Comparative Analysis of Risk Factors for Postpartum Hemorrhage in Forceps-Assisted and Vacuum-Assisted Vaginal Deliveries
Abstract
Objective: This study aims to compare the clinical outcomes of forceps-assisted vaginal delivery (FAVD) and vacuum-assisted vaginal delivery (VAVD) in primiparous women and to identify risk factors contributing to moderate and severe postpartum hemorrhage (PPH) associated with these delivery methods.
Methods: A retrospective analysis was conducted on clinical data from 1237 primiparous women who delivered at the Obstetrics Department of Hunan Maternal and Child Health Hospital between April 2018 and April 2022. Among these, 711 underwent FAVD and 526 underwent VAVD. Maternal and neonatal characteristics, including age, gestational age, prepregnancy body mass index (BMI), pregnancy weight gain, neonatal weight, and labor duration, were evaluated. The study assessed labor duration, neonatal weight, maternal complications, neonatal complications, and the incidence and severity of PPH. Binary logistic regression analysis was performed to identify risk factors for moderate (500–1000 mL blood loss) and severe (> 1000 mL blood loss) PPH associated with the two delivery methods.
Results: Compared with FAVD, VAVD was associated with a higher incidence of uterine atony (p < 0.05) and increased risks of both moderate and severe PPH (p < 0.05). Pregnant women with significant gestational weight gain more frequently underwent VAVD (p < 0.05), which also correlated with prolonged second and total labor stages compared with FAVD (p < 0.05). Logistic regression revealed that uterine atony was a significant risk factor for both moderate and severe PPH (p < 0.05). Prolonged total labor independently increased the risk of severe PPH in VAVD cases (p < 0.05 and OR 1.575), while gestational weight gain and prolonged labor were independent risk factors for moderate PPH in FAVD cases (p < 0.05, OR 1.047 and OR 1.287, respectively).
Conclusions: VAVD is associated with longer labor duration, a higher likelihood of PPH, and increased neonatal scalp hematoma incidence compared with FAVD. Prolonged total labor significantly contributes to moderate PPH risk in FAVD and severe PPH risk in VAVD. Uterine atony is an independent predictor of both moderate and severe PPH.
1. Introduction
During labor and delivery, some women may have difficulty in the second stage of labor. Assisted vaginal delivery techniques play a crucial role in reducing cesarean section rates and safeguarding maternal and neonatal health. Forceps-assisted vaginal delivery (FAVD) is a widely used technique to expedite delivery during the second stage of labor, particularly in emergencies, and is instrumental in improving maternal and neonatal outcomes [1]. However, while FAVD is associated with a heightened risk of postpartum hemorrhage (PPH), there is limited research exploring the specific risk factors contributing to this complication [2].
Vacuum-assisted vaginal delivery (VAVD), another common intervention, employs a vacuum suction device attached to the fetal head under negative pressure, facilitating delivery during contractions [3]. This method is characterized by its simplicity, reduced trauma to the pelvic walls, and minimal impact on the birth canal. VAVD is particularly advantageous for women requiring a shortened second stage of labor, those with prior cesarean sections, or those with uterine scars. It offers greater flexibility during traction and minimizes the risk of traction failure [4].
PPH remains a major cause of maternal morbidity and mortality worldwide, accounting for approximately 25% of maternal deaths globally [5, 6]. Regional disparities in PPH outcomes are stark: it contributes to 31% of maternal deaths in Asia, 34% in Africa, 21% in Latin America, and 13% in high-income countries [7–9]. In China, PPH accounts for roughly 32% of maternal deaths [10]. These statistics underscore the global burden of PPH and highlight the urgent need for improved understanding and management strategies to reduce its impact.
In this study, we retrospectively analyzed the clinical data of 1237 cases of FAVD and VAVD in recent years to analyze the effects of different methods of delivery on mothers and newborns, to discuss the risk factors of postpartum hemorrhage associated with different methods of delivery, and to provide a theoretical basis for reducing the incidence of postpartum hemorrhage.
