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Assisted Vaginal Birth
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Assisted Vaginal Birth
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Assisted Vaginal Birth
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Objectives Indications
Prerequisites
Classification
Methods of application and traction
Comparison of techniques
Documentation
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Forceps Delivery
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Function of Forceps
obstetrical forceps are for the following
functions:
- traction of the fetal head
-
rotation of the fetal head- flexion of the fetal head
- extension of the fetal head
these functions cause fetal head compression
proper use minimizes this compressive force
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Indications Fetal
- suspected fetal compromise requiring immediate
delivery
Maternal- prolonged second stage
- maternal conditions which contraindicate pushing
- conditions requiring a shortened second stage
- maternal exhaustion
- deflexed attitudes of the fetal head and malposition
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Prerequisites head engaged cervix fully dilated and ruptured
membranes
exact position of the head determined adequate pelvis
bladder empty
appropriate anaesthesia
experienced operator adequate facilities and backup available
Forceps must never be before full dilatation or with an unengaged vertex
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lassification of Forceps !eliver"Outlet Forceps
scalp visible at the introitus without separating the
labia
fetal skull has reached the pelvic floor
the sagittal suture is in:
- P diameter or
-
right!left occiput anterior or posterior position- fetal head is at or on the perineum
ACOG: "Committee in Obstetrics, Maternal and Fetal Medicin
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#ow Forceps
leading point of the skull is at station " # cm or
more
two subdivisions:
- rotation of $% degrees or less- rotation more that $% degrees
ACOG: "Committee in Obstetrics, Maternal and Fetal Medicin
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Mid Forceps
head is engaged leading position of the skull is above station " &
cm alternative to mid forceps delivery is cesarean
section ' access to cesarean is necessary if mid
forceps delivery is attempted
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$tation
%ngagement
when the biparietal diameter of the head enters
the plane of the pelvic inlet
when the leading edge of the skull is at or belowthe ischial spines (station )*
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Check the Application
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hec&ing the 'pplication ( )Position For $afet"
+, Posterior fontanelle midway between the bladesand one finger breadth above the plane of the
shanks with the lambdoid sutures a fingerbreadth
above each blade
-, Fenestrations of the blades should be barely felt
and no more than a finger tip should be able to be
inserted between the blade and the fetal head
., $agittal suture perpendicular to the plane of theshanks
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From: Human Labour & Birth, Harry Oorn
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Axis of Parturition
From: Human Labour & Birth, Harry Oxorn
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From: Human Labour & Birth, Harry Oxorn
Traction! #irection
$ Amount
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From: Human Labour & Birth, Harry Oorn
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Head Compression
A i d V i l Bi h
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Rotation
Correct
Incorrect %Ouch
From: Human Labour & Birth, Harry Oorn
A i t d V i l Bi th
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FORCEPS !EO!"C
' '/'%$01%$I''$$I$0'/%
'dequate pain relief
/eonatal support2 2#'!!%3 2ladder empt"
%34I5 Full" dilated6 membranes ruptured! !%0%3MI/% Position6 station and pelvic adequac"
0hin& possible shoulder d"stocia
% %78IPM%/0
A i t d V i l Bi th
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FORCEPS !EO!"C
F FO3%P$
Phantom application #eft blade6 left hand6 maternal left side6 pencil grip
and vertical insertion6 with right thumb directingblade
3ight blade6 right hand6 maternal right side6 pencilgrip and vertical insertion with left thumb
directing blade #oc& blade and support 9 chec& application
Posterior fontanelle + cm above plane of shan&s
Fenestration no : fingerbreadth between it andscalp
$agittal suture perpendicular to plane or shran&swith occipital sutures + cm above respectiveblades
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FORCEPS !EO!"C
; ;%/0#%03'0IO/
'pplied with contraction
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Vac##m E$traction
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4acuum
the vacuum extractor is an obstetrical forceps outlet+ low and mid applications as for forceps
rotation procedures are not to be performed
)If a person deficient in dexterit" could succeed in appl"ing the ?vacuum@
tractor ,,,it is quite probable that he would produce as much injur" as benefit
Hayes, 1831
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Indications
Fetal ' suspected fetal compromise requiring
immediate delivery
Maternal
