What’s driving Canada’s high rate of maternal trauma from operative vaginal delivery?

Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel; however, the rate of maternal trauma following OVD in Canada greatly exceeds that of any other OECD country. In Canada, maternal trauma occurred in more than one-quarter of deliveries with forceps, whereas in the UK, the rate is 8%-12%, and in Australia, it sits at ​​9.3%-14.1%.

A research study published in CMAJ found that rates of trauma following OVD in Canada are higher than previously reported, irrespective of region, level of obstetric care and volume of instrument use among hospitals. The authors argue these results support a reassessment of OVD safety in Canada. 

In this episode, Dr. Bigham and Blair and Dr. Mojola Omole speak with Dr. Giulia Muraca, the lead author of Maternal and neonatal trauma following operative vaginal delivery: a national cohort study. They explore possible causes for these troubling findings.

They then speak with Dr. Nirmala Chandrasekaran, an OB/GYN and Maternal-Fetal-Medicine specialist at St. Michael’s hospital in Toronto. Dr. Chandrasakan trained in the UK, and she describes how exposure to OVD during residency differs in the two countries. She also discusses the vital role OVD plays in safe deliveries.

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Transcript

What’s driving Canada’s high rate of maternal trauma from operative vaginal delivery?

Dr. Blair Bigham:

I'm Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole.

Dr. Blair Bigham:

And welcome to the CMAJ Podcast. Jola, in my first year of residency for emergency medicine, I had to do a month of obstetrics, and I remember being pretty terrified. I had delivered a couple of babies as a paramedic, but it's not really something that I felt very well prepared to do. It was always sort of done under an emergency circumstance. And then, you show up on the obstetrics floor, and everybody is so calm, and cool, and collected. And deliveries would come out of nowhere. It was pretty busy, but everyone seemed to have things under control.

Dr. Blair Bigham:

And then, every once in a while, you'd be in a room for a delivery, and there'd just be this atmosphere change. And all these calm, cool and collected people, they would just seem like really nervous and amped up. And I could never really pinpoint it. Usually it had something to do with the toco not looking right. And all of a sudden, out would come this vacuum, or these forceps, and boom, the baby would be out, crying, and pink, and everything would be fine. But I could sense, sort of, that anxiety amongst people when the vacuum came out. And today, we're going to be talking about an article that looks at complications from operative vaginal delivery, needing either vacuums or forceps. Have you ever had any experiences in obstetrics, Jola?

Dr. Mojola Omole:

So outside of medical school, and delivering my own child, no. But I think, as a person who has had a vaginal delivery, I definitely was really nervous about having them using forceps, knowing the complications of it. Because I, as a general surgeon, see complications from forcep deliveries that have gone wrong, with the third, and usually the fourth-degree tears that lead to complex issues after.

Dr. Blair Bigham:

Remind me, what exactly is a fourth-degree tear?

Dr. Mojola Omole:

So basically that is when it's like a complete tear into the anal verge, and that can lead to fistula formation. Third and fourth-degrees patients can have incontinence to both stool and gas, and it's one of the leading causes of incontinence in people who have babies. And also, I worked in Sub-Saharan Africa, and oftentimes, I would see women with really bad fistulas, and that's not necessarily from instrumentation, but also just from really bad tears. So that's definitely something that I think is very important to talk about. And I'm really looking forward to talking to Giulia Muraca, and our physician today, just regarding what is going on with OVD.

Dr. Blair Bigham:

Yeah. And just to briefly summarize what they've done, they've taken over a million vaginal deliveries, and taken a look at complication rates from OVD, and found that Canada has higher complication rates than other places in the world, like the UK, and New Zealand, and Australia. So let's get right into it. Let's go talk to Giulia.

Dr. Mojola Omole:

Dr. Giulia Muraca is the lead author on the study, she's currently in Vancouver. Thank you for joining us.

Giulia Muraca:

Thanks, Jola. Happy to be here.

Dr. Mojola Omole:

So let's just get right into it. What is the top line finding of your study?

