{"id":2626,"date":"2020-08-13T20:23:41","date_gmt":"2020-08-13T20:23:41","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=394"},"modified":"2020-08-13T20:23:41","modified_gmt":"2020-08-13T20:23:41","slug":"delivery","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/advanced-training\/delivery\/","title":{"rendered":"Operative Vaginal Delivery"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/TWoCopsfWqI\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 9:41<\/p>\n<input type='hidden' bg_collapse_expand='69e9b59e47b4b7035199376' value='69e9b59e47b4b7035199376'><input type='hidden' id='bg-show-more-text-69e9b59e47b4b7035199376' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b59e47b4b7035199376' value='Hide Transcript'><button id='bg-showmore-action-69e9b59e47b4b7035199376' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfafa;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b59e47b4b7035199376' ><\/p>\n<p>Hello, my name is Jia Hui,<br \/>\n00:03<br \/>\nand I&#8217;m going to talk to you<br \/>\n00:04<br \/>\nabout operative vaginal<br \/>\n00:06<br \/>\ndelivery.<br \/>\n00:06<br \/>\n00:09<br \/>\nThis is an outline<br \/>\n00:11<br \/>\nof my presentation.<br \/>\n00:13<br \/>\nI will provide an introduction<br \/>\n00:15<br \/>\nto operative vaginal delivery,<br \/>\n00:17<br \/>\nfollowed by the indications,<br \/>\n00:19<br \/>\ncontraindications,<br \/>\n00:20<br \/>\nand prerequisites of this mode<br \/>\n00:22<br \/>\nof delivery.<br \/>\n00:24<br \/>\nThis will be followed<br \/>\n00:25<br \/>\nby a little about forceps<br \/>\n00:27<br \/>\nand vacuum assisted deliveries,<br \/>\n00:30<br \/>\nand their application<br \/>\n00:31<br \/>\nand complications.<br \/>\n00:32<br \/>\n00:35<br \/>\nOperative vaginal delivery<br \/>\n00:37<br \/>\ninvolves the use of forceps<br \/>\n00:39<br \/>\nor a vacuum device<br \/>\n00:40<br \/>\nto assist the mother<br \/>\n00:41<br \/>\nin childbirth.<br \/>\n00:43<br \/>\nThe goal<br \/>\n00:43<br \/>\nof operative vaginal delivery<br \/>\n00:45<br \/>\nis to mimic<br \/>\n00:46<br \/>\nspontaneous vaginal birth<br \/>\n00:48<br \/>\nand expedite delivery, and at<br \/>\n00:50<br \/>\nthe same time<br \/>\n00:51<br \/>\nminimizing maternal and neonatal<br \/>\n00:53<br \/>\nmorbidity.<br \/>\n00:55<br \/>\nOne should balance the risks<br \/>\n00:57<br \/>\nand benefits<br \/>\n00:58<br \/>\nof operative delivery<br \/>\n00:59<br \/>\nwhen deciding on when<br \/>\n01:00<br \/>\nto intervene<br \/>\n01:01<br \/>\nduring normal labor.<br \/>\n01:04<br \/>\nIn the US, about 4.5%<br \/>\n01:06<br \/>\nof vaginal births<br \/>\n01:07<br \/>\nare operative deliveries,<br \/>\n01:10<br \/>\nwith a high success rate of 99%.<br \/>\n01:13<br \/>\nVacuum assisted births are<br \/>\n01:15<br \/>\nat least four times more<br \/>\n01:16<br \/>\npopular than forceps assisted<br \/>\n01:18<br \/>\nbirths.<br \/>\n01:18<br \/>\n01:21<br \/>\nHere is a list of indications<br \/>\n01:23<br \/>\nfor operative vaginal delivery.<br \/>\n01:25<br \/>\nHowever, one should also note<br \/>\n01:27<br \/>\nthat there are<br \/>\n01:27<br \/>\nno absolute indications<br \/>\n01:29<br \/>\nfor operative vaginal delivery,<br \/>\n01:32<br \/>\nand that Caesarian delivery is<br \/>\n01:33<br \/>\nalso an option<br \/>\n01:34<br \/>\nin those settings.