Operative obstrectric

operative procedure

1. OPERATIVES OBSTETRICS NUR FARRA NAJWA BINTI ABDUL AZIM 082015100035

2. OPERATIVE VAGINAL DELIVERY Refers to any delivery process which is assisted by vaginal operations. Delivery by Forceps Ventouse

3. FORCEPS Obstetric forceps is a pair of instruments Especially designed to assist extraction of the fetal head and thereby accomplishing delivery of the fetus. VARIETIES  OF  OBSTETRIC  FORCEPS:  Long -curved forceps with or without axistraction device Short -curved forceps Kielland’s forceps

4. LONG-CURVED OBSTETRIC FORCEPS Relatively heavy About 37 cm (15") long.  Das’s variety It is comparatively lighter and slightly shorter than its western counterpart Suited for the small pelvis and small baby of indian women.

5. Measurements: Length is 37 cm Distance in between the tips is 2.5 cm Widest diameter between the blades is 9 cm .

6. BLADES There are two blades Right or left in relation to maternal pelvis Each blade consists of the following parts: (1) blade (2) shank (3) lock (4) handle with or without screw. BLADE: The blade is fenestrated to facilitate a good grip of the fetal head. There is usually a slot in the lower part of the fenestrum of the blades to allow the upper end of the axis-traction rod to be fitted. The toe of the blade refers to the tip and the heel to the end of the blade that is attached to the shank.

7. CURVE The blade has got two curves

8. CURVE CEPHALIC CURVE It is the curve on the flat surface which when articulated grasps the fetal head without compression. The radius of the curve is 11.5 cm (4.5").

9. CURVE PELVIC CURVE The curve on the edge is to fit more or less the curve on the axis of the birth canal (curve of Carus ). It forms a part of a circle whose radius is 17.5 cm (7"). The front of the forceps is the concave side of the pelvic curve. Pelvic curve permits ease of application along the maternal pelvic axis.

10. SHANK It is the part between the blade and the lock and usually measures 6.25 cm (2.5"). It increases the length of the instrument and thereby, facilitates locking of the blades outside the vulva. When the blades are articulated, the shanks are not apposed together.

11. LOCK The common method of articulation consists of a socket system located on the shank at its junction with the handle (English lock). Such type of lock requires introduction of the left blade first.

12. HANDLE The handles are apposed when the blades are articulated. It measures 12.5 cm (5"). There is a finger guard on which a finger can be placed during traction.

13. SCREW A  screw   is  attached  usually  at  the  end  (or  at   the  base)  of  one  blade  (commonly  left ). It  helps  to  keep the blades in position.

14. HOW TO  IDENTIFY THE  BLADES WHEN ARTICULATED The blade which corresponds to the left of the maternal pelvis is the left blade and that to the right side is the right blade . WHEN ISOLATED ( 1) The tip  should  point  upwards (2 )  The   cephalic  curve  is  to  be  directed  inwards   and the pelvic curve forwards .

15. TYPES OF APPLICATION OF  FORCEPS BLADES CEPHALIC APPLICATION The blades are applied along the sides of the head grasping the biparietal diameter in between the widest part of the blades. The long axis of the blades corresponds more or less to the occipitomental plane of the fetal head. It is the ideal method of application as it has got a negligible compression effect on the cranium .

16. TYPES OF APPLICATION OF FORCEPS BLADES PELVIC APPLICATION When  the  blades  of the forceps are applied on the lateral pelvic walls ignoring the position of the head, it is called  pelvic  application.  If the head remains unrotated , this type  of  application puts serious compression effect on the cranium and thus must be avoided.

17. AXIS-TRACTION DEVICE It can be applied with advantage in midforceps operation, especially following manual rotation of the head. It provides traction in the correct axis of the pelvic curve and as such, less force is necessary to deliver the head. CONSISTS OF: (1) Traction rods (two—right and left) (2) Traction handle

18. Identification of  the  traction  rods—right  or  left? Hold the knob pointing inwards and let the rod hang. The small transverse bar at the bottom is to be directed forward .

19. 5 2 2

20. OUTLET FORCEPS It is a variety of low forceps where the head is on the perineum LOW FORCEPS The head is near the pelvic floor or even visible at the introitus . It is commonly used nowadays with advantages MIDFORCEPS Prerequisites are: Must be associated with less maternal morbidity than Cesarean section should not cause any fetal damage. Unless the prospect of successful vaginal delivery is high midforceps delivery is best avoided. Manual rotation may be needed before traction. In a selective case, delivery  by  rotational  forceps  by  an  expert  is safe. Otherwise, it is better to wait for the head descent and complete rotation. An oxytocin drip may be helpful if not contraindicated. Ventouse may be an alternative. CHOICE OF FORCEPS OPERATION

21. SHORT-CURVED OBSTETRIC FORCEPS (WRIGLEY) The instrument is lighter One third of the weight of an ordinary long-curved forceps.  The instrument is short which is due to reduction in the length of the shanks and handles . It has a marked cephalic curve with a slight pelvic curve.

