forceps delivery , vacuum extraction, ventouse extraction, indications and contraindications of forceps delivery, prerequisites for forceps and vacuum delivery, OVD, occipito posterior position, cephalopelvic disproportion, malpresentations. safe forceps delivery, instrumental delivery, chignon formation, vacuum pressure conversions, complications of vacuum delivery, complication of forceps delivery,

1. OPERATIVE VAGINAL
DELIVERY
Dr. M. GOKUL RESHMI.
OBG

2. INTRODUCTION
• Operative deliveries are vaginal deliveries(delivery of fetal head)
accomplished with the use of forceps or a vacuum device.

3. HOW IT WORKS
• Once either is applied to the fetal head, outward traction generates
forces that augment maternal pushing to deliver the fetus vaginally.
• The most important function of both devices is traction.
• Forceps used for rotation (particularly from occiput transverse and
posterior positions), traction , or simple lift out.

4. INCIDENCE
• The incidence of operative vaginal delivery varies widely.
• Ranges from 3 to 5%
• Vacuum is disproportionately selected, and the vacuum-to-forceps
delivery ratio is nearly 5:1.

5. THE OBSTETRIC FORCEPS

6. HISTORY
• Morden obstetric forceps - Peter Chamberlen 17th Century
kept secret for nearly 150 years
and surfaced in 1813.
• Forceps with cephalic
And pelvic curve - Sir James Simpson in 1845.
• Detachable angled traction
rods and traction handle - Milen Murray(1891) &
Neville(1886).

7. HISTORY
• Rotational forceps for DTA - Christian Kielland (1915)
• After coming head of
the breech - Edmund Piper (1929)
• Short light forceps - Wrigley
generous cephalic curve (1935)
• pseudo—fenestrated blades - Luikart (1937)

8. INDICATIONS
Maternal:
•Inadequate expulsive efforts
• Maternal exhaustion (distress)
• Where expulsive efforts (valsalva) are to be avoided (cerebrovascular
diseases, cardiac disease Class III or IV, hypertensive crises, myasthenia
gravis, spinal cord injury patients at risk of autonomic dysreflexia,
proliferative retinopathy)

9. INDICATIONS
Fetal:
• Non-reassuring fetal heart rate: fetal distress (e.g. low birth weight
baby, post-maturity)
• After coming head of breech , OP, OT, Face presentation
mentoanterior.
• Suspicion of fetal compromise

10. INDICATIONS
Others:
• Prolonged second stage of labour (Nullipara > 2 h; multipara > 1 h)
•To cut short the second stage of labour as in severe pre-eclampsia,
cardiac disease, post cesarean pregnancy

11. CONTRAINDICATIONS
Absolute contraindication:
• An ungagged head
• Unknown fetal position
• Malpresentation(brow , mentoposterior)
Relative contraindication:
• Fetal bleeding disorders (thrombocytopenia)
• Maternal HIV
• Cephalopelvic disproportion.

12. PREREQUISITES
Maternal criteria:
• Adequate analgesia
• Lithotomy position
• Bladder empty
• Clinical pelvimetry must be
adequate in dimension and size
to facilitate an atraumatic
delivery .
• Verbal or written consent .

13. LABIAL-PERINEAL BLOCK
• Labial - perineal block for
episiotomy during outlet
forceps/ventouse operation

14. PUDENTAL BLOCK
• A 20 mL syringe with 15 cm (6”) 22
gauge spinal needle and about 20
mL of 1% lignocaine hydrochloride
used for pudendal block .
• The needle is passed into the
vaginal wall on the apex of ischial
spine and thereafter to push a little
to pierce the sacrospinous ligament
just above the ischial spine tip.
• About 10 mL of the solution is
injected. similarly procedure is
repeated on the other side.

15. PREREQUISITES
Fetal criteria:
• Vertex presentation
• Fetal head must be engaged in
pelvis
• Fetal weight estimated
• Position of fetal head must be
known
• Attitude of fetal head and presence
of caput succedaneum and/or
molding should be noted
• No fetal coagulopathy
• No fetal demineralization disorder

16. PREREQUISITES
Uteroplacental criteria:
• Cervix fully dilated
• Membranes ruptured
• No placenta previa

17. PREREQUISITES
Other criteria:
• Experienced operator, trained with the use of the instrument.
• Willingness to abandon OVD in case of failure.
• The capability to perform an emergency cesarean delivery if
required.

