Hello, my name is Jia Hui,
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and I’m going to talk to you
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about operative vaginal
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delivery.
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This is an outline
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of my presentation.
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I will provide an introduction
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to operative vaginal delivery,
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followed by the indications,
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contraindications,
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and prerequisites of this mode
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of delivery.
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This will be followed
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by a little about forceps
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and vacuum assisted deliveries,
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and their application
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and complications.
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Operative vaginal delivery
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involves the use of forceps
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or a vacuum device
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to assist the mother
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in childbirth.
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The goal
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of operative vaginal delivery
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is to mimic
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spontaneous vaginal birth
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and expedite delivery, and at
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the same time
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minimizing maternal and neonatal
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morbidity.
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One should balance the risks
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and benefits
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of operative delivery
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when deciding on when
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to intervene
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during normal labor.
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In the US, about 4.5%
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of vaginal births
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are operative deliveries,
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with a high success rate of 99%.
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Vacuum assisted births are
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at least four times more
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popular than forceps assisted
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births.
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01:21
Here is a list of indications
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for operative vaginal delivery.
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However, one should also note
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that there are
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no absolute indications
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for operative vaginal delivery,
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and that Caesarian delivery is
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also an option
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in those settings.
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The indications
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of operative vaginal delivery
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can be broadly classified
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into fetal, maternal,
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and inadequate progress.
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Fetal indications includes
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presumed fetal compromise–
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for example,
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when there is
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abnormal cardiotocograph
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findings.
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Maternal indications include
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to shorten and reduce
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the effects of the second stage
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of labor, on the background
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of maternal medical conditions.
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And inadequate progress in labor
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will include a lack
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of continuing progress in labor
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over a stipulated period
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of time,
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as well as maternal fatigue
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or exhaustion.
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02:16
There are some contraindications
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to operative vaginal delivery,
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and these are mostly related
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to unacceptable fetal risks,
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such as suspected
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fetal-pelvic disproportion,
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fetal bleeding disorders,
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which may result
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in a cephalohematoma,
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or subdural hemorrhage.
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Fetal predisposition
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to fractures, fetal prematurity,
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which is especially
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true for vacuum extractors,
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first due to the risk
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of subdural and intracranial
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hemorrhage.
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Increased chance
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of fetal abrasion or scalp
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trauma.
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Operative delivery is also
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contraindicated
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before full cervical dilation,
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or in the presence
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of an unengaged fetal head
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or when the fetal position is
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unknown.
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Vacuum extractors in particular
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are contraindicated when there
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is face presentation,
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and when there is prior scalp
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sampling or multiple attempts
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at fetal scalp electrode
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placement.
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03:15
Before performing
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an assisted vaginal delivery,
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ensure that the fetal head is
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at most 1/5 palpable,
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that the fetus is in vertex
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presentation, the cervix
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is fully dilated,
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and the membranes have ruptured.
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Ensure that fetal presentation
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and position, lie,
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and any asynclitism are known.
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Assess the caput and moulding
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of the fetus,
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and ensure
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that the maternal pelvis is
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deemed adequate
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and there is
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no cephalo-pelvic disproportion.
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03:47
Ensure that the mother has been
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prepared for the procedure
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by making sure
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that clear explanation has been
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given,
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and informed consent has been
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obtained.
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Check that appropriate analgesia
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has been administered
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for mid-cavity rotational
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deliveries.
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Ensure that maternal bladder has
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been emptied recently,
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and
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that the in-dwelling catheter
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has been removed
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or at least deflated.
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The operator should have
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the knowledge, experience,
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and skill required to perform
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the delivery, and the procedure
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should be performed aseptically.
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Adequate facilities should be
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prepared and made available.
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A back up plan should also
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be put in place, in case
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of failure to deliver,
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such as a crash Caesarian
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delivery.
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The operator should anticipate
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complications that may arise
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during the procedure,
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such as shoulder dystocia
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and postpartum hemorrhage,
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and be prepared to address
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these complications.
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In addition to this,
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someone who is trained
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in neonatal resuscitation
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should also be present.
