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Questions and Answers
What are the two types of assisted vaginal delivery?
What are the two types of assisted vaginal delivery?
Forceps and vacuum delivery
What are some procedures discussed in the objectives? (Select all that apply)
What are some procedures discussed in the objectives? (Select all that apply)
Assisted vaginal delivery is a skill used to manage the first stage of labor.
Assisted vaginal delivery is a skill used to manage the first stage of labor.
False
What are some examples of Vacuum Extractors? (Select all that apply)
What are some examples of Vacuum Extractors? (Select all that apply)
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What are some examples of Forceps? (Select all that apply)
What are some examples of Forceps? (Select all that apply)
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How long is the second stage of labor for a nullipara using a regional anesthetic?
How long is the second stage of labor for a nullipara using a regional anesthetic?
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How long is the second stage of labor for a multipara without a regional anesthetic?
How long is the second stage of labor for a multipara without a regional anesthetic?
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What are some maternal indications for assisted vaginal delivery? (Select all that apply)
What are some maternal indications for assisted vaginal delivery? (Select all that apply)
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What are some pre-requisites for instrument use for assisted vaginal delivery? (Select all that apply)
What are some pre-requisites for instrument use for assisted vaginal delivery? (Select all that apply)
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Passage of the biparietal diameter (BPD) through the pelvic inlet is not considered engagement in assisted vaginal delivery.
Passage of the biparietal diameter (BPD) through the pelvic inlet is not considered engagement in assisted vaginal delivery.
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What is the classification of assisted vaginal delivery where the fetal skull is on the pelvic floor?
What is the classification of assisted vaginal delivery where the fetal skull is on the pelvic floor?
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What is the classification of assisted vaginal delivery where the fetal skull is at, or below, the + 2 station?
What is the classification of assisted vaginal delivery where the fetal skull is at, or below, the + 2 station?
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What is the classification of assisted vaginal delivery where the fetal head is engaged but above the + 2 station?
What is the classification of assisted vaginal delivery where the fetal head is engaged but above the + 2 station?
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What are some advantages to using the Vacuum for assisted vaginal delivery? (Select all that apply)
What are some advantages to using the Vacuum for assisted vaginal delivery? (Select all that apply)
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Which type of assisted vaginal delivery has the lowest risk of severe birth trauma?
Which type of assisted vaginal delivery has the lowest risk of severe birth trauma?
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Vacuum application must be done with a full bladder
Vacuum application must be done with a full bladder
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Match the following components of Vacuum Application with their descriptions:
Match the following components of Vacuum Application with their descriptions:
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Gentle traction with the vacuum extractor should be done at right angles to the plane of the cup.
Gentle traction with the vacuum extractor should be done at right angles to the plane of the cup.
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Vacuum traction should only be applied during contractions.
Vacuum traction should only be applied during contractions.
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Rotary force or paramedian application of the vacuum extractor should be used to help with delivery.
Rotary force or paramedian application of the vacuum extractor should be used to help with delivery.
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A vacuum procedure should be halted if there is disengagement of the cup three separate times.
A vacuum procedure should be halted if there is disengagement of the cup three separate times.
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A vacuum procedure should be halted if there is no progress after three consecutive pulls.
A vacuum procedure should be halted if there is no progress after three consecutive pulls.
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What is the maximum time a vacuum can be applied for?
What is the maximum time a vacuum can be applied for?
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An episiotomy is not necessary when a vacuum extractor is used.
An episiotomy is not necessary when a vacuum extractor is used.
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The vacuum can be removed when the jaw is reachable.
The vacuum can be removed when the jaw is reachable.
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Which of the following statements is true about the advantages of the Vacuum? (Select all that apply).
Which of the following statements is true about the advantages of the Vacuum? (Select all that apply).
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Which of the following are potential complications for vacuum delivery? (Select all that apply).
Which of the following are potential complications for vacuum delivery? (Select all that apply).
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Which of the following are contraindications for vacuum delivery? (Select all that apply).
