1.FORCEPS 2.VACUUM DELIVERY - PowerPoint Presentation

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1.FORCEPS

2.VACUUM DELIVERY

3.CAESARIAN SECTIONSlide4

Abnormal Labour

Forceps and Vacuum DeliverySlide5

VACUUM /VENTOUSESlide6

INDICATIONS

MATERNAL

Exhaustion

Prolonged second stage

Cardiac / pulmonary diseaseFETALFailure of the fetal head to rotateFetal distressShould not be used for preterm, face presentation or

breech Slide7

MNEMONIC

A – Anesthesia



adequate

 appropriate positioning & access B – Bladder  catheterization

C – Cervix  fully dilated / membranes rupturedD – Determine  position, station, pelvic adequacy E – Equipment  inspect vacuum cup, pump, tubing,  check pressure Slide8

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 contractionG – Gentle traction  pull with contractions only

traction in the axis of the birth canal

ask the mother to push during

contSlide9

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 assuredSlide10

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 /anemiaIntracranial hemorrhage  2.5%Subgaleal hematoma Slide13

FETAL

COMPLICATIONS

Birth asphyxia  2.6-12%  related to

extraction

force & time

Some studies showed decrease birth asphyxiaRetinal hemorrhage 50%

Forceps 31% SVD 19% Neonatal jaundice Slide14
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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.Slide16

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.Slide17

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.Slide18

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.Slide19

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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

-

<3

hrs

with regional

anaesthesia

<2

hrs

without regional

anaesthesia

Multipara-

<2

hrs

with regional

anaesthesia

<1hr without regional

anaesthesiaSlide20

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Indications for forceps delivery

Foetal

indications: -

Foetal

distress in second stage when prospect of vaginal delivery is safe: -Abnormal heart rate patternPassage of meconiumAbnormal scalp blood

ph

Cord prolapse in second stage

Aftercoming

head of breech

Low birth wt. Baby

Post maturitySlide21

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Indications for forceps delivery

Maternal indication: -

Maternal distress

Pre-

eclampsiaPost caesarian pregnancyHeart diseasesIntra partum infection

Neurological disorders where voluntary efforts are contraindicated or impossibleSlide22

12 October 2002

Forceps Delivery - Prof.S.N.Panda

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Prerequisites

(to be fulfilled before forceps application.

)

Suitable presentation & position: -.Vertex, anterior face or aftercoming head are the ideal positions.

Cervix must be fully dilated.

Membranes must be ruptured.

Baby should be living.

Uterus should be contracting & relaxing.

Bladder must be empty.Slide23

12 October 2002

Forceps Delivery - Prof.S.N.Panda

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Preliminaries

(before forceps application

)

Documentation: - All instrumental deliveries should be dictated in medical record as any surgical procedure & it should include: Consent of the patient, indication for operation, anaesthesia

, personnel involved, type of instrument, difficulties & remedies, resulting maternal &

foetal

complications or injuries and blood loss.

Anaesthesia

:-

Pudendal

block or

Labio-perineal

infiltration for outlet forceps.

Regional or General

anaesthesia

for low & mid forceps.

Catheterisation

:-

Internal examination: -

To asses the state of cervix & membranes, presentation & position, pelvic

outlet

Episiotomy: -

Should be done either before application of forceps or during traction when the perineum bulges.Slide24

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Technique

(of low & outlet forceps application

)

Identification of blades & their application-

The instrument should be placed in front of the pelvis with the tip pointing upwards and pelvic curve forwards. First the left blade should be applied guided by the right hand & then the right blade with the left hand.Locking of blades: -The blades should articulate with ease indicting correct application. Slide25

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Technique

(of low & outlet forceps application

)

3. Traction

: -

Steady & intermittent traction to be applied during contraction, first downwards (horizontal), backwards, forwards & lastly upwards.In outlet forceps - Only two fingers are to be introduced. Traction is applied straight horizontal, upward & then forwards.Removal of blades - Right blade should be removed first.Slide26

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Complications / Dangers

Complications/dangers of forceps delivery: - are mostly due to faulty technique rather than the instrument.

Maternal-

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 or

Anaesthetisia

.

Shock –.

Due to blood loss, dehydration or prolonged

labour

.

Sepsis –.

Due to improper asepsis or

devitalisation

of local tissues.

Anaesthetic

hazards.

Delayed or long-term sequel –.

Chronic low backache, genital prolapse & stress incontinence.Slide27

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Complications / Dangers

.

Fetal-

Asphyxia.

Trauma-

Intracranial haemorrhage.

Cephalic

haematoma

.

Facial / Brachial palsy.

