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INTRODUCTION

KEY QUESTIONS

  • What are the indications for operative vaginal delivery (OVD)?

  • What are the contraindications to OVD?

  • What are the prerequisites and techniques for OVD?

  • What are the complications of OVD?

  • How should patients be counseled properly for OVD?

CASE 67-1

A 29-y.o. G1P0 at term has been admitted in labor. The prenatal course was unremarkable, and she has progressed to full dilatation, 100% effacement, and +2/+5 station. Clinical EFW is 3200 g, and she has epidural anesthesia. You are called by the patient’s nurse because the FHR has remained in the 80-bpm range for 5 minutes.

As you enter the room, you note that resuscitative measures have been initiated. You examine the patient and confirm the dilatation and station. You note that the position of the fetal vertex is LOA. You determine that OVD is appropriate to perform, and you begin the process.

Operative vaginal delivery (OVD) is a valuable technique that can be used to expedite delivery safely in instances of potential fetal or maternal compromise. It is often faster than cesarean delivery and has lower maternal and fetal morbidity as well. In their 2014 Obstetric Care Consensus for Safe Prevention of the First Cesarean, the American College of Obstetricians and Gynecologists (ACOG) and the Society of Maternal-Fetal Medicine (SMFM) recommend using OVD as a strategy to safely lower the primary cesarean rate. Critical elements of successful OVD include a skilled accoucheur, an acceptable indication, and the ability to anticipate and perform cesarean delivery if necessary. The hospitalist is in an ideal position to utilize this technique individually and to act as a consultant for other providers. This person also can be integral in teaching the technique to others, as he or she is often the most experienced provider in the labor suite.

The incidence of OVD has dropped substantially in recent decades, from 20% of deliveries in 1983 to 0.5% in 2015. Upon completion of their training, graduating residents have participated in an average of five forceps deliveries and eight vacuum-assisted deliveries. With such low numbers of procedures, it is understandable that obtaining sufficient competency in these procedures is a challenge. As more institutions are incorporating experienced hospitalists in their models of patient care, there is an opportunity to reverse the decline in OVD rates, which can result in a decrease in cesarean rates and its associated morbidities.

ANATOMY

Knowledge of the anatomy of both the maternal pelvis and the fetal skull is critical to successful OVD. The safety of the procedure is greatly affected by correct identification of fetal position and station. The likelihood of success is affected by the degree to which the force vector of assistance both aligns with the birth canal and presents the smallest possible diameter of the fetal vertex through the pelvic outlet.

Correctly determining the position of the fetal vertex is a prerequisite ...

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