OPERATIVE DELIVERY Rukset Attar, MD, PhD Department of Obstetrics and Gynecology

OPERATIVE DELIVERY

Rukset Attar, MD, PhDRukset Attar, MD, PhD

DeparDeparttment ment of of

Obstetrics and GynecologyObstetrics and Gynecology

Operative DeliveryOperative Delivery

refers to an obstetric procedure in which active refers to an obstetric procedure in which active measures are taken to accomplish deliverymeasures are taken to accomplish delivery

can be divided into can be divided into operative vaginal deliveryoperative vaginal delivery and and cesarean deliverycesarean delivery Forceps Vacuum Extraction Cesarean section

Obstetric ForcepsObstetric Forceps

Obstetric forceps is an instrument designed to assist with Obstetric forceps is an instrument designed to assist with delivery of the baby's head. delivery of the baby's head.

The primary functions of the forceps are The primary functions of the forceps are to assist with to assist with tractiontraction of the fetal head and/or of the fetal head and/or to assist with to assist with rotationrotation of the fetal head to a more of the fetal head to a more

desirable position. desirable position.




Simpson or Elliot forcepsSimpson or Elliot forceps are most often used for are most often used for outlet outlet vaginal deliveries, whereas vaginal deliveries, whereas Kielland or Kielland or Tucker-McLane forcepsTucker-McLane forceps are used for are used for rotational rotational deliveries. deliveries.

Piper forcepsPiper forceps are used in the United States for are used in the United States for delivery of the delivery of the aftercoming headaftercoming head. .

The pelvic and cephalic curve, shank, blade, lock, The pelvic and cephalic curve, shank, blade, lock, and handle are different for each type of forcepsand handle are different for each type of forceps


Piper forceps, which are specifically designed for Piper forceps, which are specifically designed for breech deliveries, have a reverse pelvic curve breech deliveries, have a reverse pelvic curve compared to other forceps. compared to other forceps.

Simpson forceps are suited for application to the Simpson forceps are suited for application to the molded fetal headmolded fetal head

Tucker-McLane forceps or Kielland forceps are Tucker-McLane forceps or Kielland forceps are more appropriate for application to the fetal head more appropriate for application to the fetal head with little or no moldingwith little or no molding


Indications for forceps deliveryIndications for forceps delivery

nonreassuring fetal heart rate pattern nonreassuring fetal heart rate pattern shortening of the second stage of labor for fetal or shortening of the second stage of labor for fetal or

maternal reasonsmaternal reasons prolonged second stage of labor not due to dystocia prolonged second stage of labor not due to dystocia

In a nulliparous patient - more than 3 hours with a In a nulliparous patient - more than 3 hours with a regional anesthetic/more than 2 hours without a regional anesthetic/more than 2 hours without a regional anesthetic. regional anesthetic.

In a multiparous patient - more than 2 hours with a In a multiparous patient - more than 2 hours with a regional anesthetic or more than 1 hour without a regional anesthetic or more than 1 hour without a regional anesthetic. regional anesthetic.

delivery of the aftercoming head in a breech delivery of the aftercoming head in a breech presentation.presentation.

Prerequisites for a forceps-assisted vaginal Prerequisites for a forceps-assisted vaginal deliverydelivery

In order for a patient to be considered a In order for a patient to be considered a candidate, candidate, allall of the following must be met: of the following must be met: complete cervical dilatation complete cervical dilatation ruptured membranes ruptured membranes vertex presentation vertex presentation fetal head engaged with the fetal head position knownfetal head engaged with the fetal head position known empty bladderempty bladder no evidence of cephalopelvic disproportionno evidence of cephalopelvic disproportion adequate analgesiaadequate analgesia cesarean section capability and cesarean section capability and an experienced operatoran experienced operator

The classification of forcepsThe classification of forceps

Outlet forcepsOutlet forceps is the application of forceps when is the application of forceps when the fetal scalp is visible at the introitus without the fetal scalp is visible at the introitus without

separating the labia, separating the labia, the fetal skull has reached the pelvic floor,the fetal skull has reached the pelvic floor, the sagittal suture is in the anteroposterior diameter the sagittal suture is in the anteroposterior diameter

or in the right or left occiput anterior or posterior or in the right or left occiput anterior or posterior position, and the fetal head is at or on the perineum. position, and the fetal head is at or on the perineum.

According to this definition, rotation of the fetal head According to this definition, rotation of the fetal head must be equal to or less than 45 degrees.must be equal to or less than 45 degrees.

