OPERATIVE VAGINAL DELIVERY FORCEPS AND V

OPERATIVE VAGINAL DELIVERY

1. OPERATIVE VAGINAL DELIVERY

2. CONTENTS INTRODUCTION, HISTORY EPIDEMIOLOGY DESIGN OF FORCEPS FUNCTION CLASSIFICATION INDICATION/CONTRAINDICATION PREREQUISITES APPLICATION(OA,OT,OP,FACE) VACUUM EXTRACTOR CHOICE OF INSTRUMENT COMPLICATIONS

3. INTRODUCTION Operative vaginal delivery (OVD) refers to a delivery in which the operator uses forceps or a vacuum device to assist the mother in transitioning the fetus to extrauterine life. The instrument is applied to the fetal head and then the operator uses traction to extract the fetus, typically during a contraction while the mother is pushing.

4. EPIDEMIOLOGY YEAR CS(%) OVD(%) 1987 22.8 9 1997 20.8 9.4 2002 8 The rate of cesarean deliveries Vs operative vaginal deliveries in the U.S , 1987-1997

5. Of this number, the percentage of forceps deliveries has decreased Conversely, the rate of vacuum-assisted vaginal delivery more than doubled in the US b/n 1980 and 2000 to 8.4 %. U.S, 1992, vacuum > forceps deliveries 2000, ~2/3 of OVD were by vacuum

6. Decisions regarding use of instrumental delivery are now based primarily upon the fetal/neonatal impact of these procedures and are weighed against the alternative options of C esarean birth E xpectant management (prolonging the second stage) A ugmentation of contractions with oxytocin .

7. CLASSIFICATION OF FORCEPS DELIVERIES 1949, Titus created a classification that permitted GPs to perform OVD without consultation. By dividing the pelvis into thirds from the spines to the inlet and, in the opposite direction, in thirds to the outlet.

8. CLASSIFICATION cont… 1952, Dennen proposed an alternative based on the 4 major obstetric planes of the pelvis: high forceps Midforceps low- midforceps Outlet forceps

9. CLASSIFICATION cont… 1965, the ACOG created a classification system that defined Midforceps too broadly (from the spines to the pelvic floor and any rotation) and outlet forceps too narrowly defined ?? Most clinicians

10. CLASSIFICATION cont… 1988,ACOG redefined classification of forceps, to better reflect the degree of difficulty and attendant risk, by giving emphasizes on the 2 most important discriminators of risk for both mother and infant: Station& Rotation

11. Criteria for Types of Forceps & Vacuum Deliveries, AAP & ACOG Outlet forceps Scalp is visible at the interoites without separating labia. Fetal skull has reached pelvic floor. Sagital suture is in AP diameter or Rt or Lt occiput anterior or posterior position Fetal head is at or on perineum Rotation doesn’t exceed 45 o

12. Low forceps Leading point of fetal skull is at station >=+2cm & not on the pelvic floor. Rotation is 45 o or less (LOA or ROA to OA, or LOP or ROP to OP). Rotation is greater than 45 o . Midforceps Sation is above +2cm but head is engaged High forceps- Not included

13. Design > 700 varieties of forceps instruments, most of them are of historic interest only broadly categorized according to their intended use: “classic” forceps, rotational forceps, and specialized forceps designed to assist vaginal breech deliveries. sliding lock is helpful when there is asynclitism .

14. Design cont… basically consist of 2 crossing branches that articulate or "lock" . Each branch has 4 components: blade, shank, lock, and handle. Each blade has 2 curves: Cephalic curve vs. Pelvic curve solid, fenestrated, or pseudofenestrated The tip of each blade is called the toe.

