OPERATIVE VAGINAL DELIVERY (FORCEPS & VACUUM EXTRACTION)

Operative vaginal deliveries accomplished by applying direct traction on the fetal skull with forceps, or applying traction to the fetal scalp by means of a vacuum extractor POGS stats : forceps 1.43-2.44%, vacuum .07-.20% of all Phil.vag.deliveries

Parts of the forceps basically made up of two crossing branches each branch: a. handle b. lock c. shank – determines length; parallel or crossing d. blade - cephalic, pelvic curves

Functions of forceps Traction Rotation

Classification of operative vaginal delivery*** ACOG, 2002 OUTLET 1. Scalp is visible at the introitus without separating the labia 2. Fetal skull has reached the pelvic floor 3. Sagittal suture is in AP diameter, or R/L occ. anterior or posterior position 4. Fetal head is at or on perineum 5. Rotation does not exceed 45 degrees

LOW FORCEPS. Leading point of fetal skull is at station LOW FORCEPS Leading point of fetal skull is at station +2cm or more;&not on pel.floor Rotation is 45 degrees or less (L/R OA to OA; L/R OP to OP); Rotation is greater than 45 degrees

MIDFORCEPS. Station is above +2 cm, but head is MIDFORCEPS Station is above +2 cm, but head is engaged HIGH FORCEPS (abandoned in modern OB!) Forceps applied before engagement Not included in classification ***station is measured in cms. (0 to +5) rather than dividing the lower pelvis into thirds

Prerequisites for forceps application 1. The head must be engaged & preferably deeply engaged. 2. The fetus must present either by the vertex or by face with chin anterior/mentum anterior. 3. The position of the fetal head must be precisely known so that the forceps can be applied appropriately.

4. Cervix completely dilated. 5 4. Cervix completely dilated. 5. Membranes ruptured for firmer grasp of the head. 6. No cephalo-pelvic disproportion. 7. Urinary bladder empty. 8. Good anesthesia. 9. Skillful obstetrician.

Indications for the Use of Forceps -any condition threatening the life of mother & fetus that will be relieved by delivery Maternal: cardiopulmonary dses, infections, exhaustion, prolonged 2nd stage Fetal: non-reassuring fetal heart rate pattern, cord prolapse, abruptio placenta

Trial forceps vs. failed forceps Trial forceps: low or mid-forceps attempted, with the full knowledge that a certain degree of disproportion at the mid-pelvis may make the procedure incompatible with safety for the fetus. After successful application,gentle trac. Failed forceps: vigorous but unsuccessful attempt at forceps extraction; due to CPD, incomplete cx dilatation, malposition of head. May also be failure of good application.

Complications of forceps extraction Maternal: lacerations along birth canal uterine rupture hemorrhage bladder injury Fetal: cephalhematoma / skull fracture intracranial hemorrhage paralysis

APPLICATION – after Informed Consent Forceps : Vacuum / Ventouse : A Anesthesia, Assistance B Bladder C Cx fully dilated + ROM D Determine: POSITION,STATION,PELVIS E Equipment, its quality&functionality A Anesthesia, Assistance B Bladder C Cx fully dilated + ROM D Determine: POSITION,STATION,PELVIS E Equipment, vacuum cup,pump&tubing + check Pressure

FORCEPS - VACUUM - F Forceps, do phantom appl: L blade held w/ L hand, to mat. L side; pencil grip & vertical insertion w/ R thumb directing L blade; lock blade&support; check: -post.fontanel 1cm.above shank;-sag.suture at R angle G Gentle traction F Fontanelle, posn. cup over post.fontanel&sweep finger around © to clear mat. tiss. G Gentle traction

FORCEPS VACUUM H HANDLE elevation – traction in axis of birth canal don’t elevate too early I INCISION, select.episio. J JAW –remove when jaw is reachable or del. is assured H HALT if no progress w/3pulls during contraction, or 3 pop-offs I INCISION, opt to do episio. J JAW –remove when jaw is reachable or del. is assured

VACUUM EXTRACTION the use of a cup on the fetal scalp to assist the delivery of the fetal head -the vacuum cup should be placed over sagittal suture and as far posteriorly as is possible to maintain fetal head flexion & to avoid ant. fontanelle

Requirements for vacuum extraction Cervix must be completely dilated Membranes must be ruptured Fetal head must be engaged and preferably at station +2; only for vertex Facilities for CS must be available in case of vacuum failure; same with forceps del. Other requirements for forceps extraction

Additional Indications for vacuum extraction Fetal head engaged, cervix fully dilated: prolonged second stage: >nulliparous women: lack of continuing progress for 3 hours with regional anesthesia, or 2 hours without regional anesthesia; >multiparous women: lack of continuing progress for 2 hours with regional anesthesia, or 1 hour without regional anesthesia.

Suspicion of immediate or potential fetal compromise Shortening of the second stage for maternal benefit

Contraindications to vacuum/ventouse application & delivery: inappropriate in pregnancies < 34 weeks AOG, because of the risk of intra-ventricular hemorrhage if fetus has bone demineralization abnor-malities (e.g.osteogenesis imperfecta) ; or bleeding disorder (e.g. allo - immune thrombocytopenia, hemophilia or von Willebrand’s disease)

position of fetal head is unknown operator not proficient in procedure fetal head is unengaged position of fetal head is unknown operator not proficient in procedure

Complications of vacuum-assisted deliveries Scalp lacerations – if torsion excessive Cephalhematoma; subgaleal hematoma (between cranial periosteum & epicranial aponeurosis) in 26-45 per 1,000 del. 3. Intracranial hemorrhage 4. Hyperbilirubinemia 5. Retinal hemorrhage

Recommendations on assisted vaginal deliveries The following recommendations are based on good and consistent scientific evidence (Level A) Both forceps and vacuum extractors are acceptable and safe instruments for operative vaginal delivery. Operator experience should determine which instrument should be used in a particular situation The vacuum extractor is associated with an increased incidence of neonatal cephalhematoma, retinal hemorrhages, and jaundice, when compared with forceps delivery.

The following recommendations are based on limited or inconsistent scientific evidence (Level B) >Operators should attempt to minimize the duration of vacuum application because cephalhematoma is more likely to occur as the interval increases. Mid-forceps operations should be considered an appropriate procedure to teach and to use under the correct circumstances by an adequately trained individual.

> The incidence of intra-cranial hemorrhage is highest among infants delivered by caesarean section following a failed vacuum or forceps delivery. The combination of vacuum and forceps has a similar incidence of intracranial hemorrhage. Therefore, an operative vaginal delivery should not be attempted when the probability of success is very low.

The following recommendations are based primarily on consensus and expert opinion (Level C) > Operative vaginal delivery is not contraindicated in cases of suspected macrosomia or prolonged labor; however, caution should be used because the risk of shoulder dystocia increases with these conditions.

> Neonatal care providers should be made aware of the mode of delivery in order to observe for potential complications associated with operative vaginal delivery.