Operative Vaginal Delivery

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Operative Vaginal Delivery
District 1 ACOG Medical Student Teaching Module
2009
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• What Direct traction on the fetal head with
  forceps or vacuum
• Why Indications for vacuum and forceps are the
  same (see next slide)

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Indications

• Maternal benefit
• Example certain maternal cardiac conditions
  (Eisenmengers, pulmonary HTN) or history of
  aneurysm/stroke
• Concern for immediate/potential fetal compromise
• Example prolonged terminal bradycardia
• Prolonged 2nd stage
• Nulliparous no progress for 3 hrs w/epidural or
  2 hours w/o epidural
• Multiparous no progress for 2 hrs w/epidural or
  1 hr w/o epidural

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

• Presentation (Cephalic/Breech)
• Position (i.e. occiput posterior, sacrum
  anterior)
• Lie (longitudinal, oblique, transverse)
• Station
• Presence of asyncliticism
• Clinical pelvimetry
• Anesthesia

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Contraindications

• GA lt 34 weeks (contraindication for vacuum due to
  risk of fetal IVH)
• Known bone demineralization condition (e.g.
  osteogenesis imperfecta) or bleeding disorder
  e.g. VWD)
• Fetal head unengaged
• Position of fetal head unknown

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Vacuum-Assisted Vaginal Delivery

• Do not apply rocking motion or torque, only
  steady traction in the line of the birth canal
• Stop after three pop-offs of vacuum, gt 20
  minutes elapsed, three pulls with no progress

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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
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Fetal Risks VAVD
Designed to detach if traction is excessive (but
can produce traction up to 50 lbs) 5 incidence
serious complications

• Scalp lacerations if torsion excessive
• Cephalohematoma limited to suture line
• Subgaleal hematoma crosses suture line
• Intracranial/retinal hemorrhage
• Hyperbilirubinemia/jaundice
• Higher incidence of cephalohematoma/retinal
  hemorrhage/jaundice compared to forceps

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Type of Forceps Delivery

• Outlet forceps
• scalp visible at introitus w/o separating labia
• fetal skull reached pelvic floor head at/on
  perineum
• sagittal suture in AP diameter or LOA, ROA, or
  posterior position
• rotation does not exceed 45º
• Low forceps
• leading point of fetal skull at gt 2, not on
  pelvic floor
• rotation 45º or less (LOA/ROA to OA, or LOP/ROP
  to OP) or rotation greater than 45º.
• Midforceps
• above 2 cm but head engaged
• High forceps
• head not engaged not included in ACOG
  classification
• not recommended

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Forceps-Assisted Vaginal Delivery

• Identify apply blades
• Place instrument in front of pelvis with tip
  pointing up pelvic curve forward
• Apply left blade, guided by right hand, then
  right blade with left hand
• Lock blades
• Should articulate with ease

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FAVD

• Check for correct application
• Sagittal suture in midline of shanks
• Cannot place more than one fingertip between
  blade and fetal head
• Apply traction
• Steady, intermittent
• Downward, then upward
• Remove blades

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Risks Forceps

• Maternal-
• Injury (extension of episiotomy, vaginal/cervical
  lac)
• Postpartum hemorrhage
• Fetal-
• Trauma
• Intracranial haemorrhage.
• Cephalic haematoma.
• Facial / Brachial palsy.
• Injury to the soft tissues of face forehead.
• Skull fracture

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Use of Alternative Instruments

• Highest risk for injury is for combined
  forceps/vacuum extraction or cesarean delivery
  after failed operative delivery
• The weight of available evidence is against
  multiple efforts with different instruments