Instrumental deliveries
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  • 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

Transcript

  • 1. INSTRUMENTAL DELIVERIES Prof. M.C.Bansal MBBS,MS,MICOG,FICOG Professor OBGY Ex-Principal & Controller Jhalawar Medical College & Hospital Mahatma Gandhi Medical College, Jaipur.
  • 2. VACUUM /VENTOUSE
  • 3. INDICATIONSMATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary diseaseFETAL Failure of the fetal head to rotate Fetal distress Should not be used for preterm, face presentation or breech
  • 4. MNEMONICA – Anesthesia adequate  appropriate positioning & accessB – Bladder  cathterizationC – Cervix  fully dilated / membranes rupturedD – Determine  position, station, pelvic adequacyE – Equipment  inspect vacuum cup, pump, tubing,  check pressure
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. FETAL COMPLICATIONSScalp injuries  chignon  abrasion & lacerations 12.6% scalp necrosis 0.25-1.8%Cephalohematoma  25%  jaundice /anemiaIntracranial hemorrhage  2.5%Subgaleal hematoma
  • 9. FETAL COMPLICATIONSBirth asphyxia  2.6-12%  related to extraction force & timeSome studies showed decrease birth asphyxiaRetinal hemorrhage 50% Forceps 31% SVD 19%Neonatal jaundice
  • 10. FETAL COMPLICATIONS Fetal mortality 15/1000 Lower in cases delivered by vacuum 1.9%/ forceps 5.2 %No long term effects on neurological psychomotor or intellectual development up to 4 years of age
  • 11. FORCEPS
  • 12. 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
  • 13. 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
  • 14. CLASSIFICATION OF FORCEPS DELIVERYOutlet  Wrigley’sOutlet & low forceps  Simpson /ElliotMidforceps & outlet  Tucker MclaneMidforceps & rotation  KiellandAfter coming head in breech  Piper
  • 15. MNEMONICA – Anesthesia adequate /epidural or pudendal  appropriate positioning & accessB – Bladder  cathterizationC – Cervix  fully dilated / membranes rupturedD – Determine  position, station, pelvic adequacyE – Equipment complete working forceps anesthesia support
  • 16. 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
  • 17. MNEMONICCheck 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
  • 18. 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
  • 19. 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%
  • 20. 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