Operative Delivery (Forceps and Vacuum)

Prerequisites & Indications - Setting the Stage

• Prerequisites:
  • Cervix: Fully dilated (10 cm)
  • Membranes: Ruptured
  • Fetal head: Engaged (station 0 or lower, ideally +2 cm for outlet)
  • Position: Known
  • Analgesia: Adequate
  • Bladder: Empty
  • Pelvis: Adequate (no CPD)
  • Consent: Informed
  • 
• Indications:
  • Maternal: Prolonged 2nd stage (Nulli: >3h epidural, >2h no epidural; Multi: >2h epidural, >1h no epidural); maternal exhaustion; medical conditions (e.g., cardiac).
  • Fetal: Non-reassuring fetal status (NRFS) in 2nd stage; shorten 2nd stage (fetal benefit).

⭐ Full cervical dilatation and engaged fetal head are absolute prerequisites for operative vaginal delivery.

Forceps Delivery - Precision Pull

Aids fetal head extraction. Prerequisites: Cervix fully dilated, membranes ruptured, head engaged (≥0 station), known position, no CPD, empty bladder, analgesia.

• Indications:
  • Maternal: Exhaustion, cardiac/resp. disease (avoid Valsalva).
  • Fetal: NRFS, prolonged 2nd stage.
• Contraindications: Unengaged head, incomplete dilatation, CPD, fetal bleeding disorder, prematurity <34 wks (relative).
• Types (Examples):
  • Outlet (Wrigley's): Scalp visible.
  • Low (Simpson's): Station ≥ +2 cm.
  • Mid (Kielland's): Rotation; station 0 to +2 cm.
  • Piper's: Aftercoming head (breech).
• Complications:
  • Maternal: ↑Lacerations (3rd/4th°), PPH.
  • Fetal: Facial N. palsy, cephalohematoma.

⭐ Kielland's forceps: for rotational deliveries (e.g., DTA), need high skill due to ↑maternal trauma risk.

Vacuum Extraction - Suction Savvy

• Mechanism: Traction on fetal scalp via suction.
• Prerequisites: Full dilation, ruptured membranes, engaged head (station ≥0), known position.
• Contraindications:
  • Gestational age < 34 weeks.
  • Fetal coagulopathy.
  • Unengaged head, malpresentation (face/brow).
• Cup: Flexion point (3cm ant. to post. fontanelle, on sagittal suture).
• Procedure:
  • Suction: 0.6-0.8 kg/cm².
  • Traction: With contractions, along pelvic curve.
  • Limits: Max 3 pop-offs (📌 Three strikes, you're out!), max duration 20 mins, max 3 pulls.
• Complications:
  • Fetal: Chignon, scalp abrasions, cephalohematoma, subgaleal hemorrhage (⚠️ severe), retinal hemorrhage.
  • Maternal: Lacerations.

⭐ Subgaleal hemorrhage is a rare but potentially lethal complication specifically associated with vacuum extraction.

Forceps vs. Vacuum - The Showdown

Complications & Care - Safe Landing

• Maternal:
  • Perineal tears (esp. 3rd/4th degree), PPH, infection.
  • Genital tract trauma. Urinary/anal sphincter injury.
• Fetal:
  • Scalp: Lacerations, cephalohematoma, subgaleal hemorrhage.
  • Nerve palsies (facial, brachial). Retinal hemorrhage.
• Care:
  • Assess mother & baby. Repair trauma. Analgesia.
  • Monitor PPH. Antibiotics if needed. Debrief.

⭐ Failed operative vaginal delivery mandates Cesarean section; avoid sequential vacuum/forceps use due to ↑ neonatal morbidity.

High‑Yield Points - ⚡ Biggest Takeaways

• Prerequisites: Full cervical dilatation, ruptured membranes, engaged head, known fetal position, empty bladder, informed consent.
• Indications: Fetal distress, maternal exhaustion, prolonged second stage; outlet forceps (head on perineum), low forceps (station ≥ +2 cm).
• Vacuum (Ventouse): Preferred for rotational deliveries, less maternal trauma. Contraindicated < 34 weeks gestation.
• Kielland's forceps: Specialized for rotational deliveries (e.g., occiput posterior/transverse); higher risk of maternal trauma.
• Forceps complications: Maternal perineal tears (commonest); fetal facial nerve palsy, cephalhematoma.
• Vacuum complications: Fetal scalp abrasions/lacerations, subgaleal hemorrhage (most serious); less maternal trauma than forceps.
• Failed operative delivery: Proceed to Cesarean section. Maximum 3 pulls for vacuum, duration < 20-30 minutes total application time.