Abstract
Objective
To identify risk factors associated with postpartum readmission following vacuum‐assisted vaginal delivery.
Methods
A retrospective cohort study at a single university‐affiliated tertiary medical center from 2012 to 2023, including all singleton pregnancies delivered at ≥37 weeks' gestation. Women who underwent a vacuum‐assisted vaginal delivery (VAD) trial were identified. Multiple gestations, nonviable fetuses, and failed VAD requiring emergency cesarean delivery (CD) were excluded. Participants were categorized as readmitted or not readmitted within 6 weeks postpartum for obstetrical or gynecologic indications. Univariate analysis followed by multivariate logistic regression determined risk factors for readmission.
Results
Among 111 878 vaginal deliveries, 8730 (7.8%) involved VAD, with a readmission rate of 1.2% (105 women). Infectious causes accounted for 67.6% of readmissions. The most common infectious diagnosis was endometritis (27.6%), followed by urinary tract infection (14.3%), mastitis (12.4%), fever of unknown origin (8.6%), and infected laceration or episiotomy site (4.8%). Multivariate analysis revealed that pre‐eclampsia (odds ratio [OR] = 5.0, 95% confidence interval [CI]: 2.2–11.0, P < 0.001), postpartum fever (OR = 3.4, 95% CI: 1.0–11.0, P = 0.036), previous CD (OR = 2.0, 95% CI: 1.0–4.0, P = 0.046), and persistent occiput posterior fetal position (OR = 1.9, 95% CI: 1.2–3.3, P = 0.013) were significant risk factors for readmission. Notably, the primary indications for VAD, such as prolonged second stage of labor and non‐reassuring fetal heart rate monitoring, were not independently associated with an increased risk of postpartum readmission.
Conclusion
Several risk factors are associated with increased risk of postpartum readmission following VAD. Enhanced postpartum surveillance in these high‐risk groups may help reduce readmissions and improve maternal outcomes.
Keywords: occiput posterior, operative vaginal delivery, postpartum fever, pre‐eclampsia, previous cesarean delivery, readmission, vacuum‐assisted delivery
Abbreviations
- ACOG
American College of Obstetricians and Gynecologists
- ANODE
antibiotic prophylaxis for the prevention of maternal infection after operative vaginal delivery (trial acronym)
- CD
cesarean delivery
- CI
confidence interval
- GWG
gestational weight gain
- IVF
in vitro fertilization
- NRFHRM
non‐reassuring fetal heart rate monitor
- OR
odds ratio
- OVD
operative vaginal delivery
- POP
persistent occiput posterior
- PPH
postpartum hemorrhage
- PROM
premature rupture of membranes
- PSS
prolonged second stage
- RBC
red blood cell
- VAD
vacuum‐assisted delivery
1. INTRODUCTION
Vacuum‐assisted delivery (VAD) is employed to increase the likelihood of vaginal birth when maternal or fetal circumstances necessitate shortening or terminating unassisted labor. Furthermore, VAD may benefit women by reducing the likelihood of cesarean delivery (CD) and its associated risks and complications, particularly when performed under conditions of complete cervical dilation and a low fetal head position. 1 , 2 , 3
Nevertheless, VAD is associated with various maternal complications, including postpartum hemorrhage (PPH), obstetric anal sphincter injuries, manual uterine revision for retained placenta, and postpartum infections such as endometritis and wound complications. 4 , 5 Additional maternal morbidity has been linked to factors such as perineal injury, prolonged second stage of labor, maternal anemia, and high fetal birth weight. 6 Despite these risks, VAD remains an essential alternative to CD in the second stage of labor, especially when aiming to reduce the long‐term consequences associated with cesarean births at full dilation. 1 , 2 , 3
Hospital readmission after delivery is considered an important quality indicator of postpartum care, reflecting both maternal morbidity and the burden on healthcare systems, 7 as delivery methods have been identified as significant factors influencing postpartum readmission, with population‐based data showing higher readmission rates following cesarean and vacuum‐assisted births. 8 , 9
Despite growing attention to postpartum outcomes, there is limited research specifically addressing the intrapartum characteristics of VAD and their association with postpartum readmissions. Identifying those who are at a higher risk for complications following VAD may help target preventive strategies. Given these considerations, the aim of the present study was to explore specific intrapartum and postpartum risk factors for maternal readmission following VAD.
