ASSISTED VAGINAL DELIVERY · CLASSIFICATION OF OBSTETRIC FORCEPS AMERICAN COLLEGE OF OBSTETRICS &...

ASSISTED VAGINAL DELIVERY

OGUNLAJA A.O.

SENIOR LECTURER /OBSTETRICIAN GYNAECOLOGIST

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INTRODUCTION ASSISTED VAGINAL DELIVERY

WHEN VAGINAL DELIVERY REQUIRES MANOEUVRES THAT ORDINARILY ARE NOT DONE IN ROUTINE UNCOMPLICATED VAGINAL DELIVERY

ASSISTED VAGINAL DELIVERY CAN BE

• instrumental(operative) or

• non instrumental(non operative)

INSTRUMENTAL VAGINAL DELIVERY

When vaginal delivery requires the use of mechanical device(s)

common examples include • Forceps delivery

• Vacuum delivery

• Destructive operation

• Symphysiotomy

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• NON INSTRUMENTAL ASSISTED VAGINAL DELIVERY

• Assisted breech delivery

• Breech extraction

• Delivery following shoulder dystocia

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ASSISTED VAGINAL DELIVERY ESPECIALLY INSTRUMENTAL VAGINAL DELIVERY HAS EVOLVED OVER TIME. INCIDENCE VARIES WORLDWIDE.

VARIOUS FACTORS AFFECT INCIDENCE, THESE INCLUDES THE DECLINING SKILL , ADVENT OF CAESAREAN SECTION AND RISING MEDICOLEGAL CASES.

FORCEPS DELIVERY

• A tool designed to assist with the delivery of the baby’s head.

• Provide traction, rotation or both to the fetal head when the unaided expulsive efforts of the mother cannot or are insufficient to accomplish vaginal delivery.

• It is also useful in completing vaginal delivery of aftercoming head of a breech presenting fetus.

• Was first designed and used by- Chamberlain family in the 17th century

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history

• The chamberlain were french working in paris before they migrated to England in 1569 due to the religious violence in france.

• Williams and eldest son pierre practised in southampton

• Subsequently, there nephew Peter became the royal obstetrician, hence had this “secret” instruments used to assist in difficult delivery.

• This instruments underwent several modifications by mauriceau, smelliet, levret who described the pelvic curvature.

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DESIGN OF OBSTETRIC FORCEPS

• Has 2 blades which are introduced separately into the vagina

• the operator must check the pair of forceps to ensure that a matching pair has been provided and the blades lock with ease before application(ghosting)

• Parts- i) blades, ii) shank and lock and iii) the handle.

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• Blades- can be fenestrated, pseudofenestrated or solid, with a cephalic and pelvic curve.

designed to encase the fetal head and to lie within the pelvic cavity.

• Shank connects blade to handle, lock- convergent, divergent or sliding, situated on it helps to hold the 2 halves together.

• Handle- is grasped

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• Can be grouped into 2 depending on whether they are used for traction (eg. The Neville Barnes/ Simpson forceps) or for rotation (eg. Kieland’s forceps)

• ROTATIONAL FORCEPS have minimal pelvic curve to allow rotation around a fixed axis.

• NON-ROTATIONAL FORCEPS are used when the head is occipitoanterior

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CLASSIFICATION OF OBSTETRIC FORCEPS

AMERICAN COLLEGE OF OBSTETRICS & GYNAECOLOGY. • Forceps operations may be classified according to the station

and position of the fetal head at the time the forceps is applied (i.e Outlet, low or mid cavity )

1)OUTLET FORCEPS- fetal scalp is visible at the introitus without separating the labia. Fetal skull has reached the pelvic floor Sagittal suture is in the AP diameter/ Right/Left

Occipitoanterior/Occipitoposterior Fetal head is at/on the perineum Rotation is <45 degrees.

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CLASSIFICATION OF OBSTETRIC FORCEPS

2) LOW FORCEPS- leading point of fetal skull is at station +2/ > and not on the pelvic floor.

3) MID-FORCEPS- fetal head is engaged but leading point is above station +2. Rotation may be required in some cases.

