PATHOLOGIC OBSTETRICS

Topic: Operative Vaginal Delivery

Lecturer: Dr. Bautista (AJB)

OPERATIVE VAGINAL DELIVERY Perinatal Morbidity

Operative Vaginal Delivery consists of:  Cephalhematoma
 Forceps delivery  Subgaleal hemorrhage
 Vacuum delivery  Retinal hemorrhage
Acute Perinatal Injuries  Neonatal jaundice
Indications of Operational Vaginal Delivery  Shoulder dystocia
Fetal Maternal  Clavicular fracture
 Non-reassuring fetal heart pattern  Heart disease  Scalp lacerations
 Premature placental separation  Pulmonary injury or compromise  Facial nerve injury
 Prolapsed umbilical cord  Intrapartum infection Forcep-associated  Brachial plexus injury
 Neurologic conditions vaginal delivery  Depressed skull fracture
 Hypertensive condition  Corneal abrasion
 Exhaustion
 Prolonged second stage Mechanism of Acute Injury:
 Forces exerted
Contraindications of Operational Vaginal Delivery  Primary vessel laceration
 Absence of proper indication  Skull fracture with vessel laceration
 Incompletely dilated cervix – must be 10 cm dilation for assisted vaginal delivery
 Compression of nerve against the facial bones
 Marked CPD
 Angle of traction
 Unengaged fetal head
 Shoulder dystocia at the inlet
 Lack of experience on the part of the operator

Trial of Operative Vaginal Delivery

Classification of Forceps Delivery
Procedure Criteria
 Scalp is visible at introitus without separating the labia
 Fetal skull has reached pelvic floor
 Sagittal suture is in antero-posterior diameter or right
Outlet
or left occiput anterior or posterior position
 Fetal head is at or on the perineum
 Rotation does not exceed 45 degrees
 Leading point of fetal skull is at station ≥+2 cm, and not
on pelvic floor
 Rotation is 45 degrees or less (left or right occiput
Low
anterior to occiput anterior, or left or right occiput
posterior to occiput posterior)
 Rotation is greater than 45 degrees
 Station above +2 cm but head is engaged
Midpelvic
 Not performed anymore
High  Not included in classification
Prerequisites for Operative Vaginal Delivery:
 Experienced operator
 Engaged head
 Ruptured membranes
 Vertex presentation or face with chin anterior
o Face with chin anterior presentation can be done with forceps
but NOT vacuum
 Cephalopelvic disproportion not suspected
 Completely dilated cervix
 Precisely assessed fetal head position
 No fetal coagulopathy or bone demineralization disorder
 The operator attempts delivery with full knowledge that the vaginal
delivery may not be successful
 You tell your patient that this is not 100% sure successful
o If in case it fails  CS delivery will be done
Factors associated with operative delivery failure
 Persistent occiput posterior
 Absence of regional or general anesthesia
o Without the anesthesia, mother will not be relaxed and will not
be able to cooperate well
 Birthweight > 4000 grams – a big baby
o Filipino babies  3.6 kg is already big
o American/European babies  >4 kg is big
Failed Forceps
 Failure of application  The forceps cannot be applied properly to the
fetal head
o Forceps was not successfully locked onto the baby
 Failure of extraction  The forceps are applied but despite an all-out
effort, delivery cannot be accomplished
o You successfully applied the forceps and locked onto the baby
but cannot pull and deliver it
 Causes:
o Disproportion
o Malposition
o Cervix not fully dilated
o Constriction ring
o Premature interference

Maternal Morbidity FORCEPS DELIVERY

 3rd and 4th degree laceration Forceps Design
Laceration  vaginal wall laceration  Consist of two crossing branches
 cervical laceration  Four components:
 urinary & anal incontinence o blade – enclose the head
 pelvic organ prolapse o shank – connects the handle & blade
Pelvic floor disorders
 urinary retention o lock – holds the forceps together
 bladder dysfunction o handle – to grip the forceps

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 PATHOLOGIC OBSTETRICS
Topic: Operative Vaginal Delivery
Lecturer: Dr. Bautista (AJB)

