Pathologic Obstetrics Page 1 of 4

OPERATIVE VAGINAL DELIVERY

Sources: August 2020 Lecture, William’s 25th Edition

Kielland Forceps - Characteristic features:

OPERATIVE VAGINAL DELIVERY
> Sliding lock
 Accomplished with the use of 2 instruments: > Minimal pelvic curvature
o Forceps > Light weight
o Vacuum Extractor - Used for rotation of Occiput Posterior to OA
- Transverse arrest
Barton Forceps - Good forceps for rotation of head in transverse arrest.

Piper Forceps - Blade is similar to Simpson forceps (fenestrated)

- Shank is longer (to accommodate fetal body)
- It has a double pelvic curve to facilitate application to
the aftercoming head in breech presentation.
 Both function to augment maternal pushing to deliver the fetus vaginally.
 Therefore, both are used to extract the baby, which is its most important
function – TRACTION.
 The forceps has another function: Fetal Head Rotation INDICATIONS FOR FORCEPS & VACUUM DELIVERY
o Particularly from occiput transverse and posterior positions.
Fetal Indications Maternal Indications
1. Premature separation of placenta 1. Heart disease
2. Non-reassuring FHR pattern 2. Hypertensive condition
FORCEPS
3. Pulmonary injury or compromise
4. Intrapartum infection
Design of Forceps
5. Neurologic condition
 Consist of two metal crossing branches.
6. Exhaustion*
 It has 4 components:
7. Prolonged second stage*
o Blade – enclose the head, may be fenestrated or solid
*most common
o Shank – connects the handle and the blade
 A general principle in OVD: it’s done from either a LOW OR OUTLET station
o Lock – holds the forceps together
 ELECTIVE forceps or vacuum delivery may be performed when the criteria
o Handle – to grip the forceps
for an OUTLET delivery have been met.
 It has 2 curves:
o Cephalic curve – conforms to the shape of the fetal head.
 When do we apply these instruments?
o Pelvic curve – corresponds more or less to the axis of the birth canal.
o When we decide to apply these instruments, there should be a reason
 Some varieties are fenestrated or pseudofenestrated to permit a
firmer hold on the fetal head. for it – THEREFORE THERE SHOULD BE AN INDICATION because OVD
 Fenestrations reduces the degree of head slippage during forceps has its inherent risks – with maternal and neonatal morbidity.
rotation. However, it can increase friction between the vaginal wall
and the blade.  If it is technically feasible and can be safely done, the use of these instruments
is to terminate the 2nd stage of labor in any condition that threatens the mother
 In general, fenestrated blades are used for a fetus with a molded
head or for rotation. or fetus.

Types of Forceps CLASSIFICATION OF INSTRUMENTAL DELIVERIES

 Applies to both forceps and vacuum delivery,

Simpson Forceps - Most common forceps with cephalic and pelvic curve
- Components:
> Parallel shanks
> Fenestrated blade
> Wide shank in front of the English-style lock
> English lock – consists of a socket located on the
shank at the junction with the handle, into which fits
a socket similarly located on the opposite shank.
- Used to deliver fetus with molded head (nulliparous)
Tucker-Mclane - Blade is solid and the shank is narrow.
Forceps - Method of articulation: English lock
- Used to deliver fetus with rounded head (multiparous)
 This classification emphasizes the 2 most important discriminators of risk for
both the mother & fetus: STATION and ROTATION
o What does this mean? When the procedure is performed with a lower
station and a lesser degree of rotation, then this is a safer procedure.
Procedure Criteria
Outlet Scalp is visible at introitus without separating the labia
Fetal skull has reached pelvic floor
Sagittal suture is in AP diameter or right or left OA or OP position
Fetal head is at or on the perineum
Rotation does not exceed 45 degrees
Low Leading point of fetal skull is at station ≥+2 cm, and not on pelvic
(2 types) floor, AND:
 Rotation is 45 degrees or less (Left or right OA to OA, or
left or right OP to OP), or;

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Patho-OB: Disorders of AF, Placenta and Fetal Membranes
 Rotation is greater than 45 degrees  Sequential Instrumentation – is differentiated from trial of OVD because it is:
Midpelvic Station above +2 cm but head is engaged o An attempt at vacuum extraction followed by forceps application
Station is between 0 and +2 cm o Significantly increases fetal trauma
High NOT included in classification o ACOG recommends against its practice.
Instruments are applied above 0 station
FORCEPS BLADE APPLICATION & DELIVERY
Review of Fetal Head Station and Position
 The forceps blades grasp the fetal head and are applied according to the fetal
 Fetal Head Position:
head position.
o Vertex presentation landmark is posterior fontanel / occiput
 If the head is at OA, such as in the image, 2 or more fingers of the right hand
 OA  Posterior fontanel (triangular fontanel) is directly beneath
are introduced inside the left posterior portion of the vulva and then into the
the symphysis pubis
vagina beside the fetal head.
 OP  Posterior fontanel is at the sacrum
o To make it simple, the left branch of the forceps is held by the left hand,
 OT  Sagittal diameter is at the level of the transverse diameter of
inserted I the left side of the mother, guided by the right hand of the
the pelvis and the posterior and anterior fontanels occupy either
clinician.
the left or right maternal parts.