18. PREREQUISITES

19. DESCRIPTION AND TYPES OF FORCEPS

20. DESCRIPTION AND TYPES OF FORCEPS
(A) Long-curved with axis traction
device;
(B) The same with attached axis
traction device;
(C) Wrigley’s
(D) Kielland’s

21. DESCRIPTION AND TYPES OF FORCEPS
Name of forceps Level / use Features
Wrigley’s forceps Outlet forceps
Simple liftout
Cesarean section
Short, light forceps
Cephalic and pelvic curves
English lock
Simpson’s forceps
Elliot’s forceps
Low forceps Longer forceps
Cephalic and pelvic curves
English lock
Milne Murray’s forceps Low / mid forceps Axis traction forceps
Has traction rods and handle
Has cephalic , pelvic and perineal
curves
English lock , nut, and screw
Traction along curve of Carus.
Traction forceps

22. DESCRIPTION AND TYPES OF FORCEPS
Name of forceps Level / use Features
Kielland’s forceps Midforceps Cephalic and minimal pelvic curves
Sliding lock
Used in occipitotransverse position
Correct asynclitism
Barton’s forceps Midforceps One blade hinged
Sliding lock
Cephalic curve
Rotational forceps

23. DESCRIPTION AND TYPES OF FORCEPS
Name of forceps Level / use Features
Pipper’s forceps Aftercoming head
In breech delivery
Long shaft
Cephalic , pelvic , and perineal
curves
English lock.
Special forceps

24. DESCRIPTION AND TYPES OF FORCEPS
• Simpson forceps
• Low forceps
• Fenestrated blades, parallel
shanks, and English lock.
• The cephalic curve
accommodates the fetal head

25. DESCRIPTION AND TYPES OF FORCEPS
WRIGLEY’S FORCEPS:
• Outlet forceps.
• Short curved obstetric forceps.
• Generous cephalic curve.
• English lock.

26. DESCRIPTION AND TYPES OF FORCEPS
Kielland’s forceps:
• Midforceps
• Light weight.
• Cephalic and minimal pelvic
curves
• Sliding lock
• Used in occipitotransverse
position
• Correct asynclitism

27. DESCRIPTION AND TYPES OF FORCEPS
Parts of obstetric forceps:
• Two half with a lock
• Fenestrated blade
• Shank English lock
• Lock Nut and screw lock
• Handle Sliding lock
• Finger guard
• Cephalic curve
• Pelvic curve
• Perineal curve

28. ACOG classification of forceps deliveries
Outlet forceps
1.Scalp is visible at the introitus without separating the labia .
2. Fetal skull has reached the level of the pelvic floor .
3. Sagittal suture is in the direction anteroposterior diameter or in the right or left
occiput anterior or posterior position .
4. Fetal head is at or on the perineum .
5. Rotation does not exceed 45 degree.

29. ACOG classification of forceps deliveries
Low forceps Leading point of the fetal skull (station) is station +2 or more but has
not yet reached the pelvic floor .
Rotation <45 degree(LOA/ROA to OA)or (LOP/ROP to OP).
Rotation>45degree including OP.
Mid‐forceps The head is engaged in the pelvis but the presenting part is above
+2 station .
Rotation <45 degree(LOA/ROA to OA)or (LOP/ROP to OP).
Rotation>45degree including OP.
High forceps (Not included in this classification)

30. ACOG classification of forceps deliveries

31. MORBIDITY
• There is an increased risk of certain morbidities for both mother and
fetus with operative vaginal delivery.
• Maternal Morbidity
• Perinatal Morbidity

32. Maternal Morbidity
• Injuries
• Perineal lacerations
• Need for episiotomy
• Vaginal and cervical tears
• Traumatic postpartum hemorrhage
• Long term
• Urinary incontinence
• Anal sphincter dysfunction
• Puerperal endometritis

33. Perinatal Morbidity • Soft tissue injury to face
• Facial nerve palsy
• Intracranial hemorrhage
• Cephalhematoma

34. FORCEPS DELIVERY
Assessment before forceps
delivery:
• Abdominal examination
• Uterine contraction
• Descent of head
• FHR
• Weight of the baby
• Vaginal examination
• Cervical dilatation
• Rupture of membranes
• Colour of liquor
• Caput succedaneum
• presenting part
• Station
• Flexion
• Asynclitism
• Position
• Degree of molding

35. APPLICATION OF FORCEPS
For OA or LOA positions, the left handle of
the forceps is held in the left hand. The blade
is introduced into the left side of the pelvis
between the fetal head and the fingers of the
operator’s right hand.
Insertion arc of the blade. Importantly, the
thumb of the right hand, guides the blade
during placement.