Forceps design continued….. Preparation for Forceps Delivery

 Two curves:  Pudendal block analgesia for outlet forceps operations
o cephalic curve – conforms to the shape of the fetal head  Regional analgesia or general anesthesia for low-forceps or midpelvic
o pelvic curve – corresponds to the axis of the birth canal procedures
 Some varieties are fenestrated or pseudofenestrated to permit a firmer  Bladder should be emptied
hold of the fetal head o Catheterize the mother first to empty the bladder
 If spinal anesthesia is used, the anesthetic agent is introduced before
Types of Forceps placing the woman in the lithotomy position
Simpson Forceps  If general anesthesia is used, the woman is placed in the lithotomy
 Most common forceps with position, the perineum is cleansed and draped and the physician is
cephalic and pelvic curve ready to perform delivery before the induction of anesthesia
 Parallel shanks o Give general anesthesia at the least effective amount  less
 Fenestrated blade – with hole anesthetic that will go to the baby
 The English lock, consist of a socket located on the shank at the junction o Give only after the woman is positioned and draped and
with the handle, into which fits a socket similarly located on the physician is ready to deliver (physician is already scrubbed &
opposite shank gowned)
 Use to deliver fetus with molded head  The exact position of the fetal head must be known for a proper
cephalic application
Tucker-Mclane Forceps o Head low in pelvis – palpate for the sagittal suture and
 Blade is solid (no fenestration/hole) and fontanels
the shank is narrow o Head at higher station – palpate for the posterior ear
 Method of articulation – English lock
 Use to deliver fetus with rounded Forceps Application
head (multiparous)  Forceps are constructed so that
their cephalic curve is closely
Kielland Forceps adapted to the sides of the fetal
 Characteristic features are the sliding lock head
 Minimal pelvic curvature and light weight  The fetus is presenting as vertex
 For deep transverse arrest with occiput anterior crowning. The
application of the left blade of
Piper Forceps Simpson forceps is shown. Next, the
 Blade is similar to Simpson right blade is applied and the blades
 Shank is longer are articulated
 It has double pelvic curve to
facilitate application to the  The biparietal diameter of the fetal
aftercoming head in breech head corresponds to the greatest
presentation distance between the appropriately
 The baby’s body is delivered already and what is left behind is the head applied blades
 The head of the fetus is perfectly
Bartons Forceps grasped only when the long axis of the
 With one fixed curved blade and a hinged blades corresponds to the
anterior blade for application to a high occipitomental diameter. As a result,
transverse head most of the blade lies over the face 
 With a sliding lock that is useful when the infant’s head is in the occiput which is why when the baby gets
transverse position during delivery delivered, usually there will be a mark
of the forceps on the baby’s
Functions of Obstetric Forceps face/cheeks
1.) Traction  Fetus in occiput anterior position, the concave arch of each blades is
 The direction of the traction must be along the pelvic curvature as the directed toward the sagittal suture
station changes during descent so does the line of traction  Fetus in occiput posterior position, the concave arch of the blades is
o Example, when the baby’s head is about to come out, the neck directed toward the fetal face
is extending  then the pull of the forceps should be upwards  Applied as such, the forceps should not slip, and traction may be applied
 The direction of pull should be perpendicular to the plane of the level most advantageously
at which it is being applied  With most forceps, if one blade is
applied over the brow and the
2.) Rotation other over the occiput, the
 Carried best in the midpelvis instrument cannot be locked, or if
 Rotating the head from posterior to transverse position, the handle locked, the blades slip off when
should be swung through a wide arc in order to reduce the arc of the traction is applied
blades  For these reasons, the forceps must
be applied directly to the sides of
the fetal head along the
occipitomental diameter

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 PATHOLOGIC OBSTETRICS
Topic: Operative Vaginal Delivery
Lecturer: Dr. Bautista (AJB)

