Operative vaginal delivery

Question 1

What is operative vaginal delivery?

Answer 1

Use of an instrument to aid delivery of the foetus

Question 2

What percentage of deliveries are via operative vaginal delivery?

Answer 2

12%

Question 3

What are the two main instruments used in operative vaginal delivery?

Answer 3

Ventouse

Forceps

Question 4

Which instrument has a lower rate of foetal complications but higher rate of maternal complications?

Answer 4

Forceps

Question 5

Give the general rule for when attempt at operative vaginal delivery should be abandoned

Answer 5

3 contractions and pulls with any instrument and no reasonable progress

Question 6

What is ventouse?

Answer 6

An instrument that attaches a cup to the foetal head via a vacuum

Question 7

List and describe the common types of ventouse

Answer 7

Electrical pump attached to silastic cup - occipital-anterior position

Hand held, disposable device known as kiwi - omnicup and can be used for all foetal positions and rotational deliveries

Question 8

How is ventouse used?

Answer 8

Cup applied with its centre over the flexion point on the foetal skill

During uterine contractions, traction is applied perpendicular to the cup

Question 9

What are ventouse deliveries associated with?

Answer 9

Lower success rate
Less maternal perineal injury
Less pain
More cephalohematoma
More subgaleal haematoma
More foetal retinal haemorrhage

Question 10

List and describe the different types of forceps

Answer 10

Double bladed instruments

• Rhodes, Neville-barnes or simpsons - used for OA positions
• Wrigleys - used at Csection
• Kiellands - used for rotational deliveries

Question 11

Describe how forceps are used

Answer 11

Blades are introduced into the pelvis, taking care not to cause trauma to maternal tissue and placed around the sides of the foetal head, with the blades then locked together

Gentle traction is then applied during uterine contraction following the J shape of the maternal pelvis

Question 12

What is the use of forceps associated with?

Answer 12

Higher rates of 3rd and 4th degree tears
Less often used to rotate
Doesn’t require maternal effort

Question 13

What are the indications for operative vaginal delivery?

Answer 13

2nd stage of labour clinical scenario

• Is there valid clinical indication to intervene?
• Is the patient a suitable case for instrumental delivery?
• Inadequate progress
• Maternal exhaustion
• Maternal medical conditions that mean active pushing or prolonged exertion should be limitied (intracranial pathology, congenital heart disease, severe HTN)
• Foetal compromise
• Clinical concerns - significant antepartum haemorrhage

Question 14

When is instrumental delivery contraindicated?

Answer 14

Unengaged foetal head in singleton pregnancy
Incompletely dilated cervix in singleton pregnancy
True cephalopelvic disproportion
Breech and face presentations and most brow presentation
Preterm gestation - <34 weeks for ventouse - high likelihood of any foetal coagulation disorder

Question 15

In general, what are the pre-requisites for performing an instrumental delivery?

Answer 15

Fully dilated 
Ruptured membranes 
Cephalic presentation 
Defined foetal position 
Foetal head at least at level of ischial spines 
Empty bladder
Adequate pain relief 
Adequate maternal pelvis

Question 16

How are operative vaginal deliveries classified?

Answer 16

By the degree of foetal descent

Question 17

What does a lower classification equate to?

Answer 17

Lower risk of complications as less rotation is needed and fewer pulls

Question 18

List the foetal complications of instrumental delivery

Answer 18

Neonatal jaundice
Scalp lacerations 
Cephalohematoma
Subgaleal haematoma
Facial bruising 
Facial nerve damage 
Skull fractures
Retinal haemorrhage

Question 19

List the maternal complications of instrumental delivery

Answer 19

Vaginal tears - 3rd/4th degree
VTE
Incontinence 
PPH
Shoulder dystocia
Infection