OBSTETRICS II SECTION C

Maternal Morbidity Perinatal Morbidity

1. Lacerations a. Acute Perinatal Injuries more
a. 3rd (muscle, fascia, & anal common for vacuum
sphincter) and 4th (rectal b. Cephal hematoma
mucosa) degree laceration c. Subgaleal hemorrhage
(Operation Vaginal Delivery) higher in Median Episiotomy
b. Vaginal wall laceration
d. Retinal hemorrhage
e. Neonatal jaundice
AJB c. Cervical laceration
2. Pelvic floor disorders
f. Shoulder dystocia
g. Clavicular fracture
Operation Vaginal Delivery accomplish by: *there is structural compromised, h. Scalp laceration
1. Forceps delivery or pelvic floor is usually devascularized
2. Vacuum delivery secondary to the forceps inserted.
→if either of these is applied to fetal head usually there is an outward traction a. Urinary & anal incontinence
that would generate force to help augment mother to deliver the baby during the b. Pelvic organ prolapsed
second stage of labor. c. Urinary retention – short term
→doing these operative vaginal delivery is feasible and these could be safely effects subside w/in 24-48hrs
accomplish and termination of pregnancy during the second stage of labor is b. Bladder dysfunction - short term
indicated in any condition threatening for both the mother and fetus that could effects subside w/in 24-48hrs
be relieved by delivery. Forceps assisted vaginal delivery
Fetal indication Maternal indication ➢ Facial nerve injury
➢ Brachial plexus injury
1. Non-reassuring fetal heart pattern 1. Heart disease ➢ Depressed skull fracture
2. Premature placental separation 2. Pulmonary injury compromise ➢ Corneal abrasion
(abruptio placenta) 3. Intrapartum infection
Mechanism of acute injury
3. Prolapsed umbilical cord 4. Neurologic condition
➢ Forceps exerted
5. Hypertensive condition
➢ Primary vessel laceration
6. Exhaustion – most common
➢ Skull fracture w/ vessel laceration
7. Prolonged second stage – most
➢ Compression of nerve against the facial bones
common
➢ Angle of traction
Contraindications: ➢ Shoulder dystocia at the inlet.
1. Absence of proper indication Trial of Operative Vaginal Delivery
2. Incompletely dilated cervix ➢ The operator attempts delivery w/ full knowledge that the vaginal delivery
3. Marked CPD (Cephalo-Pelvic Disproportion) may not be successful.
4. Unengaged fetal head ➢ Factors associated w/ operative delivery failure
5. Lack of experience on the part of the operator ✓ Persistent occiput posterior
✓ Absence of regional or general anesthesia
ACOG Classification of forceps deliveries ✓ Birthweight >4000 grams
Failed Forceps
Procedure Criteria The forceps cannot be applied properly to the
Failure of application
1. Scalp is visible at introitus w/o separating the labia. fetal head.
2. Fetal skull has reached pelvic floor The forceps are applied but despite an all-out
3. Sagital suture is in antero-posterior diameter or right Failure of extraction
effort, delivery cannot be accomplished.
Outlet or left occipiut anterior or posterior position. Causes of Failed Forceps
4. Fetal head is at the perineum ➢ Cephalo-Pelvic disproportion
5. Rotation does not exceed 45 degrees. ➢ Malposition of fetal head
1. Leading point of fetal skull is at station > + 2cm, and ➢ Cervix not fully dilated
not on pelvic floor ➢ Constriction ring
2. Rotation is 45 degrees (left or right occiput anterior to ➢ Premature interference
Low occiput anterior, or left or right occiput posterior to Forceps Delivery
occiput posterior) Forceps design
3. Rotation is greater than 45 degrees ➢ Consist of two crossing branches.
Midpelvic Station above +2cm but head is engaged** ➢ Four components
1. Blade – enclose the head
High Not included in classification 2. Shank – connects the handle & blade
3. Lock – holds the forceps together
**Engaged – Leading Point Is At Station 0 Or Biparietal 4. Handle – to grip the forceps
Diameter Has Passed The Ischial Spine.
According to ACOG the two most important discriminator of risk
for both the mother & fetus is:
1. Station of fetal head
2. Degree of rotation
Prerequisites before the use of forceps/vacuum
1. Experienced operator
2. Engaged head
3. Ruptured membranes
4. Vertex presentation or face with chin anterior
• Face presentation the head is in hyperextension.
• Mento-Anterior – chin is toward symphysis pubis. Could be delivered
vaginally.
• Mento-Posterior – chin is away symphysis pubis. Delivered by
Caesarian Section. ➢ Two curves of the blade
5. Cephalic disproportion not suspected a. Cephalic curve – conforms to the shape of the fetal head.
6. Completely dilated cervix b. Pelvic curve – corresponds to the axis of the birth canal.
7. Precisely assessed fetal head position ➢ Some varieties are fenestrated or pseudofenestrated (w/ depression) to
8. No fetal coagulopathy or bone demineralization disorder. permit a firmer hold of the fetal head.

