OPERATIVE VAGINAL DELIVERY

Dr Rabiya Kaussar
TMO MCPS
 TYPES OF OVD

1. Forcep Vaginal Delivery

2. Vacuum Vaginal Delivery
 FORCEP
DELIVERY
 History
• Christian Kielland in 1915 devised rotational forceps for Deep Transverse Arrest

• Edmund Piper introduced forceps for after coming head of the breech in 1929

• Wrigley introduced short ligt forcep with generous cephalic curve in 1935

• Luikart in 1937 modified solid blades into pseudo—fenestrated

• Shute described forceps using “principle of parallelism” to reduce compression

of fetal skull.
 PARTS OF FORCEP

• Branches

• Blades- solid, fenestrated, Pseudo fenestrated

• Shanks

• Handle

• Lock – English, German, Sliding, Pivot, Hiesters

 CURVES OF FORCEP

• Cephalic Curve

• Pelvic Curve

• Perineal Curve
It has been classified by the The American College of Obstetricians and
Gynecologists
(ACOG) in 1994 conference at Washington.
 PREREQUISITE

• Vertex presentation
• Cervix is fully dilated and the membranes ruptured
• Head is fully engaged
• Exact position of the head can be determined so proper placement of the
instrument can be achieved
• Pelvis is deemed adequate
• Informed consent must be obtained
• Appropriate analgesia is in place
• Maternal bladder has been emptied
• Adequate facilities and backup personnel are available
• Operator must have the knowledge, experience, and skill necessary to use
the instruments and manage complications that may arise
• Backup plan
3 categories

(1) Classical
• (a)Parallel shanks: Simpson, DeLee, Irving, Hawks-Dennen
• (b)Overlapping shanks: Elliott, Tucker-McLane

(2) Rotational : Kielland, Leff forceps

(3) Special : Piper forceps

 CONTRAINDICATIONS

Absolute
• non-vertex or brow
• unengaged head
• incomplete cervix dilation
• clinical evidence of cephalopelvic disproportion
• fetal coagulopathy
 CONTRAINDICATIONS

Relative
• unfavourable attitude of fetal head
• rotation >45° from occiput anterior or occiput posterior (vacuum)
• mid-pelvic station
• fetal prematurity
• There is a small retrospective study reviewing the outcome of deliveries of
infants 1500 g to 2500 g. No difference was found in Apgar scores, umbilical
pH, or intraventricular haemorrhage when comparing vacuum extraction with
controls who delivered spontaneously
 APPLICATION PRINCIPLE AND
PROCEDURE

• Be familiar with the instrument being used.

• Use finger-strength pressure when applying forceps.

• Rotation within one plane can only be done with

forceps without a pelvic curve.
When checking the application:
• (a) the posterior fontanelle should be located midway between the sides of
the blades, with the lambdoid sutures equidistant from the forceps blades
and

• (b) the sagittal suture must be perpendicular to the plane of the shanks
throughout its length.

• (c) the fenestration of the blades should be barely felt and the amount of
fenestration felt on each side should be equal. With a solid blade, no more
than a fingertip should be able to be inserted between the blade and the fetal
head one finger-breadth above the plane of the shanks.
 MATERNAL COMPLICATIONS

• maternal lacerations
• minor external ocular trauma
• retinal hemorrhage
 FETAL COMPLICATIONS

• fetal skull fractures

• facial nerve palsies
• cephalohematomas
• subaponeurotic hemorrhages
• intracranial hemorrhages
• scalp lacerations
 FAILED OPERATIVE VAGINAL DELIVERY

Causes
• Cannot apply the branchs
• Branches do not lock
• Branches slip after application
• While effecting rotation only blades rotate
• Extraction is not possible
• There is morbidity to motality to fetus and mother
 FAILED OPERATIVE VAGINAL DELIVERY

• Application before full dilatation of cervix

• Gross Cephalopelvic Disproportion
• DTA
• Undiagnosed hydrocephalus
• Contraction ring grasping the fetus
 FAILED OPERATIVE DELIVERY

• It is well known that a failed operative delivery resulting in a cesarean

delivery is worse than an outright cesarean delivery.

• In the study performed in California by Towner et al, the rates of subdural

hemorrhage, facial-nerve palsy, convulsions, and mechanical ventilation
were significantly higher in infants delivered by caesarean section after a
failed attempt at vacuum extraction, forceps delivery, or both.
N Engl J Med. 1999 Dec 2;341(23):1709-14
• As such, a physician must often think about appropriate patient selection and
the chances of success before attempting an operative vaginal delivery.

