assisted vaginal delivery gl788 · 1. all operative vaginal deliveries will be carried out by or...

Author P Bose, Christine Harding Date December 2018

Job title Consultant Obstetrician, Consultant Midwife Review Date December 2020

Policy Lead Group Director Urgent Care Version V7.0 ratified 7/12/18

Destination Policy hub/ Clinical/ Maternity/ Intrapartum/ GL788

This document is valid only on the date last printed of 11

Assisted vaginal delivery – GL788

Approval

Approval Group Job Title, Chair of Committee Date

Maternity & Children’s Services Clinical Governance Committee

Chair, Maternity Clinical Governance Committee

7th December 2018

Change History

Version Date Author, job title Reason

6.1 Oct 2017 S Fleming, Practice Educator

Live changes following RCA to reinforce good clinical practice and pause to count swabs when new packs opened or additional clinician takes over and ensure witnessed by nominated checker and documented pg 3 Procedure (7) added

pg 4 Forceps bullet point 1 added

pg 5 Post-delivery procedure bullet point 1 & 3 clarified

6.2 May 2018 Baljinder Chohan Pg 9 – Appendix 2 updated with amended proforma which adds Carbetocin to post-delivery options

7.0 Oct 2018 P Bose, C Harding Reviewed - changes throughout to reflect current practice (pages 2, 3, 5 & 6) Appendix 1 updated, appendix 3 updated & Appendix 4 Instrumental checklist added






Assisted Vaginal Delivery (GL788) December 2018

Overview: Operative vaginal delivery rates within this Trust are between 12-18%. There is potential for maternal and fetal morbidity with assisted vaginal deliveries, in particular rotational instrumental deliveries. Therefore, a safe approach is needed to minimize the risks associated with instrumental deliveries.

Assisted vaginal deliveries should only be performed by suitably trained medical staff at Consultant or Registrar level. Approved, experienced SHO’s, ST1s & ST2s, should gain the consent and supervision of the senior Registrar or consultant on call.

Indications for Assisted Vaginal Delivery (normal)

Fetal acute fetal distress

Prolapsed cord (at 9cm (ventouse only) or full dilatation)

Maternal Maternal fatigue/exhaustion

To minimise maternal effort, e.g. severe hypertension, cardiac disease, potential intra-

cranial bleed

Inadequate progress

o Nulliparous: lack of continuing progress with 2 hours of active pushing Multipara: lack of continuing progress with 1 hour of active pushing

Indications for Assisted Vaginal Delivery (exceptional)

Delivery of second twin

After coming head of breech (forceps use only)

Suspected CPD - where it is thought that the woman has a pelvis with a high angle of inclination.

Incompletely dilated cervix (ventouse only) e.g. 9 cm with cord prolapse, but only after consultation with the Consultant on call

Contra-Indications

Large fetus

Head > 1/5 abdominally palpable

Incompletely dilated cervix

Malpresentation

Late decelerations if not fully dilated

Inadequate analgesia

Unknown position of fetal head

Un-ruptured membranes

< 36 weeks gestation (ventouse only)

Poor uterine activity

Maternal blood-borne viral infections e.g. HIV, Hepatitis B & C (avoid difficult assisted delivery)

Lack of consent from the motherPrior scalp blood sampling, unless benefits outweigh risks (ventouse only)

Suspected fetal coagulopathy (unless benefits outweigh risks)

Fetal predisposition to fractures (e.g. osteogenesis imperfecta)







Procedure (preparation)

1. Operator should be skilled and experienced enough to use the instrument of their choice and manage complications that may arise

2. Assisted deliveries that have a higher rate of failure should be conducted in theatre with quick recourse to a Caesarean section, such as deep transverse arrests or heads in occipital posterior position.

3. Informed written/oral consent must be obtained from the mother with explanation of the procedure, together with the mention of temporary chignon/forceps marks

4. Inform midwifery staff of intended procedure. A second person should be invited into the room with the mothers agreement to aid the responsible midwife

5. Complete the assisted vaginal delivery checklist (see appendix)

6. Neonatal resuscitaire in room and checked and ready for use

7. Ensure neonatal staff called to attend all Assisted Vaginal deliveries if there is evidence of fetal distress, thick meconium present or there is a plan for paediatrician to be present at delivery.

