Abstract

with caesarean sections following failed instrumental delivery. One would expect uterine angle extensions to contribute substantially to postpartum hemorrhage during caesarean sections at second stage with low stations. We would also expect significant difficulty in delivery of babies by caesarean section when the station is below spines and would like to know whether there were any babies with cranial or intracranial morbidity following caesarean section at lower stations of the head. ‘Attempted operative vaginal delivery was more common in deliveries with babies of lower birthweight, whereas caesarean delivery was more frequent in macrocosmic infants (≥4000 g)’. Was the fact that the babies were either small or macrosomic known before the delivery? If so, then the knowledge of possible fetal macrosomia may have prevented operators from attempting a vaginal delivery in these babies in favour of a caesarean section, leading to this finding. Your article mentions that severe perineal laceration rates were high among attempted midcavity operative vaginal deliveries, ranging from 8.5% following attempted vacuum deliveries for fetal distress to 23.0% among attempted forceps deliveries for dystocia. The rates of third/fourth-degree tears mentioned here are substantially higher than the rates we observe in the United Kingdom. The overall incidence of thirdand fourth-degree tears in the UK is 2.9% (range 0–8%), with an incidence of 6.1% in primiparae compared with 1.7% in multiparae. Tempest et al. reported an occurrence of third-degree tear of 2.3% even in a series of 1037 cases of Kielland forceps deliveries. Do you think there may be other possible explanations for this? This article leads us to question the use of rates of caesarean sections as standards in assessing the performance of units. It appears that it would be justifiable to have increased caesarean section rates if this leads to reduced maternal and fetal morbidity. However, proficiency in mid-cavity instrumental delivery may allow women to avoid a caesarean section and reap the benefits of a safe instrumental delivery. It can be argued that one of the options to reduce the caesarean section rates would be to train and develop more practitioners with proficiency in managing the second stage of labour and ensuring their continued presence whenever assistance in the second stage is required.&