Operative vaginal delivery is a Forceps Delivery by benbenzhou


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									Michael A. Belfort, MD, PhD
Professor, Department of Obstetrics and
Gynecology, University of Utah Health
Sciences Center, Salt Lake City, and
Director of Perinatal Research,
HCA Healthcare, Nashville, Tenn

The author reports no financial
relationships relevant to this article.

                                                                                                        ed        ia
                                                                                                                          Estimating the space between the

                                                                                   a              lt                      maternal pelvic brim (lower line) and

                                                                               n He only
                                                                                                                          the base of the fetal head (upper line)

                                                                             e                                            during abdominal examination aids in

                                                                         owd      se
                                                                                                                          determining whether the fetal head

                                                    ht D rsonal u
                                                                                                                          is engaged.
                                              opyr For pe

                                                                                                                                                          Images: Kimberly Martens
                                           Operative vaginal delivery
                                           10 components of success
 ❙ Was delivery                            The need for forceps or vacuum should not be
   successful—or                           determined on the fly, but anticipated and evaluated,
   a barely averted                        with a willing patient

   Page 56                                         perative vaginal delivery is a                less, operative vaginal delivery remains
                                                   dying art. National databases in              a viable option in some cases.
 ❙ Abdominopelvic                                  the United States and elsewhere                    This article—based on personal
                                           have shown this trend for decades.1                   opinion and experience, as well as
   assessment using                        Women no longer can be reliably pre-                  published data whenever possible—de-
   the rule of 3’s                         dicted to prefer operative vaginal deliv-             scribes 10 selected aspects of operative
   Page 62                                 ery over cesarean section, and provid-                vaginal delivery, offering recommenda-
                                           ers caring for delivering mothers (and                tions for each.
 ❙ Recommended                             their families) should not assume that
   Page 68
                                           they do. Nor does the 20th century
                                           paradigm of operative vaginal delivery
                                           as the accepted “next step” between
                                                                                                 1. obstetric history
                                           spontaneous vaginal delivery and cesar-               How a woman fared in previous deliver-
                                           ean section hold up, given the decreased              ies has a bearing on the current delivery.
                                           maternal and neonatal morbidity and                   For example, if she has a history of per-
                                           mortality associated with modern tech-                sistent occiput posterior position, as in
                                           niques of cesarean section. Neverthe-                 the case described on page 56, she may

          54                               OBG MANAGEMENT                  •    February       2007

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                                                      Operative vaginal delivery: 10 components of success

have an anthropoid pelvis, placing her          bored to complete dilation and pushed
at increased risk for another malposi-          for some time.2 In fact, a baby with a
tion.1 In such cases, the patient should be     well-engaged head can experience sig-
counseled about the potential for opera-        nificant increases in intracranial pressure
tive vaginal delivery, and the risks and        during cesarean delivery when concerted
benefits should be discussed prenatally.        efforts have to be used to deliver a deeply
    A history of obesity, excessive             engaged fetal head out of a hysterotomy
weight gain, and glucose intolerance            incision. Such maneuvering can also in-
should be considered warning signs of a         jure the fetal neck and brachial plexus.
large-for-gestational-age infant.

