Katarina Åberg

Introduction: This is the first nationwide cohort study of vacuum extraction (VE) and long‐term neurological morbidity. We hypothesized that VE per se, and not only complicated labor, can cause intracranial bleedings, which could further cause neurological long‐term morbidity. The aim of this study was to investigate the risk of neonatal mortality, cerebral palsy (CP), and epilepsy among children delivered by VE in a long‐term perspective.Material and methods: The study population included 1 509 589 term singleton children planned for vaginal birth in Sweden (January 1, 1999 to December 31, 2017). We investigated the risk of neonatal death (ND), CP, and epilepsy among children delivered by VE (successful or failed) and compared their risks with those born by spontaneous vaginal birth and emergency cesarean section (ECS). We used logistic regression to study the adjusted associations with each outcome. The follow‐up time was from birth until December 31, 2019.Results: The percentage and total number of children with the outcomes were ND (0.04%, n = 616), CP (0.12%, n = 1822), and epilepsy (0.74%, n = 11 190). Compared with children delivered by ECS, those born by VE had no increased risk of ND, but there was an increased risk for those born after failed VE (adj OR 2.23 [1.33–3.72]). The risk of CP was similar among children born by VE and those born spontaneously vaginally. Further, the risk of CP was similar among children born after failed VE compared with ECS. The risk of epilepsy was not increased among children born by VE (successful/failed), compared with those who had spontaneous vaginal birth or ECS.Conclusions: The outcomes ND, CP, and epilepsy are rare. In this nationwide cohort study, children born after successful VE had no increased risk of ND, CP or epilepsy compared with those delivered by ECS, but there was an increased risk of ND among those born by failed VE. Concerning the studied outcomes, VE appears to be a safe obstetric intervention; however, it requires a thorough risk assessment and awareness of when to convert to ECS.

Introduction: The association between vacuum extraction and intracranial hemorrhage has been debated. We sought to investigate the impact of protracted vacuum extraction on the risk for neonatal intracranial hemorrhage in term infants.Material and methods: This nationwide case‐control study covered Swedish maternity wards from 1999 to 2013. All term, live‐born infants diagnosed with neonatal intracranial hemorrhage after vacuum‐assisted delivery were included as cases (n = 167). For each case, 3 vacuum‐delivered controls, without a diagnosis for intracranial hemorrhage, were selected (n = 546 controls). Conditional logistic regression analysis was used to study the association between protracted extraction (defined as vacuum duration > 15 min, > 6 pulls or > 2 cup detachments), and neonatal intracranial hemorrhage.Results: Extractions exceeded 15 min among 33% of the cases, vs 5% of the controls. More than six pulls were used in 25% of the cases and in 4% of the controls, and more than two cup detachments occurred in 3.6% of the cases and in 0.6% of the controls. Compared with extractions adhering to safety recommendations, the odds for intracranial hemorrhage were nine‐fold (OR 8.91, 95%, CI 5.22‐15.20) among infants exposed to a protracted extraction. After adjustments for potential confounders, the OR decreased to 8.04 (95% CI 4.49‐14.38).Conclusions: The strong association between protracted extraction and intracranial hemorrhage suggests that adherence to safety recommendations may reduce the risk for intracranial hemorrhage in infants delivered by vacuum extraction. However, safe limits for vacuum duration and number of pulls are still unknown and intracranial hemorrhage may occur even when performed in accordance with safety recommendations.

Introduction: High birthweight is associated with complicated childbirth. The aim of the present study was to investigate the association between birthweight, mode of delivery, and neonatal complications among infants born at term with a birthweight ≥3000 g.Material and methods: This population‐based cohort study used data from the Swedish Medical Birth Register from 1999 to 2012, including 1 030 775 births at >36 completed weeks. Exposure was mode of delivery, categorized into non‐instrumental vaginal delivery (VD), emergency cesarean section (CS), vacuum extraction (VE) or cesarean section following attempted vacuum extraction (VE + CS), and birthweight was divided into five categories (3000–3999 g, 4000–4499 g, 4500–4999 g, and ≥5000 g). The following outcomes were assessed: 5‐min Apgar score <7, neonatal convulsions, intracranial hemorrhage, and brachial plexus injury. Infants born after VD with a birthweight of 3000–3999 g were used as reference in the logistic regression analysis.Results: The odds ratios for all complications increased at higher birthweights among infants born after VE/VE + CS and VD. The highest risks were seen after VE/VE + CS with an adjusted odds ratio for neonatal convulsions of 2.6 (95% CI 2.1–3.2) in the reference birthweight group and 6.3 (95% CI 4.3–9.2) among infants with a birthweight of ≥4500 g. The corresponding adjusted odds ratios for intracranial hemorrhage were 2.6 (95% CI 1.7–3.9) and 6.7 (95% CI 3.3–13.6) and for brachial plexus injury 4.0 (95% CI 3.3–4.9) and 88.4 (95% CI 71.9–108.4).Conclusion: Vacuum extraction is a risk factor for serious neonatal complications, in particular when used in macrosomic fetuses.

Very few studies have investigated the neonatal outcomes after vacuum extraction delivery (VE) in the preterm period and the results of these studies are inconclusive. The objective of this study was to describe the use of VE for preterm delivery in Sweden and to compare rates of neonatal complications after preterm delivery by VE to those found after cesarean section during labor (CS) or unassisted vaginal delivery (VD).