Subject: Obstetrics 2

Topic: Operative Obstetrics Part 1 (Forceps & CSD)

Lecturer: Florentina Abella-Villanueva MD
Shifting /Date: 2nd/ September 8, 2008
Trans group: Ely Buendia & Friends

FORCEPS DELIVERY  termination of the 2nd stage of labor for any condition
Components: threatening the mother or the fetus that is likely to be
1. Blade relieved by delivery
a. Fenestrated- hole, Simpson, Kielland
b. Solid- permits a firmer hold on the fetal head, Tucker, Maternal Indications
McClaine  Heart disease
2. Curves  Pulmonary injury or compromise
a. Cephalic curve- conforms to the shape of the fetal head  Intrapartum infection
b. Pelvic curve- conforms to the shape of the pelvic canal  Neurological complications
 Exhaustion
Classification (AAP & ACG 2003)  Prolonged 2nd stage of labor
Outlet Forceps  Scalp is visible through the introitus
(head >+2) without separating the labia Fetal Indications
 Fetal skull has reached the pelvic  Umbilical cord prolapse
floor  Premature separation of the placenta
 Non-reassuring FHR
 Sagittal suture is in AP diameter, ROA
or LOA or OP position Prerequisite for Successful Forceps Application
 Fetal head is at or on the perineum 1. The head must be engaged
 Rotation does not exceed 45o 2. The fetus must present as vertex or by face with chin
Low Forceps anterior
 Leading point of the fetal skull is at 3. The position of the fetal head must be precisely known
station >+2 and not on the pelvic floor 4. The cervix must be completely dilated
1. rotation < 45o 5. The membranes must be ruptured
2. rotation > 45o 6. There must be no CPD
Mid Forceps  Station above +2 but head is
Preparation for Forceps Delivery
engaged
 Anesthesia- pudendal, regional, or IV ketamine
High Forceps  Not included in the classification (not  Empty bladder
done anymore)  Identification of exact position
o Sagittal sutures
Incidence o Two fontanels
 Decline in operative vaginal deliveries, increase in CS
 Forceps: 17.7 %  4 % Forceps Application
 CS: 16.5 %  22.9 %  BPD (biparietal diameter) corresponds to the greatest
distance between approximately applied blades
Epidural Anesthesia  Long axis of blades corresponds to occipito-mental diameter
 Failure of spontaneous rotation to an OA position  Concave margin of blades
o 27 %- persistent OP o Towards sagittal suture- OA
o 8 %- persistent OP in those not given epidural o Towards face- OP
anesthesia
Traction
 Slowing of 2nd stage of labor  Gentle, intermittent, horizontal
 Decreased maternal expulsive efforts  As vulva is directed by occiput, do episiotomy
 2-fold increased rates in forceps delivery  Handles are gradually elevated as parietal bones emerge
 Apply traction only with each uterine contraction
Functions of Forceps  When head appears, remove the forceps and deliver the
 May be used as a tractor, rotator or both fetus in the usual manner
 Simpson- to deliver a fetus with molded head to nullipara
 Tucker-McLaine- for a fetus with rounded head multipara Maternal Morbidity
 Keilland- for rotation
 Elective outlet forceps delivery with rotations not >45o
o No increase in maternal morbidity
Indications
 Maternal injury increases with rotation >45o

