OPERATIVE VAGINAL DELIVERY

(OVD) - A NEW PERSPECTIVE

Although experts continue to argue about when
a C/S should be performed, few would question
the wisdom of maintaining and sharpening one’s
skills in OVD. To accomplish that goal, we’ll
review both forceps and vacuum extraction,
look at current trends in clinical practice, and
present the evidence to support the use of each
approach.
Looking back before we look forward
operative vaginal delivery has its origins
in an era when fetal and maternal
mortality and mortality rates were quite
high. Often, the death of the fetus was
deliberately induced in an effort to save a
pregnant woman who had experienced a
prolonged obstructed labor. But over
time and with the introduction of new
tools, operative vaginal delivery emerged
as a way to both minimize maternal risk
At present, both forceps and the vacuum
extractor (VE) are in widespread use.
Controversy continues concerning if and
when to conduct operative vaginal
deliveries and which instrument is best.
This and related issues are of importance
because VE is currently used in about 6%
of all births in the United States (nearly
50,000 operations per year).
Despite the growing popularity of VE, forceps
remains the instrument of choice for many
older clinicians for reasons of medical
conservatism, inclination, and original
training. The future for all instrumental
delivery remains unclear, as adequate training
in all aspects of these operations is
increasingly difficult to obtain because of the
retirement of classically trained obstetricians;
the inability to conduct training operations; a
malevolent medico-legal climate; and changes
in practice, including the high frequency of
cesarean delivery.
The rates of OVD, as well as the relative
use of forceps in comparison to vacuum
extraction, have varied considerably over
time. There have been significant
regional variations within the US and
reduced rates of OVD overall and
increased use of vacuum assisted devices
as a percentage of OVDs. The
percentage of births delivered by forceps
declined from 5.5% to 2.8% and the
vacuum extraction rate increased from
Mandatory Pre requisites
1. Informed consent (IC)
Not simply a signed form.
Proper IC includes -explanation of the need
for the operation
- a discussion of risks and
benefits
- a presentations of
alternative modes of
treatment
- opportunity to ask
questions
2. Prepared physician - i.e. competent and well experienced.
3. Prepared patients - Ruptured of
membranes
- Empty bladder
- Full Cervical
dilatation
- Engaged head
- No suspicion of
feto-pelvic
disproportion
4. Acceptable analgesia/anesthesia
Regional - Pudendal block
Major - Epidural/Spinal
Indications
Prolonged second stage This includes
nulliparous woman with failure to deliver after 2
hours without, and 3 hours with, conduction
anesthesia. It also includes multiparous woman
with failure to deliver after 1 hour without, and 2
hours with, conduction anesthesia.

Poor progress in labour requires caution, other

abnormality like malpositioning, fetopelvic
dropoportion may be present.
An extended second stage is a relative but not
absolute indication for obstetric intervention.
 Shortening of the second stage for maternal
benefits: Maternal indications include, but
are not limited to, exhaustion, bleeding,
cardiac or pulmonary disease, and history of
spontaneous pneumothorax.

.Suspicion of immediate or potential fetal

compromise in the second stage of labor.
When prompt delivery is indicated, station
and position of the fetal head, the feto-pelvic
relationship, operator skill, and judgement of
In expert hands, fetal malposition,
including the after-coming head in breech
vaginal delivery, can be indications for
forceps delivery.

However operative vaginal delivery is

appropriate in carefully selected cases of
rapidly progressing labour when pelvic
adequacy is good, the parturient is willing
and able to assist and an experienced
surgeon is present.
Trials of Instrumental delivery
A trial of instrumental delivery is an operation in
which delivery is indicated and the vaginal route
remains a possibility, but the outcome is
uncertain. In this type of procedure, the most
experienced clinician remains at the perineum,
encouraging maternal efforts of bearing down and
assisting with an instrument, while other
personnel simultaneously prepare for an urgent
cesarean delivery. If the extraction does not
proceed easily with descent of the presenting part
beginning subsequent to the initial traction effort,
the attempt at instrumentation is abandoned and a
cesarean delivery is performed.
Contraindications to vacuum extraction
 Operator inexperience
 Inability to achieve a proper application
 Inadequate trial of labor
 Uncertainty concerning fetal position/station
 Suspicion of feto-pelvic disproportion
 High fetal head
 Malpositioning (e.g. breech, face, brow)
 Known or suspected fetal coagulation defect
 Prior failed forceps
Relative contraindications
 Prematurity (fetuses <36 wk gestation)
 Prior scalp sampling
VE Instrumentation
- Rigid or flexible vacuum - Rigid cup –
1. Classic malmstrom stainless steel
vacuum cup.
2. Rigid plastic cups for use with deflexed
or posterior positioned heads. Flexible
e.g. Polyethylene, silastic plastic.
- Attached Vacuum Pump -
- A handle, wire or chain for traction

