 primiparous
women. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:985 –990.
58 Lowder JL , Burrows LJ, Krohn MA, Weber AM. Risk factors for primary and subsequent anal sphincter lacerations: a comparison of cohorts by parity
and prior mode of delivery. Am J Obstet Gynecol. 2007;196:344.e1 –5.

21
(P<0.1) with third – and fourt h-degree (severe) perineal lacerations in primigravid women.
A perineal body length of ≤3.5 cm and a duration of second stage of labor >99 minutes
were associated with an increased risk of third – and fourth -degree lacerations in
primigravid patients [50]. On the contrary, Tsai P. et al (2012) failed to show a ny
relationship between perineal body length and severe lacerations59. Khaskheli M. et al
(2012) consider that genital tract trauma is a common complication of vaginal birth mostly
seen in grand multipar a60.
Uterine r upture is a severe condition that can occur during pregnancy or during
vaginal delivery. It’s more common in women with a previously caesarean section, at the
site of caesarean section scar. Uterine rupture is considered a medical emergency be cause
it can lead to massive hemorrhage and it can be life -threatening to both the mother and
the baby (CRNP, 2016) .
Vaginal c hildbirth can also cause pelvic organ prolapse. Pelvic organ prolapse is
more likely after long or d ifficult labor, or in cases of particularly large baby . Most of the
time, a prolapsed uterus or other pelvic organ is not life threatening. However, it can affect
the mother’s quality of life and general wellbeing significantly.
1.5. Maternal complications of operative vaginal delivery
Despite significant changes in management of labor and delivery during the last
few decades, operative vaginal delivery remains an important part of labor management61.
Generally, o perative vaginal delivery yield s safe and sa tisfactory outcomes for the
mothers and babies. However, there has been an increase in medico -legal cases due to an
increasing awareness of the potential morbidity for the mother and the fetus62.
Two of major complications that may be found in association with operativ e vaginal
deliveries are an inapropriate evaluation of dystocia and misuse of an instrument to

59 Tsai PJ, Oyama IA, Hiraoka M, Minaglia S, Th omas J, Kaneshiro B. Perineal body length among diff erent racial groups in the fi rst stage of labor. Female
Pelvic Med Reconstr Surg 2012;18(3):165 –167.
60 Khaskheli M1, Baloch S , Baloch AS . Obstetrical trauma to the genital tract following vaginal delivery. J Coll Physicians Surg Pak. 2012
Feb;22(2):95 -7.
61 Operative Vaginal Delivery. The American College of Obstetricians and Gynecologists. PRACTICE BULLETIN Number 154, November 2 015
62 Keriakos R1, Sugumar S , Hilal N .Instrumental vaginal delivery –back to basics. J Obstet Gynaecol. 2013 N ov;33(8):781 -6.

22
accomplish delivery [32]. Risk to the mother and to the neonate can develop secondary to
these major complications.
There are evidence s in the lite rature that instrumental deliveries increase the
maternal morbidity, including perineal pain and lacerations, hematomas, hemorrhage and
anemia, and longterm consequences like urinary or fecal incontinence [31]. Early maternal
complications after operative vaginal deli very include lacerations and bleeding. Both
methods of operative vaginal delivery: the vacuum extractor or the forceps, are associated
with increased risk of maternal and neonatal injuries when compared to normal
spontaneous vaginal deliveries63,64. A review of 50,000 vaginal deliveries at the
University of Miami was done by Angioli R. et al (2000) and revealed that the rates of
third and fourth degree perineal lacerations were higher in vacuum -assisted (10%) and
forceps deliveries (20%) compared with spontaneous vaginal deliveries (2%)65. Gardella
C. et al (2001) reported that poor maternal and newborn outcome s might also occur after
the sequential use of vacuum and forceps delivery for assisted vaginal delivery66. Forceps
may be associated with inc reased perineal trauma and episiotomy rates, as well as fetal
scalp injuries. Vacuum extraction may be associated with lower rates of perineal trauma
but more often leads to fetal cephalhematoma. From a maternal point of view, operative
vaginal birth may r esult in a negative psychological effect, especially when it is associated
with severe perineal trauma. Gurol -Urgaanci I. et al. (2012) reported that forceps use was
associated with a six fold increase and vacuum extractor use was associated with a

63 Yancey MK, Herpolsheimer A, Jordan GD, Benson WL, Brady K. Maternal and neonatal effects of outlet forceps delivery
compared with spontaneous vaginal delivery in term pregnancies. Obstet Gynecol. 1991; 78:646 –650.
64 Prapas N1, Kalogiannidi s I1, Masoura S1, Diamanti E2, Makedos A1, Drossou D2, Makedos G1. Operative vaginal delivery in singleton term
pregnancies: Short -term maternal and neonatal outcomes. HIPPOKRATIA 2009, 13, 1: 41 -45.
65 Angioli R, Gomez -Marin O, Cantuaria G, O’Sullivan MJ. Severe perineal lacerations during vaginal delivery: the University
of Miami experience. Am J Obstet Gynecol. 2000; 182:1083 –1085.
66 Gardella C, Taylor M, Benedetti T, Hitti J, Critchlow C. The effect of sequential use of vacuum and forceps for assisted
vaginal delivery on neonatal and maternal outcomes. Am J Obstet Gynecol. 2001; 185:896 –902.

