Operative Vaginal Delivery

By Dr Javaria Aslam

History

Forceps
1500 BC 1752, William Smellie Early 19th century almost completely abandoned 1817, Princess Charlotte (GB) died of PPH after prolonged II stage for more than 24hrs, her obstetrician Sir Richard Croft. 1940, 70% of all deliveries were assisted by forceps

Vacuum
1954, Malmstrom described metal vacuum extractor 1969, Bird modified the metal cup for OP position 1980, first soft cup introduced

Learning Objectives
Recognize the common indications, pre-requisites and contraindications for instrumental delivery Appreciate the relative advantages and disadvantages of ventouse versus forceps delivery Understand how to perform forceps and ventouse delivery safely Demonstrate proper use of equipment on maternalfetal mannequin

Back Ground
An important skill to manage second stage of labour 10-15% of all deliveries require operative assistance Rates of operative delivery vary throughout the world (1.5-15%) In the UK, the overall operative delivery rate is 10% (4% and 26%)

Back Ground
There is an increase in the rates of instrumental deliveries in recent years This may be partly due to
a change in the attitudes of patients an increased use of epidural analgesia continuous electronic fetal monitoring increased litigation in obstetrics

Back Ground
There are strict criteria for safe instrumental delivery For instrumental delivery we should know
The technique The indications Relative contraindications

Assessment
Previous obstetric history
The possibility of cephalopelvic disproportion (CPD) Parity

Current pregnancy and labour

Gestational age Macrosomia Previous concerns about fetal well being Whether the labour spontaneous or induced Admission cardiotocograph (CTG)

Assessment
Examination
Fetal size, position and engagement Adequate uterine contractions A palpable bladder A careful vaginal examination
The fetal station Fetal position is determined by palpating the fontanelles and suture lines. Maternal pelvis

Maternal Indications
Prolonged second stage Maternal exhaustion (early pushing) Epidural analgesia Failure to descend due to soft tissue resistance Maternal illness (vulsalva is contra-indicated) eg; cardiac disease, raised intra cranial pressure. Hemorrhage

Prolonged Second Stage

Parity
Without Regional Block 2 hours With Regional Block 3 hours

Nullipara

Multipara

1 hour

2 hours

Indications
Fetal
Fetal distress Non-reassuring CTG

Maternal-fetal
Relative CPD Mal-position Mal-presentation

Pre-requisites
Vertex presentation Complete dilatation of cervix Rupture of membranes No known cephalopelvic disproportion Willingness to abandon the procedure

Mnemonics
A. Ask for help, Address the patient Anesthesia (adequate) B. Bladder empty C. Cervix fully dilated D. Determine position sutures and fontanels think of shoulder Dystocia E. Equipment and Extractor ready

Mnemonics
F. Vacuum Cup over sagittal suture 3 cm from anterior Fontanel Flexion point apply cup at position that maintain flexion on traction F. Forceps ready post Fontanel midway b/w shanks Fenestrations admit no more than one finger

Mnemonics
G. Vaccum: Gentle traction
at right angle to plane of cup During contractions.

G. Forceps: Gentle traction Pajots Maneuver

Axis traction follow pelvic curve first downward than J-shapped two vectorshorizontal outwards and vertical downwards

Mnemonics
H. Vacuum:

Halt traction after contraction (reduce pressure between traction) Halt procedure
if disengagement three times no progress in 3 consecutive pulls no more than 20 min of application.

H. Forceps:
Handle vertically elevated to follow the pelivic curve

Mnemonics
I. Evaluation of Incision (episiotomy) J. Stop when Jaw reachable

Forceps Vaginal Delivery

Types
Straight forceps
Simpsons Simpsons Wrigleys Neville-Barnes Andersons Wrigley's

Rotational forceps
Kielland's The Kiellands forceps Pipers

Mid cavity forceps

Forceps Relative Indications

Delayed second stage Maternal exhaustion in second stage Epidural with diminish urge to push Rotational instrumental delivery for fetal mal-position Suspected fetal distress

Forceps Absolute Indications

Where excessive caput is present over the vertex Prematurity (gestation <34 weeks) Face presentation After coming head of a breech Assisted delivery with suspected fetal coagulopathy Maternal medical conditions Instrumental delivery under GA Cord prolapse in second stage

Advantages Of Forceps Delivery

Forceps Vs Vacuum

Lower failure rate Faster in fetal distress Sequential use of instruments is less common Cephalhaematoma and retinal hemorrhage less common

Advantages Of Forceps Delivery

Forceps Vs EmLSCS

Less blood loss Shorter hospital stay NICU admission less common Re-admission is less common with forceps Subsequent SVD more likely

Disadvantages Of Forceps Delivery

Forceps Vs Vacuum

More analgesia Greater maternal perineal trauma More facial bruising and facial nerve palsy Require more clinical skills

Disadvantages Of Forceps Delivery

Forceps Vs EmLSCS

Trauma to baby is less likely with C. section Lesser perineal trauma with C. section Lesser dyspareunia Lesser urinary and fecal incontinence

Ventouse Delivery

Types
Silastic cups Metal cup Omini cup

Insertion of cup
Place over the flexing median Symmetrically over the sagittal suture At least 3cm from the cup edge to the anterior fontanelle To ensure that traction results in flexion of the fetal head

Method
Ensure no maternal tissue is trapped Negative pressure is applied to 0.2 bar, Pressure taken to 0.8 bar

Operative Notes After Instrumental Delivery

Date/Time Mode of delivery Indication Duration of 1st/2nd stage Regional analgesia Procedure
Cx dilatation Station Bladder Soft tissue Episiotomy Duration and no. of pulls

Third stage: tears, PPH Baby notes: sex, wt, apgar

Summary
10-15% of all deliveries require operative assistance All maternity care providers should be familiar with the instruments and the techniques AJ mnemonic provides systematic method for assisted delivery Providers should be aware of complications and contraindications to these procedures