Outlet Delivery Forceps

 Two or more fingers of the right
hand are introduced inside the left  Upward traction (arrow) is applied
posterior portion of the vulva and as the head is delivered
into the vagina beside the fetal head  Forceps may be disarticulated
 The handle of the left branch is then (remove the forceps) after head is
grasped between the thumb and delivered
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  Forceps have been disarticulated and
fingers of the right hand  use the fingers of the right hand to guide removed
the insertion of forceps  Modified Ritgen maneuver (arrow) is used to
 No force is applied here, the forceps should slide. Put gel on the side of complete delivery of the head
the maternal surface (not the side of the head of the baby)  You push the perineum on the chin of the
 For application of the right blade, two or more fingers of the left hand baby  to deliver the baby
are introduced into the right posterior portion of the vagina to serve as
a guide for the right blade, which is held in the right hand and
introduced into the vagina as described for the left blade. After Low and Mid Forceps
positioning, the branches are articulated  you lock now the left & right  When the head lies above, the perineum, the sagittal suture usually
blade occupies an oblique or transverse diameter of the pelvis
 In such cases, the forceps should always be applied to the sides of the
head
 Continued insertion of left blade.
 Note the arc of the handles as they rotate to be Delivery of Occiput Posterior Position
applied to the mother’s left 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 is clockwise
 If necessary, rotation to occiput  Left occiput posterior position, rotation is counterclockwise
anterior is performed before traction is
applied Forceps Delivery
 Forceps have been locked.  Application of forceps blade to the head in the
 Vertex is rotated from left occiput posterior position
anterior to occiput anterior (arrow)  Horizontal traction should be applied until the
o Picture on the right is not in base of the nose is under the symphysis
direct occiput anterior  so  The handles should then be slowly elevated until
you rotate the head to occiput anterior the occiput gradually emerges over the anterior
margin of the perineum
 The forceps are directed in a downward motion,
 The vertex is now occiput anterior and the nose, mouth, and chin successively emerge from the vulva
and the forceps are symmetrically
placed and articulated (locked) Rotations from Occiput Transverse Positions
Forceps Delivery
 Occiput obliquely anterior, it
gradually rotates spontaneously
to the symphysis pubis as
traction is exerted
 Wait for the maternal expulsive efforts  Occiput transverse, a rotary
(contraction of the uterus  bearing down of motion of the forceps is required
the mother  pull now horizontally)  Left occiput transverse, rotation is
 Horizontal traction is exerted until the counterclockwise from the left side
perineum begins to bulge toward the midline
 With traction, as the vulva is distended by the  Right occiput transverse, rotation is
occiput, an episiotomy may be performed if clockwise
indicated  This is wrong. If you pull  you will
damage the nose of the baby

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 PATHOLOGIC OBSTETRICS
Topic: Operative Vaginal Delivery
Lecturer: Dr. Bautista (AJB)

Forceps Delivery of Face Presentation Prerequisites

Forceps Delivery  Experienced operator
 The blades are applied to the sides of  Engaged head
the head along the occipitomental  Ruptured membranes
diameter, with the pelvic curve  Vertex presentation
directed toward the neck  Cephalopelvic disproportion not suspected
 Downward traction is exerted until the  Completely dilated cervix
chin appears under the symphysis  Precisely assessed fetal head position
 Then by upward movement, the face is  No fetal coagulopathy or bone demineralization disorder
slowly extracted, with the nose, eyes,
brow and occiput appearing in Techniques
succession over the anterior margin of  Proper cup placement over the flexion point is the most important
the perineum determinant of success in vacuum extraction
 For Dr. Bautista  if she have a case of face presentation, she would  Flexion (Pivot) point is found along the sagittal suture, 3 cm in front of
not attempt this as vaginal delivery because it would take so long that the posterior fontanel (triangle shape) and 6 cm from the anterior
the face of the baby will become edematous fontanel (diamond shape)

