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Assisted Delivery Introduction: In an assisted vaginal delivery, health care practitioner uses either a vacuum device or forceps to help

today out of the birth canal. Practitioner may recommend this if you have been pushing for a long time and you are completely worn out or if Practitioner is uncomfortable letting baby stay in the birth canal any longer. In other words any delivery process which is assisted by vaginal operations or delivery is done by forceps, ventouse and destructive operations are described as assisted delivery. Types of Assisted delivery: 1. Ventouse 2. Forcep 3. estructive !perations. Ventouse Delivery: It is an instrumental device designed to assist delivery by crating a vacuum between it and the fetal scalp. "he pulling force is dragging the cranium while in forceps, the pulling force is directly transmitted to the base of the s#ull. The Equipments used in Ventouse delivery$ % &uction 'up () si*es + 3,, ),,-, and ., mm /. 0 vacuum Pump. "raction rod device 1 traction tubings. 2odern vacuum e3tractors use an electrical pump, which has sensitive controls. "he vacuum is built up steadily and is maintained efficiently so that the cup is less. 4i#ely to come off. 0 metal or silastic (firm rubber/ cup is applied to the fetal head, a vacuum is created inside the cup, which is connected to the pump by rubber hibing and traction is then applied. Inside the rubber hebing is a metal handle to give the operator a good grip. Indication: 1. It is an alternative to forcep opertaions. 2. elay in descend of the high head in case of the second baby of twins. 3. 2alpostions$ !ccipitolateral and occipitoposterior. ). elay in the second stage of labor or late first stage. -. 2aternal 53haustation .. eep "ransverse arrested with ade6uate pelvis. Contradictions: 1. Fetal distress, where urgent delivery is neede. 2. Face presentation. 3. Prematurity, chance of scalp avulsion or sub%oponeurotic hemorrhage. ). Fetal bleeding disorder. Advantages of Ventouse over forceps 1. It can be used in unrotaed and malrotated occipito%positioner position of the head. Advantages of forceps over Ventouse 1. In suspected pelvic contraction, where moderate traction is re6uired, ventouse will be ineffective.

2. It can be applied even through 2. Forceps operations can 6uic#ly e3pedite the delivery incompletely dilated cervi3 (first stage of in case of fetal distress where Ventouse will be

3. ). -. .. 8.

labor./ It is not a space occupying device li#e the forceps blades. 4esser traction force is needed (1, #g/. It can be used safely even when the head remains at a high level and e3act position is unsure. It is comfortable and in7uries to the mother are less. Fetal complications are less.

unsuitable as it ta#es longer time. 3. it is safer in premahire baby. "he fetal head remains inside the protective cage. -. It can be employed in entire face or in after coming head of breech. .. 'ephalhaematoma is less compared to ventouse. 9. &implicity of the instrument,less costly and handy.

:. ;e6uires less technical s#ill (suitable for :. 4ess failure rate compared to ventouse. trained midwise/

C !DITI !" T #E $%&$I&&ED$% "here should not be slightest bony resistance below the head. "he head of a singleton baby should be engaged. 'ervi3 should be at least . cm dilated (preferably only cervical rim may be left behind/ The 'reminaries: % 1. "he operat-or must be completely familiar with the techni6ue appropriate to the particular cup design. 2. 2idwife must sure that the women is positioned well and prepared for forceps delivery. 3. "he position of the fetal head is determined and an appropriate si*e and type of cup selected accordingly. ). Pudental bloc# or perineal infilteration with one percent lignocaine is done. -. "he instrument should be assembled and the vacuum should be tested prior to its application. 'rocedure$ % a/ "tep -() Application of cup$ % "he cup is introduced after retraction of the perineum with two fingers of the hand. "he cup is placed against the fetal head nearer to the occiput. "his will facilitate fle3ion of the head. 0 vacuum of ,.2 #g1cm 2 is induced by hand pump slowly, ta#ing at least two minutes. 0 chec# is made with fingers around the cup to ensure that no crucial or vaginal tissue is trapped inside the cup. "he pressure is gradually raised at the rate of ,.1 #g1cm 2 Per minute until the effective vacuum of ,.9 #g1cm2 is reached in about 1, minutes time. "he scalp is suc#ed into the cup and artificial.caput succedaneum (chigon/ is produced. "he chigon usually disappears within few years. b/ "tep *) Traction$% "raction is e3erted using one hand in the direction of the curve of carus. "raction must be at right angles to the cup and synchronous with the uterine contractions while applying traction fingers of the other hand are to be placed against the cup to note the correct angle of traction, rotation and advancement of the head. It is usually ta#es longer than forceps delivery. If there is no advancement during four successive uterine contractions, it should be abandoned. 0s soon as the head is delivered, the vacuum is reduced by opening the screw release value and the cup is then detached. "he delivery is then completed in the normal manner. &ilicon rubber cups (silc cups/ are applied over the contour of the fetal head. "hey could be folded and introduced into the vagina before meing placed over the fetal head. Complications: In $etal: &loughing of the scalf. 'ephalhematoma.

