Operative Vaginal

Delivery
Presenter: Mbi Mbi
Year of Study: MBBS V
Rotation: OBGYN
Date: 25/02/15
 Outline
• Introduction
• Operative Vaginal Delivery Definition
• Classification, Indications and Prerequisites
• Forceps and Vacuum Delivery
• Complication
• Prevention
• Conclusion
 Introduction
• An operative delivery refers obstetric
procedure in which active measures are taken
to accomplish delivery.
• This procedures can be divided into operative
vaginal delivery and caesarean section.
 Operative vaginal Delivery (OVD)
• OVD refers to emergency or elective assisted
delivery using either vacuum extraction
(ventouse) or an obstetric forceps.
• The goal of OVD is to mimic spontaneous
vaginal birth, expediting delivery with a
minimum maternal or neonatal morbidity.
 ACOG Classification of OVD
OUTLET • Fetal scalp visible without separating the labia
• Fetal skull has reached the pelvic floor
• Sagittal suture is in the anterio-posterior diameter or right or
left occiput anterior or posterior position (rotation does not
exceed 45º)
• Fetal head is at or on the perineum

LOW Leading point of the skull (not caput) is at station plus 2 cm or more
and not on the pelvic floor
Two subdivisions:
• rotation of 45º or less from the occipito-anterior position.
• rotation of more than 45º including the occipito-posterior
position.
 ACOG Classification Cont’d
MILD Fetal head is no more than 1/5th palpable per abdomen
Leading point of the skull is above station plus 2 cm but not
above the ischial spines
Two subdivisions:
• rotation of 45º or less from the occipito-anterior position
• rotation of more than 45º including the occipito-posterior
position
HIGH Not included in the classification as operative vaginal delivery is
not recommended in this situation where the head is 2/5th or
more palpable abdominally and the presenting part is above the
level of the ischial spines
 Indication of OVD
Types Indication
Fetal • Malposition with relative dystocia (e.g. occiput posterior or
transverse).
• Suspected or anticipated fetal compromise.
Maternal Shorten and reduce the effects of the second stage of labor on
medical conditions;
• cardiac disease, NYHA III or IV
• hypertensive crises
• myasthenia gravis
• spinal cord injury patients at risk of autonomic dysreflexia
• proliferative retinopathy
Inadequate progression of labor;
• Nulliparous women 2hrs without regional anesthesia (3hrs
with)
• Multiparous women 1hr without regional anesthesia (2hrs
with)
Maternal fatigue/exhaustion
 Contraindications of OVD
Absolute
• Operator inexperience
• Incompletely dilated cervix
• Unknown fetal position
• Unengaged head
• Malpresentation e.g. brow or face
presentation
• Suspected CPD (assess with
abdominal and pelvic assessment )
• Ventouse delivery: Gestation < 36+0
weeks (risk of intracranial
hemorrhage and cephalhematoma).
Relative
• Predisposition to fracture (e.g.
osteogenesis imperfecta).
• Suspected bleeding disorder such as
haemophilia or alloimmune
thrombocytopenia.
• Vertically transmitted disease i.e.
HIV.
 RCOG Prerequisite for OVD
Full abdominal & • Head is ≤1/5th palpable per abdomen
vaginal examination • Vertex presentation.
• Cervix is fully dilated and the membranes ruptured.
• Exact position of the head can be determined so proper
placement of the instrument can be achieved.
• Assessment of caput and mouding.
• Pelvis is deemed adequate. Irreducible molding may
indicate CPD.

