Towards safe practice in instrumental vaginal delivery

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Towards safe practice in instrumental vaginal
delivery

• Leroy Edozien

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Approximately 1 in 10 deliveries is instrumental

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What could go wrong?Fetal complications

• Facial laceration
• Scalp laceration
• Facial nerve palsy
• Skull fracture
• Corneal injury
• Cervical spine injury

Subdural haematoma Subgaleal haematoma Cephalhaema
toma Retinal haemorrhage Hyperbilirubinaemia
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King SJ, Boothroyd AE. Cranial trauma following
birth in term infants. Br J Radiol 199871233-8
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What could go wrong?Maternal complications
Cervical laceration Haematoma Vaginal
laceration Perineal tear Psychological
trauma
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Avoiding harm

• Non-operative interventions
• Deciding when and when not to deliver
  instrumentally
• Using the right operative techniques

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Non-operative interventions which reduce
instrumental delivery rates

• One-to-one support in labour (Hodnett, 2003)
• Upright or lateral position (Gupta Hofmeyr,
  2003)
• Oxytocin for prolonged second stage (Saunders et
  al, 1989)
• Delayed pushing (Roberts et al, 2004)

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When and when not to deliver instrumentally

• Indications
• Fetal compromise (actual or anticipated)
• Prolonged second stage
• Where down-bearing is to be avoided

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When and when not to deliver instrumentally

• Absolute contraindications
• Malpresentation
• Unengaged fetal head
• Cephalopelvic disproportion
• Fetal clotting disorder
• GA lt 34 wk (ventouse)

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Safe practice prerequisites for instrumental
delivery

• Fully dilated cervix
• One-fifth or nil palpable abdominally
• Ruptured membranes
• Contractions present
• Empty bladder
• Presentation and position known
• Satisfactory analgesia

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Instrumental delivery before full cervical
dilatation

• Crime or expedience?
• SOGC may be considered when benefits
  significantly outweigh risks
• RCOG exceptions to the rule - cord prolapse at 9
  cm in a multip second twin

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Engagement

• Instrumental delivery should not be attempted if
  the lowest part of the babys skull has not
  reached the ischial spines.

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Crichton D. South African Medical Journal
197412784-7
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Smellie W. A treatise on the theory and practice
of Midwifery. London MDCCLII
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Communication and consent
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Safe practice abandonment

• Indications for abandonment
• Difficulty in applying instrument
• No descent
• Delivery not imminent after three pulls
• 15 minutes elapsed

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Why is the principle of abandonment frequently
breached?

• Poor training
• Confirmation bias
• Sunk costs

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Safe practice recognise conditions predictive of
difficulty/failure

• 1/5 palpable
• Station 0
• OP position
• Moulding /
• Slow progress
• Big baby
• BMI gt 30

Trial of instrumental delivery
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Sequential instrumentation

• Benefits and risks
• Decision-making

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Safe practice post-operative care

• Examine and observe the baby
• VTE risk assessment
• Bladder care
• Openness

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Safe practice Situational awareness
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Documentation

• Indication Abdominal examination
• Consent Position station
• Moulding caput Pelvis adequate
• CTG Contractions
• Ease of application No. of pulls
• Detachments Duration
• VE PR post-delivery Condition of baby
• Cord pH Details of repair

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Examples of error in instrumental delivery

• Action omitted, mistimed, misjudged
• Abdominal palpation not done
• Prolonged traction
• Continuous traction
• Rotation during a contraction
• Traction directed forwards and upwards too soon

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Examples of error in instrumental delivery

• Information wrong, incomplete or not retrieved
• Mistaken head level or position
• Moulding not assessed
• Equipment not checked
• History of diabetes disregarded

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Examples of error in instrumental delivery

• Procedural checks omitted or not properly done
• No check for correct application
• No check for descent with pull
• PR/VE not done at end of procedure
• Swabs not counted

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Examples of error in instrumental delivery

• Faulty selection (choosing from options)
• Wrong ventouse cup type
• Ill-advised sequential instrumentation

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Examples of error in instrumental delivery

• Failure to communicate
• With woman
• midwife
• senior obstetrician
• anaesthetist
• paediatrician

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Examples of error in instrumental delivery

• Cognition
• Failure to anticipate .PPH, Shoulder dystocia,
  etc.
• Failure to ask the right questions e.g. pulling
  in the right direction? forceps applied on
  babys face?

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Training, competence supervision

• Unmet training needs
• Demonstrable benefits of training
• Assessment tools

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• Dr C stated that he discussed these options with
  Mr A and Mrs B and said that they were
• happy for him to deliver their baby using
  forceps. Mr A and Mrs B considered that Dr C
• did not communicate very effectively with them
  before or during the delivery. They said it
• was often very difficult to hear and understand
  what he was saying, particularly because Dr
• C directed most of his comments to Ms F.

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Assessment occipito-posterior position, slightly
to the right presenting part slightly
tilted.Dr C applied the left blade of the
forceps directly to the babys head, followed by
the right blade. As the handles could not be
aligned properly he removed the blades and
reassessed the position of the head. At this
stage, Mrs Bs buttocks were brought down further
towards the edge of the bed and Dr C removed the
foetal scalp electrode to enable easier
application of the forceps.Dr C explained that
after re-examination he was satisfied that the
baby was in an occipito-posterior position and so
he reapplied the forceps. He stated that this
time the blades aligned without difficulty. Dr C
attempted to rotate the babys head to the right
but was unable to and so attempted rotation to
the left, which was also unsuccessful
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While kneeling on the floor, Dr C applied force
on the forceps during a contraction, in an
attempt to pull the baby down in the
occipito-posterior position while Mrs B was asked
to push. Dr C explained that sometimes the head
can be rotated at a lower level, or delivered in
that position without the need for any rotation.
He stated that only moderate traction was applied
during this procedure and that he only used his
right forearm while his left arm was resting on
top of his right hand.
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Mr A and Mrs B stated that Dr C pulled extremely
firmly on the forceps and that Mrs B was dragged
down the bed as a result. Dr C denied using any
more force than wasnecessary or than he would
normally use during such a procedure.
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Other than a small laceration on the left cheek
of the baby from the scalpel blade atthe time of
the operation, I did not see any external forceps
marks or bruises on thebabys head or the face
at the time of delivery. -Dr C
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Cord blood was obtained but had clotted and was
unsuitable for pH analysis.
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Baby born moribund. NICU. NND.This was Mrs
Bs second pregnancy and the pregnancy had been
uneventful. Her first child had died of a
congenital heartdefect (at 20 weeks gestation).
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http//www.hdc.org.nz/files/hdc/opinions/00hdc0932
4.pdf
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Joint RCOG/ENTER MEETINGRisk Management and
Medico-Legal Issues In Womens Health25 to 26
April 2007