Assisted Vaginal Delivery

Learning objectives
• To discuss the indications of assisted vaginal delivery.

• To discuss the prerequisites for the use vacuum & forceps

delivery
• To practice assessing the position of the fetal head
• To practice the application of vacuum & forceps
Why Assissted Delivery
• When there is failure to progress or fetal distress in the second
stage of labour it becomes necessary to expedite the delivery
• Any maternal medical illnesses to avoid Valsalva
Indications For Instrumental
Delivery
• Fetal compromise in second stage
• Medical illnesses to avoid Valsalva (cardiac, cerebral
disease, myasthenia gravis, spinal cord injury)
• Prolonged second stage
-Nulliparous 2hrs
-Multiparous 1hr
• To expedite delivery (maternal exhaustion, placental
abruption)
• Cord prolapse at full dilatation
• After coming head of a breech (forceps)
How To Determine The Position Of The Head

• It is important to determine the position of the head in order to

decide where to apply the vacuum cup and whether to apply
forceps.
• A choice must then be made as to the means of delivery, taking
into account the descent of the presenting part.
• It is very important to do this by taking into account both
abdominal and vaginal findings.
Diagnosis By Vaginal Examination

• Palpate fetal fontanelles and sutures, this can be difficult when

there is an advanced degree of moulding of the fetal head, with a
large caput.
• In order to determine position, try to run your finger under the
pubic symphysis anteriorly and if the position is transverse you
will feel a fetal ear.
• If the position is occipito-posterior the you will feel the fetal brow
and face as you reach up under the symphysis.
• If occipito-anterior, then you can feel fetal neck.
Abdominal palpation
• It is only by abdominal palpation that you will be able to
assess the descent correctly and ascertain whether a
vaginal delivery is going to be safe to attempt.
• Only attempt a vaginal delivery if you can feel 1/5 or less of the
fetal head above the pubic symphysis.
• If you are not sure whether you are feeling the fetal head or the
shoulders above the symphysis, then you can perform a vaginal
and an abdominal examination simultaneously (a bimanual
examination) and feel the fetal head between both hands.
Management

• Once the fetal descent and position has been established,

check that there are no other contra-indications to the
procedure before continuing.
• Before proceeding, check that the equipment is in working
order.
• The operator must have been adequately trained in the safe
use of the equipment.
• An assistant must be present
 Consent
• The procedure, including the risks and benefits and alternatives
(a caesarean section) must be explained to the mother who
should give informed consent before you begin.
• This consent may be written or verbal but if verbal, it should be
documented in the records.
 Pre-requisites

• Fetal head is < 1/5th palpable per abdomen

• Vertex presentation
• Cervix fully dilated
• Ruptured membranes
• Adequate pelvis
• Informed consent
• Adequate analgesia: Pudendal block/ perineal infiltration
• Empty bladder
• Fetal head at least at 0 station or lower
• Trained operator
 Application Of Vacuum
ACRONYM----ABCDEFGHIJ
• A—Ask for help, Address pt, Anesthesia
• B---Bladder empty
• C---Cervix fully dilated
• D—Determine position, think shoulder dystocia
• E—Equipment & extractor ready
• F---Feel maternal tissue after applying cup at flexion
point
• G----Gentle traction during contraction
• H----
 Precaution
• If you are in any doubt as to whether the procedure will
succeed, perhaps because the position of the fetal head is not
occipito-anterior.
• It is best to take the mother to theatre and prepare her as if she
is to have a caesarean section prior to proceeding.
 Precaution
• You may not need to perform an episiotomy, as the cup is
smaller than the fetal head, but if the perineum is tight as the
head descends then make an episiotomy if you consider it
necessary.
• Do not perform the episiotomy until you are absolutely sure the
baby will deliver vaginally so as to avoid leaving the mother with
both an abdominal and a vaginal scar.
 Procedure
• Women should be placed in lithotomy position.
• The bladder should be empty.
• The cup should be placed on the flexion point, with the centre 2
to 3 cms anterior to the posterior fetal fontanelle along the line
of the sagittal suture.
• Check that there is no maternal vaginal tissue trapped under
the cup before establishing suction and pulling, and that the cup
is fitting well on the fetal head.
 Procedure
• Once you have done this, place your thumb on the cup and one
finger on the fetal head then pump up the vacuum to 0.8 kg/cm2.
• Make a final check of the application of the cup. If you find any
trapped maternal tissue, deflate the vacuum and release it.
• Maintain your position with one finger or thumb on the cup and
one on the fetal head, to detect any slippage, and, during a
contraction encourage maternal bearing down effort whilst you
apply traction to the cup.
• The direction of traction should be at 90 degrees to the cup in
the line of the pelvic axis
 Procedure
• As the head descends and negotiates the pelvic curve the angle
of traction will alter. Only apply traction during contractions and
encourage maternal effort.
• Once the head is delivered, release the pressure and remove
the cup from the fetal head, then conduct the rest of the
delivery.
• Check both the fetal head and the maternal perineum and
vagina for trauma, and repair as necessary.
Failed Assisted Delivery
• If the head is not delivered or very close to delivery after three
contractions, or if the cup pulls off twice then abandon the
procedure and perform a caesarean section.
• Remember when performing a caesarean following a failed
attempt at a vacuum delivery to push the fetal head back up
vaginally.
• It is helpful to have an assistant with their hand in the vagina
pushing the head up before you open the uterus, in order to
avoid downward extensions of the angles of the uterine incision,
which can be very difficult to repair.
Key points

• Check the descent of the head by both abdominal and vaginal

palpation
• Rule out contra-indications
• Empty bladder
• Check for vaginal entrapment both before and after applying the
suction pressure
• Only pull during contractions, and with maternal effort
• If no success abandon the procedure after pulling during three
contractions.
• Choice of instrument is operator dependant