Obstetrics and Gynecology

1. Operative vaginal
delivery
Instrumental deliveries
(ventouse and forceps)
By Ahmad Azri
Supervisor Dr Yashila

2. Operative vaginal delivery
 A delivery which the operator uses forceps or vacuum device to assist the
mother in transitioning the fetus to extrauterine life.

3.  Common indications for instrumental
deliveries
Classically the indications for operative vaginal deliveries include maternal
and fetal indications. It could be either a planned instrumental delivery or an
emergency procedure.
Planned instrumental
delivery
 Mother with heart disease
 Severe pre eclampsia
 After coming head for
breech
Emergency instrumental
delivery
 Prolonged second stage of labor
 Fetal bradycardia in second
stage
 Other abnormal fetal heart rate
tracings

4. Maternal indications
 Maternal exhaustion
 Inadequate maternal expulsive
efforts (such as spinal cord
injuries or neuromuscular
diseases)
 Need to avoid maternal expulsive
efforts (such as cardiovascular
disease)
Fetal indications
 Fetal distress in 2nd stage –
abnormal CTG, IUGR, placenta
insufficiency (PE, APH, Post date)
 Delivery aftercoming head in
breech (for forceps)
Other indications
 Prolonged second stage of
labour
 Nulliparous: 3 hours with
regional analgesia or 2 hours
without regional analgesia
 Parous: 2 hours with 1 regional
analgesia or 1 hour without
regional analgesia

5. Pre-requisites
Abdominal examinations:
• Satisfactory uterine
contractions
• Longitudinal lie, cephalic
presentations
• Head per abdomen 0/5th
palpable
• Bladder catheterization
Vaginal examination (VE):
• Rupture of membrane
• Cervical os should fully dilated
• Position should be known
exactly (for forceps : OA/OP)
• Rule out signs of
obstruction : swollen cervix,
caput, moulding, exclude CPD
• Station > 0, +1, +2, +3 (at or
below ischial spine)

6.  Fetus > 35 weeks (for vacuum)
 Lithotomy position, Adequate analgesia,
 Sterile procedure, skillful operator, under
supervision
 Paediatrician needed

7. Forceps delivery

8. Obstetrical Forceps
• Obstetric forceps is a double-
bladed metal instrument used for
extraction of foetal head.
• The obstetric forceps consists of 2
matched parts that articulate, or
‘lock’. Each part is composed of a
blade, shank, lock and handle.

9. Types of forceps
Wrigley’s Forceps

10. Indication of forceps delivery
 Prolonged second stage
 It is prolongation for more 1 hour in primigravidae or 30
minutes in multiparae. This may be due to;
 Inertia and poor voluntarily bearing down
 Large foetus
 Rigid perineum
 Malpositions : persistent occipito posterior and deep transverse
arrest

11. Maternal indications
 Maternal distress manifested by:
 Exhaustion
 Pulse > 100 beats/min
 Temperature > 38 degree celcius
 Signs of dehydration
 Maternal disease as;
 Heart disease
 Pulmonary TB
 Pre eclampsia and eclampsia

12. Foetal indications
 Foetal distress
 Prolapsed pulsating cord
 Preterm delivery
 After coming head in breech delivery
 During caesarean section (used as a lever) or
the two blades may be used to extract the head
through the uterine incision
 Malposition of fetal head (occipito-transverse
or occipito-posterior)
 Muscle tone impede spontaneous rotation of
the optimal occipito anterior position

13.  Primary fetal indication for terminating the second stage prematurely
is fetal heart rate persistently less than 100 or more than 160
beats/min.
 Late deceleration patterns
 Gross irregularities

16. Criteria essential for Outlet Forceps
 Fetal skull is at or on the perineum
i.e station is +4 or +5 cm
 Scalp should be visible at the
introitus without separating the labia
 Sagital suture is at or nearly
coinciding with the AP diameter of
the vulval outlet
 Rotation required should not exceed
45 degrees

17. Criteria essential for Low Forceps
 Fetal skull is not on the
perineum, i.e station is +2
or 3 cm
 Scalp is not visible at the
introitus
 Rotation required can be
 < 45 degrees (left or right
occipital anterior to occiput
anterior or left or right
occipital posterior or occiput
posterior)
 > 45 degrees

