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College Statement C-Obs 16
1st Endorsed: July 2002 Current: November 2012 Review: November 2015
Instrumental Vaginal Delivery
Instrumental Vaginal Delivery remains an important facet of modern obstetric practice. Vacuum and forceps assisted vaginal delivery account for a fairly constant rate of 11% of deliveries in Australia (1990-2009)1 and 10% of deliveries in New Zealand.2 Rates have been reported to vary from 7.4-16% of all deliveries across a spectrum of Australian and New Zealand hospitals.3 A number of reviews and guidelines have been published.4,5,6,7 Indications for Instrumental Delivery There are few absolute indications or contraindications to instrumental delivery. Each case should be judged on its merits taking into account the relative benefits and adverse effects of the possible courses of action. Instrumental delivery is employed to accelerate delivery in the presence of:
Fetal compromise suspected or anticipated The few hours immediately prior to birth is the time of greatest risk to the well-being of most people in their entire life. The risk is even greater in the second stage of labour where fetal descent may precipitate cord compression or a combination of intense uterine activity and expulsive efforts by the mother may reduce placental blood flow to the extent that the fetus is seriously compromised. It is fortuitous that, at the time of greatest fetal risk, instrumental delivery can often be rapidly and safely accomplished. Delay in the second stage of labour There is no clear demarcation as to an appropriate length of time to wait before embarking on instrumental delivery for failure to progress. Traditionally two hours in a primigravid and one hour in a multigravid have been proposed as a cut off for prolonged second stage but there is paucity of scientific data on which to base this practice, and the duration of second stage may be altered by the presence of neuraxial anaesthesia. The upper time limit for second stage should be a matter for the senior clinician supervising the labour and patient given the particular circumstance. The following should be noted in making the decision. a. Increased fetal compromise occurs with prolonged pushing in second stage or when the presenting part is low on the perineum for an extended length of time. These concerns arise largely from publications prior to the widespread use of electronic fetal monitoring. Where electronic fetal monitoring is being utilised and shows no abnormality, the fetal risks of a prolonged second stage are likely to be low. b. Pelvic floor injury including anal sphincter dysfunction is more common both with prolonged second stages and with instrumental delivery.8 Maternal effort contraindicated Maternal valsalva may sometimes be contraindicated with maternal conditions such as cerebral aneurysm, risk of aortic dissection, proliferative retinopathy, severe hypertension or cardiac failure. Such women may benefit from epidural analgesia and elective
1 RANZCOG College Statement: C-Obs 16
instrumental delivery. Skull fracture and/or intracranial haemorrhage e. clear communication with the mother and healthcare personnel and expertise in the chosen procedure. retinal haemorrhage Facial nerve palsy and corneal abrasion are more common with forceps and retinal haemorrhage with vacuum delivery. forceps after failed vacuum) should be attempted or a caesarean section performed without further attempt at instrumental delivery. Failed Instrumental Delivery Failed instrumental delivery may be associated with adverse outcome. 2 RANZCOG College Statement: C-Obs 16 .6 Delivery is more likely to be achieved with forceps than vacuum and will occur over a shorter time interval. reports of poor outcome may reflect the indication for which instrumental delivery was being attempted (e.6 d. occurring in approximately 1 in 300 cases of vacuum delivery. Maternal complications The Cochrane review indicates a lower incidence of serious maternal injury (vaginal trauma and anal sphincter damage) with vacuum assisted delivery when compared to forceps.11 c.13 The following comments are pertinent to this situation. Cervical spine injury A consequence of rotational forceps delivery may be minimised by ensuring uterine relaxation prior to performing the rotation.12 The clinician should select the instrument based on his or her clinical experience and the clinical circumstances. Facial nerve palsy. • On occasions. Appropriate analgesia should be used.6 • Choosing between Vacuum and Forceps delivery Each instrument has a different profile of complications. Guidelines for Instrumental Delivery Safe operative vaginal delivery requires careful assessment of the clinical situation.g. corneal abrasion.9 b. Complications of instrumental delivery The adverse effects of instrumental delivery must be weighed against the consequences of awaiting vaginal delivery or alternatively performing a caesarean section with the head deep in the pelvis.g. Subaponeurotic/subgaleal haemorrhage A potentially life threatening complication. The more serious complications are very uncommon but include: • Fetal complications a. Shoulder dystocia and consequences The need to perform an instrumental delivery for lack of progress in the presence of anticipated macrosomia should alert the clinician to the increased likelihood of shoulder dystocia.10. • Each case should be assessed as to whether alternate instrumental delivery (e. • The threshold for abandoning an instrumental delivery and resorting to an alternate mode of delivery is likely to differ between clinicians and the clinical circumstances. extremely severe fetal compromise) rather than an effect of attempts at instrumental delivery.