The classification of forcepsThe classification of forceps

Low forcepsLow forceps is the application of forceps is the application of forceps when the leading point of the fetal skull is at station when the leading point of the fetal skull is at station

+2 or greater and +2 or greater and not on the pelvic floor. not on the pelvic floor. Low forceps have two subdivisions: Low forceps have two subdivisions:

rotation less than or equal to 45 degrees and rotation less than or equal to 45 degrees and rotation greater than 45 degrees. rotation greater than 45 degrees.

MidforcepsMidforceps is the application of forceps when the head is the application of forceps when the head is engaged but the leading point of the fetal skull is is engaged but the leading point of the fetal skull is above station +2.above station +2.

ComplicationsComplications

Maternal complications include Maternal complications include lacerations of the vagina and cervixlacerations of the vagina and cervix episiotomy extensions involving third- and fourth-episiotomy extensions involving third- and fourth-

degree lacerations degree lacerations pelvic hematomaspelvic hematomas urethral and bladder injuries urethral and bladder injuries uterine ruptureuterine rupture blood loss and the need for blood transfusion are blood loss and the need for blood transfusion are

increased in forceps deliveries.increased in forceps deliveries.

Neonatal complications Neonatal complications minor facial lacerationsminor facial lacerations forceps marks, forceps marks, facial and brachial plexus palsies, facial and brachial plexus palsies, cephalhematomas, cephalhematomas, skull fractures, skull fractures, intracranial hemorrhage, and intracranial hemorrhage, and seizures.seizures.

Vacuum ExtractorVacuum Extractor the indications for vacuum use are similar to those of the indications for vacuum use are similar to those of

forceps. forceps. the classification of forceps deliveries is the same the classification of forceps deliveries is the same

classification used for vacuum deliveries, and the classification used for vacuum deliveries, and the

prerequisites are similar.prerequisites are similar.

Vacuum ExtractorVacuum Extractor

Contraindications for vacuum deliveryContraindications for vacuum delivery

place the cup directly over the sagittal suture at the place the cup directly over the sagittal suture at the median flexion point located approximately 3 cm median flexion point located approximately 3 cm anterior to the posterior fontanelleanterior to the posterior fontanelle

approximately 600 mmHg at the beginning of a approximately 600 mmHg at the beginning of a uterine contraction. uterine contraction.

If more than 1 contraction is necessary, the vacuum If more than 1 contraction is necessary, the vacuum pressure can be decreased to low levels between pressure can be decreased to low levels between contractions. contractions.


While the fetal head is delivering, the cup should While the fetal head is delivering, the cup should assume a 90-degree orientation to the horizontal as assume a 90-degree orientation to the horizontal as the head is extended. the head is extended.

Once the head has completely delivered through the Once the head has completely delivered through the vagina, the suction is withdrawn and the cup vagina, the suction is withdrawn and the cup removedremoved


face presentation, face presentation, breech presentation, breech presentation, true cephalopelvic disproportion, true cephalopelvic disproportion, congenital anomalies of the fetal head (eg, congenital anomalies of the fetal head (eg,

hydrocephalus), hydrocephalus), gestational age less than 34 weeks or gestational age less than 34 weeks or estimated fetal weight less than 2000 g, estimated fetal weight less than 2000 g, estimated fetal weight greater than 4000 g, and estimated fetal weight greater than 4000 g, and

an unengaged fetal head.an unengaged fetal head.

ComplicationsComplications

neonatal neonatal retinal hemorrhageretinal hemorrhage -most common-50%-rarely has any clinical -most common-50%-rarely has any clinical

significance. significance. CephalhematomaCephalhematoma involves bleeding beneath the periosteum and involves bleeding beneath the periosteum and

complicates approximately 6% of all vacuum deliveries.complicates approximately 6% of all vacuum deliveries. Subgaleal hematomaSubgaleal hematoma, a more serious complication, occurs in 50 , a more serious complication, occurs in 50

of 10,000 vacuum deliveries-bleeding occurs in the loose of 10,000 vacuum deliveries-bleeding occurs in the loose subaponeurotic tissues of the scalp - there is the potential for subaponeurotic tissues of the scalp - there is the potential for life-threatening hemorrhage-The subgaleal space actually life-threatening hemorrhage-The subgaleal space actually extends from the orbits of the eyes to the nape of the neck. This extends from the orbits of the eyes to the nape of the neck. This potential space can occupy over half of a newborn's blood potential space can occupy over half of a newborn's blood volume. volume.

