OPERATIVE DELIVERY

Owahnah Sherene Quammie & Hilary Williams

Operative or instrumental vaginal delivery: Owahnah

Forceps delivery

Ventouse

Caesarean section: Hilary

ASSISTED VAGINAL DELIVERY The use of any surgical procedure to facilitate vaginal delivery

Uses traction to expedite delivery in second stage of labour

Used in prolonged 2nd stage to ↓ maternal/foetal death and/or complications

Both are equally effective in some cases and preference is largely based on clinician choice and experience

Assisted vaginal delivery

ForcepsVacuum

Extraction

MATERNAL

Exhaustion

Insufficient ‘pushing’- SCI

Health risk to pushing-

Cardiac/HTN

FOETUS

Fetal distress

• HR abnormalities

• Acidosis on FBS

• Meconium

Prolonged 2nd Stage

Nulliparous•3hrs + regional anaesthesia

•2hrs – regional anasthesia

Multiparous 2hrs + regional anaesthesia

1hr – regional anaesthesia

CRITERIA FOR INSTRUMENTAL VAGINAL DELIVERY 1

MOTHER

Consent from mother

Adequate anaesthesia/analgesia. Low forceps Perineal nerve block

Midforceps Epidural block, a pudendal nerve block or GA

Empty Bladder (catheterization)

Full cervical Dilation and Rupture of membranes (ROM)

Lithotomy position (legs separated, flexed, and supported in raised stirrups)

FOETUS

Fully engaged head (at spines or below) with no head palpable abdominally

Known position and attitude of foetal head (caput?)

Vertex presentation

FORCEPS: A BRIEF HISTORY 2

Controversial introduction into obstetric practice during 18th century Europe by the Chamberlen family

‘The labouring woman was blindfold lest she should see the “secret.”’

‘Only the Chamberlen’s were allowed in the locked lying-in room, from which the terrified relatives heard peculiar noises, ringing bells, and other sinister sounds as the

“secret” went to work’

Dr. Peter Chamberlen’s obstetric instruments 2

CASE: FORCEPS DELIVERY

A 28 year old nulliparous woman at term, has been in the 2nd stage of labour for over 3 hours. She initially didn’t want any anesthesia but decided on an epidural with good effect. Her contractions are regular averaging 3 in ten minutes

On vaginal examination the fetal head in in the OP position and just below the ischial spines. The consultant has discussed and consented the patient for a likely operational delivery

Which type of forceps delivery is indicated in this patient?

A. low cavity delivery with Wrigley’s forceps

B. Rotational forceps delivery with Keilland’s forceps

C. Mid-cavity delivery with Simpson’s forceps

LOW-CAVITY/OUTLET FORCEPS DELIVERY:WRIGLEY’S 3

Short and light

Used when the head is at the vaginal introitus but is being held back by the perineum OUTLET

Head has advanced beyond ischial spines LOW

Mother in lithotomy position

Bladder emptied/catheterised

Aseptic cleaning and draping of perineum

Adequate Analgesia (Pudendal + LA)

Assemble then insert forceps

Pelvic curve of forceps should be over the malar

aspect of baby’s head towards the cheeks

Traction in time with uterine contractions at an initial

angle of 60°

MID-CAVITY OUTLET FORCEPS DELIVERY:SIMPSON’S 3

Used when the sagittal suture is in the anteroposterior plane which is usually OA

If the head is not palpable abdominally but is at or just below level of ischial spines

Trial of Forceps- done in a theatre setting if risk of unsuccessful delivery to quickly transition to CS

Head position:

If OT then non-rotational forceps contraindicated

Use rotational forceps e.g. Keilland

a. Pelvic curvature

b. Cephalic curvature

c. Locking handles

ROTATIONAL FORCEPS DELIVERY:KEILLAND’S 4 Can be placed directly onto baby’s head if in OP for

gentle rotation into OA

The reduced pelvic curve allows rotation about the

axis of the handle

Delivery should ideally be done in theatre setting to

quickly perform CS if needed

Once rotated delivery continues as with mid-cavity

forceps

Successful use requires adequate skill and should only

be used by experienced obstetricians

Can be associated with ↑ injury to mother than with rotational

ventouse

a. No/slight pelvic

curvature

b. Cephalic curve

c. Sliding shanks

COMPLICATIONS

MATERNAL

Injury to vagina or cervix Haemorrhage (PPH)

