Instrumental Delivery

Incidence:-
10-12% of all deliveries

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Introduction
Operative vaginal delivery refers to a delivery
in which the operator uses forceps or a
vacuum device to assist the mother in
transitioning the fetus to extra uterine life.
The instrument is applied to the fetal head
and then the operator uses traction to extract
the fetus, typically during a contraction while the
mother is pushing.

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 Decisions regarding use of instrumental delivery
are now based primarily upon
the fetal/neonatal impact
Decisions are also weighed against the
alternative options :-
Cesarean birth,
Prolonging the second stage,
Second stage augmentation

3
CHOICE OF INSTRUMENT
The choice of instrument is determined by level
of training with the various forceps and
vacuum equipment.
Factors that might influence choice are:-
the availability of the instrument,
the degree of maternal anesthesia, and
knowledge of the risks and benefits associated
with each instrument.
Vacuum delivery is probably safer than forceps for the
mother, while forceps are probably safer than vacuum for
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the fetus.
 In general, vacuum devices are:-
Easier to apply,
Place less force on the fetal head,
Require less maternal anesthesia,
Result in less maternal soft tissue
trauma,
Do not affect the diameter of the fetal
head compared to forceps.
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 The advantages of forceps :-
Are unlikely to detach from the head,
Can be sized to a premature cranium,
May be used for a rotation,
Result in less cephalohematoma and
retinal hemorrhage, and
Do not aggravate bleeding from scalp
lacerations.

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Forceps Delivery
Hundreds of different forceps available
Classic forceps,
Rotational forceps, and
Specialized forceps designed to assist
vaginal breech deliveries.

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Design of Forceps
Basically consist of
two crossing
branches.
Each branch has
four components:
1. Blade,
2. Shank,
3. Lock,
4. Handle.
Each blade has two curves :-
The cephalic curve conforms to the shape of the fetal head, and
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The pelvic curve corresponds more or less to the axis of the birth canal
 Blades may be
Solid (Tucker-McLane),
Fenestrated (Simpson), or
Pseudofenestrated (Luikart-Simpson).
Solid or pseudofenestrated blades results in less risk of maternal soft
tissue injury, especially during rotation, but fenestrated blades provide
improved traction in comparison to solid blades.
The blades are connected to the handles by the shanks,
which are either
Parallel as in Simpson forceps, or
Crossing as in TuckerMcLane forceps.
The common method of articulation,
1. The English lock, consists of a socket located on the
shank at the junction with the handle, into which fits a
socket similarly located on the opposite shank
2. A sliding lock is used in some forceps, such as Kielland
forceps
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Kielland Forceps
A slight degree of axis
traction is produced by
the reverse pelvic
curve.
The sliding lock
permits placement of
the handles at any
level on the shank to
accommodate the
asynclitic head and
subsequent
correction of
asynclitism
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PIPER Forceps
Forceps to assist with delivery
of the aftercoming head
during vaginal breech delivery
(Piper forceps) have
A cephalic curve, a reverse
pelvic curve, long parallel
shanks and an English lock.
This design provides easy
application to the
aftercoming head,
stabilizing and protecting
the fetal head and neck
during delivery.
The long shanks permit
the body of the breech to
rest against it 11
Vectis
One forceps blade may
be used as a vectis to
assist in delivery of the
head at the time of c/s
Also possible to use as a
side prop or vectis in
aiding rotation for
otherwise SVD
Murless head extractor
-preferred
8/24/2017 Instrumental Delivery 12
 2 forceps are available which are smaller in
dimension than standard forceps and are
intended for use in the low birth weight or very
low birth weight populations.
"Baby" Elliot and "baby" Simpson forceps
are among these instruments.
Forceps have been used on fetuses
as small as 1Kg

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 CLASSIFICATION OF FORCEPS
DELIVERIES
ACOG redefined the classification of forceps delivery
in 1988 to better reflect the degree of difficulty and
attendant risk
E.g, lower fetal station and smaller degrees of
head rotation are associated with reduced
maternal and fetal injury
Classification emphasizes two most important factors:
Station (O to +5) and
Rotation (< / > 45 degree )

