OPERATIVE VAGINAL DELIVERY

DR OBIOKONKWO, A.C.

DEPARTMENT OF OBSTETRCS AND GYNAECOLOGYAHMAD SANI YARIMAN BAKURA SPECIALIST HOSPITAL, GUSAU,

ZAMFARA STATE

OUTLINE

Introduction History Epidemiology Indications for use Contraindications Prerequisites Technique Current trends and controversies Conclusion References

Introduction

Operative vaginal delivery refers to a delivery in which the operator uses forceps or vacuum device to extract the foetus from the vagina, with or without the assistance of maternal pushing [1]

This becomes necessary when there is need to shorten the second stage of labour for some reason, or for other indications

Introduction

Both methods are safe and reliable for assisting childbirth if careful attention is paid to the indications and contraindications for their use

The risks and benefit to both mother and foetus of using either instrument vis-à-vis an abdominal delivery must be considered individually

History[2, 3]

Sanskrit writings dating 1500 BC: Evidence of single and paired instruments

Egyptian, Greek, Roman and Persian writings and pictures Forceps for extracting dead foetuses

Peter Chamberlen of England, c. 1600 Precursor of modern forceps for live infants

History William Smellie, 1745

Described accurate application to the occiput

18th century: Initial application of vacuum techniques

Sir James Simpson, 1845 Developed forceps with

cephalic and pelvic curves

1792

History

Sir James Simpson, 1849 First successful vacuum extraction From breast pump – limited use

Joseph DeLee, 1920 Modified Simpson's forceps Advocated prophylactic use of forceps

Malmstrom, 1956 Stainless steel cup vacuum device. Use limited

to Europe

History

1980s: Introduction of disposable soft cup designs, new

rigid cups and hand-held vacuum pimps Became increasingly popular in the US

Epidemiology

Estimated to be less than 5% of all vaginal deliveries [4]

Most are vacuum deliveries Less than 1% are forceps deliveries Simpson's forceps is the most commonly used type [outlet]

Less commonly, Piper's forceps [aftercoming head]

Indications For Use

Maternal Prolonged second stage Maternal exhaustion Cardiac/ pulmonary disease

Foetal Foetal distress Failure of the head to rotate [forceps]

Contraindications

Absolute Absolute patient refusal Non-vertex presentation Face or brow presentation Unengaged vertex Incompletely dilated cervix Clinical evidence of CPD Known or suspected foetal bleeding diathesis Any contraindication to vaginal delivery

Contraindications

Relative EGA < 35 weeks or EFW < 2500 g Mid-pelvic station Unfavourable attitude of the foetal head

[vacuum] Prior failed forceps [vacuum] Prior scalp sampling Overlapping cranial bones, heavy caput Known or suspected foetal macrosomia

Prerequisites

Informed consent – usually incomplete Vertex presentation Engaged vertex Term foetus EFW > 2500 g Fully dilated cervix [& retracted - forceps] Ruptured membranes

Prerequisites

Exact position of the head known [forceps]– No “pelvic application”!

Adequate maternal pelvis Empty maternal bladder Appropriate analgesia Blood transfusion services & facilities for C/D

Knowledgeable health care provider Ongoing foetal and maternal assessment

Choice of instrument

Operator skill Indication Perceived danger or side effect Perceived ease of use Fear of litigation Availability ?Institution policy??

Technique - Vacuum

The safety and success depends on Proper patient selection Accuracy of initial cup application Traction technique Foetal cranial position Cup design Foeto-pelvic relationship

Not necessarily easier than forceps, just different

Ghosting

Hold the cup before the perineum in the same angle as expected once correctly applied to foetal head

If uncertain, reassess

Insertion

Lubricate cup Insert sideways if rigid

Partially collapse if soft

Position against foetal head

Exclude maternal tissue

Ensure flexion point

Flexion point

Technique

Initial vacuum pressure of 100 – 150 mmHg to fix cup to foetal head

Exclude maternal tissues Confirm flexion point Apply full vacuum at 450 – 600 mmHg Traction in the direction of pelvic curve Avoid rotational force

Technique Time traction to coincide

with uterine contraction Rest between

contraction Continuous steady

motion rather than jerky Place non-dominant

hand in the vagina -thumb on cup, fingers on scalp

Relieve vacuum pressure on extraction of head

Episiotomy not recommended as routine

Vacuum failure

When descent of delivery isn't achieved

When to halt – maximal limits 3 pulls over 3 consecutive contractions without

progress 3 unintended pop-offs 20 minutes of application without progress

Vacuum failure

Baskett et al, [2008][5] reviewed 1000 cases performed using the OmniCup device 87% procedures were successful 3 or fewer tractions were required in 95.6% of

successful procedures Successful procedures took 10 minutes or less

in 97.4% of cases

Potential complications

Foetal Localized scalp

oedema – chignon Cephalohaematoma Scalp abrasions and

lacerations Subgaleal

haemorrhages Subaponeurotic

hemorrhages Retinal haemorrhages Death

Potential complications...

Maternal Lacerations Extension of episiotomies Urinary incontinence Anal incontinence

Technique - Forceps

Safety and success depends on factors similar to those of vacuum

Applied forceps have the following functions Traction Rotation Flexion Extension

Relevant anatomy

Relevant anatomy

Relevant anatomy

Parts of a forceps

ACOG criteria for types of forceps deliveries [6]

Outlet forceps1)The scalp is visible at the introitus, without

separating the labia.

