OPERATIVE VAGINAL DELIVERY Flashcards

1
Q

What is operative vaginal delivery (OVD)?

A

Birth accomplished with assistance from forceps or a vacuum-cup device, using outward traction to augment maternal pushing.

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2
Q

What is the ratio of vacuum to forceps deliveries?

A

Approximately 4:1.

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3
Q

What are the common maternal indications for OVD?

A

-Maternal exhaustion
- prolonged second-stage labor
- pulmonary compromise
-infection-related decompensation
- neurological disease
- cardiac disorders.

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4
Q

What are frequent fetal indications for OVD?

A
  • Nonreassuring fetal heart rate
  • premature placental separation.
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5
Q

What are the three classifications of OVD based on station?

A

Outlet, low, and midpelvic.
(mc are outlet and low)

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6
Q

What is the prerequisite for fetal station in low forceps delivery?

A

Fetal station must be ≥+2 cm but not on the pelvic floor.

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7
Q

What type of regional analgesia is preferred for low or midpelvic OVD?

A

Regional analgesia is preferred; pudendal blockade may suffice for outlet deliveries.

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8
Q

Why should the maternal bladder be emptied before OVD?

A

To provide additional pelvic space and minimize bladder trauma.

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9
Q

What is OASIS in the context of OVD complications?

A

Obstetrical anal sphincter injuries, including third- and fourth-degree perineal lacerations.

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10
Q

Which episiotomy type offers greater protection against OASIS?

A

Mediolateral episiotomy.

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11
Q

What are common neonatal injuries associated with vacuum extraction during OVD?

A
  • Cephalohematoma
  • subgaleal hemorrhage
  • retinal hemorrhage
  • neonatal jaundice
  • scalp lacerations.
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12
Q

What types of injuries are more frequent with forceps delivery?

A
  • Facial nerve injury
  • brachial plexus injury
  • depressed skull fracture
  • corneal abrasion.
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13
Q

What is a proposed mechanism for brachial plexus injury during OVD?

A

Traction forces causing stretch on the brachial plexus as the fetal head descends while the shoulders remain at the pelvic inlet.

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14
Q

Is long-term neurodevelopmental morbidity associated with OVD?

A

No, studies show no significant association between OVD and long-term neurodevelopmental issues like epilepsy or cerebral palsy.

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15
Q

When is a trial of OVD recommended?

A

When the procedure is expected to be difficult, to allow immediate cesarean delivery if it fails.

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16
Q

What are the four components of a forceps branch?

A

Blade, shank, lock, and handle.
(BS-LH)
BLADE
SHANK
LOCK
HANDLE

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17
Q

What does the cephalic curve of the forceps blade conform to?

A

The round fetal head.

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18
Q

What is the function of the pelvic curve in forceps design?

A

It corresponds to the curve of the birth canal.

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19
Q

What is the advantage of fenestrated blades in forceps?

A

They reduce head slippage during forceps rotation.

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20
Q

What is the disadvantage of fenestrated blades?

A

Increased blade thickness and friction against the vaginal wall.

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21
Q

What are pseudo-fenestrated forceps blades?

A

Blades smooth on the outer maternal side but indented on the inner fetal side.

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22
Q

What is the purpose of parallel shanks in forceps?

A

They limit compression of blades against the fetal head.

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23
Q

What is a disadvantage of parallel shanks?

A

They add width against the introitus.

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24
Q

What is the benefit of overlapping shanks in forceps?

A

They raise compression forces but distend the perineum less, making them advantageous for outlet deliveries.

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25
Q

What are the three main types of forceps locks?

A

(SEP)
SLIDING LOCK
ENGLISH LOCK
PIVOT LOCK

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26
Q

How should forceps blades be applied for an OA fetal head position?

A

The left blade is inserted into the left posterior vagina first, followed by the right blade on the right side, both guided by fingers.

27
Q

What should be reassessed if forceps branches fail to articulate?

A

Blade relationships to the fetal sutures.

28
Q

How is traction applied during forceps delivery?

A

Gentle, intermittent, downward and outward traction is exerted with maternal efforts.

GENTLE
INTERMITTENT
DOWNWARD
OUTWARD

29
Q

What should be done before applying traction with forceps?

A

Rotate the fetal head to the OA position.

30
Q

Why is intermittent traction preferred during forceps delivery?

A

To prevent undue head compression and simulate spontaneous labor.

31
Q

What is the primary risk of OP position delivery with forceps?

A

Higher incidence of severe perineal lacerations and Erb/facial nerve palsies.

