Assisted vaginal birth.pptx Dr zweyan naing

Health

1. Assisted vaginal birth Green top guideline. 26 April 2020 BJOG 2020;127:e70-e112

2. Contents Type of consent Who should perform Who should supervised When should assisted vaginal birth be recommended/contraindicated Essential conditions for safety Role of ultrasound When discontinued forceps and how to manage What instruments should use When should vacuum assited birth discontinued and how should managed Role of episiotomy After care( antibiotics, thromboprophylaxis , analgesia, bladder care How can psychological morbidity be reduced What information be given What type of documentation How should serious adverse events be dealt with

3. 1. Type of consent Verbal consent for birth room procedure Written consent for trial of assisted vaginal birth in operation theatre Who should perform Performed by or presence of an operator who can complete procedure and manage complications that arise. Trainees should expertise in spontaneous birth to commencing in assisted vaginal birth. complex assisted vaginal birth only by experienced operators or direct supervision

4. 3. Who supervised An experienced operator 4. When recommended/contraindicated No indication is absolute, clinical judgment is required Suspected fetal bleeding disorder or predisposition to fracture are relative contraindication

5. Indication

6. 5. SAFETY CRITERIA Full abdominal and vaginal-examination Head is ≤ 1/5 palpable per abdomen (in most cases not palpable) Cervix is fully dilated and the membranes ruptured Station at level of ischial spines or below Position of the fetal head has been determined Caput and moulding is no more than moderate (or +2)a Pelvis is deemed adequate Preparation of mother -Clear explanation given and informed consent taken and documented in women’s case notes Trust established and full cooperation sought and agreed with woman Appropriate analgesia is in place: for midpelvic or rotational birth, this will usually be a regional block; a pudendal block may be acceptable depending on urgency; and a perineal block may be sufficient for low or outlet birth Maternal bladder has been emptied Indwelling catheter has been removed or balloon deflated Aseptic technique Preparation of staff - Operator has the knowledge, experience and skill necessary Adequate facilities are available (equipment, bed, lighting) and access to an operating theatre Backup plan: for midpelvic births, theatre facilities should be available to allow a caesarean birth to be performed without delay; a senior obstetrician should be present if an inexperienced obstetrician is conducting the birth Anticipation of complications that may arise (e.g. shoulder dystocia, perineal trauma, postpartum haemorrhage ) Personnel present who are trained in neonatal resuscitation

7. 6.Role of ultrasound insufficient evidence to recommend routine abdominal/ perineal ultrasound for assessment of station, flexion and descent of the fetal head in second stage of labour

8. 7 .What instruments should be Choice of instruments depends on clinical circumstance and expertise of the individual. Vacuum likely to have more failure and forceps make more perineal trauma. Rotational birth should be performed by experienced operator.

9. 8.When discontinued forceps and how should manage Forceps can’t be appied easily or handles do not approximate easily or lack of progressive descent with moderate traction Discontinue rotational forceps if rotation is not easy by gentle pressure Discontinue attempted forceps if birth is not imment following three pulls of correctly applied instruments by experienced operator Should inform neonatologist for failed attempt Aware that fetal head impaction, prepare to disimpact head using recognized manoeuvres

10. 9.When should vacuum assited birth discontinued and how should managed -no progressive descent with correct applied instrument by experienced operator -minimal descent with first two pulls, by less experienced operator, seek 2 nd opinion whether change approach or discontinue -Discontinue procedure if one pop-offs of instrument (less experienced operator) -Discontinue procedure if two pop-offs of instrument(experienced operator) -Inform neonatologist when sequential use of instrument -Aware of OASI

11. 10. Role of episiotomy When performing mediolateral episiotomy, 60 degree angle when the head is distending the perineum

12. 11. After care( antibiotics, thromboprophylaxis , analgesia, bladder care) -single prophylactic amoxicillin and clavulanic acid -good standards of hygiene and aseptic techniques - reaccess for risk of thromboembolism -NSAIDs and paracetamol routinely -educate patient about urinary retention post partum period Indwelling catheter in situ for patient with regional analgesia for assisted vaginal birth

13. Maternal outcomes: Episiotomy; vacuum, 50–60%; and forceps, more than or equal to 90%. Significant vulvo –vaginal tear; vacuum, 10%; and forceps, 20%. OASI; vacuum, 1–4%; and forceps, 8–12%. Postpartum haemorrhage ; vacuum and forceps, 10–40%. Urinary or bowel incontinence; common at 6 weeks, improves over time.

14. Perinatal outcomes: Cephalhaematoma ; predominantly vacuum, 1–12%. Facial or scalp lacerations; vacuum and forceps, 10%. Retinal haemorrhage ; more common with vacuum than forceps, variable 17–38%. Jaundice or hyperbilirubinaemia ; vacuum and forceps, 5–15%. Subgaleal haemorrhage ; predominantly vacuum, 3 to 6 in 1000. Intracranial haemorrhage ; vacuum and forceps, 5 to 15 in 10 000. Cervical spine injury; mainly Kiellands rotational forceps, rare. Skull fracture; mainly forceps, rare. Facial nerve palsy; mainly forceps, rare. Fetal death; very rare.

15. 12. How can psychological morbidity be reduced -share decision making, good communication, positive continuous support Offer advice and support women who have had traumatic birth Offer women with PTSD after 1 month, referral to skilled prefessionals

16. 13. What information be given Inform women that there is high probability of spontaneous vaginal birth Individual care of women with third & fourth-degree perineal tear

17. 14. What type of documentation -used a standard proforma including assessment, decision making, postnatal care, counselling -paired cord blood sample and record Report adverse outcomes, failed , major obstertric hemorrhage, OASI, shoulder dystocia and significant neonatal complocations

18. 15 . How should serious adverse events be dealt with? -obstetrician should ensure that the ongoing care of women and baby and family are paramount -have a duty of candour , professional responsibility to be honest with patient when things go wrong -should be contribute to adverse event reporting -Maternity unit should provide safe and supportive framework for women, their family and staff when serious adverse events occur

19. THANK YOU