36. APPLICATION OF FORCEPS
• In applying the second blade,
insertional force is generated
mainly by the thumb.

37. CHECKING FOR ACCURATE APPLICATION
• The blades are constructed so
that their cephalic curve is
closely adapted to the sides of
the fetal head.
• The fetal head is perfectly
grasped only when the long axis
of the blades corresponds to the
occipitomental diameter.
• As a result, most of the blade
lies over the lateral face.

38. CHECKING FOR ACCURATE APPLICATION
• The sagittal suture - perpendicular
to the shanks and equidistance
from two blades.
• Posterior fontanel – midway
between blades and one finger
breath anterior to the line joining
the shanks.
• A small part of the fenestration of
the blade to be felt on either side.

39. • Branches are removed in the
opposite order from that in
which they were originally
placed.
• The fingers of the right hand,
covered by a sterile towel,
bolster the perineum.
• The thumb is placed directly on
the head to prevent sudden
egress.

40. TRACTION• Outlet forceps : upward to
complete extension of head.
• Low forceps : horizontal until
head crowns and perineum
buldges f/b upward traction.
• Mid forceps : downward and
backward initially f/b upward
and forward and finally upward.
The vector changes with fetal descent.

41. TRACTION - OP
• In OP - horizontal until the root of
the nose hitches under the pubic
symphysis, upward and forward
until occiput is delivered and
downward and backward for the
nose, face, and chin to be born.
• The head should be flexed after the
bregma passes under the
symphysis.

42. ROTATION
If LOA, the vertex is rotated from this
position to OA
• If rotation is <45degree short of
full rotation ,application should
be cephalic with blades over
parietal bones . Vx rotates when
traction is applied .
• If rotation is >45degree, manual
rotation can be tried first if
failed, forceps can be applied
and rotation occurs during
traction.

43. ROTATION - OT
Wandering method
• A. Application of the right branch of
the Kielland forceps to a head in LOT
position. The knob on this branch will
ultimately face the occiput.
• B. The right branch is wandered to its
final position behind the symphysis.
• C. Insertion of the left branch of the
Kielland forceps directly posterior
along the hollow of the sacrum. This
branch is inserted to the maternal
right of the anterior branch to aid in
engaging the sliding lock.

44. MENTUM ANTERIOR FACE PRESENTATION
• The blades are applied to the sides of the head along the
occipitomental diameter, with the pelvic curve directed toward the
neck.
• Downward traction is exerted until the chin appears under the
symphysis. Then, by an upward movement, the face is slowly
extracted, with the nose, eyes, brow, and occiput appearing in
succession over the anterior margin of the perineum.

45. DELIVERY OF THE AFTERCOMING HEAD
Piper forceps
• A. The fetal body is held elevated
using a warm towel and the left
blade of forceps is applied to the
aftercoming head.
• B. The right blade is applied with
the body still elevated.
• C. Forceps delivery of the
aftercoming head.

46. TRIAL OF OPERATIVE VAGINAL DELIVERY
• Assisted vaginal births that have a higher risk of failure should be
considered a trial and be attempted in a place where immediate
recourse to caesarean birth can be undertaken.

47. Failed forceps
Higher rates of failure are associated with:
• Maternal BMI greater than 30
• short maternal stature
• estimated fetal weight of greater than 4 kg or a clinically big baby
• head circumference above the 95th percentile
• occipito–posterior position
• midpelvic birth or when one-fifth of the head is palpable per
abdomen.

48. Failed forceps
• When difficulty is not anticipated in forceps delivery but attempt fails
is known as failed forceps.
• Maternal and neonatal morbidity are high with failed forceps.
• Forceps delivery should be abandoned if :
• There is difficulty in application of the blades
• There is no progressive descent with moderate traction.
• Delivery is not imminent after three pulls.

49. Failed forceps
Laufe’s principle of failed forcep
• Forceps fail not only when vaginal extraction is not possible but also if
after undue pulling there is considerable damage to maternal soft
parts and the baby, which has been delivered, has suffered
considerable injury with low APGAR score and meager chances of
survival

50. VENTOUSE EXTRACTION
• Ventouse is an instrumental device designed to assist delivery by
creating a vacuum between it and the fetal scalp.

51. HISTORY
• Double valved piston with a metal cup – James Young Simpsom
• Tage Malmstorm in 1953 described the most successful model.

52. INDICATIONS
• The indications are same as those of forceps except that it cannot be
employed in face or after coming head of breech.
• Shortening second stage of labour
• Maternal Exhaustion
• Presumed fetal distress
• Occipito- Posterior position
• To deliver second twin if head is presenting part

53. CONTRAINDICATION
• Gestational age <34 weeks ( risk of IVH)
• Malpresentations
• Cephalopelvic disproportion
• Fetal bleeding disorder
• Maternal HIV infection.

