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1.FORCEPS 2.VACUUM DELIVERY 3.CAESARIAN SECTION

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Abnormal Labour Forceps and Vacuum Delivery

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VACUUM /VENTOUSE

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INDICATIONS MATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary disease FETAL Failure of the fetal head to rotate Fetal distress Should not be used for preterm, face presentation or breech

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MNEMONIC A Anesthesia adequate appropriate positioning & access B Bladder catheterization C Cervix fully dilated / membranes ruptured D Determine position, station, pelvic adequacy E Equipment inspect vacuum cup, pump, tubing, check pressure

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MNEMONIC F Fontanelle position the cup over the scalp, avoid fontanelle -ve pressure 10 cm H2O initially & between cont sweep finger around cup to clear maternal tissue pressure to 60 cm H2O with the next contraction G Gentle traction pull with contractions only traction in the axis of the birth canal ask the mother to push during cont

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MNEMONIC H Halt halt traction if no progress with three traction aided contractions vacuum pops off three times pulling for 30 min without significant progress I Incision consider episiotomy if laceration imminent J Jaw remove vacuum when jaw is reachable or delivery assured

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COMPLICATIONS Vacuum assisted delivery is less traumatic to the mother & fetus than forceps Ventouse should be the instrument of choice Maternal Vaginal laceration due to entrapment of vaginal mucosa between suction cup & fetal head

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Comparative Advantages of Vacuum Extractors and Forceps Vacuum extractors Easier to learn Quicker delivery Less maternal genital trauma Less maternal discomfort Fewer neonatal craniofacial injuries Less anesthesia required Forceps Fewer neonatal injuries, including cephalohematoma, retinal hemorrhage Higher rate of successful vaginal delivery

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FETAL COMPLICATIONS Scalp injuries abrasion & lacerations 12.6% scalp necrosis 0.25-1.8% Cephalohematoma 25% jaundice /anemia Intracranial hemorrhage 2.5% Subgaleal hematoma

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FETAL COMPLICATIONS Birth asphyxia 2.6-12% related to extraction force & time Some studies showed decrease birth asphyxia Retinal hemorrhage 50% Forceps 31% SVD 19% Neonatal jaundice

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FORCEPS HISTORY WILLIAM CHAMBERLAIN Fled from France in 1569 & practiced forceps delivery as a family secret in Southampton. This was kept as a family secret for over 100yrs and four generations. He had two sons. Peter I - had greater distinction & attended notable women in society. Peter II - who had several sons, died in 1626.

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HYSTORY Levret (1747)-introduced the pelvic curve Smellie (1751)- reinforced pelvic curve & introduced English lock and used in aftercoming head. Tarnier (1877)-introduced axis traction. Barton and Kjielland - introduced the two specialized forceps.

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Functions Traction: -This is the most important function. Pull required in a primigravida is 18 kgs & in a multipara it is 13 kgs. Compression effect: -This is minimal when properly applied & should not be more than necessary to grasp the head. However it has some pressure effect on the well- ossified base of the skull.

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Functions Rotation of head: -This occurs with the use of Kejilland's forceps and also in low forceps cephalic application with the occiput in the 2 or 10 'o' clock position. Protective cage: - When applied on a premature baby it protects from the pressure of the birth canal. When applied on the aftercoming head it lessens the sudden decompression effect.

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19 Indications for forceps delivery Delay in second stage: -. Due to uterine inertia. Failure of progress of labour- if no progress occurs for more than 20 to 30 minutes, with the head on the perineum. Definition of prolonged second stage of labour redefined by A.C.O.G.(1988/1991): - Nullipara-