2. adequate                                     3. abdominal
Ensure                                          examination is critical
informed consent                                Examination of the maternal abdomen
Patients should be informed of the risks        helps to confirm the fetal lie and presenta-
of any procedure they are offered, and          tion and may give an idea of the position
operative vaginal delivery—like any op-         of the fetal back in relation to the uterine
erative procedure—has definite risks.           midline. If the fetal back cannot be felt
      It is unbalanced to mention only the      or is palpated far laterally, the fetus may
perceived benefits of a procedure and to        be in an occiput posterior or transverse
avoid the discomfort of discussing the          position. Often this knowledge helps the
potential significant fetal and maternal        examiner make sense of an otherwise
injury that may result from a procedure.        difficult vaginal examination.
It is far better for the patient and her fam-
ily to learn—before an adverse outcome          Estimate fetal weight
occurs—that forceps delivery sometimes          Fetal weight estimations from a careful
leads to maternal and fetal lacerations,        abdominal examination can be as ac-
and that operative vaginal delivery can         curate as ultrasonographic evaluation.3 FAST TRACK
be associated with an increased risk for        It is strongly recommended that fetal Fetal weight
shoulder dystocia in some circumstances.        weight be estimated and considered in
      The best way to educate patients          context with maternal diabetes, obesity, estimations from
about operative vaginal delivery is dur-        excessive weight gain, and previous ul- a careful abdominal
ing prenatal care. I recommend a written        trasound examinations before operative examination can be
informed consent document similar to            vaginal delivery is undertaken.          as accurate
the one used for cesarean section. If such                                                     as ultrasonographic
a form is not signed during the course of       Is the fetal head engaged?
office prenatal care, it should be offered      The average term (3,200 g) fetus has a ba-     evaluation
upon admission for delivery.                    sovertical head diameter of approximately
                                                9 to 10 cm,4,5 and the average adult finger
In some cases, operative vaginal                has a diameter of 2 cm (one fifth of the
delivery may be safer than cesarean             head). Using this information, an estimate
Operative vaginal delivery clearly in-          of how many “fifths” of the fetal head
creases the risk of neonatal intracranial       are above the pelvic brim can be made by
bleeds when compared with normal                evaluating how many fingerbreadths of
spontaneous vaginal delivery or elective        fetal head can be palpated above the sym-
cesarean section.2 However, a patient           physis pubis on abdominal examination.
should understand that cesarean section              Crichton4 described this method in
carries a risk of neonatal intracranial         1974, and it is an extremely useful and
hemorrhage similar to that of operative         underutilized technique, in my opinion.
vaginal delivery once a woman has la-           He stated that no more than two fifths

w w w.o bg m a nagem ent.com           OBG MANAGEMENT              •   February     2007                    55
         Operative vaginal delivery: 10 components of success

                              Was delivery successful—
                              or a barely averted disaster?
                             E.D., a 32-year-old gravida 4 para 3,            is becoming exhausted and the baby
                             presents at 39 weeks’ gestation with             is “quite big.” The obstetrician appears
                             spontaneous rupture of membranes in              somewhat hesitant when applying the
                             early labor. Her 3 deliveries thus far have      vacuum and remarks to the nurse that he
                             all been vaginal, with the infants ranging       “thinks the baby is in a left occiput ante-
                             in weight from 3,700 to 3,900 g. Two of          rior position” but is not “100% sure.”
                             these infants were delivered with vacuum
                             extraction because of occiput posterior          When vacuum fails, a switch to forceps
                             position and a prolonged second stage.           After 2 attempts with the vacuum extrac-
                                 E.D.’s prenatal course has been relatively   tor, during which there are 2 “pop-offs,”
                             uncomplicated except for a 43-lb weight          the physician asks for Simpson forceps,
                             gain (she weighs 240 lb) and a borderline        adding that he thinks the baby is now in
                             1-hour glucose challenge test. She also had      right occiput posterior position and he
                             1 abnormal value on a 3-hour glucose toler-      needs to “get a better grip on the baby’s
                             ance test. Her prenatal pelvic examination       head.” The forceps are applied with some
                             was documented as “adequate.”                    difficulty, necessitating 2 reapplications.
                                                                                   After 5 contractions (and 6 pulling ef-
                             In early stages, all appears normal              forts), a baby boy is delivered. Because of
                             On admission, E.D. is dilated 4 cm with          a delay in delivery of the shoulders after
                             70% effacement and a cephalic presenta-          delivery of the head, the physician places
                             tion at -2 station. Electronic fetal monitor-    the patient in McRoberts position and has
                             ing is reassuring, and she is contracting        a nurse apply suprapubic pressure, and no
                             regularly every 6 minutes, with moder-           further difficulties are encountered.
                             ate pain. The physician on call instructs
                             the nurse to start oxytocin if there is no       Large baby has brachial plexus injury
                             progress in 2 hours, and to call anesthesia      The infant weighs 4,200 g and has Apgar
FAST TRACK                   to give an epidural if the patient requests      scores of 3 and 8, as well as a small lac-
Do not perform               it. E.D. asks for, and is given, an epidural 2   eration on his forehead, moderate flaccid-
                             hours later, when her cervix is dilated 5 cm.    ity of the left arm, and an elongated head.
operative vaginal                 The next morning, a different physician     The mother has a 4th-degree laceration
delivery without             examines her and reports a rim of cervix         that is repaired with some difficulty.
the necessary staff          remaining, with the fetal head at 0 to +1            The delivery note reads: “Assisted
                             station. He asks E.D. to push, and the           vaginal delivery, 4,200 g male, 3 vessel
and anesthesia for           rim is reduced over the infant’s head. The       cord, 600 cc estimated blood loss, 4th-
emergent cesarean            patient is instructed to continue pushing        degree laceration repaired in layers.” E.D.
section                      with contractions. The physician writes          ultimately requires 2 U of blood on post-
                             the admission (and only predelivery) note:       partum day 2 for symptomatic anemia.
                             “32 yr old G4P3, term, SROM, good FHTs,              Mother and baby are discharged on
                             good progress, complete, 1+ station, clear       postpartum day 4 in stable condition. The
                             fluid. Anticipate vaginal delivery.”             infant has a brachial plexus injury that
                                                                              resolves within 6 weeks.
                             When progress stalls, mother tires
                             E.D. pushes well with adequate contrac-          Lessons learned
                             tions for 2.5 hours, with minimal descent        Among the mistakes the obstetrician made
                             of the head and increasing caput and             in this case are a failure to take the ob-
                             molding. The physician examines her              stetric history into account, omission of a
                             again and reports that the baby is at +2         comprehensive abdominal exam, ignoring
                             station. He also suggests the use of the         signs of a large baby, and lack of a plan for
                             vacuum extractor, because the patient            emergent cesarean section.

