, a 32-year-old patient presented to the defendant hospital clinic for a pregnancy test, which was positive. Her estimated date of confinement (EDC) was November 15, 2013 and the gestational age was noted to be 8 weeks, 3 days. On 

, the patient presented for her initial obstetrical visit accompanied by her husband. Examination was within normal limits and the fetal heart rate (FHR) was 170. Routine prenatal labs were ordered, first-trimester screening (FTS) was scheduled for May 1, 2013, and the patient was instructed to return to the clinic in 4, 8, and 12 weeks. Over the following 5 months, she visited the clinic for prenatal care eight times and all of the findings were relatively benign. In brief, on June 10, 2013, a fetal anatomical survey was performed.

, the patient returned to the clinic for her last prenatal visit at a gestational age of 34 weeks, 6 days. She reported doing well but also said she was feeling the baby less that day than she had the prior night. She reported no contractions or loss of fluid, and some dysuria a few days previously but not that day. The patient denied headache, vision changes, epigastric pain, and/or right upper quadrant pain. Fundal height was 32 cm and fetal heart tones were in the 160s. Questionable growth restriction was noted as fundal height was unchanged since the last visit. The patient was referred for a growth scan in 1 week and was to return for a visit in 2 weeks.

Did vaginal hysterectomy result in iatrogenic injuries?

, the patient presented to the clinic and reported decreased fetal movement. On external fetal monitor the baseline was 150, with minimal variability, no accelerations, and positive decelerations. Flowsheets in the chart document findings from the tracings every 15 minutes from 20:30 to 23:45. From 20:30 to 22:00, the fetal heart rate (FHR) baseline was 145 to 155; variability was minimal; accelerations were absent except for at 21:45, when they were noted to be spontaneous; there were no decelerations. At 

, the FHR was 150 with a deceleration to 90 for 90 seconds, variability was moderate, accelerations were absent, and decelerations were noted to be variable.

, the FHR was 150 to 160 with minimal variability. A vaginal exam done at 22:50 showed 0/50/-2 and the membranes were intact. The patient was taken to an operating room (OR) at 23:57 for cesarean delivery with a preoperative diagnosis of non-reassuring FHR tracing and intrauterine growth restriction (IUGR). Her male infant weighed 1800 g and had Apgars of 2, 3, and 7. Per the operative report, “a hand was placed into the incision and the vertex of the infant delivered with the assistance of a vacuum. With gentle traction and the assistance of fundal pressure the rest of the torso was delivered.”

The infant emerged limp and apneic without cry. Positive pressure ventilation (PPV) was administered in the transitional nursery. The heart rate was initially in the 70s and remained there. With PPV via the bag-mask, the infant’s heart rate gradually increased. The infant did not appear dysmorphic with spontaneous activity and respirations. The umbilical arterial cord gas was 6.96 and PCO

 greater than 87 with a base deficit of -8. The UVC cord gas was 7.08 with a base deficit of -9.5. The infant was to be admitted to the Neonatal Intensive Care Unit as he was described to be in critical condition. Ampicillin and gentamicin were initiated, and he was to be followed closely for evidence of end-organ injury or insult.

, the infant presented for neurology evaluation. He had previously  seen a neurologist but his mother wanted a second opinion. At age 2 years, he still could not walk, sit, or pull to stand. He was weak on the left side and was found to have global developmental delay, presumably caused by prepartum and/or peripartum abnormalities of gestation. Through early intervention, he was receiving physical, speech, and occupational therapy services. A psychological evaluation had not yet been performed. Assessment was spastic infantile paralysis. Magnetic resonance imaging of the brain without contrast performed on August 28, 2015 showed gliotic signal abnormality in the bilateral centrum semiovale and corona radiate with mildly diminished supratentorial white matter volume, compatible with periventricular leukomalacia.

The importance of intervention: When was this baby in trouble?

, the infant presented to speech pathology for an initial evaluation of dysphagia. Active problems included abnormal gait, asthma, chronic vomiting, constipation, hypospadias, penoscrotal hypospadias, poor weight gain, and spastic quadriplegic cerebral palsy. The impression was that the infant had mild-moderate oropharyngeal dysphagia characterized by reduced management of oral secretions with pooling of saliva on labial surface.


	The plaintiff mother alleged that the defendant hospital failed to perform timely and proper prenatal sonograms, biophysical profiles, stress and non-stress tests, prenatal examinations, and blood tests to monitor and assess the well-being of the plaintiff and her infant; failed to properly evaluate plaintiff’s signs, symptoms, and/or complaints; chose not to perform or refer the plaintiff on October 10, 2013 for immediate sonograms and testing based upon plaintiff’s complaint that the baby was not moving as before and exam finding that baby was not growing since prior visit to assess the wellbeing of the infant-plaintiff in utero; negligently advised the plaintiff to go for a growth ultrasound in 1 week; ignored the plaintiff’s signs, symptoms, and complaints that the baby was not moving as before and had not grown since the prior visit; failed to advise the plaintiff of the signs and symptoms of fetal distress and IUGR; failed to timely diagnose and treat signs and symptoms of perinatal fetal distress, hypoxia, and IUGR; and failed to timely perform a cesarean section delivery of the infant-plaintiff.

