Operative Vaginal Deliveries

Indications for operative vaginal delivery in a low-risk mother are nonreassuring FHR, maternal exhaustion, and prolonged second stage, which is generally 3 hours for a nul-liparous woman and 2 hours for a parous woman.

Essential for safe operative vaginal delivery is optimal readiness. The laboring woman should understand the reasons why operative delivery has been chosen, with documentation in the chart. She should then be placed in a position in which her legs are maximally open, preferably in stirrups, with the perineum at the edge of the bed. Usual washing and draping is performed. The bladder is emptied. Adequate anesthesia makes placement of instruments easier and improves maternal cooperation. Pudendal block is often adequate for procedures when the fetal head is at the outlet. However, conduction anesthesia is often used. The cervix should be completely dilated and the membranes ruptured. Station, position, and attitude of the fetal head should be known. The fetal head should be engaged. Palpation, maternal sensation, or contraction monitoring can help identify the timing of contractions. Facilities for cesarean section should be available. Decision to use forceps or vacuum is based on operator skill, availability of instruments, and fetal-maternal considerations, including pelvic shape and size, fetal head position, and availability of anesthesia.

Figure 21-18 The crown-rump length (CRL) is denoted by crosses. Care should be taken to view the entire fetus in the midsagittal plane so as not to undermeasure. Conversely, the yolk sac is not a part of the CRL, so its inclusion will falsely increase the measurement.

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Figure 21-19 Outlet forceps delivery. The direction of traction is first downward so that the fetal head negotiates the pubic symphysis and then upward to deliver in extension.

Figure 21-18 The crown-rump length (CRL) is denoted by crosses. Care should be taken to view the entire fetus in the midsagittal plane so as not to undermeasure. Conversely, the yolk sac is not a part of the CRL, so its inclusion will falsely increase the measurement.

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