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 CLASSIFICATION OF FORCEPS DELIVERIES
I = Outlet Forceps
Scalp is visible at introitus without separating the labia
Fetal skull has reached pelvic floor
Sagittal suture is in AP diameter or right or left OA or posterior position
Fetal head is at or on the perineum
Rotation does not exceed 45 degrees
II = Low Forceps
Leading point of fetal skull is at station +2 cm, and not on pelvic floor
Rotation is 45 degrees or less (left or right occiput anterior to occiput
anterior, or left or right occiput posterior to occiput posterior)
Rotation is greater than 45 degrees
III = Midforceps
Station above +2 cm but head is engaged

IV = High Forceps
Not included in classification 16
 Classification of forceps application
OUTLET Foetal scalp is visible without separating the
FORCEPS vulva
Foetal skull has reached the pelvic floor
Rotation does not exceed 45 degrees
LOW The leading point of the skull is 2cm or more
FORCEPS below the ischeal spine but not on the pelvic
floor. Two subdivisions:
a) rotation of 45 degrees or less
b) rotation more than 45 degrees
MID When the head is engaged, but the leading
FORCEPS point of the skull is higher than +2 cm station.
Rotation not considered
HIGH EXCLUDED
FORCEPS
 Function of Forceps
The most important function =
4 purposes
Traction,
Compression
May also be invaluable = Extraction
Rotation (OT & OP). Rotation
Victis
In general,
Simpson forceps are used to
deliver the fetus with a molded
head, as is common in
nulliparous women.
TuckerMcLane instrument is
often used for the fetus with a
rounded head, which more
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Xtically is seen in multiparas.
 Indications for forceps delivery
Maternal exhaustion
Prolonged 2nd stage of labor
Inadequate maternal expulsive efforts
E.g. spinal cord injuries or neuromuscular diseases
To shorten the 2nd stage in cases with
E.g. cardiac or cerebrovascular diseases,
Glaucoma, Preeclampsia, eclampsia or
pulmonary diseases
Fetal distress (NRFHRP) and cord prolapse
After-coming head in breach presentation

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Contraindications
Fetal prematurity
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

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Pre-requisites for forceps delivery
1. Presentation must be vertex (with OA or OP) or by face with the
mentoanterior, After-coming head in breech (Pipers forceps)
2. Head must engaged.
3. The position of the head must be known
4. The cervix must be fully dilated.
5. The membranes should be ruptured
6. No contraindication to vaginal delivery such as CPD
7. Fetus should be alive.
8. Episiotomy:- Done during traction when the perineum bulges.
9. Other prerequisites include:
Informed consent
Emptying the urinary bladder
Appropriate analgesia
Adequate facilities and back up personnel
Knowledge, experience and skill in the use of the instrument
and manage complications. 21
Forceps application
The long axis of the blades should corresponds to
the occipitomental diameter
Three forms of application or grip are recognized
1. Biparieto-malar Optimal
2. Front-mastoid Suboptimal
Compresses the mastoid area and the
origin of the facial nerve.
3. Fronto-occipital
Is asymmetric, unsafe and should not be
used.
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23
 Steps in Outlet forceps delivery
Precise knowledge of the position of the fetal
head is essential to a proper cephalic
application.

Cephalic application: -
Blades are applied along the sides of the head,
Pelvic application: -
Blades are applied on the lateral pelvic wall ignoring
the position of the head if the head is not rotated.
Serious compression effect on the cranium can occur,
so it should be avoided. 24
Is only justified in low forceps operations.
 First apply the left blade: Lubricate the blade. Hold the handle
of the left blade with your left hand freely and apply it to the left
side of the mother guided by the two fingers of the right hand.
Apply the right blade: Hold the handle by your right hand and
place it to the right side of the mother guided by the two fingers
of the left hand. The right is always below the left when locked.
Locking is easy when applied correctly. If it is difficult,
disarticulate and apply again after re-ascertaining the position
and station. Never apply undue force to lock.
Check application is correct and no maternal tissue is
entrapped. In correct application:
Locking is easy;
The application is biparietal - bimalar.
The posterior fontanelle should be about one fingers
breadth in front of the plane of the shanks and
equidistant from the blades; the sagittal suture should
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be perpendicular to the middle of the plane of the shank.
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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.

