During the second stage of labor, vacuum-assisted delivery is an alternative to forceps delivery and emergency cesarean section. Extensive research concerning perinatal outcomes has indicated that the risk of complications, although rare, is higher than with a spontaneous vaginal delivery. An important factor related to perinatal outcomes is the traction force applied. Our research group previously developed a digital extraction handle, the Vacuum Intelligent Handle-3 (VIH3), that measures and records traction force. The objective of this study was to compare traction force profiles in children with and without severe perinatal outcomes delivered with the digital handle. A secondary aim was to establish a safe force limit.
This was an observational case-control study at the delivery ward at Karolinska University Hospital, Sweden. In total, 573 children delivered with the digital handle between 2012 and 2018 were included. Cases were defined as a composite of severe perinatal outcomes, including subgaleal hematoma, intracranial hemorrhage, hypoxic ischemic encephalopathy 1-3, seizures or death. The cases in the cohort were matched 1:3 based on five matching variables. Traction profiles were analyzed using the MATLAB® software and conditional logistic regression.
The incidence of severe perinatal outcomes was 2.3%. The 13 cases were matched with three controls each (n = 39). A statistically significant increased odds for higher total traction forces was seen in the case group (odds ratio [OR] 1.004; 95% confidence interval [CI] 1.001-1.007) and for the peak force (OR 1.022; 95% CI 1.004-1.041). Several procedure-related parameters were significantly increased in the case group. As expected, some neonatal characteristics also differed significantly. An upper force limit of 343 Newton minutes (Nmin) revealed an 86% reduction in severe perinatal outcomes (adjusted OR 0.14; 95% CI 0.04-0.5).
Children with severe perinatal outcomes had traction force profiles with significantly higher forces. The odds for severe perinatal outcomes increased for every increase in Nmin and Newton used during the extraction procedure. A calculated total force level of 343 Nmin is suggested as an upper safety limit, but this must be tested prospectively to provide validity.

Separation of the head from the body can occur for a variety of reasons and in various locations across the neck. This study presents a review of the literature to identify the patterns of decapitations in forensic cases in relation to manner of death, age, and anatomical location (n = 88). The most common manner of death was suicide, followed by homicide and then accident. Ages ranged from 32 weeks prenatal to 85 years. Decapitation is reported at higher rates for individuals between 19 and 65. The majority of decapitations occurred at the midneck (second to fifth cervical vertebrae), followed by the upper neck and then the lower neck. This pattern holds true for all manners of death; however, in homicides, the percentage occurring at the midneck decreases. The findings of this study indicate some patterns in terms of manner of death, age, and location of decapitation, which could aid the medicolegal community in interpreting neck trauma. A case study is also briefly presented to illustrate findings.

BACKGROUND: The purpose of this study was to assess the neonatal morbidity and mortality associated with vacuum-assisted vaginal deliveries compared to all other vaginal deliveries, and to identify the associated risk factors.
METHODS: We conducted a retrospective case-control study in a level iii maternity hospital between 2012 and 2016, including 1,802 vacuum-assisted vaginal deliveries and 2control groups: 1802 spontaneous deliveries and 909 forceps-assisted deliveries. We considered minor complications (soft tissue trauma, cephalohaematoma, jaundice, intensive phototherapy, transient brachial plexus injury) and major complications (hypoxic-ischaemic encephalopathy, intracranial and subgaleal haemorrhage, seizures, cranial fracture, permanent brachial plexus injury), admission to the neonatal intensive care unit and death.
RESULTS: The risk of soft tissue trauma (aOR, 2.4; P<.001), cephalohaematoma (aOR, 5.5; P<.001), jaundice (aOR, 4.4; P<.001), intensive phototherapy (aOR, 2.1; P<.001) and transient brachial plexus injury (aOR; 2.1, P=.006) was higher in vacuum deliveries compared to spontaneous deliveries. Admission to the neonatal intensive care unit was also higher in vacuum deliveries compared to spontaneous deliveries (OR, 1.9; P=.001). When we compared vacuum with forceps deliveries, we found a higher risk of soft tissue trauma (OR, 2.1; P=.004), cephalohaematoma (OR, 2.2, P=.046) and jaundice (OR, 1.4; P=.012). Major complications were more frequent in the vacuum group comparing with the control groups, but the difference was not significant. The 2deaths occurred in vacuum deliveries (1.1 per 1000).
CONCLUSIONS: The proportion of minor neonatal complications was higher in the vacuum-assisted delivery group. Although major complications and death were also more frequent, they were uncommon, with no significant differences compared to the other groups. There are obstetrical indications for vacuum delivery, but it should alert to the need to watch for potential neonatal complications.