Giulia Muraca:

The top line would be that maternal and neonatal trauma rates are high among forceps and vacuum delivery in Canada, period. This is the most compelling finding of our work. And the reason why it seems as though maybe these results aren't earth-shattering, because we know that operative vaginal delivery, or forceps and vacuum delivery, confer a high risk of these traumas. But what is really special about the work that we published recently in the CMAJ, is that we showed that these rates are consistently high, irrespective of how many of these deliveries a hospital will do each year, irrespective of the tier of obstetrics service or level of care of a hospital, whether it be a high-level tertiary care center, or a local hospital, and also among all the provinces and territories that we studied, which were all of them in Canada, except for the province of Quebec.

Dr. Mojola Omole:

So what was your initial reaction when you did your analysis and you saw the results?

Giulia Muraca:

Well, it's a great question because, truly, I've been studying these outcomes among forceps and vacuum delivery since 2016, and the rates of these traumas actually didn't surprise me at all. We've been publishing that these rates have been high among these deliveries, consistently over the last five-six years. So the sheer average trauma rates that we found weren't really surprising to me. What I did find surprising was that we didn't see a modification or a variation in those rates, based on the different factors that I just mentioned, based on the level of care of hospitals, or even based on how many of these deliveries are done among individual hospitals.

Dr. Blair Bigham:

Does that mean it's not a matter of training that, I mean, whether you do a lot or a little, or you're at a top tier, or sort of a lower-tier hospital, the outcome seemed the same? What do you think is getting at this?

Giulia Muraca:

That's certainly what it suggests. Of course, these are observational studies, and we've looked at volume of deliveries within hospitals, but what we didn't have was practitioner-level data. So had we had practitioner-level data, I could answer that with a lot more certainty. I could say, "Yes, we could see that among practitioners, they did very few of these deliveries per year. And so, this is a clear kind of link to the fact that, because obstetricians, residents, maternity care providers have less proficiency in these deliveries, that is what is associated with these higher levels of trauma." So we don't have that information. The smallest unit of information we had was at the hospital level. So we have to be mindful of the fact that some of these outcomes could have been clustered among different practitioners.

Giulia Muraca:

But certainly, what we know from this larger body of work is that, number one, our use of these deliveries is certainly declining. And as we're seeing these rates of use decline, and the opportunities for training decline, we're also seeing concurrently these rates of trauma increase. And this is particularly with forceps deliveries. So we saw, between 2004 and 2014 for example, that the rate of maternal trauma increased with forceps deliveries from 19% to 27%. So all of these trends occurring at the same time are giving us this picture that, yes, there's probably a link between the fact that we're doing these less, operators have less opportunity to gain proficiency in these deliveries, and the actual performance of the operative vaginal delivery, and perhaps even the knowledge to select the appropriate candidates, could be factors in why we're seeing these high rates of trauma.

Dr. Mojola Omole:

One part that really stuck out is that our rates are worse than other countries. Do you have any kind of ideas or thoughts on why we see a difference when we're comparing Canada to other countries?

Giulia Muraca:

Yeah, I do have some suspicions. They're all speculative, of course, but first, maybe I'll just describe what you mean when you say we're worse than other countries. So fortunately, the OECD puts forth these comparative outcomes that look at different kinds of domains of safety, among all different silos of the healthcare system. And one of the things they look at is maternal trauma, with and without the use of instruments. And so, in that comparison, Canada has shown to have had the highest rates in 2015, 2017, and 2019, and by a large margin.

Giulia Muraca:

So this is rates of maternal trauma when we aggregate forceps and vacuum together - unfortunately they don't disaggregate in this metric. So in that rate of maternal trauma, with forceps and vacuum together, Canada has had a rate around 17%, where our closest neighbor with the second highest rates have rates closer to 11%. So it's by a huge margin.

