Instrumental Vaginal Delivery Guideline

Obstetrics Clinical Guidelines August 2009 1.
ROYAL HOSPITAL FOR WOMEN Approved by
Quality & Patient Safety Committee
CLINICAL POLICIES, PROCEDURES & GUIDELINES 15/10/09
INSTRUMENTAL VAGINAL DELIVERY GUIDELINE
1. OPTIMAL OUTCOMES
• Woman given adequate information and explanation to give her informed consent for the
instrumental delivery
• Appropriate single instrument chosen to effect vaginal delivery
• Successful operation of vaginal delivery with minimal fetal and maternal trauma
• Delivery performed by adequately credentialed/supervised clinician
2. PATIENT
• Woman requiring instrumental delivery for maternal or fetal indications
3. STAFF
• Medical staff who are appropriately credentialed/supervised by a clinician who is credentialed
• Registered midwives
4. EQUIPMENT
• Personal protective equipment
• Delivery pack, episiotomy scissors and suture set
• Sterile linen drapes
• Forceps as appropriate – matching pair of blades
• Equipment for vacuum instrumental delivery
• Neonatal resuscitation trolley
• Cord blood gas syringes
5. CLINICAL PRACTICE
• Assess indications for delivery including:
o Inadequate progress in the second stage of labour in the presence of adequate
contractions
o Abnormal fetal heart rate (FHR) pattern
o Acidotic fetal scalp sample in the second stage of labour
o Maternal exhaustion or other condition resulting in the woman’s inability to actively
push
o Malposition of the fetal head
• Perform abdominal examination and document engagement, lie and position, and contraction
charastics
• Perform vaginal examination and document:
o Dilation of cervix
o Station of fetal head
o Position of fetal head
o Presence of caput and/or moulding
o Colour of liquor
• Consider confirming fetal position with ultrasound
• Plan mode of delivery, location of delivery and need for supervision. All instrumental
deliveries should be undertaken or supervised by a specialist or appropriately credentialed
medical officer.
cont’d ..../2
Reviewed August 2009
Approved Clinical Performance and Quality Committee August 2007
Reviewed June 2007
Approved Quality Council 16/12/2002

Obstetrics Clinical Guidelines August 2009 2.
ROYAL HOSPITAL FOR WOMEN Approved by
Quality & Patient Safety Committee
CLINICAL POLICIES, PROCEDURES & GUIDELINES 15/10/09
INSTRUMENTAL VAGINAL DELIVERY GUIDELINE cont’d
• Assess pre requisites for instrumental delivery:
o Appropriate explanation and information must be provided to the woman and verbal
consent obtained
o Abdominal palpation. Fetal head must be engaged and contractions strong and
frequent
o Adequate analgesia where appropriate
o Bladder empty
o Cervix should be fully dilated and the membranes ruptured. An exception to this may
be with a second twin
o Determine the position and station of the fetal head
o Elevate the woman’s legs – If lithotomy position is used the woman’s legs should be
placed in the stirrups simultaneously.
Vacuum assisted birth
o Apply the vacuum cup to the flexion point. The flexion point is 3cm anterior to the
posterior fontanelle in the mid line
o Sweep a finger around the cup to ensure no maternal tissue is trapped beneath
the cup
o Increase pressure of the vacuum device to between 40 and 60 mms of Hg
o Apply traction during contractions at right angles to the plane of the cup
o Assess the need for episiotomy when fetal head distends the perineum.
Episiotomy may not be required for vacuum delivery
o Abandon the procedure:
� When the cup is detached 3 times
� When no bony descent has occurred over 3 consecutive contractions
� When birth is not imminent within 15 minutes of the initial application
of
� the cup
• Seek advice from senior medical staff when procedure needs to be abandoned
• Document clinical events on instrumental birth record and in integrated clinical notes
Forceps delivery
o Lubricate the blades
o Apply blades between contractions
o Apply steady traction in the axis of the pelvis
o Halt the traction in between contractions (except where immediate delivery is
required)
o Perform episiotomy as the fetal head distends the perineum. It is rare for
episiotomy not to be required
o Abandon the procedure:
� when there has been no bony descent over 3 consecutive
contractions or
� when birth has not been achieved within 15 minutes of the initial
application of the forceps
• Seek advice from senior medical staff when procedure needs to be abandoned
• Auscultate and record the fetal heart following every contraction during instrumental birth
• Document clinical events on instrumental birth record and in integrated clinical notes
cont’d ..../3
Reviewed August 2009
Approved Clinical Performance and Quality Committee August 2007
Reviewed June 2007
Approved Quality Council 16/12/2002

