Teachingmoduleoperativevaginaldelivery

Operative Vaginal Operative Vaginal DeliveryDelivery

District 1 ACOG Medical Student Teaching Module 2009

What: Direct traction on the fetal head with What: Direct traction on the fetal head with forceps or vacuumforceps or vacuum

Why: Indications for vacuum and forceps Why: Indications for vacuum and forceps are the same (see next slide)are the same (see next slide)

IndicationsIndications Maternal benefitMaternal benefit

Example: certain maternal cardiac conditions Example: certain maternal cardiac conditions (Eisenmenger’s, pulmonary HTN) or history of (Eisenmenger’s, pulmonary HTN) or history of aneurysm/strokeaneurysm/stroke

Concern for immediate/potential fetal Concern for immediate/potential fetal compromise compromise Example: prolonged terminal bradycardiaExample: prolonged terminal bradycardia

Prolonged 2Prolonged 2ndnd stage stage Nulliparous – no progress for 3 hrs w/epidural or 2 Nulliparous – no progress for 3 hrs w/epidural or 2

hours w/o epiduralhours w/o epidural Multiparous – no progress for 2 hrs w/epidural or 1 hr Multiparous – no progress for 2 hrs w/epidural or 1 hr

w/o epiduralw/o epidural

What Do I Need To Know Before What Do I Need To Know Before Attempting an Operative Delivery?Attempting an Operative Delivery?

Presentation Presentation (Cephalic/Breech)(Cephalic/Breech)

Position (i.e. occiput Position (i.e. occiput posterior, sacrum anterior)posterior, sacrum anterior)

Lie (longitudinal, oblique, Lie (longitudinal, oblique, transverse)transverse)

StationStation Presence of asyncliticismPresence of asyncliticism Clinical pelvimetryClinical pelvimetry AnesthesiaAnesthesia

ContraindicationsContraindications

GA < 34 weeks (contraindication for GA < 34 weeks (contraindication for vacuum due to risk of fetal IVH)vacuum due to risk of fetal IVH)

Known bone demineralization condition Known bone demineralization condition (e.g. osteogenesis imperfecta) or bleeding (e.g. osteogenesis imperfecta) or bleeding disorder e.g. VWD)disorder e.g. VWD)

Fetal head unengagedFetal head unengaged Position of fetal head unknownPosition of fetal head unknown

Vacuum-Assisted Vaginal DeliveryVacuum-Assisted Vaginal Delivery

Do not apply rocking motion or Do not apply rocking motion or torque, only steady traction in torque, only steady traction in the line of the birth canalthe line of the birth canal

Stop after: three “pop-offs” of Stop after: three “pop-offs” of vacuum, > 20 minutes elapsed, vacuum, > 20 minutes elapsed, three pulls with no progressthree pulls with no progress

After determining position of the head, (A) insert the cup into the vaginal vault, ensuring that no maternal tissues are trapped by the cup. (B) Apply the cup to the flexion point 3 cm in front of the posterior fontanel, centering the sagittal suture. (C) Pull during a contraction with a steady motion, keeping the device at right angles to the plane of the cup. In occipitoposterior deliveries, maintain the right angle if the fetal head rotates. (D) Remove the cup when the fetal jaw is reachable

Fetal Risks: VAVDFetal Risks: VAVD

Scalp lacerations: if torsion excessiveScalp lacerations: if torsion excessive Cephalohematoma: limited to suture Cephalohematoma: limited to suture

line line Subgaleal hematoma: crosses suture Subgaleal hematoma: crosses suture

lineline Intracranial/retinal hemorrhageIntracranial/retinal hemorrhage Hyperbilirubinemia/jaundiceHyperbilirubinemia/jaundice Higher incidence of Higher incidence of

cephalohematoma/retinal cephalohematoma/retinal hemorrhage/jaundice compared to hemorrhage/jaundice compared to forcepsforceps

Designed to detach if traction is excessive (but Designed to detach if traction is excessive (but can produce traction up to 50 lbs)can produce traction up to 50 lbs)

5% incidence serious complications5% incidence serious complications

Type of Forceps DeliveryType of Forceps Delivery Outlet forcepsOutlet forceps

scalp visible at introitus w/o separating labiascalp visible at introitus w/o separating labia fetal skull reached pelvic floor & head at/on perineumfetal skull reached pelvic floor & head at/on perineum sagittal suture in AP diameter or LOA, ROA, or posterior positionsagittal suture in AP diameter or LOA, ROA, or posterior position rotation does not exceed 45ºrotation does not exceed 45º

Low forcepsLow forceps leading point of fetal skull at >= +2, not on pelvic floorleading point of fetal skull at >= +2, not on pelvic floor rotation 45º or less (LOA/ROA to OA, or LOP/ROP to OP); or rotation 45º or less (LOA/ROA to OA, or LOP/ROP to OP); or

rotation greater than 45º.rotation greater than 45º. MidforcepsMidforceps

above +2 cm but head engagedabove +2 cm but head engaged High forcepsHigh forceps

head not engaged; not included in ACOG classificationhead not engaged; not included in ACOG classification not recommendednot recommended

Forceps-Assisted Vaginal DeliveryForceps-Assisted Vaginal Delivery

Identify & apply Identify & apply bladesblades

Place instrument in Place instrument in front of pelvis with tip front of pelvis with tip pointing up & pelvic pointing up & pelvic curve forwardcurve forward

Apply left blade, Apply left blade, guided by right hand, guided by right hand, then right blade with then right blade with left handleft hand

Lock bladesLock blades Should articulate with Should articulate with

easeease

FAVDFAVD

Check for correct applicationCheck for correct application Sagittal suture in midline of shanksSagittal suture in midline of shanks Cannot place more than one fingertip Cannot place more than one fingertip

between blade and fetal headbetween blade and fetal head Apply tractionApply traction

Steady, intermittentSteady, intermittent Downward, then upwardDownward, then upward Remove blades Remove blades

Risks: ForcepsRisks: Forceps

Maternal-Maternal- Injury (extension of episiotomy, vaginal/cervical lac)Injury (extension of episiotomy, vaginal/cervical lac) Postpartum hemorrhagePostpartum hemorrhage

Fetal-Fetal- TraumaTrauma

• Intracranial haemorrhage.Intracranial haemorrhage.• Cephalic haematoma.Cephalic haematoma.• Facial / Brachial palsy.Facial / Brachial palsy.• Injury to the soft tissues of face & forehead.Injury to the soft tissues of face & forehead.• Skull fractureSkull fracture

Use of Alternative InstrumentsUse of Alternative Instruments

Highest risk for injury is for combined Highest risk for injury is for combined forceps/vacuum extraction or cesarean forceps/vacuum extraction or cesarean delivery after failed operative deliverydelivery after failed operative delivery

The weight of available evidence is The weight of available evidence is against multiple efforts with different against multiple efforts with different instrumentsinstruments