'erebral trauma, such as tentorial tear. Chignon $% "his is an area of edema and brusing where the cup was applied, all babies delivered by ventouse will have a chignon. "hese normally subside uneventfully, but may occasionally become infected. In +aternal $ % "rauma to the mother is rare. In7uries may occur due to inclusion of the soft issues such as the cervi3 or vaginal wall inside the cup. $ailure$ % 0n attempted vacuum e3traction may be unsuccessful. 53erting too much traction will result in the cup coming off. *. $orceps Delivery:- Forceps delivery is a means of e3tracting the fetus with the aid of obstetric Forceps when it is inaduisable or impossible for the mother to complete the delivery by her own efforts. #asic Construction of the $orceps : !bstetric forceps consist of two seprate blades each with a handle. 5ach blade is mar#ed <4=(left/ or <;= (right/. "hey are inserted separately on either side of the fetal head and loc#ed together by 5nglish or &mellie loc#. "he blades ar spoon shaped to accommodate the fetal hear and fenestrated to minimi*e trauma and for lightness. "he spoon shape of the blade is called the cephalic curve. >hen the blades are articulated it holds the fetal head. "he blades are attached to the handle at an angle, which corresponds to the curve of carus (curue on the a3is of birth canal/. "his is termed as the peluic curve of the blade. >hen the blades are correctly placed on the fetal head, the handles will be neatly aligned. Types of bstetric $orceps :"here are three varities of Forceps are commonly used $ 4ong%curved Forceps with or without a3is traction device. &hort%curved Forceps. ?ielland=s Forceps. 1. &ong-curved btetric $orceps$ % In India as=s variety of Forceps is commonly used. It is comparatively lighter and slightly shorter than its western counter part. Its measurements are, length is 38 cm, distance between the tips is 2.- cm and widest diameter between the blades : cm. blades are named left or right an relation to the maternal consist of the following parts$% @lade &han# 4oc# Aandle with or witout screw. The blade$ % has two curves. "he peluic curve is designed to fit the curve on the a3is of the birth canal (curve of carus/. "he front of the Forceps is the concave side of the BPeluic curveC. "he Bcephalic curveC on the flat surface, which when articulated, grasps the fetal head without compression. The "han,: %It is the part between the blade and the loc# usually measures ..2- cm (2 DC/ . It increases the length of the instrument and facilities loc#ing of the blades outside the vulva. The &oc,$ % "he common methods of articulation consist of a soc#et system located on the shan# at its 7unction with the handle. The -andle$ % "he handles are apposed when the blades are articulated. It measures 12.- cm (-C/. 0 screw may be attached usually at the end (or at the base/ of one blade, commonly left, to #eep the blades in position. 2. "hort curved $orceps ./rigley0s $orceps1 $ % "he instrument is lighter, shorter and stubby handled. It is short due to reduction in the length of the shan#s and handles. It has a mar#ed cephalic curve with a slight pelvic curve. "he instrument is used for very low Forceps deliveries for the after coming head of a breech delivery or at cesarean section. 3. 2ielland0s $orceps$ % it is a long, almost straight (very slight pelvic curve/ obstetric Forceps without any a3is traction device. It has a sliding loc# and it is used when the head is in an occipitoletral or