↑ analgesic requirements

FOETAL

Foetal trauma

Cerebral compression

Cephalohaematoma

Skull fractures

Cervical spine injuries

Facial nerve palsy

Markings/indentations

Facial bruising/lacerations

CASE: FORCEPS DELIVERY

A 28 year old nulliparous woman at term, has been in the 2nd stage of labour for over 3 hours. She initially didn’t want any anesthesia but decided on an epidural with good effect. Her contractions are regular averaging 3 in ten minutes

On vaginal examination the fetal head in in the OP position and just below the ischial spines. The consultant has discussed and consented the patient for a likely operational delivery

Which type of forceps delivery is indicated in this patient?

A. low cavity delivery with Wrigley’s forceps

B. Rotational forceps delivery with Keilland’s forceps

C. Mid-cavity delivery with Simpson’s forceps

VENTOUSE

Developed by Malmström in 1954

First type of cup used was metal (M-CUP) but current models are made of plastic or silicone

Consists of a Cup with handle

Tube- attached to cup and to suction device

Theoretical advantage that less pelvic space is required in comparison to forceps

Not used before 36 Weeks

1. The cup placed in the midline overlying, or just anterior to, the posterior fontanelle in order to encourage flexion of the head

2. Held firmly against the scalp and low suction applied 100mmHgEnsure no vaginal skin is trapped beneath cup

3. Suction pressure increased to 500-600mmHg

Downward traction in time with uterine contractions and suction released between contractions

4. Procedure stopped if the cup detaches 3 times or there is no descent of the head

5. Episiotomy ideally avoided as perineum provides pressure on vacuum cup to keep attached to head

VENTOUSE DELIVERY1

If the head is in a transverse or posterior position a manoeuvrable cup, e.g. OmniCupis used as it allows accurate placement over the fexion point

The hard cups (e.g. Malmström,OmniCup) have a lower failure rate than the soft cups (e.g. Silc,

Silastic)

lower detachment rate, 13% versus 33%.

OmniCup vacuum extractor5

COMPLICATIONS

Maternal injury to reproductive tract PPH

Failed delivery more common with soft cups

Scalp lacerations

Chignon- temporary swelling post ventouse delivery

Cephalohaematoma- bleeding into scalp

Retinal haemorrhages

Subgaleal haemorrhage following poor application of the cup

Prolonged extraction

Multiple cup detachments and reatchments

FORCEPS VENTOUSE

Vaginal Delivery

↑ ↓

Caesarean Section ↑ ↓

Maternal Injury

Pain peri and post delivery

↑ ↓

Anaesthesia ↑ ↓

Cephalohaematomas

Subgaleal haemorrhage and

Retinal haemorrhages

↓ ↑

Neonatal morbidity ↔︎ ↔︎

Concerns over appearance

of baby

↓ ↑

1. Norwitz ER, Schorge JO. Obstetrics and Gynaecology at a Glance. 4th edition. Oxford: John Wiley and Sons. 2013

2. Dunn PM. The Chamberlen family (1560–1728) and obstetric forceps. Archives of Disease in Childhood - Fetal and Neonatal Edition 1999;81:F232-F234

3. Oats J, Abraham Suzanne. Fundamentals of Obstetrics and Gynaecology. 10th edition. Elsevier. 2017

4. Magowan BA, Owen P, Thomson A. Clinical Obstetrics and gynaecology. 3rd edition. Elselvier. 2014

5. Impey L, Child T. Obstetrics and Gynaecology. 4th edition. Oxford: John Wiley and Sons 2012

Delivery of baby through abdominal surgery

https://www.gponline.com/journals-watch-incontinence-sinusitis/article/11256521

WHO recommend only if medically necessary

Global rates doubled between 2003-2018: now 21%

Locally2:

28.500 deliveries in Welsh maternity units in 2017-18

27% by Caesarean section

1794, USA Mother & baby survived: Dr Jesse Bennett operates on wife3

1865, UK 85% mortality rate

Reduced through introduction of:

