Operative Vaginal Delivery (PowerPoint)

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					Operative Vaginal

   District 1 ACOG Medical
Student Teaching Module 2011
   Maternal Benefit – Shorten the 2nd stage of
    labor, decrease the amount of pushing
       Ie: maternal cardiac conditions (Eisenmenger’s,
        pulmonary HTN) or history of aneurysm/stroke
   Concern for immediate/potential fetal
       Ie: Prolonged terminal bradycardia
   Prolonged 2nd stage
       Nulliparous = No progress for 3 hrs w/epidural or 2
        hours w/o epidural
       Multiparous = No progress for 2 hrs w/epidural or 1 hr
        w/o epidural
      Operative Vaginal Delivery
 Incidence:4.5% of vaginal deliveries
 Forceps deliveries = 0.8%
 Vacuum deliveries = 3.7%
 Success Rate = 99%
     Reflects appropriate choice of candidates
     What Do I Need To Know Before
    Attempting an Operative Delivery?
   Presentation
   Position (i.e. occiput
    posterior, sacrum anterior)
   Lie (longitudinal, oblique,
   Station
   Presence of asyncliticism
   Clinical pelvimetry
   Anesthesia?
 GA  < 34 weeks (contraindication for
  vacuum due to risk of fetal IVH)
 Known bone demineralization condition
  (e.g. osteogenesis imperfecta) or bleeding
  disorder, ie: VWD)
 Fetal head unengaged
 Position of fetal head unknown
Vacuum-Assisted Vaginal Delivery
                 Do not apply rocking
                  motion or torque, only
                  steady traction in the
                  line of the birth canal

                 Stop after: three “pop-
                  offs” of vacuum, > 20
                  minutes elapsed, three
                  pulls with no progress
After determining position of the head, (A) insert the cup into the vaginal
vault, ensuring that no maternal tissues are trapped by the cup. (B) Apply the
cup to the flexion point 3 cm in front of the posterior fontanel, centering the
sagittal suture. (C) Pull during a contraction with a steady motion, keeping
the device at right angles to the plane of the cup. In occipitoposterior
deliveries, maintain the right angle if the fetal head rotates. (D) Remove the
cup when the fetal jaw is reachable
                 Fetal Risks: VAVD
    Designed to detach if traction is excessive (but
    can produce traction up to 50 lbs)

    * 5% incidence serious complications

    Scalp lacerations: if torsion
    Cephalohematoma: limited to
     suture line
    Subgleal hematoma: crosses
     suture line
    Intracranial/retinal hemorrhage
    Hyperbilirubinemia/jaundice
    Higher incidence of
     hemorrhage/jaundice compared to
         Type of Forceps Delivery
   Outlet forceps
       Scalp visible at introitus w/o separating labia
       Fetal skull reached pelvic floor & head at/on perineum
       Sagittal suture in AP diameter or LOA, ROA, or posterior position
       rotation does not exceed 45º
   Low forceps
       Leading point of fetal skull at >= +2, not on pelvic floor
       Rotation 45º or less (LOA/ROA to OA, or LOP/ROP to OP); or
        rotation greater than 45º.
   Midforceps
       Above +2 cm but head engaged
   High forceps
       Head not engaged; not included in ACOG classification
       Not recommended
Forceps-Assisted Vaginal Delivery
       Identify & apply
         Place instrument in
          front of pelvis with tip
          pointing up & pelvic
          curve forward
         Apply left blade,
          guided by right hand,
          then right blade with
          left hand
       Lock blades
         Should articulate with
 Check    for correct application
     Sagittal suture in midline of shanks
     Cannot place more than one fingertip
      between blade and fetal head
 Apply   traction
     Steady and intermittent
     Downward and then upward
     Remove blades as fetus crowns
                     Risks: Forceps
   Maternal Risks
       Perineal Injury (extension of episiotomy)
       Vaginal and Cervical lacerations
       Postpartum hemorrhage

   Fetal Risks
       Intracranial hemorrhage
       Cephalic hematoma
       Facial / Brachial palsy
       Injury to the soft tissues of face & forehead
       Skull fracture
Using both forceps and vacuum
 Highest  risk for injury is for combined
  forceps/vacuum extraction or cesarean
  delivery after failed operative delivery
 The weight of available evidence is
  against multiple efforts with different