Instrumental Deliveries powerpoint slides

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1. Instrumental Deliveries Rahel Demissew

2. Operative vaginal delivery (Instrumental) refers to applying direct traction to the fetal skull (forceps) or the fetal scalp (vacuum) along with maternal expulsive efforts to effect a vaginal delivery

3. The first instrumental deliveries were performed to extract fetuses from parturients who were at high risk of maternal mortality due to prolonged and/or obstructed labor In these cases, saving the mother's life took precedence over possible harm to the fetus. The focus of these procedures has changed Decisions regarding use of instrumental delivery are now based primarily upon the fetal/neonatal impact Incidence: 10-12% of all deliveries

4. Factors that might influence choice: The availability of the instrument, the degree of maternal anesthesia , and knowledge of the risks and benefits associated with each instrument. Level of training

5. Vacuum delivery easier to apply, place less force on the fetal head, require less maternal anesthesia, result in less maternal soft tissue trauma, do not affect the diameter of the fetal head compared to forceps.

6. Forceps unlikely to detach from the head, can be sized to a premature cranium, may be used for a rotation, result in less cephal hematoma and retinal hemorrhage, and do not aggravate bleeding from scalp lacerations.

7. Summary: Vacuum delivery is probably safer than forceps for the mother, while forceps are probably safer than vacuum for the fetus

8. Forceps DESIGN OF FORCEPS: basically consist of two crossing branches. each branch has four components: blade, shank, lock, handle

9. 1. blade Fenestrated Solid Each blade has two curves :- The pelvic curve corresponds more or less to the axis of the birth canal The cephalic curve conforms to the shape of the fetal head 2. shanks Parallel as in Simpson forceps, or Crossing as in Tucker–McLane

10. 3.Lock The English lock , consists of a socket located on the shank at the junction with the handle, into which fits a socket similarly located on the opposite shank A sliding lock is used in some forceps, such as Kielland forceps

11. Categories of Forceps Classic Forceps Parallel shanks: Simpson, DeLee , Irving, Hawks- Dennen Overlapping shanks: Elliott, Tucker-McLane Rotational Forceps Kielland (small pelvic curve, a sliding lock), Leff 3. Special Forceps Piper forceps(to allow application to the after-coming head in breech delivery ), Wrigley(in low or outlet delivery and in cesarean section delivery, short length) Barton(for deep transverse arrest in a platypelloid pelvis)

12. CLASSIFICATION OF FORCEPS DELIVERY: ACOG redefined the classification of forceps delivery in 1988 to better reflect the degree of difficulty and attendant risk. classification emphasizes two most important factors: Station (O to +5) and rotation (< / > 45 degree )

13. Classification of forceps delivery Outlet forceps Scalp is visible at introitus without separating the labia Fetal skull has reached pelvic floor Sagittal suture is in anteroposterior diameter or right or left occiput anterior or posterior position Fetal head is at or on the perineum Rotation does not exceed 45 degrees

14. 2. Low forceps Leading point of fetal skull is at station +2 cm, and not on pelvic floor Rotation is 45 degrees or less (left or right occiput anterior to occiput anterior, or left or right occiput posterior to occiput posterior) 3. Mid Forceps Station above +2 cm but head is engaged 4.High Forceps Not included in classification

15. Functions of Forceps delivery Traction: The most important function Rotation: may also be invaluable Delivery of after coming head: Vectis : at the time of c. section, a single  vectis  blade, to turn and elevate the occiput through the uterine incision

16. Indications for forceps delivery Maternal exhaustion Inadequate maternal expulsive efforts spinal cord injuries to avoid maternal expulsive efforts cardiac or cerebrovascular diseases Lack of maternal expulsive effort Fetal distress (NRFHRP) Prolonged 2nd stage of labor

17. Contraindications for forceps delivery Known fetal demineralizing diseases ( eg , osteogenesis imperfecta ), Fetal bleeding diatheses ( eg , hemophilia, alloimmune thrombocytopenia), Unengaged head, Unknown fetal position, Malpresentation ( eg , brow), and Suspected fetal-pelvic disproportion

18. Prerequisites for forceps delivery Presentation must be vertex or by face with the chin anterior 2. Head must be engaged 3. The position of the head must be known 4. The cervix must be fully dilated The membranes should be ruptured Adequate pelvis

19. APPLICATION OF FORCEPS: The long axis of the blades should corresponds to the occipitomental diameter Insert the left blade first.

20. STEPS IN FORCEPS DELIVERY 1. Two or more fingers of the right hand are introduced inside the left, posterior portion of the vulva and into the vagina beside the fetal head.

21. STEPS IN FORCEPS DELIVERY 2. The handle and branch are held at first almost vertically, but they are depressed as the blade adapts to the fetal head, eventually to a horizontal position.

22. STEPS IN FORCEPS DELIVERY 3. Similarly, two or more fingers of the left hand are then introduced into the right, posterior portion of the vagina to serve as a guide for the right blade, which is held in the right hand and introduced into the vagina.

23. STEPS IN FORCEPS DELIVERY 4. Then the horizontally positioned branches are articulated. Episiotomy may be done if indicated. proper placement Sagittal suture lies in the midline of the shanks No more than one finger can be placed between the fetal head and the blades or fenestrations on either side Posterior fontanelle is not more than onefinger’s breadth above the plane of the shanks (in OA position)

24. STEPS IN FORCEPS DELIVERY 5. More horizontal traction is applied, and the handles are gradually elevated, eventually pointing almost directly upwards as the parietal bones emerge.