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
 Subject: Obstetrics 2
Topic: Operative Obstetrics
Page 2 of 4
 Increased blood transfusions o Anterior placement will aggravate cervical spine
o Most common morbidity secondary to hemorrhage extension
o 6.1% vacuum extraction o Asymmetric placement –worsen asynclitism
o 4.2% forceps delivery
o 1.4% CS 2. Full circumference of cup should be palpated prior to
1. Lacerations and Episiotomy traction
 Bigger episiotomies o Avoids entrapment of maternal soft tissue
 More 3rd and 4th degree lacerations 3. Gradual increase in suction pressure
o 13% outlet forceps 4. Traction
o 22% low forceps with <45̊ rotation o Intermittent and coordinated with maternal expulsive
o 44% low forceps with >45̊ rotation
o 37% mild forceps Relative Contraindications
2. Urinary and Rectal Incontinence  Face or other non-vertex presentation
 Lower febrile morbidity due to metritis secondary to  Extreme prematurity –intracranial hemorrhage
forceps than CS  Fetal coagulopathies –hemorrhage
 Known macrosomia
Perinatal morbidity  Following recent scalp blood sampling
Complications Vacuum % Forceps %
Complications
APGAR 1min <7 10 10 1. Scalp lacerations and bruising
APGAR 5min <8 2 2 2. Cephalhematomas, intracranial hemorrhage
Cephalhematoma 2.15 10-Jul 3. Neonatal Jaundice (due to hematoma formation)
Caput Succenadaeum 3.4 14 4. Subconjunctival hemorrhage
Facial mark/injury 2 18 5. Clavicular fracture
6. Shoulder dystocia
Erb palsy 1 0 7. Erb palsy
Fractured clavicle 2 0 8. Retinal hemorrhage
Retinal hemorrhage 16-37 8 9. Fetal death
Abducens nerve injury 3.2 2.4
Elevated bilirubin 20 10 CAESAREAN SECTION
Infant stay 3.4 3.1 Incidence
 From 4.5 % (1965) to 25% (1988)
Trial vs. Failed Forceps
 Trial Forceps  2002- 26.1%
o Attempt at operative vaginal delivery is anticipated to be
difficult
o OR and staff are ready for immediate CS
1. Few doctors know how to peform forceps
o If satisfactory applications or forceps cannot be
2. CS technique becomes easy – available anesthesia
achieved, abandon procedure and proceed to CS
 Failed Forceps
o The assumption is vaginal/forceps is adequate to 3. CS by request
deliver baby
o If unexpectedly, delivery is found to be too difficult, ACOG Recommendation for 2010
proceed to CS  Decrease CS rate – 15.5% for nulliparas at 37 weeks or
o Staff and OR not necessarily prepared more with singleton cephalic presentation

VACUUM EXTRACTION  Increase VBAC (Vaginal Birth After CS) rate – 37% at 37
Advantages over Forceps weeks or more after one prior to low transverse CS
1. Avoidance of insertion of space occupying steel blades
within the vagina of positioning precisely over the fetal head Causes of Increases in CS
2. ability to rotate fetal head without impinging on maternal soft 1. Reduced parity
tissues
3. less intracranial pressure during traction 2. Older women are having children
Indications and prerequisites same as in forceps delivery
3. Electronic fetal heart monitoring
Technique
1. Center of cup placed over sagittal suture 3cm in front of 4. Breech presentation
posterior fontanelles
5. Decreased forceps and vacuum deliveries
 Subject: Obstetrics 2
Topic: Operative Obstetrics
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6. Rise in rates of labor induction  ADVANTAGE: cosmetic

7. Obesity  DISADVANTAGES:

8. Malpractice litigation o Exposure is not optimal

9. Concern over pelvic floor injury o In repeat surgery, re-entry is more difficult and
time-consuming (more prone to adhesion)
Indications
 Repeat Caesarian section – most common 2. Vertical incision

 Dystocia or failure to progress in labor  ADVANTAGES

 Breech presentation o Extent of exposure

 Concern in fetal well being o Re-entry is easier

Methods to Decrease CS rates o Better healing

 Educating physicians
 DISADVANTAGES
 Peer reviewing
o Cosmetic
 Encourage trial of labor after one transverse CS delivery
o Adhesion is not common
 Restrict CS for dystocia only to those who strictly meet the
defined criteria B. Uterine incisions
1. Kerr incision - low transverse incision above the
Maternal Mortality and Morbidity
 Maternal death – rare vesicouterine fold; most common

 Morbidity  ADVANTAGES:

