Instrumental Delivery- Decision is the Ultimate Power: Operative vaginal deliveries are safe in experienced hands. Complications of operative vaginal delivery can be reduced to some extent by education of mother and preparation of staff.

1. Instrumental Delivery
Dr. Padma Shukla
MS, FICOG, FICMCH
Associate Professor
Shyam Shah Medical College, Rewa (M.P.) India

2. Instrumental Delivery-
Decision is the Ultimate Power
 Increased risk of trauma to the baby
 Increased neonatal morbidity
 Increased lower genital tract injury to
mother.
 Increased morbidity in mother.

3.  Obstetrics forceps is a pair of
instruments especially designed for
extraction of the fetal head.
 DeLee Advocated an interventional
approach to entire labour.
 Use of prophylactic forceps
advocated only if the criteria for an
outlet forceps application are met.

4. Ventouse
 Instrumental device designed to
assist delivery by creating a
vacuum between it and fetal head.

5. When to Intervene
Fetal- Presumed fetal compromise
Maternal- Shortan the 2nd stage of labour
 Cardiac disease class III and IV
 Hypertensive crises
 Myesthenia gravis
 Spinal cord injury patient
 Proliferative retinopathy

6. Inadequate Progress
 Nulliparous women - Lack of continuing
progress for 3 hours with regional
anaesthesia, or 2 hours without
anaesthesia
 Multiparous women - lack of continuing
progress for 2 hours with epidural or one
hour without anaesthesia.
 Maternal fatigue / exhaustion.

7. Prerequisites
 Full abdominal and vaginal examination
 Head is 1/5th palpable per abdomen
 Vertex presentation
 Cervix is fully dilated
 Membranes should be ruptured
 Assessment of caput and moulding
 Pelvis is deemed adequate
 Irreducible moulding indicate cephalo pelvic
disproportion

8. Preparation of Mother
 Clear explanation of procedure
 Informed consent
 Appropriate analgesia in mid cavity
deliveries
 Maternal bladder should be emptied
recently
 Remove indwelling catheter

9. Preparation of staff
 Operator must have the knowledge,
experience and skill
 Appropriate equipment, bed, lighting
 Back up plan in place in case of failure
 Anticipation of complications – shoulder
dystocia, PPH
 Trained person in neonatal resuscitation.

10. Classification for operative
vaginal delivery
Outlet
 Fetal scalp visible without separating the
labia
 Fetal skull has reached the pelvic floor
 Sagittal suture is in antero-posterior diameter
or right or left occipito anterior or posterior
position
 Fetal head is at or on the perineum.

11. Low
 Leading point of the skull is at station plus
2cm or more and not on the pelvic floor.
 Rotation of 450 or less from the occipito
anterior position.
 Rotation of more than 450 including the
occipito posterior position.

12. Mid
 Fetal heads no more than 1/5th palpable per
abdomen
 Leading point of the skull is above station
plus 2cm but not above the ischial spines.
High
 Operative vaginal delivery is not
recommended, the head is 2/5 or more
palpable.

13.  No indication is absolute
 A vacuum extractor should not be
used- less than 34 weeks.
 Safety of vacuum extraction - 34
weeks and 36 weeks is uncertain.
 Vacuum extractors are contraindicated
with face presentation.

14. What type of consent?
 Women should be informed in the
antenatal period about operative
vaginal delivery.
 Written consent should be obtained for
trial of operative vaginal delivery.

15.  Operative vaginal births that have a
higher risk of failure should be
conducted in a place where immediate
caesarean section can be done.

16.  Higher rate of failure are associated-
 Maternal body mass index over 30
 Fetal weight over 4 kg
 Occipito posterior position
 Mid cavity delivery or when 1/5 of the
head palpable per abdomen.

17. The operator should-
 Choose the instruments most appropriate
to clinical circumstances and their level of
skill.
 A randomized controlled trial has reported
that symptoms of altered faecal continence
are significantly more common following
forceps delivery compared with vacuum

18.  A five year follow-up randomized
controlled trial did not show any
significant difference in long term
outcome between the two instruments
for either the mother or the child.

19. When should procedure be
abandoned ?
 Operative vaginal delivery should be
abandoned where there is no evidence
of progressive descent with moderate
traction during each contraction.
 When delivery is not imminent following
three contractions of a correctly applied
instrument.

20. Place for sequential use of
instruments
 Use of sequential instruments is
associated with an increased risk of
trauma to the infant.
 Operator must balance the risk of
caesarean section following failed
vacuum extraction with the risk of
forceps delivery following failed vacuum
extraction.

21. Role of episiotomy
 In the absence of evidence to support
routine use of episiotomy in operative
vaginal delivery - restrictive use of
episiotomy, using the operators
judgment is supported.

22. Prophylactic Antibiotic
 Insufficient data to justify the use of
prophylactic antibiotics.
 Good standard of hygiene and aseptic
techniques are recommended.

23. After care following operative
vaginal delivery
 Women should be reassessed for risk factors for
venous thromboembolism
 Regular paracetamol or diclofenac should be
offered.
 The timing and volume of the first void urine
should be monitored and documented.
 Care should be individualized for women who
have sustained a third or fourth degree perineal

24. Conclusion
 Operative vaginal deliveries are safe
in experienced hands.
 Complications of operative vaginal
delivery can be reduced to some
extent by education of mother and
preparation of staff.