Which of the following are contraindications for vacuum delivery? (Select all that apply).
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Scalp emphysema, caput formation, and cephalohematoma are all potential signs of birth trauma.
Scalp emphysema, caput formation, and cephalohematoma are all potential signs of birth trauma.
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What are some things to document in the vacuum operative note? (Select all that apply).
What are some things to document in the vacuum operative note? (Select all that apply).
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Forceps application should be undertaken with a full bladder.
Forceps application should be undertaken with a full bladder.
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Match the following components of Forceps Application with their descriptions:
Match the following components of Forceps Application with their descriptions:
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The handle of the forceps should be elevated vertically while pulling.
The handle of the forceps should be elevated vertically while pulling.
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An episiotomy is always required for forceps delivery.
An episiotomy is always required for forceps delivery.
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The forceps should be removed when the jaw is reachable.
The forceps should be removed when the jaw is reachable.
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What are some potential complications of forceps delivery? (Select all that apply)
What are some potential complications of forceps delivery? (Select all that apply)
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Forceps marks on the baby's head are considered a serious complication.
Forceps marks on the baby's head are considered a serious complication.
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Which of the following statements is true about preventing complications from assisted vaginal delivery? (Select all that apply).
Which of the following statements is true about preventing complications from assisted vaginal delivery? (Select all that apply).
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About 10% of vaginal deliveries require assisted delivery.
About 10% of vaginal deliveries require assisted delivery.
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The A-J mnemonic provides a systematic approach to assisted vaginal delivery.
The A-J mnemonic provides a systematic approach to assisted vaginal delivery.
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Providers should be aware of complications and contraindications for both procedures.
Providers should be aware of complications and contraindications for both procedures.
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Study Notes
Assisted Vaginal Delivery
- Assisted vaginal delivery is a crucial skill for managing the second stage of labor
- All maternity care providers must have the knowledge and skills to use vacuum or forceps in emergency situations
Objectives
- Discuss indications and prerequisites for vacuum and forceps use
- Discuss pelvic landmarks and define instrument procedures
- Demonstrate proper use of equipment on a maternal-fetal mannequin
Introduction
- Assisted vaginal delivery is important for managing the second stage of labor
- All maternity care providers should have the knowledge and skills to use vacuum or forceps in emergencies
Instruments
-
Vacuum Extractors:
- Malmstrom: historical, rigid metal cup
- Soft plastic cup: instrument of choice in most situations
- Rigid cup: for posterior or asynclitism
-
Forceps:
- Simpson: all-purpose, suitable for large, molded heads
- Piper, Elliot, Kielland: special indications
Prolonged Second Stage
- Nullipara: without regional anesthetic = two hours, with regional anesthetic = three hours
- Multipara: without regional anesthetic = one hour, with regional anesthetic = two hours
Maternal Indications
- Maternal exhaustion
- Drug-induced analgesia
- Soft tissue resistance with failure to descend
- Maternal illness (e.g., cardio-respiratory, intracranial)
- Hemorrhage
Fetal Indications
- Fetal compromise needing immediate delivery in the second stage
- Non-reassuring FHR tracing
Prerequisites for Instrument Use
- Vertex presentation
- Complete dilation of cervix
- Rupture of membranes
- No known cephalopelvic disproportion
- Willingness to abandon procedure if necessary
Engagement
- Passage of the BPD (biparietal diameter) through the pelvic inlet
- Leading edge of the fetal skull at or below the ischial spines
Classification of Assisted Deliveries
- Outlet forceps or vacuum: Fetal skull on pelvic floor; scalp visible between contractions
- Low forceps or vacuum: Fetal skull at or below +2 station
- Mid forceps or vacuum: Head engaged but above +2 station
Vacuum
- Often the instrument of preference
- Rivals forceps in safety and efficacy
- Soft cups minimize maternal and fetal trauma
- Rigid flat cups for occiput posterior or asynclitism
Incidence of Severe Birth Trauma
- Lowest risk: Normal Spontaneous Vaginal Delivery (NSVD)
- Intermediate risk: Delivery by forceps or vacuum alone or by cesarean section
- Highest risk: Delivery with combined forceps and vacuum extraction or cesarean following failed operative vaginal delivery
Vacuum Application
- A: Ask for help and ensure anesthesia is adequate
- B: Ensure bladder is empty
- C: Ensure cervix is fully dilated
- D: Determine fetal position; ensure molding position is favorable, consider shoulder dystocia. Posterior fontanel: smaller, forms a Y. Anterior fontanel: larger, forms a cross. Assess for bend in ear. Molding makes assessment difficult.