    56                      OBG MANAGEMENT              •   February      2007
                                                    Operative vaginal delivery: 10 components of success

(2 fingerbreadths) of an unmolded fetal
head should be palpated abdominally
once the occiput is felt at the ischial
                                              4. molding in mind
spines. If three fifths or more of the fe-    Some (up to +2) occipito-parietal mold-
tal head is still palpable above the pubic    ing may be normal in the late stages
symphysis, regardless of whether there is     of delivery (ie, the occipital bone slips
bone palpated at or below 0 station on        under the 2 parietal bones, but can be
vaginal examination, consider the head        easily reduced), but severe parieto-pari-
unengaged and avoid operative delivery.       eto molding is never normal and should
     It is quite possible to feel the fetal   be interpreted as a sign of relative or
skull bone below the ischial spines and       absolute cephalopelvic disproportion.
still have an unengaged head.5 This is        FIGURE 1 shows a classification system for
due to molding of the head and elonga-        molding.
tion of the basovertical diameter. When
this occurs, the widest diameter of the       Traction plus severe molding may
fetal skull remains above the plain           increase the risk of intracranial injury
of the pelvic brim (unengaged), even          The most frequent causes of molding are
though the lowermost point is felt be-        asynclitism and deflexion of the head,
low the spines on vaginal examination.        commonly seen in occiput posterior and
A graphic example of such an elongated        transverse positions. Correction of the
basovertical diameter can be seen in the      asynclitism and malposition may correct
so-called cone-head baby.                     the molding and allow safe vaginal deliv-
                                              ery. Traction on a head with severe mold-
At examination, fetal head should             ing may increase the risk of intracranial
be in occiput anterior position               injury.
In order to best use the abdominal ex-             Using maximum likelihood logis-
amination to assess the amount of fe-         tic regression analyses, Knight and col-
tal head above the pelvic brim, the fe-       leagues6 demonstrated that the factor
tal head must be in an occiput anterior       of greatest importance in determining FAST TRACK
position. This is because the occiput is      whether a case would be allocated to It is possible to feel
sometimes difficult to palpate in a pos-      engaged versus unengaged groups was
terior or transverse position, and the        molding (odds ratio 2.17; 95% confi- the fetal skull bone
obstetrician may incorrectly assume full      dence intervals 0.75–6.27). The authors below the ischial
engagement. This further underscores          concluded that when abdominal and spines and still have
the importance of a careful maternal          vaginal assessments produce different an unengaged head
abdominal examination and the loca-           findings, the major factor responsible is
tion of the fetal spine.                      molding. They noted that data derived
                                              from vaginal examination alone may be
Abdominal examination is more                 misleading when molding is present.
informative than vaginal examination
Knight and colleagues6 studied the rela-      The rule of 3’s
tive value of abdominal and vaginal           With the fetus in an occiput anterior po-
examinations in the determination of          sition, determine the number of fifths of
fetal head engagement. They examined          the fetal head that can be palpated above
the records of 104 women who had              the pelvic brim abdominally, add it to
been evaluated by both methods prior          the degree of molding palpated vaginally,
to attempted operative vaginal delivery.      and avoid operative vaginal delivery if
Successful vaginal delivery was correct-      the sum is 3 or higher (FIGURE 2).7
ly predicted using abdominal criteria              For example, if two fifths (~4 cm)
(94%) more often than using vaginal           of the fetal head is palpated above the
criteria (80%) (P<.01).                       maternal pubic symphysis, and there is