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OBSTETRICS II SECTION C

Types of Forceps Preparation for Forceps Delivery

➢ Pudendal block analgesia (ishial spine is the point of reference) for
OUTLET FORCEPS operations should be sufficient.
➢ Regional analgesia or general anesthesia for low-forceps or midpelvic
procedures.
➢ Bladder should be emptied to prevent bladder injury, & to provide some
space for the entry of forceps.
➢ If spinal anesthesia is used, the anesthetic agent is introduced before
placing the woman in the lithotomy position.
➢ Inhalational anesthesia can affect the fetus
➢ If fetus has not been delivered within 8 minutes, anesthesia can also reach
and affect the fetus
1. SIMPSONS FORCEPS ➢ If general anesthesia is used, the woman is placed in the lithotomy
• Most common forceps w/ cephalic & pelvic curve. position, the perineum is cleansed and draped and the physician is ready
• Parallel shanks to perform delivery before the induction of anesthesia.
• Fenestrated blade ➢ The exact position of the fetal head must be known for a proper cephalic
• The English lock, consist of a socket located on the shank at the junction application.
w/ the handle, into w/c fits a socket similarly located on the opposite ➢ Head low in pelvis – position is determined by locating sagittal suture and
shank. fontanels.
• Use to deliver fetus w/ molded head commonly seen in nulliparous patient. ➢ Head at higher station – position is determined by locating the
posterior ear of the fetus posterior ear.

2. TUCKER-MCLANE
• Blade is solid and shank is narrow Forceps application
• Method of articulation – English lock • Forceps are constructed so that
• Use to deliver fetus w/ rounded head commonly seen in multiparous. their cephalic curve is closely
3. KIELLAND FORCEPS adapted to the sides of the fetal
• Characteristic features are the sliding lock head
• Minimal pelvic curvature & light weight. • The fetus is presenting as vertex
• For deep transverse arrest of the fetal head. with occiput anterior crowning.
Next, the right blade is applied and
the blades are articulated (joined).
• The Biparietal Diameter
corresponds to the greatest
distance between the appropriately
applied forceps
• The head of the fetus is perfectly
grasped only when the long axis of
the blades corresponds to the
occipitomental diameter. As a
result, the blade lies over the face.
• Fetus in occiput anterior position,
4. PIPER FORCEPS the concave arch of each blade is
• Blade is similar to Simpson directed toward the sagittal suture.
• Shank is longer • Fetus in occiput posterior position,
• It has double pelvic curve to facilitate application to the after coming head the concave arch of the blade is
in breech presentation directed toward the fetal face.
5. BARTONS FORCEPS • Applied as such, the forceps should
• With one fixed curved blade & a hinged anterior blade for application to a NOT slip, and traction may be
high transverse head. applied most advantageously.
• With a sliding lock that is useful when the infant’s head is in the occiput • With most forceps, if one blade is
transverse position during delivery. applied over the brow and the other
over the occiput, the instrument
cannot be locked, or if locked, the
Two Function of Obstetrics Forceps blades slip off when traction is
• Most important function. applied.
• The direction of the traction must be along the pelvic • For these reasons, the forceps must
curvature as the station changes during descent, so be applied directly to the sides of
1. Traction does the line of traction. the fetal head along the
• The direction of pull should be perpendicular to the occipitomental diameter.
plane of the level at which it is being applied.
• Carried best in the mid pelvis
• Rotating the head from posterior to transverse position,
2. Rotation • the handle should be swing through arc in order to
reduce the arc of the blade

