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Assisted vaginal delivery
Assisted vaginal delivery
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  1. 1. Assisted Vaginal Delivery supervised by Dr. Mohammed Khader
  2. 2. Definition • Operative vaginal delivery (OVD) refers to a vaginal birth with the use of any type of forceps or vacuum extractor (ventouse). The terms instrumental delivery, assisted vaginal delivery and OVD are used interchangeably. • The goal of OVD is to expedite delivery with a minimum of maternal or neonatal morbidity. As with other forms of intrapartum intervention, OVD should only be performed when the safety criteria have been met and when the benefits outweigh the risks.
  3. 3. Indications The indications for OVD can be divided into fetal or maternal, although in many cases these factors coexist. The most common fetal factor is suspected fetal compromise, usually based on a pathological cardiotocograph (CTG). The most common maternal factor is a prolonged active second stage of labour. The underlying aetiology for a prolonged second stage should be evaluated in terms of the 3 Ps.
  4. 4. Depending on the overall clinical findings it may be appropriate to use an oxytocin infusion, change the maternal position and offer further encouragement or proceed directly to instrumental delivery. In some cases the findings will be a contraindication to OVD and favour delivery by caesarean section. The indications are summarized in the following table.
  5. 5. Choice of instrument The guidelines of the RCOG recommend that obstetricians should be competent and confident in the use of both forceps and the ventouse and that practitioners should choose the most appropriate instrument for the individual circumstances. The choice of instrument should be based on a combination of indication, experience and training. The aim should be to complete the delivery successfully with the lowest possible morbidity and, where appropriate, the preferences of the mother should be taken into account.
  6. 6. Choice of instrument Ventouse and forceps have been compared in a number of RCTs analysed within a Cochrane systematic review. • Ventouse delivery is preferred as a first-line instrument by many obstetricians in terms of reduced maternal trauma, but this needs to be balanced with a failure rate of 10–20% compared to a failure rate with forceps of 5% or less for similar deliveries. The incidence of maternal pelvic floor trauma in deliveries performed with the ventouse is less than with forceps • anal sphincter injury in particular is twice as common with forceps delivery (8% versus 3–4%).
  7. 7. The ventouse compared to forceps is significantly more likely to be associated with: 1. Failure to achieve a vaginal delivery. 2. Cephalohaematoma (subperiosteal bleed). 3. Retinal haemorrhage. 4. Maternal worries about the baby. The forceps compared to ventouse is significantly more likely to be associated with: 1. Use of maternal regional/general anaesthesia. 2. Significant maternal perineal and vaginal trauma. 3. Severe perineal pain at 24 hours. Both is similar in terms of: 1. Delivery by caesarean section (where failed vacuum is completed by forceps). 2. Low 5 minute Apgar scores.
  8. 8. Place of delivery
  9. 9. Place of delivery OVDs in the midpelvis are more difficult either because there is a malposition and rotation is required or there is a degree of relative CPD (Table 13.3). These deliveries require a higher degree of skill and there is inherent uncertainty whether OVD can be achieved safely. The alternative is to deliver by caesarean section, which can also be a very challenging procedure with the head deep in the pelvis.
  10. 10. Procedure The anatomy of the birth canal and its relationship to the fetal head must be understood to become skilled in the safe use of forceps or ventouse
  11. 11. Evaluation A full abdominal and vaginal examination should take place to confirm the fetal lie, presentation, engagement, station, position, attitude and degree of caput or moulding. This will confirm whether or not the basic safety criteria for OVD have been met. A careful pelvic examination is also essential.
  12. 12. Analgesia Analgesic requirements are greater for forceps than for ventouse delivery. Where rotational forceps or midpelvic direct traction forceps are needed, regional analgesia is preferred. For a rigid cup ventouse delivery, a pudendal block with perineal infiltration may be all that is needed and if a soft cup is used, analgesic requirements may be limited to perineal infiltration with local anaesthetic.
  13. 13. Positioning OVDs are traditionally performed with the patient in the lithotomy position. The angle of traction needed requires that the bottom part of the bed be removed. In patients with limited abduction (such as those with symphysis pubis dysfunction), it may be necessary to limit abduction of the thighs to a minimum. It is the operator’s duty to ensure that the bladder is emptied.
  14. 14. Contingency planning With any OVD there is the potential for failure with the chosen instrument and the operator must have a back-up plan for such an event. It may be possible to complete a failed vacuum delivery with low-pelvic forceps, but failed or abandoned forceps delivery will almost always result in caesarean section.