15. Forceps to assist with delivery of the aftercoming head during vaginal breech delivery (Piper forceps) have a cephalic curve, a reverse pelvic curve, long parallel shanks and an English lock. This design provides easy application to the aftercoming head, stabilizing and protecting the fetal head and neck during delivery. The long shanks permit the body of the breech to rest against it

16. Function of Forceps 4 purposes Compression Extraction Rotation Victis

17. Function cont… Compression – Forceps are primarily for extraction. To accomplish this, there must be a certain amount of compression. Occasionally, however, the operator has particular intent in the use of forceps for compression, e.g.; in the delivery of hydrocephalic dead fetus . (destructive instruments are in the main better suited for such case )

18. Function cont… Extraction - The direction and dexterity of pool on forceps contributes to the ease and finesse of forceps delivery. station vs. plane of the pelvis The direction of pool at any given level should be perpendicular to the plane of that level .

19. Function cont… b/c of the pelvic curvature the line of proper traction must continually change with descent of the head within the pelvis.  the higher the forceps are applied, the greater must be the downward pool The operator should be in a single kneeling position or sitting on a low stool The arms, wrists, and hands should be in a continued straight line extension of the traction rods

20. Rotation xzed as having a cephalic curve amenable to application to the molded vertex, and either only a slight pelvic curve or none at all. include some of the classic instruments (e.g., Tucker-McLane) and those with minimal pelvic curvature (e.g., Kielland and Leff ) 1916, C. Kielland of Norway

21. Vectis One forceps blade may be used as a vectis to assist in delivery of the head at the time of CD Also possible to use as a side prop or vectis in aiding rotation for otherwise SVD Murless head extractor-preferred

22. ACOG outlined the following, recognizing that no indication is absolute CS is also an option in these clinical settings Prolonged second stage of labor Nonreassuring fetal status Maternal cardiopulmonary or cerebrovascular disease . Indication

23. Ethiopian FMOH- Indication Prolonged second stage To shorten the second stage in cases with Maternal distress Preeclampsia, eclampsia Cardiac or pulmonary diseases Glaucoma, Cerebrovascular diseases: aneurysm, CVA Fetal distress and cord prolapse After-coming head in breech presentation

24. Prerequisites The operator should be an individual experienced in OVD. 1, The cervix is fully dilated 2, The membranes are ruptured 3, The head is engaged ( station of +2 or below ) 4, Fetal presentation, position, lie, and any asynclitism are known precisely. The fetus must be in a vertex presentation(OA,OP) (unless after coming head, face MA )

25. 5, Clinical pelvimetry shows adequate mid and outlet pelvic dimensions, and no obstructions or CPD exist. 6, Maternal anesthesia is satisfactory. 7, Maternal bladder is empty 8, The patient consents to the procedure 9, The option of performing an immediate CS should be available if complications arise

26. Most CI to instrumental delivery are related to the potential for unacceptable fetal risks Fetal prematurity is a relative CI Some other contraindications include fetal demineralizing diseases fetal bleeding diatheses unengaged head unknown fetal position malpresentation suspected fetal-pelvic disproportion Contraindications  (CI)

27. A NRFHRP is not a CI to OVD Vacuum devices should not be used to assist delivery prior to 34 weeks of gestation. Prior scalp sampling or multiple attempts at fetal scalp electrode placement are also relative CI to vacuum extraction Vacuum is also not recommended to perform a rotation. CI cont…  

28. 2 forceps are available which are smaller in dimension than standard forceps and are intended for use in the low birth weight or very low birth weight populations. "Baby" Elliot and "baby" Simpson forceps are among these instruments . F orceps have been used on fetuses as small as 1Kg

29.   If an attempt at OVD is anticipated to be difficult, it should be considered a trial. With an operating room both equipped and staffed for immediate C/S, the trial may proceed. Unless the preoperative assessment is highly suggestive of successful outcome, trial of OVD is best avoided If the application is unsatisfactory, then abandone the forceps and go for either VE or C/S. Once application has been achieved, gentle downward pulls are made on the forceps. If there is no descent, the procedure is abandoned . TRIAL OF INSTRUMENTAL DELIVERY

30. Rate of neonatal morbidity after cesarean delivery

31. Multiple variables have been associated with an increased risk of failed OVD; 2 common causes are occiput posterior position macrosomia .  Other factors include one fifth of the head palpable abdominally presenting part only as far as the ischial spines excessive molding of the fetal head protracted labor maternal obesity

32. APPLICATION Preparation for Forceps Delivery Anesthesia- outlet forceps - pudendal block -low or midpelvic forceps- regional analgesia/GA The bladder should be emptied. Forceps Application A major concept to bear in mind is that the application of forceps should use finesse rather than force. Forceps are constructed so that their cephalic curve is closely adapted to the sides of the fetal head The BPD of the fetal head corresponds to the greatest distance between the appropriately applied blades. The long axis of the blades corresponds to the occipitomental diameter.