23
twofol d increase in the risk of third – and fourth -degree perineal tears compared with
patients who had a spontaneous delivery67.
According to the opinion of Hankins G. And Rowe T. (2000), the highest rates of
maternal perineal trauma are associated with deliverie s involving rotations larger than 45°
and with midforceps procedures68. Some authors consider that the risk of maternal trauma
is higher for fetuses in the occiput -posterior position69,70. Wu J. et al (2005) found that in
vacuum assisted vaginal delivery, the occiput -posterior position was associated with a 4 –
fold increased risk of anal sphincter injury compared with an occiput -anterior position
[70]. Even if assisted vaginal delivery has been recognized as a risk factor for severe
perineal lacerations and ana l sphincter injury, it is difficult to separate its contribution to
these injuries from other associated clinical factors: prolonged second stage of labor, fetal
macrosomia, greater newborn head circumference, shoulder dystocia, maternal age,
obesity, and episiotomy [27ACOG ,71].
Data of the literature suggests that maternal and neonatal outcomes and
complication rates between the two methods (vacuum extractor or forceps) are different .
Several studies have shown that maternal injury is less frequent and les s extensive with
the use of vacuum [64,72]. Some authors consider that second and third degree perineal
lacerations occur more often with the use of forceps [6 8,73,74]. In a review of 13
randomized trials of forceps delivery versus vacuum delivery, that inclu ded 3,338 women,

67 Gurol -Urganci I, Cromwell DA, Edozien LC, Mahmood TA, Adams EJ, Richmond DH, et al. Third – and fourthdegree
perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG
2013;120:1516 –25.
68 Hankins GD, Rowe TF. Operative vaginal delivery —year 2000. Am J Obstet Gynecol. 1996;175:275 –282.
69Damron DP, Capeless EL. Operative vaginal delivery: a comparison of forceps and vacuum for success rate and risk of rectal sphincter injury. Am J
Obstet Gynecol. 2004;191:907 –910.
70 Wu JM, Williams KS, Hundley AF, et al. Occiput posterior fetal head position increases the risk of anal sphincter injury in v acuum -assisted
deliveries. Am J Obst et Gynecol. 2005;193:525 –528. discussion 528 –529.
71 Hsieh WC1, Liang CC2, Wu D1, Chang SD3, Chueh HY3, Chao AS3.Prevalence and contributing factors of severe perineal damage following episiotomy –
assisted vaginal delivery. Taiwan J Obstet Gynecol. 2014 Dec;53(4):481 -5.
72 Johnson JH, Figueroe R, Garry D, Elimian A, Maulic D. Immediate maternal and neonatal effects of forceps and vacuum –
assisted deliveries. Obstet Gynecol. 2004; 103:513 –518.
73 Caughey AB, Sandberg PL, Zlatnik MG, Thiet MP, Parer JT, Laros RK., Jr Forceps compared with vacuum: rates of
neonatal and maternal morbidity. Obstet Gynecol. 2005; 106:908 –912.
74 Vacca A. Vacuum -assisted delivery. Best Pract Res Clin Obstet Gynaecol. 2002; 16:17–30.

24
forceps delivery was associated with a higher rate of third – and fourth -degree tears75. The
same revie w showed no difference in vulvar trauma or episiotomy between the forceps or
vacuum [7 1].
At the same time, numerous studies show ed no di fference in the incidence of severe
perineal lacerations between the two methods of operative vaginal delivery and that
maternal soft tissue injury rates are similar in vacuum and forceps assisted deliveries [64,
76,77]. Prapas N. et al (2009) reported a similar rate of periurethral injuries and perineal
hematomas in both ways of operative vaginal delivery [64].
According to the clinical practice guideline from the French College of
Gynaecologists and Obstetricians, the rate of urinary incontinence is simila r following
forceps, vacuum extraction and spontaneous vaginal deliveries and persistent anal
incontinence has a similar prevalence regardless of the mode of delivery (caesarean or
vaginal, instrumental or non -instrumental), suggesting the involvement of o ther factors78.
Crane A. et al (2013) questioned 109 primiparous women with spontaneous or operative
vaginal delivery and found no differences in pelvic floor function or sexual function scores
at 1 year postpartum79. Evers E. et al (2012) say that i f no ana l sphincter laceration occurs
with operative vaginal delivery, anal incontinence rates at 5 –10 years after operative
vaginal delivery are similar to those in women who had a spontaneous vaginal delivery80.
Similarly, Johanson R. et al (1999) realized a 5 -year follow -up of a cohort of 228 women

75 O’Mahony F, Hofmeyr GJ, M enon V. Choice of instruments for assisted vaginal delivery. Cochrane Database of
Systematic Reviews 2010, Issue 11. Art. No.: CD005455. DOI: 10.1002/14651858.CD005455.pub2. (Meta -analysis)
76 Lurie S, Glezerman M, Sadan O. Maternal and neonatal effects of forceps versus vacuum operative vaginal delivery. Int J
Gynecol Obstet. 2005; 89:293 –294.
77 Fitzpatrick M, Behan M, O'Connell PR, O'Herlihy C. Randomized clinical trial to assess anal sphincter function following
forceps or vacuum assisted vaginal delivery. BJOG. 2003; 110:424 –429.
78 Vayssière C1, Beucher G , Dupuis O , Feraud O , Simon -Toulza C , Sentilhes L , Meunier E , Parant O , Schmitz T , Riethmuller D , Baud O , Galley -Raulin
F, Diemunsch P , Pierre F , Schaal JP , Fournié A , Oury JF ; French College of Gynaecologists and Obstetricians . Instrumental delivery: clinical practice
guidelines from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol. 2011 Nov;159(1):43 -8.
79 Crane AK, Geller EJ, Bane H, Ju R, Myers E, Matthews CA. Evaluation of pelvic floor symptoms and sexual function in
primiparous women who underwent operative vaginal delivery versus cesarean delivery for second -stage arrest. Female
Pelvic Med Reconstr Surg 2013;19:13 –6.
80 Evers EC, Blomquist JL, McDermott KC, Handa VL. Obstetrical anal sphincter l aceration and anal incontinence 5 –10
years after childbirth. Am J Obstet Gynecol 2012;207:425.e1 –6.

