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1.  A prospective cohort study of the morbidity associated with operative vaginal deliveries performed by day and at night 
BMJ Open  2014;4(10):e006291.
Objective
To evaluate maternal and neonatal outcomes associated with operative vaginal deliveries (OVDs) performed by day and at night.
Design
Prospective cohort study.
Setting
Urban maternity unit in Ireland with off-site consultant staff at night.
Population
All nulliparous women requiring an OVD with a term singleton fetus in a cephalic presentation from February to November 2013.
Methods
Delivery outcomes were compared for women who delivered by day (08:00–19:59) or at night (20:00–07:59).
Main outcome measures
The main outcomes included postpartum haemorrhage (PPH), anal sphincter tear and neonatal unit admission. Procedural factors included operator grade, sequential use of instruments and caesarean section.
Results
Of the 597 women who required an OVD, 296 (50%) delivered at night. Choice of instrument, place of delivery, sequential use of instruments and caesarean section did not differ significantly in relation to time of birth. Mid-grade operators performed less OVDs by day than at night, OR 0.60 (95% CI 0.43 to 0.83), and a consultant supervisor was more frequently present by day, OR 2.26 (95% CI 1.05 to 4.83). Shoulder dystocia occurred more commonly by day, OR 2.57 (95% CI 1.05 to 6.28). The incidence of PPH, anal sphincter tears, neonatal unit admission, fetal acidosis and neonatal trauma was similar by day and at night. The mean decision to delivery intervals were 12.0 and 12.6 min, respectively.
Conclusions
There was no evidence of an association between time of OVD and adverse perinatal outcomes despite off-site consultant obstetric support at night.
doi:10.1136/bmjopen-2014-006291
PMCID: PMC4216855  PMID: 25354825
operative vaginal delivery; time of birth; operator experience; prospective cohort study; morbidity
2.  Study Protocol. IDUS – Instrumental delivery & ultrasound. A multi-centre randomised controlled trial of ultrasound assessment of the fetal head position versus standard care as an approach to prevent morbidity at instrumental delivery 
Background
Instrumental deliveries are commonly performed in the United Kingdom and Ireland, with rates of 12 – 17% in most centres. Knowing the exact position of the fetal head is a pre-requisite for safe instrumental delivery. Traditionally, diagnosis of the fetal head position is made on transvaginal digital examination by delineating the suture lines of the fetal skull and the fontanelles. However, the accuracy of transvaginal digital examination can be unreliable and varies between 20% and 75%. Failure to identify the correct fetal head position increases the likelihood of failed instrumental delivery with the additional morbidity of sequential use of instruments or second stage caesarean section. The use of ultrasound in determining the position of the fetal head has been explored but is not part of routine clinical practice.
Methods/Design
A multi-centre randomised controlled trial is proposed. The study will take place in two large maternity units in Ireland with a combined annual birth rate of 13,500 deliveries. It will involve 450 nulliparous women undergoing instrumental delivery after 37 weeks gestation. The main outcome measure will be incorrect diagnosis of the fetal head position. A study involving 450 women will have 80% power to detect a 10% difference in the incidence of inaccurate diagnosis of the fetal head position with two-sided 5% alpha.
Discussion
It is both important and timely to evaluate the use of ultrasound to diagnose the fetal head position prior to instrumental delivery before routine use can be advocated. The overall aim is to reduce the incidence of incorrect diagnosis of the fetal head position prior to instrumental delivery and improve the safety of instrumental deliveries.
Trial registration
Current Controlled Trials ISRCTN72230496
doi:10.1186/1471-2393-12-95
PMCID: PMC3490917  PMID: 22970933
Fetal head position; Second stage of labour; Intrapartum ultrasound; Randomised controlled trial

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