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

2. Indications
Maternal Benefit – Shorten the 2nd stage of labor, decrease the amount of pushing
Ie: maternal cardiac conditions (Eisenmenger’s, pulmonary HTN) or history of aneurysm/stroke
Concern for immediate/potential fetal compromise
Ie: Prolonged terminal bradycardia
Prolonged 2nd stage
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

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

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
Designed to detach if traction is excessive (but can produce traction up to 50 lbs)
* 5% incidence serious complications
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

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

10. Forceps-Assisted Vaginal Delivery
Identify & apply blades
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
Lock blades
Should articulate with ease

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

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