25
who delivered by forceps or vacuum extractor and reported that there were no apparent
differences in urinary incontinence or loss of bowel control between the types of
instruments used and no non -instrumental spontaneo us delivery control group81.
Since number of clinical controversies still surround the delivery -related genital
trauma and maternal lacerations associated with a spontaneous or operative vaginal
delivery, there is a need to continue to better characterize t he risk factors that can lead to
these unwanted outcomes. Further research in the area may help to identify the women
most at risk in order to make preventive interventions feasible.
Conclusion to the 1st chapter
Predisposition for lower genital track injuries begins not always at the time of the
delivery itself, but it can enter upon the early period of the pregnancy. It include s a large
spectrum of peculiarities and conditions , such as women ’s background diseases,
anatomical particularities of female pelvi s, age of the wom an, fetal parameters, etc.
Lower genital track injuries are common complica tions of vaginal birth, and may
lead to hemorrhage, shock, puerperal infection s or even death of mother. The injuries vary
greatly by their predisposing factors, causes, degree s, and locations. They may be single,
multiple, deep, superficial or mix, some of them require medical intervention during or
post-delivery and other are not requiring at all.
Operative vaginal procedures, specifically vacuum extraction and obstetric forcep s
have a long history but both still have a place in contemporary obstetric practice. Even if
assisted vaginal delivery is recognized as a risk factor for severe perineal lacerations and
anal sphincter injury, it is difficult to separate its contribution t o these injuries from other
associated clinical factors . Since number of clinical controversies still surround the
delivery -related genital trauma and maternal lacerations associated with a spontaneous or
operative vaginal delivery, there is a need to cont inue to better characterize the risk factors

81 Johanson RB, Heycock E, Carter J, et al. Maternal and child health after assisted vaginal delivery: five -year follow up
of a randomized controlled study comparing forceps and ventouse. Br J Obstet Gynaecol. 1999;106: 544 -549.

26
that can lead to these unwanted outcomes. Taking into account the exposed ones, t he aim
of the present study was to assess the rate of maternal genital trauma following
spontaneous or operative vaginal deliverie s in singleton term pregnancies.

27
II. Material and research methods
The primary aim of the present study was to investigate the incidence and extent of
maternal genital tract injuries with respect to the mode of vaginal deliv ery. The intention
was to establish the incidence, type and extent of genital tract injuries in primiparous
women with spontaneous or operative vaginal delivery, and to identify the risk factors
associated with genital tract lacerations. Further aims were to investigate the neonatal
outcomes following spontaneous or operative vaginal deliveries in primiparous patients
with singleton term pregnancies.
2.1. Study Area and Period
This study was carried out at the Department of Obstetrics , Gynecology and Huma n
Reproduction of "Nicolae Testemitanu " State University of Medicine and Pharmacy , in
Clinical Municipal Hospital nr.1 of Chisinau, with the duration of 8 months from January
2018 to September 2018. It is one of the major perinatal centers in Chisinau (abo ut 8,000
deliveries per year), Moldova. At the same time, it is a teaching center for many clinical
undergraduate and postgraduate specialty students .
2.2. Study Design and Population
The present study was retrospective hospital -based observational and compara tive
study. A total number of 180 primiparous women with singleton pregnancy and only
vaginal deliveries were included in the study. The included women were divided into two
groups:
I group – the study group included 90 women with spontaneous vaginal birth
II group – the control group included 90 women with vacuum assisted vaginal delivery
Inclusion criterias:
– Primiparous
– Singleton pregnancy
– Gestational age between 37 0/7 and 41 6/7 weeks at delivery

28
– Cephalic presentation
All the cases with non-cephalic presentation, multifetal pregnancy , women with
multiparity and fetus with congenital abnormalities were excluded from the study.
The mean age of women in test group was about 25.76 ± 3.43 years, and the mean
age of women in the control group was about 25.29 ± 3.96 years.
2.3. Data collection procedure
In order to investigate the relationship between the way of delivery and the degree
of genital trauma, the obstetric records were reviewed and data were compared between
groups . A checklist /questionnaire was develop ed and used to extract data from the
patient ’s obstetrical chart s. The first part of the questionnaire required demographic
information about patient’s age, gravidity, parity and body mass, smoking, alcohol
consumption, estimated gestation age at delivery , evolution of pregnancy, data of physical
examination and general obstetrical examination . Physiological history analysis included
the age at the menarche, the menstrual cycle character – length, range, abundance, any
cycle disorders, the onset and the par ticularities of the sexual life. The investigation of the
reproductive function in women in both groups included the number of pregnancies, the
number of spontaneous and medical abortions. From the gynaecological history,
concomitant genital and gynaecolog ical diseases were selected. The s econd part of the
tool required the parameters of labor, which were length of the first and second stages of
labour , induction of labour, uterine contractions, oxytocin use, analgesia in labour, fetal
heart rate, liquor sta te, descent of the fetal head , type of delivery . The third part of the
questionnaire included information about the mode of delivery and immediate maternal
outcomes : postpartum haemorrhage, perineal trauma/episiotomy, cervical lacerations
requiring suture, vaginal lacerations/haematomas, urinary bladder injury, bowel injury,
need of blood transfusion, hysterectomy. Primary outcome measure was genital trauma.
Five types of lacerations based on clinical diagnosis were recorded in the medical records:
perineal (with additional classification into first to fourth degree), periurethral, vaginal,

29
labial, and cervical lacerations. The fourth part of the checklist included the fetal
outcomes : neonatal birth weight, APGAR score at first and fifth minutes after delive ry,
need of resuscitation, admission to neonatal ward for special care.
2.4. Data Processing and Analysis
The results of the quantitative assessment of the studied parameters were subjected
to statistical analysis, assessing averages values and their err ors. Descriptive statistics was
used to describe the main features of the data. We first present the population
characteristics. Data are presented as numb er (%). Women with spontaneous non –
instrumental vaginal delivery were compared with women with operative delivery in order
to assess the rate and degree of genital lacerations. For statistical analysis, Student’s t -test
for independent variables and the χ2 test for categorical variables were used. Odds ratios
(ORs) and 95% confidence intervals (CIs) were also calculated to determine whether
assisted vacuum vaginal delivery is a risk factor for more severe genital traumas or
neonatal outcome. Differenc es with P < 0.05 were considered significant.
2.4. Ethical considerations
Confidentiality was assured by using numeric codes for each patient. The
permission concerning analysis from a retrospective database was obtained from the
director of the hospital.