33. Tips of the blades lie over the cheeks. The blades are equidistant from the sagittal suture, which should bisect a horizontal plane through the shanks. Fenestrated blades should admit no more than 1 finger breadth b/n the heel of the fenestration and the fetal head. No maternal tissue has been grasped

34. Applied as such, the forceps should not slip, and traction may be applied most advantageously. With most forceps, if one blade is applied over the brow and the other over the occiput , the instrument cannot be locked, or if locked, the blades slip off when traction is applied.

35. Forces Exerted by the Forceps The force produced by the forceps on the fetal skull is a complex function of pull and compression by the forceps and friction produced by the maternal tissues. It is impossible to ascertain the amount of force exerted by forceps for an individual patient

36. Outlet Forceps Delivery Delivery by outlet forceps of OA fetal head  applied as follows >=2 fingers of the Rt hand are introduced inside the Lt posterior portion of the vulva and into the vagina beside the fetal head. The handle of the Lt branch is then grasped b/n the thumb and 2 fingers of the Lt hand The tip of the blade is gently passed into the vagina b/n the fetal head and the palmar surface of the fingers of the Rt hand.

37. Appropriateness of Application OA, blades are equidistant from the sagittal suture OP, equidistant from the midline of the face and brow. Traction When it is certain that the blades are placed satisfactorily, then gentle, intermittent, horizontal traction is exerted until the perineum begins to bulge. If necessary, rotation to OA is performed before traction is applied More horizontal traction is applied, and the handles are gradually elevated, eventually pointing almost directly upward as the parietal bones emerge As the handles are raised, the head is extended .

38. With traction, as the vulva is distended by the occiput , an episiotomy may be performed During upward traction, the 4 fingers should grasp the upper surface of the handles and shanks, while the thumb exerts the necessary force on their lower surface During the birth of the head, spontaneous delivery should be simulated as closely as possible. Traction should therefore be intermittent, and the head should be allowed to recede in intervals, as in spontaneous labor.

39. It is preferable to apply traction only with each uterine contraction. Except when urgently indicated, as in severe fetal destress , delivery should be sufficiently slow, deliberate, and gentle to prevent undue head compression. After the vulva has been well distended by the head, the delivery may be completed in several ways. However, the thickness of the blades adds to the distention of the vulva, thus increasing the likelihood of laceration or necessitating a large episiotomy. In such cases, the forceps may be removed and delivery completed by the modified Ritgen maneuver.

40. Low- & Midforceps Operations When the head lies above the perineum, the sagittal suture usually occupies an oblique or transverse diameter of the pelvis. In such cases, the forceps should always be applied to the sides of the head Lt OA Position Rt OA Position OT Positions Rotation from Anterior and Transverse Positions

41. Low- & Midforceps cont… Left OA Position Rt hand, introduced into Lt posterior segment of the vagina, feel posterior located Lt ear At the same time, Rt hand serves as a guide for introduction of the Lt branch of the forceps, which is held in the Lt hand and applied over the Lt ear. 2 fingers of the Lt hand are then introduced into the Rt posterior portion of the pelvis.

