basic principles of operative vaginal delivery ppt

1. Wollo University
School of Medicine
Department of Gynecology & Obstetrics
Seminar on
Operative Vaginal Delivery(OVD)
Presenters:
Amare Tarko(C-II)
Aragaw Ayanaw (C-II)
Arebu Seid(C-II)
Moderators - Dr. Workiye (MD,Obstetrcian&Gynecologist )
- Dr. Birukalem (MD,R4 Obs/Gyn)
1

2. Outline
DEFINETION
INCIDENCE
FORCEPS DELIVERY
CLASSIFICATION AND PREREQUISITES
MORBIDITY
VACUUM-ASSISTED DELIVERY
DISTRACTIVE DELIERY
REFERENCES 2
1

3. Introduction
 Vaginal Operative deliveries(VOD) are vaginal deliveries
accomplished with the use of forceps or
a vacuum device.
 Once either is applied to the fetal head, outward traction
generates forces that augment maternal pushing to deliver the
fetus vaginally.
 The most important function of both devices is traction.
3

4. Advantage of OVD
Reduce rate of cesarean delivery
Reduce subsequent-pregnancy related morbidity
No adhesion related surgical organ injury
Postpartum wound or uterine infection is less frequent
4

5. CHOICE OF INSTRUMENT
 The choice of instrument is determined by level of
training with the various forceps and vacuum equipment.
 Factors that might influence choice are:-
 the availability of the instrument,
 the degree of maternal anesthesia, and
 knowledge of the risks and benefits associated with each
instrument.
5

6.  In general, vacuum devices are:-
 easier to apply,
 place less force on the fetal head,
 require less maternal anesthesia,
 result in less maternal soft tissue trauma,
 do not affect the diameter of the fetal head compared to forceps.
6

7.  The advantages of forceps :-
 are unlikely to detach from the head,
 can be sized to a premature cranium,
 may be used for a rotation,
 result in less cephalohematoma and retinal hemorrhage,
 and do not aggravate bleeding from scalp lacerations.
7

8.  In summery,vacuum delivery is probably safer than forceps for
the mother, while forceps are probably safer than vacuum for
the fetus.
8

9. Incidence
 Forceps- or vacuum-assisted vaginal delivery was used for 3.1
percent of births in the United States in 2015. This is a decline
from 9.0 percent in 1990
 For these deliveries, a vacuum is disproportionately selected, and
the vacuum-to-forceps delivery ratio is nearly 4:1. In general,
most of these attempts are successful.
 In 2006, only 0.4 percent of forceps trials in the
United States and 0.8 percent of vacuum extraction attempts
failed to result in
vaginal delivery
9

10. Pre-requisites
10

11. Indications
 If it is technically feasible and can be safely accomplished,
termination of second stage labor by traction instruments is
indicated in any condition threatening the
mother or fetus that is likely to be relieved by delivery
11

12. Indications…
 Maternal indications;-
 Maternal exhaustion
 prolonged second-stage labor the most common
12

13. Cont...
 To shorten second-stage labor in case of
 Preeclampsia/Eclampsia
 Maternal heart disease
 pulmonary compromise,
 intrapartum infection, and
 certain neurological conditions
13

14. Cont...
 Fetal indications;-
 nonreassuring fetal heart rate pattern
 Premature placental separation
14

15. Contraindications
Are related to the potential for unacceptable fetal risks.
 Fetal prematurity: relative contraindication.
Known fetal demineralizing diseases:
(eg, osteogenesis imperfecta),
Fetal bleeding diatheses
(eg, hemophilia, alloimmune thrombocytopenia),
Unengaged head,
Unknown fetal position,
Malpresentation
(eg, brow, face )
Suspected fetal-pelvic disproportion
15

16. Classification
 Based on station and rotation.
 Deliveries are categorized as:
o Outlet,
o Low, and
o Mid-pelvic procedures.
 High forceps, in which instruments are applied above 0
station, have no place in contemporary obstetrics.
16

17. Classification ..
17

18. Classification …
 For vacuum extraction, fetuses should also be at least 34
weeks’ gestation, and fetal scalp
blood sampling should not have been recently performed.
 Regional analgesia or general anesthesia is preferable for
low forceps or
midpelvic procedures, although pudendal blockade may
prove adequate for outlet
forceps.
 The bladder is emptied
18

