OBJECTIVE:The aim of this study was to evaluate obstetricians' views on digital fetal scalp stimulation (dFSS) and fetal blood sampling (FBS), and to establish their reported practice when performing second line tests of fetal wellbeing in labor. METHODS:A survey was distributed via email and post to every trainee and consultant obstetrician in maternity units in the Republic of Ireland. The survey explored current practice, views on test performance, and the management of clinical scenarios with abnormal intrapartum cardiotocography. RESULTS:We received 177 responses from 430 doctors (41 %). There was a perception that dFSS is easier (93 %) and faster to perform (94 %), but that FBS is the most reliable test (59 % FBS, 5 % dFSS, 22 % no difference). The need for a well-designed randomized controlled trial to determine which test performs best was recognized (80 %). Willingness to participate in such a trial was higher among trainees than consultants (91 % versus 67 %, p = 0.001). There was marked variation in reported practice for the clinical scenarios and diverse views were expressed within the free-text comments. CONCLUSION:Perspectives on dFSS and FBS vary between clinicians. This uncertainty about commonly used intrapartum tests supports the need for randomized controlled trials to provide robust evidence on the effectiveness of each test.

ABSTRACTObjectiveTo establish whether digital foetal scalp stimulation (dFSS) performs better than foetal blood sampling (FBS) in terms of reducing the rate of caesarean section (CS) in labour, without adversely affecting perinatal outcomes.DesignA multicentre parallel‐group randomised controlled trial.SettingMaternity centres in Ireland.PopulationThe study aimed to randomise 2500 nulliparous women who required a second‐line test of foetal well‐being in labour due to abnormal cardiotocography (CTG).MethodsParticipants were randomly allocated to dFSS or FBS in a 1:1 ratio. Analysis was according to the published protocol and included a meta‐analysis of the pilot study data and trial data.Main Outcome MeasuresThe primary outcome was CS.ResultsDue to lower‐than‐expected randomisations, the trial concluded early. Of 534 consented participants, 124 had a second‐line test of foetal well‐being in labour and 43 (34.7%) were randomised; 20 to dFSS and 23 to FBS. The rate of CS was 40.0% (8/20) in the dFSS group and 47.8% (11/23) in the FBS group (absolute difference 7.8%; OR 0.73, 95% CI 0.22–2.44). The rate of CS was lower in the dFSS group when the trial data were included in a meta‐analysis with the pilot data (n = 50), although the confidence limits were wide (OR 0.41, 95% CI 0.17–0.96). There was no significant difference in rates of adverse perinatal and maternal outcomes. Of the nonrandomised participants who received a second‐line test, 65% (53/81) received dFSS.ConclusionsThe small sample size limits the ability to conclude whether dFSS performs better as a second‐line test of foetal well‐being in labour than FBS. A clinician preference for dFSS was apparent, even though robust evidence is lacking.Trial Registration: This trial was prospectively registered on ClinicalTrials.gov on the 31st of March 2022. ClinicalTrials.gov Identifier: NCT05306756 (Access at https://clinicaltrials.gov/study/NCT05306756?cond=fetal%20blood%20sampling&rank=3)

BACKGROUND:Continuous fetal heart rate monitoring by cardiotocography (CTG) is used in labour for women with complicated pregnancies. Fetal heart rate abnormalities are common and may result in the decision to expedite delivery by caesarean section. Fetal scalp stimulation (FSS) is a second-line test of fetal well-being that may provide reassurance that the labour can continue. OBJECTIVES:To evaluate methods of FSS as second-line tests of intrapartum fetal well-being in cases of non-reassuring CTG. FSS and CTG were compared to CTG alone, and to CTG with fetal blood sampling (FBS). SEARCH METHODS:We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, the WHO ICTRP and conference proceedings), ClinicalTrials.gov (18 October 2022), and reference lists of retrieved studies. SELECTION CRITERIA:Eligible studies were randomised controlled trials (RCTs) that compared any form of FSS to assess fetal well-being in labour. Quasi-RCTs, cluster-RCTs and studies published in abstract form were also eligible for inclusion, but none were identified. DATA COLLECTION AND ANALYSIS:Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS:Two trials, involving 377 women, met the inclusion criteria for this review. Both trials were conducted in hospital settings and included women with singleton, term (37+0 weeks or more) pregnancies, a cephalic presentation, and abnormal CTG. Follow-up was until hospital discharge after the birth. A pilot trial of 50 women in a high-income country (Ireland) compared CTG and digital fetal scalp stimulation (dFSS) with CTG and fetal blood sampling (FBS). A single-centre trial of 327 women in a lower middle-income country (India) compared CTG and manual fetal stimulation (abdominal or vaginal scalp stimulation) with CTG alone. The two included studies were at moderate or unclear risk of bias. Both trials provided clear information on allocation concealment but it was not possible to blind participants or health professionals in relation to the intervention. Although objective outcome measures were reported, outcome assessment was not blinded or blinding was unclear. dFSS and CTG versus FBS and CTG There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. The risk of caesarean section (CS) may be lower with dFSS compared to FBS (risk ratio (RR) 0.38, 95% confidence interval (CI) 0.16 to 0.92; 1 pilot trial, 50 women; very low-certainty evidence) but the evidence is very uncertain. There were no cases of neonatal encephalopathy reported. The evidence was also very uncertain between dFSS and FBS for assisted vaginal birth (RR 1.44, 95% CI 0.76 to 2.75; very low-certainty evidence) and for the spontaneous vaginal birth rate (RR 2.33, 95% CI 0.68 to 8.01, very low-certainty evidence). Maternal acceptability of the procedures was not reported. FSS and CTG versus CTG alone Manual stimulation of the fetus was performed either abdominally (92/164) or vaginally (72/164). There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. There may be little differences in the risk of CS on comparing manual fetal stimulation and CTG with CTG alone (RR 0.83, 95% CI 0.59 to 1.18; 1 trial, 327 women; very low-certainty evidence), but again the evidence was very uncertain. There were no cases of neonatal encephalopathy reported. There may be no differences in the risk of assisted vaginal birth (RR 1.43, 95% CI 0.78 to 2.60; very low-certainty evidence) or in the rates of spontaneous vaginal birth (RR 1.01, 95% CI 0.85 to 1.21, very low-certainty evidence), but again the evidence is very uncertain. Maternal acceptability of abdominal stimulation/FSS was not reported although 13 women withdrew consent after randomisation due to concerns about fetal well-being. AUTHORS' CONCLUSIONS:There is very low-certainty evidence available which makes it unclear whether stimulating the fetal scalp is a safe and effective way to confirm fetal well-being in labour. Evidence was downgraded based on limitations in study design and imprecision. Further high-quality studies of adequate sample size are required to evaluate this research question. In order to be generalisable, these trials should be conducted in different settings, including broad clinical criteria at both preterm and term gestational ages, and standardising the method of stimulation. There is an ongoing study (FIRSST) that will be incorporated into this review in a subsequent update.

