Operative Delivery

Presenters: Yonas Gudeta (RMHS/402/09)

Yohannes Negesse (RMHS/399/09)
Yonathan Belay (RMHS/404/09)

Moderator: DR. Admassu (M.D)

Introduction

 An operative delivery refers to an obstetric procedure in which active

measures are taken to accomplish delivery.
 Operative delivery can be divided into
 Operative vaginal delivery and
 Caesarean delivery
 steady decline in the operative delivery with an increase in the caesarean
section rate.
 The success and safety of these procedures are based on
 operator skill, proper timing, and
 ensuring that proper indications are met while contraindications are
avoided.
 Contd…

Operative vaginal
deliveries are
accomplished with the use
of
forceps or a vacuum
device.
The most important
function of both devices is
traction.
Forceps may also be used
for rotation, particularly
from occiput transverse
Contd…
Comparison of forceps and vacuum extractor
 Ventouse is more likely to fail.
 Ventouse is more likely to cause fetal trauma such as:
 Cephalohaematoma
 Retinal hemorrhage
 Ventouse is more likely to be associated with maternal concerns about the
baby.
 Forceps are more likely to cause significant maternal genital tract trauma.
 There is:
 slightly less CS delivery with ventouse delivery
 no difference in low 5min Apgar scores
 no difference in need for neonatal phototherapy.
Bottom line—ventouse appears safer for mother but forceps may be
Contd…
Indication
Any condition threatening the mother or fetus that is likely to be
relieved by delivery.
Fetal indications
Nonreassuring fetal heart rate pattern
Premature placental separation
Maternal indications
Heart disease
Pulmonary compromise
Intrapartum infection
Neurological conditions.
The most common are exhaustion and prolonged second-
stage labor.
Forceps Delivery

 The obstetric forceps is an instrument designed to assist with delivery

of the baby’s head.
 It is used either to expedite delivery or to assist with certain
abnormalities
 Functions
 assist with traction of the fetal head (typically during a contraction
while the mother is pushing.)
 assist with rotation of the fetal head (from occiput transverse and
posterior positions.)
 Vacuum to-forceps ratio is approximately 4:1.
Contd…

 Factor for decline in the use of forceps

 Medico legal implications and fear of litigation
 Reliance on caesarean section as a remedy for abnormal labor and
suspected fetal jeopardy
 Perception that the vacuum is easier to use and less risky to fetus
and mother
 Decreased number of residency programs that actively train
residents in the use of forceps
Contd…
 Forceps consists of 2 matched parts that articulate or “lock.”
 Each part is called branch (left or right according to the side of the
maternal pelvis to which they are applied) composed of a
 blade
 Shank
 parallel or overlapping
 Lock
 connect the right and left branches
 located
 at the end of the shank nearest to the handles (English lock),
 at the ends of the handles (pivot lock)
 along the shank (sliding lock).
 Handle
Contd…
 Each blade has
 Toe,
 Heel, and
 Two curves.
 The cephalic curve, to the sides of the baby’s head, and the pelvic curve, to
the curved axis of the maternal pelvis.
 Some blades have an opening within or a depression along the blade surface and are
termed fenestrated or pseudo fenestrated, respectively.
 True fenestration reduces the degree of head slippage during forceps rotation.
Disadvantageously, it can increase friction between the blade and vaginal wall.
 Pseudo fenestration, the forceps blade is smooth on the outer maternal side but
indented on the inner fetal surface.
 The goal is to reduce head slipping yet improve the ease and safety of
application and removal of forceps compared with pure fenestrated blades.
 In general, fenestrated blades are used for a fetus with a molded head or for rotation.
Contd…