Giulia Muraca:

And so, when we look at that, there's a lot of differences that we could infer that this was due to differences in reporting, and probably likely some of the reason for these differences is differences in reporting, but when we see that the results of the study that came out last week in the CMAJ, that looked at these rates, sliced in all these different ways, it's apparent that these inflated rates could not be 100% due to reporting error. It just doesn't make any sense that we would see it in every tier of service. We would see it in every hospital, in every province, in all the multitude of ways that we've cut this up, and tried to analyze it, to try to figure this out.

Giulia Muraca:

So it doesn't look like it's a reporting issue. Also, we have validation studies on the codes that we use to identify these cases, and they all have very high sensitivity and specificity. And so, those issues with reporting, they probably have some of an effect, but I speculate that it's definitely not the majority of the reason why we're seeing these different system rates.

Dr. Blair Bigham:

Giulia, do other countries have as rigorous a data set? Is it just that we report more frequently? I know that within Canada, the reporting seems quite solid, but for these comparisons, are we actually worse off, or do you think we just know that it happens better?

Giulia Muraca:

That's a great question, Blair. In different countries that have national health registers of demonstrated high accuracy, I question whether that is a huge factor in the differences that we're seeing. Of course, there are other countries that are also compared in these analyses for which we don't have such evidence of rigorous data collection, but for a good proportion, we do.

Dr. Blair Bigham:

And is it that they... Do they just go to C-section quicker, or are they more patient to wait for a spontaneous delivery? I don't know. I don't have a lot of-

Giulia Muraca:

Yeah, these are-

Dr. Blair Bigham:

... sense of why the countries are so different.

Giulia Muraca:

Yeah. We're comparing between Sweden, we're comparing with the US, we're comparing with Finland, we're comparing with Denmark, so when you think of that subgroup, we're seeing that in places like Denmark, Finland, Sweden, they have far lower rates of Cesarean delivery, so these lower rates of trauma can't be explained by, "Oh, well they're just doing more Cesarean deliveries in those scenarios." Perhaps in the US it could, but their rates of Cesarean delivery are higher, but the differential isn't great enough that would be the reason.

Giulia Muraca:

You also mentioned maybe it's because… are they just waiting it out longer, are they allowing women to deliver? I think arguably, that is one of the reasons why we're seeing lower rates in some of the Nordic countries. I mean, it's well established that they're non-interventional relative to Canadian or North American standards, so that could be a reason, but again, this is all speculative.

Giulia Muraca:

I do want to mention that one of the big differences we see, and the real comparator we should be looking at, in my opinion, is the United Kingdom, because they have a similar distribution of the use of these instruments. The UK has maternal trauma rates with forceps and vacuum delivery that are far lower, so 4% in vacuum, 8% in forceps, for example. And one of the big differences we see is the use of episiotomy. We know from all of the excellent randomized studies, many of which were conducted in Canada in the '90s, that routine use of episiotomy is not recommended with spontaneous vaginal delivery - so unassisted vaginal delivery. So we have seen the rates of episiotomy decline with spontaneous vaginal delivery over the last 20 years, which is fantastic, and appropriate given the evidence.

Giulia Muraca:

We've also seen these declines in forceps and vacuum delivery, in Canada, not in the United Kingdom, and we're seeing much lower use of episiotomy with these instruments. Now, another analysis that we published in the CMAJ in 2018 showed that when we use forceps and episiotomy in nulliparous women, it actually confers a high protective value.

Dr. Blair Bigham:

So they're less likely to get a bad tear if you do the episiotomy before the forceps?

Giulia Muraca:

In nulliparous women. The same is true in nulliparous for vacuum. Important to note, it was not the case in parous women, which I guess is intuitive, so women who have had a previous vaginal birth, we did not see any effect, and in fact, with vacuum, we saw an increase in obstetric anal sphincter injury with episiotomy. So, really, the take-home message of that work is that vaginally nulliparous women, or women who have not had a previous vaginal delivery, have lower rates of maternal trauma if an episiotomy is conducted alongside their forceps or vacuum delivery. And we're not doing that in Canada at nearly the same rates as they're doing in the United Kingdom, or even in Australia and New Zealand for example. So I speculate that this is one of the main reasons why we're seeing these higher rates of trauma in Canadian women compared to women in these other countries.

