Instrumental Delivery 2016

Instrumental delivery
(Operative vaginal delivery)
Dr Vrunda Joshi
Professor, OB/GY
GRMC, GWL, M.P.
Instrumental delivery
(Operative vaginal delivery)
• Obstetric Forceps
• Vacuum extractor
• Destructive operations
The Obstetric Forceps
• Seventeenth century
secret for three
generations of
Chamberlen family
• Curved blade - Cephalic curve for fetal head
- solid or fenestrated
• The Shank - straight between blade & lock
• The lock or joint – Double slot / sliding
• The handle - Finger grip
Modes of action :
• Traction
• Compression
• Lateral lever action
• Improves uterine contractions
Indications for the use of forceps:
• Maternal distress
• Fetal distress
• Prolongation of the second stage
• Prophylactic forceps
Maternal distress (exhaustion) late in labour
• Loss of morale
• Failure to co-operate with instructions of the
attendants
• Hysterical outbursts
• Rising temperature & pulse rate
• Signs of ketosis/ shock due to prolonged
physical efforts, starvation and dehydration
Fetal distress:
• Prolonged fetal bradycardia
• Irreular fetal heart rate
• Fresh meconium
Prolongation of the second stage:
• More than 2 hours in primipara without
analgesia
• More than 3 hours with analgesia
• More than 1 hour in multipara
To cut short the second stage:
• Heart disease class III or IV
• Severe anaemia
• Severe asthma
• Hypertensive crisis, Eclampsia
• Cerebrovascular disease- malformations
• Myaesthenia Gravis
• Spinal cord injury
Prerequisites- conditions to be fulfilled
• Suitable presentation- fetal head
vertex OA or OP
Face
Aftercoming head of breech
• Engaged fetal head
• Cervix fully dilated and effaced
• Adequate pelvic outlet
Prerequisites continued:
• The uterus contracting & relaxing
• The bladder must be empty
• Bowel evacuated
• Membranes ruptured
• Informed consent with risks explained
• Proper anaesthesia & analgesia
Forceps Applications :
• Cephalic-
Blades lie along the sides of fetal head
Long axis of blades ‖ occipitomental dia.
BPD occupies widest interval between.
Secure & safe grip
Minimum compression force
Applications contd :
• Pelvic application:
Along the sides of the pelvis
Insecure grip
Injurious pressure on fetal head
Easier to apply
Safest application : Cephalic & pelvic coinside

‘OUTLET FORCEPS’
Classification:
• Outlet forceps
• Low forceps
• Midcavity forceps
Type of Forceps Delivery
• Outlet forceps
– Scalp visible at introitus without separating labia
– Fetal skull reached pelvic floor & head at/on perineum
– Sagittal suture in AP diameter or LOA, ROA, or posterior position
– rotation does not exceed 45º
• Low forceps
– Leading point of fetal skull at >= +2, not on pelvic floor
– Rotation 45º or less (LOA/ROA to OA, or LOP/ROP to OP); or rotation greater
than 45º.
• Midforceps
– Above +2 cm but head engaged
• High forceps
– Head not engaged; not included in ACOG classification
– Not recommended
The Forceps Operation
• Careful aseptic preparations
Hair clipped short, skin washed, dried & painted
with antiseptic
• Operator: prepare hands & arms. Put on cap,
mask, gown & gloves
• Confirm all the prerequisites
• Position- Dorsal lithotomy, thighs flexed &
abducted, supported by stirrups or held by
assistants.
Step I
• Mock locking
• Left blade in left hand on left side of the pelvis
Step II
Right blade in right hand in right side of pelvis
Locking the blades- should be easy.
Difficulty in locking & adjustment- suggests

faulty position of the head.
Forceps-Assisted Vaginal Delivery
• Identify & apply blades
– Place instrument in
front of pelvis with tip
pointing up & pelvic
curve forward
– Apply left blade, guided
by right hand, then right
blade with left hand
• Lock blades
– Should articulate with
ease
FAVD
• Check for correct application
– Sagittal suture in midline of shanks
– Cannot place more than one fingertip between
blade and fetal head
• Apply traction
– Steady and intermittent
– Downward and then upward
– Remove blades as fetus crowns
Extraction of the head:
• Extract the head slowly.
• Pull during ut contractions & to pause during
intervals
• To separate the handles slightly without
unlocking them.
• Direct traction in the axis of pelvis.
Outlet forceps- Downwards then forwards.
Complications of outlet forceps
Maternal:
• Perineal tear extension
• Vaginal & cervical lacerations
• PPH
Fetal
• Facial nerve injury
• Cephalhematoma
• Intracranial hemorrhage
• Trial of forceps
Uncertainity about achieving a safe vaginal delivery.
marked caput and moulding
prolonged labor with second stage dystocia
suspected macrosomia
• Failed forceps
Unsuccessful attempt to deliver with forceps
-unrotated occipitoposterior
-incompletely dilated cervix
-disproportion
- contraction ring
Vacuum /ventouse
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
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
• F – Fontanelle  position the cup over the
posterior fontanelle
 -ve pressure ↑ 10 cm H2O initially & between
contraction
 sweep finger around cup to clear maternal
tissue
 ↑ pressure to 60 cm H2O with the next
contraction
• G – Gentle traction  pull with contractions
traction in the axis of the birth canal
ask the mother to push during contraction
• 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
Steps of ventouse application
40
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
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
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
Destructive operations
• Craniotomy forceps
cephalic presentation
Intrauterine death
Fully dilated cervix
Engaged fetal head
Parietal bone
perforated, brain
drained, ↓BPD
THANK YOU
&
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Instrumental delivery

(Operative vaginal delivery)

Safest application : Cephalic & pelvic coinside

Locking the blades- should be easy.

Difficulty in locking & adjustment- suggests

• C – Cervix  fully dilated / membranes

• D – Determine  position, station, pelvic adequacy

• J – Jaw remove vacuum when jaw is

• Vacuum –assisted delivery is less traumatic to the

• Cephalohematoma  25%  jaundice /anemia

• Intracranial hemorrhage  2.5%

• Birth asphyxia  2.6-12%  related to

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