w w w.o bg m a nagem ent.com         OBG MANAGEMENT             •   February    2007                   59
     Operative vaginal delivery: 10 components of success

            FIGURE 1
                                                                                                already +1 of parieto-parieto molding,
         How to characterize the degree of molding                                              significant cephalopelvic disproportion is
                                                                                                likely and operative vaginal delivery will
                                           0+ molding                                           probably fail, with an increased risk of
                                                                                                fetal and maternal damage. Obviously,
                                                                                                if three fifths or more of the fetal head
                                                                                                is palpated abdominally, the head is not
                                                                                                engaged and operative vaginal delivery is
                                                                                                contraindicated, regardless of whether the
                                                                                                scalp is felt at or below the ischial spines.

                                                                                                Knowledge of fetal head
                                           1+ molding                                           diameters is useful
                                                                                                Using measurements of fetal head di-
                                                                                                ameters (FIGURE 3), it is easy to see why
                                                                                                a vertex presentation in an occiput an-
                                                                                                terior position (presenting diameter =
                                                                                                suboccipitobregmatic diameter = 9.5
                                                                                                cm) will deliver more easily than a baby
                                                                                                in a deflexed occiput posterior position
                                                                                                (presenting diameter = occipitofrontal
                                                                                                diameter ≥ 11.5 cm). The presenting di-
                                           2+ molding
                                                                                                ameter of a brow presentation will nev-
                                                                                                er negotiate a normally proportioned
                                                                                                female pelvis, whereas that of a mentum
                                                                                                anterior face presentation is clearly ad-
                                                                                                equate for a vaginal delivery if all other
                                                                                                factors are favorable.

                                                                                                5.aware of fetal head
                                           3+ molding
                                                                                                position throughout labor
                                                                                                Early documentation of fetal head posi-
                                                                                                tion during labor may help tremendously
                                                                                                when decisions regarding the mode of de-
                                                                                                livery have to be made in a hurry. If one is
                                                                                                aware that the head has been persistently in
                                                                                                a deflexed occiput posterior position (or a
                          Tear in dura           Suture                                         transverse position) throughout the labor, a
                        mater and vessel      membrane torn                                     prolongation or arrest of descent can be ex-
                                                                                                plained by progressive deflexion of the head
                                                                                                and increasing presenting diameters (or deep
                                                                                                transverse arrest, as the case may be).
                                                                                                     In such a case, if sudden fetal decom-
                                                                                                pensation necessitates emergent delivery,
                                                                                                operative vaginal delivery is a much less
                                                                         Images: Rob Flewell
                                                                                                viable option than it would be with a
                                                                                                well-flexed occiput anterior position at
        Excessive molding may lead to tears in dura and underlying vessels.                     the same station.

