Instrumental delivery

Question 1

What is the purpose of an instrumental delivery? (RCOG 2011)

Answer 1

is to mimic spontaneous vaginal birth, thereby expediting delivery with a minimum of maternal or neonatal morbidity

Question 2

What are the two types of instrumental delivery?

Answer 2

Forceps:

Low- cavity and mid-cavity

Vacuum extraction (ventouse):

Kiwi, silicone rubber cup and Metal cup

Question 3

Why may a woman need an instrumental delivery?

Answer 3

Delay in 2nd stage (diagnose delay in the active second stage when it has lasted 2 hours (Primiparous) or 1 hour (multiparous) and refer the woman to a healthcare professional trained to undertake an operative vaginal birth if birth is not imminent NICE 2014)

Malposition

Fetal distress

Obstetric emergency (when there is a need to expedite delivery and the woman is in the 2nd stage)

Multiple birth

Breech birth

Elective (e.g. due to cardiac condition)

Question 4

What are the NICE guidelines to expediting birth, in terms of assessment and management?

Answer 4

0NICE (2014) Intrapartum Care

• 1.13.34 If the birth needs to be expedited for maternal or fetal reasons, assess both the risk to the baby and the safety of the woman. Assessments should include:
• the degree of urgency
• clinical findings on abdominal and vaginal examination
• choice of mode of birth (and whether to use forceps or ventouse if an instrumental birth is indicated)
• anticipated degree of difficulty, including the likelihood of success if instrumental birth is attempted
• location
• any time that may be needed for transfer to obstetric-led care
• the need for additional analgesia or anaesthesia
• the woman’s preferences.

[new 2014]

• 1.13.35 Talk with the woman and her birth companion(s) about why the birth needs to be expedited and what the options are.

[new 2014]

•1.13.36 Inform the team about the degree of urgency.

[new 2014]

•1.13.37 Record the time at which the decision to expedite the birth is made [new 2014]

Question 5

What are the contraindications for an instrumental delivery?

Answer 5

Unengaged head

Malpresentation (face/brow) Inability to define position

Large baby

Inexperienced operator

Less than 36 weeks for vacuum extraction

Not fully dilated

Question 6

What factors must be considered when choosing which instrumental delivery to use?

Answer 6

Presence /or not of fetal distress

Position of fetus (abdominal palpation and VE)

Station of fetus

?maternal distress

?analgesia/anaesthesia present

?Skill of the operator

?equipment available

Need to consider risks of each type of delivery to the mother and fetus

Question 7

What midwifery care needs to be offered during a ventouse delivery?

Answer 7

Help – inform DS co-ordinator

Informed consent

Pain relief

Bladder care-empty? Catheter?

Position (lithotomy?- doesn’t have to be)

Active management 3rd stage- more at risk of PPH and perineal trauma

Neonatal resuscitation equipment

DOCUMENTATION - timing of when instruments are applied and every part of process(*medicolegal)

Sensitive communication to the mother and her partner

Question 8

What pain relief options are available?

Answer 8

Epidural anesthesia and pudendal block

Question 9

What is a pudendal block?

Answer 9

pudendal nerves are blocked with the use of 0.5% lidocaine. The pudendal nerve pass under and slightly posterior to the ischial spine

Question 10

How does a ventouse delivery work?

Answer 10

Ventouse cup on sagittal suture, over the flexion point

This is approximately 3cm in front of posterior fontanelle and 6cm behind the anterior fontanelle

NB – important not to trap vaginal skin in the cup

Do not use excessive traction

Question 11

What is a useful mneumonic to help remember what to do in a ventouse delivery?

Answer 11

Ask for help, Address the woman, Analgesia

Bladder empty

Cervix must be fully dilated

Determine position of the fetus

Equipment and extractor ready

Fontanelle (identified and suction cup placed over the sagittal suture); Forceps lubricated

Gentle traction

Halt traction and reduce pressure, repeat with next contraction (Handles elevated for forceps delivery)

Incision (episiotomy) if needed

Jaw is reachable so remove suction or forceps to deliver head

Question 12

Why is it important to avoid fontanelles when applying a ventouse?

Answer 12

To avoid causing internal bleeding

Question 13

What are the potential neonatal complications of a ventouse delivery?

Answer 13

Cephalohaematoma

scalp abrasions

subdural haematoma

retinal haemorrahages

ventouse morer risky than forceps

Question 14

What are the potential maternal complications of a ventouse delivery?

Answer 14

Trauma (physical and psychological)

Increased risk of PPH (however less risk of PPH than forceps)

Worries about the baby

Question 15

What are the potential neonatal complications of a forceps delivery?

Answer 15

Marks, bruising on the face

Facial palsy due to pressure on a facial nerve

There are less neonatal risks with a forceps delivery than a ventouse

Question 16

What are the potential maternal complications with forceps?

Answer 16

Soft tissue injuries (perineum, vagina, cervix)

Damage to the urethra

Haemorrhage

There are more physical maternal risks with a forceps delivery

Question 17

Do all women who have an instrumental delivery require

an episiotomy?

Answer 17

Leeuw et al (2007) found that a mediolateral episiotomy protected against anal sphincter injury in primiparous and OP deliveries and should be routinely used

Macleod et al(2013) found that a restrictive approach to the use of episiotomy may increase rates of urinary morbidity, in particular stress incontinence and perineal pain, in the immediate postpartum period.

RCOG (2011) recommend restrictive use of episiotomy

Question 18

Why is it more risky to do a c section than a instrumental delivery?

Answer 18

2nd stage of labour, baby’s head is quite low down, c section is major abdominal surgery

Question 19

What is a trial in theatre?

Answer 19

Some instrumental deliveries are performed in an operating theatre with a high epidural block/spinal anaesthetic so a caesarean section may be performed

Question 20

When do you know an instrumental delivery has failed?

Answer 20

Instrumental delivery should be abandoned if there is no progressive descent with gentle traction or if delivery is not imminent after 3 contractions using correctly applied instruments with an experienced operator (RCOG 2011)

Neonatal and maternal morbidity is increased if there is a trial that proceeds to a CS

An episiotomy should not be performed if a delivery is not imminent

Question 21

What are the possible maternal complications of an instrumental delivery?

Answer 21

Anal sphincter injury – dependent on type of instrumental delivery

Retention of urine (increased risk if spinal/high epidural block – may require an indwelling urinary catheter (RCOG, 2011)

Increased risk of urine incontinence (Brown & Lumley, 1998)

Increased risk of faecal incontinence (Fitzpatrick et al 2003)

Perineal trauma

Pain – genital tract, perineal, backache, haemorrhoids

Increased risk of UTIs / Genital tract infections

Increased risk of DVT- may require thromboprophylaxis

Sexual problems

Tiredness

Loss of expectations

Acute trauma symptoms (PTSD)

Postnatal depression?

Compromised first mother-infant interaction; can lead to persistent adverse relationship

Women often do not report all the postnatal concerns/problems they are experiencing

Effects on the partner

Increased hospital stay

Medico-legal issue

Question 22

What are the possible postnatal complications of an instrumental delivery for the neonate?

Answer 22

Headache!! (?analgesia required)

Irritable

Possible feeding problems

Possible eye problems (e.g. Conjunctivitis)

Attachment issues

Increased risk of admission to SCBU

Increased risk of jaundice