Instrumental deliveries 1-Indications for instrumental deliveries include T1-Prolonged 2 nd stage T2-Fetal distress F3-Transverse lie F4-Compound presentation T5-Maternal cardiac disease
2-Prerequisite for instrumental delivery include T1-Cervix must be fully dilated T2-Membranes ruptured F3-Fetal head not engaged F4-Obstetrician unsure about position of the fetal head due to caput T5- Bladder empty/ cathetrized
3-Complications of ventouse delivery F1-Ventouse causes 3 rd & 4 th degree perineal tears more frequent than forceps F2-Long term effects on neurological & intellectual development of children delivered by ventouse are evident by 4 years of age T3-Cephalohematoma occur in up to 25% of babies T4-Birth asphyxia is related to the force of traction & prolonged procedure (time from application of vacuum until delivery) T5-Cephalohematomas may result in jaundice & anemia of the neoborne
4-Forceps T1-can be applied to the after coming head in assisted vaginal breech delivery T2-Can be applied to face presentation T3-It is not contraindicated for preterm fetuses T4-Can result in facial nerve damage of the fetus T5-Is associated with a higher fetal mortality than ventouse
INSTRUMENTAL DELIVERIES Prof. M.C.Bansal MBBS,MS,MICOG,FICOG Professor OBGY Ex-Principal & Controller Jhalawar Medical College & Hospital Mahatma Gandhi Medical College, Jaipur.
MNEMONICF – Fontanelle position the cup over the posterior fontan -ve pressure ↑ 10 cm H2O initially & between cont sweep finger around cup to clear maternal tissue ↑ pressure to 60 cm H2O with the next contractionG – Gentle traction pull with contractions only traction in the axis of the birth canal ask the mother to push during cont
MNEMONICH – Halt halt traction if no progress with three traction aided contractions vacuum pops off three times pulling for 30 min without significant progressI – Incision consider episiotomy if laceration imminentJ – Jaw remove vacuum when jaw is reachable or delivery assured
COMPLICATIONSVacuum –assisted delivery is less traumatic to the mother &fetus than forcepsVentouse should be the instrument of choiceMaternal Vaginal laceration due to entrapment of vaginal mucosa between suction cup & fetal head
INDICATIONSMATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary diseaseFETAL Failure of the fetal head to rotate Fetal distress Control of the fetal head in vaginal beech delivery
CLASSIFICATION OF FORCEPS DELIVERYOutlet forceps Scalp visible at the vulva without separating the labiaLow forceps Vertex at +2 stationMidforceps Head is engaged but leading part above +2 station Sagittal suture not in the AP plane of the mother
CLASSIFICATION OF FORCEPS DELIVERYOutlet Wrigley’sOutlet & low forceps Simpson /ElliotMidforceps & outlet Tucker MclaneMidforceps & rotation KiellandAfter coming head in breech Piper
MNEMONICF – Forceps phantom application Lt blade , LT hand, maternal Lt side pencil grip & vertical insertion with Rt thumb directing blade Rt blade , RT hand, maternal Rt side pencil grip & vertical insertion with Lt thumb directing blade Lock blades
MNEMONICCheck application: Post fontanelle 1cm above the plane of the shanks Sagittal suture lies in the midline of the shanks /perpindicular to the plane of the shanks The operator can not place more than a fingertip between the fenestration of the blade & the fetal head on either side
MNEMONICG – Gentle traction applied with contraction & maternal expulsive effortsH – Handle elevated traction in the axis of the birth canal do not elevate handle to earlyI – Incision consider episiotomy if laceration imminentJ – Jaw remove forceps when jaw is reachable or delivery assured
COMPLICATIONSMaternal trauma to soft tissue 3rd/4th degree double the risk compared to ventouse bleeding from lacerations trauma to urethra & bladder fistula Pain 17% ventouse 11%
COMPLICATIONS Fetal bruising & laceration to the face Injury to the fetal scalp cephalohematoma 9% Vent 25% retinal hemorrhage 30% Vent 50% skull fracture permanent nerve damage / Facial nerveThe risk of shoulder dystocia is increased following instrumental deliveries
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