Injury to the soft tissues of face & forehead.

Skull fracture

Remote-cerebral palsy.

Foetal

death-around 2%.Slide28
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REMEMBER

RESPECT INDICATION

DON’T HESITATE TO APPLY FORCEPS WHEN NEEDED

DON’T WASTE TIME

DO IT GENTLY Slide31

http://www.youtube.com/watch?v=KYtd1mgBO1QSlide32

CESARIAN SECTION

Cesarean Section is removal of a fetus from the uterus by

abdominal

and uterine incisions, after 28 weeks of pregnancy

.

It is called hysterotomy

, if removal is done before 28 weeks of pregnancy.Slide33

The five Most Common Causes of Cesarean Section

CS on Request

Routine repeat cesareans .

Dystocia (non-progressive labor) .

Abnormal fetal presentation

eg breech , transverse , cord presentation . Fetal distress . Slide34

Reasons suggested for the increase in caesarean section rates

Advancing maternal age, -Socioeconomic factors, - Reduced parity

Improvements in surgical techniques -- Decreased morbidity and mortality

The obstetrician

’

s experience and type of training

Choose the time and day of deliveryProcedures as high forceps and difficult mid forceps are abandoned in favour of Caesarean Section (C.S.)The introduction of epidural anaesthesia has reduced the anaesthetic risks of the procedure. This has led to a lower threshold for doing a Caesarean section in the second stage of labour

rather than performing rotational/high cavity forceps deliveries which led to maternal and neonatal morbidity.

The increased use of electronic fetal monitoring has increased our awareness of fetal distress although the majority of babies are born in good condition despite an abnormal CTG and/or low pH at fetal blood sampling.

The reduction in the number of rotational forceps deliveries has led to a deskilling of obstetricians who do not feel confident to carry out these procedures.

The evidence that breech presentation babies have a reduced morbidity and mortality if delivered by elective Caesarean section

An increasing demand from women for elective Caesarean sections with no medical reason. Slide35

Avoiding First C-Section Should Be Priority

Avoiding primary cesarean sections unless there is a medical necessity Slide36

Timing Of CS

Elective cesarean delivery

elective caesarean section may be justified, but decisions must take into account the risk to the infant associated with delivery before 39 weeks' gestation

It is now clear that respiratory distress syndrome is indeed seen in "term" infants and is a considerable source of morbidity and mortality in this group

Emergency cesarean section

In cases of suspected or confirmed acute fetal compromise, delivery should be accomplished as soon as possible.The accepted standard is within 30 minutes.Slide37

Elective caesarian section (Planned operation)

Advantages

are:-

Patient with empty stomach and surgeon usually with full breakfast

Best anesthetist available at that time

Best assistant and nursing staff.

Disadvantage

s are :-

If wrong judgment, premature child may

be

born

.

Cervix may not be dilated and hence

poor

drainage

of lochia

Lower segment is not formed and hence

uterine

incision in lower part of upper

segment

.

Emergency caesarian section (Unplanned)

Working under adverse circumstances:-

Patient may be with full stomach

and

surgeon may be with empty belly

Odd working hours either of day or

night

Anesthetist, assistant and nursing

staff

may not be of your choice

Advantage is :-

Mature child as patient is in labor

Cervix is open, better drainage of

lochia

.

Lower segment is well formedSlide38

Preoperative testing and preparation for CS

Pregnant women should be offered

a

haemoglobin

assessment

before CS to identify those who have anaemia. Although blood loss of more than 1000ml is infrequent after CS (it occurs in 4 to 8% of CS) it is a potentially serious complication.

Pregnant women having CS for ante partum haemorrhage, abruption, uterine rupture and placenta praevia are at increased risk of blood loss greater than 1000 ml and should have the CS carried out at a maternity unit with on-site blood transfusion services.Prescribe antibiotics

(one dose of first-generation cephalosporin or ampicillin)

Assess risk for thromboembolic disease (offer

graduated stockings, hydration, early

mobilisation

and low molecular weight heparin

)

To reduce the risk of aspiration pneumonitis: Empty stomach,

an antacid

(sodium citrate 0.3% 30 mL or magnesium

trisilicate

300 mg) +

Cimetidine

IV 1

hr

before CS

an indwelling urinary catheter

to prevent over-distension of the bladderSlide39

Anaesthesia

1

General

anaesthetic

.