Fenestrated Pseudo fenestrated

Contd…
Type of forceps
Classical instruments: -
Originally designed by James Young Simpson, Wrigley & George L. Elliot Jr
in mid 19th century
Commonly used for outlet & low pelvic rotational delivery.
Modified classical instruments: -
Overlapping solid blades with extended shanks like Tucker-Mclane forceps,
Elliot type
Commonly used as mid pelvic rotators or outlet blades.
Specialized instruments : -
Barton's for transverse arrest in platypeloid pelvis,
Keilland's for mid pelvic rotation & correction of asynclitism, &
Piper's for delivery of After coming head in breech.
Contd…
Contd…
 Indications for forceps delivery
 Nonreassuring fetal heart rate  Fetal distress and cord prolapse
pattern,  Prolonged second stage of labor
 To shorten the second stage in not due to dystocia
cases with  In a nulliparous: >3 hours
 Maternal distress with a regional anesthetic or
 Preeclampsia, eclampsia >2 hours without a regional
 Cardiac or pulmonary anesthetic.
diseases  In a multiparous patient, >2
 Glaucoma, hours with a regional
 Cerebrovascular diseases: anesthetic or >1 hour without
aneurysm, CVA etc a regional anesthetic
 Delivery of the aftercoming head
in a breech presentation.
Contd…
Contraindications
 Fetal prematurity
 is a relative contraindication.
 Known fetal demineralizing diseases
 (e.g. osteogenesis imperfecta),
 Fetal bleeding diatheses
 (e.g. hemophilia, alloimmune thrombocytopenia),
 Unengaged head,
 Unknown fetal position,
 Malpresentation
 (e.g. brow, face), and
 Suspected fetal-pelvic disproportion
 Contd…
 Candidate for forceps-assisted vaginal delivery with a cephalic
presentation, all of the following prerequisites must be met:

 Complete cervical dilatation,

 Ruptured membranes,
 Fetal head engaged with the fetal head position known,
 Empty bladder,
 No evidence of cephalopelvic disproportion,
 Adequate analgesia,
 Caesarean section capability, and
 An experienced operator.
Contd…
Classification of forceps delivery
 Outlet forceps is the application of forceps when
 the fetal scalp is visible at the introitus without separating the labia,
 the fetal skull has reached the pelvic floor,
 the sagittal suture is in the anteroposterior diameter or in the right or left
occiput anterior or posterior position, and
 the fetal head is at or on the perineum. According to this definition, rotation
of the fetal head must be ≤45 degrees.
 Low forceps is the application of forceps when the leading point of the fetal
skull is at station +2 or greater and not on the pelvic floor.
 Low forceps have 2 subdivisions: (a) rotation ≤45 degrees and (b) rotation
>45 degrees.
 Midforceps is the application of forceps when the head is engaged but the
leading point of the fetal skull is above station +2.
Contd…

 Only rarely should an attempt be made at forceps delivery above

station +2.
 Under unusual circumstances, such as:
 sudden onset of severe fetal or maternal compromise or transverse
arrest, application of forceps above station +2 can be attempted
while simultaneously initiating preparation for a caesarean delivery
in case the forceps maneuver is unsuccessful.
Contd…
Preparation of patient for forceps delivery

 The patient must be placed in the dorsal lithotomy position and the
bladder should be emptied.
 legs should be comfortably placed in stirrups with the hips flexed and
abducted.
 The abdomen and legs should be adequately draped, and the vagina
and the perineum should be prepped in usual fashion.
 If conduction (spinal/epidural) anesthesia is to be used, it must be
administered prior to the foregoing steps in delivery.
 If pudendal block or local infiltration is to be used, it should be
administered after the preliminary examination has been performed
and all is in readiness for delivery.
Contd…
The Preliminary Examination
1. The position of the fetal head,
 Determined by first locating the lambdoid sutures and then
determining the direction of the sagittal suture.
 The posterior fontanelle is readily evident after the 3 sutures running
into it are identified.
 If the most accessible fontanelle is found to have 4 sutures running into
it, it is the anterior fontanelle and the position usually is occiput
posterior.
 In the presence of marked edema of the scalp or caput succedaneum,
both sutures and fontanelles may be masked, and the position can only
be determined by feeling an ear and noting the direction of the pinna.
Contd…
2. The station of the fetal head, the amount of space between the spine
which is the relationship of the and the side of the fetal
presenting part to the ischial spines, head;
If the head can be felt above the the contour of the accessible portion
symphysis pubis, forceps should not of the sacrum and the amount of
be used. space posterior to
3. The adequacy of the pelvic the head usually based on the length
diameters of the midpelvis and outlet of the sacrospinous ligament; and
is determined by noting the following: (c) the width of the
the prominence of the ischial spines, subpubic arch. This kind of
the degree to which they shorten the appraisal is neither needed nor
transverse feasible for outlet forceps, but is
diameter of the midpelvis, and essential for indicated low forceps or
midforceps.
Contd…
Contd…
Application of forceps
 Before the forceps a “phantom application” should be performed first.
 Ensure the forceps consist of a complete and matched set and
articulate (lock) easily.
 Forceps should be applied in a delicate fashion in order to avoid
potential injury to the vagina and perineum.
 The blades should lie evenly against the side of the head, covering the
space between the orbits and ears.(correct application prevents soft
tissue and nerve injury, as well as bony injuries to the fetal head.)
 The forceps cannot be easily articulated, the forceps should be
removed and a second attempt made.
 The following checks should be performed for delivery of an occiput
anterior position before any traction is placed on the fetal head.
Contd…

 The sagittal suture should be perpendicular to

the plane of the shanks.
 The posterior fontanelle should be 1 finger-
breadth away from the shanks equidistant from
the sides of the blades, and directly in front of
the articulated forceps.
 If fenestrated (open) blades are used, the amount
of fenestration in front of the fetal head should
admit no more than the tip of 1 finger.
Contd…
How to apply in OA position

 Insert the left blade first.

