Instrumental delivery refers to vaginal birth assisted by forceps or vacuum extraction. Indications for instrumental delivery include suspected fetal compromise, failure to progress in labor, or medical risks that contraindicate prolonged pushing. Operative vaginal delivery requires careful patient evaluation and selection of the appropriate instrument. While instrumental delivery can assist difficult births, both forceps and vacuum extraction carry risks of complications for both mother and baby if not performed correctly. Thorough training and strict adherence to safety guidelines are necessary to minimize risks when providing this intervention.

1. INSTRUMENTAL
DELIVERY
DR. MARIA MURTAZA, DR SUMAIRA ASAF & DR ZAINAB

2. OVD
Operative Vaginal Delivery (OVD) refers to a vaginal birth with the use of any type of forceps or vacuum extractor (ventouse).
The terms instrumental delivery assisted vaginal delivery and OVD are used interchangeably.
Indications: The indications for OVD can be divided into fetal or maternal.
Fetal Suspected fetal compromise, CTG pathological, abnormal pH or lactate on fetal blood sampling, thick
meconium
Maternal Nulliparous Woman- Lack of Continuing progress for 3 hours (total of active & passive second stage of
labour) with regional anesthesia or 2 hours without regional anesthesia.
Multiparous women - lack of continuing progress for 2 hours (total of active & passive second stage of
labour) with regional anesthesia or 1 hours without regional anesthesia.
Maternal exhaustion/vomiting/distress
Medical indications to avoid prolonged pushing or Valsalva (e.g. cardiac disease, hypertensive crisis,
cerebral vascular disease, particularly uncorrected cerebral vascular malformation, myasthenia gravis,
spinal cord injury.

3. Classification of OVD
Contraindications
 A high fetal head two fitth palpable abdominally with station above the ischial spine.
 Ventose should not be used in gestations of less than 34 complted weeks because of risk of cephalohematoma and
intracranial hemorrhage it should not be used for a face or breech presentation.
 Forceps and vacuum extractor deliveries before full dilatation of cervix are contraindicated although possible
exceptions occur (e.g with the vacuum delivery of a second twin where the cervix has contracted somewhat in
interval between delivery of the first and second twin).
Outlet Fetal scalp visible without separating the labia
Fetal skull has reached the pelvic floor
Low Leading point of the skull (not caput) is at station plus 2 cm or more but not on the pelvic
floor. Two sub divisions (a) rotation of 45 degree or less (b) rotation more than 45
High Not appropriate, therefore not included in classification (Station-1 or above)

4. The ventouse compared to forceps is significantly more likely to be associated with
 Failure to achieve a vaginal delivery.
 Cephalohematoma (subperiosteal bleed)
 Retinal hemorrhage
 Maternal worries about the baby.
The ventouse compared to forceps is significantly less likely to be associated with
 Use of maternal regional/general anesthesia
 Significant maternal perineal and vaginal trauma.
 Severe perineal pain at 24 hours.
Evaluation
A thorough abdominal and vaginal examination should take place to confirm the fetal lie, presentation, engagement,
station, position, attitude and degree of caput or moulding. This will confirm whether or not the basic safety criteria
for OVD have been met.

5. Types of Vacuum
A: Metal Cup B: Silicon Rubber Cup C: Omni Cup

6. Analgesia
Analgesic requirements are greater for forceps than for ventouse delivery where rotational forceps or mid pelvic
direct traction forceps are needed regional anesthesia is preferred. For a rigid cup ventouse delivery, a pudendal
block with perineal infiltration may be all that is needed and if a soft cup is used, analgesic requirements may be
limited to perineal infiltration with local anesthetic.
Positioning
OVDs are traditionally performed with the patient in lithotomy position. The angle of traction needed requires that
the bottom part of the bed be removed.
Contingency planning
With any OVD, there is the potential for failure with the chosen instrument and the operation must have a backup
plan for such event. It may be possible to complete a failed vacuum delivery with low-pelvic forceps but failed or
abandoned forceps delivery will almost always result in c-section. With any difficult instrumental delivery the risk of
shoulder dystocia occurring after successful delivery of the fetal head should be considered, as should the potential
for PPH.

7. Technique
Soft vacuum 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 trauma. The soft cups are
appropriate for un complicated deliveries with an osipito-anterior position (0A), metal cups appear to be more
suitable for ocipito-posterior (0P), transverse and potentially difficult OA position deliveries where the infant is larger
or there is marked caput.
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. Center of the cup should be positioned directly over this as failure to do this will lead to a
progressive deflexion of the fetal head during the traction, and inability to deliver the baby safely.
Vacuum pressure for all types of devices between .6 and .8 kg /cm2 .It is prudent to increase the suction to .2kg/ cm2 .
and to recheck that no maternal tissue is caught under the cup edge.
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 degree to the cup and operator should keep a thumb and forefinger on the cup and fetal scalp to ensure
that the traction direction if correct and to feel for the slippage. The safe and gentle traction is than applied
coordinated with urtine contractions and voluntary maternal expulsive effort.

8. There is a descent phase bringing the head onto the perineum usually achieved in at most three pulls. The crowning
phase should occur shortly afterwards and depending on the resistance of the perineum, may occur with one further
pull or some operators prefer to use up to three very small pulls to minimize perineal trauma. With any ventouse, the
operator should allow no more than two episodes of breaking the suction 'pop-offs' in a vacuum delivery and the
maximum time from application to delivery should ideally be less than fifteen minutes.
It 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 CPD
 The operator is inexperienced in the use of the instrument

9. Type of Forceps
• The basic forceps design has not changed radically over many years all type in use today consist of two blades
with shanks, joined together at a lok, with handles to provide a point for traction.
• Non-rotational forceps are used when the head is OA with no more than 45 degree deviation to the left or right
(LOA, ROA).
• If the head is positioned more than 45 degree from the vertical rotation must be accomplished before traction ,
forceps designed for rotation such as kielland forceps, minimal pelvic curve to allow rotation around a fixed axis,
the sliding lock of the kielland forceps facilitate correction of asynclitism.
Kielland’s Rotational Forceps
Simpson Non Rotational Forceps

10. By convention, the left blade is inserted before the right with operator hand protecting vaginal wall from the blade.
With proper placement of the forceps blade, they come to lie parallel to the axis of fetal head and between the fetal
head and the pelvic wall. The operator then articulate and locks the blades, checking their application before
applying traction.
Traction should be applied intermittently, coordinated with the utrine contractions and maternal expulsive efforts.
Axis of tractions changes during the delivery and is guided along the T shape curve of the pelvis. As the head began
to crown the blades are directed to the vertical and the head is delivered.
Majority of the forceps deliveries will be completed in no more than 3 pulls.

11. Maternal Complications:
 The risk of fetal trauma in relation to forceps delivery particularly rotational procedures has been long
established.
 Maternal pelvic floor injuries following OVD
 Cervical tear
 Faecal incontinence
 PPH
Fetal Complications
 Fetal Intracranial hemorrhage
 Cephalo haematomo
 Subgaleal hemorrhage
There is now a growing recognition that vacuum delivery can also be associated with significant morbidity.

12. .