Instrumental delivery (forceps/vacuum)

Question 1

Instrumental delivery - indications

Answer 1

Maternal

1. Exhaustion
2. Prolonged 2nd stage (>1h active pushing in multip and >2h in primip)
3. Medical indications for avoiding Valsalva (e.g. severe cardiac disease)
4. Pushing not possible (paraplegia/tetraplegia)

Fetal
5. Fetal compromise

Question 2

Instrumental delivery (forceps) - complications

Answer 2

1. Associated with increased maternal trauma (including spiral tears of vagina with rotational forceps, anal sphincter trauma)

Fetal injuries rare; mostly occur due to incorrect application of blades

2. Facial nerve palsy
3. Skull fractures
4. Orbital injury
5. Intracranial haemorrhage

Question 3

Instrumental delivery (ventouse) - complications

Answer 3

Associated with fetal injuries

1. Scalp lacerations and avulsions
2. Cephalohaematoma
3. Retinal haemorrhage
4. Rarely - subgaleal/intracranial haemorrhage
5. Rarely - alopecia in long-term

Question 4

Types of forceps (3)

Answer 4

1. Low cavity forceps = Wrigley’s
2. Mid-cavity non-rotational forceps = Neville-Barnes’/Simpson’s
3. Mid-cavity rotational forceps (Keilland’s)

Question 5

Types of ventouse (3)

Answer 5

1. Metal cup
2. Soft cup
3. Kiwi cup

Question 6

Instrumental delivery - criteria

Answer 6

F - fully dilated cervix (i.e. confirm second stage)

O - obstruction excluded (head =/

Question 7

Instrumental delivery - trial

Answer 7

1. Term used when not possible to determine with sufficient confidence that an instrumental delivery will be successful
2. Should take place in theatre (possible to move to immediate CS)
3. Inform woman of likely success. Consent form = ‘trial of instrumental vaginal delivery +/- emergency CS’

When to abandon and deliver by emergency CS:

4. No evidence of progressive descent with each pull
5. Delivery not imminent following three pulls of a correctly applied instrument by an experienced operator

Question 8

Failed instrumental vaginal delivery - RF

Answer 8

1. BMI >30
2. EFW>4kg or clinically large baby
3. OP position
4. Mid-cavity delivery (?)
5. Head >1/5 palpable abdominally