13. Operative Delivery

Question 1

Operative vaginal delivery using vacuum extractor or forceps should only be performed if there is immediate ability to do what?

Answer 1

Perform C-section in case the procedure fails!

Question 2

What is operative delivery?

Answer 2

Not spontaneous delivary via vaginal (forceps or vacuum) or c-section.

Question 3

When is operative vaginal delivery CI?

Answer 3

1. Fetal head is not engaged
2. Position of fetal head is unknown
3. Fetus has bone dimeralization condition (osteogenesis imperfecta)
4. Bleeding disorder

Question 4

What are maternal indications for use of operative vaginal delivery?

Answer 4

1. Mother is exhausted/lack of expulsive effort
2. Inability to have expulsive effort: spinal cord injuries or neuromuscular disorders (i.e., MS)
3. Needs to avoid maternal expulsive efforts: certain cardiac conditions (i.e., aortic stenosis) or CVD (i.e., aneurysm or brain tumor)

Question 5

What is the fetal indication for performing operative vaginal delivery?

Answer 5

Non-reassuring fetal status (i.e., bradycardia, repetitive HR decelerations)

Question 6

Prolonged 2nd stage of labor is a CI for operative vaginal delivery.

What qualifies as prolonged 2nd stage of labor in a nulliparous vs. multiparous W?

Answer 6

1. • Nulliparous: >2 hours w/o regional anesthesia or >3 hourswith
2. • Multiparous: >1 hour w/o regional anesthesia or >2 hourswith

Question 7

What must mom do before operative vaginal delivery?

Answer 7

1. Adequate analgesia
2. Lithotomy position
3. Bladder empty
4. Verbal or written consent

Question 8

5 Fetal Criteria must be met if you are to perform Operative Vaginal Delivery

Answer 8

1. Vertex presentation
2. Fetal head MUST be engaged (0 station)
3. Must know position of fetal head w/ certainty
4. Station of the fetal head must be >+2
5. Fetal weight was estimated

Question 9

3 uteroplacental criteria for Operative Vaginal Delivery

Answer 9

1. Cervix fully dilated
2. Membranes ruptured
3. NO placenta previa

Question 10

What are 5 maternal complications which can occur with forceps delivery?

Answer 10

1. Laceration of the vagina/cervix
2. Injure the urethra, bladder and uterus
3. Episiotomy extension
4. Pelvic hematomas

Question 11

What are 6 fetal complications which can occur with forceps delivery?

Answer 11

1. Minor facial lacerations
2. Forceps marks
3. Facial and brachial plexus injuries
4. Neuro: Skull fractures, Intracranial hemorrhage, Seizures

Question 12

When is low operative vaginal delivery?

Answer 12

• Leading point of the fetal head is at +2 station and NOT on the pelvic floor (is rotational/non-rotational)

Question 13

When is a midpelvis and high forceps operative vaginal delivery performed?

Answer 13

• Fetal skull is above +2 station, but NOT EVER indicated today.

Question 14

When should you NOT APPLY forceps?

Answer 14

1. If not positive of position
2. If they dont articulate easily, reapply. If they still don’t articulate well, don’t apply.

Question 15

ALWAYS check to make sure that no ______________ are caught in the forceps.

Answer 15

no vaginal tissue or cervix

Question 16

What should ALWAYS be done before applying traction?

Answer 16

1. Blade should fit the head evenly
2. Should lie against the fetal head so that they cover the space in between the orbit and ears

Question 17

How is traction applied when using forceps to deliver?

Answer 17

Plane of least resistance and follow the pelvic curve. If not easy, STOP.

Question 18

Indications for Vacuum Assisted Vaginal Delivery

• Indications
• Advantage

Answer 18

• Indications: Same as forceps
• Advantage: Delivery can be acheived with little maternal analgesia.

Question 19

4 CI to using Vacuum Assisted Vaginal Delivery

Answer 19

1. Gestational age < 34 wks
2. Breech
3. Suspected fetal coagulation disorder
4. Suspected fetal macrosomia

Question 20

Where should the cup of a vacuum assisted vaginal device be placed on the infants head?

Answer 20

2cm anterior to the posterior fontanelle over the sagittal suture.

Question 21

How do the complications of using vacuum assisted vaginal extractors compare to that of forceps?

Answer 21

1. More failed deliveries with vacuums
2. Fewer perineal injuries to mother
3. ↑ incidence of fetal caphalohematoma, scalp lacerations and bruising

Question 22

3 things to check for during vacuum extraction

Answer 22

1. No maternal tissue is trapped in cup
2. Cup should be midline of the sagittal suture
3. Vacuum port of the suction cup should point TOWARD the occipiut

Question 23

Vacuum extractor

• Release the suction between _____
• No more than ____ pop offs
• Should not be applied for more than ____ minutes

Answer 23

• release between contractions
• 2
• 20 minutes

Question 24

What are 4 maternal-fetal indications for doing a C-section?

Answer 24

1. Cephalopelvic disproportion (kids too big)
2. Failure to progress
3. Abruption of placenta/placenta previa (other placental problems)

Question 25

What are 6 maternal indications for C-section?

Answer 25

1. Obstructive benign and malignant tumors
2. Large vuvlar condyloma
3. Abdominal cervial cerclage
4. Prior vaginal colporrhaphy
5. Conjoined twins
6. Maternal request

Question 26

What are the 6 fetal indications for a C-section?

Answer 26

1. Non-reassuring fetal HR
2. Very LBW (less than 1500gms)
3. Active HSV infection
4. Immune thrombocytopenia purpura
5. Breech/transverse
6. Congenital anomalies

Question 27

7 Intraoperative C-section Complications?

Answer 27

1. Lacerate uterine artery
2. Bladder injuries
3. Ureteral injuries
4. GI tract injury
5. Uterine atony
6. Placenta accreta
7. Cesarean hysterectomy

Question 28

What are 6 post-op complications of C-section?

Answer 28

1. Endomyometritis (infection of uterus)
2. Wound complications: infection, separation, dehiscence
3. Urinary complications (retention, infection)
4. GI complications (ileus, diarrhea)
5. Thromboembolic disorders (pulmonary emboli/DVT)
6. Septic pelvic thrombophlebitis (most commonly of ovarian v.)