Maternal Complications Related to Operative Vaginal Delivery and Their Associated Factors among Women Delivered at NEMCS Hospital, Southwest Ethiopia

Background Operative vaginal delivery refers to vaginal delivery performed with the use of instruments such as forceps or vacuum. Operative vaginal delivery-related maternal complications are still a serious problem, but they are one of the least investigated in Ethiopia, particularly in the study area. Increased difficulties have been attributed to a lack of understanding on how to anticipate the procedure's complications. Identifying typical OVD complications can assist health providers in detecting and intervening early. The goal of this study was to find out which characteristics contributed to maternal problems during surgical vaginal birth. Methods A health facility-based cross-sectional study design was used. From December 2019 to November 2021, a total of 326 mother's OVD medical records were selected from a total of 1000 OVD medical records using a simple random sampling method. A checklist was used to collect the data. Binary logistic regression was computed and variables with a p value ≤0.2 in the bivariate logistic regression were taken to multivariate logistic regression analysis to examine the real relationship or statistical association with the outcome variable. The p value of <0.05 with a 95% confidence interval was considered a significant variable. The results are presented using tables, figures, and texts. Results Maternal complications were prevalent in 62 of the cases (19%). The type of operative vaginal delivery instrument used (AOR = 2.248; 95% CI (1.144, 4.416)), the station of the presenting part at which the OVD was performed (AOR = 3.199; 95% CI (1.359, 7.533)), neonatal birth weight (AOR = 3.342; 95% CI (1.435, 7.787)), and duration of the second stage (AOR = 2.556; 95% CI (1.039, 6.284)) were significantly associated with the unfavorable maternal outcomes of operative vaginal delivery. Conclusions Maternal complications are high in the study area. The type of operative vaginal delivery used, the duration of the second stage, the station of the presenting part at which the OVD was performed, and neonatal birth weights were all significantly related to maternal complications. While using the instrument, mothers with the identified factors should be given special attention.


Introduction
Labor and childbirth are complex physiological processes involving two human beings, the mother and the baby. Operative vaginal delivery is a vaginal delivery performed with instruments such as forceps or a vacuum [1]. Forceps, vacuum delivery, manual rotation, episiotomy, and, on rare occasions, symphysiotomy can all be used for vaginal childbirth [2]. Te force generated in a closed space (vacuum) can be increased to aid in the delivery of a fetus while forceps apply traction on the fetal skull's parietal and malar bones [3].
Each pregnant woman expects spontaneous vaginal childbirth with little or no requirement for surgical procedures at the end of her pregnancy. Some, however, require assistance to avoid negative outcomes for the mother and the fetus [4].
To achieve the best possible results, current global obstetric practice advocates the use of instrumental vaginal delivery procedures. Poor labor progress, maternal exhaustion, presumed fetal risk, medical issues necessitating a shortening of the second stage of labor, and other common clinical problems are indications of OVD [5]. According to the Royal College of Obstetricians and Gynecologists, forceps/vacuum-assisted vaginal delivery was used in approximately 11% of the cases in Australia [6].
It is logical that not all operative vaginal births are the same in terms of difculty or maternal risk [7]. Numerous studies compared the use of forceps and vacuum, and the risk of maternal injury was higher in forceps groups than in vacuum groups. Serious complications are uncommon with forceps and vacuum deliveries, but they can result in longterm maternity complications [8].
Cervical tear, vaginal tear, bleeding, third and fourth degree tear of the perineum, and anal sphincter lesions are all complications of OVD that can cause serious health problems for the mother. She could be chronically ill, which could lead to divorce and the loss of fnancial support [9].
Te increase in problems might be due to a lack of understanding of the procedure's potential complications. Te ability to recognize typical OVD issues aids healthcare workers in detecting complications and intervening as soon as possible. OVD-related maternal complications are still a serious problem, but they are one of the least investigated in Ethiopia, as well as in the study area. As a result, the study's goal is to look at maternal complications and their associated factors in operational vaginal deliveries at Nigist Eleni Mohammed Memorial Compressive Specialized Hospital in Haddiya, SNNPR, Ethiopia.

Inclusion Criteria.
Te study included all selected medical records of mothers who gave birth by forceps or vacuum-assisted delivery.

Exclusion Criteria.
Incomplete medical records of mothers who gave birth by OVD were excluded.

Sample Size Determination and
Sampling Procedure

Sample Size Determination.
Te sample size was calculated by using a single population proportion formula by taking the proportion of maternal complications of operative deliveries in Hawassa (30.6%) [10]. By assuming a 5% margin of error and 95% CI, the minimum desired sample size was calculated as n � (zα/2) 2 P(1 − p)/d 2 , where "p" is the proportion of maternal complications of operative vaginal, "n" is the minimum sample size, "d" is the degree of precision (how large error be tolerated) (5%), and "z α/2 " is the 95% confdence interval (which is 1.96).

Sampling Procedure.
A simple random sampling technique was used to select maternal medical records to be reviewed from those 1000 medical records by using their medical registrar number as the sampling frame.

Study Variables
Te dependent variables include the following: (i) Maternal complication of OVD Te independent variables are as follows: (i) Sociodemographic characteristics (age, marital status, residence, occupation, and religion). (ii) Obstetric characteristics (parity, weight of fetus, position of the fetal head, station of the fetal head, gestational age, ANC follow-up visits, health institution where ANC was attended, episiotomy, previous health institution delivery, and previous mode of delivery). (iii) Indications of operative vaginal delivery (prolonged 2 nd stage of labor, severe preeclampsia and/or eclampsia, heart disease, maternal exhaustion, severe anemia, and fetal distress), (iv) Procedure-related (operator of the procedure, duration of second stage, and type of instrument used).

