under and post graduate best presentation ever about the assisted vaginal delivery,operative vaginal delivery, or instrumental vaginal delivery. done by waill salan al.timeemi/stager 2014-2015/ Iraq-al.qadisiyyah college of medicine.

1. Operative vaginal delivery

2. operative vaginal delivery refers to
any surgical procedure designed to
expedite vaginal delivery, and
includes episiotomy, forceps
delivery and vacuum extraction.

6. The incidence of instrumental intervention
varies widely both within and between
countries and may be performed as
infrequently as 1.5 per cent, or as often as
26 per cent. These differences are often
related to variations in labour ward
management.

7. In Iraq 42.1% of hospitals
are able to provide assisted
vaginal delivery(*)
(*)http://www.ncbi.nlm.nih.gov/pubmed/19946792 from an article
"Challenges to the provision of emergency obstetric care in Iraq"

9. • The obstetric forceps consists
of 2 matched parts that
articulate, or “lock.” Each
part is composed of a blade,
shank, lock, and handle

10. Classification of forcepses
1.Classic forceps (such as Simpson
forceps), which have a pelvic curvature, a
cephalic curvature, and locking handles.

11. • 2.Rotational forceps (such as Kielland
forceps), which lack a pelvic
curvature and have sliding shanks.

12. • 3.Forceps designed to assist breech
deliveries (such as Piper forceps), which
lack a pelvic curve and have long handles
on which to place the body of the breech
while delivering the head.

14. Maternal & Fetal Indications for Forceps Delivery
• Maternal and fetal indications for forceps delivery
include circumstances in which continuation of the
second stage of labor would constitute a significant
threat to the mother or the baby, as well as those
circumstances in which the mother can no longer
satisfactorily assist in delivering the infant as with
regional anesthesia.

15. A. MATERNAL INDICATIONS
The second stage can be shortened in cases of
exhaustion, severe cardiac or pulmonary problems
accompanied by dyspnea.

16. B. FETAL INDICATIONS
The most common fetal indications are those concerning
malpositions of the fetal head (occipito-transverse and occipito-
posterior). Such positions occur more frequently with regional
anaesthesia as a consequence of alterations in the tone of the
pelvic fl oor that impede spontaneous rotation to the optimal
occipito-anterior position.
occipito-transverse occipito-posterior Normal occipito-anterior position

17. • The primary fetal indication for terminating the
second stage prematurely is fetal heart tones (FHTs)
with a rate persistently less than 100 or more than
160 beats/min, late deceleration patterns, or gross
irregularity.

18. Prerequisites for any instrumental delivery
o The cervix must be fully dilated. (except second twin and rare other
situations).
o The membranes must be ruptured.
o The head must be engaged to a station 0 or below.
o The head must present correctly.
o There must be no significant cephalopelvic disproportion.
o Empty bladder/no obstruction below the fetal head (contracted
pelvis/pelvic kidney/ovarian cyst, etc.).
o Adequate analgesia/anaesthesia.
o A knowledgeable and experienced operator with adequate preparation to
proceed with an alternative approach if necessary.
o An adequately informed and consented patient (consent must be sought
though not necessarily written).

19. FORCEPS DELIVERY: POSITION OCCIPUT ANTERIOR
• Technique
• By convention, the left blade is inserted before the
right with the accoucheur’s hand protecting the
vaginal wall from direct trauma.

20. • The same is performed by right blade

21. • With proper placement of the
forceps blades, they come to
lie parallel to the axis of the
fetal head and between the
fetal head and the pelvic wall.
• The operator then articulates
and locks the blades, checking
their application before
applying traction.

22. • Traction should be applied intermittently in concert
with uterine contractions and maternal expulsive
efforts. The axis of traction changes during the
delivery and is guided along the ‘J’-shaped curve of
the pelvis. As the head begins to crown, the blades
are directed to the vertical, and the head is
delivered.

24. Forceps Delivery in Face Presentation
• If the chin is anterior, the same indications,
conditions, and stipulations apply for forceps delivery
as in the OA position. The classic forceps are applied
to the occipitomental diameter of the head);
elevating the handles as the head advances causes
the chin to come under the symphysis, and the
occiput emerges posteriorly.

25. Forceps Delivery in Brow Presentation
• Some brow presentations convert to an occiput
presentation spontaneously during the first stage of
labor or can be converted to either occiput or face
presentation, in which case labor should be managed
accordingly. If a brow presentation fails to convert to
a favorable position (chin anterior or occipital
presentation) or cannot be converted readily, the
infant must be delivered by cesarean section.

26. Forceps Delivery in breech presentation
• Piper's forceps have a perineal curve to allow
application to the after-coming head in breech
delivery.

28. • The basic premise of such instruments is
that a suction cup, of a silastic or rigid
construction, is connected, via tubing, to a
vacuum source .
• Either directly through the tubing or via a
connecting ‘chain’, direct traction can then
be applied to the presenting part to expedite
delivery.

