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Instrumental delivery 2016.pptx
- 1. Instrumental delivery (Operative vaginal delivery) Dr Vrunda Joshi Professor, OB/GY GRMC, GWL, M.P.
- 2. Instrumental delivery (Operative vaginal delivery) • Obstetric Forceps • Vacuum extractor • Destructive operations
- 3. The Obstetric Forceps • Seventeenth century secret for three generations of Chamberlen family
- 4. The Obstetric Forceps • Curved blade - Cephalic curve for fetal head - solid or fenestrated • The Shank - straight between blade & lock • The lock or joint – Double slot / sliding • The handle - Finger grip
- 6. The Obstetric Forceps Modes of action : • Traction • Compression • Lateral lever action • Improves uterine contractions
- 7. The Obstetric Forceps Indications for the use of forceps: • Maternal distress • Fetal distress • Prolongation of the second stage • Prophylactic forceps
- 8. The Obstetric Forceps Maternal distress (exhaustion) late in labour • Loss of morale • Failure to co-operate with instructions of the attendants • Hysterical outbursts • Rising temperature & pulse rate • Signs of ketosis/ shock due to prolonged physical efforts, starvation and dehydration
- 9. The Obstetric Forceps Fetal distress: • Prolonged fetal bradycardia • Irreular fetal heart rate • Fresh meconium
- 10. The Obstetric Forceps Prolongation of the second stage: • More than 2 hours in primipara without analgesia • More than 3 hours with analgesia • More than 1 hour in multipara
- 11. The Obstetric Forceps To cut short the second stage: • Heart disease class III or IV • Severe anaemia • Severe asthma • Hypertensive crisis, Eclampsia • Cerebrovascular disease- malformations • Myaesthenia Gravis • Spinal cord injury
- 12. The Obstetric Forceps Prerequisites- conditions to be fulfilled • Suitable presentation- fetal head vertex OA or OP Face Aftercoming head of breech • Engaged fetal head • Cervix fully dilated and effaced • Adequate pelvic outlet
- 13. The Obstetric Forceps Prerequisites continued: • The uterus contracting & relaxing • The bladder must be empty • Bowel evacuated • Membranes ruptured • Informed consent with risks explained • Proper anaesthesia & analgesia
- 14. The Obstetric Forceps Forceps Applications : • Cephalic- Blades lie along the sides of fetal head Long axis of blades ‖ occipitomental dia. BPD occupies widest interval between. Secure & safe grip Minimum compression force
- 15. The Obstetric Forceps Applications contd : • Pelvic application: Along the sides of the pelvis Insecure grip Injurious pressure on fetal head Easier to apply Safest application : Cephalic & pelvic coinside ‘OUTLET FORCEPS’
- 16. The Obstetric Forceps Classification: • Outlet forceps • Low forceps • Midcavity forceps
- 17. Type of Forceps Delivery • Outlet forceps – Scalp visible at introitus without separating labia – Fetal skull reached pelvic floor & head at/on perineum – Sagittal suture in AP diameter or LOA, ROA, or posterior position – rotation does not exceed 45º • Low forceps – Leading point of fetal skull at >= +2, not on pelvic floor – Rotation 45º or less (LOA/ROA to OA, or LOP/ROP to OP); or rotation greater than 45º. • Midforceps – Above +2 cm but head engaged • High forceps – Head not engaged; not included in ACOG classification – Not recommended
- 18. The Forceps Operation • Careful aseptic preparations Hair clipped short, skin washed, dried & painted with antiseptic • Operator: prepare hands & arms. Put on cap, mask, gown & gloves • Confirm all the prerequisites • Position- Dorsal lithotomy, thighs flexed & abducted, supported by stirrups or held by assistants.
- 19. The Forceps Operation Step I • Mock locking • Left blade in left hand on left side of the pelvis
- 20. The Forceps Operation Step II Right blade in right hand in right side of pelvis Locking the blades- should be easy. Difficulty in locking & adjustment- suggests faulty position of the head.
- 21. Forceps-Assisted Vaginal Delivery • Identify & apply blades – Place instrument in front of pelvis with tip pointing up & pelvic curve forward – Apply left blade, guided by right hand, then right blade with left hand • Lock blades – Should articulate with ease
- 22. FAVD • Check for correct application – Sagittal suture in midline of shanks – Cannot place more than one fingertip between blade and fetal head • Apply traction – Steady and intermittent – Downward and then upward – Remove blades as fetus crowns
- 24. The Forceps Operation Extraction of the head: • Extract the head slowly. • Pull during ut contractions & to pause during intervals • To separate the handles slightly without unlocking them. • Direct traction in the axis of pelvis. Outlet forceps- Downwards then forwards.
- 25. Complications of outlet forceps Maternal: • Perineal tear extension • Vaginal & cervical lacerations • PPH Fetal • Facial nerve injury • Cephalhematoma • Intracranial hemorrhage
- 26. The Forceps Operation • Trial of forceps Uncertainity about achieving a safe vaginal delivery. marked caput and moulding prolonged labor with second stage dystocia suspected macrosomia • Failed forceps Unsuccessful attempt to deliver with forceps -unrotated occipitoposterior -incompletely dilated cervix -disproportion - contraction ring
- 27. Vacuum /ventouse
- 30. Indications MATERNAL • Exhaustion • Prolonged second stage • Cardiac / pulmonary disease FETAL • Failure of the fetal head to rotate • Fetal distress • Should not be used for preterm, face presentation or breech
- 31. MNEMONIC • A – Anesthesia adequate appropriate positioning & access • B – Bladder cathterization • C – Cervix fully dilated / membranes ruptured • D – Determine position, station, pelvic adequacy
- 32. • E – Equipment inspect vacuum cup, pump, tubing, check pressure
- 33. • F – Fontanelle position the cup over the posterior fontanelle -ve pressure ↑ 10 cm H2O initially & between contraction sweep finger around cup to clear maternal tissue ↑ pressure to 60 cm H2O with the next contraction
- 34. • G – Gentle traction pull with contractions traction in the axis of the birth canal ask the mother to push during contraction
- 35. • H – Halt halt traction if no progress with three traction aided contractions vacuum pops off three times pulling for 30 min without significant progress
- 36. • I – Incision consider episiotomy if laceration imminent • J – Jaw remove vacuum when jaw is reachable or delivery assured
- 38. Steps of ventouse application
- 39. 40
- 40. Complications • Vacuum –assisted delivery is less traumatic to the mother & fetus than forceps • Ventouse should be the instrument of choice Maternal Vaginal laceration due to entrapment of vaginal mucosa between suction cup & fetal head
- 41. Fetal complications • Scalp injuries chignon abrasion & lacerations 12.6% scalp necrosis 0.25-1.8% • Cephalohematoma 25% jaundice /anemia • Intracranial hemorrhage 2.5% • Subgaleal hematoma
- 42. 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
- 43. Destructive operations • Craniotomy forceps cephalic presentation Intrauterine death Fully dilated cervix Engaged fetal head Parietal bone perforated, brain drained, ↓BPD