30
III. Results and discussions
The potential effects of vacuum assisted vaginal delivery on the lower genital track
injuries is a frequent clinical concern since is highly associated with postpartum morbidity
and mortality, furthermore the complication is dir ectly related to the severity of perineal
trauma. There is substantial evidence that instrumental deliveries increase maternal
morbidity, including perineal pain at delivery, pain in the immediate postpartum period,
perineal lacerations, hematomas, blood l oss and anemia, urinary retention, and long -term
problems with urinary and fecal incontinence (Unzila A Ali, 2009) .
The aim of present study was to evaluate the lower genital tract injury in relation to
mode of vaginal deliver y among women who gave their first vaginal birth.
The study was carried out at the Department of Obstetrics, Gynaecology and Human
Reproduction, in the Clinical Municipal Hospital nr. 1 of Chisinau, from January 2018 to
September 2018. A total of 180 women who gave their first child birth were included in
the study. The above mentioned women were divided into two groups:
I group – the study group included 90 women with vacuum assisted vaginal delivery
II group – the control group included 90 women with spon taneous vaginal birth
In order to investigate the relationship between lower genital track injuries in
relation to the mode of vaginal delivery, the prenatal and obstetric records of patients with
vacuum assisted vaginal delivery were reviewed , and compar ed with data of women with
non-instrumental spontaneous vaginal birth. Demographic variables, age, parity,
gestational age at delivery, mode of delivery, and labour complications, maternal and
neonatal morbidity were recorded and analyzed.
The mean age of women in test group was about 25.76 ± 3.43 years, and the mean
age of women in the control group was about 25.29 ± 3.96 years. According to the age,
the patients were divided into the following categories:
I group: 17 -24 years – 34 women (37.78 ±1.81%), 25-29 years – 40 women
(44.44±1.36%), ≥30 years – 16 women (17.78±0.70%).

31
II group (control): 17 -24 years – 40 women (44.44±1.84%), 25 -29 years – 37 women
(41.11±1.35%), ≥30 years – 13 women (14.44±1.70%).
According to details of collected material, our data indicates that the majority of
women who were at their first child birth in both groups were between 25 .0-29.9 years of
age. The age distribution of patients is shown in Figure 3. 1.

Fig. 3.1 . Age distribution of pregnant women included in the study .

Our results reflect t he fact that the vast majority of women included in the study
were from urban areas. Further, the obtained in the study data showed a slightly increased
incidence of vacuum assisted vaginal delivery in women who have had exposed to
stressful factors in the ir life such as occupational field. No statistically significant
differences were found between the groups in terms of origin or marital status . Table 3.1.
shows the socio -demographic characteristics in the patients with non-instrumental and
operative vagi nal delivery.
0,00%5,00%10,00%15,00%20,00%25,00%30,00%35,00%40,00%45,00%
17-24.9 25-29.9 >3037,78%44,44%
17,78%44,44%
41,11%
14,44%
Test group
Control GroupДобавлено примечание ([A1]): The age is a fixed
value. In the chart must be changed!!!
Добавлено примечание ([A2]): The name of the
groups must be c hanged!!!

32

Analyzing the obtained information about the menarche and character of the
menstrual cycle (table 3. 2.), it was found that in women in group I the average ag e of
menarche was 12.88±0.88 years. In the control group, the average of menarche was
12.77±0.92. No statistically significant differences were found between the groups in
terms of the age of menarche.
Table 3.1.
Sociodemographic characteristics of women included in the study

Parameter Group I – operative
delivery
(n=90) Group II –
spontaneous delivery
(n=90) P
n % n %
1. Age

17-24 34 37.78 40 44.44 0.3652
25-29 40 44.44 37 41.11 0.6525
>30 16 17.78 13 14.44 0.5433
2. Area

Urban 85 94.44 82 91.11 0.3896
Rural 5 5.56 8 8.89 0.3896
3. Occupation

Unemployed 37 41.11 43 47.78 0.9285
Student 12 13.33 11 12.22 0.8240
Active work 41 45.56 36 40.00 0.4522
4. Marital status

Married 78 86.67 77 85.56 0.8300
Single 12 13.33 13 14.44 0.8300 Добавлено примечание ([A3]): To arrange the spaces
in the table

33
Our results reflect the fact that the majority of patients included in the study , before
pregnancy, had a normal menstrual period and duration of menstrual bleeding. No
statistically significant differences were found between the groups in terms of
characteristics of the menstrual function . A normal menstrua l cycle of 21 -35 days and a
normal menstrual bleeding were found in both groups, with normal interval, duration and
amount of bleeding (Table 3.2.) .
Table. 3.2 .
Characteristics of the menstrual function in pregnant women included in the study
Parameter Group I – vacuum
assisted delivery
(n=90) Group II –
spontaneous delivery
(n=90) P
n % n %
1. Menarche
<11 years 3 3.33 2 2.22 0.6512
12 -15 87 96.67 88 97.78 0.6512
>16 0 0.00 0 0.00 –
2. Duration of flow
Normal ( 3-7 days) 90 100.00 90 100.00 –
Short (< 3 days) 0 0 0 0 –
Prolonged (>7 days) 0 0 0 0 –
3. Intensity of
menstrual bleeding
Normal 86 95.56 87 96.67 0.7008
Light 2 2.22 2 2.22 1.000
Heavy 2 2.22 1 1.11 0.5617
4.Menstrual interval
<21 days 0 0.00 0 0.00 –
21-35 90 100.00 90 100.00 –
>35 0 0.00 0 0.00 –

34
Parity has been studied as a risk factor for the chance of spontaneous lower genital
tract injuries. Njoku Ch. (2015) affirms that among primiparous women, vaginal and
perineal tears are mor e common and may be due to rigid perineum (Charles Njoku, 2015,
p. 194) . Emechebe C.I. (2015) studied the prevalence and pattern of genital tract injuries
in relation to parity and found that the prevalence of vaginal lac erations and third/fourth
degree perineal tear were highest among primigravida, while cervical laceration was
highest among primiparous82. Hsieh W.Ch. et al. (2014) demonstrated that nulliparity
(odds ratio =3.626, p<0.001) was an independent risk factors of severe perineal
lacerations83. Khaskeli M. et al. (2012) evaluated the type of obstetrical injuries in relation
to parity and reported that the most frequent obstetrical trauma seen in primiparous were
vaginal tears (25.39%) and perineal tears (19.04%). Ce rvical tears were the most frequent
obstetrical trauma in multiparous women (26.53%) , while in g rand multiparous most
frecquent were cervical tears (44.4%) and uterine rupture (37.01%)84. On the contrary,
Adaji S.E. et al. (2007), din not found a significan t relation between lower genital tract
trauma and age (p >0.000) or parity (p > 0.000)85.
The aim of the present study was to compare maternal outcomes, especially the rate
and extension of genital tract lacerations in primiparous women after spontaneous no n-
instrumental or operative vaginal delivery. Due to this fact, multiparous women were
excluded from the study. In this way, we could compare and concentrate on the traumatic
outcomes of vaginal labour in relation to mode of delivery.
In the present study, the analysis of obstetrical history showed 9 (10.0%) women from
the group I and 7 (7.78%) women in the group II had one or more spontaneous abortions

