For difficult vaginal delivery,forceps delivery,vacuum application are done to assist the vaginal delivery.Many types of forceps are there divided in 3 categories.

1. OPERATIVE VAGINAL DELIVERY
Dr. Niranjan Chavan

3. FORCEP DELIVERY

4. HISTORY
• The Chamberlens were innovators, opportunists and entrepreneurs of
forceps.
• Dr Peter, in 1634, proposed a Sisterhood of Midwives of London, antedating
the formation of the Central Midwives Board by over 250 years.

5. HISTORY
• The Chamberlens were French ,William Chamberlen, the patriarch of the
family, was most likely a surgeon; he had two sons, one named Pierre, who
became maverick surgeons that specialized in midwifery.
• He was succeeded by his nephew, Dr. Peter Chamberlen, as royal
obstetrician. The success of this dynasty of obstetricians with the Royal
family and high nobles was related in part to the use of this "secret"
instrument allowing release of live child in difficult cases.

6. • In fact, the instrument was kept secret for 150 years by the Chamberlen
family, although there is evidence for its presence as far back as 1634.
• Models derived from the Chamberlen instrument finally appeared gradually
in England and Scotland in 1735. About 100 years after the invention of the
forceps by Peter Chamberlen Sr. a surgeon by the name of Jean Palfyn
presented his obstetric forceps to the Paris Academy of Sciences in 1723.
• They contained parallel blades and were called the Hands of Palfyn.

7. • Tarnier's idea was to "split" mechanically the grabbing of the fetal head
(between the forceps blades) on which the operator does not intervene after
their correct positioning, from a mechanical accessory set on the forceps
itself, the "tractor" on which the operator exercises traction needed to pull
down the fetal head in the correct axis of the pelvic excavation.
• Tarnier forceps (and its multiple derivatives under other names) remained the
most widely used system in the world until the development of the cesarean
section

8. • Christian Kielland in 1915 devised rotational forceps for Deep Transverse Arrest
• Edmund Piper introduced forceps for after coming head of the breech in 1929
• Wrigley introduced short ligt forcep with generous cephalic curve in 1935
• Luikart in 1937 modified solid blades into pseudo—fenestrated
• Shute described forceps using “principle of parallelism” to reduce compression
of fetal skull.

9. PARTS OF FORCEPS
• Branches
• Blades- solid, fenestrated, Pseudo fenestrated
• Shanks
• Handle
• Lock – English, German, Sliding, Pivot, Hiesters

10. CURVES OF FORCEPS
• Cephalic Curve
• Pelvic Curve
• Perineal Curve

11. It has been classified by the The American College of Obstetricians and Gynecologists
(ACOG) in 1994 conference at Washington.

12. PREREQUISITES
• Vertex presentation
• Cervix is fully dilated and the membranes ruptured
• Head is fully engaged
• Exact position of the head can be determined so proper placement of the
instrument can be achieved
• Pelvis is deemed adequate
• Informed consent must be obtained
• Appropriate analgesia is in place

13. • Maternal bladder has been emptied
• Adequate facilities and backup personnel are available
• Operator must have the knowledge, experience, and skill necessary to use
the instruments and manage complications that may arise
• Backup plan

15. Types
700+ varieties
3 categories
(1) Classical
• (a)Parallel shanks: Simpson, DeLee, Irving, Hawks-Dennen
• (b)Overlapping shanks: Elliott, Tucker-McLane
(2)Rotational : Kielland, Leff forceps
(3)Special : Piper forceps

19. CONTRAINDICATIONS
Absolute
• non-vertex or brow
• unengaged head
• incomplete cervix dilation
• clinical evidence of cephalopelvic disproportion
• fetal coagulopathy

20. CONTRAINDICATIONS
Relative
• unfavourable attitude of fetal head
• rotation >45° from occiput anterior or occiput posterior (vacuum)
• mid-pelvic station
• fetal prematurity
• There is a small retrospective study reviewing the outcome of deliveries of
infants 1500 g to 2500 g. No difference was found in Apgar scores, umbilical
pH, or intraventricular haemorrhage when comparing vacuum extraction with
controls who delivered spontaneously

21. APPLICATION PRINCIPLES AND
PROCEDURE
• Be familiar with the instrument being used.
• Use finger-strength pressure when applying forceps.
• Rotation within one plane can only be done with
forceps without a pelvic curve.