2. Materials and Methods
2.1. General Materials
This study retrospectively analyzed clinical data from 1237 primiparous women who delivered at the Obstetrics Department of Hunan Maternal and Child Health Hospital between April 2018 and April 2022. The study was reviewed and approved by the Ethics Committee of Hunan Medical Center for Maternal and Child Health (no. 2022HNFYBJ-16).
2.2. Inclusion Criteria
Participants were included if they required assisted vaginal delivery due to prolonged second-stage labor caused by uterine inertia, the use of analgesic drugs, or maternal exhaustion. Additional inclusion criteria were abnormal fetal presentations, cephalopelvic disproportion, placental abnormalities, or intrauterine fetal distress necessitating expedited delivery. Candidates included women with prior cesarean deliveries or uterine scars who needed to minimize the duration of the second stage of labor.
2.3. Exclusion Criteria
Exclusion criteria included gestational age < 34 weeks, suspected or diagnosed fetal conditions such as intraventricular hemorrhage or chondrodystrophy, and unengaged or unclear fetal head positions.
2.4. Study Design and Methods
Participants were included if they required assisted vaginal delivery due to prolonged second-stage labor caused by uterine inertia, the use of analgesic drugs, or maternal exhaustion. Additional inclusion criteria were abnormal fetal presentations, cephalopelvic disproportion, placental abnormalities, or intrauterine fetal distress necessitating expedited delivery. Candidates included women with prior cesarean deliveries or uterine scars who needed to minimize the duration of the second stage of labor.
2.5. Exclusion Criteria
Exclusion criteria included gestational age < 34 weeks, suspected or diagnosed fetal conditions such as intraventricular hemorrhage or chondrodystrophy, and unengaged or unclear fetal head positions.
2.6. Study Design and Methods
The study included 1237 women who met the inclusion criteria and excluded those falling under the predefined exclusion criteria. Participants were categorized into two groups based on the delivery method: FAVD (n = 711) and VAVD (n = 526). Maternal data included age, gestational age, prepregnancy body mass index (BMI), pregnancy weight gain, neonatal birth weight, duration of hospitalization, and hospitalization costs. Pregnancy weight gain was calculated as the difference between maternal weight at the last prenatal visit (37–40 weeks of gestation) and prepregnancy weight, which was recorded during the first trimester visit or self-reported by the patient.
Labor onset was classified as spontaneous or induced, with spontaneous labor accounting for 65.2% of cases and induction required in 34.8% due to medical or obstetric indications. Indications for operative vaginal delivery included maternal exhaustion, nonreassuring fetal heart rate patterns, prolonged second-stage labor, and fetal distress. Labor stages were defined as follows: First Stage of Labor: From the onset of regular uterine contractions leading to complete cervical dilation (10 cm). Second Stage of Labor: From complete cervical dilation to fetal delivery. Total Labor Duration: The cumulative time of the first and second stages. Labor durations were systematically recorded by clinical staff during delivery and analyzed for both groups. Neonatal and maternal outcomes, including PPH, were compared between the groups. The severity of PPH was categorized as moderate (500–1000 mL blood loss) or severe (≥ 1000 mL blood loss). Risk factors for PPH were assessed using binary logistic regression, which included clinically relevant variables and those with p < 0.10 in univariate analyses.
2.7. Statistical Analysis
Statistical analyses were performed using SPSS software (version 25.0). Categorical variables were presented as frequencies and percentages and compared using chi-square tests. Continuous variables were expressed as mean ± standard deviation and analyzed using independent sample t-tests. Binary logistic regression was used to identify risk factors for moderate and severe PPH. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to quantify associations. Variables with p < 0.05 in the logistic regression model were considered statistically significant.
