2. Operative vaginal delivery
Operative vaginal birth refers to a birth in
which the operator uses forceps , a
vacuum device, or another instrument to
extract the fetus from the vagina, with or
without the assistance of maternal pushing
3. Indication
Fetal
1 fetal distress
2 after coming head of
breech
3 suspicion of fetal
compromise
Maternal
1. Prolonged second stage of labour
( nulliparous 2 hours, multiparous 1 hour)
2. Exhaustion /distress
3. Medical indications to shorten second
stage(severe PE , cardiac disease , post
cesarean)
4. When expulsive efforts are to be
avoided( cerebrovascular disease, cardiac
disease, spinal cord injuries)
8. History
• The Chamberlens were innovators, opportunists and entrepreneurs of forceps.
• In fact, the instrument was kept secret for 150 years by the Chamberlen family,
although there is evidence for its presence as far back as 1634.
• Models derived from the Chamberlen instrument finally appeared gradually in England
and Scotland in 1735. About 100 years after the invention of the forceps by Peter
Chamberlen Sr. a surgeon by the name of Jean Palfyn presented his obstetric forceps
to the Paris Academy of Sciences in 1723.
• • They contained parallel blades and were called the Hands of Palfyn.
9. • Tarnier's idea was to "split" mechanically the grabbing of the fetal head
(between the forceps blades) on which the operator does not intervene after
their correct positioning, from a mechanical accessory set on the forceps
itself, the "tractor" on which the operator exercises traction needed to pull
down the fetal head in the correct axis of the pelvic excavation.
• Tarnier forceps (and its multiple derivatives under other names) remained the
most widely used system in the world until the development of the cesarean
section
12. Classification of operative vaginal delivery
Outlet
• Fetal scalp visible without separating the labia
• Fetal skull has reached the pelvic floor
• Sagittal suture is in the anterio-posterior diameter or right or left occiput anterior
or posterior position (rotation does not exceed 45)
• Fetal head is at or on the perineum
13. Low
• Leading point of the skull (not caput) is at station plus 2 or more and not on the pelvic
floor
• Two subdivisions:
• rotation of 45° or less from the occipito-anterior position
• rotation of more than 45° including the octipito-posterior position
14. Mid
• Fetal head is no more than 1/sth palpable per abdomen
• Leading point of the skull is above station plus 2 but not above the ischial spines
• Two subdivisions:
• rotation of 45° or less from the occipito-anterior position
• rotation of more than 45° including the occipito-posterior position
15. High
• Not included in the classification as operative vaginal delivery is not recommended in
this situation where the head is 2/5th or more
• palpable abdominally and the presenting part is above the level of the ischial spines
19. Relative
• unfavourable attitude of fetal head
• rotation >45° from occiput anterior or occiput posterior (vacuum)
• mid-pelvic station
• fetal prematurity
20. Preparation
• Team preparation
• Confirm consent
• Ensure adequate space for operator to sit or kneel
• Check swabs , instruments and other essential equipments
• Ensure adequate analgesia
• Patient position
• Careful clinical assessment
21. Procedure
• Assemble the forceps
• Application of blades
• Checking the application
• Traction
• Removal
28. Application of blades in LOA &ROA
• INSERTION OF BLADES REMAINING SAME
• IT SHOULD BE ENSURED BLADES REMAIN PARALLEL TO FETAL SAGITTAL
SUTURE
• ROTATION FROM LOA/ROA TO DOA can be achieved prior to traction
• Handle should be elevatedbt 30 to 40 degree ( towards 1 o’clock to 2 o’clock position
in LOA and 10 o’clock to 11o’clock position in ROA)
• Gentle rotation should be given between the contractions
31. Forceps for after coming head of breech
• Indications
• Prophylactic i.e. to prevent sudden compression and decompression of after coming
head
• Arrest of after coming head
• Different forceps which can be used
• Long Pipers forceps
• Simpsons long forceps
• Kielland's forceps
34. Failed operative delivery
• Forceps do not lock
• Forceps slip after application
• While effecting rotation only blades rotate
• Extraction is not possible
• •There is morbidity to motality to fetus and mother
• • Application before full dilatation of cervix
• • Gross Cephalopelvic Disproportion
• • DTA
• • Undiagnosed hydrocephalus
• • Contraction ring grasping the fetus
40. History
• • James Young Simpsom devised double valved piston with a metal cup - like a breast
pump
• Tage Malmstorm in 1953 described the most successful model
• Pelosi, Apuzzio introduced Sialistic Cup with metal traction
41. Types of vaccum
• Malmstorms Vacuum Extractor
Parts
Metal Cup with Plates (3.4.5.6 mm)
Traction Chain attached to the plate
• Traction Handle
Pressure rubber tube which encloses the traction chain
Vacuum Bottle with pressure gauge
• Vacuum pump
• Bird's Modification -
In this Vacuum tube is attached to the opening near periphery of
the cup and the traction chain to the hook in the cere of the cup
Flat metal plate and the pin have been discarded
42.
