Instrumental
delivery
Instrumental deliveries
forceps and vacuum
extraction
Vacuum /ventouse
INDICATIONS
MATERNAL
• Exhaustion
• Prolonged second stage
• Cardiac / pulmonary disease
FETAL
• Failure of the fetal head to rotate
• Fetal distress
• Should not be used for preterm, face presentation or
breech
MNEMONIC
• A – Anesthesia adequate
appropriate positioning & access
• B – Bladder cathterization
• C – Cervix fully dilated / membranes ruptured
• D – Determine position, station, pelvic adequacy
• E – Equipment inspect vacuum cup, pump, tubing,
check pressure
• F – Fontanelle position the cup over the posterior fontan
-ve 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 births canal
ask the mother to push during cont
• 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
COMPLICATIONS
• Vacuum –assisted delivery is less traumatic to the mother & fetus than forceps
• Maternal Vaginal laceration due to entrapment of vaginal
mucosa between suction cup & fetal head
FETAL COMPLICATIONS
• Scalp injuries chignon
abrasion & lacerations 12.6%
scalp necrosis 0.25-1.8%
• Cephalohematoma 25% jaundice /anemia
• Intracranial hemorrhage 2.5%
• Subgaleal hematoma
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
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
FORCEPS
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
Classification of forceps delivery
• Outlet forceps Scalp visible at the vulva without
separating the labia
• Low forceps Vertex at +2 station
After coming head in breech (Piper)
MNEMONIC
• A – Anesthesia adequate /epidural or pudendal
appropriate positioning & access
• B – Bladder cathterization
• C – Cervix fully dilated / membranes ruptured
• D – Determine position, station, pelvic adequacy
• E – Equipment complete working forceps
Episiotomy
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%
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