3. Results
3.1. General Maternal Data
The clinical characteristics of 1237 eligible mothers are summarized in Table 1. Most participants were aged between 20 and 35 years, with a mean gestational age of 39.61 ± 1.02 weeks and a prepregnancy BMI of 20.91 ± 2.65 kg/m2. The average gestational weight gain was 13.23 ± 3.74 kg, and the mean neonatal weight was 3278.30 ± 364.99 g. The average hospital stay was 4.87 ± 2.70 days, and hospitalization costs averaged 9.28 ± 3.70 thousand dollars. The mean duration of the first, second, and total labor stages was 11.81 ± 4.41 h, 1.21 ± 1.37 h, and 12.98 ± 4.75 h, respectively. Among the participants, 57.5% underwent FAVD (n = 711), while 42.5% underwent VAVD (n = 526).
| Characteristics | N | Mean ± SD |
|---|---|---|
| Age (years) | ||
| ≤ 19 | 3 | 16.67 ± 2.51 |
| 20–35 | 1126 | 29.15 ± 2.82 |
| ≥ 35 | 108 | 37.15 ± 2.16 |
| Gestational age (weeks) | 1237 | 39.61 ± 1.02 |
| Prepregnancy BMI (kg/m2) | 1237 | 20.91 ± 2.65 |
| Pregnancy weight gain (kg) | 1237 | 13.23 ± 3.74 |
| Neonatal weight (g) | 1237 | 3278.30 ± 364.99 |
| Hospitalization stay (days) | 1237 | 4.87 ± 2.70 |
| Hospitalization expenses (thousand dollars) | 1237 | 9.28 ± 3.70 |
| First stage of labor (hours) | 1237 | 11.81 ± 4.41 |
| Second stage of labor (hours) | 1237 | 1.21 ± 1.37 |
| Total labor duration (hours) | 1237 | 12.98 ± 4.75 |
| Labor onset [n (%)] | ||
| Spontaneous | 807 (65.2%) | |
| Induced | 430 (34.8%) | |
| Mode of delivery [n (%)] | ||
| Forceps | 711 (57.5%) | |
| Vacuum | 526 (42.5%) | |
| Blood loss [n (%)] | ||
| < 500 mL | 686 | 169.29 ± 35.05 |
| 500–1000 mL | 476 (38.5%) | 597.21 ± 118.28 |
| ≥ 1000 mL | 75 (6.1%) | 1339.33 ± 453.76 |
Regarding PPH, 55.5% of participants (n = 686) experienced blood loss < 500 mL, with an average volume of 169.29 ± 35.05 mL. Moderate PPH (500–1000 mL) was observed in 38.5% (n = 476), with a mean blood loss of 597.21 ± 118.28 mL. Severe PPH (> 1000 mL) occurred in 6.1% of the cases (n = 75), with an average volume of 1339.33 ± 453.76 mL. The overall PPH rate was 44.5%, with moderate and severe cases comprising 38.5% and 6.1%, respectively.
3.2. Comparison of Labor and Delivery Characteristics Between FAVD and VAVD
Women were categorized into the FAVD group (n = 711) and the VAVD group (n = 526). The comparative analysis of labor and delivery characteristics is summarized in Table 2. Women in the FAVD group had significantly higher gestational weight gain (13.48 ± 3.98 kg vs. 12.89 ± 3.36 kg, p < 0.05). In contrast, the VAVD group demonstrated prolonged second-stage labor (1.32 ± 1.67 h vs. 1.13 ± 1.10 h, p < 0.05) and total labor duration (13.33 ± 4.67 h vs. 12.73 ± 4.80 h, p < 0.05). Furthermore, in the postpartum bleeding comparison, in the moderate bleeding group (41.4% vs. 36.3%) and the severe bleeding group (7.2% vs. 5.2%), the VAVD group had more bleeding than the FAVD group, with a statistically significant difference of p < 0.05. The probability of uterine inertia in the VAVD group was more obvious (52% vs. 42.2%), p < 0.05, and the difference was statistically significant. Induced labor was associated with prolonged total labor duration and an elevated risk of moderate PPH in both groups (p < 0.05).
