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Practice bulletins > #219 Operative Vaginal Birth > Flashcards

#219 Operative Vaginal Birth Flashcards

1
Q

What % of deliveries are operative vaginal deliveries?

A

3.3%

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2
Q

What are some indications for operative vaginal delivery?

A

Prolonged second stage of labor, suspicion of immediate or potential fetal compromise, shortening of the second stage of labor for maternal benefit

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3
Q

What are criteria for outlet forceps?

A
  • Fetal scalp visible at introitus without separating the labia
  • Fetal skull has reached pelvic floor
  • Fetal head is at or on perineum
  • Sagittal suture is in an anteroposterior diameter or right or left OA or posterior position
  • Rotation does not exceed 45 degrees
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4
Q

What are criteria for low forceps?

A
  • Leading point of fetal skull is at +2cm or more and not on the pelvic floor
  • Without rotation: rotation is 45 degrees or less (right or left occiput anterior to occiput anterior, or right or left occiput posterior to occiput posterior)
  • With rotation: rotation is greater than 45 degrees
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5
Q

What are criteria for midforceps?

A

Station is above +2cm, but head is engaged

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6
Q

Is vacuum extraction or forceps believed to be easier to learn?

A

Vacuum

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7
Q

Is a vaginal birth more likely to be achieved with forceps or vacuum extractors?

A

Forceps (RR 0.65)

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8
Q

Is vacuum or forceps associated with high risk of third or fourth degree perineal tears?

A

Forceps (RR 1.89)

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9
Q

Is vacuum or forceps more likely to be associated with neonatal cephalohematomas?

A

No difference

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10
Q

Is forceps or vacuum more associated with long-term urinary incontinence or anal sphincter?

A

No difference

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11
Q

At what gestational age can you use vacuum for delivery? Forceps?

A

Vacuum extraction discouraged <34wks (although a safe lower limit not established); no limit for forceps

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12
Q

What are prerequisites for operative vaginal birth?

A
  • Cervix fully dilated and retracted
  • Membranes ruptured
  • Engagement of the fetal head
  • Position of the fetal head has been determined
  • Fetal weight estimation performed
  • Pelvis thought to be adequate for vaginal birth
  • Adequate anesthesia
  • Maternal bladder emptied
  • Informed consent, willingness to abandon trial and back-up plan in place in case of failure
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13
Q

Where should vacuum be placed on fetal head?

A

2cm anterior to the posterior fontanelle and centered over the sagittal suture, ensuring that no maternal tissue is included

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14
Q

How should forceps be applied?

A

Sagittal suture aligned with shanks, posterior fontanelle is one finger breadth above the shanks, and that the lambdoid sutures are equidistant from the forceps blades.

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15
Q

True or false, episiotomy should be routinely performed for operative vaginal deliveries

A

False

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16
Q

What are the risks/benefits of mediolateral episiotomy compared to midline episiotomy?

A

Lower risk of anal sphincter injury, increased likelihood of long-term perineal pain and dyspareunia

17
Q

Does a vacuum or forceps delivery have a higher risk of anal sphincter injury?

A

Forceps

18
Q

What is the difference in bowel or urinary dysfunction 5 years postpartum between women who had vacuum vs forceps assisted vaginal deliveries?

A

No difference

19
Q

True or false, absolute rate of newborn injury with forceps and vacuum deliveries is low?

A

True

20
Q

One in how many operative vaginal deliveries result in intracranial hemorrhage? One in how many result in neurologic complications?

A

1 in 650-850 for ICH.
1 in 220-385 with neurologic complications. (some question as to whether these outcomes are due to indication for operative delivery rather than delivery itself)

21
Q

What neonatal injuries/complications have been reported with vacuum delivery?

A

Laceration, cephaliohematoma, subgaleal, ICH, retinal hemorrhage, increased hyperbilirubinemia

22
Q

What neonatal injuries/complications have been reported with fprceps delivery?

A

facial lacerations, facial nerve palsy, corneal abrasions and external ocular trauma, skull fracture, ICH.

23
Q

What is the rate of neonatal encephalopathy per 1,000 term neonates after operative vaginal birth compared to cesarean birth?

A
  1. 2 per 1,000 in operative vaginal delivery.

3. 9 per 1,000 in cesarean delivery

24
Q

Is suspected macrosomia a contraindication to operative vaginal delivery?

A

No

25
Q

What are contraindications to operative vaginal delivery?

A

Fetal head is unengaged, positional of fetal head is unknown, live fetus is known or strongly suspected to have a bone demineralization condition (eg, osteogenesis imperfecta), or a bleeding disorder (eg, hemophilia or von Willebrand)

26
Q

What is the failure rate of operative vaginal deliveries?

A

2.9-6.5%

27
Q

What factors are significantly associated with failure of operative vaginal delivery (when controlling for operator experience)?

A

Birth weight and second stage labor duration

28
Q

What is the neonate at increased risk for after cesarean section after failed operative delivery?

A

Increased rates of subdural or cerebral hemorrhage, mechanical ventilation, and seizures

29
Q

How many forceps pulls or vacuum detachments are allowed prior to moving to cesarean section?

A

No adequate data to generate evidence-based guidelines. Descent should be expected with traction, if no descent with first several pulls, a reappraisal is necessary

30
Q

Compared with single operative vaginal delivery device alone, what does a combo of forceps and vacuum increase the risk of?

A

higher rates of subdural or cerebral hemorrhage, subarachnoid hemorrhage, facial nerve injury, and brachial plexus injury, severe perineal lacerations/sphincter tears, lower umbilical artery pH

31
Q

What is most significantly associated with increased risk of cephalohematoma after vacuum assisted delivery?

A

Application time. 28% for those with application time >5 mins.

32
Q

What is the rate (%) of cephalohematoma in neonates with vacuum application >5 minutes?

A

28%

33
Q

During vacuum operative delivery, does reducing vacuum pressure between contractions decrease the rate of fetal scalp injury? Improve outcomes?

A

No x 2

34
Q

What are Kielland forceps used for?

A

Rotational operative deliveries

35
Q

Comparing Kielland forceps delivery to emergency cesarean delivery in second stage of labor, which has higher rates of NICU admission? Other measures of neonatal morbidity?

A

no difference

36
Q

How do outcomes compare to forceps delivery in OP position compared to forceps delivery after either forceps or manual rotation to OA?

A

Forceps delivery without rotation has higher rate of severe perineal laceration (OR 3.67)

37
Q

Should antibiotics be given at the time of operative delivery?

A

Not necessarily. But may consider if a 3rd or 4th degree laceration occurs

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