Download - Operative Vaginal Delivery
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Operative Vaginal Delivery
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Normal Birth Mechanism
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Introduction US incidence of Operative Vaginal
Delivery (OVD) – 4.5%* Overall rate of OVD declining, but the
proportion of vacuum deliveries is 4-times the rate of forceps
Forceps deliveries = 0.8% of vaginal births
Vacuum deliveries = 3.7% of vaginal births
UpToDate: September 2010
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Indications for OVD
No indication is absolute Prolonged 2nd stage
Nulliparous: lack of continuous progress >3hrs with regional anesthesia >2hrs w/o regional anesthesia
Multiparous: lack of continuous progress >2hrs with regional anesthesia >1hr w/o regional anesthesia
Fetal compromise Maternal benefit to shortened 2nd stage
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Station At the 0 station, the fetal
head is at the bony ischial spines and fills the maternal sacrum.
Positions above the ischial spines are referred to as -1 through -5
As the head descends past the ischial spines, the stations are referred to as +1 through +5 (head visible at the introitus).
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Four Pelvic Types
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Important Landmarks
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Fetal attitude & lateral flexion of the fetal head
A: Synclitism—The plane of the biparietal diameter is parallel to the plane of the inlet
B: Asynclitism—Lateral flexion of the fetal head leads to anterior parietal or posterior parietal presentation.
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Prerequisites for OVD
Informed consent Vertex Engaged ≥34 weeks (vacuum delivery)
Fully dilated Membranes ruptured Adequate maternal pelvis Adequate anesthesia Maternal empty bladder Backup plan Ongoing fetal and maternal assessment
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Contraindication-OVD Non-cephalic, face or brow presentation Unengaged vertex Incompletely dilated cervix Clinical evidence of CPD < 34 weeks gestation (vacuum)
Need for device rotation (vacuum)
Deflexed attitude of fetal head Fetal conditions (e.g. thrombocytopenia)
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Classification of OVD Outlet
Scalp visible @ introitus w/o separating labia Fetal skull @ pelvic floor Saggital suture in AP plane (or ROA/LOA) Fetal head at or on perineum Rotation < 45 degrees
Low Leading point of fetal skull > or = +2 station Rotation < 45 degrees Rotation > 45 degrees
Mid Station above +2 station but the head is
engaged High
Not included in classification
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Vacuum versus Forceps
“Selection of the appropriate instrument and decisions about the maternal and fetal consequences should be based on clinical findings at the time of delivery.”
A meta-analysis comparing vacuum extraction to forceps delivery showed that vacuum extraction was associated with significantly: Less maternal trauma Less need for general and regional
anesthesia
*ACOG Practice Bulletin #17 (June 2000)**Johnson RB. The Cochrane Library Issue 4, 1999
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Effect of Delivery on Neonatal InjuryTowner D et al. Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury. NEJM 1999;341:1709
Delivery Death ICH Other
NSVD 1/5,000
1/1,900
1/216
C/S in Labor 1/1,250
1/952 1/71
C/S p Vac or Forceps
N/R 1/333 1/38
C/S w/o Labor 1/1,250
1/2,040
1/105
Vacuum 1/3,333
1/860 1/122
Forceps 1/2,000
1/664 1/76
Vacuum & Forceps
1/1,666
1/280 1/58
ICH – Intracranial Hemorrhage
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Classification of Forceps
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Williams Obstetrics - 22nd Ed. (2005)
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Williams Obstetrics - 22nd Ed. (2005)
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Williams Obstetrics - 22nd Ed. (2005)
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Williams Obstetrics - 22nd Ed. (2005)
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Williams Obstetrics - 22nd Ed. (2005)
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Williams Obstetrics - 22nd Ed. (2005)
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