1. Puerperal infection – most common o easier to repair

2. Hemorrhage o less likely to rupture

3. Thromboembolism o does not promote adhesion of bowel or

omentum at the incisional line
4. Re-hospitalization
 DISADVANTAGES

CS by Choice o extension to uterine arteries

 Controversial
o adhesion to the bladder
 Avoidance of pelvic floor injury during vaginal birth
2. Classical incision- vertical incision over the anterior
 Reduction in fetal injury part of the uterus, from the fundus to just above the
bladder.
 Convenience  ADVANTAGES:

 Ethical to accede to an informed patient’s request for o bigger exposure

elective CS
o faster delivery of the baby
Techniques/Incisions
A. Abdominal Incision – incision on the skin  DISADVANTAGES
1. Horizontal/Pfannensteil incision
o more prone to uterine rupture
 aka “bikini incision”
 Subject: Obstetrics 2
Topic: Operative Obstetrics
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o more bloody a. Uterine atony – most common
b. Laceration of major uterine vessels
 Kronig incision- c. Bleeding associated with uterine incision or placental
implantation
o modified classical incision in the lower uterine 2. Placenta accrete
3. Large myoma
segment. 4. Severe cervical dysplasia or CIS
o Easy to repair Complications:
A. Increased blood loss (>3L)
o Less likely to rupture B. urinary tract injury
C. Morbidity associated with an emergency procedure is
o Does not promote adhesion of bowel or increased compared to an elective hysterectomy.
omentum to incisional line D. 90% undergoing emergency hysterectomy required
transfusion.
Indications for classical CS
Peripartum Management for CS and CS Hysterectomy
1. lower uterine segment cannot be exposed due to:  recheck Hct; prepare blood if necessary
 bladder densely adherent  NPO for at least 8 hours
 Sedative
 myoma in LUS  Antacid – 30 mL before anesthesia
 Shaving
 invasive carcinoma of the cervix  IV fluids
o 1500 mL – usual blood loss in elective surgery
2. transverse lie of the a large fetus, especially if the shoulder  Prevention of post-operative infection
is impacted in the birth canal o 2g dose of B-lactam drug after delivery of infant
3. placenta previa with anterior implantation  Recovery room
4. very small fetuses, breech presentation and lower segment o Vital signs
has not thinned out
o Amount of bleeding from vagina
5. massive maternal obesity precluding safe access to LUS
o Pain relief
6. more useful in the following:
 Malpresentation Subsequent Care
 multiple fetuses 1. Analgesia
 premature (not in labor) 2. Vital Signs – hourly for the first 24 hours then every 4 hours
minimum for the first 24 hours
3. T- incision 3. 3L of fluid for the first 24 hours are adequate, unless urine
 Least strong, prone to rupture output falls below 30 ml/hr
4. Remove the bladder catheter after 12 hours.
5. If uncomplicated, may start diet 8 hours after surgery
Techniques/ Steps in CS 6. Ambulation – the day after surgery to prevent venous
1. Uterine incisions thrombosis and pulmonary embolism
7. Laboratory – repeat Hct a day after surgery
2. BOW rupture
8. Breast care – breastfeeding starts the day after surgery
3. Head is scooped with one hand
4. Head is delivered followed by the rest of the fetal body 9. Hospital discharge – 3rd or 4th postpartum day
5. Cord is doubly clamped and cut in between
6. The placenta is manually extracted and delivered. The
uterus is inspected for retained placenta fragments
7. Uterus is repaired in the 3 layers ( it depends on the OB-
either 1, 2, 3). Check for bleeders.
8. Ovaries and the fallopian tubes are inspected
9. The abdomen is closed in the layers. (the schedule of CS is
around 39 weeks)

POSTMORTEM CS
Caesarian delivery is performed on a woman who has just died
or is expected to die momentarily.

PERIPARTUM HYSTERECTOMY
Indications:
1. Arrest hemorrhage