25. FAILED FORCEPS DELIVERY Difficulty of articulation Failure of descent using appropriate force (arm)

26. COMPLICATIONS OF FORCEPS DELIVERY 1. Maternal lacerations 2. Minor external ocular trauma 3. Retinal hemorrhage 4. Fetal skull fractures 5. Facial nerve palsies 6. Cephalhematoma 7. Subaponeurotic hemorrhage 8. Intracranial hemorrhage 9. Scalp laceration

27. VACUUM DELIVERY Is an operative vaginal procedure to facilitate vaginal delivery with an application of a cup over the fetal head for brief duration and minimal traction forces. Vacuum Extractor: USA Ventouse : In Europe

28. VACUUM DELIVERY Principle traction on a metal cap designed = so that the suction creates an artificial caput, or chignon , within the cup that holds firmly and allows adequate traction.

29. VACUUM DELIVERY Instrumentation consists of a vacuum pump, a cup to attach to the fetal head some type of handle attached to the cup which is pulled to generate traction Pump Cup handle

30. generated manually or with an electrical suction device VACUUM DELIVERY 1. vacuum pump

31. Rigid- metal, rigid plastic, polyurethane, or polyethylene Soft- plastic, silicone, rubber, or polyethylene generated manually or with an electrical suction device VACUUM DELIVERY 1. vacuum pump 2. Extractor cup a rigid cup a soft cup

32. VACUUM DELIVERY 1. vacuum pump 2. Extractor cup 3. Handle Most cups have a relatively rigid rod connecting the handle & cup

33. INDICATIONS AND PRE-REQUISITES Are generally like that for forceps delivery except it is not used for face and breech presentation. VACUUM DELIVERY

34. INDICATIONS AND PRE-REQUISITES Are generally like that for forceps delivery except it is not used for face and breech presentation. VACUUM DELIVERY

35. INDICATIONS AND PRE-REQUISITES Are generally like that for forceps delivery Non- vertex presentations Extreme prematurity (generally, vacuum extraction is reserved for fetuses >=34 weeks) Recent scalp blood sampling CONTRAINDICATIONS VACUUM DELIVERY

36. TECHNIQUE OF VACUUM DELIVERY APPLICATION OF VACUUM CUPS: Ideal application “ Flexing Median ” when the center of the cup is superimposed on the flexion point ( 3 cm infront of the posterior fontanelle on the sagittal suture) and the cup is symmetrically placed over the sagittal suture.

37. TECHNIQUE OF VACUUM DELIVERY Determine the flexion point

38. TECHNIQUE OF VACUUM DELIVERY 2. Place the cup Spread the labia and introduce the cup by compressing and inserting it into the vagina while angling the device posteriorly.

39. TECHNIQUE OF VACUUM DELIVERY 2. Place the cup The entire 360º circumference of the cup must then be digitally inspected to insure that no vaginal, cervical, or vulvar tissues are trapped

40. TECHNIQUE OF VACUUM DELIVERY 2. Place the cup After correct placement of the cup is confirmed, vacuum pressure should be raised to 100-150 mmHg to maintain the cup's position.

41. TECHNIQUE OF VACUUM DELIVERY 3. Apply suction 500 to 600 mmHg have been recommended during traction, although pressures in excess of 450 mmHg are rarely necessary ( 80 kpa (0.8 kg/cm2).

42. TECHNIQUE OF VACUUM DELIVERY 4. Exert traction Traction is applied gradually as the contraction builds and is maintained for the duration of the contraction, but only in coordination with the mother's pushing

43. TECHNIQUE OF VACUUM DELIVERY 4. Exert traction Place a finger on the scalp next to the cup to assess the progress of descent and prevents cup detachment by counter pressure with the thumb

44. TECHNIQUE OF VACUUM DELIVERY 4. Exert traction Traction is applied along the axis of the pelvic curve to guide the fetal vertex, led by the flexion point, through the birth canal

45. TECHNIQUE OF VACUUM DELIVERY 4. Exert traction A maximum of 2 to 3 cup detachments, 3 sets of pulls for the descent phase, 3 sets of pulls for the outlet extraction phase a maximum total vacuum application time of 15 to 30 min are commonly recommended.

46. TECHNIQUE OF INSTRUMENTAL DELIVERY 1st pull  should cause flexion of the head and some descent = Dislodge 2nd pull  the head should be on the pelvic floor = Descent 3rd pull  delivery of the head should be complete or imminent = Deliver “3Ds”

47. COMPLICATIONS OF VACUUM DELIVERY Scalp laceration or bruising Subgaleal hematoma Cephalhematoma Intra-cranial hemorrhage Neonatal jaundice Subconjunctival hemorrhage Clavicular fracture Shoulder dystocia Injury to 6th and 7th cranial nerves

48. ODON DEVICE A new low-cost device for delivery of the fetus during prolonged second stage labour .

49. ODON DEVICE A new low-cost device for delivery of the fetus during prolonged second stage labour . The device is made of film-like polyethylene material and may be potentially safer and easier to apply than forceps and vacuum extractor (contraindicated in cases of HIV infection) for assisted deliveries.

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