The plaintiff maintained that as a result of the alleged negligence, the infant allegedly sustained the following injuries: perinatal asphyxia; perinatal hypoxia; perinatal metabolic acidosis; perinatal fetal distress; perinatal cyanosis; intrauterine growth restriction; hypotonia; muscle weakness and contractures; spastic quadriplegic cerebral palsy; spastic tetraparesis of extremities, particularly the hands; global developmental delay; periventricular leukomalacia; inability to stand, walk, or speak; severe cognitive impairment and delay; pulmonary and respiratory complications; inability to eat normally; neuropsychological delay and impairments; and social delay and impairments. Those impairments included autism spectrum disorder involving mood disorders, attention deficit hyperactivity disorder (ADHD); muscle spasms and spasticity of the arms and legs; bowel/bladder incontinence; severe language and communication deficits; respiratory insufficiency and infection; and total immobility with scissoring of the legs and severe functional deficits.


	The maternal-fetal medicine (MFM) expert initially opined that the mother’s complaint of decreased fetal movement as well as the lack of change in fundal height since her last visit on September 23, 2010, would have prompted 95% of physicians to send her for a non-stress test on October 10. However, he felt that the documentation was unclear as to whether the reported decreased fetal movement represented a radical decrease in movement or simply a decrease in movement. The MFM indicated that he would not have sent the mother for a NST if she reported a minimal kick count versus if there was a radically different level of activity. If the latter, the doctor would have referred the mother for further evaluation that day.

The neonatology expert disagreed with the MFM and opined that the mother’s  complaints of decreased fetal movement warranted an immediate BPP and it was a departure not to perform one on October 10. Both the MFM and the neonatology expert believed that there were no issues with management of the mother after her presentation on October 11, and felt that there was no evidence to have warranted an emergent delivery. Our neonatology expert believed that the infant’s injuries may have been the result of both hypoxic-ischemic encephalopathy (HIE) and fetal thrombotic vasculopathy (FTV). However, the expert also believed the infant was timely delivered. He believed that during the prenatal period,a chronic or acute event-or both- caused the infant’s injuries, but he could not conclusively state when the event(s) occurred. Based on the scans and the pathology, our neonatology expert believed that this infant suffered from both HIE and FTV, which resulted in the alleged injuries.

The mother testified that she told the doctor that she was worried after not feeling the baby. Upon further questioning, she testified that she specifically told the doctor that she felt the baby “less than the night before.” The doctor told her that the lack of movement was normal, but given her concern, he referred her for an ultrasound within 5 days.  The woman proceeded to defendant hospital the following day and was not feeling her baby when she arrived there. The resident who sent the patient home on October 10 was only 3 months into her residency and did not document the extensive conversation regarding fetal movement she claimed occurred.


	While the patient’s attorneys demanded $15 million for settlement of the matter, defendant hospital ultimately settled the case for $3.4 million at mediation.


	It goes without saying that “brain-damaged” infant cases portend significant exposure for those involved in the claims. Here, given that we had a disagreement among our experts about the cause of the infant’s injuries, whether they resulted from deviations in standards of care, and also faced a credibility battle between a credible, sympathetic mother and a resident only 3 months into her training, the decision was made to attempt mediation in the hopes of arriving at a pretrial resolution. Due to the exposure in the case for the physicians as well as the defensible aspects of the care rendered, the plaintiff would have had significant hurdles. For these reasons, an acceptable resolution was ultimately reached. 

Articles

This month's web-exclusive Legally Speaking article examines a case where conflicting expert testimony and a sympathetic mother made for a difficult decision.

Did delay in assessing decreased fetal movement result in brain injury? 

The most frequent struggles are usually encountered in initial placement – particularly of the second blade – and less commonly during traction. It is important that the cephalic curve (or “palm side” of the blade) is as closely apposed to the fetal scalp as possible, or if the fetal scalp is not visible, then to the maternal introitus. Importantly, as the forceps begins its motion, there can be no movement forward or backward of the handle until the maternal thigh is reached. Doing so starts the blade of the forceps down the sacrum/face (in an OA fetus) rather than along the more hollow space between parietal bone and vagina. A forceps blade on the correct trajectory should require almost no force, and I remind learners of this by encouraging them to hold the handle with only their fingertips.

As the forceps lock, if the left blade was placed first, this allows the English lock to come together easily. If, however, the right blade was placed first (as would be the case in a ROA or LOP presentation placing the posterior blade first), then they will appear to come together and be unable to lock. This is easily resolved by moving the left handle so that it falls under the right and the English lock will come together correctly. Last, the correct direction of traction is best achieved by visualizing the presenting part and cardinal movements necessary for delivery. For an OA presentation, this requires direct downward (axis) traction. Only after the occiput clears the symphysis is this then transitioned to outward then upward to minimize perineal injury. For OP presentations, the biparietal diameter is typically much higher than anticipated and Dennen recommends depressing the shanks against the perineum before locking (effectively inching them higher and more anterior on the parietal bone). We have found also that there is typically a much greater need for downward traction initially before then turning outward and upward to take the fetus into flexion for delivery.

Forceps delivery: Contemporary tips for a classic obstetric tool

Videos

Dr. Melissa S. Wong demonstrates a forceps delivery from beginning to end and provides step-by-step instructions.

Forceps delivery technique

The two most commonly used types of forceps for the cephalic presenting fetus are Simpson type and Elliot or Tucker-McLane forceps. The main differences between the two are that the Simpson forceps have shanks that are separated (remember “Simpson shanks separated”) whereas those of the Elliot/Tucker-McLane type are overlapping (remember “Tucker tucked in”). The separated shanks as well as the longer tapering cephalic curve allow for the Simpson type forceps to be used on longer, more molded heads whereas the Elliot or Tucker-McLane types are narrower and might be chosen for the easier pull in a multiparous patient, for example.