19. Some factors associated with operative delivery failure are
 persistent occiputposterior position and
birthweight >4000 g
In general, to avert morbidity with failed forceps or vacuum
delivery ACOG cautions that these trials should be
attempted only if the clinical assessment suggests a
successful outcome.
Lack of proper training.
19

20. Instruments
1. Forceps Instruments
2. Vacuum Extraction Devices
20

21. Forceps delivery
 Forceps refers to the paired instrument, and each member of
this pair is called a branch.
 Branches are designated left or right according to the side of
the maternal pelvis to which they are applied
 Each branch has four components: blade, shank, lock, and
handle
 Each blade has a toe, a heel, and two curves. Of these, the
outward cephalic curve conforms to the round fetal head,
whereas the upward pelvic curve corresponds more or less to
the curve of the birth canal
21

22. Function of Forceps
 The most important function = Traction,
 may also be invaluable = Rotation, (OT & OP).
 In general,
 Simpson forceps are used to deliver the fetus with a molded head, as
is common in nulliparous women.
 Tucker–McLane instrument is often used for the fetus with a rounded
head, which more characteristically is seen in multiparas.
 In most situations, however, either instrument is appropriate.
22

23. Four components forceps
23

24. Forceps …
 Blades can be
1. Fenestrated or
2. Pseudofenestrated (solid).
24

25. Types of forceps
25

26. Types of forceps …
26

27. Types of forceps …
27

28. Blade application and delivery
 The long axis of the blades should corresponds to the
occipitomental diameter
 Three forms of application or grip are recognized
1. Biparieto-malar – Optimal
2. Fronto-mastoid – Suboptimal
 compresses the mastoid area and the origin of the facial
nerve.
3. Fronto-occipital
– is asymmetric, unsafe and should not be used.
28

29. Steps in Outlet forceps delivery…
 Precise knowledge of the position of the fetal head is essential to a
proper cephalic application.
 Insert the left blade first.
1) Two or more fingers of the right hand are introduced inside the
left, posterior portion of the vulva and into the vagina beside
the fetal head.
29

30. Steps in Outlet forceps delivery
2. The handle of the left branch is grasped b/n the thumb and 2 fingers
of the left hand, and
 The tip of the blade is gently passed into the vagina b/n the fetal
head and the palmar surface of the fingers of the right hand (serves
as a guide).
 The handle and branch are held at first almost vertically, but they are
depressed as the blade adapts to the fetal head, eventually to a
horizontal position.
30

31. Steps in Outlet forceps delivery…
3) Two or more fingers of the left hand are then introduced into the
right, posterior portion of the vagina to serve as a guide for the
right blade, which is held in the right hand and introduced into
the vagina.
31

32. Steps in Outlet forceps delivery…
3) Then the horizontally positioned branches are articulated.
4) If necessary, one and the other blade should be gently
maneuvered until the handles are repositioned to effect easy
articulation.
32

33. 33

34. 34

35. 35

36. 36

37. Correct application
 Forceps grasp the occiput anterior fetal head
 The long axis of the blades corresponds to the occipitomental
diameter
 The tips of the blades lie over the cheeks
 The blades are equidistant from the saggital suture
 Posterior fontanel should be one finger below the plane
 No maternal tissue has been grasped
 Bimalar ,biparietal application
37

38. Incorrect application
38

39. Traction
Traction
 The pelvis is curved in a J-shape, and it is in this direction that the
series of force vectors should be applied.
 Traction is always applied gently and never with excessive force.
 More horizontal traction is applied, and the handles are gradually
elevated, eventually pointing almost directly upwards as the
parietal bones emerge.
39

40. Traction..
 As the vulva is distended by the occiput, episiotomy may be done
if indicated.
 It is preferable to apply traction with each uterine contraction,
except when delivery is urgently indicated.
40

41. 41

42. 42

43. Failed Forceps
A failed forceps is diagnosed if:
 Fetal head does not descend with each pull,
 Fetus is undelivered after three pulls with no descent
or
Fetus is undelivered after 30 minutes
43

44. Failed Forceps
• The possible causes are:
– Undiagnosed CPD
– Incomplete cervical dilatation
– Wrong diagnosis of position
– Incorrect application ,
o After a failed forceps, Cesarean delivery is undertaken if
the fetus is alive.
44

45. Complications of forceps delivery
 Fetal:
 Minor external ocular trauma
 Retinal hemorrhage
 Fetal skull fractures
 Facial nerve palsies
 Cephalhematoma
 Subaponeurotic hemorrhage
 Intracranial hemorrhage
 Scalp laceration
45

