Obstetrics Delivery Techniques

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Questions and Answers

What is the maximum degree of rotation allowed for outlet forceps if the fetal head is not in the OA position?

45 degrees (correct)

30 degrees

90 degrees

60 degrees

Which of the following is NOT a prerequisite for performing low forceps delivery?

Presence of a fetal coagulopathy (correct)

Completely dilated cervix

Fetal station is ≥+2 cm

Ruptured membranes

What complication is associated with higher fetal station and greater degrees of rotation during operative vaginal delivery (OVD)?

Increased incidence of cervical cancer

Higher rates of perineal lacerations (correct)

Increased fetal heart rate variability

Decreased maternal blood pressure

Which maneuver can help prevent obstetrical anal sphincter injuries (OASIS) during operative vaginal delivery?

Modified Ritgen maneuver Signup and view all the answers

In which scenario would midforceps delivery be indicated?

Fetal station is between 0 and +2 cm Signup and view all the answers

What is the purpose of the Pinard maneuver during a breech delivery?

To facilitate spontaneous knee flexion by applying pressure to the popliteal fossa Signup and view all the answers

Which maneuver involves the application of fingers over the malar prominence for the delivery of the aftercoming head?

Mauriceau-Smellie-Veit maneuver Signup and view all the answers

During the delivery of the arms, what should be done when the wing of the scapula is visible?

Sweep the humerus across the chest Signup and view all the answers

What is the key feature of the delivery technique known as the Bracht maneuver?

Assisting the delivery of the aftercoming head with suprapubic pressure Signup and view all the answers

Which statement correctly describes a consideration during the delivery of the nape of the neck?

Apply suprapubic pressure and avoid over-extension Signup and view all the answers

What is the primary purpose of the manual rotation technique during childbirth?

To move the fetal head to a position allowing for successful rotation Signup and view all the answers

Which two curves are designed into forceps to conform to the fetal head and birth canal?

Cephalic and pelvic curves Signup and view all the answers

In a forceps delivery, what should the position of the sagittal suture be relative to the plane of the shanks?

Perpendicular to the plane of the shanks Signup and view all the answers

What should be done to the bladder prior to forceps assistance in delivery?

Ensure it is empty Signup and view all the answers

Which of the following is NOT a pelvic floor disorder?

Retinal hemorrhage Signup and view all the answers

What is the primary implication for choosing to perform a Trial of Operative Vaginal Delivery?

The clinical assessment suggests a successful outcome. Signup and view all the answers

Which type of forceps is described as having a fenestrated blade and a wide shank?

Simpson forceps Signup and view all the answers

What is a key action that must be taken once the forceps are in place?

Apply gentle traction in alignment with contractions Signup and view all the answers

What complication is commonly associated with vacuum extraction delivery?

Scalp lacerations Signup and view all the answers

Which type of forceps is specifically used to facilitate rotation from occiput posterior to occiput anterior positions?

Kielland forceps Signup and view all the answers

Which component of the forceps is responsible for holding them together?

Lock Signup and view all the answers

What is a contraindication for using forceps during delivery?

Persistent occiput posterior presentation Signup and view all the answers

What is the purpose of performing an episiotomy during a forceps delivery?

To avoid tearing and facilitate easier delivery Signup and view all the answers

What is a key feature of the Bill axis traction device?

Indicates traction along the path of least resistance Signup and view all the answers

Which lock type is found at the end of the shank nearest to the handles of a forceps?

English lock Signup and view all the answers

Which condition would most likely lead to the failure of an operative vaginal delivery after an attempt?

Birthweight exceeding 4000 g Signup and view all the answers

What is a primary advantage of using vacuum extraction over forceps?

Easier positioning on the fetal head Signup and view all the answers

Which option describes a disadvantage of vacuum extraction?

Higher chance of scalp laceration Signup and view all the answers

Which condition must be met before vacuum extraction can be performed?

The cervix must be fully dilated Signup and view all the answers

What is the purpose of positioning the vacuum cup over the posterior fontanelle?

To minimize the risk of cup detachment Signup and view all the answers

How frequently should vacuum pressure be increased during the procedure?

Every 2 minutes Signup and view all the answers

What is a necessary condition for the vacuum extraction technique regarding fetal age?

Must be at least 34 weeks Signup and view all the answers

What is the recommended initial pressure to start with during vacuum extraction?

100 mm Hg Signup and view all the answers

Which type of forceps is best suited for delivering a fetus with a rounded head in multiparous women?

