The document outlines the objectives, methods, and considerations for operative vaginal delivery, comparing the use of forceps and vacuum extraction, including their benefits, risks, and indications. It highlights the importance of operator skill, informed consent, and careful assessment of the maternal and fetal conditions before proceeding. Detailed steps for both delivery methods, along with indications and contraindications, are discussed to ensure safe practices in obstetrics.

1. Operative Vaginal Delivery

2. Objectives
 Compare and contrast the methods available for
operative vaginal delivery including the benefits, risks
and indications for each method.
Describe the mnemonic for the safe use of vacuum and
forceps for operative vaginal delivery.
Describe the appropriate documentation that should be
recorded after every operative vaginal delivery
OVD2

3. Operative Vaginal Delivery
OVD3
 A delivery in which the operator uses forceps / vacuum and
other device to assist the mother during delivery.
 The instrument is applied to the fetal head and then the operator
uses traction to extract the fetus, typically during a contraction
while the mother is pushing.
Vacuum delivery has been increasing while using forceps has
started declining.
The success and safety of these procedures are based upon
operator skill, proper timing, and ensuring that proper
indications are met while contraindications are avoided

4. Introduction….
 Decision to use an instrument to deliver the fetus balances
the maternal, fetal, and neonatal impact of the procedure
against the alternative options of cesarean birth or expectant
management
Purpose is to mimic spontaneous vaginal birth, thereby
expediting delivery with a minimum of maternal or neonatal
morbidity
Operative vaginal delivery rates have remained stable at
between 10% and 13% in UK (Ranges from 1 to 23 percent,
world wide)
OVD4

5. Introduction….
 The choice of instrument should suit both the clinical
circumstances, the skill of the health care provider and
the acceptance of the woman.
The health care provider should have training,
experience and judgmental ability with the instrument
chosen
 Both methods are safe and reliable for assisting
childbirth, if appropriate attention is paid to the
indications and contraindications
 Informed consent is an essential step in preparing for an
operative vaginal deliveryOVD5

6. Choice of instrument
The accoucheur must carefully consider:
The fetal condition
Available resources,
Extent of analgesia
Likelihood of maternal cooperation
Personal skill level when choosing the
instrument for operative vaginal delivery

7. Forceps delivery
OVD7

8. Obstetric forceps
The obstetric forceps are designed to cradle the fetal
head inside the vagina.
Traction is applied during a contraction, with maternal
effort to expediate delivery of the fetus
Assess the alternative methods of delivery—namely,
caesarean section and vacuum extraction.
Forceps deliveries have been replaced by the increased
use of cesarean section.

9. Forceps delivery in modern obstetrics
Obstetricians are increasingly choosing caesarean section
when complications arise in the second stage of labour
Injury to the pelvic floor and trauma to the baby are
more common after forceps delivery, but major
maternal haemorrhage and separation from the baby are
more common after caesarean section
Women are more likely to achieve a spontaneous vaginal
delivery in a subsequent pregnancy after forceps delivery
than after caesarean section
Forceps delivery is skill-dependent and training-
dependent

10. Introduction…
an instrument designed to assist with delivery of the baby's
head.
True forceps were first devised in the late 16th or beginning
of the 17th century
OVD10

11. 1. Forceps delivery
OVD11
 Design of Forceps:
→ 2 crossing branches each having 4 components:
 Blade - cephalic & pelvic curves
- fenestrated or solid
- elongated or round
 Shan - wide or narrow
 Lock – English or sliding
 Handle – with or without a finger guard

12. Types of forceps
Outlet forceps
, e.g. Wrigley's forceps, are small forceps used for
lift-out deliveries and at caesarean section.