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 OBSTETRICS II
OUTLET FORCEPS DELIVERY
• Two Or More Fingers of the right
hand are introduced inside the left
posterior portion of the vulva and
into the vagina beside the fetal
head.
• The handle of the left branch is then
grasped between the thumb and
two fingers of the left hand and the
tip of the blade is gently passed into
the vagina between the fetal head
and the palmar surface of the
fingers of the right hand.
• Continued insertion of the left blade.
Note the arc of the handles as they
rotate to be applied to the mother's
left.
• If necessary, rotation to occiput
anterior is performed before traction
is applied
• Forceps have been locked. Vertex is
rotated from left occiput anterior to
occiput anterior (arrow).
• The vertex is now occiput anterior
and the forceps are symmetrically
placed and articulated.
• Horizontal Traction is exerted until
the perineum begins to bulge.
• With traction, as the vulva is
distended by the occiput, an
episiotomy may be performed if
indicated
• Upward traction (arrow) is applied
as the head is delivered.
• Forceps may be disarticulated after
the head is delivered.
• Modified Ritgen Maneuver (arrow)
• Support the perineum of mother to
prevent too much laceration, to
maintain fetal head in flex position,
prevent fetus from having contact
with the rectum to prevent the fetus
from being contaminated with the
feces coming from the mother
• Used to complete the delivery of
fetal head
LOW AND MIDFORCEPS
• When the head lies above the perinuem, the sagittal suture usually occupies
an oblique or transverse diameter of the pelvis.
• In such cases, the forceps should always be applied to the sides of the
head.
SECTION C
DELIVERY OF OCCIPUT POSTERIOR POSITION
Manual Rotation
• An open hand is inserted into the vagina. The palm straddles the sagittal
suture of the fetal head.
• Right Occiput Posterior Position,
rotation: clockwise
• Left Occiput Posterior Position,
rotation: counterclockwise
Forceps Delivery
• Application of forceps blade to the head in posterior position
• Horizontal traction should be applied until the base of the nose is under
the symphysis
• Episiotomy should be done if head is bulging at the perineum
• The handles should be slowly elevated until the occiput gradually emerges
over the anterior margin of the perineum
• The forceps are directed in a downward motion, and the nose, mouth and
chin successively emerge from the vulva
ROTATION FROM OCCIPUT TRANSVERSE POSITION
(KIELLAND Forceps is used)
• Occiput obliquely anterior, it gradually rotates spontaneously to the
symphysis pubis as traction is exerted
• Occiput transverse, o rotary motion of the forceps is required
• Left Occiput Transverse, rotation is counterclockwise from the left side
toward the midline
• Right Occiput Transverse, rotation is clockwise
FORCEPS DELIVERY OF FACE PRESENTATION
• The blades are applied to the sides of
the head along the occipitomental
diameter, with the pelvic curve
directed towards the neck
• Downward traction is exerted until the
chin appears under the symphysis
• Then by upward movement, the face
is slowly extracted, with the nose,
eyes, brow and occiput appearing in
succession over the anterior margin of
the perineum
• Forceps should not be applied to the
mentum posterior presentation,
because vaginal delivery is impossible
as such.
VACUUM EXTRACTION
Vacuum Extractor Design
➢ Suction is created within a cup placed on the fetal scalp such that traction
on the cup aids fetal expulsion.
o US - Vacuum Extractor
o Europe - Ventouse
o French - "soft cup"
• Use of a metal cup or ft cup vacuum extractors
• High - pressure vacuum generates large amounts of force regardless of
the cup used.
Silastic Cup is a reusable instrument with a soft, 65-mm-
Vacuum Device diameter cup
Mityvac uses a disposable 60-mm-diameter cup and
Instrument the CMI Tender Touch uses a 62-mm cup
FIGURE 29-15 Vacuum delivery systems.
A. The Kiwi OmniCup contains a handheld vacuum-generating pump, which is attached via
flexible tubing to a rigid plastic mushroom cup.
B. The Mityvac Mystic II MitySoft Bell Cup has a soft bell cup attached by a semirigid shaft to
a handheld pump.
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 OBSTETRICS II SECTION C