 Two or more fingers of the right hand are introduced inside the left,
posterior portion of the vulva and into the vagina beside the fetal head.
 The handle of the left branch is grasped between the thumb and two fingers
of the left hand, and the tip of the blade is gently passed into the vagina
between the fetal head and the palmar surface of the fingers of the right
hand (serves as a guide).
Contd…

 The handle and branch are held at first almost vertically, but they are
depressed as the blade adapts to the fetal head, eventually to a horizontal
position.
Similarly, two or more fingers of the left hand are then introduced into the
right, posterior portion of the vagina to serve as a guide for the right blade,
which is held in the right hand and introduced into the vagina.
 Then the horizontally positioned branches are articulated.
 If necessary, one and the other blade should be gently maneuvered until the
handles are repositioned to effect easy articulation.
Contd…
Traction
 The pelvis is curved in a J-shape, and it is in this direction that the series
of force vectors should be applied.
 Traction is always applied gently and never with excessive force.
 More horizontal traction is applied, and the handles are gradually
elevated, eventually pointing almost directly upwards as the parietal
bones emerge.
 As the vulva is distended by the occiput, episiotomy may be done if
indicated.
 It is preferable to apply traction with each uterine contraction, except
when delivery is urgently indicated.
Contd…

Upward traction
(arrow) is applied as
the head is delivered.
Forceps may be
disarticulated after
head is delivered
Contd…
Complications
Fetal complications:
 Facial nerve injury which is usually self-limiting
 Newborn’s face or scalp laceration; cephalhematoma
 Fracture of the face or scalp: Usually need observation as they heal by
themselves
Maternal complications:
 Tear or laceration to the cervix, vagina, or vulva
 Rupture of the uterus
 Postpartum hemorrhage (Traumatic PPH)
 Contd…

Operative vaginal delivery: trial

 This term is used when it is not possible to determine with sufficient confidence
that an instrumental delivery will be successful
 Moving the woman to an operating room for this attempt, which could be
followed by immediate cesarean delivery if operative delivery fails, has merit.
 With such caveats, cesarean delivery after an attempt at operative vaginaldelivery
was not associated with adverse neonatal outcomes if there was a reassuring fetal
heart rate tracing
Vacuum delivery
Definition
Indication
Contraindications
Pre-requisites
 Procedure
Complications
Recommendation
Advantages
Introduction
The idea of using a suction device applied to the fetal scalp to help
facilitate deliver of the fetal head originated in the 1700s. The first
vacuum cup was not designed until 1890.
The vacuum device did not gain much popularity until malmström
introduced a metal vacuum cup in 1954.
 In the united states, vacuum extractor is the preferred term, whereas in
Europe it is commonly called a ventouse.
 The most common type of vacuum in use today is a pliable, silastic cup
with a handheld pump.
Indication
1. Fetal distress (NRFHRP) : an assisted delivery in the face of a non-
reassuring FHR tracing may be more challenging than one accompanied
by a reassuring FHR tracing, because of the possible underlying fetal
compromise, as well as the speed in which it is carried out.
2. Shortening of 2nd stage of labor for fetal or maternal reasons:
preeclampsia ,eclampsia, maternal distress, cardiac and pulmonary
distress
3. Prolonged 2nd stage of labor
4. Delivery of after coming head in breech delivery
Contraindication
subject Contraindications

Fetal Bleeding disorder

Predisposition to fracture

Face presentation

High station of fetal head

Gestational age <34 weeks

Breech presentation

Congenital anomalies of fetal head

Maternal Incomplete dilated cervix

True CPD
Prerequisite
Clear indication
Informed consent of the mother
The cervix must be fully dilated
The membranes must be ruptured.
The position and station must be known, and the head must be engaged
The maternal pelvis must be adequate .
The bladder should be empty.
A skilled operator must be present.
Adequate anesthesia is needed before vacuum application.
Procedure

An important step in vacuum extraction is proper cup placement over

the flexion point.
The flexion point is located 3 cm anterior to the posterior fontanelle
along the sagittal suture and approximately 6 cm from the anterior
fontanel.
Press the center of the cup directly over the median flexion point
 this cup placement should allow for adequate maintenance of flexion
of the fetal head during the entire procedure.
The flexion point
Contd

 No maternal tissue should be included under the cup margin.