42. Low- & Midforceps cont… The Rt branch of the forceps, held in the Rt hand, is then introduced along the Lt hand as a guide. It must then be applied over the anterior ear of the fetus by gently sweeping the blade anteriorly until it lies directly opposite the blade that was introduced first Right OA Position blades are introduced similarly but in opposite directions

43. Low- & Midforceps cont… OT Positions forceps introduced similarly, with the 1 st blade applied over the posterior ear and the 2 nd rotated anteriorly to a position opposite the 1 st In this case, one blade lies in front of the sacrum and the other behind the symphysis . Simpson or Tucker–McLane forceps, or one of their modifications, or Kielland forceps may be used

44. Occiput Posterior Positions Prompt delivery may at times become necessary when the occiput is directed toward one of the sacroiliac synchondroses , viz., in ROP or LOP positions. When delivery is required in either instance, the head is often imperfectly flexed.

45. Manual Rotation - the effective method is to rotate the sinciput posteriorly. - Determine the exact position. - For ROP use the right hand to grasp the sinciput, displacing upward to increase flexion.

46. Middle finger in the frontal suture as a marker. The thumb and other fingers around the bitemporal region. For the LOP we use the left hand The free hand applied over the maternal flank to promote rotation.

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48. …cont Causes of failure of rotation - failure to employ sinciput grip - failure to dislodge the head from its impacted position - failure to insert the hand sufficient far to get a firm grip. - hand too small - contracted pelvis

49. Forceps Rotations of Oblique OP If performed with Tucker–McLane or Simpson forceps, the head must be flexed, but not with Kielland forceps because they have a more straightened pelvic curve The oblique occiput may be rotated 45 o to the posterior position or 135 o to the anterior In rotating anteriorly with Tucker–McLane or Simpson, the pelvic curvature, originally directed upward, at the completion of rotation is inverted and directed posteriorly delivering with the instrument in that position is likely to cause vaginal sulcus tears and sidewall lacerations remove & reapply the instrument

50. Forceps Delivery of OP With direct OP, apply horizontal traction until the base of the nose is under the symphysis then slowly elevate handles until the occiput gradually emerges over the anterior margin of the perineum Then, the forceps are directed in a downward motion, and the nose, face, and chin successively emerge from the vulva. OP delivery causes greater distention of the vulva, a large episiotomy may be needed

51. Low forceps (Simpson) delivery as an OP

52. Forceps Delivery of Face Presentation With MA-forceps can be used blades are applied to the sides of head along the occipitomental diameter, with the pelvic curve directed toward the neck Downward traction is exerted until the chin appears under the symphysis , then upward!! Then, by an upward movement, the face is slowly extracted, with the nose, eyes, brow, and occiput appearing in succession over the anterior margin of the perineum With MP- NO FORCEPS!

53. Vacuum Extraction U.S- vacuum extractor , Europe- ventouse (from French, soft cup). 1953, T. Malmström introduced a hollow disc-shaped stainless steel metal cup for vacuum assisted delivery 1970s, ventouse virtually replaced forceps for assisted deliveries in northern European countries However, in many English-speaking countries, including the U.S & the UK, adoption of the vacuum device was slower

54. INSTRUMENTATION  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

55. INSTRUMENTATION cont.. Vacuum  Suction can be generated manually or with an electrical suction device. Extractor cup  Vacuum cups may be soft (pliable) or rigid and the shape may be bell or "M" shaped Rigid- metal, rigid plastic, polyurethane, or polyethylene Soft- plastic, silicone, rubber, or polyethylene.

56. Handle   Most plastic bell shaped cups have a relatively rigid rod connecting the handle & cup This impedes accurate placement of the instrument on deflexed or posterior heads Higher success rates may be achieved with rigid, plastic "M" cups, attached by a wire to a combined handle/vacuum pump (Kiwi Omnicup ).

57. Indications and Prerequisites Generally, the indications and prerequisites for the use of the vacuum extractor are the same as for forceps delivery. A vacuum assisted delivery should only be attempted when a specific obstetric indication is present. The three major categories of indication are prolonged second stage of labor nonreassuring fetal status maternal cardiac or neurological disease. But there is no absolute indication.