82 Emechebe C. I. The Pattern and Maternal Outcome of Lower Genital Trac t Injuries Among Women With Vaginal Deliveries in Calabar;
A Niger Delta State of Nigeria International Journal of Wom en's Health and Reproduction Sciences Vol. 3(No. 4):190 -195 · October 2015
83 Wu-ChiaoHsieha Ching -ChungLiangab DennisWua Shuenn -DhyChangabHo-YenChuehabAn-ShineChaoabPrevalence and contributing factors
of severe perineal d amage following episiotomy -assisted vaginal delivery Taiwanese Journal of Obstetrics and Gynecology Volume 53, Issue
4, December 2014, Pages 481 -485
84 Meharunnissa Khaskheli1, Shahla Baloch1 and Aneela Sheeba Baloch2 Obstetrical Trauma to t he Genital Tract Following
Vaginal Delivery Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (2): 95 -97
85 S E Adaji, O S Shittu, S Nasir Lower Genital Tract Trauma during Spontaneous vaginal delivery. Journal Home > Vol 51, No 1 -2 (2007)

35
in the history, and 1 (1.11%) woman from the group I and 4 (4.44%) women in the group
II had one or more medical abortions (Table 3.3.). No statistically significant differences
were found between the groups in terms of characteristics of the reproductive hystory.
The incidence of spontaneous and medical abortion in women with spontaneous
vaginal delivery and in those with operative vaginal delivery was unsignificant different
from statistical point of view (Table 3.3.).
Table 3.3.
Particularities of reproductive history in women included in the study
Parameter Group I – vacuum
assisted delivery
(n=90)
Group II –
spontaneous
delivery (n=90)
P
n % n %
Spontaneous
abortions 1 abortion 7 7.78 5 5.56 0.5517
2-3 abortions 2 2.22 1 1.11 0.5617

4 abortions 0 – 1 1.11 –
Medical
abortions 1 abortion 1 1.11 2 2.22 0.5617
2-3 abortions 0 – 1 1.11 –

4 abortions 0 – 1 1.11 –

Analysing the obtained data , we determined that the mean height of women was
164.67±5.75 cm in the first group and 165.58±5.44 cm in the second group (p>0.05). The
mean weight of pregnant women was 76.13±11.78 kg in the first group and 73.52±9.19
kg in the second group (p>0.05).
Obesity is associated with increased risk for adverse pregnancy outcomes including
pre-eclampsia or eclampsia, gestational diabetes, macrosomia, postpartum hemorrhage,

36
and increased rate of cesarean delivery86,87. According to existing evidences, maternal
obesity is associated with fetal macrosomia , which in turn is associated with increased
rates of genital tract trauma88,89. In the present study, the mean body mass index of wo men
in the first group was 28.0±3.73 and the mean body mass index of women in the second
group was 26.8±2.75. For analyses, we d istributed women into those who were obese in
the antepartum period (BMI ≥ 30 kg/m ²), normal (BMI ≥ 18.5 and < 25 kg/m ²), overweight
(BMI ≥ 25 and < 30 kg/m ²) or underweight (BMI<18.5 kg/m ²). In the first group, 26
(28.9%) women had BMI ≥ 30 kg/m ² at booking, 46 (51.1%) were overweight at booking
(BMI ≥ 25 and < 30 kg/m ²) and 18 (20%) women had a normal weight before pregnancy.
In the second group, 12 (13.3%) women had BMI ≥ 30 kg/m ² at booking, 56 (62.2%) were
overweight at booking (BMI ≥ 25 and < 30 kg/m ²) and 22 (24.4%) women had a normal
weight before pregnancy. Most women in both groups: 51 (56.7%) women in the first
group and 49 (54.4%) women in the second group gained more than the recommended
weight for their pre -pregnancy BMI .
The mean systolic blood pressur e of pregnant women included in the first group
was 118.9±11.2 mmHg and the mean diastolic pressure was 77.6±8.7 mmHg. In the
second group, the mean systolic blood pressure of pregnant women was 116.64±9.84
mmHg and the mean diastolic pressure was 77.89±7. 93 mmHg. No statistically significant
differences were found between the groups in terms of height, mean body mass index or
blood pressure.
Analyzing the extragenital and gynecologic history in pregnant women included in
the study , we determined that in the first group, 10 (11.1%) women had a hystory of

86 Ovesen P, Rasmussen S, Kesmodel U. Effect of prepregnancy maternal overweight and obesity on pr egnancy
outcome. Obstetrics & Gynecology. 2011; 118:305 –312.
87 Kelly Gallagher , Laura Migliaccio , Rebecca G Rogers , Lawrence Leeman , Elizabeth Hervey , Clifford Qualls The impact of first time mother’s
body mass index or excessive weight gain in pregnancy on genital tract trauma at birth. J Midwifery Womens Health. 2014 Jan -Feb; 59(1):
54–59.
88 Vinayagam D, Chandraharan E. The adverse impact of maternal obesity on intrapartum and perineal outcomes . ISRN
Obstetrics and Gynecology, 2012. 2012:939762 –939762.
89 Landy H, Laughon S, Bailit J, et al. Characteristics associated with severe perineal and cervical lacerations during
delivery. Obstet Gynecol. 2011; 117:627 –635.

