From the Guidelines
The key takeaways for the assessment of operative vaginal delivery include thorough evaluation for cephalopelvic disproportion (CPD) and careful consideration of the risks and benefits of vaginal delivery versus cesarean delivery (CD) 1. When assessing the need for operative vaginal delivery, it is crucial to evaluate for known associations with arrested active phase, such as CPD, and to intervene accordingly 1. The clinical importance of arrested active phase is its strong association with CPD and the related potential risks, with 40% to 50% of parturients with arrest of the active phase having concomitant CPD 1. Some key points to consider in the assessment of operative vaginal delivery include:
- Thorough cephalopelvimetry to exclude the presence of disproportion 1
- Recognition of potential problems, such as malposition or excessive molding, before the limits of safe vaginal delivery are reached 1
- Awareness of other factors that signal concern, such as maternal diabetes and obesity, pelvic shape and size, fetal macrosomia, malposition, malpresentation, asynclitism, and excess molding 1
- Differentiation between molding and true descent by means of serial suprapubic palpation of the base of the fetal skull to ensure that descent is actually occurring 1 If evidence of CPD is found or cannot be ruled out with a reasonable degree of certainty, CD is a more prudent and safer choice 1.
From the Research
Key Takeaways for the Assessment of Operative Vaginal Delivery
- The assessment of labor is crucial in determining the need for operative vaginal delivery, and requires skillful physical diagnosis and the ability to translate acquired information into meaningful prognostic decision-making 2.
- Factors such as cephalopelvic disproportion, excess analgesia, fetal malpositions, intrauterine infection, and maternal obesity are strongly associated with the development of labor disorders, which may necessitate operative vaginal delivery 2.
- The use of a partograph is associated with a reduction in the use of forceps, but not vacuum extraction 3.
- Early correction of lack of progress in dilatation by oxytocin perfusion can reduce the number of operative vaginal deliveries 3.
- The choice of instrument for operative vaginal delivery depends on various factors, including the position of the fetus and the expertise of the operator 3, 4, 5, 6.
- Vacuum extraction is becoming increasingly popular, but is associated with a higher risk of neonatal cephalohematoma compared to forceps 4, 5.
- Forceps delivery is associated with a higher risk of maternal trauma, but has a lower failure rate compared to vacuum extraction 3, 6.
- Simulation training can enhance residents' understanding of mechanical principles and should logically precede clinical work in operative vaginal delivery 6.
- The "ABCDEFGHIJ" mnemonic can facilitate proper use and application of the vacuum device and minimize risks 5.