  15. 15. Assisted vaginal delivery by forceps Rama Murad
  16. 16. •An Obstetric forceps is: a double- bladed metal instrument used for extraction of the fetal head
  17. 17. • Parts: • Forceps have 4 major components, as follows: • Blades: The blades grasp the fetus. Each blade has a curve to fit around the fetal head. The blades are oval or elliptical and can be fenestrated (with a hole in the middle) or solid. Many blades are also curved in a plane 90° from the cephalic curve to fit the maternal pelvis (pelvic curve). Cephalic curve Pelvic curve
  18. 18. • Shanks: The shanks connect the blades to the handles and provide the length of the device. • Lock: The lock is the articulation between the shanks. Many different types have been designed. • Handles: The handles are where the operator holds the device and applies traction to the fetal head.
  19. 19. Classification of forceps: 1- Non-rotational forceps: are used when the head is OA with no more than 45º deviation to the left or right (LOA, ROA). Ex: Simpson forceps , Elliot forceps , Wrigley's Forceps 2-Rotational forceps: when the head is positioned more than 45º from the vertical, rotation must be accomplished before traction. Ex: Kielland forceps , piper forceps
  20. 20. Simpson forceps: *which have a pelvic curvature, a cephalic curvature, and locking handles *Was commonly used. *Used for aid in delivery a baby in an ideal occiput anterior position.
  21. 21. Kielland's forceps: *Not used nowadays . *Sliding lock, minimal pelvic curvature. *Used for rotation and extraction of the head which is arrested in the deep transverse or occipito-posterior position.
  22. 22. Piper forceps: *Allows for application to the after coming head in breech deliveries. *No pelvic curve *Long handles to contain the body
  23. 23. Function of forceps: • 1) Traction: the most important function. • 2) Rotation of head: (Kielland's forceps) never done now. • 3) Protective cage: When applied on a premature baby it protects from the pressure of the birth canal, and when applied on the after coming head it reduces the sudden decompression
  24. 24.  Safety criteria for forceps vaginal delivery (assisted) After full abdominal and vaginal examination • Head engagement is 1/5 or 0/5 in role of fife (stations 0/+1/=2+3) • Fully dilated cervix • Membrane ruptured • Exact position of the head must be determined to place the instrument correctly • Can use in breech, face, and preterm babies. • Caput or molding are no than moderate • Pelvis is deemed adequate • Adequate analgesia and empty bladder ensured
  25. 25. Technique of forceps vaginal delivery Safety criteria for forceps vaginal delivery (assisted) After full abdominal and vaginal examination -Head engagement is 1/5 or 0/5 in role of fife (stations 0/+1/=2+3) - Fully dilated cervix -Membrane ruptured -Exact position of the head must be determined to place the instrument correctly -Can use in breech, face, and preterm babies. -Caput or molding are no than moderate -Pelvis is deemed adequate -Adequate analgesia and empty bladder ensured
  26. 26. Technique -The first thing to do is adequate verbal consent. -Application technique for occiput anterior position. -The presence of the sagittal suture in the anteroposterior diameter of the pelvic outlet is confirmed. 29
  27. 27. 30 Step 1: The left handle of the Simpson forceps is held in the left hand. The blade is introduced into the left side of the pelvis between the fetal head and fingers of the operator's right hand. Continued insertion of left blade.
  28. 28. 31 Step 2: Next, the right blade is introduced into the right side of the pelvis in the same fashion.
  29. 29. 32 Step 3: The forceps should lock easily with minimal force and stand parallel to the plane of the floor, depending on fetal station. Note: In a proper cephalic application, the long axis of the blades corresponds to the occipitomental diameter. With the ends of the blades lying over the posterior cheeks the blades should lie symmetrically on either side of the head.
  30. 30. 33 Step 4: Traction should be applied intermittently coordinated with uterine contractions and maternal expulsive efforts. The axis of traction changes during the delivery and is guided along the ‘J’- shaped curve of the pelvis
  31. 31. 34 Episiotomy may be performed. Left mediolateral episiotomy is shown here. Step 5: As the fetal head crowns, the forceps blades are disarticulated and removed and the remainder of the delivery proceeds as for a spontaneous vaginal delivery.
