OPERATIVE VAGINAL DELIVERY

VACUUM ASSISTED DELIVERY

Fetal Indication – evidence of fetal compromise requiring immediate delivery
Maternal Indications
>failure to deliver spontaneously following appropriate management of second stage
>maternal medical conditions (ie heart disease) where pushing is contraindicated
>maternal exhaustion

Contraindications:
Absolute – non vertex, face or brow presentation, unengaged vertex, incompletely dilated cervix, clinical evidence of
CPD
Relative – preterm less than35 weeks or EFBW < 2500 g, midpelvic station, unfavorable attitude of the head

Prerequisites:
Informed consent
Vertex presentation
Engaged vertex
Term fetus
EFW > 2500 g
Fully dilated cervix
Ruptured membranes
Adequate clinical pelvimetry
Empty maternal bladder
Appropriate analgesia, if available
Adequate facilities and back-up available
Healthcare provider knowledgeable of the procedure
Ongoing fetal and maternal assessment

Technique:
INFORMED CONSENT!!!
A Anesthesia assistance
B Bladder empty
C Cervix fully dilated, membranes ruptured
D Determine position, station, pelvic adequacy
E Equipment (vacuum cup, pump, tubing); check pressure
F Fontanelle (position cup of over posterior fontanelle), swip finger around cup to clear maternal tissue
G Gentle Traction (100 mmHg initially between contractions); pull with contractions (600 mmHg)
With maternal expulsive efforts; Initially downward then upward (pelvic curvature)
H Halt if no progress with THREE aided contraction, Vacuum pops off three times, no significant progress after
20 MINUTES
I Incision (consider episiotomy if laceration imminent)
J Jaw; Remove vacuum when JAW is reachable or delivery assured

CHECK FOR VAGINAL AND CERVICAL LACERATIONS. MANAGE ACCORDINGLY IF PRESENT

Complications:
FETAL – scalp edema, cephalhematoma (requires observation), scalp abrasions (common and harmless), lacerations
(clean and inspect if require suturing), Intracranial bleeding (extremely rare)
MATERNAL – genital tract tears/lacerations
FORCEPS ASSISTED VAGINAL DELIVERY
Functions: Traction, Rotation, Flexion, Extension

Indications: similar to vacuum, but forceps may be used when there is suboptimal attitude of the fetal head

Contraindications:
Absolute – non vertex, face or brow presentation, unengaged vertex, incompletely dilated cervix, clinical evidence of
CPD, any contraindication to vaginal delivery
Relative – preterm less than35 weeks or EFBW < 2500 g, midpelvic station,

Prerequisites:
Informed consent
Engaged head
Fully dilated and retracted cervix
Ruptured membranes
Exact position of the head determined
Adequate clinical pelvimetry
Empty maternal bladder
Appropriate analgesia, if available
Adequate facilities and back-up available
Healthcare provider knowledgeable of the procedure
Ongoing fetal and maternal assessment

Technique:
INFORMED CONSENT!!!
A Anesthesia assistance
B Bladder empty
C Cervix fully dilated, membranes ruptured
D Determine position, station, pelvic adequacy; think possible shoulder dystocia
E Equipment; verify quality and functionality of equipment
F Forceps (phantom application)
-Left blade, left hand, maternal left side, pencil grip and vertical insertion, with right thumb directing blade
-right blade, righ hand, maternal right side, pensil grip and vertical insertion with left thumb directing blade
-lock blade and support, and check application
-posterior fontanelle 1 cm above the plane of shanks
-Fenestration no more than a fingerbreadth bweteen it and scalp
-sagittal suture perpendicular to plane of shanks with occipital sutures 1 cm above respective blades
G Gentle Traction - applied with contractions materrnal expulsive efforts
H Handle Elevated – traction in axis of birth canal; do not elevate handle too early
I Incision (consider episiotomy if laceration imminent)
J Jaw; Remove vacuum when JAW is reachable or delivery assured

FORCEPS FAILURE: fetal head does not advance with each pull, fetus undelivered after 3 pulls or with no descent after 30
minutes

Complications:
FETAL – injury to facial nerves (requires observation, self-limiting); lacerations of the head and face; fractures of the face
and skull (requires observation)
MATERNAL – genital tract tears/laceration; UTERINE RUPTURE may occur and require immediate treatment

OUTLET FORCEPS:
-scalp is visible at the introitus without separating the labia
-fetal skull has reached the pelvic floor
-sagittal suture in AP diameter, right or left occiput anterior or posterior position (</- 45 degrees)
-fetal head is at or on the perineum

LOW FORCEPS:
-head is at station +2 or lower
-two subdivisions: rotation of >/-45 deg, rotation of </- 45 degrees

MID FORCEPS:
-head is engaged at station 0 to +1
-leading position of the skull is above station +2

CHECK FHTs AND APPLICATION OF FORCEPS BETWEEN CONTRACTIONS!!!

FORCEPS DELIVERY WITH GENITAL TRACT LACERATION

28 year old G2P1(1001), 38 weeks AOG unremarkable medical history and PNCU, came it at 3-4 m, fully effaced, station
-3, intact BOW
Dx: PU 38 weeks AOG, CIL, G2P1(1001)

Handout: At the 8th hour of labor, fully effaced and fully dilated for 2 hours at station +3, ROA position, FHT 90-100 bpm

Management: OUTLET FORCEPS DELIVERY (If all prerequisites are met)

Handout: Forceps done. BW = 3.8kg, BP =80/60, HR 100, pale, cold and clammy, midline episiotomy with minimal
bleeding, 2 cm laceration at the right vaginal wall, cervical laceration at the 9 0’clock position, the edge of which cannot
be appreciated, mass felt at the right posterior fornix.

Etiology (give 4):

Big Baby
Operative Vaginal delivery (Forceps)
Oxytocin Use – uncertain
Congenital uterine anomaly – walls become too thin during pregnancy and delivery
Inadequate Episiotomy

Diagnosis: Postpartum Hemorrhage secondary to Genital Tract Laceration, with Broad Ligament Hematoma
Management:
Check Maternal ABCs
Intravenous Hydration using crystalloids
Prepare and Transfuse Blood Products
Ensure asepsis and antisepsis
Examine extent of laceration
Provide pain relief appropriate for the severity of the repair
(If accessible, repair cervical laceration by grasping the cervix at either side of the tear with ring forceps. Start suture
from the apex of the tear using uninterrupted continuous suturing.)
Emergengy Exploratory Laparotomy since the edge of the tear cannot be appreciated (possible uterine extension with
uterine artery injury – broad ligament hematoma) – repair of laceration, possible hysterectomy
Broad spectrum antibiotics (Ampi, Genta, plus metronidazole)