13. Types….
Low or mid-cavity forceps
Low or mid-cavity forceps, e.g. Neville Barnes,
Andersons, Simpsons.


14. Types….
Rotational forceps
Rotational forceps, e.g. Kielland's forceps


15. Forceps design…
OVD15

16. Commonly used forceps
OVD16

17. Functions of forceps:
OVD17
1. Traction e.g. Wrigley forceps/short curved
2.Rotation e.g.Kielland’s in oblique positions
3. Protection e.g. Standard forceps
4. Flexion
5. Extension

18. Classification of Forceps: Station and
Rotation
OVD18
A) Outlet forceps:
 Scalp is visible at introitus without separating the
labia
 Fetal skull has reached pelvic floor / perineum
 Sagittal suture is in AP diameter or in oblique
positions
 Rotation does not exceed 45 degrees

19. Classification….
OVD19
B) Low forceps:
 Leading point of fetal skull is at station +2 cm or below,
and not on pelvic floor/perineum.
 Rotation is 450
or less (LOA or ROA to OA, or LOP or
ROP to OP positions).
 Rotation is greater than 45o
.
C) Midpelvic forceps & High forceps – Replaced by C/S

20. Indications
OVD20
 Maternal:
 Heart disease, pulmonary injury or compromise,
intrapartum infection
 Certain neurological conditions, exhaustion
 History of aneurysm, stroke, glaucoma.
 Fetal:
 Fetal distress
 Aftercoming head in a breech presentation.
 NRFHRPs
 Prolonged 2nd
stage – no dystocia
 At cesarean section

21. Indications for forceps delivery
Relative indications (vacuum extraction or
caesarean section may be an alternative option)
Delay or maternal exhaustion in the second stage of
labour
Epidural block with diminished urge to push
Malpositioned fetus
Suspected fetal distress

22. Indications ….
Specific indications :
Forceps delivery is usually superior to
vacuum extraction or caesarean section
Delivery of the head at assisted breech delivery
Assisted delivery of preterm infant (< 34 weeks'
gestation)
Controlled delivery of head at caesarean section
Assisted delivery with a face presentation

23. Indications ….
Assisted delivery with suspected coagulopathy or
thrombocytopenia in fetus
Instrumental delivery for maternal medical conditions
Instrumental delivery under general anesthesia
Cord prolapse in the second stage of labour

24. Contraindications
Absolute
Non-vertex presentation
Face or brow presentation
Unengaged vertex
Incompletely dilated cervix
Clinical evidence of CPD
Any contraindication to vaginal delivery
Relative
Preterm less than 35 weeks or estimated fetal weight <2500
grams
Mid-pelvic station
OVD24

25. Forceps delivery
 Prior to performing an operative delivery, it is essential to
determine that the vertex is fully engaged. Descent of the
baby may be assessed abdominally or vaginally.
When there is a significant degree of caput (swelling) or
molding (overlapping of the fetal skull bones), assessment by
abdominal palpation using fifths of head palpable is more― ‖
useful than assessment by vaginal examination
OVD25

26. Prerequisites
OVD26
1. Informed consent
2. Engaged head
3. Fully dilated and retracted cervix
4. Ruptured membranes
5. Exact position of the head determined
6. Adequate pelvis
7. Empty bladder
8. Appropriate anesthesia in effect, if available
9. Adequate facilities and backup available
10. Health care provider knowledgeable about the instruments, their
use and the complications that can arise from their use
11. Ongoing fetal and maternal assessment

27. Preparations
OVD27
Lithotomy position with the buttock of the parturient at the
edge of the delivery table
Empty bladder (catheterization)
Apply anesthesia if local or general is used.
Regional anesthesia has to be given earlier.

28. Steps in forceps delivery
 Hold a complete (locked) forceps in front of the
perineum to orient and identify the right and left blades.
The right is the one on the right side of the mother and
the left on the left
Disassemble the forceps and place it on the tray
First apply the left blade: Hold the handle of the left
blade with your left hand freely and apply it to the left
side of the mother guided by the two fingers of the right
hand.
Apply the right blade: Hold the handle by your right
hand and place it to the right side of the mother guided
by the two fingers of the left hand
OVD28

