OPERATIVE
OBSTETRICS
[Link] Mohamed Abdelaziz
Ass. Prof OBGYN AUW
Forceps Delivery
Forceps are a surgical instrument that resembles a pair of
tongs and can be used in surgery for grabbing, maneuvering,
or removing various things within or from the body. They
can be used to assist the delivery of a baby as an alternative
to the ventouse (vacuum extraction) method.
Classification: 1. Outlet forceps
2. Low forceps
3. Midforceps
4. High Forceps
The basic forceps design
• two blades with shanks,
• joined together at a lock,
• handles to provide a point for traction.
Forceps Delivery
Outlet forceps
1. Scalp is visible at the introitus without separating the labia.
2. Fetal skull has reached the pelvic floor.
3. Sagittal suture is in the A-P diameter or ROA,ROP, LOA,
LOP
4. Fetal head is at or on perineum.
5. Rotation does not exceed 45 .
O=occiput
Forceps Delivery
• Low forceps delivery, when the baby's head is at +2
station or lower. There is no restriction on rotation for this
type of delivery.
• Midforceps delivery, when the baby's head is above +2
station. There must be head engagement before it can be
carried out.
• High forceps delivery is not performed in modern obstetrics
practice. It would be a forceps-assisted vaginal delivery
performed when the baby's head is not yet engaged.
Uses of forceps
1. Maternal or fetal indications
2. Prophylactic
3. Elective
Indications for Forceps Delivery
Any condition threatening the mother or fetus that is likely to
be relieved by delivery.
Maternal Indications
1. Heart disease
2. Pulmonary compromise or Injury
3. Intrapartum infection
4. Certain neurological conditions
5. Exhaustion
6. Prolonged second stage : Nullipara: 3hours with and 2hours
without regional anaesthesia. Multipara: 2 hours with and 1
hour without regional anaesthesia
Fetal Indications
7. Prolapse of umbilical cord
8. Premature separation of the placenta
9. Non-reassuring fetal heart rate pattern
Contraindications
i. Forceps and vacuum extractor
deliveries before full
dilatation of the cervix are
contraindicated.
ii. Ventouse should not be used
in:
iii. gestations of less than 34
completed weeks because of
the risk of cephalohaematoma
and intracranial
haemorrhage.
iv. face or breech presentation.
Pre-requisites for application of Forceps Delivery
1. head engaged less than 1/5th
palpable per abdomen
2. presentation vertex or chin
anterior
3. position known
4. cervix completely dilated
5. membranes ruptured
6. no disproportion between head &
pelvis
Techniques of Forceps Delivery
the left blade is inserted
before the right with the
accoucheur ’s hand protecting
the vaginal wall from direct
trauma.
The axis of traction changes
during the delivery and is
guided along the ‘J’-shaped
curve of the pelvis.
It has been recommended
that an episiotomy be cut
whenever an instrumental
vaginal delivery is performed.
Complications of forceps delivery
A. Maternal
1. episiotomy,lacerations & Injuries to the bladder or urethra
2. uterine rupture
3. urinary and rectal incontinence
4. febrile morbidity
B. Fetal
1. trauma, Cuts and bruises
2. cephalo-hematoma
3. temporary facial nerve injury
4. clavicle fracture
[Link] Extraction
Ventouse is a vacuum device used to assist the delivery of
a baby when the second stage of labour has not progressed
adequately.
It is an alternative to a forceps delivery and caesarean section.
It cannot be used when the baby is in the breech position or
for premature births. This technique is also called vacuum-
assisted vaginal delivery or vacuum extraction (VE).
Principle
• Creation of an artificial caput by attaching a traction device
by suction to the fetal scalp
Indications & pre-requisites
• Same as in forceps delivery
Ventouse extraction
Indications for use of vacuum
There are several indications to use a ventouse to aid delivery:
• Maternal exhaustion
• Prolonged second stage of labor
• Foetal distress in the second stage of labor, generally
indicated by changes in the fetal heart-rate
• Maternal illness where prolonged "bearing down" or
pushing efforts would be risky (e.g. cardiac conditions, blood
pressure, aneurysm, glaucoma).
Techniques of Vaccum Extraction
The woman is placed in
lithotomy position and
assists throughout the
process by pushing.
A suction cup is placed
onto the head of the
baby and the suction
draws the skin from the
scalp into the cup.
Techniques of Vacuum Extraction
Correct placement of the cup directly over the flexion point,
about
3 cm anterior from the occipital (posterior) fontanelle, is critical
to the success of a VE. Ventouse devices have handles to allow
for traction. When the baby's head is delivered, the device is
detached, allowing the accoucheur and the mother to complete
the delivery of the baby.
Techniques of Vacuum Extraction
vacuum pressure (0.6 and
0.8 kg/cm2) is built
the traction plane is at 90º to the cup.
no more than two episodes of
breaking suction in any vacuum
delivery are safe.
Maximum time from application to
delivery should ideally be less than 15
minutes.
Complications
Fetal:
◦ Scalp or cranial effects:
• Subgaleal bleed
• Cephalhematoma
◦ Intracranial injuries:
• Intracranial hemorrhage
• Retinal hemorrhage
• Cerebral irritation/asphyxia
◦ Neonatal jaundice
◦ Maternal complications
◦ Trauma
◦ Hemorrhage
◦ Sepsis
Comparison
The ventouse, when compared to the forceps is significantly
more likely to:
fail to achieve a vaginal delivery.
be associated with maternal worries about the Baby.
The ventouse, when compared to the forceps is significantly
less likely to:
use of maternal regional/general anaesthesia.
significant maternal perineal and vaginal Trauma.
severe perineal pain at 24 hours.
The ventouse, when compared to the forceps is equally likely
to:
delivery by Caesarean section;
low 5 minute Apgar scores.
Summary : Vaccum Extraction
Positive aspects
• An episiotomy may not be required.
• The mother still takes an active role in the birth.
• No special anesthesia is required.
• The force applied to the baby can be less than that of a
forceps delivery, and leaves no marks on the face.
• There is less potential for maternal trauma compared
to
forceps and caesarean section.
Negative aspects
• The baby will be left with a temporary lump on its head,
known as a chignon.
• There is a possibility of cephalohematoma formation, or
subgaleal hemorrhage.
factors contribute to delivery failure:
Inadequate initial case assessment – high head, misdiagnosis
of the position and attitude of the head.
failure due to traction in the wrong plane.
poor maternal effort with inadequate use of Syntocinon to
aid expulsive efforts in the second stage.
failure to select the correct ventouse cup type and/or
incorrect cup position.
Summary : Vaccum Extraction
Positive aspects
• An episiotomy may not be required.
• The mother still takes an active role in the birth.
• No special anesthesia is required.
• The force applied to the baby can be less than that of a
forceps delivery, and leaves no marks on the face.
• There is less potential for maternal trauma compared
to
forceps and caesarean section.
Negative aspects
• The baby will be left with a temporary lump on its head,
known as a chignon.
• There is a possibility of cephalohematoma formation, or
subgaleal hemorrhage.
Thank You..!!