Towards safe practice in Towards safe practice in instrumental vaginal instrumental vaginal

deliverydelivery

Leroy EdozienLeroy Edozien

Approximately 1 in 10 Approximately 1 in 10 deliveriesdeliveries

is instrumental is instrumental

What could go wrong?What could go wrong?

Fetal complicationsFetal complications

Facial lacerationFacial lacerationScalp lacerationScalp lacerationFacial nerve palsyFacial nerve palsySkull fractureSkull fractureCorneal injuryCorneal injuryCervical spine Cervical spine injuryinjury

Subdural Subdural haematomahaematomaSubgaleal Subgaleal haematomahaematomaCephalhaematomaCephalhaematomaRetinal Retinal haemorrhagehaemorrhageHyperbilirubinaemiHyperbilirubinaemiaa

King SJ, Boothroyd AE. Cranial trauma following birth in term infants. Br J Radiol 1998;71:233-8

What could go wrong?What could go wrong?

Maternal complicationsMaternal complications

Cervical laceration Haematoma

Vaginal laceration Perineal tear

Psychological trauma

Avoiding harmAvoiding harm

Non-operative interventionsNon-operative interventions Deciding when and when not to Deciding when and when not to

deliver instrumentallydeliver instrumentally Using the right operative techniquesUsing the right operative techniques

Non-operative interventions which Non-operative interventions which reduce instrumental delivery ratesreduce instrumental delivery rates

One-to-one support in labour One-to-one support in labour (Hodnett, 2003)(Hodnett, 2003)

Upright or lateral position Upright or lateral position (Gupta & Hofmeyr, (Gupta & Hofmeyr, 2003)2003)

Oxytocin for prolonged second stage Oxytocin for prolonged second stage (Saunders et al, 1989)(Saunders et al, 1989)

Delayed pushing Delayed pushing (Roberts et al, 2004)(Roberts et al, 2004)

When and when not to deliver When and when not to deliver instrumentallyinstrumentally

Indications:Indications:

Fetal compromise (actual or Fetal compromise (actual or anticipated)anticipated)

Prolonged second stageProlonged second stage

Where down-bearing is to be Where down-bearing is to be avoidedavoided

When and when not to deliver When and when not to deliver instrumentallyinstrumentally

Absolute contraindications:Absolute contraindications:

MalpresentationMalpresentationUnengaged fetal headUnengaged fetal head

Cephalopelvic disproportionCephalopelvic disproportionFetal clotting disorderFetal clotting disorder

GA < 34 wk (ventouse)GA < 34 wk (ventouse)

Safe practice: prerequisites Safe practice: prerequisites for instrumental deliveryfor instrumental delivery

FFully dilated cervixully dilated cervix OOne-fifth or nil palpable abdominallyne-fifth or nil palpable abdominally RRuptured membranesuptured membranes CContractions presentontractions present EEmpty bladdermpty bladder PPresentation and position knownresentation and position known SSatisfactory analgesiaatisfactory analgesia

Instrumental delivery before full Instrumental delivery before full cervical dilatationcervical dilatation

Crime or expedience?Crime or expedience?

SOGC: ‘may be considered when SOGC: ‘may be considered when benefits significantly outweigh risks’benefits significantly outweigh risks’

RCOG: exceptions to the rule - cord RCOG: exceptions to the rule - cord prolapse at 9 cm in a multip; second prolapse at 9 cm in a multip; second

twintwin

EngagementEngagement

Instrumental delivery should not Instrumental delivery should not be attempted if the lowest part of be attempted if the lowest part of the baby’s skull has not reached the baby’s skull has not reached

the ischial spines.the ischial spines.

Crichton D. South African Medical Journal 1974;12:784-7

Smellie W. A treatise on the theory and practice of Midwifery.

London; MDCCLII

Communication and consentCommunication and consent

Safe practice: abandonmentSafe practice: abandonment

Indications for abandonment:Indications for abandonment:

Difficulty in applying instrumentDifficulty in applying instrument

No descentNo descent

Delivery not imminent after three Delivery not imminent after three pullspulls

15 minutes elapsed15 minutes elapsed

Why is the principle of Why is the principle of abandonment frequently abandonment frequently

breached?breached?

Poor trainingPoor training

Confirmation biasConfirmation bias

Sunk costsSunk costs

Safe practice: recognise Safe practice: recognise conditions predictive of conditions predictive of

difficulty/failuredifficulty/failure

1/5 palpable 1/5 palpable Station 0Station 0

OP positionOP positionMoulding ++/+++Moulding ++/+++

Slow progressSlow progressBig babyBig babyBMI > 30BMI > 30

Trial of instrumental

delivery

Sequential instrumentationSequential instrumentation

Benefits and risks

Decision-making

Safe practice: post-operative Safe practice: post-operative carecare

Examine and observe the babyExamine and observe the baby

VTE risk assessmentVTE risk assessment

Bladder careBladder care

OpennessOpenness

Safe practice: Situational Safe practice: Situational awarenessawareness

DocumentationDocumentation

IndicationIndication Abdominal examination Abdominal examination

ConsentConsent Position; stationPosition; station

Moulding; caputMoulding; caput Pelvis adequatePelvis adequate

CTGCTG ContractionsContractions

Ease of application Ease of application No. of pullsNo. of pulls

DetachmentsDetachments DurationDuration

VE; PR post-deliveryVE; PR post-delivery Condition of babyCondition of baby

Cord pHCord pH Details of repairDetails of repair

Examples of error in Examples of error in instrumental deliveryinstrumental delivery

