Instrumental delivery

Obstetrics

Clinicals - History

Fact Explanation
Breech presentation Forceps are used for delivery of the head at assisted breech delivery (singleton or twin) Breech presentation
Forceps are used for delivery of the head at assisted breech delivery (singleton or twin)
Face presentation Indication for forcep delivery (Assisted delivery with a face presentation) Face presentation
Indication for forcep delivery (Assisted delivery with a face presentation)
Delay or maternal exhaustion in the second stage of labour / prolong second stage of labour Indication for instrumental delivery

The advantages of metal-cup vacuum extraction over soft-cup extraction include a higher success rate and easier cup placement in the occipitoposterior (OP) position, especially when an OP cup is used.
Compared with metal-cup devices, soft-cup vacuum extractors cause fewer neonatal scalp injuries. However, these instruments have a higher failure rate
Delay or maternal exhaustion in the second stage of labour / prolong second stage of labour
Indication for instrumental delivery

The advantages of metal-cup vacuum extraction over soft-cup extraction include a higher success rate and easier cup placement in the occipitoposterior (OP) position, especially when an OP cup is used.
Compared with metal-cup devices, soft-cup vacuum extractors cause fewer neonatal scalp injuries. However, these instruments have a higher failure rate
Severe hypertension, heart failure Instrumental deliveries are indicated when maternal effort is contraindicated Severe hypertension, heart failure
Instrumental deliveries are indicated when maternal effort is contraindicated
Caesarean section Forceps are used for Controlled delivery of head at caesarean section Caesarean section
Forceps are used for Controlled delivery of head at caesarean section

Clinicals - Examination

Fact Explanation
Breech presentation, face presentation (mento-anterior) Forcep deliveries are indicated Breech presentation, face presentation (mento-anterior)
Forcep deliveries are indicated
Full dilatation of the Cervix and membranes ruptured. Engagement of the Fetal Head pre-requisites for Instrumental Vaginal Delivery

Mid forceps (Neville-Barnes are used when the baby's head is engaged, but is sitting higher than station +2 (or 2 centimetres below the ischial spines of the pelvis).

Low forceps are the ones most commonly used today. The baby's head is below station +2, which is fairly low in the vaginal canal. Simpson's forceps are the most common type of low forceps used.

Outlet forceps are used when the baby's head can be easily seen at the opening of the woman's vagina, but the baby's head is not emerging any further. Wrigley's forceps are commonly used for this.

Rotational forceps (such as Kielland's) have straighter handles that are capable of having some 'slip' instead of locking together. They are used to turn the baby into a more favourable anterior position, and then traction is used with the same forceps to deliver the baby.
Full dilatation of the Cervix and membranes ruptured. Engagement of the Fetal Head
pre-requisites for Instrumental Vaginal Delivery

Mid forceps (Neville-Barnes are used when the baby's head is engaged, but is sitting higher than station +2 (or 2 centimetres below the ischial spines of the pelvis).

Low forceps are the ones most commonly used today. The baby's head is below station +2, which is fairly low in the vaginal canal. Simpson's forceps are the most common type of low forceps used.

Outlet forceps are used when the baby's head can be easily seen at the opening of the woman's vagina, but the baby's head is not emerging any further. Wrigley's forceps are commonly used for this.

Rotational forceps (such as Kielland's) have straighter handles that are capable of having some 'slip' instead of locking together. They are used to turn the baby into a more favourable anterior position, and then traction is used with the same forceps to deliver the baby.
Fetal heart rate Instrumental deliveries are indicated in fetal distress (fetal tachycardia or bradycardia) Fetal heart rate
Instrumental deliveries are indicated in fetal distress (fetal tachycardia or bradycardia)

Investigations - Diagnosis

Fact Explanation
Vaginal examination Obstetric pre-requisites for Instrumental Vaginal Delivery are: Full dilatation of the Cervix and membranes ruptured.
Engagement of the Fetal Head
Vaginal examination
Obstetric pre-requisites for Instrumental Vaginal Delivery are: Full dilatation of the Cervix and membranes ruptured.
Engagement of the Fetal Head

Investigations - Management

Fact Explanation
Neonatal examination Subgaleal hemorrhage is a serious neonatal complication of vacuum extraction. This complication occurred in 1.0 to 3.8 percent of vacuum extractions in one series but has been much less common in more recent studies. Infants with subgaleal hemorrhage present with a boggy scalp, swelling crossing the suture lines and an expanding head circumference. They may also have signs of hypovolemia, pallor, tachycardia and a falling hematocrit.

