{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T12:29:47Z","timestamp":1791462587700,"version":"4.3.4"},"reference-count":18,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2014,11,21]],"date-time":"2014-11-21T00:00:00Z","timestamp":1416528000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"funder":[{"name":"Health Research Board Ireland","award":["POR\/2010\/55"],"award-info":[{"award-number":["POR\/2010\/55"]}]}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["BJOG"],"published-print":{"date-parts":[[2015,3]]},"abstract":"<jats:sec><jats:title>Objectives<\/jats:title><jats:p>To identify risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design<\/jats:title><jats:p>Observational study, nested within a randomised controlled trial.<\/jats:p><\/jats:sec><jats:sec><jats:title>Setting<\/jats:title><jats:p>Two university\u2010affiliated maternity hospitals.<\/jats:p><\/jats:sec><jats:sec><jats:title>Sample<\/jats:title><jats:p>A cohort of 478 nulliparous women at term (\u226537\u00a0weeks of gestation) undergoing instrumental delivery.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Univariable and multivariable logistic regression analyses were performed.<\/jats:p><\/jats:sec><jats:sec><jats:title>Main outcome measures<\/jats:title><jats:p>Risk factors for suboptimal application of vacuum or forceps, maternal and neonatal morbidity, and the sequential use of instruments, second operator, and caesarean section following failed instrumental delivery.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Instrument placement was suboptimal in 138 of 478 (28.8%) deliveries. Factors associated with suboptimal instrument placement included fetal malposition (<jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> 2.44, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 1.62\u20133.66), mid\u2010cavity station (<jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> 1.68, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 1.02\u20132.78), and forceps as the primary instrument (<jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> 2.01, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 1.33\u20133.04). Compared with optimal instrument placement, suboptimal placement was associated with prolonged hospital stay (adjusted <jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> 2.28, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 1.30\u20134.02) and neonatal trauma (adjusted <jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> 4.25, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 1.85\u20139.72). Suboptimal placement was associated with a greater use of sequential instruments (adjusted <jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> 3.99, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 1.94\u20138.23) and caesarean section for failed instrumental delivery (adjusted <jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> 3.81, 95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 1.10\u201313.16). The mean decision to delivery interval (<jats:styled-content style=\"fixed-case\">DDI<\/jats:styled-content>) was 4\u00a0minutes longer in the suboptimal group (95% <jats:styled-content style=\"fixed-case\">CI<\/jats:styled-content> 2.1\u20135.9\u00a0minutes).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Suboptimal instrument placement is associated with increased maternal and neonatal morbidity and procedural complications. Greater attention should be focused on instrument placement when training obstetricians for instrumental delivery.<\/jats:p><\/jats:sec>","DOI":"10.1111\/1471-0528.13186","type":"journal-article","created":{"date-parts":[[2014,11,21]],"date-time":"2014-11-21T10:13:59Z","timestamp":1416564839000},"page":"558-563","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":61,"title":["Risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery: observational study nested within the Instrumental Delivery &amp; Ultrasound randomised controlled trial <scp>ISRCTN<\/scp> 72230496"],"prefix":"10.1111","volume":"122","author":[{"given":"M","family":"Ramphul","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynaecology Trinity College Dublin Coombe Women and Infants University Hospital Dublin Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"MM","family":"Kennelly","sequence":"additional","affiliation":[{"name":"University College Dublin Coombe Women &amp; Infant's University Hospital Dublin Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G","family":"Burke","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynaecology Graduate Entry Medical School University of Limerick Mid\u2010Western Regional Maternity Hospital Limerick Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"DJ","family":"Murphy","sequence":"additional","affiliation":[{"name":"Academic Department of Obstetrics and Gynaecology Trinity College Dublin Coombe Women and Infants University Hospital Dublin Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2014,11,21]]},"reference":[{"key":"e_1_2_6_2_1","doi-asserted-by":"publisher","DOI":"10.1046\/j.1471-0528.2003.01463.x"},{"key":"e_1_2_6_3_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.38971.466979.DE"},{"key":"e_1_2_6_4_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199912023412301"},{"key":"e_1_2_6_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(04)15730-9"},{"key":"e_1_2_6_6_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.329.7456.24"},{"key":"e_1_2_6_7_1","unstructured":"BirthChoiceUK[Internet]. 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