58. Contraindications  operator inexperience inability to assess fetal position high station suspicion of cephalopelvic disproportion known fetal demineralization diseases connective tissue disorders fetal bleeding diatheses Generally, vacuum extraction is reserved for fetuses ≥ 34 weeks

59. TECHNIQUE Proper cup placement is the most important determinant of success good placement of a vacuum cup requires proper assessment of the fetal position and station, with care taken to identify molding, caput, and asynclitism . the location of cup placement becomes the leading point of the fetal head The flexion point is a critical landmark for the safe and effective use Unlike forceps, which will usually correct asynclitism after application, failure to place the cup over the flexion point impedes delivery, rather than assisting it

60. Patient preparation   The woman's bladder should be empty The patient is placed in the dorsal lithotomy position and the fetal presentation, position, and station are confirmed and documented. Adequate anesthesia can be obtained with neuraxial anesthesia or a local block.

61. Determine the flexion point ( Fpt ) is the location on the fetal head where outward traction pulls the head so as to allow flexion at the neck, while keeping the mentovertical diameter in the direction of the birth canal In the normally molded head, the Fpt is in the midline, over the sagittal suture, ~6 cm from anterior fontanelle and 3 cm from the posterior fontanelle

62. When the center of the cup is placed over the Fpt , the edges of the cup should be ~3 cm from the anterior fontanelle and just at the edge of the posterior fontanelle Anterior placement on the fetal cranium—near the anterior fontanelle rather than over the occiput —will result in cervical spine extension unless the fetus is small. asymmetrical placement relative to the sagittal suture may worsen asynclitism

63. Place the cup   Spread the labia and introduce the bell shaped cup by compressing and inserting it into the vagina while angling the device posteriorly. If an M-shaped or rigid cup is used, the device is flexed at the base of the shaft and inserted sideways into the vagina while angling posteriorly When contact is made with the fetal head, the center of the cup is placed over the flexion point and symmetrically across the sagittal suture

64. The entire 360º circumference of the cup must then be digitally inspected to insure that no vaginal, cervical, or vulvar tissues are trapped b/n the cup and the fetal surface, nor should the cup cover either fontanelle . Entrapment of maternal soft tissue predisposes the mother to lacerations and hemorrhage and virtually assures cup "pop-off”. After correct placement of the cup is confirmed, vacuum pressure should be raised to 100-150 mmHg to maintain the cup's position.

65. The vacuum cup is now properly in place and the higher suction pressures required for traction can be administered. In contrast, when the indication for delivery is failure to descend caused by occipital malposition , with or without asynclitism or deflexion , cup placement can be very difficult.

66.  Occiput posterior position   B/c the Fpt on OP presentations is positioned more posterior and higher in the vx than with OA, certain adjustments must be employed Specifically, the cup needs to be placed much deeper in the posterior vx This accommodation usually necessitates a vacuum device with a discoid , rather than a bell-shaped cup, and a nonfixed traction cord rather than a firm stem To meet these needs, special cups have been designed for occiput posterior presentation

67. Apply suction 500 to 600 mmHg have been recommended during traction, although pressures in excess of 450 mmHg are rarely necessary While lower suction pressures increase the risk of cup "pop-offs," pressures beyond 600 mmHg increase the risks of fetal scalp trauma and cerebral, cranial and scalp hemorrhage

68. A slow, stepwise increase in vacuum pressure was initially practiced, but is no longer deemed necessary as the size of the cup increases, the total force applied will rise even with the same amount of applied suction (P = F/A) the notion that the vacuum is " designed to pop-off before damage occurs " is erroneous and should not be considered a safety mechanism. The max pressure shouldnt be >600 mmHg

69. Exert traction The absolute "safe“ traction force for vacuum extraction is unknown A theoretical advantage of the vacuum cup is that it usually will detach prior to creating tractive forces sufficient to cause fetal injury Baskett TF et al (2008)- 1000 deliveries with OmniCup device.; J Obstet Gynaecol Can 87.1% completed 95.6% required <or = 3 pulls 85.7% required <or = 11.4kg traction force

70. Traction cont… As soon as a contraction starts and the mother begins pushing, the vacuum suction pressure is rapidly raised to 500-600 mmHg. 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 ( 1 "set of pulls“/contraction) 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

