1. The Walker project Deirdre J Murphy University of Dundee

2. Overview  Walker cohort  Epidemiology of operative delivery  Forceps and epilepsy in adulthood  Forceps and pelvic floor surgery  Conclusions

3. Walker Cohort

4. 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

5. Walker dataset  Birth record cards  Predefined dataset  Parental demographics  Past obstetric history  Past medical history  Current pregnancy  Intrapartum care and outcome  Postnatal factors

6. Record linkage  CHNo  MEMO 1993-2004  SMR 1980-2004  DARTS 1992-2004  GRO 1990-2004

7. Epidemiology of operative delivery

8. Background  Rising caesarean section rate  UK - constant instrumental delivery rate  US – fall in instrumental delivery rate  Increasing preference for vacuum  Increasing preference for caesarean

9. Regional Caesarean section rates

10. Instrumental delivery – UK 2001

14. Alternatives to Forceps

17. Balance of Risks  Short-term versus Long-term  Maternal versus Fetal  Indication versus Procedure

18. Forceps and Epilepsy in Adulthood Murphy et al AJOG 2004 (In Press)

19. 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

20. Hypothesis Does delivery by forceps increase the baby’s 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

21. Results Forceps delivery8.6% Caesarean section5.6% Adult epilepsy2.8%

22. Risk factors Family historyOR 2.36 (1.72, 3.22) Carstairs score OR 1.14 (1.04, 1.24) Male gender OR 1.36 (1.03, 1.79)

23. 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)

24. Summary Reassuring data on long-term neurological consequences of delivery by forceps

25. Forceps and Pelvic Floor surgery in later life Ramalingam et al (Peer-review)

26. Mode of Del & Pelvic Floor surgery  Management of first pregnancy  Record linkage SMR1 (1980-2003) All hospital admissions for PFR  352 cases  1408 controls

27. 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/O’Herlihy 1999

28. Results  Grand multiparity OR 1.68 (1.22, 2.32)  Carstairs score OR 0.83 (0.62, 1.10)

29. Mode of delivery  Forceps vs SVD OR 0.95 (0.71, 1.27)  Caesarean vs SVD OR 0.40 (0.22, 0.72)

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

31. 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

32. Acknowledgement  Prof James Walker  Walker Group  Uma Ramalingam  Gillian Libby  Tenovus Scotland