18. Criteria essential for mid forceps
 Station of head is 0 to 2 cm
 Rotation required can be
 < 45 degrees (left or right
occipital anterior to occiput
anterior or left or right
occipital posterior to occiput
posterior)
 > 45 degrees

19. Pre requisites for forceps delivery
 Experienced operator
 Correct indication
 Cervix fully dilated & membrane ruptured
 Operator aware the presentation and position of
the fetus
 Head not palpable PA
 Bladder catheterized
 Paediatric team present
 Fully prepared for neonatal resuscitation
 Adequate episiotomy
 Fetal HR monitored by CTG

20. Favourable position and presentation
 Occipito anterior
 Occipito posterior

21. Favourable position and presentation
 Face presentation
 After coming head in breech

22. Favourable position and presentation
 Deep transverse arrest

23. Procedure (1)
 Strict aseptic procedure
 Verbal consent
 Patient in lithotomy
position
 Assemble forceps blade to
form a pair
 Repeat VE to confirm
findings

24. Procedure (2)
 If no epidural, infiltrate pudendal block/local
infiltration with lignocaine 1%
 Episiotomy can be performed before/after
applying the forceps
 Apply left blade first. Hold blade between finger
and thumb.
 Handle parallel to the inguinal ligament. Blade
applied by sweeping around in an arc. Right blade
applied by the opposite hand.
 Blade should be locked with ease.
 Don’t forcibly lock the blades.

26. Procedure (3)
 Traction is applied with fingers placed between
the shanks of the forceps.
 Apply traction only during contractions.
 Direction of traction is initially downwards and
outwards. Blades are directed vertically.
 Change upwards and outwards when crowing
about to happen. (in the axis of birth canal)
 Deliver fetus within 3 pulls. If not stop the
procedure.
 Remove blades once head is out.
 Once placenta delivered, check vagina & cervix for lacerations and repaired.
 Baby is examined for injury.

27. Clinical checks for correct forceps
application
 The sagittal suture lies in the midline of the shanks
 The operator cannot place more than finger tip between
the fenestration of the blade and the foetal head
 The posterior fontanelle is not more than one finger
breadth above the plane of the shanks

28. Traction should be:
 Gentle by the force of the arm only
 Intermittent with uterine contractions only
 In correct direction, i.e downwards and backwards till the
occiput appears at the vulva, then downwards and
forwards
 The 2 blades are unlocked between contractions to
minimise the period of the head compression

29. Abandon the procedures!!!
1. Failure to insert the blades
2. Failure to lock the blades
3. No progress in decent of traction

30. Kielland’s forceps in deep transverse
arrest
 The forceps is locked outside
with the knobs towards the
occiput to know the anterior
blade
 The anterior blade is applied
first by one of the following
method :

31. I. The wandering method : the anterior blade is guided into the lateral
side of the pelvis with the cephalic curve facing the foetal head. It is
then slid over the forehead to fit against the anterior parietal
eminence.
II. The direct method : when the head is low down in the pelvis, the
anterior blade is slid between the head and symphysis pubis with the
cephalic curve facing the foetal head
III. The old (classical method) : the anterior blade is applied with the
cephalic curve towards the symphysis pubis then it is rotated 180 to
fit with the head. This method is not recommended as the lower
uterine segment and bladder may be injured.
 The posterior blade is applied along the concavity of the
sacrum
 The 2 blades are locked, head is rotated and extracted as
occipito anterior

32. Piper’s forceps in breech presentation
 Piper’s forceps have perineal curve
and long handles to allow application
to the after coming head in breech
delivery

33. After coming head in breech

34. Forceps delivery in face precentation
 Blades are introduce along the occipito-mental
diameter.
 Traction is applied downwards till the chin
appears below symphysis pubis and then
upward delivering the nose, eyes, brows, and
occiput.

