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  1. 1. Operative Vaginal Delivery District 1 ACOG Medical Student Teaching Module 2009
  2. 2. <ul><li>What: Direct traction on the fetal head with forceps or vacuum </li></ul><ul><li>Why: Indications for vacuum and forceps are the same (see next slide) </li></ul>
  3. 3. Indications <ul><li>Maternal benefit </li></ul><ul><ul><li>Example: certain maternal cardiac conditions (Eisenmenger’s, pulmonary HTN) or history of aneurysm/stroke </li></ul></ul><ul><li>Concern for immediate/potential fetal compromise </li></ul><ul><ul><li>Example: prolonged terminal bradycardia </li></ul></ul><ul><li>Prolonged 2 nd stage </li></ul><ul><ul><li>Nulliparous – no progress for 3 hrs w/epidural or 2 hours w/o epidural </li></ul></ul><ul><ul><li>Multiparous – no progress for 2 hrs w/epidural or 1 hr w/o epidural </li></ul></ul>
  4. 4. What Do I Need To Know Before Attempting an Operative Delivery? <ul><li>Presentation (Cephalic/Breech) </li></ul><ul><li>Position (i.e. occiput posterior, sacrum anterior) </li></ul><ul><li>Lie (longitudinal, oblique, transverse) </li></ul><ul><li>Station </li></ul><ul><li>Presence of asyncliticism </li></ul><ul><li>Clinical pelvimetry </li></ul><ul><li>Anesthesia </li></ul>
  5. 5. Contraindications <ul><li>GA < 34 weeks (contraindication for vacuum due to risk of fetal IVH) </li></ul><ul><li>Known bone demineralization condition (e.g. osteogenesis imperfecta) or bleeding disorder e.g. VWD) </li></ul><ul><li>Fetal head unengaged </li></ul><ul><li>Position of fetal head unknown </li></ul>
  6. 6. Vacuum-Assisted Vaginal Delivery <ul><li>Do not apply rocking motion or torque, only steady traction in the line of the birth canal </li></ul><ul><li>Stop after: three “pop-offs” of vacuum, > 20 minutes elapsed, three pulls with no progress </li></ul>
  7. 7. After determining position of the head, (A) insert the cup into the vaginal vault, ensuring that no maternal tissues are trapped by the cup . (B) Apply the cup to the flexion point 3 cm in front of the posterior fontanel, centering the sagittal suture . (C) Pull during a contraction with a steady motion, keeping the device at right angles to the plane of the cup . In occipitoposterior deliveries, maintain the right angle if the fetal head rotates. (D) Remove the cup when the fetal jaw is reachable
  8. 8. Fetal Risks: VAVD <ul><li>Scalp lacerations: if torsion excessive </li></ul><ul><li>Cephalohematoma: limited to suture line </li></ul><ul><li>Subgaleal hematoma: crosses suture line </li></ul><ul><li>Intracranial/retinal hemorrhage </li></ul><ul><li>Hyperbilirubinemia/jaundice </li></ul><ul><li>Higher incidence of cephalohematoma/retinal hemorrhage/jaundice compared to forceps </li></ul>Designed to detach if traction is excessive (but can produce traction up to 50 lbs) 5% incidence serious complications
  9. 9. Type of Forceps Delivery <ul><li>Outlet forceps </li></ul><ul><ul><li>scalp visible at introitus w/o separating labia </li></ul></ul><ul><ul><li>fetal skull reached pelvic floor & head at/on perineum </li></ul></ul><ul><ul><li>sagittal suture in AP diameter or LOA, ROA, or posterior position </li></ul></ul><ul><ul><li>rotation does not exceed 45º </li></ul></ul><ul><li>Low forceps </li></ul><ul><ul><li>leading point of fetal skull at >= +2, not on pelvic floor </li></ul></ul><ul><ul><li>rotation 45º or less (LOA/ROA to OA, or LOP/ROP to OP); or rotation greater than 45º. </li></ul></ul><ul><li>Midforceps </li></ul><ul><ul><li>above +2 cm but head engaged </li></ul></ul><ul><li>High forceps </li></ul><ul><ul><li>head not engaged; not included in ACOG classification </li></ul></ul><ul><ul><li>not recommended </li></ul></ul>
  10. 10. Forceps-Assisted Vaginal Delivery <ul><li>Identify & apply blades </li></ul><ul><ul><li>Place instrument in front of pelvis with tip pointing up & pelvic curve forward </li></ul></ul><ul><ul><li>Apply left blade, guided by right hand, then right blade with left hand </li></ul></ul><ul><li>Lock blades </li></ul><ul><ul><li>Should articulate with ease </li></ul></ul>
  11. 11. FAVD <ul><li>Check for correct application </li></ul><ul><ul><li>Sagittal suture in midline of shanks </li></ul></ul><ul><ul><li>Cannot place more than one fingertip between blade and fetal head </li></ul></ul><ul><li>Apply traction </li></ul><ul><ul><li>Steady, intermittent </li></ul></ul><ul><ul><li>Downward, then upward </li></ul></ul><ul><ul><li>Remove blades </li></ul></ul>
  12. 13. Risks: Forceps <ul><li>Maternal- </li></ul><ul><ul><li>Injury (extension of episiotomy, vaginal/cervical lac) </li></ul></ul><ul><ul><li>Postpartum hemorrhage </li></ul></ul><ul><li>Fetal- </li></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><ul><li>Intracranial haemorrhage. </li></ul></ul></ul><ul><ul><ul><li>Cephalic haematoma. </li></ul></ul></ul><ul><ul><ul><li>Facial / Brachial palsy. </li></ul></ul></ul><ul><ul><ul><li>Injury to the soft tissues of face & forehead. </li></ul></ul></ul><ul><ul><ul><li>Skull fracture </li></ul></ul></ul>
  13. 14. Use of Alternative Instruments <ul><li>Highest risk for injury is for combined forceps/vacuum extraction or cesarean delivery after failed operative delivery </li></ul><ul><li>The weight of available evidence is against multiple efforts with different instruments </li></ul>