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FORCEPS and vaccum obstetrics and gynaecological nursing
- 2. FORCEPS DELIVERY &VENTOUSE DELIVERY
- 3. FORCEPS DELIVERY INTRODUCTION Forceps andvacuum delivery is a Kind of assisted vaginal deliver, a way that the health care team can assist when labor has stalled. It’s only used when vaginal delivery is in its final stages, but not progressing and when the babies health are at risk from prolonged labor. Forceps and vacuum are medical tool that looks like a metal salad tongs. A trained healthcare provider can use the forceps to grasp the baby inside the birth canal and help guide them out.
- 4. DEFINITION FORCEPS DELIVERY Obstetric forcepsis a pair of instruments specially designed to extraction of the fetal head and there by accomplishing delivery of the fetus
- 5. PURPOSE To assistin delivery after coming head of breech. To take out head up and out of pelvis at caesarean section. To rotate and take out of head in an unfavorable position of baby in vertex presentation. To deliver baby quickly in case of fetal distress after fulfilling the conditions for use of forceps.
- 6.
- 7. MATERNAL Maternal exhaustionfollowing prolonged labour. Prolonged second stage of labour. Maternal stress as shown by maternal tachycardia, dehydration and urine showing the presence of acetone or mild pyrexia. In maternal medical disorders such as cardiac disease, severe anemia, tuberculosis, pregnancy-induced hypertension, eclampsia or debilitating illness, to shorten the second stage and obviate the need for prolonged bearing down. Failure of descent or internal rotation for 2 hours in a primigravida and 1 hour in a multipara in the second stage of labour.
- 8. FETAL INDICATIONS Foetaldistress After coming head of breech Cord prolapse Low birth weight baby Post maturity
- 9. Miscellaneous/Others Poor uterinecontractions Malposition's like right or left occipitoposterior positions Deflexed head Prolonged second stage of labour Nullipara > 2 hours Multipara > 2 hours
- 10. CONTRAINDICATIONS Absence offull dilatation of the cervix Cephalopelvic disproportion High station of the fetal head Uterine contractions cease Extreme prematurity (< 34 weeks) Suspected bleeding disorder Macrosomia
- 12. TYPES OF FORCEPS Long curved forceps with or without axis traction Short curved forceps Killend’s forceps Long curved forceps. Long curved obstetrics forceps relatively heavy and is about 37cm long . It is lighter & slightly shorter.
- 13. It is suitedfor the comparatively small pelvis and small baby of Indian women. SHORT CURVED FORCEPS: The instrument is higher about a third of the weight of ordinary long curved forceps. The instrument is short, which is due to reduction in the length of the shanks and Handles. It has marked Cephalic curve with slight pelvic curve.
- 14. Killend’s Forceps It is a long almost straight obstetric forceps without any axis traction device.
- 15. CLASSIFICATION OF FORCEPSDELIVERIES ACCORDING TO STATION AND ROTATION High forceps Head is not engaged This type, not included in classification. Mid forceps Head is engaged in the pelvis but presenting part is above +2 station. Low forceps Leading point of the fetal skull +2 or more but has not yet reached the pelvic floor. (1)Rotation < 45° (2) Rotation > 45°
- 17. Outlet forceps : Scalp is visible at the introitus without separating the labia. Fetal skull has reached the level of the pelvic floor. Sagittal suture is in direct anterior posterior diameter or in the right or left occiput anterior or posterior position. Rotation forceps When the baby is to be turned from posterior position.
- 18. Non Rotational Forceps Used to bring baby down into the birth canal without changing the position of the head. Choice of Forceps Operation When the head is at or near the level of ischial spine. Internal rotation of the head is incomplete. Manual rotation may be is needed before traction.
- 19. Low Forceps Thehead is near the pelvic floor or even visible at introitus. It is commonly used now a days with advantage. Outlet Forceps It is a variety of low forceps where the head is on the perineum.