• (NOTE: THE USE OF FORCEPS ON AN UNENGAGED HEAD IS CONTRAINDICATED.)

• BELOW ARE SOME EXAMPLES OF FORCEPS.

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PREPARING PATIENT FOR FORCEPS DELIVERY

• Counsel the patient and obtain a consent after establishing an indication and excluding contraindication.

• Inform the paediatrician, Anaesthesiologist , Midwives • Epidural analgesia may be required • Dorsal lithotomy position- legs on stirrups with flexed and abducted

hips • Apply a sterile pair of gloves • Empty the urinary bladder • Clean the vaginal and perineum and Drape abdomen and legs • Examination- position of fetal head, station of fetal head, adequacy

of pelvic diameter • Ghosting of the forceps • Stand by preparation for caesarean section

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Williams Obstetrics - 22nd Ed. (2005)

APPLICATION TECHNIQUE

• Goal- to fit the fetal head as evenly and symmetrical as possible

• Left blade is usually inserted before the right with the operator’s hand protecting the vaginal wall from direct trauma.

• With proper placement of the forceps blades, they come to lie parallel to the axis of the fetal head and between the fetal head and the pelvic wall.

• The blades are articulated and locked

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• Traction applied intermittently in concert with uterine contractions and maternal efforts

• The axis of traction changes during delivery and is guided along the “J” shaped curve of the pelvis.

• As the head begins to crown, the blades are directed

to the vertical and head is delivered.

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CONDITIONS FOR FORCEPS DELIVERY

a) Bladder must be empty

b) Cervix must be fully dilated

c) Membrane must be ruptured

d) Fetal head engaged with fetal head position known

e) No evidence of Cephalopelvic Disproportion.

f) Caesarean section capability

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CONDITIONS FOR FORCEPS DELIVERY

g) Adequate analgesia should be provided

h) Uterine contraction must be present- syntocinon to treat uterine atony in 2nd stage in the absence of disproportion.

i) Episiotomy is necessary

j) Experienced operator

k) Uterine rupture must have been excluded

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INDICATIONS OF FORCEPS DELIVERY

• MATERNAL

Delay in second stage of labour- malpositioning

Obstetric- pre-eclampsia, eclampsia

Medical- cardiac disease, pulmonary disease, sickle cell disease.

Conditions in which strenuous pushing is hazardous to the mother

Maternal exhaustion in second stage of labour

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INDICATIONS FOR FORCEPS DELIVERY

• FETAL

Fetal distress/ presumed fetal compromise- nonreassuring fetal heart rate in second stage of labour

Delivery of the after coming head in a breech presentation (Piper forceps)

Preterm delivery( Anderson forceps)

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AFTER COMING HEAD DELIVERY

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COMPLICATIONS OF FORCEPS DELIVERY

• MATERNAL

Damage to maternal soft tissue- abrasions to lacerations of uterus, cervix, vaginal and perineum.

VesicoVaginal Fistula, Rectovaginal Fistula, fecal incontinence may develop

PostPartum Haemorrhage

Increased risk for blood transfusion and its attendant complications

Infection

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• FETAL

Bruising of face and cephalhematoma, scalp lacerations, skull fractures and intracranial hemorrhage and seizures

Facial and brachial plexus palsies

Neonatal jaundice- breakdown of blood trapped in cephalhaematoma

• NOTE-Many of these injuries result from errors in judgment rather than lack of technical skill

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• The potential for injury increases due to POOR SKILL and POOR JUDGEMENT, this is particularly common in the following settings;

1. Intervention occurs too early

2. Continued traction is used in the presence of unrecognized CPD

3. Errors in diagnosis of the position of the fetal head

4. Unwillingness to abandon the procedure and perform C/S

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FORCEPS DELIVERY

• The use of forceps is becoming a lost art due to the following reasons;

1. Medicolegal implications and fear of litigation 2. Reliance on Caesarean section as a remedy for abnormal

labour and suspected fetal jeopardy 3. Perception that vacuum is easier to use and less risky 4. Decreased number of training programs in the use of

obstetric forceps 5. Improved safety of caesarean section 6. Increased acceptance of caesarean section 7. Change in perception as it concerns the obsession of

patients to achieve vaginal delivery at all cost

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VACUUM DELIVERY

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ventouse delivery /vacuum extractor Or vacuum extractor

• An instrument that employs a suction cup applied to the fetal head to produce traction which aids the maternal expulsive effort to effect vaginal delivery.

