operative vaginal delievery

By Majid Nawaz (final year MBBS)

Bannu Medical College

Bannu

a delivery in which the operator uses forceps or a vacuum device to assist the mother in transitioning the fetus to extrauterine life.

If performed by proper selection of cases and careful & timely application, operative delivery can be useful in reducing not only

unnecessary caesarean sections but also fetal & maternal complications due to prolonged labor.

1)prolonged second stage of labour

• Nullipara- • >3 hrs with regional anaesthesia • >2 hrs without regional anaesthesia

• Multipara-• >2 hrs with regional anaesthesia • >1hr without regional anaesthesia

2)Foetal indications: - Foetal distress

Cord prolapse in second stage

Aftercoming head of breech

Low birth wt. Baby Post maturity

3)Maternal indication: - Maternal distress Pre-eclampsia Heart diseases Neurological disorders where voluntary efforts are contraindicated or impossible

Absolute Contraindications : Moderate to severe CPD. Abnormal presentations (vacuum…NO, forceps…

YES). High head except in 2nd twin (vacuum can be used)

Relative Contraindications: MATERNAL:

Before full cervical dilatation . There are a few exceptions

prolapsed cord at 9 cm in a multiparous woman. or a second twin.

General anesthesia (vacuum…YES, forceps…NO). Fetal:

Fetal bleeding disorders Predisposition to fracture (e.g., osteogenesis imperfecta). Fetal Distress (vacuum…YES, forceps…NO).

Vacuum and forceps delivery can be associated with significant complications, both maternal and fetal.

Risks of complications are increased significantly among babies exposed to attempts at both vacuum and forceps delivery.

Complications/dangers of operative delivery: - are mostly due to faulty technique rather than the instrument.

Injury-. Extension of the episiotomy involving anus & rectum or

vaginal vault. Vaginal lacerations and cervical tear if cervix was not fully

dilated. Post partum haemorrhage –.

Due to trauma, Atonic uterus Shock –.

Due to blood loss, or prolonged labor. Sepsis –.

Due to improper asepsis of local tissues. Anaesthetic hazards.

Delayed or long-term sequel –. Chronic low backache. genital prolapse . stress incontinence.

Asphyxia

Trauma- Intracranial hemorrhage. Cephalic haematoma. Facial / Brachial palsy. Injury to the soft tissues of face & forehead. Skull fracture

Fetal death-around 2%

A- Ask for help (experience, and skills necessary to use the instruments) , Anesthesia is needed. (A pudendal block may be appropriate )

and Anticipation of complications (e.g., shoulder dystocia,

postpartum ). Adequate Pelvis.

B- Bladder empty.

C- complete Asepsis.

D- Dilated cervix.

E- Episiotomy. F- Favorable presentation (vertex or

aftercoming head) G-

Gentle traction in the proper axis. Good uterine contraction.

H- Head is engaged

I- Informed consent.

M- Membranes are Ruptured.

N- Neonatal resuscitation trained Personnel are present.

The operators should choose the instrument most appropriate to the clinical circumstances and their level of skill.

RCOG audit standard says that “vacuum is the first choice of instrument for instrumental vaginal delivery”.

Consist of a silicone or metal cup connected by a tube

to a vaccum source.

cup is applied over the vertex

Operating pressure is

0.6_0.8kg/cm2

Maximum time of application

should be less than 15 minutes

Traction is applied at angle of 90 degree to the cup

Safe and gental traction is applied in concert with

uterine contraction and voluntary expulsive efforts

2 types Non rotational forceps e.g simpson

forceps_____ used when the head is in occipitoanterior plus or minus 15 degree

Rotational forceps e.g kielland forceps_____ used when when head is positioned greater than 15 degree from the vertical. They are designed for rotation.

By convention 1st left blade is inserted and then right one

The operator then articulates both the jaws and lock it.

Gental intermittent traction is applied in concert with uterine contraction and expulsive efforts of mother.

The axis of traction changes along with the j shape curve and as the head begins to crown the blades are directed vertical and head is delivered.

CAN BE USED FOR: After coming head of breech

Dead fetus.

Face presentation

1) Can be used with local anesthesia or with no anesthesia.

2) Can be used before full cx dilatation.

3) Can be used for rotation and extraction by single application.

4)Less traumatic to mother.

5) Less traumatic to fetal head.

6) less Compression and traction force (1/20th as compared to forceps)

7) Does not require additional space between tight fitting head and pelvis.

8)No special skill is neded.