Traction: - Steady & intermittent traction during contraction,

First downwards (horizontal), backwards, forwards &
lastly upwards.
Failed Forceps
A failed forceps is diagnosed if:
Fetal head does not descend with each pull,
Fetus is undelivered after three pulls with no descent or
after 30 minutes
The possible causes are:
Undiagnosed CPD
Incomplete cervical dilatation
Wrong diagnosis of position
Incorrect application
Cervical entrapment
When application of forceps or traction does not yield, reassess
for possible cause. After a failed forceps, Cesarean delivery
is undertaken if the fetus is alive.
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 Complications of forceps delivery
Fetal complications:
Facial nerve injury which is usually self-limiting
Newborns 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)
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 Documentation of Procedure
Indication, date and time
The prerequisites
The estimated fetal weight and the maternal pelvis
Statement about the FHR and maternal contractions
Maternal condition and type of anesthesia
Record of discussion with the woman of the risks, benefits
and options.
Number of application of forceps, ease of application
and any complication with the application
Duration and force of each traction attempt and the
number of traction attempts
Description of maternal or neonatal injuries
Cord blood gases and Apgar scores
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 VACUUM DELIVERY
Vacuum delivery is effected using the
ventouse (vacuum extractor).
The main action of the ventouse is traction
with an additional effect of rotation.
Its main components are the
Suction cup,
vacuum pump and
traction devices. 31
Principle
Traction on a metal cup designed= so that
the suction creates an artificial caput, or
chignon, within the cup that holds firmly and
allows adequate traction.
Use a metal or a soft cup (Silastic cap)
Malmstrom = Metal
Mitavac = Soft
CMI tender touch = Soft
Difference?

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Cups
40 60 mm size
Bell versus mushroom shape
Rigid (plastic or metal) Vs Soft cups (silicone or
plastic)
Metal Cups
Slightly higher success rates than plastic cups
More difficult to apply and more uncomfortable
Higher incidence of fetal scalp injuries
Plastic Cups (pliable to semi-rigid)
Disposable and reusable
Easier assembly & application
Less pronounced chignon
Fewer fetal scalp injuries 34
 Indications and pre-requisites
Are generally like that for forceps delivery Except for :-
Face and
Aftercoming head

Indications Prerequisites
1. Prolonged 2nd stage of Vertex presentation
labor
with fetal position
2. To shorten 2nd stage in:
Maternal distress identified
Preeclampsia/ eclampsia Fully dilated cervix
Cardiac or pulmonary Engaged head: station
diseases at 0 or not more than
Glaucoma, 2/5 above symphysis
Cerebrovascular disease:
pupis
CNS aneurisms etc.
3. Fetal distress and cord Ruptured membranes
prolapse Live fetus
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Term fetus
 Contra indications
1. Cephalopelvic disproportion
2. High station (above 0-station)
3. Non-vertex presentations such face,
breech (after-coming head)
4. Extreme prematurity (<34 weeks)
5. Known macrosomia
6. Recent scalp blood sampling
7. Lack of experienced provider
8. Inadequate trial of labor
9. Inadequate strength & frequency of
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contractions
Application of Vacuum Cups

Proper cup placement is the most

important determinant of success in
vacuum extraction

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 Ideal application Flexing Median is when
The center of the cup is superimposed on the flexion point
(3 cm infront of the posterior fontanelle on the sagittal
suture).The cup is symmetrically placed over the sagittal
suture.
If the center of the cup = more than 1cm to either side
of the sagittal suture, the application is described as
paramedian, and
When the application distance is less than 3cm, it is
called deflexing.

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 Thus, there are four types of cup applications:-
1. Flexing median ( correct/ideal application)
2. Flexing paramedian
3. Deflexing median
4. Deflexing paramedian

Deflexing and paramedian applications promote:-

Extension and
Asynclitism of the head and
Effectively increase or fail to decrease the size and the
area of the presenting part.

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40
Technique for Application of Vacuum cup