The other two commonly used forceps are for special indications. Kielland forceps are used for rotational maneuvers (you “turn a key”) owing to their very slight reverse pelvic curve and sliding lock which allows for correction of asynclitism. The Piper forceps, with their long backward curving shanks and reverse pelvic curve, are designed specifically for stabilization and delivery of the aftercoming head in a breech presentation.

Dr. Wong discusses the parts of the forceps and highlights the differences between various types.

Anatomy of the forceps

Most women who traverse menopause experience significant symptoms and many require at least temporary pharmacological treatment for maintenance of quality of life. Despite the controversy surrounding it, hormone therapy (HT) with either estrogen alone (E) or estrogen plus progestin (E+P) remains the most effective treatment for menopausal symptoms. This article provides a brief history of menopausal hormone therapy (HT) and discusses practical aspects of treatment and discontinuation.


	HT has had a cyclical history of high acceptance and uptake, followed by reduced use related to emergence of risk. Its efficacy for symptoms was recognized in the 1950s and 1960s.

 Shortly thereafter, increased risk of endometrial cancer associated with E preparations was followed by the addition of progestin to regimens for women with a uterus, and a transient reduction in enthusiasm for HT.

In the 1980s, the strong observational association between hormone use and reduced risk of coronary heart disease (CHD)

 led to exploration of systemic benefits of HT beyond symptom relief, which triggered another surge in use. However, when the effectiveness of HT as a preventive medication was tested in a randomized clinical trial, the 

(WHI), there was no observed reduction in CHD in women with or without a uterus, and a small signal for initial harm emerged, with differential risks depending upon whether a woman had a uterus and was randomized to E+P or had a hysterectomy and therefore took E Alone (Table 1).

 Differences in treatment with E+P compared to E alone reveal an elevated risk of CHD, venous thromboembolism (VTE), breast cancer in the E+P arm and no risk for breast cancer in the E-only arm (Table 1). The association between breast cancer in the E+P arm was further corroborated by an 11-year follow-up study among participants of the WHI study, which demonstrated a small increase in breast cancer incidence (HR, 1.25 [95%CI 1.07-1.46; 

 = 0.004]) and mortality (HR, 1.96 [95%CI: 1.00-4.04, 

 After publication of these findings, HT prescriptions dropped by 32% overall with a > 60% drop in prescriptions for conjugated equine estrogen (CEE)/medroxyprogesterone acetate (MPA).

Based upon these findings, HT is not recommended for preventive use by 

The American College of Obstetricians and Gynecologists

 Despite its rigor, the WHI was designed in the late 1980s and was constructed to test the hypothesis that CHD would be prevented by the then-commonly-used preparation of CEE plus MPA (in women with a uterus) or CEE alone in women without a uterus. Subclinical coronary disease was not considered in participant recruitment, and women were stratified into 10-year age bins that included many women who would otherwise not be taking HT for current indications (i.e., symptom relief). This makes some of the endpoints difficult to interpret when advising a current patient in her early 50s who requires symptom control.

Current evidence from WHI and other trials


	More recent follow-up of women who participated in the WHI, now 17 years after its original outcome publication, provide a very reassuring perspective on the long-term harms and benefits of exposure to HT for women in different age groups, and can be helpful for clinicians in guiding their recommendations.

 Studies subsequent to the WHI have examined a series of

intermediate endpoints to help explain the discrepancy between the WHI and observational studies, specifically the Nurses’ Health Study,

 with respect to the outcome of CHD. When the WHI data are limited to women in the youngest age group (50-59), there is no increased risk of CHD associated with HT. Follow-up studies such as the 

 (KEEPS) provided similar reassurance about the safety of “early initiation” of HT with respect to carotid intimal medical thickness (CIMT) and coronary calcium scores. The 

 (ELITE) study demonstrated reduced CIMT accrual with early initiation of HT following menopause and minimal cardiovascular effects with later treatment initiation compared to placebo.

 Taken together, these findings support the notion that use of HT in women who are in the early postmenopause does not confer CHD risk, and may be of some benefit. 


	Because of its unmatched effectiveness, HT is the treatment of choice for many symptomatic women, and more recent review of clinical guidelines indicates situations in which extended use for more than just a few years can be considered (as opposed to the “lowest possible dose for the shortest possible time”) after informed, shared decision-making.

While hot flashes and night sweats are the most prevalent symptoms of menopause, vaginal dryness or genitourinary syndrome of menopause (GSM), adverse mood (depression and/or anxiety), and poor sleep are additional clinical complaints that are attributable to menopause and likely to be relieved by HT.

 This is not an all-encompassing list of symptoms, however, and clinicians may consider a 3- to 6-month empiric trial of HT for atypical symptoms that appear strongly related to menopause. If HT is ineffective, it should be stopped, and other causes and treatments will need to be considered.

Common indications for initiating hormonal therapy in women include vasomotor symptoms (VMS) and genitourinary dysfunction. While the mechanism for VMS is not fully understood and is likely multifactorial, symptoms can be severe and affect quality of life. Average duration of vasomotor symptoms is 7.4 years but durations up to 10 years have been reported.

 HT has been shown to reduce hot flash frequency and severity by about 75%.

 Genitourinary symptoms include vaginal or vulvar dryness, discharge, itching, and dyspareunia as a result of vaginal atrophy from hypoestrogenism-GSM. These symptoms can cause sexual dysfunction and detrimental effects on quality of life, self-esteem, and sexual intimacy. With local therapy for atrophic vaginitis, the addition of progesterone is usually not indicated due to no evidence of increased risk of endometrial cancer although very-long-term data are lacking.

