Operative Vaginal Delivery

Question 1

What reduces need of operative delivery?

Answer 1

Companion in labour
Upright or lateral position for delivery
Delay in pushing with epidural

Question 2

What are criteria for operative vaginal delivery?

Answer 2

Consent and explanation of procedure
1/5th or less head plapable per abdomen
Ruptured membranes
Adequate analgesia: epidural or pudendal block
Adequate contractions
Bladder empty and catheter balloon deflated
Fully dilated cervix with head at ischial spines or below
Check presentation - must be cephalic
Check instrument
Neonatal doctor in attendance

Question 3

What are maternal indications for operative vaginal delivery?

Answer 3

Prolonged second stage
-Fetal malposition such as OP or OT
- dense epidural block
- diminished urge to push
Maternal exhaustion
Medical avoidance of pushing - severe cardiac disease
Pushing not possible - quadriplegia, paraplegia

Question 4

What are fetal indications for operative vaginal delivery?

Answer 4

Suspected fetal distress

For the after-coming head in a breech delivery

Question 5

What are specific indications for forceps delivery?

Answer 5

Assisted breech delivery, forceps to deliver head
Assisted delivery of preterm infant < 34 weeks gestation
Controlled delivery of head at Caesarian section
Assisted delivery with face presentation
Assisted delivery with suspected coagulopathy or thrombocytopenia in fetus
Instrumental delivery where maternal condition precludes pushing
Cord prolapse in second stage
Instrumental delivery under GA
Presence of significant caput

Question 6

What are forceps?

Answer 6

Cured blades designed to fit around the fetal head allowing traction to be applied via handles
Require less maternal effort for successful delivery than ventouse and are less likely to fail.
Forceps may be safer for the baby but can cause significant maternal tract trauma (add 1cm to diameter of head)

Question 7

What are low-cavity forceps

Answer 7

Wrigley’s
Lift out deliveries when head is on perineum
Short shank and are lighter in weight
Sometimes used at LSCS to help control delivery of head

Question 8

What are mid-cavity non-rotational forceps?

Answer 8

Have a long shank, cephalic and pelvic curves and must only be used when the saggital suture lies in the AP diameter

Question 9

What are mid-cavity rotational forceps?

Answer 9

Reduced pelvic curve making them suitable for rotation

Question 10

What is ventouse extraction?

Answer 10

Suction device to suck fetal scalp tissues into a ventouse cup

Question 11

What warning before Ventouse?

Answer 11

Artificial caput (swelling) created - chignon 
Takes 24-48 hours to resolve

Question 12

What are requirements for ventouse extraction?

Answer 12

> 34 weeks gestation

No maternal coagulopathy

Question 13

What are complications of operative vaginal delivery?

Answer 13

Maternal genital tract trauma, especially with forceps
Spiral vaginal tears with rotational forceps
Fetal injuries

Question 14

What are fetal injuries with forceps?

Answer 14

Facial nerve palsy
Skull fractures
Orbital injuries
Intracranial haemorrhage

Question 15

What are fetal injuries with Ventouse?

Answer 15

Cephalhaematoma
Retinal haemorrhage
Scalp lacerations and scalp avulsions

Question 16

When should you abandon an operative vaginal delivery?

Answer 16

No descent after with each subsequent pull
Delivery not imminent after 3 pulls when the instrument is correctly applied and the operator is experienced
Proceeding to emergency LSCS: the head may be impacted in the pelvis and difficult to deliver

Question 17

What management after operative delivery?

Answer 17

Vitamin K
Regular analgesia
Document time and volume of first urine void (catheters for 12h if epidural or spinal)
Pass catheter if residual urine is suspected
Consider thromboprophylaxis

Question 18

What are risk factors for obstetric brachial plexus injury?

Answer 18

LArge birthweight
Shoulder dystocia with prolonger 2nd stage of labour
Forceps delivery
Vacuum extraction
DM
Breech presentation