occipitoposterior position. 0fter the blades are applied, the head is rotaed to an occipito anterior position. "he sliding loc# allows correction of asynclitism. &imitations of 2ielland0s $orceps $ % @ecause of the comple3ity in the techni6ue of its applications, there are chances of in7uries to the vagina or perineum. eep medio%lateral espisiotomy is mandatory. Classifications According to the &evel of the $etal -ead at 3hich the $orceps are applied $% 1. -igh $orceps peration$ % "he application of Forceps on a fetal head where the biparietal diameter has not yet passed the Pelvic brim (non%engaged head/. 'esaream section is preferred to this type of Forceps application. 2. +id $orceps peration$ % It refers to the application of the Forceps where the biparietal diameter has passed the brim of the peluis but not passed the level of ischial spines. 3. &o3 $orceps peration$ % It refers to the application of the Forceps where the biparietal diameter has passed the level of ischial spines. ). utlet $orceps$% "he Forceps are applied on the fetal head lying on the preneum and is visible at the introitus in between contractions. Indications of $orceps perations$ % 1. elay in the second stage due to uterine inertia.1 if the head is on the perineum for 2,%3, min without advancement, then Forceps application may be decided. 2. +aternal Indications li,e$ % a. 2aternal distress. b. Preeclampsia, eclampsia. c. Vaginal birth after cesarean section. d. Aeart disease e. Failure to bear down during the second stage of labor due to regional bloc#s, Paraplegia or psychiatric disturbance 3. $etal Indications li,e$ % 0ppearance of fetal distress in the second stage. 'ord prolapse. 0fter coming head of breech 4ow birth weight baby Postmaturity Intra uterine growth restriction. Prematurity 'rerequisites for forceps Delivery: - "here are certain conditions which must e3ist before forceps delivery can beperformed. 'are of the bladder $ % toprevent harm or in7ury. "he bladder must #ept empty. 0nalyser$ % this is generally by epidural or pundental bloc# plus perineal infilteration of local anaesthetic. Information giving and consent $% the couple must be #ept informed of the course of events and must be involved in the decision ma#ing process. Eeontal resuscitation e6uipment$ %this must be chec#ed and prepared in case it becames necessary. "he cervi3 must be fully dilated and effaced 2embranes must be ruphired. Presentation and position must be suitable to apply the blades correctly to the sides of the head. "he head must be engaged with nopart of the head palpable abdominally. "here should not be appreciable cephalopeluic disproportion. Preparation of the women$% this is the infiltration of the area around the pudendal nerve by local anaesthetic. "he ransvaginal routc is used to locate the ischial spine as the pudendal nerve emerges

from vertebral s2%s) and croses this. 1, ml of local anaesthetic usually 1F lcdocaine is en7ectedinto the region 7ust below the ischial spine. For this procedure, position the women in licthotomy. @oth legs must be placed simultaneously to avoid strain on the women bac# and hips. "he women should be hilted towards the left at an angle of 1-o by the se pillow or a rubber wedge under the matterss to prevent aortocaual occlusion. Procedure of 4ow Forceps !peration $ % 1 "he women=s vulval area is thoroughly cleaned and draped with sterile towels using aseptic techni6ue ."he bledder is emptied usinga straight catheter. 2. 0 vaginal e3amination is performed by the obstetrician to confirm the station and e3act position of the fatel head. 3. 0n episiotomy may be done priorto introduction of the blades or during traction when the perineum becomes brelged and thinned out by the aduanced head. ). "he forceps are identified as left or right by assembling them briefly before proceeding. -. "he left blade is passed gently between the perineum and fatel head with the first two fingers of the operator=s right hand lying alongside the fetal head protecting the maternal tissue. "he tip of the forceps blades slides lightly over the head into the hollow of the sacrum and is then wandered to the left side of the peluices where it should sit alongside the head. .. uring the application stage of the forceps, the women should be given full support and attention by the midwife. 8. "he midwife should monitor the heart rate through out the procedure. 9. 0s soon as the operator is ready and the uterus contracts, the midwife should encourage the women to push. "o supplement her efforts the obstetrician e3erts steady, downward traction on the forceps. "raction should release between contractions. Intermittent tranction is continued in a downward and bac#ward direction until the head comes to the perineum. "he pull is then directed hori*ontally straight towards the operator until the head is almost crowned. "he directionof pull is gradually changed towards the mother=s abdomento deliver the head by e3tension. :. "he blades are removed one after the other, the right one first. 1,. Following the birth of the head,visual procedures are to be followed as in normal delivery li#e intravenous methergine ,.2 mg is to be administered with the delivery of the anterior shoulder. 2anual ;otation of the Fetal head followed by 2id%forceps !peration$ &ome obstetricians prefer to rotate the fatel head manually in cases of occipitoposterior position, as this is li#ely to be less traumatic than instrumental rotation. "he e3act position of the fetal head must be determined. "he obstetrician grapes the head usually by sincipit and rotates it as encouraging fle3ion. In this the blades are introduced as in the low forceps operation. 0n assistant is re6uired to hold the left handle after its introduction. If d3is traction rod is used, this must be already attached to the blade. uring introduction of the right blade, the traction rod must be held forwards otherwise it will prevent loc#ing of the blades.