  32. 32. complications 35 Mostly due to faulty technique rather than the instrument, and its more than in vacuum delivery. Maternal: 1) Injury: • Extension of the episiotomy involving anus & rectum or vaginal vault. • Vaginal lacerations and cervical tear if cervix was not fully dilated. 2) Postpartum hemorrhage: Due to trauma or Atonic uterus. 3) Shock due to blood loss, dehydration or prolonged labor. 4) Increase the Use of maternal regional anesthesia. 5) general index of pelvic floor disorders (incontinence of urine and feces and pelvic organ prolapse) due to decrease in pelvic muscle strength. -Urinary incontinence has been reported in up to 24% of women within 6 months of a forceps delivery
  33. 33. 36 Fetal complications: a. Asphyxia :Cerebral palsy, mental retardation, and behavioral problems b. Trauma: i. Intracranial haemorrhage. ii. Cephalic haematoma. iii. Facial / Brachial palsy. iv. Injury to the soft tissues of face & forehead. v. Skull fractures. c. The risk for serious morbidity is 1.5% and the risk of fetal or neonatal death is 0.05%.
  34. 34. Contraindications: • Any contraindication to vaginal delivery • Inability to obtain adequate verbal consent • A cervix that is not fully dilated or retracted • Inability to determine the presentation and fetal head position • Inadequate pelvic size • Confirmed cephalopelvic disproportion relative contraindication • Unsuccessful trial of vacuum extraction • Absence of adequate anesthesia or analgesia • Inadequate facilities and support staff • An insufficiently experienced operator
  35. 35. vacuum-assisted vaginal delivery vacuum extraction (VE)
  36. 36. Definition : Traction of fetal head by CREATING Negative pressure through a SUCTION cup applied to the head .
  37. 37. Safety criteria for vacuum vaginal delivery (assisted) • After full abdominal and vaginal examination • Head engagement is 1/5 or 0/5 in role of fife (stations 0/+1/=2+3) • Fully dilated cervix • Membrane ruptured • Exact position of the head must be determined to place the instrument correctly • Cannot use in breech and preterm babies. • Caput or molding are no than moderate
  38. 38. Rigid VS Soft cups • Soft Cups (polyethylene or silastic ) are associated with less scalp injuries and appropriate for occipitoanterior position . • There is higher rate of failure with soft cups . • Rigid cups (Metal or Plastic ) are more suitable for occipitoposterior , transverse , and difficult occipitoanterior position where the infant is larger.
  39. 39. Vacuum Extraction Technique • Insertion: the labia are gently spread, and the device is slipped into the vagina and then positioned against the fetal head. • Correct application : the vector of traction is directed through the cranial FLEXION point. • Flexion of fetal head must be maintained to provide the smallest diameter to the maternal pelvis by the correct application .
  40. 40. 360°checkshouldbeperformedtoensurethatthepelvictissueofthe mother(cervixorvagina)orumbilicalcord. isnottrappedinthevacuumcup
  41. 41. Traction : Once the doctor has verified cup placement, full vacuum is applied (450-600 mm Hg) with onset of contraction and the traction pulls along the axis of the pelvis , handle perpendicular to the cup , paralleling the uterine contractions with the aid of maternal pushing effort .
  42. 42. • Applying rotational force to rotate the head of the fetus is contraindicated because it can lead to detachment of the cup, cephalohematoma of the fetus, and scalp laceration . • Pop-off Detachment of the suction cup from the fetal head during traction • IF two “pop-offs” occur , the procedure should be discontinued in favor of CS . • Maximum time from application to delivery should ideally be less than 15-20 minutes .
  43. 43. Fetal injury:  fetal death or severe fetal injury from vacuum extraction (VE) is low, ranging from 0.1-3 cases per 1,000 extraction procedures.  The most common injuries are to the fetal scalp.  Cephalo-hematomas: collection of blood between fetal scalp and skull  Caput succedaneum  Subgaleal hemorrhages: bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis.  Intracranial hemorrhage, Scalp Lacerations  radiographic or ultrasonic studies of the CNS performed on newborns who were delivered by instrumental assistance ,help to discover injuries more frequently than clinical examination .
  44. 44. Cephalohematoma Caputsuccedaneum
  45. 45. Maternal injury • Vacuum extraction has a low rate of maternal injury in comparison with forceps operations or cesarean delivery • such as urinary incontinence, fecal incontinence, pelvic organ prolapse, and occasionally fistula formation. • Advantages : • 1- no risk of excessive traction • 2-less injury to mother • Disadvantages : • 1-cannot used for preterm , face or breech presentation • 2-more trauma for baby