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Operative Vaginal Delivery

Operative Vaginal Delivery. District 1 ACOG Medical Student Teaching Module 2011. Indications. Maternal B enefit – Shorten the 2 nd stage of labor, decrease the amount of pushing Ie: maternal cardiac conditions (Eisenmenger’s, pulmonary HTN) or history of aneurysm/stroke

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Operative Vaginal Delivery

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  1. Operative Vaginal Delivery District 1 ACOG Medical Student Teaching Module 2011

  2. Indications • Maternal Benefit – Shorten the 2nd stage of labor, decrease the amount of pushing • Ie: maternal cardiac conditions (Eisenmenger’s, pulmonary HTN) or history of aneurysm/stroke • Concern for immediate/potential fetal compromise • Ie: Prolonged terminal bradycardia • Prolonged 2nd stage • Nulliparous = No progress for 3 hrs w/epidural or 2 hours w/o epidural • Multiparous = No progress for 2 hrs w/epidural or 1 hr w/o epidural

  3. Operative Vaginal Delivery • Incidence: 4.5% of vaginal deliveries • Forceps deliveries = 0.8% • Vacuum deliveries = 3.7% • Success Rate = 99% • Reflects appropriate choice of candidates

  4. What Do I Need To Know Before Attempting an Operative Delivery? • Presentation (Cephalic/Breech) • Position (i.e. occiput posterior, sacrum anterior) • Lie (longitudinal, oblique, transverse) • Station • Presence of asyncliticism • Clinical pelvimetry • Anesthesia?

  5. Contraindications • GA < 34 weeks (contraindication for vacuum due to risk of fetal IVH) • Known bone demineralization condition (e.g. osteogenesis imperfecta) or bleeding disorder, ie: VWD) • Fetal head unengaged • Position of fetal head unknown

  6. Vacuum-Assisted Vaginal Delivery • Do not apply rocking motion or torque, only steady traction in the line of the birth canal • Stop after: three “pop-offs” of vacuum, > 20 minutes elapsed, three pulls with no progress

  7. After determining position of the head, (A) insert the cup into the vaginal vault, ensuring that no maternal tissues are trapped by the cup.(B) Apply the cup to the flexion point 3 cm in front of the posterior fontanel, centering the sagittal suture.(C) Pull during a contraction with a steady motion, keeping the device at right angles to the plane of the cup. In occipitoposterior deliveries, maintain the right angle if the fetal head rotates. (D) Remove the cup when the fetal jaw is reachable

  8. Fetal Risks: VAVD Designed to detach if traction is excessive (but can produce traction up to 50 lbs) * 5% incidence serious complications • Scalp lacerations: if torsion excessive • Cephalohematoma: limited to suture line • Subgleal hematoma: crosses suture line • Intracranial/retinal hemorrhage • Hyperbilirubinemia/jaundice • Higher incidence of cephalohematoma/retinal hemorrhage/jaundice compared to forceps

  9. Type of Forceps Delivery • Outlet forceps • Scalp visible at introitus w/o 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

  10. 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

  11. 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

  12. Risks: Forceps • Maternal Risks • Perineal Injury (extension of episiotomy) • Vaginal and Cervical lacerations • Postpartum hemorrhage • Fetal Risks • Intracranial hemorrhage • Cephalic hematoma • Facial / Brachial palsy • Injury to the soft tissues of face & forehead • Skull fracture

  13. Using both forceps and vacuum • Highest risk for injury is for combined forceps/vacuum extraction or cesarean delivery after failed operative delivery • The weight of available evidence is against multiple efforts with different instruments

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