OPERATIVE vaginal birth (OVB) can offer a safe alternative to caesarean section in appropriate clinical scenarios, but poor outcomes have been linked to misidentification of fetal head position, inadequate communication, and non-adherence to clinical guidelines. In response to these concerns, a structured safety bundle was introduced, aimed at improving outcomes during OVB. The bundle included routine intrapartum ultrasound, a structured time-out with a procedural checklist, a birth experience survey, and a formalised postnatal debrief process. A key finding from a study on this initiative was a significant reduction in severe neonatal birth trauma following the intervention.
The study compared clinical outcomes for term, singleton, non-anomalous cephalic births that involved either operative vaginal delivery or fully dilated caesarean section, before and after implementation of the safety bundle. The pre-intervention cohort (November 2019 to November 2021) included 2,914 births, while the post-intervention cohort (August 2022 to August 2024) comprised 2,427 births. Outcomes were assessed using an interrupted time-series analysis.
Routine ultrasound use increased substantially (55.8% vs. 5.0%; p<0.001), and documentation improved, with a sharp decline in missing clinical assessments (0.8% vs. 3.4%; p<0.001). While the composite neonatal morbidity did not change significantly (14.2% vs. 13.9%; p=0.80), the rate of unexpected fetal position at delivery dropped markedly (0.7% vs. 2.8%; p<0.001). There were also reductions in severe neonatal birth trauma (1.3% vs. 2.5%; p<0.001) and NICU admissions (1.8% vs. 2.7%; p=0.02). The rates of unsuccessful OVB and caesarean delivery for failed OVB both declined significantly, as did the use of excessive tractions or multiple cup detachments. However, a small but statistically significant increase in postpartum haemorrhage >1000 mL was observed (17.6% vs. 15.2%; p=0.02), without a corresponding rise in blood transfusion or severe perineal injury.
These findings suggest that a structured safety bundle can improve procedural planning, documentation, and neonatal outcomes, even without a reduction in overall morbidity. For clinical practice, this underscores the value of ultrasound guidance and team communication during assisted birth. Limitations include reliance on a historical control group and absence of long-term neonatal outcomes. Future research could explore staff perceptions and cost-effectiveness to further refine implementation strategies.
Reference
Skinner SM et al. Clinical outcomes following implementation of an operative vaginal birth safety bundle: A prospective observational study and time-series analysis. Am J Obstet Gynecol. 2025;DOI: 10.1016/j.ajog.2025.07.013.
