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

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Presentation on theme: "Operative Vaginal Delivery District 1 ACOG Medical Student Teaching Module 2011."— Presentation transcript:

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

2 Indications  Maternal Benefit – 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 Ie: maternal cardiac conditions (Eisenmenger’s, pulmonary HTN) or history of aneurysm/stroke  Concern for immediate/potential fetal compromise Ie: Prolonged terminal bradycardia Ie: Prolonged terminal bradycardia  Prolonged 2 nd stage Nulliparous = No progress for 3 hrs w/epidural or 2 hours w/o epidural 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 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 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 Fetal Risks: VAVD  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 Designed to detach if traction is excessive (but can produce traction up to 50 lbs) * 5% incidence serious complications

9 Type of Forceps Delivery  Outlet forceps Scalp visible at introitus w/o separating labia Scalp visible at introitus w/o separating labia Fetal skull reached pelvic floor & head at/on perineum Fetal skull reached pelvic floor & head at/on perineum Sagittal suture in AP diameter or LOA, ROA, or posterior position Sagittal suture in AP diameter or LOA, ROA, or posterior position rotation does not exceed 45º rotation does not exceed 45º  Low forceps Leading point of fetal skull at >= +2, not on pelvic floor 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. 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 Above +2 cm but head engaged  High forceps Head not engaged; not included in ACOG classification Head not engaged; not included in ACOG classification Not recommended Not recommended

10 Forceps-Assisted Vaginal Delivery  Identify & apply blades Place instrument in front of pelvis with tip pointing up & pelvic curve forward 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 Apply left blade, guided by right hand, then right blade with left hand  Lock blades Should articulate with ease Should articulate with ease

11 FAVD  Check for correct application Sagittal suture in midline of shanks Sagittal suture in midline of shanks Cannot place more than one fingertip between blade and fetal head Cannot place more than one fingertip between blade and fetal head  Apply traction Steady and intermittent Steady and intermittent Downward and then upward Downward and then upward Remove blades as fetus crowns Remove blades as fetus crowns

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

14 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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