First, test the instrument

Recheck the position of the occiput and locate the
flexion point.
Connect cup tubing to the tube of the vacuum pump.
Smear the outside of the cup lightly with obstetric
cream.
Press the cup against the fetal head and maneuver
until its center lies over the flexion point
Check that there is no maternal tissue/fetal electrode
trapped.
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Application:
Apply the largest cup that can fit near to the occiput
with knob of the cup pointing to the occiput. The
center of the cup being at about 1 cm anterior to the
posterior fontanel and on the sagittal suture.
The ideal application of vacuum extraction is achieved
when the centre of the cub is superimposed on the
flexion point. The flexion point is 3 cm in front of the
posterior fontanelle at the sagittal suture.
A wrong application of the cub center anterior to the
flexion point leads to defluxion attitude while by more
than a cm lateral of the sagittal suture exacerbates
asynclitism.
Check for correct application and entrapment of
maternal tissue. If there is maternal tissue entrapment,
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release it before creating vacuum.
 Induce a vacuum pressure of 20 kpa (0.2 kg/cm2)
and recheck the cup position.
Then increase the vacuum in one step to the
recommended pressure of 80 kpa (0.8 kg/cm2)
0.8 kg/cm2 of atmospheric pressure = 600 mmHg = 23.6
inches of Hg = 11.6 lb/in.
Delay traction for 2 minutes to allow chignon to
form although gentle traction may be commenced
sooner if necessary.
0.2kg/2min = rigid cap
0.8kg/1min = soft cap Lower suction pressures
increase the risk of cup
"pop-offs," 43
Traction
Should be directed in such a way that the flexion
point on the head is aligned with the axis of the
pelvis
Traction should be a 2- handed exercise
1. The right hand holds the traction handle and
pulling in the direction of descent
2. The thumb of the non- pulling hand presses
against the dome of the cup

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 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

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 Traction is discontinued
Between contractions or
If an audible hiss is heard signaling loss of
vacuum.
After delivery of the head, the vacuum is released, the
cup eased off the scalp and the birth completed in
the normal manner.
Vacuum extraction should be considered a trial, if
there is no evidence of descent, consider C/S =
3Ds
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 WHO, Vacuum extraction failed if the:
Fetal head doesnt advance with each pull
Fetus is undelivered after 3 pulls with no
descent, or after 30 min
Cup slips off the head twice at the proper
direction of pull with a max negative pressure
Every application should be considered a
trial of vacuum extraction
If VE fails, use VE in combination with
symphisiotomy or perform C/S (WHO)
This procedure should be carried out only in
combination with vacuum extraction.

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 1
Pulling Downward 2

3
48
Crowning

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 Reasons to Discontinue the Procedure
(Abandoning the procedure)

Evidence of CPD
Trauma on fetal head (abrasions/lacerations).
Usually seen after pop-off
No significant progress after 2-3 pulls
Cup disengages 2-3 times (pop-offs) with
proper application.
Fetus does not deliver after:
Time set by protocols (recommended
limits 15-30 minutes)
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Complications
Scalp laceration or bruising
Subgaleal hematoma
Cephalhematoma
Intra-cranial hemorrhage
Neonatal jaundice
Subconjunctival hemorrhage
Clavicular fracture
Shoulder dystocia
Injury to 6th and 7th cranial nerves 51
Advantages of Vacuum Compared to
Forceps
Baby and Delivery Factors
Less force to fetal head
Allows autorotation of fetal head
Can be used to correct deflection and
asynclitism
Maternal and attendant factors
Fewer reproductive tract injuries,
Less maternal discomfort during & after delivery
Less anesthesia is necessary
Less maternal blood loss
Easier to learn
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Advantages of Forceps Compared to
Vacuum
Easier to apply with caput
Used with breech presentation
Use for pre-mature cranium
Less difficult to apply to deflexed head
Used for a rotation of fetal head
Are unlikely to detach from the head,
Less cephalohematoma & retinal hemorrhage,
Less scalp lacerations less risk of MTCT
of HIV 53
 Recommendations Regarding Vacuum Delivery
The classification of vacuum deliveries should be the
same as that utilized for forceps
The same indications and contraindications
utilized for forceps deliveries should be applied
The vacuum should not be applied to an
unengaged vertex, that is, above 0 station.
The individual performing or supervising the
procedure should be an experienced operator.
The operator should be willing to abandon the
procedure if it does not proceed easily or if the
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cup pops off more than three times.
Destructive Vaginal Deliveries
(Embryotomies)

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Definitions
DVD ( embryotomies) refer to reductive surgical
procedures performed on the dead fetus in utero
to reduce its size or otherwise aid in making
vaginal delivery possible
Are performed on dead fetuses in situations of
obstructed labor due to mechanical causes with
disproportionate fetal and maternal pelvic size
Embryotomies aid in avoiding a caesarean delivery
in mothers with dead fetuses and a setting in
which the risk of serious infectious postoperative
morbidity is highly likely
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prerequisites
Dead baby,
Cervix fully dilated or nearly so,
Presenting part fixed in pelvis, uterus not
ruptured
Laparatomy Ux intact deliver vaginally
Cephalic with normal/ hydrocephalic head
Breech with stuck normal/ hydrocephalic
head
Transverse lie with prolapsed arm
Cephalopelvic dystocia with dead fetus
Types of Destructive Vaginal Deliveries