37
arterial hypertension , one (1.1%) woman had a hysory of pulmonary disease, 2 (2.2%)
women had a hystory of gastrointestinal disease , 2 (2.2%) women had a hystory of cardiac
disease (Table 3.4.).
Table 3.4.
Extragenital and gynaecologic history of the pregnant women included in the study
Parameter Group I –
vacuum assisted
delivery
(n=90)
Group II –
spontaneous vaginal
delivery
(n=90) P
n % n %
Rheumatism – – 2 2.22 –
Arterial hypertension 10 11.1 5 5.6 0.18
Pulmonary disease 1 1.1 1 1.1 1.00
Gastrointestinal disease 2 2.2 2 2.2 1.00
Cardiac disease 2 2.2 – – –
Pyelonephritis 6 6.7 3 3.3 0.29
Diabetes mellitus 4 4.4 2 2.2 0.41
Hypothyroidism 1 1.1 – – –
Coagulation disorders 2 2.2 – – –
Cholecystitis 1 1.1 – – –
Colon surgery 2 2.2 2 2.2 1.00
Anaemia 2 2.2 1 1.1 0.56
PCOS 1 1.11 – – –
Mastopathy – – 1 1.11 –
Vulvovaginitis 4 4.4 5 5.6 0.71

38

6 (6.7%) women in the first group had a hystory of pyelonephritis, one woman
(1.1%) had a hystory of hypothyroidism and 2 (2.2%) women had coagulation desorders
in the past.
In the second group, 5 (5.6%) women had a hystory of arterial hypertension, one
(1.1%) woman had a hysory of pulmonary disease, 2 (2.2%) women had a hystory of
gastroin testinal disease, 3 (3.3%) women had a hystory of pyelonephritis (Table 3.4.).
Anemia was found in 2 (2.2%) pregnant women from the first group and in one (1.1%)
woman from the second group. One pregnant woman (1.1%) from the second group had
a hystory of mastopahy. Four women (4.4%) in the first group and 5 women (5.6%) in the
second group had a hystory of vulvovaginitis.
A normal pregnancy lasts from about 37 -42 weeks approximately 280 days, and
considered as being at term (Midd leton P, 2018) . At this time the child should be fully
developed and be ready enough to survive outside the women womb. Post term
pregnancy can carry a greater risk for both the mother and the infant, including fetal
malnutrition. After the 42nd week of gestation, the placenta, which supplies the baby with
nutrients and oxygen from the mother, starts aging and will eventually fail. Numerous
conditions are associated with postterm pregnancy as meconium aspiration syndrome,
macrosomia, shoulder dystocia, an d increase necessity for assisted vaginal delivery with
forceps or vacuum. (Postterm pregnancy, 2016) .
Preterm pregnancy carries various severe and life threatening conditions for the
fetus as temperature instability, ARDS, lun g collapse, chronic pulmonary diseases,
pneumothorax, cardiovascular anomalies (patent ductus arteriosus, hypotension,
bradycardia etc.), neurological (intracranial bleeding, periventricular leukomalacia, poor
muscle tone, seizures, retinopathy of immaturi ty), and gastrointestinal problems
(necrotizing enterocolitis, malabsorption etc.) (Preterm Labor, n.d.) .

39
One of the major criteria of this study was to take nulliparous women, at full term
pregnancy with spontaneous onset of la bor in order to avoid the complications based on
different gestational age. The intention was to obtain the results related to the mode of
vaginal delivery and not on the gestational age of the fetus.
The mean term of pregnancy was 39.6 ±0.9 weeks of gestat ion in the first group and
39.1±1. 2 weeks of gestation in the control group, demonstrating a fully term children
(p>0.05) .
The duration of labor is another very important factor that predispose women to
medical intervention. Prolonged second stage of labo r increase risk for neonatal morbidity
such as sepsis, asphyxia, and perinatal mortality (Prolonged second -stage labor may carry
risks, 2014) . Maternal complications (infection, urinary retention, haematoma or ruptured
sutures) in the early postpartum period. One of the indications for assisted vacuum vaginal
delivery is prolonged second stage of labor.
In the present study, the duration of the first, second and third stages of labor were
similar in both groups (Table 3.5.).
Table 3.5.
Durations of stages of labor in women included in the study
Stage of labour Group I – vacuum
assisted delivery
(n=90)
M ± σ Group II – spontaneous
vaginal delivery
(n=90)
M ± σ P
First stage, hours 8.4±3.4 8.6±4.4 0.73
Second stage, minutes 36.6±16.4 32.4±11.7 0.049
Third stage, minutes 6.7±3.8 6.4±2.9 0.06

40
In the study group the mean duration of the first stage of labor was 8.4 ±3.4 hours,
and 8.6±4.4 hours in the second (control) group. However, a small distinction may be
observed in the duration of second stage of labor. In group I the duration of second sta ge
of labor was 36.6 ±16.4 minutes and 32.4±11.71 in group II.
The third stage of labor lasted for an average time of 6.72±3.83 minutes in study
group and an average of 6.43±2.88 minu tes in the control group, without significant
statistical differences between groups.
Operative vaginal delivery refers to a delivery in which forceps, a vacuum, or other
devices are applied to extract the fetus from the vagina, with or without the assista nce of
maternal pushing. The decision to use an instrument to deliver the fetus depends on the
maternal, fetal, and neonatal impact of the procedure against the alternative options of
cesarean birth or expectant management (Elisa beth K Wegner, 2017) . The indications for
the assisted vaginal delivery are the follow:
 Prolonged second stage of labor
 Fetal compromise (based on heart pattern)
 Maternal medical disorders
Evaluating the indications for vacuum assisted delivery in our study, we fo und that
in 4 cases (4.44%) the vacuum was applied because of maternal cardiac pathology, in 4
cases (4.44%) the indication for vacuum assisted delivery was dynamic dystocia (uterine
contractions insufficiency). The main indication for vacuum assisted deli very, in 91.1%
of cases (82 women) was fetal distress or non -reassuring state (fig. 3.2.).

41

Figure 3.2. Indications for vacuum assisted delivery (%).

The conditions for application of the vacuum device are: term fetus, cervix fully
dilated and the head at least at 0 station or no more than 2/5 above symphysis pubis
(doctors, n.d.) . In the study of Royal College of obstetrics and gynecology was found that
there is a greater risk of failure associated with mid -cavity delivery or when 1/5 -th of the
head palpable trough the abdomen (26, 2011) .
As shown below, in 72 (80%) of the cases the fetal head station during the vacuum
application was at station 1/5, in 13 (14.4%) of the cases 2/5, and in 5 (5.6%) the head
station was 0/5 (fig. 3.3.).
4,44% 4,44%
91,10%
Maternal cardiac desease Dynamic dystocia Fetal distress

42

Figure 3.3. Fetal head station at the momen t of vacuum application (%).

