Operative Vaginal Delivery Flashcards
Can operative vaginal delivery be avoided?
- All women should be encouraged to have continuous support during labour as this can reduce the need
for operative vaginal delivery. - Use of upright or lateral positions and avoiding epidural analgesia can reduce the need for operative
vaginal delivery.
Delayed pushing in primiparous women with an epidural can reduce the need for rotational and midcavity deliveries.
How should operative vaginal delivery be classified?
- A standard classification of operative vaginal delivery should be used.
When should operative vaginal delivery be offered?
- Operators should be aware that no indication is absolute and should be able to distinguish ‘standard’
from ‘special’ indications. - A vacuum extractor should not be used at gestations of less than 34 weeks +0 days. The safety of vacuum extraction at between 34 weeks +0 days and 36 weeks +0 days of gestation is uncertain and should therefore be used with caution.
What are the essential conditions for safe operative vaginal delivery?
- Safe operative vaginal delivery requires a careful assessment of the clinical situation, clear communication with the mother and healthcare personnel and expertise in the chosen procedure.
What type of consent is required?
- Women should be informed in the antenatal period about operative vaginal delivery, especially during their first pregnancy.
- For deliveries in the delivery room, verbal consent should be obtained before an operative vaginal delivery and the discussion documented in the notes. If circumstances allow, written consent may also be obtained.
- Written consent should be obtained for trial of operative vaginal delivery in theatre.
Who should perform operative vaginal delivery?
- An operative vaginal delivery should be performed by an operator who has the knowledge, experience and skills necessary to assess and to use the instruments and manage complications that may arise.
- Obstetricians should achieve experience in spontaneous vertex delivery before commencing training in operative vaginal delivery.
- Obstetric trainees should receive appropriate training in operative vaginal delivery. Competency should be achieved before conducting unsupervised deliveries and should be monitored regularly thereafter.
- An experienced operator, competent at mid-cavity deliveries, should be present from the outset for all
attempts at rotational or mid-cavity operative vaginal delivery
Where should operative vaginal delivery take place?
Operative vaginal births that have a higher risk of failure should be considered a trial and conducted in
a place where immediate recourse to caesarean section can be undertaken.
Higher rates of failure are associated with:
● maternal body mass index over 30
● estimated fetal weight over 4000 g or clinically big baby
● occipito-posterior position
● mid-cavity delivery or when 1/5th of the head palpable per abdomen
What instruments should be used for operative vaginal delivery?
- The operator should choose the instrument most appropriate to the clinical circumstances and their level of skill. Forceps and vacuum extraction are associated with different benefits and risks. Failed delivery with selected instrument is more likely with vacuum extraction.
- The options available for rotational delivery include Kielland forceps, manual rotation followed by direct traction forceps or rotational vacuum extraction. Rotational deliveries should be performed by
experienced operators, with the choice depending on the expertise of the individual operator.
-There is insufficient evidence to favour either a rapid (over 2 minutes) or a stepwise increment in negative pressure with vacuum extraction.
When should operative vaginal delivery be abandoned?
- Operative vaginal delivery should not be attempted unless the criteria for safe delivery have been met (see Table 3).
Operative vaginal delivery should be abandoned where there is no evidence of progressive descent with
moderate traction during each contraction or where delivery is not imminent following three
contractions of a correctly applied instrument by an experienced operator.
Adverse outcomes, including unsuccessful forceps or vacuum delivery, should trigger an incident report
as part of effective risk management processes. - Paired cord blood samples should be processed and recorded following all attempts at operative vaginal delivery
Is there a place for sequential use of instruments?
- The use of sequential instruments is associated with an increased risk of trauma to the infant; however, the operator must balance the risks of a caesarean section following failed vacuum extraction with the risks of forceps delivery following failed vacuum extraction.
- Obstetricians should be aware of increased neonatal morbidity with failed operative vaginal delivery and/or sequential use of instruments and should inform the neonatologist when this occurs to ensure appropriate management of the baby
What is the role of episiotomy for operative vaginal delivery?
- In the absence of robust evidence to support routine use of episiotomy in operative vaginal delivery, restrictive use of episiotomy, using the operator’s individual judgement, is supported.
Should prophylactic antibiotics be given?
- There are insufficient data to justify the use of prophylactic antibiotics in operative vaginal delivery.
- Good standards of hygiene and aseptic techniques are recommended.
Should thromboprophylaxis be given?
- Women should be reassessed after an operative vaginal delivery for risk factors for VTE and, if appropriate, thromboprophylaxis should be prescribed.
What analgesia should be given after delivery?
- Regular paracetamol and diclofenac should be offered after an operative vaginal delivery in the absence of contraindications.
What precautions should be taken for care of the bladder after delivery?
- The timing and volume of the first void urine should be monitored and documented.
- A post-void residual should be measured if retention is suspected.
- Women should be offered physiotherapy-directed strategies to prevent urinary incontinence.