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04:55
Here is a picture of the anatomy
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of the forceps.
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The key structures
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of the forceps are the plates,
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shank, lock, finger guards,
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and handle.
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The handles transmit
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the applied force.
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The screw or lock represent
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the fulcrum, and the blades
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transmit the load.
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The Kielland forceps are a type
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of rotational forceps.
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They possess a slightly backward
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pelvic curve, with overlapping
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shanks and a sliding lock.
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It allows for rotation
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of the vertex
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without moving the handles
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of the forceps
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through a wide arch.
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The Neville-Barnes forceps
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is a mid-cavity, non-rotational
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forceps.
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It is used when the fetal head
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is 1/5 palpable per abdomen,
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or when the leading point
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of the skull
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is above station plus 2,
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but not
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above the ischial spines.
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05:51
Wrigley forceps
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is a low cavity forceps that
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is used when the fetal scalp is
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visible without separating
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the labia,
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or when the fetal skull has
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reached the pelvic floor,
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or when the fetal head is
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at or on the perineum.
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It can also be used
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during Caesarian section.
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The vacuum extractor,
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such as a Kiwi Cup,
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works on the principle
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of creating negative pressure
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to allow fetal scalp tissues
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to be sucked into the vacuum
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cup.
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The Kiwi Cup can be applied
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to the flexion joint
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in the occipital, lateral, and
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posterior position.
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Overall, the vacuum extractor
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appears to be safer
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for the mother,
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whereas the foreceps may be
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safer for the baby.
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06:39
The forceps should grasp
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the occiput anterior fetal heat,
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and the long axis of the blades
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should correspond
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to the occipitomental diameter.
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The tips of the blades
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will lie over the cheeks,
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and the blades will be
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equidistant
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from the sagittal suture.
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The posterior fontanelle should
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be 1 finger breadth anterior
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to the horizontal plane
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of the blades.
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Fenestrated blades should admit
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a maximum of one finger breadth
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between the heel
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of the fenestration
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and fetal head.
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Make sure
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that no maternal tissue is
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grasped.
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For the application
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of the vacuum extractor,
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determine the location
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of the flexion point
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and apply the cup
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at that position.
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The flexion point is normally
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located along the midline,
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over the sagittal suture,
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approximately 6
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cm from the anterior fontanelle
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and 3 cm
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from the posterior fontanelle.
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Sweep the edges with a finger
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to ensure
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that no maternal tissues are
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entrapped.
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Then rapidly apply
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a maximum suction of 600
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millimeters of mercury.
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Apply gentle traction
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along the axis
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of the pelvic curve,
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in synchrony with maternal
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pushing.
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Vacuum assistance should be
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limited to three contractions
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for the descent phase,
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three contractions
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for the outlet extraction phase,
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2 to 3 pop-offs,
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and a total time of 15 to 30
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minutes.
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08:07
Complications
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of operative vaginal delivery
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can be broadly classified
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into maternal complications
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and fetal complications.
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Maternal complications can be
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short term or long term.
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Short term maternal
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complications include
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maternal trauma, especially
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where a rotational or midcavity
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forceps delivery were performed.
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It also includes pain, lower
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genital tract lacerations,
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and hematomas, urinary retention
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and incontinence, anemia,
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anal incontinence,
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and rehospitalization.
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Long term maternal complications
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are urinary
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or fecal incontinence,
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pelvic organ prolapse,
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and fistula formation.
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Similarly,
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neonatal complications can be
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short term or long term.
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Short term neonatal
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complications include
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subgaleal hematoma,
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intracranial hemorrhage,
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bruises, abrasions,
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and lacerations, facial nerve
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palsy, cephalohematoma,
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retinal hemorrhage, skull
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fractures, hyperbilirubinemia,
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shoulder dystocia,
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brachial plexus injury,
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extraocular trauma, as well as
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lipoid necrosis.
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Long term neonatal complications
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are intracranial hemorrhage
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and neuromuscular injury.
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Here are the references.
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You have come to the end
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of the presentation,
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and thank you very
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much for your attention.