Dr. Mojola Omole:

Another topic that you touched on in your article was talking about women knowing about the risks associated with these. As we all kind of have an idea - that at that moment when there needs to be a progression to using an operative vaginal delivery- that it always tends to be quite hectic, and maybe not necessarily the best time to be communicating these discussions. In terms of, from your position, how do you think that could improve for people who are giving birth - being more knowledgeable about this?

Giulia Muraca:

Yeah. This brings up a whole kind of world of scholarship around informed consent in pregnancy, which is another three podcasts on its own. Most of the literature on when we should have these discussions with women concludes that we should have these conversations antenatally. Now, this is easy to say, but we know that time is short, and we're really trying to pack in a lot of information, and we don't want to overwhelm pregnant individuals, so I realize that sometimes, we like to throw this word around, like, "We should counsel antenatally," but truly, this is happening in one in four pregnant individuals who undergo these interventions.

Giulia Muraca:

These are very high frequencies, and if we aren't telling women about this, we're really doing a huge disservice to women's autonomy, and their opportunity to have informed consent, and really choose... be informed about the outcome of their childbirth, or potential outcomes of their childbirth. So, I think that it has to be a priority that we start speaking about the risks of not just operative vaginal delivery, of course, but all of the potential outcomes of halting the progression of labor or if there are risks that require an intervention.

Dr. Mojola Omole:

What do you think is next in terms of this research? Like, where do you see this going next for you, and for your team?

Giulia Muraca:

One of the things that needs to be discussed, I think front and center, is the long-term consequences of some of these injuries: complications like sexual problems, dyspareunia, PTSD, other mental health morbidities, but perhaps most distressingly, fecal and anal incontinence. We're seeing rates, after 20 years post-delivery, of between 20 and 25% of fecal incontinence in women who have had an injury like this. And when I speak about fecal incontinence, this is involuntary loss of solid or liquid stool. This is a serious, horrible complication, and this is only what we know is reported. There are many individuals who never come forth and never seek care, because of the shame and stigma associated with these complications. So, I am very interested in seeing what the medium and long-term outcomes are in the Canadian population. And the other area is to look at some of the modifiers.

Giulia Muraca:

I want to take a closer look again at the use of episiotomy, and how we might be able to bundle care packages, and quality improvement care packages to reduce these rates of injuries. And, lastly, I am very excited, I have a brilliant master's student, Mi Jinh Park, who's interested in looking at the intersectional effects of race and immigration status in these outcomes in Canada. We know that Asian women have more than twofold higher rates of obstetric anal sphincter injury compared to other races, and this data comes from Canada, from the US, and from European countries, so this has consistently been found, that Asian women have higher rates of these injuries, so we're really interested in looking at or trying to figure out what the reasons for that are.

Dr. Mojola Omole:

That's great. Thank you so much.

Dr. Blair Bigham:

Thank you so much.

Giulia Muraca:

Thanks, Jola, thanks Blair.

Dr. Mojola Omole:

Dr. Giulia Muraca is an assistant professor in obstetrics and gynecology at McMaster University, and the lead author of the National Cohort Study, titled Maternal Neonatal Trauma Following Operative Vaginal Delivery. It's in the CMAJ. Now, while the findings in Dr. Muraca's study might surprise some of us, neither one of us are OB-GYNs, so we wanted help to understand what they mean to practitioners and their patients.

Dr. Blair Bigham:

And for that, we turned to Nirmala Chandrasekaran, an obstetrician and gynecologist and maternal-fetal medicine specialist at St. Michael's Hospital in Toronto. Nirmala, thanks for joining us.

Dr. Nirmala Chandrasekaran:

Thanks for having me.

Dr. Blair Bigham:

Before we get into the study, can you just help me understand what circumstances arise where OBs decide to turn to OVD?