Tucker-McLane forceps Signup and view all the answers

Study Notes

Delivery of Legs

Pinard's maneuver is used to help deliver legs.
This involves a lateral rotation of the thighs and flexion of the knees.
The maneuver also keeps the sacrum anterior.

Delivery of Arms

The delivery of the arms begins when the wing of the scapula is seen.
Rotate each arm to an anterior position.
The Loveset maneuver can be used to deliver the arms.
This maneuver involves sweeping the humerus across the chest and then delivering the arm.

Nape of Neck

When presenting the fetus, make sure the nape of the neck is positioned on the arm opposite your delivering hand
Apply suprapubic pressure and be careful to avoid over-extending the fetus.

Delivery of Aftercoming Head

The Mauriceau-Smellie-Veit maneuver can be used to deliver the aftercoming head.
This involves using the second and third fingers to apply pressure over the malar prominence, keeping the baby's nape nestled in your palm.
It is possible to use Piper's forceps during this maneuver, depending on the situation.

Inspection

After delivery, inspect the baby for any signs of fractures or injuries.
You should also inspect the birth canal for any lacerations.

Documentation

Documented all relevant details regarding the delivery.

Delivery Technique in Breech Delivery

Many techniques can be used
Some techniques may be used together.
They may be used sequentially.

Pinard Maneuver

This technique is used to facilitate the transition from a frank breech to a footling breech.
Pressure is applied to the popliteal fossa, which prompts spontaneous knee flexion.

Bickenbach and Løvset's Maneuvers

Can help with nuchal arm delivery or reduction.

Bracht Maneuver

This technique assists with the delivery of the aftercoming fetal head.
It involves applying suprapubic pressure to encourage the baby's head to come out.

Mauriceau Maneuver

This is frequently used to deliver the aftercoming head.
Involves placing the index and middle fingers of one hand over the baby's maxillary prominence to flex the head while the body of the fetus rests on the other hand.
Rotation of the head to OA position can be performed before traction.

Operative Vaginal Delivery Prerequisites and Classification According to Station and Rotation

OVD is categorized into three categories depending on the station of the fetus and rotation of the head.
The procedures differ in their prerequisites and criteria for application.

Outlet Forceps

This OVD involves using forceps to deliver the fetus when the head is visible at the introitus without separating the labia.
The fetal head should be at or on the perineum.
The head must be in the OA or OP position.
The head can be in the right or left OA or OP position, but rotation must be les than 45 degrees.
The prerequisites for this procedure include an estimated fetal weight, known fetal position, engaged head, and no suspected CPD.

Low Forceps

Low forceps are used when the fetal station is ≥+2 cm, but not on the pelvic floor.
Rotation of the head can be ≤45 degrees or >45 degrees, depending on the specific type of low forceps used.
Prerequisites include an experienced operator, ruptured membranes, fully dilated cervix, adequate anesthesia, and an emptied maternal bladder.

Midforceps

Midforceps are used when the station is between 0 and +2 cm.
Prerequisites for midforceps include no fetal coagulopathy, no fetal demineralization disorder, informed consent completed, and willingness to abandon OVD (operative vaginal delivery).

Operative Vaginal Delivery (OVD)

Higher station and greater degrees of rotation create greater difficulty and increase the chance of injuries for the procedure.
Morbidity rates for operative vaginal deliveries are the same as Cesarean sections (CS).

Lacerations

OVD has higher rates of third- and fourth-degree perineal lacerations (obstetrical anal sphincter injuries (OASIS)), vaginal wall lacerations, and cervical tears.
To prevent OASI, clinicians use various methods, including indicated episiotomy, early forceps disarticulation and removal, cessation of maternal pushing during disarticulation or as the head begins to crown, a dedicated assistant to bolster the perineum, manual or forceps rotation to an OA position (modified Ritgen maneuver).

Pelvic Floor Disorders

OVD can lead to pelvic floor disorders like urinary incontinence, anal incontinence, and pelvic organ prolapse (POP).
These problems are commonly due to structural compromise or pelvic floor denervation.

Infection

OVD can result in puerperal infection rates of 11% with a single intravenous dose of amoxicillin plus clavulanic acid.
This is especially true for cases of third- and fourth-degree perineal lacerations.

Acute Perinatal Injury

Vacuum extraction can lead to acute perinatal injuries, including cephalohematoma, subgaleal hemorrhage, retinal hemorrhage, neonatal jaundice, clavicular fracture, and scalp lacerations.
Forceps delivery can cause facial nerve injury, brachial plexus injury, depressed skull fracture, and corneal abrasion.

