1. SAEED MAHMOUD, MRCOG,MRCPI,MIOG,MBSCCP ASSISTANT PROFESSOR & CONSULTANT DEPARTMENT OF OBSTETRICS & GYNECOLOGY COLLEGE OF MEDICINE KING SAUD UNIVERSITY Operative DELIVERIES

2. Operative Deliveries 1.Instrumental deliveries A. Vacuum /Ventouse B.Forceps 2. Cesarean Section CS, C/S

3. VACUUM /VENTOUSE

5. INDICATIONS MATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary disease FETAL Failure of the fetal head to rotate Fetal distress in the second stage

6. Conditions to be fulfilled : MNEMONIC A – Anesthesia  adequate B – Bladder  cathterization C – Cervix  fully dilated / membranes ruptured D – Determine  position, station, pelvic adequacy E – Equipment  inspect vacuum cup, pump, tubing,  check pressure

7. MNEMONIC F – Fontanelle  position the cup over the posterior fontan  low pressure 10 cm H2O initially & between cont  sweep finger around cup to clear maternal tissue  ↑ pressure to 60 cm H2O with the next contraction G – Gentle traction  pull with contractions only  traction in the axis of the birth canal  ask the mother to push during cont

9. MNEMONIC H – Halt  halt traction if no progress with three traction aided contractions  vacuum pops off three times  pulling for 30 min without significant progress I – Incision  consider episiotomy if laceration imminent J – Jaw  remove vacuum when jaw is reachable or delivery assured

10. Key points Vacuum –assisted delivery is less traumatic to the mother & fetus than forceps Ventouse should be the instrument of choice Should not be used for preterm, face presentation or breech

11. COMPLICATIONS Maternal  Vaginal laceration due to entrapment of vaginal mucosa between suction cup & fetal head FETAL Scalp injuries  abrasion & lacerations 12.6%  scalp necrosis 0.25-1.8% Cephalohematoma  25%  jaundice /anemia Intracranial hemorrhage  2.5% Subgaleal hematoma

12. Fetal Complications

13. FETAL COMPLICATIONS Birth asphyxia  2.6-12%  related to extraction force & time Some studies showed decrease birth asphyxia Retinal hemorrhage 50% Forceps 31% SVD 19% Neonatal jaundice

14. FETAL COMPLICATIONS Fetal mortality 15/1000 Lower in cases delivered by vacuum 1.9%/ forceps 5.2 % No long term effects on neurological psychomotor or intellectual development up to 4 years of age

15. FORCEPS

16. INDICATIONS MATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary disease FETAL Failure of the fetal head to rotate Fetal distress Control of the fetal head in vaginal beech delivery

17. CLASSIFICATION OF FORCEPS DELIVERY Outlet forceps  Scalp visible at the vulva without separating the labia Low forceps  Vertex at +2 station

18. Midforceps  Head is engaged but leading part above +2 station  Sagittal suture not in the AP plane of the mother

19. CLASSIFICATION OF FORCEPS DELIVERY Outlet  Wrigley’s Outlet & low forceps  Simpson /Elliot Midforceps & outlet  Tucker Mc lane Midforceps & rotation  Kielland After coming head in breech  Piper

20. Conditions to be fulfilled : MNEMONIC A – Anesthesia  adequate /epidural or pudendal B – Bladder  cathterization C – Cervix  fully dilated / membranes ruptured D – Determine  position, station, pelvic adequacy E – Equipment  Know your forceps

21. MNEMONIC F – Forceps  phantom application  Lt blade, LT hand, maternal Lt side pencil grip & vertical insertion with Rt thumb directing blade  Rt blade, RT hand, maternal Rt side pencil grip & vertical insertion with Lt thumb directing blade  Lock blades

22. MNEMONIC  Check application:  Post fontanelle 1cm above the plane of the shanks  Sagittal suture lies in the midline of the shanks /perpindicular to the plane of the shanks  The operator can not place more than a fingertip between the fenestration of the blade & the fetal head on either side

23. MNEMONIC G – Gentle traction  applied with contraction & maternal expulsive efforts H – Hand elevated  traction in the axis of the birth canal I – Incision  consider episiotomy if laceration imminent J – Jaw  remove forceps when jaw is reachable or delivery assured

24. COMPLICATIONS Maternal  trauma to soft tissue  3 rd /4 th degree double the risk compared to ventouse  bleeding from lacerations  trauma to urethra & bladder  fistula  Pain 17% ventouse 11%

25. COMPLICATIONS Fetal  bruising & laceration to the face  Injury to the fetal scalp  cephalohematoma 9% Vent 25%  retinal hemorrhage 30% Vent 50%  skull fracture  permanent nerve damage / Facial nerve The risk of shoulder dystocia is increased following instrumental deliveries

26. CESAREAN SECTION CS

27. TYPES OF CS Lower segment CS Classical CS

28. INDICATIONS FOR ELECTIVE CS Repeat CS Placenta previa VV fistula repair HIV (poor controlled) Active herpes Fetal macrosomia > 4500 gm Uterine surgery eg. Hystrotomy, myomectomy Severe IUGR Breech Multiple pregnancy Transverse lie Ca of the Cx/ TR obstructing the birth canal

29. Indications for classical CS Transverse lie back down (with SROM) Structural abnormality that makes lower segment approach difficult (Fibroids) Anterior Placenta Previa & abnormally vascular lower segment Poorly developed lower segment in Very preterm fetus in breech presentation Cervical cancer

30. TIMING OF ELECTIVE CS Usually at 38-39 wks

31. COMPLICATIONS Bleeding & the need for bl transfusion Hysterectomy Complications of anaesthesia Damage to the bladder, ureter, colon, retained placental tissue Fetal injury Infection DVT/PE

32. MODE OF DELIVERY IN NEXT PREGNANCY CRITERIA FOR VBAC Pt must agree to the procedure A low transverse uterine incision Non recurrent cause of the previous CS No macrosomia, malposition, multiple gestation, breech

33. CONDUCT OF LABOUR Observe for Progress Fetal wellbeing Maternal well being Epidural HOSPITAL SHOULD PROVIDE BLOOD, OPERATING ROOM 24 HRS, NEONATAL RESUSCITATION, NURSING ANAESTHESIA &SURGICAL PERSONNEL CAN START CS WITHIN 30 MIN

34. Risk of SCAR RUPTURE O.5% for LSCS 4-9% for classical

35. SCAR RUPTURE Signs OF SCAR RUPTURE Fetal distress Ease of fetal palpation Cessation of contractions Elevation of presenting part Scar pain Bleeding / shock

36. Thank you Any Questions