Dr. Nirmala Chandrasekaran:

The OVDs are actually done in order to facilitate vaginal delivery for three indications. One is when the mother is exhausted, having had a long second stage of pushing, so in order to assist vaginal delivery, we do that. The second indication is when there is fetal distress, and the baby needs to be delivered sooner, so we help the mother with OVD. And the third is for maternal indications, where the mother cannot Valsalva, or push a lot, because of various health conditions. Then we may have to reduce the second stage of labor by cutting it short using an instrumental delivery.

Dr. Mojola Omole:

And just to make it clear, the choices that you have at these stages are either OVD or taking that patient to a C-section, just to give our listeners an understanding of what's going through your mind when you're trying to deliver? "Do I do forceps, or should I take this person to a C-section?"

Dr. Nirmala Chandrasekaran:

Well, there are a few things that we actually look at to decide between one or the other, really. The first and foremost is whether or not the patient is fully dilated. And, second, what is the station of the fetal head, which is where the head is in relation to the ischial spines. That is how low the head is in the pelvis, in other words.

Dr. Nirmala Chandrasekaran:

So if the head is really low in the pelvis, and the maternal effort is good, and the pelvis seems adequate, then operative vaginal delivery would be the go-to for all of us. But if the fetal head is about the station at which we would be uncomfortable doing an instrumental delivery, or if it is malpositioned, or if we think it is not going to work, then we choose a cesarean section.

Dr. Nirmala Chandrasekaran:

So it's not exactly black and white, but you know sometimes we do have to think twice. And sometimes we do it in the OR. Because if we are doubtful whether or not it's going to work, then we take the call that is safe.

Dr. Blair Bigham:

So what do you think of these numbers in Dr. Muraca's study? Do you think they're real? Do you think there's some artifact? Are they higher? Are they lower?

Dr. Nirmala Chandrasekaran:

It could be a little lower, but I'm sure it is not that low, because of certain reasons, right? In North America, the use of forceps has been reducing. And we know that.

Dr. Nirmala Chandrasekaran:

They actually did a study in the US, which actually looked at what the comfort level of physicians and residents and fellows is for forceps. And almost more than half of them said they were not comfortable. So it is a training issue in North America, compared to Europe. So maybe that is playing a part.

Dr. Blair Bigham:

In terms of training, Giulia was talking about how fewer and fewer forceps deliveries are happening, and how residents might not be getting enough exposure to that in training. She had quoted a study that said, "In a five-year residency, they might only do a handful, less than, of forceps deliveries."

Dr. Blair Bigham:

Now, you did your residency in the UK, which I know has a very long training route. I'm wondering, do you think that there's a role for residency education here, to help reduce the risk of fourth degree injury?

Dr. Nirmala Chandrasekaran:

Oh, absolutely. Absolutely. So the training pattern is quite different. Yes, we did have a longer training route in the UK. And the way the training works is also that it's a seven-year program. And, from the third year onwards, you are practicing independently, which means you do not have a staff holding your hand.

Dr. Nirmala Chandrasekaran:

So, by two years, you're meant to be signed off for your forceps, your vacuum, and cesarean sections, and things like that. And, after that, it is you, and that's it. What is difficult in training somebody is actually not the technical aspects of it. It's easy to train them to... Okay, this is how you apply the blades, and this is how you make the direction of pull. That's easy. We can do the simulations no problem, which, in fact, we do a lot at St Michael's Hospital.

Dr. Nirmala Chandrasekaran:

But what is difficult in training residents is actually when not to use forceps, when to choose the right instrument, when not to resort to operative vaginal delivery at all, and go for cesarean sections, and when not to choose the instrument where you won't have to need a second instrument. So those are the things that is difficult to train, especially-

Dr. Blair Bigham:

More around the judgment in the clinical decision.

Dr. Nirmala Chandrasekaran:

Correct. Correct. And the clinical decision-making as to what to do and what not to do, that I find a little bit difficult. And that may not be possible in a five-year residency program, where you have consultant-present all the time.