22. When checking the application:
• (a) the posterior fontanelle should be located midway between the sides of
the blades, with the lambdoid sutures equidistant from the forceps blades
and
• (b) the sagittal suture must be perpendicular to the plane of the shanks
throughout its length.
• (c) the fenestration of the blades should be barely felt and the amount of
fenestration felt on each side should be equal. With a solid blade, no more
than a fingertip should be able to be inserted between the blade and the fetal
head one finger-breadth above the plane of the shanks.

24. • VIDEO

25. FORCEP FOR AFTER COMING HEAD OF
BREECH
Indications –
• Prophylactic i.e. to prevent sudden compression and decompression of after
coming head
• Arrest of after coming head
Different forceps which can be used
• Long Pipers forceps
• Simpsons long forceps
• Kielland’s forceps

27. MATERNAL
COMPLICATIONS
• maternal lacerations
• minor external ocular trauma
• retinal hemorrhage

28. FETAL
COMPLICATIONS
• fetal skull fractures
• facial nerve palsies
• cephalohematomas
• subaponeurotic hemorrhages
• intracranial hemorrhages
• scalp lacerations

29. FAILED OPERATIVE DELIVERY
Causes
• Cannot apply the branchs
• Branches do not lock
• Branches slip after application
• While effecting rotation only blades rotate
• Extraction is not possible
• There is morbidity to motality to fetus and mother

30. FAILED OVD
• Application before full dilatation of cervix
• Gross Cephalopelvic Disproportion
• DTA
• Undiagnosed hydrocephalus
• Contraction ring grasping the fetus

31. • 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

32. FAILED OPERATIVE DELIVERY
• It is well known that a failed operative delivery resulting in a cesarean
delivery is worse than an outright cesarean delivery.
• In the study performed in California by Towner et al, the rates of subdural
hemorrhage, facial-nerve palsy, convulsions, and mechanical ventilation
were significantly higher in infants delivered by caesarean section after a
failed attempt at vacuum extraction, forceps delivery, or both.

33. • As such, a physician must often think about appropriate patient selection and
the chances of success before attempting an operative vaginal delivery.
• However, fewer than 3% of women in whom an operative vaginal delivery
has been attempted go on to deliver by cesarean. Rotational and midpelvic
(0 to +1 station) forceps, however, are more difficult, with higher rates of
failure, and require more skill.

34. VACUUM EXTRACTION

35. HISTORY
• James Young Simpsom devised double valved piston with a metal cup – like
a breast pump
• Tage Malmstorm in 1953 described the most successful model
• Pelosi,Apuzzio introduced Sialistic Cup with metal traction

36. TYPES OF VACUUM
• Malmstorms Vacuum Extractor –
• Parts –
• Metal Cup with Plates (3.4.5.6 mm)
• Traction Chain attached to the plate
• Traction Handle
• Pressure rubber tube whch encloses the traction chain
• Vacuum Bottle with pressure gauge
• Vacuum pump

37. • Bird’s Modification –
• In this Vacuum tube is attached to the opening near periphery of
the cup and the traction chain to the hook in the cetre of the cup.
• Flat metal plate and the pin have been discarded

39. • Soft Cup –Bell shaped 6.5 mm. Produces symmetric, less cosmetic alarming
caput saccundaneum and less scalp abrasion
• Silastic Cups – Pliable, softer, less traumatic and safer. Described by
Koyabashi
• Plastic Cups (Mityvac) – Consists of disposable plastic cup and handle,
suction tube and hand pump. It builds pressure quickly and can be used evn
in the absence f electricity.

