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Saeed Mahmoud,MRCOG,MRCPI,MIOG,MBSCCP

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Title: Saeed Mahmoud,MRCOG,MRCPI,MIOG,MBSCCP

1
Operative DELIVERIES

Saeed Mahmoud,MRCOG,MRCPI,MIOG,MBSCCP
Assistant Professor Consultant
Department of Obstetrics Gynecology
College of Medicine
King Saud University

2
Operative Deliveries

1.Instrumental deliveries
A. Vacuum /Ventouse
B.Forceps
2. Cesarean Section CS, C/S

3
VACUUM /VENTOUSE
4
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5
INDICATIONS

MATERNAL
Exhaustion
Prolonged second stage
Cardiac / pulmonary disease
FETAL
Failure of the fetal head to rotate
Fetal distress in the second stage

6
Conditions to be fulfilled

MNEMONIC
A Anesthesia ?adequate
B Bladder ? cathterization
C Cervix ? fully dilated / membranes
ruptured
D Determine ? position, station, pelvic
adequacy
E Equipment ? inspect vacuum cup, pump,
tubing,
? check pressure

7
MNEMONIC

F Fontanelle ? position the cup over the
posterior fontan
? low pressure 10 cm H2O initially
between cont
? sweep finger around cup to clear
maternal tissue
? ? pressure to 60 cm H2O with the
next contraction
G Gentle traction ? pull with contractions only
?traction in
the axis of the birth canal
?ask the
mother to push during cont

8
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9
MNEMONIC

H Halt ? halt traction if no progress with
three
traction aided contractions
?vacuum pops off three
times
?pulling for 30 min without
significant progress
I Incision ?consider episiotomy if laceration
imminent
J Jaw ?remove vacuum when jaw is
reachable or
delivery assured

10
Key points

Vacuum assisted delivery is less traumatic to
the mother fetus than forceps
Ventouse should be the instrument of choice
Should not be used for preterm, face presentation
or
breech

11
COMPLICATIONS

Maternal ? Vaginal laceration due to
entrapment of
vaginal mucosa between suction cup
fetal head
FETAL
Scalp injuries
? abrasion
lacerations 12.6
?scalp necrosis
0.25-1.8
Cephalohematoma ? 25 ? jaundice /anemia
Intracranial hemorrhage ? 2.5
Subgaleal hematoma

12
Fetal Complications
13
FETAL COMPLICATIONS

Birth asphyxia ? 2.6-12 ? related to extraction
force time
Some studies showed decrease birth asphyxia
Retinal hemorrhage 50
Forceps 31
SVD 19
Neonatal jaundice

14
FETAL COMPLICATIONS

Fetal mortality 15/1000
Lower in cases delivered by vacuum 1.9/
forceps
5.2
No long term effects on neurological psychomotor
or intellectual development up to 4 years of age

15
FORCEPS
16
INDICATIONS

MATERNAL
Exhaustion
Prolonged second stage
Cardiac / pulmonary disease
FETAL
Failure of the fetal head to rotate
Fetal distress
Control of the fetal head in vaginal beech
delivery

17
CLASSIFICATION OF FORCEPS DELIVERY

Outlet forceps ? Scalp visible at the vulva
without
separating the
labia
Low forceps ? Vertex at 2 station

Midforceps ? Head is engaged but leading
part
above 2 station
? Sagittal suture
not in the AP plane
of the mother

19
CLASSIFICATION OF FORCEPS DELIVERY

Outlet ? Wrigleys
Outlet low forceps ? Simpson /Elliot
Midforceps outlet ? Tucker Mc lane
Midforceps rotation ? Kielland
After coming head in breech ? Piper

20
Conditions to be fulfilled

MNEMONIC
A Anesthesia ?adequate /epidural or pudendal
B Bladder ? cathterization
C Cervix ? fully dilated / membranes
ruptured
D Determine ? position, station, pelvic
adequacy
E Equipment ?Know your forceps

21
MNEMONIC

F Forceps ?phantom application
?Lt blade , LT hand, maternal Lt side
pencil grip
vertical insertion with Rt thumb
directing blade
?Rt blade , RT hand, maternal Rt side
pencil grip
vertical insertion with Lt thumb
directing blade
?Lock blades

22
MNEMONIC

?Check application
Post fontanelle 1cm above the plane of the shanks
Sagittal suture lies in the midline of the shanks
/perpindicular to the plane of the shanks
The operator can not place more than a fingertip
between the fenestration of the blade the fetal
head on either side

23
MNEMONIC

G Gentle traction ? applied with contraction
maternal
expulsive
efforts
H Hand elevated ? traction in the axis of the
birth canal
I Incision ? consider episiotomy
if laceration
imminent
J Jaw ? remove forceps when
jaw is reachable
or
delivery assured

24
COMPLICATIONS

Maternal ? trauma to soft tissue ?3rd/4th degree
double the risk
compared to ventouse
?bleeding from lacerations
?trauma to urethra bladder
? fistula
?Pain 17 ventouse 11

25
COMPLICATIONS

Fetal ? bruising laceration to the face
? Injury to the fetal scalp
?cephalohematoma 9 Vent
25
?retinal hemorrhage 30
Vent 50
? skull fracture
?permanent nerve damage /
Facial nerve
The risk of shoulder dystocia is increased
following instrumental deliveries

26
CESAREAN SECTION CS
27
TYPES OF CS

Lower segment CS
Classical CS

28
INDICATIONS FOR ELECTIVE CS

Repeat CS
Placenta previa
VV fistula repair
HIV (poor controlled)
Active herpes
Fetal macrosomia gt 4500 gm

Uterine surgery eg. Hystrotomy, myomectomy
Severe IUGR
Breech
Multiple pregnancy
Transverse lie
Ca of the Cx/ TR obstructing the birth canal

29
Indications for classical CS

Transverse lie back down (with SROM)
Structural abnormality that makes lower segment
approach difficult (Fibroids)
Anterior Placenta Previa abnormally vascular
lower segment
Poorly developed lower segment in Very preterm
fetus in breech presentation
Cervical cancer

30
TIMING OF ELECTIVE CS

Usually at 38-39 wks

31
COMPLICATIONS

Bleeding the need for bl transfusion
Hysterectomy
Complications of anaesthesia
Damage to the bladder, ureter, colon , retained
placental tissue
Fetal injury
Infection
DVT/PE

32
MODE OF DELIVERY IN NEXT PREGNANCY

CRITERIA FOR VBAC
Pt must agree to the procedure
A low transverse uterine incision
Non recurrent cause of the previous CS
No macrosomia, malposition, multiple gestation,
breech

33
CONDUCT OF LABOUR

Observe for
Progress
Fetal wellbeing
Maternal well being
Epidural
HOSPITAL SHOULD PROVIDE BLOOD , OPERATING ROOM 24
HRS, NEONATAL RESUSCITATION, NURSING ANAESTHESIA
SURGICAL PERSONNEL CAN START CS WITHIN 30 MIN

34
Risk of SCAR RUPTURE