INSTRUMENTAL DELIVERIES

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VACUUM /VENTOUSE. . . INDICATIONS. MATERNALExhaustion Prolonged second stageCardiac / pulmonary diseaseFETALFailure of the fetal head to rotateFetal distress in the second stageShould not be used for preterm, face presentation or breech . MNEMONIC. A

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INSTRUMENTAL DELIVERIES

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1. INSTRUMENTAL DELIVERIES Ghadeer Al-Shaikh, MD, FRCSC Assistant Professor & Consultant Obstetrics & Gynecology Urogynecology & Pelvic Reconstructive Surgery

2. VACUUM /VENTOUSE

4. INDICATIONS MATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary disease FETAL Failure of the fetal head to rotate Fetal distress in the second stage Should not be used for preterm, face presentation or breech Instrumental deliveries 1-Indications for instrumental deliveries include T1-Prolonged 2nd stage T2-Fetal distress F3-Transverse lie F4-Compound presentation T5-Maternal cardiac diseaseInstrumental deliveries 1-Indications for instrumental deliveries include T1-Prolonged 2nd stage T2-Fetal distress F3-Transverse lie F4-Compound presentation T5-Maternal cardiac disease

5. MNEMONIC A – Anesthesia ?adequate B – Bladder ? cathterization C – Cervix ? fully dilated / membranes ruptured D – Determine ? position, station, pelvic adequacy E – Equipment ? inspect vacuum cup, pump, tubing, ? check pressure 2-Prerequisite for instrumental delivery include T1-Cervix must be fully dilated T2-Membranes ruptured F3-Fetal head not engaged F4-Obstetrician unsure about position of the fetal head due to caput T5- Bladder empty/ cathetrized2-Prerequisite for instrumental delivery include T1-Cervix must be fully dilated T2-Membranes ruptured F3-Fetal head not engaged F4-Obstetrician unsure about position of the fetal head due to caput T5- Bladder empty/ cathetrized

6. MNEMONIC F – Fontanelle ? position the cup over the posterior fontan ? low pressure 10 cm H2O initially & between cont ? sweep finger around cup to clear maternal tissue ? ? pressure to 60 cm H2O with the next contraction G – Gentle traction ? pull with contractions only ?traction in the axis of the birth canal ?ask the mother to push during cont

8. MNEMONIC H – Halt ? halt traction if no progress with three traction aided contractions ?vacuum pops off three times ?pulling for 30 min without significant progress I – Incision ?consider episiotomy if laceration imminent J – Jaw ?remove vacuum when jaw is reachable or delivery assured

9. COMPLICATIONS Vacuum –assisted delivery is less traumatic to the mother & fetus than forceps Ventouse should be the instrument of choice Maternal ? Vaginal laceration due to entrapment of vaginal mucosa between suction cup & fetal head 3-Complications of ventouse delivery F1-Ventouse causes 3rd & 4th degree perineal tears more frequent than forceps F2-Long term effects on neurological & intellectual development of children delivered by ventouse are evident by 4 years of age T3-Cephalohematoma occur in up to 25% of babies T4-Birth asphyxia is related to the force of traction & prolonged procedure (time from application of vacuum until delivery) T5-Cephalohematomas may result in jaundice & anemia of the neoborne3-Complications of ventouse delivery F1-Ventouse causes 3rd & 4th degree perineal tears more frequent than forceps F2-Long term effects on neurological & intellectual development of children delivered by ventouse are evident by 4 years of age T3-Cephalohematoma occur in up to 25% of babies T4-Birth asphyxia is related to the force of traction & prolonged procedure (time from application of vacuum until delivery) T5-Cephalohematomas may result in jaundice & anemia of the neoborne

10. FETAL COMPLICATIONS Scalp injuries ? abrasion & lacerations 12.6% ?scalp necrosis 0.25-1.8% Cephalohematoma ? 25% ? jaundice /anemia Intracranial hemorrhage ? 2.5% Subgaleal hematoma

11. Fetal Complications

12. FETAL COMPLICATIONS Birth asphyxia ? 2.6-12% ? related to extraction force & time Some studies showed decrease birth asphyxia Retinal hemorrhage 50% Forceps 31% SVD 19% Neonatal jaundice

13. FETAL COMPLICATIONS Fetal mortality 15/1000 Lower in cases delivered by vacuum 1.9%/ forceps 5.2 % No long term effects on neurological psychomotor or intellectual development up to 4 years of age

14. FORCEPS

15. INDICATIONS MATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary disease FETAL Failure of the fetal head to rotate Fetal distress Control of the fetal head in vaginal beech delivery

16. CLASSIFICATION OF FORCEPS DELIVERY Outlet forceps ? Scalp visible at the vulva without separating the labia Low forceps ? Vertex at +2 station Midforceps ? Head is engaged but leading part above +2 station ? Sagittal suture not in the AP plane of the mother 4-Forceps T1-can be applied to the after coming head in assisted vaginal breech delivery T2-Can be applied to face presentation T3-It is not contraindicated for preterm fetuses T4-Can result in facial nerve damage of the fetus T5-Is associated with a higher fetal mortality than ventouse 4-Forceps T1-can be applied to the after coming head in assisted vaginal breech delivery T2-Can be applied to face presentation T3-It is not contraindicated for preterm fetuses T4-Can result in facial nerve damage of the fetus T5-Is associated with a higher fetal mortality than ventouse

17. CLASSIFICATION OF FORCEPS DELIVERY Outlet ? Wrigley’s Outlet & low forceps ? Simpson /Elliot Midforceps & outlet ? Tucker Mclane Midforceps & rotation ? Kielland After coming head in breech ? Piper

18. Simpsons

19. Piper

20. MNEMONIC A – Anesthesia ?adequate /epidural or pudendal B – Bladder ? cathterization C – Cervix ? fully dilated / membranes ruptured D – Determine ? position, station, pelvic adequacy E – Equipment ?Know your forceps

21. MNEMONIC F – Forceps ?phantom application ?Lt blade , LT hand, maternal Lt side pencil grip & vertical insertion with Rt thumb directing blade ?Rt blade , RT hand, maternal Rt side pencil grip & vertical insertion with Lt thumb directing blade ?Lock blades

23. MNEMONIC ?Check application: Post fontanelle 1cm above the plane of the shanks Sagittal suture lies in the midline of the shanks /perpindicular to the plane of the shanks The operator can not place more than a fingertip between the fenestration of the blade & the fetal head on either side

24. MNEMONIC G – Gentle traction ? applied with contraction & maternal expulsive efforts H – Hand elevated ? traction in the axis of the birth canal I – Incision ? consider episiotomy if laceration imminent J – Jaw ? remove forceps when jaw is reachable or delivery assured

25. COMPLICATIONS Maternal ? trauma to soft tissue ?3rd/4th degree double the risk compared to ventouse ?bleeding from lacerations ?trauma to urethra & bladder ? fistula ?Pain 17% ventouse 11%

26. COMPLICATIONS Fetal ? bruising & laceration to the face ? Injury to the fetal scalp ?cephalohematoma 9% Vent 25% ?retinal hemorrhage 30% Vent 50% ? skull fracture ?permanent nerve damage / Facial nerve The risk of shoulder dystocia is increased following instrumental deliveries

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