OBJECTIVES:Apparently uncomplicated low-risk pregnancies, especially first time births, account for a significant proportion of adverse birth outcomes. Improved risk stratification with a simple bedside scan on admission in early labor could potentially reduce adverse intrapartum outcomes. The aim of this feasibility study was to assess a cohort of low-risk subjects with admission ultrasonography at the onset of labor with a view to conducting a future randomized controlled trial (RCT). The objectives were three-fold; i) to determine the logistics of performing a labor admission ultrasound scan ii) to establish whether abnormal ultrasound features can be identified and iii) whether they are associated with emergency delivery and/or poor condition of the neonate at birth. METHODS:We performed a prospective cohort study of 295 participants with term singleton cephalic pregnancies admitted in early labor or for labor induction with non-fetal indications. The setting was a university teaching hospital in Ireland with almost 8000 births annually. A bedside ultrasound scan was performed to assess fetal biometry, amniotic fluid volume and placental maturity. Patients and their babies were followed up until hospital discharge. The outcomes of interest included image quality, time to perform a scan, oligohydramnios (Single Deepest Pool ≤ 2 cm), small for gestational age (SGA; abdominal circumference <10th centile), mature placenta (Grannum 2 or 3), pathological CTG, emergency cesarean section (CS), fetal acidosis (cord arterial pH <7.10 or base excess <-12.0), low Apgar score <7 at 5 min and neonatal unit admission. RESULTS:Image quality was optimal in 274 of the 295 scans (93%) and 271 (92%) were completed in less than 10 min. Of this low-risk population, 67 of 294 (23%) had oligohydramnios, 11 (4%) were small for gestational age and 87 (30%) had a mature placenta (Grannum grade 2). The incidence of pathological CTG and emergency CS was higher among patients with oligohydramnios than those with a normal scan but did not reach statistical significance; Odds Ratio 3.40 (95% Confidence Intervals 0.55 to 20.92) and OR 1.43 (95% CI 0.66 to 3.08) respectively. The mean birthweight was significantly lower in those with oligohydramnios -139 g (95% CI -248 to -30) and admission scan detected SGA -357 g (95% CI -557 to -137). Adverse perinatal outcomes were uncommon with a higher incidence of fetal acidosis (pH < 7.10) in the oligohydramnios group. The incidence of neonatal unit admission >24 h was higher in the oligohydramnios group but not statistically significant; OR 3.75 (95% CI 0.61 to 22.97). Results for SGA alone were non-significant and results for oligohydramnios and SGA combined were similar to those for oligohydramnios alone. CONCLUSIONS:Admission ultrasonography is feasible in a routine clinical setting, but evidence of benefit is weak and does not currently justify a randomized controlled trial.

Background Cardiotocography (CTG) is a screening test used to detect fetal hypoxia in labour. It has a high false positive rate resulting in many potentially unnecessary caesarean sections. Fetal blood sampling (FBS) is a second-line test of the acid-base status of the fetus. It is used to provide either reassurance that it is safe for labour to continue or objective evidence of compromise so that delivery can be expedited. Digital fetal scalp stimulation (dFSS) to elicit a fetal heart rate acceleration is an alternative less invasive second-line test of fetal wellbeing. This study aims to provide robust evidence on the role of these two second-line tests in assessing fetal wellbeing and potentially preventing operative delivery. Methods A multi-centre parallel group randomised controlled trial (RCT) is planned in four maternity centres in Ireland. The study aims to recruit 2500 nulliparous women with a term (≥37+0 weeks) singleton pregnancy who require a second-line test of fetal wellbeing in labour due to an abnormal CTG. Women will be allocated randomly to dFSS or FBS on a 1:1 ratio. The primary outcome is caesarean section. With 1250 women in each arm, the study will have 90% power to detect a difference of 5–6%, at a two-sided alpha significance level of 5%, assuming a caesarean section rate of at least 20% in the dFSS group. Discussion If the proposed study shows evidence that dFSS is a safe, reliable and effective alternative to FBS, this would have ground-breaking implications for labour management worldwide. It could potentially lead to a reduction in invasive procedures and emergency caesarean sections. Trial registration ClinicalTrials.gov NCT05306756. Registered on 31 March 2022. The trial commenced enrolment on 10 May 2022. Ethical committee approval has been granted by the Research Ethics Committee (REC) of each hospital: Dublin/CWIUH REC: 12.06.2019; Cork/UCC REC: 29.11.2019; Galway/NUIG REC: 06.09.2019; Limerick/UL REC: 30.09.2019.

Induction of labour is one of the most common interventions experienced by pregnant women. There are two overlapping components to labour induction, which include cervical ripening and the initiation of regular contractions. A large number of clinical studies have been conducted for evaluating the methods used for induction of labour, their effectiveness and safety, and pregnancy outcomes. Randomised controlled trials (RCTs) provide the strongest form of evidence for clinical practice. These data are brought together in systematic reviews and have been incorporated into national and international guidelines. Despite this, there is considerable variation in the recommendations between guidelines. Heterogeneity between studies, inconsistency in the definitions of trial outcomes, and underpowered sample size contribute to the difficulty in making robust recommendations. There are pharmacological and non-pharmacological approaches that can be compared with each other and with placebo or no treatment. There are also complementary therapies that may appeal to women but lack evidence of their effectiveness. These issues have been addressed in the current chapter, with a critical review of the research evidence presented in clinical trials and systematic reviews.