32
Q

What is the preferred forceps for rotations from OP to OA positions?

A

Kielland forceps.

33
Q

What is the success rate of manual rotation for OP positions?

A

> 90%, according to studies like those by Le Ray et al.

34
Q

What are the benefits of manual rotation for OP positions?

A

Lower cesarean delivery rates, reduced OVD, less perineal trauma, and decreased chorioamnionitis risk.

35
Q

What technique is used for manual rotation of an ROP fetal head?

A

The right palm cups the fetal head, rotates clockwise while flexing and destationing the head.

36
Q

What should be avoided during manual rotation destationing?

A

Disengaging the fetal head from the maternal pelvis.

37
Q

What complications are associated with OP forceps delivery?

A
  • Severe perineal trauma
  • higher risk of nerve palsies
  • extensive episiotomy.
38
Q

What direction is traction initially applied during low forceps delivery?

A

Downward, bringing the fetal head beneath the symphysis.

39
Q

When should forceps blades be removed during delivery?

A

After the head crowns to reduce vulvar distention and prevent laceration.

40
Q

How is a fetal head rotated from LOT to OA using Kielland forceps?

A

The anterior blade is first wandered posteriorly, swept around to an anterior position, and the second blade is inserted posteriorly.

41
Q

How do overlapping forceps shanks benefit outlet deliveries?

A

They reduce perineal distention compared to parallel shanks.

42
Q

What is the advantage of sliding locks in forceps?

A

They allow adjustment of branch alignment during asynclitism corrections.

43
Q

Why is ultrasound used during forceps application?

A

To document and guide fetal head rotation.

44
Q

What is vacuum-assisted operative vaginal delivery (OVD) commonly referred to in Europe?

A

Ventouse

45
Q

What are the theoretical benefits of a vacuum extractor compared to forceps?

A

Simpler requirements for precise positioning on the fetal head and avoidance of space-occupying blades within the vagina to reduce maternal trauma.

46
Q

What are the primary components of a vacuum device?

A

(CS-HV)
Cup, shaft, handle, and vacuum generator.

47
Q

What are the two main types of vacuum cups?

A

Soft bell cups and rigid mushroom cups.

48
Q

Which type of vacuum cup generates significantly more traction force?

A

Rigid mushroom cups.

49
Q

Which vacuum cup type is associated with higher scalp laceration rates?

A

Rigid mushroom cups.

50
Q

What is the advantage of soft bell cups in vacuum-assisted delivery?

A

They are associated with a lower incidence of scalp injuries compared to rigid cups.

51
Q

Why are flexible shafts preferred for OP positions or asynclitism?

A

They permit better seating of the cup.

52
Q

What is the correct placement of the vacuum cup on the fetal scalp?

A

Over the flexion point, 3 cm from the posterior fontanel and 6 cm from the anterior fontanel along the sagittal suture.

53
Q

What are the benefits of proper cup placement during vacuum-assisted delivery?

A

Maximizes traction, minimizes cup detachment, flexes the neck, and delivers the smallest head diameter through the pelvic outlet.

54
Q

What should be avoided during vacuum-assisted delivery traction?

A

Jerking, rocking, or applying rotational forces to the cup.

55
Q

What is the recommended maximum negative pressure for creating suction during vacuum-assisted delivery?

A

0.8 kg/cm².

56
Q

What is the general guideline for vacuum-assisted delivery regarding traction attempts?

A

Progressive descent should accompany each traction attempt, and lack of descent warrants alternative delivery approaches.

57
Q

What is a common reason for cup dislodgement during vacuum-assisted delivery?

A

Maternal soft tissue entrapment or improper cup placement.

58
Q

What is the median number of OVD procedures completed by recent trainees in accredited programs?

A

Approximately 20 procedures.

59
Q

What is the minimum number of OVD procedures required for residents completing training in 2021?

A

15 procedures.

60
Q

How can residency programs improve training in OVD?

A

Through simulation-based education and having skilled instructors readily available.

61
Q

What was the result of implementing an OVD simulation curriculum in one study?

A

22-percent reduction in OASIS rates and a decline in severe maternal and neonatal morbidity.

62
Q

What is the role of the non-dominant hand during vacuum-assisted delivery pulls?

A

Placed within the vagina to judge descent, adjust traction angle, and assess cup edge-to-scalp relationship.

63
Q

What should be done between contractions during vacuum-assisted delivery in some cases?

A

Lower suction levels to reduce scalp injury rates or maintain suction to aid rapid delivery if there is a nonreassuring fetal heart rate.