Operative/Assisted Delivery

Question 1

Incidence of assisted delivery in SA

Answer 1

Ventouse approx 7%

Forceps approx 5%

Question 2

Comparison of forceps v ventouse deliveries

Answer 2

Ventouse:
- More likely to cause cephalhaematoma, subgaleal and retinal haemorrhage in neonate
- Not suitable in less than 36w GA for above reason
- Less likely to result in successful vaginal delivery
- less use of regional and general anaesthesia
- Less pain 24 hours after delivery
FORCEPS:
- more likely to cause maternal soft tissue injury

Question 3

Indications for operative delivery

Answer 3

Maternal:
- Inability to push
- Delay in second stage
- Cardiopulmonary or vascular conditions
- Neurological or muscular disease
- Significant vaginal bleeding
Foetal:
- malposition with relative dystocia (OP or OT)
- Suspected or anticipated foetal compromise

Question 4

Absolute contraindications to operative delivery (7)

relative contraindications - 3

Answer 4

• Operator inexperience
• Incompletely dilated cervix
• Unknown foetal position
• Unengaged head
• Malpresentation (e.g. face or brow)
• Suspected cephalopelvic disproportion

For Ventouse only: gestation less than 36 weeks (risk of ICH or cephalhaematoma)

• neonatal predisposition to fracture (e.g. OI)
• neonatal bleeding disorder (e.g. haemophilia)
• Maternal hep B/C or HIV (vertical transmission)

Question 5

Prerequisites before operative delivery (8)

Answer 5

• Head less than 1/5 palpable in abdo
• Vertex presentation
• Cervix fully dilated
• Membranes ruptured
• exact position of head known
• Pelvis considered to be adequate (?wat)
• Empty maternal bladder
• Adequate analgesia (regional block preferred if possible)

Question 6

Serious maternal risks of operative delivery

Answer 6

3rd and 4th degree tear
Extensive tearing of vaginal/vulval area

Both occur commonly

Question 7

Frequently occurring maternal complications of operative delivery

Answer 7

Shoulder dystocia
PPH
Vaginal tear/abrasion
Anal sphincter dysfunction/voiding dysfunction

Question 8

Serious foetal complications of operative delivery

Answer 8

Generally are uncommon

Subaponeurotic/subgaleal haemorrhage
Intracranial haemorrhage
Skull fracture
Facial nerve palsy
Corneal abrasion
Cervical spine injury (more with rotational instrumental delivery)

Question 9

Frequently occurring foetal complications of operative delivery

Answer 9

Forceps marks/bruising on face
Cup marking on scalp
Cephalhaematoma
Facial or scalp lacerations
Neonatal jaundice/hyperbilirubinaemia
Retinal haemorrhage

Question 10

Types of Ventouse

Answer 10

Synthetic cups

• soft or rigid
• less neonatal scalp injuries
• higher failure rate
• suitable for straightforward deliveries

Metal cups
- preferred for OP, OT and difficult OA positions

Question 11

Position of woman for operative delivery

Answer 11

Dorsal lithotomy position

Question 12

Types of forceps for instrumental delivery

Answer 12

Outlet forceps: (head on perineal floor)
- Wrigley

Low forceps (head at +2 station or lower)

• Simpson
• Neville-Barnes
• Piper
• Lauffe

Mid forceps rotational (head above +2 station)
- Khelland

Question 13

When to abandon instrumental delivery procedure

Answer 13

Ventouse:

• no progress after 3 consecutive pulls
• evidence of foetal scalp injury
• cup dislodges 3 times

Forceps:
- failure to produce descent