- 20. PREREQUISITES FOR FORCEPSDELIVERY Fetal and uteroplacental criteria The fetal head must be engaged The cervix must be fully dilated and effaced The membranes must be ruptured The Position and station of the fetal head must be known with certainly.
- 21. Maternal Criteria: Nomajor cephalopelvic disproportion by clinical pelvimetry. Bladder must be emptied Adequate analgesia Safe guard to postpartum hemorrhage Others Experienced operator Verbal or written consent
- 22.
- 23. Mnemonic for forceps F - Favorable head position and station O - Open os (Fully dilated) R – Ruptured membrane C – Contraction present and consent E – Engaged head, empty bladder P – Pelvimetry – no major CPD S – Stirrups, Lithotomy position
- 24. PREPARATION OF THEWOMEN Full Explanation of the procedure and the need for it must be given to the women Once the decision has been made adequate and appropriate analgesia must be offered Women’s legs must be placed simultaneously to avoid strain on the woman’s back and hips. The women should be tilted towards the left at an angle of 15° by the use of a pillow or rubber wedge under. Preparation must also be done for the baby including equipment for resuscitation.
- 25. PROCEDURE Procedure of LowForceps Operation 1. The woman's vulval area is thoroughly cleaned and draped with sterile towels using aseptic technique. The bladder is emptied using a straight catheter. 2.A vaginal examination is performed by the obstetrician to confirm the station and exact position of the fetal head. 3. A pudendal block, supplemented by perineal and labial infiltration with 1% lignocaine hydrochloride, is given to produce effective local anesthesia.
- 26. 4. An episiotomymay be done prior to introduction of the blades or during traction when the perineum becomes bulged and thinned out by the advanced head. 5. The forceps are identified as left or right by assembling them briefly before proceeding. 6. The left blade is passed gently between the perineum and fetal head with the first two fingers of the operator’s hand lying along side the fetal head protecting from maternal tissues. The tips of the forceps blades slides lightly over the head into the hallow of the sacrum and is then wandered to the left side of the pelvis. Where it should sit alongside the head.
- 27. 7. The procedureis repeated with the right blade until it sits on the right of the pelvis It should be easy to lock the two blades and there should be little or no gap between the handles. A significant gap suggests that the forceps are wrongly positioned and they should be reapplied after carefully checking the position of the head. 8. During the application stage of the forceps the women should be given full support and attention by the midwife. 9. The fetal heart rate is to be monitored throughout.
- 28. 10. Assoon as the operator is ready and the uterus contracts, the woman is encouraged to push. To supplement her efforts, the obstetrician exerts steady, down-ward traction on the forceps. Traction is released between contractions. Intermittent traction is continued in a down-ward and backward direction until the head comes to the perineum. The pull is then directed horizontally straight toward the operator until the head is almost crowned. The direction of pull is gradually changed toward the mother's abdomen to deliver the head by extension.
- 29. 11. The bladesare removed one after the other, the right one first. 12. Following the birth of the head, usual procedures are to be followed as in normal delivery. IM Syntocin 10 units is to be administered with the delivery of the anterior shoulder. Episiotomy is repaired as quickly as possible and the woman is made comfortable.
- 30. DIFFICULTIES IN FORCEPSOPERATION The difficulties are encountered mainly due to faulty assessment of the case before the operative delivery undertaken. During application of the blades- The causes are: (1) Incompletely dilated cervix (2) Unrotated or non-engaged head
- 31. Difficulty in locking Thecauses are: (1) Application in unrotated head (2) Improper insertion of the blade (3) Failure to depress the handle against the perineum (4) Entanglement of the cord or fetal parts inside the blades.
- 32. Difficulty in traction Thecauses of failure to deliver with traction are: (1) Undiagnosed occipitoposterior position (2) Faulty cephalic application (3) Wrong direction of traction (4) Mild pelvic contraction (5) Constriction ring.
