Instrumental delivery

1. INSTRUMENTAL DELIVERIES
seminar
By - Suraj Abdella
- Tewodros Sileshi
- Tinsae Yihune
- Tomas Beyene
Moderators
Dr. Negassie

3. Out line
• Introduction to instrumental deliveries
• Forceps delivery
• Vacuum extraction
• Destructive deliveries

4. Introduction
Definition
• Operative vaginal delivery (OVD) is birth
accomplished with assistance from forceps or
a vacuum-cup device.
• vacuum-to-forceps delivery ratio
approximates 4:1
• are applied to the fetal head, outward traction
generates forces that augment maternal
pushing to deliver the fetus.

5. • Helps us determine and control maternal and
fetal outcome
• Main idea is to hasten the delivery when the
labor is obstructed or prolonged labor and
fetal compromise is suspected
• These deliveries carry a risk of trauma and
we perform them when use of the procedures
outweigh the possible harm of the devices.
• There are safety rules on application of the
instruments

6. Prerequisites of operative deliveries
• Engaged head
• Experienced operator
• No fetal coagulopathy
• Vertex presentation
• Ruptured membranes
• No fetal demineralization
disorder
• Known fetal head position
• Completely dilated cervix
• Informed consent
• CPD not suspected
• Adequate anesthesia
• Willingness to abandon
OVD
• Fetal weight estimated
• Emptied maternal bladder

7. Complications of OVD
Maternal
• Lacerations
 Perineal, vaginal wall, cervical tear
• Infection and Subsequent-pregnancy
Morbidity
• Pelvic Floor Disorders

8. Perinatal
• Cephalohematoma
• Subgaleal hemorrhage
• Retinal hemorrhage
• Jaundice 20 to
hemorrhage
• Clavicular fracture
• Scalp lacerations
• Shoulder dystocia
• Facial nerve injury
• Brachial plexus injury
• Depressed skull fracture
• Corneal abrasion

9. Forceps Delivery
• Forceps is an instrument designed to
assist the delivery of the baby`s head.
• The primary function of forceps is to
assist traction of the fetal head and to
assist rotation of the fetal head to a
desirable position.

10. • Basically consists of two crossing branches
and each branch has five components
1. blade (consists of toe and heal)
2. shank
3. Lock (Sliding, English, Pivot)
4. Handle
5. Finger guard

11. Types
• More than 600
Most common types are;
1) Simpson or Elliot forceps
2) Kielland or Tucker Mclane
3) Piper forceps

12. Function of Forceps
• The most important function = Traction,
• may also be valuable in = Rotation, (OT &OP)
• Compression

13. • Each blade has two curves :-
 The cephalic curve conforms to the shape of
the fetal head, and
 The pelvic curve corresponds more or less to
the axis of the birth canal
• Some varieties are
 Fenestrated: most commonly used
 Solid
 Pseudo-fenestrated to permit a firmer hold on
the fetal head.

14. Classification
A. Outlet forceps
1. Scalp is visible at the introits without
separating the labia
2. Fetal skull has reached pelvic floor
3. Sagittal suture is in anteroposterior
diameter or right or left anterior
transverse
4. Fetal head is at or on perineum
NB. Rotation does not exceed 45 degrees

15. B. Low forceps
• Leading point of fetal skull is at station >+2 cm,
and not on the pelvic floor
• Rotation is 45 degrees or less, or
• Rotation is greater than 45 degree
C. Mid forceps
• Station is between 0 and +2 cm.
D. High Forceps
•Station is above 0.
•Is obsolete nowadays

16. Prerequisites to be candidate for
forceps delivery
1. Complete cervical dilation.
2. Ruptured membranes.
3. Vertex presentation.
4. Fetal head engaged.
5. Empty bladder.
6. No evidence of CPD.
7. Adequate analgesia.
8. Cesarean section capability.
9. An experienced operator.