2)The foetal skull has reached the pelvic floor

3)The sagittal suture is in the AP diameter, ROA, LOA, ROP or LOP

4)The foetal head is at or on the perineum and rotation does not exceed 45°

ACOG criteria for types of forceps deliveries [6]

Low forceps The leading point of the foetal skull is at a

station ≥ +2 cm and not on the pelvic floor; any degree of rotation may be present

Mid forceps The station is above +2 cm, but the head is

engaged

ACOG criteria for types of forceps deliveries [6]

High forceps [historic value only!]

Head is not engaged (previous classification).

Not currently part of the classification

High forceps delivery is not recommended

Types of forceps

Outlet Wrigley’s

Outlet & low forceps Simpson /Elliot

Midforceps & outlet Tucker Mclane

Midforceps & rotation Kielland

After coming head in breech Piper

Types of forceps

Technique

Confirm pelvic adequacy - pelvimetry Assemble forceps before application Ensure that the parts fit together and lock well

Lubricate blades of forceps Insert two fingers of the right hand into the vagina on the side of the foetal head

Slide the left blade gently between the fingers and the foetal heat to rest on the side of the head

Technique

Technique Repeat manoeuvre on the other side using left hand, right blade

Depress the handles and lock forceps

Difficulty locking? Remove blades and recheck position of head. Reapply ONLY if position is confirmed

Apply steady traction inferiorly and posteriorly with each contraction

Technique

Check of proper application

– Sagittal suture perpendicular to plane of shanks

– Posterior fontanelle should be a fingerbreadth away from plane of shanks, equidistant from sides of blades and directly in front of articulated forceps

– The amount of fenestration should not be more than one finger tip

Technique

Sequence of traction

*DBHUF Downwards Backwards Horizontally Upwards Forwards

*APPLIES TO VACUUM ALSO

Technique

Between contractions, check: Foetal heart rate Application of forceps

Remove forceps on crowning and complete by Ritgen manoeuvre

Note that application should be between contractions, and avoid use of excessive force

Apply traction in the plane of least resistance

Forceps failure

Forceps has failed if: Foetal head does not advance with each

pull Foetus is undelivered after 3 pulls with no

descent or after 30 minutes[7]

Every application should be considered a trial of forceps. Do not persist if no progress with each pull

Potential complications

Foetal Injury to facial nerves Lacerations of face and scalp Fracture of skull and face

Maternal [early] Lacerations of genital tract Uterine rupture

Potential complications

Maternal [late] Fistulae Rectal sphincter dysfunction → faecal

incontinence Urinary incontinence – less common

Post OP care

Active management of third stage Newborn resuscitation Umbilical arterial blood gas analysis Examination for maternal and neonatal trauma Documentation of indication, definition and

method of operative technique Review birth with family If no major injury, usual 4 – 6 week PNC visit

Vacuum vs Forceps

Requires less analgesia/anaesthesia

More likely to fail Less incidence of perineal tears

More incidence of intracranial haemorrhage

Requires more analgesia/anaesthesia

Less likely to fail More incidence of perineal tears

Less incidence of ICH

Vacuum vs Forceps

Traction of scalp Cannot be used to apply rotational forces

Requires maternal effort

Traction of head Can apply rotational forces

Requires little or no maternal effort

Vacuum vs Forceps [maternal]

Vacuum vs Forceps [neonatal]

Novel devices

Thierry or Teissier spatula

Odon device

The future of OVD ...

Forceps – in doubt! Skill is declining Loss of experienced accouchers 2011 records of US vital statistics – 0.7% for

forceps Forceps still an acceptable and safe option –

ACOG[6]

Vacuum or caesarean delivery favoured over forceps

Controversies... If and when OVD should be performed Use of episiotomy Best instrument to use in specific clinical settings

The place of mid-cavity forceps in current obstetrics practice

Whether or not to obtain bedside consent in acute situations

What constitutes a reasonable attempt at AVD

Sequential instrumental use Prophylactic antibiotics

Conclusion

Operative vaginal delivery is an invasive procedure that requires good communication with the woman

The need for the delivery must convincing, compelling and documented

Use the mnemonic to ensure safe technique and to reduce harm to the woman and her foetus

Update the following ...

Elective OVD indications Risk factors to a failed OVD Local studies and statistics Forceps and vacuum in C/D Current PMTCT guideline for OVD when

indicated Include destructive operations and

episiotomies

THANKS FOR YOUR AUDIENCE

References

1.http://www.uptodate.com/contents/operative-vaginal-delivery 2.http://emedicine.medscape.com/article/263603-overview#a6 3.http://emedicine.medscape.com/article/271175-overview#a1 4.http://emedicine.medscape.com/article/263603-overview#a7 5.Baskett TF , Fanning CA, Young DC. A prospective

observational study of 1000 vacuum assisted deliveries with the OmniCup device. J Ostet Gynaecol Can. 2008 Jul. 30(7) 573-80

6.American College of Obstetricians and Gynaecologists. American College of Obstetricians and Gynaecologists Practice Bulletin. Operative Vaginal Delivery. American College of Obstetricians and Gynaecologists, June, 2000.

7.WHO, Managing complications in pregnancy and childbirth: a guide for doctors and midwives. Geneva: World Health Organization; 2003. Available http://www.who.int/reproductive-health/impac/mcpc.pdf

History

Sir James Simpson, 1849 First successful vacuum extraction From breast pump – limited use

Joseph DeLee, 1920 Modified Simpson's forceps Advocated prophylactic use of forceps

Malmstrom, 1956 Stainless steel cup vacuum device. Use limited

to Europe