2. MATERIALS AND METHODS
This retrospective cohort study, performed at a single university‐affiliated tertiary medical center from January 2012 to December 2023, included all singleton pregnancies delivered at ≥37 weeks' gestation. Within this population, we identified women who underwent a VAD. Data were obtained from computerized delivery room logbooks and institutional electronic medical records. Hospital readmission was defined as any pregnancy or childbirth‐related rehospitalization occurring within 6 weeks postpartum at our institution. Women with multiple readmissions within the 6‐week postpartum period were counted once. Non‐obstetric and non‐gynecologic readmissions were systematically excluded. All participants were uniformly followed for 6 weeks postpartum through institutional electronic medical records. Exclusion criteria were multiple gestations, non‐viable fetuses. Emergency CDs following failed VAD were excluded in order to focus the analysis on completed VADs and to avoid confounding by complications related to surgical intervention rather than the VAD itself.
Participants were divided into two groups: those readmitted within 6 weeks after delivery and those who were not. We compared demographic, labor, and postpartum characteristics. Only postpartum readmissions to the index hospital were captured. Women readmitted to other medical centers could not be identified and were therefore excluded from the analysis. Women with more than one postpartum readmission were counted once, based on their first readmission episode.
The indications for performing VAD were either a prolonged second stage of labor, a non‐reassuring fetal heart rate monitoring (NRFHRM), or maternal exhaustion. 3 A VAD was attempted only if the fetal head station was engaged and at least at spinous +1. All VADs were performed by either a senior physician or a resident supervised by a senior physician, using MADELA metal cups or Kiwi, by physician's preference. Prior to VAD, sonographic assessments were performed routinely to assess fetal head presentation and angle of progression.
According to our institutional protocols, no prophylactic antibiotics were administered following VAD.
The study was approved by the local Institutional Review Board. Data analysis was performed with an unidentified database. Hence, informed consent was not required.
2.1. Data collection
All medical charts from which the study data were retrieved from the computerized delivery room logbooks. The database included demographic, obstetric, and clinical characteristics, such as maternal age, pre‐gestational body mass index, height, gestational weight gain (GWG), parity, previous CD, mode of conception (spontaneous vs in vitro fertilization [IVF]), smoking, pre‐eclampsia gestational diabetes, gestational age at delivery, onset of labor (spontaneous vs medical induction), epidural anesthesia, premature rupture of membranes (PROM), temperature during delivery, meconium‐stained amniotic fluid, length of the second stage, newborn birthweight, episiotomy, third/fourth degree perineal tears, red blood cell transfusion (RBC), and manual removal of placenta.
Data on fetal head position during labor (occiput anterior vs occiput posterior) and the fetal head station were also recorded, measured on a scale from −2 to +3. This measurement was estimated according to the classification system based on subjective assessment, whereas the new classification relies on the estimated distance in centimeters between the leading bony edge and the ischial spines, with the midpoint (0 station) aligned with the maternal ischial spines. In classification system, fetal head stations at +1 and +2 correspond to the new classification of (+1) to (+2) and (+3) to (+4), respectively. 10
Prolonged second stage of labor was defined according to institutional criteria as a second stage exceeding 3 h in nulliparous women and 2 h in multiparous women with regional anesthesia. Persistent occiput posterior position was defined as occiput posterior presentation at the time of vacuum application. Pre‐eclampsia was defined according to the American College of Obstetricians and Gynecologists (ACOG) guidelines. 11 Intrapartum fever was defined as a fever (≥38°C) during delivery. Postpartum partum fever was defined as a fever (≥38°C) occurring after delivery during hospitalization. The Sultan classification and the American College of Obstetrics and Gynecology criteria were used to classify perineal tears. 12
2.2. Statistical analysis
The categorical variables are presented as frequency and percentage. Normality of the continuous variables was tested using the Kolmogorov–Smirnov test and given as means ± standard deviation (SD) if normally distributed or median and interquartile range if normality could not be assumed. Comparisons between the groups were performed with the student t‐test for normally distributed continuous variables and with the Mann–Whitney rank sum test for non‐normally distributed continuous variables. The Chi‐square and Fisher exact tests were used for comparing categorical variables.