During cup placement, maternal soft tissue entrapment predisposes the
mother to lacerations and virtually ensures cup dislodgement, colloquially
called a “pop off”.
 The cup should be placed in the midline over the sagittal suture and
not off to the side of the head.
If the center of the cup is more than 1cm to either side of the sagittal
suture, the application is described as para median, and when the
application distance is less than 3cm, it is called Deflexing.
Contd
Gradual vacuum creation is advocated by some and is generated by increasing
the suction in increments of 0.2 kg/cm2 every 2 minutes until a total negative
pressure of 0.8 kg/cm2 is reached.
Once suction is created, the instrument handle is grasped, and traction is
initiated.
 As the mother pushes, traction is applied downward along the pelvic axis. If
more than 1 contraction is necessary, the vacuum pressure can be decreased to
low levels between contractions. The axis of traction is then extended upward
to a 45-degree angle to the floor as the head emerges. Once the head has
completely delivered through the vagina, the suction is withdrawn and the cup
“3DS”

1st pull  should cause flexion of the head and some descent = Dislodge

2nd pull  the head should be on the pelvic floor = Descent

3rd pull  delivery of the head should be complete or imminent = Deliver

 Type of procedure classification
 Outlet Scalp is visible at the introits without separating the labia
Fetal skull has reached the pelvic floor sagittal suture is in anteroposterior diameter.
Right or left occiput anterior or posterior position
Fetal head is at or on perineum
Rotation does not exceed 45 degrees
 Low - leading point of fetal skull is at station +2 cm, and not on the pelvic floor rotation <45 degrees(Left or
right occiput anterior to occiput anterior)
- (left or right occiput posterior to occiput posterior) rotation >45 degrees
 Mid - station above +2 cm but head engaged
 High - not included in classification
Effectiveness & failures

Most reports demonstrate that the vacuum is effective, with a failure rate of approximately
10%.
Effectiveness is determined by 1.Nature of device
2.Fetal factors
3.Maternal factors
Most authorities agree that injury can be significantly decreased or eliminated if the
following protocol is used
(1) Traction is applied only when the patient is actively pushing.
(2) Applying torsion or twisting the cup in an attempt to rotate the head is prohibited.
(3) The duration of time during which the cup is applied to the fetal head
should not exceed 20 minutes.
(4) The procedure should be abandoned after the cup has dislodged or
“popped off” from the fetal head twice. It should not be applied a third time.
(5) The procedure should be abandoned if there is no fetal descent after a
single pull.
(6) Neonatal staff should be present at the time of the vacuum delivery.
(7) Under no circumstances should the operator switch from vacuum to
forceps or vice versa
Failed vacuum

Any one of the following conditions

The head does not advance with each pull
The fetus is not delivered with 3 pulls
The fetus is not delivered within 30 minute
The cup that is applied appropriately and pulled in the proper direction
with maximum negative pressures slips off the head twice
Maternal complication

Short term Long term

Perineal pain(24 hours) Urine incontinence

Lower genital tract laceration Fecal incontinence

anemia Pelvic organ prolapse

Urine retention Fistula formation

Re hospitalization
Scalp laceration or bruising
Subgaleal hematoma
Cephalhematoma
Intra-cranial hemorrhage
Subconjunctival hemorrhage
Clavicular fracture
Shoulder dystocia
Injury to 6th and 7th cranial nerves
So recommendations are:
(1) The vacuum should be used only when a specific obstetric indication is
present
(2) Persons using the vacuum should be experienced and aware of the
indications, contraindications, and precautions
(3) Those who use the vacuum should read and understand the instructions
for the particular instrument being used.
(4) The neonatal care staff should be educated about the potential
complications of vacuum
(5) Individuals responsible for the care of the neonate should be alerted that
vacuum has been used.
Advantage of vacuum vs forceps

Less force to fetal head

Allows autorotation of fetal head
Augments pushing and assists vaginal delivery
Fewer reproductive tract injuries
Less maternal discomfort during & after delivery
Less anesthesia is necessary
Less maternal blood loss
Destructive vaginal delivery (Embryotomy)