29. Steps in forceps delivery
Lock; the right is always below the left when locked
Locking should be very easy
If locking is difficult disarticulate and apply again after
ascertaining the absence of CPD, position and station.
Never apply undue force to lock
IF FORCEPS LOCKS EASILY DO THE THREE
CHECKS
1. Plain of the shanks is as close to the Occiput as
possible
2. Shanks are equidistant
3. Fenestra doesn't accommodate more than two
fingers.OVD29

30. Application
OVD30
Cephalic application:
The blades are over the parietal bones in an occipito-
mental application
The front of the forceps (concave edges)point to the
denominator (occiput)
Pelvic application:
The left blade is next to the left sidewall of the pelvis
and the right blade near the right sidewall.
The concavity edges points to the pubis.
The convex edges pints to the sacrum.
The diameter of the forceps is in the transverse
diameter of the pelvis

31. Traction
After locking, apply steady traction inferiorly and
posteriorly with each contraction.
Between contractions check:
- fetal heart rate, and
- application of forceps.
Lift the head slowly out of the vagina between
contractions.
OVD31

32. Delivery of the head
OVD32
Traction is synchronized with uterine contractions and
should follow the Pelvic Curve.
With each pull, the head should descend.
Two or three pulls are usually needed to effect delivery of
the head
In-between tractions, check fetal heart beat and application
is correct
Perform an episiotomy with crowning of the head
Once the head reaches the pelvic outlet, lift it out using the
forceps
Removal the right first followed by the left forceps

33. Forceps Application
OVD33

34. Forceps Application…
OVD34

35. Forceps Application…
OVD35

36. Forceps Application…
OVD36

37. Forceps correctly applied along
occipitomental diameter
OVD37

38. Forceps Application…
OVD38
 Check for correct application
 Blade along occiptomental diameter
 Sagittal suture in midline of shanks
 Cannot place more than one fingertip between
blade and fetal head
 Apply traction
 Steady, intermittent, downward, then upward
force
 Remove blades

39. Forceps Application…
OVD39

40. Forceps Application…
OVD40

41. Forceps Delivery of OP
OVD41

42. Forceps Delivery of Face Presentation
– MA position
OVD42

43. Risks: Forceps
OVD43
 Maternal:
 Injury (extension of episiotomy, vaginal/cervical
laceration)
 Postpartum hemorrhage
FistulaFistula
 Fetal:
Trauma
 Intracranial hemorrhage.
 Cephalhematoma.
 Facial / Brachial palsy.
 Injury to the soft tissues of face & forehead.
 Skull, clavicular fracture

44. Complications due to forceps
Increased risk of maternal complication:
Cervical laceration,
Post partum infection and other complications,
Prolonged hospital stay were more common
(Kabiru WN, Et al 2001)
Hemorrhage, pelvic floor injury, incontinence
(Liebling et al, 2004 )

45. Complications ………
Fetal and neonatal morbidity
No significant differences in Apgar scores at one and
five minutes and few serious injuries in neonates
Neonatal trauma and fetal acidosis were more
common
Neonatal encephalopathy, associated with cerebral
palsy and neonatal death

46. Difficulties in forceps
operation
During Application –
Incompletely dilated cervix Un rotated or unengaged
head
During locking
Application with un rotated head Compound
presentation Improper insertion of blades (too far in)
Failure to depress handle properly before locking
Difficult traction
Undiagnosed mal position (O.P.) Faulty cephalic
application Wrong direction of pull Mid pelvic
contraction Constriction ring
Faulty application : Blades should be equidistant from
the &sinciput and occiputOVD46

47. Trial of forceps:
 A tentative attempt to deliver by Forceps in
presence of doubtful mid pelvic - contraction
with prior preparation for C.S in case the attempt
fails.
It is to be attempted in OR and by an expert
obstetrician
OVD47

48. Failed Forceps
OVD48
A failed forceps is diagnosed if:
Fetal head does not descend with each pull,
Fetus is undelivered after three pulls with no descent or
after 30 minutes
The possible causes are:
Undiagnosed CPD
Incomplete cervical dilatation
Wrong diagnosis of position
Incorrect application
Cervical entrapment
When application of forceps or traction does not yield,
reassess for possible cause. After a failed forceps, Cesarean
delivery is undertaken if the fetus is alive.

