Assisted delivery

ASSISTED DELIVERY

PRESENTED TO- MS SIMRANDEEP

KAUR

Presented by-Palvi kumari

MSc Nsg 1st year

ASSSTED DELIVERY

It refers to any delivery process which is assisted by vaginal operation. Delivery by forceps, Ventouse is generally included.

Forceps

Obstetric forceps is a pair of instruments specially designed to assist extraction of the head and thereby accomplishing delivery of the fetus.

Types of obstetric forcepsThree varieties are

commonly used in present day obstetric practice. There are :-

1.Long curve forceps with or without axis traction device.

2.Short curve forceps(Wrigley)3.Kielland’s forceps.

Long curved obstetric forceps

Long curved forceps is relatively heavy and is about 37 cm long. In India Das’s variety (named after Sir Kedar Nath) is commonly used with advantages. It is comparatively lighter & slightly shorter than its western counterpart but is quite suited for the comparatively small pelvis and small baby of Indian women

Measurement

Length is 37 cm. Distance in between the lips is 2.5 cm and widest diameter between the blades is 9cm.

Blade

There are two blades and are named right or left in relation to maternal pelvis in which they lie when applied. Each blade consist of the following parts-

BladesShankLockHandles with or without screw

blade

Pelvic curve: The curve on the edge is to fit more or less the curve on the axis of the birth canal. It forms a part of a circle whose radius is 17.5 cm. The concave side of the pelvis curve.

Cephalic curve: It is the curve on the flat surface which when articulated grasps the fetal head without compression. The radius of the curve is 11.5 cm

Shank

It is the part between the blade and the lock and usually measure 6.25cm. It increases the length of the instruments and thereby, facilitate locking of the blades outsides.

Lock:-

The common method of articulation consists of a socket system located on the shank at its junction with the handle. Such type of lock requires introduction of the left blade first.

Handle

The handles are apposed when the blade are articulated. It measures 12.5 cm. There is a finger guard on with a finger can be placed during traction.

A screw may be attached usually at the end of one blade (commonly left).It helps to keep the blades in position.

Short curve obstetric forceps (Wrigley’s)  The instrument is lighter, about a

third of the weight of an ordinary long curved forceps. The instrument is short which is due to reduction in the length of the shanks and handles. It has a marked cephalic curve with a slight pelvic curve

Kielland’s forceps  It is a long almost straight (very slight

pelvic curve) obstetrics forceps without any axis traction device. It has got a sliding lock with facilities correction of asynclitism of the head.

types of Forceps OperationThe operation are classified according to

the station of the fetal head at which the forceps are applied.

1.High forceps operation: Refer to the application of the forceps on the fetal head where the biparietal diameter has not yet passed the plane of the pelvic inlet.(not engaged head)

2.Mid forceps operation: refer to the application of the forceps is where the biparietal diameter has passed the plane of the inlet but has not passed the level of ischial spines.

3. Low Forceps operation: refer to the application of the forceps where the biparietal diameter has passed the level of ischial spine.

4. Outlet Forceps: It is a variety of low forceps operation, where the forceps are applied on the fetal head lying on the perineum and is visible at the introitus in between contraction. The sagital suture should lie in the antero- posterior diameter of the outlet.

Function

1.Traction is the most important function of the forceps. In primigravidae, the pull required is estimated to be about 18 kg and that in multigravidae about 13 kg.

2. It’s compression effect on cranium should be minimal when correctly applied over the biparietal plane and should not be more than required to grasp the fetal head. However it has got some pressure effect on the well ossified base of the skull.

3. Rotation of the head can be achieved by Kielland’s forceps. However, in the low forceps operation with the sagital suture placed obliquely with the occiput placed at 2 or 10 clock. Position cephalic application of the blades of ordinary forceps and traction cause rotation of the sagital suture so as to bring it in antero-posterior diameter of the outlet.

4.To provide a protective cage for the head from the pressure of birth canal as in premature baby or to control the delivery of the after coming head to lessen the dangers of sudden decompression.

Indication of Forceps operation 1.Delay in the second stage:-

The forceps operation commonly indicated for delay in the second stage of labour due to uterine inertia. Failure of satisfactory advancement of the head for a period of expel limit of 20-30 min while the head is on the perineum , is an ideal time to apply forceps.