Multivariate logistic regression analysis included parameters with a P value less than 0.05 in the univariate analysis. All statistical analyses were performed using SPSS software (SPSS version 29, IBM, Chicago).
This retrospective study was approved by the Institutional Review Board of Tel Aviv Sourasky Medical Center (approval no. 0284‐08‐TLV) and conducted in accordance with the principles of the Declaration of Helsinki (2000). The dataset was fully anonymized prior to analysis, rendering individual informed consent unnecessary according to institutional policies.
3. RESULTS
A total of 111 878 women underwent vaginal delivery, of whom 8730 (7.8%) had a VAD and met the inclusion criteria. Among them, 105 women (1.2%) were readmitted postpartum (Figure 1). The distribution of readmission diagnoses is illustrated in Figure 2. The most common indication was endometritis (27.6%), followed by urinary tract infection (14.3%), mastitis (12.4%), and fever of unknown origin (8.6%). Other less frequent causes included postpartum pre‐eclampsia (5.7%), infected perineal laceration or episiotomy (4.8%), PPH (3.7%), and retained placenta (3.7%).
FIGURE 1.
Study design.
FIGURE 2.
Distribution of diagnosis for readmissions in the study group.
Demographic and maternal characteristics are presented in Table 1. Women who were readmitted had higher rates of previous CD (9.5% vs 5.1%, P = 0.044), and pre‐eclampsia (6.7% vs 1.6%, P < 0.001) compared to those who were not.
TABLE 1.
Maternal characteristics of the study and control groups.
| Characteristic | Readmission (n = 105) | No‐readmission (n = 8625) | P value |
|---|---|---|---|
| Maternal age at delivery (years), mean (±SD) | 32.8 (±4.8) | 32.1 (±4.5) | 0.679 |
| Nulliparity, n (%) | 90 (85.7%) | 7596 (87.9%) | 0.494 |
| IVF mode of conception, n (%) | 14 (13.3%) | 812 (9.4%) | 0.170 |
| Pregestational BMI, median IQR (25%–75%) | 22.1 (20.0–24.2) | 21.6 (19.8–24.1) | 0.657 |
| BMI ≥30, n (%) | 5 (4.8%) | 373 (4.3%) | 0.823 |
| GWG (kg), median IQR (25%–75%) | 13 (10–15) | 13 (10–16) | 0.604 |
| Maternal height (m), median IQR (25%–75%) | 1.63 (1.58–1.69) | 1.63 (1.6–1.68) | 0.412 |
| Maternal height <160 cm, n (%) | 29 (27.6%) | 1905 (22.0%) | 0.171 |
| Gestational diabetes, n (%) | 10 (9.5%) | 796 (9.2%) | 0.912 |
| Pre‐eclampsia, n (%) | 7 (6.7%) | 136 (1.6%) | <0.001 |
| Smoking, n (%) | 9 (8.6%) | 431 (5.0%) | 0.095 |
| Previous CD, n (%) | 10 (9.5%) | 444 (5.1%) | 0.044 |
Note: BMI, calculated as weight in kilograms divided by the square of height in meters. Significant differences (P < 0.05) are presented in bold.
Abbreviations: BMI, body mass index; CD, cesarean delivery; GWG, gestational weight gain; IQR, interquartile range; IVF, in vitro fertilization; SD, standard deviation.
Labor and postpartum characteristics are shown in Table 2, revealing an increased prevalence of persistent occiput posterior (POP) position (16.2% vs 9.2%, P = 0.013) and postpartum fever (2.9% vs 0.8%, P = 0.027) in the study group. No significant differences were noted between groups, including maternal age, parity, mode of conception, intrapartum fever, episiotomy, or birth weight.
TABLE 2.
Obstetrical characteristics of the study population during labor.