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
 US – vacuum extractor
 Europe – ventouse
 French – “soft cup”
 Use of a metal cup or ft cup vacuum extractors  Flexing (Pivot) Points
 High-pressure vacuum generates large amounts of force regardless of o Maximizes traction
the cup used o Minimizes cup detachment
 Silastic cup vacuum device is a reusable instrument with a soft, 65 mm o Flexes but averts twisting of the fetal head
diameter cup o Delivers the smallest head diameter through pelvic outlet
 Mityvac instrument uses a disposable
 60 mm diameter cup and the CMI
 Anterior placement on the fetal
 Tender Touch uses a 62 mm cup
cranium – near the anterior fontanel
rather than over occiput will result in
Advantages
cervical spine extension
 Simpler requirements for precise positioning on the fetal head
 Entrapment of maternal soft tissue
 Avoidance of space-occupying blades within the vaginal
predisposes the mother to lacerations
 Lower maternal trauma rates – less chance of maternal lacerations
and hemorrhage and virtually assures
cup “pop-off”
Indications
 Full circumference of the cup should
Fetal Maternal
be placed both before and after the
 Non-reassuring fetal heart  Heart disease
vacuum has been created, as well as
pattern  Pulmonary injury or
prior to traction
 Premature placental separation compromise
 Traction should be intermittent and coordinated with maternal
 Prolapsed umbilical cord  Intrapartum infection
expulsive efforts
 Neurologic conditions
 Hypertensive condition o Just same with forceps delivery, when there is maternal
 Exhaustion expulsive effort, that’s when you also do the traction (pull)
 Prolonged second stage  Traction may be initiated by using a two-handed technique – the
fingers of one and are placed against the suction cup, while the other
Contraindications hand grasps the handle instrument
 Operator inexperience  Manual torque to the cup should be avoided as it may cause
 Inability to assess fetal position cephalhematomas and with metal cups, “cookie-cutter”-type scalp
 High station lacerations
 Suspicion of CPD o Do not rotate the cup!  may lead to cephalhematomas or
“cookie-cutter”-type scalp
 Face or nonvertex presentation
 Vacuum extraction should be considered a trial. And without early and
 Breech
clear evidence of descent toward delivery, an alternate delivery
 Fetal coagulopathy
approach should be considered
 Recent scalp blood sampling
Example you already did 3 pulls and the head of the baby does not
 Macrosomia
appear to go down  do CS delivery

 As a general guideline, progressive descent should accompany each

traction attempt  so for every traction (pull), the head must go down

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 PATHOLOGIC OBSTETRICS
Topic: Operative Vaginal Delivery
Lecturer: Dr. Bautista (AJB)

Complications of Vacuum Extraction

 Scalp lacerations and
 Shoulder dystocia
bruising
 Injury of sixth and seventh
 Subgaleal hematomas
 cranial nerves
 Cephalhematomas
 Erb palsy
 Intracranial hemorrhage
 Retinal hemorrhage
 Neonatal jaundice
 Fetal death
 Subconjucntival hemorrhage
 Clavicular fracture

Recommendations Regarding Vacuum Delivery

Considering the 1998 FDA Public Health Advisory, the following
recommendations seems reasonable:
1. The classification of vacuum deliveries should be the same as that
utilized for forceps deliveries (including station)
o Exception: you do not do vacuum on face presentation
2. The same indications and contraindications utilized for forceps
deliveries should be applied to vacuum-assisted deliveries
3. The vacuum should not be applied to an unengaged vertex, that is
above 0 station
4. The individual performing or supervising the procedure should be an
experienced operator
5. The operator should be willing to abandon the procedure if it does not
proceed easily or if the cup pops off more than three times

Comparison of Vacuum Extraction with Forceps

Method of Delivery
Complications Vacuum n = 41 (%) Forceps n = 40 (%)
Apgar scores
1 min <7 4 (10) 4 (10)
5 min <8 1 (2) 1 (2)
Cephalohematoma
Mild 6 (15) 3 (10)
Moderate 1 (2) 2 (7)
Caput 14 (34) 7 (14)
Facial mark or injury 1 (2) 7 (18)
Trauma
Erb palsy (mild) 1 (2) 0
Fractured 1 (2) 0
Elevated bilirubin 8 (20) 4 (10)
Retinal hemorrhage
Mild 6/37 (16) 3/36 (8)
Moderate or Severe 8/37 (37) 3/36 (8)
Infant stay 3.4 days 3.1 days
**Just ignore this table, explanation of this table is below**

 Vacuum Extraction
o increase incidence of neonatal jaundice
o shoulder dystocia and cephalhematoma is doubled

 Forceps Delivery
o higher frequency of maternal trauma and blood loss
o more 3rd and 4th degree laceration

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