• Was 1st devised by James Yonge in 1705, 1st vacuum cup was designed in 1890

• Since then it has undergone several improvements • Malmstrong popularised it in the 50s • Bird modified it thereafter • It has evolved from metal to silastic cup • Consists of; Cup, Rubber tube/hose, Pump, Vacuum bottle

and Traction chain.

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VACUUM (PROCEDURE)

• ghosting/pretesting

• guided application

• apply some vacuum (0.2kg/cm2)

• exclude trapped maternal tissues

• apply needed vacuum pressure (0.8kg/cm2) or 550-600mmHg

• 2 handed technique

• traction along curve of birth canal

• traction to coincide with contractions

• proper cup placement essential

• flexure point/application distance

TECHNIQUE

• The cup is applied to the scalp

• Air is sucked out by means of the pump and rubber tube.

• A vacuum is created

• The air that has been sucked out from the cup passes through a vacuum bottle which has 2 uses;

Estimation of the level of vacuum

Deposition of accompanying fluids or secretions

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TECHNIQUE

• Cup should be applied to the point of flexure

• A pressure of not >0.8kg/cm2 is produced

• A perpendicular traction force is applied to the cup in the direction of the birth canal.

• This is timed with uterine contractions

• NOTE: if the fetus is not delivered with 3pulls in 20mins, the procedure should be abandoned.

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CONDITIONS FOR VENTOUSE DELIVERY

• Same as forceps delivery with the following exceptions;

A minimum of 8cm cervical dilatation was required in the past , but recent evidence allows for a full cervical dilatation to be reached before necessary traction is made.

Episiotomy is less necessary

Analgesia is not often required.

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INDICATIONS FOR VENTOUSE DELIVERY

• Similar to those of forceps delivery

• MATERNAL

Delay in second stage of labour- abnormal uterine action or failure of fetal head to rotate adequately

Obstetric- pre-eclampsia, eclampsia

Medical- cardiac disease, pulmonary disease, sickle cell disease.

Maternal exhaustion in second stage of labour

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• FETAL

Fetal distress/ presumed fetal compromise- nonreassuring fetal heart rate in second stage of labour

Completion of symphysiotomy (i.e delivery of the fetus)

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CONTRAINDICATIONS TO VENTOUSE DELIVERY

• Preterm delivery(<34wks) fetal head and scalp are prone to injury from suction cup

• Cephalopevic disproportion

• Face or breech presentation

• Congenital anomaly of fetal head- hydrocephalus

• Unengaged fetal head

• Obstructed labour

• Suspected fetal bleeding diatheses eg haemophilia

• HIV positive mothers

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COMPLICATIONS

• Vaginal laceration from entrapment of vaginal mucosa between the suction cup and the fetal head.

• Fetal scalp injuries- subaponeurotic hemorrhage, cephalohematoma (6%)

• Serious eye damage when used for face presentation= retinal hemorrhage (50%)

• Intracranial hemorrhage- 0.35%

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Portable vacuum devices

Do not apply rocking motion, 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

ADVANTAGES OF VENTOUSE OVER FORCEPS DELIVERY

1) Its easier to apply

2) Occupies less space in the pelvis

3) Requires little or no analgesia

4) Safer for both mother and fetus

5) Requires less skill

6) Encourages autorotation in malpositions of the fetal head

7) Less likely to cause maternal injury

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DISADVANTAGES OF VENTOUSE OVER FORCEPS DELIVERY

• Takes longer to assemble and apply (especially the non portable types)

• Requires maintenance and careful handling

• Less portable.