17. Indications for forceps delivery
• Non reassuring fetal heart rate pattern.
• Shortening of the second stage of labor.
• Delivery of the after coming head after breech
presentation.
• Prolonged second stage of labor

18. Contraindications for forceps
delivery
Are related to the potential for unacceptable fetal
risks.
• Known fetal demineralizing diseases (eg,
osteogenesis imperfecta),
• Fetal bleeding diatheses (eg, hemophilia,
alloimmune thrombocytopenia),
• Unengaged head,
• Unknown fetal position,
• Malpresentation (eg, brow, face), and
• Suspected fetal-pelvic disproportion

19. Preparation
• Dorsal lithotomy position
• Legs comfortably placed in stirrups with hips flexed and
abducted
• Abdomen and legs adequately draped
• Vagina and perineum should be prepared
• Spinal /epidural anesthesia prior to the foregoing step in
delivery.
• Pudendal block/local infiltration, after the preliminary
examination
• Adequate and effective anesthetics

20. Forceps application
1. Insert two fingers of right hand into the vagina
on the side of the fetal head. Slide the left blade
gently between the head and fingers to rest on
the side of the head.
2. Repeat the same maneuver on the other side
using
the left hand and the right blade of the forceps.
3. Depress the handles and lock the forceps.
If forceps locks easily do the three checks

21. 4.After locking, apply steady traction inferiorly and
posteriorly with each contraction. Ask the mother to
push
with each contraction.
5. Between contractions check:
-fetal heart rate
-application of forceps
6. When the head crowns make an adequate episiotomy.
the head should descend with each pull only two or
three
pulls should be necessary.

22. 7. Perform active management of the third stage of
labor
to deliver the placenta.
8. Check birth canal for tears following child birth
and
repair, if necessary.
9. Repair the episiotomy.

23. Failed forceps
• fetal head does not advance with each pull.
• the fetus is undelivered after three pulls or after 30
minutes.
• Every application should be considered a trial of
forceps.
• Do not persist if the head does not descend.
• Failure-perform cesarean section

24. Complications
Maternal complications
▪ Lacerations of the vagina
and cervix
▪ Episiotomy extension
▪ Pelvic hematomas
▪ Urethral and bladder
injuries
▪ Uterine rupture
▪ Blood loss
Fetal complications
▪ minor facial lacerations
▪ Forceps marks
▪ Brachial plexus palsies
▪ Cephalohematomas
▪ Skull fractures
▪ Intracranial hemorrhage

25. The advantages of forceps over
vacuum
➢ Are unlikely to detach from the head,
➢ May be used for a rotation,
➢ Result in less cephalohematoma and
retinal hemorrhage,

26. Vacuum Extraction (Ventouse)
• It is an instrumental device designed to assist
delivery by creating a vacuum between it and the
fetal scalp
• Vacuum delivery is an assisted instrumental
vaginal delivery using vacuum extractor(ventouse)

27. INDICATIONS
• Prolonged second stage of labor.
• Non reassuring fetal heart rate pattern.
• To shorten second stage in eclampsia,
significant cardiac or pulmonary disease and
cerebrovascular disease (e. g. CNS
aneurysms).
• Cord prolapse in 2nd stage of labour where
vaginal delivery is believed to be faster than
CS.

28. Contraindications
• Operator inexperience
• Inability to assess fetal position
• High station(above 0 station)
• Suspicion of cephalopelvic disproportion
• Other presentations otherthan vertex.
• Premature fetus(<34 weeks).
• Intact membranes.

29. Pre-requisites of the Procedure
• Vertex presentation
• Fully dilated cervix
• Engaged head: station at 0 and below
• Ruptured membranes
• Gestational age 34 weeks and above
• Adequate pelvis
• No contraindication to vaginal delivery

30. Application of the cup
• Identification of the flexion point-
-It is situated 3 cm in front of the posterior fontanelle.
-Centre of the cup should be overlying the flexion
point. This placement promotes flexion ,descent and
autorotation.
• If traction is directed from this point the fetal head is
flexed to the narrowest sub-occipitobregmatic
diameter(9.5 cm).

31. Creating the negative pressure
• When using the rigid cups, the negative pressure is
gradually increased by 0.2 kg/cm2 every 2 minutes
until - 0.8 kg/cm2 is attained. This creates an
artificial caput within the cup.
• With soft cups negative pressure can be increased
to 0.8 kg/cm2 over as little as 1 minute

32. Traction
• Traction should be intermittent and co- ordinated
with maternal expulsive efforts and with uterine
contractions.
• Traction should be in line of the pelvic axis and
perpendicular to the plane of the cup.
• Between contractions, check the fetal heart beat
and cup application

33. Traction

34. Failure of vacuum
• Vacuum extraction is considered failed if-
-fetal head does not advance with each pull
-fetus is undelivered after 3 pulls with no descent or
after 30 minutes
-cup slips off the head twice at the proper direction of
pull with the maximum negative pressure.
NB: If vacuum delivery fails, the fetus should be
delivered by Cesarean section.

