2. Session objectives
Describe operative delivery
Discus the indication for each operative
delivery
Discus the prerequisite, contraindication,
procedure for each operative delivery
Discus the complication for each operative
delivery
Describe the pre & post operative care
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3. Introduction
Operative vaginal delivery refers to a delivery in
which the operator uses forceps or a vacuum
device to assist the mother in transitioning the
fetus to extra uterine life.
The instrument is applied to the fetal head and
then the operator uses traction to extract the fetus,
typically during a contraction while the mother is
pushing.
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4. A. Vacuum Extraction(ventouse)
It is an instrumental device designed to assist delivery by
creating a vacuum between it and the fetal scalp.
Figs 1 (A) Malmstrom device; (B) Mityvac pump with tube and
soft cup 12/21/2023
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5. Types of vacuum
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Instrument
◦ Manual
◦ Automatic/ Electrical
Cup
◦ Metallic/ M-style
Rigid
Has more traction force
Size: 40, 50, & 60 mm
◦ Soft/ Pliable
Has higher failure rate
Causes less scalp injury
Easier to manipulate
7. Contra indications
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1. Cephalopelvic disproportion(CPD)
2. High station (above 0-station)
3. Non- vertex presentations(like: face, brow,etc)
4. Extreme prematurity
5. Known macrosomia
6. Suspected fetal coagulation disorder
8. Prerequisites
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Vertex presentation with fetal position identified
Fully dilated cervix
Engaged head: station at 0 or not more than 2/5 above
symphysis pubis
Ruptured membranes
Live fetus
Term fetus
Good ux contractions
Empty bladder
Experienced operator present
Informed consent
10. Duration/Safety Rules
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A maximum of two to three cup detachments,
Three sets of pulls for the descent phase
three sets of pulls for the outlet extraction phase,
Maximum total vacuum application time of 15 to
30 minutes are commonly recommended
11. Failed vacuum
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Diagnosis is based on any one of the ff conditions:
The head does not advance with each pull;
The fetus is not delivered with 3 pulls;
The fetus is not delivered within 30 minutes;
The cup that is applied appropriately and pulled
in the proper direction with maximum negative
pressures slips off the head more than twice.
NB: After failed vacuum, the fetus is delivered by
Cesarean section
12. Reasons for failure
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Fetopelvic disproportion
Incorrect technique
Head too high misdiagnosis of position
Finally, vacuum cup selection may play a role of
successful vaginal delivery.
E.g. Soft VS rigid vacuum extractor cups determined
that the average failure rates were 16% and 9% for the
soft and metal cups, respectively
13. Complication
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Maternal : Vaginal laceration
Fetal
◦ Artificial caput (chignon) / scalp edema
◦ Scalp bruising & laceration
◦ Cephalhematoma
◦ Increased transmission of HIV
15. Advantages Over Forceps
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Doesn't occupy more space (Doesn’t affect
the diameter of the fetal head)
Needs less analgesia
Needs less training & experience
Causes less maternal trauma
Has clear-cut rules
16. 2. Forceps Delivery
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Obstetric forceps is a pair of instruments
used to effect delivery of the fetus.
The primary functions of the forceps are:
to assist with traction of the fetal head and/or
to assist with rotation of the fetal head to a
more desirable position.
18. TYPES
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Obstetric Forceps
Simpson or Elliot forceps are most often used for
outlet vaginal deliveries, whereas
• Kielland or Tucker-McLane forceps are used for
rotational deliveries.
• Piper forceps are used for delivery of the after
coming head.
20. Classification Of Forceps Deliveries
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Outlet forceps :
the scalp is visible at the introitus without separating the labia,
the fetal skull has reached the pelvic floor,
the sagittal suture is in anteroposterior diameter or a right or
left occiput anterior or posterior position,
the fetal head is at or on the perineum,
rotation does not exceed 45 degrees.
Low forceps :
the fetal skull at least + 2 cm station; but not on the pelvic
floor.
Midforceps : the head is engaged, but higher than +2 cm
station.
High forceps: Prior to engagement
Not included in classifications
21. Indication
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Prolonged second stage
To shorten the second stage in cases:
• Maternal distress
• Preeclampsia, eclampsia
• Cardiac or pulmonary diseases
• Cerebrovascular diseases
NRFHRP and cord prolapse
After-coming head in breach presentation
22. Prerequisite
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Fully dilated cervix
Ruptured membranes
Empty bladder
Deeply engaged head/ station > +2cm
Adequate analgesia/ anesthesia
No CPD
Vertex, or after-coming head
Experienced operator or supervisor
Capability to perform Cesarean delivery
Consent
24. complications
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Fetal complications:
o Facial nerve injury, facial bruising and laceration
o Newborn’s face or scalp laceration;
o Cephalhematoma
o Fracture of the face or scalp
o Increased transmission of HIV
o Intracranial hemorrhage
25. …complication
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Short-term :
pain at delivery,
perineal pain at 24 hours,
lower genital tract lacerations and hematomas,
urinary retention and incontinence,
anal incontinence, and rehospitalization
Perineal tears- 1st, 2nd, 3rd, 4th degree
Vaginal, cervical tears, uterine rupture
Post partum hemorrhage due to genital trauma
26. …. complications
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Maternal complication
Long-term complication :
potential disturbance in urinary and anal function, such
as urinary incontinence, fecal incontinence, pelvic organ
prolapse and occasionally fistula
Psychological feeling of inadequacy for not delivering
spontaneously
28. Choice Of Instrument
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The choice of instrument is determined by level
of training with the various forceps and vacuum
equipment.