Aseptic surgery

Antibiotics

Anaesthesia,

Transfusion

Pfannensteil/Joseph Cohen cut

Placenta praevia (minor or major)

Abnormal lie –IECV

Pelvic deformity/cephalopelvic disproportion

Previous classical section3

Morbidly adherent placenta

Pre eclampsia

IUGR small baby with placental insufficiency

Concurrent HIV/HCV or third trimester maternal herpes

Mother anxious despite perinatal mental health support4

Relative:

Breech at 36 weeks4

Diabetes

Older nulliparous

Previous section

Elective: suit patient or staff

Classific

ation

Time limit Urgency Indication

Category

1

30 minutes imminent threat to life Abruption

Abnormal foetal heart rate

Cord prolapse

Scar rupture

Prolonged Bradycardia

Category

2

60/75(nice

is 75)

No immediate threat to life Failure to progress

Pathological CTG

Category

3

Scheduled Pre term: early not urgent Pre eclampsia

IUGR

Failed induction

Category

4

None Equates to elective Term breech

Maternal infection

Placenta praevia

Consent

VTE prophylaxis: TED stockings/LMWH/hydration

FBC to assess Hb.

H2 receptor agonist: gastric aspiration

Foleys catheter to drain bladder and minimise risk of damage

Tilt bed 15⁰ to ease pressure on IVC and reduce risk of hypotension

Clean and prepare skin: hair removal if necessary

Anaesthesia:

Spinal/epidural anaesthetic

Transverse abdominal incision*5

3 cm above pubic symphysis (Joseph Cohen)

Blunt opening of lower tissue layers using scissors not knife

Tear from either end of incision

Part rectus abdominus muscle

Reflect utero-vesicular peritoneum

Protect bladder using retractor

*Classical CS still used if adhesions/fibroids/anterior placenta praevia

Allow uterus to relax

Push on cervix (from vagina) to release head

Try to keep foetal head flexed and use flat of hand where possible

Insert balloon catheter to release vacuum if head remains engaged

Wrigleys forceps if head difficult5

Delay cord clamp 1 minute

Remove placenta

5IU oxytocin to contract uterus and minimise blood loss

Syntocinon helps to deliver placenta

IM ergometrine helps prevent PPH

Close uterus-secure corners first to close area around uterine arteries

Double suture uterus

Do not suture peritoneal layers

Close skin using suture

1:1 until airway safe if general anaesthetic has been given

Hourly observations if opioid analgesia given, otherwise 2 hourly

Remove catheter 12 hours post epidural

Analgesia: diamorphine

Vigilance re pyrexia, wound dehiscence/infection

Early mobilization to reduce VTE risk

2% risk foetal laceration

9/1000 women need HDU/ITU care postoperatively

Mortality 1/5000

4% women experience stress incontinence following C-section4

8% infection: endometritis/UTI/Wound

VTE

G1+1 P1. 38 weeks

Previous forceps delivery following induction-18 months ago

Normal labour, reassuring CTG

Twin one born by spontaneous vaginal delivery

Syntocinon administered 45 minutes later. Dose increased to maximum

Contractions slow

What happens next? A. Natural delivery B. Operative vaginal C. C-section?

1. https://www.gponline.com/journals-watch-incontinence-sinusitis/article/1125652

2. Http://gov.wales/statistics-and-research/maternity-statistics/?lang=en

3. http://content.time.com/time/magazine/article/0,9171,815000,00.html

4. NICE guidance https://www.nice.org.uk/guidance/cg132/chapter/1-Guidance#ftn.footnote_2

5. http://www.wisdom.wales.nhs.uk/sitesplus/documents/1183/Caesarean%20Section%20Techniques_ABMU%20Maternity%20Guideline%202018.doc.pdf

6. Abdominal surgical incisions for caesarean section. Cochrane Database Syst Rev. 2007 Jan 24; (1):CD004453. Epub 2007 Jan 24. [Cochrane Database Syst Rev. 2007]

7. Hacker and moore's essentials of obstetrics and gynecology, 5th ed. (2009, 06). Scitech Book News, 33 Retrieved from https://search.proquest.com/docview/200159257?accountid=14680