ASSISTED DELIVERY

I. Preventing assisted delivery

  1. Any upright or lateral position (vs. supine or lithotomy positions) ass'd with reduced incidence of assisted deliveries (as well as shorter second stage but increase in 2nd-degree perineal tears) (Cochrane review, cited in 2002 ALSO syllabus; see below)
  2. Presence of a support person reduces likelihood of assisted delivery
  3. Waiting to push in stage 2 until mom has the urge, to avoid maternal exhaustion

II. Indications for assisted delivery:

  1. Maternal indications
    1. Prolonged second stage (see Labor Progress and Dystocia for normal durations) due to any of the following:
      1. Maternal exhaustion & inability to push--Note that augmentation might be an alternative to assisted delivery in such situations
      2. Reduced maternal expulsive efforts due to epidural analgesia
      3. Failure to descend due to soft tissue resistance
    2. Maternal illness for which pushing is hazardous, e.g. cardiovascular or intracranial disease
    3. Hemorrhage
  2. Maternal-fetal indications
    1. Relative bony fetal-pelvic disproportion
    2. Malposition esp. OP or OT
    3. Malpresentations (forceps only for face presentation)
  3. Fetal indications
    1. Any condition which makes it unsafe for fetus to remain in uterus during second stage
    2. Non-reassuring fetal heart rate tracing

III. Prerequisites to assisted delivery:

  1. Vertex presentation
  2. Cervix completely dilated
  3. Membranes ruptured
  4. No suspected severe cephalopelvic disproportion
  5. Engagement (leading edge of skull past ischial spines, implying that bi-parietal diameter is at or past pelvic inlet)

IV. Classification of assisted delivery

  1. "Outlet" = Scalp is visible between contractions; sagittal suture is in AP diameter, not more than 45' from midline (i.e., not OT)
  2. "Low" = Leading edge of fetal skull is +2cm station or more
  3. "Mid" = Head is engaged but leading edge of fetal skull is above +2cm station

V. Vacuum extraction

  1. Options include soft plastic (MityVac, Columbia, Kiwi) vs. metal cup (Malmstrom)--NOTE--Do NOT use non-metal vacuum devices to rotated fetus!  Can lacerate scalp.
  2. May be associated with serious complications including subgaleal hematoma (outside skull periosteum, can result in hypovolemic shock) and intracranial hemorrhage; also minor complications including cephalhematomas and, if scalp electrode was present, scalp emphysema
  3. Contraindications to use of vaccum:
    1. Prematurity (esp. < 34wks)
    2. Delivery requiring excessive traction
    3. Absence of prerequisites listed above
  4. MNEMONIC FOR VACCUM EXTRACTION:

Ask for help, Advise patient, consider Anesthesia

Bladder empty

Cervix-make sure completely dilated

Determine position and consider risk of shoulder Dystocia

Equipment ready

Fontanelle--Apply vacuum centered at vertex (3cm anterior to
posterior fontanel, i.e. with posterior edge of cup on fontanel);
sweep w/Finger to makes ure no maternal tissue is trapped beneath the cup)

Gentle traction perpendicular to plane of the cup--Pressure Gauge should
be in Green area when pulling and in yellow area in between contractions

Halt when:

  • Contraction over (unless urgent delivery indicated)
  • If 3 pop-offs
  • If no progress in 3 pulls
  • If > 20 minutes since application of forceps

Incision--Evaluate for (episiotomy); not clear that this is indicated

Jaw--Remove vacuum when jaw is delivered

V. Forceps extraction

  1. Options include Piper, Elliott, Kielland, and Simpson; Simpson are "all-purpose" and taught in the ALSO course
  2. Blades of forceps are named "right" and "left" according to which side of the mother they go on when applied
  3. Can be associated with perineal injury, fetal injury (cephalhematoma, lacerations, abrasions, facial nerve palsy)
  4. MNEMONIC FOR FORCEPS EXTRACTION:

Ask for help, Advise patient, consider Anesthesia

Bladder empty

Cervix-make sure completely dilated

Determine position and consider risk of shoulder Dystocia

Equipment ready

Forceps and soap ready (apply soap to forceps)--Apply left side first.
Think "PFS," "Position for Safety":

  • Posterior fontanel should be midway between shanks, 1cm above
  • Fenestrations of forceps admit no more than a fingertip; otherwise blades aren't
    inserted far enough
  • Sutures--Lambdoidal sutures should be above & equidistant from superior
    surfaces of blades, to ensure that saggital suture is perpendicular to plane of
    the blades

Gentle traction ("Pajot's Maneuver"--One hand pulls longitudinally while
the other presses down on shanks of the forceps)

Handle elevated to vertical, following "J"-shaped curve

Incision--Evaluate for (episiotomy)

Jaw--Remove vacuum when jaw is delivered (remove right side first)

(Sources include 2002 Advanced Life Support in Obstetrics course syllabus; American Academy of Family Physicians)