- 33. Slipping of theblades The causes are: (1) The blades are not introduced far enough in (2) Faulty application in occipito Posterior position. The blades should be equidistant from the sinciput and occiput
- 34. APPLICATIONS OF FORCEPSBLADE Cephalic application The blades are applied along the side of head of fetus. Biparietal diameter is grasped between the widest part of blades. Pelvic application The blades are applied on the lateral pelvic wall ignoring the position of head. This type of application has serious compression effect on cranium when the head remains un rotated, so this type of application should be avoided.
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- 36. COMPLICATIONS OF FORCEPSDELIVERY The hazards of the forceps operation are mostly related to the faulty technique and to the indications for which the forceps are applied. In the mother Immediate Injury Extension of the episiotomy towards rectum or upwards up to the vault of vagina Vaginal lacerations
- 37. Cervical tearespecially when applied through an incompletely dilated cervix Bruising and trauma to the urethra Postpartum hemorrhage due to trauma, or atonic uterus related to prolonged labor or effect of anesthesia Shock due to blood loss, prolonged labor and dehydration Sepsis due to devitalization of local tissues and improper asepsis
- 38. Late Complications Chroniclow backache due to tension imposed on softened ligaments of lumbosacral or sacroiliac joints during lithotomy position Genital prolapse or stress incontinence In the Infant Immediate Asphyxia due to intracranial stress out of prolonged compression Intracranial hemorrhage due to mal-application of the blades Cephalhematoma
- 39. Facial palsydue 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. Tentorial tear from compression of the fetal head by the forceps.
- 40. VENTOUSE DELIVERY INTRODUCTION Vacuum extractionis one kind of assisted delivery procedure that can get the baby through the birth canal when labor is stalled in the second stage. The vacuum extractor applies suction and traction to the baby’s head to help pull it out while push.
- 41. DEFINITION VACUUM EXTRACTION Ventouse isan instrumental device designed to assist delivery by creating a vacuum between it and the fetal scalp. INSTRUMENTS Ever since Malmstrom in 1956 reintroduced and popularized its use venous modification of the instruments are now available.
- 42. It consists ofthe following basic components Suction cup with 4 sizes (30, 40, 50, 60mm) A vacuum pump with a manometer attached to it (modern vacuum extraction consists of an electrical pump) Traction rod device Rubber tubing with a chain in the center.
- 43.
- 44. MATERNAL INDICATION Maternaldistress, exhaustion after a long, painful labor, due to inefficient uterine contractions. Prolonged second stage of labour Maternal medical disorders such as heart disease, hypertensive disorders and moderate to severe anaemia. .
- 45. FETAL INDICATION 1. Delayin descend of the high head in case of the second baby of twins. 2. Malposition – occipito latral and occipito posterior 3. Foetal distress 4. Prematurity
- 46. CONTRAINDICATION Any presentationother than vertex(Face, brow, breech) Preterm foetus (<34 weeks) chance of scalp avulsion or subaponeurotic haemorrhage Suspected foetal coagulin disorder Suspected foetal macrosomia(> 4kg)
- 47. Condition to befulfilled There should not slightest bony resistance below the head The head of a singleton baby should be engaged. Cervix should be at least 6cm dilated. PROCEDURE Preliminaries Explain the procedure to mother and family Obtain informed consent from mother
- 48. Instruct motherto empty the bladder. If not possible catheterization done. Maintain the lithotomy position and start I.V.line. Assess FHR frequently. Assess for decent of fetal head with mother's uterine contraction. Infiltrate perineum with 1% lignocaine Perform episiotomy when the contraction arise strong.
- 49. Assist obstetricianin applying suction cup and traction and maintenance of pressure. The instrument should be assembled and the vacuum is tested prior to its application. STEP I Application of the cup The largest possible cup according to the dilatation of the cervix is to be selected.
- 50. The cupis introduced after retraction of the perineum with two fingers of the other hand. The cup is placed against the fetal head nearer to the occiput with the knob of the cup pointing towards the occiput. Vacuum created by increasing the suction is increased 0.2 kg/cm every 2minutes until 0.8 kg/cm is achieved in about 10 minutes times.
