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Instrumental deliveries
1. INSTRUMENTAL DELIVERIES
Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.
3. 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
4. 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
5. MNEMONIC
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 birth canal
ask the mother to push during cont
6. 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
7. COMPLICATIONS
Vacuum –assisted delivery is less traumatic to the mother &
fetus than forceps
Ventouse should be the instrument of choice
Maternal Vaginal laceration due to entrapment of vaginal
mucosa between suction cup & fetal head
9. 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
10. 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
12. 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
13. 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
14. CLASSIFICATION OF FORCEPS
DELIVERY
Outlet Wrigley’s
Outlet & low forceps Simpson /Elliot
Midforceps & outlet Tucker Mclane
Midforceps & rotation Kielland
After coming head in breech Piper
15. 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
anesthesia support
16. 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
17. 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
18. MNEMONIC
G – Gentle traction applied with contraction & maternal
expulsive efforts
H – Handle elevated traction in the axis of the birth canal
do not elevate handle to early
I – Incision consider episiotomy if laceration
imminent
J – Jaw remove forceps when jaw is reachable
or delivery assured
19. 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%
20. 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
Notas do Editor
Instrumental deliveries 1-Indications for instrumental deliveries include T1-Prolonged 2 nd stage T2-Fetal distress F3-Transverse lie F4-Compound presentation T5-Maternal cardiac disease
2-Prerequisite for instrumental delivery include T1-Cervix must be fully dilated T2-Membranes ruptured F3-Fetal head not engaged F4-Obstetrician unsure about position of the fetal head due to caput T5- Bladder empty/ cathetrized
3-Complications of ventouse delivery F1-Ventouse causes 3 rd & 4 th degree perineal tears more frequent than forceps F2-Long term effects on neurological & intellectual development of children delivered by ventouse are evident by 4 years of age T3-Cephalohematoma occur in up to 25% of babies T4-Birth asphyxia is related to the force of traction & prolonged procedure (time from application of vacuum until delivery) T5-Cephalohematomas may result in jaundice & anemia of the neoborne
4-Forceps T1-can be applied to the after coming head in assisted vaginal breech delivery T2-Can be applied to face presentation T3-It is not contraindicated for preterm fetuses T4-Can result in facial nerve damage of the fetus T5-Is associated with a higher fetal mortality than ventouse