49. Failed forceps
Higher rates of failure are associated with:
 Maternal body mass index over 30
 Estimated fetal weight over 4000 g
Occipito-posterior position
Mid-cavity delivery or when 1/5th of the head
palpable per abdomen

50. 2. Vacuum Extraction
OVD50

51. Objectives
OVD51
At the end of the session, you will be able to:
State indications and contraindications for the use of
the vacuum extractor
State complications associated with vacuum extractor
use for mother and baby
Demonstrate the steps for using the vacuum extractor
using fetal and pelvis models and a skills checklist,
including identification of the flexion point

52. Introduction
It cannot be used to apply rotational forces.
Trying to complete a rotation can cause a skull
fracture or a hemorrhage resulting in serious
harm to the baby.
The vacuum will not succeed in the absence of
maternal expulsive effort.
The vacuum may be used judiciously to correct
attitude (deflexion), if it is properly applied and
appropriate traction used.
OVD52

53. Definition
OVD53
It is an instrument designed to effect
vaginal delivery by creating vacuum
between its cup and fetal scalp, thus
synonym is vacuum delivery.
Using a suction device applied to the fetal scalp
to help facilitate delivery of the fetal head
Usually has same indications, contraindications &
classification as forceps.

54. Vacuum: components
OVD54
Bottle with manometer
Handle
Rubber tubing connected between bottle, cup and
pump.
Metal or plastic cups that comes in 3 sizes: 5cm, 4cm,
3cm, diameter connected to the traction chain enclosed
in a piece of rubber tubing.
Suction cups of 4-size s (30,40,50 & 60 mm)
Metal or soft silastic cup -Vacuum pump/ Electrical
vacuum pump

55. Types of Vacuum Cups
Malmstrom cup
A metal cup to its centre attached a metal chain passed through the
rubber tube. The other end of the chain is attached to a handle for
traction.
Bird’s cup
The suction rubber tube is attached to the periphery of the cup
while the handle of traction is attached by a separate short metal
chain to the centre of the cup.
Soft cup
It is a bell-shaped 6.5 cm diameter soft cup which is made of
silastic material.
Advantage: It produces symmetric, less cosmetically alarming caput
succedaneum and less scalp abrasions.
Disadvantage: It slips more than the metal cup but with less scalp
injuries.

56. Types of Vacuum Devices
A) The Kiwi Omnicup
A rigid, disc-shaped, plastic
cup suited for
occipitoposterior deliveries.
Comparably safe
Newer devices allow (B) for
an assistant to hand-pump
suction using a separate
device or
(C) for the user to hand-pump
suction with a single
handheld device.

57. Manual VE: Malström
OVD57

58. Mityvac obstetrical vacuum
OVD58

59. New technology: Kiwi vacuum device
OVD59

60. Vacuum suction cups
OVD60

61. Types of Vacuum Devices
Soft and rigid cups were more likely to fail to achieve
vaginal delivery (Johanson R and Et al, 2000)
Failure rates were 10 percent with rigid cups and 22
percent with soft cups.
Soft cups were associated with less scalp injury
The Kiwi Omnicup for occipitoposterior and
occipitoanterior deliveries showed increased failure rate

62. Indication
OVD62
Fetal
Evidence of fetal compromise that requires immediate
delivery
Maternal
Failure to deliver spontaneously following the
appropriate management of the second stage of labour
Conditions which require a shortened second stage or
in which pushing is contraindicated (e.g. some
maternal medical conditions)
Maternal exhaustion

63. Contraindication
Contraindications – Absolute
Non-vertex presentation
Face or brow presentation
Unengaged vertex
Incompletely dilated cervix
Clinical evidence of cephalopelvic disproportion
(CPD)
Contraindications – Relative
Preterm less than 35 weeks or estimated fetal weight
< 2500 grams
Mid-pelvic station
Unfavourable attitude of the fetal headOVD63