 Fetal Head Station: Landmark is ischial spine

o Station 0 – leading point of fetal skill is at the level of the ischial spine
o Station +1,2,3 – 1 / 2 / 3 cm BELOW the ischial spine
o Station -1,2,3 – 1 / 2 / 3 cm ABOVE the ischial spine

PREREQUISITES FOR APPLICATION

 Once the station and position are assessed, several pre-requisites must be
met before application of operative vaginal delivery.
 Classification for the vacuum delivery system is the same as for forceps
EXCEPT that vacuum is used for traction but not rotation.
 Forceps, but not vacuum extractor, may be used for delivery of a face
presentation with mentum anterior.
 Piper forceps may be used to deliver the head during breech delivery.
 Bladder is emptied to provide additional space & to minimize bladder trauma.
o Usually, patients are catheterized.
 Adequate Anesthesia:
o Low or Midpelvic  Regional analgesia or general anesthesia preferable
o Outlet  Pudendal blockade may be adequate
 For vacuum extraction, fetuses should be at least 34 weeks gestation and
fetal scalp blood sampling should not have been recently performed.
 (In the image) The fetus is presenting as vertex with OA position.
 The application of the left blade of the Simpson forceps is shown.
 2 or more fingers of the right hand introduced inside the left posterior portion
of the vulva and then into the vagina beside the fetal head.
 The blade tip is then gently passed in the vagina between the fetal head and
palmar surface of fingers of the right hand.
o Notice that with each blade the thumb of the right hand is positioned
behind the heel and most of the force comes from the thumb.
 Next, the right blade is applied in the same way and the blades are articulated
and locked. Articulation is easy with correct application.
 If the head is in LOA or ROA, then the lower of the 2 blades are placed first.

TRIAL OF OVD
Principles to Remember
 The biparietal diameter of the fetal head corresponds to the greatest
• An attempt to perform an operative delivery that is expected to be difficult
distance between the appropriately applied blades.
• Performed in the operating room where an immediate Cesarean section
TRIAL may be performed  The head of the fetus is perfectly grasped only when the long axis of
the blades corresponds to the occipitomental diameter.
• Trial of forceps
o When the blades are along the OM diameter, the major portion
• If cannot be satisfactorily applied, procedure is stopped. of the blade is lying over the face.
FORCEPS  Applied as such, the forceps should not slip, and traction may be
applied most advantageously.
• With vacuum, the fetus should descend with traction.  With most forceps, if one blade is applied over the brow and the other
• IF NOT then cesarean delivery is performed.
VACUUM over the occiput, the instrument cannot be locked, or if locked, the
OR CS blades slip off when traction is applied.
o Suboptimal blade placement can increase morbidity.

 Factors associated with failure of OVD:

o Disproportion; birthweight > 4000 grams
o Malposition: persistent occiput posterior
o Premature interference

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Patho-OB: Disorders of AF, Placenta and Fetal Membranes
DELIVERY OF LEFT OCCIPUT ANTERIOR FACE PRESENTATION
 Forceps have been locked.  Mentum anterior  delivered by forceps
 Vertex is rotated from left occiput anterior to occiput  Blade application along the occipitomental diameter
anterior (arrow).  Downward traction until the chin appears under the symphysis pubis
 Lower blade is typically inserted first.  Upward movement until the face is extracted, nose, eyes, brow and occiput.