Factors that might influence choice are
The availability of the instrument,
The degree of maternal anesthesia, and
Knowledge of the risks and benefits associated
with each instrument.
29. Advantages Over Vacuum
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Fast
Active rotation possible
Traction independent of contraction
Also used in after coming head of breech
Can be used for preterm
Less fetal trauma
Less failure to effect delivery
30. summary
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Advantages of forceps Advantages of ventouse
•Can be applied in
malpresentations – face and
after coming head in breech
•Faster application, traction
and delivery time in fetal
distress
•Less fetal trauma compared
to forceps
•Safer than vacuum for the
preterm fetus
•Can be applied at higher station (
station 0 and lower) ;
•can be applied at even higher
station in cases of second twin
•No need for active rotation; rotation
can spontaneously occur as traction
proceeds
•Risk of maternal injury lower
compared to forceps
•Relatively easier to train and
acquire skill for application
compared to forceps
31. Destructive Delivery/ Reductive
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For obstructed labour with a dead fetus a
destructive operation is usually, but not always,
better than CS
Operation designed to reduce the bulk of the fetus
to allow easy passage through the birth canal
It may done in dead fetus and
Cephalic presentation with normal or
hydrocephalic head
Breech delivery after coming head has stuck
Transverse lie with prolapsed arm
32. Destructive Delivery(Reductive)
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Advantages over CS
Can be done in a health center( fewer
instruments and less anesthesia needed)
Leaves an intact uterus (no fear of rupture in
subsequent pregnancies)
Less spread of infection to the peritoneum
Less risk of hemorrhage
Easy recovery
33. Types
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1. Craniotomy: by opening the fetal skull with large
scissors or special perforator and remove the
brain.
Prerequisites
Dead fetus or hydrocephalus with CPD
Engaged/Impacted fetal head
Cervix at least 7 cm dilated/ preferably fully cx
Uterus not ruptured/ no sign of imminent uterine rupture
Technique
Perforation of the fetal skull using Simpson’s perforator
Evacuation of the content
Delivering the fetus with Cranio clast
34. 2. Decapitation
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Decapitation: separate the neck from the body
Indication
Transverse lie with neck accessible
Locked twins
Prerequisites
Dead fetus
Fully dilated cervix
Uterus not in imminent danger of rupture
Technique
Separation of the fetal head from the trunk
Extraction per vaginam of the trunk & the head
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3.Evisceration/Embryotomy
• Open the trunk and
removed the organs from
the chest and abdomen
Indication: Obstruction
due to large trunk and
Transverse lie where
head is not reachable
Technique: Opening the
abdomen/ thorax
Removal of abdominal/
thoracic contents
4. Cleidotomy: Cut the
clavicles
Indication: Shoulder
dystocia with dead fetus
Technique: Dividing the
clavicles using scissors
36. Pre and postoperative care
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Preoperative care
Confirming diagnosis
Hgb, Blood group & Rh
Analgesia / Anesthesia
Antibiotics
Emptying the bladder
Post operative care
•Active management
of 3rd stage
•Uterine lower
genital tract
exploration
•Catheterization for
5-10 days
37. Cesarean section
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Cesarean delivery (also called cesarean
section and cesarean birth) refers to the
delivery of a baby through surgical incisions
in the abdomen and uterus after 28 wks of
gestation.
The cesarean delivery rate worldwide is about 15
percent of births.
The mean cesarean delivery rate in developed
countries is 21.1 percent, but only 2 percent in the
least developed countries.
38. Indication
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The four most common indications for CS account
for approximately 80 % of these deliveries:
Failure to progress during labor (30 %)
Previous hysterotomy (usually related to cesarean
delivery, but also related to myomectomy or other
uterine surgery) (30 percent)
Nonreassuring fetal status (10 percent)
Fetal malpresentation (11 percent)
39. Indication
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Additional, less common indications for CS:
Abnormal placentation (PP, vasa previa, placenta
accreta)
Maternal infection (eg, herpes simplex or HIV)
Multiple gestation
Funic presentation or cord prolapse
Macrosomia
Mechanical obstruction to vaginal birth (large
leiomyoma or condyloma acuminata, severely
displaced pelvic fracture, fetal anomalies)
40. Operative Procedure
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Preoperative preparation
• Assessment of fetal maturity
• Anesthesiology consultation
• Maternal preparation: NPO, consent, catheter,
antacid, and v/s
• Laboratory testing
• Fetal heart rate monitoring ; The fetal heart rate
should be documented prior to cesarean delivery.
• Fetal presentation and placental location
• Bladder catheterization
42. Abdominal incision
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Transverse (Pfannenstiel) or Joel-Cohen incision is
most commonly used for cesarean delivery since it is
associated with
less postoperative pain,
greater wound strength, and
better cosmetic results than the vertical midline
incision .
However, vertical incisions generally allow faster
abdominal entry, cause less bleeding and nerve injury,
and can be easily extended cephalad if more space is
required for access.
43. …..
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Uterine incision
Low transverse incision
Classic incision
Low vertical incision
Others
Delivery of the fetus
Placental expulsion
Manual Vs spontaneous
Repair of uterine incision
Abdominal closure
44. Post Operative Care
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Analgesia
Ambulation
Oral intake
Bladder management
Fluid intake
Wound care
Lab studies
Length of stay
Discharge management