 HT has also been shown to reduce the rate of postmenopausal osteoporotic fractures, with some studies showing a reduction in hip fracture of as much as 33%.

 While prevention of osteoporosis is not usually an indication for HT, it is an additional benefit that will accrue to women who take it for symptom control. Some studies have shown HT to be effective in postmenopausal women with chronic insomnia although it should not be used as a first-line agent for chronic insomnia, and should only be considered in the presence of other comorbid conditions and if the benefits outweigh the risks of HT.

 The benefit of HT for reducing joint pain is controversial with preclinical studies showing positive effects that have not been consistently seen with follow-up clinical studies.

 In the WHI, women randomized to HT were less likely to have joint stiffness compared to placebo.

Estrogen therapy, when combined with exercise, has shown efficacy in maintaining and increasing muscle mass, strength, and performance.


	There are many options when it comes to HT, so the best treatment regimen for each patient can be optimized given the patient’s specific goals and risk factors. Women who have a uterus should take a progestin or a selective estrogen receptor modulator (SERM) in combination with estrogen to avoid the effects of unopposed E on the endometrial lining. For women with prior hysterectomy, if hormone therapy is indicated, E alone should be used as there is no benefit and potential harm to adding P.

 (FDA)-approved formulations of E are available (Table 3). E can be delivered orally, transdermally, or vaginally. Retrospective studies and meta-analyses have shown that the transdermal mode of delivery carries less risk of VTE, presumably due to bypass of the liver.

 However, there are no RCTs that have compared oral and transdermal routes directly. A recent observational study of oral estradiol use indicated that its VTE risks were similar to transdermal and less than oral CEE.

Application of transdermal estrogen can be done via patches, gels or sprays. Although there is high acceptability of transdermal routes, complaints from patients with patches include skin irritation and lack of adhesion. There are many blogs and reviews of patches online that may discourage women from trying this effective option. It may be useful to give patients a set of steps to troubleshoot issues with patches when initiating therapy (Table 4). CEE has similar efficacy for vasomotor and genitourinary symptoms when compared to transdermal estradiol.

If GSM is a patient’s primary concern, then vaginal E can be provided in a low dose that improves local symptoms without having systemic effects. It can take the form of a low-dose vaginal ring, cream, tablet or insert. Note that high-dose vaginal creams and rings have systemic effects and may require P for endometrial protection. Table 3 lists vaginal E formulations.

The treatment goal for HT is symptom relief using the lowest effective dose. For this reason, it is most often appropriate to start with lower doses of E and titrate up on a biweekly to monthly basis until symptom relief is optimally balanced against side effects. Starting dose varies by compound and route: oral CEE can be started at 0.45 mg/daily, oral estradiol 0.5 mg/daily, and transdermal estradiol 0.025 mg/daily. Patients with surgical menopause may require higher doses for symptomatic relief. Common side effects of E include breast tenderness, vaginal bleeding, bloating, and headaches, which occur less frequently at lower doses. Higher starting doses may be needed for women with severe vasomotor symptoms and significant distress.

Progestins have the same routes of administration as E, as well as delivery via an intrauterine device. However, progesterone is not available in a transdermal formulation. Progestins can be combined with E in a pill or a patch or given separately. Whether treatment is E only or E+P, continuous (daily) use is advised. Exceptions in which cycling E+P is indicated may be for women in their first years of menopause, as they are more prone to breakthrough bleeding, and women with premature menopause who want to have a monthly bleed. For women who do not tolerate E therapy, P can be given alone for treatment of vasomotor symptoms. Oral synthetic progestins and micronized progesterone have been shown to be effective in the treatment of hot flashes.

 However, micronized progesterone has a less negative effect on serum lipoproteins compared to MPA, reduces postprandial increases in glucose,

 and can also induce a soporific effect when taken at bedtime. For these reasons, it may be the preferred progestin by many women.

Bioidentical hormones refer to plant-based hormones such as phytoestrogens that share the same chemical or structural composition as hormones produced by the body. In addition, the idea of bioidentical hormones has often been conflated with a product that is more “natural” and therefore safer than conventional pharmaceuticals.

 Although there are FDA-approved bioidentical hormones such as micronized progesterone and estradiol in numerous forms including the pill, patch, gel, and ring, compounded formulations are readily available but are not under the scrutiny of the FDA approval process. Due to concerns regarding reliability of dosage, purity, lack of evidence regarding superior effectiveness over FDA-approved hormonal formulations and lack of FDA oversight, use of compounded hormonal therapy is not recommended.

Innovations in menopause symptom treatment have led to creation of symptom-specific medications (Table 4).

Patients on HT should be monitored every 1 to 3 months when starting the treatment, then every 1 to 2 years once treatment is optimized. Age-appropriate breast cancer screening should be maintained. Any vaginal bleeding that arises after the first 6 months of HT should be investigated further for endometrial hyperplasia and cancer, unless the patient is clearly not yet menopausal.

Dr. Santoro is on the Scientific Advisory Boards of Astellas/Ogeda and Menogenix, Inc., and holds stock options in Menogenix, Inc. The other authors have nothing to disclose.

Wilson RA. Feminine Forever: M. Evans and Company, Inc.; 1966.

Weiss NS, Szekely DR, English DR, Schweid AI. Endometrial cancer in relation to patterns of menopausal estrogen use. 

Stampfer MJ, Colditz GA, Willett WC, Manson JE, Rosner B, Speizer FE, et al. Postmenopausal estrogen therapy and cardiovascular disease. Ten-year follow-up from the nurses’ health study. 

Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. 

