1. Operative births

2. Assisting a vaginal birth
-Assisted vaginal birth is a frequently and widely practiced intervention in the provision of care to women during childbirth.
the alternative management strategies employed during labor in different units

3. Useful techniques to help lower the operative birth rate
One-to-one care in labor
Active management of the second stage with Syntocinon
Upright birth posture/mobilization
Delaying the onset of the active second stage by 1–2 hours in women with regional analgesia/anesthesia
Fetal blood sampling rather than expediting birth when fetal heart rate abnormalities occur

4. -other interventions, such as epidural analgesia, have been observed to be associated with an increased risk of instrumental vaginal birth and have been suggested to be linked to an increased risk of birth by caesarean section (CS)
such ‘disadvantages’ must be balanced against the higher rates of maternal satisfaction that this form of analgesia provides.
It is up to the woman to make an informed choice as to which of the benefits and risks are most important, not up to the attending medical staff to make didactic decisions on her behalf.

5. Indications for ventouse or forceps
Fetal
@Malposition of the fetal head (occipitolateral and occipitoposterior), occur more frequently in the presence of regional anaesthesia, as alterations in the tone of the pelvic floor may impede the spontaneous rotation to the optimal occipitoanterior position during the decent of the presenting part (vertex of the fetal head).

6. @Fetal ‘distress’ is a commonly cited indication for instrumental intervention; however, ‘presumed fetal compromise’ is a more comprehensive term (unless a fetal blood sample has been obtained showing hypoxia and acidosis, in which case ‘fetal hypoxia’ should be used)

7. @Elective instrumental intervention for infants of reduced weight
@Elective instrumental intervention for infants of reduced weight. <1.5 kg, delivery with forceps does not confer an advantage over spontaneous birth and,may increase the incidence of intracranial haemorrhage.
Ventouse carries the same risks, should be avoided in infants of <34+6 weeks of gestation.
@Assisted vaginal breech birth. Forceps can be applied to the after-coming head to control the birth of the vertex, a situation where the ventouse is contraindicated.

9. Maternal
@maternal distress, exhaustion, or prolongation of the second stage of labour. This has been suggested as greater than 2 hours in a primigravida (3 hours if an epidural is in situ), or more than 1 hour in a multipara (2 hours if an epidural is in situ)

10. @aortic valve disease with significant outflow obstruction
@ myasthenia gravis
@ significant antepartum haemorrhage due to placental abruption or vasa praevia
@ severe hypertensive disease
@ previous CS (to minimize the risk of scar rupture).

11. Contraindications to an instrumental vaginal birth
Absolute
The vertex is ≥1/5th palpable abdominally.
The position as determined by a vaginal examination (occipitoanterior/posterior or lateral) of the fetal head is unknown.
Before full dilatation of the cervix (although a possible exception occurs with the ventouse birth of a second twin).
the operator is inexperienced in instrumental vaginal birth.

12. In gestations of <34+6 weeks because of the increased risk of intracranial haemorrhage in the fetus.
With the fetus presenting by the face.
If there is a significant degree of caput that may either preclude correct placement of the cup or, more sinisterly, indicate a substantial degree of cephalopelvic disproportion CPD).

13. Relative contraindications (for forceps or ventouse)
Fetal bleeding disorders (e.g. alloimmune thrombocytopenia) or a predisposition to fractures (e.g. osteogenesis imperfecta) are relative contraindications specifically to an operative birth with the ventouse.
risks of a birth by a difficult second stage caesarean section must also be considered and a discussion undertaken antenatally about the most appropriate plan for birth (it may be wiser to recommend that such women have an elective CS).

14. There is minimal risk of fetal haemorrhage if the vacuum extractor is employed following fetal blood sampling or application of a scalp electrode.
Prerequisites for any operative vaginal birth
Rupture of the membranes must be confirmed.
The cervix must be fully dilated.
Cephalic presentation with identification of the position (occipitoanterior/posterior or lateral).
Adequate pelvis as ascertained by clinical pelvimetry.
The fetal head must be <1/5th palpable per abdomen, with the presenting part at or below the ischial spines.

15. Adequate analgesia/anaesthesia.
Empty bladder/no obstruction below the fetal head (contracted pelvis/ovarian cyst).
A knowledgeable and experienced operator with adequate preparation to proceed with an alternative approach if necessary.
An adequately informed woman (with signed consent form detailing appropriate risks/benefits/complications as the situation demands).

16. Birth by ventouse
a suction cup (made from plastic or metal) that is connected (via tubing) to a vacuum source.
Following the placement of the cup onto the fetal head, traction can be applied to assist the birth.
the ventouse cup may not be successful at securing birth and therefore obstetric forceps should be chosen if there is:
1-suspected fetal macrosomia
2-excessive caput or moulding

17. 3-poor maternal effort due to exhaustion (which may be compounded by epidural analgesia and poor sensation)
4-gestation <34 completed weeks.

18. Types of ventouse
‘soh’ or silicone cup design (reducing maternal trauma by being more easy to correctly place within the vagina) and having a reduced incidence of fetal scalp trauma when compared to other cup
soh cups have a poorer success rate than metal cups in achieving a vaginal birth

21. -Metal cup ventouse, which have a centrally placed traction
They come in diameters of 4, 5 and 6 cm.
require two operators for their successful use (one to control the placement of the ventouse and assist the birth, the other midwife, to control the degree of vacuum that is generated.

22. safe and may be useful for rotational births
higher failure rate than the conventional metal cup ventouse, with cup detachments occurring more frequently.

24. The use of the ventouse
ventouse is less likely to achieve a successful vaginal birth than forceps, although both types of instruments are associated with a lowering of the overall CS rate

25. Complications of ventouse
neonatal complications such as cephalohaematoma ,
facial (nerve palsies) ,cranial injuries (fractures) are more common with forceps.

26. Procedure
The procedure is explained and consent obtained (written consent )
placed into the lithotomy position.
inhalational analgesia may be sufficient (entonox – N2O), more commonly a pudendal nerve block with perineal infiltration may be administered, or an epidural, if already in situ.
adequate analgesia is assured
the maternal bladder is emptied.
(FHR) must be continuously monitored (with a – CTG).

27. determine the flexion point, which is located, in an average term infant, along the sagittal suture 3 cm anterior to the posterior fontanelle (and thus 6 cm posterior to the anterior fontanelle).
The centre of the cup should be placed directly over this
-The operating vacuum pressure is between 500–800 cmH2O).

28. When the vacuum is achieved, traction must be applied to coincide with a contraction
thus maternal expulsive efforts.

29. Traction initially in a downwards and backwards direction, then in a forward and upward manner.
Once the fetal head has crowned, the vacuum is released, the cup removed and with further maternal efforts the baby will be born

30. Precautions in use
-the operator should allow ≤2 episodes of breaking the suction in any vacuum assisted birth,
the maximum time from application to birth should ideally b e ≤15 minutes.
no evidence of descent with the first pull, the woman should be reassessed to ascertain the reason for failure to progress.
ensure that no vaginal skin is trapped in the edges of the cup as this can result in complex degrees of perineal trauma that can be extremely difficult to repair

31. The midwife ventouse practitioner
reducing the psychological trauma to a woman during a birth by limiting the number of carers
midwife ventouse practitioner would be the primary carer for every pregnant women on every occasion that required an assisted vaginal birth.
midwife ventouse practitioners, must be well educated and trained before carrying out a ventouse birth