1. OPERATIVE VAGINAL DELIVERY (FORCEPS & VACUUM EXTRACTION)

2. 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 %,
vacuum % of
all Phil.vag.deliveries

3. 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

4. Functions of forceps
Traction
Rotation

5. 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

6. 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

7. 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

8. 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.

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

10. 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

11. 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.

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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.

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

20. 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)

21. 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

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

23. 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.

24. 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.

25. > 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.

26. 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.

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