60                              OBG MANAGEMENT                       •        February         2007
         Operative vaginal delivery: 10 components of success

          FIGURE 2

                                    Abdominopelvic assessment using the rule of 3’s

                                            3/5 above                                    2/5                                                 2/
                                                                                            above                                              5 above
                                             symphysis                                   symphysis +2+                                       symphysis +0+
                                                                                         molding = 4                                         molding = 2

                     Ischial   Pelvic                              Excessive caput                               Appropriate for operative
                     spine     brim                                may be misleading                             vaginal delivery

                                                                                                                                        Images: Rob Flewell

     If the sum of the number of fifths of the fetal head palpated above the pelvic brim abdominally and the degree of molding palpated vaginally equals
     or exceeds 3, operative vaginal delivery is unlikely to be successful.

                                             When there is knowledge of a fetal                 with adequate contractions, may appear to
                                        malposition, cesarean section may be the                have, on the surface, a valid indication—
FAST TRACK                              wisest choice in an emergency, even if the              but clearly this situation calls for extreme
When the fetus                          fetal head is at an appropriate station, un-            caution. The size of the infant and the lack
                                        less the operator has the requisite skills at           of progress suggest at the least the potential
is malpositioned,                       operative vaginal delivery and is certain               for cephalopelvic disproportion.
cesarean section                        of a high chance of a successful outcome.                    In my opinion, operative vaginal
may be the wisest                                                                               delivery for maternal exhaustion should
choice in an
emergency, even                     6. a valid indication
                                                                                                probably be reserved for someone who
                                                                                                has progressed at a normal rate to crown-
                                                                                                ing and who simply does not have the en-
if the fetal head is                    Operative vaginal delivery should not                   ergy to push out a normal-sized baby.
at an appropriate                       proceed without a valid indication8 that
station                                 conforms to accepted guidelines.             Judicious use is key
                                                                                     Operative vaginal delivery can be used
                                        Consider the pathology                       judiciously to remedy situations that have
                                        underlying the indication                    the potential to escalate. For example, a
                                        For example, although maternal exhaustion persistent transverse fetal head position in
                                        is clearly a valid indication for operative a primigravida with a platypelloid pelvis
                                        vaginal delivery, it is important to examine who has pushed for 1 hour with increas-
                                        the underlying reason for the exhaustion. ing caput and molding is highly unlikely
                                        A diabetic mother who is known to have a to resolve. If the fetus is an appropriate
                                        large-for-gestational-age infant, who has a candidate for rotational forceps, and the
                                        prolonged active phase (8 hours) and is ex- physician has the requisite training and
                                        hausted after 3 hours of excellent pushing experience, a rotational delivery after only

    62                                  OBG MANAGEMENT                 •     February          2007
                                                        Operative vaginal delivery: 10 components of success

1 hour is entirely appropriate to avoid              FIGURE 3
potential maternal and fetal injury that
could follow 3 hours of pushing.                            Know the basic term fetal head diameters
    Persistent variable decelerations
are another indication of potential fetal
compromise and justify judicious use of             Basovertical                                                                      Submento-
operative vaginal delivery in appropri-             (9 cm)                                                                            bregmatic
                                                                                                                                      (9.5 cm)
ate candidates.

7.not use instruments
                                                    (14 cm)

                                                                                                                                      (11.5 cm)

sequentially                                        (9.5 cm)
The use of sequential operative vaginal
delivery methods to complete a vaginal
delivery is no longer acceptable. Signifi-       Image: Rob Flewell