| Variable | VAVD (n = 526) | FAVD (n = 711) | t/χ2 | p |
|---|---|---|---|---|
| Prepregnancy BMI (kg/m2) | 21.02 ± 2.53 | 20.83 ± 2.74 | −1.274 | 0.203 |
| Pregnancy weight gain (kg) | 12.89 ± 3.36 | 13.48 ± 3.98 | 2.807 | 0.005 ∗ |
| Neonatal weight (g) | 3306.52 ± 373.69 | 3267.79 ± 355.26 | 1.924 | 0.166 |
| First stage of labor (h) | 12.08 ± 4.32 | 11.61 ± 4.48 | −1.823 | 0.069 |
| Second stage of labor (h) | 1.32 ± 1.67 | 1.13 ± 1.10 | −2.286 | 0.022 ∗ |
| Total labor duration (h) | 13.33 ± 4.67 | 12.73 ± 4.80 | −2.202 | 0.028 ∗ |
| Blood loss [n (%)] | 0.032 # | |||
| < 500 mL | 270 (51.3%) | 416 (58.8%) | ||
| 500–1000 mL | 218 (41.4%) | 258 (36.3%) | ||
| ≥ 1000 mL | 38 (7.2%) | 37 (5.2%) | ||
| Uterine atony [n (%)] | 273 (52.0%) | 300 (42.2%) | 11.457 | 0.001 # |
| Episiotomy [n (%)] | 514 (97.7%) | 704 (99.0%) | 3.362 | 0.067 |
| Perineal wound oozes blood [n (%)] | 164 (31.2%) | 191 (26.9%) | 2.751 | 0.097 |
- Note: The black part represents a significant difference.
- ∗Means using of the t-test and significant difference between groups (p < 0.05).
- #Means using the chi-square test and significant difference between groups.
3.3. Effect of Delivery Methods on Maternal and Neonatal Complications
The maternal and neonatal complications associated with FAVD and VAVD are presented in Table 3. For maternal complications, comparing the VAVD and forceps groups, perineal lacerations (9.7% vs. 8.0%), vaginal wall lacerations (6.8%), cervical lacerations (7.2% vs. 6.8%), urinary retention (37.1% vs. 36.8%), puerperal infections (3.6% vs. 5.6%), gestational diabetes (19.7% vs. 20.4%), hyperlipidemia (14.6% vs. 26.3%), and hypothyroidism (12.5% vs. 12.2%), where postpartum complications of hyperlipidemia were statistically significant in the women who underwent FAVD than that in the VAVD group, p < 0.05. Regarding neonatal complications, comparing neonatal weight (3293.89 ± 372.11 g vs. 3267.72 ± 358.86 g), neonatal asphyxia (0.8% vs. 1.7%), neonatal scalp hematoma (6.3% vs. 3.7%), neonatal hyperbilirubinemia (26% vs. 26.2%), and neonatal pneumonia (9.5% vs. 12.2%), the incidence of neonatal scalp hematoma was higher in the VAVD group, and the difference was statistically significant at p < 0.05.
