Instrumental Delivery Forceps Vacuum Dr. Sara Haghshenas 06 March 2017 Iran, Isfahan University of Medical Science

the Statics … ( Instrumental Delivery ) in USA 3.2% of all deliveries (in year of 2014) were accomplished via an Operative Vaginal Approach Forceps deliveries accounted for 0.57% of vaginal births Vacuum deliveries accounted for 2.64% of vaginal births

Protracted 2nd stage ( Instrumental Delivery ) for Nulliparous Women, a protracted second stage can be defined as no progress (descent, rotation) after ~04:00:00 with Epidural Anesthesia and ~03:00:00 without Epidural Anesthesia for Multiparous Women, a protracted second stage can be defined as no progress (descent, rotation) after ~02:00:00 with Epidural Anesthesia and ~01:00:00 without Epidural Anesthesia

Allowed Situations ( Instrumental Delivery ) Forceps or Vacuum, to shorten the second stage of labour. IF : a) the Valsalva maneuver is contraindicated b) exertion should be minimized because of maternal medical disorders: -- typically cardiac/neurologic, also cystic lung disease -- IF : a) pushing is ineffective (maternal neurologic) b) muscular disease Operative Intervention is performed: 1. uterine contractions descend the fetus to a station 2. the clinician believes Forceps/Vacuum extraction can be performed safely and effectively.

Contraindications ! ( Instrumental Delivery ) Extreme Fetal Prematurity Fetal Demineralizing Disease (eg. osteogenesis imperfecta) Fetal Bleeding Diathesis (eg. fetal hemophilia) Unengaged Head Unknown Fetal Position Brow or Face Presentation Suspected Fetal–Pelvic Disproportion Relative Contraindications to use of Vacuum devices: a) include gestational age < 34 weeks b) prior scalp sampling

the Prerequisites … ( Instrumental Delivery ) Cervix is fully dilated Membranes are ruptured Head is engaged, at least +2/5 cm station, Forceps should never be used when the head is not engaged. Fetal presentation, position, station, and any asynclitism are known. Extent of molding is estimate large infants, extreme molding, extension of the fetal head, pelvic deformities, asynclitism may falsely suggest engagement.

the Prerequisites … ( Instrumental Delivery ) Clinical Pelvimetry suggests an adequate pelvis, with no obstructions or contractures. the patient consents to the procedure. Fetal size is neither too large, nor too small. the option of performing an Immediate Cesarean Delivery is available the patient has adequate anesthesia for the planned procedure.

the Consideration … ( Instrumental Delivery ) Estimating Fetal Weight one of several factors to assess, considering Operative Delivery of a suspected macrosomic infant. Multiple Maternal Factors (Diabetes, body mass index [BMI], prior infant size in successful vaginal deliveries, clinical pelvimetry, progress in the second stage) Fetal Factors (head position and station, caput and molding, estimated abdominal circumference compared with head circumference)

some Reports ( Instrumental Delivery ) in general, patients with morbid obesity, diabetes, slow progress in the second stage of labour with significant caput/molding, an infant estimated to be over 4,000 gr. Probably Should Not be considered for operative Vaginal Delivery! use of Vacuum devices is limited to deliveries ≥ 34 weeks of gestation (Risk of intraventricular Hemorrhage may increase) “baby Elliot” and “baby Simpson” forceps have smaller dimensions than standard forceps (used to deliver fetuses as small as 1,000 gr.) generally consider using Forceps for Fetuses estimated to weigh ≥ 2,000 gr.

before Operation ( Instrumental Delivery ) in an operative vaginal delivery: maternal anesthesia should be satisfactory. the maternal bladder should be empty. Do Not administer antibiotic prophylaxis! Do Not routinely perform an episiotomy! Choose Vacuum extraction, when an easy extraction is anticipated. if a difficult extraction is anticipated, Choose Forceps despite a slightly higher risk of maternal injury

the Facts ( Instrumental Delivery ) Vacuum delivery is less traumatic (for mother) than forceps delivery. Forceps delivery is less traumatic (for fetus) than vacuum delivery. Vacuum devices are easier to apply Birth trauma is the major complication the most serious sequelae of trauma is intracranial hemorrhage. Vacuum-assisted deliveries >>> lower rates of birth injury, seizures.

Success Rate ( Instrumental Delivery ) over 2,000,000 deliveries certificates 18% of operative vaginal delivery attempts Failed using Forceps/Vacuum extraction. Failed Forceps is more likely to lead to cesarean delivery than a failed Vacuum attempt. Failed Vacuum extraction may be followed by a successful trial of forceps, but the converse rarely occurs. Midforceps delivery is more likely to fail than low forceps delivery. Failure Rates were 8.9% and 0.3%

an Investigation … ( Instrumental Delivery ) a follow-up Evaluations (comparing outcome at school age) upon 3,000 five-year-olds >>> No Differences in Cognitive Testing Operative Vaginal Delivery should be abandoned, IF: 1) difficult to apply the instrument, 2) descent does not easily proceed with traction, 3) baby has not been delivered within a reasonable time (15 to 20 min.) 4) after three pulls with no progress.

the Conclusion ( Instrumental Delivery ) Spontaneous Vaginal delivery is less traumatic for mother than operative vaginal delivery. Operative Vaginal deliveries are associated with less short-term maternal morbidity than cesarean delivery. particularly Lower Rates of postpartum fever & venous thromboembolism longitudinal Cohort Studies: Operative Vaginal delivery 1) a higher long-term risk of urinary incontinence 2) anal incontinence 3) prolapse symptoms than cesarean delivery after full dilation morbidity of operative Vaginal vs. Cesarean delivery: 2nd stage cesarean delivery greater maternal morbidity

Thank You! for the attention any Question? Dr. Sara Haghshenas 06 March 2017 Iran, Isfahan University of Medical Science