Operative vaginal delivery Flashcards
What are indications for operative delivery
- Prolonged second stage of labor
- suspending impending fetal compromise
- need to shorten second stage for maternal indication
What are contraindications to operative vaginal delivery?
- fetal head unengaged
- position of fetal head unknown
- fetal conditions (bleeding disorder - VWF, thrombocytopenia, hemophilia; bone demineralization disorder- OI)
- no staff/facility for emergency cesarean birth
- gestation < 34 weeks if using vacuum
Pre-requisites to operative vaginal delivery
- Informed consent
- Engaged head
- known position (station, position, attitude, asynclitism)
- operator appreciation of anatomy
- adequate pelvis (prior assessment to +2/+3 station)
- operator appreciation of mechanism of labor
- operator expertise with forceps/vacuum
- adequate anesthesia
- empty bladder/rectum
- patient appopriately positioned on the table
- membranes ruptured
- cervix fully dilated
- facility/staff to perform CD if necessary
Define outlet forceps
- scalp is visible at introitus without separating labia
- fetal skull at pelvic floor (+2/+3); not caput
- fetal head is at perineum
head in OA or OP position wiht rotation not exceeding 45 degrees
Define low forceps
- vertex higher than outlet; but below +2 station
- fetal skull is >/= +2 station
- fetal head not at perineum
- head in OA or OP postiiton; rotation not exceeding 45 degrees
- low forceps with rotation -> if greater than 45 degrees
Define mid forceps delivery
- station above +2
- head engaged
- not typically done anymore
- appropriate option in certain clinical circumstances***
Complications of operative vaginal delivery
Fetal
- scalp laceration
- retinal hemorrhage (38% with VAVD) - usually asymp and resolve spontaneously
- cephalohematoma
- subgaleal hematoma (30-40/1000)
- intracranial hemorrhage
Maternal
- obstetrical laceration
- pelvic hematoma
Cepahlohematoma more common with vacuum delivery- increases with prolonged application of suction
FAVD increases risk of OASIS but not FI at 1 year
How do you manage operative delivery in a patient with suspected macrosomia?
Risk of birth injury in infants delivered by operative vaginal delivery weighing greater than 4,000 g was higher than those weighing less. But this mirrors spontaneous delivery findings as well.
Operative delivery with fetal macrosomia is not contraindicated. Need to consider progress in labor, maternal pelvis,
Role of trial of operative birth?
This defines trying operative birth with understanding that will proceed with cesarean section. No hard and fast rule on number of pulls; but generally progress to be made with each one. If no delivery after “several pulls”, then proceed with cesarean.
What type of vaccum would you use?
Pliable soft cup compared to rigid. This is because of lower rates of fetal scalp laceration. No evidence of relieved suction bewteen pushes decreases risk of cephalohematoma or scalp laceration; although overall duration is correlated with cephalohematoma.
are abx required at time of operative delivery?
no
parts of a forceps
blade (toe and heel), shank, and handle with lock
- blade can be smooth, fenestrated, or pseudofenestrated
- shank can be parallel or overlapping
types of forceps - why they are good for certain purposes
simpsons - parallel shanks, longer blade -> better for mid forceps, molded heads
piper - overlapping shanks - better for unmolded/preterm
piper - no pelvic curve
application check points for vacuum
in OA position: 1 cm from posterior fontanelle, on sagittal suture, no maternal tissue. 3 cm from anterior fontanelle. at flexion point
application check points for forceps
in OA position: blade 1 cm anterior to posterior fontanelle, sagittal suture perpendicular to shank, posterior fenestration/blade not more than 1 cm from face
