Assisted vaginal delivery

synopsis
• Introduction
• Definition
• Prevalences
• How to lower OVD rates
• Types of AVD
• indications
 introduction
• Assisted vaginal delivery or operative vaginal
delivery or instrumental vaginal delivery
• Is the hallmark of obstetric practice
• AVD offers the option of an operative procedure
to accomplish delivery with the potential of safely
and quickly removing the infant, mother and the
obstetrian from a difficult or even hazardous
situation.
• When a spontaneous vag delivery does not
occur within a reasonable period of time, a
successful AVD avoids the need for C/S with its
resultant uterine scar which has implication for
future pregnancy.
 definition
• Operative vaginal delivery is an obstetric
procedure in which active measures with
specialized instruments is used to
accomplish the delivery of the fetus
through the vaginal route.
• Absence of such assistance results in
prolonged labour, undue delay in delivery
with resultant fetal and or maternal
jeopardy.
 Prevalence of OVD
• The prevalence varies between 1.5-15 per
cent of deliveries – reason for the wide
variance is due to the different method of
labour management.
• UPTH prevalence: 2001(3.1), 2002 (1.7)
 How to lower OVD rates
• Companionship during labour
• Active management of the second stage
of labour with syntocin
• Upright posture during the second stage
• A more liberal attitude to the duration of
the second stage of labour when epidural
analgesia is used in labour
• Confirming fetal distress with fetal scalp
sampling – in situations of fetal heart rate
deceleration rather than a delivery.
 Factors that determine success of
operative vaginal delivery
• Clear-cut indication for their use
• The operator must have sufficient skill for
the procedure.
• The procedure must be appropriately
timed.
 Types of operative vag deli
• Forceps delivery
• Vacuum extraction
• In developing countries include
symphysiotomy and destructive operations
– craniotomy, embryotomy, decapitation,
cleidotomy.
 Indications for OVD
Major categories
- To relieve dystocia
- To prevent fetal jeopardy
- To prevent maternal jeopardy
 Maternal indications
• Maternal distress
• Maternal exhaustion
• Medical conditions – cardiopulm dx, imminent Sickle cell crisis, eclampsia,
intrapartum haemorrhage – abruptio placentae

• Undue prolongation of the 2nd stage of labour

Duration of 2nd stage of labour – no specific time limit,
provided no evidence of fetal distress and there is
progress.
However, consider intervention if duration of 2nd stage is longer than
Primigravidae – 2 hrs; multip – 1 hr. (with regional anaesthesia
primigravidae – 3hrs; multip – 2 hrs) - provided mother gives consent and fetal
condition is satisfactory.
 Fetal indications
• Malposition – occipitoposterior or occipito-
transverse
• Delivery of premature infant –
controversial
• Delivery of the aftercoming head in
assisted breech delivery
• Fetal distress in second stage of labour.
 Obstetric Forceps
• These are specially designed instrument
for delivery of the fetal head or correction
of abnormal cephalopelvic relationship –
asynclitism.
• Instrument is made up of 2 halves,
coupled by a lock – either English lock or
the sliding lock.
• Each half is comprised of the handle,
shank and the blade which has a pelvic
curve and cephalic curve
 Types of obst forceps
• Traction forceps – wrigley,Piper
• Rotational forceps – kielland
 Types of forceps delivery
• Outlet forceps – the fetal head is at the perineum, visible
at the introitus without separating the labia: i.e. the fetal
skull has reached the pelvic floor and the sagittal suture
is either in the anteroposterior direction or does not have
to rotate for more than 450 to achieve this position.
• Low forceps – in which the leading point of the skull (not
caput) is at station +2 or more from the ischial spine, but
does not reach the pelvic floor.
• Mid forceps – the head is engaged, the station is not up
to +2 below the ischial spine.
 Prerequisites for forcep delivery
• Cervix must be fully • Suitable presenting part –
dilated. vertex, face (mento-
anterior), aftercoming head
• Membrane must be of the breech.
ruptured. • Anaesthesia should be
• Bladder and rectum given.
must be empty. • Episiotomy is given.
• Head must be engaged. • The operator must have the
necessary skill.
• Position must be known
• There must be informed
• No cephalopelvic consent for the procedure.
disproportion.
 Complication of forcep use
Maternal complications Fetal complications
- Anaesthetic complications – - Transient facial marks.
esp if GA. - Facial palsies
- Genital tract injury – vaginal, - Fractured facial bones or
cervical or uterine injury, skull.
lacerations or haematoma. - Intracranial haemorrhage.
- Bladder or urethral injury. - Brachial plexus injury
- Acute postpartum urinary
retention.
- sepsis
- Vesicovaginal fistula.
- Rectovaginal fistula.
 Vacuum extractor
• Works on the principle of a cup device
attached by tubing to a pump to create
enough negative pressure to allow traction
on the cup which transfer this traction to
the fetal head which as a result is pulled
along the birth canal axis. Traction is
applied during uterine contraction resulting
in descent of the fetal head by a push-pull
effect.
 Types of ventouse cup
• Metal cups (Malmstrom)
• Silicone-rubber cup

Bird’s modification of the metal cup

- Anterior cup
- Posterior cup
 Prerequisite for ventouse
• Cervical dilatation – 8cm
• Cooperation of patient
• Good contractions should be present.
Basic rules for ventouse delivery
- The head should descend with each pull.
- The cup should be reapplied not more than twice.
- The delivery should be completed within
15minutes of application of ventouse.
- Following failure of ventouse, there is no place
for trial of forcep.
• Indications for ventouse same as for
forceps.

• Contraindications
- Face presentation.
- GA less than 34 weeks
- Prior fetal scalp sampling.
Examination –
- No head palpable per abdomen.
- Position and the attitude of vertex must be known.
 Delivery by ventouse
• Position – lithotomy (commonest), dorsal,
lateral or squatting.
• Catheterisation (may or may not)
• Anaesthesia – yes or no, perineal
infiltration if there is need for episiotomy.
• Set up and test ventouse.
• Determine the cup type and size.
• Insert the cup gently into the vagina –
ensuring that no genital tissue is trapped
within the cup.
• Cup placement over the point of flexion –
anterior to the posterior fontanelle such
that the edge of the cup is 3cm from the
anterior fontanelle along the sagittal
suture.
• Proper cup placement results in flexion
and synclitism.
• The vacuum is created (8kg/cm2)
• Traction is applied with uterine contraction
and the parturient bearing down (pushing).
• One hand rest on the cup in the vagina to
determine descent with the traction and
early cup detachment.
• Initial traction is downwards at 450 along
the pelvis axis for the duration of uterine
contraction.
• When the head crowns, the direction of
pull changes upwards through an arc of
over 900
• At crowning – may give episiotomy.
 complications
Maternal Fetal
- Less than with - cephalhaematoma.
forceps - Subgaleal haematoma.
- Genital trauma. - Intracranial haemorrhage
- Cervical – repeated application.
incompetence (rare). - Transient neonatal
neurological depression.
 symphysiotomy
• Borderline cephalopelvic disproportion to
achieve vaginal delivery – live baby.
• Women abhor caesarean delivery – care
of subsequent delivery.
• Main disadvantage – permanent instability
of the pelvic girdle.
 Destructive operations
• Cephalopelvic disproportion with IUFD
Types
• Craniotomy
• Decapitation
• Cleidotomy
• Embryotomy.