Introduction Women presenting with suspected pre-eclampsia are currently triaged on the basis of hypertension and dipstick proteinuria. This may result in significant false positive and negative diagnoses resulting in increased morbidity or unnecessary intervention. Recent data suggest that placental growth factor testing may be a useful adjunct in the management of women presenting with preterm pre-eclampsia. The primary objective of this trial is to determine if the addition of placental growth factor testing to the current clinical assessment of women with suspected preterm pre-eclampsia, is beneficial for both mothers and babies. Methods and analysis This is a multicentre, stepped wedge cluster, randomised trial aiming to recruit 4000 women presenting with symptoms suggestive of preterm pre-eclampsia between 20 and 36+6 weeks’ gestation. The intervention of an unblinded point of care test, performed at enrolment, will quantify maternal levels of circulating plasma placental growth factor. The intervention will be rolled out sequentially, based on randomisation, in the seven largest maternity units on the island of Ireland. Primary outcome is a composite outcome of maternal morbidity (derived from the modified fullPIERS model). To ensure we are not reducing maternal morbidity at the expense of earlier delivery and worse neonatal outcomes, we have established a co-primary outcome which will examine the effect of the intervention on neonatal morbidity, assessed using a composite neonatal score. Secondary analyses will examine further clinical outcomes (such as mode of delivery, antenatal detection of growth restriction and use of antihypertensive agents) as well as a health economic analysis, of incorporation of placental growth factor testing into routine care. Ethics and dissemination Ethical approval has been granted from each of the seven maternity hospitals involved in the trial. The results of the trial will be presented both nationally and internationally at conference and published in an international peer-reviewed journal. Trial registration number NCT02881073.

Objective To examine the birth outcomes for women and babies following water immersion for labour only, or for labour and birth. Design Prospective cohort study. Setting Maternity hospital, Ireland, 2016–2019. Participants A cohort of 190 low-risk women who used water immersion; 100 gave birth in water and 90 laboured only in water. A control group of 190 low-risk women who received standard care. Methods Logistic regression analyses examined associations between water immersion and birth outcomes adjusting for confounders. A validated Childbirth Experience Questionnaire was completed. Main outcome measures Perineal tears, obstetric anal sphincter injuries (OASI), postpartum haemorrhage (PPH), neonatal unit admissions (NNU), breastfeeding and birth experiences. Results Compared with standard care, women who chose water immersion had no significant difference in perineal tears (71.4% vs 71.4%, adj OR 0.83; 95% CI 0.49 to 1.39) or in OASI (3.3% vs 3.8%, adj OR 0.91; 0.26–2.97). Women who chose water immersion were more likely to have a PPH ≥500 mL (10.5% vs 3.7%, adj OR 2.60; 95% CI 1.03 to 6.57), and to exclusively breastfeed at discharge (71.1% vs 45.8%, adj OR 2.59; 95% CI 1.66 to 4.05). There was no significant difference in NNU admissions (3.7% vs 3.2%, adj OR 1.06; 95% CI 0.33 to 3.42). Women who gave birth in water were no more likely than women who used water for labour only to require perineal suturing (64% vs 80.5%, adj OR 0.63; 95% CI 0.30 to 1.33), to experience OASI (3.0% vs 3.7%, adj OR 1.41; 95% CI 0.23 to 8.79) or PPH (8.0% vs 13.3%, adj OR 0.73; 95% CI 0.26 to 2.09). Women using water immersion reported more positive memories than women receiving standard care (p<0.01). Conclusions Women choosing water immersion for labour or birth were no more likely to experience adverse birth outcomes than women receiving standard care and rated their birth experiences more highly.

