03 ch13 assisted vaginal birth

7/25/2019 03 CH13 Assisted Vaginal Birth

1/55

Assisted Vaginal Birth

International



2/55


International

Objectives Indications

Prerequisites

Classification

Methods of application and traction

Comparison of techniques

Documentation


3/55


International

Forceps Delivery


4/55


International

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


5/55


International

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


6/55


International

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


7/55


International

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


8/55


International

#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


9/55


International

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


10/55


International

$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 )*


11/55


International

Check the Application


12/55


International


13/55


International

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


14/55


International

From: Human Labour & Birth, Harry Oorn


15/55


International

Axis of Parturition

From: Human Labour & Birth, Harry Oxorn


16/55


International

From: Human Labour & Birth, Harry Oxorn

Traction! #irection

$ Amount


17/55


International



18/55


International

Head Compression

A i d V i l Bi h


19/55


International

Rotation

Correct

Incorrect %Ouch


A i t d V i l Bi th


20/55


International

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


21/55


International

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



22/55


International

FORCEPS !EO!"C

; ;%/0#%03'0IO/

'pplied with contraction


23/55


International

Vac##m E$traction



24/55


International

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



25/55


International

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



26/55


International

ontraindications ( 'bsolute

nonvertex+ face or brow

presentation

unengaged vertex

incompletely dilated cervix

clinical evidence of CPD



27/55


International

ontraindications ( 3elative

prematurity or ,-. / #%)) g

mid'pelvic station

unfavourable attitude

Previous fetal scalp sampling is not a

contraindication



28/55


International

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



29/55

g

International

'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


30/55

g

International

4acuum up 'pplication

pplication over sagittal suturetouching posterior fontanelle



31/55

g

International



32/55

International

A$is o% Part#rition



33/55

International



34/55

International

Vac##m Application&Traction

CorrectIncorrect



35/55

International

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



36/55

International

4acuum Pop(Off ( auses

fault" equipment


37/55

International

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



38/55

International VAC'' !EO!"C

; ;%/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



39/55

International

Comparison o%

Forceps and Vac##mDelivery



40/55

International

omparison of vacuum to forceps 0 randomi1ed+ prospective trials

2utcomes

-

delivery by intended method- cesarean delivery

- maternal analgesia requirements

- maternal and neonatal morbidity



41/55

International

Forceps vers#s Vac##m( aternal



42/55

International

Forceps vers#s Vac##m( !eonatal



43/55

International

$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



44/55

International

'dvantages of 4acuum %xtraction

7o increase in significant neonatal morbidity

8ess need for maternal regional!generalanesthetic

8ess maternal vaginal!perineal trauma



45/55

International

!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



46/55

International

!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



47/55

International

4'88M %503'0IO/

'8!I0 0OO#

Patient !emographics

IndicationsPrerequisites

Procedure

Outcome


2esaran ;a"a 4a&um


48/55

International2esaran ;a"a 4a&um

Dcm!

r "#$% D!

&uas&ingkara

n Cup

'ekanan Negatifkgf$cm%!

()* ()+ (),- % #%)* +). ,), #()#

) *+) ,-+. ,,+/ ,0+/ ,)+1

* / %,)/ #+)( #0), %%)*



49/55

International



50/55

International



51/55

International


I i l


52/55

International


I t ti l


53/55

International


International


54/55

International


International


55/55

International

03 ch13 assisted vaginal birth

Documents