46. Maternal complications
Acute Late
 Genital tract ,bladder
laceration
 Extension of episiotomies
 Increase in blood loss
 Hematoma
 Uterine rupture
 Postpartum hemorrhage
(traumatic PPH)
 Related to pelvic supportive
structures injury
 Urinary stress incontinence
 Fecal incontinence(Anal
sphincter injuries)
 Pelvic organ prolapse
46

47. Vacuum extraction (ventouse)
 Is an operative vaginal procedure to facilitate vaginal
delivery with an application of a cup over the fetal
head for brief duration and minimal traction forces.
 With vacuum delivery, suction is created within a cup
placed on the fetal scalp such that traction on the cup
aids fetal expulsion.
47

48. 48

49. Vacuum extraction …
 The benefits of this tool compared with forceps
include ;
simpler requirements for precise positioning on the fetal
head and
avoidance of space-occupying blades within the vagina,
thereby mitigating maternal trauma.
49

50. Vacuum extraction …
Principle
 traction on a metal cap designed = so that the suction creates an
artificial caput, or chignon, within the cup that holds firmly and
allows adequate traction.

50

51. Indications and pre-requisites
 Are generally like that for forceps delivery except
o Face presentation and
o Breech presentation (after –coming head)
51

52. Contra indications
1. Cephalopelvic disproportion
2. High station (above 0-station)
3. Non- vertex presentations
4. Extreme prematurity
5. Known macrosomia
6. Recent scalp blood sampling
52

53. Technique of Vacuum
 Proper cup placement is the most important
determinant of success in vacuum extraction
53

54. Vacuum extraction …
 Vacuum devices contain a cup, shaft, handle, and vacuum
generator.
 Vacuum cups may be metal or hard or soft plastic, and
they may also differ in their shape, size, and reusability.
54

55.  nonmetal cups are two main types.
 soft cup is a pliable bell-shaped dome,
 rigid type has a firm flattened mushroom-shaped cup
and circular ridge around the cup rim .
When compared, rigid mushroom cups generate
significantly more traction force
55

56. Vacuum extraction …
 Metal cups provide higher success rates but greater
rates of scalp injuries, including cephalohematomas
 Importantly, high-pressure vacuum generates large
amounts of force
regardless of the cup used
56

57. 57

58.  Ideal application “Flexing Median” is when the center of the
cup is superimposed on the flexion point (3 cm in front of the
posterior fontanelle on the sagittal suture)
 the cup is symmetrically placed over the sagittal suture.
 If the center of the cup = more than 1cm to either side of the
sagittal suture, the application is described as paramedian, and
 when the application distance is less than 3cm, it is called
deflexing.
58

59. Four types of cup applications
1. Flexing median ( correct/ideal application)
2.Flexing paramedian
3.Deflexing median
4.Deflexing paramedian
 Deflexing and paramedian applications promote:-
 Extension and
 Asynclitism of the head and
 Effectively increase or fail to decrease the size and the area
of the presenting part.
59

60. Technique for Application of Vacuum cup.
 First, test the instrument
 Recheck the position of the occiput and locate the flexion
point.
 Connect cup tubing to the tube of the vacuum pump.
 Smear the outside of the cup lightly with obstetric cream.
 Press the cup against the fetal head and maneuver until its
center lies over the flexion point
 Check that there is no maternal tissue / fetal electrode
trapped.
60

61. Technique…
 Induce a vacuum pressure of 20 kpa (0.2 kg/cm2) and
recheck the cup position.
 Then increase the vacuum in one step to the
recommended pressure of 80 kpa (0.8 kg/cm2)
 Delay traction for 2 minutes to allow chignon to form
although gentle traction may be commenced sooner if
necessary.
 0.2kg/2min = rigid cap
 0.8kg/1min = soft cap
61

62. Traction
 Should be directed in such a way that the flexion point
on the head is aligned with the axis of the pelvis
 Traction should be a 2- handed exercise
1.The right hand holds the traction handle and pulling in
the direction of descent
2.The thumb of the non-pulling hand presses against
the dome of the cup
62

63. “3Ds”
1st pull  should cause flexion of the head and some descent
= Dislodge
2nd pull  the head should be on the pelvic floor = Descent
3rd pull  delivery of the head should be complete or
imminent = Deliver
63

