ESMOE: Assisted Delivery

Indications for instrumental delivery
Pre-requisites
Procedure
Vacuum vs. forceps

Indications for instrumental delivery

Maternal:

• Exhaustion
• Prolonged second stage
• Maternal illness
• Haemorrhage

Fetal:

• Abnormalities in FH tracing

Pre-requisites

• Maternal consent
• Cervix fully dilated
• No disproportion
• Membranes ruptured
• No fetal head palpable above symphysis pubis
• Position defined
• Willingness to abandon procedure

Preparation of the patient

• Verbal consent
• Asepsis
• Empty bladder
• Check equipment
• Pudendal block/perineal skin infiltration with 1-2% lignocaine
• Post-procedure
• Dispose of waste
• Wash hands
• Write-up
• Debrief patient

Abandon procedure if:

• No descent with 3 consecutive pulls
• Not delivered within 30 minutes of application
• Ventouse cup disengages twice

Procedure

Vacuum

• Assess position
• Apply largest cup that will fit with centre of cup 1 cm anterior to posterior fontanelle
• Check application and ensure no trapped maternal soft tissue
• Create vacuum
• Traction with contraction and maternal effort in line perpendicular to cup, and in curve of the pelvis
• Consider episiotomy

Forceps

• Assess position
• Assemble forceps, lubricate and orientate
• Insert left blade with left hand protecting maternal tissues with right hand
• Repeat on other side
• Depress handles and lock forceps
• Check application
• Apply traction inferiorly and posteriorly
• Episiotomy required

Vacuum vs. forceps

• Advantages of vacuum - easier to use, less force applied, less maternal damage, allows rotation and can improve flexion
• Disadvantage of vacuum - more likely to fail, higher incidence of scalp injury and cephalhaematoma, higher incidence of minor neonatal jaundice and retinal haemorrhages
• Contraindication to vacuum - preterm <34 weeks, breech/face, not fully dilated, at Caesarean section, HIV +ve, cephalopelvic disproportion, vertex not engages, lack of user experience
• Contraindications to forceps - not fully dilated, cephalopelvic disproportion, vertex not engaged, lack of user experience