Craniotomy Cranioclasm crushing of cranium

Encephalocentesis/ Craniocentesis
Decapitation
Evisceration
Cleidotomy

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Indications, Pre requisites and Contraindications
Indications Contraindications Prerequisites
Dead fetus with Imminent Fully dilated cervix
mechanical Dead fetus confirmed
uterine rupture by three separate
obstruction
providers auscultations
Alive/dead fetus Suspected/diag for FHB or Sonography
whenever available
with shoulder nosed uterine Station > 0
dystocia not rupture No imminent uterine
amenable to known rupture
maneuvers Experienced operator
(Cleidotomy)
Inexperienced Back up operative
operator facilities
Alive fetus with Adequate analgesia/
anesthesia
hydrocephalus Inaccessible Indwelling bladder
with mechanical fetal drainage for 5-7 days
obstruction and Antibiotic
minimal brain
presentation
administration
tissue (per vaginum) Hgb and cross match59
 Procedure Indications Procedure
Craniotomy: Obstructed labor Scalp held with tissue forceps,
Perforation of with a vertex, face incised with scissors and skull
the skull and and Arrested perforated through a suture or the
emptying the aftercoming head eyeballs in face presentations and
head of brain Hydrocephalus- brain tissue drained and the
tissue so that the Interlocked head of collapsed skull held with bone
head collapses. twins forceps and removed by traction.

Decapitation: Obstructed labor in a The neck is identified on vaginal

Cutting the neck shoulder presentation exam and decapitated either with a
and separating the with or without hand decapitating hook or saw.
head from the prolapse
truncus followed by The trunk and head are then
version and delivered separately.
extraction
Evisceration: Obstructed labor in a The ribs are identified below the
Perforation of the shoulder presentation scapula and thoracotomy
truncus with with or without hand performed and thoracic contents
removal of all prolapse and abdominal contents removed
internal organs so Fetal malformation through the fetal diaphragm.
that the body (ascites , huge The reduction will bring the neck
collapses version & distended bladder, ) down and make it accessible for
extraction decapitation and delivery.
61
Greatly distended
bladder, ascites/
enlargement of kidneys/
liver.

62
 Specifics of Destructive Delivery
Procedure Indications Procedure

Cleidotomy: Shoulder dystocia The clavicle is identified by

Cutting of one where the usual palpation and fractured either
or both clavicles maneuvers have through the pressure of the
to reduce the failed to deliver thumb or by scissors after
width of the the fetus incising the covering skin.
shoulder
Encephalocentesis Hydrocephalus with Transabdominal or Transvaginal
obstructed labor and needle aspiration of
minimal brain tissue cerebrospinal fluid through the
on sonography skull along the sutures.
indicating poor extra Encephalocentesis may not
uterine chance of necessarily kill the fetus but is
survival for practical purposes regarded
as a fatal procedure for the fetus.

63
 Post-destructive operation care
Explore the uterus, cervix and vagina and treat
accordingly. Repair episiotomy.
Keep a self retaining catheter for 7-14 days if there is
prolonged pressure of the presenting part on the bladder
(obstructed labor) or trauma to the wall of the vagina;
Manage the 3rd stage actively and start 1000 ml D/S, RL or
saline fluid with oxytocin 20-40 IU intravenous drip;
Treat infection: Broad spectrum antibiotics. Debridement of
the dead tissue under general anesthesia may be needed to
control infection from devitalized vaginal tissue.
Continue with IV fluid and record vital signs and input/ output.
Correct anemia and shock as indicated.
Suppress possible breast engorgement
Help the woman morn loss of her fetus and counsel her on
future pregnanacy
 Complications of Destructive Deliveries

Iatrogenic uterine rupture

Cervical and vaginal lacerations
Post partum hemorrhage
Bladder and rectal injury
Inadvertent destructive delivery on an
alive fetus
Vesicovaginal and rectovaginal fistulas
Shock
Puerperal sepsis 65
Thank You All

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