Operative Vaginal Operative Vaginal DeliveryDelivery

District 1 ACOG Medical Student Teaching Module 2011

IndicationsIndications Maternal Benefit – Shorten the 2Maternal Benefit – Shorten the 2ndnd stage of stage of

labor, decrease the amount of pushinglabor, decrease the amount of pushing Ie: maternal cardiac conditions (Eisenmenger’s, Ie: maternal cardiac conditions (Eisenmenger’s,

pulmonary HTN) or history of aneurysm/strokepulmonary HTN) or history of aneurysm/stroke Concern for immediate/potential fetal Concern for immediate/potential fetal

compromise compromise Ie: Prolonged terminal bradycardiaIe: Prolonged terminal bradycardia

Prolonged 2Prolonged 2ndnd stage stage Nulliparous = No progress for 3 hrs w/epidural or 2 Nulliparous = No progress for 3 hrs w/epidural or 2

hours w/o epiduralhours w/o epidural Multiparous = No progress for 2 hrs w/epidural or 1 hr Multiparous = No progress for 2 hrs w/epidural or 1 hr

w/o epiduralw/o epidural

Operative Vaginal DeliveryOperative Vaginal Delivery

Incidence: 4.5% of vaginal deliveriesIncidence: 4.5% of vaginal deliveries Forceps deliveries = 0.8%Forceps deliveries = 0.8% Vacuum deliveries = 3.7%Vacuum deliveries = 3.7% Success Rate = 99%Success Rate = 99%

Reflects appropriate choice of candidatesReflects appropriate choice of candidates

What Do I Need To Know Before What Do I Need To Know Before Attempting an Operative Delivery?Attempting an Operative Delivery?

Presentation Presentation (Cephalic/Breech)(Cephalic/Breech)

Position (i.e. occiput Position (i.e. occiput posterior, sacrum anterior)posterior, sacrum anterior)

Lie (longitudinal, oblique, Lie (longitudinal, oblique, transverse)transverse)

StationStation Presence of asyncliticismPresence of asyncliticism Clinical pelvimetryClinical pelvimetry Anesthesia?Anesthesia?

ContraindicationsContraindications

GA < 34 weeks (contraindication for GA < 34 weeks (contraindication for vacuum due to risk of fetal IVH)vacuum due to risk of fetal IVH)

Known bone demineralization condition Known bone demineralization condition (e.g. osteogenesis imperfecta) or bleeding (e.g. osteogenesis imperfecta) or bleeding disorder, ie: VWD)disorder, ie: VWD)

Fetal head unengagedFetal head unengaged Position of fetal head unknownPosition of fetal head unknown

Vacuum-Assisted Vaginal DeliveryVacuum-Assisted Vaginal Delivery

Do not apply rocking Do not apply rocking motion or torque, only motion or torque, only steady traction in the steady traction in the line of the birth canalline of the birth canal

Stop after: three “pop-Stop after: three “pop-offs” of vacuum, > 20 offs” of vacuum, > 20 minutes elapsed, three minutes elapsed, three pulls with no progresspulls with no progress

After determining position of the head, (A) insert the cup into the vaginal vault, ensuring that no maternal tissues are trapped by the cup. (B) Apply the cup to the flexion point 3 cm in front of the posterior fontanel, centering the sagittal suture. (C) Pull during a contraction with a steady motion, keeping the device at right angles to the plane of the cup. In occipitoposterior deliveries, maintain the right angle if the fetal head rotates. (D) Remove the cup when the fetal jaw is reachable

Fetal Risks: VAVDFetal Risks: VAVD

Scalp lacerations: if torsion excessiveScalp lacerations: if torsion excessive Cephalohematoma: limited to suture Cephalohematoma: limited to suture

line line Subgleal hematoma: crosses suture Subgleal hematoma: crosses suture

lineline Intracranial/retinal hemorrhageIntracranial/retinal hemorrhage Hyperbilirubinemia/jaundiceHyperbilirubinemia/jaundice Higher incidence of Higher incidence of

cephalohematoma/retinal cephalohematoma/retinal hemorrhage/jaundice compared to hemorrhage/jaundice compared to forcepsforceps

Designed to detach if traction is excessive (but Designed to detach if traction is excessive (but can produce traction up to 50 lbs)can produce traction up to 50 lbs)

* 5% incidence serious complications* 5% incidence serious complications

Type of Forceps DeliveryType of Forceps Delivery

Outlet forcepsOutlet forceps Scalp visible at introitus w/o separating labiaScalp visible at introitus w/o separating labia Fetal skull reached pelvic floor & head at/on perineumFetal skull reached pelvic floor & head at/on perineum Sagittal suture in AP diameter or LOA, ROA, or posterior positionSagittal suture in AP diameter or LOA, ROA, or posterior position rotation does not exceed 45ºrotation does not exceed 45º

Low forcepsLow forceps Leading point of fetal skull at >= +2, not on pelvic floorLeading point of fetal skull at >= +2, not on pelvic floor Rotation 45º or less (LOA/ROA to OA, or LOP/ROP to OP); or rotation Rotation 45º or less (LOA/ROA to OA, or LOP/ROP to OP); or rotation

greater than 45º.greater than 45º.

MidforcepsMidforceps Above +2 cm but head engagedAbove +2 cm but head engaged

High forcepsHigh forceps Head not engaged; not included in ACOG classificationHead not engaged; not included in ACOG classification Not recommendedNot recommended

Forceps-Assisted Vaginal DeliveryForceps-Assisted Vaginal Delivery

Identify & apply Identify & apply bladesblades

Place instrument in Place instrument in front of pelvis with tip front of pelvis with tip pointing up & pelvic pointing up & pelvic curve forwardcurve forward

Apply left blade, Apply left blade, guided by right hand, guided by right hand, then right blade with then right blade with left handleft hand

Lock bladesLock blades Should articulate with Should articulate with

easeease

FAVDFAVD

Check for correct applicationCheck for correct application Sagittal suture in midline of shanksSagittal suture in midline of shanks Cannot place more than one fingertip Cannot place more than one fingertip

between blade and fetal headbetween blade and fetal head Apply tractionApply traction

Steady and intermittentSteady and intermittent Downward and then upwardDownward and then upward Remove blades as fetus crownsRemove blades as fetus crowns

Risks: ForcepsRisks: Forceps

Maternal RisksMaternal Risks Perineal Injury (extension of episiotomy)Perineal Injury (extension of episiotomy) Vaginal and Cervical lacerationsVaginal and Cervical lacerations Postpartum hemorrhagePostpartum hemorrhage

Fetal RisksFetal Risks Intracranial hemorrhageIntracranial hemorrhage Cephalic hematomaCephalic hematoma Facial / Brachial palsyFacial / Brachial palsy Injury to the soft tissues of face & foreheadInjury to the soft tissues of face & forehead Skull fractureSkull fracture

Using both forceps and vacuumUsing both forceps and vacuum

Highest risk for injury is for combined Highest risk for injury is for combined forceps/vacuum extraction or cesarean forceps/vacuum extraction or cesarean delivery after failed operative deliverydelivery after failed operative delivery

The weight of available evidence is The weight of available evidence is against multiple efforts with different against multiple efforts with different instrumentsinstruments