In an efort to lower rates of third-and fourth-degree lacerations, and coincident with overall eforts to reduce routine episiotomy use, many advocate only indicated episiotomy with operative delivery. If episiotomy is required, a protective efect against these more extensive perineal lacerations may be aforded by mediolateral episiotomy (de Leeuw, 2008; de Vogel, 2012; Hirsch, 2008). Early disarticulation of forceps and cessation of maternal pushing during disarticulation can also be protective. Last, these injuries are more common with an occiput posterior position (Damron, 2004). Thus, manual or forceps rotation to an occiput anterior position and then subsequent traction delivery may decrease rates oflower reproductive tract injury (Bradley, 2013).
his term encompasses urinary incontinence, anal incontinence, and pelvic organ prolapse. Operative vaginal delivery has been suggested as a possible risk for each of these. Proposed mechanisms include structural compromise and/or pelvic loor denervation secondary to forces exerted during delivery.
Parity and speciically vaginal delivery are risk factors for urinary incontinence (Gyhagen, 2013; Rortveit, 2003). But, many studies do not support an increased risk compared with vaginal delivery alone (Gartland, 2016; Leijonhuvud, 2011;
MacArthur, 2016; Tahtinen, 2016).
Evidence linking anal incontinence with operative vaginal delivery is conlicting. Some studies show that anal sphincter disruption caused by higher-order episiotomy, but not delivery mode, is the main etiological factor strongly associated with anal incontinence (BoIs, 2010; Evers, 2012; Nygaard, 1997). In con trast, others directly link operative delivery with this complica tion (Dolan, 2010; Marthur, 2013). But, these studies may not be incongruous-recall that operative delivery is associated with increased rates of higher-order episiotomy. Importantly, several studies and reviews have not found cesarean delivery to be protec tive for anal incontinence (Nelson, 2010). Last, evidence linking pelvic organ prolapse with operative delivery also indicates mixed results (Gyhagen, 2013; Handa, 2012; Vo1l0yhaug, 2015).
hese injuries are more frequent with operative vaginal delivery than with cesarean delivery or spontaneous vaginal delivery. Injuries may be seen with either method. hey are more common with vacuum extraction, and types associated with this device include cephalohematoma, subgaleal hemorrhage, retinal hemorrhage, neonatal jaundice secondary to these hemorrhages, shoulder dystocia, clavicular fracture, and scalp lacerations. Cephalohematoma and subgaleal hemorrhage are both extracranial lesions described in Chapter 33 (p. 628). Forceps-assisted vaginal delivery has higher rates of facial nerve injury, brachial plexus injury, depressed skull fracture, and corneal abrasion (merican College of Obstetricians and Gynecologists, 2015; Demissie, 2004; Dupuis, 2005). For intracranial hemorrhage, some studies have associated vacuum extraction with higher rates, whereas others show similar rates with either of the two methods (Towner, 1999; Wen, 2001; Werner, 201l).