Definition
Reductive surgical procedure performed on the dead fetus to reduce its
size and make vaginal delivery possible in case of obstructive labor
Important features
• Prevention of cesarean delivery and dissemination of infection
associated with obstructed labor
• Prevention of maternal trauma
• Shorter time in bed
Rate of DVD in Ethiopia
Study done in TAH (1997-2002)
7.8 DVD per 1000 deliveries
Craniotomy (94%) & for CPD(89%) 
Average bw -2957gm
Preterm(13%), post term(7%), term (54%)
Labor >24hrs in 88%
Fistulas , infection & genital trauma 
Currently almost never practiced in the developed world
Indications of DVD
Cephalo-pelvic disproportion (CPD)
Breech delivery with entrapped after-coming head
Transverse lie
Shoulder dystocia if other maneuvers aren’t working
Prerequisites for DVD
Dead fetus, but there are exceptions (malformation or tumor
incompatible with life)
Fully dilated cervix
No gross pelvic contracture
No risk of uterine rupture
2/5 or less of the head must be above the brim
Back up operative facilities should be available and ready
Preparation
Avail consent of the patient
Put up an IV drip, hydrate and resuscitate the woman as required
Determine hemoglobin, blood group, cross match and others based on complications
Give broad spectrum antibiotics
Use aseptic & antiseptic care
Give pain medication: local, spinal or general anesthesia as required
Alert the OR staff, because it is preferred to perform the procedure in the OR
Put patient in lithotomy position
Clean and drape the vulva and perineum
Catheterize the bladder
Types
Craniotomy
Decapitation
Evisceration
Cleidotomy
Craniotomy

Most commonly performed DVD procedure

Perforation of the head of the dead fetus to evacuate the brain tissue
and decrease its size to effect extraction of the fetus
It is used when the fetus presents with the head or in a case of retained
head in a breech
Craniotomy indications
Obstructed labor with a vertex, face or brow presentation
Arrested after coming head
Contracted pelvis is the most common indication
Contraindications
 Severely contracted pelvis with true conjugate less than 7.5 cm
won’t allow the delivery of the uncompressible bimastoid which
has 7.5 cm diameter
 Ruptured uterus
 Doubtful fetal demise
 Dead fetus without obstruction
Procedure
Scalp is held with a tissue forceps and incision is made with a perforator or
scissors and contents of the brain are evacuated
Site of entry
Vertex- between parietal bone
Face- orbit/hard palate
Brow- frontal bone
After coming head- foramen magnum
Cont.…
 Make an incision at the base of the neck inter the cranium by
inserting the perforator or scissors through the incision and tunneling
subcutaneously to reach the occiput
 Then, perforate the occiput to drain the brain tissue
Decaptiation

Cutting the neck and separating the head from the truncus followed by version
and extraction

Indication -
Obstructed labor with dead fetus in shoulder presentation when the neck is
easily accessible

Instrument
Decapitating wire or decapitating hook

If the neck is at a higher position, cesarean section and evisceration are
considered
Evisceration
Evisceration is removal of thoracic and or abdominal contents through
an opening at most accessible site on the abdomen or thorax
Indication-
Shoulder presentation with dead fetus & neck not accessible for
decapitation
 Fetal malformation like ascites, huge distended bladder, hydronephrosis
Procedure

Pull on the prolapsed arm & the axilla

Protect the vaginal wall with speculum

Make an opening in the chest or abdominal wall

Remove the viscera using hands(liver, heart, intestine and lungs)

If necessary perforate his diaphragm with scissors

Cleidotomy

Cutting of one or both clavicles to reduce the width of the shoulder

Indication -
Shoulder dystocia and if other maneuvers for shoulder dystocia have
been unsuccessful
Post destructive operation care
Explore the uterus, cervix and vagina and treat accordingly
Manage the third stage actively and start 1000 ml D/S, ringer’s or
saline fluid with oxytocin 20-40 IU intravenous drip
Treat infection: with broad spectrum antibiotics
Continue with IV fluid and record vital signs and input/output
Correct anemia and shock as indicated
Suppress possible breast engorgement
Counsel her on future pregnancy
Complications
Trauma to birth canal
PPH (due to atonic uterus or genital trauma)
Shock (due to hemorrhage or sepsis)
Puerperal sepsis
Injury to adjacent organs- VVF, UVF or RVF
Iatrogenic uterine rupture
Inadvertent destructive delivery on an alive fetus
70
References

• Williams obstetrics 25th edition

• Current Oby & Gyn 11 edition
• Oxford handbook of Oby and Gyn
• FMOH protocol