2. Definition: A surgically planned incision on the
perineum and the posterior vaginal wall during the
second stage of labour is called episiotomy.
It is also called as periniotomy.
It is the most common obstetric operation
performed during vaginal delivery.
Rigid or inelastic perineum – usually in primi and elderly
Suspected perineal tear – in case of big baby, breech
delivery, shoulder dystocia, etc.,
Operative delivery such as forceps delivery, ventouse
Previous perineal surgery – Pelvic floor repair, Perineal
7. Timing of episiotomy
If episiotomy done early, thee blood loss will be
If done late, it fails to prevent the perineal
Bulging thinned perineum during contractions, just
prior to crowning is the ideal time.
Clear & controlled incision
is easy to repair and heals
better than a lacerated
Reduces the duration of
second stage of labour.
Prevents perineal tear.
injuries specially in
10. 1. MEDIO-LATERAL: The incision is made downwards and
outwards from the midpoint of the fourchette either to the right
or to the left.
Right- Right medio-lateral episiotomy (RMLE)
Left- Left medio-lateral episiotomy (LMLE)
2. MEDIAN: The incision commences from the centre of the
fourchette and extends posteriorly along the midline for about 2.5
12. • LATERAL:
The incision starts from about 1 cm away from the
center of the fourchette and extends laterally. It has
got many drawbacks including chance of injury to the
Bartholin’s duct. It is totally condemned.
• ‘J’ SHAPED:
The incision begins in the center of the fourchette and is
directed posteriorly along the midline for about 1.5 cm
and then directed downwards and outwards along 5 or 7
O’clock position to avoid the anal sphincter. This is also
not done widely.
16. STEP I
• The perineum is thoroughly swabbed with
antiseptic (povidone-iodine) lotion and draped
• The perineum, in the line of proposed incision
is infiltrated with 10 mL of 1% solution of
17. STEP II
Two fingers are placed in the vagina between the presenting part and the
posterior vaginal wall.
The incision is made by a curved or straight blunt pointed sharp scissors (scalpel
may also be used)
One blade of which is placed inside, in between the fingers and the posterior
vaginal wall and the other on the skin.
The incision should be made at the height of an uterine contraction when an
accurate idea of the extent of incision can be better judged from the stretched
Deliberate cut should be made starting from the center of the fourchette extending
laterally either to the right or to the left.
It is directed diagonally in a straight line which runs about 2.5 cm away from the
The incision ought to be adequate to serve the purpose for which it is needed,
The bleeding is usually not sufficient to use artery forceps unless the operation is
done too early or the perineum is thick.
19. STRUCTURES CUT ARE
(1) Posterior vaginal wall
(2) Superficial and deep transverse perineal
muscles, bulbospongiosus and part of levator
(3) Fascia covering those muscles
(4) Transverse perineal branches of pudendal
vessels and nerves
(5) Subcutaneous tissue and skin.
22. STEP III
Timing of repair
1. The repair is done soon after expulsion of placenta.
2. If repair is done prior to that, disruption of the wound
is inevitable, if subsequent manual removal or
exploration of the genital tract is needed.
3. Oozing during this period should be controlled by
pressure with a sterile gauze swab and bleeding by
the artery forceps.
4. Early repair prevents sepsis and eliminates the
patient’s prolonged apprehension of “stitches”.
23. REPAIR STEPS
• Lithotomy position.
• A good light source
• Cleansed with antiseptic solution.
• Blood clots are removed from the vagina and the wound
• The patient is draped properly and repair should be done
under strict aseptic precautions.
• If the repair field is obscured by oozing of blood from
above, a vaginal pack may be inserted and is placed high
• Done in three layers.
• The principles to be followed are:
(1) perfect hemostasis
(2) to obliterate the dead space and
(3) suture without tension.
• The repair is to be done in the following order:
(1) Vaginal mucosa and submucosal tissues
(2) Perineal muscles
(3) Skin and subcutaneous
27. REPAIR STEPS
• The vaginal mucosa is sutured first.
• The first suture is placed at or just above the apex of
• Thereafter, the vaginal walls are apposed by
interrupted sutures with polyglycolic acid suture
(Dexon) or No. “0” chromic catgut, from above
downwards till the fourchette is reached.
• The suture should include the deep tissues to
obliterate the dead space.
• A continuous suture may cause puckering and
shortening of the posterior vaginal wall.
• Care should be taken not to injure the rectum.
29. IMMEDIATE COMPLICATIONS
(1) Extension of the incision to involve the rectum.
