Operative vaginal delivery

Question 1

What is initial management of prolonged deceleration?

Answer 1

Arrive in room with fHR in 70s: assess vitals, resuscitative measures (LL decubitus, fluid bolus, stop pitocin), perform cervical exam, check that OR is available.

Question 2

Describe how you apply the vacuum onto the fetal head?

Answer 2

Place vacuum over the sagittal suture, approximately 3cm from posterior fontanelle and 6cm from anterior fontanelle. Apply downward traction.

Question 3

What are contraindications for operative vaginal delivery?

Answer 3

• Unengaged fetal head
• unknown fetal position
• Bone disease (eg. osteogenesis imperfect)
• Fetal bleeding disorder (AIT, vWD, hemophilia)
• vacuum < 34wks
• provider inexperience
• pt refusal
• incomplete cervical dilation, lack of proximity to OR
• maternal HIV/hepB

Question 4

Describe how you would apply forceps to the fetal head?

Answer 4

Elliot and Simpsons.

Question 5

How long would you do vacuum or forceps for?

Answer 5

If there was no descent of the fetal head. 3 pop-offs for vacuum.
If fetus not delivered in reasonable time (~15-20 min or after 3 pulls).
Do not do sequential use of operative delivery methods. It can increase morbidity

Question 6

What are indications for operative vaginal delivery?

Answer 6

Maternal:
- exhaustion, inability to push effectively, cardiac disease/need to avoid pushing in second stage, prolonged second stage, arrest of descent

Fetal:
- NRFHR in second stage

Assess EFW, adequacy of pelvis and anesthesia, fetal station/position, adequate

Question 7

What are the different types of forceps?

Answer 7

Outlet: fetal scalp visible at introitus or on perineum. skull at pelvic floor, rotation < 45 degrees.

Low: leading pt of fetal skull at +2 station or below. can have rotation < 45 or > 45 degrees

Mid: head above +2 station (but engagement has occurred so 0 to +2)

Question 8

What are maternal complications of OVD?

Answer 8

anal sphincter tears (more w/ forceps)

Question 9

What are neonatal complications of OVD?

Answer 9

Rare (<0.3%), similar to CD

VACUUM: laceration
- cephalohematoma (accumulation of blood under scalp)
- subgaleal (under scalp but can cross suture lines)
- ICH, retinal hemorrhage
- hyperbilirubinemia.

FORCEPS:
- facial laceration, facial nerve palsy, corneal damage, skull fracture, ICH

Question 10

What are fetal presentations that require a CS?
Which presentation requires a classical CS?

Answer 10

Face - mentum posterior
Breech
Brow - if at high station can flex into vertex or extend into face
Transverse lie, back down- requires CLASSICAL CS.

Question 11

What are pre-requisites for operative vaginal delivery?

Answer 11

• cervix fully dilated
• membranes ruptured
• engaged fetal head
• known position
• operator experience
• pelvis adequate
• EFW known
• adequate analgesia
• EMPTY BLADDER
• OR available
• pt consented and been informed of risks