Anderson GL, Limacher M, Assaf AR, Bassford T, Beresford SA, Black H, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. 

Chlebowski RT, Anderson GL, Gass M, Lane DS, Aragaki AK, Kuller LH, et al. Estrogen plus progestin and breast cancer incidence and mortality in postmenopausal women. 

Majumdar SR, Almasi EA, Stafford RS. Promotion and prescribing of hormone therapy after report of harm by the Women’s Health Initiative. 

ACOG Practice Bulletin No. 141: management of menopausal symptoms. 

The NHTPSAP. The 2017 hormone therapy position statement of The North American Menopause Society. 

Stuenkel CA, Davis SR, Gompel A, Lumsden MA, Murad MH, Pinkerton JV, et al. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. J 

Manson JE, Aragaki AK, Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, et al. Menopausal hormone therapy and long-term all-cause and cause-specific mortality: The Women’s Health Initiative randomized trials. 

LaCroix AZ, Chlebowski RT, Manson JE, Aragaki AK, Johnson KC, Martin L, et al. Health outcomes after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy: a randomized controlled trial. 

Miller VM, Naftolin F, Asthana S, Black DM, Brinton EA, Budoff MJ, et al. The Kronos Early Estrogen Prevention Study (KEEPS): what have we learned? 

Hodis HN, Mack WJ, Henderson VW, Shoupe D, Budoff MJ, Hwang-Levine J, et al. Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol. 

Sherman S, Miller H, Nerurkar L, Schiff I. Research opportunities for reducing the burden of menopause-related symptoms. 

Crandall CJ, Hovey KM, Andrews CA, Chlebowski RT, Stefanick ML, Lane DS, et al. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observational Study. 

Attarian H, Hachul H, Guttuso T, Phillips B. Treatment of chronic insomnia disorder in menopause: evaluation of literature. 

Xiao YP, Tian FM, Dai MW, Wang WY, Shao LT, Zhang L. Are estrogen-related drugs new alternatives for the management of osteoarthritis? Arthritis Res Ther. 2016;18:151.

de Klerk BM, Schiphof D, Groeneveld FP, Koes BW, van Osch GJ, van Meurs JB, et al. Limited evidence for a protective effect of unopposed oestrogen therapy for osteoarthritis of the hip: a systematic review. 

Chlebowski RT, Cirillo DJ, Eaton CB, Stefanick ML, Pettinger M, Carbone LD, et al. Estrogen alone and joint symptoms in the Women’s Health Initiative randomized trial. 

Rovinski D, Ramos RB, Fighera TM, Casanova GK, Spritzer PM. Risk of venous thromboembolism events in postmenopausal women using oral versus non-oral hormone therapy: A systematic review and meta-analysis. 

Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. 

Santoro N, Allshouse A, Neal-Perry G, Pal L, Lobo RA, Naftolin F, et al. Longitudinal changes in menopausal symptoms comparing women randomized to low-dose oral conjugated estrogens or transdermal estradiol plus micronized progesterone versus placebo: the Kronos Early Estrogen Prevention Study. 

Prior JC. Progesterone for treatment of symptomatic menopausal women. 

Barrett-Connor E, Slone S, Greendale G, Kritz-Silverstein D, Espeland M, Johnson SR, et al. The Postmenopausal Estrogen/Progestin Interventions Study: primary outcomes in adherent women. 

Thompson JJ, Ritenbaugh C, Nichter M. Why women choose compounded bioidentical hormone therapy: lessons from a qualitative study of menopausal decision-making. 

Cobin RH, Goodman NF. American Association of Clinical Endocrinologists and American College of Endocrinology position statement on menopause-2017 update. 

Simon JA, Kaunitz AM, Kroll R, Graham S, Bernick B, Mirkin S. Oral 17beta-estradiol/progesterone (TX-001HR) and quality of life in postmenopausal women with vasomotor symptoms. 

Kharode Y, Bodine PV, Miller CP, Lyttle CR, Komm BS. The pairing of a selective estrogen receptor modulator, bazedoxifene, with conjugated estrogens as a new paradigm for the treatment of menopausal symptoms and osteoporosis prevention. 

Pickar JH, Boucher M, Morgenstern D. Tissue selective estrogen complex (TSEC): a review. 

Shin JJ, Kim SK, Lee JR, Suh CS. Ospemifene: A novel option for the treatment of vulvovaginal atrophy. 

Labrie F, Archer DF, Koltun W, Vachon A, Young D, Frenette L, et al. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. 

Aslan E, Bagis T, Kilicdag EB, Tarim E, Erkanli S, Kuscu E. How best is to discontinue postmenopausal hormone therapy: immediate or tapered? 

Canonico M, Oger E, Plu-Bureau G, Conard J, Meyer G, Levesque H, et al. Hormone therapy and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration and progestogens: the ESTHER study. 

American College of Obstetricians and Gynecologists. ACOG committee opinion no. 556: Postmenopausal estrogen therapy: route of administration and risk of venous thromboembolism. 

Hormonal therapy is not without controversy but it is still one of the most effective treatments for patients with symptoms.

Practical approach to managing menopause

Operative vaginal delivery remains an important skill for obstetricians to provide the full spectrum of care for pregnant patients. It can reduce the need for cesarean deliveries, an important goal of both our specialty nationwide and of individual providers and patients. Notably, 2017 was the first year the cesarean delivery rate increased since 2009, suggesting an even greater urgency in focusing on tools to reduce it.

 The top two reasons for cesarean delivery – labor dystocia and abnormal or indeterminate fetal heart rate tracings – can both potentially be resolved by operative vaginal delivery.

