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    Instrumental Delivery

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    جویریہ اسلم
    Operative vaginal delivery techniques like forceps and vacuum extraction are important skills that can assist in 10-15% of deliveries. The document outlines the history of forceps and vacuum development and reviews indications, prerequisites, techniques and complications of these procedures. It emphasizes that maternity providers should be familiar with instrumental delivery methods and assessments in order to perform them safely according to strict criteria. A mnemonic is provided to guide the systematic steps of the procedures.

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    Instrumental Delivery

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    جویریہ اسلم
    365 views39 pages
    Operative vaginal delivery techniques like forceps and vacuum extraction are important skills that can assist in 10-15% of deliveries. The document outlines the history of forceps and vacuum development and reviews indications, prerequisites, techniques and complications of these procedures. It emphasizes that maternity providers should be familiar with instrumental delivery methods and assessments in order to perform them safely according to strict criteria. A mnemonic is provided to guide the systematic steps of the procedures.

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    Operative vaginal delivery techniques like forceps and vacuum extraction are important skills that can assist in 10-15% of deliveries. The document outlines the history of forceps and vacuum development and reviews indications, prerequisites, techniques and complications of these procedures. It emphasizes that maternity providers should be familiar with instrumental delivery methods and assessments in order to perform them safely according to strict criteria. A mnemonic is provided to guide the systematic steps of the procedures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    365 views39 pages

    Instrumental Delivery

    Uploaded by

    جویریہ اسلم
    Operative vaginal delivery techniques like forceps and vacuum extraction are important skills that can assist in 10-15% of deliveries. The document outlines the history of forceps and vacuum development and reviews indications, prerequisites, techniques and complications of these procedures. It emphasizes that maternity providers should be familiar with instrumental delivery methods and assessments in order to perform them safely according to strict criteria. A mnemonic is provided to guide the systematic steps of the procedures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
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    10-15% of all deliveries require operative assistance. All maternity care providers should be familiar with the instruments and techniques for instrumental delivery.

    The different types of forceps discussed are Simpson's, Wrigley's, Neville-Barnes, Anderson's and Kielland's forceps.

    Some indications for forceps delivery discussed are prolonged second stage, maternal exhaustion, epidural analgesia, failure to descend, fetal distress and non-reassuring CTG.

    Operative Vaginal Delivery

    By Dr Javaria Aslam

    History

    Forceps
    1500 BC 1752, William Smellie Early 19th century almost completely abandoned 1817, Princess Charlotte (GB) died of PPH after prolonged II stage for more than 24hrs, her obstetrician Sir Richard Croft. 1940, 70% of all deliveries were assisted by forceps

    Vacuum
    1954, Malmstrom described metal vacuum extractor 1969, Bird modified the metal cup for OP position 1980, first soft cup introduced

    Learning Objectives
    Recognize the common indications, pre-requisites and contraindications for instrumental delivery Appreciate the relative advantages and disadvantages of ventouse versus forceps delivery Understand how to perform forceps and ventouse delivery safely Demonstrate proper use of equipment on maternalfetal mannequin

    Back Ground
    An important skill to manage second stage of labour 10-15% of all deliveries require operative assistance Rates of operative delivery vary throughout the world (1.5-15%) In the UK, the overall operative delivery rate is 10% (4% and 26%)

    Back Ground
    There is an increase in the rates of instrumental deliveries in recent years This may be partly due to
    a change in the attitudes of patients an increased use of epidural analgesia continuous electronic fetal monitoring increased litigation in obstetrics

    Back Ground
    There are strict criteria for safe instrumental delivery For instrumental delivery we should know
    The technique The indications Relative contraindications

    Assessment
    Previous obstetric history
    The possibility of cephalopelvic disproportion (CPD) Parity

    Current pregnancy and labour


    Gestational age Macrosomia Previous concerns about fetal well being Whether the labour spontaneous or induced Admission cardiotocograph (CTG)

    Assessment
    Examination
    Fetal size, position and engagement Adequate uterine contractions A palpable bladder A careful vaginal examination
    The fetal station Fetal position is determined by palpating the fontanelles and suture lines. Maternal pelvis