35. Complications of forceps delivery
Maternal complications
 Complications of anaesthesia
 Lacerations:
 Extension of the episiotomy
 Perineal tear
 Vaginal tears
 Cervical lacerations
 Bladder injury
 Ureteric injury
 Rupture uterus
 Bone injuries: to pelvic joints,
coccyx or symphysis pubis
 Pelvic nerve injuries
 Postpartum haemorrhage: due
to lacerations or atony
 Puerperal infections
 Remote effects: genital
prolapse, stress incontinence,
cervical incompetence and
genito urinary fistulas

36. Complications of forceps delivery
Foetal complications
 Fracture of the skull
 Intracranial haemorrhage
 Facial nerve palsy
 Trauma to the face, eyes or scalp
 Asphyxia due to;
 Intracranial haemorrhage or,
 Cord compression between the head and the forceps

37. Vacuum extraction
 Also known as ventouse extraction
 Advantages
 Compared to the forceps, ventouse has advantage of
encouraging flexion and spontaneous autorotation of
the fetal head during traction.
 Also associated with less usage of regional/general
anaesthesia, maternal perineal and vaginal trauma.
 Disadvantages
 Higher risk of failure
 Higher incidence of cephalo hematoma
 Risk of retinal haemorrhage.

38. Prerequisites for vacuum extraction
 Same as forceps delivery.
 Only difference : can be used in fetal head position which is not in
direct OA or OP
 For successful use of the ventouse, determination of the flexion point
is vital. This is located at the vertex, which, in an average term
infant, is on the saggital suture 3cm anterior to the posterior
fontanelle and thus 6 cm posterior to the anterior fontanelle.
 Centre of the cup should be positioned directly over this, as failure to
do so will lead to a progressive deflexion of the fetal head during
traction and an inability to deliver the baby.

39. Flexion point for vacuum delivery

40. Procedures (1)
 Assemble the whole vacuum system & checked
 Select cup with appropriate size
 Insert cup in vertical position to vagina. Cup
placed as close as possible to occiput to
promote flexion of the head. Avoid the
fontanelle.
 Raise the vacuum pressure to 0.2kg/cm2, run
finger around cup to check no vaginal tissue is
caught.
 Raise the vacuum pressure to 0.8kg/cm2,
maintain this level for 2-3 mins to allow
chignon formation.
 Apply traction during uterine contractions
together with bearing down effort.

41. Procedure (2)
 Initial direction is downwards and outwards
 Progressively changed to upward and outwards until the
fetal head descends
 Force perpendicular to cup
 Thumb of one hand on the cup. Index finger on the
fetal.
1. Detect head descent
2. Cup os getting
dislonged
3. Caput is enlarging
without head
descending

42. Procedure (3)
 Head should descend with every pull, delivery should be achieved or is
eminent at the 3rd pull
 If cup slips or dislodges, abandon the procedure.
 Episiotomy is to be done.
 Don’t apply cup more than 20 mins
 Release vacuum after head is delivered.
 After placental delivery, check vaginal & cervical injury
Avoid scalp necrosis

43. Unacepptable use of ventouse
 Position of the head is unknown
 There is a significant degree of caput that may either preclude correct
placement of the cup or more sinisterly, indicate a substantial degree of
cephalopelvic disproportion
 The operator is inexperienced in the use of the instrument.

44. Failed forceps delivery & vacuum
extraction
 Choice of instrument is wrong
 Positioning of the ventouse cup is wrong
 When the position is wrongly defined, leading to inappropriately large
diameters presenting to the pelvis.
 Failure is also more common if the fetus is large or maternal effort is poor.
 No progress/descent with each pull
 Head not reaching perineum within 3 pulls
 Cup off twice(vacuum)
 Delivery is not completed within 15 minutes

45. Complications of instrumental vaginal
delivery.
Maternal
 Perineal and vaginal lacerations
 PPH
 Puerperal genital infection
 Urinary retention
Fetal
 Face, eyes, nose injuries
 Facial nerve palsy
 ICH
 Cephalohematoma
 Scalp laceration
 Cignon (vacuum)

46.  Fetal complications are no less important; the incidence of
cephalohaematoma is increased with the use of the ventouse and there are
rare reports of severe intracranial injuries.
 Cephalohematoma is a traumatic subperiosteal haematoma that
occurs underneath the skin, in the periosteum of the infant’s skull bone.

47. Reference
 CURRENT Obstetric & Gynecologic Diagnosis & Treatment, 9th edition
 Ten Teachers, 19 E – Kenny, Louise, Baker, Philip N
 Obstetrics & gynecology At a glance, 4th edition
 Netters Obstetrics and Gynecology 2nd Ed
 http://www.cbi.nlm.nih.gov/pubmed

48. Thank You