(2) Vulval hematoma
(A) throbbing pain on the perineum
(B) rise in temperature
(C) the wound area looks moist, red and swollen and
(D) offensive discharge
(a) Tofacilitate drainage of pus
(b) Local dressing with antiseptic powder or ointment
(c) MgSO4 compression or application of infrared heat to the area to
reduce edema and pain
(d) Systemic antibiotic (IV).
(4) Wound dehiscence
(5)Injury to anal sphincter causing incontinence
of flatus or feces.
(6) Rectovaginal fistula and rarely.
(7)Necrotizing fasciitis (rare) in a woman who is
diabetic or immunocompromised
33. Operative vaginal delivery refers to any delivery process which
is assisted by vaginal operations. Delivery by forceps,
ventouse and destructive operations are generally included.
FORCEPS DELIVERY: means extracting the fetus with the aid of
obstetric forceps when it is inadvisable or impossible for the
mother to complete the delivery by her own efforts.
Forceps are also used to assist the delivery after coming
head in breech presentation and on occasion to withdraw the
head up and out of the pelvis at cesarean section.
35. Obstetric forceps is a pair of instruments specially
designed to assist extraction of the fetal head and
thereby accomplishing delivery of the fetus.
VARIETIES OF OBSTETRIC FORCEPS:
• Ever since either Peter I or Peter II of the Chamberlin
family invented the forceps around AD 1600, more
than 700 varieties were invented or modified.
• Most of them are of historical interest only. But only
three varieties are commonly used in present day
36. These are:-
1.Long-curved forceps with or without axis
2. Short-curved forceps
3. Kielland’s forceps
The basic construction of these forceps is the
same in that each consists of two halves (blades)
articulated by a lock.
39. Long-curved obstetric forceps is relatively heavy and is
about 37cm (15”) long. In India, Das’s variety (named after
Sir Kedar Nath Das) is commonly used with advantages. It
is comparatively lighter and slightly shorter than its
Western counterpart but is quite suited for the
comparatively small pelvis and small baby of Indian
Measurements:-Length is 37cm (15”);distance in between
the tips is 2.5 cm and widest diameter between the blades
is 9 cm.
i. BLADES: There are two blades and are named right or
left in relation to maternal pelvis in which they lie when
iv. Handle with or without screw.
41. i. Blade: - The blade is fenestrated to facilitate a good
grip of the fetal head. There is usually a slot in the
lower part of the fenestrum of the blades to allow the
upper end of the axis traction rod to be fitted.
The toe of the blade refers to the tip and the heel to
the end of the blade that is attached to the shank.
The blade has got two curves: -
Pelvic curve:-The curve on the edge is to fit more or
less the curve on the axis of the birth canal (curve of
Carus). The front of the forceps is the concave side of
the pelvic curve. Pelvic curve permits ease of
application along the maternal pelvic axis.
Cephalic curve:-It is the curve on the flat surface
which when articulated grasps the fetal head without
42. ii.Shank:-It is the part between the blade and the lock
and usually measures 6.25 cm(2.5”).It increases the
length of the instrument and thereby, facilitates
locking of the blades outside the vulva.
iii.Lock: -The common method of articulation consists
of a socket system located on the shank at its
junction with the handle (English lock). Such type of
lock requires introduction of the left blade first.
iv.Handle: -The handles are apposed when the blades
are articulated. It measures 12.5 cm(5”). There is a
finger guard on which a finger can be placed during
traction. A screw may be attached usually at the end
(or at the base) of one blade (commonly left). It helps
to keep the blades in position.
46. 3.Kielland’s Forceps
It is a long almost straight (very slight pelvic
curve) obstetric forceps without any axis traction
device. It has got a sliding lock which facilitates
correction of the head. One small knob on each
blade is directed towards the occiput.
47. IDENTIFICATION OF BLADE OF
Take the blade of forceps
Place it in front of maternal pelvis, tip of the forceps
directed towards fetal head, concavity of pelvic curve
directed toward the midline of pelvis
The tip point of blade should be upwards.
The cephalic curve is to be directed inwards and the
pelvic curve forwards.
The blade which correspond to left side of mother is left
blade and right side right blade.
48. Type of procedure
Outlet Forceps Operation (1) Scalp is visible at the introitus without separating the
(2) Fetal skull has reached the level of the pelvic floor
(3) Sagittal suture is in direct anteroposterior diameter.