<br \/>\n01:36<br \/>\nThe indications<br \/>\n01:37<br \/>\nof operative vaginal delivery<br \/>\n01:39<br \/>\ncan be broadly classified<br \/>\n01:40<br \/>\ninto fetal, maternal,<br \/>\n01:42<br \/>\nand inadequate progress.<br \/>\n01:44<br \/>\nFetal indications includes<br \/>\n01:46<br \/>\npresumed fetal compromise&#8211;<br \/>\n01:49<br \/>\nfor example,<br \/>\n01:49<br \/>\nwhen there is<br \/>\n01:50<br \/>\nabnormal cardiotocograph<br \/>\n01:52<br \/>\nfindings.<br \/>\n01:54<br \/>\nMaternal indications include<br \/>\n01:55<br \/>\nto shorten and reduce<br \/>\n01:56<br \/>\nthe effects of the second stage<br \/>\n01:58<br \/>\nof labor, on the background<br \/>\n02:00<br \/>\nof maternal medical conditions.<br \/>\n02:03<br \/>\nAnd inadequate progress in labor<br \/>\n02:05<br \/>\nwill include a lack<br \/>\n02:06<br \/>\nof continuing progress in labor<br \/>\n02:08<br \/>\nover a stipulated period<br \/>\n02:09<br \/>\nof time,<br \/>\n02:10<br \/>\nas well as maternal fatigue<br \/>\n02:12<br \/>\nor exhaustion.<br \/>\n02:12<br \/>\n02:16<br \/>\nThere are some contraindications<br \/>\n02:18<br \/>\nto operative vaginal delivery,<br \/>\n02:19<br \/>\nand these are mostly related<br \/>\n02:21<br \/>\nto unacceptable fetal risks,<br \/>\n02:24<br \/>\nsuch as suspected<br \/>\n02:25<br \/>\nfetal-pelvic disproportion,<br \/>\n02:27<br \/>\nfetal bleeding disorders,<br \/>\n02:29<br \/>\nwhich may result<br \/>\n02:30<br \/>\nin a cephalohematoma,<br \/>\n02:31<br \/>\nor subdural hemorrhage.<br \/>\n02:33<br \/>\nFetal predisposition<br \/>\n02:35<br \/>\nto fractures, fetal prematurity,<br \/>\n02:38<br \/>\nwhich is especially<br \/>\n02:39<br \/>\ntrue for vacuum extractors,<br \/>\n02:40<br \/>\nfirst due to the risk<br \/>\n02:42<br \/>\nof subdural and intracranial<br \/>\n02:44<br \/>\nhemorrhage.<br \/>\n02:45<br \/>\nIncreased chance<br \/>\n02:46<br \/>\nof fetal abrasion or scalp<br \/>\n02:48<br \/>\ntrauma.<br \/>\n02:50<br \/>\nOperative delivery is also<br \/>\n02:51<br \/>\ncontraindicated<br \/>\n02:52<br \/>\nbefore full cervical dilation,<br \/>\n02:55<br \/>\nor in the presence<br \/>\n02:56<br \/>\nof an unengaged fetal head<br \/>\n02:57<br \/>\nor when the fetal position is<br \/>\n02:59<br \/>\nunknown.<br \/>\n03:00<br \/>\nVacuum extractors in particular<br \/>\n03:03<br \/>\nare contraindicated when there<br \/>\n03:05<br \/>\nis face presentation,<br \/>\n03:06<br \/>\nand when there is prior scalp<br \/>\n03:08<br \/>\nsampling or multiple attempts<br \/>\n03:09<br \/>\nat fetal scalp electrode<br \/>\n03:11<br \/>\nplacement.<br \/>\n03:12<br \/>\n03:15<br \/>\nBefore performing<br \/>\n03:16<br \/>\nan assisted vaginal delivery,<br \/>\n03:18<br \/>\nensure that the fetal head is<br \/>\n03:20<br \/>\nat most 1\/5 palpable,<br \/>\n03:21<br \/>\nthat the fetus is in vertex<br \/>\n03:23<br \/>\npresentation, the cervix<br \/>\n03:25<br \/>\nis fully dilated,<br \/>\n03:26<br \/>\nand the membranes have ruptured.<br \/>\n03:29<br \/>\nEnsure that fetal presentation<br \/>\n03:30<br \/>\nand position, lie,<br \/>\n03:32<br \/>\nand any asynclitism are known.<br \/>\n03:35<br \/>\nAssess the caput and moulding<br \/>\n03:36<br \/>\nof the fetus,<br \/>\n03:38<br \/>\nand ensure<br \/>\n03:39<br \/>\nthat the maternal pelvis is<br \/>\n03:40<br \/>\ndeemed adequate<br \/>\n03:41<br \/>\nand there is<br \/>\n03:42<br \/>\nno cephalo-pelvic disproportion.