Advantages ➢ Full circumference of the cup should be placed both before and after the
vacuum has been created, as well as prior to traction
o Simpler requirements for precise positioning on the fetal head
o When using RIGID CUPS, it is recommended that the vacuum
o Avoidance of space-occupying blades within the vagina
be created gradually by increasing the suction by 0.2 kg/cm2
o Lower maternal trauma rates
every 2 minutes until a negative pressure of 0.8 kg/cm2 is
INDICATIONS reached
Fetal indication Maternal indication o With SOFT CUPS, negative pressure can be increased to 0.8
kg/cm2 over as little as 1 minute
1. Non-reassuring fetal heart pattern 1. Heart disease ➢ Traction should be intermittent and coordinated with maternal expulsive
2. Premature placental separation 2. Pulmonary injury compromise efforts
(abruptio placenta) 3. Intrapartum infection ➢ Traction may be initiated by using a two-handed technique: the fingers of
3. Prolapsed umbilical cord 4. Neurologic condition one are placed against the suction cup, while the other hand grasps the
hand instrument
5. Hypertensive condition
➢ Manual torque to the cup should be avoided as it may cause
6. Exhaustion – most common cephalhematomas and with metal cups, "cookie-cutter" type scalp
7. Prolonged second stage – most lacerations
common ➢ Vacuum extraction should be considered a trial. Without early and clear
evidence of descent toward delivery, an alternate delivery approach should
CONTRAINDICATIONS be considered
1. Operator Inexperience
➢ As a general guideline, progressive descent should accompany each
2. Inability to asses fetal position
traction attempt.
3. High station
4. Suspicion of CPD – cephalopelvic disproportion COMPLICATIONS
5. Face or nonvertex presentation 1. Scalp lacerations and bruising
6. Fetal Coagulopathy 2. Subgaleal Hematomas
7. Recent Scalp Blood Sampling 3. Cephalhematomas
8. Macrosomia 4. IntracranialHemorrhages
PREREQUISITES 5. Neonatal Jaundice
6. SubconjuctivalHemorrhage
1.Experienced Operator
7. Clavicular Fracture
2.Engaged Head
8. Shoulder Dystocia
3.Ruptured Membranes
9. Injury of the 6th and 7th cranial nerve
4.Vertex presentation or face with Chin Anterior
10. Erb Palsy
5.Cephalopelvic Disproportion NOT suspected
11. Retinal Hemorrhage
6.Completely dilated cervix
12. Fetal Death
7.Precisely assessed fetal head position
8.No fetal coagulopathy or bone demineralization disorder RECOMMENDATIONS REGARDING VACUUM DELIVERY
9.Specific for vacuum: fetus>34 weeks AOG bec if premature there is 1. The classification of vacuum deliveries should be the same as that
higher chance of intracranial haemorrhage (forceps may be applied even utilized for forceps deliveries (including station)
in preterm infants) 2. The same indications and contraindications utilized for forceps
**One prerequisite that is specific for vacuum extraction fetus should deliveries should be applied to vacuum-assisted deliveries
be more than 34 week AOG. Because if applied in less than 34 weeks 3. The vacuum should NOT be applied to an unengaged vertex, that is
higher chance of intracranial hemorrhage. above 0 station
**Unlike in forceps even preterm fetus you can apply forceps 4. The individual performing or supervising the procedure should be an
extraction. experienced operator
Techniques 5. The operator should be willing to abandon the procedure if it does
NOT proceed easily or if the cup pops off more than 3 times
➢ Proper cup placement over the flexion point is the most important
determinant of success in vacuum extraction
COMPARISON OF VACUUM EXTRACTION WITH FORCEPS
Vacuum Extraction Forceps Delivery
• Increased incidence of Neonatal • Higher frequency of maternal
Jaundice trauma and blood loss
• Shoulder Dystocia and • More 3rd and 4th degree laceration
Cephalhematoma is doubled

Complications Method of Delivery

Vacuum Forceps
n=41 (%) n=40 (%)
APGAR scores
1min <7 4 (10) 4 (10)
➢ Flexion Point: along the sagittal suture, 3cm in front of the posterior fontanel
5 min <8 1 (2) 1 (2)
and 6cm from the anterior fontanel
Cephalhematoma
➢ Pivot Point:
o Maximizes traction Mild 6 (15) 3 (10)
o Minimizes cup detachment Moderate 1 (2) 2 (7)
o Flexes but averts twisting of the fetal head Caput 14 (34) 7 (14)
o Delivers the smallest head diameter through the pelvic outlet Facial Mark or Injury 1 (2) 7 (18)
➢ Anterior placement on the fetal cranium - near the anterior fontanel rather Trauma
than over occiput will result in cervical spine extension Erb Palsy (mild) 1 (2) 0
➢ Entrapment of maternal soft tissue predisposes the mother to lacerations Fractured Clavicle 1 (2) 0
and hemorrhage and virtually assures cup "pop-off" Elevated Bilirubin 8 (20) 4 (10)
Retinal Hemorrhage
Mild 6/37 (16) 3/36 (8)
Mod – Severe 8/27 (27) 3/26 (8)

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