| Characteristic | Readmission (n = 105) | No readmission (n = 8625) | P value |
|---|---|---|---|
| Epidural analgesia, n (%) | 94 (89.5%) | 7907 (91.5%) | 0.475 |
| Induction of labor, n (%) | 32 (30.5%) | 2562 (29.7%) | 0.856 |
| Length of second stage of labor (min), median IQR (25%–75%) | 148 (95–194) | 143 (77–188) | 0.279 |
| Head station compared to ischial spine <2+, n (%) | 27 (25.7%) | 2346 (27.1%) | 0.743 |
| PROM, n (%) | 3 (2.9%) | 659 (7.6%) | 0.066 |
| Meconium, n (%) | 29 (27.6%) | 2178 (25.2%) | 0.570 |
| Persistent occiput posterior, n (%) | 17 (16.2%) | 791 (9.2%) | 0.013 |
| Gestational age (weeks), median IQR (25%–75%) | 40.0 (39.4–41.0) | 40.0 (39.1–40.5) | 0.047 |
| Birth weight (g), mean (±SD) | 3268 (±396) | 3240 (±408) | 0.798 |
| Prolonged second stage of labor, n (%) | 37 (35.2%) | 2622 (30.3%) | 0.278 |
| NRFHRM, n (%) | 71 (67.6%) | 6168 (71.4%) | 0.399 |
| Episiotomy, n (%) | 48 (45.7%) | 3569 (41.3%) | 0.307 |
| Third/fourth grade perineal tear, n (%) | 0 | 73 (0.8%) | 0.344 |
| Manual removal of placenta, n (%) | 5 (4.8%) | 459 (5.3%) | 0.803 |
| RBC transfusion, n (%) | 2 (1.9%) | 270 (3.1%) | 0.474 |
| Intrapartum fever, n (%) | 5 (4.8%) | 440 (5.1%) | 0.879 |
| Postpartum fever, n (%) | 3 (2.9%) | 73 (0.8%) | 0.027 |
Note: Significant differences (P < 0.05) are presented in bold.
Abbreviations: IQR, interquartile range; NRFHRM, non‐reassuring fetal heart rate monitoring; PROM, premature rupture of membranes; RBC, red blood cell; SD, standard deviation.
Multivariate analysis identified several significant risk factors for readmission: pre‐eclampsia (OR = 5.0, 95% CI: 2.2–11.0, P < 0.001), postpartum fever (OR = 3.4, 95% CI: 1.0–11.0, P = 0.036), previous cesarean delivery (OR = 2.0, 95% CI: 1.0–4.0, P = 0.046), and POP position (OR = 1.9, 95% CI: 1.2–3.3, P = 0.013) (Table 3).
TABLE 3.
Multivariate analysis for readmission following vacuum‐assisted delivery.
| Characteristic | OR | 95% CI | P value |
|---|---|---|---|
| Pre‐eclampsia | 5.0 | 2.2–11.0 | <0.001 |
| Postpartum fever | 3.4 | 1.0–11.0 | 0.036 |
| Previous cesarean delivery | 2.0 | 1.0–4.0 | 0.046 |
| Persistent occiput posterior | 1.9 | 1.2–3.3 | 0.013 |
| Gestational age at delivery | 1.2 | 0.9–1.5 | 0.117 |
Note: Significant differences (P < 0.05) are presented in bold.
Abbreviations: CI, confidence interval; OR, odds ratio.
4. DISCUSSION
4.1. Main findings
This study aimed to identify risk factors for postpartum readmission following VAD. Significant risk factors for readmission following VAD included pre‐eclampsia, postpartum fever, previous CD, and POP position.
4.2. Results in the context of previous studies
The readmission rate observed in our study (1.2%) aligns with previously reported rates from 1.3% to 1.8%. 7 , 8 , 9 , 11 While the ANODE trial evaluated approximately 3400 women and demonstrated the benefits of prophylactic antibiotics following operative vaginal deliveries (OVD), 9 there are no recent studies that specifically investigate the risk factors and readmission rates for women undergoing VAD.