IFF'G4"I5& IE F!; '5P& !P5;0"I!E$%


ifficulties in the application of blades are caused by incompletely deleted cervi3 and unrotated or non% engaged head. ifficulties in luc#ing are caused by$% 0pplication an unrotated head. Improper insertion of the blade( not for enough in / Failure to depress the handle against the perineum 5nlargement of the cord of fertal parts inside the blades '0G&5& !F F0I4G;5$% "he causes of failure to deliverwith traction are $%

Gndiagnosed occipito% posterior position Faulty cephalic application >rong direction of traction 2ild peluic contraction 'onstriction ring

'!2P4I'0"I!E& !F F!;'5P& !P5;0"I!E$% 1. In the 2other, Immediate $%


53tension of the episiotomy towards rectim or upwards up to the vault of vagina Vaginal lacerations 'ervical tear especially when applied through an incompletely dilated cervi3.. @ruising and trauma to the urethra Postpartum hemorrhage due to trauma or atomic uterus related to prolonged labor or effect of anesthesia &hoc# due to blood loss, prolonged labor and dehydration &epsis due to devitali*ation of local tissues and improper asepsis 2. 4ate 'omplications$% 'hronic low bac#ache due to tension imposed on softened ligaments of lumbosacral or sacroiliac 7oints during lithotomy position Henital prolepses or stress incontinence. 3. In the Infant$%

Immediate
0sphy3ia due to intracranial stress out of prolonged compression Intracranial hemorrhage due to mal% application of the blades. 'ephalhematoma Facial palsy due to damage to facial nerve 0brasions on the soft tissues of the face and forehead by the forceps blade, severe bruising will cause mar#ed 7aundice. "entorial tear from compression of the fetal head by the forceps P;!PAI40'"I' F!;'5P& (545'"IV5/$% It refers to forceps delivery only to shorten the second stage of labor when maternal and fetal complications are anticipated. "he indications are$% 1 5clampsia 2. Aeart disease 3. Previous history of cesarean section ). Postmahirity -. low%birth weight baby .. Patients under epidural anesthesia 8. "o curtail the painful second stage.

"rail Forceps$%
It is a tentative attempts of forceps delivery in a case of suspected mid% pelive contraction. "he procedure is conducted in an operating room #eeping everything ready for cesarean section. It moderate traction leads to completed vaginally. If not cerarean section is done immediately

Failed Forceps$%

>hen a deliberate attempt in vaginal delivery with forceps has failed to e3pedite the process is called failed forceps. 'auses for failed forceps$% Incompletely dilated cervi3 Gnrotated brow or hydrocephalus or fetal ascites. 'onstriction ring 4arge baby with the ahoulders impacted at the brim

20E0H525E"$%
0sses the effect on mother and fetus 2idwife should start IV infusion with - percent de3trose parenteral antibiotic Eurse should chec# the general position of the patient Eurse should chec# vital signs fre6uently and women should be shifted to an e6uipped area to provide proper treatment and prevent further complication. 5&";G'"IV5 !P5;0"I!E&$% "he destructive operations are designed to diminish the bul# of the fetus to facilitate easy delivery through the birth canal. It may occasionally be necessary to destroy the fetus in the interest of saving the mother=s life. "here are four types of operations$%