64. Advantages over forceps:
OVD64
Avoidance of insertion of space-occupying steel blades
within the vagina and of the requirement for precise
positioning over the fetal head
Decreased intracranial pressure during traction
Less complications
Need No episiotomy
Lesser traction force (maxim 10kg)
Safely used for high head without CPD
Less traumatic to mother & fetus
Requires less technical skill

65. Disadvantage
OVD65
It is not an instrument for fetal distress where quick
delivery is required
It is not safe for premature fetus
Cannot be used for face presentation or after coming
head where forceps could be used
Technical failure is more common with Venous as it is
not simple as Forceps

66. Prerequisite of ventouse delivery
OVD66
No pelvic contraction of any degree
Engaged Vx presentation;
Cervix should be at least 8 cm dilated
Membrane should be ruptured
Empty bladder
Local infiltration of anesthesia & episiotomy
The instrument is to be assembled and vacuum to be
tested prior its application

67. Preparation
OVD67
Empty bladder
Local anesthesia infiltration for episiotomy
Assembled and tested vacuum extractor

68. Vacuum Application
OVD68
 3 checks prior to application of traction to the fetal head.
1. No maternal tissue should be included under the cup margin.
2. The cup should be placed in the midline over the sagittal suture
and not off to the side of the head.
3. The marker or vacuum port of the suction cup should point
toward the occiput.
Apply steady traction with maternal pushing effort.

69. Vacuum Application
OVD69
Assemble to ensure that no leaks are present.
Insert cup into the vagina by directing pressure toward
the posterior aspect of the vagina.
Place cup over the sagittal suture at the flexion point 2 -
3 cm anterior to the posterior fontanelle.

70. Procedure
OVD70
Application:
Apply the largest cup that can fit near to the
occiput with knob of the cup pointing to the
occiput.
The center of the cup being at about 1 cm
anterior to the posterior fontanel and on the
sagittal suture.
The ideal application of vacuum extraction is
achieved when the centre of the cub is
superimposed on the flexion point.
The flexion point is 3 cm in front of the
posterior fontanelle at the sagittal suture

71. A successful vacuum
extraction
OVD71
Accurate cup application
Appropriate traction technique
A favorable flexed fetal cranial position and low
station at the time of application
Use of the most appropriate cup design,
Absence of fetopelvic disproportion

72. Flexion point in relation to fetal
skull landmarks
OVD72

73. vacuum pressure
OVD73
Measured in various units: 0.8 kg/cm2 of atmospheric pressure =
600 mmHg = 23.6 inches of Hg = 11.6 lb/in(2).
Raised to 100 to 150 mmHg to maintain the cup's position.
Pressures of 500 - 600 mmHg recommended during traction,
although pressures in excess of 450 mmHg are rarely necessary

74. Negative pressure in AVD
In the past:
 Slow incremental increase in vacuum pressure was
recommended before applying traction
Starting at 0.2 kg/cm2
every 2 minutes to 0.8
kg/cm2
(alternatively expressed as 0.6 to 0.8
kg/cm2
(500–600 mm Hg), within 8–10 minutes.
Rapid technique was associated with a significant
reduction in the duration of vacuum extraction by an
average of 6 minutes without adversely impacting fetal
and maternal outcome.
All deliveries were achieved with a maximum traction
force of 13.5 kg (500–600 mm Hg)

75. Steps performed in vacuum
extraction…………

76. Traction
OVD76
Start traction with contraction with a finger on the scalp
Pull in line with the pelvic axis and perpendicular to the cup
Between contractions, check for fetal heart and cup
application;
With progress and absence of fetal distress, continue traction
with contraction for 30 minutes or till three successive pulls
fail to advance the head;
As soon as the head is delivered, release the vacuum and
proceed with the delivery of the fetus;

77. Axis Animation
OVD77

78. Vacuum pressure gauge
OVD78

79. Recommendations are based more upon
common sense and experience than
scientific data
82% of successful deliveries were achieved within 1 to 3
pulls
More than 3 pulls was associated with a 45% risk of neonatal
trauma
Maximum of 2 to 3 cup detachments (pop-offs).
The total vacuum application time should be limited to 20 to
30 minutes.