71. Traction cont… During the extraction, the stem of the device is kept perpendicular to the plane of the cup to maintain the seal with the fetal head. The device is more likely to detach if angular traction is applied. Jerking the device will lead to unnecessary pop-offs and rocking motions may injure the cranium and should be avoided If the head is tilted to one side or not flexed well, traction should be directed in a line that will try to correct the tilt or deflexion

72. Traction cont… Traction is applied along the axis of the pelvic curve to guide the fetal vertex, led by the flexion point, through the birth canal Initially, the angle of traction is downward then extended upwards to a 45 o angle to the floor as the head emerges from the pelvis and crowns the handle of the device is allowed to passively turn as the head auto-rotates from OT or other off-midline positions to a direct OA or OP position as it descends

73. Traction cont… B/n contractions, suction pressure can be maintained or reduced to <200 mmHg ( similar fetal morbidity ) Check fetal heart rate & application of the cup Descent should occur with each application of traction, beginning with the first. When the head is delivered; release the suction,& cup Routine episiotomy is not necessary

74. DURATION The maximum time to safely complete a vacuum assisted delivery and the number of acceptable "pop-offs" are unknown. 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, and/or a maximum total vacuum application time of 15 to 30 min are commonly recommended. With progress, & in the absence of fetal distress, continue the ‘’guiding’’ pulls for a max of 30 min(WHO )

75. Baskett TF et al (2008)- 1000 deliveries with OmniCup device.; J Obstet Gynaecol Can ≤3 pop-offs in 99.9 % , ≤3 pulls in 95.6%, ≤5 pulls in 98.7 % , and ≤10 min cup application time in 97.4 %

76. Some reasons for failure include: Fetopelvic disproportion Incorrect technique- Pulling the stem too quickly or when maternal expulsive efforts are weak upwards traction before the head is crowning Incorrect cup size also increases the risk of failure Paramedian or deflexing applications Large caput succedaneum — lets more of the scalp to be drawn into the cup

77. FAILURE WHO, Vacuum extraction failed if the: Fetal head doesn’t advance with each pull Fetus is undelivered after 3 pulls with no descent, or after 30 min Cup slips off the head twice at the proper direction of pull with a max negative pressure EVERY APPLICATION SHOULD BE CONSIDERED A TRIAL OF VACUUM EXTRACTION.

78. What’s next? multiple attempts at OVD using different instruments (vacuum, different types of forceps) be avoided due to the greater potential for maternal and/or fetal injury Prompt cesarean delivery is advised after an unsuccessful vacuum assisted procedure.

79. Factors that might influence choice are the availability of the instrument level of training and experience the degree of maternal anesthesia knowledge of the risks and benefits associated with each instrument. In general, vacuum delivery is probably safer than forceps for the mother , while forceps are probably safer than vacuum for the fetus. CHOICE OF INSTRUMENT

80. The theoretical advantages of the vacuum extractor over forceps include avoidance of insertion of space-occupying steel blades within the vagina avoidance of the requirement for precise positioning over the fetal head ability to rotate the fetal head without impinging on maternal soft tissues decreased intracranial pressure during traction it will detach prior to creating tractive forces sufficient to cause fetal injury

81. Vacuum devices Clear–cut rules, easier to apply, less training and experience place less force on the fetal head, no risk of excessive traction require less maternal anesthesia result in less maternal soft tissue trauma required rotation of the baby occurs spontaneously do not affect the diameter of the fetal head compared to forceps.

82. By comparison, the advantages of forceps are they are unlikely to detach from the head can be used on premature fetuses, face presentation, after-coming head in breech & for a rotation result in less neonatal complications

83. COMPLICTIONS, Maternal When considering maternal morbidity from OVD, it is important to compare it with the morbidity from CS and not to that from SVD. Some generalizations can be made; Elective outlet forceps with rotations not exceeding 45 o are associated with little, if any, increase in maternal morbidity Maternal injury increases significantly with rotations of >45 o and at higher stations . The need for blood transfusions is increased with OVD, VE(6.1%) and forceps (4.2%), compared with 1.4% with uncomplicated C/S.