22. Marked Cephalic Curve

23. KIELLAND’S FORCEPS It is a long almost straight (very slight pelvic curve) obstetric forceps without any axis-traction device. It has got a sliding lock which facilitates correction of asynclitism of the head. One small knob on each blade is directed towards the occiput . 

24. ASYNCLITISM

25. FORCEPS FUNCTION

26. LOW FORCEPS OPERATION PRELIMINARIES Same as those mentioned earlier The following are specially emphasized: Anesthesia : Pudendal block supplemented by perineal and labial infiltration with 1% lignocaine hydrochloride is quite effective in producing local anesthesia Catheterization Internal examination to assess : ( a) State of the cervix (b ) membranes status ( c) presentation and position of the head ( d) assessment of the pelvic outlet ( sacro-coccygeal plateau, TDO and subpubic arch ). Episiotomy : It is usually done during traction when the perineum becomes bulged and thinned out by the advancing head .

27. PRELIMINARIES ANESTHESIA —either general or local is used. In some cases, the operation may be performed with intravenous diazepam sedation. LITHOTOMY position. Full SURGICAL ASEPSIS  is to be taken: Surgical team is to wear sterile cap, mask, thorough hand wash and to wear gown and gloves Vulva and vagina are to be swabbed with antiseptic solution Cervix is cleaned with povidone -iodine solution Leggings. To empty the EMPTY  THE  BLADDER  before  she  is placed on the table or catheterization Vaginal examination  is done

28. Cont. Pudendal block or perineal infiltration with 1% lignocaine is sufficient. It may be applied even without anesthesia, especially in parous women.  The instrument should be assembled The vacuum is tested prior to its application

29. STEPS Identification of the blades and their application Locking of the blades Traction Removal of the blade

30. Step I Identification and application of the blades The identification of the blades is to be made after articulation as mentioned earlier The left or lower blade is to be introduced first The four fingers of the semi- supinated right hand are inserted along the left lateral vaginal wall, the palmar surface of the fingers rest against the side of the head  The fingers are used to guide the blade during application and to protect the vaginal wall. The handle of the left blade is taken lightly by three fingers of the left hand – index, middle and thumb in a pen holding manner and is held vertically almost parallel to the right inguinal ligament. The fenestrated portion of the blade is placed on the right palm with the tip (toe) pointing upwards. The right thumb is placed at the junction of the blade and the shank (heel). The blade is introduced between the guiding internal fingers and the fetal head, manipulated by the thumb.

31. Step I As the blade is pushed up and up, the handle is carried downwards and backwards, traversing wide arc of a circle towards the left until the shank is to lie straight on the perineum. Utmost gentleness is required while introducing the blade. No assistant is usually required to hold the handle in low forceps operation. When correctly applied, the blade should be over the parietal eminence, the shank should be in contact with the perineum and the superior surface of the handle should be directed upwards.

32. INTRODUCTION OF THE RIGHT BLADE The two fingers of the left hand are now introduced into the right lateral wall of the vagina alongside the baby’s head. The right blade is introduced in the same manner as with left one but holding it with the right hand.

33. Step  II Locking of the blades When correctly applied ( bimalar , biparietal placement) , the blades should be articulated with ease. Minor difficulty in locking can be corrected by depressing the handles on the perineum. In case of major difficulty, the blades are to be removed, the causes are to be sought for and the blades are to be reinserted. The handles should never be forced to lock them.

34. Step  III and IV Traction and removal of blades Before traction is applied, correct application of the blades is to be ensured . CORRECT APPLICATION IS EVIDENCED BY ( a) easy locking ( b) the blades are equidistant from the lambdoid suture ( c) firm gripping of the head on the biparietal diameter – as judged by a few tentative pulls.

35. PRINCIPLES Steady but intermittent traction should be given if possible during contraction. However , in outlet forceps the  pull may be continuous. Strong traction is not needed as the only resistance to overcome is the perineum and the coccyx

36. GRIPPING OF THE ARTICULATED FORCEPS DURING TRACTION The traction is given by gripping the handle, placing the middle finger in between the shanks with the ring and index fingers on either side on the finger guard. During the final stage of traction,  the four  fingers  are placed in between the  shanks and  the thumb  which is placed on the  under surface of the handles and exerts the necessary force.

37. DIRECTION OF THE PULL The direction of the pull corresponds to the axis of the birth canal In low forceps operation depending upon the station of the head, the direction of the pull is downwards and backwards until the head comes to the perineum. The pull is then directed horizontally straight towards the operator till the head is almost crowned . The direction of pull is  gradually changed to upwards and forwards, towards the mother’s abdomen to deliver the head by extension.  The blades are removed one after the other, the right one first.