43. • Soft Cup -Bell shaped 6.5 mm. Produces symmetric, less cosmetic alarming caput
succundaneum and less scalp abrasion
• • Silastic Cups - Pliable, softer, less traumatic and safer. Described by Koyabashi
• Plastic Cups (Mityvac) - Consists of disposable plastic cup and handle, suction tube
and hand pump. It builds pressure quickly and can be used evn in the absence of
electricity.
44. Type of cup application
• Flexing Median
• Flexing Paramedian
• Deflexing Median
• Deflexing Paramedian
45.
46.
47. • Shortening second stage of labour
• Maternal Exhaustion
• Presumed fetal distress
• Occipito- Posterior position
• To deliver second twin if head is presenting part
INDICATIONS
48. CONTRADICATION
Absolute
• Operator inexperience
• Inability to properly attach
• Inadequate trial of Labour
• High fetal head
• Malpositions
• Aftercoming head of breech
• Known fetal coagulation defect
Relative
-
• Prematurity
• Intrauterine fetal Demise
• Congenital Anomalies
• 'Prior Scalp Sampling
49. CHIGNON FORMATION
• A chignon is a temporary swelling left on an infant's head after a ventouse suction cap
has been used to deliver him or her
Chignon in french : a knot of hair that is worn at the back of the head
50. Procedure
• • A proper vacuum extraction depends on
• The accuracy of the cup application
• The traction technique
• Fetal cranial position
• Cup design
• • The feto-pelvic relationship
51. • Patient is in litotomy position
• Written informen consent taken
• Bladder is emptied
• The position ,station and the attitude of the fetal head is verified
• Phantom application is performed before an attempt
52.
53. • Place the cup
• The practitioner spreads the labia and introduces the bell shaped cup by compressing
and inserting it into the vagina while angling the device posteriorly.
• When contact is made with the fetal head, the center of the cup is placed over the
flexion point and symmetrically across the sagittal suture
• After correct placement of the cup is confirmed, vacuum pressure should be raised to
100 to 150 mmHg to maintain the cup's position.
• The edges of the cup should again be swept with a finger to insure that no maternal
tissues are entrapped
Procedure
54. • Apply suction
• Suction pressure is measured in various units: 0.8 kg/cm2 of atmospheric pressure =
600 mmHg = 23.6 inches of Hg = 11.6 Ib/in
• Vacuum suction pressures of 500 to 600 mmH have been recommended during
traction, although pressures in excess of 450 mmHg are rarely necessary
• While lower suction pressures increase the risk of cup "pop-offs," pressures beyond
600 mmHg increase the risks of fetal scalp trauma and cerebral, cranial and scalp
hemorrhage
55. • Exert traction
• The absolute "safe" traction force for vacuum extraction is unknown. In 1962, one
group determined a total traction force of 17.6 kg was typically necessary to affect
delivery
• Traction is applied along the axis of the pelvic curve to guide the fetal vertex, led
by the flexion point, through the birth canal.
• Initially, the angle of traction is downward (toward the floor) the higher the
beginning station, the steeper the angle of downward traction required.
• The axis of traction is then extended upwards to a 45 degree angle to the floor as
the head emerges from the pelvis and crowns
59. Duration
• 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 and/or a maximum total
vacuum application time of 15 to 30 minutes are commonly recommended, with most
authors advising lesser time limits
61. Advantage of ventouse over forceps
• It can be used in unrotated or malrotated head (OP, OT position). It helps in autorotation It is not a space-
occupying device like the forceps blades
• Traction force is less (10 kg) compared to forceps .It is comfortable and has lower rates of maternal trauma
and genital tract lacerations
• Analgesia need is less. Pudendal block with perineal infiltration is adequate but for forceps regional or
general anesthesia is often needed
• Reduced maternal pelvic floor injuries and is advocated as the instrument of first choice.
• Perineal injury (3rd and 4th degree tears) are less compared to forceps
• Postpartum maternal discomfort (pain) are less compared to forceps
• Easier to learn comparing to forceps
• Simplicity of use in delivery makes it convenient to the operator (suitable for trained midwives)
62. Advantage of forceps over ventouse
• In cases, where moderate traction is required, forceps will be more effective compared to ventouse
.Forceps operation can quickly expedite the delivery in case of fetal distress where ventouse will be
unsuitable as it takes longer time
• It is safer at any gestational age baby (even < 36 weeks). The fetal head remains inside the protective cage
• It can be employed in anterior face or in after-coming head of breech presentation, where ventouse is
contraindicated
• Lesser neonatal scalp trauma, retinal hemorrhage, jaundice or cephalhematoma compared to ventouse
• Higher rate of successful vaginal delivery as ventouse has got higher failure rates than forceps
• Cup detachment (Pop-off ) occurs when the vacuum is not maintained in ventouse. No such problems once
forceps blades are correctly applied
• Number of types of forceps (p. 651) are available for outlet, mid-cavity or rotational delivery. Traction
force is more (about 20 kg for a primary and about 13 kg in a multi)