84. Short-term   Short-term maternal risks from instrumental delivery include pain at delivery, perineal pain at 24 hours, lower genital tract lacerations and hematomas, urinary retention and incontinence, anemia, anal incontinence, and rehospitalization . Severe maternal trauma is primarily associated with rotational and midforceps operation. Additional maternal morbidities occur when episiotomy is performed at the time of the operative vaginal delivery.

85. These morbidities include an increased risk of PPH and perineal infection, and a greater need for moderate or strong analgesia. Fetal position also has an impact on the risk of maternal trauma during delivery. It should be noted that surgical trauma is intrinsic to all CS Although SVD is less traumatic for the mother than operative vaginal delivery, the latter is associated with less short-term maternal morbidity than cesarean delivery.

86. Long-term  Long-term maternal sequelae from operative delivery are primarily related to potential disturbances in urinary and anal function, such as urinary incontinence, fecal incontinence, pelvic organ prolapse , and, occasionally, fistula formation.

87. Short-term effects of forceps and vacuum deliveries, especially midcavity deliveries, include postpartum urinary retention and bladder dysfunction . Although the short-term effects on anorectal function associated with operative vaginal delivery are of concern, it is unclear what role these have in long-term morbidity. Other factors have been associated with fecal incontinence in older women. Some of these are high parity, menopause, prior hysterectomy, and irritable bowel syndrome . Febrile Morbidity Postpartum metritis is more frequent, and often more severe, in women following cesarean delivery compared with that following operative vaginal delivery .

88. Neonatal complications Short-term  Since a serious complication, like a subgaleal hematoma , can occur within hours of delivery, it is important that the infant care providers be informed by either a reliable charting method or direct notification. The short-term complications to the fetus from OVD are usually caused by head compression and traction on the fetal intracranial structures, face, and scalp The most serious complication is intracranial hemorrhage .

89. Other complications include: bruises, abrasions and lacerations, facial nerve palsy, cephalohematoma , retinal hemorrhage, subgaleal hemorrhage, and skull fracture . Long-term   Acute fetal injuries with potential long-term sequelae include intracranial hemorrhage (subdural, subarachnoid, intraventricular and/or intraparenchymal hemorrhage) and neuromuscular injury ; however, these sequelae are rare.

90. Vacuum-assisted deliveries Torsion and traction of the vacuum cup can cause fetal scalp abrasions and lacerations, separation of the scalp from underlying structures leading to cephalohematoma , subgaleal hematoma , intracranial hemorrhage, hyperbilirubinemia , and retinal hemorrhage.

91. Forceps-assisted deliveries Short-term complications resulting from forceps deliveries include skin markings and lacerations, external ocular trauma, subgaleal hematomas, hyperbilirubinemia , retinal hemorrhage, lipoid necrosis, nerve injury, skull fractures, and death. Facial palsies and depressed skull fractures are more common with use of forceps than vacuum devices.

92. Conclusions Regarding Morbidity from Forceps The greatest risk is incurred with true midforceps operations and when rotations of greater than 45°are performed The impact of epidural analgesia on the incidence of low- and midforceps deliveries cannot be discounted. The majority of such cases result from inadequate maternal expulsive forces against a relaxed pelvic sling, and thus they are not usually associated with either relative or absolute CPD.

93. Effect of Delivery on Neonatal Injury, 583,340 singleton infants born to nulliparous women in California, Towner D, et al, 1999 Delivery Method Death Intracranial Hemorrhage other Spontaneous vaginal delivery 1/5,000 1/1,900 1/216 C/S during labor 1/1,250 1/952 1/71 C/S after vacuum/forceps N/R 1/333 1/38 Cesarean delivery with no labor 1/1,250 1/2,040 1/105 Vacuum alone 1/3,333 1/860 1/122 Forceps alone 1/2,000 1/664 1/76 Vacuum and forceps 1/1,666 1/280 1/58

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