Preparation of Mother • Clear explanation should be given and informed consent

obtained.
• Appropriate analgesia is in place for mid-cavity rotational
deliveries. This will usually be a regional block.
• A pudendal block may be appropriate, particularly in the
context of urgent delivery.
• Maternal bladder has been emptied recently. In-dwelling
catheter should be removed or balloon deflated.
• Aseptic technique.
 RCOG Prerequisite Cont’d
Preparation of • Operator must have the knowledge, experience and
staff skill necessary.
• Adequate facilities are available (appropriate
equipment, bed, lighting).
• Back-up plan in place in case of failure to deliver.
• When conducting mid-cavity deliveries, theatre staff
should be immediately available to allow a caesarean
section to be performed without delay (less than 30
minutes).
• A senior obstetrician competent in performing mid-
cavity deliveries should be present if a junior trainee
is performing the delivery.
• Anticipation of complications that may arise (e.g.
shoulder dystocia, postpartum hemorrhage)
• Personnel present that are trained in neonatal
resuscitation.
 Obstetric Forceps
• This is an instrument designed to aid in the
delivery of the fetus by applying traction on
the head.
• The credit for the invention of the precursor of
the modern forceps to be used on live infants
goes to Peter Chamberlen of England (circa
1600).
• Modifications have led to more than 700
different types and shapes of forceps.
Basic Design of Obstetric Forceps

PELVIC CURVE

NB: The blades are oval or elliptical and can be fenestrated or solid.
 Commonly Used Forceps
Simpson forceps Elliot forceps
• The most • Has adjustable pin
commonly used for regulating the
types of forceps lateral pressure
in outlet delivery. on the handles.
• Has elongated • They are used
cephalic curve. most often when
• These are used when there is minimal
there is substantial molding.
molding of the fetal • More suitable for
head. outlet delivery.
 Commonly Used Forceps Cont’d
Kielland forceps Piper's forceps
• Has small pelvic • Distinct perineal
curve and a sliding curve.
lock. • Allows for
• Suitable for head with application
little molding. to the after-coming
• The most common head in breech
forceps used for
delivery.
rotational delivery.
• Helps correct
asynclitism.
 Commonly Used Forceps Cont’d
Tucker-McLane Braton Forceps
Forceps and Traction
• Suitable for fetal
head with
Handle
• Rotational delivery.
little molding.
• Most importantly
• Used in rotational
used for delivery
delivery.
of OT positions in
a platypelloid pelvis.
 Application of Obstetric Forceps
The left handle of the 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 the left blade.
Note the arc of the handles as they
rotate to be applied to the mother’s
left.
 Application Cont’d

First blade in situ. Blades symmetrically placed

and articulated along
occipitomental diameter.
 Gentle Traction

Additional horizontal traction is applied,

With intermittent traction, as the and the handles are gradually elevated,
vulva is distended by the occiput, as the handles are raised, the head is
an episiotomy may be performed if extended.
indicated.
 Delivery of the Head

Forceps may be disarticulated as the head

Upward traction is continued as the is delivered. Modified Ritgen maneuver
headis delivered. may be used to complete delivery of the
head.
 Vacuum Assisted Delivery
Synthetic Cups (soft or rigid) Metal Cups

• Hand held disposable rigid Mityvac Preferred for delivery of;

(down below), Kiwi Omnicup or • Occipito-posterior.
conventional soft cup ventouse (silastic). • Transverse.
• Higher failure rate than metal cups. • Difficult occipito-anterior positions .
• Less neonatal scalp injuries than metal
cups.
• Suitable for straightforward deliveries
(no significant caput).
 Newer Model Vacuums
• The Kiwi OmniCup vacuum
is a disposable one hand device.
• It consists of an palm pump,
traction indicator, flexible stem
and a cup.
• The Kiwi OmniCup is designed
for use in all fetal head positions
OA, OP, OT and during C-sections.
• RCOG associates it with high
OVD failure rates.
 Performing Vacuum Delivery
• Position woman in dorsal lithotomy.
• insert cup, check no maternal tissue is trapped beneath the cup.
• The center of the cup should be over the sagittal suture and
about 3 cm in front of the posterior fontanel toward the face
• Increase scalp suction pressure to around 440 mm Hg (60 kPa).
• In coordination with contractions and maternal expulsive effort,
apply gentle traction in line with the pelvic axis.
• Maintain pressure and moderate traction between contractions.
 Vacuum Delivery Cont’d
• Adequate descent should be verified during
each pull.
• If the cup dislodges, exclude fetal scalp or
maternal injury before reapplying
• Obtain arterial and venous cord blood gases
immediately after delivery.
• Assess and repair any maternal trauma.
 Discontinuing OVD
Abandon the procedure if:
• There is no progress after 3 consecutive pulls.
• There is evidence of fetal scalp injury.
• The cup dislodges 3 times.
 Considering Discontinuity
Consider abandoning the procedure if:
• The cup dislodges 2 times despite good technical
application and delivery is not imminent
• Delivery is not imminent after 15 minutes
(evaluate whether to continue with OVD or
consider recourse to c-section).
• Sequential use of vacuum and forceps to achieve
delivery may result in increased maternal and
neonatal morbidity.
 Serious Complication of OVD
Complication Instrument
Maternal 3rd and 4th degree perineal tears > Forceps
Extensive or significant vaginal / vulval > Forceps
tear
PPH > Forceps
Neonatal Subaponeurotic (subgaleal > Vacuum
haemorrhage)
Intracranial haemorrhage > Vacuum
Injury of sixth and seventh cranial nerves, Mixed
Erb palsy
Cervical spine injury > Forceps
(rotational)
 Frequently Occurring Complications