| Variable | VAVD (n = 526) | FAVD (n = 711) | t/χ2 | p |
|---|---|---|---|---|
| Maternal complications | ||||
| Perineal laceration [n (%)] | 51 (9.7%) | 57 (8.0%) | 1.069 | 0.301 |
| Vaginal wall laceration [n (%)] | 36 (6.8%) | 44 (6.2%) | 0.215 | 0.643 |
| Cervix laceration [n (%)] | 38 (7.2%) | 48 (6.8%) | 0.105 | 0.746 |
| Uroschesis [n (%)] | 195 (37.1%) | 262 (36.8%) | 0.006 | 0.953 |
| Puerperal infection [n (%)] | 19 (3.6%) | 40 (5.6%) | 2.699 | 0.100 |
| Gestational diabetes mellitus [n (%)] | 105 (19.7%) | 145 (20.4%) | 0.035 | 0.852 |
| Hyperlipidemia [n (%)] | 77 (14.6%) | 187 (26.3%) | 24.495 | 0.0001 # |
| Hypothyroidism [n (%)] | 66 (12.5%) | 87 (12.2%) | 0.027 | 0.869 |
| Neonatal complications | ||||
| Neonatal weight (g) | 3293.89 ± 372.11 | 3267.72 ± 358.86 | −1.248 | 0.212 |
| Neonatal asphyxia [n (%)] | 4 (0.8%) | 12 (1.7%) | 2.036 | 0.154 |
| Neonatal scalp hematoma [n (%)] | 33 (6.3%) | 26 (3.7%) | 1.999 | 0.033 # |
| Neonatal hyperbilirubinemia [n (%)] | 137 (26.0%) | 186 (26.2%) | 0.002 | 0.964 |
| Neonatal pneumonia [n (%)] | 50 (9.5%) | 87 (12.2%) | 2.289 | 0.130 |
- Note: The black part represents a significant difference.
- #Means using the chi-square test and significant difference between groups.
3.4. Logistic Regression Analysis of Postpartum Hemorrhage Complicated by FAVD
According to Table 4, the factors associated with moderate and severe postpartum hemorrhage affecting the FAVD group were analyzed separately. The OR (95% CI) of factors affecting moderate postpartum hemorrhage: gestational weight gain, first stage of labor, second stage of labor, total labor, neonatal scalp hematoma, and maternal hyperlipidemia were 1.047 (1.006–1.089), 0.802 (0.624–1.029), 1.089 (0.920–1.290), 1.287 (1.012–1.638), 0.637 (0.345–1.173), and 0.797 (0.560–1.134), where gestational weight gain and prolonged total labor were risk factors for moderate postpartum blood loss due to FAVD, p < 0.05. Factors affecting severe postpartum blood loss: gestational weight gain, OR (95% CI) for the first stage of labor, the second stage of labor, total labor, neonatal scalp hematoma, and maternal hyperlipidemia were 1.009 (0.920–1.107), 0.767 (0.293–2.004), 0.813 (0.300–2.205), 1.473 (0.565–3.839), 0.412 (0.123–1.260), and 1.727 (0.644–4.634). Uterine atony was the risk factor for moderate and severe postpartum bleeding of FAVD (p < 0.05), OR (95% CI) were 13.395 (9.135–19.643) and 25.372 (9.899–153.392), respectively.
| Variable | Moderate PPH (500–1000 mL) | Severe PPH (≥ 1000 mL) | ||
|---|---|---|---|---|
| OR (95% CI) | p | OR (95% CI) | p | |
| Pregnancy weight gain (kg) | 1.047 (1.006–1.089) | 0.023 # | 1.009 (0.920–1.107) | 0.847 |
| First stage of labor (h) | 0.802 (0.624–1.029) | 0.083 | 0.767 (0.293–2.004) | 0.588 |
| Second stage of labor (h) | 1.089 (0.920–1.290) | 0.323 | 0.813 (0.300–2.205) | 0.684 |
| Total labor duration (h) | 1.287 (1.012–1.638) | 0.040 # | 1.473 (0.565–3.839) | 0.428 |
| Neonatal scalp hematoma | 0.637 (0.345–1.173) | 0.148 | 0.412 (0.123–1.260) | 0.120 |
| Hyperlipidemia | 0.797 (0.560–1.134) | 0.207 | 1.727 (0.644–4.634) | 0.278 |
| Uterine atony | 13.395 (9.135–19.643) | 0.0001 ## | 25.372 (9.899–153.392) | 0.001 ## |
- Note: The black part represents a significant difference.
- #Significant difference between groups (p < 0.05).
- ##Highly significant difference (p < 0.01).
