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Towards safe practice in Towards safe practice in instrumental vaginal instrumental vaginal
deliverydelivery
Leroy EdozienLeroy Edozien
Approximately 1 in 10 Approximately 1 in 10 deliveriesdeliveries
is instrumental is instrumental
What could go wrong?What could go wrong?
Fetal complicationsFetal complications
Facial lacerationFacial lacerationScalp lacerationScalp lacerationFacial nerve palsyFacial nerve palsySkull fractureSkull fractureCorneal injuryCorneal injuryCervical spine Cervical spine injuryinjury
Subdural Subdural haematomahaematomaSubgaleal Subgaleal haematomahaematomaCephalhaematomaCephalhaematomaRetinal Retinal haemorrhagehaemorrhageHyperbilirubinaemiHyperbilirubinaemiaa
King SJ, Boothroyd AE. Cranial trauma following birth in term infants. Br J Radiol 1998;71:233-8
What could go wrong?What could go wrong?
Maternal complicationsMaternal complications
Cervical laceration Haematoma
Vaginal laceration Perineal tear
Psychological trauma
Avoiding harmAvoiding harm
Non-operative interventionsNon-operative interventions Deciding when and when not to Deciding when and when not to
deliver instrumentallydeliver instrumentally Using the right operative techniquesUsing the right operative techniques
Non-operative interventions which Non-operative interventions which reduce instrumental delivery ratesreduce instrumental delivery rates
One-to-one support in labour One-to-one support in labour (Hodnett, 2003)(Hodnett, 2003)
Upright or lateral position Upright or lateral position (Gupta & Hofmeyr, (Gupta & Hofmeyr, 2003)2003)
Oxytocin for prolonged second stage Oxytocin for prolonged second stage (Saunders et al, 1989)(Saunders et al, 1989)
Delayed pushing Delayed pushing (Roberts et al, 2004)(Roberts et al, 2004)
When and when not to deliver When and when not to deliver instrumentallyinstrumentally
Indications:Indications:
Fetal compromise (actual or Fetal compromise (actual or anticipated)anticipated)
Prolonged second stageProlonged second stage
Where down-bearing is to be Where down-bearing is to be avoidedavoided
When and when not to deliver When and when not to deliver instrumentallyinstrumentally
Absolute contraindications:Absolute contraindications:
MalpresentationMalpresentationUnengaged fetal headUnengaged fetal head
Cephalopelvic disproportionCephalopelvic disproportionFetal clotting disorderFetal clotting disorder
GA < 34 wk (ventouse)GA < 34 wk (ventouse)
Safe practice: prerequisites Safe practice: prerequisites for instrumental deliveryfor instrumental delivery
FFully dilated cervixully dilated cervix OOne-fifth or nil palpable abdominallyne-fifth or nil palpable abdominally RRuptured membranesuptured membranes CContractions presentontractions present EEmpty bladdermpty bladder PPresentation and position knownresentation and position known SSatisfactory analgesiaatisfactory analgesia
Instrumental delivery before full Instrumental delivery before full cervical dilatationcervical dilatation
Crime or expedience?Crime or expedience?
SOGC: ‘may be considered when SOGC: ‘may be considered when benefits significantly outweigh risks’benefits significantly outweigh risks’
RCOG: exceptions to the rule - cord RCOG: exceptions to the rule - cord prolapse at 9 cm in a multip; second prolapse at 9 cm in a multip; second
twintwin
EngagementEngagement
Instrumental delivery should not Instrumental delivery should not be attempted if the lowest part of be attempted if the lowest part of the baby’s skull has not reached the baby’s skull has not reached
the ischial spines.the ischial spines.
Crichton D. South African Medical Journal 1974;12:784-7
Smellie W. A treatise on the theory and practice of Midwifery.
London; MDCCLII
Communication and consentCommunication and consent
Safe practice: abandonmentSafe practice: abandonment
Indications for abandonment:Indications for abandonment:
Difficulty in applying instrumentDifficulty in applying instrument
No descentNo descent
Delivery not imminent after three Delivery not imminent after three pullspulls
15 minutes elapsed15 minutes elapsed
Why is the principle of Why is the principle of abandonment frequently abandonment frequently
breached?breached?