    Maternal Indications
    Prolonged second stage Maternal exhaustion (early pushing) Epidural analgesia Failure to descend due to soft tissue resistance Maternal illness (vulsalva is contra-indicated) eg; cardiac disease, raised intra cranial pressure. Hemorrhage

    Prolonged Second Stage


    Parity
    Without Regional Block 2 hours With Regional Block 3 hours

    Nullipara

    Multipara

    1 hour

    2 hours

    Indications
    Fetal
    Fetal distress Non-reassuring CTG

    Maternal-fetal
    Relative CPD Mal-position Mal-presentation

    Pre-requisites
    Vertex presentation Complete dilatation of cervix Rupture of membranes No known cephalopelvic disproportion Willingness to abandon the procedure

    Mnemonics
    A. Ask for help, Address the patient Anesthesia (adequate) B. Bladder empty C. Cervix fully dilated D. Determine position sutures and fontanels think of shoulder Dystocia E. Equipment and Extractor ready

    Mnemonics
    F. Vacuum Cup over sagittal suture 3 cm from anterior Fontanel Flexion point apply cup at position that maintain flexion on traction F. Forceps ready post Fontanel midway b/w shanks Fenestrations admit no more than one finger

    Mnemonics
    G. Vaccum: Gentle traction
    at right angle to plane of cup During contractions.

    G. Forceps: Gentle traction Pajots Maneuver

    Axis traction follow pelvic curve first downward than J-shapped two vectorshorizontal outwards and vertical downwards

    Mnemonics
    H. Vacuum:

    Halt traction after contraction (reduce pressure between traction) Halt procedure
    if disengagement three times no progress in 3 consecutive pulls no more than 20 min of application.

    H. Forceps:
    Handle vertically elevated to follow the pelivic curve

    Mnemonics
    I. Evaluation of Incision (episiotomy) J. Stop when Jaw reachable

    Forceps Vaginal Delivery

    Types
    Straight forceps
    Simpsons Simpsons Wrigleys Neville-Barnes Andersons Wrigley's

    Rotational forceps
    Kielland's The Kiellands forceps Pipers

    Mid cavity forceps

    Forceps Relative Indications


    Delayed second stage Maternal exhaustion in second stage Epidural with diminish urge to push Rotational instrumental delivery for fetal mal-position Suspected fetal distress

    Forceps Absolute Indications


    Where excessive caput is present over the vertex Prematurity (gestation <34 weeks) Face presentation After coming head of a breech Assisted delivery with suspected fetal coagulopathy Maternal medical conditions Instrumental delivery under GA Cord prolapse in second stage

    Advantages Of Forceps Delivery


    Forceps Vs Vacuum

    Lower failure rate Faster in fetal distress Sequential use of instruments is less common Cephalhaematoma and retinal hemorrhage less common

    Advantages Of Forceps Delivery


    Forceps Vs EmLSCS

    Less blood loss Shorter hospital stay NICU admission less common Re-admission is less common with forceps Subsequent SVD more likely

    Disadvantages Of Forceps Delivery


    Forceps Vs Vacuum

    More analgesia Greater maternal perineal trauma More facial bruising and facial nerve palsy Require more clinical skills

    Disadvantages Of Forceps Delivery


    Forceps Vs EmLSCS

    Trauma to baby is less likely with C. section Lesser perineal trauma with C. section Lesser dyspareunia Lesser urinary and fecal incontinence

    Ventouse Delivery

    Types
    Silastic cups Metal cup Omini cup

    Insertion of cup
    Place over the flexing median Symmetrically over the sagittal suture At least 3cm from the cup edge to the anterior fontanelle To ensure that traction results in flexion of the fetal head

    Method
    Ensure no maternal tissue is trapped Negative pressure is applied to 0.2 bar, Pressure taken to 0.8 bar

    Operative Notes After Instrumental Delivery


    Date/Time Mode of delivery Indication Duration of 1st/2nd stage Regional analgesia Procedure
    Cx dilatation Station Bladder Soft tissue Episiotomy Duration and no. of pulls

    Third stage: tears, PPH Baby notes: sex, wt, apgar

    Summary
    10-15% of all deliveries require operative assistance All maternity care providers should be familiar with the instruments and the techniques AJ mnemonic provides systematic method for assisted delivery Providers should be aware of complications and contraindications to these procedures

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