The use of forceps increases the risk of perineal, vaginal
laceration and sphincter rupture.
Operative delivery (10-15%) can be decreased by continuous support during upright or lateral position and avoiding epidural analgecia.
Oxytocin in primiparus women with epidudral anaesthesia starting in the second state of labour can reduce the need for vaginal operative delivery. Operative intervention can be reduced if pushing is delayed 1-2 hours until the woman have a strong urge to push.
There is an insufficient evidens to support the hypotesis that discontinuing epudiral analgecia reduce the incidens of operative vaginal delivery.
Indication:
Prolonged second stage of labour
- Primigravidas: More than 3 hours with a
regional anesthetic or more than 2 hours
without a regional anesthetic.
- Multiparas: More than 2 hours with a
regional anesthetist or more than 1 hour
without a regional anesthetic.
** if there is no maternal or fetal distress and the patient is not pushing during the whole second stage, the definition of prolonged second stage should be liberally extended.
Maternal exhaustion
Fetal distress
Contraindications to maternal expulsive efforts:
cardiac disease, previous retinal detachment,
maternal vascular intracranial pathology -
(increased intracranial pressure is hazardous
i.e. severe preeclampsia).
Special Indication:
Cord prolapse with fully dilated cervix and the
baby would appear to be delivered easily.
For forceps
Face presentation
Aftercoming head (Kjelland or Piper)
For vacuum
Fetal distress in case of multiparas with
almost fully dilated
cervix (> 8 cm)
Twin B, fetal distress when the head is still
high
What instrument should be used:
Vacuum extraction more likely to fail to give cephalohaematona and retinal haemorrhage. Vacuum less likely to give maternal perinal and vaginal trauma. A five year follow-up did not show any significant different in the long term outcome for either mothers and infants whether the infant was delivered by operational vaginal delivery or Caesarean section.
Vacuum followed by forceps increase the risk for neonatal trauma.
Contraindications:
Gestational age of < 34 weeks
Suspected bleeding disturbances on the infants
Conditions:
Vacuum:
cervix fully dilated and membranes ruptured
Caput + 1, NOT PALPABLE OVER THE
SYMPHYSIS extended caput succedeaneum
often mistaken as caput is more distended
than is actually the case.
Check adequacy of the pelvis (contour of
sacrum, prominence of the spine, the sub-pubic
angle)
Outlet forceps:
Cervix should be fully dilated
and caput at least at or on the perineum.
Rotation does not exceed 45% the pelvic floor.
Low forceps should be performed by an experienced operator. Skull is at station = +2 and not on the pelvic ± rotation.
Mid forceps: (Vacuum is often preferable) the
station is above 2 cm but head is engaged.
Place of Instrumental Delivery
If in doubt, vaginal delivery is feasible or
potential fetal distress, vacuum/forceps should
be performed in the operating room.
Application of the Cup:
In the midline towards the fetal occiput, 3 cm
from anterior fontanelle in occiput posterior
under symphysis and in other presentation
place the cup posteriorly.
Applied vacuum 0.2 kg/cm = (180 mmHg and
insure there is no interposition tissue). The
cup can thereafter be increased to 0.8
kg/cm (600 mmHG). The same should occur in
the first contraction permit no more than 3(-5)
contractions with uterine contractions (20
minutes or 2 episodes of breaking of suction
any trial of vacuum).
There is little evidence of increased maternal and neonatal morbibidity following failed vaginal delivery compared with immediate Caesarean section.
This rule can be broken if slow delivery is performed
to protect the perineum. If no fetal distress, vacuum
can be discharged and the woman can deliver the
head by pushing the head alone.
References:
(1) Johansen, RB. A randomised prospective study comparing the new vacuum extractor policy with forceps delivery. Br J Obstet Gynaecol. 1993 Jun;100(6):524-30.
(2) Operative Vaginal Delivery. RCOG Guideline No. 26, October 2005
(3) Vacca A. Handbook of vacuum extraction in obstetric practice. ISBN 0-340-54849-5.
(4) Vacuum extraction versus forceps for assisted vaginal delivery Cochrane Review.
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