• Higher risk of shoulder dystocia

• Maternal effort is needed

• Greater incidence of fetal craniofacial injury

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CHALLENGES

• Failure may occur due to;

o Wrong choice of instrument

o Wrong positioning of the ventouse cup

o Position of fetal head was wrongly defined

o Fetus too large

o Poor maternal effort

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Vacuum versus Forceps

PARAMETER VACUUM FORCEPS

NEED FOR ANALGESIA REDUCED INCREASED NEED FOR EPISIOTOMY REDUCED INCREASED RISK OF PEERINEAL TRAUMA REDUCED INCREASED USE IN OCCIPITO-POSTERIOR POSITION ENCOURAGED DISCOURAGED EASE OF USE EASIER LESS EASY EASE OF TRANSPORT/ASSEMBLY/MAINTENANCE

LESS EASY EASIER

OCCUPATION OF VAGINAL SPACE REDUCED INCREASED PRESENTING PART OF FETUS ONLY CEPHALIC CEPHALIC & BREECH FULL CERVICAL DILATATION NOT NECESSARY NECESSARY AUTOROTATION ADDED ADVANTAGE NIL INBUILT SAFETY MECH PRESENT ABSENT DIFFERENTIAL COMPLICATION CEPHALHEMATOMA,RETINAL

HEMORRHAGE FACIAL N INJURY, PERINEAL SPHINCTERIC ANOMALY

DESTRUCTIVE OPERATION

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DESTRUCTIVE OPERATIONS

• Defined as a surgical procedure performed on a dead fetus in order to allow vaginal delivery.

• Aim is to deliver the baby as a whole or in piece meal.

• This practice is considered by some authorities as not dignifying though it still has a role in contemporary obstetrics.

• Prolonged obstructed labour is still prevalent in many developing countries= in some cases fetal death as C/S are culturally unacceptable, destructive operations

become imperative.

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CONDITIONS FOR DESTRUCTIVE OPERATIONS

• Fetus must be dead

• Bladder must be empty

• Cervix fully dilated

• Patient fully resuscitated

• Anaesthesia

• Uterine rupture must be excluded

• Operator ‘s skill

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TYPES OF DESTRUCTIVE OPERATIONS

1) CRANIOTOMY- hole created in fetal presenting head to extrude cranial contents and subsequent collapse of fetal head= delivery by traction.

It is indicated in after coming head in breech presentation or obstruction in a cephalic presentation.

Simpson’s perforator, Morris bone holding forceps, vulsella or Kocher’s forceps are used

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2) DECAPITATION- relief of obstruction in impacted transverse lie.

Neck is cut, fetal head and body are delivered separately.

Instrument used- Blond-Heidler Saw and thimble. Or embryotomy scissors.

Skilled operator is required

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3) CLEIDOTOMY- impaction of fetal shoulders, clavicles are cut to reduce size of shoulder girdle using stout scissors.

Indication includes traverse lie with impacted shoulder.

4) EMBRYOTOMY- complement to craniotomy and cleidotomy when fetus is large, incisions are made into thorax or abdomen to empty its content.

Indication includes congenital anomaly like gastroschisis, omphalocoele.

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COMPLICATIONS

Usually due to lack of skill of the operator the common complications that may occur includes

• PPH- injury to genital tract, laceration of cervix, vagina, perineum are common, rupture of uterus

• Sequelae from injury to adjacent structures VVF/ RVF- rupture of bladder and rectum

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BREECH DELIVERY

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BREECH DELIVERY

• Breech presentation occurs when the buttock of the fetus is occupying the lower uterine pole.

• In this case the presenting diameter is the bitrochanteric diameter as against the biparietal diameter.

• There are 3 types of breech delivery- assisted breech delivery, breech extraction and spontaneous breech delivery(this may happen in extreme preterms and should not be encouraged.)