Our findings demonstrate a significant association between POP position and an increased risk of readmission following VAD, reinforcing its role as a known risk factor for labor complications. 13 , 14 In the current study, 2.1% of women with a POP position were readmitted postpartum, with 52.9% of these readmissions attributed to infectious causes. This association may result from extended procedure durations that elevate the risk of postpartum infections by prolonging exposure to potential pathogens. 15 Such prolonged exposure may promote the onset of endometritis and increase the likelihood of infection in susceptible perineal wounds, including episiotomies or lacerations. 16 , 17
In addition, pre‐eclampsia emerged as the strongest predictor of postpartum readmission, associated with a five‐fold increased risk. Among those readmitted with pre‐eclampsia, 71.4% were hospitalized due to worsening of the condition. Although VAD is widely employed in obstetric practice, there is no evidence to suggest that it contributes to the progression of hypertensive disorders such as pre‐eclampsia. According to ACOG guidelines, the mode of delivery in women with pre‐eclampsia should be guided by obstetric indications and the overall clinical scenario, rather than by the diagnosis of pre‐eclampsia alone. 11 Notably, the relationship between pre‐eclampsia and the risk of postpartum infectious morbidity remains a subject of ongoing debate. 18 , 19
Additionally, we found an association between a history of previous CD and readmission after VAD, corroborating existing evidence that indicates higher maternal morbidity for women with a prior CD. Women with a history of CD are at increased risk for complications, including postpartum hemorrhage and the need for blood transfusion, retained placenta, and uterine rupture compared to those without prior CD. 20 , 21 This heightened risk may stem from various factors, including infectious and hemorrhagic complications. Infection risk may be elevated due to a uterine scar from a previous CD, particularly if there is disruption or dehiscence during labor, allowing bacterial entry into the uterine cavity. 21 , 22 Moreover, previous CD has been linked to an increased risk of postpartum hemorrhage and retained placenta, potentially contributing to readmission. 20 Scar tissue from a previous CD may complicate normal placental separation, further increasing the risk of retained placenta and subsequent hemorrhage. 20
The relationship between OVD, including VAD, and postpartum infection is well documented; most studies report increased infectious morbidity, notably endometritis and perineal wound complications, among women undergoing OVD. 9 , 23 , 24 The ANODE trial, 9 a significant randomized controlled trial, demonstrated that prophylactic antibiotics following OVD substantially reduced postpartum infections, prompting several international guidelines to recommend routine antibiotic use in these cases. 25 , 26 However, ACOG has not endorsed this practice, citing limitations in the ANODE trial and insufficient evidence to warrant universal antibiotic administration. 3
4.3. Clinical implications
The findings of this study underscore the need for improved postpartum care strategies in women undergoing VAD, particularly those with identifiable risk factors such as pre‐eclampsia, postpartum fever, prior cesarean delivery, and POP fetal position. These clinical variables were found to be independently associated with an increased risk of postpartum readmission and should inform discharge planning and follow‐up protocols.
From a maternal‐fetal medicine perspective, incorporating risk‐based stratification into postpartum care may enhance patient outcomes. Women with high‐risk features may benefit from earlier outpatient follow‐up, blood pressure monitoring, or infection screening in the days following discharge. Moreover, these findings can support real‐time decision making by maternal‐fetal medicine consultants during labor management, particularly when weighing the use of VAD in patients with hypertensive disorders or prior uterine surgery.
A nuanced understanding of these risk factors enables clinicians to individualize postpartum surveillance, optimize resource allocation, and potentially reduce avoidable maternal morbidity and hospital readmissions.
4.4. Research implications
This study highlights the need for refined, physiology‐based approaches to understanding maternal morbidity following VAD. The identification of specific maternal and intrapartum characteristics, such as pre‐eclampsia, postpartum fever, prior cesarean delivery, and POP fetal position, as significant predictors of postpartum readmission, emphasizes the importance of moving beyond procedural factors toward individualized risk profiling.
Future research should focus on validating these clinical risk markers in broader populations and exploring the underlying mechanisms linking them to infectious morbidity and delayed postpartum recovery. In particular, the role of immune response modulation, uterine healing in previously scarred uterus, and fetal malposition during VAD merit further investigation.
Additionally, these findings support the development of risk‐adapted postpartum care models that prioritize early follow‐up and targeted surveillance in women with identifiable risk profiles. Such strategies could reduce preventable readmissions and contribute to the optimization of post‐discharge care pathways in vacuum assisted vaginal births.
4.5. Strengths and limitations
This study has several notable strengths. A significant advantage is its focus on postpartum readmission following VAD, a subject that has been relatively understudied in recent years. Additionally, the large sample size enhances the reliability of our findings. This study specifically examines risk factors for readmission in women after VAD, an area that has not received extensive attention. Moreover, our analysis included obstetrical factors specifically relevant to VAD that have not been evaluated in previous studies, thereby strengthening the comprehensiveness and relevance of our research.
