Operative Vaginal Delivery: Forceps And Vacuum

Clinical description

Operative vaginal delivery (or assisted vaginal delivery) may be performed via forceps or vacuum.

Indications Forceps Vacuum Maternal • Poor maternal expulsive effort

• Conditions in which expulsive efforts should be avoided (i.e.,

cardiac disease, h/o stroke) (VBAC is not indication for assisted delivery) Fetal • Delivery of head in breech • Fetal distress delivery • Delay in descent of the

• Fetal distress fetal head, especially
• Prematurity second twin
• Other indications

Signs and symptoms

History/Exam/Investigations Document indication(s) for operative vaginal delivery clearly in the file

Treatment

Check that following conditions are fulfilled prior to operative vaginal delivery:

Criteria Forceps Vacuum Maternal • Fully dilated cervix

• Ruptured membranes
• No signs or symptoms of cephalopelvic disproportion
• Empty bladder
• Adequate analgesia
• Adequate contractions
• +/- Episiotomy for forceps

Fetal • Scalp visible at introitus; • Term or late preterm (GA > 34 descent at 0/5 or head at ≥ +2 wks) fetus station • Vertex presentation

• Sagittal suture in direct AP • Head at ≥ 0 station or ≤ 2/5

position with occiput anterior above symphysis pubis

• If face presentation, then

anterior chin Procedure

• Make sure theater space is available when attempting an operative vaginal delivery
• Use aseptic technique
• Performed by obstetrician or experienced/trained midwife
• Explain procedure and provide emotional support and encouragement to mother (who should continue to

push if not contraindicated)

• For forceps application
• Test the locking mechanism
• Lubricate the blades with sterile lubricant
• Insert left blade first +/- episiotomy
• If difficulty with locking, then recheck position of fetal head and re- apply blades as indicated

Clinical description

• For vacuum application
• Identify the posterior fontanelle
• Place cup ~2-3 cm anterior to posterior fontanelle
• Check that there is no maternal tissue trapped within cup
• Create vacuum seal slowly from 0.2 kg/cm2 to 0.8 kg/cm2
• Pull in direction of birth canal axis (initially, downward and forward) with each contraction; expect descent

with each combination of pulling and maternal pushing

• Proceed to Caesarean delivery if there is no descent after 2 pulls or after 30 min or 2 pop-offs occur.

Clinical description

MNEMONIC FOR VACUUM DELIVERY MNEMONIC FOR FORCEPS DELIVERY A Address the patient A Address the patient Ask for help Ask for help Anesthesia adequate? Anesthesia adequate? B Bladder empty B Bladder empty C Cervix must be completely dilated C Cervix must be completely dilated D Determine position of head D Determine position of head Think of Dystocia Think of Dystocia E Equipment ready E Equipment ready F Place cap in proper position to posterior Fontanelle F Forceps ready Feel for maternal tissue before and after suction Posterior fontanelle midway between shanks, G Gentle traction following the pelvic curve 1 cm above plane of shanks H Halt traction between contractions Fenestrations admit no more than 1 fingertip Halt procedures if pop-off 3 times G Gentle traction Halt procedure if no progress in 3 pulls H Handle elevated to follow the pelvic curve Halt procedure after 20 minutes of use I Incision: evaluate for episiotomy when crowning I Incision: evaluate for episiotomy when crowning (episiotomy not usuallyrecommended) (episiotomy not usually recommended) J Remove cup when Jaw is reachable J Remove forceps when Jaw is reachable