This is determined clinically by both abdominal palpation and vaginal examination. Between 34 and 36 weeks. Clinical Forum on Caesarean Sections Briefing Kit 2001. • Clear explanation given and consent obtained.26. • Favourable presentation Instrumental delivery may occur with a vertex. A vacuum extraction should not be used on a face presentation or at a gestational age of less than 34 weeks. pp. ACOG Practice Bulletin. Consideration should be given to written consent if a forceps delivery is to be attempted in theatre. Australia’s Mothers & Babies Report (1999-2009). • Engagement of the Fetal Head The presenting part must be engaged before beginning an instrumental vaginal delivery. Perinatal Statistics Reports. osteogenesis imperfecta) are relative contraindications to instrumental delivery but will also be associated with considerable fetal and maternal risk if the baby is to be delivered abdominally with the head deep in the pelvis. Women’s Hospitals Australasia. References 1. 5.org. post-partum haemorrhage).g.uk/files/rcog-corp/GTG26.pdf 3 RANZCOG College Statement: C-Obs 16 . 2004) New Zealand Minister of Health Publications.Obstetrics. RCOG Clinical Green Top Guidelines. deflexed vertex or face (mento-anterior) presentation. Available at: http://www. alloimmune thrombocytopenia) or predisposition to fracture (e.govt. • Anticipation of complications which may arise (e. Reports on maternity (1999-2002.nsf/page/Perinatal+Statistics 2. shoulder dystocia. • Personnel present who are trained in neonatal resuscitation.preru.nz/publications/births 3. 4-5.health.rcog. 47. • Back-up plan exists in case of failure to deliver. o Verbal consent.au/PRERUWeb. is reasonable in the labour ward setting. (2011) Available at: www. • Maternal bladder has been recently emptied.unsw. • Appropriately skilled personnel available for neonatal resuscitation.g.g. The latter is a contraindication to vacuum delivery. AIHW National Perinatal Epidemiology & Statistics Unit. there is no clear safety data to guide clinical practice. 2000: 17 (reaffirmed 2012). Fetal contraindications to Instrumental Delivery A fetal bleeding disorder (e. 4. o Consideration given to performance in theatre with a view to proceeding to caesarean section if there is concern in this regard.edu. preferably witnessed by a health care professional and later documented in the medical record.Obstetric pre-requisites for Instrumental Vaginal Delivery: • Full dilatation of the Cervix and membranes ruptured. Engagement is defined as the maximum diameter of the presenting part having entered the pelvic inlet. Royal College of Obstetricians and Gynaecologists Guidelines and Audit Committee. Available at: http://www. ACOG Committee on Practice Bulletins . • The exact position of the fetal head has been determined so proper placement of the instrument can be achieved (ultrasound may assist this assessment). • The pelvis is assessed clinically to be adequate for safe delivery. Instrumental Vaginal Delivery No.
Musci TJ. Lopez A. Anal incontinence after vaginal delivery: a prospective study in primiparous women. This College statement has been prepared having regard to the information available at the time of its preparation. Siu YK. Br J Obstet Gynaecol 1999. The statement has been prepared having regard to general circumstances. Choice of Instruments for Assisted Vaginal Delivery (Review) IN: The Cochrane Library 2010. and each Practitioner must have regard to relevant information. clinical management must always be responsive to the needs of the individual patient and the particular circumstances of each case. O’Mahony F. 106: 324-330.edu.sogc.au/component/docman/doc_download/894-c-gen-15-evidence-based-medicineobstetrics-and-gynaecology. Zetterstrom JP. 177: 37-41.edu.ranzcog. 13. MacKenzie IZ. 106: 868-870. 11. Decision to delivery intervals for assisted vaginal vertex delivery. Norman M. 4 RANZCOG College Statement: C-Obs 16 . Anzen B. SOGC Clinical Practice Guidelines 2004. Available at: http://onlinelibrary. Failed instrumental delivery: How safe is the use of a second instrument? J Obstet Gynaecol 1999.ranzcog. and the application of this statement in each case.CD005455. Incidence of persistent birth injury in macrosomic infants: association with mode of delivery.pub2/pdf 7.html?Itemid=341 Disclaimer This College Statement is intended to provide general advice to Practitioners. Kolderup LB. Obstetrics and Gynaecology http://www. Fortune PM.au/component/docman/doc_download/945-c-obs-11-management-of-term-breechpresentation-. 19: 460-2. Edozien LC.edu.wiley. Lewindon PJ. Dolk A. 84: 1065-1069. Guidelines for Operative Vaginal Birth. Links to other related College Statements (C-Obs 11) Breech deliveries at term http://www. It is the responsibility of each Practitioner to have regard to the particular circumstances of each case. research or material which may have been published or become available subsequently.org/guidelines/public/148E-CPG-august2004. Menon V. 9.html (C-Obs 13) Rotational forceps http://www.ranzcog. 12.au/component/docman/doc_download/947-c-obs-13-rotational-forceps-. Acta Paediatr 1995. 10.pdf 8. DOI: 10.html (C-Gen 15) Evidence-based Medicine. Thomas RM. Ng PC. Cooke I. In particular.com/doi/10.html (C-Obs 28) Prevention detection and management of Subgaleal Haemorrhage in the newborn http://www. The statement should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. 107: 467-471.CDOO5455. Br J Obstet Gynaecol 2000.1002/14651858. Issue 11.ranzcog. Hofmeyr G J. Okunwobi-Smith Y.6.edu. Subaponeurotic haemorrhage in the 1990s: a 3 year surveillance. Mellgren A. Available at: http://www. Am J Obstet Gynecol 1997. Br J Obstet Gynaecol 1999.pub2.au/component/docman/doc_download/960-c-obs-28-prevention-detectionand-management-of-subgaleal-haemorrhage-in-the-newborn-. Laros LK.1002/14651858. Sub-aponeurotic haemorrhage: a rare but life-threatening neonatal complication associated with ventouse delivery.
it takes no responsibility for matters arising from changed circumstances or information or material that may have become available after the date of the statements.Whilst the College endeavours to ensure that College statements are accurate and current at the time of their preparation. 5 RANZCOG College Statement: C-Obs 16 .
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