BJOG: An International Journal of Obstetrics & GynaecologyVolume 127, Issue 9 p. e70-e112 RCOG Green-top GuidelinesFree Access Assisted Vaginal Birth Green-top Guideline No. 26 DJ Murphy, DJ MurphySearch for more papers by this authorBK Strachan, BK StrachanSearch for more papers by this authorR Bahl, R BahlSearch for more papers by this authoron behalf of the Royal College of Obstetricians and Gynaecologists, Corresponding Author the Royal College of Obstetricians and Gynaecologists clinicaleffectiveness@rcog.org.uk Correspondence: Royal College of Obstetricians and Gynaecologists, 10–18 Union Street, London SE1 1SZ. Email: clinicaleffectiveness@rcog.org.ukSearch for more papers by this author DJ Murphy, DJ MurphySearch for more papers by this authorBK Strachan, BK StrachanSearch for more papers by this authorR Bahl, R BahlSearch for more papers by this authoron behalf of the Royal College of Obstetricians and Gynaecologists, Corresponding Author the Royal College of Obstetricians and Gynaecologists clinicaleffectiveness@rcog.org.uk Correspondence: Royal College of Obstetricians and Gynaecologists, 10–18 Union Street, London SE1 1SZ. Email: clinicaleffectiveness@rcog.org.ukSearch for more papers by this author First published: 28 April 2020 https://doi.org/10.1111/1471-0528.16092Citations: 49 This is the fourth edition of this guideline, first published in October 2000 under the title Instrumental vaginal delivery, and revised in January 2011 and October 2005 under the title Operative Vaginal Delivery. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Executive summary Preparation for assisted vaginal birth Can assisted vaginal birth be avoided? Encourage women to have continuous support during labour as this can reduce the need for assisted vaginal birth. Grade of recommendation: A Inform women that epidural analgesia may increase the need for assisted vaginal birth although this is less likely with newer analgesic techniques. [New 2020] Grade of recommendation: A Inform women that administering epidural analgesia in the latent phase of labour compared to the active phase of labour does not increase the risk of assisted vaginal birth. [New 2020] Grade of recommendation: A Encourage women not using epidural analgesia to adopt upright or lateral positions in the second stage of labour as this reduces the need for assisted vaginal birth. Grade of recommendation: A Encourage women using epidural analgesia to adopt lying down lateral positions rather than upright positions in the second stage of labour as this increases the rate of spontaneous vaginal birth. [New 2020] Grade of recommendation: A Recommend delayed pushing for 1–2 hours in nulliparous women with epidural analgesia as this may reduce the need for rotational and midpelvic assisted vaginal birth. Grade of recommendation: B Do not routinely discontinue epidural analgesia during pushing as this increases the woman’s pain with no evidence of a reduction in the incidence of assisted vaginal birth. [New 2020] Grade of recommendation: A There is insufficient evidence to recommend any particular regional analgesia technique in terms of reducing the incidence of assisted vaginal birth. [New 2020] Grade of recommendation: A There is insufficient evidence to recommend routine oxytocin augmentation for women with epidural analgesia as a strategy to reduce the incidence of assisted vaginal birth. [New 2020] Grade of recommendation: A There is insufficient evidence to recommend routine prophylactic manual rotation of fetal malposition in the second stage of labour to reduce the risk of assisted vaginal birth. [New 2020] Grade of recommendation: B How should assisted vaginal birth be defined? Use a standard classification system for assisted vaginal birth to promote safe clinical practice, effective communication between health professionals and audit of outcomes. Grade of recommendation: D When should assisted vaginal birth be recommended/contraindicated? Operators should be aware that no indication is absolute and that clinical judgment is required in all situations. Grade of recommendation: D Suspected fetal bleeding disorders or a predisposition to fracture are relative contraindications to assisted vaginal birth. [New 2020] Grade of recommendation: ✓ Blood borne viral infections in the woman are not an absolute contraindication to assisted vaginal birth. [New 2020] Grade of recommendation: D The use of a vacuum is not contraindicated following a fetal blood sampling procedure or application of a fetal scalp electrode. [New 2020] Grade of recommendation: B Operators should be aware that there is a higher risk of subgaleal haemorrhage and scalp trauma with vacuum extraction compared with forceps at preterm gestational ages. Vacuum birth should be avoided below 32 weeks of gestation and should be used with caution between 32+0 and 36+0 weeks of gestation. [New 2020] Grade of recommendation: C What are the essential conditions for safe assisted vaginal birth? Safe assisted vaginal birth requires a careful assessment of the clinical situation, clear communication with the woman and healthcare personnel, and expertise in the chosen procedure ( Table 3 ). Grade of recommendation: D Does ultrasound have a role in assessment prior to assisted vaginal birth? Ultrasound assessment of the fetal head position prior to assisted vaginal birth is recommended where uncertainty exists following clinical examination. [New 2020] Grade of recommendation: A There is insufficient evidence to recommend the routine use of abdominal or perineal ultrasound for assessment of the station, flexion and descent of the fetal head in the second stage of labour. [New 2020] Grade of recommendation: C What type of consent is required prior to attempting assisted vaginal birth? Women should be informed about assisted vaginal birth in the antenatal period, especially during their first pregnancy. If they indicate specific restrictions or preferences then this should be explored with an experienced obstetrician, ideally in advance of labour. Grade of recommendation: ✓ For birth room procedures verbal consent should be obtained prior to assisted vaginal birth and the discussion should be documented in the notes. Grade of recommendation: ✓ When midpelvic or rotational birth is indicated, the risks and benefits of assisted vaginal birth should be compared with the risks and benefits of secondstage caesarean birth for the given circumstances and skills of the operator. Written consent should be obtained for a trial of assisted vaginal birth in an operating theatre. [New 2020] Grade of recommendation: ✓ Performing assisted vaginal birth Who should perform assisted vaginal birth? Assisted vaginal birth should be performed by, or in the presence of, an operator who has the knowledge, skills and experience necessary to assess the woman, complete the procedure and manage any complications that arise. Grade of recommendation: D Advise obstetric trainees to achieve expertise in spontaneous vaginal birth prior to commencing training in assisted vaginal birth. Grade of recommendation: ✓ Ensure obstetric trainees receive appropriate training in vacuum and forceps birth, including theoretical knowledge, simulation training and clinical training under direct supervision. [New 2020] Grade of recommendation: ✓ Competency should be demonstrated before conducting unsupervised births. [New 2020] Grade of recommendation: ✓ Complex assisted vaginal births should only be performed by experienced operators or under the direct supervision of an experienced operator. Grade of recommendation: D Who should supervise assisted vaginal birth? An experienced operator, competent at midpelvic births, should be present from the outset to supervise all attempts at rotational or midpelvic assisted vaginal birth. Grade of recommendation: D Where should assisted vaginal birth take place? Non-rotational low-pelvic and lift out assisted vaginal births have a low probability of failure and most procedures can be conducted safely in a birth room. [New 2020] Grade of recommendation: C Assisted vaginal births that have a higher risk of failure should be considered a trial and be attempted in a place where immediate recourse to caesarean birth can be undertaken. Grade of recommendation: C What instruments should be used for assisted vaginal birth? The operator should choose the instrument most appropriate to the clinical circumstances and their level of skill. Grade of recommendation: ✓ Operators should be aware that forceps and vacuum extraction are associated with different benefits and risks; failure to complete the birth with a single instrument is more likely with vacuum extraction, but maternal perineal trauma is more likely with forceps. [New 2020] Grade of recommendation: A Operators should be aware that soft cup vacuum extractors have a higher rate of failure but a lower incidence of neonatal scalp trauma. [New 2020] Grade of recommendation: A Rotational births should be performed by experienced operators; the choice of instrument depending on the clinical circumstances and expertise of the individual. The options include Kielland’s rotational forceps, manual rotation followed by direct traction forceps or vacuum, and rotational vacuum extraction. Grade of recommendation: C When should vacuum-assisted birth be discontinued and how should a discontinued vacuum procedure be managed? Discontinue vacuum-assisted birth where there is no evidence of progressive descent with moderate traction during each pull of a correctly applied instrument by an experienced operator. [New 2020] Grade of recommendation: ✓ Complete vacuum-assisted birth in the majority of cases with a maximum of three pulls to bring the fetal head on to the perineum. Three additional gentle pulls can be used to ease the head out of the perineum. [New 2020] Grade of recommendation: ✓ If there is minimal descent with the first two pulls of a vacuum, the operator should consider whether the application is suboptimal, the fetal position has been incorrectly diagnosed or there is cephalopelvic disproportion. Less experienced operators should stop and seek a second opinion. Experienced operators should re-evaluate the clinical findings and either change approach or discontinue the procedure. [New 2020] Grade of recommendation: ✓ Discontinue vacuum-assisted birth if there have been two ‘pop-offs’ of the instrument. Less experienced operators should seek senior support after one ‘pop-off’ to ensure the woman has the best chance of a successful assisted vaginal birth. [New 2020] Grade of recommendation: GPP The rapid negative pressure application for vacuum-assisted birth is recommended as it reduces the duration of the procedure with no difference in maternal and neonatal outcomes. [New 2020] Grade of recommendation: GPP The use of sequential instruments is associated with an increased risk of trauma to the infant. However, the operator needs to balance the risks of a caesarean birth following failed vacuum extraction with the risks of forceps birth following failed vacuum extraction. Grade of recommendation: B Obstetricians should be aware of the increased neonatal morbidity following failed vacuum-assisted birth and/or sequential use of instruments, and should inform the neonatologist when this occurs to ensure appropriate care of the baby. Grade of recommendation: GPP Obstetricians should be aware of the increased risk of obstetric anal sphincter injury (OASI) following sequential use of instruments. [New 2020] Grade of recommendation: C When should attempted forceps birth be discontinued and how should a discontinued forceps procedure be managed? Discontinue attempted forceps birth where the forceps cannot be applied easily, the handles do not approximate easily or if there is a lack of progressive descent with moderate traction. [New 2020] Grade of recommendation: B Discontinue rotational forceps birth if rotation is not easily achieved with gentle pressure. [New 2020] Grade of recommendation: B Discontinue attempted forceps birth if birth is not imminent following three pulls of a correctly applied instrument by an experienced operator. [New 2020] Grade of recommendation: B If there is minimal descent with the first one or two pulls of the forceps, the operator should consider whether the application is suboptimal, the position has been incorrectly diagnosed or there is cephalopelvic disproportion. Less experienced operators should stop and seek a second opinion. Experienced operators should re-evaluate the clinical findings and either change approach or discontinue the procedure. [New 2020] Grade of recommendation: ✓ Obstetricians should be aware of the potential neonatal morbidity following a failed attempt at forceps birth and should inform the neonatologist when this occurs to ensure appropriate management of the baby. [New 2020] Grade of recommendation: ✓ Obstetricians should be aware of the increased risk of fetal head impaction at caesarean birth following a failed attempt at birth via forceps and should be prepared to disimpact the fetal head using recognised manoeuvres. [New 2020] Grade of recommendation: ✓ What is the role of episiotomy in preventing maternal pelvic floor morbidity at assisted vaginal birth? Mediolateral episiotomy should be discussed with the woman as part of the preparation for assisted vaginal birth. [New 2020] Grade of recommendation: ✓ In the absence of robust evidence to support either routine or restrictive use of episiotomy at assisted vaginal birth, the decision should be tailored to the circumstances at the time and the preferences of the woman. The evidence to support use of mediolateral episiotomy at assisted vaginal birth in terms of preventing OASI is stronger for nulliparous women and for birth via forceps. [New 2020] Grade of recommendation: B When performing a mediolateral episiotomy the cut should be at a 60 degree angle initiated when the head is distending the perineum. [New 2020] Grade of recommendation: B Aftercare following assisted vaginal birth Should prophylactic antibiotics be given? A single prophylactic dose of intravenous amoxicillin and clavulanic acid should be recommended following assisted vaginal birth as it significantly reduces confirmed or suspected maternal infection compared to placebo. [New 2020] Grade of recommendation: A Good standards of hygiene and aseptic techniques are recommended. Grade of recommendation: ✓ Should thromboprophylaxis be given? Reassess women after assisted vaginal birth for venous thromboembolism risk and the need for thromboprophylaxis. Grade of recommendation: D What analgesia should be given after birth? In the absence of contraindications, women should be offered regular nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol routinely. Grade of recommendation: A What precautions should be taken for care of the bladder after birth? Women should be educated about the risk of urinary retention so that they are aware of the importance of bladder emptying in the postpartum period. [New 2020] Grade of recommendation: GPP The timing and volume of the first void urine should be monitored and documented. [New 2020] Grade of recommendation: C A post void residual should be measured if urinary retention is suspected. Grade of recommendation: ✓ Recommend that women who have received regional analgesia for a trial of assisted vaginal birth in theatre have an indwelling catheter in situ after the birth to prevent covert urinary retention. This should be removed according to the local protocol. [New 2020] Grade of recommendation: ✓ Offer women physiotherapy-directed strategies to reduce the risk of urinary incontinence at 3 months. Grade of recommendation: B How can psychological morbidity be reduced for the woman? Shared decision making, good communication, and positive continuous support during labour and birth have the potential to reduce psychological morbidity following birth. [New 2020] Grade of recommendation: ✓ Review women before hospital discharge to discuss the indication for assisted vaginal birth, management of any complications and advice for future births. Best practice is where the woman is reviewed by the obstetrician who performed the procedure. Grade of recommendation: ✓ Offer advice and support to women who have had a traumatic birth and wish to talk about their experience. The effect on the birth partner should also be considered. [New 2020] Grade of recommendation: ✓ Do not offer single session, high-intensity psychological interventions with an explicit focus on ‘reliving’ the trauma. [New 2020] Grade of recommendation: ✓ Offer women with persistent post-traumatic stress disorder (PTSD) symptoms at 1 month referral to skilled professionals as per the NICE guidance on PTSD. [New 2020] Grade of recommendation: D What information should women be given for future births? Inform women that there is a high probability of a spontaneous vaginal birth in subsequent labours following assisted vaginal birth. [New 2020] Grade of recommendation: B Individualise care for women who have sustained a third- or fourth-degree perineal tear, or who have ongoing pelvic floor morbidity. Grade of recommendation: ✓ Governance issues What type of documentation should be completed for assisted vaginal birth? Documentation for assisted vaginal birth should include detailed information on the assessment, decision making and conduct of the procedure, a plan for postnatal care and sufficient information for counselling in relation to subsequent pregnancies. Use of a standardised proforma is recommended. [New 2020] Grade of recommendation: ✓ Paired cord blood samples should be processed and recorded following all attempts at assisted vaginal birth. [New 2020] Grade of recommendation: ✓ Adverse outcomes, including unsuccessful assisted vaginal birth, major obstetric haemorrhage, OASI, shoulder dystocia and significant neonatal complications should trigger an incident report as part of effective risk management processes. [New 2020] Grade of recommendation: ✓ How should serious adverse events be dealt with? Obstetricians should ensure that the ongoing care of the woman, baby and family is paramount. [New 2020] Grade of recommendation: ✓ Obstetricians have a duty of candour; a professional responsibility to be honest with patients when things go wrong. [New 2020] Grade of recommendation: ✓ Obstetricians should contribute to adverse event reporting, confidential enquiries, and take part in regular reviews and audits. They should respond constructively to outcomes of reviews, taking necessary steps to address any problems and carry out further retraining where needed. [New 2020] Grade of recommendation: ✓ Maternity units should provide a safe and supportive framework to support women, their families and staff when serious adverse events occur. [New 2020] Grade of recommendation: ✓ 1 Purpose and scope The aim of this guideline is to provide evidence-based recommendations on the use of forceps and vacuum extraction for both rotational and non-rotational assisted vaginal births. In order to provide safe care for the full range of clinical scenarios, obstetricians should develop competency in the use of both vacuum and forceps for non-rotational birth and at least one specialist technique for rotational birth. The scope of this guideline includes indications, procedures and governance issues relating to assisted vaginal birth. 