29. Metal venouse cup;
silicone rubber cup

30. Recent developments have removed the need for cumbersome
external suction generators and have incorporated the vacuum
mechanism into ‘hand-held’ pumps, e.g. OmniCup™.
Such devices appear to be more acceptable to patients than
standard equipment and have no obvious effects on
instrumental delivery success or on the incidenceof maternal
or fetal complications, but large trials have yet to be
performed.

31. Technique
• Soft cups are
significantly more
likely to fail to
achieve vaginal
delivery than rigid
cups, however, they
are associated with
less scalp injury.
There appears to be
no difference in
terms of maternal
injury.

32. • The soft cups are appropriate for
straightforward deliveries with an
occipitoanterior position; metal
cups appear to be more suitable
for ‘occipitoposterior’, transverse
and difficult ‘occipitoanterior’
position deliveries where the
infant is larger or there is a marked
caput.

33. • For successful use of the ventouse, determination of the
flexion point is vital. This is located at the vertex, which, in an
average term infant, is on the saggital suture 3 cm anterior to
the posterior fontanelle and thus 6 cm posterior to the
anterior fontanelle. The centre of the cup should be positioned
directly over this, as failure to do so will lead to a progressive
deflexion of the fetal head during traction, and an inability to
deliver the baby.

34. Ant.
fontanelle
3cm6cm
post.
fontanelle

35. • The operating vacuum pressure for nearly all
ventouse is between 0.6 and 0.8 kg/cm2. It
is prudent to increase the suction to 0.2
kg/cm2 first and then to recheck that no
maternal tissue is caught under the cup
edge. When this is confirmed the suction can
then be increased.

36. • Traction must occur in the plane of least resistance
along the axis of the pelvis – the traction plane.This
will usually be at exactly 90‫؛‬ to the cup and the
operator should keep a thumb and forefinger on the
cup at the traction insertion to ensure that the
traction direction is correct and to feel for slippage.
Safe and gentle traction is then applied in concert
with uterine contractions and voluntary expulsive
efforts. With the ventouse, the operator should
allow no more than two episodes of breaking the
suction in any vacuum delivery, and the maximum
time from application to delivery should ideally be
less than 15 minutes. Rotation is achieved by the
natural progression of the head through the pelvis.

39. is not acceptable to use a ventouse
when:
• The position of the fetal head is unknown.
• There is a significant degree of caput that
may either preclude correct placement of the
cup or, more sinisterly, indicate a substantial
degree of cephalopelvic disproportion.
• The operator is inexperienced in the use of
the instrument.

40. Choice of instruments for assisted
vaginal delivery according to WHO
• For situations in which there is no clear clinical
indication for a specific instrument to facilitate
delivery, the findings of this review support the
use of vacuum extraction as the first-line
method for assisted birth. When a relatively
easy procedure is anticipated, soft-cup vacuum
extraction is indicated. When it is expected that
more traction force may be needed, vacuum
extraction with a metal cup should be the
method of choice, except in women known to
have HIV or hepatitis infection.

41. The ventouse, when compared to the
forceps is signifi cantly more likely to:
• fail to achieve a vaginal delivery;
• be associated with a cephalohaematoma
(subperiosteal bleed);
• be associated with retinal haemorrhage;
• be associated with maternal worries about the baby;
and is signifi cantly less likely to be associated with:
• use of maternal regional/general anaesthesia;
• signifi cant maternal perineal and vaginal trauma;
• severe perineal pain at 24 hours; and is equally likely
to be associated with:
 delivery by Caesarean section;
 low 5 minute Apgar scores.

42. ADDITIONAL NOTES
*Failures can occur when:
1. the choice of instrument is wrong (e.g. a silastic
cup ventouse for a rotationaldelivery),
2. when the positioning of the ventouse cup is wrong
or
3. when the position has been wrongly defined,
leading to inappropriately large diameters
presenting to the pelvis. Failure is also more
common if the fetus is large or maternal effort is
poor.
 the rates of third- and fourth-degree tears are
higher when a second instrument is used.(so failure
of forceps delivery contraindicate the use of
ventouse & vice-versa.

43. Complications of instrumental vaginal delivery
• Maternal deaths have been reported with
vacuum deliveries, associated with cervical
tears in women delivered before full
dilatation.
• Traumatic vaginal delivery is considered the
most important risk factor for faecal
incontinence in women .
• Postpartum haemorrhage is more common
in women needing instrumental vaginal
delivery compared to women who deliver

44. • spontaneously, but less common than in
women delivered by Caesarean section in
the second stage.
• Measures to limit this include:
1. prophylactic syntocinon infusion post
delivery;
2. prompt suturing;
3. careful identifi cation of high tears.

45. • Fetal complications are no less important;
the incidence of cephalhaematoma is
increased with the use of the ventouse, and
there are rare reports of severe intracranial
injuries.

46. References
• CURRENT Obstetric & Gynecologic Diagnosis &
Treatment, 9th Edition
• Ten Teachers, 19E - Kenny, Louise, Baker, Philip N
• Obstetrics & gynecology At a Glance, 4th edition.
• Netters Obstetrics and Gynecology.2nd.Ed
• http://www.ncbi.nlm.nih.gov/pubmed