Manisha is a 25 years primigravida in labour. She has spend 1 hr during second stage of labour (after complete dilatation of cervix). Now on examination the leading point of fetal skull is at +2 station and rotation is 45. You can manage this case fuher by -
Basics of Instrumental delivery The criteria for applying low forceps (1) Leading point of fetal skull at station= 2 cm and not on the pelvic floor, (2) Rotation is 45 or less. If the fetal head is at station below this or rotation doesn't exceed 45, then one can apply outlet forceps. Mid forceps are for station above+ 2 cm and high forceps are not applied and considered unsafe It's better to do a 'Safe' caesarean section than to do a 'complicated' high forceps Classification for operative vaginal delivery Outlet Fetal scalp visible without separating the labia Fetal skull has reached the pelvic floor Sagittal suture is in the anterio - posterior diameter or right or left occiput anterior or posterior position (rotation does not exceed 45o) Fetal head is at on the perineum Low Leading point of the skull (not caput) is at station plus 2 cm or more and not on the pelvic floor. Two Subdivisions: Rotation of 45o or less from the occipito - anterior position. Rotation of more than 45o including the occipito - posterior position Mid Fetal head is no more than 1/5th palpable per abdomen Leading point of the skull as is above station plus 2 cm but not above the ischial spines. Two Subdivisions: Rotation of 45o or less from the occipito - anterior position Rotation of more than 45o including the occipito - posterior position. High Not included in the classification as operative vaginal delivery is not recommended in this situation where the head is 2/5th or more palpable abdominally and the presenting pa is above the level of the ischial spines. Indications of Operative delivery: Fetal Indication: Presumed fetal compromise Maternal To shoen and reduce the effects of the second stage Cardiac disease Class III or IV hypeensive crises, myasthenia gravis, spinal cord injury patients at risk of autonomic dysreflexia, proliferative retinopathy Inadequate progress Nulliparous women - lack of continuing progress for 3 hours with regional anaesthesia, or 2 hours without regional anaesthesia Multiparous women - lack of continuing progress for 2 hours with regional anaesthesia, or 1 hour without regional anaesthesia Maternal fatigue/exhaustion Prerequisites for operative vaginal delivery Head is <=1/5th palpable per abdomen Veex presentation Cervix is fully dilated and the membranes ruptured. Assessment of caput and moulding. Pelvis is deemed adequate. Irreducible moulding may indicate cephalo-pelvic dispropoion Although traditional teaching says that vacuum can be applied after 6-7 cms cervical dilatation, Forceps and vacuum extractor deliveries before full dilatation of the cervix are contraindicated. Forceps can be used for the after-coming head of the breech Avoid use of vacuum extraction below 34 weeks +0 days of gestation susceptibility of the preterm infant to cephalohaematoma, intracranial haemorrhage, subgaleal haemorrhage and neonatal jaundice. Higher rates of failure with instrumental delivery are associated with: maternal body mass index over 30 estimated fetal weight over 4000 g or clinically big baby occipito-posterior position mid-cavity delivery or when 1/5th of the head palpable per abdomen. Vacuum extraction compared with forceps is: more likely to fail delivery more likely to be associated with cephalhaematoma more likely to be associated with retinal haemorrhage less likely to be associated with significant maternal perineal and vaginal trauma Forceps and Vacuum have same likelihood of Delivery by caesarean section Associated with low 5-minute Apgar Associated with the need for phototherapy
Applying outlet forceps
Applying low forceps
Applying mid forceps
Applying high forceps
Obstetrics