cantly increased neonatal and maternal
                                               Depending on the presentation, the fetal head will deliver easily, as in occiput anterior position, when the
risks have been demonstrated in at least       presenting diameter is 9.5 cm, or with difficulty, as when the presenting diameter is 11.5 cm or more.
3 well-designed studies. Data indicate
that a failed operative vaginal delivery
attempt,2,9,10 more than 3 hours of ma-        more pull” will effect delivery, but ex-
ternal pushing,10 and more than 3 trac-        ceeding the recommended number of at-
tion episodes (regardless of ultimate          tempts can lead to excessive traction and
success with the instrument)10 are asso-       maternal or fetal damage. It can be easy
ciated with an increased risk of neonatal      to become fixated on achieving vaginal
intracranial hemorrhage.                       delivery, and rational thought can be-
    Because we lack a standard of care for     come clouded.
the optimal number of traction efforts or           I recommend that each department
“pop-offs” for operative vaginal delivery, I   establish clear and agreed-upon limits                              FAST TRACK
suggest that any practitioners be familiar     for their practitioners. To this end, there                         Use of the vacuum
with, and adhere to, the manufacturer’s        should be an appropriately cooperative
suggested guidelines. These guidelines will    atmosphere in each delivery unit that                               extractor to bring
usually be designed to fall on the conser-     encourages the provider team to work                                the fetal head
vative side of safety issues.                  together to prevent adverse outcomes                                to a lower position
    I have heard of physicians who some-       from operative vaginal delivery. Proto-                             in order to
times use the vacuum extractor to bring        cols or checklists that help the nursing                            apply forceps
the head down to a place where they feel       staff keep the physician informed of the
more comfortable applying forceps. This        number of traction efforts and/or pop-                              is completely
practice is unacceptable. By the same to-      offs that occur will help prevent inad-                             unacceptable
ken, proceeding with vacuum extraction         vertent exceeding of the limits estab-
after concluding there is too much mold-       lished for that unit.
ing or caput for forceps is untenable.              Prior to attempting an operative
                                               vaginal delivery, the obstetrician should

8. a clear endpoint
                                               have a clear exit strategy, and this strate-
                                               gy should be outlined to the patient and
                                               the nursing/ancillary staff. When the pre-
and exit strategy                              determined criteria are met, operative
Resist the temptation to persist with          vaginal delivery should be abandoned
operative vaginal delivery in the face of      without delay, and cesarean section
inadequate descent or progress. It may         should be performed expeditiously. Ob-
sometimes seem as though “just one             viously, this requires that preparations

w w w.o bg m a nagem ent.com          OBG MANAGEMENT                       •     February           2007                                       67
         Operative vaginal delivery: 10 components of success

                                                                          Never resume maternal pushing
                              Recommended                                 after failed forceps or vacuum
                                                                          There is no place for “rest and descend”
                              prerequisites for                           protocols or further attempts at spon-
                              operative vaginal                           taneous vaginal delivery after a failed
                                                                          operative vaginal delivery. Once an easy
                              delivery                                    operative vaginal delivery becomes im-
                                                                          possible, immediate cesarean section is
                             • A valid indication documented
                                                                          the best option.
                             • Unambiguous knowledge of the
                               fetal head position
                             • Complete dilatation of the cervix
                                                                          Document, document
                             • Confirmed engagement of the                Under ideal circumstances, the obste-
                               fetal head                                 trician initiates a discussion with the
                             • Station at or below +2, unless the         patient during prenatal care and men-
                               operator is experienced and there is       tions the possibility of vacuum extrac-
                               a justifiable reason for a midpelvic       tion or forceps delivery. This discussion
                               delivery                                   is documented in the prenatal chart.
                             • Rule of 3’s satisfied                      The note includes a statement discuss-
                                                                          ing the relative risks and benefits of the
                             • A documented estimate of appropriate
                                                                          alternative delivery modes, the patient’s
                               fetal weight and adequate maternal
                                                                          expressed desire for a vaginal delivery,
                               pelvic anatomy
                                                                          including operative vaginal delivery,
                             • Adequate anesthesia                        and why, in the physician’s best judg-
                             • Preparations in place for immediate        ment, an operative vaginal delivery is a
                               cesarean section and resuscitation         reasonable option.
                               of the neonate, if needed
FAST TRACK                   • An informed, willing, and cooperative      Document the events
Once an easy                   patient who understands that cesarean      of labor and delivery
                               section may be an appropriate              Clear, concise progress notes from nurs-
operative vaginal              alternative mode of delivery (depending    ing and obstetric care providers are
delivery becomes               on the circumstances)                      extremely important. All pertinent ma-
impossible, immedi-          In addition, the person intending to         ternal and fetal information should be
ate cesarean section         perform the delivery should personally       addressed at each examination of the
is the best option           examine the patient before the attempt       patient, and some comment on the rate
                             to confirm that the prerequisites have       of progress, threshold limits, manage-
                             been met. I would go so far as to state      ment plan, and preparations should be
                             that, unless there is a high expectation     included.
                             of an easy operative vaginal delivery, it        In my opinion, each progress note
                             should not be attempted.                     should describe maternal vital signs,
                                                                          adequacy of contractions, use of labor
                                                                          augmentation and the dose, fetal toler-
                            for emergent cesarean section be made         ance of contractions, reassuring nature
                            prior to use of the forceps or vacuum         of the monitoring, cervical dilation,
                            extractor.                                    fetal head position (if discernible), sta-
                                The necessary anesthesia and neo-         tion, and any molding and caput. If ma-
                            natal and operating room personnel            ternal or fetal monitoring is inadequate
                            should be ready and in position at the        with external devices, the notes should
                            time the operative vaginal delivery is        include details of the plan to improve
                            attempted.                                    the situation.

