operative vaginal delievery

1. By Majid Nawaz
(final year MBBS)
Bannu Medical College
Bannu

2. a delivery in which the operator uses forceps or a vacuum device to assist the
mother in transitioning the fetus to extrauterine life.
If performed by proper selection of cases and careful & timely application,
operative delivery can be useful in reducing not only unnecessary caesarean
sections but also fetal & maternal complications due to prolonged labor.

3. 1)prolonged second stage of labour
• Nullipara-
• >3 hrs with regional anaesthesia
• >2 hrs without regional anaesthesia
• Multipara-
• >2 hrs with regional anaesthesia
• >1hr without regional anaesthesia
2)Foetal indications: -
 Foetal distress
 Cord prolapse in second stage
 Aftercoming head of breech
 Low birth wt. Baby
 Post maturity

4.  3)Maternal indication: -
 Maternal distress
 Pre-eclampsia
 Heart diseases
 Neurological disorders
where voluntary efforts are
contraindicated or impossible

5.  Absolute Contraindications :
 Moderate to severe CPD.
 Abnormal presentations (vacuum…NO, forceps…YES).
 High head except in 2nd twin (vacuum can be used)
 Relative Contraindications:
 MATERNAL:
 Before full cervical dilatation .
 There are a few exceptions
 prolapsed cord at 9 cm in a multiparous woman.
 or a second twin.
 General anesthesia (vacuum…YES, forceps…NO).
 Fetal:
 Fetal bleeding disorders
 Predisposition to fracture (e.g., osteogenesis imperfecta).
 Fetal Distress (vacuum…YES, forceps…NO).

6.  Vacuum and forceps delivery can be associated with
significant complications, both maternal and fetal.
 Risks of complications are increased significantly
among babies exposed to attempts at both vacuum
and forceps delivery.
 Complications/dangers of operative delivery: - are
mostly due to faulty technique rather than the
instrument.

7.  Injury-.
 Extension of the episiotomy involving anus & rectum or vaginal vault.
 Vaginal lacerations and cervical tear if cervix was not fully dilated.
 Post partum haemorrhage –.
 Due to trauma, Atonic uterus
 Shock –.
 Due to blood loss, or prolonged labor.
 Sepsis –.
 Due to improper asepsis of local tissues.
 Anaesthetic hazards.
 Delayed or long-term sequel –.
 Chronic low backache.
 genital prolapse .
 stress incontinence.

8.  Asphyxia
 Trauma-
 Intracranial hemorrhage.
 Cephalic haematoma.
 Facial / Brachial palsy.
 Injury to the soft tissues of face & forehead.
 Skull fracture
 Fetal death-around 2%

9.  A-
 Ask for help (experience, and skills necessary to use the instruments) ,
 Anesthesia is needed. (A pudendal block may be appropriate ) and
 Anticipation of complications (e.g., shoulder dystocia, postpartum ).
 Adequate Pelvis.
 B-Bladder empty.
 C- complete Asepsis.
 D- Dilated cervix.

10. 
E-Episiotomy .
 F- Favorable presentation (vertex or
aftercoming head)
 G-
 Gentle traction in the proper axis.
 Good uterine contraction.
 H- Head is engaged

11.  I- Informed consent.
 M- Membranes are Ruptured.
 N- Neonatal resuscitation trained Personnel are
present.

12. The operators should choose the
instrument most appropriate
to the clinical circumstances
and their level of skill.
RCOG audit standard says
that “vacuum is the first
choice of instrument for
instrumental vaginal
delivery”.

13.  Consist of a silicone or metal cup connected by a tube to a
vaccum source.
 cup is applied over the vertex
 Operating pressure is
0.6_0.8kg/cm2
 Maximum time of application
should be less than 15 minutes
 Traction is applied at angle of 90 degree to the cup
 Safe and gental traction is applied in concert with uterine
contraction and voluntary expulsive efforts

15.  2 types
 Non rotational forceps e.g simpson
forceps_____ used when the head is in
occipitoanterior plus or minus 15 degree
Rotational forceps e.g kielland forceps_____
used when when head is positioned greater
than 15 degree from the vertical. They are
designed for rotation.

16.  By convention 1st left blade is inserted and then right one
 The operator then articulates both the jaws and lock it.
 Gental intermittent traction is
applied in concert with uterine
contraction and expulsive
efforts of mother.
 The axis of traction changes
along with the j shape curve
and as the head begins to
crown the blades are
directed vertical
and head is delivered.

18.  CAN BE USED FOR:
 After coming head of breech
 Dead fetus.
 Face presentation

19.  1) Can be used with local anesthesia or with no
anesthesia.
 2) Can be used before full cx dilatation.
 3) Can be used for rotation and extraction by single
application.
 4)Less traumatic to mother.

20.  5) Less traumatic to fetal head.
 6) less Compression and traction force (1/20th as
compared to forceps)
 7) Does not require additional space between
tight fitting head and pelvis.
 8)No special skill is neded.