Intracranial hemorrhageIntracranial hemorrhage occurs in approximately 0.35% of occurs in approximately 0.35% of vacuum deliveries. It can be a catastrophic complication that vacuum deliveries. It can be a catastrophic complication that includes subdural, subarachnoid, intraventricular, and/or includes subdural, subarachnoid, intraventricular, and/or intraparenchymal hemorrhage. intraparenchymal hemorrhage.

Cesarean SectionCesarean Section A A cesarean sectioncesarean section refers to the delivery of a fetus, refers to the delivery of a fetus,

placenta, and membranes through an abdominal placenta, and membranes through an abdominal and uterine incision. and uterine incision.

The first documented cesarean section on a living The first documented cesarean section on a living person was performed in 1610. The patient died 25 person was performed in 1610. The patient died 25 days later. days later.

Cesarean SectionCesarean Section Abd wall insition Abd wall insition transverse (transverse (PfannenstiePfannenstiel) incision l) incision CClassical cesarean section lassical cesarean section

is the simplest to perform. is the simplest to perform. is associated with the greatest loss of blood and is associated with the greatest loss of blood and

may result in uterine rupture with subsequent may result in uterine rupture with subsequent pregnanciespregnancies

accepted indications for classical cesarean section accepted indications for classical cesarean section are are placenta previa, transverse lie (especially back placenta previa, transverse lie (especially back down), and preterm delivery down), and preterm delivery in which the lower in which the lower uterine segment is poorly developeduterine segment is poorly developed

A classical cesarean section may be preferred if A classical cesarean section may be preferred if extremely rapid delivery is neededextremely rapid delivery is needed

Cesarean SectionCesarean Section low-transverse uterine incision low-transverse uterine incision

Less Less blood blood loss loss Less frequently Less frequently result in uterine rupture with result in uterine rupture with

subsequent pregnanciessubsequent pregnancies

Cesarean SectionCesarean Section Maternal indications Maternal indications

repeat cesarean delivery; repeat cesarean delivery; obstructive lesions in the lower genital tract including obstructive lesions in the lower genital tract including

malignancies, malignancies, large vulvovaginal condylomas, large vulvovaginal condylomas, obstructive vaginal septa, and obstructive vaginal septa, and leiomyomas of the lower uterine segment that leiomyomas of the lower uterine segment that

interfere with engagement of the fetal head; and interfere with engagement of the fetal head; and pelvic abnormalities that preclude engagement or pelvic abnormalities that preclude engagement or

interfere with descent of the fetal presentation in interfere with descent of the fetal presentation in labor. labor.

left heart valvular stenosis, left heart valvular stenosis, dilated aortic valve root, dilated aortic valve root, certain cerebral AVMs, and certain cerebral AVMs, and recent retinal detachment. recent retinal detachment. Women with a prior vaginal or perineal reparative Women with a prior vaginal or perineal reparative

surgery, such as colporrhaphy and repair of major surgery, such as colporrhaphy and repair of major anal involvement from inflammatory bowel diseaseanal involvement from inflammatory bowel disease

Fetal indicationsFetal indications Malpresentation Malpresentation Twin gestations Twin gestations Congenital anomalies: fetal neural tube defects Congenital anomalies: fetal neural tube defects

hydrocephalus with an enlarged biparietal diameter, hydrocephalus with an enlarged biparietal diameter, and some skeletal dysplasias such as type III and some skeletal dysplasias such as type III osteogenesis imperfecta. a fetal abdominal wall osteogenesis imperfecta. a fetal abdominal wall defect (ie, gastroschisis and omphalocele defect (ie, gastroschisis and omphalocele

Fetal distress Fetal distress Maternal infections Maternal infections Human immunodeficiency virus infectionsHuman immunodeficiency virus infections

Abnormal placentation, Abnormal placentation, Abruptio placenta Abruptio placenta Cord prolapsus or presentationCord prolapsus or presentation Transvers presentationTransvers presentation Oblique presentationOblique presentation Breech presentationBreech presentation

most common complications that result from cesarean most common complications that result from cesarean section are section are postpartum hemorrhage, postpartum hemorrhage, endometritis, and endometritis, and wound infection.wound infection.

Documents

OPERATIVE DELIVERY Rukset Attar, MD, PhD Department of Obstetrics and Gynecology