( Wrigley's forceps)
Low Forceps Operation Leading point of the fetal skull (station) is at +2 cm or more
but has not yet reached the pelvic floor. (Long curved
Mid Forceps Operation Fetal head is engaged. Leading point of the fetal skull
(station) is at +2 cm or less above the spine.(Kielland's
High(Excluded) High Head is not engaged. This type is not included in
Types of application of forceps:
Forceps application is classified according to the station and rotation of the fetal
52. INDICATIONS OF FORCEPS
Post caesarean pregnancy
Prolonged 2nd stage
It is the prolongation for more than 1 hour in
primigravidae or 30 mins in multiparae. This may be
Poor voluntary bearing down
Malposition: persistent occipito posterior and
deep transverse arrest.
Maternal distress are manifested by
Pulse greater than 100 beats per min
Temperature greater than 38 C
Sign of dehydration
Maternal diseases as:
Pre eclampsia and eclampsia
55. PREREQUISITES FOR FORCEPS APPLICATION
There are certain conditions which must exist before delivery
can be performed.
• The cervix must be completely dilated.
• The membranes must be ruptured.
• The head must be engaged.
• No appreciable Cephalopelvic disproportion.
• The bladder must be emptied.
• Presence of good uterine contractions as a safeguard to
• The fetus must be vertex, or present a face with chin anterior.
• The position of the fetal head must be known.
Verbal or written consent need to be obtained in some
56. TYPES OF FORCEPS APPLICATION
The forceps is applied on the sides of the foetal head in the
mento- vertical diameter so, injury of the fetal face, eyes and
facial nerve is avoided.
The forceps is applied along the maternal pelvic wall
irrespective to the position of the head.it is easier for
application but carries a great risk of foetal injuries.
It is the ideal and possible application when the occiput is
directly anterior or in mento-anterior diameter position.
58. PROCEDURE (LOW FORCEPS OPERATION)
Preparation of mother-
Clear explanation should be given and informed consent
Appropriate analgesia is in place for mid-cavity rotational
deliveries. This will usually be a regional block.
A pudendal block may be appropriate, particularly in the
context of urgent delivery.
Maternal bladder has been emptied recently.
59. Preparation of staff-
Operator must have the knowledge, experience
and skill necessary.
Adequate facilities are available (appropriate
equipment, bed, lighting).
Back-up plan in place in case of failure to deliver.
When conducting mid-cavity deliveries, theatre
staff should be immediately available to allow a
caesarean section to be performed without delay
(less than 30 minutes).
60. A senior obstetrician competent in performing mid-
cavity deliveries should be present if a junior trainee
is performing the delivery.
Anticipation of complications that may arise (e.g.
shoulder dystocia, postpartum haemorrhage)
Personnel present that are trained in neonatal
61. The women should be prepared in advances for the possibility
of a forceps delivery.
The women should be placed in lithotomy position.
Both legs must be placed simultaneously to avoid strain on the
woman’s back and hips.
Anaesthesia- can be given by perineal infiltration with 1%
lignocaine as local anaesthesia.
If bladder was not emptied, catheterisation to be done.
Internal examination to be done to assess-
• state of the cervix
• Membranes status
• Presentation and position of the head (station)
Episiotomy- It can be done prior to application of forceps to
62. Steps of forceps delivery
The operation consists of the following steps:
Identification of the blades and their application
Locking of the blades
Removal of the blades
63. 1. Identification of the blades and their application
The women’s vulval area is thoroughly cleaned and draped with
sterile towels using aseptic technique.
The forceps are identified as left or right by assembling them
briefly before proceeding.
The left blade is passed gently between the perineum and fetal
head with the first two figures of the operator’s hand lying alongside
the fetal head protecting the maternal tissue. The tip of the forceps
blade slides lightly over the head, in to the hollow of the sacrum and
is then ‘wandered’ to the left side of the pelvis where it should sit
alongside the head.
The procedure is repeated with the right blade until it sits on the
right of the pelvis.
66. 2. Locking of the blades
It should then be easy to lock the two blades and there should be
little or no gap between the handles.
Minor difficulty in locking can be corrected by depressing the
handles on the perineum.
A significant gap suggests that the forceps are wrongly
positioned and they should be reapplied after carefully checking
the position of head.
The handles should never be forced to lock them.
67. 2. Traction & Removal of the blades
As soon as the operator is ready and the uterus contracts, the woman is
encouraged to push.
To supplement her efforts the obstetrician exerts steady, downwards
traction on the forceps.