Based on the results we can establish that the vacuum application was performed
according the required conditions, in the acceptable head station.
Perineal trauma following vaginal delivery has been reported since ancient time,
and continue to occur despite improved care affecting maternal health and quality of
life90,91. Short-term and long -term morbidities include perineal injuries of 3rd and 4th
degree, cervical lacerations , uterine rupture, bladder injury, vesico -vaginal fistula , and
recto -vaginal fistula [90].
The incidence of perineal trauma following vaginal delivery varies markedly
between studies. According to World Health Organization (WHO) International
Classification of Diseases, birth related perineal trauma with anal s phincter injuries has

90 Khaskheli M., Baloch Sh., Baloc h A.S. Obstetrical Trauma to the Genital Tract Following Vaginal Delivery. Journal of the College of Physicians and
Surgeons Pakistan 2012, Vol. 22 (2): 95 -97.
91 Turki1 R, Abduljabbar H.S., Manikandan J., Thiagarajan J., Bajou O., Gauthaman K. Severe peri neal lacerations during childbirth in Saudi women -a
retrospective report from King Abdulaziz University Hospital. Biomedical Research 2017; 28 (8): 3350 -3354 .
Добавлено примечание ([A4]): Change the percent
like in text

43
an incidence of 4% to 6.6% in women following vaginal delivery92. A global survey from
24 countries on maternal and perinatal health reported that the prevalence of third – and
fourth -degree lacerations ranged from 0.1% to 15%93.
Perine al trauma may result either due to spontaneous tear of perineal tissue
occurring during childbirth or following episiotomy. Third or fourth degree perineal
lacerations represent a serious adverse outcome of vaginal delivery . Associated symtoms
include flatus and stool incontinence, urinary incontinence and sexual dysfunction, recto –
vaginal fistula, perineal pain.
Various risk factors influencing genital tract injuries were reported by the systemic
review of 14 studies. These factors include multiparity, pri miparity, cephalo -pelvic
disproportion, malposition, labor induction, manipulation by unskilled birth attendants,
prolonged second stage of labor. Instrumental -assisted vaginal delivery and
macrosomia were cited to be significantly associated with severe p erineal
lacerations [83],94. Other risk factors include epidural anesthesia, maternal age, postterm
pregnancies, and episiotomy.
The focus of the prese nt study was to find out the relation between lower genital
tract injuries and the mode of vaginal delivery. Many authors state that there is an
increased risk for lower genital tract injuries in assisted vaginal delivery. (Assis ted
Vaginal Delivery, 2016) (Elisabeth K Wegner, 2017) (Assisted Vaginal Delivery, 2016) .
Labor by itself is a process that predispose women to lower genital tract injuries. Thus,
the present stud y was conducted to evaluate the obstetrical injuries following spontaneous
or assisted vaginal delivery with regard to their frequencies, types, severity and
complications. Perineal lacerations and their severity were assessed based on the

92 World Health Organization. International Classification of Diseases (ICD). Geneva (CG): WHO; 20 15.
93 F. Hirayama, A. Koyanagi, R. Mori, J. Zhang, J.P. Souza, A.M. Gülmezoglu Prevalence and risk factors for third – and fourth -degree
perineal lacerations during vaginal delivery: a multi -country study . BJOG, 119 (2012), pp. 340-347
94 D.N. Samarasekera, M.T. Bekhit, J.P. Preston, C.T. Speakman Risk factors for anal sphincter disruption during child birth. Langenbecks
Arch Surg, 394 (2009), pp. 535-538

44
classification b y the Royal College of Obstetricians and Gynaecologists95. A third and
fourth degree tear s were defined as an injury to the perineum involving the anal sphincter
muscles and rectal mucosa respectively. Table 3.6. reflects the lower genital trauma
incidence during labor in pregnant women included in the present study.
Table 3.6.
Lower genital tract injuries during labour
Parameter Group I – vacuum
assisted delivery
(n=90) Group II – spontaneous
vaginal delivery
(n=90) P
n % n %
Cervical
lacerations 37 41.1 57 63.3 0.003
Vaginal
lacerations 66 73.3 54 60.0 0.003
Labial
lacerations 30 33.3 30 33.3 1.000
Episiotomy 21 23.3 2 2.2 < 0.0001
Perineal trauma 58 64.4 35 38.9 0.0006
1st degree
perineal
laceration 12 13.3 12 13.3 1.000
2nd degree
perineal
laceration 45 50.0 – – –
3rd degree
perineal
laceration 1 1.1 – – –
4th degree
perineal
laceration – – – – –

95 RCOG (2001): Management of Third and Fourth Degree Perineal Tears Following Vaginal Delivery. In RCOG Gu ideline no.
29. RCOG Press, London.

45
A total of 37 (41.1%) women in the study group, and 57 women (63.3%) in the
control group acquired cervical lacerations (p=0.003). Vaginal lace rations were most
common in pregnant women after vacuum assisted delivery (73.3% in vacuum assisted
delivery vs 60.0% in spontaneous vaginal delivery), the differences being statistically
significant (p=0.003). Labial lacerations rate was similar in both g roups of pregnant
women included in the study (p=1.000).
Perineal lacerations have been commonly associated with episiotomy and operative
deliveries . In the present study, a total of 58 (64.4%) women with vacuum assisted
delivery and 35 (38.9%) women with spontaneous vaginal delivery acquired perineal
lacerations, the incidence of perineal trauma being statistically higher in case of assisted
instrumental vaginal delivery (p=0.0006) than in spontaneous vaginal delivery . In
addition, vacuum assisted delivery was associated with increased incidence of episiotomy
(23.3%) compared to spontaneous vaginal delivery (Table 3.6.).
According to previous reports, episiotomy itself poses a risk of severe perineal
lacerations following vaginal delivery96. Hsieh W. et al. , in a logistic regression analyses
on all variables, demonstrated that instrument -assisted vaginal delivery came out as a
common independent risk factor of severe lacerations among both nulliparous and
multiparous population [83].
Our results showed that the incidence of 1st degree perineal lacerations was similar
in vacuum assisted and spontaneous vaginal delivery (p=1.000). The incidence of 2nd and
3rd degree perineal lacerations was higher in vacuum assisted vaginal delivery compared
with spontaneous va ginal delivery (Table 3.6.).
Vacuum assisted vaginal delivery was identified to be a strong predictor of
lacerations in this study with odds ratio of 2.85 (95% CI 1.5555 – 5.2152; P=0.0007 ). An

