PowerPoint Presentation on Forceps & Ventouse.pptx

Gynaecological

1. Dr.Aklima Akter Assistant Professor ( Gynae ) Sheikh Hasina Medical College, Tangail

2. Forceps delivery Obstetric forceps is a double-bladed metal instrument used for extraction of the fetal head Types : Long curved obstetric forceps Wrigley’s forceps Kielland's forceps Piper’s forceps Barton's forceps Action of the Forceps Traction : is the main action. Rotation : in deep transverse arrest, persistent occipito - posterior and mento -posterior.

3. Indications of Forceps Delivery 1. Prolonged 2nd stage: P rolongation for more than 1 hour in primigravidae or 30 minutes in multiparae . This may be due to: ( i )Inertia and poor voluntary bearing down (ii)Rigid perineum. (iii) Malpositions : persistent occipito -posterior and deep transverse arrest.

4. Maternal indication: Exhaustion. Pulse >100 beats / min. Temperature >38 o c . Signs of dehydration. Maternal diseases as: Heart disease, Asthma Pre- eclampsia and eclampsia .

5. Foetal indications 3.Fetal indication Fetal distress. Prolapsed pulsating cord. Preterm delivery . After-coming head in breech delivery. During caesarean section One (used as a lever) or the two blades may be used to extract the head through the uterine incision.

6. Pre-requisites for Forceps Application Anaesthesia : general, epidural, spinal or pudendal block. Adequate pelvic outlet. Aseptic measures. Bladder and Bowel evacuation. Contractions of the uterus should be present . Dilatation of the cervix should be fully. Engaged head . Forewater rupture. Favourable position and presentation : Occipito -anterior. Occipito -posterior Face presentation. After -coming head in breech.

7. How to know Right and Left Blades Putting in consideration that the mother is in the lithotomy position, the blade will be applied with the pelvic curve directed anteriorly and the cephalic curve directed medially. If the blade will be applied to the left maternal side it is a left blade and vice versa.

8. Technique of Forceps Delivery In occipito - anterior position The left blade is applied first. It is held by its handle between the thumb and fingers of the left hand almost parallel with the right inguinal ligament and passed along the left side of the maternal pelvis between the guiding palm of the right hand and foetal head. As the blade passes into the birth canal the handle is carried backwards and towards the midline. It is now the lower blade.

9. The fingers of the left hand are introduced along the right side of the pelvis and the right blade is held and passed in the same manner. It is now the upper blade. The 2 blades should be locked easily, if not this means that they were not correctly applied and should be removed and re-assess the position of the head.

10. Clinical checks for correct forceps application The sagittal suture lies in the midline of the shanks. The operator cannot place more than a finger tip between the fenestration of the blade and the foetal head. The posterior fontanelle is not more than one finger- breadth above the plane of the sha

11. Traction should be gentle by the force of the arm only, intermittent with uterine contractions only, in correct direction i.e. downwards and backwards till the occiput appears at the vulva, then downwards and forwards. The 2 blades are unlocked between contractions to minimise the period of head compression.

12. Complications of Forceps Delivery Maternal complications : Extension of the episiotomy. Perineal tear. Vaginal tears. Cervical lacerations. Bladder injury . Rupture uterus

13. Bone injuries: to pelvic joints, coccyx or symphysis pubis. Pelvic nerve injuries. Postpartum haemorrhage : due to lacerations or atony . Puerperal infections. Remote effects: genital prolapse, stress incontinence, cervical incompetence and genito -urinary fistulas.

14. Foetal complications Fracture of the skull. Cephalohaematoma . Intracranialhaemorrhage . Facial nerve palsy. Trauma to the face, eyes or scalp. Asphyxia due to: > intracranial haemorrhage or, > cord compression between the head and the forceps.

15. FAILED FORCEPS Failure to extract the foetus by the forceps which may be due to failure to apply the forceps or to deliver the head with it . Causes: Cephalo -pelvic disproportion. Contracted outlet. Incomplete cervical dilatation. Constriction ring. Head is not engaged. Malpositions as persistent occipito -posterior. Malpresentations as brow. Foetal congenital anomalies as hydrocephalus, ascitis and conjoined twins.

16. Management after failed forceps Reassessment: The forceps is removed and the patient is re-examined to detect the cause and correct it if possible. Caesarean section: is indicated in uncorrectable causes as cephalo -pelvic disproportion, and contracted outlet. Exploration of the birth canal: for any injuries.

17. Vacuum Extraction ( Ventouse ) Definition It is traction of the foetal head by a created negative pressure through a cup applied to the head.

18. Description of the instrument Vacuum extractor is composed of : A specially designed cup with a diameter of 3, 4, 5 or 6 cm. A rubber tube attaching the cup to a glass bottle with a screw in between to release the negative pressure. A manometer fitted in the mouth of the glass bottle to declare the negative pressure. Another rubber tube connecting the bottle to a suction piece which may be manual or electronic creating a negative pressure that should not exceed - 0.8 kg per cm2.

19. Indications The same as forceps : but it is not recommended in preterm babies and not used for the after-coming head in breech delivery. During the 1st stage: The small cup 3 or 4 cm may be used in a soft, stretchable cervix of not less than 7 cm dilatation. During caesarean section: It may be used to extract the foetal head through the uterine incision . N.B. Vacuum is not an instrument for rotation of the head but it rotates spontaneously when meets the pelvic floor. Trial to rotate the head with the cup will cause it to slip.

20. Contraindications Moderate or severe cephalopelvic disproportion. Other presentations than vertex. Premature infants . Intact membranes.

21. Procedure Lithotomy position. Antiseptic measures for the vagina, vulva and perineum. Vaginal examination to check pelvic capacity, cervical dilatation, presentation, position, station and degree of flexion of the head and that the membranes are ruptured.

22. Application of the cup: The largest cup that can easily passed is introduced sideways into the vagina by pressing it backwards against the perineum. It is then applied as near as possible to the posterior fontanelle over the mid sagittal line with its edge 3 cm from the anterior fontanelle . This position will promote flexion of the head and brings the smallest diameters of the foetal skull into the maternal passages. Be sure that there is no cervical or vaginal tissues nor the umbilical cord or a limb in complex presentation is included in the cup.

23. Creating the negative pressure: holding the cup in place, the negative pressure is gradually increased by 0.2 kg/cm2 every 1 minute until - 0.8 kg/cm2 is attained. This creates an artificial caput within the cup. Traction on the handle is made perpendicular to the cup and intermittently during uterine contractions, the direction of pull is changing as the head descends through the birth canal

24. Release of the cup: when the head is delivered the vacuum is reduced as slowly as it was created using the screw as this diminishes the risk of scalp damage. The head must be completely or partially delivered with no more than 3 pulls. The head is at least begin to move with the first pull. The cup must not be applied more than twice. Application of the cup must not exceed 20 minutes.

25. Advantages of Vacuum over Forceps Anaesthesia is not required so it is preferred in cardiac and pulmonary patient. The ventouse is not occupying a space beside the head as forceps. Less compression force (0.77 kg/cm2) compared to forceps (1.3 kg/cm2) so injuries to the head is less common. Less genital tract lacerations. Can be applied before full cervical dilatation. It can be applied on non-engaged head.

26. Complications Maternal: Vaginal and cervical lacerations. Annular detachment of the cervix, cervical incompetence and may be future prolapse if used with incompletely dilated cervix . Foetal : Cephalohaematoma . Scalp lacerations. Rarely , intracranial haemorrhage .