1. INSTRUMENTAL DELIVERIES
Ghadeer Al-Shaikh, MD, FRCSC
Assistant Professor & Consultant
Obstetrics & Gynecology
Urogynecology & Pelvic Reconstructive Surgery

2. VACUUM /VENTOUSE

4. INDICATIONS MATERNAL Exhaustion Prolonged second stage
Cardiac / pulmonary disease
FETAL
Failure of the fetal head to rotate
Fetal distress in the second stage
Should not be used for preterm, face presentation or
breech
Instrumental deliveries
1-Indications for instrumental deliveries include
T1-Prolonged 2nd stage
T2-Fetal distress
F3-Transverse lie
F4-Compound presentation
T5-Maternal cardiac disease

5. MNEMONIC A – Anesthesia adequate B – Bladder  cathterization
C – Cervix  fully dilated / membranes ruptured
D – Determine  position, station, pelvic adequacy
E – Equipment  inspect vacuum cup, pump, tubing,
 check pressure
2-Prerequisite for instrumental delivery include
T1-Cervix must be fully dilated
T2-Membranes ruptured
F3-Fetal head not engaged
F4-Obstetrician unsure about position of the fetal
head due to caput
T5- Bladder empty/ cathetrized

6. MNEMONIC F – Fontanelle  position the cup over the posterior fontan
 low pressure 10 cm H2O initially & between cont
 sweep finger around cup to clear maternal tissue
 ↑ pressure to 60 cm H2O with the next contraction
G – Gentle traction  pull with contractions only
traction in the axis of the birth canal
ask the mother to push during cont

8. MNEMONIC H – Halt  halt traction if no progress with three traction
aided contractions
vacuum pops off three times
pulling for 30 min without significant progress
I – Incision consider episiotomy if laceration imminent
J – Jaw remove vacuum when jaw is reachable or
delivery assured

9. COMPLICATIONS
Vacuum –assisted delivery is less traumatic to the mother & fetus than forceps
Ventouse should be the instrument of choice
Maternal  Vaginal laceration due to entrapment of vaginal
mucosa between suction cup & fetal head
3-Complications of ventouse delivery
F1-Ventouse causes 3rd & 4th degree perineal tears more frequent than forceps
F2-Long term effects on neurological & intellectual development of children delivered by ventouse are evident by 4 years of age
T3-Cephalohematoma occur in up to 25% of babies
T4-Birth asphyxia is related to the force of traction
& prolonged procedure (time from application of
vacuum until delivery)
T5-Cephalohematomas may result in jaundice &
anemia of the neoborne

10. FETAL COMPLICATIONS Scalp injuries  abrasion & lacerations 12.6%
scalp necrosis %
Cephalohematoma  25%  jaundice /anemia
Intracranial hemorrhage  2.5%
Subgaleal hematoma

11. Fetal Complications

12. FETAL COMPLICATIONS Birth asphyxia  2.6-12%  related to extraction
force & time
Some studies showed decrease birth asphyxia
Retinal hemorrhage %
Forceps %
SVD %
Neonatal jaundice

13. FETAL COMPLICATIONS Fetal mortality 15/1000
Lower in cases delivered by vacuum 1.9%/ forceps
5.2 %
No long term effects on neurological psychomotor or intellectual development up to 4 years of age

14. FORCEPS

15. INDICATIONS MATERNAL Exhaustion Prolonged second stage
Cardiac / pulmonary disease
FETAL
Failure of the fetal head to rotate
Fetal distress
Control of the fetal head in vaginal beech delivery

16. CLASSIFICATION OF FORCEPS DELIVERY
Outlet forceps  Scalp visible at the vulva without
separating the labia
Low forceps  Vertex at +2 station
Midforceps  Head is engaged but leading part
above +2 station
 Sagittal suture not in the AP plane
of the mother
4-Forceps
T1-can be applied to the after coming head in
assisted vaginal breech delivery
T2-Can be applied to face presentation
T3-It is not contraindicated for preterm fetuses
T4-Can result in facial nerve damage of the fetus
T5-Is associated with a higher fetal mortality than
ventouse

17. CLASSIFICATION OF FORCEPS DELIVERY
Outlet  Wrigley’s
Outlet & low forceps  Simpson /Elliot
Midforceps & outlet  Tucker Mclane
Midforceps & rotation  Kielland
After coming head in breech  Piper

18. Simpsons

19. Piper

20. MNEMONIC A – Anesthesia adequate /epidural or pudendal
B – Bladder  cathterization
C – Cervix  fully dilated / membranes ruptured
D – Determine  position, station, pelvic adequacy
E – Equipment Know your forceps

21. MNEMONIC F – Forceps phantom application
Lt blade , LT hand, maternal Lt side pencil grip &
vertical insertion with Rt thumb directing blade
Rt blade , RT hand, maternal Rt side pencil grip &
vertical insertion with Lt thumb directing blade
Lock blades

23. MNEMONIC Check application:
Post fontanelle 1cm above the plane of the shanks
Sagittal suture lies in the midline of the shanks /perpindicular to the plane of the shanks
The operator can not place more than a fingertip between the fenestration of the blade & the fetal head on either side

24. MNEMONIC G – Gentle traction  applied with contraction & maternal
expulsive efforts
H – Hand elevated  traction in the axis of the birth canal
I – Incision  consider episiotomy if laceration
imminent
J – Jaw  remove forceps when jaw is reachable
or delivery assured

25. COMPLICATIONS Maternal  trauma to soft tissue 3rd/4th degree
double the risk compared to ventouse
bleeding from lacerations
trauma to urethra & bladder  fistula
Pain 17% ventouse 11%

26. COMPLICATIONS Fetal  bruising & laceration to the face
 Injury to the fetal scalp
cephalohematoma 9% Vent 25%
retinal hemorrhage 30% Vent 50%
 skull fracture
permanent nerve damage / Facial nerve
The risk of shoulder dystocia is increased following instrumental deliveries