Operative Vaginal Delivery.
It refers to a delivery in which the operator uses forceps or a vacuum device to assist the mother in transitioning the fetus to extrauterine life during the second stage of labor.

Maternal Complications.
Mother who developed at least one of the following maternal complications such as PPH, perianal tear such as the second-degree vaginal tear, thirddegree, or fourth-degree tear, episiotomy extension, periuretheral/labial tear, cervical tear, traumatic PPH, and death.

Incomplete Charts.
Incomplete charts were the medical records of mothers which lacked history and delivery summary.

Data Collection Tools.
Closed and open-ended extraction format which is developed in the English language by reviewing pieces of literature was used to collect data. Data were collected using the pretested and structured questionnaire.

Data Collection Process.
Four data collectors who had completed their BSc in midwifery from a recognized university and two MSc in maternity as supervisors were recruited and the hospital's chief executive ofcer and the head of the gynecology and obstetrics ward were met and asked for permission. Te data collection was held for a total of 60 days.

Data Quality Control and Assurance Management.
Pretest was carried out on 5% of the sample one month before the actual data collection in Durame General Hospital and the questions were revised based on the response obtained so that the questions that created ambiguity were rephrased. Te data collectors and supervisors were trained for two days on techniques of sampling, data collection, and important points. Data entry and cleaning were performed in EpiData.  (Table 2). Te majority of the interventions, that is, 115 (35.3%) were conducted by BSc Midwives professionals followed by IESO with 69 students (21.2%) (Figure 1).

Maternal Outcome of OVD.
Among the 326 mothers whose records were used for the study, 62 (19%) of them encountered maternal complications due to the OVD procedure. In 21 PPH cases, no maternal records of postpartum hysterectomy was found, with only three (0.9%) mothers receiving 2−3 units of blood (Figure 2).
Te majority of mothers, that is, 232 (71.2%) stayed at the hospital for about 6 to 24 hours. 67 (20.6%) of the mothers stayed for 25 to 72 hours and 27 (8.3%) mothers stayed ≥73 hours. On discharge, almost all 324 (99.4%) of the mothers were free of maternal complications, but 2 (0.6%) of them had low hemoglobin levels.

Factors Afecting Maternal Outcome.
In a bivariate analysis, variables such as place of residence, position of the fetal head, episiotomy, station during OVD application, duration of 2 nd stage of labor, types of operative vaginal delivery used, neonatal weight, prolonged second stage, fetal distress, and malposition were associated with maternal complications.

Obstetrics and Gynecology International
After ftting multivariate analyses, neonatal weight, types of OVD used, station during OVD application, and duration of the second stage were found to be signifcantly associated with maternal complication (Table 4).

Discussion
In this study, the extent of the mother's unfavorable outcome with diferent complications proved to be 19%. Tis fnding is similar to the study conducted at Lumbini Medical College Teaching Hospital, Nepal (17.3%) [11]. Te disparity could be attributed to the study design, sample size, and study area. However, this study is smaller than that conducted at Suhul General Hospital (45.4%) [15]. Tis variation might be sample sizes or the attendant ability to attend an OVD.
Tis study revealed that the most common maternal complication was a frst-degree vaginal tear (48.39%), followed by a cervical tear (17.74%) and episiotomy extension (11.29%). Tis study was consistent with the study conducted in Hyderabad, Pakistan [16].
Neonatal birth weight (≥4000 gm) was signifcantly associated with unfavorable maternal outcome. Tis result is consistent with another study conducted in Jimma [11,19].
A low station during OVD application is signifcantly associated with unfavorable maternal outcomes. Tis might be a low station that increases the risk of injury to maternal tissue during application when compared with the midstation and outlet application of forceps or vacuum. However, the study conducted in Suhul Shire showed that midtypes of the instrument were associated with maternal complications [13]. Tis diference may be due to the varieties of OVD types which have been applied.
Te study also revealed that forceps device types were signifcantly associated with an unfavorable maternal outcome. Similar results were reported at Hawassa University Teaching and Referral Hospital; Liverpool Hospital, Australia; Shankar Nagar, India; and Jinnah Hospital, Lahore [10,12,15]. Te notion is that the operator has greater familiarity with the type of instrument, more manipulation, and issues with proper evaluation and application. Te study by the University of Port Harcourt Teaching Hospital in Nigeria found that vacuum instrument types were signifcantly associated with maternal morbidity as forceps [21]. Tis variation could be the diference in operator competence and the choice of instrument with properly selected indications. But, the study conducted at the Jimma Medical Centre and Suhul County Hospital found that there is no diference in maternal complication in the two types of OVD used [13,19]. Tis variation could be due to the sequential use of both types of operative vaginal delivery and equality of competence and expertise on both types of OVD.
Mothers whose second stage of labor was longer than 3 hours and who were assisted by a OVD had a signifcant association with the adverse mother outcome variable. However, a study conducted in the Stockholm/ Gotland region of Sweden found that one and half hours  of the second stage were at high risk after three hours or longer [20]. Tis variation could be the study area, the decision variety to conduct an OVD, and the intervention variety.

Conclusion
Te magnitude of maternal complications of OVD is high. Te types of instrument used for OVD, fetal head station, duration of second stage of labor, and neonatal birth weight were signifcantly associated with the maternal complications of OVD. Measures such as performing OVD with appropriate indications should be strengthened.

Data Availability
Te data used is available from the author upon request.

Ethical Approval
Ethical approval was obtained from the Wachemo University College of Health Science IRB (Research Committee). A formal letter was submitted to Wachemo University, Nigist Eleni Memorial Comprehensive Specialized Hospital, and permission was assured. Data were collected anonymously, and confdentiality was assured throughout the study period.

Conflicts of Interest
Te authors declare that they have no conficts of interest. Obstetrics and Gynecology International 7