SOLWEZI GENERAL HOSPITAL assisted vaginal delivery.pdf

Overview and methods of assisted vaginal delivery

1. SOLWEZI GENERAL HOSPITAL
DEPARTMENT OF
OBSTETRICS AND
GYNAECOLOGY
ASSISTED VAGINAL DELIVERY
PRESENTER: DR MWEWA
MODERATOR: DR KAPANDA

2. •Assisted vaginal birth (also called operative
vaginal birth ) refers to any surgical
procedure designed to expedite vaginal
delivery and includes; episiotomy, forceps
delivery and vacuum extraction.

3. INDICATIONS FOR OPERATIVE VAGINAL DELIVERY
(FORCEPS/VENTOUSE)
Maternal Fetal Others
Inadequate expulsive efforts
Maternal exhaustion (distress)
Where expulsive efforts (valsalva)
are to be avoided (e.g. cardiac
disease, hypertensive crises,
cerebrovascular diseases)
Nonreassuringfetalheart rate—
fetaldistress (e.g. low birth weight
baby, postmaturity)
After coming head of breech
Suspicion of fetalcompromise
Prolonged second stage of labor
(Nullipara > 2 h; multipara > 1 h)
To cut short the second stage of
laboras in severe pre- eclampsia,
cardiac disease, postcesarean
pregnancy

4. PREREQUISITES FOR OPERATIVE VAGINAL
DELIVERY
(FORCEPS OR VACUUM APPLICATION
Maternal and fetal Others
• Fetalhead engaged (head is ≤
1/5
palpable per abdomen)
• The cervix must be fully dilated
• The membranes must be
ruptured
• Fetalhead position is exactly
known
• Pelvis deemed adequate
• Bladder must be emptied
• Adequate maternal anlgesia
(regional block for midcavity or

• Experienced operator
• Aseptic techniques
• Back up plan in case of failure
• Presence of a neonatologist
• Willingness to abandon the
procedure
when difficulties faced

5. FORCEPS
•Obstetric forceps is a pair of instruments specially designed to assist
extraction of the fetalhead and thereby accomplishing delivery of the fetus.
•There are different varieties;
• Long-curved forceps with or without axis traction device
• Short-curved forceps
• Kielland’sforceps

16. KIELLAND’S FORCEPS
In the hands of an expert, it is an useful and preferred instrument. Its advantages over
the widely used long curved forceps are : (1) It can be used with advantages in unrotated
vertex or face presentation (2) Facilitates grasping and correction of asynclitichead
because of its sliding lock

17. DANGERS OF FORCEPS OPERATION

18. VENTOUSE
•Ventouseis an instrumental device designed
to assist delivery by creating a vacuum
between it and the fetalscalp. The pulling
force is dragging the cranium while in
forceps, the pulling force is directly
transmitted to the base of the skull.

20. •INDICATIONS:ofventousedelivery are the same as those of forceps
•CONTRAINDICATIONS OF VENTOUSE: ( i) Any presentation other than vertex (face,
brow, breech) (ii) Preterm fetus(< 34 weeks). Chance of scalp avulsion or
subaponeurotichemorrhage(iii) Suspected fetalcoagulation disorder. (iv) Suspected
fetalmacrosomia (> 4 kg).
•CONTRAINDICATIONS:foroperative vaginal delivery (both for ventouseor forceps) :
(i) Unengaged fetalhead (ii) Obvious CPD (iii) Patient’s refusal (iv) Fetushaving
unacutebleeding diathesis (hemophilia).

27. •Mc Roberts maneuver: Abduct the maternal thighs
and sharply flex them onto her abdomen. There is
rotation of symphysis pubis upwards and decrease in
angle of pelvic inclination. This does not increase
pelvic dimensions but straightens the sacrum relative
to lumbar vertebrae. It needs two assistants.

28. EPISIOTOMY
•A surgically planned incision on the perineum and the posterior vaginal wall during
the second stage of laboris called episiotomy (Perineotomy). It is in fact an inflicted
second degree perineal injury. It is the most common obstetric operation performed.
•OBJECTIVES
• To enlarge the vaginal introitus so as to facilitate easy and safe delivery of the
fetus–spontaneous or manipulative.
• To minimize overstretching and rupture of the perineal muscles and fascia; to reduce
the stress and strain on the fetalheadtetricoperation performed.

29. INDICATIONS
• In elastic (rigid) perineum: Causing arrest or delay in descent of the presenting part as
in elderly primigravidae.
• Anticipating perineal tear: (a) Big baby (b) Face to pubis delivery (c) Breech delivery
(d) Shoulder dystocia.
• Operative delivery: Forceps delivery, ventouse delivery.
• Previous perineal surgery: Pelvic floor repair, perineal reconstructive surgery

30. TIMING OF THE EPISIOTOMY
•The timing of performing the episiotomy requires judgment. If done early,
the blood loss will be more. If done late, it fails to prevent the invisible
lacerations of the perineal body and thereby fails to protect the pelvic floor
–the very purpose of the episiotomy is thus defeated. Bulging thinned
perineum during contraction just prior to crowning (when 3–4 cm of head is
visible) is the ideal time. During forceps delivery, it is made after the
application of blades.

31. TYPES OF EPISIOTOMY
•Mediolateral—The incision is made downwards and outwards from the midpoint of the fourchette
either to the right or left. It is directed diagonally in a straight line which runs about 2.5 cm away
from the anus (midpoint between anus and ischial tuberosity).
•Median—The incision commences from the centerof the fourchette and extends posteriorly along
the midline for about 2.5 cm.
•Lateral—The incision starts from about 1 cm away from the centerof the fourchette and extends
laterally. It has got many drawbacks including chance of injury to the Bartholin’s duct. It is totally
condemned.
•‘J’ shaped—The incision begins in the centerof the fourchette and is directed posteriorly along the
midline for about 1.5 cm and then directed downwards and outwards along 5 or 7 O’clock position
to avoid the anal sphincter. Apposition is not perfect and the repaired wound tends to be puckered.
This is also not done widely. Thus, only mediolateral or median episiotomy is done commonly.

33. REFERENCES
1.Phillip N Baker (2006) OBSTETRICS BY TEN TEACHERS 19
th
Ed University
of Alberta, Edmonton, Canada.
2.D C Dutta’s (2013) TEXTBOOK OF OBSTETRICS 7
th
Jaypee Brothers
Medical Publishers, Bangladesh, Indish.
3.RCOG ‘INFORMATION FOR YOU –ASSISTED VAGINAL BIRTH’ ( Ventouseor
forceps) published April 2020.