<br \/>\n03:43<br \/>\n03:47<br \/>\nEnsure that the mother has been<br \/>\n03:48<br \/>\nprepared for the procedure<br \/>\n03:50<br \/>\nby making sure<br \/>\n03:51<br \/>\nthat clear explanation has been<br \/>\n03:52<br \/>\ngiven,<br \/>\n03:53<br \/>\nand informed consent has been<br \/>\n03:55<br \/>\nobtained.<br \/>\n03:56<br \/>\nCheck that appropriate analgesia<br \/>\n03:59<br \/>\nhas been administered<br \/>\n04:00<br \/>\nfor mid-cavity rotational<br \/>\n04:02<br \/>\ndeliveries.<br \/>\n04:03<br \/>\nEnsure that maternal bladder has<br \/>\n04:04<br \/>\nbeen emptied recently,<br \/>\n04:06<br \/>\nand<br \/>\n04:06<br \/>\nthat the in-dwelling catheter<br \/>\n04:08<br \/>\nhas been removed<br \/>\n04:09<br \/>\nor at least deflated.<br \/>\n04:10<br \/>\n04:13<br \/>\nThe operator should have<br \/>\n04:15<br \/>\nthe knowledge, experience,<br \/>\n04:16<br \/>\nand skill required to perform<br \/>\n04:17<br \/>\nthe delivery, and the procedure<br \/>\n04:19<br \/>\nshould be performed aseptically.<br \/>\n04:22<br \/>\nAdequate facilities should be<br \/>\n04:23<br \/>\nprepared and made available.<br \/>\n04:26<br \/>\nA back up plan should also<br \/>\n04:27<br \/>\nbe put in place, in case<br \/>\n04:29<br \/>\nof failure to deliver,<br \/>\n04:30<br \/>\nsuch as a crash Caesarian<br \/>\n04:32<br \/>\ndelivery.<br \/>\n04:34<br \/>\nThe operator should anticipate<br \/>\n04:36<br \/>\ncomplications that may arise<br \/>\n04:37<br \/>\nduring the procedure,<br \/>\n04:39<br \/>\nsuch as shoulder dystocia<br \/>\n04:40<br \/>\nand postpartum hemorrhage,<br \/>\n04:43<br \/>\nand be prepared to address<br \/>\n04:44<br \/>\nthese complications.<br \/>\n04:46<br \/>\nIn addition to this,<br \/>\n04:48<br \/>\nsomeone who is trained<br \/>\n04:49<br \/>\nin neonatal resuscitation<br \/>\n04:51<br \/>\nshould also be present.<br \/>\n04:52<br \/>\n04:55<br \/>\nHere is a picture of the anatomy<br \/>\n04:57<br \/>\nof the forceps.<br \/>\n04:58<br \/>\nThe key structures<br \/>\n04:59<br \/>\nof the forceps are the plates,<br \/>\n05:01<br \/>\nshank, lock, finger guards,<br \/>\n05:05<br \/>\nand handle.<br \/>\n05:06<br \/>\nThe handles transmit<br \/>\n05:07<br \/>\nthe applied force.<br \/>\n05:09<br \/>\nThe screw or lock represent<br \/>\n05:11<br \/>\nthe fulcrum, and the blades<br \/>\n05:13<br \/>\ntransmit the load.<br \/>\n05:14<br \/>\n05:17<br \/>\nThe Kielland forceps are a type<br \/>\n05:18<br \/>\nof rotational forceps.<br \/>\n05:20<br \/>\nThey possess a slightly backward<br \/>\n05:22<br \/>\npelvic curve, with overlapping<br \/>\n05:24<br \/>\nshanks and a sliding lock.<br \/>\n05:26<br \/>\nIt allows for rotation<br \/>\n05:28<br \/>\nof the vertex<br \/>\n05:29<br \/>\nwithout moving the handles<br \/>\n05:30<br \/>\nof the forceps<br \/>\n05:31<br \/>\nthrough a wide arch.<br \/>\n05:33<br \/>\nThe Neville-Barnes forceps<br \/>\n05:34<br \/>\nis a mid-cavity, non-rotational<br \/>\n05:36<br \/>\nforceps.<br \/>\n05:38<br \/>\nIt is used when the fetal head<br \/>\n05:39<br \/>\nis 1\/5 palpable per abdomen,<br \/>\n05:42<br \/>\nor when the leading point<br \/>\n05:43<br \/>\nof the skull<br \/>\n05:44<br \/>\nis above station plus 2,<br \/>\n05:46<br \/>\nbut not<br \/>\n05:46<br \/>\nabove the ischial spines.