40. TYPES OF CUP APPLICATION
• Flexing Median
• Flexing Paramedian
• Deflexing Median
• Deflexing Paramedian

42. • KIWI Vacuum Device

43. INDICATIONS
• Shortening second stage of labour
• Maternal Exhaustion
• Presumed fetal distress
• Occipito- Posterior position
• To deliver second twin if head is presenting part
Non Conventional
• Can be used in Caesarean section
• To deliver frank breech (Charmers)
• Compound presentation

44. CONTRAINDICATIONS
• Absolute –
• Operator inexperience
• Inability to properly attach
• Inadequate trial of Labour
• High fetal head
• Malpositions
• Aftercoming head of breech
• Known fetal coagulation defect

45. • Relative –
• Prematurity
• Intrauterine fetal Demise
• Congenital Anomalies
• ‘Prior Scalp Sampling

46. CHIGNON FORMATION
• A chignon is a temporary swelling left
on an infant's head after
a ventouse suction cap has been
used to deliver him or her
• Chignon in french : a knot of hair
that is worn at the back of the head

47. PROCEDURE
• A proper vacuum extraction depends on
• The accuracy of the cup application
• The traction technique
• Fetal cranial position
• Cup design
• The feto-pelvic relationship

48. • Patient is in litotomy position
• Written informen consent taken
• Bladder is emptied
• The position ,station and the attitude of the fetal head is verified
• Phantom application is performed before an attempt

50. • Place the cup —
• The practitioner spreads the labia and introduces the bell shaped cup by
compressing and inserting it into the vagina while angling the device
posteriorly.
• When contact is made with the fetal head, the center of the cup is placed
over the flexion point and symmetrically across the sagittal suture
• After correct placement of the cup is confirmed, vacuum pressure should be
raised to 100 to 150 mmHg to maintain the cup's position.
• The edges of the cup should again be swept with a finger to insure that no
maternal tissues are entrapped.

51. • Apply suction —
• Suction pressure is measured in various units: 0.8 kg/cm2 of atmospheric
pressure = 600 mmHg = 23.6 inches of Hg = 11.6 lb/in
• Vacuum suction pressures of 500 to 600 mmHg have been recommended
during traction, although pressures in excess of 450 mmHg are rarely
necessary
• While lower suction pressures increase the risk of cup "pop-offs," pressures
beyond 600 mmHg increase the risks of fetal scalp trauma and cerebral,
cranial and scalp hemorrhage

52. • Exert traction —
• The absolute "safe" traction force for vacuum extraction is unknown. In 1962,
one group determined a total traction force of 17.6 kg was typically
necessary to affect delivery
• Traction is applied along the axis of the pelvic curve to guide the fetal vertex,
led by the flexion point, through the birth canal.
• Initially, the angle of traction is downward (toward the floor)
• the higher the beginning station, the steeper the angle of downward traction
required.
• The axis of traction is then extended upwards to a 45 degree angle to the
floor as the head emerges from the pelvis and crowns

53. DURATION
• A maximum of two to three cup detachments,
• three sets of pulls for the descent phase,
• three sets of pulls for the outlet extraction phase,
• and/or a maximum total vacuum application time of 15 to 30 minutes are
commonly recommended, with most authors advising lesser time limits

54. FAILED PROCEDURES
• Fetopelvic disproportion
• Incorrect technique
• Large caput succedaneum

55. SUMMARY- OVD
• PROPER DOUBLE SETUP
• INFORMED WRITTEN CONSENT BY PATEINT AND RELATIVES
• CHOOSE THE RIGHT EQUIPMENT
• CHOOSE PROPER INDICATION
• RULE OUT THE CONTRAINDICATION
• FULL FILL ALL THE PREREQUSITES
• ATTEMPT A PHANTOM APPLICATION BEFORE THE ACTUAL APPLICATION
• SUPERVISION BY QUALIFIED PERSON
• NO FORCE APPLIED
• IF FAILED OVD
• ABANDON THE PROCEDURE
• KEEP DOUBLE SET UP READY FOR EMERGENCY LSCS