Soft flexible cups – have higher incidence of failure

than either rigid or forceps, however they produce less
cosmetic injury – scalp injury.
Technique

Safety and success of VE depends on:

1. The accuracy of cup application

2. The traction technique
3. Fetal cranal position and station
at the time of application
4. The cup design
5. The fetopelvic relationship
Stages 1. Ghosting
2. Insertion
3. Check application of cup -
(Identify anterior
fontanelle/sagital suture line)
4. Traction: Traction efforts are
timed to coincide with contractions.
 Use of continuous vacuum through out the
procedures versus intermittent vacuum with vacuum
relaxed in between contractions. NO
DIFFERENCES BETWEEN GROUPS WITH
Respect to speed of delivery, rates of instruments
failure or maternal or fetal outcome exist.
For standard VE – Recommendation
1. Limit the no of tractions to 4 or 5
2. Limit unintended cup detachments
or “pop-offs” to 2 or 3
3. Requires advancement of the
presenting part with initial traction
4. Restrict the overall duration of the
procedure to 30 minutes (some propose 20
minutes).
5. Detailed documentation of the
operative delivery in the medical
records.
 Sequential Instrument Use

(i.e. forceps operation followed

by VE or Vice Versa)

This is no longer recommended as

this is associated with an increase
risk of fetal intracranial
haemorrhage.
BIRTH INJURIES
Reported incidence of sever fetal injury or death from
VE is low 0.1 to 3 cases per 1000 extraction
procedures. Vacuum use results in shearing forces to
the scalp.
• Subgaleal/subaporenotic hage.
This is the most feared complication of VE. Usually
due to rupture of the emissary veins. Condition can be
life threatening and a mortality rate reaching as high
as 22.8%.
Reported incidence of SG hage ranges from6 – 50 per
1000 VE operative deliveries, SG is rare unless
excessive forces and / or multiple instrumentation is
performed.
• Scalp bruising/lacerations/scalp sloughs
This occur when recommended limits to
total cup applications are exceeded.
Cephal haematoma. Clinically
unimportant

Long term neonatal outcome

Nil of significance in terms of
neurological sequelae.
Maternal Injury
Low rate of maternal injury in comparison to
forceps.
1. Perineal Lacerations. Severe laceration i.e. 3rd
and 4th degree reported incidence from 10 – 30%.

Women with laceration in previous delivery are

at a significantly greater risk.
This is one area in which vacuum has a clear
advantage.
2. Pelvic floor dysfunction (Stress Urinary and anal
Incontinence).
Recent studies evaluation outcome show no
difference in these two conditions in mothers
delivering with the aid of VE and forceps.
FORCEPS DELIVERY

Forceps are instruments designed to aid in

the delivery of the fetus by applying
traction to the fetal head. Many different
types of forceps have been described and
developed throughout time. Generally,
forceps consist of 2 mirror image metal
instruments that are maneuvered to cradle
the fetal head and are articulated, after
which traction is applied to effect delivery.
Forceps have 4 major components, as
follows:

Blades:

Shanks:

Lock:

Handles:
ACOG criteria for types of forceps deliveries
Outlet forceps: (1) The scalp is visible at the
introitus, without separating the labia. The
fetal skull has reached the pelvic floor. (2)
The sagittal suture is in anteroposterior
diameter, right or left occiput anterior or
posterior position (i.e. the fetal head is at or
on the perineum and rotation does not exceed
45o).
Low forceps: The leading point of the fetal
skull is at a station greater than or equal to +2
cm and is not on the pelvic floor; any degree
of rotation may be present.
Mid forceps: The station is above +2 cm,
but the head is engaged.
High forceps: This is not included in the
classification. Previous systems
classified high-forceps deliveries as
procedures performed when the head is
not engaged. High-forceps deliveries are
not recommended.
Prerequisites for forceps delivery
include the following:
The head must be engaged
The cervix must be fully dilated and
retracted
The position of the head must be known
The type of pelvis should be known
The membranes must be ruptured
No disproportion should be suspected
between the size of the head and the size
of the pelvic inlet and mid pelvis.
The patient must have adequate
anesthesia.
Adequate facilities and supportive
elements should be available
The operator should be fully competent
in the use of the instruments and the
recognition and management of
potential complications. The operator
should also know when to stop so as not
to force the issue.
Contraindications: The following are
contraindications to forceps-assisted vaginal
deliveries:
Any contraindication to vaginal delivery Refusal of
the patient to consent to the procedure
Cervix not fully dilated or retracted
Inability to determine the presentation and fetal head
position or pelvic adequacy
Cephalopelvic disproportion
Unsuccessful trial of vacuum extraction (relative
contraindication)
Absence of adequate anesthesia
Inadequate facilities and support staff
Inexperienced operator
Maternal complications
 Early (i.e. acute) complications include
(1) lacerations to the cervix, vagina, peril
bladder; (2) extension of episiotomies; (3)
increase in blood loss; (4) hematoma
intrapartum rupture of the unscarred uterus.

 Late complications are mainly related to

injury to the pelvic support tissues and
include (1) urinary stress incontinence, (2)
fecal incontinence, (3) anal sphincter, (4)
pelvic organ prolapse.
• Fetal complications
 Transient facial forceps marks, bruising,lacerations,

and cephalohematomas
 Facial nerve injuries may be seen
 Skull fractures, intracranial hemorrhage with falx,

or tentorial lacerations have a been reported

 Reports exist of an increased incidence of shoulder
dystocia in patients delivered with forceps,
although this had not been confirmed in other
studies.
 Cerebral palsy, mental retardation, and behavioral
problems may be more related to the episodes that
required emergent delivery or other intrapartum,
environmental, operative factors
CHOICE OF INSTRUMENT

Debate among clinicians persists

concerning which instrument is best
either the vacuum or forceps.

Factors Involved
• Anaesthesia
• Instrument failure
• Serious birth injury
Outlet/low pelvic operation rotation < 45% with
adequate analgesia vacuum & forceps are equivalent
instruments.
Low-pelvic operations (relation > 45) and mid pelvic
operations – VE.
Forceps can be used in direct face to press & rotation in
an experienced hand.
Breech presentation – Piper or Kjellard forceps.
Multiple gestations – delivery of second presenting
cephalic – vacuum must suitable.
Prematurity < 36 wk
The use of any instrument to assist delivery of a
premature infant is controversial.
The conclusion is that a great caution must be exercised
In clinical practice the accocheur must
consider:
1. The fetal condition
2. The available resources
3. Extent of contractions and
likelihood of maternal cooperation
4. Personal skill level

Greater success and less danger result

when instruments are chosen based on
operator experience and skill.
- In presumed fetal jeopardy at low station many
prefer to apply forceps rather than vacuum
however trials have demonstrated no difference.

- When no urgency required then careful

attention to palpation of the cranial fontanelles,
suture lines, orbital ridges or the fetal ear helps
establish the correct cranial orientation.

In difficult cases, real-time ultrasound scanning is

useful in evaluating fetal cranial position.

The instrument chosen should best fit the clinical

condition.
Developing one’s technique To perform a safe
and successful OVD, a clinician must be well-
trained and observe proper technique. He or
she should do the following.
• Perform clinical pelvimetry to determine
adequate mid- and outlet-pelvic dimensions
and ensure to obstructions or contractures
exist;
• Provide adeq2uate maternal anesthesia should
be in effect;
• Assess fetal size, presentation, position, lies,
and any asynclitism;
• Determine the level of engagement of the fetal
head as precisely as possible.