<br \/>\n05:47<br \/>\n05:51<br \/>\nWrigley forceps<br \/>\n05:52<br \/>\nis a low cavity forceps that<br \/>\n05:54<br \/>\nis used when the fetal scalp is<br \/>\n05:56<br \/>\nvisible without separating<br \/>\n05:57<br \/>\nthe labia,<br \/>\n05:58<br \/>\nor when the fetal skull has<br \/>\n06:00<br \/>\nreached the pelvic floor,<br \/>\n06:02<br \/>\nor when the fetal head is<br \/>\n06:04<br \/>\nat or on the perineum.<br \/>\n06:06<br \/>\nIt can also be used<br \/>\n06:08<br \/>\nduring Caesarian section.<br \/>\n06:10<br \/>\nThe vacuum extractor,<br \/>\n06:11<br \/>\nsuch as a Kiwi Cup,<br \/>\n06:14<br \/>\nworks on the principle<br \/>\n06:15<br \/>\nof creating negative pressure<br \/>\n06:16<br \/>\nto allow fetal scalp tissues<br \/>\n06:19<br \/>\nto be sucked into the vacuum<br \/>\n06:20<br \/>\ncup.<br \/>\n06:22<br \/>\nThe Kiwi Cup can be applied<br \/>\n06:24<br \/>\nto the flexion joint<br \/>\n06:26<br \/>\nin the occipital, lateral, and<br \/>\n06:28<br \/>\nposterior position.<br \/>\n06:30<br \/>\nOverall, the vacuum extractor<br \/>\n06:32<br \/>\nappears to be safer<br \/>\n06:33<br \/>\nfor the mother,<br \/>\n06:34<br \/>\nwhereas the foreceps may be<br \/>\n06:35<br \/>\nsafer for the baby.<br \/>\n06:36<br \/>\n06:39<br \/>\nThe forceps should grasp<br \/>\n06:41<br \/>\nthe occiput anterior fetal heat,<br \/>\n06:44<br \/>\nand the long axis of the blades<br \/>\n06:45<br \/>\nshould correspond<br \/>\n06:46<br \/>\nto the occipitomental diameter.<br \/>\n06:49<br \/>\nThe tips of the blades<br \/>\n06:50<br \/>\nwill lie over the cheeks,<br \/>\n06:52<br \/>\nand the blades will be<br \/>\n06:53<br \/>\nequidistant<br \/>\n06:53<br \/>\nfrom the sagittal suture.<br \/>\n06:56<br \/>\nThe posterior fontanelle should<br \/>\n06:58<br \/>\nbe 1 finger breadth anterior<br \/>\n06:59<br \/>\nto the horizontal plane<br \/>\n07:00<br \/>\nof the blades.<br \/>\n07:02<br \/>\nFenestrated blades should admit<br \/>\n07:04<br \/>\na maximum of one finger breadth<br \/>\n07:06<br \/>\nbetween the heel<br \/>\n07:07<br \/>\nof the fenestration<br \/>\n07:08<br \/>\nand fetal head.<br \/>\n07:10<br \/>\nMake sure<br \/>\n07:10<br \/>\nthat no maternal tissue is<br \/>\n07:12<br \/>\ngrasped.<br \/>\n07:12<br \/>\n07:15<br \/>\nFor the application<br \/>\n07:16<br \/>\nof the vacuum extractor,<br \/>\n07:18<br \/>\ndetermine the location<br \/>\n07:20<br \/>\nof the flexion point<br \/>\n07:21<br \/>\nand apply the cup<br \/>\n07:22<br \/>\nat that position.<br \/>\n07:24<br \/>\nThe flexion point is normally<br \/>\n07:25<br \/>\nlocated along the midline,<br \/>\n07:27<br \/>\nover the sagittal suture,<br \/>\n07:29<br \/>\napproximately 6<br \/>\n07:30<br \/>\ncm from the anterior fontanelle<br \/>\n07:31<br \/>\nand 3 cm<br \/>\n07:32<br \/>\nfrom the posterior fontanelle.<br \/>\n07:35<br \/>\nSweep the edges with a finger<br \/>\n07:36<br \/>\nto ensure<br \/>\n07:37<br \/>\nthat no maternal tissues are<br \/>\n07:39<br \/>\nentrapped.<br \/>\n07:40<br \/>\nThen rapidly apply<br \/>\n07:41<br \/>\na maximum suction of 600<br \/>\n07:43<br \/>\nmillimeters of mercury.