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Instrumental deliveries
- 1. INSTRUMENTAL DELIVERIES Prof. M.C.Bansal MBBS,MS,MICOG,FICOG Professor OBGY Ex-Principal & Controller Jhalawar Medical College & Hospital Mahatma Gandhi Medical College, Jaipur.
- 3. INDICATIONS MATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary disease FETAL Failure of the fetal head to rotate Fetal distress Should not be used for preterm, face presentation or breech
- 4. MNEMONIC A – Anesthesia adequate appropriate positioning & access B – Bladder cathterization C – Cervix fully dilated / membranes ruptured D – Determine position, station, pelvic adequacy E – Equipment inspect vacuum cup, pump, tubing, check pressure
- 5. MNEMONIC F – Fontanelle position the cup over the posterior fontan -ve pressure ↑ 10 cm H2O initially & between cont sweep finger around cup to clear maternal tissue ↑ pressure to 60 cm H2O with the next contraction G – Gentle traction pull with contractions only traction in the axis of the birth canal ask the mother to push during cont
- 6. MNEMONIC H – Halt halt traction if no progress with three traction aided contractions vacuum pops off three times pulling for 30 min without significant progress I – Incision consider episiotomy if laceration imminent J – Jaw remove vacuum when jaw is reachable or delivery assured
- 7. COMPLICATIONS Vacuum –assisted delivery is less traumatic to the mother & fetus than forceps Ventouse should be the instrument of choice Maternal Vaginal laceration due to entrapment of vaginal mucosa between suction cup & fetal head
- 8. FETAL COMPLICATIONS Scalp injuries chignon abrasion & lacerations 12.6% scalp necrosis 0.25-1.8% Cephalohematoma 25% jaundice /anemia Intracranial hemorrhage 2.5% Subgaleal hematoma
- 9. FETAL COMPLICATIONS Birth asphyxia 2.6-12% related to extraction force & time Some studies showed decrease birth asphyxia Retinal hemorrhage 50% Forceps 31% SVD 19% Neonatal jaundice
- 10. FETAL COMPLICATIONS Fetal mortality 15/1000 Lower in cases delivered by vacuum 1.9%/ forceps 5.2 % No long term effects on neurological psychomotor or intellectual development up to 4 years of age
- 11. FORCEPS
- 12. INDICATIONS MATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary disease FETAL Failure of the fetal head to rotate Fetal distress Control of the fetal head in vaginal beech delivery
- 13. CLASSIFICATION OF FORCEPS DELIVERY Outlet forceps Scalp visible at the vulva without separating the labia Low forceps Vertex at +2 station Midforceps Head is engaged but leading part above +2 station Sagittal suture not in the AP plane of the mother
- 14. CLASSIFICATION OF FORCEPS DELIVERY Outlet Wrigley’s Outlet & low forceps Simpson /Elliot Midforceps & outlet Tucker Mclane Midforceps & rotation Kielland After coming head in breech Piper
- 15. MNEMONIC A – Anesthesia adequate /epidural or pudendal appropriate positioning & access B – Bladder cathterization C – Cervix fully dilated / membranes ruptured D – Determine position, station, pelvic adequacy E – Equipment complete working forceps anesthesia support
- 16. MNEMONIC F – Forceps phantom application Lt blade , LT hand, maternal Lt side pencil grip & vertical insertion with Rt thumb directing blade Rt blade , RT hand, maternal Rt side pencil grip & vertical insertion with Lt thumb directing blade Lock blades
- 17. MNEMONIC Check application: Post fontanelle 1cm above the plane of the shanks Sagittal suture lies in the midline of the shanks /perpindicular to the plane of the shanks The operator can not place more than a fingertip between the fenestration of the blade & the fetal head on either side
- 18. MNEMONIC G – Gentle traction applied with contraction & maternal expulsive efforts H – Handle elevated traction in the axis of the birth canal do not elevate handle to early I – Incision consider episiotomy if laceration imminent J – Jaw remove forceps when jaw is reachable or delivery assured
- 19. COMPLICATIONS Maternal trauma to soft tissue 3rd/4th degree double the risk compared to ventouse bleeding from lacerations trauma to urethra & bladder fistula Pain 17% ventouse 11%
- 20. COMPLICATIONS Fetal bruising & laceration to the face Injury to the fetal scalp cephalohematoma 9% Vent 25% retinal hemorrhage 30% Vent 50% skull fracture permanent nerve damage / Facial nerve The risk of shoulder dystocia is increased following instrumental deliveries
Editor's Notes
- Instrumental deliveries 1-Indications for instrumental deliveries include T1-Prolonged 2 nd stage T2-Fetal distress F3-Transverse lie F4-Compound presentation T5-Maternal cardiac disease
- 2-Prerequisite for instrumental delivery include T1-Cervix must be fully dilated T2-Membranes ruptured F3-Fetal head not engaged F4-Obstetrician unsure about position of the fetal head due to caput T5- Bladder empty/ cathetrized
- 3-Complications of ventouse delivery F1-Ventouse causes 3 rd & 4 th degree perineal tears more frequent than forceps F2-Long term effects on neurological & intellectual development of children delivered by ventouse are evident by 4 years of age T3-Cephalohematoma occur in up to 25% of babies T4-Birth asphyxia is related to the force of traction & prolonged procedure (time from application of vacuum until delivery) T5-Cephalohematomas may result in jaundice & anemia of the neoborne
- 4-Forceps T1-can be applied to the after coming head in assisted vaginal breech delivery T2-Can be applied to face presentation T3-It is not contraindicated for preterm fetuses T4-Can result in facial nerve damage of the fetus T5-Is associated with a higher fetal mortality than ventouse