2.Fetal Indication:-a) appearance of fetal distress in the

second stage when prospect of vaginal delivery is safe.

b) cord prolapsedc) After coming head in breech

presentationd) Low birth weight babye) Post maturity

3. maternal Indication:-a) maternal distressb)pre- eclampsiac) post caesareans pregnancyd) Heart disease   

Condition to be fulfill prior to forceps operation a)fetal and uteroplacental criteria :-1.The fetal head must be engaged2.The cervix must be fully dilated3.The membrane must be ruptured 4.The position and station of the fetal

head must be known with certainty.

maternal criteria:-1.No major cephalopelvic disproportion

by clinical Pelvimetry.2.Bladder must be emptied.3.Adequate analgesiac)othersExperienced operatorVerbal or written consent.

Danger of forceps operation The hazards are grouped in to:1.Maternal2. Fetal1. Maternal:- It is of two typea)Immediate:- the immediate complication

are:Injury--vaginal lacerations-cervical tear specially when applied through

incompletely dilated cervixPost partum hemorrhage due to trauma

-Atonic uterus due to prolonged labour or effect of anesthesia;

Shock due to-blood loss, prolonged labour and dehydration

Sepsis due to-improper asepsis and devitalisation of the local tissues

b)remote:-Chronic low backache- Due to tension

imposed on softened ligaments guarding the Lumbo sacral or sacro iliac joints during lithotomy position.

Genital prolapse or stress incontinence- This may occur specially when the head is dragged down through incompletely dilated cervix or in unrotated position or due to faculty repair of perineal lacerations.

Fetal :- It is of two type a)Immediate:- Asphyxia due to

intracranial stress out of prolonged compression.

Intracranial hemorrhage due to mal application of blades leading to over compression.

Cephallohaemotoma

Facial palsy Abrasions on the soft tissue of the

face and forehead by forceps blade.

b)Remote:- Cerebral and spastic palsy due to residual cerebral injury

Ventouse

Ventouse is an instrument device designed to assist delivery by creating a vacuum between it and the fetal scalp. The pulling force is directly transmitted to the base of the skull

Instruments  Ever since Malmstrom in 1956

reintroduced and popularized its use, various modification of the instrument is now available. Each however consist of the following basic components:-

a)Suction cup with 4 sizes(30,40,50,60mm)

b)A vacuum pumpc)Traction rod device

INDICATION

1.Delay in descent of the head in case of the second baby of twins

2.Delay in late first stage due to uterine inertia or cervical dystocia

3.An alternative to forceps operation4.Fetal distress or prematurity

Contraindication

1.Any presentation other than vertex2.Preterm fetus less than 34 weeks3.Contracted pelvis4.fetal bleeding disorder 

Procedure  The procedure is performed under

local anesthesia. The instrument should be assembled and the vacuum is tested prior to its application.

Step-1 largest possible cup according to the

dilatation of the cervix is to be selected. The cup is introduced after retraction of the perineum with two finger of other hand. The cup is placed against the fetal head nearest to the occiput with knob of the cup pointing towards the occiput.

A vacuum of 0.2kg/cm2 is induced by the pump slowly ,taking at least two minute. A check is made by using the finger round the cup to ensure that no cervical and vaginal tissue is flapped inside the cup. The pressure is gradually at the rate of 0.1 kg / cm2 /minute until the effective vacuum of 0.8 kg / cm2 is achieved in about 10 minutes time. The scalp is sucked into the cup and an artificial caput succedaneum (chignon) is produced . the chignon usually disappears within few hours.

As soon as the head is delivered, the vacuum is reduced by opening the screw –release value and the cup is then detached. The delivery is then completed in the normal way

Complications

Fetal- (a) sloughing of the scalp. (b) Cephallohaemotoma  (c) sub –aponeuratic

hemorrhage (d) intra – cranial hemorrhage

(rare)

Maternal The injury may be due to inclusion of

the soft tissue such as the cervix or vaginal wall inside the cup.

summarization

Assisted delivery Forceps delivery Indication contraindication Types Ventouse delivery indication and contraindication of

ventouse delivery complication

REFERENCE

1) “Dutta D.C.” ,“Texbook of obstetrics”, “Published by-New central book agency pvt. Ltd.”,6 th edition”, Page No .570-582

2)”Myles”, “ Textbook for midwifery” , “ Published by -Churcill Livingstone”, “14 edition”

3)”sanju sira”, “textbook of midwifery and obstetrics “lotus publisher, 412-473

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