38. FOLLOWING THE BIRTH OF THE HEAD Usual procedures are to be taken as in normal delivery. Routine injection oxytocin 10 iu , im or intravenous methergine 0.2 mg is to be administered with the delivery of the baby. Episiotomy is repaired in the usual method . Lacerations on the vaginal walls or perineum are to be excluded

39. OUTLET FORCEPS OPERATION Wrigley’s forceps Used exclusively in outlet forceps operation. Perineal and vulval infiltration with 1% lignocaine is enough for local anesthesia. The blades are introduced as in the low forceps operation with long-curved forceps except that two fingers are to be introduced into the vagina for the application of the left blade. Traction is given holding the articulated forceps with the fingers placed in between the shanks and the thumb on the under surface of the handles.  The direction of the pull is straight horizontal and then upwards and forwards

40. MIDFORCEPS OPERATION The   most  common  indication  of midforceps operation is following manual rotation of the head in malrotated occipitoposterior position . The commonly used forceps is long curved one with or without axis-traction device Kielland is useful in the hands of an expert

41. Procedures General anesthesia is preferable. INTRODUCTION OF THE BLADES The introduction of the blades is to be done after prior correction of the malrotation . (A)  WITHOUT AXIS-TRACTION DEVICE:   The blades are introduced as in the low forceps operation.  An assistant is required to hold the left handle after its introduction

42. Procedures B) WITH AXIS-TRACTION DEVICE While applying the left blade, the traction-rod already attached to the blade is held backwards. During introduction of the right blade, the traction-rod must be held forwards otherwise it will prevent locking of the blades.  

43. Procedures TRACTION (A) WITHOUT AXIS-TRACTION DEVICE The direction of pull is first downwards and backwards, then (horizontal or straight pull) and finally upwards and forwards  (B) WITH AXIS-TRACTION DEVICE  The traction handle is to be attached to the traction rods.  During traction,  the traction rods should remain parallel with the shanks.  When  the base of the  occiput comes  under the symphysis pubis, the traction-rods are to be removed

44. FORCEPS IN OCCIPITO-SACRAL POSITION Usual application of the blades as like that of occipitoanterior position is made.  The blades should lie equidistant from the sinciput and occiput , otherwise the blades may slip during traction. Horizontal traction is given until the root of the nose is under the symphysis pubis . The direction is changed to upwards and forwards to deliver the occiput . By a downward movement of the instrument, the nose and chin are delivered.

45. FORCEPS IN FACE PRESENTATION Forceps delivery is only reserved for mentoanterior position. The blades are applied as in occipitoanterior position. But the handles should be kept well forward to avoid grasping of the neck by the tips of the blade. Traction is made like that of occipitoanterior to bring the chin well below and then round the symphysis pubis .

46. APPLICATION OF FORCEPS TO THE AFTER-COMING HEAD The head must be in the cavity.  THE ADVANTAGES (a) Delivery can be controlled by  giving pull directly on the head and the force is not transmitted through the neck, ( b) Flexion is better maintained and ( c) Mucus can be sucked out  from the mouth more effectively.

47. PIPER FORCEPS  A specialized  forceps,used  to assist  the delivery of the after-coming  head  of  breech.  It  has  a cephalic curve, reverse pelvic curve, long parallel shanks that permit the baby’s body to rest against it during head delivery.

48. Procedure The head should be brought as low down  as possible by  allowing the baby  to hang by  its own weight  aided by  suprapubic pressure .  When the occiput lies  against  the back of the symphysis pubis ,  an assistant raises the legs of the child as much to facilitate introduction of the blades from below. Too much elevation of the trunk may cause extension of the head. The forceps pull maintains an arc, which follows the axis of the birth canal Piper forceps is especially designed (absent pelvic curve) for use in this condition. The head should be delivered  slowly (over 1 minute) to reduce  compression-decompression forces as that may cause intracranial bleeding

49. KIELLAND’S FORCEPS it is an useful and preferred instrument.  ITS ADVANTAGES ( 1)  It can be  used  with  advantages in  unrotated   vertex  or  face  presentation (2)  facilitates grasping and  correction  of asynclitic head because of its sliding lock

50. IDENTIFICATION OF  THE BLADES The articulated blades are to be held in front of the vulva in a position to be taken up when applied to the head. The concavity of the slight pelvic curve should correspond to the side towards which the occiput lies The blades are named anterior and posterior.  The anterior blade is to  be  introduced first.

51. METHODS OF APPLICATION There are three methods: (1) Classical (obsolete) (2) Wandering (3) Direct Indications  of rotational forceps are few. It is commonly used in deep transverse arrest with asynclitism of the fetal  head.