2 Introduction and background Assisted vaginal birth by vacuum or forceps is used to assist birth for maternal and fetal indications. In the UK, between 10% and 15% of all women give birth by assisted vaginal birth.1 Almost one in every three nulliparous women gives birth by vacuum or forceps, with lower rates in midwifery-led care settings.2, 3 There has been a rise in the rate of caesarean births in the second stage of labour; this may reflect concerns about assisted vaginal birth morbidity or a loss of clinical skills.4 The majority of births by vacuum and forceps, when performed correctly by appropriately trained personnel, result in a safe outcome for the woman and baby.5 Women who achieve an assisted vaginal birth rather than have a caesarean birth with their first child are far more likely to have an uncomplicated vaginal birth in subsequent pregnancies.6-8 However, obstetricians, midwives and neonatologists should be aware that serious rare complications, such as subgaleal haemorrhage, intracranial haemorrhage, skull fracture and spinal cord injury, can result in perinatal death and that these complications are more likely to occur with midpelvic, rotational and failed attempts at assisted vaginal birth.5, 9 The alternative choice of a caesarean birth late in the second stage of labour can be very challenging and result in significant maternal and perinatal morbidity. As a result, complex decision making is required when choosing between assisted vaginal birth and second-stage caesarean birth. Two new developments have occurred since the publication of the 2011 guideline: i) the Montgomery ruling has emphasised the importance of informed consent; and ii) a number of high profile manslaughter convictions on the grounds of gross negligence have highlighted the risk of a criminal conviction, where serious shortcomings are identified in medical care provided to a patient who dies. The Royal College of Obstetricians and Gynaecologists (RCOG) has also received reports of a number of neonatal fatalities associated with traumatic birth-related injuries. It is in this context that the safety aspects of this guideline have been reviewed and updated. 3 Identification and assessment of evidence This guideline was developed using standard methodology for developing RCOG Green-top Guidelines (GTGs). The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects [DARE] and the Cochrane Central Register of Controlled Trials [CENTRAL]), EMBASE, MEDLINE and Trip were searched for relevant papers. The search was inclusive of all relevant articles published until May 2019. The databases were searched using the relevant Medical Subject Headings (MeSH) terms, including all subheadings and synonyms, and this was combined with a keyword search. Search terms included ‘obstetrical forceps’, ‘manual rotation’, ‘assisted deliver*’, ‘assisted vaginal deliver*’, ‘instrumental deliver*’ and ‘operative birth’. The search was limited to studies on humans and papers in the English language. Relevant guidelines were also searched for using the same criteria in the National Guideline Clearinghouse and the National Institute for Health and Care Excellence (NICE) Evidence Search. The full search strategy is available to view online as supporting information (Appendix S1 and S2). Where possible, recommendations are based on available evidence. Areas lacking evidence are highlighted and annotated as ‘good practice points’. Further information about the assessment of evidence and the grading of recommendations may be found in Appendix 1. 4 Preparation for assisted vaginal birth 4.1 Can assisted vaginal birth be avoided? Encourage women to have continuous support during labour as this can reduce the need for assisted vaginal birth. Grade of recommendation: A Inform women that epidural analgesia may increase the need for assisted vaginal birth although this is less likely with newer anaesthetic techniques. Grade of recommendation: A Inform women that administering epidural analgesia in the latent phase of labour compared to the active phase of labour does not increase the risk of assisted vaginal birth. Grade of recommendation: A Encourage women not using epidural analgesia to adopt upright or lateral positions in the second stage of labour as this reduces the need for assisted vaginal birth. Grade of recommendation: A Encourage women using epidural analgesia to adopt lying down lateral positions rather than upright positions in the second stage of labour as this increases the rate of spontaneous vaginal birth. Grade of recommendation: A Recommend delayed pushing for 1–2 hours in nulliparous women with epidural analgesia as this may reduce the need for rotational and midpelvic assisted vaginal birth. Grade of recommendation: B Do not routinely discontinue epidural analgesia during pushing as this increases the woman’s pain with no evidence of a reduction in the incidence of assisted vaginal birth. Grade of recommendation: A There is insufficient evidence to recommend any particular regional analgesia technique in terms of reducing the incidence of assisted vaginal birth. Grade of recommendation: A There is insufficient evidence to recommend routine oxytocin augmentation for women with epidural analgesia as a strategy to reduce the incidence of assisted vaginal birth. Grade of recommendation: A There is insufficient evidence to recommend routine prophylactic manual rotation of fetal malposition in the second stage of labour to reduce the risk of assisted vaginal birth. Grade of recommendation: B As assisted vaginal birth can be associated with maternal and neonatal morbidity, strategies that reduce the need for intervention should be used. Continuous support for women during childbirth has been shown to increase the likelihood of spontaneous vaginal birth (26 trials; n = 15 858; risk ratio [RR] 1.08, 95% CI 1.04–1.12) and reduce the likelihood of assisted vaginal birth (RR 0.90, 95% CI 0.85–0.96), particularly when the carer is not a member of staff.10 Evidence level 1++ Epidural analgesia compared with non-epidural methods is associated with an increased incidence of assisted vaginal birth (23 trials; n = 7935; OR 1.42, 95% CI 1.28–1.57), but provides better pain relief than non-epidural analgesia (3 trials; n = 1166; mean difference in maternal perception of pain –3.36; 95% CI –5.41 to –1.31).2 A post hoc subgroup analysis did not replicate this increase in assisted vaginal births suggesting that approaches to epidural analgesia in labour (use of lower concentrations of local analgesic or patient-controlled epidural analgesia (PCEA)) do not have this outcome.” Evidence level 1++ Administering epidural analgesic in the latent phase of labour compared to the active phase does not increase the risk of assisted vaginal birth in nulliparous women (6 trials; n = 15 399; RR 0.96, 95% CI 0.89–1.05).11 Evidence level 1+ The use of any upright or lateral position in the second stage of labour, compared with supine or lithotomy positions, is associated with a reduction in assisted births in women not using epidural analgesia (21 trials; n = 6481; RR 0.75, 95% CI 0.66 to –0.86).12 Evidence level 1+ A randomised trial included 3236 nulliparous women with a low-dose epidural to determine whether being upright in the second stage of labour increases the chance of spontaneous vaginal birth compared with lying down. Significantly fewer spontaneous vaginal births occurred in women in the upright group at 35.2% (548/1556) compared with 41.1% (632/1537) in the lying down group (adjusted RR 0.86, 95% CI 0.78–0.94). This represents a 5.9% absolute increase in the chance of spontaneous vaginal birth in the lying down group (number needed to treat 17; 95% CI 11–40).13, 14 Evidence level 1+ A meta-analysis demonstrated that nulliparous women with epidurals are likely to have fewer rotational or midpelvic operative interventions when pushing is delayed for 1 to 2 hours or until they have a strong urge to push (RR 0.59, 95% CI 0.36–0.98),15 although a more recent meta-analysis concluded that, when the analysis is restricted to high-quality studies, the effect was smaller and did not reach statistical significance.16 Evidence level 1++ There is insufficient evidence to support the hypothesis that discontinuing epidural analgesia reduces the incidence of assisted vaginal birth (23% versus 28%; RR 0.84, 95% CI 0.61–1.15), but there is evidence that it increases the woman’s pain (22% versus 6%; RR 3.68, 95% CI 1.99–6.80).17 Evidence level 1++ There is no difference between the rates of assisted vaginal birth for combined spinal–epidural and standard epidural techniques (19 trials; n = 2658; OR 0.82, 95% CI 0.67–1.00),18 or patient-controlled epidural analgesia (PCEA) and standard epidural technique. A meta-analysis of nine studies, including 641 women, comparing PCEA to continuous infusion showed that obstetric outcomes were comparable in all included studies.19 A randomised controlled trial (RCT) of 126 women comparing PCEA with continuous epidural infusion reported similar rates of normal birth.20 Evidence level 1+ A systematic review evaluating the use of oxytocin at 6 cm dilatation onwards did not report a significant reduction in assisted vaginal birth (two studies; n = 319; RR 0.88, 95% CI 0.72–1.08). The review reported a higher rate of uterine rupture in multiparous women where oxytocin had been commenced.21 The NICE intrapartum care guideline22 h