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.
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.
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).
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.

Brachial plexus birth injury (BPBI) and phrenic nerve injury can sometimes occur concurrently in neonates following difficult deliveries like breech presentation, shoulder dystocia, forceps or vacuum extraction. Phrenic nerve palsy should be suspected in a newborn with respiratory distress and an elevated hemidiaphragm on the imaging studies in presence of the associated risk factors. The right side is affected more often than the left side and most of it is associated with BPBI. We present here a rare case of a newborn baby with a left-sided Erb\'s palsy and a contralateral/right-sided diaphragmatic paralysis who recovered from the persistent respiratory distress and feeding difficulties following plication of the diaphragm. The left-sided Erb\'s palsy also fully recovered at follow-up examination.

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BACKGROUND: In rural Tanzania access to emergency obstetric and newborn care is threatened by poor roads and understaffed facilities among other challenges. Districts in Kigoma, Pwani and Morogoro regions were targeted by a local non-governmental organization to assist local government to build capacity and improve access to clinical management of severe obstetric and newborn complications. The program upgraded ten primary health care centres to provide comprehensive emergency obstetric and newborn care. This paper describes the process of reintroducing vacuum extraction into ten health centres and five hospitals, highlighting patterns in uptake, mode of delivery and lessons learned.
METHODS: This observational study uses facility-based trend data collected between 2011 and 2016.Descriptive outcomes include institutional caesarean delivery rates, vacuum extraction rates, and the ratio of caesareans to vacuum-assisted deliveries.
RESULTS: Institutional caesarean delivery rates remained stable at about 10-11% and the vacuum extraction rate rose from virtually no procedures in 2011 to about 2% in 2016. The increase was more visible in upgraded health centres than in hospitals. In 2016 vacuum extraction rates in newly upgraded health centres ranged from 0.5 to 7.8%. Between 2011 and 2016, the ratio of caesareans to vacuum extractions in hospitals changed from 304 caesareans to 1 vacuum extraction to 10:1, while in health centres the ratio changed from 22: 1 to 3: 1.
CONCLUSIONS: Reintroduction of vacuum extraction into clinical practice in primary health care facilities with task-shifting is feasible. Reintroduction of this procedure was more successful when part of an integrated upgrading of health centres to provide comprehensive emergency obstetric care than when reintroduced into busy hospital environments. Turnover of trained staff in hospitals contributed to the uneven uptake of vacuum extraction. Lessons learned are applicable to further national scale up and to other countries.

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This article reviews the literature for the management and repair of perineal hernias and presents a previously undescribed case of perineal bladder herniation after intrapartum pubic symphysis rupture.
A review of the literature was completed through the PubMed database using the search terms \"bladder,\" \"canal of Nuck,\" \"labial hernia,\" \"gynecology,\" \"hernia,\" \"obstetrics,\" \"perineal hernia,\" \"postpartum,\" \"pubic diastasis,\" \"pubic symphysis,\" \"vaginal delivery,\" \"symphyseal rupture,\" and \"symphyseal separation.\" The electronic medical record for the patient was reviewed and used with the consent of the patient.
There were no reports of peripartum perineal hernias in the English language literature on human subjects. Literature review with the previously mentioned search terms demonstrated that there is not a standardized approach to repair given the rarity of these defects. There are data to support the use of mesh as opposed to primary repair but no data to support abdominal versus perineal versus combined approach. We describe a successful repair of a complicated peripartum perineal hernia using a combined abdominal-perineal approach with mesh.
Obstetric trauma is a previously unreported cause of perineal hernias. Perineal hernias are rare conditions that must be considered in any patient who presents with a bulging perineal mass. Puerperal pubic symphysis rupture can lead to a large bladder hernia. Our combined abdominal-perineal approach of repair resulted in minimal perioperative morbidity and short-term resolution of the hernia.

Maternal complete heart block can pose significant challenges for the anesthesiologist in the antepartum, peripartum, and postpartum periods. Some patients may present for the first time in the puerperium with dizziness, weakness, syncope, or congestive heart failure as a result of the additional hemodynamic burden that accompanies pregnancy. Although there is an increase in permanent pacemaker placement in young symptomatic patients before pregnancy, prophylactic placement of pacemakers in asymptomatic parturients is not always indicated. The need for temporary or permanent pacemakers in asymptomatic women should be assessed on a case-by-case basis; many of these patients may be safely managed during labor and delivery without pacing. The parturient with complete heart block must be followed vigilantly during pregnancy and post delivery, as the need for pacemaker insertion can also arise in the postpartum period. We present a case of third-degree heart block in a 26-year-old parturient.