 Despite this, the overall trend for operative deliveries has shown a dramatic decline. While approximately 10% of deliveries were performed via operative delivery in the 1990s, the most recent National Vital Statistics Survey shows a 2.58% rate for vacuum deliveries and 0.56% for forceps deliveries. It is these latter deliveries – forceps-assisted vaginal deliveries – which will be the focus of this article.


	The history of the obstetric forceps is one of the more theatrical tales in medical literature. Invented by the two 

 (Peter the Elder and Peter the Younger) in the 1600s, the timing was particularly fortuitous because malnourishment, rickets and thus pelvic dystocia were on the rise. The two male midwives were so maligned, however, and so obsessed with the secrecy of their invention that before employing the forceps they would make all attendees leave the room and blindfold the laboring woman before applying them. The secret method ultimately remained with the family for another century and the instruments unseen until their discovery under the floorboards of Peter’s son’s house in 1813. And though some modifications were made in the following years, the two most commonly used forceps designs of today – Simpson and Elliot-type forceps – were each invented about a century and a half ago.

Indications and contraindications for forceps deliveries


	Indications and prerequisites for proceeding with a forceps delivery mirror those for a vacuum delivery and include prolonged second stage of labor, suspicion of fetal compromise, and shortening of the second stage for maternal benefit. Prerequisites include the cervix being fully dilated, membranes ruptured, and the head being fully engaged. An estimation of fetal weight, fetal position, and pelvic adequacy should also have been previously performed. Regarding the patient, adequate anesthesia should be in place, the bladder empty, and consent obtained. At a system level, there should be a willingness and ability to have a back-up plan in place in case of failure to deliver. A helpful mnemonic for recalling these may be to remember A-B-Cs and is described in Table 1.

Contraindications for both forceps and vacuum include a strong suspicion for a fetal bone demineralizing or bleeding disorder. But while vacuum delivery has been discouraged for the fetus less than 34 weeks, there is no lower limit for gestational age for forceps delivery.


	Knowledge of the fetal head position is particularly critical for forceps deliveries, since it determines the type of forceps delivery being performed (Table 2) and incorrect assessment of position can make forceps placement both less effective and more prone to cause fetal injury. Provider determination of fetal head position is fraught with error with studies showing accuracy ranging from 27% to 80% by digital palpation even by experienced providers.

 Ultrasound assessment, on the other hand, has consistently proven more accurate than digital palpation, including in a large, multicenter randomized trial where the accuracy of ultrasound assessment was found to be 98.4%.

 Given the importance of correct determination of fetal position, it is reasonable to consider a bedside ultrasound in patients for whom a forceps delivery is being considered; an excellent expert review was published on the topic by Bellussi, et al and includes an accompanying video demonstrating the technique.


	The basic anatomy of the forceps is described in the video, “


	The two most commonly used types of forceps for the cephalic presenting fetus are Simpson type and Elliot or Tucker-McLane forceps. The main differences between the two are that the Simpson forceps have shanks that are separated (remember “Simpson shanks separated”) whereas those of the Elliot/Tucker-McLane type are overlapping (remember “Tucker tucked in”). The separated shanks as well as the longer tapering cephalic curve allow for the Simpson type forceps to be used on longer, more molded heads whereas the Elliot or Tucker-McLane types are narrower and might be chosen for the easier pull in a multiparous patient, for example.


	When attempted, forceps are very likely to be successful. A Cochrane review on choice of instruments for assisted vaginal delivery found that failure was 35% less likely with forceps compared to vacuum delivery (9% vs 14% of those attempted).

It is important, however, to only attempt an operative delivery when it is likely to be successful. A study by Towner, et al found that the likelihood of injury was greatest when sequential interventions were required whether that was an operative attempt then cesarean or sequential operative attempts compared to when a single intervention was successful (i.e., a successful operative delivery or cesarean delivery).

 Improving the likelihood of success in performing a forceps delivery can be achieved by choosing the appropriate candidates, utilizing optimal technique, and avoiding pitfalls that can contribute to failure.


	While we will never be able to perfectly choose only those candidates in whom an operative delivery will be successful, certain characteristics can make success less likely.

 Macrosomia has been associated with an increased likelihood of failure in an operative delivery.

 This association holds for both vacuum and forceps deliveries; one study found increased odds of failure of 14% for every 100 g increase in estimated fetal weight.

 In addition, macrosomia and operative delivery are independent risk factors for shoulder dystocia. A study performed reviewing 175,000 births in California noted a synergistic effect particularly in diabetic mothers, suggesting additional concerns when considering a forceps delivery in a macrosomic fetus.

Other factors that have been associated with failure of operative delivery include station at application (low is more likely to fail than outlet), arrest as the indication for operative delivery, prolonged second stage, and occiput posterior presentation.

 When possible, occiput posterior presentation can be resolved either by digital rotation or by Scanzoni maneuver (instrumental rotation ideally using Kielland forceps). It is preferable to resolve it since while it is possible to deliver directly OP (as described below in Technique), it is often more difficult, more prone to higher-order lacerations, and was thus discouraged by Dennen in his original forceps textbook.

 of a forceps-assisted vaginal delivery for a cephalic presenting fetus in an occiput anterior position delivery and the steps listed in Table 3. 