3.5. Logistic Regression Analysis of Postpartum Hemorrhage Complicated by FAVD
According to Table 5, the factors associated with moderate and severe postpartum hemorrhage affecting the VAVD group were analyzed separately, and the ORs (95% CI) for the factors affecting moderate postpartum hemorrhage: gestational weight gain, first stage of labor, second stage of labor, total labor, neonatal scalp hematoma, and maternal hyperlipidemia were 1.052 (0.997–1.109), 1.101 (0.915–1.325), 0.986 (0.879–1.106), 0.966 (0.812–1.148), 0.830 (0.341–2.016), and 1.100 (0.664–1.822), respectively. The OR (95% CI) of the factors affecting severe postpartum blood loss: gestational weight gain, first stage of labor, second stage of labor, total labor, neonatal scalp hematoma, and maternal hyperlipidemia were 1.007 (0.913–1.110), 0.713 (0.469–1.083), 1.575 (1.069–2.322), 1.575 (1.069–2.322), 1.601 (0.201–12.771), and 0.828 (0.325–2.109), in which the probability of a vaginal delivery assisted by vacuum complicated by severe postpartum hemorrhage increased by 57.5% for each hour of prolongation of total labor, with a statistically significant difference, p < 0.05. Uterine atony was a risk factor for moderate and severe postpartum hemorrhage of VAVD (p < 0.05), OR (95%CI) was 11.078 (7.115–17.247) and 34.751 (4.622–277.407), respectively.
| Variable | Moderate PPH (500–1000 mL) | Severe PPH (≥ 1000 mL) | ||
|---|---|---|---|---|
| OR (95% CI) | p | OR (95% CI) | p | |
| Pregnancy weight gain (kg) | 1.052 (0.997–1.109) | 0.064 | 1.007 (0.913–1.110) | 0.893 |
| First stage of labor (h) | 1.101 (0.915–1.325) | 0.309 | 0.713 (0.469–1.083) | 0.112 |
| Second stage of labor (h) | 0.986 (0.879–1.106) | 0.811 | 1.575 (1.069–2.322) | 0.474 |
| Total labor duration (h) | 0.966 (0.812–1.148) | 0.691 | 1.575 (1.069–2.322) | 0.022 & |
| Neonatal scalp hematoma | 0.830 (0.341–2.016) | 0.680 | 1.601 (0.201–12.771) | 0.657 |
| Hyperlipidemia | 1.100 (0.664–1.822) | 0.711 | 0.828 (0.325–2.109) | 0.692 |
| Uterine atony | 11.078 (7.115–17.247) | 0.001 & | 34.751 (4.692–257.407) | 0.001 & |
- Note: The black part represents a significant difference.
- &Means using the chi-square test and significant difference between groups (p < 0.05).
4. Discussion
In recent years, PPH has remained the leading cause of maternal morbidity and mortality worldwide. Current risk factors for PPH include weak uterine contractions, genital tract injury, coagulation abnormalities, multiple pregnancies, and placental abnormalities [11]. Our findings that uterine atony is a primary risk factor for moderate and severe PPH aligns with previous research by Nyfløt et al. and others, who identified weak uterine contractions as a leading cause of PPH (80% of the cases) [12]. Studies have found that FAVD and VAVD increase the postpartum hemorrhage incidence [13–16]. However, there are fewer reports that compare the two assisted reproductive techniques alone to cause postpartum hemorrhage. This study included 1237 maternal cases for a comparative study and found that compared with FAVD, VAVD increased moderate postpartum hemorrhage (500–1000 mL) and severe (1000 mL). The probability of postpartum hemorrhage (p < 0.05) was not found in the Ganga L et al.’s study. The difference in the incidence of postpartum hemorrhage between the two delivery assistance techniques may be related to the statistical method and statistical sample [17]. In our cohort, FAVD and VAVD were applied in 57.5% and 42.5% of the cases, respectively, reflecting institutional protocols and balanced application. This balanced approach minimizes selection bias, providing robust comparative insights into the complications of these delivery techniques.
