Operative Deliveries

Amira Illyani
Ainin Sofia
Noorsyafiza

TUTORIAL CONTENTS
Assisted vaginal deliveries (vacuum and forcep)
The differences between vacuum and forceps
Indications and contraindications of each
Technical aspect & application of each instrument
The advantages / disadvantages of using each
Prerequisite criteria of each instrument
Preference / choice between vacuum and forceps
Complications (maternal & fetal).

Caesarean section
Incidence, indications (maternal/fetal),
Types (Lower segment/classical) and indications
Complications intra/post operative (short/long term)

ASSISTED VAGINAL
DELIVERY
Delivery of baby vaginally using an
instrument for assistance

INDICATIONS & CONTRAINDICATION

OF AVD
No indication is absolute and be able to distinguish
'standard' from 'special' indications.
For both instruments, no indication for operative vaginal delivery
is absolute and each case should be considered individually

The most important contraindications are

Operator inexperience with the chosen instrument and
An inability to achieve a proper application due to the fetal
position or station (RCOG 2000)

INDICATIONS OF AVD
MATERNAL

FETAL

Malposition of the fetal

Maternal distress,
maternal exhaustion, or
head
Undue prolongation of
Protection for premature
2nd stage of labour (relative infant (with forcep)
indication)
Fetal distress
cardiopulmonary /
Forcep for aftercoming
vascular conditions
head in vaginal breech
delivery

CONTRAINDICATIONS OF AVD
1. Lack of engagement

Leading bony point at or above the level of ischial spines

Considered an absolute contraindication

2. Pelvic abnormality with fetopelvic disporportion

3. Fetal anomalies that may obstructed /damage
4. Fetal malposition : ~ not suitabale
Brow / face presentation (other than chin anterior)
Dead fetus with postmortem changes

5.
6. Inability to accurately diagnosed the position of
fetal head
7. Inability to apply the instrument properly

CONTRAINDICATIONS OF AVD
Relative contraindications :
Fetal macrosomia increased risk
of shoulder dystocia
Skill & experience of the operator
Fetus who has had a fetal scalp
sampling performed
Caution when performed a ventouse
procedure
Possibility of enhanced fetal scalp
bleeding
Fetal scalp sampling
7

Prerequisites For Instrumental Delivery

Confirmed rupture of the membrane.

Cervix must be fully dilated (except second twin and

rare other situations)

Vertex presentation with identification of position.

For occipitoanterior & transverse position, no part of
fetal head should be palpable abdominally. For
occipito-posterior positions, it is acceptable to feel
1/5 of the head. Presenting part should be at +1 or
more below ischial spine.

Adequate analgesia/anaesthesia.

Prerequisites For Instrumental Delivery

Empty bladder/no obstruction below fetal head (eg:
contracted pelvis/pelvic kidney/ovarian cyst).
A knowledgeable and experienced operator with
adequate preparation.
An adequately Informed and consented patient.

* For forceps, check the pair of forceps to ensure that a matching pair is
provided and the blades lack with ease

What Do I Need To Know Before Attempting

an Operative Vaginal Delivery?
Presentation (Cephalic/Breech)
Position (i.e. occiput posterior, sacrum
anterior)
Lie (longitudinal, oblique, transverse)
Station
Presence of asyncliticism
Clinical pelvimetry
Anaesthesia

Fetal attitude & lateral flexion of the fetal

head

A: Synclitism The plane of the biparietal

diameter is parallel to the plane of the inlet
B: Asynclitism Lateral flexion of the fetal head
leads to anterior parietal or posterior parietal
presentation

VENTOUSE/VACUUM
EXTRACTORS

 Depicted are two vacuum devices demonstrating the

hand-held pump and pressure gauge device.
Unlike the cup in B, the stem on the cup in A, OmniCup is
flexible and can be laid flat against the cup.

Technique
Determination of the flexion point is vital.
Centre of the cup should be positioned over the
flexion point.
Failure to do so will lead to a progressive
deflexion of the fetal head during traction and
inability to deliver the baby.

 At vertex: on saggital suture 3cm anterior to the

posterior fontanelle and thus 6cm posterior to the
anterior fontanelle

 Operating vacuum pressure is between 0.6 and 0.8kg/cm 2 .

Increase the suction to 0.2kg/cm 2 first, then recheck that no maternal
tissue is caught under cup edge.
After confirmed, the suction can be increased.
Traction must occur in the plane of least resistance along the axis of the
pelvis the traction plane.
Should be exactly 90 to the cup and the operator should keep a thumb
and forefinger on the cup at the traction insertion.
Safe and gentle traction is then applied in concert with uterine
contractions and voluntary expulsive efforts.

 No more than two episodes of breaking the

suctions in any vacuum delivery.
Maximum time from application to delivery should
ideally be less than 15 minutes.
Rotation is achieved by the natural progression of
the head through pelvis.

After determining position of the head,

(A) insert the cup to the fetal scalp
ensuring that no maternal tissues are
trapped by the cup.
(B) Apply the cup to the flexion point 3 cm in
front of the posterior fontanel, centering the
sagittal suture.
(C) Pull during a contraction with a steady
motion, keeping the device at right angles to
the plane of the cup. In occipitoposterior
deliveries, maintain the right angle if the fetal
head rotates.
(D) Remove the cup when the fetal jaw is
reachable

Placement of the OmniCup with flexible stem at the point of

flexion of a fetal head in the occiput posterior position,
which is otherwise difficult to accomplish with the traditional
vacuum devices.

