Saeed Mahmoud,MRCOG,MRCPI,MIOG,MBSCCP

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Operative DELIVERIES

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

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Operative Deliveries

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

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VACUUM /VENTOUSE
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INDICATIONS

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

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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

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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

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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

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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

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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

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Fetal Complications
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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

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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
  

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FORCEPS
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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

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CLASSIFICATION OF FORCEPS DELIVERY

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

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

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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

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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

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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

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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

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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

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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

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COMPLICATIONS

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

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CESAREAN SECTION CS
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TYPES OF CS

• Lower segment CS
• Classical CS

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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

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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

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TIMING OF ELECTIVE CS

• Usually at 38-39 wks

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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

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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

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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

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Risk of SCAR RUPTURE

• O.5 for LSCS
• 4-9 for classical

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SCAR RUPTURE

• Signs OF SCAR RUPTURE
• Fetal distress
• Ease of fetal palpation
• Cessation of contractions
• Elevation of presenting part
• Scar pain
• Bleeding / shock

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• Thank you
• Any Questions