Uterine atony has been identified as a potential cause of up to 80% of postpartum hemorrhage [18, 19]. Our study also confirmed that uterine atony was an independent risk factor for moderate and severe postpartum hemorrhage complicated by forceps and vacuum aspiration (p < 0.05). Furthermore, in this study, the probability of weakness of uterine contraction in the VAVD group was significantly increased compared with that of the FAVD group (p < 0.05), resulting in an increased risk of postpartum hemorrhage after vacuum suction midwifery. Previous research by Holly B et al. noted a similar trend but lacked detailed mechanistic insights. Our study adds to this understanding by linking uterine atony with prolonged labor duration, particularly in the VAVD group [20].
Gestational weight gain has been associated with increased risks of obstetric interventions [21]. In our analysis, excessive weight gain during pregnancy was more frequently observed in women undergoing FAVD and was significantly associated with moderate PPH. These findings may reflect differences in maternal characteristics, such as baseline comorbidities or delivery preferences influenced by clinical protocols. In addition, prepregnancy obesity has been linked to higher success rates with FAVD, as previously reported [22]. Future research should consider these confounding factors to clarify the relationship between weight gain, delivery mode, and PPH risk.
In recent years, with the widespread use of vacuum suction in assisted obstetric labor, it has become an important means of assisted obstetric labor because of its simple operation and easy mastery. However, clinical studies have found that vacuum suction is prone to slippage during use and can prolong the second stage of labor [23, 24]. Our study verified that VAVD prolongs the second and total stages of labor (p < 0.05) and that prolongation of the total stage of labor is an independent risk factor for severe postpartum hemorrhage complicated by VAVD (p < 0.05). This is consistent with most studies [25–27]. With a prolonged second stage of labor, VAVD was more likely to cause neonatal scalp hematoma (p < 0.05). It is consistent with the current study [28, 29]. Therefore, to ensure the safety of vacuum-assisted delivery, the clinic should try to place the suction cup in the sagittal suture position and prevent slippage during traction, while maintaining smooth and continuous traction, helping to improve the effectiveness of assisted delivery.
FAVD is used as the traditional mode of delivery assistance for women who deliver vaginally. Compared with VAVD, FAVD reduces the risk of adverse neonatal neurological outcome [30]. Chang xu et al. found that forceps-assisted delivery increases the risk of severe postpartum hemorrhage. The prolonged second stage of labor has also been found to be a risk factor for severe postpartum hemorrhage in patients undergoing assisted delivery [31]. Our study found that prolonged total labor was an independent risk factor for moderate postpartum hemorrhage that complicates FAVD (p < 0.05). The risk of progression to severe postpartum hemorrhage was greater in menstruating women with forceps-assisted delivery method than that in menstruating women with vaginal delivery [32].
This study has several limitations. Accurate measurement of PPH volume remains challenging, and some data may have been excluded due to strict inclusion and exclusion criteria. Nevertheless, the large sample size and rigorous analysis provide robust insights, compensating for these limitations to some extent.
5. Conclusions
VAVD is associated with prolonged labor, increased risk of PPH, and higher incidence of neonatal scalp hematoma compared with FAVD. Excessive gestational weight gain was more frequent among women undergoing FAVD and correlated with moderate PPH. Prolonged labor duration emerged as an independent risk factor for moderate PPH in FAVD and severe PPH in VAVD. Optimizing delivery techniques and addressing modifiable risk factors can improve maternal and neonatal outcomes.
Ethics Statement
The authors are responsible for all aspects of the work to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Institutional Review Board of Hunan Mother and Child Health Hospital (no. 2022HNFYBJ-16).
Consent
All study subjects gave their informed consent.
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
Hui Li and Hua Pan conceived and designed the study. Hui Li and Yurong Jiang provided clinical advice. Hui Li and Hua Pan analyzed the data. Hui Li and Hua Pan prepared the manuscript. All the authors have read and approved the final version of the manuscript.
Funding
This study was financed by the Hunan Provincial Health Commission Project (D202305028321).
Open Research
Data Availability Statement
All data are provided in this study, and raw data can be obtained from the corresponding author upon reasonable request.