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BREECH DELIVERY • ASSISTED BREECH DELIVERY

– MANUAL- – (Lovset) maneuvre. – (Mariceau Smelleit Veit) maneuvre/Burns Mashall

maneuvre. – FORCEPS ASSISTED especially for delivery of the

after coming head of breech with pipers forceps

• BREECH EXTRACTION here no maternal assistance is required, it is used in delivery of second twin, during caesarean delivery of a breech presenting foetus or in instances of suspectected fetal distress

SHOULDER DYSTOCIA

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SHOULDER DYSTOCIA • This is an documented difficulty in delivery of

the shoulder after the head has been delivered vaginally, this condition is associated with an increased risk of morbidity and mortality to the fetus and even the mother.

• WILL REQUIRE ASSISTED VAGINAL DELIVERY • VARIOUS MANOEUVRES TO EFFECT DELIVERY • The accoucher needs to be very familiar with

the steps towards uncomplicated delivery.

MAPS

• Mc Roberts maneuvre

• Anterior maneuvre

• Posterior maneuvre

• Salvage procedure

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M- Mc Roberts manouvre

• Needs an experienced obstetrician.

• Help should be summoned immediately.

• Generous episiotomy.

• Correct positioning of the mothers legs

– MC ROBERT’S MANOUVRE

• Maternal hips are abducted flexed and rotated outwards.

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• Two assistants are required to maintain this position.

• Thus the lumbosacral angle is straightened and the pubic symphisis is rotated superiorly.

• Mother should now push and

• Lateral neck traction restarted.

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A-Anterior manouvres

–An assistant places the flat of the hand behind the anterior shoulder and applies lateral suprapubic pressure. • The shoulder is dislodged from the pubic symphysis.

• The assistant must stand on the same side of the fetal spine to achieve this continuous pressure.

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• Internal rotation of the posterior shoulder

– The posterior shoulder is rotated 180 degrees in a corkscrew fashion towards its back so that the impacted anterior shoulder can be released (WOODS’ CORKSCREW MANOUVRE)

– Normal delivery of the baby is then completed by gentle neck traction and maternal expulsive effort.

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• RUBIN’S MANOUVRE – A modification to the woods’ manouvre.

– Recommends that either the anterior or posterior shoulder, which ever is more accessible, be adducted and brought towards the fetal chest.

– The operator places his hand on the posterior aspect (scapular) of the anterior or posterior shoulder and also rotates the baby 180 degrees to reduce the obstruction

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– Concurrent application of lateral supra pubic manouvre (RUBIN’S ORIGINAL MANOUVRE) .

– Attempt delivery through application of gentle downward traction in conjunction with maternal expulsive efforts.

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P-Posterior manouvres

• JACQUEMIER’S MANOUVRE OR BARNUM’S MANOUVRE

– Attempt to deliver the posterior arm and shoulder

– The attendant passes his hand up to the fetal axilla and the posterior shoulder is hooked down.

– Attempt to reach the cubital fossa and backward pressure on it disengages the arm.

– The arm is then brought down by getting hold of the hand and sweeping it across the chest.

– Disimpact the anterior shoulder.

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S-Salvage manouvre

• CLEIDOTOMY-delibrate fracture of the clavicle to reduce the bisacromial diameter.

• ZAVANELLI’S MANOUVRE

– Pushing the fetal head back in with performing a caesarean section.

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SYMPHYSIOTOMY

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SYMPHYSIOTOMY

• considered also by many to be obsolete

• originally used amongst rachitic dwarf

• Practised in Nigeria around Eboyin State.

• skill dying very fast

• largely overshadowed by caesarean section

• still very useful in less developed regions of the world

• May be used in patients with unrepentant aversion to caesarean section

• very safe in skilled hands

• reported complications usually exergerated

Procedure

• involves positioning of the patient in lithotomy

• Catheterization using a steep catheter

• Use of a zarate knife to divide the anterior fibres of the pubis symphysis

• Attempt is made to push the urethra laterally to prevent urethra injury

• An increase of about 2cm is achieved

• The head of the fetus is delivered completely by use of vacuum

• Immobilisation is necessary after the procedure

• Initial ambulation may be with a walking frame

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Thank you for listening

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ASSISTED VAGINAL DELIVERY · CLASSIFICATION OF OBSTETRIC FORCEPS AMERICAN COLLEGE OF OBSTETRICS &...

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