Dr. Mojola Omole:

I guess, to speak a little bit about that, residency programs are changing to being competency by design, versus just sheer numbers. When I went through residency training, it was just volume. We had to have a sticker book of all the cases that I've done.

Dr. Mojola Omole:

But now they're switching to competency by design. So there's actually not knowing how many they've done. Does there need to be a bit of a standard, in the sense of you have to have been involved in this many forceps or vacuum delivery, and actually quantify the number, given that it could be a bit of a hit or miss, depending on where you are and which hospital you're based in during your training?

Dr. Nirmala Chandrasekaran:

I mean, if you look at the study itself, they have addressed one thing: when the number of forceps deliveries are about 30, there is actually a slight drop in OAC and the maternal morbidity. So there is that element of, when you do more, you have less complications.

Dr. Nirmala Chandrasekaran:

But with regards to the technical aspects of it, I don't think it's the number that actually matters. I do think the judgment issues, we need to go through it. And I don't believe they have to do a lot more, but definitely doing enough is important, in order to maintain your competencies.

Dr. Nirmala Chandrasekaran:

But what is important is actually perhaps we have all these CBDs, and all those things that are coming up now. So maybe for the discussion as to when you would not do it, and when you would do it, and all that, more of that.

Dr. Blair Bigham:

We've been talking a lot about training and the frequency that you get during your residency training, for doing these procedures to gain competence. I'm having a little bit of trouble jiving that with the data from the study that showed that it didn't really matter about the annual volume of OVDs, or if you were in a very high class center or more of a smaller center. It seemed that the rates of injury were about the same.

Dr. Blair Bigham:

Can we really pin all of this on training and experience? Or are there other factors at play that might explain why Canada has a 17% rate, while the Scandinavian countries, and Australia, New Zealand, and the UK had much lower rates? Is there something other than training that can help us understand this problem?

Dr. Nirmala Chandrasekaran:

There are a little bit of unknown factors in the study, because it's a database one. The study does say that it doesn't depend on the institutions. It doesn't depend on the tier of maternity care and all that.

Dr. Nirmala Chandrasekaran:

But, still, if you are going through a five-year training program, where you have done only five forceps or six forceps, then you go on to become the staff, of course, then that is an issue. And, of course, we haven't teased out that data at all. And it's very hard to do that. I do think training plays a big part.

Dr. Mojola Omole:

I guess the other question is that we're talking about the volume that the residents are seeing, but why is it that we have less of OVDs in Canada, just in general, compared to the UK?

Dr. Nirmala Chandrasekaran:

Excellent question, actually, which I was actually thinking when I came to Canada. Why are we doing less compared to what was happening in the UK? I think it is... I mean, even in our institution, not all obstetricians are comfortable with forceps deliveries. And that is the case with every single institution.

Dr. Nirmala Chandrasekaran:

There would be only a handful of people that actually do forceps deliveries. And, again, because of that, the training also gets affected for the residents. I mean, they're not going to get trained, because there are only a couple of physicians that do in every single unit.

Dr. Nirmala Chandrasekaran:

So I don't know whether the comfort level went down because of lack of training, or lack of experience, or people became comfortable doing cesarean sections. And that could be one of the reasons also, because we do cesarean sections all the time. And so we become very comfortable, and we resort to cesarean sections.

Dr. Mojola Omole:

Do you think that explains a decrease in forceps deliveries over time, that people go to C-section instead of forceps?

Dr. Nirmala Chandrasekaran:

For sure. For sure. I mean, if you look at the WHO data regarding what the safe number of cesarean deliveries is, and they only code like 15%. And after 15%, there is no benefit in improving maternal or neonatal morbidity or mortality.

Dr. Nirmala Chandrasekaran:

But, now, the current rates of cesarean sections are close to 30%. So the cesarean section rates are going up. And, hence, there is a big drive to actually reduce the number of cesarean sections. Because cesarean sections are not benign either. They do have short term problems, but they do have long term problems also. The amount of placenta accreta spectrum disorders have gone up tremendously. We're seeing more and more of them.