8. Perform instrument and swab count with an appropriate witness. It is the responsibility of the clinician undertaking the delivery to ensuring the count is done and correct

9. Ensure adequate analgesia (epidural/spinal +/- local infiltration, make sure patient can still push)

10. Palpate abdomen to check fetal lie, size and engagement of head

11. Place patient in lithotomy position

12. Aseptic technique

13. Confirm full dilatation & position of head on vaginal examination

14. Empty bladder







Procedure (application & traction)

Ventouse

1. Apply kiwi or silk cup by compressing vertically and inserting through introitus

2. Check vaginal skin not trapped between cup and head

3. Position cup such that centre of the cup is 3 cm in front of posterior fontanelle and equally across Saggital suture

4. Establish negative pressure to 0.2 bar and exclude entrapment of maternal tissue

5. Increase pressure to 0.8 bar

6. Do not pull before full negative pressure established

7. Recheck that vaginal skin is not trapped

8. Pull only during contraction

9. Encourage patient to push

10. Apply traction in axis of birth canal (remember it changes as delivery proceeds)

11. The head will rotate spontaneously if necessary

12. Use index finger or thumb of non-pulling hand to confirm fetal head descent

If the cup puckers before coming off, reduce traction under these circumstances.

Make an episiotomy if necessary

Relieve negative pressure once the head is delivered

Remove cup gently

Complete delivery and take cord bloods

Take a formal pause to perform swab and instrument count with an appropriate witness.

Forceps

Perform instrument and swab count with an appropriate witness. It is the responsibility of the clinician undertaking the delivery to ensuring the count is done and correct.

Check forceps are a matched pair

Ensure uterus relaxed before applying forceps

Apply left blade first with one hand guiding blade in while other protects maternal tissues, followed by right blade

Blades should lock easily, adjacent to the Lamboidal sutures and equi-distance from them on each side

If blades do not lock remove them and reassess presenting position

Once locked and during a contraction, dominant hand should apply traction along axis of forceps while second hand applies downward pressure on shank

Episiotomy should be done once perineum has thinned out and delivery imminent







Procedure (giving up)

1. Failure to deliver head after 3 pulls/15 minutes

2. No descent of head after appropriate placement and traction on forceps

3. Deteriorating fetal heart rate patterns and delivery not imminent

4. The cup pulling off

N.B. Sequential instrument use should be avoided if possible and is only indicated if use of the first instrument has led to descent of the head/rotation, and a second instrument is required for lift out. If the head is on the perineum, the risk of Caesarean section is greater than completing delivery vaginally.

RISKS - Potential fetal trauma

Examine baby’s scalp for trauma and note any abrasions in the neonatal record and complete an incident form and provide diagrammatic detail on pre-printed proforma – Injury to baby at delivery (see Appendix 1)

Chignon

Cephalohaematoma

Sub-galeal haemorrhage (can be life threatening) Refer to Paediatrician

Severe trauma – take photographs and keep copies in the maternal notes

Post delivery procedure

1. Check swab and instrument count before disposing of pack, ensuring instruments and swabs are counted with another member of staff. If any item is missing appropriate action should be taken. Details should be recorded on Instrumental checklist (Appendix 4)

2. Ensure paired cord blood samples are taken and review the results. Ensure results documented in the mother’s notes on reverse of partogram and the print out stored in brown intrapartum envelope. Inform paediatrician of abnormal results (see FBS/ paired cord blood sampling guideline GL839).

3. Record blood loss volume at delivery by weighing all swabs and incos, assessing blood loss in conical drape. Take into account liquor

4. If perineal suturing required, remove forceps pack, remove inco pads and replace with clean pads, rescrub and open sterile suture pack. Ensure pre-procedure swab and instrument count is performed. Repair perineal trauma under aseptic techniques. After procedure dispose of all sharps appropriately and count swabs and instruments with another member of staff, clear away pack and make mother clean and comfortable

5. Record blood loss volume during third stage and suturing by weighing all swabs and incos and add this volume to the total assessed immediately following the delivery