Obstetrics Clinical Guidelines August 2009 3.
ROYAL HOSPITAL FOR WOMEN Approved by
Quality & Patient Safety Committee
CLINICAL POLICIES, PROCEDURES & GUIDELINES 15/10/09
INSTRUMENTAL VAGINAL DELIVERY GUIDELINE cont’d
6. HAZARDS/SUB-OPTIMAL OUTCOMES
• No evidence-based indication for instrumental delivery
• Inadequate pain relief
• Medical officer inadequately skilled/supervised to undertake the instrumental delivery
• Selection of incorrect forceps
• Use of a forceps after vacuum
• Episiotomy performed prior to abandoning procedure
7. DOCUMENTATION
• Integrated clinical notes
• Instrumental birth record
• Partogram
• ObstetriX
8. EDUCATIONAL NOTES
• Compared to forceps the use of a vacuum extractor is associated with a higher risk of failure,
more cephalohaematoma, sub-galeal haemorrhage and retinal haemorrhages but less use of
regional anaesthesia and less maternal genital tract trauma.
• Correct application of the vacuum cup:
o promotes flexion of the fetal head when traction is being applied
o allows the smallest diameter of the fetal head to present
• Vacuum - Generally the Vacuum cup (soft and rigid cup) places less force to the fetal head,
teaches the operator to follow the pelvic curve and requires less anaesthesia. Cup
detachment may occur in 34% of cases for a variety of reasons.
o Fetal injury increases significantly between 11 to 20 minutes duration as compared to
less than 10 minutes
• Classification of Instrumental Delivery:
o Mid-cavity - The head is engaged but the leading edge of the skull is between the
level of the spines and + 2cms from the spines
o Low-cavity -- The leading edge of the fetal skull is at station ≥ + 2 cms. and not on
the pelvic floor
o Outlet forceps or Vacuum - The fetal scalp has reached the pelvic floor and is visible
at the introitus without separating the labia
o Rotational forceps – Keillands forceps
o The use of an axis traction handle facilitates traction in the direction of the pelvic
curve. Pajot's manoeuvre consists of applying traction in the same direction that the
forceps handles extend, outward and away from the mother, whilst the other hand
applies downward traction on the shanks of the forceps. These opposing forces will
bring the head down under the symphysis pubis following the pelvic curve.
• Caution should be used in attempting a Forceps birth after an unsuccessful Vacuum
• Forceps can effect a more rapid delivery than the vacuum, this may be important when birth
needs to occur quickly.
• A variety of forceps are available for different clinical situations
9. RELATED POLICIES/ PROCEDURES/CLINICAL PRACTICE GUIDELINES
• Neonatal Resuscitation
• Vaginal Examination
• Second stage of labour
• PPH
• Obesity management in pregnancy
• Accountable items in the birthing environment
cont’d ..../4
Reviewed August 2009
Approved Clinical Performance and Quality Committee August 2007
Reviewed June 2007
Approved Quality Council 16/12/2002

Obstetrics Clinical Guidelines August 2009 4.
ROYAL HOSPITAL FOR WOMEN Approved by
Quality & Patient Safety Committee
CLINICAL POLICIES, PROCEDURES & GUIDELINES 15/10/09
INSTRUMENTAL VAGINAL DELIVERY GUIDELINE cont’d
10. REFERENCES
• Johanson RB, Menon BKV. Vacuum extraction vs forceps delivery. (Cochrane Review). In:
the Cochrane Library, Issue 4 1999. Oxford Update Software.
• Teng FY. Sayre JW. Vacuum extraction: does duration predict scalp injury? Obstetrics &
Gynaecology. Feb, 1997;89(2):281-5.
• Damos JR. Assisted vaginal delivery. Advanced Life Support in Obstetrics (ALSO) Course
Syllabus, Chapter H, 4 th Ed. American Academy of Family Physicians, Kansas 2000.
• Adapted from ACOG: Operative vaginal delivery. Practice Bulletin No 17, June 2000
• Vacca A. Vacuum assisted delivery: An analysis of traction force and maternal and neonatal
outcomes Australian & New Zealand Journal of Obstetrics & Gynaecology 2006; 46: 124-127
• NSW Health Safety Notice 016/09 Safe Instrumental Birth, 28 July 2009
…./attachment
Reviewed August 2009
Approved Clinical Performance and Quality Committee August 2007
Reviewed June 2007
Approved Quality Council 16/12/2002

MIDWIFERY RECORD OF INSTRUMENTAL BIRTH
INDICATION:
Delay in second stage
Non-reassuring fetal heart rate trace
Breech – after coming head
Other
ANALGESIA
Analgesia/Anaestheti
c
Paediatrician Present
Yes No
• Epidural effective Yes No
• Top up required – Time: hrs
• Other Analgesia
Place patient address label here
Time notified _________hrs Time arrived ___________hrs
VENTOUSE Time Ventouse Applied: ________ hrs Total mins of suction: _________
1 ST Contraction
2 nd Contraction
3 rd Contraction
Time Pressure Descent
Yes/No
Head Born @___________Baby born @ __________
Pop off
Yes/No
Time
reapplied
Cord Blood Gases collected: No Yes Arterial ______________Venous_____________
FORCEPS Forceps undertaken in Delivery suite Operating Theatres
Decision to transfer to theatre: Time________Transfer to OT: Time ______________
FHR
Forceps Type: FHR
1 st Blade applied @ Hrs 2 nd Blade applied @ Hrs
1 st Contraction Visual Progress Yes No
2 nd Contraction Visual Progress Yes No
3 rd Contraction Visual Progress Yes No
Forceps Type:
1 st Blade applied @ Hrs 2 nd Blade applied @ Hrs
1 st Contraction Visual Progress Yes No
2 nd Contraction Visual Progress Yes No
3 rd Contraction Visual Progress Yes No
Forceps Successful Yes No Time decision made for LSCS ____________hrs
Head Born @_______________Baby born @ __________ Apgars 1min ______5mins_______
Cord Blood Gases collected: No Yes Arterial ______________Venous_____________
SIGNATURE: PRINT NAME:
Reviewed August 2009
Approved Clinical Performance and Quality Committee August 2007
Reviewed June 2007
Approved Quality Council 16/12/2002