Cephalohematoma is another fetal complication of vacuum extraction. This complication has a mean incidence of 6 percent (range: 1 to 26 percent) in vacuum-assisted deliveries.
Neonatal examination
Subgaleal hemorrhage is a serious neonatal complication of vacuum extraction. This complication occurred in 1.0 to 3.8 percent of vacuum extractions in one series but has been much less common in more recent studies. Infants with subgaleal hemorrhage present with a boggy scalp, swelling crossing the suture lines and an expanding head circumference. They may also have signs of hypovolemia, pallor, tachycardia and a falling hematocrit.

Cephalohematoma is another fetal complication of vacuum extraction. This complication has a mean incidence of 6 percent (range: 1 to 26 percent) in vacuum-assisted deliveries.
Blood pressure Instrumental deliveries are indicated in severe high blood pressure where maternal effort is contraindicated. Blood pressure
Instrumental deliveries are indicated in severe high blood pressure where maternal effort is contraindicated.
Echocardiogram To detect the ejection fraction.
Instrumental deliveries are indicated in heart failure where maternal effort is contraindicated.
Echocardiogram
To detect the ejection fraction.
Instrumental deliveries are indicated in heart failure where maternal effort is contraindicated.
Partogram To screen for prolong second stage of labour. Prolonged second stage -
Nullipara - >2 h (>3 h)
Multipara - >1 h (>2 h)
Partogram
To screen for prolong second stage of labour. Prolonged second stage -
Nullipara - >2 h (>3 h)
Multipara - >1 h (>2 h)
cardiotocography To screen for fetal distress.
Non-reassuring patterns seen on cardiotocography:
increased or decreased fetal heart rate (tachycardia and bradycardia), especially during and after a contraction
decreased variability in the fetal heart rate
late decelerations
cardiotocography
To screen for fetal distress.
Non-reassuring patterns seen on cardiotocography:
increased or decreased fetal heart rate (tachycardia and bradycardia), especially during and after a contraction
decreased variability in the fetal heart rate
late decelerations

Management - Supportive

Fact Explanation
Analgesics In the immediate post partum period forceps have been associated with increased perineal and vaginal trauma and a greater requirement for analgesia. Analgesics
In the immediate post partum period forceps have been associated with increased perineal and vaginal trauma and a greater requirement for analgesia.

Management - Specific

Fact Explanation
looking for neonatal and maternal complications - Fetal complications
a. Shoulder dystocia and consequences
The need to perform an instrumental delivery for lack of progress in the presence of anticipated macrosomia should alert the clinician to the increased likelihood of shoulder
dystocia.
b. Subaponeurotic/subgaleal haemorrhage
A potentially life threatening complication, occurring in approximately 1 in 300 cases of
vacuum delivery.
c. Facial nerve palsy, corneal abrasion, retinal haemorrhage
Facial nerve palsy and corneal abrasion are more common with forceps and retinal
haemorrhage with vacuum delivery.
d. Skull fracture and/or intracranial haemorrhage
e. Cervical spine injury
A consequence of rotational forceps delivery may be minimised by ensuring uterine
relaxation prior to performing the rotation.

rigidity of metal cups can make application difficult and uncomfortable, and their use is associated with an increased risk of fetal scalp injuries than soft cups.

-Maternal complications
Pelvic trauma (more in forcep deliveries than vacuum deliveries).
Suturing of tears.
looking for neonatal and maternal complications
- Fetal complications
a. Shoulder dystocia and consequences
The need to perform an instrumental delivery for lack of progress in the presence of anticipated macrosomia should alert the clinician to the increased likelihood of shoulder
dystocia.
b. Subaponeurotic/subgaleal haemorrhage
A potentially life threatening complication, occurring in approximately 1 in 300 cases of
vacuum delivery.
c. Facial nerve palsy, corneal abrasion, retinal haemorrhage
Facial nerve palsy and corneal abrasion are more common with forceps and retinal
haemorrhage with vacuum delivery.
d. Skull fracture and/or intracranial haemorrhage
e. Cervical spine injury
A consequence of rotational forceps delivery may be minimised by ensuring uterine
relaxation prior to performing the rotation.

rigidity of metal cups can make application difficult and uncomfortable, and their use is associated with an increased risk of fetal scalp injuries than soft cups.

-Maternal complications
Pelvic trauma (more in forcep deliveries than vacuum deliveries).
Suturing of tears.

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