The Walker project

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The Walker project

• Deirdre J Murphy
• University of Dundee

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Overview

• Walker cohort
• Epidemiology of operative delivery
• Forceps and epilepsy in adulthood
• Forceps and pelvic floor surgery
• Conclusions

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Walker Cohort
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Walker cohort

• Dundee Hospital Birth cohort
• 1952-1966
• 75.4 of all births
• City archives confirm representative
• CH numbers identified
• 21,915 current Tayside residents
• Follow-up of babies 37-53 years

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Walker dataset

• Birth record cards
• Predefined dataset
• Parental demographics
• Past obstetric history
• Past medical history
• Current pregnancy
• Intrapartum care and outcome
• Postnatal factors

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Record linkage

• CHNo
• MEMO 1993-2004
• SMR 1980-2004
• DARTS 1992-2004
• GRO 1990-2004

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Epidemiology of operative delivery
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Background

• Rising caesarean section rate
• UK - constant instrumental delivery rate
• US fall in instrumental delivery rate
• Increasing preference for vacuum
• Increasing preference for caesarean

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Regional Caesarean section rates
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Instrumental delivery UK 2001
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Alternatives to Forceps
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Balance of Risks

• Short-term versus Long-term
• Maternal versus Fetal
• Indication versus Procedure

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Forceps and Epilepsy in Adulthood

• Murphy et al AJOG 2004 (In Press)

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Forceps and Epilepsy

• 21,441 babies
• Record linkage to MEMO
• All anti-convulsant prescriptions
• Record linkage to SMR1
• All hospital admissions with epilepsy
• Sensitivity analysis excluding carbamazepine

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Hypothesis

• Does delivery by forceps increase the
• babys risk of epilepsy in adulthood?
• Assoc with neonatal encephalopathy
• Assoc with trauma,intracranial bleed
• Perinatal events assoc with first fit in
  adulthood
• Badawi BMJ 98/Towner NEJM 99/Leone Neur Sc 02

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Results

• Forceps delivery 8.6
• Caesarean section 5.6
• Adult epilepsy 2.8

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Risk factors

• Family history OR 2.36 (1.72, 3.22)
• Carstairs score OR 1.14 (1.04, 1.24)
• Male gender OR 1.36 (1.03, 1.79)

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Forceps delivery

• Forceps vs All other deliveries
• OR 1.00 (0.56, 1.80)
• Forceps vs SVD
• OR 0.75 (0.18, 3.10)
• Preterm birth OR 1.95 (1.19, 3.19)

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Summary

• Reassuring data on long-term
• neurological consequences
• of delivery by forceps

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Forceps and Pelvic Floor surgery in later life

• Ramalingam et al (Peer-review)

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Mode of Del Pelvic Floor surgery

• Management of first pregnancy
• Record linkage SMR1 (1980-2003)
• All hospital admissions for PFR
• 352 cases
• 1408 controls

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Hypothesis

• Does mode of delivery influence the
• risk of pelvic floor surgery
• in later life ?
• Assoc between forceps delivery and increased risk
  of incontinence
• Elective CS assoc with reduced risk of
  incontinence
• Van Kessel AJOG 2001/MacLennan BJOG
  2000/OHerlihy 1999

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Results

• Grand multiparity
• OR 1.68 (1.22, 2.32)
• Carstairs score
• OR 0.83 (0.62, 1.10)

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Mode of delivery

• Forceps vs SVD
• OR 0.95 (0.71, 1.27)
• Caesarean vs SVD
• OR 0.40 (0.22, 0.72)

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Summary

• Forceps delivery appears to be no worse than SVD
• Caesarean section appears to protect against
  pelvic floor surgery
• even in the 50s!!

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Conclusions

• Reassuring data on long-term neurological risk to
  infant following forceps
• Caesarean section may protect against pelvic
  floor surgery
• Walker cohort is a powerful resource
• Further research

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Acknowledgement

• Prof James Walker
• Walker Group
• Uma Ramalingam
• Gillian Libby
• Tenovus Scotland