It is not acceptable to use a ventouse when:

The position of the fetal head is unknown
There is a significant degree of caput that may either
preclude correct placement of the cup or indicate a
substantial degree of cephalopelvic diproportion
The operator is inexperienced in the used of the
instruments

PREREQUISITES FOR VACUUM

DELIVERY
The cervix must be completely dilated
The membranes must be ruptured
The size of the baby and the shape of the
birth canal must be estimated, and the
doctor must believe that the baby will "fit"
through the birth canal
The pregnancy must be term or near term

Fetal risks

Scalp lacerations: if torsion excessive

Cephalohematoma: limited to suture line
Subgaleal hematoma: crosses suture line
Intracranial/retinal hemorrhage
Hyperbilirubinemia/jaundice
Higher incidence of cephalohematoma/retinal
hemorrhage/jaundice compared to forceps

* 5% incidence serious complications

MATERNAL RISK
Cervical tear in women delivered before
full dilatation
Maternal death

FORCEPS DELIVERY

TYPES OF FORCEPS
DELIVERY
Outlet forceps
Scalp is visible at the introitus without separating the labia.
Fetal skull has reached the level of the pelvic floor.
Sagittal suture is in the direct anteroposterior diameter or in
the right or left occiput anterior or posterior position.
Fetal head is at or on the perineum.
Rotation does not exceed 45 degree.

Low forceps
Leading point of the fetal skull (station) is >/= +2/5 cm or more
but has not as yet reached the pelvic floor.
Rotation is 45 degrees or less.
Rotation is > 45 degrees

TYPES OF FORCEPS
Midforceps DELIVERY
Above 2 cm but head engaged

High forcep
Head not engaged; not included on ACOG
classification
Not recommended

TECHNIQUE
Identify & apply blades
Place instrument in front
of pelvis with tip pointing up &
pelvic curve forward
Apply left blade, guided by
right hand, then right blade with
left hand
Lock blades
Should articulate with ease

TECHNIQUE
Check for correct application
Sagittal suture in midline of shanks
Cannot place more than one fingertip
between blade and fetal head
Apply traction
Steady and intermittently in concert with
uterine contraction and maternal expulsive
effort
Downward and then upward
Remove blades as fetus crowns

 Position : lithotomy

Engaged head, Empty bladder, adequate anesthesia/Epidural, Experienced

operator

P
E

Rupture of membrane

Contraction present, no cephalopelvic disproportion and consent taken

Occipito anterior no part of fetal head should be palpable abdominally

Occipito- posterior acceptable if one-fifth of head is palpable
Full cervical dilatation

O
F

PREREQUISITES FOR FORCEPS

DELIVERY

RISKS (forceps)
MATERNAL RISKS

FETAL RISKS

Perineal injury
(extension of
episiotomy)
Vaginal and cervical
lacerations
Postpartum
haemorrhage

Intracranial
haemorrhage
Cephalohaematoma
Facial/ brachial palsy
Injury to the soft
tissue of face &
forehead
Skull fracture

VACUUM vs FORCEP
VACUUM

FORCEP

Failure rate is high.

Failure rate is low.

May be associated with

cephalohaematoma, retinal He of
the newborn.

Not usually associated with

cephalohaematoma, retinal
hemorrhage of the newborn.

Not associated with significant

Associated with significant
maternal perineal & vaginal trauma. maternal perineal & vaginal trauma.
Can not be applied in face &
breech presentation.

Can be applied in face & breech

presentation

Caesarean section

Definition

Surgical procedure in which incisions are

made through laparotomy and
hysterotomy to deliver one or more babies

 Article Influence of Private Practice as Compared to Public

Hospitals on Modes of Deliveries in Malaysia
The total lower segment Caesarean section rate in
Malaysia increased from 20.8% in 2008-09 to 21.9% in
2010.

Indications

MATERNAL
Cephalopelvic disproportion
Abruptio placenta
Major degree of placenta previa
Previous history of 2 Caesarean sections
Umbilical cord prolapse without adequate cervical dilatation
Failure of labour to progress despite adequate stimulation
Cervical carcinoma stage >1b

Indications

FETAL
Malposition or malpresentation
Fetal distress

Timing

Elective: when the operation is done at a

prearranged time to ensure the best
quality of obstetrics, anaesthesia,
neonatal resuscitation and nursing
services.
Emergency: when the operation is
performed due to unforeseen or acute
obstetric emergencies.

Types and indication

Pfannenstiel incision
Skin and subcutaneous tissue are incised using a
transverse curvilinear incision two fingerbreadths
above symphysis pubis extending from lateral to
the lateral margins of the abdominal rectus
muscles

Infraumbilical incision (vertical)

Made from lower border of umbilicus to symphysis
pubis and may extend caudally until xiphisternum

Indications of Classical Caesarean

Section
When the lower segment can not be
identified due to insufficient development
(extreme prematurity), adhesion, myoma,
obesity
Some cases of placenta previa with an illformed lower segment
Fibroid distorting the uterus

Lower Segment vs Upper Segment

Anatomical demarcation
Why lower segment is more favourable
Muscle is less thick
Less blood vessels
Healing takes shorter time

Advantages and disadvantage

Advantages of the lower segment
Ease of repair and healing scar is better.
Hemorrhage is less.
Low incidence of dehiscence or rupture.
Placenta is away from the incision.
Disadvantage of classical operation
The scar is more liable to rupture.

Complications

Intraoperative complications
Hemorrhage

Due to uterine atony or placenta previa

Tx: bimanual compression, oxytocin infusion,
uterine compression suture/hysterectomy

Caesarean hysterectomy
Urinary tract and bowel damage

Complications

Post operative complications

Infection (uterus, skin, UTI)
Pulmonary embolism and deep vein
thrombosis
Psychological
Placenta previa, accreta, increta, percreta
Risk of future uterine rupture
Endometriosis