Trial of Operative Vaginal Delivery

A trial of operative vaginal delivery is attempted if the clinical assessment suggests a successful outcome, despite anticipated difficulties.
If an OVD attempt is unsuccessful, a Cesarean delivery may be necessary.
Attempts at vacuum or forceps deliveries should be stopped or abandoned if difficulty arises.
Sequential instrumentation, such as attempting vacuum assisted OVD followed by forceps, is generally discouraged unless there is a compelling and justifiable reason.
If the outcome of the trial is unsuccessful (i.e., persistent OP positions or birthweight >4000 g), the patient may require Cesarean delivery.

Bill Axis Traction Device

The Bill axis traction device provides an arrow and indicator line that can help the clinician determine the path of least resistance, ensuring accurate placement of the forceps.

Forceps Delivery

Forceps are a surgical instrument with two crossing branches that are used to grasp the baby's head.
There are four components:
- Blades, which enclose the head and can be fenestrated (with open spaces) or solid.
- Shanks, which connect the blades and handles.
- A lock, which holds the forceps together.
- Handles, which grip the forceps.
There are two curves in the forceps:
- Cephalic curve - conforms to the shape of the fetal head
- Pelvic curve - conforms to the axis of the birth canal.
There are various types of forceps available, each with its own design and intended use.

Types of Forceps

Simpson is a commonly used forceps with a cephalic and pelvic curve.
Tucker-McLane are suitable for rounded heads.
Kielland for deep transverse arrest.
Piper are useful for aftercoming head in breech.
Barton for rotating the head in a transverse arrest.

Forceps Mnemonic AFCD-EG-HIJ

This mnemonic helps illustrate the essential considerations for using forceps during delivery.
A - Anesthesia (adequate pain relief), Assistance (neonatal support)
B - Bladder (empty)
C - Cervix (fully dilated, membranes ruptured)
D - Determine (position, station, and pelvic adequacy)
E - Equipment (inspect vacuum cup, pump, tubing, and check pressure)
F - Forceps (check application, blade positioning, and alignment)
G - Gentle Traction (applied with contraction/expulsive effort)
H - Handle Elevated (traction in axis of birth canal)
I - Incision (consider episiotomy)
J - Jaw (remove forceps when jaw is reachable or delivery assured)

Vacuum Extraction

Vacuum extraction (ventouse) is a delivery method using suction applied via a cup placed on the fetal scalp that helps with delivering the baby.
It is an option when forceps delivery isn't suitable.

Vacuum Pressure

The initial vacuum pressure starts at 0.2 kg/cm² and is increased by 0.2 kg/cm² every 2 minutes up to a maximum of 0.8 kg/cm² (600).

Advantages Over Forceps

Simpler application for precision positioning on the fetal head.
Helps to minimize maternal trauma as the blades do not occupy as much space within the vagina.

Disadvantages

Vacuum extraction has a higher risk of scalp lacerations.

Criteria for Vacuum Extraction

Should not be considered for babies younger than 34 weeks.
It's crucial to ensure the fetal head is correctly positioned.
Fetal scalp blood sampling shouldn't have been performed recently.

Anesthesia

Regional analgesia is commonly used for deliveries at low or midpelvic stations.
Pudendal blockade is an option for outlet deliveries.

Application of the Vacuum Cup

The flexion point or pivot point is located along the sagittal suture, approximately 3 cm from the posterior fontanel's center and 6 cm from the anterior fontanel's center.
This placement maximizes traction, minimizes cup detachment, flexes the neck, and delivers the smallest head diameter through the pelvic outlet.

Vacuum Mnemonic ABCD-EF

This mnemonic outlines the essential considerations for using vacuum extraction during delivery.
A - Anesthesia (adequate pain relief), Assistance (neonatal support)
B - Bladder (empty)
C - Cervix (fully dilated, membranes ruptured)
D - Determine (position, station, and pelvic adequacy)
E - Equipment (inspect vacuum cup, pump, tubing, and check pressure)
F - Fontanelle (position the cup correctly, clear maternal tissue, and manage pressure)

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Description

This quiz explores various techniques used in obstetrics for the delivery of a fetus, focusing on maneuvers such as Pinard's, Loveset, and Mauriceau-Smellie-Veit. Key aspects of leg, arm, and head delivery are covered in detail. Test your knowledge on these critical procedures.