	Common pitfalls gathered from both performing and teaching learners to perform forceps deliveries are reviewed in Table 4. The most frequent struggles are usually encountered in initial placement – particularly of the second blade – and less commonly during traction. It is important that the cephalic curve (or “palm side” of the blade) is as closely apposed to the fetal scalp as possible, or if the fetal scalp is not visible, then to the maternal introitus. Importantly, as the forceps begins its motion, there can be no movement forward or backward of the handle until the maternal thigh is reached. Doing so starts the blade of the forceps down the sacrum/face (in an OA fetus) rather than along the more hollow space between parietal bone and vagina. A forceps blade on the correct trajectory should require almost no force, and I remind learners of this by encouraging them to hold the handle with only their fingertips.


	Perhaps the greatest potential threat to forceps deliveries is the dwindling provider base. This has resulted in a subsequent trickle-down effect with fewer providers able to teach the skills, less comfort in offering the method to patients, and then fewer opportunities to demonstrate or involve trainees in these deliveries.

Will vacuum delivery go the way of vaginal breech delivery?

The decline in utilization of obstetrical forceps is, however, a reversible trend. Training programs today have more resources at their disposal for simulation than ever before, and high-fidelity forceps simulations (as demonstrated in the video, “Forceps delivery technique”) offer realistic approximations of the procedure. In addition, attendings should be encouraged to allow trainees to attempt placement because – unlike the cut-clamp that occurs when transecting a uterine artery at hysterectomy – a misguided forceps blade is an easily remedied misstep. Similarly, traction can be performed hand-over-hand so that direct manual supervision for optimal safety is readily achievable.

Finally, a junior attending who has completed training with a handful of forceps deliveries under her belt should be encouraged to continue to identify patients for whom a forceps delivery is appropriate and perfect her craft. One study comparing 118 attending physicians at varying levels of training in fact showed no difference in lacerations or adverse neonatal outcomes between experience levels.

The author reports no potential conflicts of interest with regard to this article.

Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: Final Data for 2017. National vital statistics reports : from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 2018 Nov;67(8):1-50.

Caughey AB, Cahill AG, Guise J-M, Rouse DJ, Obstetricians ACo, Gynecologists. Safe prevention of the primary cesarean delivery. 

Young RL. Obstetrical Forceps: History, Mystery, and Morality.  Houston History of Medicine Lectures. DigitalCommons@TMC: John P. McGovern Historical Collections and Research Center; 2011.

Bulletins-Obstetrics CoP. ACOG Practice Bulletin No. 154: operative vaginal delivery. 

Akmal S, Kametas N, Tsoi E, Hargreaves C, Nicolaides K. Comparison of transvaginal digital examination with intrapartum sonography to determine fetal head position before instrumental delivery. 

Chou MR, Kreiser D, Taslimi MM, Druzin ML, El-Sayed YY. Vaginal versus ultrasound examination of fetal occiput position during the second stage of labor. 

Ramphul M, Ooi PV, Burke G, Kennelly MM, Said SA, Montgomery AA, et al. Instrumental delivery and ultrasound : a multicentre randomised controlled trial of ultrasound assessment of the fetal head position versus standard care as an approach to prevent morbidity at instrumental delivery. 

Bellussi F, Ghi T, Youssef A, Salsi G, Giorgetta F, Parma D, et al. The use of intrapartum ultrasound to diagnose malpositions and cephalic malpresentations. 

O’Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. 

Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. 

Majoko F, Gardener G. Trial of instrumental delivery in theatre versus immediate caesarean section for anticipated difficult assisted births. 

Gopalani S, Bennett K, Critchlow C. Factors predictive of failed operative vaginal delivery. 

Aiken CE, Aiken AR, Brockelsby JC, Scott JG. Factors influencing the likelihood of instrumental delivery success. 

Palatnik A, Grobman WA, Hellendag MG, Janetos TM, Gossett DR, Miller ES. Predictors of failed operative vaginal delivery in a contemporary obstetric cohort. 

Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and associated risk factors with macrosomic infants born in California.

. 4th ed. Washington, DC: The American College of Obstetricians and Gynecologists; 2001.

Miller ES, Barber EL, McDonald KD, Gossett DR. Association between obstetrician forceps volume and maternal and neonatal outcomes. 

Forceps deliveries are a unique and effective tool to assist patient and provider in achieving a vaginal delivery

A new study by Italian investigators points to a link between perimenopause and sharp decline in sexual function. The 

, show that vaginal atrophy-a treatable condition-is the factor that has the most impact on the negative trend.

The cross-sectional study enrolled 518 women aged 40 to 55 years at 30 centers across Italy. The authors analyzed relationships between vaginal atrophy and symptoms associated with it and the 

 (FSFI) score, which is composed of 19 questions around the domains of desire, arousal, orgasm dyspareunia, lubrication, and sexual satisfaction.

Vaginal atrophy was defined as presence of a pH > 5, subjective vaginal dryness, and an objective sign, as assessed by a medical doctor. Mucosal pallor and dryness, thinning of vaginal rugae, mucosal fragility, and presence of petechiae were the signs considered.

Overall, 70.6% of participants had sexual dysfunction, as defined by a FSFI score < 26.55. It was seen in 55% of those aged 40 to 45, compared with 82.8% of those aged 52 to 55 (

 < 0.01). From 48 to 51 versus 46 to 48 years, mean FSFI score and sexual dysfunction increased: 23.13 ± 9.76 vs. 19.49 ± 9.88; 

 < 0.05). A similar trend was seen from ages 48 to 51 vs. 52 to 55: 21.3 ± 8.06 to 17.59 ± 9.11; 

Age, weight, ex-smoking status, sedentary lifestyle, menopausal status, subjective vaginal dryness, dyspareunia, and vaginal atrophy were all inversely related to a woman’s FSFI score. Age, vaginal atrophy, and presence of vaginal dryness were all independent determinants of FSFI (R2 02.08; 

 = 0.011). The score was independently correlated (R2 0.116) with weight (CR -0.067; 95% confidence interval [CI] -0.126, -0.006; 

 < 0.032), menopausal status (CR -2.406; 95% CI -4.180, -0.63; 

 < 0.008), and vaginal dryness (CR -5.647; 95% CI -7.677, -3.618; 

The only variable that correlated independently with each FSFI domain-including desire, arousal, lubrication, orgasm, satisfaction, and dyspareunia-was vaginal atrophy. The authors concluded that it is the symptom most closely related to all domains of female sexuality. They believe that prospective studies are needed to determine whether selective treatment of vaginal dryness improves female sexual function in perimenopausal women.