Action omitted, mistimed, misjudged:Action omitted, mistimed, misjudged:

Abdominal palpation not doneAbdominal palpation not doneProlonged tractionProlonged tractionContinuous tractionContinuous tractionRotation during a contractionRotation during a contractionTraction directed forwards and Traction directed forwards and upwards too soonupwards too soon

Examples of error in Examples of error in instrumental deliveryinstrumental delivery

Information wrong, incomplete or not Information wrong, incomplete or not retrieved:retrieved:

Mistaken head level or positionMistaken head level or position

Moulding not assessedMoulding not assessed

Equipment not checkedEquipment not checked

History of diabetes disregardedHistory of diabetes disregarded

Examples of error in Examples of error in instrumental deliveryinstrumental delivery

Procedural checks omitted or not properly Procedural checks omitted or not properly done:done:

No check for correct applicationNo check for correct application

No check for descent with pullNo check for descent with pull

PR/VE not done at end of procedurePR/VE not done at end of procedure

Swabs not countedSwabs not counted

Examples of error in Examples of error in instrumental deliveryinstrumental delivery

Faulty selection (choosing from options):Faulty selection (choosing from options):

Wrong ventouse cup typeWrong ventouse cup type

Ill-advised sequential instrumentationIll-advised sequential instrumentation

Examples of error in Examples of error in instrumental deliveryinstrumental delivery

Failure to communicate:Failure to communicate:

With womanWith woman midwifemidwife

senior obstetriciansenior obstetriciananaesthetistanaesthetist

paediatricianpaediatrician

Examples of error in Examples of error in instrumental deliveryinstrumental delivery

Cognition:Cognition:

Failure to anticipate ….PPH, Shoulder Failure to anticipate ….PPH, Shoulder dystocia, etc.dystocia, etc.

Failure to ask the right questions e.g. Failure to ask the right questions e.g. pulling in the right direction? … pulling in the right direction? …

forceps forceps applied on baby’s face?applied on baby’s face?

Training, competence supervisionTraining, competence supervision

Unmet training needsUnmet training needs

Demonstrable benefits of Demonstrable benefits of trainingtraining

Assessment toolsAssessment tools

‘Dr C stated that he discussed these options with Mr A and Mrs B and said that they were

happy for him to deliver their baby using forceps. Mr A and Mrs B considered that Dr C

did not communicate very effectively with them before or during the delivery. They said it

was often very difficult to hear and understand what he was saying, particularly because Dr

C directed most of his comments to Ms F.’

Assessment: occipito-posterior position, slightly to the right; presenting part slightly tilted.

‘Dr C applied the left blade of the forceps directly to the baby’s head, followed by the right blade. As the handles could not be aligned properly he removed the blades and reassessed the position of the head. At this stage, Mrs B’s buttocks were brought down further towards the edge of the bed and Dr C removed the foetal scalp electrode to enable easier application of the forceps.Dr C explained that after re-examination he was satisfied that the baby was in an occipito-posterior position and so he reapplied the forceps. He stated that this time the blades aligned without difficulty. Dr C attempted to rotate the baby’s head to the right but was unable to and so attempted rotation to the left, which was also unsuccessful’

While kneeling on the floor, Dr C applied force on the forceps during a contraction, in an attempt to pull the baby down in the occipito-posterior position while Mrs B was asked to push. Dr C explained that sometimes the head can be rotated at a lower level, or delivered in that position without the need for any rotation. He stated that only moderate traction was applied during this procedure and that he only used his right forearm while his left arm was resting on top of his right hand.

Mr A and Mrs B stated that Dr C pulled extremely firmly on the forceps and that Mrs B was dragged down the bed as a result. Dr C denied using any more force than wasnecessary or than he would normally use during such a procedure.

‘Other than a small laceration on the left cheek of the baby from the scalpel blade atthe time of the operation, I did not see any external forceps marks or bruises on thebaby’s head or the face at the time of delivery’. -Dr C

Cord blood was obtained but had clotted and was unsuitable for pH

analysis.

Baby born moribund. NICU. NND.

This was Mrs B’s second pregnancy and the pregnancy had been uneventful. Her first child had died of a congenital heartdefect (at 20 weeks’ gestation).

http://www.hdc.org.nz/files/hdc/http://www.hdc.org.nz/files/hdc/opinions/00hdc09324.pdfopinions/00hdc09324.pdf

Joint RCOG/ENTER MEETING

Risk Management and Medico-Legal Issues In Women’s Health

25 to 26 April 2007