<br \/>\n07:45<br \/>\nApply gentle traction<br \/>\n07:46<br \/>\nalong the axis<br \/>\n07:47<br \/>\nof the pelvic curve,<br \/>\n07:49<br \/>\nin synchrony with maternal<br \/>\n07:50<br \/>\npushing.<br \/>\n07:52<br \/>\nVacuum assistance should be<br \/>\n07:53<br \/>\nlimited to three contractions<br \/>\n07:55<br \/>\nfor the descent phase,<br \/>\n07:56<br \/>\nthree contractions<br \/>\n07:57<br \/>\nfor the outlet extraction phase,<br \/>\n07:59<br \/>\n2 to 3 pop-offs,<br \/>\n08:01<br \/>\nand a total time of 15 to 30<br \/>\n08:03<br \/>\nminutes.<br \/>\n08:03<br \/>\n08:07<br \/>\nComplications<br \/>\n08:07<br \/>\nof operative vaginal delivery<br \/>\n08:09<br \/>\ncan be broadly classified<br \/>\n08:11<br \/>\ninto maternal complications<br \/>\n08:12<br \/>\nand fetal complications.<br \/>\n08:14<br \/>\nMaternal complications can be<br \/>\n08:16<br \/>\nshort term or long term.<br \/>\n08:17<br \/>\nShort term maternal<br \/>\n08:19<br \/>\ncomplications include<br \/>\n08:20<br \/>\nmaternal trauma, especially<br \/>\n08:22<br \/>\nwhere a rotational or midcavity<br \/>\n08:24<br \/>\nforceps delivery were performed.<br \/>\n08:26<br \/>\nIt also includes pain, lower<br \/>\n08:29<br \/>\ngenital tract lacerations,<br \/>\n08:30<br \/>\nand hematomas, urinary retention<br \/>\n08:33<br \/>\nand incontinence, anemia,<br \/>\n08:36<br \/>\nanal incontinence,<br \/>\n08:38<br \/>\nand rehospitalization.<br \/>\n08:40<br \/>\nLong term maternal complications<br \/>\n08:42<br \/>\nare urinary<br \/>\n08:43<br \/>\nor fecal incontinence,<br \/>\n08:45<br \/>\npelvic organ prolapse,<br \/>\n08:47<br \/>\nand fistula formation.<br \/>\n08:48<br \/>\n08:51<br \/>\nSimilarly,<br \/>\n08:52<br \/>\nneonatal complications can be<br \/>\n08:54<br \/>\nshort term or long term.<br \/>\n08:56<br \/>\nShort term neonatal<br \/>\n08:57<br \/>\ncomplications include<br \/>\n08:58<br \/>\nsubgaleal hematoma,<br \/>\n09:00<br \/>\nintracranial hemorrhage,<br \/>\n09:02<br \/>\nbruises, abrasions,<br \/>\n09:04<br \/>\nand lacerations, facial nerve<br \/>\n09:06<br \/>\npalsy, cephalohematoma,<br \/>\n09:09<br \/>\nretinal hemorrhage, skull<br \/>\n09:11<br \/>\nfractures, hyperbilirubinemia,<br \/>\n09:14<br \/>\nshoulder dystocia,<br \/>\n09:16<br \/>\nbrachial plexus injury,<br \/>\n09:18<br \/>\nextraocular trauma, as well as<br \/>\n09:20<br \/>\nlipoid necrosis.<br \/>\n09:23<br \/>\nLong term neonatal complications<br \/>\n09:24<br \/>\nare intracranial hemorrhage<br \/>\n09:27<br \/>\nand neuromuscular injury.<br \/>\n09:28<br \/>\n09:31<br \/>\nHere are the references.<br \/>\n09:32<br \/>\n09:36<br \/>\nYou have come to the end<br \/>\n09:37<br \/>\nof the presentation,<br \/>\n09:38<br \/>\nand thank you very<br \/>\n09:38<br \/>\nmuch for your attention.<\/p>\n<p><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Duration 9:41<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":160,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2626","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2626","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=2626"}],"version-history":[{"count":0,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2626\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/160"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=2626"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}