Dr. Nirmala Chandrasekaran:

I mean, we know that cesarean sections have a higher chance of stillbirth in the next pregnancies, preterm birth, ectopic pregnancies. So it is not entirely benign. It's not about, okay, forceps deliveries versus second stage cesarean sections, but what is the long term effect of cesarean sections also?

Dr. Mojola Omole:

That is a really important point that I think often is missed out in understanding that. I guess the question I was going to ask you regarding that is, does medico-legal play into it? Because if you look at the US data, they don't have a lot of forceps and OVDs. And that's because they're a very litigious country.

Dr. Mojola Omole:

So do you think, in Canada... I was looking at the CMPA of Obs Gyn, of, basically, what do you guys get sued for the most? And this is one of the things that you guys get dinged on a lot. So does that also play into it?

Dr. Nirmala Chandrasekaran:

I do think it does have a role to play. And the one thing that has increased the Cesarean section rates, and it is well known in the literature, is continuous fetal monitoring. We keep putting everybody, whether low risk or high risk, even though there is no reason to put everybody on the continuous tocogram. We do end up doing more Cesarean sections. We do see more fetal heart rate decelerations, and we have to act on it.

Dr. Nirmala Chandrasekaran:

And if you look at the HIROC and CMPA, the reasons for medical legal suits against OBs is abnormal fetal heart tracings. So, of course, that does play a major role. And that probably... I mean, that did increase the Cesarean section rates, the continuous electronic fetal monitoring. And it's well known.

Dr. Blair Bigham:

This is so interesting. HIROC being the CMPA equivalent for hospitals, the insurance company for hospitals in Canada. And CMPA covering us as individual physicians.

Dr. Nirmala Chandrasekaran:

Physicians. Yeah.

Dr. Blair Bigham:

So what's the bottom line here, Nirmala? When you look at this study and this data, is this going to change your behavior tomorrow at work? Are you going to be more likely to jump to C-section, to avoid a fourth degree injury? Tell me what an obstetrician takes away from this study.

Dr. Nirmala Chandrasekaran:

So there are two things to take away from this study. One is, yes, we do need some data to counsel women as to what the implications are for having an operative vaginal delivery. And so it is a data that can guide physicians to counsel women. And the second thing to take is, okay, how do we actually, I mean, we don't want to do either. We don't want to do instrumental deliveries. We do not want to do second stage Cesarean sections also.

Dr. Nirmala Chandrasekaran:

So how do we reduce this? Maybe we have to concentrate a little bit on that, rather than saying these procedures should not be done, so we can educate women well. One-to-one care, which is actually proven again and again, with multiple studies and even the Cochrane database, has reduced the amount of interventions during labor. So concentrate on that, manage labor-

Dr. Mojola Omole:

So what do you mean by one-to-one care?

Dr. Nirmala Chandrasekaran:

So from, I think it was about 14 studies in the Cochrane database. They actually say, if a woman has a one-to-one care, like either with a midwife or a doula or a nurse, maternity nurse who actually stays with them constantly and provides emotional support throughout labor - a lot of interventions can be reduced - and coach them as to how to labor, how to push, what positions to adapt and emotionally, keeping them strong, use of oxytocin at the right time, intervening at the right time. So those could be done to reduce all these interventions. And the third thing is training, training, training.

Dr. Blair Bigham:

The one thing we haven't touched on yet is the app episiotomy rate that Dr. Muraca was saying, is very different between different countries and she had pointed to some guideline differences between SOGC and a couple of other national forums. In Canada, is there a recommendation that's a bit weak on episiotomy, or is that maybe not borne out in the field?

Dr. Nirmala Chandrasekaran:

I mean, honestly, none of the guidelines actually say you have to episiotomy, and none of the guidelines actually say that episiotomy actually prevents third or fourth degree tears.

Dr. Blair Bigham:

Okay.