- prolonged second stage
- maternal conditions which contraindicate pushing
- conditions requiring a shortened second stage
- maternal exhaustion
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ontraindications ( 'bsolute
nonvertex+ face or brow
presentation
unengaged vertex
incompletely dilated cervix
clinical evidence of CPD
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ontraindications ( 3elative
prematurity or ,-. / #%)) g
mid'pelvic station
unfavourable attitude
Previous fetal scalp sampling is not a
contraindication
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Prerequisites
vertex presentation6 term fetus6 %F> -ABB g vertex engaged
cervix full" dilated and membranes ruptured
adequate maternal pelvis b" clinical assessment
appropriate analgesia
maternal bladder empt"
experienced operator
bac&up plan if procedure not successful
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g
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'voidance of complications
onfirm indications and conditions for use Proper anatomical placement
'void entrapment of maternal soft tissue
orrect angle of traction 'void excessive force
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g
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4acuum up 'pplication
pplication over sagittal suturetouching posterior fontanelle
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A$is o% Part#rition
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Vac##m Application&Traction
CorrectIncorrect
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4acuum Failure ( 3ules of 0hrees
. pulls6 over . contractions6 no
progress
. Pop(offs: after one pop off6 reassesscarefull" before reappl"ing
'fter .B minutes of application with no
progress reassess
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4acuum Pop(Off ( auses
fault" equipment
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VAC'' !EO!"C
' '/'%$01%$I''$$I$0'/%
'dequate pain relief /eonatal support
2 2#'!!%3 2ladder empt" %34I5 Full" dilated6 membranes ruptured! !%0%3MI/% Position6 station and pelvic adequac"
0hin& possible shoulder d"stocia
% %78IPM%/0 Inspect vacuum cup6 pump6 tubing and chec&pressure
F FO/0'/%##% Position the cup over the posterior fontanelle
$weep finger around cup to clear maternal tiss
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; ;%/0#%
03'0IO/
+BB mm1g initiall" and between contractions
pull with contractions onl" as contraction begins:
o increase pressure to DBB mm1g
o prompt mother for good expulsive effort
o traction in axis of birth canal
1 1'#0
no progress with three traction aided contraction vacum pops(off three times
no significant progress after .B minutes ofassisted vaginal deliver"
I I/I$IO/ onsider episiotom" if laceration imminent
= ='> 3emove vacuum when jaw is reachable or deliver"assured
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Comparison o%
Forceps and Vac##mDelivery
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omparison of vacuum to forceps 0 randomi1ed+ prospective trials
2utcomes
-
delivery by intended method- cesarean delivery
- maternal analgesia requirements
- maternal and neonatal morbidity
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Forceps vers#s Vac##m( aternal
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Forceps vers#s Vac##m( !eonatal
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$oft versus Metal 4acuum ups
- $oft cups has higher rates of deliver" failure ? esp, with
occiput posterior6 occiput transverse and difficult occiput
anterior positions@
7ualit" of evidence Ia
$trength of recommendation '
- Metal cups has higher rates of neonatal scalp trauma
7ualit" of evidence Ia
$trength of recommendation '
3ohanson 4+ Menon 56+ Cochrane database of systematic reviews+ issue
#62xford(#)))*6
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'dvantages of 4acuum %xtraction
7o increase in significant neonatal morbidity
8ess need for maternal regional!generalanesthetic
8ess maternal vaginal!perineal trauma
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!isadvantages of 4acuum %xtraction Cephalohematoma
- subaponeurotic (subgaleal* hemorrhage
7eonatal retinal hemorrhages- uncertain clinical significance
More likely to fail to deliver+ requiring alternative
Patients must be made aware of these risks
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!ocumentation of Operative !eliver"
the procedure must be clearly recorded in every
case
this documentation should provide an
explanation of the operative intervention whichhas taken place
including a description of the operative
technique employed and its indication
Need for Intervention must be: con'incin(, com)ellin(,consented to, charted
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4'88M %503'0IO/
'8!I0 0OO#
Patient !emographics
IndicationsPrerequisites
Procedure
Outcome
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2esaran ;a"a 4a&um
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International2esaran ;a"a 4a&um
Dcm!
r "#$% D!
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n Cup
'ekanan Negatifkgf$cm%!
()* ()+ (),- % #%)* +). ,), #()#
) *+) ,-+. ,,+/ ,0+/ ,)+1
* / %,)/ #+)( #0), %%)*
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I i l
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I t ti l
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