Operative Vaginal Birth (OVB) refers to the birth of a baby where the operator assists the delivery using either a forceps or vacuum device. The obstetrician in training needs to develop expertise in both vacuum and forceps for non-rotational delivery and at least one technique for rotational delivery. The aim of a successful operative vaginal birth is to expedite delivery of the baby with a minimum of maternal or neonatal morbidity.

Background Induction of labour involves stimulating uterine contractions artificially to promote the onset of labour. There are several pharmacological, surgical and mechanical methods used to induce labour. Membrane sweeping is a mechanical technique whereby a clinician inserts one or two fingers into the cervix and using a continuous circular sweeping motion detaches the inferior pole of the membranes from the lower uterine segment. This produces hormones that encourage effacement and dilatation potentially promoting labour. This review is an update to a review first published in 2005. Objectives To assess the effects and safety of membrane sweeping for induction of labour in women at or near term (>= 36 weeks' gestation). Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (25 February 2019), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (25 February 2019), and reference lists of retrieved studies. Selection criteria Randomised and quasi-randomised controlled trials comparing membrane sweeping used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed on a predefined list of labour induction methods. Cluster-randomised trials were eligible, but none were identified. Data collection and analysis Two review authors independently assessed studies for inclusion, risk of bias and extracted data. Data were checked for accuracy. Disagreements were resolved by discussion, or by including a third review author. The certainty of the evidence was assessed using the GRADE approach. Main results We included 44 studies (20 new to this update), reporting data for 6940 women and their infants. We used random-effects throughout. Overall, the risk of bias was assessed as low or unclear risk in most domains across studies. Evidence certainty, assessed using GRADE, was found to be generally low, mainly due to study design, inconsistency and imprecision. Six studies (n = 1284) compared membrane sweeping with more than one intervention and were thus included in more than one comparison. No trials reported on the outcomes uterine hyperstimulation with/without fetal heart rate (FHR) change, uterine rupture or neonatal encephalopathy. Forty studies (6548 participants) compared membrane sweeping with no treatment/sham Women randomised to membrane sweeping may be more likely to experience: spontaneous onset of labour (average risk ratio (aRR) 1.21, 95% confidence interval (CI) 1.08 to 1.34, 17 studies, 3170 participants, low-certainty evidence). but less likely to experience: induction (aRR 0.73, 95% CI 0.56 to 0.94, 16 studies, 3224 participants, low-certainty evidence); There may be little to no difference between groups for: caesareans (aRR 0.94, 95% CI 0.85 to 1.04, 32 studies, 5499 participants, moderate-certainty evidence); spontaneous vaginal birth (aRR 1.03, 95% CI 0.99 to 1.07, 26 studies, 4538 participants, moderate-certainty evidence); maternal death or serious morbidity (aRR 0.83, 95% CI 0.57 to 1.20, 17 studies, 2749 participants, low-certainty evidence); neonatal perinatal death or serious morbidity (aRR 0.83, 95% CI 0.59 to 1.17, 18 studies, 3696 participants, low-certainty evidence). Four studies reported data for 480 women comparing membrane sweeping with vaginal/intracervical prostaglandins There may be little to no difference between groups for the outcomes: spontaneous onset of labour (aRR, 1.24, 95% CI 0.98 to 1.57, 3 studies, 339 participants, low-certainty evidence); induction (aRR 0.90, 95% CI 0.56 to 1.45, 2 studies, 157 participants, low-certainty evidence); caesarean (aRR 0.69, 95% CI 0.44 to 1.09, 3 studies, 339 participants, low-certainty evidence); spontaneous vaginal birth (aRR 1.12, 95% CI 0.95 to 1.32, 2 studies, 252 participants, low-certainty evidence); maternal death or serious morbidity (aRR 0.93, 95% CI 0.27 to 3.21, 1 study, 87 participants, low-certainty evidence); neonatal perinatal death or serious morbidity (aRR 0.40, 95% CI 0.12 to 1.33, 2 studies, 269 participants, low-certainty evidence). One study, reported data for 104 women, comparing membrane sweeping with intravenous oxytocin +/- amniotomy There may be little to no difference between groups for: spontaneous onset of labour (aRR 1.32, 95% CI 88 to 1.96, 1 study, 69 participants, low-certainty evidence); induction (aRR 0.51, 95% CI 0.05 to 5.42, 1 study, 69 participants, low-certainty evidence); caesarean (aRR 0.69, 95% CI 0.12 to 3.85, 1 study, 69 participants, low-certainty evidence); maternal death or serious morbidity was reported on, but there were no events. Two studies providing data for 160 women compared membrane sweeping with vaginal/oral misoprostol There may be little to no difference between groups for: caesareans (RR 0.82, 95% CI 0.31 to 2.17, 1 study, 96 participants, low-certainty evidence). One study providing data for 355 women which compared once weekly membrane sweep with twice-weekly membrane sweep and a sham procedure There may be little to no difference between groups for: induction (RR 1.19, 95% CI 0.76 to 1.85, 1 study, 234 participants, low-certainty); caesareans (RR 0.93, 95% CI 0.60 to 1.46, 1 study, 234 participants, low-certainty evidence); spontaneous vaginal birth (RR 1.00, 95% CI 0.86 to 1.17, 1 study, 234 participants, moderate-certainty evidence); maternal death or serious maternal morbidity (RR 0.78, 95% CI 0.30 to 2.02, 1 study, 234 participants, low-certainty evidence); neonatal death or serious neonatal perinatal morbidity (RR 2.00, 95% CI 0.18 to 21.76, 1 study, 234 participants, low-certainty evidence); We found no studies that compared membrane sweeping with amniotomy only or mechanical methods. Three studies, providing data for 675 women, reported that women indicated favourably on their experience of membrane sweeping with one study reporting that 88% (n = 312) of women questioned in the postnatal period would choose membrane sweeping in the next pregnancy. Two studies reporting data for 290 women reported that membrane sweeping is more cost-effective than using prostaglandins, although more research should be undertaken in this area. Authors' conclusions Membrane sweeping may be effective in achieving a spontaneous onset of labour, but the evidence for this was of low certainty. When compared to expectant management, it potentially reduces the incidence of formal induction of labour. Questions remain as to whether there is an optimal number of membrane sweeps and timings and gestation of these to facilitate induction of labour.

