1. Instrumental Vaginal delivery AUDIT

2. Vacuum & forceps

3. 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

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

5. OBSTETRIC FORCEPS

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

7. 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.

8. Forceps left this boy brain damaged facial palsy

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

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

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

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

13. 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.

14. 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

15. 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

16. Our audit

19. 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

20. 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

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

22. 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 ! .

23. 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 .

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

25. 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

26. 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

27. 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 .

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

29. Improve Documentation system
Recommendations
Improve Documentation system

30. Thanks