Rukset Attar, MD, PhD Department of Obstetrics and Gynecology OPERATIVE DELIVERY Rukset Attar, MD, PhD Department of Obstetrics and Gynecology

can be divided into operative vaginal delivery and cesarean delivery Operative Delivery refers to an obstetric procedure in which active measures are taken to accomplish delivery can be divided into operative vaginal delivery and cesarean delivery Forceps Vacuum Extraction Cesarean section

Obstetric Forceps Obstetric forceps is an instrument designed to assist with delivery of the baby's head. The primary functions of the forceps are to assist with traction of the fetal head and/or to assist with rotation of the fetal head to a more desirable position.

Obstetric Forceps

Obstetric Forceps

Obstetric Forceps Simpson or Elliot forceps are most often used for outlet vaginal deliveries, whereas Kielland or Tucker-McLane forceps are used for rotational deliveries. Piper forceps are used in the United States for delivery of the aftercoming head. The pelvic and cephalic curve, shank, blade, lock, and handle are different for each type of forceps

Obstetric Forceps Piper forceps, which are specifically designed for breech deliveries, have a reverse pelvic curve compared to other forceps. Simpson forceps are suited for application to the molded fetal head Tucker-McLane forceps or Kielland forceps are more appropriate for application to the fetal head with little or no molding

Obstetric Forceps

Indications for forceps delivery nonreassuring fetal heart rate pattern shortening of the second stage of labor for fetal or maternal reasons prolonged second stage of labor not due to dystocia In a nulliparous patient - more than 3 hours with a regional anesthetic/more than 2 hours without a regional anesthetic. In a multiparous patient - more than 2 hours with a regional anesthetic or more than 1 hour without a regional anesthetic. delivery of the aftercoming head in a breech presentation.

Prerequisites for a forceps-assisted vaginal delivery In order for a patient to be considered a candidate, all of the following must be met: complete cervical dilatation ruptured membranes vertex presentation fetal head engaged with the fetal head position known empty bladder no evidence of cephalopelvic disproportion adequate analgesia cesarean section capability and an experienced operator

The classification of forceps Outlet forceps is the application of forceps when the fetal scalp is visible at the introitus without separating the labia, the fetal skull has reached the pelvic floor, the sagittal suture is in the anteroposterior diameter or in the right or left occiput anterior or posterior position, and the fetal head is at or on the perineum. According to this definition, rotation of the fetal head must be equal to or less than 45 degrees.

The classification of forceps Low forceps is the application of forceps when the leading point of the fetal skull is at station +2 or greater and not on the pelvic floor. Low forceps have two subdivisions: rotation less than or equal to 45 degrees and rotation greater than 45 degrees. Midforceps is the application of forceps when the head is engaged but the leading point of the fetal skull is above station +2.

Complications Maternal complications include lacerations of the vagina and cervix episiotomy extensions involving third- and fourth-degree lacerations pelvic hematomas urethral and bladder injuries uterine rupture blood loss and the need for blood transfusion are increased in forceps deliveries.

Neonatal complications minor facial lacerations forceps marks, facial and brachial plexus palsies, cephalhematomas, skull fractures, intracranial hemorrhage, and seizures.

Vacuum Extractor the indications for vacuum use are similar to those of forceps. the classification of forceps deliveries is the same classification used for vacuum deliveries, and the prerequisites are similar.

Vacuum Extractor

Contraindications for vacuum delivery place the cup directly over the sagittal suture at the median flexion point located approximately 3 cm anterior to the posterior fontanelle approximately 600 mmHg at the beginning of a uterine contraction. If more than 1 contraction is necessary, the vacuum pressure can be decreased to low levels between contractions.

Contraindications for vacuum delivery While the fetal head is delivering, the cup should assume a 90-degree orientation to the horizontal as the head is extended. Once the head has completely delivered through the vagina, the suction is withdrawn and the cup removed

Contraindications for vacuum delivery face presentation, breech presentation, true cephalopelvic disproportion, congenital anomalies of the fetal head (eg, hydrocephalus), gestational age less than 34 weeks or estimated fetal weight less than 2000 g, estimated fetal weight greater than 4000 g, and an unengaged fetal head.

Complications neonatal retinal hemorrhage -most common-50%-rarely has any clinical significance. Cephalhematoma involves bleeding beneath the periosteum and complicates approximately 6% of all vacuum deliveries. Subgaleal hematoma, a more serious complication, occurs in 50 of 10,000 vacuum deliveries-bleeding occurs in the loose subaponeurotic tissues of the scalp - there is the potential for life-threatening hemorrhage-The subgaleal space actually extends from the orbits of the eyes to the nape of the neck. This potential space can occupy over half of a newborn's blood volume. Intracranial hemorrhage occurs in approximately 0.35% of vacuum deliveries. It can be a catastrophic complication that includes subdural, subarachnoid, intraventricular, and/or intraparenchymal hemorrhage.

Cesarean Section A cesarean section refers to the delivery of a fetus, placenta, and membranes through an abdominal and uterine incision. The first documented cesarean section on a living person was performed in 1610. The patient died 25 days later.

Cesarean Section Abd wall insition transverse (Pfannenstiel) incision Classical cesarean section is the simplest to perform. is associated with the greatest loss of blood and may result in uterine rupture with subsequent pregnancies accepted indications for classical cesarean section are placenta previa, transverse lie (especially back down), and preterm delivery in which the lower uterine segment is poorly developed A classical cesarean section may be preferred if extremely rapid delivery is needed

Cesarean Section low-transverse uterine incision Less blood loss Less frequently result in uterine rupture with subsequent pregnancies

Cesarean Section Maternal indications repeat cesarean delivery; obstructive lesions in the lower genital tract including malignancies, large vulvovaginal condylomas, obstructive vaginal septa, and leiomyomas of the lower uterine segment that interfere with engagement of the fetal head; and pelvic abnormalities that preclude engagement or interfere with descent of the fetal presentation in labor.

left heart valvular stenosis, dilated aortic valve root, certain cerebral AVMs, and recent retinal detachment. Women with a prior vaginal or perineal reparative surgery, such as colporrhaphy and repair of major anal involvement from inflammatory bowel disease

Fetal indications Malpresentation Twin gestations Congenital anomalies: fetal neural tube defects hydrocephalus with an enlarged biparietal diameter, and some skeletal dysplasias such as type III osteogenesis imperfecta. a fetal abdominal wall defect (ie, gastroschisis and omphalocele Fetal distress Maternal infections Human immunodeficiency virus infections

Abnormal placentation, Abruptio placenta Cord prolapsus or presentation Transvers presentation Oblique presentation Breech presentation

most common complications that result from cesarean section are postpartum hemorrhage, endometritis, and wound infection.