    68                      OBG MANAGEMENT              •   February     2007
         Operative vaginal delivery: 10 components of success

                            Include a preoperative note                                   of traction efforts, progress of the fetal
                            I strongly recommend a preoperative note                      head with each traction effort, duration
                            if there is time. It should clearly document                  of the procedure, personnel present, and
                            the pertinent obstetric and prenatal care the                 the preparations made for the delivery
                            patient has received, the progress of labor,                  should all be documented. Physicians
                            the indication for operative vaginal deliv-                   and nurses should agree on what consti-
                            ery, estimated fetal weight, adequacy of the                  tutes a traction effort, to avoid conflicts
                            maternal pelvis for an infant of the antici-                  in the various sets of notes.
                            pated weight, fetal head position, degree of                      Document postdelivery vaginal
                            molding, complete dilation of the cervix,                     and rectal examinations, which should
                            station of the fetal head, and some assess-                   alert you to the presence of any retained
                            ment of flexion of the neck, if possible.                     sponges, vaginal hematomas or sulcus
                                 Once the decision to proceed has                         tears, or a previously unidentified recto-
                            been made, I would add a statement in-                        vaginal fistula.
                            dicating that the chances of success are
                            high and, in your considered opinion,
                            operative vaginal delivery is a safe and                      10. bad outcomes
                            indicated option.
                                                                                          with compassion
                            Write a detailed postoperative note                           Do not avoid contact with the family in
                            I suggest a dictated postoperative note                       the event of a bad outcome. Rather, con-
                            for every operative vaginal delivery,                         front the outcome as honestly and com-
                            successful or not. The elements includ-                       passionately as possible. If you correctly
                            ed in the preoperative note should be                         assessed and informed the patient and
                            reiterated and details of the delivery                        proceeded to operative vaginal delivery
                            explained. The position and station of                        with her full understanding of the indica-
                            the fetal head at the time the instru-                        tion, she will have accepted a small risk
                            ment was applied (especially if this                          of an untoward outcome. In general, if
FAST TRACK                  contrasts with what was stated in the                         she perceives your behavior to have been
Dictate a                   preoperative note), the degree of caput                       professional and caring, she is much less
                            and molding, the number and duration                          likely to seek retribution. ■
postoperative note
for every operative         References
vaginal delivery,           1. Gardberg M, Stenwall O, Laakkonen E. Recurrent
                               persistent occipito-posterior position in subsequent
                                                                                                parison of abdominal and vaginal examinations for
                                                                                                diagnosis of engagement of the fetal head. Aust N Z J
successful or not              deliveries. BJOG. 2004;111:170–171.                              Obstet Gynaecol. 1993;33:154–158.
                             2. Towner D, Castro MA, Eby-Wilkens E, Golbert WM. Effect     7.   Philpott RH. The recognition of cephalopelvic dispro-
                                of mode of d elivery in nulliparous women on neonatal           portion. Clin Obstet Gynecol. 1982;9:609–624.
                                intracranial injury. N Engl J Med. 1999;341:1709–1714.     8.   Operative vaginal delivery. American College of Ob-
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