However, there were also several limitations to this study. First, its retrospective design may have introduced selection bias, potential recording errors, and challenges in controlling for exposures and outcomes. Additionally, detailed information on several difficult‐to‐measure factors, such as traction force, fetal engagement, uterine tone, estimated fetal weight, and operator experience, was lacking. These factors could influence the risk of VAD failure and neonatal outcomes, but quantifying their impact is challenging due to the absence of standardized criteria. Second, while the extensive database allowed for the investigation of numerous cases and parameters, this study was conducted at a single center serving a relatively homogeneous population of young, multiparous women, which may limit the generalizability of our findings. Although the overall cohort was large, the relatively small number of readmitted cases reflects the low incidence of postpartum readmission following VAD. This limitation may reduce the ability to detect additional risk factors. Although postpartum readmission events were relatively infrequent in our cohort (n = 105), limiting the ability to detect additional predictors, future multicenter studies with larger sample sizes and standardized assessments of operator experience and fetal engagement metrics are warranted to validate and expand these findings.
5. CONCLUSION
Our study identified several factors associated with an increased risk of readmission following VAD, including pre‐eclampsia, postpartum fever, previous cesarean delivery, and POP position. These findings emphasize the importance of individualized postpartum monitoring, especially for high‐risk women such as those with pre‐eclampsia, a history of CD, or postpartum fever. Early recognition of these risk factors may facilitate tailored postnatal care strategies to enhance maternal outcomes, reduce hospital readmissions, and potentially lower healthcare costs.
AUTHOR CONTRIBUTIONS
Itamar Gilboa: Conceptualization, data curation, investigation, writing – original draft. Keren‐Or Wertheimer: Data curation, investigation, writing – validation, review and editing. Daniel Gabbai: Data curation, investigation, writing – review and editing. Emmanuel Attali: Data curation, investigation, writing – original draft. Yariv Yogev: Writing – validation, review and editing. Anat Lavie: Conceptualization, visualization, writing – original draft, review and editing, project administration. All authors revised the article for important intellectual content and approved the final version submitted for publication.
FUNDING INFORMATION
This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
DATA AVAILABILITY STATEMENT
The data are available from the corresponding author upon reasonable request.
REFERENCES
- 1. Attali E, Reicher L, Many A, Maslovitz S, Gamzu R, Yogev Y. Pregnancy outcome after cesarean section following a failed vacuum attempt. J Matern Fetal Neonatal Med. 2022;35(22):4375‐4380. [DOI] [PubMed] [Google Scholar]
- 2. Allen VM, O'Connell CM, Baskett TF. Maternal and perinatal morbidity of caesarean delivery at full cervical dilatation compared with caesarean delivery in the first stage of labour. BJOG. 2005;112(7):986‐990. [DOI] [PubMed] [Google Scholar]
- 3. Operative vaginal birth: ACOG practice bulletin, number 219. Obstet Gynecol. 2020;135(4):e149‐e159. [DOI] [PubMed] [Google Scholar]
- 4. Bahl R, Hotton E, Crofts J, Draycott T. Assisted vaginal birth in 21st century: current practice and new innovations. Am J Obstet Gynecol. 2024;230(3S):S917‐S931. [DOI] [PubMed] [Google Scholar]
- 5. Sagi‐Dain L, Sagi S. Morbidity associated with episiotomy in vacuum delivery: a systematic review and meta‐analysis. BJOG. 2015;122(8):1073‐1081. [DOI] [PubMed] [Google Scholar]
- 6. Chawanpaiboon S, Titapant V, Pooliam J. Maternal complications and risk factors associated with assisted vaginal delivery. BMC Pregnancy Childbirth. 2023;23(1):756. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Combs CA, Goffman D, Pettker CM, Society for Maternal‐Fetal Medicine (SMFM) Patient Safety and Quality Committee . Society for Maternal‐Fetal Medicine Special Statement: a critique of postpartum readmission rate as a quality metric. Am J Obstet Gynecol. 2022;226(4):B2‐B9. [DOI] [PubMed] [Google Scholar]