52. Wandering method is popular ! The  anterior  (superior)  blade  is  applied  first.  The  blade  is  inserted along the side wall of the pelvis and then wandered by swinging it round the fetal face to its anterior position . The posterior blade is inserted directly under guidance of the right hand placed between the head and the hollow of the sacrum. The forceps handles are depressed down and the handle tips are brought into alignment to correct the asynclitism . The occiput is rotated anteriorly . Slight upward dislodgement of the head may facilitate rotation. The position is rechecked and traction is applied. Sitting on a low foot stool or kneeling is convenient for the operator.

53. LIMITATIONS Because of complexity in the technique of its application, one should be sufficiently trained before independent use.

54. DIFFICULTIES IN  FORCEPS OPERATION The difficulties are encountered mainly due to faulty assessment of the case before the operative delivery is undertaken . However, there is hardly any difficulty in low forceps operation .

55. During application of the blades (1) Incompletely dilated cervix (2) unrotated or nonengaged head.

56. Difficulty in locking (1) Application in unrotated head (2) Improper insertion of the blade (not far enough in) (3) Failure to depress the handle against the perineum and (4) Entanglement of the cord or fetal parts inside the blades

57. Difficulty in traction (1) Undiagnosed occipitoposterior position (2) Faulty cephalic application (3) Wrong direction of traction (4) Mild pelvic contraction and (5) Constriction ring.

58. Slipping of the blades (1) The blades are not introduced far enough in (2) faulty application in occipitoposterior position.  The blades should be equidistant from the sinciput and occiput .

59. HAZARDS FETAL Facial bruising, Laceration, Facial nerve palsy, Skull fractures, Intracranial hemorrhage.

60. HAZARDS MATERNAL Perineal sulcus tear, Complete perineal tear.  Deep mediolateral episiotomy is mandatory.

61. COMPLICATIONS OF FORCEPS OPERATION The complications of the forceps operation  are mostly related to the faulty technique and to the indication for which the forceps are applied rather than the instrument.

62. PROPHYLACTIC FORCEPS (ELECTIVE)  It refers  to forceps  delivery only to  shorten the second stage of labor when maternal and/or  fetal complications are anticipated. INDICATIONS (1) Eclampsia (2) heart disease (3) previous history of cesarean section (4) postmaturity (5) low-birth-weight baby (6) to curtail the painful second stage and (7) patients under epidural analgesia. It prevents possible fetal cerebral injury and spares the mother from the strain of bearing down efforts.  Prophylactic forceps should not be applied until the criteria of low forceps are fulfilled

63. TRIAL FORCEPS It  is  a  tentative  attempt  of forceps  delivery in  a case of  suspected midpelvic contraction The procedure should be conducted in an operation theater The conduct of trial forceps requires great deal of skill and judgment If moderate traction leads to progressive descent of the fetal head, the delivery is completed vaginally, if not cesarean section is done immediately

64. CONDITIONS  FOR  TRIAL OF  FORCEPS (1) Maternal obesity (BMI ≥ 30) (2) Clinically big baby  (wt ≥ 3 kg) (3) Occipitoposterior position (4) Mid-cavity delivery (5) When 1/5th fetal head palpable per abdomen.

65. FAILED FORCEPS When a deliberate attempt in vaginal delivery with forceps has failed to expedite the process,  it is called failed forceps. (3 ATTEMPTS IN 15 MINUTES INTERVAL)

66. Causes (1) Incompletely dilated cervix (2) Unrotated occipitoposterior position (3) Cephalopelvic disproportion (4) Unrecognized malpresentation (brow) or hydrocephalus (5) Constriction ring (6) Clinically big baby (≥  4 kg) (7) Maternal BMI  ≥  30 and (8) In a case with midcavity delivery.

67. PREVENTION It is a preventable condition. Only through skill and judgment, proper selection of the case ideal for forceps can be identified.  Even if applied in wrong cases ,  one should resist the temptation to give forcible traction in an attempt to hide the mistake.

68. MANAGEMENT (1) To assess the effect on the mother and the fetus (2) to start a Ringer’s solution drip and to arrange for blood transfusion (3) to administer parenteral antibiotic (4) to exclude rupture of the uterus (5) the procedure is abandoned and delivery is done by cesarean section and (6) laparotomy should be done in a case with rupture of uterus. 

69. REFERENCES Mudaliar and Menon’s Clinical Obstetrics, 11 th edition, Sarala Gopalan and Vanita Jain, Ventouse DC Dutta’s Textbook of Obstetrics, 9 th edition, Hiralal Konar , Ventouse Essential Of Obstrectric , Lakshmi Seshadri , Gita Arjun , Ventouse