80. Vacuum cont’d…
December 19, 201780

81. Vacuum cont’d…
December 19, 201781
Swellings and bleeds
associated with normal
and operative vaginal
delivery.
Effectiveness and Safety
of Vacuum
 is effective, with a
failure rate of
approximately 10%.
may cause serious or
fatal complications
when improperly used

82. Vacuum cont’d…
December 19, 201782
Injury can be significantly decreased or eliminated if the
following protocol is used.
• Traction is applied only when the patient is actively pushing.
• Applying torsion or twisting the cup in an attempt to rotate the
head is prohibited.
• The duration of time during which the cup is applied to the
head should not exceed 20 minutes.
• The procedure should be abandoned after the cup has dislodged
from the fetal head twice.
• The procedure should be abandoned if there is no fetal descent
after a single pull.
• The vacuum should not be used when the estimated fetal
weight is less than 2000 g or greater than 4000 g.

83. Complications
OVD83
Fetal complications
Laceration of scalp: provide local wound care as appropriate;
Cephal-hematoma requires observation: usually clears within 3-4
weeks
Sub-aponuerotic hemorrhage
Intracranial hemorrhage: very rare but requires immediate
intensive care
Maternal complications
Tears of the vagina or cervix are repaired as appropriate

84. Complications
Cephalohematoma versus subgaleal hematoma.
(A) Cephalohematomas are limited to suture lines.
(B) In subgaleal hematomas, the bleeding crosses
suture lines, causing diffuse swelling that can indent
on palpation.

85. Signs and Symptoms of Serious
Intracranial Injury in a Neonate
Intracranial hemorrhage
Apnea
Bradycardia
Bulging fontanel
Convulsions
Irritability
Lethargy
Poor feeding
Subgaleal hematoma
Diffuse head swelling
that shifts with
repositioning and
indents on palpation
Signs of hypovolemic
shock (hypotension,
pallor, tachycardia,
tachypnea)
Swelling not limited
by suture lines (unlike
cephalohematoma)

86. OVD complications
Forceps
Complications Vacuum delivery Forceps
delivery
Maternal
Maternal soft-tissue
trauma
less High
General and regional
anesthetic
Less required Mandatory
Degree of failure High less
Rates of third- and
fourth-degree
lacerations
Decreased Increased

87. OVD complications……..
Complications Vacuum assisted
delivery
Forceps assisted
delivery
Neonatal
Rates of neonatal
cephalohematoma
Increased Decreased
Retinal hemorrhage Increased Decreased
Development
impairment
No difference Similar
shoulder dystocia Common Less common

88. Further care
OVD88
After delivery inspect the vagina and cervix; and repair if
there is any tear
Proceed with the immediate neonatal examination and care
ƒAssure that vitamin k is provided within one hour of
delivery.
Check for scalp abrasions and lacerations;
The chignon gradually disappears in few hours.

89. Post delivery Care
Carefully inspect:
The mother for:
Any cervical or anal sphincter tears
Anal sphincter lacerations are often missed and can lead
to anal incontinence.
The mother should be questioned about her
perceptions on the need for operative vaginal delivery
and how the delivery went
The neonate should also be examined to look for signs of trauma.
Good documentation is essential

90. Component of well documetation
following OVD
Indications for intervention
Position and station of the fetal head
Amount of molding and caput present
Assessment of maternal pelvis
Assessment of fetal heart rate and contractions
Record of discussion with the woman of the risks, benefits, and
options
Number of attempts and ease of application of vacuum or forceps
Duration of traction and force used
Description of maternal and neonatal injuries

91. Summary
Main Points
An operative vaginal delivery should only be performed if
there is an appropriate indication..
A number of clinical situations exist in which operative
vaginal delivery should not be attempted because of the
potential risks to the fetus.
A series of criteria all need to be fulfilled before an operative
vaginal delivery can be attempted.