- E: Equipment and extractor are ready
- F: "Flexion point" - proper application results in flexion of fetal head when traction is applied. Check for maternal tissue before and after applying vacuum
- G: Gentle traction at right angles to the plane of the cup. Only during contractions. Bend, rotary force, or paramedian application will cause detachment
- H: Halt traction after each contraction. Reduce pressure between contractions, disengagement of cup 3 times = Stop procedure. No progress in three consecutive pulls = stop procedure. Total application duration should not exceed 20 minutes
- I: Evaluate for incision (episiotomy) when the head is being delivered. Not necessary for vacuum, but may be necessary for shoulder dystocia or difficult delivery
- J: Remove vacuum when jaw is reachable
Vacuum Contraindications
- Severe prematurity
- Breech, face, or brow presentation
- Transverse lie
- Incomplete cervical dilation
- Unengaged head
- Delivery requiring excessive traction
Post-Vacuum Care
- Cervix and vaginal exam
- Evidence of birth trauma (e.g., scalp emphysema, caput formation, cephalohematoma, hyperbilirubinemia, subgaleal hematoma)
Vacuum Operative Note
- Preoperative diagnosis
- Postoperative diagnosis
- Operation
- History
- First stage
- Second stage
- Third stage
- Procedure
Forceps Application
-
A: Ask for help, ensure anesthesia is adequate
-
B: Ensure bladder is empty
-
C: Ensure cervix is fully dilated
-
D: Determine fetal head position, consider shoulder dystocia
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E: Equipment is ready
-
F: Forceps are ready
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Apply to left side of mother's pelvis, in a cephalic curve towards the vulva.
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Shank vertical at start. Apply to left side of fetal head using right hand to protect maternal tissue and apply force. Repeat for right side. Articulate handles and lock.
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Gently traction using Pajot's maneuver. Axis traction follows pelvic curve, initial traction downward, sweeping in a large J-shaped arc. Non-dominant hand exerts downward traction causing horizontal outward and vertical downward vectors of force.
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Position for safety; posterior fontanel midway between shanks; 1cm above shanks. Fenestrations admit no more than one fingertip. Sutures: lambdoidal above and equidistant from upper surface of each blade; sagittal is midline
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Handle forceps vertically along J-shaped pelvic curve
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Evaluate for incision (episiotomy)
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Remove forceps when jaw is reachable.
Post-Forceps Care
- Cervical and vaginal exam
- Evidence of birth trauma (e.g., fractured clavicle, cephalohematoma, lacerations, facial nerve palsy)
- Forceps marks are normal and benign
Complications
- Fetal trauma
- Genital tract trauma
Prevention
- Upright or lateral position during labor to avoid prolonged second stage.
- Support person associated reduces labor length and likelihood of operative vaginal delivery
- Nulliparas with epidurals may benefit from oxytocin augmentation in second stage.
Summary
- About 5% of vaginal deliveries require operative assistance
- All maternity care providers must be familiar with instruments and techniques.
- A → J mnemonic provides a systematic method for assisted delivery.
- Providers must be aware of complications and contraindications.
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Description
This quiz covers the essential skills required for assisted vaginal delivery, focusing on the use of vacuum extractors and forceps in maternity care. Participants will learn about the indications, equipment, and procedures necessary for safe interventions during the second stage of labor. The importance of these skills for maternity care providers in emergency situations is emphasized.