Traction is released between contractions. Intermittent traction is
continued in a downward and backward direction until the head comes to the
The pull is then directed horizontally straight towards the operator until
the head is almost crowned.
The direction of pull is gradually changed towards the mother’s abdomen
to deliver the head by extension.
The blades are removed one after the other, the right one first.
Following the birth of the head, usual procedures are to be followed as in
normal delivery. Intravenous methergine 0.2mg is to be administered with the
delivery of the anterior shoulder. Episiotomy is repaired as quickly as possible
and the woman made comfortable.
70. OUTLET FORCEPS OPERATION
Wrigley's forceps are used exclusively in outlet
Procedure is same as low forceps operation except
the traction – the direction of the pull is straight
horizontal and then upwards & forwards.
71. CONTRAINDICATIONS FOR FORCEPS
-Absence of full dilatation of cervix.
-In case of cephalopelvic disproportion.
-High station of fetal head.
-If uterine contraction cease.
-Lack of experience of operator.
-Mentum posterior face presentation.
72. Difficulties in forceps operation
The difficulties are encountered mainly due to faulty
assessment of the case. Difficulties occurs in four areas.
During application of blades – due to incompletely dilated
cervix and non-engaged head.
Difficulty in locking – due to improper insertion of blades and
failure to depress the handle.
Difficulty in traction – due to faulty cephalic application, wrong
direction of traction and constriction ring.
Slipping of blades – due to faulty application.
73. The hazards of the forceps operation are mostly
related to the faulty technique and to the indication
for which the forceps are applied.
MATERNAL (In the mother)
Extension of the episiotomy towards rectum or
upwards up to the vault of vagina
Cervical tear especially when applied through an
incompletely dilated cervix.
Bruising and trauma to the urethra.
74. Postpartum hemorrhage due to trauma, or atonic uterus related
to prolonged labor or effects of anesthesia.
Shock due to blood loss, prolonged labor and dehydration.
Sepsis due to devitalization of local tissues and improper asepsis.
Chronic low backache due to tension imposed on softened
ligaments of lumbosacral or sacroiliac joints during lithotomy
75. FETAL (In the infant)
Asphyxia due to intracranial stress out of prolonged
Intracranial hemorrhage due to misapplication of the blades.
Facial palsy due to damage to facial nerve.
Abrasions on the soft tissues of the face and forehead by the
forceps blade, severe bruising will cause marked jaundice.
• Cerebral palsy
78. Prevention: It is a preventable condition. Only
through skill and judgment, proper selection of the
case ideal for forceps can be identified. Even if
applied in wrong cases, one should resist the
temptation to give forcible traction in an attempt to
hide the mistake.
(1)To assess the effect on the mother and the fetus.
(2)To start a Ringer’s solution drip and to arrange
for blood transfusion, if required.
(3)To administer parenteral antibiotic.
(4)To exclude rupture of the uterus.
(5)The procedure is abandoned and delivery is done
by cesarean section
(6)Laparotomy should be done in a case with rupture
81. Vacuum Extraction (Ventouse)
Ventouse is a vacuum device used to assist the delivery of a
baby when the second stage of labour has not progressed
It is an alternative to a forceps delivery and caesarean
section. It cannot be used when the baby is in the breech
position or for premature births. This technique is also called
vacuum- assisted vaginal delivery or vacuum extraction
It is an instrumental device designed to assist delivery by creating
a vacuum between it and the fetal scalp
In the United states the device is referred to as the vacuum
extractor whereas in Europe it is called as Ventouse- from the
french word literally meaning soft cup.
82. Historical background
In 1705, Yonge described an attempted vaginal
delivery using a cupping glass
In 1848 Simpson devised a bell shaped device
called an “air tractor vacuum extractor”
In 1953 a metal cup extractor was developed
by Malmstrom .
Vacuum extractor is composed of:
A specially designed cup with a diameter of 3, 4,
5 or 6 cm.
A rubber tube attaching the cup to a glass bottle
with a screw in between to release the negative
A manometer fitted in the mouth of the glass
bottle to declare the negative pressure.
Another rubber tube connecting the bottle to a
suction piece which may be manual or electronic
creating a negative pressure that should not
exceed - 0.8 kg per cm2.
86. Types of vacuum extractors
Vacuum extractors are divided on the basis of the
type of cup- -metal or plastic
1.Metal cup vacuum extractors
2.Soft cup vacuum extractors
87. Metal cup
• The metal-cup vacuum extractor is a mushroom-shaped
metal cup varying from 40 to 60 mm in diameter.
