Operative Delivery

Question 1

Indications for operative vaginal delivery

Answer 1

o Prolonged second stage of labor
o Suspicion of immediate or potential fetal compromise
o Shortening of the second stage of labor for maternal benefit

Question 2

Why do operative vaginal delivery?
1992 – 9% of all deliveries
2013 – 3.3% of all deliveries (associated increase in c-sec)

Used to achieve or expedite safe vaginal birth for maternal or fetal indications. (sometimes quicker than c-sec)

Answer 2

o	Maternal exhaustion
o	Inability to push effectively
o	Maternal cardiac disease (avoid pushing in the 2nd stage)
o	Prolonged second stage of labor
o	Arrest of descent
o	Rotation of the fetal head
o	NRFHTs

Question 3

Benefits

o Avoids c-section

Answer 3

o	Hemorrhage
o	Infection
o	Prolonged healing time
o	Increased cost
o	Future cesarean sections deliveries
o	Future placental anomalies (accreta)

Question 4

Types of Forceps

Answer 4

Outlet
o Fetal scalp is visible at the introitus without separating the labia
o Fetal skull has reached the pelvic floor
o Fetal head is at/on the perineum
o Sagittal suture is in an AP diameter or ROA/LOA or ROP/LOP position
o Rotation does not exceed 45 degrees
Low forceps
o Leading point of the fetal skull is at station +2 cm or more and not on the pelvic floor
o Without rotation: less than 45 degrees ROA/LOA rotates to OA; ROP/LOP rotates to OP
o With rotation: greater than 45 degrees
o Rotation w/Kielland (90% resulted in vaginal birth)
Midforceps
o Station is above +2 cm but head is engaged

Question 5

Prerequisites for operative delivery

Answer 5

o Cervix fully dilated and retracted
o Membranes ruptured
o Engagement of fetal head
o Position of the fetal head has been determined
o Fetal weight estimation performed
o Pelvis thought to be adequate for vaginal birth
o Adequate anesthesia
o Maternal bladder has been emptied
o Informed consent has been obtained
o Willingness to abandon trial of vaginal birth if failure to deliver (failure of operative delivery is 2.9-6.5%)
o C-sec following failed op vag del shows increased rates of subdural/cerebral hemorrhage, mechanical ventilation and seizures
o No guidelines on number of pulls or vacuum detachments but if no descent is seen with the first several pulls, a reappraisal is necessary
o Sequential use of vacuum followed by forceps or vice versa should not routinely be performed

Question 6

Contraindicated operative delivery if:

Answer 6

o Fetal head is not engaged in the pelvis
o Position of the vertex cannot be determined
o Known/suspected bone demineralization (osteogenesis imperfecta)
o Known/suspected bleeding disorder (hemophilia, von Willebrand, alloimmune thrombocytopenia)
o MUST OBTAIN INFORMED CONSENT (discuss procedure, risks, alternatives)

Question 7

Vacuum

Answer 7

o Easier to learn
o Used when asynclitism prevents proper forceps placement
o No difference in cephalohematoma compared to forceps
o Use is discouraged if less than 34 weeks (no safe lower limit has been established)

Old metal cup (more trauma) Newer soft cups (more detachments)
Cephalohematoma more likely with increased duration of vacuum use
o 28% if time from application to delivery is > 5 min
o Releasing pressure inbetween contractions does not appear to be associated with improved outcomes

o Applied 2 cm anterior to the posterior fontanelle and centered over the sagittal suture

o Ensure maternal tissue is free

Question 8

Forceps

Answer 8

o More secure applications
o Allows for rotation of fetal head
o Higher degree of successful vaginal delivery
o Associated with more 3rd and 4th degree lacerations

o Ensure the sagittal suture is aligned with the shanks
o Posterior fontanelle is one finger breadth above the shanks
o Lambdoid sutures are equidistant from the forceps blades

Question 9

Episiotomy

Answer 9

Routine episiotomy is not recommended for operative vaginal delivery
Mediolateral – less risk of anal sphincter injury than midline but associated poor healing and prolonged discomfort.
Midline – increased risk of anal sphincter injury and extension to the rectum

Question 10

Maternal Complications

Answer 10

o Anal sphincter injury (difficult due to confounding factors ie. Size, age, obesity, shoulder dystocia, episiotomy, prolonged 2nd stage)
o Recurrent anal sphincter tear is low (3.2%) but higher if operative delivery occurs
o Similar pelvic floor function and sexual function scores as those with c-section
o 5 years postpartum, vacuum and forceps have similar bowel and urinary dysfunction

Question 11

Newborn/Long-term Complications

Answer 11

no significant long-term consequences comparted to spontaneous vaginal birth (5 and 10 year cognition)
o Rate of intracranial hemorrhage – 1 in 650-850 operative vaginal deliveries
o Similar for forceps, vacuum and cesarean delivery
o Rate of neurologic complications – 1 in 220-385 operative vaginal deliveries
o Rate of neonatal encephalopathy 4.2/1000 (3.9/1000 with c-sec)
o These risk could be associated with the indication for delivery rather than the procedure itself (c-section would not necessarily lessen the risk

Question 12

o Vacuum risks

Answer 12

o	Laceration
o	Cephalohematoma (higher than in forceps)
o	Subgaleal or intracranial hemorrhage
o	Retinal hemorrhages
o	Hyperbiirubinemia

Question 13

o Forceps

Answer 13

o	Facial lacerations
o	Facial nerve palsy
o	Corneal abrasions
o	External ocular trauma
o	Skull fracture
o	Intracranial hemorrhage