Despite touchs about potential dam...

Despite touchs about potential damage to the baby and the maternal pelvic floor, use of instrumental vaginal delivery has been propos as the same strategy to decrease the rate of cesarean delivery. To assess the consequences of instrumental vaginal delivery in succession subsequent pregnancies, Bahl and colleagues studied women who had undergone the procedure

The authors studied 283 women who had an instrumental or cesarean delivery at filled dilation at two British teaching hospitals. Inclusion criteria were instrumental point delivery of a live singleton after 37 weeks of gestation or cesarean delivery at abounding dilation. Study participants were observeed by mail three years after delivery to obtain information about following pregnancies and deliveries. The primary interest was the mode of delivery in subsequent pregnancies. Other consequences measured included subfertility, early pregnancy los preterm delivery, and fear of following pregnancy. Responses from the 133 mothers who had instrumental vaginal delivery were compared with answers of the 150 mothers who had cesarean delivery.

Women who had a cesarean delivery reported greater difficulty conceiving than women who delivered vaginally. Overall, 67 percent of women in the cesarean arrange and 79 percent of women in the instrumental delivery assemblage achieved a planned pregnancy within three years. Of the 91 women who did not plan a further pregnancy, 42 stated that they were sufficiently afraid of childbirth after instrumental or operative delivery to avoid a further pregnancy.

The sum of two units groups did not differ significantly in fear of succeeding childbirth. Women who had instrumental vaginal delivery were more likely than women who had cesarean delivery to attempt and succe in vaginal birth in a following pregnancy. Nevertheless, 94 percent of mothers who attempted vaginal birth following cesarean delivery were successful

The authors close that fear of childbirth is for the use of all in women who have had instrumental or operative deliveries. This fear is sufficiently hardy to cause a significant number of women to avoid further pregnancies. Of women who do have following pregnancies, more women are likely to have a spontaneous vaginal birth delivery following an instrumental vaginal delivery than a cesarean delivery. However, the majority of women in the one and the other groups who attempt vaginal delivery in a later pregnancy are successful. The authors call for increased efforts to achieve vaginal delivery in the first pregnancy, and for appropriate patient education and emotional counseling following instrumental or operative delivery to cut short negative concerns about childbirth.

ANNE D WALLING, MD

Bahl R et al. issue of subsequent pregnancy three years after previous operative delivery in the secondary stage of labour: cohort thought BMJ February 7, 2004;328:311-5.

EDITOR'S NOTE: I inquiring surprise how many more women feared posterior childbirth but did not want to disclose their feelings to the investigators? Important questions to ask are: for what reason frequently do women find the proces of childbirth in the same manner unpleasant or frightening that they are unwilling to conceive again, and to what degree do these emotions influence a woman's relationship with her partner and her family? Besides great sadness that single of the most joyful experiences in life is instead a negative and distressing result what other pathologies are created from the ramifications of an unpleasant childbirth experience? Family physicians have become aware of the ne to sieve for depression in new mothers. Perhaps we also should ask about the birth experience and be vigilant for a pervasive emotional pathology, especially in mothers who have operative or instrumental deliveries. The profitable news from this study is that as it was mothers are likely to achieve vaginal deliveries in following pregnancies. However, we know little of the mother's perspective of the experience. Childbirth is now a generally safe event; physicians and nurtures should try to make the proces as positive, emotionally and psychologically, as possible for everyone involved.--A.D.W.

COPYRIGHT 2004 American Academy of Family Physicians

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