- 8. Liu S, Heaman M, Joseph KS, et al. Risk of maternal postpartum readmission associated with mode of delivery. Obstet Gynecol. 2005;105(4):836‐842. [DOI] [PubMed] [Google Scholar]
- 9. Knight M, Chiocchia V, Partlett C, et al. Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial. Lancet. 2019;393(10189):2395‐2403. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Gabbe SG, Niebyl JR, Simpson JL. Dedication. Obstetrics: Normal and Problem Pregnancies. Elsevier; 2017:v. [Google Scholar]
- 11. Gestational hypertension and preeclampsia: ACOG practice bulletin summary, number 222. Obstet Gynecol. 2020;135(6):1492‐1495. [DOI] [PubMed] [Google Scholar]
- 12. Pundir J, Coomarasamy A. Management of third‐ and fourth‐degree perineal tears. Obstetrics: Evidence‐Based Algorithms. Cambridge University Press; 2016:258‐261. [Google Scholar]
- 13. Schreiber H, Cohen G, Shechter Maor G, Haikin Herzberger E, Biron‐Shental T, Markovitch O. Head position and vacuum‐assisted delivery using the kiwi Omnicup. Int J Gynaecol Obstet. 2023;160(3):836‐841. [DOI] [PubMed] [Google Scholar]
- 14. Gilboa I, Gabbai D, Lavie A, Yogev Y, Attali E. Clinical chorioamnionitis is a major risk factor for failed vacuum‐assisted births—a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol. 2025;313:114632. [DOI] [PubMed] [Google Scholar]
- 15. Mohamed‐Ahmed O, Hinshaw K, Knight M. Operative vaginal delivery and post‐partum infection. Best Pract Res Clin Obstet Gynaecol. 2019;56:93‐106. [DOI] [PubMed] [Google Scholar]
- 16. Axelsson D, Brynhildsen J, Blomberg M. Postpartum infection in relation to maternal characteristics, obstetric interventions and complications. J Perinat Med. 2018;46(3):271‐278. [DOI] [PubMed] [Google Scholar]
- 17. Humphreys ABC, Linsell L, Knight M. Factors associated with infection after operative vaginal birth‐a secondary analysis of a randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth. Am J Obstet Gynecol. 2023;228(3):328.e1‐328.e11. [DOI] [PubMed] [Google Scholar]
- 18. Harrison RK, Egede LE, Palatnik A. Peripartum infectious morbidity in women with preeclampsia. J Matern Fetal Neonatal Med. 2021;34(8):1215‐1220. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Hsu CD, Witter FR. Urogenital infection in preeclampsia. Int J Gynaecol Obstet. 1995;49(3):271‐275. [DOI] [PubMed] [Google Scholar]
- 20. Tamir Yaniv R, Farladansky‐Gershnabel S, Gluska H, et al. Cesarean delivery complicated by peripartum infection and risk of uterine rupture during subsequent trial of labor. J Womens Health (Larchmt). 2024;33(7):986‐990. [DOI] [PubMed] [Google Scholar]
- 21. Chaim W, Bashiri A, Bar‐David J, Shoham‐Vardi I, Mazor M. Prevalence and clinical significance of postpartum endometritis and wound infection. Infect Dis Obstet Gynecol. 2000;8(2):77‐82. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Dunk SA, Owen J, Lu MY, Kim D‐J, Szychowski JM, Subramaniam A. Operative vaginal delivery as an independent risk factor for maternal postpartum infectious morbidity. Am J Obstet Gynecol MFM. 2022;4(6):100705. [DOI] [PubMed] [Google Scholar]
- 23. Rottenstreich M, Rotem R, Katz B, Rottenstreich A, Grisaru‐Granovsky S. Vacuum extraction delivery at first vaginal birth following cesarean: maternal and neonatal outcome. Arch Gynecol Obstet. 2020;301(2):483‐489. [DOI] [PubMed] [Google Scholar]
- 24. Gommesen D, Nohr EA, Drue HC, Qvist N, Rasch V. Obstetric perineal tears: risk factors, wound infection and dehiscence: a prospective cohort study. Arch Gynecol Obstet. 2019;300(1):67‐77. [DOI] [PubMed] [Google Scholar]
- 25. Murphy DJ, Strachan BK, Bahl R, Royal College of Obstetricians and Gynaecologists . Assisted vaginal birth: green‐top guideline No. 26. BJOG. 2020;127(9):e70‐e112. [DOI] [PubMed] [Google Scholar]
- 26. WHO . (World Health Organization) Recommendation on Routine Antibiotic Prophylaxis for Women Undergoing Operative Vaginal Birth. World Health Organization; 2021. [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data are available from the corresponding author upon reasonable request.