 The vertex is now occiput anterior & the forceps are  With a mentum posterior, the forceps should not be applied because vaginal
symmetrically placed & articulated. delivery is impossible EXCEPT in very small fetuses.
o Therefore the route of delivery for these fetuses is CS.
TRACTION  The vacuum of course is not applied to the face.
 When it is certain that the blades are properly
placed, gentle intermittent downward and MORBIDITY
outward traction is exerted until the perineum
begins to bulge.
MATERNAL
 As the vulva is distended by the occiput, an
episiotomy may be performed if indicated.  Morbidity is related to the ease of delivery
 Traction should be intermittent, with the head  Morbidity is compared to CS because the alternative to indicated OVD is CS.
allowed to recede between contractions  Lacerations: higher degree; vaginal and cervical lacerations – to decrease:
 Apply traction only with each uterine contraction. o Indicated episiotomy: mediolateral episiotomy is protective
 Maternal pushing augments traction. o Early disarticulation of forceps, with cessation of maternal pushing
during disarticulation
 Upward traction (arrow) is applied as the head o Manual or forceps rotation of an OP to an OA, then traction delivery
is delivered. Forceps may be disarticulated after  Pelvic floor disorders
head is delivered. o Urinary incontinence: Higher parity and vaginal delivery are risk factors
o Keeping the forceps in place increases the o Anal incontinence: Caused by higher order episiotomy
likelihood of laceration or necessitate a
large episiotomy. PERINATAL
 Acute perinatal injury
o More frequent with OVD than CS or NSD
o More common with vacuum extraction:
 (In the picture) Forceps have been disarticulated  Cephalhematoma
and removed, and modified Ritgen maneuver is  Neonatal jaundice
used to complete delivery of the head.  Shoulder dystocia
o Allows fetal head extension  Clavicular fractures
 Scalp lacerations
OCCIPUT POSTERIOR POSITIONS o Similar maternal and neonatal morbidities with rotational OVD and
 The small occipital fontanel is directed toward one of the sacroiliac performance of 2nd stage CS
synchondroses. Head often imperfectly flexed. o Explained by forces exerted and angle of traction for shoulder dystocia
 Options for delivery:  Studies on long term infant morbidity are reassuring  Regardless of delivery
o Spontaneous delivery mode, rates of physical or cognitive impairments are similar.
o Rotation to OA manually or with forceps
o Delivered OP with forceps or vacuum, which is safest to be done if
manual rotation cannot be achieved VACUUM EXTRACTION
 Larger episiotomy needed  larger fetal head diameter will go out perineum.
 Newborns delivered OP higher Erb and facial nerve palsies  Benefits over forceps:
 With OP delivery, downward and outward traction is applied until the base of o Simpler requirements for positioning.
the nose passes under the symphysis, then the hands are gradually elevated o Avoidance of space–occupying blades within the
until the occiput gradually emerges over the perineum; then downward vagina  lesser maternal morbidity
traction again until the nose, mouth, and chin emerge.
TECHNIQUE
OCCIPUT TRANSVERSE POSITION  PROPER CUP PLACEMENT is the most important determinant of success.
 Rotation is required for delivery o the center of the cup should be
 Here, the right branch of Kielland forceps is applied and wandered to its final over the flexion point (flexion
position behind the symphysis pubis. The left branch is directly applied point is found along the sagittal
posteriorly along the hollow of the sacrum. suture 3 cm in front of the
 Delivery accomplished with: posterior fontanel, 6 cm from the
o Kielland forceps using bimanual grip anterior fontanel)
o Replace Kielland forceps with conventional forceps  Flexion point: pivot point
o Maximizes cup detachment
o Flexes the fetal head
o Delivers the smallest fetal head diameter

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Patho-OB: Disorders of AF, Placenta and Fetal Membranes
 Anterior placement on the fetal cranium—near the anterior fontanelle rather COMPARISON OF VACUUM EXTRACTION WITH FORCEPS
than over the occiput—will result in cervical spine extension unless the fetus is
small.
Method of Delivery
CUP PLACEMENT Complications Vacuum n = 41 (%) Forceps n = 40 (%)
 To ensure proper cup placement, full circumference of the cup should be
palpated both before and after the vacuum has been created, as well as prior Apgar scores
to traction 1 min < 7 4 (10) 4 (10)
 Vacuum created gradually by increasing the suction (Figure 4)
5 min < 8 1 (2) 1 (2)

Cephalohematoma

Mild 6 (15) 3 (10)

Moderate 1 (2) 2 (7)

Caput 14 (34) 7 (14)

Facial mark or injury 1 (2) 7 (18)a

Trauma

Erb palsy (mild) 1 (2) 0

Fractured clavicle 1 (2) 0

Elevated bilirubin 8 (20) 4 (10)

Retinal hemorrhage

Mild 6/37 (16) 3/36 (8)

Moderate or severe 8/37 (37) 3/36 (8)

Infant stay 3.4 days 3.1 days

 Vacuum Extraction
o Increase incidence of neonatal jaundice
 Maternal soft tissue entrapment predisposes to lacerations and ensures cup o Shoulder dystocia and ephalhematoma is doubled
dislodgement: CUP “POP OFF”  Forceps Delivery
o Higher frequency of maternal trauma and blood loss
TRACTION
o More 3rd and 4th degree laceration
 Traction may be initiated by using a two-hand technique: o Neonatal: Facial nerve injury, brachial plexus, depressed skull fracture,
o The fingers of one hand are placed against the suction cup, while the other corneal abrasion
hand grasps the handle of the instrument.
 Efforts are intermittent and coordinated with maternal expulsive efforts.
 Manual torque to the cup should be avoided as it may cause cephalohematomas
and, with metal cups, "cookie-cutter"–type scalp lacerations
 In general, progressive descent should accompany each traction attempt.
 Vacuum extraction should be considered a trial, and without early and clear
evidence of descent toward delivery, an alternate delivery approach should be
considered.

COMPLICATIONS

 Scalp lacerations and bruising

 Subgaleal hematomas
 Cephalohematomas
 Intracranial hemorrhage
 Neonatal jaundice
 Subconjunctival hemorrhage
 Clavicular fracture
 Shoulder dystocia
 Injury of sixth and seventh cranial nerves
 Erb palsy
 Retinal hemorrhage
 Fetal death

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