Instrumental Vaginal delivery AUDIT

Vacuum & forceps

Definition - Operative obstetrics refers to any method used to deliver the fetus other than uterine contractions and maternal pushing efforts , It may include vaginal or cesarean routes

OBSTETRIC FORCEPS - Indications Prolonged second stage . Fetal compromise . Avoid maternal pushing . Breech presentation .

OBSTETRIC FORCEPS

OBSTETRIC FORCEPS- Prerequisites Clinically adequate pelvic dimensions Experienced operator Full cervical dilation Engaged fetal head Orientation of fetal head is certain

OBSTETRIC FORCEPS- Complications • Maternal: lacerations to the vagina, cervix, perineum, and uterus. • Fetal-neonatal: soft-tissue compression or cranial injury caused by incorrectly placed forceps blades.

Forceps left this boy brain damaged facial palsy

VACUUM EXTRACTOR These are cuplike instruments that are held against the fetal head with suction .

VACUUM EXTRACTOR Advantages Over Forceps : - Fetal head orientation , Space required , Perineal trauma , Head rotation . Disadvantages Over Forceps :- Cup pop-offs , Scalp trauma , others .

VACUUM EXTRACTOR- Prerequisites Clinically adequate pelvic dimension Experienced operator Full cervical dilation Engaged fetal head Gestational age is >34 weeks

VACUUM EXTRACTOR - Complications Maternal: vaginal laceration . Neonatal: cephalohematoma and scalp lacerations , subgaleal hematoma or intracranial hemorrhage associated with vacuum duration >10 min.

Health annual report – Palestine 2014 Reported Live Births: The total number of reported live births in Palestine was (121,330); 65,778 (54.2%) in West Bank and 55,552 (45.8%) in Gaza Strip.

US operative delivery incidence The incidence of an operative obstetric delivery in US ( 35% to 40%) . ( 10% to 15% ) are operative vaginal deliveries using either a forceps or vacuum device. ( 25% to 30% ) cesarean births

According to the records in al Emarati hospital Number of live births and instrumental delivery in 7 months . Instrumental Births Month 1 405 March 2 254 April 320 may - 312 June 455 July 466 august 410 September 6 2622 Total 0.22 % Percentage

Our audit

Aims & Objectives Identify at least 25 audits ( vacuum or forceps ) Compare with international standard for instrumental delivery and complication rates Check adherence to local protocol Check standard of documentation

Our audit Vacuum deliveries only are performed on labour ward Forceps deliveries are performed only in the operating room This is neither recorded in the notes nor in the operations records book

So we looked for the cases which is recorded as VAD in the labour ward and the results as Follow :

23 cases registered in 5 months in Birth registration book . 20 out of 23 files found in the archive . 7 out of remaining 20 files recorded as NVD in the files ! .

10 out of 13 recorded as VAD but 10 out of 13 recorded as VAD but ! Either there was no instrumental delivery form or it is empty . So only 3 files were properly documented and contained the instrumental delivery form .

In the 3 files :- All of them were full term , and silastic vacuum used in all of them . Number of pulls :

Prolonged second stage of labour We couldn’t assess maternal tissue entrapment ? Indication for instrumental delivery in the 3 cases Prolonged second stage of labour

Fetal station in all cases was +1 the bladder was emptied In the 3 cases :- Fetal station in all cases was +1 the bladder was emptied the doctor who perform the delivery was Resident cervical dilatation was adequate

One of the cases needed episiotomy , and 2 didn't . No maternal or fetal complication occurred in 2 of the cases , while in the third one there was 4th degree tear , without fetal complication .

Conclusions protocols with too small sample (3 files !) The documentation of the vaginal deliveries was significantly substandard .

Improve Documentation system Recommendations Improve Documentation system

Thanks