Dr. Nirmala Chandrasekaran:

But we have to look back on the data which is published regarding operative vaginal deliveries and the use of episiotomies, and it is protective. And all the data, all the guidelines, say use it with the operator's discretion, but the operator should know when to use it, and that's the thing.

Dr. Mojola Omole:

And do you think because the UK does more of it, there's just a higher comfort level with doing the episiotomies with the OVDs

Dr. Nirmala Chandrasekaran:

I think so. I think so. And also, it's not just the episiotomies there's data to suggest how to do an episiotomy also. So what is the angle that you should be using to avoid third and fourth degree tears?

Dr. Mojola Omole:

I thought you guys just cut down. I didn't know there was an angle to it.

Dr. Nirmala Chandrasekaran:

There is.

Dr. Mojola Omole:

This is actually scaring me to not want a second child.

Dr. Nirmala Chandrasekaran:

Please don't do that. Please don't do that. All of us obstetricians have multiple children and we were all fine.

Dr. Mojola Omole:

You guys are a special breed. You're like pediatricians, you're like, “I want five kids.” And I'm like-

Dr. Blair Bigham:

That's a strong endorsement there.

Dr. Nirmala Chandrasekaran:

No, no, no. So honestly, operative delivery has its place and will always have its place in obstetric practice. I don't think we should give out messaging saying they should not be used at all. I don't want to be a baby with bathwater situation. We have to think of how to improve these morbidity rates. And we also have to take the data with a grain of salt because this is a database study. So there are a lot of limitations. So we shouldn't be using it entirely to guide our practice, but we should take away certain things from the study for sure.

Dr. Blair Bigham:

Nirmala, thank you so much for joining us. This has been so interesting.

Dr. Nirmala Chandrasekaran:

My pleasure. Thank you for having me.

Dr. Blair Bigham:

Thank you. Dr. Nirmala Chandrasekaran is an OBGYN and specialist in maternal fetal medicine at St. Michael's Hospital in Toronto. Mojola, we cut the recording just before Nirmala said something so revealing.

Dr. Mojola Omole:

Yes.

Dr. Blair Bigham:

She said OVD is going to be a lost art and she was sad about it because she really does feel that there are women and babies who benefit from OVD. Maybe they're in a center that can't just go straight to C-section or maybe we're doing a few too many C-sections, which in and of themselves can come with complications. I thought that was so revealing. I wish we got it on tape.

Dr. Mojola Omole:

Yeah, I think it's a very important point that supported the whole entire article in the sense of, this is such an important tool in the toolkit of obstetrics. And it seems that it is a dying art and maybe that's what's reflected in the data, is that because of the numbers and volumes that are being done, we are seeing more complications in Canada than in other countries.

Dr. Blair Bigham:

Especially with what sounds like a more conservative approach to episiotomy and maybe some other ways that through training, we could reduce some of the grade three and grade four injuries that people are experiencing.

Dr. Mojola Omole:

Yes. And I think from just talking to both Dr. Muraca and Dr. Chandrasekaran, it seems as if training is an important aspect of trying to get these complication rates lower in Canada. Exactly how we can do that, still needs to be fleshed out a bit more. And so that seems to maybe the next part of this, is how do we equip the trainees that are coming out with the ability to make an informed decision as Dr. Chandrasekaran said, it's not necessarily about how to do it, but when to do it.

Dr. Blair Bigham:

And it sounds like at St. Mike's they're already doing a fair amount of simulation around this type of stuff. It makes me think, in the emergency department we have this term called HALO, these high acuity, low opportunity skills, like a lateral canthotomy or a thoracotomy. And I just think about how we train for those. We spend time in cadaver labs and anatomy labs and simulators for that once in a lifetime opportunity to do something that may have a big impact.

Dr. Mojola Omole:

So this was a really great episode and hopefully as much as we learned our listeners also learned from it.

Dr. Blair Bigham:

That's it for this week on the CMAJ podcast. Tune in, in two weeks for our next episode, I'm Blair Bigham.

Dr. Mojola Omole:

And I'm Mojola Omole.