Operative Vaginal Delivery (OVD)

• Deliveries that require assistance in delivering the baby are referred to as Operative Vaginal Delivery (OVD) and include vacuum extraction and forceps delivery and are required in the event of dysfunction of the 5 P's of labor.

OVD Indications

• Prolonged second stage of labor
• Ineffective maternal pushing
• Excessive regional anesthesia
• Delayed or arrested second stage of labor
• Fetal distress
• Maternal compromise

OVD Requirements

• Maternal consent
• Skilled physician
• Ability to perform cesarean prn
• Fully dilated cervix
• Engaged fetal head
• Empty maternal bladder
• Adequate anesthesia

Vacuum Extraction

• A soft suction cup is applied to the fetal occiput.
• Suction is applied with each contraction.
• Vacuum extraction has fewer maternal side effects.
• Vacuum extraction may cause subgaleal hematoma and scalp lacerations in the fetus.
• Protocols should be followed carefully.
• Increased risk of perineal tear.

Forceps Assisted Birth

• Metal blades shaped to fit on either side of the fetal head are used.
• Blades are then interlocked and gentle traction is applied.
• May be used for rotation and descent.
• There is an increased risk of maternal injury with forceps delivery.
• Hard pressure should not be applied because it can cause nerve damage.
• Increased risk of perineal tear.
• Increased risk of infection, so prophylactic antibiotics are administered.

Risks of Cesarean Birth

• Risks of cesarean birth include:
  • Immediate risks include less early contact with newborn, emergency hysterectomy, thromboembolism and CVA, surgical injury, hemorrhage, infection, incidental surgical injuries, and extended hospitalization.
  • Delayed risks include poor overall mental health and self-esteem, chronic pain and bowel obstruction, readmission, pain, adhesions, abnormal placentation with future pregnancy, and uterine rupture with future pregnancy.

Risks for Newborn

• Risks for the newborn include:
  • Neonatal death
  • Respiratory difficulties, such as TTN and RDS, which may require placing the newborn on their tummy to drain fluid if they are not crying
  • Asthma in childhood and adulthood
  • Iatrogenic prematurity
  • Surgical injuries
  • Failure to breastfeed

Cesarean Birth: Indications

• Cesarean birth may be indicated for maternal or fetal reasons:
  • Maternal indications include CPD (cephalopelvic disproportion), active infection, previous cesarean, failure to progress, and placenta previa.
  • Fetal indications include non-reassuring fetal status, abnormal lie/presentation, macrosomia, multiple gestation, and cord prolapse.
  • Maternal request

Cesarean Birth: Classical

• Classical cesarean birth involves a vertical incision through the uterus.
• More rapid birth can be achieved with a classical incision.
• There is a higher likelihood of uterine rupture in subsequent pregnancies with a classical incision.

Low Transverse Incision

• The low transverse incision allows for future TOL (trial of labor)/VBAC (vaginal birth after cesarean).
• There is less blood loss with the low transverse incision.
• There is a reduced risk of GI complications and postpartum infection with this approach.

Preoperative Care

• Essential teaching
• Informed consent (by doctor)
• Hair clip (no shaving)
• IV, pre-op labs
• Pre-op meds
• Jewelry/metal removal
• Foley catheter insertion
• SCDs or TED hose application
• Support person present

Post Op Care

• Assess ABCs
• Vital signs q 15 min x 1-2 hours
• Temp hourly and prn
• Assess incision, fundus, vaginal bleeding with vital signs
• I&O
• Managing N/V (nausea & vomiting)
• SCDs, TED hose
• Assess and treat pain
• Facilitate bonding and breastfeeding

VBAC

• VBAC may be attempted if:
  • The fetus is in the vertex position
  • The fetus is not macrosomic.
  • Original reason for C/S is not present in current pregnancy
  • The woman is healthy

VBAC Risks

• Uterine rupture
• Complications of vaginal birth

VBAC Contraindications

• 2 previous C/S without ever having delivered vaginally
• 3 previous C/S
• Any scarring above the lower uterine segment, uterine anomalies
• Previous uterine rupture
• Multiple pregnancy
• Maternal DM or HTN

Operative Vaginal Delivery (OVD) includes vacuum extraction and forceps delivery and is required in the event of dysfunction of the 5 P's of labor. Indications for OVD include prolonged second stage of labor, ineffective maternal pushing, fetal distress or maternal compromise. Requirements include maternal consent, skilled physician, fully dilated cervix and engaged fetal head.