- 51. Proper cupplacement over flexion point Exclude maternal soft tissue entrapment by palpation Vacuum creation by increasing the suction in increments of 0.2 kg/cm2 every 2 mins until 0.8 kg/cm2 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 0.1kg/cm2 per minute until the effective vacuum of 0.8kg/cm2 is achieved in about 10 minutes time.
- 52. The scalpis sucked into the cup and an artificial caput succedaneum is produced, which disappears within few hours. Instrument handle is grasped, and initiation of traction Traction is initiated by using a two-handed technique, i.e the fingers of one hand are placed against the suction cup, while the other hand grasps the handle of the instrument STEP II Traction must be at right angle to the cup Traction directed initially downward then progressively extended upward as head emerge
- 53. Traction shouldbe synchronous with the uterine contractions released in between the contractions. Once head is extracted, vacuum pressure is relieved; cup is removed; vaginal delivery followed. The total time from the application until delivery should not exceed 20 minutes . As soon as the head is delivered the vacuum is reduced by opening the screw release value and the cup is then detached.
- 54. The deliveryis the completed the normal way.
- 55. FETAL COMPLICATIONS SuperficialScalp abrasion Sloughing of the scalp Cephalhematoma- due to rupture of emissary veins beneath the periosteum. Subaponeurotic haemorrhage (rare) MATERNAL COMPLICATIONS Soft tissue injuries such as cervical vaginal wall inside the cap.
- 56. SUMMARY So far, wehave discussed about definition, purpose, instrument, indication, contraindication, procedure, complication and management of forceps and vacuum delivery.
- 57. CONCLUSION Forceps and vacuumdelivery has been proven to be useful in assisting with vaginal delivery. The potential for the foetal and maternal injury does exist the operator must be familiar with indications contraindications, application and use of the vacuum device. Safe and effective guidelines should exist to facilitate a safe and effective delivery.
- 58. Assignment A 23year old primigravida 38 weeks of gestation admitted in Labor room having cardiac disease the FHR is 100 beats /min. and is exhausted. Write in detail about mode of delivery and management.
- 59. THEORY APPLICATION GENERAL SYSTEMTHEORY I INPUT The student lack of knowledge regarding Forceps and vacuum delivery. THROUHPUT Taking lecture class on Forceps and vacuum delivery. OUTPUT The students gain knowledge regarding Forceps and vacuum delivery. FEED BACK
- 60. JOURNAL APPLICATION Author: SonawaneAnurag Topic: A study of feto maternal outcome in instrumental vaginal deliveries at a tertiary teaching hospital Conducted a retrospective study to assess the maternal and neonatal outcome undergoing instrumental vaginal delivery (vacuum & forceps delivery) at department of obstetrics and gynaecology, Government medical college Aurangabad. In this study total 266 patients most common indication for instrument and vaginal delivery was delayed second Stage (32%) followed by foetal disorders (26%) Medical disorders (18%) and noted Cervical laceration (15%) PPH requiring blood transfusion (13%) vaginal laceration (10%) episiotomy extension (5%) & perineal injury (2%) neonatal jaundice was most common. Instrumental Vaginal delivery remains useful procedure if applied by a trained obstetrician helps improve neonatal and maternal outcome also helps to reduce caesarean delivery rate.
- 61. BIBLIOGRAPHY Dutta. D.C.(2004) Text book of obstetrics 6th edition. New central book agency, Calcutta. Bhaskar Nima (2012) midwifery and obstetrical nursing Bangalore EMMESS medical publishers. Jacob Annamma (2015) A comprehensive Text book of Midwifery & Gynaecological nursing. Fourth edition New Delhi Jaypee Brothers Medical publishers (P) Ltd.
- 62. Neelam kumari(2011) A text book of midwifery and gynaecological nursing S. Vikas & company medical publishers, Jalandhar city. Sandeep Kaur(2019) Text book of midwifery and gynaecological nursing I edition CBS publishers & Distributors(P) Ltd. https://journalbarpetoysco.in