54. PREREQUISITES
• Bladder should be empty
• Cervix fully dilated
• Cephalic presentation
• Head 1/5th palpable
• Station + 2 or below

55. DESCRIPTION AND TYPES
• Rigid cups
• Rigid metal cup (Malmstrom cup)
• Rigid plastic, polyurethane, or polyethylene cups
• Soft cups
• Soft silastic / plastic cups.(Kiwi cup)
• Bird’s cup : tube attached excentrically near the rim of the cup. Used
for OP and OT. Position.

56. Difference b/w Soft and Rigid cup
SOFT CUPS RIGID CUPS
More likely to fail
Less scalp injury
More suitable for OA position.
Size :50, 60mm.
Chignon not formed
Less likely to fail
More scalp injury
More suitable for OP positions, asynclitism and larger
fetus
Size : 40, 50, 60mm.
Chignon formed

57. DESCRIPTION AND TYPES

58. DESCRIPTION AND TYPES

59. CHIGNON FORMATION
• The scalp is sucked into the cup
and an artificial caput
succedaneum (chignon) is
produced.
• The chignon usually disappears
within few hours.
• Chignon in french : a knot of hair
that is worn at the back of the
head

60. MORBIDITY
• Episiotomy; vacuum, 50–60%; and forceps, more than or equal to
90%.
• Significant vulvo–vaginal tear; vacuum, 10%; and forceps, 20%.
• Postpartum haemorrhage; vacuum and forceps, 10–40%.
• Urinary or bowel incontinence; common at 6 weeks, improves over
time.
Maternal outcomes:

61. MORBIDITY
Perinatal outcomes:
• Cephalhaematoma; predominantly vacuum, 1–12%.
• Facial or scalp lacerations; vacuum and forceps, 10%.
• Retinal haemorrhage; more common with vacuum than forceps, variable 17–38%.
• Jaundice or hyperbilirubinaemia; vacuum and forceps, 5–15%.
• Subgaleal haemorrhage; predominantly vacuum, 3 to 6 in 1000.
• Intracranial haemorrhage; vacuum and forceps, 5 to 15 in 10 000.
• Cervical spine injury; mainly Kiellands rotational forceps, rare.
• Skull fracture; mainly forceps, rare.
• Facial nerve palsy; mainly forceps, rare.
• Fetal death; very rare.

63. APPLICATION OF THE CUP:
• The cup is placed against the
fetal head nearer the occiput
(flexion point) with the “knob”
of the cup pointing towards the
occiput.
• Flexion or pivot point is an
imaginary site located
midsagittally about 6 cm from
the center of the anterior
fontanel or about 3 cm in front
of the posterior fontanel.

64. SUCTION
• A vacuum of 0.2 kg/cm2 is induced by the pump slowly, taking at least
2 minutes.
• A check is made using the fingers round the cup to ensure that no
cervical or vaginal tissue is trapped inside the cup.
• The pressure is gradually raised at the rate of 0.1 kg/cm2 per minute
until the effective vacuum of 0.8 kg/cm2 is achieved in about 10
minutes time.
• The scalp is sucked into the cup and an artificial caput succedaneum
is formed.

65. VACUUM PRESSURE CONVERSIONS

66. TRACTION
• Traction must be at right angle to the cup
• Traction should be synchronous with the uterine contractions
• Traction is released in between uterine contractions
• Traction should be made using one hand along the axis of curve of
Carus.

67. • Indicating the directions of
traction at different stations of
the fetal head.
• Traction over this flexion or pivot
point either by ventouse or
forceps promotes flexion and
presents smaller diameter to the
pelvis

68. • Operative vaginal delivery (forceps/ventouse) should be abandoned,
where there is no descent of the presenting part with each pull or
when delivery is not imminent after three pulls with correctly applied
instruments by an experienced operator.
• On no account, traction should exceed 30 minutes

70. The relative merits of vacuum extraction and forceps have been
evaluated in a Cochrane systematic review of ten randomised
controlled trials, involving 2923 primiparous and multiparous women.
• More likely to fail delivery with the selected instrument
• More likely to be associated with cephalhaematoma
• More likely to be associated with retinal haemorrhage
• More likely to be associated with maternal worries about baby

71. The relative merits of vacuum extraction and forceps have been
evaluated in a Cochrane systematic review of ten randomised
controlled trials, involving 2923 primiparous and multiparous women.
• Less likely to be associated with significant maternal perineal and vaginal
trauma
• No more likely to be associated with delivery by caesarean section
• No more likely to be associated with low 5-minute apgar scores
• No more likely to be associated with the need for phototherapy

73. THANK YOU…