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LETTERS.
Forceps/Incontinence Questions
I read the article "Forceps Linked to Stress Urinary Incontinence" with great interest, but Dr. Katherine Van Kessel's study posed many questions Jan. 15, 2001, p. 13).
Operative vaginal delivery (OVD) and the clinical indications for OVD have long been implicated in the development of pelvic floor dysfunction (PFD). Nearly all the studies in the recent literature evaluating this putative relationship were retro spective, had short-term follow-up, small sample sizes, and lacked randomization.
It seems reasonable that OVD would be associated with urinary incontinence, but what are the mechanisms that increase the risk of PFD? In Dr. Van Kessel's study, which controlled for several important cofactors such as duration of the second stage of labor and birth weight, this question was not addressed.
What about other cofactors such as fetal station and position at the time of forceps application? Is outlet different from low or mid? What about asynclitism, occiput posterior and face presentations, and deliveries requiring rotation? One might think that it is the relatively rapid nature of OVD that causes pelvic floor damage. Pelvic floor tissue may not have adequate time to accommodate delivery.
One should, therefore, see a similar in cidence of PFD in vacuum deliveries. This was not the case in Dr. Van Kessel's study, but in other studies it has been implicated. Perhaps Dr. Van Kessel's study lacked sufficient statistical power to detect such a difference. Or is there an intrinsic difference between forceps and vacuum? Per haps it is the additional profile that for cepsblades, when applied to the fetal head, present the pelvic floor that increases pelvic floor damage. The average thickness of forceps blades, however, is only 3-5 mm and seems insignificant.
Is there a correlation between vaginal lacerations caused by forceps and incontinence? Probably, but this study did not show chat to be the case. Would you expect to see the same effect with Laufe divergent forceps, which have a pivot lock and act ...
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