64. Cont…
 Traction is discontinued
 between contractions or
 if an audible hiss is heard signaling loss of vacuum.
 After delivery of the head, the vacuum is released, the cup
eased off the scalp and the birth completed in the normal
manner.
 Vacuum extraction should be considered a trial, if there is
no evidence of descent, consider C/S = “3Ds”
64

65. Failed Vacuum
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
• After failed vacuum, the fetus is delivered by Cesarean section
65

66. Complications
• Scalp laceration or bruising
• Subgaleal hematoma
• Cephalhematoma
• Intra-cranial hemorrhage
• Neonatal jaundice
• Subconjunctival hemorrhage
• Clavicular fracture
• Shoulder dystocia
• Injury to 6th and 7th cranial nerves
66

67. Recommendations Regarding Vacuum
Delivery
o The classification of vacuum deliveries should be the
same as that utilized for forceps
o The same indications and contraindications utilized for
forceps deliveries should be applied
o The vacuum should not be applied to an unengaged
vertex, that is, above 0 station.
67

68. Recommendations Regarding Vacuum
Delivery
o The individual performing or supervising the
procedure should be an experienced operator.
o The operator should be willing to abandon the
procedure if it does not proceed easily or if the cup
pops off more than 3 times.
68

69. DESTRUCTIVE VAGINAL DELIVERY
 Definition:
 Reductive surgical procedure performed on the dead fetus
to reduce its size and make vaginal delivery possible
69

70. Important features
 Need few instruments
 Leaves the mother with intact uterus
 If she is already infected, low risk of
spread of infection to the peritoneum
 Shorter time in bed
70

71. Types
 Craniotomy
 Decapitation
 Evisceration
 Cleidotomy
71

72.  Indications of DVD :-
 CPD-
 Breach delivery-
 Transverse lie
72

73. Prerequisites for DVD
 Dead fetus
 exceptions (malformation or tumor incompatible with life,
Cleidotomy & needle aspiration for hydrocephalus)
 Fully dilated cervix
 No gross pelvic contracture
 No risk of uterine rupture
 2/5 or less of his head must be above the brim
 Back up operative facilities
73

74. CRANIOTOMY
 Perforation of the skull and emptying the head of brain
tissue so that the head collapses.
 It is used when the fetus presents with the head or in a
case of retained head in a breech
74

75. CRANIOTOMY INDICATIONS
 Obstructed labor with a vertex or face –
 Arrested after coming head –
 Hydrocephalus-
 Interlocked head of twins –
 Contracted pelvis is the most common
indication
75

76. CRANIOTOMY
 Scalp is held with a tissue forceps and
incision is made with a perforator and contents of the brain
are evacuated.
 Sites-
 vertex- parietal bone
 face- orbit/hard palate
 brow- frontal bone
 After coming head- foramen magnum
 Hydrocephalus- craniocentesis
76

77. Decapitation
 Cutting the neck and separating the head
from the truncus followed by version and extraction
 Indication :-
1. obstructed labor in shoulder presentation when the neck is
easily accessible,
2. locked twins
 Instrument-
 decapitating wire
77

78. Evisceration
 Perforation of the truncus (chest or abdomen) with
removal of all internal organs so that the
body collapses and a version and extraction can be
done without the risk of rupturing the uterus.
78

79. Cont..
 Indication-
1. Shoulder presentation where it is difficult to reach the
neck
2. Fetal malformation
- (ascites , huge distended bladder , hydronephrosis)
79

80. Evisceration Procedure
 Pull on the prolapsed arm & his axilla
 protect the vaginal wall with speculum
 make an opening in the chest or abd. wall
 Remove the viscera
 (liver, heart, and lungs)
 If necessary perforate his diaphragm with scissors
80

81. Cleidotomy
 Cutting of one or both clavicles to reduce the width of the
shoulder
 Indication :-
 Shoulder dystocia and other
maneuvers for shoulder dystocia have been unsuccessful
81

82. COMPLICATIONS
 Trauma to birth canal
 PPH
 Shock
 Puerperal sepsis
 Injury to adjacent organs-
 VVF,UVF or RVF
 Iatrogenic Ux rupture
82

83. Reference
1. Williams_obstetrics 26th edition
2. Gabbe 7th edition
3. Obstetrics Managemnt Protocol, FMOH, 2021
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84. Thank you!
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