Operative Vaginal
Delivery
District 1 ACOG Medical
Student Teaching Module 2011
Indications

Maternal Benefit – Shorten the 2nd stage of
labor, decrease the amount of pushing


Concern for immediate/potential fetal
compromise


Ie: maternal cardiac conditions (Eisenmenger’s,
pulmonary HTN) or history of aneurysm/stroke
Ie: Prolonged terminal bradycardia
Prolonged 2nd stage


Nulliparous = No progress for 3 hrs w/epidural or 2
hours w/o epidural
Multiparous = No progress for 2 hrs w/epidural or 1 hr
w/o epidural
Operative Vaginal Delivery
 Incidence:
4.5% of vaginal deliveries
 Forceps deliveries = 0.8%
 Vacuum deliveries = 3.7%
 Success Rate = 99%

Reflects appropriate choice of candidates
What Do I Need To Know Before
Attempting an Operative Delivery?

Presentation
(Cephalic/Breech)
 Position (i.e. occiput
posterior, sacrum anterior)
 Lie (longitudinal, oblique,
transverse)
 Station
 Presence of asyncliticism
 Clinical pelvimetry
 Anesthesia?
Contraindications
 GA
< 34 weeks (contraindication for
vacuum due to risk of fetal IVH)
 Known bone demineralization condition
(e.g. osteogenesis imperfecta) or bleeding
disorder, ie: VWD)
 Fetal head unengaged
 Position of fetal head unknown
Vacuum-Assisted Vaginal Delivery

Do not apply rocking
motion or torque, only
steady traction in the
line of the birth canal

Stop after: three “popoffs” of vacuum, > 20
minutes elapsed, three
pulls with no progress
After determining position of the head, (A) insert the cup into the vaginal
vault, ensuring that no maternal tissues are trapped by the cup. (B) Apply the
cup to the flexion point 3 cm in front of the posterior fontanel, centering the
sagittal suture. (C) Pull during a contraction with a steady motion, keeping
the device at right angles to the plane of the cup. In occipitoposterior
deliveries, maintain the right angle if the fetal head rotates. (D) Remove the
cup when the fetal jaw is reachable
Fetal Risks: VAVD
Designed to detach if traction is excessive (but
can produce traction up to 50 lbs)
* 5% incidence serious complications






Scalp lacerations: if torsion
excessive
Cephalohematoma: limited to
suture line
Subgleal hematoma: crosses
suture line
Intracranial/retinal hemorrhage
Hyperbilirubinemia/jaundice
Higher incidence of
cephalohematoma/retinal
hemorrhage/jaundice compared to
forceps
Type of Forceps Delivery

Outlet forceps





Low forceps



Leading point of fetal skull at >= +2, not on pelvic floor
Rotation 45º or less (LOA/ROA to OA, or LOP/ROP to OP); or
rotation greater than 45º.
Midforceps


Scalp visible at introitus w/o separating labia
Fetal skull reached pelvic floor & head at/on perineum
Sagittal suture in AP diameter or LOA, ROA, or posterior position
rotation does not exceed 45º
Above +2 cm but head engaged
High forceps


Head not engaged; not included in ACOG classification
Not recommended
Forceps-Assisted Vaginal Delivery

Identify & apply
blades



Place instrument in
front of pelvis with tip
pointing up & pelvic
curve forward
Apply left blade,
guided by right hand,
then right blade with
left hand
Lock blades

Should articulate with
ease
FAVD
 Check


Sagittal suture in midline of shanks
Cannot place more than one fingertip
between blade and fetal head
 Apply



for correct application
traction
Steady and intermittent
Downward and then upward
Remove blades as fetus crowns
Risks: Forceps

Maternal Risks




Perineal Injury (extension of episiotomy)
Vaginal and Cervical lacerations
Postpartum hemorrhage
Fetal Risks





Intracranial hemorrhage
Cephalic hematoma
Facial / Brachial palsy
Injury to the soft tissues of face & forehead
Skull fracture
Using both forceps and vacuum
 Highest
risk for injury is for combined
forceps/vacuum extraction or cesarean
delivery after failed operative delivery
 The weight of available evidence is
against multiple efforts with different
instruments