6. Document delivery details on Assisted Delivery page in maternal notes or on the K2 electronic patient record

7. Document perineal repair details on Perineal Repair page or on the K2 electronic patient record

http://www.royalberkshire.nhs.uk/Downloads/GPs/GP%20protocols%20and%20guidelines/Maternity%20Guidelines%20and%20Policies/Intrapartum/FBS%20guideline_V8.0_GL839.pdf

http://www.royalberkshire.nhs.uk/Downloads/GPs/GP%20protocols%20and%20guidelines/Maternity%20Guidelines%20and%20Policies/Intrapartum/FBS%20guideline_V8.0_GL839.pdf







8. Prescribe regular analgesia and stool softeners as appropriate

9. Assess for need for thromboprophylaxis and prescribe as necessary

10. Debrief parents and offer a postnatal appointment to discuss consequences for future deliveries if appropriate

11. Fill incident form if required (e.g. third/fourth degree tear, PPH, fetal scalp trauma)

12. Replace urinary catheter if spinal/epidural. Ensure appropriate bladder care regime instituted. After any assisted delivery the catheter should remain in place for 12 hours or until mobility and pelvic floor control are assessed positively (See guideline Bladder care for women with epidural anaesthesia GL793)

13. Ensure mother given patient information leaflet on assisted vaginal delivery, perineal repair and that this is documented in the maternity notes

14. If possible the surgeon should review the woman on the postnatal ward

15. Ensure postnatal follow up in specific circumstances, e.g. third/fourth degree tear, fetal trauma

Auditable standards:

1. All operative vaginal deliveries will be carried out by or under the supervision of an obstetric registrar, ST3-ST7, consultant or staff grade.

2. An assessment prior to performing the procedure and the indication for the operative vaginal delivery will be documented in the Operative Vaginal Delivery form and filed in the maternity health records.

3. Effectiveness of anaesthesia will be checked before starting the operative vaginal delivery procedure. This delivery will be documented in the Operative Vaginal Delivery form and filed in the maternity health records.

4. Informed consent will be obtained for all operative vaginal deliveries. This will be documented and filed in the maternal health record.

5. The Operative Vaginal Delivery form will be fully completed for all assisted vaginal deliveries.

6. Sequential instruments will be used only if the risk of CS is greater than completing delivery vaginally. This will be documented in the Operative Vaginal Delivery form and filed in the maternity health record

7. All attempt of operative vaginal deliveries will be abandoned if:

Failure to deliver head after 3 pulls or after 15 minutes, or

No descent of head after correct placement and traction on forceps, or

Deteriorating FHR patterns and delivery not imminent

The cup pulling off

This will be documented in the Operative Vaginal Delivery form and filed in the maternity health records

8. Analgesia will be prescribed post delivery following all operative vaginal deliveries

9. All women undergoing an operative vaginal delivery will have the bladder emptied prior to procedure and a bladder catheter sited post procedure for at least 12 hours.

http://www.royalberkshire.nhs.uk/Downloads/GPs/GP%20protocols%20and%20guidelines/Maternity%20Guidelines%20and%20Policies/Intrapartum/Bladder_Care_for_women_with_epidural_analgesia_V4.0_GL793.pdf

http://www.royalberkshire.nhs.uk/Downloads/GPs/GP%20protocols%20and%20guidelines/Maternity%20Guidelines%20and%20Policies/Intrapartum/Bladder_Care_for_women_with_epidural_analgesia_V4.0_GL793.pdf







This will be documented in the Operative Vaginal Delivery form and filed in the maternity health records

10. The urgency and timing of all operative vaginal deliveries will be classified by completing the “operative delivery in theatre” sticker (see appendix 3) and it will be attached to the maternal health records.

References

1. Royal College of Obstetricians & Gynaecologists. Green top guideline 26: Operative vaginal delivery (2011)

2. National Institute for Health & Clinical excellence. (2015). Routine postnatal care of women and their babies (CG37). London: NICE

3. National Institute for Health & Clinical Excellence. (2014). Intrapartum care: Care of healthy women and their babies (CG190). London: NICE.

Appendix 1 – Injury to baby at delivery


Appendix 2 – Operative Vaginal Delivery Record


Appendix 3 – Operative delivery stickers


Appendix 4 - Instrumental delivery checklist


assisted vaginal delivery gl788 · 1. all operative vaginal deliveries will be carried out by or...

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