96 K. Hartmann, M. Viswanathan, R. Palmieri, G. Gartlehner, J. Thorp, K. LohrOutcomes of routine
episiotomy: a systematic review . JAMA, 293 (2005), pp. 2141 -2148

46
important fact is that vacuum assisted vaginal delivery was id entified to be a very strong
predictor of 2nd and 3rd degree perineal lacerations in this study with odds ratio of 189.13
(95% CI 11.3899 – 3140.6711 ; P=0.000 3).
Newborn weight and fetal head circumference are other factors that have been
found to be assoc iated with genital tract lacerations during labor. In the study conducted
by Turki R. et al., birth weight of the baby being more than 4000 grams was identified to
be the strongest predictor of lacerations in this model with odds ratio of 8.62 (95% CI
2.848-26.108) [91]. Aytan H. et al reported that the newborn's head circumference was
significantly greater in women with severe perineal lacerations when compared with those
without severe lacerations97.
There was no significant difference between vacuum -assisted and spontaneous
vaginal deliveries as regards to newborn weight and head circumference . The mean weight
of the newborn in the st udy group (vacuum assisted delivery) was 3.432±383 gr and
3.289±413.5 gr in the control group (spontaneous vaginal delivery) , p=0.9981 (Tabl e
3.7.).
Table 3.7.
Newborn Apgar score, weight and head circumference and volume of blood loss
depending on the type of deliver y
Parameter Group I – vacuum
assisted delivery
(n=90) Group II –
spontaneous
vaginal delivery
(n=90) P
Newborn weight, gr 3.432±383 3.289±413.5 0.9981
Newborn head
circumference , cm 34.3±0.7 34.1±0.8 0.0760
Apgar score at 5 minutes 7.6±0.5 8.5±0.7 <0.0001

97 H. Aytan, O.L. Tapisiz, G. Tuncay, F.A. Avsar Severe peri neal lacerations in nulliparous women and
episiotomy type . Eur J Obstet Gynecol Reprod Biol, 121 (1) (2005), pp. 46-50

47

Foetal head circumference was described to be connected with severe perineal
lacerations . In our study, the mean head circumference was 34.3±0.7 cm in vacuum
assisted delivery group and 34.1±0.8 cm in spontaneous vaginal delive ry group
(P=0.0760). Mean Apgar score at 5 minute was signific antly lower among neonates after
vacuum assisted delivery (7.6±0.5 ) compared with neonates after spontaneous vaginal
delivery ( 8.5±0.7 ), P<0.0001 (Table 3.7.) .
There was no significant difference between vacuum -assisted and spontaneous
vaginal deliveries as regards to maternal blood loss (371.3±131.6 and 365.3±172.6
milliliters , respectively ; P=0.7934 ). How ever, maternal blood loss was slightly higher in
the vacuum assisted delivery group (fig. 3.4.).

Figure 3.4. Maternal blood loss during labor (ml).

The incidence of postpartum hemorrhage (>500 ml) was similar in both groups of
patients included in the study: 15.6% in vacuum assisted delivery group and 14.4% in
spontaneous vaginal delivery group (P >0.05). 371,3
365,3
356358360362364366368370372374376
Group I (vacuum assisted delivery) Group II (spontaneous vaginal
delivery)

48
The results of our study confirm previous findings of higher incidence of perineal
trauma following vacuum assisted vaginal delivery and a strong association between
assisted delivery and perineal trauma. The strength of present study was the inclusion of
only primi parous women. Thus, excluding multiparous patients excludes the potential bias
of parity on perineal body length . At the same t ime, several limitations in our study should
be declared as the retrospective design and the small sample of included patients . The
diagnosis of lacerations was based on clinical judgment in our study and the classification
of the degree of perineal laceration could vary from physician to physician. The long-term
maternal and neonatal outcomes were not the objective of the presen t study.

Conclusion s to th e 3rd chapter
This study was performed to estimate the relationship between the way of delivery
and the degree of genital trauma . The goal of operative vaginal delivery is to assist the
spontaneous vaginal birth provi ding minimum maternal and neonatal morbidity.
According to our results, perineal damage, such as second and third degree lacerations has
been shown to oc cur more often with the use of vacuum assisted delivery. Vacuum
assisted vaginal delivery was identified to be a strong predictor of lacerations in this study
with odds ratio of 2.85 (95% CI 1.5555 – 5.2152; P=0.0007 ). An important fact is that
vacuum assisted vaginal delivery was id entified to be a very strong predictor of 2nd and
3rd degree perineal lacerations in this study with odds ratio of 189.13 (95% CI
11.3899 – 3140.6711 ; P=0.000 3). There was no significant difference between vacuum –
assisted and spontaneous vaginal deliveries as regards to newborn weight and head
circumference . However, from the present study it seems that neonates deliv ered by
vacuum are more likely to have a low er Apgar score at 5 min compared with neonates
after spontaneous vaginal delivery . Most of our findings are consistent with previous
literature.

49
Conclusions
1. The risk of maternal perineal injury is higher with vacuum assisted compared with
spontaneous vaginal delivery . Vacuum assisted vaginal delivery was id entified to
be a very strong predictor of 2nd and 3rd degree perineal lacerations in this study
with odds ratio of 189.13 (95% CI 11.3899 – 3140.6711 ; P=0.000 3).
2. This study confirms previous findings of overall high incidence of perineal trauma
following vaginal delivery and a strong association between vacuum delivery and
perineal trauma.
3. This study found an assoc iation between use of vacuum -assisted vaginal deliveries
and lower neonatal Apgar scores ant 5 min. There was no significant difference
between vacuum -assisted and spontaneous vaginal deliveries as regards to newborn
weight and head circumference .
4. An operative vaginal delivery should be performed only if there is an appropriate
indication. Informed patient consent must be obtained. In all instances, the potential
risks and benefits of a vacuumassisted delivery must be weighed .

50
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