Assisted births lowering instrumental birth rates. Women who use epidural as a form of pain relief are at increased risk of having an instrumental assisted birth

Birth by ventouse -used more commonly than forceps. - The vacuum extractor is an instrument that applies traction. - an alternative to forceps. -The cup cleaves to the baby's scalp by suction with maternal effort.

The use of the ventouse a delay in labour and the head is engaged no cephalopelvic disproportion CPD. useful in the case of a second twin, when the head relatively high. vacuum extractor is less likely to achieve a successful vaginal delivery than forceps.

the ventouse is associated with cephalohaematoma facial and cranial injuries are common with forceps. The cup is positioned over the sagittal suture. Soft and rigid vacuum extractor cups -The metal cups , or the Malstrom type ,have a central traction chain and a vacuum conduit. - silicone rubber cup( malleable silicone cup) is shaped to the contour of the baby's head -Soft cups have a poorer success rate than metal cups, but are less likely to be associated with scalp trauma.

Procedure - lithotomy position - Local anaesthesia ,or inhalational analgesia. - Pudendal nerve block or epidural - Episiotomy is not routinely carried out. -The procedure is explained and consent obtained - the bladder is emptied. -The fetal heart rate is recorded regularly. - The cup of the ventouse is placed on the flexing point of the fetal head.

- traction is applied with a contraction, with maternal effort, -This traction is done in a downwards and backwards direction, then in a forwards and upwards manner, thus following the curve of Carus. -The vacuum is released and the cup then removed at the crowning of the fetal head. Precautions in use • ensure that no vaginal skin is trapped in the edges of the cup • Prolonged or excessive traction should not be used. • Ask for help, Address the client, Adequate anaesthesia • Bladder empty • Cervix must be completely dilated •

Determine the position of the fetus • Equipment and extractor ready • Fontanelle, apply the cup over the sagittal suture • Gentle traction at right angles • Halt traction and reduce the pressure, repeat the cycle with the next contraction • Incision, of episiotomy, if necessary • Jaw is reachable, so, remove the vacuum cup

Complications - prolonged traction will increase the likelihood of scalp abrasions, cephalohaematoma or subaponeurotic bleeding -Failure of the ventouse ,This is more likely in the presence of excessive caput, less experienced practitioners.

The midwife ventouse practitioner Midwife ventouse practitioners must be well educated and trained before carrying out this procedure. Birth by forceps delivery of the fetal head or to protect the fetus or the mother used to assist the delivery of the after-coming head of the breech to draw the head of the baby up and out of the pelvis at caesarean section birth.

Characteristics of obstetric forceps - composed of two separate blades - a right and a left. -The forceps are inserted separately on each side of the head -The forceps are locked together by either an English or a Smellie lock. -Rotational forceps have a sliding lock. -The blades are spoon shaped (cephalic curve) - the blade is attached to the handle at an angle that corresponds to the pelvic curve

Classification of obstetric forceps -low and mid-cavity. - Low-cavity forceps are used when the head has reached the pelvic floor and is visible at the vulva. -Mid-cavity forceps are used when the head is engaged and the leading part is below the level of the ischial spines. -High-cavity forceps are considered unsafe and a caesarean section will be carried out.

Types of obstetric forceps non-rotational or rotational -Adequate analgesia is required prior to their application to the fetal head. Wrigley's forceps -use when the head is on the perineum. - a short and light type of forceps, with both pelvic and cephalic curves and an English lock. - used after-coming head of a breech delivery, or at caesarean section. Neville-Barnes or Simpson's forceps used for a low or mid cavity forceps delivery when the sagittal suture is in the anteroposterior diameter of the cavity/outlet of the pelvis. They have cephalic and pelvic curves - the handles are longer and heavier than those of the Wrigley's. Anderson's and Haig-Ferguson's forceps are also similar in shape and size

Kielland's forceps designed to deliver the fetal head at or above the pelvic brim. used for the rotation and extraction of the head that is arrested in the deep transverse or in the occipitoposterior position. The blades have little pelvic curve . The shallow curve allows safe rotation of the forceps in the vagina. Downward traction encourages rotation of the head.

Indications for the use of obstetric forceps delay in the second stage of labour fetal compromise and maternal distress.

Delay in the second stage of labour may be due to: • insufficient contractions (but this is better corrected by oxytocin infusion) • epidural analgesia • mal-rotation of the head • maternal fatigue. Fetal compromise may be due to: • prematurity • hypoxia • intrauterine growth restriction • a maternal obstetric or medical condition (e.g. pre-eclampsia). Maternal distress may be caused by: • hypertension • cardiac condition • maternal exhaustion or long labour.

Prerequisites for forceps delivery • Care of the bladder. To prevent harm or injury • Analgesia. by epidural or pudendal block plus perineal infiltration of local anaesthetic • Information giving and consent. The couple must be kept informed • Paediatrician. The paediatrician or advanced neonatal practitioner may not be required at birth • Neonatal resuscitation equipment. This must be checked and prepared in case it becomes necessary.

Pudendal block the infiltration of the area around the pudendal nerve by local anaesthetic. The transvaginal route is used to locate the ischial spine, as the pudendal nerve emerges from vertebrae S2–S4 and crosses this. Use a pudendal block needle. About 10 mL of local anaesthetic, usually 1% lidocaine (lignocaine), is injected into the region just below the ischial spine -Both motor and sensory nerves are affected as both lie in this region.

The pudendal nerve supplies the levator ani muscles, also the deep and superficial perineal muscles It may be used to provide analgesia for the lower vagina and perineum, and is therefore used for forceps and ventouse deliveries. this technique does not harm the baby.

Perineal infiltration -A local anaesthetic is used to infiltrate the perineum prior to episiotomy or suturing Technique - the presentation and position are identified - The membranes ruptured - full dilatation of the cervix - head engaged -no CPD. - Episiotomy is not routinely carried out

Complications OF forceps: Maternal complications include: • trauma or soft tissue damage occur to the perineum, vagina, or cervix • hemorrhage from the above • dysuria or urinary retention, which may result from bruising or oedema to the urethra • painful perineum • postnatal morbidity intervention

Neonatal complications • marks on the baby's face, which can be caused by the pressure of the forceps, but resolve quite rapidly • excessive bruising from the forceps • facial palsy, which may result from pressure from a blade compressing a facial nerve, and is usually temporary.

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