2 Regional anaesthesia ( Epidural block. -

Spinal block ).3 Infiltration of local anaesthetic agents. Regional anaesthesia is regarded as considerably safer than general

anaesthesia

with respect to maternal mortality

Regional anesthesia is generally preferred because it allows the mother to remain awake, experience the birth, and have immediate contact with her infant. It is usually safer than general anesthesia. Many practitioners prefer spinal or CSE to epidural techniques because of more rapid onset and better blockage of pain Slide40

Abdominal entrySlide41

Visceral Peritoneal Incision

Place a bladder retractor over the pubic bone

.

Use forceps to pick up the loose peritoneum covering the anterior surface of the lower uterine segment and incise with scissors

.

Extend the incision by placing the scissors between the uterus and the loose serosa and cutting about 3 cm on each side in a transverse fashion

. Use two fingers to push the bladder downwards off of the lower uterine segment. Replace the bladder retractor over the pubic bone and bladder.Slide42
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DELIVERY OF THE BABY

To deliver the baby, place one hand inside the uterine cavity between the uterus and the baby

’

s head.

  With the fingers, grasp and flex the head.

  Gently lift the baby’s head through the incision taking care not to extend the incision down towards the cervix. With the other hand, gently press on the abdomen over the top of the uterus to help deliver the head. 

If the

baby

’

s head is deep down in the pelvis or vagina

Ask an assistant (wearing high-level disinfected gloves) to reach into the vagina and push the baby

’

s head up through the vagina. Then lift and deliver the head

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Give Newborn To PediatritionSlide45

http://www.youtube.com/watch?v=eanpNoc0q8USlide46

The placenta was manually removed or spontaneously delivered

At CS, the placenta should be removed using controlled cord traction and not manual removal as this reduces the risk of

endometritis

.

Spontaneous delivery of the placenta may reduce blood loss and decrease the chance of postoperative

endometritis By Keeping gentle traction on the cord and massage (rub) the uterus through the abdomen. Deliver the placenta and membranesSlide47

Uterine repair

chromic catgut

vs

vicryl

- continuous vs interrupted sutures

peritoneal closure vs non-closure (Pelvic, parietal, both ) Non-closure associated with less post-op fever

but no

significant effect on wound infection or

endometritis

.

New trial

fewer adhesions in closureSlide48
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Prophylactic antibiotics with cesarean section

(immediately after the cord is clamped versus pre-operative

)

Give a single dose intravenously of prophylactic antibiotics after the cord is clamped and cut:

- ampicillin 2 g IV OR

cefazolin

1 g IV provides adequate prophylaxis. No additional benefit has been demonstrated with the use of multiple-dose regimens. however, no consensus on the optimal timing of administration and dosesThere is also no evidence that the transplacental passage of prophylactic ampicillin increases immediate or delayed neonatal infections Slide50

Cesarean section

The laparotomy pads put in abdominal cavity are all

removed & counted doubly

by surgeon himself and then by nurse.Slide51

Ambulation after cs

Ambulation started earlier in the simplified technique group (6-8 hours post-op vs 10-12 hours post-op).

Ambulation enhances circulation, encourages deep breathing and stimulates return of normal gastrointestinal function. Encourage foot and leg exercises and mobilize as soon as possible, usually within 24 hours Slide52

Cesarean Hysterectomy

Hysterectomy is carried out after caesarean section in the same sitting for one of the following reasons:

Uncontrollable postpartum haemorrhage.

Unrepairable rupture uterus.

Operable cancer cervix. Couvelaire uterus. Placenta accreta cannot be separated.       Severe uterine infection particularly that caused by Cl. welchii.

Multiple uterine myomas in a woman not desiring future pregnancy although it is preferred to do it 3 months later. Slide53

Repeated CS is safer than VBAC

should we be promoting VBAC which may carry greater risks

to the individual for the purposes of reducing

“

an undesirable statistic

”? In our country where family sizes are now voluntarily limited,

is it in the woman’s interests to try for a VBAC?Slide54

Causes of a weak scar

Improper

haemostasis

Imperfect

coaptation

Inversion of decidua

Extension of the anglesInfection during healingPlacental implantationOverdistension

of the uterus

The most weak scar is that of the upper segment of the uterusSlide55

Assessment of scar integrity

Hysterogram

Defect in the lateral view

Ultrasonic measurement

Scar defects

Scar thickness

Cut-off value of 3.5 mm at 36 weeks (NPV of 99.3% (Rozenberg et al 1996)Manual explorationBleedingThird stage troubles Slide56

Impending scar rupture

Pain over the scar

Maternal tachycardia

Fetal distress

Poor progress

Vaginal bleedingSlide57

Consider CS complications

Endometritis

if excessive vaginal bleeding

Thromboembolism if cough or swollen calf

Urinary tract infection if urinary symptoms

Urinary tract trauma (fistula) if leaking urine