• However, fewer than 3% of women in whom an operative vaginal delivery

has been attempted go on to deliver by cesarean. Rotational and midpelvic
(0 to +1 station) forceps, however, are more difficult, with higher rates of
failure, and require more skill.
VACUUM DELIVERY
 HISTORY

• James Young Simpsom devised double valved piston with a metal cup – like
a breast pump

• Tage Malmstorm in 1953 described the most successful model

• Pelosi,Apuzzio introduced Sialistic Cup with metal traction

 TYPES OF VACUUM

• Malmstorms Vacuum Extractor –

• Parts –
• Metal Cup with Plates (3.4.5.6 mm)
• Traction Chain attached to the plate
• Traction Handle
• Pressure rubber tube whch encloses the traction chain
• Vacuum Bottle with pressure gauge
• Vacuum pump
• Soft Cup –Bell shaped 6.5 mm. Produces symmetric, less cosmetic alarming
caput saccundaneum and less scalp abrasion

• Silastic Cups – Pliable, softer, less traumatic and safer. Described by

Koyabashi

• Plastic Cups (Mityvac) – Consists of disposable plastic cup and handle,

suction tube and hand pump. It builds pressure quickly and can be used evn
in the absence f electricity.
 TYPES OF CUP APPLICATION

• Flexing Median

• Flexing Paramedian

• Deflexing Median

• Deflexing Paramedian
 INDICATIONS

Conventional
• Shortening second stage of labour
• Maternal Exhaustion
• Presumed fetal distress
• Occipito- Posterior position
• To deliver second twin if head is presenting part

Non Conventional
• Can be used in Caesarean section
• To deliver frank breech (Charmers)
• Compound presentation
 CONTRAINDICATIONS

• Absolute –
• Operator inexperience
• Inability to properly attach
• Inadequate trial of Labour
• High fetal head
• Malpositions
• Aftercoming head of breech
• Known fetal coagulation defect
• Relative –

• Prematurity
• Intrauterine fetal Demise
• Congenital Anomalies
• ‘Prior Scalp Sampling
CHIGNON FORMATION

• A chignon is a temporary swelling left

on an infant's head after
a ventouse suction cap has been
used to deliver him or her

• Chignon in french : a knot of

hair that is worn at the back of the
head
 PROCEDURE

• A proper vacuum extraction depends on

• The accuracy of the cup application

• The traction technique
• Fetal cranial position
• Cup design
• The feto-pelvic relationship
 PREREQUSITES

• Patient is in litotomy position

• Written informen consent taken
• Bladder is emptied
• The position ,station and the attitude of the fetal head is verified
• Phantom application is performed before an attempt
• Place the cup —

• The practitioner spreads the labia and introduces the bell shaped cup by
compressing and inserting it into the vagina while angling the device
posteriorly.

• When contact is made with the fetal head, the center of the cup is placed
over the flexion point and symmetrically across the sagittal suture

• After correct placement of the cup is confirmed, vacuum pressure should

be
raised to 100 to 150 mmHg to maintain the cup's position.

• The edges of the cup should again be swept with a finger to insure that no
maternal tissues are entrapped.
• Apply suction —

• Suction pressure is measured in various units: 0.8 kg/cm2 of atmospheric

pressure = 600 mmHg = 23.6 inches of Hg = 11.6 lb/in

• Vacuum suction pressures of 500 to 600 mmHg have been recommended

during traction, although pressures in excess of 450 mmHg are rarely
necessary

• While lower suction pressures increase the risk of cup "pop-offs," pressures
beyond 600 mmHg increase the risks of fetal scalp trauma and cerebral,
cranial and scalp hemorrhage
• Exert traction —
• The absolute "safe" traction force for vacuum extraction is unknown. In 1962,
one group determined a total traction force of 17.6 kg was typically
necessary to affect delivery

• Traction is applied along the axis of the pelvic curve to guide the fetal vertex,
led by the flexion point, through the birth canal.
• Initially, the angle of traction is downward (toward the floor)
• the higher the beginning station, the steeper the angle of downward traction
required.

• The axis of traction is then extended upwards to a 45 degree angle to the

floor as the head emerges from the pelvis and crowns
 DURATION

• A maximum of two to three cup detachments,

• three sets of pulls for the descent phase,
• three sets of pulls for the outlet extraction phase,
• and/or a maximum total vacuum application time of 15 to 30 minutes are
commonly recommended, with most authors advising lesser time limits
 FAILED PROCEDURE

• Fetopelvic disproportion
• Incorrect technique
• Large caput succedaneum