Poor trainingPoor training
Confirmation biasConfirmation bias
Sunk costsSunk costs
Safe practice: recognise Safe practice: recognise conditions predictive of conditions predictive of
difficulty/failuredifficulty/failure
1/5 palpable 1/5 palpable Station 0Station 0
OP positionOP positionMoulding ++/+++Moulding ++/+++
Slow progressSlow progressBig babyBig babyBMI > 30BMI > 30
Trial of instrumental
delivery
Sequential instrumentationSequential instrumentation
Benefits and risks
Decision-making
Safe practice: post-operative Safe practice: post-operative carecare
Examine and observe the babyExamine and observe the baby
VTE risk assessmentVTE risk assessment
Bladder careBladder care
OpennessOpenness
Safe practice: Situational Safe practice: Situational awarenessawareness
DocumentationDocumentation
IndicationIndication Abdominal examination Abdominal examination
ConsentConsent Position; stationPosition; station
Moulding; caputMoulding; caput Pelvis adequatePelvis adequate
CTGCTG ContractionsContractions
Ease of application Ease of application No. of pullsNo. of pulls
DetachmentsDetachments DurationDuration
VE; PR post-deliveryVE; PR post-delivery Condition of babyCondition of baby
Cord pHCord pH Details of repairDetails of repair
Examples of error in Examples of error in instrumental deliveryinstrumental delivery
Action omitted, mistimed, misjudged:Action omitted, mistimed, misjudged:
Abdominal palpation not doneAbdominal palpation not doneProlonged tractionProlonged tractionContinuous tractionContinuous tractionRotation during a contractionRotation during a contractionTraction directed forwards and Traction directed forwards and upwards too soonupwards too soon
Examples of error in Examples of error in instrumental deliveryinstrumental delivery
Information wrong, incomplete or not Information wrong, incomplete or not retrieved:retrieved:
Mistaken head level or positionMistaken head level or position
Moulding not assessedMoulding not assessed
Equipment not checkedEquipment not checked
History of diabetes disregardedHistory of diabetes disregarded
Examples of error in Examples of error in instrumental deliveryinstrumental delivery
Procedural checks omitted or not properly Procedural checks omitted or not properly done:done:
No check for correct applicationNo check for correct application
No check for descent with pullNo check for descent with pull
PR/VE not done at end of procedurePR/VE not done at end of procedure
Swabs not countedSwabs not counted
Examples of error in Examples of error in instrumental deliveryinstrumental delivery
Faulty selection (choosing from options):Faulty selection (choosing from options):
Wrong ventouse cup typeWrong ventouse cup type
Ill-advised sequential instrumentationIll-advised sequential instrumentation
Examples of error in Examples of error in instrumental deliveryinstrumental delivery
Failure to communicate:Failure to communicate:
With womanWith woman midwifemidwife
senior obstetriciansenior obstetriciananaesthetistanaesthetist
paediatricianpaediatrician
Examples of error in Examples of error in instrumental deliveryinstrumental delivery
Cognition:Cognition:
Failure to anticipate ….PPH, Shoulder Failure to anticipate ….PPH, Shoulder dystocia, etc.dystocia, etc.
Failure to ask the right questions e.g. Failure to ask the right questions e.g. pulling in the right direction? … pulling in the right direction? …
forceps forceps applied on baby’s face?applied on baby’s face?
Training, competence supervisionTraining, competence supervision
Unmet training needsUnmet training needs
Demonstrable benefits of Demonstrable benefits of trainingtraining
Assessment toolsAssessment tools
‘Dr C stated that he discussed these options with Mr A and Mrs B and said that they were
happy for him to deliver their baby using forceps. Mr A and Mrs B considered that Dr C
did not communicate very effectively with them before or during the delivery. They said it
was often very difficult to hear and understand what he was saying, particularly because Dr
C directed most of his comments to Ms F.’
Assessment: occipito-posterior position, slightly to the right; presenting part slightly tilted.
‘Dr C applied the left blade of the forceps directly to the baby’s head, followed by the right blade. As the handles could not be aligned properly he removed the blades and reassessed the position of the head. At this stage, Mrs B’s buttocks were brought down further towards the edge of the bed and Dr C removed the foetal scalp electrode to enable easier application of the forceps.Dr C explained that after re-examination he was satisfied that the baby was in an occipito-posterior position and so he reapplied the forceps. He stated that this time the blades aligned without difficulty. Dr C attempted to rotate the baby’s head to the right but was unable to and so attempted rotation to the left, which was also unsuccessful’
While kneeling on the floor, Dr C applied force on the forceps during a contraction, in an attempt to pull the baby down in the occipito-posterior position while Mrs B was asked to push. Dr C explained that sometimes the head can be rotated at a lower level, or delivered in that position without the need for any rotation. He stated that only moderate traction was applied during this procedure and that he only used his right forearm while his left arm was resting on top of his right hand.
Mr A and Mrs B stated that Dr C pulled extremely firmly on the forceps and that Mrs B was dragged down the bed as a result. Dr C denied using any more force than wasnecessary or than he would normally use during such a procedure.
‘Other than a small laceration on the left cheek of the baby from the scalpel blade atthe time of the operation, I did not see any external forceps marks or bruises on thebaby’s head or the face at the time of delivery’. -Dr C
Cord blood was obtained but had clotted and was unsuitable for pH
analysis.
Baby born moribund. NICU. NND.
This was Mrs B’s second pregnancy and the pregnancy had been uneventful. Her first child had died of a congenital heartdefect (at 20 weeks’ gestation).
http://www.hdc.org.nz/files/hdc/http://www.hdc.org.nz/files/hdc/opinions/00hdc09324.pdfopinions/00hdc09324.pdf
Joint RCOG/ENTER MEETING
Risk Management and Medico-Legal Issues In Women’s Health
25 to 26 April 2007