35. Complications
Maternal
Perineal, vaginal ,labial, periurethral and cervical
lacerations.
Annular detachment of the cervix when applied with
incompletely dilated cervix.
Cervical incompetence and future prolapse if used with
incompletely dilated cervix.

36. Complications
Fetal
• Cephalohaematoma.
• Scalp lacerations and bruising
• Subgaleal hematomas
• Intracranial haemorrhage.
• Fetal death

37. Destructive vaginal deliveries
(embryotomies)
• refer to reductive surgical procedures performed
on the dead fetus in utero to reduce its size or
otherwise aid in making vaginal delivery possible
• They are aimed at reducing the size of the head,
shoulder girdle or body of the fetus to permit the
passage through the maternal pelvis and birth
canal

38. • Embryotomies aid in avoiding a caesarean delivery
in mothers with dead fetuses and a setting in which
the risk of serious infectious postoperative
morbidity is highly likely

39. Types of Destructive Vaginal
Deliveries
• Craniotomy
• Decapitation
• Evisceration
• Cleidotomy
• Encephalocentesis
• Spondylotomy

40. Indications
• Dead fetus with mechanical obstruction
• Alive/dead fetus with shoulder dystocia not
amenable to known maneuvers (Cleidotomy)
• Alive fetus with hydrocephalus with mechanical
obstruction and minimal brain tissue

41. Prerequisites
• Fully dilated cervix
• Dead fetus – confirmed by three separate providers auscultations
for FHB or Sonography whenever available
• Station > 0
• No imminent uterine rupture
• Experienced operator
• Back up operative facilities
• Adequate analgesia/anesthesia
• Indwelling bladder drainage for 5-7 days
• Antibiotic administration
• Hgb and cross match

42. Contraindications
• Imminent uterine rupture
• Suspected/diagnosed uterine rupture
• Inexperienced operator
• Inaccessible fetal presentation (per vaginum)

43. Preparation
• Consent of the patient
• Rh , blood group
• Start IV line with crystalloid
• Adequate anesthesia
• Confirm position and presentation of the fetus
• Indwelling bladder drainage

44. Craniotomy
Indications
• Obstructed labor with a vertex, face and arrested
aftercoming head
Procedure
• Scalp held with tissue forceps, incised with scissors and skull
perforated through a suture or the eyeballs in face
presentations and brain tissue drained and the collapsed
skull held with bone forceps and removed by traction.

45. Decapitation
Indications
• Obstructed labor in a shoulder presentation with or
without hand prolapse
Procedure
• The neck is identified on vaginal exam and
decapitated either with a decapitating hook or saw.
The trunk and head are then delivered separately.

46. Evisceration
Indications
• Obstructed labor in a shoulder presentation with or
without hand prolapse
Procedure
• The ribs are identified below the scapula and
thoracotomy performed and thoracic contents and
abdominal contents removed through the fetal
diaphragm. The reduction will bring the neck down
and make it accessible for decapitation and delivery.

47. Cleidotomy
Indications
• Shoulder dystocia where the usual maneuvers have
failed to deliver the fetus
Procedure
• The clavicle is identified by palpation and fractured
either through the pressure of the thumb or by
scissors after incising the covering skin.

48. Encephalocentesis
Indications
• Hydrocephalus with obstructed labor and minimal brain
tissue on sonography indicating poor extra uterine chance
of survival
Procedure
• Transabdominal or Transvaginal needle aspiration of
cerebrospinal fluid through the skull along the sutures.
Encephalocentesis may not necessarily kill the fetus but is
for practical purposes regarded as a fatal procedure for the
fetus.

49. Spondylotomy
• CSF can be drained by opening the spinal canal If
the fetus has spina-bifida, the draining may be
achieved by reaching the cranium through the
defect and spinal cord.

50. Complications of destructive vaginal
deliveries
• Trauma to birth canal
• PPH secondary to atonic uteruses & genital trauma
• Vesicovaginal and rectovaginal fistula
• Puerperal sepsis :- endomyometritis, UTI
• Injury to adjacent organs-VVF, UVF or RVF

51. Postoperative care
• Explore uterovaginal canal for any lacerations or
trauma
• Keep self retaining catheter in the bladder for 4-5
days
• Consider IV line or blood transfusion
• Correct dehydration or hypovolemia
• Cover with double or broad-spectrum antibiotics

52. THANK YOU