Assisted vaginal birth

Question 1

What position is good for passive decent with an epidural

Answer 1

lateral position. Lower risk of needing instrumental

Question 2

Which positions have a reduced rate of instrumental delivery

Answer 2

upright and lateral

although slight increased risk of 2nd degree tears

Question 3

Situations in which forceps will be chosed over vacuum

Answer 3

1. Malpresentation - face or breech extraction
2. Dense epidural may impeded ability to push which is necessary for vacuum
3. If birth needs to be quicker
4. Less than 34 weeks

Question 4

Complciations for assisted delivery for mums

Answer 4

Tears
Need for episiotomy
Birth trauma (mentally)
PPH
Pelvic floor damage
Urinary retention
Dyspareunia

Question 5

Reasons why vacuum > forceps

Answer 5

Lower rates of epis/tears
Lower pain after delivery

Question 6

Neonatal complications assisted deliveries

Answer 6

Facial trauma
Higher need for resus
Cephalohaematoma
Subgaleal haematoma
Subdural/subarachnoid haemorrhage
neurological injury
skull fracture
shoulder dystocia
jaundice

Question 7

What are the two injuries on baby’s head that vacuum cups are at higher risk of and which one do we care about?

Answer 7

Cephalhaematomas - limited space. Deeper. Do not cross suture line.
Subgaleal haematomas - more superficial - BAD - mortality 20%. Large potential space and can result in shock

Question 8

Why do assisted deliveries have a higher rate of early cessation of breastfeeding?

Answer 8

facial nerve injury
maternal or fetal pain
jaundice causing sedation

Question 9

Materal indications for instrumental delivery

Answer 9

Maternal exhaustion - do not push until really feel the urge. Prolonged 1/2nd stage results in tiredness

Insufficient uterine activity - consider use of synto

Epidurals - impaired sensation. Definitely do passive decent if able

Maternal illness - extensive valsalva might be contrindicated for maternals disease e.g. cardiac

Question 10

Materno-fetal indications for instrumental delivery

Answer 10

Malposition - OP babies can be manually rotated. OR rotated using forceps OR delivered with forceps/vacuum as OP

Malpresentation - mentum anterior can be delivered with facial forceps. NOT VACUUM

Macrosomia - might need instrumental but size needs to be assessed with examination prior to trying this

Question 11

Fetal indications for instrumental delivery

Answer 11

Dodgy CTG in 2nd stage

2nd stage:
- nullips - after 2h 2nd stage or 3h with epidural
- multips - after 1h 2nd stage or 2h epidural

Question 12

What are the conditions that need to be satisfied before instrumental birth attempted

Answer 12

1. Maternal consent
2. Baby in appropriate position
3. Baby low enough
4. Full dilatation
5. Adequate pain relief
6. Operative theatre if a trial
7. Membranes ruptured
8. No known disproportion of head and pelvis

Question 13

What is an outlet procedure/low pelvic procedure/mid pelvic procedure/high pelvic procedure

Answer 13

Outlet - head at perineum, can be seen in contractions
Low - lower than +2
Mid - higher than +2
High - not engaged (these are not done anymore)

Question 14

What is classified as a rotational procedure

Answer 14

more than 45 degree rotation

Question 15

What is the acronym for vacuum cup delivery

Answer 15

Address woman - explain everything
Ask for help
Abdo palpation
Analgesia

Bladder - make sure empty with in-out catheter

Cervix - make sure fully dilated

Determine position

Equipment - make sure have birth tray and resus availability

Flexion point - 3cm anterior to posterior fontanelle

Gentle traction - constant gentle traction

Halt the procedure after 3 pop offs or if no decent after 3 pulls
Halt if been more than 20 minutes or consider after 10 to stop

Incision - episiotomy when crowning

Jaw - when jaw reachable remove vacuum and deliver

Question 16

What analgesia for forceps

Answer 16

If no epidural may need pudendal block

Question 17

Acronym for how to do FORCEPS

Answer 17

Address woman
Analgesia - epidural or pudendal block
Abdo palp
Ask for help

Bladder - empty

Cervix - dilated

Determine position

Equipment for birth/resus

Forceps applied - COVER IN JELLY
Try them outside the body first
Left always first
Shank anterior when putting it in then right hand to protect the maternal tissues
Rigth over left
Should link together easily

Gentle traction - pagot’s manouver. HAnd on top of shanks pushing downwards and one hand on shanks pulling outward in horizontal direction - creates a out and down direction and then once occiput is under the symphsis then can arc upwards

Handles now elevated so the shanks are upwards.

Incision - when head crowning can do epis. Neville barnes allow epis cutting through the split

Jaws - remove forceps (right blade first - up and anteriorly) and deliver baby after you can feel the jaw

Question 18

How do you check that the forceps are applied correctly?

Answer 18

Position for Safety

Posterior fontanelle - should be central and 1cm above the plane of the shanks

Fenestration - should onyl emit a finger and not more than this. Make sure they are far enough in

Lambdoind Sutures should be equidistant to the upper surfaces of the blades - makes sure the sagittal suture is midline

Question 19

What to do after an assisted birth has been done

Answer 19

Think about PPH

Look at perineum

Evaluate baby for injury (vit K as soon as possible for babies at risk of subgaleal haematomas)

Think about bladder care

Question 20

How to document after assisted delivery

Answer 20

Indication

Examination findings

Consent

Procedure (can do A-J)

Management of third stage

Instructions for care

Question 21

Indications for a trial of assisted delivery

Answer 21

BMI >30

Still 1/5 palpable abdominally

Baby weight >4kg or clinical suspiscion that it is large

OP position