operative vaginal delievery
DESCRIPTION
operative vaginal delieveryTRANSCRIPT
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By Majid Nawaz (final year MBBS)
Bannu Medical College
Bannu
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a delivery in which the operator uses forceps or a vacuum device to assist the mother in transitioning the fetus to extrauterine life.
If performed by proper selection of cases and careful & timely application, operative delivery can be useful in reducing not only
unnecessary caesarean sections but also fetal & maternal complications due to prolonged labor.
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1)prolonged second stage of labour
• Nullipara- • >3 hrs with regional anaesthesia • >2 hrs without regional anaesthesia
• Multipara-• >2 hrs with regional anaesthesia • >1hr without regional anaesthesia
2)Foetal indications: - Foetal distress
Cord prolapse in second stage
Aftercoming head of breech
Low birth wt. Baby Post maturity
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3)Maternal indication: - Maternal distress Pre-eclampsia Heart diseases Neurological disorders where voluntary efforts are contraindicated or impossible
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Absolute Contraindications : Moderate to severe CPD. Abnormal presentations (vacuum…NO, forceps…
YES). High head except in 2nd twin (vacuum can be used)
Relative Contraindications: MATERNAL:
Before full cervical dilatation . There are a few exceptions
prolapsed cord at 9 cm in a multiparous woman. or a second twin.
General anesthesia (vacuum…YES, forceps…NO). Fetal:
Fetal bleeding disorders Predisposition to fracture (e.g., osteogenesis imperfecta). Fetal Distress (vacuum…YES, forceps…NO).
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Vacuum and forceps delivery can be associated with significant complications, both maternal and fetal.
Risks of complications are increased significantly among babies exposed to attempts at both vacuum and forceps delivery.
Complications/dangers of operative delivery: - are mostly due to faulty technique rather than the instrument.
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Injury-. Extension of the episiotomy involving anus & rectum or
vaginal vault. Vaginal lacerations and cervical tear if cervix was not fully
dilated. Post partum haemorrhage –.
Due to trauma, Atonic uterus Shock –.
Due to blood loss, or prolonged labor. Sepsis –.
Due to improper asepsis of local tissues. Anaesthetic hazards.
Delayed or long-term sequel –. Chronic low backache. genital prolapse . stress incontinence.
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Asphyxia
Trauma- Intracranial hemorrhage. Cephalic haematoma. Facial / Brachial palsy. Injury to the soft tissues of face & forehead. Skull fracture
Fetal death-around 2%
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A- Ask for help (experience, and skills necessary to use the instruments) , Anesthesia is needed. (A pudendal block may be appropriate )
and Anticipation of complications (e.g., shoulder dystocia,
postpartum ). Adequate Pelvis.
B- Bladder empty.
C- complete Asepsis.
D- Dilated cervix.
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E- Episiotomy. F- Favorable presentation (vertex or
aftercoming head) G-
Gentle traction in the proper axis. Good uterine contraction.
H- Head is engaged
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I- Informed consent.
M- Membranes are Ruptured.
N- Neonatal resuscitation trained Personnel are present.
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The operators should choose the instrument most appropriate to the clinical circumstances and their level of skill.
RCOG audit standard says that “vacuum is the first choice of instrument for instrumental vaginal delivery”.
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Consist of a silicone or metal cup connected by a tube
to a vaccum source.
cup is applied over the vertex
Operating pressure is
0.6_0.8kg/cm2
Maximum time of application
should be less than 15 minutes
Traction is applied at angle of 90 degree to the cup
Safe and gental traction is applied in concert with
uterine contraction and voluntary expulsive efforts
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2 types Non rotational forceps e.g simpson
forceps_____ used when the head is in occipitoanterior plus or minus 15 degree
Rotational forceps e.g kielland forceps_____ used when when head is positioned greater than 15 degree from the vertical. They are designed for rotation.
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By convention 1st left blade is inserted and then right one
The operator then articulates both the jaws and lock it.
Gental intermittent traction is applied in concert with uterine contraction and expulsive efforts of mother.
The axis of traction changes along with the j shape curve and as the head begins to crown the blades are directed vertical and head is delivered.
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CAN BE USED FOR: After coming head of breech
Dead fetus.
Face presentation
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1) Can be used with local anesthesia or with no anesthesia.
2) Can be used before full cx dilatation.
3) Can be used for rotation and extraction by single application.
4)Less traumatic to mother.
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5) Less traumatic to fetal head.
6) less Compression and traction force (1/20th as compared to forceps)
7) Does not require additional space between tight fitting head and pelvis.
8)No special skill is neded.
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