Complication Instrument
Maternal 1st and 2nd degree perineal tear. > Forceps
Anal sphincter dysfunction & voiding dysfunction. > Forceps (OP
position)

Neonatal Forceps marks on face Forceps

Cup marking on the scalp (Chignon) Vacuum
Cephalhaematoma > Vacuum
Neonatal jaundice / hyperbilirubinaemia > Vacuum
Retinal haemorrhage > Vacuum
 Comparison of Forceps and Vacuum
FORCEPS
• Less likely to result in neonatal
morbidity (e.g.
cephalhaematoma, subgaleal
and retinal haemorrhage).
• More likely to result in maternal
soft tissue injury.
• More likely to result in
successful vaginal delivery and
will occur over a shorter time
frame.
• Suitable for assisted vaginal
deliveries < 36+0 of gestation.
VACUUM
• There is an increased incidence
of cephalhaematoma, subgaleal
and retinal haemorrhage in the
newborn.
• Less likely than forceps to result
in successful vaginal delivery.
• Less use of regional anesthesia.
• Less serious maternal injury.
• Less pain 24 hours after delivery.
 Predicators of Complications
Higher rates of failure and serious or frequent
complications are associated with:
• Higher maternal body mass index (BMI > 30).
• Ultrasound estimated fetal weight > 4,000 g or
clinically large baby.
• OP position.
• Mid-cavity delivery or when 1/5 fetal head
palpable abdominally.
 Preventative Measures Against OVD
RCOG recommends the following;
• All women should be encouraged to have continuous support
during labor as this can reduce the need for operative vaginal
delivery.
• Use of upright or lateral positions during 2nd stage of labor.
• Avoiding epidural analgesia.
• Delayed pushing for 1 to 2hrs in primiparous women with an
epidural until the urge to push becomes stronger.
 Conclusion
• OVD should be undertaken by a skilled obstetrician with
adequate knowledge of pelvic and fetal skull anatomy.
• The same indications and contraindications used for
forceps deliveries should be applied to vacuum-assisted
deliveries.
• Forceps are associated mostly with maternal morbidity
where as vacuums have higher rates of neonatal morbidity.
• Early recognition and abandonment of failing procedure
and paramount importance.
• When performed right, children born via OVD have no
neurodevelopmental delay when compared to those born
via spontaneous vaginal delivery.
 References
1. A. H. Decherney et al (2013). Current Diagnosis &
Treatment Obstetrics and Gynecology 11th ed. Pg 334-
340.
2. F. G. Cunningham et al (2009). Williams Obstetrics
23rd ed. 511-525.
3. Royal College of Obstetrics and Gynecology (2011).
Green Top Guide No.26 Operative Vaginal Delivery.
4. SA Maternal & Neonatal Clinical Network (2013).
South Australian Perinatal Practice Guidelines –
operative vaginal deliveries.
5. http://emedicine.medscape.com/article/263603-
treatment
Thank You !!!!