92. Cont….
Selection of the appropriate instrument depends on both the
clinical situation and the operator’s level of comfort and
experience with the specific instrument.
Soft bell-shaped cups are associated with fewer scalp injuries
and no increased risk of maternal perineal injury.
Soft bell-shaped cups should be considered for
straightforward occiput-anterior deliveries and rigid M cups
should be reserved for more complicated deliveries.

93. Cont…..
A successful vacuum-assisted vaginal delivery is dependent
on several factors, including patient selection and a number
of technical considerations.
There is evidence that instrumental deliveries increase
maternal morbidity. The risk of maternal injury is much
higher with forceps compared with vacuum-assist devices.
Pediatricians should be notified whenever an operative
vaginal delivery has been attempted.

94. Reference
1. Review Vacuum extraction versus forceps for assisted vaginal delivery.Johanson
RB, Menon BK cochrane Database Syst Rev. 2000; (2):CD000224. [PubMed] [Ref list]
2. Intrapartum risk factors for newborn encephalopathy: the Western Australian
case-control study.Badawi N, Kurinczuk JJ, Keogh JM, Alessandri LM, O'Sullivan F,
Burton PR, Pemberton PJ, Stanley FJ BMJ. 1998 Dec 5; 317(7172):1554-8.[PubMed] [
Ref list]
3. Johanson R, Menon V. Soft versus rigid vacuum extractor cups for assisted vaginal
delivery. Cochrane Database Syst Rev. 2000;(2):CD000446.
4. Society of Obstetricians and Gynaecologists of Canada. Guidelines for operative vaginal
birth. Number 148, May 2004. Int J Gynaecol Obstet. 2005;88(2):233.
5. Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries–myth
or reality? BJOG. 2006;113(2):195–200.
6. Eason E, Labrecque M, Marcoux S, Mondor M. Anal incontinence after
childbirth. CMAJ. 2002;166(3):326–330.

95. Failed Vacuum
OVD95
Diagnosis is based on any one of the following conditions
− The head does not advance with each pull;
− The fetus is not delivered with 3 pulls;
− The fetus is not delivered within 30 minutes;
− The cup that is applied appropriately and pulled in the
proper direction with maximum negative pressures slips off
the head twice

96. OVD96
I THANK YOU!!!

97. Quiz
Case: A 36 year-old gravida-2 para-1 woman visited your
facility with full cervical dilation. A calculated gestational age
is 35 weeks. The presentation was vertex with occipito-
anterior position. She had ANC follow up and her record
indicates that she is known cardiac patient. She had no any
previous scar. She had three contractions in ten minutes
which stays 20-30 seconds. She claimed a leakage of clear
fluid per vagina a day before.
What type of instrument is your choice?
OVD97

98. Question 1
An advisable forceps delivery for arrested after coming head
is:
A.Simpsons forceps
B. Piper forceps
C.Kielland forceps
D.Elliot forceps
OVD98

99. Question 3
A 35 weeks, gravida -2, para- 1 woman was arrived at the
labor ward with a pushing down sensation of 8 hours
duration. She delivered her last baby at home without
complication. On vaginal examination: face presentation
with mento-anterior position, cervix fully dilated, station
+1, no molding and caput. She is in second stage of labor for
3 hours. Fetal heart beat is 100/min. The most likely forceps
delivery to be used is:
A.Simpsons forceps
B. Piper forceps
C.Kielland forceps
D.Elliot forcepsOVD99

100. Question 4
All of the following are evidences for correct application of
forceps delivery, except:
A.Biparietal-bimalar application
B. Sagittal suture bisects the shank
C.Occiput 3 to 4 cm above the shank
D.More than two finger space between the head and the heel of
the blade
OVD100

101. Question 5
Based on the above case scenario, one of the following make
her to be a relative contraindication for vacuum delivery:
A.Fetal heart beat
B. Station
C.Gestational age
D.Descent
OVD101