Women undergo operative vaginal delivery (OVD) as an alternative to caesarean section when complications arise in the second stage of labour. The perinatal mortality associated with OVD is very low, and most of the perinatal morbidity is minor. However, when serious adverse events occur, such as traumatic birth injury, shoulder dystocia, cerebral palsy and perinatal death, there are medico-legal implications. There is also the potential for litigation in relation to maternal pelvic floor injury, which is increased with OVD. Obstetricians performing and supervising OVDs need to be aware of the potential pitfalls and minimise the risk of adverse outcomes. Given that most obstetricians will be involved in adverse birth-related events, it is important that they are aware of the legal processes that may ensue. It is also important when reviewing adverse OVD-related outcomes that association is differentiated from causation. These issues are addressed in the current chapter with attention drawn to the Montgomery ruling, which redefines the legal standards expected in relation to informed consent.

Forceps are a commonly used instrument for assisting vaginal birth. Accepted indications include prolonged labour, suspected foetal distress and maternal medical conditions that benefit from a shortened second stage of labour. Maternal and offspring outcomes of forceps-assisted birth have been extensively reported in observational studies, but randomised trial evidence is limited. Forceps-assisted delivery has a lower failure rate than vacuum-assisted delivery but is associated with a higher incidence of maternal pelvic floor trauma. Second-stage caesarean section is associated with less foetal-neonatal trauma than forceps-assisted delivery but markedly reduces the chance of a subsequent vaginal birth. This review outlines the existing evidence on prevention, indications and contraindications for forceps-assisted birth (non-rotational and rotational), short- and long-term complications for mother and baby, alternatives to use of forceps and how to manage an abandoned forceps-assisted birth. The essential components of informed consent are also discussed.

Operative vaginal delivery (OVD) refers to a vaginal birth with the use of any type of forceps or vacuum extractor. Obstetricians should be confident and competent in the use of both instruments for non-rotational delivery and in the use of at least one technique for rotational delivery. The potential for increased maternal and neonatal morbidity in relation to OVD is long established although with careful practice the risk of significant trauma is low. Caesarean section in the second stage of labour is an alternative to operative vaginal delivery, but also carries the risk of significant morbidity and implications for future births. This case-based review gives three illustrative scenarios that highlight the complexity and diversity of the decision making process, and the considerations that must be taken into account when providing care to individual women.

A 35-year old woman with ileocolonic, perianal, and vulval Crohn's disease was treated with subcutaneous ustekinuamb [USK] throughout pregnancy. Dose intervals were shortened from 6-weekly to 4-weekly to maintain clinical remission. The last dose of USK was administered at 33 weeks of gestation, and a healthy baby boy was delivered by caesarean section at 37 weeks. Maternal trough USK levels remained stable during pregnancy. Cord blood USK levels were nearly 2-fold higher than contemporaneous maternal serum levels. To our knowledge, this is the first report of maternal and cord USK levels in a patient with Crohn's disease.

Primary postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality worldwide. The most common cause of primary PPH is uterine atony. Atonic PPH rates are increasing in developed countries despite routine active management of the third stage of labour. In less-developed countries, primary PPH remains the leading cause of maternal death.