• Metal-cup vacuum extractors have a higher success rate
and easier cup placement in the occipitoposterior (OP)
• The rigidity of metal cups can make application difficult
and uncomfortable, and their use is associated with an
increased risk of fetal scalp injuries.
89. Soft cup
• Traditionally soft cups are bell or funnel shaped.
• Soft-cup instruments can be used with a manual vacuum
pump or an electrical suction device. Soft-cup vacuum
extractors may be disposable or reusable.
• Compared with metal-cup devices, soft-cup vacuum
extractors cause fewer neonatal scalp injuries. However,
these instruments have a higher failure rate.
91. Indications of vacuum extraction
Generally vacuum extraction is reserved for fetuses who
have attained a gestational age of 34 weeks.
Otherwise, the indications and pre-requisites for its use
are the same as for forceps delivery.
Delay in descent of the head in case of twins.
Delay in first stage of labour.
Inability to assess fetal position
High station(above 0 station)
Suspicion of cephalopelvic disproportion
Other presentations than vertex.
Premature fetus(<34 weeks).
Fetal macrosomia - >4kg
93. Pre-requisites of the Procedure
Procedure should be explained to the patient and
consent should be taken
Emotional support and encouragement
Bladder should be emptied.
Antiseptic measures for the vagina, vulva and
Vaginal examination to check pelvic capacity,
cervical dilatation, presentation, position, station
and degree of flexion of the head and that the
membranes are ruptured.
94. Pre-requisites cont..
Cervix should be at least 6cm dilated.
Head should be engaged.
Procedure to be taken with perineal infiltration
with 1% lignocaine.
It may be applied even without anaesthesia
specially in parous women.
The instrument should be assembled and the
vacuum is tested prior to its application.
1. Application of the cup
Identification of the flexion point-
-It is situated 3 cm in front of the posterior fontanelle.
-Centre of the cup should be overlying the flexion
point. This placement promotes flexion ,descent and
If traction is directed from this point the fetal head is
flexed to the narrowest sub-occipito bregmatic
• The largest cup that can be easily passed
is introduced sideways into the vagina by
pressing it backwards against the
• Be sure that there is no cervical or vaginal
tissues nor the umbilical cord or a limb in
complex presentation is included in the
100. 2. Creating the negative pressure
When using the rigid cups, the negative
pressure is gradually increased by 0.2 kg/cm2
every 2 minutes until - 0.8 kg/cm2 is attained.
This creates an artificial caput within the cup.
With soft cups negative pressure can be
increased to 0.8 kg/cm2 over as little as 1
An episiotomy may be needed for proper placement of the cup
If not, then delay the episiotomy till the head stretches the perineum
or perineum interferes with the axis of traction
This will minimize unnecessary blood loss.
104. 3. Traction
Traction should be intermittent and co- ordinated
with maternal expulsive efforts and with uterine
Traction should be in line of the pelvic axis and
perpendicular to the plane of the cup
105. Traction contd..
Traction may be initiated by using a two handed technique
Fingers of one hand are placed against the suction cup while
the other hand grasps the handle of the instrument
This allows one to detect negative traction.
Manual torque to the cup should be avoided as it may cause
cephalohematoma and scalp lacerations.
Between contractions, check for fetal heart rate and proper
application of the cup
107. 4. Release
When the head is delivered the vacuum is reduced
as slowly as it was created using the screw as this
diminishes the risk of scalp damage.
The chignon should be explained to the patient and
109. Reapplication of the cup
If the cup detaches for the first time, reassess the situation.
If favorable ,then reapply.
If cup detaches for the second time, reassess if vaginal
delivery is safe or move to caesarean section
Caesarean section is necessary if there is inadequate
descent and rotation
110. Failure of vacuum
Vacuum extraction is considered failed if-
-fetal head does not advance with each pull
-fetus is undelivered after 3 pulls with no descent or
after 30 minutes
-cup slips off the head twice at the proper direction of pull
with the maximum negative pressure.
111. Advantages of Vacuum over Forceps
Regional Anaesthesia is not required so it is preferred in
cardiac and pulmonary patient.
The ventouse is not occupying a space beside the head
Less compression force (0.77 kg/cm2) compared to
forceps (1.3 kg/cm2) so injuries to the head is less
Less genital tract lacerations.
Can be applied before full cervical dilatation.
Perineal, vaginal ,labial, periurethral and cervical
Annular detachment of the cervix when applied with
incompletely dilated cervix.
Cervical incompetence and future prolapse if used with
incompletely dilated cervix.