 Medical Director Dr. Stephanie Faubion in a press release, “Given the high prevalence of sexual dysfunction in women, identifying an eminently treatable contributing factor such as vaginal dryness may allow women to maintain their sexual function during the menopause transition.”    

According to research published in Menopause, vaginal atrophy-a treatable condition-appears to be the most impactful factor for perimenopausal women and declining sexual function.

Perimenopause’s negative impact on sexual function

Social media is ubiquitous today, but one area that has not been fully investigated is its effect on medical diagnoses. A recent 

 looked at crowd-diagnoses via social media to determine whether they were for a second opinion after seeing a health care professional.

, a social media website with 330 million monthly active users that hosts more than 232 health forums. The research focused exclusively on the subreddit, (

), which allows users to publicly share “stories, concerns, and questions” about “anything and everything STD [sexually transmitted disease]-related.”

The authors obtained all posts from the inception of the subreddit in November 2010 through February 2019. They then drew a random sample of 500 posts and independently coded whether each post requested a crowd-diagnosis, and if so, whether that request was made to obtain a second opinion after seeing a healthcare professional.


	The r/STD subreddit included 16,979 total posts. There was an 80% agreement among all coders on crowd-diagnoses (Cohen Îº = 0.73) and 88% agreement on whether the crowd-diagnoses were requests for a second opinion (Cohen Îº = 0.53) among an overlapping sample of 50 posts.

58% (95% CI, 54%-63%) of posts requested a crowd-diagnosis and

31% (95% CI, 26%-36%) of posts included an image of the physical signs.

20% of those requesting a crowd-diagnosis posted to receive a second opinion after their initial diagnosis by a healthcare professional.

87% (95% CI, 83%-91%) of all posts requesting a crowd-diagnosis received a reply. Median time for the first response was 3.04 hours (range, 59 seconds to 8.8 weeks), but 79% of requests (95% CI, 74%-84%) were answered in less than 1 day.


	The authors admit that there are a few limitations to this study. It was limited to one social media platform and a single medical condition. Perhaps more importantly, the accuracy of the diagnoses and whether individuals acted on the provided advice were not investigated.

The authors suggest that health care professionals could “partner with social media outlets to promote the potential benefits of crowd-diagnosis while suppressing potential harms, for example by having trained professionals respond to posts to better diagnose and make referrals to health care centers.”

A recent research letter in JAMA looked at crowd-diagnoses via social media to determine whether they were for a second opinion after seeing a health care professional.

How often do patients turn to social media for STD second opinions?

Women with endometriosis seeking pain relief may want to consider cannabis or cannabidiol (CBD), according to a recent study presented at the 

2019 American Association of Gynecologic Laparoscopists (AAGL) Global Congress 

in Vancouver, Canada. The survey aimed to identify the prevalence of medical cannabis use among endometriosis patients as well as the effectiveness of both cannabis and cannabidiol in their pain management.

 invited participants through email and contained 50 to 75 questions based on branching logic. The questions focused on pelvic pain history, demographics, and experience with cannabis and CBD for management of pelvic pain. Participants were identified through an ICD-10 code for endometriosis diagnosis at a clinic or from the mailing list of the 

Anna Reinert, MD, the presenting author noted “Our participation was very different between our two groups. The invitation stressed that this was an anonymous survey, but I think there’s still a lot of taboo around this topic. For the Endometriosis Association, only 1.4% of participants replied, which is much lower than the participation rates for other surveys that were being sent out around the same time frame. From our clinic population, we had about 16%.”


	Of the 240 respondents from the Endometriosis Association, 77 (32.1%) reported having tried cannabis, with the majority of these participants (52 of 77, 67.5%) reporting cannabis to be very or moderately effective. Of the 124 clinic respondents, 58 (46.8%) reported having tried marijuana, with the majority of patients (44 of 58, 75.9%) reporting cannabis to be very or moderately effective.

Sixty-seven respondents from the Endometriosis Association reported having tried CBD, with 50% (34 of 67) reporting CBD to be very or moderately effective. Fifty-seven clinic respondents reported having tried CBD, with 64.9% (37 of 57) reporting that CBD was very or moderately effective in pain reduction.

In terms of effectiveness, participants from both groups were more likely to report cannabis as very effective (40.2% of Endometriosis Association participants, 53.4% of clinic participants) on a Likert scale. CBD was more likely to be reported on a Likert scale as moderately effective in both groups (31.4% of Endometriosis Association participants, 36.8% of clinic participants).

Looking ahead, Dr. Reinert said, “Further research is needed to explore the potential benefits and clarify the limitations and risks of the use of cannabis for the management of chronic pelvic pain and endometriosis.”

Women with endometriosis seeking pain relief may want to consider cannabis or cannabidiol (CBD), according to a recent study presented at the 2019 American Association of Gynecologic Laparoscopists Global Congress.

Vol 64 No 12